Skip to main content Accessibility help

Neuropsychological Recovery Trajectories in Moderate to Severe Traumatic Brain Injury: Influence of Patient Characteristics and Diffuse Axonal Injury

  • Amanda R. Rabinowitz (a1) (a2), Tessa Hart (a1), John Whyte (a1) and Junghoon Kim (a1)
  • Please note a correction has been issued for this article.


Objectives: The goal of the present study was to elucidate the influence of demographic and neuropathological moderators on the longitudinal trajectory neuropsychological functions during the first year after moderate to severe traumatic brain injury (TBI). In addition to examining demographic moderators such as age and education, we included a measure of whole-brain diffuse axonal injury (DAI), and examined measures of processing speed (PS), executive function (EF), and verbal learning (VL) separately. Methods: Forty-six adults with moderate to severe TBI were examined at 3, 6, and 12 months post-injury. Participants underwent neuropsychological evaluation and neuroimaging including diffusion tensor imaging. Using linear mixed effects modeling, we examined longitudinal trajectories and moderating factors of cognitive outcomes separately for three domains: PS, VL, and EF. Results: VL and EF showed linear improvements, whereas PS exhibited a curvilinear trend characterized by initial improvements that plateaued or declined, depending on age. Age moderated the recovery trajectories of EF and PS. Education and DAI did not influence trajectory but were related to initial level of functioning for PS and EF in the case of DAI, and all three cognitive domains in the case of education. Conclusions: We found disparate recovery trajectories across cognitive domains. Younger age was associated with more favorable recovery of EF and PS. These findings have both clinical and theoretical implications. Future research with a larger sample followed over a longer time period is needed to further elucidate the factors that may influence cognitive change over the acute to chronic period after TBI. (JINS, 2018, 24, 237–246)


Corresponding author

Correspondence and reprint requests to: Amanda Rabinowitz, Moss Rehabilitation Research Institute, 50 Township Line Road, Elkins Park, PA 19027. E-mail:


Hide All
Baayen, R.H., Davidson, D.J., & Bates, D.M. (2008). Mixed-effects modeling with crossed random effects for subjects and items. Journal of Memory and Language, 59(4), 390412.
Beglinger, L.J., Gaydos, B., Tangphao-Daniels, O., Duff, K., Kareken, D.A., Crawford, J., & Siemers, E.R. (2005). Practice effects and the use of alternate forms in serial neuropsychological testing. Archives of Clinical Neuropsychology, 20(4), 517529.
Benton, L., Hamsher, K., & Sivan, A. (1994). Controlled oral word association test. Multilingual aphasia examination. Iowa City, IA: AJA Associates.
Bigler, E.D., Johnson, S.C., Anderson, C.V., Blatter, D.D., Gale, S.D., Russo, A.A., &Hopkins, R.O. (1996). Traumatic brain injury and memory: The role of hippocampal atrophy. Neuropsychology, 10(3), 333.
Christensen, B.K., Colella, B., Inness, E., Hebert, D., Monette, G., Bayley, M., & Green, R.E. (2008). Recovery of cognitive function after traumatic brain injury: A multilevel modeling analysis of Canadian outcomes. Archives of Physical Medicine and Rehabilitation, 89(12), S3S15.
Corrigan, J.D., & Hammond, F.M. (2013). Traumatic brain injury as a chronic health condition. Archives of Physical Medicine and Rehabilitation, 94(6), 11991201.
Dawson, D.R., & Chipman, M. (1995). The disablement experienced by traumatically brain-injured adults living in the community. Brain Injury, 9(4), 339353.
Delis, D.C., Kaplan, E., & Kramer, J.H. (2001). Delis-Kaplan executive function system (D-KEFS). San Antonio, TX: Psychological Corporation.
Dikmen, S.S., Corrigan, J.D., Levin, H.S., Machamer, J., Stiers, W., & Weisskopf, M.G. (2009). Cognitive outcome following traumatic brain injury. The Journal of Head Trauma Rehabilitation, 24(6), 430438.
Farbota, K.D., Bendlin, B.B., Alexander, A.L., Rowley, H.A., Dempsey, R.J., & Johnson, S.C. (2012). Longitudinal diffusion tensor imaging and neuropsychological correlates in traumatic brain injury patients. Frontiers in Human Neuroscience, 6, 160.
Fitzmaurice, G.M., Laird, N.M., & Ware, J.H. (2012). Applied longitudinal analysis, (Vol. 998). New York: John Wiley & Sons.
Green, R.E., Colella, B., Christensen, B., Johns, K., Frasca, D., Bayley, M., & Monette, G. (2008). Examining moderators of cognitive recovery trajectories after moderate to severe traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 89(12), S16S24.
Håberg, A., Olsen, A., Moen, K., Schirmer‐Mikalsen, K., Visser, E., Finnanger, T., & Eikenes, L. (2015). White matter microstructure in chronic moderate‐to‐severe traumatic brain injury: Impact of acute‐phase injury‐related variables and associations with outcome measures. Journal of Neuroscience Research, 93(7), 11091126.
Hellawell, R., Taylor, B., & Pentland, D.J. (1999). Cognitive and psychosocial outcome following moderate or severe traumatic brain injury. Brain Injury, 13(7), 489504.
Himanen, L., Portin, R., Isoniemi, H., Helenius, H., Kurki, T., & Tenovuo, O. (2006). Longitudinal cognitive changes in traumatic brain injury: A 30-year follow-up study. Neurology, 66(2), 187192.
Hoofien, D., Vakil, E., Gilboa, A., Donovick, P.J., & Barak, O. (2002). Comparison of the predictive power of socio-economic variables, severity of injury and age on long-term outcome of traumatic brain injury: Sample-specific variables versus factors as predictors. Brain Injury, 16(1), 927.
Hurvich, C.M., & Tsai, C.-L. (1989). Regression and time series model selection in small samples. Biometrika, 297307.
Jackson, W.T., Novack, T.A., & Dowler, R.N. (1998). Effective serial measurement of cognitive orientation in rehabilitation: the Orientation Log. Archives of Physical Medicine and Rehabilitation, 79(6), 718721.
Kesler, S.R., Adams, H.F., Blasey, C.M., & Bigler, E.D. (2003). Premorbid intellectual functioning, education, and brain size in traumatic brain injury: An investigation of the cognitive reserve hypothesis. Applied Neuropsychology, 10(3), 153162.
Kraus, M.F., Susmaras, T., Caughlin, B.P., Walker, C.J., Sweeney, J.A., & Little, D.M. (2007). White matter integrity and cognition in chronic traumatic brain injury: A diffusion tensor imaging study. Brain, 130(10), 25082519.
Kumar, R., Gupta, R.K., Husain, M., Chaudhry, C., Srivastava, A., Saksena, S., & Rathore, R.K. (2009). Comparative evaluation of corpus callosum DTI metrics in acute mild and moderate traumatic brain injury: its correlation with neuropsychometric tests. Brain Injury, 23(7-8), 675685.
Lannoo, E., Colardyn, F., Jannes, C., & De Soete, G. (2001). Course of neuropsychological recovery from moderate-to-severe head injury: A 2-year follow-up. Brain Injury, 15(1), 113.
Lezak, M., Howieson, D., Bigler, E., & Tranel, D. (2012). Neuropsychological assessment (5th ed.). New York, NY: Oxford University Press.
Lezak, M. (2004). Neuropsychological assessment. New York, NY: Oxford University Press.
Lipton, M.L., Kim, N., Park, Y.K., Hulkower, M.B., Gardin, T.M., Shifteh, K., & Branch, C.A. (2012). Robust detection of traumatic axonal injury in individual mild traumatic brain injury patients: intersubject variation, change over time and bidirectional changes in anisotropy. Brain Imaging and Behavior, 6(2), 329342.
Mayer, A.R., Bedrick, E.J., Ling, J.M., Toulouse, T., & Dodd, A. (2014). Methods for identifying subject‐specific abnormalities in neuroimaging data. Human Brain Mapping, 35(11), 54575470.
Newcombe, V., Chatfield, D., Outtrim, J., Vowler, S., Manktelow, A., Cross, J., & Menon, D. (2011). Mapping traumatic axonal injury using diffusion tensor imaging: Correlations with functional outcome. PLoS One, 6(5), e19214.
Niogi, S.N., Mukherjee, P., Ghajar, J., Johnson, C.E., Kolster, R., Lee, H., & McCandliss, B.D. (2008). Structural dissociation of attentional control and memory in adults with and without mild traumatic brain injury. Brain, 131(12), 32093221.
Novack, T.A., Bush, B.A., Meythaler, J.M., & Canupp, K. (2001). Outcome after traumatic brain injury: pathway analysis of contributions from premorbid, injury severity, and recovery variables. Archives of Physical Medicine and Rehabilitation, 82(3), 300305.
Palacios, E.M., Sala-Llonch, R., Junque, C., Fernandez-Espejo, D., Roig, T., Tormos, J.M., & Vendrell, P. (2013). Long-term declarative memory deficits in diffuse TBI: correlations with cortical thickness, white matter integrity and hippocampal volume. Cortex, 49(3), 646657.
Ponsford, J., Draper, K., & Schönberger, M. (2008). Functional outcome 10 years after traumatic brain injury: its relationship with demographic, injury severity, and cognitive and emotional status. Journal of the International Neuropsychological Society, 14(02), 233242.
Ponsford, J.L., Downing, M.G., Olver, J., Ponsford, M., Acher, R., Carty, M., & Spitz, G. (2014). Longitudinal follow–up of patients with traumatic brain injury: Outcome at two, five, and ten years post-injury. Journal of Neurotrauma, 31(1), 6477.
Rabinowitz, A.R., & Smith, D.H. (2016). Traumatic brain injury and rationale for a neuropsychological diagnosis of diffuse axonal injury. In G.T. Orly Lazarov (Ed.), Genes, environment and Alzheimer’s disease (pp. 267293). Cambridge, MA: Elsevier.
Reitan, R.M., & Wolfson, D. (1985). The Halstead-Reitan neuropsychological test battery: Theory and clinical interpretation (Vol. 4): Reitan neuropsychology. New York: Springer.
Ruff, R.M., Marshall, L.F., Crouch, J., Klauber, M.R., Levin, H.S., Barth, J., & Eisenberg, H.M. (1993). Predictors of outcome following severe head trauma: Follow-up data from the Traumatic Coma Data Bank. Brain Injury, 7(2), 101111. doi: 10.3109/02699059309008164
Salthouse, T.A. (2010). Selective review of cognitive aging. Journal of the International Neuropsychological Society, 16(5), 754.
Schretlen, D.J., & Shapiro, A.M. (2003). A quantitative review of the effects of traumatic brain injury on cognitive functioning. International Review of Psychiatry, 15(4), 341349.
Schultz, R., & Tate, R.L. (2013). Methodological issues in longitudinal research on cognitive recovery after traumatic brain injury: Evidence from a systematic review. Brain Impairment, 14(3).
Senathi-Raja, D., Ponsford, J., & Schönberger, M. (2010). Impact of age on long-term cognitive function after traumatic brain injury. Neuropsychology, 24(3), 336.
Sherer, M., Stouter, J., Hart, T., Nakase-Richardson, R., Olivier, J., Manning, E., &Yablon, S.A. (2006). Computed tomography findings and early cognitive outcome after traumatic brain injury. Brain Injury, 20(10), 9971005.
Spitz, G., Maller, J.J., O’Sullivan, R., & Ponsford, J.L. (2013). White matter integrity following traumatic brain injury: the association with severity of injury and cognitive functioning. Brain Topography, 26(4), 648660.
Stern, Y. (2002). What is cognitive reserve? Theory and research application of the reserve concept. Journal of the International Neuropsychological Society, 8(03), 448460.
Ware, J.B., Hart, T., Whyte, J., Rabinowitz, A., Detre, J.A., & Kim, J. (2017). Inter-subject variability of axonal injury in diffuse traumatic brain injury. Journal of Neurotrauma, 34(14), 22432253.
Watts, R., Thomas, A., Filippi, C.G., Nickerson, J.P., & Freeman, K. (2014). Potholes and molehills: Bias in the diagnostic performance of diffusion-tensor imaging in concussion. Radiology, 272(1), 217223.
Wechsler, D. (2014). Wechsler adult intelligence scale–fourth edition (WAIS–IV). San Antonio, TX: Pearson.
White, T., Magnotta, V.A., Bockholt, H.J., Williams, S., Wallace, S., Ehrlich, S., & Lim, K.O. (2009). Global white matter abnormalities in schizophrenia: A multisite diffusion tensor imaging study. Schizophrenia Bulletin, 37, 222232.
Whiteneck, G., Brooks, C., Mellick, D., Harrison-Felix, C., Terrill, M.S., & Noble, K. (2004). Population-based estimates of outcomes after hospitalization for traumatic brain injury in Colorado. Archives of Physical Medicine and Rehabilitation, 85, 7381.
Wilde, E.A., Whiteneck, G.G., Bogner, J., Bushnik, T., Cifu, D.X., Dikmen, S., & von Steinbuechel, N. (2010). Recommendations for the use of common outcome measures in traumatic brain injury research. Archives of Physical Medicine and Rehabilitation, 91(11), 16501660. e1617.
Wood, R.L., & Rutterford, N.A. (2006). Demographic and cognitive predictors of long-term psychosocial outcome following traumatic brain injury. Journal of the International Neuropsychological Society, 12(03), 350358.
Yuh, E.L., Cooper, S.R., Mukherjee, P., Yue, J.K., Lingsma, H.F., & Gordon, W.A., . . . TRACK-TBI INVESTIGATORS. (2014). Diffusion tensor imaging for outcome prediction in mild traumatic brain injury: A TRACK-TBI study. Journal of Neurotrauma, 31(17), 14571477.



Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

A correction has been issued for this article: