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Original Investigation
July 6, 2021

Functional Outcomes Over the First Year After Moderate to Severe Traumatic Brain Injury in the Prospective, Longitudinal TRACK-TBI Study

Author Affiliations
  • 1Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
  • 2Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
  • 3Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston
  • 4Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
  • 5Department of Neurological Surgery, University of Washington, Seattle
  • 6Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
  • 7Department of Family Medicine and Public Health, University of California, San Diego, San Diego
  • 8Neurological Surgery, University of California, San Francisco, San Francisco
  • 9Department of Neurology, University of Pennsylvania, Philadelphia
  • 10Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
JAMA Neurol. Published online July 6, 2021. doi:10.1001/jamaneurol.2021.2043
Key Points

Question  How do functional outcomes change from the acute to chronic phases of recovery after moderate to severe TBI (msTBI)?

Findings  In this cohort study of 484 participants with msTBI, by 12 months postinjury, approximately half of those with severe TBI and three-quarters of those with moderate TBI recovered the ability to function independently at home for at least 8 hours per day. Among participants in a vegetative state at 2 weeks, 77% recovered consciousness and 25% regained orientation by 12 months.

Meaning  In this study, the presence of acute severe impairment did not universally portend poor functional outcomes after msTBI; clinicians should refrain from making early, definitive prognostic generalizations about the likelihood of poor functional outcomes following moderate and severe TBI.


Importance  Moderate to severe traumatic brain injury (msTBI) is a major cause of death and disability in the US and worldwide. Few studies have enabled prospective, longitudinal outcome data collection from the acute to chronic phases of recovery after msTBI.

Objective  To prospectively assess outcomes in major areas of life function at 2 weeks and 3, 6, and 12 months after msTBI.

Design, Setting, and Participants  This cohort study, as part of the Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study, was conducted at 18 level 1 trauma centers in the US from February 2014 to August 2018 and prospectively assessed longitudinal outcomes, with follow-up to 12 months postinjury. Participants were patients with msTBI (Glasgow Coma Scale scores 3-12) extracted from a larger group of patients with mild, moderate, or severe TBI who were enrolled in TRACK-TBI. Data analysis took place from October 2019 to April 2021.

Exposures  Moderate or severe TBI.

Main Outcomes and Measures  The Glasgow Outcome Scale–Extended (GOSE) and Disability Rating Scale (DRS) were used to assess global functional status 2 weeks and 3, 6, and 12 months postinjury. Scores on the GOSE were dichotomized to determine favorable (scores 4-8) vs unfavorable (scores 1-3) outcomes. Neurocognitive testing and patient reported outcomes at 12 months postinjury were analyzed.

Results  A total of 484 eligible patients were included from the 2679 individuals in the TRACK-TBI study. Participants with severe TBI (n = 362; 283 men [78.2%]; median [interquartile range] age, 35.5 [25-53] years) and moderate TBI (n = 122; 98 men [80.3%]; median [interquartile range] age, 38 [25-53] years) were comparable on demographic and premorbid variables. At 2 weeks postinjury, 36 of 290 participants with severe TBI (12.4%) and 38 of 93 participants with moderate TBI (41%) had favorable outcomes (GOSE scores 4-8); 301 of 322 in the severe TBI group (93.5%) and 81 of 103 in the moderate TBI group (78.6%) had moderate disability or worse on the DRS (total score ≥4). By 12 months postinjury, 142 of 271 with severe TBI (52.4%) and 54 of 72 with moderate TBI (75%) achieved favorable outcomes. Nearly 1 in 5 participants with severe TBI (52 of 270 [19.3%]) and 1 in 3 with moderate TBI (23 of 71 [32%]) reported no disability (DRS score 0) at 12 months. Among participants in a vegetative state at 2 weeks, 62 of 79 (78%) regained consciousness and 14 of 56 with available data (25%) regained orientation by 12 months.

Conclusions and Relevance  In this study, patients with msTBI frequently demonstrated major functional gains, including recovery of independence, between 2 weeks and 12 months postinjury. Severe impairment in the short term did not portend poor outcomes in a substantial minority of patients with msTBI. When discussing prognosis during the first 2 weeks after injury, clinicians should be particularly cautious about making early, definitive prognostic statements suggesting poor outcomes and withdrawal of life-sustaining treatment in patients with msTBI.

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