Good Recovery, Poor Participation? A Secondary Analysis of the Dissociation Between Global Disability and Real-Life Participation Five Years After Traumatic Brain Injury

<b>Background/Objectives</b>: Global disability scales such as the Glasgow Outcome Scale-Extended (GOS-E) may not fully capture real-life participation after traumatic brain injury (TBI). This secondary analysis quantified mismatch between global disability and participation 5 years after moderate-to-severe TBI and identified predictors of a "good recovery, poor participation" profile. <b>Methods</b>: We analysed the TBIMS National Database Public Use Data Set, including adults ≥ 16 years with moderate-to-severe TBI, 5-year follow-up, and valid GOS-E, PART-O, and employment data. High versus low global outcome was defined as GOS-E 7-8 versus 3-6; good versus poor participation was defined using PART-O total (≥median vs. ≤25th percentile) plus productive role engagement. Four outcome profiles were derived and compared using 2 × 2 factorial analyses and regression. <b>Results</b>: The analytic cohort included 6363 participants; among those with high GOS-E, 16.8% met criteria for poor participation. Profiles with poor participation showed lower participation and lower life satisfaction and higher mood symptoms than Group A (high GOS-E, good participation), whereas those with low GOS-E but good participation showed preserved participation with greater emotional burden. Older age, lower education, minority race/ethnicity, pre-injury unemployment or retirement, longer post-traumatic amnesia, and lower 2-year GOS-E independently predicted mismatch. Sensitivity analyses using alternative GOS-E and participation cut-offs and life-satisfaction outcomes yielded similar patterns. <b>Conclusions</b>: Five years after moderate-to-severe TBI, good global recovery does not guarantee successful reintegration, and some individuals maintain participation despite persisting disability. Routine assessment of participation and life satisfaction alongside global disability is needed to identify high-risk profiles and target vocational and psychosocial interventions.