Outcome after traumatic brain injury: pathway analysis of contributions from premorbid, injury severity, and recovery variables

OBJECTIVE: To examine the relationship of premorbid variables, injury severity, and cognitive and functional status to outcome 1 year after traumatic brain injury (TBI) and to assess the feasibility of multivariate path analysis as a way to discover those relationships. DESIGN: Prospective, longitudinal. SETTINGS: Level I trauma center, acute inpatient rehabilitation hospital. PATIENTS: One hundred seven subjects (87 men, 20 women; mean age, 33.91 +/- 14.2 yr) who had experienced severe TBI, typically from motor vehicle crashes. INTERVENTIONS: Acute medical and rehabilitation care. MAIN OUTCOME MEASURES: Disability Rating Scale, Community Integration Questionnaire, and return to employment. Evaluated in acute rehabilitation, and at 6 and 12 months' postinjury. RESULTS: Path analyses revealed that premorbid factors had significant relationships with injury severity, functional skills, cognitive status, and outcome; injury severity affected cognitive and functional skills; and cognitive status influenced outcome. No significant relationships were found between injury severity and emotional status, injury severity and outcome, emotional status and outcome, and functional skills and outcome. CONCLUSIONS: Multivariate analysis is important to understanding outcome after TBI. Injury severity, as measured in this study, is less important to 12-month outcome than the premorbid status of the person and the difficulties (particularly cognitive deficits) exhibited at follow-up 6 months after the trauma.     

Outcome after mild to moderate traumatic brain injury: the role of dizziness

OBJECTIVE: To assess the specific effect of dizziness on psychosocial outcome after mild to moderate traumatic brain injury (TBI). DESIGN: Six-month cross-sectional study. Setting An outpatient TBI clinic in a tertiary care referral center. Participants A consecutive sample of 207 adults with mild to moderate TBI, 138 (66.7%) of whom had subjective complaint of posttraumatic dizziness. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Psychosocial indices (Glasgow Outcome Scale [GOS], General Health Questionnaire [GHQ], Rivermead Head Injury Follow-Up Questionnaire [RHFUQ], return to work status) were collected from dizzy and nondizzy patients. RESULTS: Despite similar demographic, TBI, and global disability (GOS) profiles of both groups, psychosocial functioning (GHQ, RHFUQ, return to work) was significantly worse in dizzy subjects ( P <.01 for all indices). A logistic regression analysis identified dizziness ( P =.006), total GHQ ( P =.001), and psychotropic and analgesic use ( P =.05) as significant independent predictors of reemployment. CONCLUSIONS: Although dizziness was closely linked to psychologic distress at 6 months after head injury, it also emerged as an independent predictor of failure to return to work, suggesting that not all its adverse effects on outcome are psychologically mediated. Clinicians need to be alert to the presence of dizziness as an adverse prognostic indicator after mild to moderate TBI.     

A comparison of substance abuse and violence in the prediction of long-term rehabilitation outcomes after traumatic brain injury

OBJECTIVE: To determine the relative contributions of substance abuse history and violent etiology to the prediction of outcomes for individuals who sustained a traumatic brain injury (TBI) requiring inpatient rehabilitation. DESIGN: Longitudinal study of outcomes 1 year postdischarge from rehabilitation. SETTING: Specialized TBI acute rehabilitation unit. PARTICIPANTS: Three hundred fifty-one individuals consecutively admitted for rehabilitation. INTERVENTIONS: Gathered data from patients' medical records (including etiology of injury, initial Glasgow Coma Scale scores, and FIMtrade mark instrument scores at discharge), demographic details, and history of substance abuse; phone and mail survey data from individuals (Satisfaction with Life Scale [SWLS]; Community Integration Questionnaire [CIQ]). MAIN OUTCOME MEASURES: CIQ and SWLS; relative contributions of injury etiology, demographic and injury-related dependent variables, and substance abuse history to predictive model. RESULTS: Almost 80% of persons with injuries from violence-related causes had a history of substance abuse. Substance abuse was found to contribute to the prediction of life satisfacton and productivity, while violent etiology was not a significant contributor to predictive models. CONCLUSION: Substance abuse history proved to be a strong predictor of long-term outcomes, while violent etiology of injury was less influential. The results of this study emphasize the need to include substance abuse history in all studies of outcomes after TBI, and to increase prevention efforts to limit the effects of such a history.     

Return to productive activity after traumatic brain injury: relationship with measures of disability, handicap, and community integration.

OBJECTIVES: To identify which factors are associated with successful return to productive activity (RTPA) 1 year after hospitalization with traumatic brain injury (TBI) and to examine the relations between successful RTPA and other measures of impairment, disability, handicap, and integration into the community. DESIGN: Prospective study with 1-year follow-up. SETTING: Level I trauma center. PARTICIPANTS: One hundred five respondents from a cohort of 378 adults hospitalized with TBI admitted between September 1997 and May 1998. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Return to productive work 1 year after injury; Disability Rating Scale (DRS); and Community Integration Scale (CIQ). RESULTS: Of the 105 participants, 72% achieved RTPA. Logistic regression showed an association between RPTA and the following factors: premorbid educational level, premorbid psychiatric history, violent mechanism of injury, discharge status after acute hospitalization, prior alcohol and drug use, and injury severity. Handicap and community integration at 1-year postinjury, as measured by subscales of the DRS and the CIQ, were also associated with RTPA. CONCLUSION: Premorbid and injury-related variables and measures of handicap and community integration were associated with RTPA at 1 year. To understand and effectively support vocational pursuits in the TBI population, future studies are needed to define further causality and origin of these relationships.     

Acute predictors of return to employment after traumatic brain injury: a longitudinal follow-up

OBJECTIVE: To investigate the relation between selected acute injury and patient characteristics and subsequent return to work 1 to 5 years postinjury. DESIGN: Longitudinal design with prospectively collected data. Data were collected on patients at the time of injury and each year postinjury for up to 5 years. SETTING: Four medical centers in the federally sponsored Traumatic Brain Injury Model Systems project that provide emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services. PARTICIPANTS: Patients were selected from a national database of 538 rehabilitation inpatients admitted to acute care within 8 hours of traumatic brain injury (TBI) and seen at 1 to 5 years follow-up. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Employment status (employed vs not employed) at 1 to 5 years postinjury. Logistic regression analyses were performed to determine the extent to which selected variables predicted employment status at years 1 to 5 postinjury. RESULTS: At year 1 postinjury, preinjury productivity, age, education, and rehabilitation length of stay were all significantly associated with postinjury employment. Preinjury employment and productivity and age significantly predicted employment at postinjury year 2. At year 3 postinjury, preinjury productivity, age, and FIMtrade mark instrument discharge score significantly predicted employment status. Age was significantly associated with employment status at year 4 postinjury. Preinjury employment and productivity and Disability Rating Scale discharge score were found to be significant predictors of postinjury employment at year 5 follow-up. CONCLUSIONS: The relationship between certain acute injury and patient variables (eg, age, preinjury productivity, education, discharge FIM) and subsequent return to work may provide rehabilitation professionals with useful information regarding the intensity and types of services needed for individuals in the vocational rehabilitation planning process.     

Validation of a model for evaluating outcome after traumatic brain injury

OBJECTIVE: To validate a model that examines the contribution of premorbid variables, injury severity, and functional and cognitive status to outcome 1 year after traumatic brain injury (TBI). DESIGN: Cross-validation study using a larger, national, prospective, longitudinal sample. SETTING: Acute inpatient rehabilitation hospitals at Traumatic Brain Injury Model Systems centers. PARTICIPANTS: Two sample populations followed through acute rehabilitation to 1 year after TBI. The original sample included 107 patients, and the cross-validation sample included 294 patients. Participants were predominantly young men who had experienced moderate to severe TBI in motor vehicle crashes. INTERVENTIONS: Acute medical and rehabilitation care. MAIN OUTCOME MEASURES: Disability Rating Scale, Community Integration Questionnaire, and return to employment. RESULTS: Structural equation modeling was used to compare the fit of the data to a path analysis developed through clinical use and previous research. Both samples provided adequate goodness of fit, supporting the model's validity. Injury severity affected cognitive and functional status, and cognitive and functional status significantly influenced 1-year outcome. Premorbid factors and injury severity did not directly influence outcome. CONCLUSIONS: Both samples supported the proposed model, which was cross-validated. Injury severity indirectly influences outcome through its effects on cognitive and functional status. Although treatment to decrease injury severity is obviously important, concentrated rehabilitation interventions aimed at improving patients' cognitive and functional status may have a more significant impact on 1-year outcome and should be the focus of future research.     

Etiology of traumatic brain injury: characterization of differential outcomes up to 1 year postinjury

OBJECTIVE: To characterize outcomes after traumatic brain injury (TBI) resulting from vehicular crashes, violence, falls, or other causes. DESIGN: Prospective, multicenter, longitudinal. SETTING: Seventeen Traumatic Brain Injury Model Systems. PARTICIPANTS: A total of 1,170 individuals with moderate to severe TBI with data from initial medical and rehabilitation stays and 1-year follow-up. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: At rehabilitation discharge, FIM instrument, Disability Rating Scale (DRS), and Rancho Los Amigo Levels of Cognitive Functioning Scale. At 1 year postinjury, FIM, DRS, Community Integration Questionnaire (CIQ), employment, residence, marital status, and seizure occurrence. RESULTS: The 4 etiology groups could be distinguished based on premorbid characteristics. Severity of injury indices indicated that individuals in vehicular crashes showed a trend toward incurring more severe injuries than the other 3 groups. At rehabilitation discharge, there were no functional differences between groups. At 1 year postinjury, the groups could be differentiated: individuals in violence-related TBI had higher unemployment rates and lower CIQ scores; persons in vehicular crashes reported the best functional and psychosocial outcomes; and individuals in the falls and other groups had outcomes lying between the vehicular and violence groups. CONCLUSION: This study elucidated important differences between persons with violence-related TBI and those with non-violence-related TBI. Further research is needed to find effective interventions to address these differences.     

Depression as a Predictor of Long-term Employment Outcomes Among Individuals With Moderate-to-Severe Traumatic Brain Injury

ObjectiveTo examine the predictive ability of depression when considering long-term employment outcomes for individuals with moderate-to-severe traumatic brain injury (TBI) after controlling for key preinjury and injury-related variables.DesignSecondary data analysis.SettingCommunity follow-up after discharge from an inpatient rehabilitation center.ParticipantsIndividuals between 18 and 60 years old with moderate-to-severe TBI enrolled in the Traumatic Brain Injury Model Systems database.InterventionsNot applicable.Main Outcome MeasuresEmployment status.ResultsThe prevalence of employment at 2 and 5 years post injury was 40.3% and 44.5%, respectively. Individuals identified as depressed at 1 year were more likely to be unemployed at 2 years post injury (odds ratio [OR], 1.77; 95% CI, 1.38-2.27; P<.0001). Similar relations between current depression and future employment were observed from 1- and 2-year depression status predicting 5-year employment (1-year: OR, 1.88; 95% CI, 1.48-2.40; P<.0001: 2-year: OR, 1.72; 95% CI, 1.36-2.17; P<.0001).ConclusionsAfter controlling for baseline predictors variables, the experience of postinjury depression—a modifiable condition—contributes predictive ability to future employment outcomes. Incorporating assessments and/or interventions for depression into postacute rehabilitation programs could promote favorable employment outcomes after TBI.     

Predictors of success for state vocational rehabilitation clients with traumatic brain injury

OBJECTIVES: To determine the characteristics of individuals with traumatic brain injury (TBI) who request state vocational rehabilitation services and to determine the best predictors of their successful vocational outcomes. DESIGN: Observational study. SETTING: Vocational services data from the Missouri Division of Vocational Rehabilitation (DVR). PARTICIPANTS: Seventy-eight individuals with TBI who requested services from the Missouri DVR. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographic, injury severity, neuropsychologic variables, vocational services offered, and vocational status at time of case closure (successful, unsuccessful, services interrupted, no services provided). RESULTS: Individuals requesting DVR services were primarily men (71%), white (82%), single (47%), of low average intelligence (Wechsler Adult Intelligence Scales-III full scale IQ score, 84.8), and of limited education (11.8 y). The majority experienced a significant TBI (ie, 66% were hospitalized after their TBI; 56% reported loss of consciousness; 37% reported posttraumatic amnesia; 32% reported multiple TBIs; avg time since injury, 9.2 y). At DVR case closure, 17% were rated as being successfully employed, with nearly all working in industrial, service, or clerical positions (2 in a sheltered workshop, 1 in a professional position). Stepwise logistic regressions indicated that delivery of DVR services (ie, vocational guidance and counseling, on-the-job training) predicted vocational outcome and demographic, injury severity, and neuropsychologic variables did not. CONCLUSIONS: DVR clients have multiple impairments that affect them several years postinjury; the provision of DVR services may be more important in determining vocational outcomes than traditional medical, psychologic, and demographic variables.     

Psychosocial conditions do not affect short-term outcome of multidisciplinary rehabilitation in chronic obstructive pulmonary disease

OBJECTIVES: To characterize patients referred for pulmonary rehabilitation on a large number of psychologic and sociodemographic variables and to determine the contribution of these variables on the response to rehabilitation. DESIGN: Cross-sectional, explorative. SETTING: University hospital and outpatient clinic. PARTICIPANTS: Eighty-one consecutive patients with chronic obstructive pulmonary disease (forced expiratory volume in 1 second, 40%+/-16% of predicted) were included in outpatient pulmonary rehabilitation. INTERVENTION: Multidisciplinary rehabilitation program. MAIN OUTCOME MEASURES: Pulmonary function, exercise capacity (Wmax, 6-minute walk test [6MWT]), Chronic Respiratory Disease Questionnaire (CRDQ), Modified Pulmonary Functional Status and Dyspnea Questionnaire (PFSDQ-M), anxiety and depression (Hospital Anxiety and Depression Scale [HADS]) were assessed before and after 3 months rehabilitation. In addition, psychosocial adjustment, social support, marital status, mode of transportation, education, employment, and smoking status were assessed at the start of the rehabilitation. RESULTS: Rehabilitation improved exercise performance (Wmax, 6+/-12W; P<.01; 6MWT, 41+/-72 m; P<.001), quality of life (CRDQ score, 12+/-13 points; P<.001), functional status (PFSDQ-M activity score, -8+/-11 points; PFSDQ-M dyspnea score, -6+/-12 points; PFSDQ-M fatigue score, -4+/-8 points; all P<.01), HADS anxiety score (-2+/-3 points, P<.01), and HADS depression score (-3+/-3 points, P<.001). In single regression analysis, only baseline depression was weakly negatively correlated with the change in maximal workload. No other relations of initial psychologic or sociodemographic variables with outcome were observed. CONCLUSIONS: The effects of rehabilitation are not affected by baseline psychosocial factors. Patients with less favorable psychologic or sociodemographic conditions can also benefit from pulmonary rehabilitation. The multidisciplinary approach of the rehabilitation program might have contributed to this improvement.     

Preinjury predictors of life satisfaction at 1 year after traumatic brain injury

Davis LC, Sherer M, Sander AM, Bogner JA, Corrigan JD, Dijkers MP, Hanks RA, Bergquist TF, Seel RT. Preinjury predictors of life satisfaction at 1 year after traumatic brain injury.ObjectiveTo investigate the predictive value of preinjury factors for satisfaction with life (SWL) at 1-year posttraumatic brain injury (TBI).DesignSecondary analysis of prospective, longitudinal registry using data collected during inpatient rehabilitation and at 1-year post-TBI.SettingFifteen specialized brain injury units providing acute rehabilitation care as part of the Traumatic Brain Injury Model Systems (TBIMS) program.ParticipantsCommunity-dwelling persons (N=444) with moderate to severe TBI aged 16 to 64 years enrolled in the TBIMS program between October 2007 and October 2008 with 1-year follow-up data.InterventionsNot applicable.Main Outcome MeasureSatisfaction With Life Scale (SWLS).ResultsHierarchical stepwise linear regression revealed that injury-related and demographic variables did not contribute significantly to the explained variance in SWLS scores. In contrast, the preinjury functioning (education, productivity/employment) and preinjury condition (psychiatric and substance use problems, severe sensory dysfunction, learning problems, prior TBI) blocks each contributed significantly to the explained variance in SWLS scores. Preinjury functioning accounted for 2.9% of the variance and preinjury conditions for 3.8%.ConclusionsAlthough their contributions are small, preinjury functioning and preinjury conditions are important to consider in the prediction of SWL post-TBI. Educational level and history of psychiatric and other premorbid difficulties are particularly important for clinicians to consider when implementing or developing interventions for persons with moderate to severe TBI.     

A prospective study on employment outcome 3 years after moderate to severe traumatic brain injury

Grauwmeijer E, Heijenbrok-Kal MH, Haitsma IK, Ribbers GM. A prospective study on employment outcome 3 years after moderate to severe traumatic brain injury.ObjectivesTo evaluate the employment outcome in patients with moderate to severe traumatic brain injury (TBI) and to identify which patients are at risk of unemployment 3 years after injury.DesignProspective cohort study.SettingPatients with moderate and severe TBI discharged from the neurosurgery departments of 3 level 1 trauma centers in The Netherlands.ParticipantsPatients aged 18 to 65 years (N=113; mean age ± SD, 33.2±13.1y; 73% men) who were hospitalized with moderate (26% of patients) to severe (74% of patients) TBI.InterventionsNot applicable.Main Outcome MeasuresThe main outcome measure was employment status. Potential predictors included patient characteristics, injury severity factors, functional outcome measured at discharge from the acute hospital with the Glasgow Outcome Scale (GOS), Barthel Index (BI), and FIM, and cognitive functioning measured with the Functional Assessment Measure (FAM).ResultsNinety-four patients (83%) completed the 3-year follow-up. The employment rate dropped from 80% preinjury to 15% at 3 months postinjury and gradually increased to 55% after 3 years. The employment rate significantly increased from 3 months up to 1 year, but it did not change significantly from 1 to 3 years postinjury. Age, length of hospital stay, discharge to a nursing home (vs home), psychiatric symptoms, and BI, GOS, FIM, and FAM scores were found to be significant univariate determinants for employment status. By using multiple logistic regression analysis, the FAM score (adjusted odds ratio 1.1; P<.000) and psychiatric symptoms (adjusted odds ratio .08; P<.019) were selected as independent predictors for employment status. A FAM cutoff score of less than 65 to identify patients at risk of long-term unemployment had a good diagnostic value.ConclusionsPatients with TBI with psychiatric symptoms and impaired cognitive functioning at hospital discharge are at the highest risk of long-term unemployment. These factors should be the focus of vocational rehabilitation.     

Recovery of ambulation during inpatient rehabilitation: physical therapist prognosis for children and adolescents with traumatic brain injury

BACKGROUND AND PURPOSE: Evidence to guide physical therapist prognosis for recovery of the ability to ambulate in children and adolescents with traumatic brain injury (TBI) is limited. The aim of this study was to delineate a predictive model and determine the value of key demographic and clinical variables in establishing a prognosis for ambulation without the assistance of a device or person over 15.24 m on a flat, level surface following inpatient rehabilitation. SUBJECTS AND METHODS: For this retrospective study, a consecutive series of 95 children and adolescents with TBI (aged 2-18 years) admitted to an inpatient rehabilitation program was assessed using information from medical records. A multiple logistic regression analysis was conducted to identify predictors for ambulation at the time of discharge from the rehabilitation setting. RESULTS: Fifty-six percent of the children achieved ambulation at discharge. Lower-extremity hypertonicity (measured on physical therapist examination as resistance to passive stretch), brain injury severity, and lower-extremity injury together were predictors of the ability to ambulate. DISCUSSION AND CONCLUSION: Impairment and injury-related variables were important in predicting a minimal level of unassisted ambulation after discharge from inpatient rehabilitation. Awareness of predictors of recovery of the ability to ambulate that are gathered as part of a physical therapist's examination may assist in developing a prognosis for ambulation and in establishment of an appropriate plan of care.     

Vocational development following severe spinal cord injury: a longitudinal study

Vocational development of individual with spinal cord injury was studied from shortly after injury to two years after discharge from inpatient rehabilitation. Objectives included examining differences in the course of vocational development by level of functional independence, and predicting vocational outcomes two years after injury. Thirty-three spinal cord injury patients (17 quadriplegics, 16 paraplegics) were followed during the study. The Goldberg Scale of Vocational Development was used to measure changes in vocational development over time. The Barthel Index was used to measure level of functional independence. Results revealed that vocational development was markedly depressed during initial inpatient rehabilitation and for six months after injury. Gradual improvement occurred after six months, but two years after discharge the level of vocational development remained lower than that before injury. Changes in vocational development over time did not differ significantly by level of functional independence. Best predictors of successful vocational outcomes were educational attainment, educational plans made before injury, and origin of interests in work.     

Recovery from diffuse traumatic brain injury in Johannesburg: a concurrent prospective study.

Three hundred and twenty-six persons with light, moderate, or severe diffuse traumatic brain injury (TBI) were assessed during initial hospitalization in Johannesburg. One hundred and forty-four were followed up at approximately six months, 83 at 12 months, and 71 at 24 months posttrauma. The sample attrition rate was high. When patients could not be found, data were obtained from their caregivers. Recovery was measured in five different areas of functioning: family relationships, psychologic problems, activities of daily living (ADL), employment status, and physical status. Psychologic problems and family relationships worsened with time, but proficiency in ADL improved; physical and employment status remained relatively stable during the survey period. Severity of injury was significantly correlated with outcome in each functional area at some point in the follow-up period. Discrepancies between patients' and caregivers' perceptions of outcome were noted, particularly in the area of psychologic functioning. Caregivers tended to rate the recovery made by the patient as better than the outcome patients perceived themselves to have made. These differences in perception diminished with time. The multifactorial nature of recovery after TBI is indicated by the improvements seen in some functional areas and the worsening of outcome in other areas. These findings suggest that rehabilitation programs for persons with TBI should (1) include caregivers, (2) focus on the adjustment of both parties to their new circumstances, and (3) facilitate a convergence in their perceptions. Adequately defining recovery is a first step to estimating the prevalence of TBI, but necessitates further work. Epidemiology awaits a better understanding of the recovery process after TBI.     

Outcome after traumatic brain injury: effects of aging on recovery

OBJECTIVE: To identify differences in outcome after traumatic brain injury (TBI) compared with orthopedic injuries as a function of age. DESIGN: Longitudinal data analyses from an inception cohort. SETTING: Outpatient rehabilitation program. PARTICIPANTS: Eighty-two orthopedic injury patients and 195 TBI patients. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Independent living, employment, and level of functioning 1 to 2 years after injury. RESULTS: Older patients and those with TBI were more likely to have increased dependence postinjury. Older TBI patients were more likely to have changes in employment status compared with orthopedic injury patients younger or TBI. The Mayo-Portland Adaptability Inventory and Disability Rating Scale were moderately predictive of level of functioning, return to employment, and independent living status 1 to 2 years postinjury. Injury severity was only mildly predictive of outcome. CONCLUSIONS: The effect of age on outcome affects recovery from neurologic injuries and, to a lesser extent, orthopedic injuries. Outcome after TBI is best predicted by patients' age and estimates of level of function at discharge. Findings suggest that older patients and those with TBI have a greater likelihood of becoming physically and financially dependent on others. Rehabilitation efforts should focus on maximizing levels of independence to limit financial and emotional costs to patients and their families.     

Return to work after spinal cord injury in Taiwan: the contribution of functional independence

OBJECTIVE: To study the employment rate and determinants of return to work for persons with traumatic spinal cord injury (SCI) in Taiwan. DESIGN: Cross-sectional. SETTING: Taiwan community. PARTICIPANTS: One hundred sixty-nine people who had sustained traumatic SCI, had been completely rehabilitated in a university hospital between 1989 and 2002, and who were between 18 and 60 years of age at the time of interview in 2003. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A structured questionnaire was used to identify demographic and injury-related status, functional status, and pre- and postinjury work-related information. RESULTS: At the time of survey, only 47% of the participants were engaged in remunerative employment. Cox regression analysis, with time elapsed between injury and survey as the underlying time axis, showed that education and functional independence were associated with employment. Subjects with a high school education had a 2.2-fold higher chance (95% confidence interval [CI], 1.3-3.8) of returning to work than those without. Subjects with higher scores on the Barthel Index and ability to use public or private transport independently had a 2.7-fold higher chance (95% CI, 1.5-4.9) of returning to work than those unable to travel independently. Other factors significantly associated with employment included marital status, with marriage having a favorable influence; age at injury, with age below 25 years being favorable; preinjury occupation; and vocational training after injury. The importance of functional independence training in rehabilitation is stressed. CONCLUSIONS: Functional independence was a strong factor predicting return to work. Rehabilitation focused on education, vocational training, self-care ability, community mobility, and environmental modifications could improve employability after SCI.     

Assessing traumatic brain injury outcome measures for long-term follow-up of community-based individuals

OBJECTIVES: To determine which outcome measures are best and least suited for assessing long-term functional outcome of individuals with traumatic brain injury (TBI) in the community. DESIGN: Survey of participants in the community an average of 5 years after TBI. A battery of outcome measures was given. SETTING: Community in northern California after inpatient rehabilitation. PARTICIPANTS: Forty-eight adult individuals with prior moderate to severe TBI. All subjects had received inpatient rehabilitation 2 to 9 years previously and could be reached for telephone interview. MAIN OUTCOME MEASURES: The Community Integration Questionnaire, Neurobehavioral Functioning Inventory (NFI), Patient Competency Rating Scale (PCRS), Level of Cognitive Functioning Scale (LCFS), FIM instrument, Functional Assessment Measure (FIM+FAM), Supervision Rating Scale (SRS), Disability Rating Scale (DRS), Revised Craig Handicap Assessment and Reporting Technique (R-CHART), and Glasgow Outcome Scale (GOS). The number of maximal scores on each of the surveys was studied to determine which instruments continued to reveal deficits years after TBI. RESULTS: Most individuals obtained maximum scores, ie, functional independence, on these scales: LCFS, FIM motor subscale and total score, R-CHART physical independence subscale, FIM+FAM, GOS, and the SRS. Measures with the fewest maximum scores (<36%, measuring deficits still extant in the group) were the R-CHART cognition subscale and the NFI memory/attention and communication subscales, and employment subscales. Items, subscales, and total scores that showed good variability and correlated most highly and frequently with other scales also demonstrating good variability were the PCRS, the DRS and FIM+FAM employment items, the R-CHART cognition subscale, and the NFI motor, memory/attention, communication, and depression subscales (the R-CHART cognition subscale and NFI memory/attention subscale were highly correlated with the PCRS;.84,.83). CONCLUSIONS: Measures that appeared to contribute little to assessing functional status of a TBI sample years postinjury were the FIM, FIM+FAM, SRS, GOS, and LCFS. Measures that showed a range of deficits across participants were DRS employability, the NFI, PCRS, and the R-CHART cognition subscale.     

Outcome of a comprehensive neurorehabilitation program for patients with traumatic brain injury

OBJECTIVE: To evaluate the outcome of a comprehensive neurorehabilitation program compared with that of conventional clinical care and rehabilitation for patients with traumatic brain injury (TBI). DESIGN: Nonrandomized, controlled trial with a 2-year follow-up. SETTING: Nationwide rehabilitation center and level I trauma center, both in Finland. PARTICIPANTS: We studied 19 consecutive adults with a significant TBI who underwent a comprehensive neurorehabilitation program and 20 control patients who received conventional rehabilitation referred by physicians in the general health care system. The outcome of the control patients was not known before the selection. The groups were similar in age, sex, education, injury severity (assessed on the Glasgow Coma Scale, radiologic and neuropsychologic findings, neurosurgical interventions), time from the injury, and preinjury employment status. INTERVENTIONS: A postacute, intensive, interdisciplinary, 6-week rehabilitation program for TBI patients who are considered to have adequate potential to achieve productivity by this means; focus on neuropsychologic rehabilitation and psychotherapy with vocational interventions and follow-up support. MAIN OUTCOME MEASURE: Status of productivity, judged as productive (defined as working, studying, or participating in volunteer activities) or nonproductive, evaluated on questionnaires filled in by patients and their significant others at the time of follow-up evaluation. RESULTS: At follow-up, 89% of the treated patients were productive compared with 55% of the controls. The rehabilitation program was significantly predictive of the productive status at follow-up (odds ratio=6.96; 95% confidence interval, 1.26-38.44; P=.017). Other factors did not explain the better productivity of the treatment group. Two neuropsychologist-evaluators, who were blind to the rehabilitation history of patients and to each other's evaluations, were perfectly consistent in their classification of patients' productivity statuses. CONCLUSIONS: The findings support the proposition that comprehensive neuropsychologically oriented rehabilitation programs can improve psychosocial functioning in terms of productivity in postacute patients with moderate to severe TBI. Additional larger controlled studies are needed to establish the efficacy of TBI rehabilitation interventions.