Functional outcomes and quality of life in patients with brain tumors: a preliminary report.

OBJECTIVES: To determine the relationship between functional outcome and quality of life (QOL) in patients with brain tumors receiving inpatient rehabilitation, and to assess the sensitivity of 4 assessment tools in measuring changes in that population. DESIGN: Prospective study using longitudinal data collected from consecutively admitted patients. SETTING: Acute inpatient rehabilitation unit. PARTICIPANTS: Ten patients with primary brain tumors admitted to an acute inpatient rehabilitation unit. INTERVENTIONS: Patients participated in an inpatient interdisciplinary rehabilitation program that used the following disciplines: occupational therapy, rehabilitation therapy, recreational therapy, speech therapy, physical therapy, rehabilitation nursing and case management. MAIN OUTCOME MEASURES: The FIM instrument, Disability Rating Scale (DRS), Karnofsky Performance Status Scale (KPS), Functional Assessment of Cancer Therapy-Brain (FACT-BR). RESULTS: Improvement in total functional outcome was indicated by all 3 functional measures (FIM: F = 46.84, p < .05; DRS: F = 19.25, p < .05; KPS: F = 10.11, p < .05). Significant improvements were found between admission and discharge scores for the FIM and DRS. The KPS revealed significant improvement between admission and 3-month follow-up scores. All admission and discharge functional scales (FIM, DRS, KPS) correlated significantly with each other. No significant change was noted in the FACT-BR between admission and discharge scores, but FACT-BR scores did improve at 1- and 3-months postdischarge relative to admission. The FIM, KPS, and DRS did not show significant correlation with the FACT-BR. Ninety percent of patients were initially discharged to a home environment. CONCLUSION: Although patients make functional gains during and after inpatient rehabilitation, gains in QOL are not significant until 1 month postdischarge. QOL does not appear to correlate well with functional outcomes. Further, the KPS is less sensitive than the FIM and DRS in detecting change in functional status.

Charges and lengths of stay for acute and inpatient rehabilitation treatment of traumatic brain injury 1990-1996.

This investigation evaluated yearly trends in charges and lengths of stay for patients with brain injury in acute care and rehabilitation settings over a 7 year period. Data was collected from 800 consecutive patients enrolled in four NIDRR Model Systems Traumatic Brain Injury programmes. Acute care daily charges showed almost routine increases, averaging nearly $550 per year. Conversely, lengths of stay generally showed a downward trend, with annual reductions averaging 2.25 days. Admission lengths of stay averaged 22-29 days between 1990-1994. Admissions averaged less than 20 days beginning in 1995, with the 1996 average of 16 days, nearly half that of the 1993 average. Between 1990-1996, average daily rehabilitation charges increased each year, with the rise averaging $83 or 7%. The rise in daily rehabilitation charges was offset by corresponding decreases in lengths of stay averaging 3.65 days or 8% annually. Increases in daily charges for brain injury rehabilitation care were roughly comparable to those for general medical care prices. However, the rate of change in acute care charges was substantially greater, with annual increases averaging 10% more than national medical care prices. The steady downward trend in lengths of stay raises serious concerns about the future availability of health care services to persons with brain injury.

Return to work after brain injury: a self-directed approach.

For many, returning to work after a brain injury is an extremely difficult task. Many factors influence a person's decision whether or not to work. While some people with brain injury are excited to return to their old jobs, others are afraid of the physical, emotional, and financial consequences of returning to work, and some just do not want to work at all. The following manuscript provides a framework for persons with brain injury to address concerns regarding returning to work and alternatives to living productively. There are a number of ideas discussed within the framework of a self-guided therapeutic return to work program. Clinicians are encouraged to use the information provided to facilitate return to work discussions with their clients with brain injury and to adapt as necessary for use with persons with other neurological disabilities.

Long-term neuropsychological outcome after traumatic brain injury.

OBJECTIVE: To describe neuropsychological outcome 5 years after injury in persons with traumatic brain injury (TBI) who received inpatient medical rehabilitation. To determine the magnitude and pattern neuropsychological recovery from 1 year to 5 years after injury. DESIGN: Longitudinal cohort study with inclusion based on the availability of neuropsychological data at 1 year and 5 years after injury. SETTING: National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems of Care. PARTICIPANTS: One hundred eighty-two persons with complicated mild to severe traumatic brain injury. PRIMARY OUTCOME MEASURES: Digits Forward and Backward, Logical Memory I and II, Token Test, Controlled Oral Word Association Test, Symbol Digit Modalities Test, Trail Making Test, Rey Auditory Verbal Learning Test, Visual Form Discrimination, Block Design, Wisconsin Card Sorting Test, and Grooved Pegboard. RESULTS: Significant variability in outcome was found 5 years after TBI, ranging from no measurable impairment to severe impairment on neuropsychological tests. Improvement from 1 year after injury to 5 years was also variable. Using the Reliable Change Index, 22.2% improved, 15.2% declined, and 62.6% were unchanged on test measures. CONCLUSIONS: Neuropsychological recovery after TBI is not uniform across individuals and neuropsychological domains. For a subset of persons with moderate to severe TBI, neuropsychological recovery may continue several years after injury with substantial recovery. For other persons, measurable impairment remains 5 years after injury. Improvement was most apparent on measures of cognitive speed, visuoconstruction, and verbal memory.

Long-term life quality and family needs after traumatic brain injury.

OBJECTIVES: This investigation assessed the life quality and long-term family needs of caregivers of persons with brain injury. DESIGN: Respondents completed the Virginia Traumatic Brain Injury Family Needs Assessment Survey. SETTING: Community-based sample. PARTICIPANTS: Respondents included 57 caregivers of persons with traumatic brain injury who were at least 4 years after injury and who resided in Virginia. Respondents ranged in age from 19 to 82 years and were primarily women and Caucasian. OUTCOME MEASURES: The Family Needs Questionnaire (FNQ) and quality of life questions. RESULTS: Results indicate diminished life quality after injury. With regard to family needs, Health Information (51.43%) and Involvement with Care (47.93%) needs were most often rated as met. Instrumental Support (31.52%) and Professional Support (28.38%) needs were most often rated as not met. CONCLUSIONS: Family needs and support systems for those needs change over time. This investigation provides evidence that unmet family needs extend well beyond the acute setting and that caregiver life quality diminishes over time. The importance of appreciating long-term family needs and other life quality issues should not be underestimated.

Using early neuropsychologic testing to predict long-term productivity outcome from traumatic brain injury.

OBJECTIVE: To evaluate whether early neuropsychologic testing is useful in predicting long-term productivity outcome after traumatic brain injury (TBI). DESIGN: Validation cohort prediction study. SETTING: Four inpatient brain injury rehabilitation programs participating in the Traumatic Brain Injury Model Systems project. PARTICIPANTS: A total of 293 adults with nonpenetrating TBI. MAIN OUTCOME MEASURES: Fifteen neuropsychologic tests were administered to patients who emerged from posttraumatic amnesia before rehabilitation discharge. Test scores were classified in the normal range or impaired range, using objective criteria. Outcome was defined as productive if the patient was competitively employed or enrolled full time in regular education. RESULTS: Productivity at follow-up was predicted by completion of at least 1 neuropsychologic test before discharge, by an injury-test interval of less than 2 months, and by normal range scores on 10 of the 15 neuropsychologic tests. Normal range scores on these tests increased the probability of a productive outcome by 40% to 130%. CONCLUSIONS: Neuropsychologic testing can help predict long-term productivity even when performed before discharge from inpatient rehabilitation and at variable injury-test intervals. Early testing should be interpreted in relation to injury-test interval. Because tests of multiple neuropsychologic domains predicted outcome, comprehensive evaluations might be more useful in predicting outcome.

The prevalence and symptom rates of depression after traumatic brain injury: a comprehensive examination.

PRIMARY OBJECTIVE: Differing definitions of depression, limited sample sizes, and variability in methodologies have contributed to equivocal findings about the prevalence of depression among persons with traumatic brain injury. The present investigation used standardized diagnostic criteria and a large sample to identify the manifestations of depression after TBI. METHODS AND PROCEDURES: 722 outpatients with brain injury, referred for comprehensive assessment at a regional Level I trauma centre, were studied. Depressive symptoms were characterized utilizing standard DSM-IV criteria and the Neurobehavioural Functioning Inventory. RESULTS: Forty-two per cent of patients with brain injury met the prerequisite number of symptoms for a DSM-IV diagnosis of major depressive disorder. Fatigue (46%), frustration (41%), and poor concentration (38%) were the most commonly cited manifestations of depression. CONCLUSIONS: Many patients with brain injury are at great risk for developing depressive disorders. Future research should focus on prognostic factors, developing protocols for identification of high risk patients, and examining the efficacy of treatment interventions.

Benefits of an inpatient pulmonary rehabilitation program: a prospective analysis.

OBJECTIVE: To examine the effect of an inpatient pulmonary rehabilitation program on functional outcome, supplemental oxygen use, quality of life (QOL), and rehospitalization. DESIGN: A prospective study. SETTING: Inpatient pulmonary rehabilitation unit. PATIENTS: One hundred fifty-seven patients with moderate to severe chronic obstructive pulmonary disease (COPD) admitted to an inpatient pulmonary rehabilitation program over a 3-year period. INTERVENTION: Comprehensive interdisciplinary inpatient pulmonary rehabilitation program with an average length of stay of 21 days. MAIN OUTCOME MEASURES: Improvements in QOL questionnaire scores, COPD knowledge questionnaire scores, 6-minute walking test (with 3 ambulation categories: bed-bound, household ambulators, community ambulators), and supplemental oxygen use. Rehospitalization 1 year after completion of the program was also assessed and compared with hospital days for the year before the program. RESULTS: On discharge from the program, 88% of individuals walked farther (p <.0001), and community ambulators doubled their walking distance, whereas bed-bound patients decreased 10-fold; supplemental oxygen use dropped 33% during the day (p <.0001) and 57% during the night (p <.0001); 82% showed improved QOL (p <.0001); 67% showed improved knowledge of COPD (p <.0001); and 67% of the sample spent less time in the hospital during the 12 months after program completion compared with the 12 months before admission (p <.001). CONCLUSIONS: An inpatient pulmonary rehabilitation program leads to improved endurance and functional ambulation, decreased supplemental oxygen use, and fewer hospitalizations 1 year after discharge for patients with COPD.

Predicting "charge outliers" after spinal cord injury: a multicenter analysis of demographics, injury characteristics, outcomes, and rehabilitation charges.

OBJECTIVE: To describe the distribution of charges, to distinguish between "charge outliers" and nonoutliers, and to identify a model that uses demographics and injury characteristics to predict charge outlier status in individuals with spinal cord injury (SCI). DESIGN: Retrospective data analysis of patients admitted to 24 acute inpatient rehabilitation national Spinal Cord Injury Model Systems centers. Statistical analysis, including proportions, means, and standard deviations (SDs), were compiled for the following variables: demographic and injury information, rehabilitation charges, medical complications, associated injuries, and surgical procedures. SETTING: Tertiary, university medical centers participating in the National Institute on Disability and Rehabilitation Research's SCI Model Systems project. PARTICIPANTS: A total of 13,392 patients who were admitted to 24 acute, intensive, interdisciplinary rehabilitation settings after traumatic SCI between November 1972 and August 1996. MAIN OUTCOME MEASURES: Statistical data analysis was used to determine significance between charge outliers and nonoutliers on the basis of demographic, injury characteristics, and clinical factors. Outliers, under the current diagnostic-related group system, are defined as cases in which lengths of stay exceed the mean by the lesser of 20 days or 1.94 SDs. RESULTS: Statistically significant differences were found between SCI charge outliers and nonoutliers based on ethnicity, education, employment, level of injury, American Spinal Injury Association impairment classification, and sponsor of hospitalization. On average, outliers were 4 years older than nonoutliers, and tended to have more associated injuries, pressure ulcers, surgical procedures, and medical complications. A forward-conditional stepwise multiple logistic regression analysis was used to confirm univariate analysis and to predict the presence or absence of outliers based on the predictor variables. A model for the prediction of SCI charge outlier status was defined. CONCLUSIONS: SCI charge outliers are most likely to be retired, insured, have high cervical level injuries, and be educated beyond high school. Improved treatment efficiency serves as a means of cost reduction and is a reason to identify outlier characteristics.

Pre-injury crime, substance abuse, and neurobehavioural functioning after traumatic brain injury.

There is limited information regarding the effects of pre-injury history of arrest or history of substance use on neurobehavioural functioning after brain injury. The current study included 211 patients with traumatic brain injury, who were seen for a follow-up neuropsychological evaluation in an outpatient setting. An effort was made to distinguish between (1) patients with a history of pre-injury arrests and patients without a history of pre-injury arrests, (2) patients classified as substance abusers and non-abusers, and (3) patients with and without a history of pre-injury illicit drug use on the basis of demographic characteristics, injury characteristics, and neurobehavioural functioning. Results indicate significant differences between patients with a history of pre-injury arrests and patients without a history of pre-injury arrests in terms of demographic and injury characteristics. Differences were also noted between persons classified as substance abusers and non-abusers in terms of demographic and injury characteristics, and neurobehavioural functioning. Clinical implications and future research are discussed.

The Community Integration Questionnaire revisited: an assessment of factor structure and validity.

OBJECTIVE: To investigate the factor structure and concurrent validity of the Community Integration Questionnaire (CIQ), using a large sample of persons with traumatic brain injury (TBI). DESIGN: Principal components analysis with varimax rotation was performed on CIQ items completed through interview with patients at 1 year after injury. Correlational analyses compared CIQ scores to scores on other widely used outcome measures. SETTING: Outpatient clinics affiliated with four TBI Model System rehabilitation centers funded by the National Institute on Disability and Rehabilitation Research. PARTICIPANTS: Three hundred twelve patients with medically documented TBI who were enrolled in the TBI Model Systems Project. The majority of patients were Caucasian males with severe TBI. MAIN OUTCOME MEASURES: CIQ; Functional Independence Measure (FIM); Functional Assessment Measure (FAM); Disability Rating Scale (DRS). RESULTS: Three factors emerged: Home Competency, Social Integration, and Productive Activity. The financial management item was moved from Social Integration to Home Competency, and the travel item was moved from Productive Activity to Social Integration. Each CIQ scale score showed significant correlations in the expected direction with the FIM+FAM and DRS items. CONCLUSIONS: The results provide further evidence for the validity of the CIQ and improve the scoring system. The factor structure is clinically and theoretically meaningful. The subscale and total scores show significant relationships with other widely used measures of outcome. Future research should focus on increasing the range of questions, accounting for changes from preinjury functioning, and obtaining normative data on the new factors.

Substance abuse, violence, and outcome after traumatic spinal cord injury.

Alcohol and drug use have been shown to contribute to the onset of traumatic spinal cord injury and to be a marker for later onset substance abuse issues. Admission toxicology (drug and alcohol) screens were collected from 87 consecutive rehabilitation medicine patients with a diagnosis of acute traumatic spinal cord injury. Forty-six patients (53%) presented with positive screens (44% alcohol only, 30% drug only, 26% both). Seventy-five percent of those with positive alcohol screens met state criteria for alcohol intoxication (blood alcohol level, > or =0.08 mg/dl). Compared with individuals with negative screens, those with positive screens were significantly (P < 0.05) younger and unmarried. Compared with nonviolence-related spinal cord injury, patients with violence-related spinal cord injury (gunshot wound and assault) were significantly (P < 0.01) more likely to have positive admission toxicology screens (76% v 41%), drug screens (62% v 14%), and intoxication screens (72% v 34%). Rehabilitation outcome comparisons between those with positive and negative screens revealed similar length of stay, admission and discharge Functional Independence Measure (FIM) scores, FIM change scores, and FIM efficiency scores. This study has important implications with regard to substance abuse issues and their impact on traumatic spinal cord injury outcome, which may assist in better targeting prevention.

A multicenter investigation of age-related differences in lengths of stay, hospitalization charges, and outcomes for a matched tetraplegia sample.

OBJECTIVE: To examine the effects of age at injury on lengths of stay, treatment costs, and outcomes using a matched sample of tetraplegic spinal cord injury (SCI) patients. DESIGN: Differences were examined by separating the sample into three age categories (18 to 34, 35 to 64, and 65+ years old) matched for American Spinal Injury Association (ASIA) Motor Impairment Classification and level of neurologic preservation bilaterally. Analysis of variance was used to examine age group differences for lengths of stay, medical expenses, and functional outcome. SETTING: Sixteen medical centers in the federally sponsored Spinal Cord Injury Model Systems Project. PARTICIPANTS: Three hundred seventy-five adult patients with tetraplegic SCI admitted between 1988 and 1996 were assessed at acute care admission, inpatient rehabilitation admission, and inpatient rehabilitation discharge. MAIN OUTCOME MEASURES: ASIA Motor Index and Functional Independence Measure (FIM) admission, discharge, and efficiency scores; acute care and rehabilitation lengths of stay and medical care charges; and discharge disposition. RESULTS: Analyses revealed equivalent lengths of stay and charges for all age groups. There were no age-related differences in ASIA and FIM Motor scores at acute care and inpatient rehabilitation admission. Younger patients' scores on the FIM Motor subscale improved significantly more than did middle and older patients'. The two younger groups of patients had a more significant improvement than did older patients, as indicated by ASIA Motor Index scores. When taking lengths of stay into account, the FIM motor scores of the youngest group of patients improved more quickly than those of the two older groups. Furthermore, the younger and middle age groups demonstrated greater treatment efficiency than the older patient group based on ASIA Motor Index score ratios. Younger patients were least likely to be discharged to institutional settings. CONCLUSIONS: Along with neurologic and functional status, age should be considered when formulating treatment plans and prognostic statements. For older patients, alternative rehabilitation settings with lower-intensity treatment and lower charges may prove to be a more efficacious use of resources.

Etiology and incidence of rehospitalization after traumatic brain injury: a multicenter analysis.

OBJECTIVE: To investigate incidence and etiology of rehospitalizations at 1, 2, and 3 years after traumatic brain injury. DESIGN: Descriptive statistics were computed in a prospective study of etiology and incidence of rehospitalization at years 1, 2, and 3 postinjury. Analysis of variance (ANOVA) and chi2 were used to identify factors relating to rehospitalization; factors included length of stay, admission and discharge functional status, payer source, medical complications, injury severity, and demographics. SETTING: Four medical centers in the federally sponsored Traumatic Brain Injury Model Systems. In each setting, the continuum of care includes emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services. PARTICIPANTS: Six hundred sixty-five rehabilitation patients admitted to acute care within 24 hours of traumatic brain injury between 1989 and 1996. MAIN OUTCOME MEASURES: Annual incidence and etiology of rehospitalization. RESULTS: The annual incidence of rehospitalization ranged from 20% to 22.5%. Approximately half the rehospitalizations were for elective reasons. The most common reason for rehospitalization was for orthopedic or reconstructive surgery, followed by infectious disorders and general health maintenance. After the first year, the incidence of readmissions for seizures and psychiatric difficulties increased substantially. ANOVA and chi2 analyses were performed on data from the first year postinjury. No statistically significant associations were noted between incidence and etiology of rehospitalization and: demographics; injury severity; payer source for rehabilitation; concurrent injuries; acute care and rehabilitation length of stays; discharge Functional Assessment Measure; and discharge residence (p > .05). CONCLUSIONS: There is a relatively stable but high rate of rehospitalization for at least 3 years after injury. The costs of rehospitalization should be considered when evaluating the long-term consequences of injury.

Pre-injury substance abuse among persons with brain injury and persons with spinal cord injury.

Alcohol and drug use at the time of injury have been strongly implicated as causal factors of spinal cord injury (SCI) and traumatic brain injury (TBI). Researchers have only begun their efforts to investigate the pre-injury incidence of substance abuse in an effort to identify persons at risk for traumatic injury. No studies have compared brain and spinal cord injury populations. This investigation was based in an urban, level one trauma center federally designated as a model system of comprehensive rehabilitative services for persons with TBI and persons with SCI. Pre-injury patterns of alcohol and illicit drug use were compared among patients with SCI and patients with TBI, matched for age, gender, race, and mechanism of injury (n= 52). In accordance with previous research, participants were primarily young, unmarried, males with at least a high school education. Eighty-one percent of patients with TBI and 96% of patients with SCI reported pre-injury alcohol use. The rate of pre-injury heavy drinking for both groups was alarmingly high. Fifty-seven percent of persons with SCI and 42% of persons with TBI were heavy drinkers. Implications for risk identification, treatment, and future research are discussed.

Brain injury online: accessing and using the Internet for consumers and healthcare professionals.

This article provides both consumers and healthcare professionals who share a common interest in brain injury with a basic overview of both how to access the Internet and how to use it effectively to gather and exchange online information. Recommendations regarding computer hardware requirements, connection options and popular software programs for web browsing, sending e-mail and searching topics are addressed. Some of the more interesting brain injury-related Internet sites and newsgroups are listed. Finally, specific technologic advancements that may facilitate computer use in a disabled population are discussed.