Deborah L. Wood

Functional measures after traumatic brain injury : ceiling effects of FIM, FIM+FAM, DRS, and CIQ.

Objective:The characteristics of the Disability Rating Scale (DRS), Functional Independence Measure (FIM), Functional Independence Measure and Functional Assessment Measure (FIM+FAM), and Community Integration Questionnaire (CIQ) are examined, especially in regard to a “celling effect” after rehabilitation discharge (ie, how well each of the instruments detects meaningful change in level of function). Design:Data were collected prospectively at admission and discharge from acute inpatient rehabilitation and at years 1 and 2 after injury (the CIQ was collected only at years 1 and 2). Analyses are reported on a subsamplc of cases with listwise deletion, although the analyses were also done using all data available, and results compared to ensure stability of findings between samples. Setting:National database of the four Traumatic Brain Injury (TBI) Model Systems in San Jose, Calif; Detroit, Mich; Richmond, Va; and Houston, Tex. Patients:All consenting patients with TBI age 16 and older admitted to a Model System within 24 hours of Injury and receiving inpatient rehabilitation within the Model System qualified for the study. Data on 612 individuals were collected, with a minimum of 80 cases having complete data over time. Main Outcome Measures:The DRS, FIM, FIM+FAM, and CIQ. Results:There is a substantial ceiling effect of the FIM, even by inpatient rehabilitation discharge (ie, one half of the cases have an average score of 6 to 7 [“independent or modified independence—no helper] across the 18 FIM Items). The FIM+FAM shows a ceiling effect In one third of the cases. The DRS shows less ceiling effect at discharge, 1 year, and 2 years than the FIM or the FIM+FAM. CIQ scores have a ceiling effect on home and social integration subscales when compared with scores from a sample of individuals without disabilities. The productivity subscale remains well below the norm. Conclusions:Celling effects for the FIM, FIM+FAM, and two of the three CIQ subscales indicate that these measures are not as sensitive to changes, especially in the community, as may be needed to assess progress in areas most commonly causing dysfunction for the TBI population. More emphasis must be placed on improved measurement of relevant goals in the postacute and home settings with brief and precise scales

Relationship between Glasgow coma scale and functional outcome.

The Glasgow Coma Scale (GCS) is routinely used in the acute care setting after traumatic brain injury (TBI) to guide decisions in triage, based on its ability to predict morbidity and mortality. Although the GCS has been previously demonstrated to predict mortality, efficacy in prediction of functional outcome has not been established. The purpose of this study was to assess the value of the acute GCS in predicting functional outcome in survivors of TBI. This study used the Multicenter National Institute on Disability and Rehabilitation Research TBI Model Systems database of 501 patients who had received acute medical care and inpatient rehabilitation within a coordinated neurotrauma program for treatment of TBI. Initial and lowest 24 hr GCS scores were correlated with the following outcome measures: the Disability Rating Scale (DRS), Rancho Los Amigos Levels of Cognitive Functioning Scale (LCFS), and cognitive and motor components of the Functional Independence Measure (FIM(SM)-COG and FIM(SM)-M). Outcome data were collected at admission to and discharge from the inpatient TBI rehabilitation unit. Correlation analysis revealed only modest, but statistically significant, relationships between initial and lowest GCS scores and outcome variables. Initial and lowest GCS score comparison with outcome demonstrated the following correlation coefficients: admission DRS, -0.25 and -0.28; discharge DRS, -0.24 and -0.24; admission LCFS, 0.31 and 0.33; discharge LCFS, 0.27 and 0.25; admission FIM-COG, 0.36 and 0.37; discharge FIM-COG, 0.23 and 0.23; admission FIM-M, 0.31 and 0.31; discharge FIM-M, 0.25 and 0.21. The GCS as a single variable may have limited value as a predictor of functional outcome.

Posttraumatic amnesia: Its relation to functional outcome

OBJECTIVE To investigate the relation between duration of posttraumatic amnesia (PTA) and functional outcome in a traumatically brain injured population. PATIENTS Two hundred seventy-six patients with traumatic brain injury (TBI) who were admitted to a Level I university trauma center and required inpatient rehabilitation. MEASURES Duration of PTA was assessed by serial administrations of the Galveston Orientation Amnesia Test (GOAT). Functional Independence Measure (FIM) total scores, FIM cognitive and motor subscores, and Disability Rating Scale (DRS) scores were obtained at admission and discharge from inpatient rehabilitation. RESULTS Duration of PTA was a significant predictor of all admission and discharge DRS and FIM scores. Duration of PTA and age at the time of injury, in combination, contributed significantly to the prediction of the DRS score and FIM total, cognitive, and motor scores at discharge. CONCLUSION Duration of PTA appears to be a useful variable in predicting specific functional outcome in the TBI population receiving inpatient rehabilitation services. The use of age as a factor in addition to duration of PTA enhances the prediction of functional outcome.

Sitting balance following brain injury : does it predict outcome?

Balance dysfunction is commonly observed following traumatic brain injury. There are many proposed predictors of functional outcome in the traumatic brain injury population. It was hypothesized that the degree of balance dysfunction on admission to rehabilitation would be a significant predictor of the need for assistance at discharge, as measured by the Functional Independence Measure (FIM). This study involved 237 cases of traumatic brain injury patients admitted to a rehabilitation unit between November 1989 and September 1996. Using a multiple regression model, controlling for age, initial Glasgow Coma Score (GCS), rehabilitation admission strength, sitting balance and standing balance, it was found that the degree of impairment in sitting balance at admission to rehabilitation was a significant predictor of Discharge FIM-Total (FIM-T) score (p < 0:0001) and also of selected elements from the Discharge FIM-Motor (FIM-M) score (p < 0:0005). The combination of age, initial admission GCS, rehabilitation admission strength, standing balance and sitting balance accounted for 29% of the variance in the Discharge Total FIM score. Among these, sitting balance was the second most powerful predictor of both selected elements of the Discharge FIM motor score and discharge FIM-T. Sitting balance predictive capacity was exceeded in power only by age. Impairments in sitting balance appear to have a significant impact on functional outcome. Emphasis on unique rehabilitation techniques to treat balance dysfunction in the adult TBI population is warranted.Balance dysfunction is commonly observed following traumatic brain injury. There are many proposed predictors of functional outcome in the traumatic brain injury population. It was hypothesized that the degree of balance dysfunction on admission to rehabilitation would be a significant predictor of the need for assistance at discharge, as measured by the Functional Independence Measure (FIM). This study involved 237 cases of traumatic brain injury patients admitted to a rehabilitation unit between November 1989 and September 1996. Using a multiple regression model, controlling for age, initial Glasgow Coma Score (GCS), rehabilitation admission strength, sitting balance and standing balance, it was found that the degree of impairment in sitting balance at admission to rehabilitation was a significant predictor of Discharge FIM-Total (FIM-T) score (p < 0.0001) and also of selected elements from the Discharge FIM-Motor (FIM-M) score (p < 0.0005). The combination of age, initial admission GCS, rehabilitation admission strength, standing balance and sitting balance accounted for 29% of the variance in the Discharge Total FIM score. Among these, sitting balance was the second most powerful predictor of both selected elements of the Discharge FIM motor score and discharge FIM-T. Sitting balance predictive capacity was exceeded in power only by age. Impairments in sitting balance appear to have a significant impact on functional outcome. Emphasis on unique rehabilitation techniques to treat balance dysfunction in the adult TBI population is warranted.

Risk factors for acute care transfer among traumatic brain injury patients

OBJECTIVE Acute inpatient traumatic brain injury (TBI) rehabilitation has seen a jump in complexity of medical patient care over the past several years, often necessitating transfer back to an acute care facility. The purpose of this study was to determine the association between selected clinical variables and transfer from inpatient rehabilitation to an acute care facility. DESIGN A retrospective review of cases from 1992 to 1994. SETTING A TBI unit in a freestanding rehabilitation hospital. PATIENTS Twenty-two patients were identified as having received acute care transfer. This group was compared with 78 patients, admitted in the same interval, who did not require acute care transfer. The variables evaluated included recent surgery, pneumonia, fracture, intracranial blood, tracheostomy use, percutaneous feeding tube use, deep venous thrombosis, focal neurological examination, following simple commands, serum sodium level of < 135 mmol/L, serum white blood cell count of > 11,000 cells/microL, and serum hemoglobin level of < 10.0 g/dl. ANALYSIS Chi-square analysis was performed on the association between acute care transfer and the noted variables. RESULTS History of pneumonia (p < .03) and history of recent surgery (p < .02) were both associated with acute care transfer, and serum hemoglobin of < 10.0 g/dL had a trend towards association (p < .10). CONCLUSION Physiatrists caring for the TBI patient may warrant more acute observation of individuals with these parameters to prevent the problems necessitating acute care transfer.

Functional outcome after violence related traumatic brain injury

Violent injuries have become an increasingly prevalent cause of traumatic brain injury (TBI). These injuries can be classified as either penetrating or non-penetrating in nature. While much of the research on violence has been within a military population, there exists a marked difference between military and civilian injuries. Prior work has reported relatively poor outcomes for those individuals who have suffered penetrating TBIs, but little has been done to assess specific functional outcome parameters in survivors. We examined 25 subjects that had sustained blunt injuries and 25 cases with penetrating injuries as a result of a violent act. Cases were matched by initial Glasgow Coma Scale (GCS), age and educational level. Mean GCS for this study sample was 8.8. The following outcome variables were assessed at rehabilitation admission and discharge and at 1 year post injury: Disability Rating Scale (DRS), Rancho Los Amigos Scale (LCFS), Functional Independence Measure (FIM) (ambulation, expression items), length of stay, and cost of care. Students t-tests were performed to assess for differences between the two groups. No significant differences were noted between the groups for any of the outcome variables. Although penetrating injuries may have a higher initial mortality, those who survive to come to rehabilitation appear to have similar outcomes to those patients with non-penetrating violence related injuries.

Impact of age on functional outcome following traumatic brain injury

Objective:To examine whether increasing age is associated with poorer rehabilitation outcome. It was hypothesized that older individuals would benefit less from rehabilitation since increasing age is associated with greater morbidity and mortality. Design:Retrospective analysis of data collected at the beginning and end of inpatient medical rehabilitation. No experimental manipulation was performed. Injury severity, demographic information, initial level of functioning, and age were used in a hierarchical regression analysis to predict level of independent functioning. Setting:Inpatient traumatic brain injury units at four model system programs. Patients: 365 patients with traumatic brain injuries (39 mild, 67 moderate, 259 severe; 78% male; mean age=34 years). Interventions:All subjects participated in a comprehensive rehabilitation program including services from rehabilitation medicine, neuropsychology, nursing, social work, physical therapy, occupational therapy, speech and language pathology, vocational rehabilitation, and therapeutic recreation. Main Outcome Measures:Functional Independence Measure (FIM) and Disability Rating Scale (DRS). Results:After controlling for injury etiology, injury severity, and other demographic information, age had no statistically significant predictive value for functional outcome. Level of functioning on admission, independent of other factors, was the strongest predictor of functioning at discharge. Conclusions:Although increasing age has been strongly associated with higher rates of morbidity and mortality, it did not affect the level of functional improvement individuals achieved during inpatient rehabilitation. Hence, there does not appear to be justification for limiting access to rehabilitation solely on the basis of advanced age.

Penetrating head injury: a prospective study of outcomes.

Abstract The purpose of our study was to describe the outcomes of persons with penetrating brain injury resulting from a gunshot wound to the head. It is a prospective study of 442 patients admitted with gunshot wounds to the head over a 7 year period to our University Trauma Center Emergency Department, an urban trauma center and an inpatient rehabilitation hospital with a specialized brain injury unit. Measures and factors described include initial Glasgow Coma Scale score, Revised Trauma Score, the Disability Rating Scale, Functional Independence Measure, levels of cognitive functioning, patient demographics, length of stay, hospital charges, and discharge disposition. Initially 36% of patients expired in or were dead upon arrival to the Emergency Department; 64% of patients survived to be admitted for inpatient care. Of those admitted, 41% expired within the first 48 h of admission. Fifty-two percent of those admitted had severe injuries, 7% moderate injuries, and 42% had mild head injuries. Sixty-two percent of the survivors were discharged from acute care to private residences. The remaining 38% were discharged to programs providing varying levels of care depending upon their level of functioning and care needs. Patients sustaining severe injuries following gunshot wound(s) to the head have high early mortality. Survivors able to participate in an inpatient rehabilitation program have good potential for functional improvement. [Neurol Res 2001; 23: 219-226]

Spinal epidural abscess: study of early outcome.

Abstract Objective: To evaluate the course, complications, and outcomes of individuals with spinal epidural abscess (SEA) and to compare these factors in individuals who had sustained a traumatic spinal cord injury (TSCI) . Method: This is a retrospective study evaluating risk factors , functional change, and neuromedical complications. Thirty-two adults with SEA, treated on a rehabilitation unit at an urban university medical center, were compared with 3 2 individuals with TSCI. Groups were matched by lesion level and American Spinal Injury Association classification. Results: Both groups made significant functional improvement as measured by the functional independence measure (FIM), although the SEA group only averaged a 15-point increase, whereas the TSCI group averaged approximately 30 points. When compared with the TSCI group, the SEA group had a higher frequency of pressure ulcers (P < 0.04), and exhibited greater intravenous drug use (P < 0.008). There were no differences between the groups with respect to discharge placement or neuromedical risk factors. Conclusion: A number of predisposing factors and neuromedical complications that have significant medical implications were noted in the SEA group. In general, predisposing factors and outcomes were similar between those with SEA and those with TSCI, except for drug use and rate of pressure ulcers. These factors do not appear to relate to differential outcome in discharge placement, however. Although it is important to be aware of factors that place an individual at risk for SEA and appreciate the risks for complications, significant functional improvement can be achieved in this population.

Blunt versus penetrating violent traumatic brain injury: frequency and factors associated with secondary conditions and complications.

Objective:To compare types and frequency of medical complications and comorbidities associated with violence-related penetrating traumatic brain injury (TBI) as compared to violence-related blunt TBI. Method:Data were collected prospectively at four medical centers participating in the TBI Model Systems (TBIMS) of Care project. A total of 317 individuals met the inclusion criteria for the TBIMS (i.e., showed evidence of a TBI, were age 16 or older, presented to the TBIMS emergency department within 24 hours of injury, and received acute and rehabilitation services within the model system). Main Outcome Measures:Frequency of medical complications and comorbid diseases. Results:Patients with penetrating injuries suffered significantly higher rates of respiratory failure (P = .004), pneumonitis/pneumonia, (P = .002), skull fracture (P = .001), cerebrospinal fluid leak (P = .0005), and hypotonia (P = .001) than did patients with blunt injuries. Prediction of complications and comorbidities via multiple regression revealed that a penetrating violent injury and the severity of injury were independent predictors of a higher rate of medical complications, whereas age and gender did not account for unique variance in the equation. Conclusions:Penetrating injuries are associated with higher rates of certain medical complications, especially to the pulmonary and central nervous systems. Acute care physicians and physiatrists must be prepared to treat these complications more often in patients with penetrating injuries.