Karyl M. Hall

Characteristics and comparisons of functional assessment indices: Disability Rating Scale, Functional Independence Measure, and Functional Assessment Measure

The Model Systems assessed the functional level of individuals with traumatic brain injury (TBI) using the Disability Rating Scale, the Functional Independence Measure, and the Functional Assessment Measure at admission and discharge from acute inpatient rehabilitation. In this article, the reliabil

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

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.

Descriptive Findings from the Traumatic Brain Injury Model Systems National Data Base

Objectives:To describe the current status of the Traumatic Brain Injury Model Systems (TBIMS) National Data Base and present major descriptive findings based on the original research and demonstration issues for which the database was developed, and to describe patient outcomes at discharge from inpatient rehabilitation and at 1 year post injury. Design:Prospective, longitudinal multicenter study. Setting:TBIMS located at the Medical College of Virginia, Richmond, Va; Wayne State University/Rehabilitation Institute of Michigan, Detroit, Mich; The Institute for Rehabilitation and Research, Houston, Tex; and Santa Clara Valley Medical Center, San Jose, Calif. Data Set:Demographic, diagnostic, treatment, and outcome data on 660 individuals consecutively discharged from the four TBIMS between March 1989 and September 1995. Results:TBIMS individuals are typically in their mid-30s, male (77%), and white (51%); have a high school education or less (71%); and are as likely as not to be employed at the time of injury (50%). Vehicle-related injuries are the leading cause of injury (56%). Individuals tend to suffer moderate to severe brain injuries, with 77% experiencing loss of consciousness and 98% experiencing posttraumatic amnesia. The average combined length of stay for acute care and inpatient rehabilitation decreased approximately 25%, from 83 days in 1989 to 63 days in 1994. The Functional Independence Measure scores indicated overall functional improvement from an average level of requiring “Moderate Assistance” at the time of rehabilitation admission to an average level between “Moderate Independence” and “Complete Independence” at 1 year post injury. As indicated by the Community Integration Questionnaire, individuals tended to do best in the social aspects of community integration and worst in productivity. Conclusion:This article addresses the original research and demonstration issues posed by the creators of the TBIMS National Data Base. It describes the TBIMS population and presents outcomes at rehabilitation discharge and at 1 year post injury. This information provides a benchmark for future study.

Neuromuscular reeducation versus traditional programs for stroke rehabilitation.

This study compares long-term effectiveness of traditional functional retraining (TFR) with neuromuscular retraining techniques (NRT) after cerebrovascular accident (CVA). Groups of post-CVA patients from two different rehabilitation programs were matched according to early prognostic indicators. In one program NRT was emphasized while in the other the emphasis was restricted to TFR of spontaneously acquired upper extremity dexterity. Follow-up was possible in 19 of the TFR group and 20 of the NRT group who survived eight months after CVA. At least eight months post-CVA patients/families completed a telephone questionnaire regarding current functional abilities. With the single exception of self-feeding, no statistically significant differences in skill levels were found. NRT patients showed a slightly greater independence in feeding than the patients in functional retraining. It was also noted that rehabilitation hospitalization was significantly longer in the NRT group (28.57 days vs 68.3 days). The reason for this is not clear. If choice of therapeutic techniques was a contributing factor to increased lengths of stay, however, this would have major cost/effectiveness implications for program planning.

The benefit of rehabilitation in traumatic brain injury: A literature review

The efficacy and cost effectiveness of rehabilitation is being closely scrutinized, and demand for cost containment and outcome accountability will most likely increase. Clinically, it has long been believed that timely and appropriate rehabilitation leads to Improved functional recovery in brain-in

Occult head injury: Its incidence in spinal cord injury

This study investigated the suspicion that a significant proportion of individuals having spinal cord injury (SCI) also sustain a concomitant undiagnosed occult head injury during the trauma accident. The criteria for high risk of head injury included the following: (1) quadriplegia with high energy deceleration accident, (2) loss of consciousness at time of injury, (3) brainstem or cortical neurologic indicators, or (4) respiratory support required at time of injury. In this study, 67 patients admitted to the rehabilitation unit were given a neuropsychologic evaluation a median of 48 days after injury. Motor free scales used were the Galveston Orientation and Amnesia Test (GOAT), Quick Test, Raven Progressive matrices, serial 7s, Shipley Hartford, Stroop Color/Word Interference, and the Wechsler Memory Scale Associate Learning Tests. Forty-three of the 67 patients (64%) scored mildly to profoundly impaired on the test battery. Evidence of poor premorbid academic history was present in 19 (44%) of those with impaired performance on the neurologic evaluation and in only three (13%) of those scoring unimpaired. Consequently, 56% (24/43) of the impaired had no previous record of scholastic difficulties, presumably acquiring cognitive impairment at the time of injury. The implications of this high incidence of impaired cognitive functioning for treatment of individuals with SCI are significant.

Evaluation of the acute management of tetraplegia: conservative versus surgical treatment

A retrospective study of 106 tetraplegic patients admitted consecutively to the Santa Clara Valley Medical Center (SCVMC) between August, 1981 and September, 1983 was conducted. The average age was 28; and 20 (19%) were female. The majority sustained their spinal cord injury in a motor vehicle accident (65%) or in a diving accident (19%). Forty-nine percent (52/106) of these patients had acute surgical intervention, and 63% (33/52) of these patients had this prior to admission to SCVMC. The majority (35/52) had posterior fusion alone. Twelve patients had an anterior fusion (11 at other hospitals) and four a laminectomy alone (three carried out at other hospitals).The length of rehabilitation stay was 133 days for those having surgery, and 119 days for non-surgical cases; statistically a non-significant difference. When acute medical/surgical hospitalisation and rehabilitation days were combined, those having surgery had a significantly longer stay (197 versus 153 days), but only when surgery was done other than at SCVMC. Complications occurred in 50/106 (47%) of the patients: 50% who had surgery and 44% who were treated conservatively. The most commonest complication was respiratory (43%), including 20% who had pneumonia. Complications were no greater in those patients who underwent posterior fusion than in those who had no spinal surgery. However, other types of surgery carried a higher risk of complications by approximately 20%. Anterior fusions and laminectomies, performed almost totally at other institutions (15/17), had a higher rate of complications.

Factors Affecting Hospital Length of Stay and Charges Following Traumatic Brain Injury

Objective:To examine the effect of Initial severity of traumatic brain injury (TBI), level of functional Independence at admission to rehabilitation, medical complications, mechanism of injury, and payer source on hospital length of stay (LOS) and charges. Design:Cohort analysis. Setting:Inpatient rehabilitation. Patients:525 subjects from the National Institute on Disability and Rehabilitation Research TBI Model Systems National Data Base with relatively mild to severe TBI, an average Glasgow Coma Scale (GCS) score of 8.5 (SD=3.9), and average duration of impaired consciousness (DIC) of 15.1 days (SD=40.6). Intervention:Inpatient rehabilitation. Main Outcome Measures:Hospital LOS, hospital charges. Results:Persons with lower initial GCS scores generally reached the rehabilitation setting later and stayed longer than persons with higher initial GCS scores. Within each GCS level, lower initial Functional Independence Measure (FIM) scores were associated with longer acute care and rehabilitation LOS. For persons admitted to rehabilitation with relatively high or medium FIM scores, greater severity of injury resulted in relatively modest increases in rehabilitation LOS. In contrast, low admission FIM scores were associated with much longer rehabilitation LOS for patients with severe injuries, compared with those with relatively mild injuries. Initial GCS score, DIC, admission FIM, and acute LOS accounted for 48% (adjusted 7?2) of the variance in rehabilitation LOS and 42% of the variance In rehabilitation hospital charges. Of the medical complications examined, only neurologic complications and intracranial operations added significantly to the model, explaining an additional 2% of the variance in rehabilitation LOS. The effect of payer source on LOS is complicated by age as well as by severity and mechanism of injury. Conclusions:Age, severity of Injury, and medical complications are powerful predictors of rehabilitation LOS and hospital charges. Other factors, such as functional independence at rehabilitation admission and length of acute hospitalization, explain additional variance. None of these factors in isolation is able to sufficiently predict rehabilitation LOS or charges. Multidimensional analysis of these factors is necessary to plan or administer the delivery of brain injury services

Evaluation of acute surgical intervention in traumatic paraplegia

A retrospective study was conducted over a two-year perod of 95 consecutive admissions for traumatic paraplegia. The average age was 32 years. Seventy-two (76%) of these patients had acute surgical intervention. Fifty had Harrington rod placement with posterior fusion, 10 had additional laminectomy and one had rodding and anterior fusion. Seven laminectomies (alone) were performed at other hospitals.For those with rodding and/or fusion, rehabilitation stay was 70 days; for those with no surgery, 81 days. This difference was not statistically significant. However, when days of acute medical/surgical and rehabilitation hospitalization were combined, those having spinal surgery of any kind had a significantly shorter stay than those not having surgery (95 vs. 136 days). Complications were significantly greater in the patients who underwent internal fixation surgery. The neurological condition did not appear to be jeopardized by rodding and fusion.