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Community integration following moderate to severe traumatic brain injury: A longitudinal investigation

Community integration following moderate to severe traumatic brain injury: A longitudinal... J Rehabil Med 2009; 41: 521–527 ORIGINAL REPORT COMMUNITY INTEGRATION FOLLOWING MODERATE TO SEVERE TRAUMATIC BRAIN INJURY: A LONGITUDINAL INVESTIGATION 1,2 1, 2 3 Agnes H. P. Willemse-van Son, PhD , Gerard M. Ribbers, MD, PhD , Wim C. J. Hop, PhD and Henk J. Stam, MD, PhD, FRCP 1 2 From the Department of Rehabilitation Medicine, Erasmus Medical Centre, Rijndam Rehabilitation Centre and Department of Biostatistics, Erasmus Medical Centre, Rotterdam, The Netherlands Objective: To evaluate the course and identify determinants and prognosis following TBI is necessary to determine which of community integration for up to 3 years following moder- patients are at risk for unfavourable outcomes, and to optimize ate to severe traumatic brain injury. the use of limited healthcare and social resources. For patients Design: Prospective cohort study. with TBI and their families, early prognostic information is Patients: A total of 119 patients with moderate to severe important for coping and anticipating long-term consequences. traumatic brain injury aged 16–67 years. To date, most studies on patients with TBI have focused on Methods: The Community Integration Questionnaire was short-term outcomes, with a maximum of 6–12 months post- completed at 3, 6, 12, 18, 24 and 36 months post-injury. injury. Although a recent review addressed prognostic factors Repeated measures analysis of variance was performed to of long-term activity limitations and participation restrictions determine changes over time in the Community Integration (2), the clinical and sociodemographic determinants of such Questionnaire and its subscales. Bivariate and multivariate restrictions are unknown. regression analyses were used to identify determinants of Post-acute rehabilitation programmes for patients with TBI community integration 36 months post-injury. are aimed at optimizing functioning at all levels defined by Results: Compared with pre-injury, mean home integra- the World Health Organization (WHO); body functions and tion, social integration, productivity, and total questionnaire structures, activities and participation. Measuring participation scores decreased 3 months post-injury. Patient scores showed is a challenge. It is a multilayered concept encompassing such maximal improvement during the first year post- injury. domains as mobility, domestic life, interpersonal interactions Mean home integration, productivity, and total scores in- and relationships, as well as community, social and civic life creased to a lesser extent during years 1–3 post-injury. Age, (3). The Community Integration Questionnaire (CIQ) (3) has Barthel Index scores, hospital discharge destination, and been designed to assess participation in patients with TBI pre-injury community integration scores were the major de- (4). Earlier studies revealed that several clinical and socio- terminants of community integration 36 months post-injury demographic factors may be related to community integration. (R = 60%). Conclusion: After an initial decline, mean community inte- Clinical determinants of poor community integration following gration scores gradually improve following moderate to se- TBI include a more severe injury, poorer functional perform- vere traumatic brain injury. Understanding the course and ance and disability, extended post-traumatic amnesia (5, 6), determinants of community integration is necessary in order prolonged acute hospital stay (5), loss of emotional control to determine functional prognosis following traumatic brain (6), poor cognition (5, 7), poor physical condition (5), poor injury. pre-morbid functioning (7), and more severe activity limitation Key words: prognosis, craniocerebral trauma, traumatic brain (5, 6). Furthermore, patients injured by a violent mechanism injury, community integration, participation. have lower levels of community integration (8), whereas pa- tients injured by motor vehicle accidents have higher levels J Rehabil Med 2009; 41: 521–527 of community integration (9). Correspondence address: Agnes H. P. Willemse-van Son, Relevant sociodemographic determinants of community Erasmus MC, Department of Rehabilitation Medicine, PO integration are male gender, living with others, emotional Box 2040, NL-3000 CA, Rotterdam, The Netherlands. E-mail: distress (4), being a member of a minority race (10–12), lower a.vanson-willemse@erasmusmc.nl educational level (8, 11), and unemployment at the time of Submitted July 9, 2008; accepted March 2, 2009 injury (8, 11). Some studies show that older age is a risk fac- tor for poor community integration (5, 11), whereas one study reported that younger patients were at higher risk for poor INTRODUCTION community integration (6). Outcome following traumatic brain injury (TBI) can vary Most studies of community integration following TBI have from complete recovery to death, with many survivors having methodological weaknesses. A majority of studies used a long-term disabilities (1). Information regarding the course limited follow-up of 1 year (7–11, 13). The 2 studies that used © 2009 The Authors. doi: 10.2340/16501977-0377 J Rehabil Med 41 Journal Compilation © 2009 Foundation of Rehabilitation Information. ISSN 1650-1977 522 A. H. P. Willemse-van Son et al. (e.g. spinal cord injury, psychiatric disorder, cancer) that may interfere longer follow-up periods had retrospective designs (5, 6). Only with TBI-related disability assessment. one study had a follow-up of 3–4 years and used a prospective design; however, the sample size was small (14). As a conse- Measures quence, conclusions on determinants of community integration Community integration. Community integration was assessed using are limited. It is also unclear whether outcome following TBI the CIQ, which is designed specifically to assess issues affecting pa- stabilizes one year post-injury or whether community partici- tients with TBI (3, 22). The survey consists of 15 questions about how pation levels change over time. Hammond et al. (15) found certain activities are usually performed (alone, with another person, or by someone else), or how frequently activities are performed. Total that, although the majority of patients remained stable during scores vary from 0 to 29, with higher scores indicating better com- years 1–5 post-injury, some made dramatic gains, whereas a munity integration. The CIQ addresses 3 domains: home integration minority declined. In contrast, a study by Sander et al. (14) (range 0–10), social integration (range 0–12), and productivity (0–7). showed no changes in mean community integration between The reliability and validity of the CIQ has been well established (3, the first and third or fourth year. In a second study Sander et 23–27). The CIQ scores obtained from family members and patients were statistically similar (28), there appeared to be no floor or ceiling al. (16) found no significant changes after discharge from a effects (27). The CIQ was designed to assess community integration in post-acute rehabilitation programme. However, they stated that patients living at home; therefore, the CIQ was not assessed at times CIQ scores can fluctuate over time in individual cases (16). that patients were admitted to inpatient rehabilitation or a nursing home Therefore, the present study was conducted as a prospective after discharge from the acute care hospital, but only at time-points when patients lived in their homes. In contrast, data on independent cohort study measuring community integration at multiple time variables were collected at time-points that patients resided in a re- points post-injury in comparison with the pre-injury level of habilitation centre or nursing home. community integration. It was aimed: (i) to evaluate the course of participation after moderate to severe TBI until 36 months Independent variables. Potential sociodemographic and clinical determinants were identified by reviewing the published literature. post-injury; and (ii) to identify determinants of community Sociodemographic characteristics assessed included age in years, integration at 36 months post-injury. sex, pre-injury residence (alone vs with others), nationality (Dutch vs other nationality), pre-injury education level (secondary vs post- secondary education), and pre-injury work status (employed vs not METHODS employed). Pre-injury community integration levels were assessed Procedure retrospectively. Clinical characteristics assessed included lowest GCS score within 24 h of injury, cause of injury (motor vehicle accident vs The study consecutively enrolled 119 patients with TBI between other cause), length of stay in hospital (in days), hospital discharge January 1999 and April 2004 at 3 Dutch acute care hospitals which destination (home vs a inpatient rehabilitation or a nursing home), and were all level-1 trauma centres: Erasmus Medical Centre, Rotterdam computed tomography (CT) results (normal vs abnormal). Presence (January 1999 to April 2004); Medical Centre Haaglanden, The Hague or absence of hypoxia (PaO (January 2003 to February 2004); and University Medical Centre ≤ 8; SaO ≤ 90%), hypotension (systolic 2 2 blood pressure ≤ 90 mmHg), and hypothermia (≤ 35°C) at admission Utrecht, Utrecht (April 2003 to February 2004) (17). All study centres served as treatment centres for acute hospital care for all patients with was noted; a clinical diagnosis was also considered sufficient evidence of these conditions. moderate to severe TBI within their regions. Patients were treated in accordance with the European Brain Injury Consortium guidelines Post-acute functional measures included the Barthel Index (BI) (29) and the Functional Independence Measure plus Functional Assessment (18). In the Netherlands patients are discharged from the acute care hospitals to their homes (with or without outpatient rehabilitation), Measure (FIM+FAM) (30) measured at time of discharge from the acute care hospital. The BI, which has good reliability and validity (31), inpatient rehabilitation, or a nursing home (19). Upon admission, patients with acute TBI or family members consists of 10 items on activities of daily living (e.g. bowel and blad- der status, grooming, dressing, and bathing) each with 2 or 4 response received verbal and written information about the study and were asked if they were willing to participate. When possible, patients gave categories (0–3 points). Total scores range from 0 (severely restricted) to 20 (no restrictions). The FIM+FAM, which has good reliability and informed consent. Otherwise, a family member gave informed consent and patients were asked to give consent at a later time. The medical validity (32–35), consists of 30 items that are evaluated on a 7-point scale (completely independent to totally dependent). The FIM+FAM ethics committee of Erasmus MC approved this study. Baseline measurements were collected at hospital admission and evaluates motor and cognitive functioning with respect to self-care, sphincter control, transfers, locomotion, communication, psychosocial patients were followed prospectively at 3, 6, 12, 18, 24, and 36 months post-injury. Two study psychologists collected data using structured in- adjustment, and cognitive functioning. The FIM+FAM motor scale ranges from 16 (totally dependent) to 112 (totally independent) and terviews at the patients’ homes or at the rehabilitation centre or nursing home where the patient resided. If a patient interview was not possible, the FIM+FAM cognitive scale ranges from 14 (totally dependent) to 98 (totally independent). a family member or professional caregiver was interviewed. Patients Statistical analysis Inclusion criteria were: (i) admission to a hospital for moderate Descriptive analyses were performed using the Statistical Package for (Glasgow Coma Scale (GCS) (20) of 9–13) or severe (GCS of 3–8) the Social Sciences (SPSS), version 12.0.1. Baseline characteristics TBI due to a blunt or penetrating trauma. We classified patients with for patients followed-up and not followed-up at 36 months post-injury a GCS of 13 as moderate TBI, according to a study (21) that showed were compared using the Mann-Whitney U test for continuous vari- that patients with a GCS of 13 have similar complications, mostly ables and χ test for categorical variables. due to intracranial haematomas, as patients with a GCS of 9–12; (ii) To determine whether the course changed over time for home in- aged 16–67 years; and (iii) survival until discharge from the acute tegration, social integration, productivity, and total CIQ, a repeated care hospital. Exclusion criteria were: (i) insufficient knowledge of measures analysis of variance (ANOVA) was performed using the the Dutch or English language to participate in the study; or (ii) seri- PROC MIXED procedure in SAS 8.2. The advantage of this procedure ous pre-traumatic neurological, oncological, or systemic impairments is that it does not require complete follow-up data. Likelihood meth- J Rehabil Med 41 Community integration following traumatic brain injury 523 ods allow for missing data with this procedure. For all patients, time FIM+FAM cognitive score at discharge from hospital was 76. was included as a categorical variable in the model to test changes The mean pre-injury CIQ score was 19.3. over time. CIQ measurements were available for 91 patients pre-injury, To identify possible predictors of total CIQ score at 36 months, we 52 patients at 3 months, 65 patients at 6 months, 82 patients at first tested all independent variables for bivariate relationships using 12 months, 85 patients at 18 months, 84 patients at 24 months, SPSS 16.0.1. Bivariate relationships between community integration and independent variables were tested with Spearman’s correlations and 94 patients at 36 months. At the 36-month follow-up, 25 for continuous variables and with t-tests for dichotomous variables. measurements were unavailable because 3 patients had died, Because of the small sample size and relatively large number of in- 16 were lost to follow-up, 4 were residing in a nursing home, dependent variables, we selected variables only with p < 0.10 for the and 2 were not assessed due to logistical problems. Patients multivariate analysis. p < 0.05 (2-sided) was chosen as the level of who completed 36-monhts follow-up had a higher education significance for the multivariate analysis. level (p = 0.020), were more likely to be employed prior to injury (p = 0.017), and were more likely to have an episode of RESULTS hypoxia (p = 0.017), than the patients who did not complete the final follow-up (n = 25). There were no other significant Population differences between patients followed-up and not followed up Table I presents baseline characteristics, post-acute functional at 36 months post-injury. level, and pre-injury CIQ for the study participants (n = 119). The mean age was 34 years; the male to female ratio was 3:1; Community integration most patients were of Dutch nationality; most patients lived Fig. 1 shows the course of home integration, social integra- with a partner or parent; mean GCS score was 7.1; and 94% tion, productivity, and total CIQ from pre-injury to 36 months had an abnormal computed tomography (CT) scan. The BI post-injury. Time was significantly associated with home inte- score at discharge from hospital was 15. The mean FIM+FAM gration (p < 0.001), social integration (p < 0.001), productivity motor score at discharge from hospital was 87 and the mean (p < 0.001), and total CIQ (p < 0.001). Regarding home integration, 558 out of a potential 833 scores (119 patients × 7 time-points) were available for Table I. Characteristics of patients with moderate to severe traumatic brain injury (n = 119) ANOVA. Compared with pre-injury, the mean home integra- tion score decreased at 3 months post-injury (decrease 1.30 Patient characteristics points, standard error (SE) = 0.33, p < 0.001). At 6 months Age, years, mean (SD) 34 (13.2) post-injury, home integration scores improved, but the mean Gender, men/women, n 86/33 Dutch nationality, n (%) 111 (93) level remained below the mean pre-injury level (p = 0.019). At Lived alone pre-injury, n (%)* 17 (14) 12 months, mean home integration scores attained pre-injury Low pre-injury education level (secondary levels; a modest increase beyond pre-injury levels occurred education), n (%)* 58 (50) during the subsequent 24 months (p = 0.014). Employed pre-injury, n (%)* 93 (80) Pre-injury home integration, mean (SD)* 4.9 (3.3) Pre-injury social integration, mean (SD)* 8.9 (2.1) Pre-injury productivity, mean (SD)* 5.7 (1.3) Pre-injury total CIQ, mean (SD)* 19.3 (4.3) Motor vehicle accident cause of injury, n (%)* 85 (73) Lowest GCS score in the first 24 h, mean (SD) 7.1 (3.0) Length of hospital stay, days, median (range) 32 (4–173) Hospital discharge destination to inpatient rehabilitation or a nursing home, n (%) 62 (52) Abnormal CT pattern, n (%) 97 (94) Hypoxia present, n (%) * 32 (32) Hypotension present, n (%) * 12 (12) Hypothermia present, n (%) * 16 (21) FIM+FAM motor, mean (SD)* 87 (25.0) FIM+FAM cognitive, mean (SD)* 76 (20.3) Barthel Index, mean (SD)* 15 (6.3) *Data missing for: living status (n = 1), education level (n = 4), pre-injury work status (n = 3), pre-injury home integration (n = 27), pre-injury social integration (n = 28), pre-injury productivity (n = 27), pre-injury total CIQ (n = 28), cause of injury (n = 2), CT pattern (n = 16), presence of hypoxia (n = 20), presence of hypotension (n = 21), presence of hypothermia (n = 44), FIM+FAM motor (n = 21), FIM+FAM cognitive (n = 23), Barthel Index (n = 25). Fig. 1. The course of the total Community Integration Questionnaire SD: standard deviation; CT: computed tomography; CIQ: Community (CIQ), home integration, social integration, and productivity scores Integration Questionnaire; GCS: Glasgow Coma Scale; FIM+FAM: from pre-injury to 36 months post-injury. Data presented are estimated Functional Independence Measure plus Functional Assessment means (± standard error of the mean (SEM)) as calculated with repeated Measure. measurements analysis of variance. J Rehabil Med 41 524 A. H. P. Willemse-van Son et al. For social integration, 555 scores were available for ANO- Table II. Bivariate linear regression analyses for the Community Inte g ration VA. Compared with pre-injury, the mean social integration Questionnaire (CIQ) total scores at 36 months post-injury (n = 94) score decreased 3 months post-injury (decrease 1.00 points, Bivariate analysis SE = 0.23, p < 0.001). The mean social integration score sta- Predictive variable Mean (SEM) p-value bilized at the 3-month level, experienced a small increase Sociodemographic characteristics at 24 months post-injury, but remained low compared with Age, years* –0.32 < 0.002 pre-injury levels at the 36-month follow-up (difference 0.69 Sex points, SE = 0.21, p = 0.002). Male 16.97 (0.68) 0.012 Female 19.50 (0.71) For productivity, 558 scores were available for ANOVA. Nationality Compared with pre-injury, the mean productivity score de- Dutch 17.82 (0.54) 0.580 creased 3 months post-injury (decrease 3.69 points, SE = 0.28, Other 16.50 (3.05) p < 0.001). Subsequently, the mean productivity level increased Pre-injury living status at 6 and 12 months post-injury, stabilized, then showed a small Alone 21.00 (1.06) 0.018 With parent or partner 17.27 (0.57) increase at 24 months post-injury. At 36 months post-injury, Pre-injury education level the mean productivity level remained significantly low com- Secondary 16.96 (0.78) 0.167 pared with the mean pre-injury level (difference 1.45 points, Post-secondary 18.45 (0.73) SE = 0.20, p < 0.001). Pre-injury work status For total CIQ, 553 scores were available for ANOVA. Com- Employed 17.84 (0.61) 0.596 Unemployed 17.04 (0.93) pared with the mean pre-injury level, the mean community Pre-injury CIQ scores†* 0.54 < 0.001 integration score decreased 3 months post-injury (decrease Clinical characteristics 6.20 points, SE = 0.50, p < 0.001). Subsequently, the mean Cause of injury community integration scores significantly increased at 6 and Motor vehicle accident 17.65 (0.61) 0.945 12 months, then stabilized. Increased mean levels of commu- Other 17.74 (1.09) nity integration were noted at 24 months and remained stable Lowest GCS score in the first 24 h* 0.054 0.605 Length of hospital stay, days* –0.19 0.062 at 36 months. Hospital discharge destination Home 19.16 (0.61) 0.009 Determinants of community integration Inpatient rehabilitation or nursing home 16.45 (0.82) Computed tomography Table II presents bivariate relationships between independent Abnormal 17.50 (0.55) 0.007 variables and 36-month post-injury CIQ scores. The following Normal 23.55 (1.56) patients had lower community integration scores 36 months Hypoxia post-injury: males, older patients, those living with others pre- Present 18.69 (1.04) 0.311 Absent 17.51 (0.65) injury, those with longer hospital stays, those with abnormal Hypotension CT scans, those with lower BI scores (more dependence), those Present 17.77 (1.78) 0.923 with lower FIM+FAM motor scores (more dependence), those Absent 17.94 (0.60) with lower FIM+FAM cognitive scores (more dependence), Hypothermia those with low pre-injury CIQ scores, and those who were Present 17.04 (1.66) 0.651 Absent 17.77 (0.704) discharged to inpatient rehabilitation or a nursing home. As Post-acute functioning expected, the BI correlate strongly with the FIM+FAM motor FIM+FAM motor at discharge from hospital†* 0.37 0.001 scores (Spearman’s rho = 0.89, p < 0.001), and therefore could FIM+FAM cognitive at discharge from not be entered simultaneously into the multivariate analysis. hospital†* 0.32 0.005 We chose the BI score for the multivariate model because the Barthel Index at discharge from hospital†* 0.39 0.001 questionnaire requires less time to administer, and therefore *Results for continuous data calculated by Spearman’s correlation. would be more valuable in clinical practice. †CIQ pre-injury (n = 83); FIM+FAM motor (n = 78); FIM+FAM cognitive Table III shows the multivariate results for community (n = 76); Barthel Index (n = 74). integration at 36 months post-injury. Age, BI score, hospital SEM: standard error of mean; GCS: Glasgow Coma Scale; FIM+FAM: Functional Independence Measure plus Functional Assessment discharge destination, and pre-injury CIQ score were the major Measure. determinants of community integration and explained 60% of the variance (F(4,63) = 23.30, p< 0.001). The addition of age, BI score, and hospital discharge destination to the model explained more variance than the pre-injury CIQ score alone significant determinants. When the FIM+FAM motor score (which explained 31% of the variance). Older age, a lower BI was entered into the model in place of the BI, a model with score (more dependence), discharge from hospital to inpatient similar predictive value was found (F(4,65) = 22.8, p < 0.001, rehabilitation or a nursing home, and lower pre-injury CIQ R = 59%): age, hospital discharge destination, pre-injury CIQ score predicted lower levels of community integration. Adding score and FIM+FAM motor score determined community other independent variables to this model did not reveal other integration. J Rehabil Med 41 Community integration following traumatic brain injury 525 (14). Post-acute measures of levels of functioning have also Table III. Multivariate model for predicting community integration at 36 months post-injury. Results are presented as regression coefficients (β) predicted long-term disability and productivity level (2). with 95% confidence intervals (CI) and p-values In contrast to several other researchers (7, 8, 11, 13), we found no prognostic value for pre-injury work status. However, Predictive variable β 95% CI (β) p-value 80% of our study participants were employed prior to injury; Intercept 8.39 1.63 (15.15) Age, years –0.12 –0.19 (–0.05) 0.001 this percentage is much higher compared with other studies. Barthel Index 0.25 0.08 (0.43) 0.006 It is possible that the effect of pre-injury employment could Hospital discharge destination not be detected due to small sample variability. (to inpatient rehabilitation or a Pre-injury education level and nationality were not predictive nursing home) –2.10 –4.05 (–0.15) 0.036 in this study, although they were found to be predictors in other Pre-injury CIQ score 0.54 0.34 (0.74) < 0.001 studies (8, 10–12). No prognostic value was found for the GCS CIQ: Community Integration Questionnaire. score in this study of patients with moderate to severe TBI. However, the GCS has predicted community integration in a study including also patients with mild TBI (7). An abnormal DISCUSSION CT scan showed a bivariate relationship with community inte- In this prospective study we evaluated the course of com- gration, whereas cause of injury, presence of hypoxia, presence munity integration from pre-injury to 36 months post-injury of hypotension and presence of hypothermia did not. for patients with moderate to severe TBI. Furthermore, we Multivariate analysis did not show that any of these clinical identified determinants of community integration at 36 months characteristics were significant determinants of community post-injury. All CIQ subscales initially declined following integration. According to the International Classification of injury, but slowly increased over time. Maximal improvement Functioning, Disability and Health (ICF) (40) published by occurred during the first year following injury and several the World Health Organization, activities and participation domains showed small improvements between years 1 and 3 restrictions are determined by many factors. These include post-injury. However, most domains did not reach pre-injury disease factors such as injury severity, as well as personal levels. Some increases were transient and non-sustained at factors and environmental factors, which are especially use- 36 months. ful in predicting long-term outcome. Although most clinical Because there are no standardized normal values for CIQ, characteristics were predictive for short-term outcome (i.e. some researchers (36, 37) have used a non-disabled sample up to 6 months post-injury), they may be less important than as a referent to interpret findings in patients with TBI (22, 23, personal or environmental factors (e.g. coping style, social 38). Others have used retrospectively collected pre-injury CIQ environment, and depression) in predicting long-term out- scores (12). Pre-injury CIQ scores and non-disabled CIQ scores come. Others have concluded that injury severity may be a range from 17.4 to 20.5, whereas post-injury TBI patient CIQ less important predictor than pre-morbid status and 6-month scores range from 13.0 to 17.7 (3, 12, 22, 37). Our findings post-injury cognitive status (14, 39). for pre-injury and post-injury CIQ scores were consistent with Pre-injury community integration level, age, hospital dis- these previously reported ranges. Our finding that participation charge destination, and the post-acute BI can assist clinicians modestly increased one year following TBI contrasts with a in identifying which patients are at risk for lower community longitudinal study by Sander et al. (14), which showed no integration and which might benefit from additional care or changes in community integration between the first and third long-term facility placement. This information would also as- or fourth year (14). Differences in study populations and power sist clinicians in providing more detailed information regarding may explain this difference. functional prognosis. In our study sample, patients with low Pre-injury community integration, age, hospital discharge pre-injury community integration, older age, discharged from destination, and the post-acute BI score were the major deter- hospital to inpatient rehabilitation or a nursing home, or a lower minants of community integration at 36 months post-injury in BI were at risk for more long-term community integration this study. Our finding that older persons had lower community problems, than patients without these characteristics. integration levels than younger persons is consistent with other This study has some limitations. Although the CIQ is studies (5, 10, 11, 13). This may be partly explained by the considered sensitive for measuring differences between diag- observation that most persons reduce their activity patterns noses (23), it is not yet evident whether the CIQ is sensitive as they age. Another possibility is that older patients have a to changes over time (41). Furthermore, standardized normal poorer recovery compared with younger patients, which leads values for the CIQ do not exist. Previous studies assessing to participation restrictions. The hospital discharge destination the CIQ cross-sectionally presented challenges in determin- was a determinant in this study. The discharge destination can ing whether statistically significant changes were clinically reflect poorer functioning, which was also related to commu- relevant. Although drawing conclusions is difficult, the decline nity integration in other studies (5, 6). The post-acute BI score in community integration at 3 months post-injury was relatively was a significant predictor of community integration in this large. Comparisons of mean pre-injury scores with mean scores study. Previous research indicates that post-acute functional at 3 months post-injury, showed a decrease of 6.20 points for factors predict several aspects of community integration at one the total CIQ (1.30 points for home integration, 1.00 points for year post-injury (14, 39) but not at 2 or 3–4 years post-injury social integration, and 3.69 points for productivity). Especially J Rehabil Med 41 526 A. H. P. Willemse-van Son et al. 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Sander AM, Seel RT, Kreutzer JS, Hall KM, High WM, Jr., Rosenthal M. Agreement between persons with traumatic brain 40. World Health Organization. International Classification of Func- tioning, Disability and Health. Geneva: World Health Organiza- injury and their relatives regarding psychosocial outcome using the Community Integration Questionnaire. Arch Phys Med Rehabil tion; 2001. 41. Corrigan JD, Harrison-Felix C, Bogner J, Dijkers M, Terrill MS, 1997; 78: 353–357. 29. Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Whiteneck G. Systematic bias in traumatic brain injury outcome studies because of loss to follow-up. Arch Phys Med Rehabil Md State Med J 1965; 14: 61–65. 30. Turner-Stokes L, Nyein K, Turner-Stokes T, Gatehouse C. The UK 2003; 84: 153–160. J Rehabil Med 41 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Rehabilitation Medicine Unpaywall

Community integration following moderate to severe traumatic brain injury: A longitudinal investigation

Journal of Rehabilitation MedicineJan 1, 2009

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J Rehabil Med 2009; 41: 521–527 ORIGINAL REPORT COMMUNITY INTEGRATION FOLLOWING MODERATE TO SEVERE TRAUMATIC BRAIN INJURY: A LONGITUDINAL INVESTIGATION 1,2 1, 2 3 Agnes H. P. Willemse-van Son, PhD , Gerard M. Ribbers, MD, PhD , Wim C. J. Hop, PhD and Henk J. Stam, MD, PhD, FRCP 1 2 From the Department of Rehabilitation Medicine, Erasmus Medical Centre, Rijndam Rehabilitation Centre and Department of Biostatistics, Erasmus Medical Centre, Rotterdam, The Netherlands Objective: To evaluate the course and identify determinants and prognosis following TBI is necessary to determine which of community integration for up to 3 years following moder- patients are at risk for unfavourable outcomes, and to optimize ate to severe traumatic brain injury. the use of limited healthcare and social resources. For patients Design: Prospective cohort study. with TBI and their families, early prognostic information is Patients: A total of 119 patients with moderate to severe important for coping and anticipating long-term consequences. traumatic brain injury aged 16–67 years. To date, most studies on patients with TBI have focused on Methods: The Community Integration Questionnaire was short-term outcomes, with a maximum of 6–12 months post- completed at 3, 6, 12, 18, 24 and 36 months post-injury. injury. Although a recent review addressed prognostic factors Repeated measures analysis of variance was performed to of long-term activity limitations and participation restrictions determine changes over time in the Community Integration (2), the clinical and sociodemographic determinants of such Questionnaire and its subscales. Bivariate and multivariate restrictions are unknown. regression analyses were used to identify determinants of Post-acute rehabilitation programmes for patients with TBI community integration 36 months post-injury. are aimed at optimizing functioning at all levels defined by Results: Compared with pre-injury, mean home integra- the World Health Organization (WHO); body functions and tion, social integration, productivity, and total questionnaire structures, activities and participation. Measuring participation scores decreased 3 months post-injury. Patient scores showed is a challenge. It is a multilayered concept encompassing such maximal improvement during the first year post- injury. domains as mobility, domestic life, interpersonal interactions Mean home integration, productivity, and total scores in- and relationships, as well as community, social and civic life creased to a lesser extent during years 1–3 post-injury. Age, (3). The Community Integration Questionnaire (CIQ) (3) has Barthel Index scores, hospital discharge destination, and been designed to assess participation in patients with TBI pre-injury community integration scores were the major de- (4). Earlier studies revealed that several clinical and socio- terminants of community integration 36 months post-injury demographic factors may be related to community integration. (R = 60%). Conclusion: After an initial decline, mean community inte- Clinical determinants of poor community integration following gration scores gradually improve following moderate to se- TBI include a more severe injury, poorer functional perform- vere traumatic brain injury. Understanding the course and ance and disability, extended post-traumatic amnesia (5, 6), determinants of community integration is necessary in order prolonged acute hospital stay (5), loss of emotional control to determine functional prognosis following traumatic brain (6), poor cognition (5, 7), poor physical condition (5), poor injury. pre-morbid functioning (7), and more severe activity limitation Key words: prognosis, craniocerebral trauma, traumatic brain (5, 6). Furthermore, patients injured by a violent mechanism injury, community integration, participation. have lower levels of community integration (8), whereas pa- tients injured by motor vehicle accidents have higher levels J Rehabil Med 2009; 41: 521–527 of community integration (9). Correspondence address: Agnes H. P. Willemse-van Son, Relevant sociodemographic determinants of community Erasmus MC, Department of Rehabilitation Medicine, PO integration are male gender, living with others, emotional Box 2040, NL-3000 CA, Rotterdam, The Netherlands. E-mail: distress (4), being a member of a minority race (10–12), lower a.vanson-willemse@erasmusmc.nl educational level (8, 11), and unemployment at the time of Submitted July 9, 2008; accepted March 2, 2009 injury (8, 11). Some studies show that older age is a risk fac- tor for poor community integration (5, 11), whereas one study reported that younger patients were at higher risk for poor INTRODUCTION community integration (6). Outcome following traumatic brain injury (TBI) can vary Most studies of community integration following TBI have from complete recovery to death, with many survivors having methodological weaknesses. A majority of studies used a long-term disabilities (1). Information regarding the course limited follow-up of 1 year (7–11, 13). The 2 studies that used © 2009 The Authors. doi: 10.2340/16501977-0377 J Rehabil Med 41 Journal Compilation © 2009 Foundation of Rehabilitation Information. ISSN 1650-1977 522 A. H. P. Willemse-van Son et al. (e.g. spinal cord injury, psychiatric disorder, cancer) that may interfere longer follow-up periods had retrospective designs (5, 6). Only with TBI-related disability assessment. one study had a follow-up of 3–4 years and used a prospective design; however, the sample size was small (14). As a conse- Measures quence, conclusions on determinants of community integration Community integration. Community integration was assessed using are limited. It is also unclear whether outcome following TBI the CIQ, which is designed specifically to assess issues affecting pa- stabilizes one year post-injury or whether community partici- tients with TBI (3, 22). The survey consists of 15 questions about how pation levels change over time. Hammond et al. (15) found certain activities are usually performed (alone, with another person, or by someone else), or how frequently activities are performed. Total that, although the majority of patients remained stable during scores vary from 0 to 29, with higher scores indicating better com- years 1–5 post-injury, some made dramatic gains, whereas a munity integration. The CIQ addresses 3 domains: home integration minority declined. In contrast, a study by Sander et al. (14) (range 0–10), social integration (range 0–12), and productivity (0–7). showed no changes in mean community integration between The reliability and validity of the CIQ has been well established (3, the first and third or fourth year. In a second study Sander et 23–27). The CIQ scores obtained from family members and patients were statistically similar (28), there appeared to be no floor or ceiling al. (16) found no significant changes after discharge from a effects (27). The CIQ was designed to assess community integration in post-acute rehabilitation programme. However, they stated that patients living at home; therefore, the CIQ was not assessed at times CIQ scores can fluctuate over time in individual cases (16). that patients were admitted to inpatient rehabilitation or a nursing home Therefore, the present study was conducted as a prospective after discharge from the acute care hospital, but only at time-points when patients lived in their homes. In contrast, data on independent cohort study measuring community integration at multiple time variables were collected at time-points that patients resided in a re- points post-injury in comparison with the pre-injury level of habilitation centre or nursing home. community integration. It was aimed: (i) to evaluate the course of participation after moderate to severe TBI until 36 months Independent variables. Potential sociodemographic and clinical determinants were identified by reviewing the published literature. post-injury; and (ii) to identify determinants of community Sociodemographic characteristics assessed included age in years, integration at 36 months post-injury. sex, pre-injury residence (alone vs with others), nationality (Dutch vs other nationality), pre-injury education level (secondary vs post- secondary education), and pre-injury work status (employed vs not METHODS employed). Pre-injury community integration levels were assessed Procedure retrospectively. Clinical characteristics assessed included lowest GCS score within 24 h of injury, cause of injury (motor vehicle accident vs The study consecutively enrolled 119 patients with TBI between other cause), length of stay in hospital (in days), hospital discharge January 1999 and April 2004 at 3 Dutch acute care hospitals which destination (home vs a inpatient rehabilitation or a nursing home), and were all level-1 trauma centres: Erasmus Medical Centre, Rotterdam computed tomography (CT) results (normal vs abnormal). Presence (January 1999 to April 2004); Medical Centre Haaglanden, The Hague or absence of hypoxia (PaO (January 2003 to February 2004); and University Medical Centre ≤ 8; SaO ≤ 90%), hypotension (systolic 2 2 blood pressure ≤ 90 mmHg), and hypothermia (≤ 35°C) at admission Utrecht, Utrecht (April 2003 to February 2004) (17). All study centres served as treatment centres for acute hospital care for all patients with was noted; a clinical diagnosis was also considered sufficient evidence of these conditions. moderate to severe TBI within their regions. Patients were treated in accordance with the European Brain Injury Consortium guidelines Post-acute functional measures included the Barthel Index (BI) (29) and the Functional Independence Measure plus Functional Assessment (18). In the Netherlands patients are discharged from the acute care hospitals to their homes (with or without outpatient rehabilitation), Measure (FIM+FAM) (30) measured at time of discharge from the acute care hospital. The BI, which has good reliability and validity (31), inpatient rehabilitation, or a nursing home (19). Upon admission, patients with acute TBI or family members consists of 10 items on activities of daily living (e.g. bowel and blad- der status, grooming, dressing, and bathing) each with 2 or 4 response received verbal and written information about the study and were asked if they were willing to participate. When possible, patients gave categories (0–3 points). Total scores range from 0 (severely restricted) to 20 (no restrictions). The FIM+FAM, which has good reliability and informed consent. Otherwise, a family member gave informed consent and patients were asked to give consent at a later time. The medical validity (32–35), consists of 30 items that are evaluated on a 7-point scale (completely independent to totally dependent). The FIM+FAM ethics committee of Erasmus MC approved this study. Baseline measurements were collected at hospital admission and evaluates motor and cognitive functioning with respect to self-care, sphincter control, transfers, locomotion, communication, psychosocial patients were followed prospectively at 3, 6, 12, 18, 24, and 36 months post-injury. Two study psychologists collected data using structured in- adjustment, and cognitive functioning. The FIM+FAM motor scale ranges from 16 (totally dependent) to 112 (totally independent) and terviews at the patients’ homes or at the rehabilitation centre or nursing home where the patient resided. If a patient interview was not possible, the FIM+FAM cognitive scale ranges from 14 (totally dependent) to 98 (totally independent). a family member or professional caregiver was interviewed. Patients Statistical analysis Inclusion criteria were: (i) admission to a hospital for moderate Descriptive analyses were performed using the Statistical Package for (Glasgow Coma Scale (GCS) (20) of 9–13) or severe (GCS of 3–8) the Social Sciences (SPSS), version 12.0.1. Baseline characteristics TBI due to a blunt or penetrating trauma. We classified patients with for patients followed-up and not followed-up at 36 months post-injury a GCS of 13 as moderate TBI, according to a study (21) that showed were compared using the Mann-Whitney U test for continuous vari- that patients with a GCS of 13 have similar complications, mostly ables and χ test for categorical variables. due to intracranial haematomas, as patients with a GCS of 9–12; (ii) To determine whether the course changed over time for home in- aged 16–67 years; and (iii) survival until discharge from the acute tegration, social integration, productivity, and total CIQ, a repeated care hospital. Exclusion criteria were: (i) insufficient knowledge of measures analysis of variance (ANOVA) was performed using the the Dutch or English language to participate in the study; or (ii) seri- PROC MIXED procedure in SAS 8.2. The advantage of this procedure ous pre-traumatic neurological, oncological, or systemic impairments is that it does not require complete follow-up data. Likelihood meth- J Rehabil Med 41 Community integration following traumatic brain injury 523 ods allow for missing data with this procedure. For all patients, time FIM+FAM cognitive score at discharge from hospital was 76. was included as a categorical variable in the model to test changes The mean pre-injury CIQ score was 19.3. over time. CIQ measurements were available for 91 patients pre-injury, To identify possible predictors of total CIQ score at 36 months, we 52 patients at 3 months, 65 patients at 6 months, 82 patients at first tested all independent variables for bivariate relationships using 12 months, 85 patients at 18 months, 84 patients at 24 months, SPSS 16.0.1. Bivariate relationships between community integration and independent variables were tested with Spearman’s correlations and 94 patients at 36 months. At the 36-month follow-up, 25 for continuous variables and with t-tests for dichotomous variables. measurements were unavailable because 3 patients had died, Because of the small sample size and relatively large number of in- 16 were lost to follow-up, 4 were residing in a nursing home, dependent variables, we selected variables only with p < 0.10 for the and 2 were not assessed due to logistical problems. Patients multivariate analysis. p < 0.05 (2-sided) was chosen as the level of who completed 36-monhts follow-up had a higher education significance for the multivariate analysis. level (p = 0.020), were more likely to be employed prior to injury (p = 0.017), and were more likely to have an episode of RESULTS hypoxia (p = 0.017), than the patients who did not complete the final follow-up (n = 25). There were no other significant Population differences between patients followed-up and not followed up Table I presents baseline characteristics, post-acute functional at 36 months post-injury. level, and pre-injury CIQ for the study participants (n = 119). The mean age was 34 years; the male to female ratio was 3:1; Community integration most patients were of Dutch nationality; most patients lived Fig. 1 shows the course of home integration, social integra- with a partner or parent; mean GCS score was 7.1; and 94% tion, productivity, and total CIQ from pre-injury to 36 months had an abnormal computed tomography (CT) scan. The BI post-injury. Time was significantly associated with home inte- score at discharge from hospital was 15. The mean FIM+FAM gration (p < 0.001), social integration (p < 0.001), productivity motor score at discharge from hospital was 87 and the mean (p < 0.001), and total CIQ (p < 0.001). Regarding home integration, 558 out of a potential 833 scores (119 patients × 7 time-points) were available for Table I. Characteristics of patients with moderate to severe traumatic brain injury (n = 119) ANOVA. Compared with pre-injury, the mean home integra- tion score decreased at 3 months post-injury (decrease 1.30 Patient characteristics points, standard error (SE) = 0.33, p < 0.001). At 6 months Age, years, mean (SD) 34 (13.2) post-injury, home integration scores improved, but the mean Gender, men/women, n 86/33 Dutch nationality, n (%) 111 (93) level remained below the mean pre-injury level (p = 0.019). At Lived alone pre-injury, n (%)* 17 (14) 12 months, mean home integration scores attained pre-injury Low pre-injury education level (secondary levels; a modest increase beyond pre-injury levels occurred education), n (%)* 58 (50) during the subsequent 24 months (p = 0.014). Employed pre-injury, n (%)* 93 (80) Pre-injury home integration, mean (SD)* 4.9 (3.3) Pre-injury social integration, mean (SD)* 8.9 (2.1) Pre-injury productivity, mean (SD)* 5.7 (1.3) Pre-injury total CIQ, mean (SD)* 19.3 (4.3) Motor vehicle accident cause of injury, n (%)* 85 (73) Lowest GCS score in the first 24 h, mean (SD) 7.1 (3.0) Length of hospital stay, days, median (range) 32 (4–173) Hospital discharge destination to inpatient rehabilitation or a nursing home, n (%) 62 (52) Abnormal CT pattern, n (%) 97 (94) Hypoxia present, n (%) * 32 (32) Hypotension present, n (%) * 12 (12) Hypothermia present, n (%) * 16 (21) FIM+FAM motor, mean (SD)* 87 (25.0) FIM+FAM cognitive, mean (SD)* 76 (20.3) Barthel Index, mean (SD)* 15 (6.3) *Data missing for: living status (n = 1), education level (n = 4), pre-injury work status (n = 3), pre-injury home integration (n = 27), pre-injury social integration (n = 28), pre-injury productivity (n = 27), pre-injury total CIQ (n = 28), cause of injury (n = 2), CT pattern (n = 16), presence of hypoxia (n = 20), presence of hypotension (n = 21), presence of hypothermia (n = 44), FIM+FAM motor (n = 21), FIM+FAM cognitive (n = 23), Barthel Index (n = 25). Fig. 1. The course of the total Community Integration Questionnaire SD: standard deviation; CT: computed tomography; CIQ: Community (CIQ), home integration, social integration, and productivity scores Integration Questionnaire; GCS: Glasgow Coma Scale; FIM+FAM: from pre-injury to 36 months post-injury. Data presented are estimated Functional Independence Measure plus Functional Assessment means (± standard error of the mean (SEM)) as calculated with repeated Measure. measurements analysis of variance. J Rehabil Med 41 524 A. H. P. Willemse-van Son et al. For social integration, 555 scores were available for ANO- Table II. Bivariate linear regression analyses for the Community Inte g ration VA. Compared with pre-injury, the mean social integration Questionnaire (CIQ) total scores at 36 months post-injury (n = 94) score decreased 3 months post-injury (decrease 1.00 points, Bivariate analysis SE = 0.23, p < 0.001). The mean social integration score sta- Predictive variable Mean (SEM) p-value bilized at the 3-month level, experienced a small increase Sociodemographic characteristics at 24 months post-injury, but remained low compared with Age, years* –0.32 < 0.002 pre-injury levels at the 36-month follow-up (difference 0.69 Sex points, SE = 0.21, p = 0.002). Male 16.97 (0.68) 0.012 Female 19.50 (0.71) For productivity, 558 scores were available for ANOVA. Nationality Compared with pre-injury, the mean productivity score de- Dutch 17.82 (0.54) 0.580 creased 3 months post-injury (decrease 3.69 points, SE = 0.28, Other 16.50 (3.05) p < 0.001). Subsequently, the mean productivity level increased Pre-injury living status at 6 and 12 months post-injury, stabilized, then showed a small Alone 21.00 (1.06) 0.018 With parent or partner 17.27 (0.57) increase at 24 months post-injury. At 36 months post-injury, Pre-injury education level the mean productivity level remained significantly low com- Secondary 16.96 (0.78) 0.167 pared with the mean pre-injury level (difference 1.45 points, Post-secondary 18.45 (0.73) SE = 0.20, p < 0.001). Pre-injury work status For total CIQ, 553 scores were available for ANOVA. Com- Employed 17.84 (0.61) 0.596 Unemployed 17.04 (0.93) pared with the mean pre-injury level, the mean community Pre-injury CIQ scores†* 0.54 < 0.001 integration score decreased 3 months post-injury (decrease Clinical characteristics 6.20 points, SE = 0.50, p < 0.001). Subsequently, the mean Cause of injury community integration scores significantly increased at 6 and Motor vehicle accident 17.65 (0.61) 0.945 12 months, then stabilized. Increased mean levels of commu- Other 17.74 (1.09) nity integration were noted at 24 months and remained stable Lowest GCS score in the first 24 h* 0.054 0.605 Length of hospital stay, days* –0.19 0.062 at 36 months. Hospital discharge destination Home 19.16 (0.61) 0.009 Determinants of community integration Inpatient rehabilitation or nursing home 16.45 (0.82) Computed tomography Table II presents bivariate relationships between independent Abnormal 17.50 (0.55) 0.007 variables and 36-month post-injury CIQ scores. The following Normal 23.55 (1.56) patients had lower community integration scores 36 months Hypoxia post-injury: males, older patients, those living with others pre- Present 18.69 (1.04) 0.311 Absent 17.51 (0.65) injury, those with longer hospital stays, those with abnormal Hypotension CT scans, those with lower BI scores (more dependence), those Present 17.77 (1.78) 0.923 with lower FIM+FAM motor scores (more dependence), those Absent 17.94 (0.60) with lower FIM+FAM cognitive scores (more dependence), Hypothermia those with low pre-injury CIQ scores, and those who were Present 17.04 (1.66) 0.651 Absent 17.77 (0.704) discharged to inpatient rehabilitation or a nursing home. As Post-acute functioning expected, the BI correlate strongly with the FIM+FAM motor FIM+FAM motor at discharge from hospital†* 0.37 0.001 scores (Spearman’s rho = 0.89, p < 0.001), and therefore could FIM+FAM cognitive at discharge from not be entered simultaneously into the multivariate analysis. hospital†* 0.32 0.005 We chose the BI score for the multivariate model because the Barthel Index at discharge from hospital†* 0.39 0.001 questionnaire requires less time to administer, and therefore *Results for continuous data calculated by Spearman’s correlation. would be more valuable in clinical practice. †CIQ pre-injury (n = 83); FIM+FAM motor (n = 78); FIM+FAM cognitive Table III shows the multivariate results for community (n = 76); Barthel Index (n = 74). integration at 36 months post-injury. Age, BI score, hospital SEM: standard error of mean; GCS: Glasgow Coma Scale; FIM+FAM: Functional Independence Measure plus Functional Assessment discharge destination, and pre-injury CIQ score were the major Measure. determinants of community integration and explained 60% of the variance (F(4,63) = 23.30, p< 0.001). The addition of age, BI score, and hospital discharge destination to the model explained more variance than the pre-injury CIQ score alone significant determinants. When the FIM+FAM motor score (which explained 31% of the variance). Older age, a lower BI was entered into the model in place of the BI, a model with score (more dependence), discharge from hospital to inpatient similar predictive value was found (F(4,65) = 22.8, p < 0.001, rehabilitation or a nursing home, and lower pre-injury CIQ R = 59%): age, hospital discharge destination, pre-injury CIQ score predicted lower levels of community integration. Adding score and FIM+FAM motor score determined community other independent variables to this model did not reveal other integration. J Rehabil Med 41 Community integration following traumatic brain injury 525 (14). Post-acute measures of levels of functioning have also Table III. Multivariate model for predicting community integration at 36 months post-injury. Results are presented as regression coefficients (β) predicted long-term disability and productivity level (2). with 95% confidence intervals (CI) and p-values In contrast to several other researchers (7, 8, 11, 13), we found no prognostic value for pre-injury work status. However, Predictive variable β 95% CI (β) p-value 80% of our study participants were employed prior to injury; Intercept 8.39 1.63 (15.15) Age, years –0.12 –0.19 (–0.05) 0.001 this percentage is much higher compared with other studies. Barthel Index 0.25 0.08 (0.43) 0.006 It is possible that the effect of pre-injury employment could Hospital discharge destination not be detected due to small sample variability. (to inpatient rehabilitation or a Pre-injury education level and nationality were not predictive nursing home) –2.10 –4.05 (–0.15) 0.036 in this study, although they were found to be predictors in other Pre-injury CIQ score 0.54 0.34 (0.74) < 0.001 studies (8, 10–12). No prognostic value was found for the GCS CIQ: Community Integration Questionnaire. score in this study of patients with moderate to severe TBI. However, the GCS has predicted community integration in a study including also patients with mild TBI (7). An abnormal DISCUSSION CT scan showed a bivariate relationship with community inte- In this prospective study we evaluated the course of com- gration, whereas cause of injury, presence of hypoxia, presence munity integration from pre-injury to 36 months post-injury of hypotension and presence of hypothermia did not. for patients with moderate to severe TBI. Furthermore, we Multivariate analysis did not show that any of these clinical identified determinants of community integration at 36 months characteristics were significant determinants of community post-injury. All CIQ subscales initially declined following integration. According to the International Classification of injury, but slowly increased over time. Maximal improvement Functioning, Disability and Health (ICF) (40) published by occurred during the first year following injury and several the World Health Organization, activities and participation domains showed small improvements between years 1 and 3 restrictions are determined by many factors. These include post-injury. However, most domains did not reach pre-injury disease factors such as injury severity, as well as personal levels. Some increases were transient and non-sustained at factors and environmental factors, which are especially use- 36 months. ful in predicting long-term outcome. Although most clinical Because there are no standardized normal values for CIQ, characteristics were predictive for short-term outcome (i.e. some researchers (36, 37) have used a non-disabled sample up to 6 months post-injury), they may be less important than as a referent to interpret findings in patients with TBI (22, 23, personal or environmental factors (e.g. coping style, social 38). Others have used retrospectively collected pre-injury CIQ environment, and depression) in predicting long-term out- scores (12). Pre-injury CIQ scores and non-disabled CIQ scores come. Others have concluded that injury severity may be a range from 17.4 to 20.5, whereas post-injury TBI patient CIQ less important predictor than pre-morbid status and 6-month scores range from 13.0 to 17.7 (3, 12, 22, 37). Our findings post-injury cognitive status (14, 39). for pre-injury and post-injury CIQ scores were consistent with Pre-injury community integration level, age, hospital dis- these previously reported ranges. Our finding that participation charge destination, and the post-acute BI can assist clinicians modestly increased one year following TBI contrasts with a in identifying which patients are at risk for lower community longitudinal study by Sander et al. (14), which showed no integration and which might benefit from additional care or changes in community integration between the first and third long-term facility placement. This information would also as- or fourth year (14). Differences in study populations and power sist clinicians in providing more detailed information regarding may explain this difference. functional prognosis. In our study sample, patients with low Pre-injury community integration, age, hospital discharge pre-injury community integration, older age, discharged from destination, and the post-acute BI score were the major deter- hospital to inpatient rehabilitation or a nursing home, or a lower minants of community integration at 36 months post-injury in BI were at risk for more long-term community integration this study. Our finding that older persons had lower community problems, than patients without these characteristics. integration levels than younger persons is consistent with other This study has some limitations. Although the CIQ is studies (5, 10, 11, 13). This may be partly explained by the considered sensitive for measuring differences between diag- observation that most persons reduce their activity patterns noses (23), it is not yet evident whether the CIQ is sensitive as they age. Another possibility is that older patients have a to changes over time (41). Furthermore, standardized normal poorer recovery compared with younger patients, which leads values for the CIQ do not exist. Previous studies assessing to participation restrictions. The hospital discharge destination the CIQ cross-sectionally presented challenges in determin- was a determinant in this study. The discharge destination can ing whether statistically significant changes were clinically reflect poorer functioning, which was also related to commu- relevant. Although drawing conclusions is difficult, the decline nity integration in other studies (5, 6). The post-acute BI score in community integration at 3 months post-injury was relatively was a significant predictor of community integration in this large. Comparisons of mean pre-injury scores with mean scores study. Previous research indicates that post-acute functional at 3 months post-injury, showed a decrease of 6.20 points for factors predict several aspects of community integration at one the total CIQ (1.30 points for home integration, 1.00 points for year post-injury (14, 39) but not at 2 or 3–4 years post-injury social integration, and 3.69 points for productivity). Especially J Rehabil Med 41 526 A. H. P. Willemse-van Son et al. 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Journal of Rehabilitation MedicineUnpaywall

Published: Jan 1, 2009

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