EARLY POSTACUTE REHABILITATION services for

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1 1447 Preliminary Outcome Analysis of a Long-Term Rehabilitation Program for Severe Acquired Brain Injury D. Shaun Gray, MD, PhD, Robert S. Burnham, MSc, MD ABSTRACT. Gray DS, Burnham RS. Preliminary outcome analysis of a long-term rehabilitation program for severe acquired brain injury. Arch Phys Med Rehabil 2000;81: Objectives: To describe the general characteristics and functional outcomes of individuals treated in a publicly funded, long-term, acquired brain injury rehabilitation program and investigate variables affecting functional outcomes in this patient population. Design: Retrospective database review of demographic, descriptive, and functional outcome assessment data. Setting: Publicly funded, comprehensive, multidisciplinary, long-term, residential brain injury rehabilitation program in Alberta, Canada (64 beds). Patients: All rehabilitation patients admitted to and discharged from the brain injury program from February 1991 to March 1999 (n 349). Interventions: Multidisciplinary rehabilitation program. Main Outcome Measures: Demographic and descriptive information included sex, age at admission, type and severity of injury, time from injury to long-term program admission, and length of stay (LOS). Functional outcome information included level of care required at admission and discharge, admission and discharge Rappaport disability rating scale scores, and admission and discharge FIM instrument and Functional Assessment Measure scores for a subset of patients. Results: Fifty-nine percent of the subjects had severe traumatic brain injuries (TBI) and 41% had severe nontraumatic brain injuries (NTBI) of various causes. Mean age at admission was older and LOS was longer for NTBI compared with TBI; there were no other differences between the groups in demographic or descriptive measures. The TBI group had significantly lower admission motor subscale scores than the NTBI group, but the groups did not differ on cognitive scores. All functional assessment measures showed statistically significant improvement from admission to discharge, and 85.6% of patients were discharged to community living after a mean LOS of days. Functional status at admission, age at admission, length of time between injury and admission, and LOS in the rehabilitation program significantly correlated with functional improvement. Conclusions: Patients with severe TBI and NTBI who were not candidates for other more conventional forms of rehabilitation showed significant improvement in functional outcomes after extended program admissions. Consideration was also From the Division of Physical Medicine and Rehabilitation, University of Alberta (Gray, Burnham) and the Brain Injury Rehabilitation Program, Alberta Hospital Ponoka, Alberta Mental Health Board (Gray), Edmonton, Alberta, Canada. Accepted in revised form March 14, No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to D. Shaun Gray, MD, PhD, Div of Physical Medicine and Rehabilitation, University of Alberta, Glenrose Rehabilitation Hospital, Ave, Edmonton, A1b, Canada T5G 0B7, gray@telusplanet.net /00/ $3.00/0 doi: /apmr given to the potential insensitivity of commonly used outcome assessment measures in this population. Key Words: Brain injuries; Length of stay; Outcome assessment (health care); Rehabilitation by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation EARLY POSTACUTE REHABILITATION services for severe acquired brain injury (ABI) are typically provided in a short-term comprehensive rehabilitation (STCR) setting, with the duration of rehabilitation measured in weeks. 1-5 However, not every survivor of a severe traumatic brain injury (TBI) is a candidate for admission to STCR program 6,7 because some may have a low level of cognitive or physical functioning that precludes participation in a rehabilitation program or behavior disorders that prevent admission or interfere with participation in rehabilitation activities. Occasionally, these lowfunctioning patients are admitted to STCR on a trial basis but make little progress over the course of their admission and are subsequently discharged. If low-functioning patients are not admitted to a rehabilitation program, they are often discharged to nonspecialized extended care facilities or nonspecialized peripheral health facilities, excluding them from further specialized rehabilitation services. Although these low-functioning survivors may not be considered good candidates for admission to STCR programs, a brief literature review suggests that survivors of severe ABI are capable of significant functional gains months or even years postinjury It is this group of slow-to-recover patients that has stimulated calls for specialized subacute, slow-stream, or long-term comprehensive rehabilitation settings to maximize recovery of function, minimize disability, and reduce long-term costs of care over the remaining life of the survivor. 2,7,21-23 Although the potential benefits of programs that specifically address this patient population are recognized, there are few published data from these programs to evaluate the effectiveness of the long-term rehabilitation approach. Despite this general lack of specific evidence, a few studies provide support for this concept. For example, Hedrick et al 23 showed that almost half the 42 patients with TBI in a subacute transition program recovered sufficiently after an average admission of 144 days (5mo) to be eligible for acute intensive rehabilitation, and almost all patients showed reduced disability during their stay. In a small study of 5 patients, Bell and Tallman 14 indicated that late ( 1yr postinjury) admission to a rehabilitation program from extended care facilities resulted in enough functional improvement for all 5 patients to be discharged to the community. Eames et al 24 found that prolonged (11mo) admission to a specialized rehabilitation center was associated with a significant increase in functional independence and a subsequent decrease in long-term costs of care, although long-term rehabilitation was not the focus of their report. A more recent study by Willer et al 25 examining community-based residential rehabilitation showed that a mean program length of stay (LOS) of 8 months was associated with improved function compared with matched controls receiving

2 1448 LONG-TERM REHABILITATION OF SEVERE BRAIN INJURY, Gray home-based services of similar duration. A British study 26 examining the benefits of comprehensive multidisciplinary rehabilitation recently showed that rehabilitation with an average LOS of 7 months was more effective than other communitybased rehabilitation lasting a mean of only 4 months. This small cadre of studies supports the suggestion that slow-to-recover survivors of severe brain injury are capable of significant functional gains postinjury, but the preponderance of evidence to date is low and based on relatively small patient numbers. In addition, no study specifically addressed outcomes of facility-based programs designed to offer long-term comprehensive services to survivors of severe brain injury. The purpose of the present study was to add to the literature concerning the slow-to-recover survivor of ABI and the potential effectiveness of long-term rehabilitation in this population by examining data from a large publicly funded facility-based residential brain injury rehabilitation program. This program was specifically created to offer long-term rehabilitation services to survivors of ABI. More specifically, the study addresses (1) demographic and descriptive characteristics of the program population for both TBI and non-tbi (NTBI) causes, (2) degree of change in functional status from admission to discharge, and (3) preliminary hypothesis testing for variables that may correlate with the degree of functional change over the course of admission. METHODS Setting Data analyzed in this study were obtained from the database maintained by the Brain Injury Rehabilitation Program at Alberta Hospital Ponoka (Ponoka, Alberta, Canada). This 64-bed publicly funded program was designed to offer long-term rehabilitation to survivors of ABI and has been in operation in its present form since February The program offers a comprehensive rehabilitation program in a hospital setting and provides multidisciplinary team-based services that include medicine, psychiatry, nursing, physical therapy, occupational therapy, dietetics, speech/language pathology, psychology, neuropsychology, social work, and recreation therapy. Until recently, physiatric services were available on an out-of-facility consultative basis only because of a shortage of appropriately qualified staff. Criteria for admission to the program include ABI, adult age, and the perceived potential to participate and benefit from services offered by the program. The program is not a long-term residential setting, and discharge is expected when the patient realizes maximal benefit as perceived by the patient, family, or treatment team. Database The program has maintained a demographic and functional outcomes database since Demographic information includes patient descriptors, type and severity of injury, time from injury to admission, LOS, and type of care required at admission and discharge. The type of care needed is categorized with a loose ordinal score based on level of independence, level of supervision needed, and intensity of resources needed for daily care. The coded categories include independent living with employment, independent living with social agency financial support, independent living with some caregiver support (family or home care), semi-independent (group home) living, in-home supervised care, extended care (nursing home), extended care with extra nursing support (auxiliary hospital), or acute care hospital. The acute care category includes such early rehabilitation facilities as acute care hospital rehabilitation wards or STCR program hospitals. The functional outcomes measures used include the Rappaport disability rating scale (RDRS) 27 and FIM instrument and Functional Assessment Measure (FIM FAM). 28 RDRS data were available for patients admitted and discharged during the study period from February 1991 to March Information concerning the adequate reliability and validity of this scale has been published elsewhere. 27,29,30 In 1993, the program began using the FIM FAM 28 as an assessment tool; thus, these data were available for a smaller subset of the total number of patients. The FIM FAM is completed by the treatment team at admission, serial intervals of approximately 3 months during admission, and discharge from the program. These serial FIM FAM data are marked by approximately 3-month intervals between data points. Assessment intervals are approximate because of such factors as conference scheduling or unexpected discharges, but attempts are made to ensure a minimum 8-week separation between each assessment. Information showing the reliability of the FIM FAM in this specific setting has been published elsewhere. 31 Data Analysis Frequency, ordinal, and interval data were analyzed using nonparametric and parametric statistics as appropriate. FIM FAM data and change scores were analyzed using repeated-measures analysis of variance (ANOVA) with covariance, general linear regression, and general linear stepwise regression. FIM FAM data were analyzed as aggregate total scores and motor and cognitive subscales, as suggested by Hall. 28 Missing data were handled by deleting the missing case record from the analysis. RESULTS Demographic and Descriptive Statistics Demographic and other descriptive statistics are listed in table 1. Number of subjects. The complete patient group included 349 records. FIM FAM data were available for a subset of 197 patients. The exact number is reported in the remaining analyses as appropriate for missing data. Type of injury. Closed or open TBI accounted for 60% of the known injury types (n 345). Stroke (16%), subarachnoid hemorrhage (9%), anoxia (7%), and other (9%) accounted for Table 1: Mean Admission Demographic and Functional Status Data for Patient Sample by Brain Injury Type TBI NTBI Total No. of patients (% of total) 207 (60) 138 (40) 349 Men (%) Women (%) Age at admission (yr) * 39.4 Glasgow coma scale score at Injury Days from Injury to admission LOS (d) * RDRS score at admission FIM FAM motor score * 67.5 at admission FIM FAM cognitive score at admission Values expressed as mean SD unless noted otherwise. * p.05, TBI versus NTBI.

3 LONG-TERM REHABILITATION OF SEVERE BRAIN INJURY, Gray 1449 the remaining 40%. Because TBI may have different characteristics relative to other forms of brain injury and the relative frequencies of other causes were low, subsequent analyses compare groups with respect to TBI (n 207) and NTBI (n 138) causes. Age at admission and sex. There was a significant (t ; p.05) difference in age at admission; the TBI group (mean standard deviation, yr) was younger than the NTBI group (mean, yr; table 1). This difference provides further support for the appropriateness of examining these 2 groups separately. Sex distribution showed 77.3% men and 22.7% women in the TBI group and 69.6% men and 30.4% women in the NTBI group. Mean ages at admission and sex split in the TBI group are similar to those reported for the Model Systems database. 3,4,38 Severity of injury. Severity of initial injury is reflected by the Glasgow coma scale (GCS) score. 39 GCS scores were available for 136 patients with TBI and 47 patients with NTBI. The accuracy of these GCS scores is largely unknown because they were obtained from referral information and the timing of score acquisition early postinjury is unknown. However, there was no significant difference (Mann-Whitney U ; z.617; p.54) between the TBI (mean score, ) and NTBI (mean score, ) groups. Of the 183 available scores, 81.9% had GCS scores of 8 or less, reflecting severe brain injury. 40 The distribution of GCS scores is shown in figure 1. Posttraumatic amnesia (PTA) scores were available for some patients. These scores were derived from clinical information rather than such objective measures as the Galveston orientation and amnesia test. Because clinical information was used, no attempt was made to quantify the duration of PTA other than to ensure that PTA exceeded 7 days. Of the 260 available scores, 89.6% exceeded 7 days, indicating very severe brain injury. 41 Time from injury to admission. Mean time from injury to admission was days for the TBI group (n 207) and days for the NTBI group (n 136; table 1). This difference approached statistical significance (t ; p.052, 2-tail). These times from injury to admission are noticeably longer than times reported in STCR programs (eg, mean time to admission, 27 days, reported by Dahmer et al 3 ). Time from injury to admission to STCRs is an important variable with regard to outcome prediction, with longer times to admission predictive of poorer outcome Distribution of time to admission is shown in figure 2. In the present sample, only 17.6% of admissions occurred fewer than 50 days after injury. Length of stay. The overall mean LOS for both groups was days, with a longer mean LOS for the TBI group of days compared with days for the NTBI group. Differences between the groups were statistically significant (t ; p.014). The overall distribution for LOS is shown in figure 3. These mean LOSs exceed those reported for conventional STCR programs. 3,4,36,46 Type of care. The distribution of care required at admission is shown in figure 4. TBI and NTBI groups did not differ significantly in term of their level of care distribution ( 2 (6) 6.09; p.412) at admission. Of the 179 patients in the acute care group at admission, 69 (38.5%) were referred from STCR programs because they were slow to progress or otherwise were found to be unsuitable for continued admission to these types of programs. It should be noted that all patients admitted to this program were not appropriate for other community- or facility-based rehabilitation programs. Functional status at admission. Admission RDRS scores were available for 305 patients. Mean RDRS scores were and for TBI and NTBI groups, respectively (table 1). There was no significant difference between groups (Mann-Whitney U ; z.124; p.05). The distribution of scores is shown in figure 5. Approximately 85.5% of all patients were in the moderate or greater disability categories, suggesting that these patients had significant disability resulting from ABI. Admission FIM FAM motor and cognitive subset scores were available for 197 patients and are shown in table 1 and figure 6. The t tests showed that the TBI group had significantly (t ; p.008) lower mean FIM FAM motor scores at admission ( ; n 109) than did the NTBI group (mean score, ; n 88). The TBI and NTBI groups did not differ (t ; p.09) in the admission FIM FAM cognitive scores. Outcome Measures Three functional outcome measures were available at the time of discharge: discharge level of care required, discharge RDRS scores, and for a subset of patients, discharge FIM FAM scores. These data were analyzed by comparison with data obtained from the same subjects at the time of admission in a repeated-measures design. Level of care. Level of care required or received at the time of discharge was recorded for 306 patients. When compared with the levels of care required at admission, there was a significant change in the frequency distribution of care levels for both the TBI ( 2 (6) ; p.001) and NTBI ( 2 (6) ; p.001) groups, with a shift toward the less Fig1. Distribution of Glasgow coma scale scores in TBI and NTBI groups.

4 1450 LONG-TERM REHABILITATION OF SEVERE BRAIN INJURY, Gray Fig2. Time from injury to admission to long-term rehabilitation for TBI and NTBI groups. resource-intensive end of the care spectrum. Overall, 85.6% of patients were discharged to community locations, including group homes or community living with family or other support (fig 4). RDRS scores. RDRS scores (fig 5) significantly decreased from admission to discharge for both TBI (Wilcoxon s matched pairs signed rank, z 10.37; p.001) and NTBI (Wilcoxon s matched pairs signed rank, z 8.16; p.001) groups. When the mean degree of change in RDRS scores between TBI (5.01 5; n 189) and NTBI ( ; n 116) groups was compared, differences were not significant (Mann-Whitney U ; z 1.47; p.141). FIM FAM scores. FIM FAM data at admission and discharge were available for a subset of 197 patients. FIM FAM scores were analyzed separately for cognitive and motor subsets for the TBI and NTBI groups using repeated-measures ANOVA (table 1, fig 6). Motor subset scores showed a significant pre-effect and post-effect of exposure to the rehabilitation environment, with scores at discharge greater than those at admission (F 1, ; p.001). The effect of injury type (TBI vs NTBI) on motor subset scores was not significant (F 1, ; p.061), but there was a significant interaction of rehabilitation exposure and injury type (F 1, ; p.003). Cognitive subset scores showed a significant increase from admission to discharge (F 1, ; p.001). As with the motor subset scores, cognitive subset scores showed no effect of injury type (F 1, ; p.712), but there was a significant interaction of rehabilitation exposure and injury type (F 1, ; p.003). Covariance analysis. The significant interaction of rehabilitation exposure and injury type for both motor and cognitive subscales suggests that injury type may affect the degree of FIM FAM change shown over the course of admission. This suggestion is confounded because TBI and NTBI groups were found to differ significantly in both age at admission and LOS, with differences in time from injury to admission between the groups approaching significance. These variables have been shown to correlate with change in functional status in other studies When age at admission, LOS, and time from injury to admission were used as covariates in the analysis (ANCOVA), the interaction between type of injury and change in motor (F 1, ; p.111) and cognitive (F 1, ; p.178) subscale scores was not significant. For the motor subscale, the main effect of injury type was significant (F 1, ; p.034), suggesting that patients with TBI had lower motor scores than patients with NTBI at both admission and discharge. However, both groups showed significant improvement over the course of admission (F 1, ; p.001). The TBI and NTBI group did not differ in cognitive subscale scores (F 1,186.97; p.327), although both groups showed significant score increases over the course of admission (F 1, ; p.001). This analysis suggests that when confounding variables are accounted for, there is significant improvement for both TBI and NTBI subscale scores over the course of admission but no significant effect of type of injury on degree of improvement. TBI and NTBI groups did not differ in degree of cognitive Fig3. LOS in long-term rehabilitation distribution for TBI and NTBI groups.

5 LONG-TERM REHABILITATION OF SEVERE BRAIN INJURY, Gray 1451 Fig4. Level of care required (top) at admission to and (bottom) at discharge from longterm rehabilitation for TBI and NTBI groups. Levels of care are independent with social support (ind-sup), independent with minor assistance (ind-asst), semi-independent (semi-ind), home with fulltime supervision (sup-home), continuingcare facility at nursinghome level (LTC-NH), continuingcare facility at auxiliary hospital level (LTC-AUX), or acute care level facility (Acute). subscale impairment, but the TBI group had significantly lower motor subscale scores at admission and discharge. Regression analysis. Because age, LOS, and time from injury to admission appeared to be related to outcome, further regression analysis was performed using motor and cognitive subscale FIM FAM change scores as the dependent variable and initial subscale score, age at admission, time from injury to admission, and LOS as independent variables. These variables have been shown to correlate with change in functional status A summary correlation matrix is shown in table 2. All subscale change scores significantly and negatively correlated with the total subscale score at the time of admission, suggesting that lower functioning patients showed greater improvement in functional status over the course of admission. Age at admission significantly and negatively correlated with outcome in only the TBI group; whereas LOS significantly and positively correlated in only the NTBI group. Time from injury to admission was a significant negative correlate for all but the NTBI cognitive subscale scores. These findings suggest that (1) the higher functioning a patient with TBI or NTBI is at admission, (2) the older a patient with TBI is at admission, or (3) the longer the time

6 1452 LONG-TERM REHABILITATION OF SEVERE BRAIN INJURY, Gray Fig5. RDRS scores (top) at admission and (bottom) discharge for TBI and NTBI groups. from injury to admission for patients with TBI or NTBI, the smaller the overall change in functional status from admission to discharge. LOS correlated positively with the amount of functional change seen in the NTBI group but not in the TBI group. When these variables were entered into the regression equation in a stepwise fashion, LOS was excluded from the regression equation for all outcome measures because it failed to meet the criterion (F probability.10) for inclusion in the model. Patterns of FIM FAM change. To explore the pattern of functional change over the course of long rehabilitation admissions, an additional subset of 94 patients who had a minimum of 5 serial FIM FAM assessments completed over the course of admission were examined in more detail. As noted, serial FIM FAM assessments were completed approximately every 3 months after admission. Of these 94 patients, 28 had 5 FIM FAM scores (mean age at admission, 42.14yr), 27 had 6 (mean age, 39.5yr), 19 had 7 (mean age, 37.1yr), 12 had 8 (mean age, 35yr), 4 had 9 (mean age, 28.25yr), none had 10, 3 had 11 (mean age, 30.6yr), and 1 had 12 (age, 25yr). There were 55 patients with TBI (59%) and 39 patients with NTBI (41%) overall, with a mean time from injury to first FIM FAM assessment of 8.05 months and a mean age at admission of 33.9 years.

7 LONG-TERM REHABILITATION OF SEVERE BRAIN INJURY, Gray 1453 Fig6. FIM FAM (top) motor and (bottom) cognitive subscale scores at admission and discharge for TBI and NTBI groups. As with the overall FIM FAM data, this subset of patients showed a significant increase in both motor (t ; p.001) and cognitive scores (t ; p.001) from admission to discharge. The mean FIM FAM subscale change score was for the motor subscale and for the cognitive subscale. Plotting the percentage of Fig7. Percentage of total FIM FAM (top) motor and (bottom) cognitive change score achieved on serial FIM FAM assessments over the course of admission for groups with different numbers of total FIM FAM assessments. motor and cognitive score change as a function of serial FAM assessments for each group (fig 7) shows correspondence between the number of FAM assessments (and hence approximate length of admission) and the speed with which Table 2: Summary Correlation Matrix for TBI and NTBI Group FIM FAM Subscale Change Scores Subscale Total Score at Admission Days From Injury to Admission Age at Admission (yr) LOS (d) TBI (n 106) FIM FAM motor score change (p.001)* (p.002)* (p.023)* (p.083) FIM FAM cognitive score change (p.001)* (p.017)* (p.003)* (p.389) NTBI (n 85) FIM FAM motor score change (p.001)* (p.030)* (p.192) (p.001)* FIM FAM cognitive score change (p.001)* (p.081) (p.233) (p.020)* * p.05.

8 1454 LONG-TERM REHABILITATION OF SEVERE BRAIN INJURY, Gray FIM FAM subscale improvement was attained. Longer admissions correlated with a smaller percentage of FIM FAM gain at given times in the course of admission (at the fifth FIM FAM, r.437; p.001 for motor scores; r.213; p.042, for cognitive scores). This change in FIM FAM scores over the course of admission was not linear, and all groups had achieved at least 70% of their motor and cognitive score change by approximately the fifth serial assessment except the group that had 11 serial FIM FAM assessments. That group showed 56.9% total motor score change by the fifth FIM FAM (but 92.5% cognitive score change). The amount of FIM FAM change seen in the groups with higher numbers of serial FIM FAM assessments (therefore longer admissions) appears to diminish with increasing number of assessments, suggesting that greatly prolonged admissions ( 12mo) added little to the expected overall change in FIM FAM motor or cognitive scores. Patients with admission duration exceeding approximately 1 year (number of FAM 6) showed only a mean 21.2% gain in motor scores and a mean 12.9% gain in cognitive scores over the remaining course of their admissions. DISCUSSION The patients admitted to the long-term rehabilitation program described here had generally sustained severe brain injury, mostly traumatic, and were an average of days postinjury at admission. A range of disability measured by standard functional assessment tools (RDRS, FIM FAM) was shown, but the majority of patients showed significant motor or cognitive disability at admission. The mean LOS in the program was days. The age range and sex distribution are similar to data described for STCR programs. 3,4,46 It should be noted that the present long-term rehabilitation population was composed of survivors of severe brain injury who were unsuited for admission to or continued stay in other programs because they were slow to recover or had rehabilitation needs that could not be addressed by other community or facilitybased programs. Thus, we believe that this population is somewhat unique in the spectrum of brain injury rehabilitation services and fits within the poorly described slow-stream, slowto-recover, or long-term rehabilitation service. 2,6,7,21-23 Analysis of functional outcome data indicates significant improvement over the course of admission for both TBI and NTBI groups on both the RDRS and FIM FAM measures. In addition, the level of care deemed necessary at discharge changed significantly; 85.6% of patients were discharged to community living situations defined as group homes, family homes, or independent living situations. A number of variables appeared to correlate significantly with the degree of change in functional status measured by the change in motor and cognitive FIM FAM subscale scores. These variables included functional status at admission, age at admission, and length of time from admission to injury. The correlation of poorer initial functional status with greater apparent improvement may superficially appear somewhat counterintuitive. One explanation may be that the functional assessment tools used were not overly sensitive to some of the disabilities and handicapping conditions that initially precipitated program admission. For example, behavior dysfunction may be a profoundly impairing disability with respect to community reintegration, but this area of function is represented by only small components of the RDRS or FIM FAM and thus may contribute relatively little to the overall score. Another possible explanation may concern the nature of the FIM FAM itself. The FIM FAM is a 30-item scale that uses a 7-point ordinal rating scale to assess performance on each item. 52,53 By design, the scale has an inherent ceiling effect. 52 Patients who have higher scores at admission have little room to improve their scores because of this ceiling effect. The use of total scores in this fashion on these types of rating scales has been criticized because the psychometric properties of the items and their essentially ordinal scaling suggest nonlinearity and noninterval properties. Use of data transformation has been advocated for these reasons We caution readers that these properties of ordinal level data may also violate the assumptions on which parametric statistics are based. The parametric statistics we used, such as t tests, ANOVA, ANCOVA, and regression analyses, should be interpreted cautiously and with regard for this possible confound. Other significant correlates of functional change were age at admission and time from injury to admission, at least for the TBI group. These correlations suggest that the older one is at admission and the further in time one is from TBI, the smaller the change in functional status seen over the course of admission. These data are consistent with previous studies showing older age and greater time to admission as correlates of poorer functional outcome in more typical STCR settings. 42,43,45,47,48,50,57,58 Although type of injury did not appear to be a significant factor overall, patient age at admission was significantly greater in the NTBI group, likely reflecting a greater risk for stroke, aneurysmal rupture, and other NTBI causes in the older population. The correlation of greater time to admission with smaller changes in functional outcome may reflect such variables as a time-related decrease in spontaneous recovery, or problems that precipitated admission to the program at greater times postinjury were types that although significantly handicapping, were not well assessed by the outcome measures used. This potential failure of standardized and widely used outcome assessment tools 59 to detect change raises the issue of measuring what matters in rehabilitation 60,61 and refocuses interest on such techniques as goal-attainment scaling. 62,63 This problem is not unique to rehabilitation and has been the focus of much attention in other fields, such as mental health. 64 That 69 of the 349 patients (19.8%) were referred from STCR programs highlights the differences in patients in their pre long-term rehabilitation exposure experience. It is possible that at least some of the patients with longer times to admission had significant rehabilitation experience and had thus maximized functional gain measured by the assessment scales used. The type and duration of preadmission experience and how this may affect both reasons for referral to long-term rehabilitation and outcomes of longer term rehabilitation were not a focus of the present preliminary outcomes study but certainly deserve further analysis. The lack of a control group in this study raises the obvious question of whether change over the course of admission was a function of exposure to rehabilitation or a matter of spontaneous recovery over time. This is a difficult question and one that has plagued rehabilitation research because of problems establishing appropriate control populations. Despite the use of the designation slow-to-recover, it is not completely clear whether the present population is a distinct population or an artifact of the existence of a specific program in this particular geographic area. The outcomes of patients with similar injuries in other jurisdictions is not known, but it is likely that many are not admitted to specific rehabilitation programs and are discharged to nursing homes or other care facilities. 12 If this is the case, this group may serve as a control group by which to evaluate the effectiveness of long-term rehabilitation programs. Multicenter studies then may be a solution to this need for comparison populations.

9 LONG-TERM REHABILITATION OF SEVERE BRAIN INJURY, Gray 1455 In our study, LOS, a variable that may reflect the amount of exposure to the rehabilitation environment and hence indirectly an effect of rehabilitation, contributed relatively little in a regression equation predicting outcome measured by FIM FAM motor and cognitive subscale change scores over the course of admission. This suggests that some patients with marked improvements had relatively short stays, whereas others with the same degree of improvement had longer stays. It is difficult to interpret this finding because it may reflect the relative insensitivity of the outcome measures, as discussed previously, or that LOS can be affected by many other variables in a publicly funded system, such as the availability of suitable discharge locations. It is possible in this population that the patients who showed relatively little improvement remained the most disabled and hence may have had more limited suitable discharge options that required more time to find before discharge. The effect of the rehabilitation environment remains an open question. 1,51 In the more recent literature, some support for the use of rehabilitation in severe brain injury is provided in an elegant case-control study by Willer et al. 25 In that study, patients with severe brain injury admitted to a community residential program with a mean LOS of 8 months were compared with a matched control group that received home-based rehabilitation. Comparisons using the Health and Activity Limitations Survey showed significantly greater benefit of specific residential services versus home-based rehabilitation. A similar study in Britain 26 recently showed that comprehensive multidisciplinary rehabilitation appeared to be more effective than other community-based rehabilitation. Thus, these 2 studies support the contention that organized comprehensive rehabilitation is at the very least additive to the process of natural recovery. The pattern of change in FIM FAM scores shown in figure 7 suggests different rates of improvement in different subgroups of this population, with patients who stayed longer improving less rapidly than those with a shorter stay. Of interest, regardless of the overall LOS, the rate of FAM change slows over the course of admission, with relatively little change shown in the latter phases of admission. In the very prolonged stay groups (number of FIM FAM 5), only a small remaining percentage of change was shown over an additional period of up to 6 serial assessments (corresponding with up to 18mo additional stay). Overall, these patterns of percentage of change over the course of admission suggest that although extended periods of rehabilitation may benefit this population, extending these periods much beyond 12 months adds little to the functional change measured by the FIM FAM. This interpretation must be viewed cautiously because group sizes are small and unequal and the amount of FAM change varied considerably between groups. The previous caveat of whether the FIM FAM adequately measures the primary disability experienced by these patients also applies in this situation. CONCLUSION This study reviewed data from a long-term rehabilitation program for patients with severe brain injury who were in the general category of slow to recover, slow-stream, or otherwise not appropriate for admission to other types of brain injury rehabilitation programs. 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