1103
Functional Outcome After Rehabilitation for Severe
Traumatic Brain Injury
James A. Whitlock, Jr., MD, Byron B. Hamilton, MD, PhD
ABSTRACT. Whitlock JA Jr, Hamilton BB. Functional out-
come after rehabilitation for severe traumatic brain injury. Arch
Phys Med Rehabil 1995;76:1103-12.
Objective: (1) Define functional status at rehabilitation dis-
charge and follow-up for patients admitted with Functional In-
dependence Measure (FIM) of 18 after traumatic brain injury;
(2) describe patterns of function measured at discharge, rehabili-
tation lengths of stay and costs, and disposition.
Design: Retrospective, descriptive study using data from the
Uniform Data System for Medical Rehabilitation (UDSMR) da-
taset.
Setting: Acute rehabilitation hospitals and, for follow-up
data, variety of settings, from community to long-term care.
Patients: 328 patients with rehabilitation admission FIM of
18 (principal impairment group "Brain Dysfunction, Trau-
matic") drawn from 5,430 TBI patients entered into the data
set during 1989-1991. Excluded were 22 persons readmitted to
rehab, 5 deaths, I case without recorded disposition, and 49
cases without ICD-9 code consistent with brain trauma.
Main Outcome Measures: FIM scores at rehab discharge
and follow-up; disposition; length of stay; cost. Results: (1)
Mean FIM score at discharge for the group overall (n = 328)
was 53 (median = 42 with interquartile range of 18 to 87); (2)
7.6% had functional scores consistent with independence in
motor areas measured by FIM; (3) 2.7% had functional scores
consistent with independence in cognitive areas measured by
FIM; (4) 26.1% showed no change in FIM score between admis-
sion and discharge; (5) 53% were discharged to community
settings, 25% to long-term care, 11% to acute facilities, and
11% to other rehab facilities; (6) average length of stay in acute
rehab was 110 days (SD = 70.9, median = 99 days, interquartile
range = 57 to 153 days); (7) average rehabilitation charges (n
= 322) were $110,891; (8) for those with follow-up data (n =
59), average FIM score was 79 (median, 90); 24% were in
school and 5% worked in sheltered workshops.
Conclusions: (1) Even the most severely disabled persons
admitted to acute rehabilitation after traumatic brain injury can
show a large degree of measurable functional improvement; (2)
while about 25% of patients showed no measured FIM change,
some showed dramatic degrees of functional recovery; (3) most
common discharge setting was home (and community).
© 1995 by the American Congress of Rehabilitation Medicine
and the American Academy of Physical Medicine and Rehabili-
tation
From the Northeast Rehabilitation Hospital, Salem, NH (Dr. Whitlock) and the
State University of New York-Buffalo (Dr. Hamilton).
Submitted for publication January 30, 1995. Accepted in revised form June 12,
1995.
Supported by a grant from National Medical Enterprises.
Dr. Hamilton is now associated with the Department of Veterans Affairs Medi-
eal Center, Durham, NC.
No commercial party having a direct or indirect interest in the subject matter
of this article has or will confer a benefit upon the authors or upon any organization
with which the authors are associated.
Reprint requests to James Whitlock, Jr., MD, Northeast Rehabilitation Hospital,
70 Butler Street, Salem, NH 03079.
© 1995 by the American Congress of Rehabilitation Medicine and the American
Academy of Physical Medicine and Rehabilitation
0003-9993/95/7612-339053.00/0
N RECENT YEARS the functional outcomes of persons un-
I dergoing formal rehabilitation after severe brain injury have
been the subject of several studies ~-8 that generally examined
samples of patients with widely varying degrees of initial im-
pairment. A few studies were restricted to the most profoundly
affected--persons who remain noninteractive weeks to months
after the initial i n j u r y . 9-L2 Although each study described patients
who made little on no functional progress over ensuing months,
it is apparent that some survivors of apparently very severe
traumatic brain injury (TBI) can exhibit much more recovery
than earlier studies have suggested. 13'~4 Variables that might
allow early prediction of which survivors have a chance at
meaningful recovery have been elusive. 12'~5 Even less under-
stood are variables or interventions that influence recovery
weeks to months after the injury, during the rehabilitative pe-
riodJ 6 The present study examined a minority of the traumati-
cally brain-injured population, the most severely impaired pa-
tients who are admitted to hospital-level rehabilitation
programs. These completely dependent patients were dis-
charged from centers across the United States during a 3-year
period.
A retrospective descriptive analysis of this sub-population of
brain-injured persons was undertaken to summarize salient
group characteristics and functional changes recorded during
rehabilitation. Information about further functional change at
follow-up after discharge from the rehabilitation facility is pre-
sented on a subset of these patients. Specifically, the following
questions are addressed:
1. Were there any distinguishing demographic features of
this population sample compared with published epidemi-
ological data regarding traumatic brain injury?
2. What was the functional status of this patient sample at
discharge from acute rehabilitation? Where did these peo-
ple go after acute rehabilitation?
3. How long did these persons undergo acute rehabilitation?
At what cost?
4. What was the relationship between functional change and
time since injury in the people with admission functional
indices placing them at the bottom of the functional mea-
surement scale used in this study?
5. What patterns of functional scores at rehabilitation dis-
charge were observed in groups discharged to community?
To acute care? To long-term care? To other rehabilitation
services?
6. Were the levels of functional recovery observed main-
tained, surpassed, or lost as assessed in a sub-sample for
which follow-up information is available? How many indi-
viduals experienced a change in living setting or voca-
tional status during the follow-up interval?
METHODS
The Center for Functional Assessment Research at the State
University of New York (SUNY) at Buffalo has been collecting
and reporting data on rehabilitation patients under the Uniform
Data System for Medical Rehabilitation (UDSMR) since 1987.~7
Currently, more than 500 comprehensive rehabilitation facilities
in the US voluntarily use this service. The data set includes
Arch Phys Med Rehabil Vol 76, December 1995
1104 OUTCOME AFTER REHABILITATION FOR SEVERE TBI, Whitlock
Table 1: Functional Independence Measure: Item Levels
and Functional Categories
FIM Levels
No Helper
7 Complete independence (timely, safely)
6 Modified independence (device)
Helper
Modified dependence
5 Supervision
4 Minimal assist (subject = 75%+)
3 Moderate assist (subject = 50%+)
Complete dependence
2 Maximal assist (subject = 25%+)
1 Total assist (subject = 0%+)
Functional Categories
Self care
A. Eating
B. Grooming
C. Bathing
D. Dressing, upper body
E. Dressing, lower body
F. Toileting
Sphincter control
G. Bladder management
H. Bowel management
Transfers
I. Bed, chair, wheelchair transfers
J. Toilet transfers
K. Tub, shower transfers
Locomotion
L. Walk/wheelchair
M. Stairs
Communication
N. Comprehension
O. Expression
Social cognition
P. Social interaction
Q. Problem solving
R. Memory
From Research Foundation, State University of New York at Buffalo. 4°
measures of functional state (admission, discharge, and follow-
up), as well as demographic, diagnostic, impairment group,
length of stay, charges, discharge disposition, vocational, and
follow-up information on each patient admitted to these pro-
grams. The centerpiece of this data set is its functional assess-
ment instrument, the Functional Independence Measure (FIM)
scale (table 1). It assesses self-care, bowel and bladder control,
transfers, locomotion, communication, cognition, and social in-
teraction using 18 items of function, each rated on a seven-
point scale. The lowest possible total FIM score is 18. The
highest is 126. A score of 1 on any item corresponds with
complete dependency; a score of 7 represents complete indepen-
dence without the need for assistive technology or environmen-
tal adaptation.
Key staff persons responsible for functional assessment of
patients at participating hospitals receive training that focuses
on use of the FIM scale through a written guide, attendance at
a workshop, or instruction via videotape. For data to be admitted
to the central database at SUNY-Buffalo, each clinician submit-
ting data from a participating facility must periodically pass an
interrater reliability assessment.
The FIM is an ordinal rating scale, the interrater rehability
of which has been shown to be between .86 and .97. ~8.~9Formal
study has shown it to have high internal consistency and ade-
quate discriminative capabilities for brain-injured rehabilitation
patients. It is responsive to functional change over time and
provides a good indication of burden of care. 2°
The problems posed by the multidimensionality and ordinal
level of measurement represented by rating scales like the FIM2~
have been addressed by application of Rasch analysisY'23 The
Rasch model specifies that the probability that a person will be
Arch Phys Med Rehabil Vol 76, December 1995
rated as independent on an item depends upon both the difficulty
of the task and the functional ability of the person. Analysis of
FIM scores using a Rasch model was conducted on more than
27,000 records from rehabilitation inpatients, including 2,427
with traumatic and nontraumatic (nonstroke) brain dysfunc-
tion.24 The results suggest a strong grouping of separate "mo-
tor" and "cognitive" FIM measures and provide a table for
conversion of FIM motor and cognitive subscores to measures
that lie on an interval scale with common units. This transforma-
tion was performed on the FIM scores in this study to provide
data in a form that can be used for statistical comparisons with
other patient samples and to facilitate statistical analysis of
relationships between FIM and other outcome measures.
Our study examined a subset of data on 328 patients with a
principal impairment group of "traumatic brain injury" who
had a rehabilitation admission FIM score of 18. Only persons
with a principal or associated ICD-925 coded diagnosis consis-
tent with traumatic injury to brain were included (table 2). The
study sample represented patients experiencing their first admis-
sion to one of 66 acute rehabilitation facilities (55 free-standing
and 11 hospital rehabilitation units) and who were discharged
from acute rehabilitation between January 1989 and December
1991. The subset studied was drawn from 5,340 cases of TBI
entered during this period into the UDS database (unpublished
UDS data).
The study sample excluded 22 readmissions to rehabilitation,
5 patients who died, and 1 case without a recorded disposition.
Of the remaining sample, an additional 49 cases were excluded
when no accepted ICD-9 code was listed.
The complete UDSMR data set includes patient and facility
identifier information to which the principal investigator was
blinded. Each record was assigned a unique random number
identifier before off-loading from the UDSMR data base. Rec-
ords were transferred to a file in which initial analysis was
performed using Paradox 3.5.26 Subsequent analysis and statisti-
cal procedures were performed using Quattro Pro (versions 4.0
and 5.0) 27 and STATA.28
Basic descriptive statistical methods were used to profile data.
FIM items are separately sensitive to motor and cognitive as-
pects of disability.29 Discharge F1M scores were therefore sepa-
rated into "motor" and "cognitive" domains. Rasch transfor-
mations of FIM motor and cognitive scores were performed
using conversion factors for a "brain injury" impairment
group. 24 One-tailed Student's t tests for unpaired samples with
Table 2: ICD-9-CM Codes Accepted
Code n Definition
310.2 49 Postconcussion syndrome, includes: postcontusion
syndrome or encephalopathy; posttraumatic brain
syndrome, nonpsychotic; Status post commotio
cerebri.
800-801 30 Closed fracture of vault or base of skull; open
fracture of vault or base of skull; with or without
mention of intracranial injury; includes associated
forms of hemorrhage, laceration, and contusion.
803.0-9 18 Other and unqualified skull fractures.
850.4 0 Concussion with prolonged loss of consciousness.
850,5 0 Concussion with loss of consciousness of
unspecified duration.
850.9 0 Concussion, unspecified.
851.0-9 35 Cerebral laceration and contusion.
852.0-5 44 Subarachnoid, subdural, and extradural hemorrhage
following injury.
853.0-1 35 Other and unspecified intracranial hemorrhage
following injury.
854.0-1 124 Intracranial injury of other and unspecified nature.
907.0 61 Late effect of intracranial injury without mention of
skull fracture
n = Number of individuals with principal or associated diagnoses.
 OUTCOME AFTER REHABILITATION FOR SEVERE TBI, Whitlock 1105

Table 3: Patient Characteristics at Rehabilitation Admission

70 ~ 68
n %
Gender
Male 228 69.5
Female 100 30.5 ~S0
Race ¢
White 289 88.1 ~,0
Other 39 11.9 ¢e

Language 30
English Speaking 322 98.2
Non-English Speaking 6 1.8
Marital Status
Single 199 60.7
10
Married 94 28.7
Widowed 5 1.5
Separated 2 0.6 6-9 16-19 26-29 36-39 4649 55-59 65-69 >76
Divorced 27 8.2 10-14 20-24 30-34 40-44 60-54 60-64 70-74
Age in Years
Living Arrangement
Lived home before injury 316 96.3
Lived elsewhere 12 3.7 Fig 1. Age distribution; total n represented at top of each bar (B, no
Vocational Status improvement; [], improved).
Employed (before injury) 164 50.0
Student 83 25.3
Homemaker 9 2.7
Not working 39 11.9
an acute hospital unit in another hospital means that the majority
Retired (due to age) 22 6.7 of the study population was experiencing rehabilitation in an
Retired (due to disability) 8 2.4 acute, free-standing rehabilitation hospital (rather than a rehabil-
Sheltered employment 2 0.6 itation unit within an general acute hospital). Eight persons
(2.4%) were admitted from home. Only 10 (3%) were admitted
from a chronic hospital or nursing home setting (table 4).
unequal variances were used post hoc to assess the significance
of differences in mean age, days to admission, and length of
stay between the group of patients who progressed and those Functional Changes During Rehabilitation--Entire
who did not. An c~ of .01 was used for these analyses. Compari- Sample
sons of age, days between injury and admission, and rehabilita- The study sample showed a wide range in functional level
tion length of stay for each discharge setting, using "improved" at discharge (fig 2A). A bimodal distribution of FLM scores
(FLM at discharge greater than 18) and "unimproved" as group- was observed, with just over 25% of patients being discharged
ing variables were performed using one-way analysis of vari- without having demonstrated measurable functional change.
ance (ANOVA). The relation between cognitive and motor Rasch transformation of discharge FIM scores shows a spectrum
Rasch-transformed measures was explored using multiple re- of functional gain distributed almost normally in patients who
gression. progressed during rehabilitation (fig 2B). Mean discharge FIM
When initial analysis found a strongly bimodal distribution was 53 for the entire group. Median discharge FIM was 42 with
of discharge functional scores, further analyses were done after a range from 18 to 126 (interquartile range, 18 to 87). Median
separating the sample into patients who showed measurable discharge FIM motor score was 29 (interquartile range, 13 to
FIM gain and those whose FIM score at discharge remained 72), whereas median FIM cognitive score was 12 (interquartile
18. A higher discharge FIM score (eg, 27) would have removed range, 5 to 32). For Rasch-transformed measures, median motor
the bimodality, but it also would have relied on the assumption measure was 35 (interquartile range, 0 to 60), with that for
that " l o w " F1M gains are the same as " n o " FIM gains, an cognitive measure also 35 (interquartile range, 0 to 77). Inde-
assumption we declined to make. pendence in all motor FIM components was attained by dis-
RESULTS charge in 25 (7.6%), with only 9 (2.7%) achieving independence
in all cognitive areas. Two individuals (0.6%) were independent
Patient Characteristics (scores 6 or 7) in all 18 of the FIM functional items.
Demographic features of this group are presented in table 3.
The ratio of males to females was 2.3:1. Seven percent of this Functional Changes During Rehabilitation--Patients Who
study population was black, with a total of 12% being nonwhite. Made Gains
Almost all were English-speaking and almost two thirds were
single. Ninety-six percent lived at home before their injury and The frequency distribution of patients who made functional
87% lived with another person. Most were either employed gains (FIM score greater than 18 at discharge) is depicted in
(50%) or students (25%), with 14% being either unemployed figure 2C. Separate examination of this group found a mean
or retired because of disability. discharge FIM score of 65 (SEM = 2.1), with motor scores
The age distribution showed a prominent peak in the 15 to averaging 48 (SEM = 1.7) and cognitive scores 16.8 (SEM =
25 year range (fig 1). The mean age of patients in this study 0.5). The mean Rasch transformed motor measure for those
was 31 (SEM = .91; median 26) with a range of 6 to 87.
Twenty-three individuals (7%) were age 15 years or less. Table 4: Location Prior to Acute Rehabilitation Admission
Almost all of the patients were coded as having "Closed
Traumatic Brain Injury." Ten (6.1%) were coded with "Open Admitted From n %
Injury." Acute hospital unit in another hospital 277 84.5
Acute unit of same facility 28 8,5
Settings From Which Patients Were Admitted Home 8 2.4
Ninety-three percent of patients were admitted to rehabilita- Long-term care facility 10 3.0
Other 5 1.5
tion from an acute care setting. The fact that 84.5% came from

Arch Phys Med Rehabil Vo176, December 1995

 1106 OUTCOME AFTER REHABILITATION FOR SEVERE TBI, Whitlock

FIM gains in bowel and bladder lag in patients at the bottom

quartiles, and that independence with negotiation of stairs re-
mains the most difficult item, even in those nearly independent
in all other areas. Progress is proportionately greater in motor
compared with cognitive FIM item levels in the upper two
quartiles. Among the cognitive domain items, "comprehen-
sion" levels are consistently higher than other cognitive items
g
in all quartiles. Gains in FIM scores related to communication
o¢ 15.
v appear to be greater than those related to memory and problem
solving. The levels of function attained by those in the bottom
quartile depict generally profound persisting disability.
The distributions of cognitive and motor domain gains ap-
peared to show a similar pattern. In an effort to further explore
their relationship and to discover how many individuals showed
marked difference between cognitive and motor gains, Rasch-
transformed motor measures were plotted against cognitive
measures for all patients who had shown any improvement (fig
A FIM Score at Rehab Discharge 4). A correlation between motor and cognitive measures was
found, with very few individuals showing dramatic cognitive
25
or motor gains in the absence of progress in the other domain
(Multiple R = .692, R 2 = .48, p < .05).
The relationship between age and Rasch motor and cognitive
20
measures is depicted in figure 5. Although the highest average
motor and cognitive gains were achieved in the group between 10
and 19 years of age, a scatterplot of age versus Rasch motor and
cognitive measures failed to suggest a relationship between age
c
and degree of fimctional gain. However, analysis of differences in
mean age showed that those who progressed were significandy
10
younger than those who did not (mean 30 - SEM = 1.0 versus
35 - SEM = 2.0 years; t = -2.1, df = 126, p < .018).
Disposition at Discharge
More than two thirds of those who improved went home after
acute rehabilitation. As a group, these individuals were the least
0
O 1-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 91-100 disabled, among the youngest, were admitted the earliest, and
B Rasch-transformed DischargeFIM stayed in rehabilitation the longest (tables 5 and 6). Not surpris-
ingly, those who were discharged to long-term care or acute
facilities showed the greatest degree of persisting disability (fig
6). Approximately 8% of the overall group was discharged to
home in a state of profound dependency (FIM < 30). Although
these individuals might be expected to have been among the
youngest of the entire sample, their average age was 27 years
(range, 11 to 63).
Differences in disposition by age, days to rehabilitation ad-
mission, and rehabilitation length of stay for those who pro-
gressed versus those who did not are highlighted in table 6.
o.
Analysis of age by discharge settings of patients who improved
and those who did not improve failed to show significant differ-
ences. The features that most distinguished patients who im-
proved from those who did not included a much higher percent-
age of discharge to community, significandy shorter time to
rehabilitation admission in the groups who went home or to
long-term care, and significantly longer rehabilitation stays for
FIM Scores at Rehab Discharge those who progressed, regardless of disposition. The shortest
lengths of stay were associated with discharge to acute facilities
Fig 2. (A} Discharge raw t o t a l FIM scores, entire sample. (B) Distribution for both groups. Overall, patients without gains were admitted
of Rasch-transformed functional measures at discharge (patients with
on average almost three weeks later and stayed in acute rehabili-
discharge FIM scores greater than or equal to 19; n = 245). (C) Frequency
distribution of raw cognitive and motor FIM scores at discharge for those tation for about half as long.
who improved; range of scores represented by each bar listed at top ([],
raw motor scores; D, raw cognitive score). Days to Admission and Inpatient Acute Rehabilitation
Length of Stay
who improved was 44.5 (SEM = 1.5) with cognitive measures The average time between injury and rehabilitation admission
averaging 42.0 (SEM = 1.3). was 55 days for the entire sample (median, 41 days), with a
Categorical levels of FIM item function by quartile for pa- wide variation (4 to 307 days). Only 32 (10%) in the present
tients who made gains during rehabilitation are depicted in fig- study were admitted less than three weeks after injury. Examina-
ttre 3. The patterns of motor domain achievement suggest that tion of the differences in days to admission for those with and

Arch Phys Med Rehabii Vol 76, December 1995

 OUTCOME AFTER REHABILITATION FOR SEVERE TBI, Whitlock 1107

o
..I

-~4
Lt.
¢-

O
=E

Fig 3. Mean FIM item levels at

discharge (by quartile) for pa- 2
tients who improved. Cognitive
items are grouped on the right.
Order on X axis corresponds to
highest to lowest means for
each item by motor and by cog- 1
I I I I I
nitive domains. II, Bottom Feeding Dressing-upper Bowel ToiletTransfer Locomotion Tthleting Stairs Comprehension SocialInteraction ProblemSolving
quartile; @, 3rd quartile; A, 2nd Grooming Bed Transfer Bladder Dressing-lower Tub Transfer Bathing Expression Memory
quartile; A, top quartile. Functional Item at Discharge

without gains showed a much shorter interval between injury Acute Rehabilitation Charges
and admission for those who progressed (mean = 50 days, SEM Recorded charges reflect reported billings in over 90% of
= 2.4, vs. mean = 70 days, SEM = 5.8, respectively; t = patients for hospital services provided during rehabilitation stay
-3.28, df = 110, p < .001). (physician fees were not included and there were no adjustments
Length of stay differences were also striking between the
made for inflation). For those with documented charge data (n
subgroups. Mean length of stay was 124 days (SEM = 4.4) for
= 322), this figure averaged $110,891 or roughly $1,000 per
those who improved compared with 67 days (SEM = 6.1) for
day. The highest average daily charges ($1,277) were recorded
the others (t = 7.54, df = 175, p < .001). Average length of
for those whose discharge FIM was less than or equal to 19 (ie,
stay for the entire group was 110 days (SEM = 3.9). Regression
people who exhibited little or no functional change). The lowest
of days to rehabilitation admission against rehabilitation length
average daily charge ($965) was observed in those whose dis-
of stay failed to show a relationship (R 2 = .019, p < .015) in
the overall sample. charge FIM was greater than or equal to 108 (a level associated
Although the subgroup of individuals without FIM gains did with functional independence). Those with discharge FIMs be-
not experience a greater frequency of interruption in rehabilitation tween 30 and 108 averaged charges of $974 per day. Commer-
due to acute transfer (18.1% versus 18.8% of those who improved), cial sources were the largest proportion of payers, although
the average duration of their interruption was 5 days longer (13.5 public funding accounted for just about one third.
days versus 8.5 days) and the overall percentage of rehabilitation
days "lost" to acute transfer was higher (4.0% versus 1.5%). Functional Status at F o l l o w - U p
Of the 328 patients with admission FIM of 18, follow-up
100
data were available for only 59 (18%). These data had been
obtained by phone (73%) or in person (24%) with family (44%)
or from someone other than the patient (39%) providing the
8O
information. Data were recorded at an average interval of 252
days after injury (SEM = 12.3; median, 242) and an average of
• ,. "-. ; - . ~ 99 days (SEM = 5.8; median, 98 after rehabilitation discharge.
4)
s; 60 • .. =. ..
". : : ~ " • =
Ongoing functional progress was almost universal in tiffs sub-
°
• • sample. Only five patients had lower scores (loss of between 1
.~...,~ ."
." ..
: • . • ~ and 8 points). Average total FIM score at follow-up was 79
• i
(median 90) for a group that had an average rehabilitation dis-
° $ •.
charge FIM score of 66 (median 75).
20 Mean levels of independence achieved is depicted in figure 7
(with data restricted to those who had improved at rehabilitation
discharge). The small sample number and the biases that tend
to be associated with follow-up data collection preclude general-
0 10 20 30 40 50 60 70 80 90 100
Rasch Cognitive Measure ization from tiffs data, but it is encouraging to note the consis-
tency of ongoing gains in all functional areas. The upper quartile
Fig 4. Scattergraph showing correlation between Rasch-transformed FIM of the follow-up group had mean scores in the "independent"
motor and cognitive measures (Ra = ,48, p < .05). range for all items.

Arch Phys Med RehabU Vol 76, December 1995

1108 OUTCOME AFTER REHABILITATION FOR SEVERE TBI, Whitlock

35

2.J [ .omo,Comm0n,
] re I
2, n:161

1 14

0
l l J I
19-27 ~ql-36 37.,~ 4&M $6-83 114-72 73-8t ~ 01-N 100-101 tGG.tt7 ttlkt28 t¢-27 2146 17"46 44.M 84-72 7341 12-00 RI.WI t0&fal 1W-117 t t l k l ~
FIM Scoreat Discharge FIM So:oreat Discharge

28-
Acute Facility ] J Other Rehab

n=24
~ 21 -
n=12

7-

i i i
10-27 211-~ 37-46 4e.54 f6413 1~'/2 1~411 112410 01-0g 100-tM 108-tll I10-1:~ tg.T/ ~ ~46 4e44 ~ II,t*72 73111 ~ |t-Ill l~lm 100"117 111klN
FIM Scoreat Discharge FIM Score at Discharge

Fig 5. Distribution of discharge total r a w FIM scores by disposition (patients with functional gains).

Changes in living situation were characterized by an increase follow-up FIM score of 45 (range, 21 to 93) at an average
in percentage living in the community, from 54% at rehabilita- follow up interval of 120 days after discharge. This small group
tion discharge to 64% at follow-up. At the time of follow-up, was distinctive in that their average rehabilitation length of stay
fewer were in long-term care (20%, versus 25% at discharge). had been only 38 days. Of the seven, 3 had gone to skilled
None of the patients in this group were gainfully employed, nursing facilities, 2 to acute facilities, and 1 each to home and
but 24% had returned to school, the majority of those on a full- to another rehabilitation setting. At follow-up, 4 were receiving
time basis. Three (5%) were working in sheltered workshops. rehabilitation as inpatients, 2 were home, and only 1 was still
Twenty-two percent were retired because of disability, with an in a skilled nursing facility.
additional 10% retired due to age. Only 10 persons (17%) were
not receiving any ongoing therapy. F I M Score and Time Since Injury
Of the 59 persons for whom follow-up data were available, The interval between injury and functional assessment at dis-
11 had been discharged from rehabilitation with FIM of 18 charge for the entire sample (n = 328) was an average of 165
(or "unchanged"). Five of them had gone to skilled nursing days (SEM = 4.3; median, 155 days). The mean interval be-
facilities; one each had gone home, acute unit of same and other tween injury and discharge for the group that improved was
facility, another rehabilitation facility, and to a chronic hospital. slightly longer at 174 days (SEM = 4.9; median 165). The
Of these 11, seven individuals had progressed to an average variability in functional level with respect to time since injury

Table 5: Discharge FIM Scores and Measures: Patients With Functional Gains
Discharge FIM Score Motor Measure (*) Cognitive Measure (*)
Disposition n % Mean SEM Median Mean SEM Median Mean SEM Median
Home/community 161 67 75.0 2.5 85.0 51.0 1.8 54.0 47.4 1,5 51.0
Long-term care 42 18 44.4 3.6 38.5 30.5 3.0 36.5 31.7 2.9 34.0
Acute facility 12 5 44.7 9.7 31.5 32.8 7.8 30.5 20.8 5.9 14.0
Other rehabilitation 24 10 52.9 6.1 48.5 35.3 4.7 37.5 37.5 3.6 37.0
Total r 239 100 65.9 2.1 66.0 44.9 1.6 45.0 42.3 1.3 46.0
* Motor and cognitive measures represent Rasch-transformed discharge FIM motor and cognitive scores.
r Excludes 6 who improved and 2 who did not improve with discharge setting of "other."

Arch Phys Med Rehabil Vol 76, December 1995

 OUTCOME AFTER REHABILITATION FOR SEVERE TBI, Whitlock 1109

Table 6: Age, Length of Rehabilitation Stay, Days to Admission

Improved At Discharge No Functional Rehab Gains
Disposition n % Age DTA LOS n % Age DTA LOS

Home/community 161 67 27 48*** 132"* 10 12 22 83 80

Long-term care 42 18 43 53* 109"* 37 46 36 70 79
Acute facility 12 5 40 51 75* 24 30 43 71 44
Other rehabilitation 24 10 28 52 130"* 10 12 28 49 69

Total ~ 239 100 30 49 125 81 100 35 69 68

Averages listed for age, DTA, and LOS.
Abbreviations: DTA, days between injury and rehab admission; LOS, length of stay.
* p < .10.
* * p < .05.
* * * p < .01.
tExcludes 6 who improved and 2 who did not improve with discharge setting of "other."

is depicted graphically in figure 8. This plot depicts the latest
available total FIM score for each of those persons who showed
measurable functional change after being admitted to rehabilita-
tion with FIM of 18. Follow-up FIM scores were used when
available. For the remainder, the score reflects the FIM at dis-
charge from acute rehabilitation. All persons with a discharge
or follow-up FIM of 18 are excluded from this figure.
Because the point in time at which the best scores were first
achieved in each case is unknown (ie, the discharge or follow-
up FIM scores do not of necessity represent " b e s t " scores, and
an individual with a high discharge FIM may have had the same
score weeks earlier as well), it was impossible to define with
any precision the relationship between FIM and time since in-
jury using the present data. This illustration is meant to highlight
the lack of an obvious simple relationship between time and
the wide range of functional scores observed in the study popu-
lation. Regression analysis of FIM score (as dependent variable)
against number of days between injury and score (as indepen-
dent variable) shows no trend toward improvement with time.
Time alone fails to explain any of the wide variability observed
(R 2 = .00004).
DISCUSSION
In a separate, clinically detailed study of a small sample of
rehabilitation patients who also had an admission FIM of 18,
injury day median Glasgow Coma Score (GCS) 3° was 4. lz On
arrival at rehabilitation an average of 44 days postinjury, their
median GCS was 9. Interactivity was either absent or intermit-
tent and extremely limited in this group. The majority of the
55
so
= 45
}4o
~ 35 •
<
25
20
5~9 • tsS19 • 25.~29 ' 3s~39
10-14 20-24 30-34
Age in Years
Fig 6. Average Rasch-transformed FIM motor and cognitive measures by
age group. ~, Motor measure; @, cognitive measure.
group had major extracranial trauma, structural pathology visi-
ble on computed tomography of the brain, persisting visual
dysfunction, and prominent brainstem signs? 2 In the National
Institute on Disability and Rehabilitation Research TBI model
system database, 26 TBI patients with a rehabilitation admission
FIM of 18 had a median GCS of 4 on the day of injury (unpub-
fished data, 1993). Rasch-transformed FIM motor and cognitive
scales have been shown to correlate with several measures of
brain injury severity including GCS, length of coma, length of
post-traumatic amnesia and Ranchos Los Amigos scale score. 3~
Thus, although an admission FIM score of 18 is not in itself an
absolute index of severity in assessing the consequences of TBI,
individuals in this study sample probably represent the most
severely injured survivors of TBI who enter acute rehabilitation
facilities after their acute hospitalization.
The present study is the largest examination to date of acute
rehabilitation outcomes for persons with the most severe levels
of disability after TBI. It supports earlier findings of much
functional recovery even in persons who are completely depen-
dent at rehabilitation admission. 9'j2 An earlier study by one of
the present authors ]2 exploring the relationship of discharge
FIM score to Glasgow Outcome Scale32 suggested that FIM
scores greater than 91 at rehabilitation discharge were compati-
ble with "good recovery" or "moderate disability" at 6 months
after injury. Twenty-two percent of the persons in the present
sample had discharge FIM scores in this range. Substantial fur-
ther functional gains were noted in those for whom postrehabili-
tation follow-up information was available.
The age, gender, and racial composition of our study group
mirror those in published epidemiological studies of TBI in
general. 33'34 It should be noted that the present series included
a small number of persons younger than 16 years (7%) (the
median age of this subset was 13). Average days to admission
(52) and rehabilitation length of stay (110 days) for this pediatric
subgroup were closer to those for the group of patients who
improved than for those who showed no functional change. The
significance of younger age as a favorable prognostic indicator
is well k n o w n , 35'36 and although range of discharge FIM scores
was broad (18 to 117), these children did have a higher average
discharge FIM score (72.3). Only two persons younger than 16
years of age went home with an FIM score of 18 (ie, no func-
",, / tional change between admission and discharge). The influence
of young age on outcomes in the present sample is highlighted
by higher average discharge F1M and higher percentage of dis-
charges to home (83%) for those younger than 16 years.
A prolonged acute hospital course and, in general, longer
' >,16
40-44 periods of hospital-based rehabilitation have been shown to
correlate with comorbidity of both neurological and extracere-
bral nature in those with TBI. 37 Spettell and colleagues38 have
shown that the length of acute hospital stay positively correlates

Arch Phys Med Rehabil Vol 76, December 1995

 1110 OUTCOME AFTER REHABILITATION FOR SEVERE TBI, Whitlock

5
-$

--I

IL
e"

-0- Rehabilitation Discharge :E Follow-Up (n=48)

Fig 7, Mean FIM levels by item

at rehabilitation discharge and
at follow-up (patients who im-
Id
Fee ing Bowel
I i i i
ToiletTransfer Dressing-upper Bathing Dressiag-lower Stairs
I I I ~ i I I I I I I
ComprehensionSocialInteraction ProblemSolving proved) with order correspond-
Grooming BedTransfer Bladder Locomotion TubTransfer Toiletng Expression Memory ing from highest t o l o w e s t fol-
Functional Item l o w - u p means by domain.

with duration of post-traumatic coma. Acute length of stay may of weeks) after severe brain injury may display impairment
thus be an indirect measure of severity. If duration of acute amplified by readily reversible metabolic or drug effect. Fever,
hospitalization is an index of injury severity or serious comor- hyponatremia, sedating antispasticity medication, anticonvul-
bidity, one would expect this variable to be quite different in sant toxicity, or other factors can magnify the behavioral effects
those who showed functional improvement versus those who of neurological injury. Successful address of these issues may
did not after rehabilitation admission with an FIM of 18. This be followed by rapid clinical improvement. If such medically
is what was observed and suggests that the subgroup who failed reversible factors were present in a large proportion of the pres-
to progress had the most serious cerebral injuries and the great- ent sample, one would expect early admission to be associated
est number of extracerebral complications. This could account with a relatively short length of rehabilitative stay. The fact
for the much higher relative number of discharges to acute that early admission was associated with longer durations of
facilities after a short (average 44 day) rehabilitation stay. Such rehabilitation length of stay argues against the idea that ob-
a conclusion is also supported by the finding that a proportion- served progress was largely due to correction in rehabilitation
ately greater number of rehabilitation days were lost to tempo- of metabolic or pharmacological impediments to recovery.
rary transfers back to acute care in the group that remained In two studies examining the relationship between time of
totally dependent at discharge. rehabilitation admission and rehabilitation length of stay in per-
Some persons who begin rehabilitation soon (within a couple sons with TBI, longer periods of acute hospitalization appeared
to be associated with longer rehabilitation stays. 2'38In the pres-
ent study, such a relationship was not present. The present
126 A ~ JL A
A • • • • sample was characterized by high degrees of variability in both
lengths of stay and acute hospitalization.
108 Thirty-six of the individuals in our sample were discharged
to acute care facilities. By definition, this means that they expe-
90 rienced at least 31 days in acute care without being readmitted
8 A • A &A• A to the rehab facility from which they had been discharged. This
u~
does not mean that some of them did not go on to experience
72 rehabilitation later or somewhere else. Unfortunately, the struc-
I--
ture of the UDSMR dataset used in this study did not allow
54 h,
A m.
greater description of the fate of these people. Given the associa-
tion between short lengths of rehabilitation stay, poor functional
36
outcome, high cost and discharge to acute facilities, it would
• • ~• =t.-. •.~` • == be worthwhile to undertake a focused review of this population
in the future to clarify both the types of medical complication
18 i i r i b J
they are experiencing and how they do after the repeat stay in
5 65 125 185 245 305 365 425 485 545
Days from Injury to Scoring
acute care.
Information on postacute rehabilitation course was limited to
Fig 8. FIM score versus time since injury in days (with line depicting 18% of the total sample (13.2% of those who did not improve
regression of "'FIM t o t a l score" against "Days from onset to scoring"). and 19.6% of those with gains), a percentage remarkably close

Arch Phys Med Rehabil Vol 76, December 1995

 OUTCOME AFTER REHABILITATION FOR SEVERE TBI, Whitlock
to that reported for an outcome study of stroke patients derived
from the UDSMR. 39 In the latter study, it was found that the
19% of patients for w h o m follow-up data were reported had
shown a higher level of function at rehabilitation discharge.
The authors speculated that the finding may have been due to
mortality or more difficulty in establishing contact with lower-
functioning patients. Most of the follow-up information in the
present study was collected by phone and may be subject to a
sampling bias. Although the follow-up data in this study was
thought worthy of report, it should not be construed as a reliable
depiction of functional changes after acute rehabilitation in the
overall sample.
Prospective studies featuring repeated functional scoring at
set intervals from the time of injury and extending through the
follow-up period until at least the 6-month mark would help
clarify the influence of time on recovery of function in popula-
tions like this. FIM scores at (or even before) rehabilitation
admission and then at intervals representing 2- to 4-week epochs
postinjury could help to elucidate the pattern of recovery from
severe TBI and make it easier to study the contributions of
pathology, time, environment, and interventional factors to vari-
ability in outcomes.
Are there any significant facility-specific differences in out-
come within a group like this? If so, a closer look at differences
in admission criteria, interventions, measurement practice, staff
experience levels, and discharge criteria might lead to better
prediction of outcomes. Little interfacility variability in out-
comes for cases such as those described in this study would
suggest that the most important factors influencing variability of
outcome among those exposed to hospital-based rehabilitation
programs in the United States are related to extent and degree
of pathology, to interventions (such as pharmacological, surgi-
cal, or supportive) occurring before acute rehabilitation, or to
some factor common to the rehabilitation process or setting in
general (eg, passive mobilization, frequency of human contact,
degree of medical surveillance).
This study represents a benchmark reference point with re-
spect to several measures of acute rehabilitative outcome in an
easily identified subgroup o f severely brain-injured persons. It
is a snapshot of patient characteristics, functional gain and dis-
charge disposition, how long acute rehabilitation took, and how
much it cost in 66 US acute rehabilitation facilities during an
epoch of time. Benchmarks are increasingly important as the
field of neurorehabilitation evolves and as the systems used for
providing care continue to undergo dramatic transformation. If
our system of p o s t - a c u t e care for those with TBI is evolving
in the right direction, functional outcomes of persons such as
those we have described should continue to improve. If health
care system changes place excessive limits on rehabilitative
care for those with extremely severe brain injury, the undesir-
able effects might be expected to show up earliest in a popula-
tion similar to our present study. Continuous, timely feedback
from a centralized information collection and analysis resource
could help us all to understand how ongoing changes in systems
of care affect the functional recovery of individuals with TBI
so that we may continually refine our focus on clinical and
social interventions that work while abandoning those that
do not.
Acknowledgements: The authors extend their appreciation to Ed-
win D. Huff, PhD, for assistance with statistical analyses.
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