Brain Injury, June 2012; 26(6): 825–833

Health-related quality of life of individuals with traumatic brain

injury in Barranquilla, Colombia

JUAN CARLOS ARANGO-LASPRILLA1, DENISE KRCH2,3, ALLISON DREW1,

CARLOS JOSE DE LOS REYES ARAGON4, & LILLIAN FLORES STEVENS1
Brain Inj Downloaded from informahealthcare.com by Tomkins Mccaw Library on 06/29/12

1
Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA,
2
Kessler Foundation Research Center, West Orange, NJ, USA, 3Department of Physical Medicine and Rehabilitation,
UMDNJ – New Jersey Medical School, Newark, NJ, USA, and 4Department of Psychology, Universidad del Norte,
Barranquilla, Colombia

(Received 6 January 2011; revised 1 July 2011; accepted 3 August 2011)

Abstract
For personal use only.

Objective: To assess health-related quality of life (HRQoL) of individuals with traumatic brain injury (TBI) in Barranquilla,
Colombia.
Participants/methods: Thirty-one individuals with TBI and 61 healthy controls completed the SF-36, a self-report HRQoL
measure composed of eight component areas: physical health problems, pain, role limitations due to physical problems or
due to emotional problems, emotional well-being, social functioning, energy/fatigue and general health perceptions.
Results: The samples were statistically similar with respect to age, gender and education and statistically different
with respect to depression, SES, social support and cognition. Compared to healthy controls, individuals with TBI had
significantly lower means on all SF-36 sub-scales. However, after adjusting for depression, SES, social support and cognitive
performance, significant differences remained on three of the SF-36 sub-scales. Specifically, individuals with TBI had lower
adjusted means on Role-Physical (p-value < 0.005), Role-Emotional (p-value < 0.005) and Bodily Pain (p-value < 0.05).
Conclusion: Even after controlling for depression, SES, social support and cognitive performance, individuals with TBI
living in Barranquilla Colombia report having poorer quality of life across various domains, including Role-Physical,
Role-Emotional and Bodily Pain. These findings suggest the need for rehabilitation health professionals to develop and
implement culturally-appropriate interventions to improve quality of life in Colombian individuals with TBI.

Keywords: Quality-of-life, traumatic brain injury, depression, cognition

Introduction
Traumatic brain injury (TBI) is a leading cause of
death and disability, affecting more than 10 million
people around the world [1, 2]. Survivors of TBI
are often left with emotional/behavioural, physical
and cognitive deficits, which may create barriers
to regaining a normal and productive life [3–9]. The
persistence of these problems often contributes to
physical and emotional costs and economic burden,
not only for individuals with TBI, but also for their
families and communities [10, 11]. For the patient,
these deficits may lead to poorer health-related
quality of life (HRQoL) [12–16].
Quality of life (QoL) is a measure of an individ-
ual’s ability to function in psychological, physical
and social health domains at a level consistent with
experiences, beliefs and expectations. More specifi-
cally, HRQoL refers to the direct impact of a medical

Correspondence: Juan Carlos Arango-Lasprilla, PhD, Associate Professor, Department of Physical Medicine and Rehabilitation, Virginia Commonwealth
University, Rehabilitation Psychology and Neuropsychology, School of Medicine, Theater Row Building, 4th floor, Room 4230a. PO Box 843038, 730 E
Broad Street, Richmond, VA 23219, USA. Tel: (804) 828 87 97. Fax: (804) 827 06 63. E-mail: jcarangolasp@vcu.edu
ISSN 0269–9052 print/ISSN 1362–301X online ß 2012 Informa UK Ltd.
DOI: 10.3109/02699052.2012.655364
 826 J. C. Arango-Lasprilla et al.
condition or treatment on an individual’s perception
of their physical, emotional or social well-being [17].
HRQoL may be measured through both objective
assessment of function and the subjective percep-
tions of the patient [18]. Previous research has
shown that individuals with TBI often report worse
HRQoL post-injury than the general population and
patients who have sustained other types of trauma
[19]. Studies have also shown QoL and HRQoL
to be associated with a variety of other factors. For
example, lower overall QoL following TBI has been
reported for individuals who have a poorer self-view
[20], poorer employment-related self-efficacy [21],
lower levels of perceived independence [22], are
unemployed [23], report more depressive symptoms
Brain Inj Downloaded from informahealthcare.com by Tomkins Mccaw Library on 06/29/12
[20, 24], use less problem-solving coping and more
passive coping [25] and who receive less emotional
support [24]. Findings for other factors are mixed.
For example, one study found that women reported
poorer QoL than men and that younger patients
reported poorer QoL than did older patients [26];
however, another study found that women reported
higher QoL and that age was not significantly related
to QoL [24]. Likewise, milder injury severity is
For personal use only.
reported by one study [27] to be associated with
lower QoL, whereas more severe injury has been
associated with lower QoL in another study [22].
Other factors associated with a better post-injury
QoL include better material well-being, greater
productivity and increased community integration
[28, 29].
More specifically related to HRQoL, individuals
with TBI who are employed and vocationally
productive after injury [12, 16, 24] have less
disability and more community participation [30],
are more satisfied with social support [31], use
task-oriented coping strategies [31] and have more
optimistic life orientation [31] report higher
HRQoL. In contrast, individuals with TBI who
have higher fatigue [32, 33], suffer headaches and
have a history of psychiatric illness [14] experience
poorer HRQoL. Long-term follow-up studies reveal
that there is little improvement in HRQoL over time
[34] and that factors salient to HRQoL many years
after brain injury remain similar to those pertinent
more acutely. That is, individuals who have greater
social and emotional support, assistance with daily
activities and less depressive symptoms experience
higher QoL [24, 34]. Individuals who have stronger
spiritual beliefs and access to congregationally-based
social support tend to enjoy improved HRQoL [35].
Studies that have assessed HRQoL in individuals
with TBI have done so using a wide variety of
measures, the most common of which has been the
SF-36. Studies using the SF-36 have assessed
samples ranging in size from 10 to 7612 patients
[36, 37], varying in time post-injury from 3 months
to 22 years [12, 14, 19, 32, 37–40], with approxi-
mately half of the assessments conducted at greater
than 5 years post-injury [12, 14, 16, 32, 41].
Research conducted with the SF-36 has investigated
HRQoL by gender [14, 16], symptoms [33] and
intervention outcome [36, 41]. Countries in which
research with the SF-36 has been conducted with
TBI populations include Norway, Scotland, the US,
Sweden, Germany and the Netherlands [16, 38–41].
Several studies used all eight sub-scales of the SF-36
plus the Physical and Mental Component Summary
scores [12, 14, 19, 32, 39], some used only the eight
sub-scales [16, 38, 40, 41] and others included only
one or both of the component scores or selected
sub-scales [33, 36, 37]. In general, studies using the
SF-36 have concluded that individuals with TBI
have worse HRQoL than healthy controls over
both the short- and long-term, specifically in the
areas of vitality, physical role and emotional role.
Although there is a considerable amount of
research on HRQoL of individuals with TBI, there
is a lack of research focusing on the HRQoL of
Spanish-speaking individuals with TBI in general
and in Latin American countries in particular.
Latin America has the highest rates of TBI following
road traffic injuries and the second highest rates for
TBI due to violence [42]. However, individuals with
TBI in countries such as Colombia are less likely
than TBI survivors in developed countries to have
access to services such as support groups, individual
psychological treatment, financial assistance, health
care facilities, nursing homes and adult day care
[43]. Lack of resources may contribute to lower
reported HRQoL in individuals with TBI, which in
turn may affect family members and the community.
The purpose of this study was to assess the current
level of HRQoL in Spanish-speaking individuals
with TBI in Colombia.
Method
Participants
Thirty-one Spanish-speaking, Colombian, individ-
uals with a history of moderate-to-severe TBI and 60
Spanish-speaking, Colombian, healthy controls were
recruited for participation in the present study. TBI
was confirmed through patients’ medical records
(loss of consciousness, positive computed tomogra-
phy or magnetic resonance imaging findings) and all
were at least 6 months post-injury. Inclusion criteria
required that each participant be between the ages of
18–65 years and participants were excluded if they

had a history of neurological or psychiatric condi-
tions, alcohol or drug abuse or learning disabilities.
The sample of individuals with TBI consisted of
19 men (61.3%) and 12 women (38.7%), with an
average age of 34 years (SD ¼ 11.5) and 11 years
(SD ¼ 3.7) of education. Their mean Glasgow Coma
Scale score at the time of admission to the hospital
was 10 (SD ¼ 1.8), with 90% of the sample falling
under the moderate category and 10% falling under
the severe TBI category. Mean time since injury was
17 months (SD ¼ 28.5). Median time since injury
was 9 months, with a range of 6–122 months.
Most of the injuries resulted from motor vehicle
accidents (78%), followed by pedestrian-related
incidents (6.4%) and violence (16%). Nineteen
Brain Inj Downloaded from informahealthcare.com by Tomkins Mccaw Library on 06/29/12
percent had received outpatient occupational ther-
apy, 32% physical therapy, 16% psychotherapy and
9% speech therapy. None of the subjects reported
receiving cognitive rehabilitation therapy or voca-
tional rehabilitation. Thirty-two per cent of the
participants were single, 29% were married, 3%
were divorced, 13% were separated and 23% were
cohabiting. The Colombian government bases peo-
ples’ socioeconomic status (SES) on income and
location of residence, ranging from 1 (low) to
For personal use only.
6 (high). Thirty-five percent of individuals with
TBI were at level 1, 32% at level 2, 19% at
level 3 and 13% at level 4.
The healthy control group was comprised of
39 males (64%) and 22 (36%) females. The majority
(47%) were single, 31% were married, 2% were
divorced, 3% were separated, 2% were widowed and
15% were cohabiting. The average age of the healthy
controls was 33.56 (SD ¼ 11.7) years and they had
an average of 12 (SD ¼ 3.7) years of education.
Thirty-four percent of the participants in the healthy
control group were at level 1 SES, 8% at level 2,
26% at level 3, 16% at level 4, 13% at level 5 and 2%
at level 6.
Instruments
In order to be part of the present study, participants
were a part of a comprehensive evaluation that
included demographic information, cognitive and
psychosocial evaluation and QoL. Below is the
description of each of the instruments used to
assess these areas.
Participants completed the Short Form 36
(SF-36), a self-report health questionnaire that
measures HRQoL [44]. The SF-36 is one of the
most widely used instruments to assess HRQoL in
individuals with TBI [45]. The instrument consists
of 36 items that focus on eight different health
dimensions: physical functioning, role limitations
due to physical problems, bodily pain, general
HRQoL of individuals with TBI 827
health, vitality, social functioning, mental health
and role limitations due to emotional problems.
Responses are scored on a 0–100 scale, with higher
scores representing higher HRQoL. It has been
translated into many languages, including Spanish,
and has well-established reliability and validity in
Spanish-speaking populations [46].
Cognitive functioning was assessed using a com-
prehensive Spanish-language neuropsychological
instrument (NEUROPSI [47]). The NEUROPSI
was designed as a basic neuropsychological battery
to assess nine domains: Orientation; Attention/
Concentration; Memory; Language; Visuomotor;
Executive Function; Reading; Writing and
Calculation. Total scores range from 2–130, with
higher scores indicating better cognitive functioning.
Depression was assessed using the Patient Health
Questionnaire (PHQ) depression module (PHQ-9).
This is a reliable and valid measure of the severity
of depressive symptoms and is regarded as highly
useful in both clinical and research applications [48].
The examination consists of nine items that
reflect typical symptoms of depression. Higher
scores reflect higher levels of depressive symptoms
and categories regarding severity of depressive
symptoms are also available. The Spanish version
used for this study [49] has demonstrated good
reliability and validity in assessing depression in
Spanish speakers [50, 51].
Social support was evaluated using the
Interpersonal Support Evaluation List–Short
Version (ISEL-12), which consists of a list of 12
statements concerning the perceived availability
of potential social resources [52]. The items are
counter balanced for desirability. The ISEL-12 was
shortened from the 40-item version ISEL [52] and
designed to not only provide a measure of overall
support, but also assesses the perceived availability
of three separate functions of social support (the
‘tangible’ sub-scale measures perceived availability
of material aid; the ‘appraisal’ sub-scale measures
perceived availability of someone to talk to about
one’s problems; and the ‘belonging’ sub-scale mea-
sures perceived availability of people one can do
things with). The ISEL has been used widely
in health-related research and demonstrated good
internal consistency and test–re-test reliability [52].
The present study uses the Spanish version of the
ISEL-12 [53].
Procedure
Local researchers reviewed medical records to iden-
tify individuals with TBI who were treated at a
hospital, Clı́nica Cervantes, between December 2007
and December 2008 in Barranquilla. Each candidate
 828 J. C. Arango-Lasprilla et al.

was screened by telephone to determine if he or she
met inclusion and exclusion criteria. Fifty individuals
were identified who met inclusion/exclusion criteria
and, of these, 13 did not respond to invitations to
participate and six were unable to participate due to
transportation issues. The healthy control group was
recruited from the general population through flyers
at neighbourhood churches, stores and restaurants
and by general word-of-mouth. After the details of
the study were explained to each eligible candidate,
individuals who expressed interest were invited to
participate. Once the individuals with TBI and
healthy controls agreed to participate in the study,
they were asked to sign a form that indicated their
informed consent in accordance with regulations
Brain Inj Downloaded from informahealthcare.com by Tomkins Mccaw Library on 06/29/12
depression, total cognitive performance and social
support.
Results
Data from 91 subjects (30 individuals with TBI and
61 healthy controls) were included in the analyses.
The groups did not differ significantly with regard
to age (p-value ¼ 0.65), gender (p-value ¼ 0.82) or
education (p-value ¼ 0.17). However, there were
significant differences between individuals with
TBI and healthy controls in terms of SES
(p-value < 0.05), depression (p-value < 0.005), cog-
nitive performance (p-value < 0.001) and social
support (p-value < 0.005). In general, healthy con-

approved by the ethics committee of Universidad del
Norte in Barranquilla, Colombia. All of the partici-
pants completed an interview with a graduate student
under the supervision of a university professor.
The student collected demographic information,
conducted a neuropsychological evaluation with
TBI survivors and completed a psychosocial evalua-
tion (depression, social support) and administered
the SF-36. The interviews lasted for 1 hour.
For personal use only.
trols reported a significantly lower level of depres-
sion, higher SES, better cognitive performance and
higher social support.
Compared to healthy controls, individuals with
TBI had significantly lower means on all SF-36 sub-
scales (p < 0.001). After adjusting for SES, depres-
sion, social support and cognitive performance,
significant differences were found between the
healthy controls and individuals with TBI on three

of the SF-36 sub-scales (see Table I). Specifically,

Statistical analysis
Patients’ and healthy controls sociodemographic
(gender, age, education and SES) and psychosocial
(depression, cognition, social support) characteris-
tics were compared using t-tests for continuous
variables and chi-square tests for nominal variables.
An analysis of covariance was conducted to compare
the means of each individual SF-36 sub-scale
between the two groups after controlling for SES,
individuals with TBI had lower adjusted means on
Role Physical (p-value < 0.008), Role Emotional
(p-value ¼ 0.010) and Bodily Pain (p-value ¼ 0.040).
Discussion
The purpose of the present study was to assess
HRQoL of individuals with TBI in Barranquilla,
Colombia. After adjusting for SES, depression,
social support and cognitive performance, results

Table I. Differences in health-related quality-of-life between individuals with TBI and healthy controls from
Colombia, South America.

Adjusted mean 95% Confidence

SF-36 sub-scale Group (LSMean) p-value Limits for LSMean

Physical Functioning TBI 86.18 0.977 79.14 93.21

Healthy Control 86.31 81.45 91.16
Role-Physical TBI 57.71 0.008 46.07 69.35
Healthy Control 78.10 70.06 86.14
Role-Emotional TBI 53.89 0.010 41.49 66.28
Healthy Control 74.94 66.38 83.49
Vitality TBI 73.58 0.365 67.02 80.14
Healthy Control 69.73 65.21 74.26
Mental Health TBI 71.53 0.967 64.61 78.44
Healthy Control 71.71 66.94 76.48
Social Functioning TBI 75.99 0.718 67.25 84.73
Healthy Control 78.03 72.00 84.06
Bodily Pain TBI 69.21 0.040 61.64 76.78
Healthy Control 79.37 74.14 84.59
General Health TBI 73.31 0.490 67.22 79.40
Healthy Control 76.04 71.83 80.24

indicated that individuals with TBI reported greater
role limitations related to physical problems, greater
role limitations related to emotional problems
and higher bodily pain. To the authors’ knowledge,
this is the first study that examines HRQoL in a
sample of Spanish-speaking individuals with TBI
from Latin America.
The results in the current study are consistent
with previous research evidencing lower HRQoL in
individuals with TBI compared to the general
population and healthy individuals [12, 14, 32].
Whereas the current findings revealed that work and
daily activities were limited only by pain and
problems in physical and emotional health, other
TBI samples found decreased HRQoL to be more
Brain Inj Downloaded from informahealthcare.com by Tomkins Mccaw Library on 06/29/12
pervasive. In a Norwegian sample of predominantly
mild TBI patients, individuals reported poorer
HRQoL on the Physical and Mental Component
Summary Scales as well as on all sub-scales (except
Physical Function) as compared to the general
population [14]. In a US-based mild-to-moderate
TBI cohort, significantly poorer functioning was
found in all areas of HRQoL relative to a sample
of non-injured controls [32]. A Swedish sample of
individuals with mild-to-severe TBI reported signif-
For personal use only.
icantly lower scores on the Physical Component
Summary and on all sub-scales (except Role-
Emotional) in comparison to an age- and gender-
matched reference population [12]. The current
study found relatively fewer differences in HRQoL
than existing studies, which may be related to the
differential time since injury. Individuals in the
current study were 17 months post-TBI, whereas
average time since injury in the other studies ranged
from 6–22 years [12, 14, 32]. This pattern may
suggest that the burden from brain injury sequelae
incrementally increases over time or that the ability
to cope with such sequelae diminishes.
An alternative explanation is the differential selec-
tion and control of potentially confounding variables
across studies. Cantor et al. [32], Nestvold and
Stavem [14] and Jacobbson et al. [12] examined
only the contribution of demographic variables
(i.e. age, gender, education, SES, race/ethnicity) to
their analyses. In the current study, in addition
to demographic variables (i.e. age, gender, educa-
tion, SES), the impact of psychosocial variables
(i.e. depression, social support and cognitive perfor-
mance) was considered in the analyses. It is possible
that some of the HRQoL differences found between
TBI and healthy samples in other studies may be
explained by psychosocial factors that, if parcelled
out, would allow a more refined pattern to emerge,
such as that observed in the current study.
Qualitative consideration of the HRQoL pro-
file in the current TBI sample relative to other
TBI samples in the literature reveals several
HRQoL of individuals with TBI 829
interesting findings. In contrast with individuals
who sustained mild TBIs [14, 39], the current
moderate-to-severe TBI sample reported consider-
ably greater role limitations due to physical and
emotional problems, but greater vitality. Relative to
a sample that most closely matched the current study
with regards to injury severity and time since injury
[40], the current sample reported greater bodily pain
and role limitations secondary to emotional prob-
lems, but better general health, vitality, social func-
tioning and mental health. In general, the levels
of HRQoL reported in moderate-to-severe TBI
samples ranged quite broadly, with up to 38 points
difference between minimum and maximum values
on some sub-scales. Given such broad intervals, the
current sample’s reported QoL scores were well
within these ranges, with role limitations due to
physical problems and bodily pain falling approxi-
mately in the middle of reported ranges and role
limitations due to emotional problems falling toward
the lower end of the reported ranges. One exception
was vitality, which was substantially higher in the
current sample as compared to levels reported in
all other reviewed studies.
Broad differences in the degree of HRQoL
reported in various patient groups across studies
may be attributed to pre-morbid patient character-
istics, the heterogeneous nature of TBI or varying
study methodologies. However, one important factor
to consider, which may contribute notably to differ-
ential outcome, is culture. With the SF-36 translated
for use in more than 40 countries, various world-
views of illness and disability are likely reflected
in HRQoL across cultures. Even among studies
from different countries reviewed in this paper,
a number of differences were revealed. This TBI
Colombian sample reported greater vitality than
individuals from Germany, Scotland, the US,
Norway and Sweden [12, 14, 16, 19, 32, 38–40].
The Colombian sample reported better general
health than the US [19, 32] and Scotland [38]
cohorts, better social functioning and mental health
than German study participants [40] and better
health in all SF-36 health-related domains relative to
US samples [19, 32]. Greater role limitations due
to emotional problems were found relative to
participants in Scandinavian [12, 14, 16, 39] and
Scottish studies [38] and more bodily pain and
greater role limitations due to physical problems
were found relative to the Scotland sample [38].
In all, HRQoL varied considerably by sub-scale as a
function of culture.
Although the version of the SF-36 used in the
current study has been validated in Spanish-speaking
samples [54, 55], the authors are unaware of the
existence of population-based norms using this
particular translation. However, it is meaningful to
 830 J. C. Arango-Lasprilla et al.
note that the Colombian healthy control profile of
scores is quite similar to the US population-based
normative means on all sub-scales [44]. Comparison
of the Colombian samples to the Swedish refer-
ence group reveals a somewhat different pattern;
Colombian healthy controls report overall worse
social functioning, greater role limitations secondary
to emotional problems and poorer mental health
[12]. Differences among the Colombian healthy
control group and the US and Swedish normative
samples may be attributed to instrument translation.
Alternatively, differences may be reflective of the
different world views and perceptions of health
and illness in these countries, underscoring, again,
the importance of culture in HRQoL.
Brain Inj Downloaded from informahealthcare.com by Tomkins Mccaw Library on 06/29/12
Given the current dearth of research on HRQoL
in Latin Americans with TBI, characterization of this
Colombian-based sample is an important step in
helping to better understand health perceptions and
QoL in under-developed Spanish-speaking coun-
tries, where rates of TBI are elevated and access to
services limited. When psychological and emotional
problems are not targeted for treatment, individuals
with TBI may not be able to reach their recovery
For personal use only.
potential. As such, differences found in the current
study between the TBI and healthy control groups
on physical and emotional role limitations and on
pain suggest that particular attention to these areas
in provision of TBI rehabilitation services is crucial.
Limited outpatient services available to Colombian
TBI survivors will place greater burden on providers
to target these critical issues prior to discharge from
inpatient treatment centres.
One unexpected, yet important, finding was the
consistently elevated level of vitality in the current
sample. Vitality was reported to be greater in the
current TBI group relative to its own reference
group, as well as to English population-based norms
and, to a lesser degree, Swedish population
norms. Additionally, the current TBI group also
rated vitality higher than TBI samples from all other
countries in the literature reviewed. This curious
elevation of the Vitality sub-scale may be explained
by translation and adaptation challenges. For exam-
ple, one of the items on the Vitality sub-scale
(‘did you feel full of pep’) uses the word ‘pep’, for
which there is no word in Spanish. The closest
translation of ‘pep’, vitalidad (back-translated into
English as vitality), was used in the Spanish version
of the SF-36. Although pep and vitality have similar
meaning in English, the use of vitalidad in Spanish
may be quite different from the meaning or intensity
originally intended by utilization of the word ‘pep’ in
English. There may be a tendency toward stronger
endorsement of the word vitality in Spanish than
if there had been a translation for ‘pep’. An
additional consideration is that even when words
translate directly from an origination to a target
language, the target culture may place a different
degree of importance on the concept relative to
the origination culture. Therefore, different cultural
perceptions of ideas and concepts within the Vitality
sub-scale may also offer an explanation for the
observed differences across studies.
In spite of these possible explanations, the eleva-
tion of the Vitality sub-scale in the current sample
is especially striking considering that the Vitality
sub-scale is bipolar in nature, such that higher
scores indicate not just absence of limitations or
disability, but, more importantly, the presence of a
positive state [44]. The fact that the current TBI
group rated vitality higher than TBI samples from all
other countries in the literature reviewed suggests
that vitality may be an inherent cultural character-
istic in Colombians. From a rehabilitation stand-
point, favourable self-evaluation of ‘pep’ and energy
represents a patient asset that has the potential to
positively impact functional outcome. Rehabilitation
clinicians are encouraged to capitalize on such
strengths in order to assist their patients in improv-
ing QoL in related areas of health functioning.
There are several limitations that should be taken
into account when interpreting the results of this
study. As individuals with TBI included in this study
were from an urban Colombian city, results may not
generalize to those in more rural areas who have
access to fewer resources. Because rehabilitation
resources are generally scarce in Colombia, this may
also limit comparisons of the findings with those
from studies conducted with individuals who
have access to more comprehensive rehabilitation
services. The cross-sectional design of this study
does not allow conclusions to be drawn regarding
how HRQoL may change over time. An additional
consideration regarding the study design is that it
was chosen to control for SES, depression, social
support and cognitive performance in comparing
TBI and healthy control groups. Differences in study
design further make it difficult or impossible to
directly compare the results of this study to the
findings of other studies because other studies either
did not control for any variables or controlled for
different variables than those included in this
study. The median length of injury for individuals
with TBI was 9 months. Caution should be advised
when trying to generalize these findings to individ-
uals with TBI in Colombia with more recent or long-
term injury. The majority of individuals in this
study sustained moderate TBI; more research is
needed to understand the impact mild or severe TBI

has on HRQoL for individuals living in Colombia.
Another limitation concerns the measures selected
to quantify HRQoL; this study utilized the SF-36.
Due to the complexity of TBI sequelae, it is possible
that some aspects that impact the QoL of an
individual with TBI may not have been completely
captured and reported by this instrument. Further,
a specific measure of physical disability was not
included in this study; however, the SF-36 has sub-
scales that target this (e.g. physical functioning, role
limitations due to physical problems) and no signif-
icant differences between groups were noted on
these sub-scales. Nonetheless, it would be helpful
to include a specific measure of physical disability,
as this factor may impact findings above and beyond
Brain Inj Downloaded from informahealthcare.com by Tomkins Mccaw Library on 06/29/12
level of cognitive impairment.
Conclusion
In conclusion, the purpose of this study was to
determine differences in HRQoL between individ-
uals with TBI and healthy controls in Barranquilla,
Colombia. Individuals with TBI reported having
For personal use only.
poorer QoL across various domains, emphasizing
the need for rehabilitation professionals to develop
and implement interventions that improve the QoL
for individuals with TBI, particularly regarding pain
management and role limitations due to physical and
emotional problems. Teaching pain management
strategies, increasing the availability of adaptive
equipment and providing support groups and other
psychoeducational programmes may improve the
HRQoL for these individuals. The findings of this
study also suggest that providers and researchers
working with Spanish-speaking individuals with TBI
in the US and other Latin American countries
should pay attention to the particular aspects of
QoL that most affect their patients and be aware that
cultural differences may influence QoL.
Acknowledgements
The contents of this article were developed partially
under a grant from the Department of Education,
NIDRR grant number H133P090009. However,
those contents do not necessarily represent the
policy of the Department of Education, and you
should not assume endorsement by the Federal
Government.
Declaration of Interest: The authors report no
conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
HRQoL of individuals with TBI 831
References
1. International Brain Injury Association (IBIA). Brain
injury facts: worldwide. Available online at: http://
www.internationalbrain.org/?q=Brain–Injury–Facts, accessed
12 August 2010.
2. Zitnay GA. Lessons from national and international TBI
societies and funds like NBIRTT. Acta Neurochirurgica
Supplement 2005;93:131–133.
3. Brooks DN. Cognitive deficits after head injury. In: Brooks
DN, editor. Closed head injury: Psychological, social, and
family consequences. Oxford: Oxford University Press; 1984.
pp 148–178.
4. Molloy M. New perspectives in cognitive rehabilitation.
Australian Rehabilitation Review 1983;7:34–37.
5. Tate RL, Fenelon B, Manning ML. Patterns of neuropsy-
chological impairment after severe blunt injury. Journal of
Nervous and Mental Diseases 1991;179:117–126.
6. Cunningham JM, Chan F, Jones J. Brain injury rehabil-
itation: A primer for case managers. In: Chan F, Leahy
MJ, editors. Health care and disability case management.
Illinois: Vocational Consultants Press; 1999. pp 475–526.
7. Prigatano GP. Personality disturbances associated with trau-
matic brain injury. Journal of Consulting and Clinical
Psychology 1992;60:360–368.
8. Smith LM, Godfrey HPD. Family support programmes and
rehabilitation: A cognitive-behavioural approach to traumatic
brain injury. New York: Plenum Press; 1995.
9. Lynch RT. Traumatic brain injury: Implications for rehabi-
litation counseling. In: Riggar TF, Maki DR, Wolf AW,
editors. Applied rehabilitation counseling. New York:
Springer; 1986. pp 262–270.
10. Bell KR, Temkin NR, Esselman PC, Doctor JN,
Bombardier CH, Fraser RT, Hoffman JM, Powell JM,
Dikmen S. The effect of a scheduled telephone intervention
on outcome after moderate to severe traumatic brain injury:
A randomized trial. Archives of Physical Medicine and
Rehabilitation 2005;86:851–856.
11. Thurman DJ, Alverson C, Dunn KA, Guerrero J, Sniezek JE.
Traumatic brain injury in the United States: A public
health perspective. Journal of Head Trauma Rehabilitation
1999;14:602–615.
12. Jacobsson LJ, Westerberg M, Lexell J. Health-related quality-
of-life and life satisfaction 6–15 years after traumatic brain
injuries in northern Sweden. Brain Injury 2010;24:
1075–1086.
13. Souza LGMDN, Braga LW, Filho GN, Dellatolas G.
Quality-of-life: Child and parent perspectives following
severe traumatic brain injury. Developmental
Neurorehabilitation 2007;10:35–47.
14. Nestvold K, Stavem K. Determinants of health-related
quality of life 22 years after hospitalization for traumatic
brain injury. Brain Injury 2009;23:15–21.
15. Horneman G, Folkesson P, Sintonen H, von Wendt L,
Emanuelson I. Health-related quality of life of adolescents
and young adults 10 years after serious traumatic brain injury.
International Journal of Rehabilitation Research 2005;28:
245–249.
16. Andelic N, Hammergren N, Bautz-Holter E, Sveen U,
Brunborg C, Roe C. Functional outcome and health-related
quality of life 10 years after moderate-to-severe traumatic
brain injury. Acta Neurologica Scandinavica 2009;120:16–23.
17. Cella DF. Measuring quality of life in palliative care.
Seminars in Oncology 1995;22(2 Suppl 3):73–81.
18. Testa MA, Simonson DC. Assessment of quality-of-life
outcomes. The New England Journal of Medicine
1996;334:835–840.
 832 J. C. Arango-Lasprilla et al.
19. Brown SA, McCauley SR, Levin HS, Contant C, Boake C.
Perception of health and quality of life in minorities after
mild-to-moderate traumatic brain injury. Applied
Neuropsychology 2004;11:54–64.
20. Vickery CD, Gontkovsky ST, Caroselli JS. Self-concept and
quality of life following acquired brain injury: A pilot
investigation. Brain Injury 2005;19:657–665.
21. Tsaousides T, Warshowsky A, Ashman TA, Cantor JB,
Spielman L, Gordon WA. The relationship between employ-
ment-related self-efficacy and quality of life following trau-
matic brain injury. Rehabilitation Psychology 2009;54:
299–305.
22. Anderson V, Brown S, Newitt H. What contributes to quality
of life in adult survivors of childhood traumatic brain injury?
Journal of Neurotrauma 2010;27:863–870.
23. Webb CR, Wrigley M, Yoels W, Fine PR. Explaining quality
of life for persons with traumatic brain injuries 2 years after
injury. Archives of Physical Medicine and Rehabilitation
Brain Inj Downloaded from informahealthcare.com by Tomkins Mccaw Library on 06/29/12
1995;76:1113–1119.
24. Steadman-Pare D, Colantonio A, Ratcliff G, Chase S,
Vernich L. Factors associated with perceived quality of life
many years after traumatic brain injury. Journal of Head
Trauma Rehabilitation 2001;16:330–342.
25. Wolters G, Stapert S, Brands I, Van Heugten C. Coping
styles in relation to cognitive rehabilitation and quality of
life after brain injury. Neuropsychological Rehabilitation
2010;20:587–600.
26. Seibert PS, Reedy DP, Hash J, Webb A, Stridh-Igo P,
Basom J, Zimmerman CG. Brain injury: Quality of life’s
For personal use only.
greatest challenge. Brain Injury 2002;16:837–848.
27. Brown M, Vandergoot D. Quality of life for individuals
with traumatic brain injury: Comparison with others living
in the community. Journal of Head Trauma Rehabilitation
1998;13:1–23.
28. Kalpakjian CZ, Lam CS, Toussaint LL, Hansen
Merbitz NK. Describing quality of life and psychosocial
outcomes after traumatic brain injury. Brain Injury 2004;83:
255–265.
29. Man DWK, Lee EWT, Tong ECH, Yip SCS, Lui WF,
Lam CS. Health services needs and quality of life assessment
of individuals with brain injuries: A pilot cross-sectional
study. Brain Injury 2004;18:577–591.
30. Huebner RA, Johnson K, Bennett CM, Schneck C.
Community participation and quality of life outcomes
after adult traumatic brain injury. American Journal of
Occupational Therapy 2003;57:177–185.
31. Tomberg T, Toomela A, Pulver A, Tikk A. Coping
strategies, social support, life orientation, and health-related
quality of life following traumatic brain injury. Brain Injury
2005;19:1181–1190.
32. Cantor JB, Ashman T, Gordon W, Ginsberg A, Engmann C,
Egan M, Spielman L, Dijkers M, Flanagan S. Fatigue after
traumatic brain injury and its impact on participation and
quality of life. Journal of Head Trauma Rehabilitation
2008;23:41–51.
33. Stulemeijer M, van der Werf S, Bleijenberg G, Biert J,
Brauer J, Vos PE. Recovery from mild traumatic brain injury:
A focus on fatigue. Journal of Neurology 2006;253:
1041–1047.
34. Tomberg T, Toomela A, Ennok M, Tikk A. Changes in
coping strategies, social support, optimism and health-related
quality of life following traumatic brain injury: A longitudinal
study. Brain Injury 2007;21:479–488.
35. Johnstone B, Yoon DP, Rupright J, Reid-Arndt S.
Relationships among spiritual beliefs, religious practices,
congregational support and health for individuals with
traumatic brain injury. Brain Injury 2009;23:411–419.
36. Bédard M, Felteau M, Mazmanian D, Fedyk K, Klein R,
Richardson J, Parkinson W, Minthorn-Biggs MB. Pilot
evaluation of a mindfulness-based intervention to improve
quality of life among individuals who sustained traumatic
brain injuries. Disability and Rehabilitation 2003;25:
722–731.
37. McCarthy ML, Dikmen SS, Langlois JA, Selassie AW,
Gu JK, Horner MD. Self-reported psychosocial health
among adults with traumatic brain injury. Archives of
Physical Medicine and Rehabilitation 2006;87:953–961.
38. Blair H, Wilson L, Gouick J, Gentleman D. Individualized vs.
global assessments of quality of life after head injury and their
susceptibility to response shift. Brain Injury 2010;24:
833–843.
39. Emanuelson I, Holmkvist EA, Bjorklund R, Stalhammar D.
Quality of life and post-concussion symptoms in adults after
mild traumatic brain injury: A population-based study in
western Sweden. Acta Neurologica Scandinavica 2003;108:
332–338.
40. Lippert-Gruner M, Maegele M, Haverkamp H, Klug N,
Wedekind C. Health-related quality of life during the first
year after severe brain trauma with and without polytrauma.
Brain Injury 2007;21:451–455.
41. Gordon WA, Sliwinski M, Echo J, McLoughlin M,
Sheerer M, Meili TE. The benefits of exercise in
individuals with traumatic brain injury: A retrospective
study. Journal of Head Trauma Rehabilitation 1998;13:
58–67.
42. Hyder AA, Wunderlich CA, Puvanachandra P, Gururaj G,
Kobusingye OC. The impact of traumatic brain injuries:
A global perspective. NeuroRehabilitation 2007;22:341–353.
43. Arango-Lasprilla JC, Quijano MC, Aponte M, Cuervo MT,
Nicholls E, Rogers HL, Kreutzer J. Family needs in
caregivers of individuals with traumatic brain injury
from Colombia, South America. Brain Injury 2010;24:
1017–1026.
44. Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 Health
Survey: Manual and interpretation guide. Lincoln, RI:
QualityMetric Inc.; 1993, 2000.
45. Findler M, Cantor J, Haddad L, Gordon W, Ashman T. The
reliability and validity of the SF-36 health survey question-
naire for use with individuals with traumatic brain injury.
Brain Injury 2001;15:715–723.
46. Ayuso-Mateos JL, Lasa L, Vazquez-Barquero JL, Oviedo A,
Diez-Manrique JF. Measuring health status in psychiatric
community surveys: Internal and external validity of the
Spanish version of the SF-36. Acta Psychiatrica Scandinavica
1999;99:26–32.
47. Ostrosky-Solı́s F, Ardila A, Rosselli M. NEUROPSI: A brief
neuropsychological test battery in Spanish with norms by age
and education level. Journal of the Intrernational
Neuropsychogical Society 1999;5:413–433.
48. Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: Validity
of a brief depression severity measure. Journal of General
Internernal Medicine 2001;16:606–613.
49. Wulsin L, Somoza E, Heck J. The feasibility of using the
Spanish PHQ-9 to screen for depression in primary care
in Honduras. Primary Care Companion to the Journal of
Clinical Psychiatry 2002;4:191–195.
50. Diez-Quevado C, Rangil T, Sanchez-Planell L, Kroenke K,
Spitzer RL. Validation and utility of the Patient Health
Questionnaire in diagnosing mental disorders in 1003 general
hospital Spanish inpatients. Psychosomatic Medicine
2001;63:679–686.
51. Donlan W, Lee J. Screening for depression among
indigenous Mexican migrant farmworkers using the Patient
Health Questionnaire-9. Psychological Reports 2010;106:
419–432.

52. Cohen S, Hoberman H. Positive events and social supports
as buffers of life change stress. Jurnal of Applied Social
Psychology 1983;13:99–125.
53. Carnegie Mellon University. Laboratory for the Study of
Stress, Immunity and Disease. Available online at: http://
www.psy.cmu.edu/*scohen/, accessed 14 May 2009.
54. Augustovski FA, Lewin G, Elorrio EG, Rubinstein A. The
Argentine-Spanish SF-36 Health Survey was successfully
Brain Inj Downloaded from informahealthcare.com by Tomkins Mccaw Library on 06/29/12
For personal use only.
HRQoL of individuals with TBI 833
validated for local outcome research. Journal of Clinical
Epidemiology 2008;61:1279–1284.
55. Machnicki G, Allegri RF, Ranalli CG, Serrano CM,
Dillon C, Wyrwich KW, Taragano FE. Validity and reliability
of the SF-36 administered to caregivers of patients with
Alzheimer’s disease: Evidence from a South American
sample. Dementia and Geriatric Cognitive Disorders
2009;28:206–212.