| | Rehabilitation Outcomes of Terror Victims With Multiple TraumasAbstract Schwartz I, Tsenter J, Shochina M, Shiri S, Kedary M, Katz-Leurer M, Meiner Z. Rehabilitation outcomes of terror victims with multiple traumas. ObjectivesTo describe the rehabilitation outcomes of terror victims with multiple traumas, and to compare those outcomes with those of patients with nonterror-related multiple traumas treated in the same rehabilitation facility over the same time period. DesignRetrospective chart reviews. SettingRehabilitation department in a university hospital in Jerusalem, Israel. ParticipantsBetween September 2000 and September 2004, we treated 72 victims of terrorist attacks who had multiple traumas. Among them, 47 (65%) had multiple traumas without central nervous system involvement (MT subgroup), 19 (26%) had multiple traumas with traumatic brain injury (TBI subgroup), and 6 (8%) had multiple traumas with spinal cord injury (SCI subgroup). We matched, according to their types of injury and demographic data, each terror victim with a control patient treated in the same period in our rehabilitation department. InterventionInterdisciplinary inpatient and outpatient rehabilitation. Main Outcome MeasuresHospital length of stay (LOS) in acute care departments, inpatient and outpatient rehabilitation departments, functional outcome (FIM instrument score), occupational outcome (returning to previous occupation), and psychologic outcome (Solomon PTSD [post-traumatic stress disorder] Inventory). ResultsThe mean LOS of terror victims was 218±131 days; for the nonterror group it was 152±114 days (P<.01). In comparison with the control subgroups, the MT subgroup of terrorist victims had significantly longer LOS in the acute care and outpatient rehabilitation departments (P=.06) and the terror TBI subgroup had a longer LOS in outpatient department only (P<.05). The LOS of the SCI patients, both terror victims and control patients, was significantly longer than that of the other 2 subgroups. The difference between FIM value at entry and discharge (ΔFIM) was significantly higher for terror victims than for the controls (41.1±21.6 vs 30.8±21.8, P=.002). This difference was mainly the result of the significantly higher ΔFIM achieved by the terror MT subgroup than by the MT controls. The rate of PTSD was higher among terror victims than among controls (40.9% vs 24.2%, P=.04). The rate of return to previous occupations was similar between terror victims and nonterror patients (53% vs 46.9%, respectively). ConclusionsVictims of terror spent longer periods in rehabilitation than the nonterror group; however, they regained most activity of daily living functions similar to the nonterror group. Despite the higher rate of PTSD, terror victims succeeded in returning to their previous occupations at a similar rate to that of the nonterror group. IN ISRAEL, DEATHS AND INJURIES resulting from acts of terrorism have escalated in the past 6 years. Israel has been attacked by continuing acts of terrorism known as the Al-Aqsa Intifada since late September 2000. Terrorist attacks that occur almost daily include suicide bombings, drive-by shootings, intrusions into homes, and attacks by knives or guns. Each attack leaves behind people whose lives take dramatic turns. Terrorism has claimed the lives of 1 in every 6302 Israelis; 1 in every 943 has been injured. Thus, during this period, 1084 people have been killed and 7633 have been wounded, most have been civilians.1 One in every 300 families has been affected by terrorism through the loss of a loved one or the serious injury of a family member.2 Medical care for victims of earlier periods of terrorism was predominantly for stab wounds, for injuries resulting from being hit by objects such as rocks and stones, and for injuries caused by concealed explosives detonated by remote control.3 The recent eruption of terrorist activity comprises 2 major forms: suicide bomber explosions and gunfire. Such attacks result in injuries that are more complex and severe than those sustained in earlier periods of terror activity.4, 5 Although trauma in general is common among the young, terrorist acts in Israel seem to affect even younger populations. The Israeli population hospitalized as a result of terrorist attacks has a median age of 21 years, significantly younger than the casualties of previously known trauma types.6 This can partly be explained by the locations of many of the acts: restaurants, discos, or other social meeting places, and partly by the presence of young people, especially soldiers in regions of conflict. Several articles5, 6, 7, 8, 9 have compared terror casualties with nonterror patients regarding the severity, outcome, and the use of services in acute care management in Israel. According to recent data, terror victims sustain more severe injuries and have a higher mortality rate than patients with any other form of trauma, which has resulted in ever-increasing demands on health care resources. Their use of health care resources is higher in terms of length of stay (LOS) in hospitals, procedures done in operating rooms, intensive-care treatment, and so on; this is especially true when patients sustain penetrating wounds, which increases the cost of their treatment. Studies10, 11 have shown that 60% of terror victims underwent surgical procedures and one third were admitted to intensive care units. This extra demand on resources resulting from terrorist attacks is a burden on both the health care system and on society in general. There is also a severe psychologic effect on terror victims, their families, and the whole of society.12, 13 The cited studies focused on the acute medical care of terror-related injuries; however, the outcome of long-term care and rehabilitation of terror victims is not well established. The majority (54%) of terror-related injuries were caused by explosions from suicide bombings, while 36% were caused by gunshot wounds.14 The injuries from explosions include blast injury; penetrating trauma resulting from bomb fragments and nails, bolts, and steel pellets embedded in the bomb striking the victim; and blunt trauma sustained when the victim is propelled against an object by the blast wind. The severity of the injuries is increased when the blasts occur in confined spaces as opposed to open spaces. In a recent review of 29 terrorist bombings that collectively produced 8364 casualties,15 the highest mortality rate (24%) was among people in collapsed structures, then among people in confined spaces (8%), and then among those in open areas (4%). In explosions due to terrorist bombs, biphasic distributions—immediate and later in a hospital—of mortality were identified, which contrasts with the triphasic distribution of death described in conventional blunt and penetrating trauma.15 Among these terror victims, the main injuries were penetrating soft tissue injuries, burns, chest blast, and fractures. Gunshots cause more severe penetrating injuries because of the high velocity of the bullets.14 According to Israel’s national trauma registry, 30% of terror victims in general sustained head injuries.4 Comparing blast and gunshot injuries, the rate of traumatic brain injury (TBI) was 18% in blast injuries versus 10% in gunshot injuries. The rate of spinal cord injury (SCI) was 6% in blast injuries versus 5% in gunshot injuries.14 In a recent study of terror victims with gunshot injuries only,16 the overall percentage of head injury was 9.3% and was more frequent among civilian patients than among soldiers. Patients with TBI were more severely injured than terror victims without TBI. The rate of deaths and admissions to intensive care units was also higher among terror victims with TBI. In the pediatric population of terror victims, the TBI rate was 22% and the SCI rate was 5%.8 During wartime, head injuries account for almost half of all combat deaths, while 14% of all wounded survivors have head injuries.17, 18 During the Vietnam War, 9% of all patients admitted to U.S. Army hospitals had spinal cord injuries.19 The practice of physical medicine and rehabilitation (PM&R) has been involved in wars since the turn of the 20th century. Initiation of rehabilitation methods soon after war-related injuries are incurred is well documented in the literature.20, 21, 22, 23, 24 Early rehabilitation intervention was found to be essential in optimizing the care of war casualties and resulted in improved outcomes. The rehabilitation process and resultant outcomes for victims of terrorism have not been described in the literature. In this article, we summarize the rehabilitation outcomes of terror victims treated in a rehabilitation department in Jerusalem between September 29, 2000, and September 1, 2004. Jerusalem has a unique role in the Israel-Palestinian conflict and therefore almost 20% of terror attacks have been committed in that city.25 To our knowledge, this is the first article to report the rehabilitation outcomes of victims of terrorism compared with the outcomes of nonterror-related multiple trauma victims. Methods  This study is a historical prospective chart review of people injured through terrorist acts who were treated from September 29, 2000, to September 1, 2004, in the PM&R department of Hadassah University Hospital in Jerusalem. The hospital is a tertiary care center with both inpatient and rehabilitation day-care facilities. We extracted relevant data from a database containing information about patients discharged from the PM&R department and rehabilitation day-care department over this period. Participants Participants were 72 casualties of terror attacks who were treated in our PM&R department. All patients were screened with brain and spine computed tomography for central nervous system (CNS) involvement on admission to acute care departments. During the same time period, 322 casualties were hospitalized in the same rehabilitation departments because of nonterror-related multiple trauma. For each patient in the terror group, we randomly selected 72 control patients from the nonterror-related multiple trauma group (MT subgroup), matched according to age, sex, and type of injury. In the SCI subgroup, control patients were also selected according to the severity of injury as determined by their American Spinal Injury Association (ASIA) grade26 and level of injury. Inpatient and Outpatient Rehabilitation Program All patients were treated with comprehensive, interdisciplinary inpatient rehabilitation programs directed by a physiatrist in the PM&R department. Terror victims were treated using a goal-directed approach used for multiple trauma patients. Each patient received approximately 3 hours of supervised therapy daily from both physical and occupational therapists. After gaining independence in basic activities of daily living (ADLs), patients were discharged and continued the rehabilitation program as outpatients in our rehabilitation day-care facility, where each received approximately 3 hours of physical and occupational therapy 3 times weekly. During all rehabilitation periods, special attention was given to psychologic and social issues. Each patient was evaluated and treated by a psychologist as needed. A social worker was involved with each patient regarding his/her connection with families, community, and the National Insurance Institute. Data Collection Procedures and Measures The hospitalized patients’ medical data were collected from the trauma registry records and reviewed. The data included: age, sex, injury mechanism, LOS in the acute care departments, type of injury, surgical interventions, and complications. Additional data for TBI patients included their Glasgow Coma Scale (GCS) scores and coma duration, and for the SCI patients, their ASIA grade and level of injury. Data obtained from the rehabilitation records included the following variables: LOS in the rehabilitation departments, functional outcome according to the FIM instrument,27 occupational outcome evaluated by whether the patient returned to his/her previous occupation, and psychologic outcome as estimated by a Revised PTSD (Post-Traumatic Stress Disorder) Inventory28 based on the Brief Symptoms Inventory.29 For TBI patients the variables were the Glasgow Outcome Scale (GOS)30 and the post-traumatic epilepsy rate. All patients were assessed on admission and on discharge from the rehabilitation department and at the end of their stays as outpatients in rehabilitation day care in the same center. Psychologic Outcome We assessed PTSD by asking subjects to describe if and to what degree they had experienced each of the 17 symptoms listed in the Revised PTSD Inventory.28 This questionnaire is aimed at diagnosing PTSD in accordance with the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Text Revision. The Revised PTSD Inventory has high convergent validity based on high correlation with other instruments for PTSD diagnosis.28 We evaluated all subjects through semi-structured interviews. Data collected during the interviews included: historical data (interpersonal, educational and occupational history, psychiatric history, present illness) and mental status data (appearance, speech, attitude toward examiner, mood, affective expression, perception, thought processes, orientation, memory, impulse control, judgment). These evaluations were done at the end of patients’ stay as outpatients in rehabilitation day care. Statistical Evaluation Data were compared between the victims of terror and the nonterror-related patients. Statistical tests included the chi-square for categorical data, t tests for continuous variables, and—to test differences between groups over time—repeated-measures analysis of variance with a between-subjects variable of group (terror vs nonterror) and pathology (multiple trauma, TBI, SCI), and a within-subjects variable of time (rehabilitation entry time, end of in- and outpatient rehabilitation periods). We used SPSS statistical softwarea for data analysis. A value of P less than .05 was considered statistically significant. The SCI subgroup was too small to permit statistical comparison. Results Demographic Data The terror group consisted of 72 terror victims (48 men, 24 women) with multiple trauma, TBI, and SCI. Forty-seven (65%) had multiple trauma without CNS involvement, 19 (26%) had multiple trauma with TBI, and 6 (8%) had multiple trauma with SCI. Their mean age was 30 years (range, 9–76y); the majority was Israeli born and was married. Almost half of the casualties were employed in either blue- or white-collar jobs and the others were soldiers or students. The mean age of the control group was 33 years and demographically they were most similar to the terror group. Only a significantly higher number of students were found in the terror group (table 1). Causes and Characteristics of Injury Most of the terror victims (70%) had blast and penetrating injuries caused by explosions, while 30% had gunshot injuries or wounds inflicted by other types of weapons. The main causes of injury in the control group were motor vehicle collisions and falls from heights. In the MT subgroup, more patients in the control group sustained long bone fractures (47 vs 31, P<.01) whereas more patients in the terror group had vascular lesions and burns (17 vs 6 and 14 vs 0, P<.01, respectively) (table 2). Figure 1 shows examples of the injuries to the terror victims. In the TBI subgroup, there were no differences in the severity of injury as assessed by the GCS and coma duration, but there were more patients in the control group who had long bone fractures (14 vs 6, P<.01). In the SCI subgroup, 4 patients were injured in explosions, 1 by gunfire, and 1 patient had a knife wound. Four SCI patients were severely injured, according to the ASIA scale (ASIA grade A), 1 patient was ranked as ASIA grade B, and 1 was ranked as ASIA grade D. Four SCI patients also had abdominal and chest injuries, 2 had long bone fractures, and 1 had vascular and peripheral nerve injuries. | | |  | | Multiple Trauma | TBI | |
|---|
| Characteristics | Terror (n=47) | Nonterror (n=47) | P | Terror (n=19) | Nonterror (n=19) | P | |
|---|
| Mechanism of injury | | |  Explosions | 34(72.3) | | | 13(68.4) | | | | | Gunshot injuries | 13(27.7) | | | 4(21.1) | | | | | Stone/knife | | | | 2(10.5) | 1(5.3) | | | | MVC | | 41(87.3) | | | 13(68.4) | | | | Fall from height | | 6(12.7) | | | 5(26.4) | | | | Long bone fracture | 31 | 47 | <.01 | 7 | 17 | <.01 | | | Vascular lesions | 17 | 6 | <.01 | 6 | 2 | .11 | | | Burns | 14 | 0 | <.01 | 1 | 0 | .31 | | | Traumatic amputation | 3 | 0 | .10 | 1 | 0 | .31 | | | Peripheral nerve injury | 23 | 17 | .10 | 4 | 5 | .70 | | | Abdominal injury | 8 | 3 | .10 | 3 | 4 | .67 | | | Chest injury | 11 | 4 | .04 | 8 | 6 | .50 | | | GCS score | NA | NA | | | | .20 | | | 3–8 | | | | 12 | 6 | | | | 9–12 | | | | 2 | 6 | | | | 13–15 | | | | 5 | 7 | | | | Coma duration (d) | | | | 7.0±8.7 | 8.1±12.4 | .76 | | | | |
Length of Hospitalization in Different Departments The mean total LOS of all terror victims was longer than for nonterror controls (218±131d vs. 152±114d, P<.01). The LOS of all terror victims in acute care departments and in the rehabilitation outpatient department was significantly longer than that of the nonterror patients (P=.01, P=.001, respectively) (fig 2). In the MT subgroup, the mean total LOS in rehabilitation of terror victims was longer than that of the nonterror patients but did not reach statistical significance (211±142.9d vs 115±67.2d, P=.26). The LOS in the rehabilitation inpatient department was similar for all the patients. The LOS of the terror group in acute care departments and in the rehabilitation outpatient department was, however, significantly longer than that of the nonterror patients (P=.06) (table 3). In the TBI subgroup, the mean LOS in the outpatient department was significantly longer than that of the nonterror patients (P<.05) (see table 3). In both terror victims and nonterror patients, there was a strong inverse correlation between the severity of injury according to the GCS and total LOS (Pearson r=−.42, P<.05). There was no difference in LOS between terror and nonterror patients in any period in the SCI subgroup (see table 3). The number of SCI patients was too small to detect any significant correlation between ASIA grade or level of injury and LOS. In comparing the 3 subgroups, we found no significant difference between LOS of the MT subgroup and the TBI subgroup of terror or nonterror patients. LOS of the SCI subgroup was significantly longer than that of the TBI subgroup (P=.03) and the MT subgroup (P=.003), both for terror victims and the control patients (see table 3). There was no statistically significant correlation between any of the demographic variables and LOS in the different departments. ADL Function The mean total FIM score of all terror victims at the start of their rehabilitation was lower than that of nonterror patients but did not reach statistical significance (78.9±32 vs 86.5±22, P=.099). The mean FIM score on entry into rehabilitation did not differ significantly (table 4) between the 3 subgroups of terrorist victims. | | | | | MT | TBI | SCI | Total | |
|---|
| FIM | Terror (n=47) | Nonterror (n=47) | Terror (n=19) | Nonterror (n=19) | Terror (n=6) | Nonterror (n=6) | Terror (n=72) | Nonterror (n=72) | |
|---|
| FIM entrance | 80±6.6⁎ | 90±20.9⁎ | 78.2±27.0 | 83.0±23.4 | 74.1±13.0 | 71.6±18.1 | 78.9±32 | 86.5±22 | | | FIM inpatient | 106±13.4 | 100±20.4 | 107±16.6 | 110±12.5 | 97.0±19.6 | 109.1±12.3 | 105.5±12.8 | 103.6±12 | | | FIM outpatient | 122±4.35 | 114±18.0 | 119.5±12.4 | 120.6±4.9 | 108.0±12.2 | 112.0±11.8 | 120±8.5⁎ | 115.4±6.6⁎ | | | | |
In the MT subgroup, the mean FIM score at admission to the rehabilitation inpatient department was significantly lower for the terror patients than for the nonterror patients (P<.01). In the TBI and SCI subgroups, the mean FIM score at admission was similar for both the terror patients and the nonterror patients (see table 4). All 3 subgroups (MT, TBI, SCI) showed significant improvement in mean total FIM value during all rehabilitation periods (P<.01). Figure 3 shows the change in mean total FIM value (ΔFIM) for all patients and the 3 subgroups. The total ΔFIM of terror victims was significantly higher than that of the nonterror patients (41.1±21.6 vs 30.8±21.8, P=.002). In the MT subgroup, there was a significant increase in ΔFIM for the terror victims in comparison with the nonterror patients (42 ±6.0 vs 24.0±23.2, P<.01). This change was significantly greater in favor of the terror victims in both inpatient and outpatient rehabilitation periods (data not shown). In the TBI subgroup, there was a significant improvement in the ΔFIM between the start and the completion of rehabilitation in both terror and nonterror patients without a significant difference between them (terror TBI victims, 41±25.3 points; nonterror TBI patients, 37±22.8 points). In the SCI subgroup, there was a significant improvement in ΔFIM from entry to completion of rehabilitation in both terror and nonterror patients without a significant difference between them (34±6.7 vs 41±10.8). The mean total FIM at the end of rehabilitation period was significantly higher among terror victims than nonterror patients (P<.001) (see table 4). There was a strong correlation between FIM at entry into rehabilitation and the total LOS; lower FIM at entry was related to longer total LOS and vice versa. In all TBI patients, there was a strong correlation between the severity of injury according to the GCS and the mean FIM value at admission (data not shown; r=.54, P<.01). There was no correlation between any of the demographic data and ADL functions at the end of each of the rehabilitation periods. Psychologic Outcome Among all terror victims, 40.9% developed symptoms of PTSD according to the Solomon PTSD Inventory,28 as opposed to only 24.2% in the nonterror group (P=.04). This difference was profound in the terror MT subgroup, in which 19 (40%) developed PTSD symptoms as compared with 8 (17%) patients in the nonterror group (see table 5). This difference was significant (P<.01) and reflects the more psychologic impact of the injury on the victims of the terrorist attacks. In the TBI subgroup, 8 (42.1%) patients (including both terror and nonterror patients, developed PTSD symptoms. In the SCI subgroup, 3 (50%) of each group (terror and nonterror patients) developed such symptoms (data not shown). Other psychologic symptoms such as anxiety and depression were more prevalent among the terror group (data not shown). There was a correlation between the occurrence of PTSD and the LOS in the outpatient rehabilitation department. Patients with PTSD stayed 58±22 days longer in outpatient rehabilitation than did patients without PTSD symptoms (P<.01). We found no correlation between the presence of PTSD and rehabilitation outcome, and there was no correlation between any of the demographic data and the psychologic outcome. Occupational Outcome Among all terror victims, 53% returned to their previous occupation, compared with 46.9% in the nonterror group (not significant) (see table 5). There was no difference in the MT subgroup in the rate of return to previous occupations; however, in the TBI subgroup, the rate of return of terrorist victims was significantly higher than that of the nonterror patients (47.3% vs 15.7%, P=.05) (see table 5). Four of the 6 SCI terrorist victims returned to their previous occupations. There was no correlation between FIM at entry or at discharge, total LOS, the occurrence of PTSD symptoms, and the rate of return to previous occupations. There was no correlation between any of the demographic data and the rate of return to previous occupations. Discussion Our study found that although victims of terrorism sustained more severe injuries than did those subjects in the nonterror group, their functional outcome after rehabilitation period was similar. The mean total FIM score of terror victims on entry into rehabilitation was lower than nonterror patients, which reflects the severity of their injuries. However, the mean FIM score of terror victims at the end of the rehabilitation period was significantly higher than the nonterror group. Therefore, terror victims achieved significantly greater change in FIM score during the rehabilitation period. This functional improvement was acquired during a significantly longer stay of terror victims in rehabilitation departments. Terror victims had a high prevalence of psychologic complications (mainly PTSD), however, the majority returned to their previous occupations. Mechanisms of the Injury in Terror Victims and Its Influence on Rehabilitation Parameters Explosions were the cause of injury to most of our terrorist victims (70%), while the other 30% sustained gunshot wounds or were injured by other types of assault. This rate was similar in all 3 subgroups of injuries: MT, TBI, and SCI. This distribution in our group was similar to data from the Israel National Trauma Registry,4, 14 which shows that 54% of casualties were injured by explosions and 36% by gunfire. Injuries from explosions include blast injuries, penetrating trauma, and blunt trauma, whereas bullets travel at a higher velocity and therefore cause more severe penetrating wounds. In a comparison of the 2 mechanisms, Peleg et al14 found a higher death rate in the group with gunshot wounds, whereas injury severity and LOS were greater in the group injured by explosions. In our group, however, we did not find any difference in rehabilitation outcome parameters between explosion and gunshot victims (data not shown). Severity of the Injury in Terror Victims and Its Influence on Rehabilitation Parameters It is well known that the severity of an injury is greater in terror victims than in nonterror-related trauma.3, 4, 5, 6, 7 Victims of terror-inflicted injuries have a high Injury Severity Score (30% >16), a high rate of intensive care unit admissions (22.8% in Israel), and have a more prolonged hospital course and higher mortality than victims of any other form of trauma.3, 4, 5, 6, 7 Therefore it was not unexpected that the mean total FIM score of terror victims on entry into our rehabilitation department was lower than it was for nonterror patients. This finding, however, reflected the lower FIM at entry of the MT subgroup only. As in previous studies, our terror MT subgroup spent a longer period (32d vs 18d) in acute care units than did the nonterror controls. The extended stay in acute care is known to correlate with a higher rate of complications, including bed sores, infections, respiratory complications requiring tracheotomies, anemia, and more.9 These factors may explain why terrorist victims in the MT group started the rehabilitation program with lower functional ability as reflected in their lower FIM values of 80, versus 90 for nonterror victims. Terror victims also had more penetrating injuries, such as chest and abdominal injuries, vascular lesions, peripheral nerve lesions, and amputations. These complications led to more infections, soft tissue injuries, and neurologic complications, and therefore prolonged the LOS of terror victims in rehabilitation. Another unique injury to terror victims is the burns caused by the explosions. The rehabilitation of burn patients is cumbersome and prolonged. Surprisingly, the other 2 groups of terror victims, TBI and SCI, spent similar periods in acute care departments and had FIM values at entrance to rehabilitation that were similar to those of the corresponding nonterror groups. We can explain this in TBI patients by the similar severity of injury, according to the GCS, and the similar coma duration of the 2 groups. There were also less general complications such as long bone fractures in the terror TBI group as compared with the nonterror group, which may be because of the different causes of the injuries. As previously noted, the SCI group of terrorist victims was too small to permit statistical analysis. Age and Sex of Terror Victims and Their Influence on the Rehabilitation Parameters Two parameters are characteristic of the population of terrorist victims: younger age and male predominance.7 We found the same demographic parameters in our population. The mean age of our terror victims was 28 years, which is similar to the mean age (21y) of all terror victims in Israel, and significantly younger than the mean age of other trauma victims in Israel.4, 6 More that half (56.9%) of our patients were between the ages of 15 and 29 years—similar to data reported by Peleg et al,4 in which 62% of all terror victims in Israel were between the ages of 15 to 29. These data differ from the ages of general trauma patients, in which there are 3 equally distributed groups: children (0−14y), adolescence (15−29y), and older patients (>60y).4 This difference reflects the small numbers of children and elderly among the terrorist victims. In our group, 66.7% of the casualties were male, which is similar to the male predominance of 75% in all terror victims in Israel; this is partially because of the high number of soldiers, 19.1% in our group and 19% of all terror victims in Israel.4 It is known that younger people have better rehabilitation outcomes than older people,31 which can influence the overall better outcomes of terror victims. This was not the case in our study, however, because we chose a control group similar in age to the terror victims. Type of Injury and Its Influence on Rehabilitation Parameters In our group, 47 (65%) of 72 patients had multiple traumas without CNS involvement, 19 (26%) had multiple traumas with TBI, and 6 (8%) had multiple traumas with SCI. The rate of CNS involvement is similar to the rate in the overall population of terrorist victims in Israel, including adults and pediatric populations,8, 14 and is higher than the rate among the victims of terrorist activities around the world.15 In rehabilitation, our subgroup of SCI terrorist victims, as well as our control subgroup, spent a longer time in the inpatient department than did the 2 other subgroups and therefore the overall LOS of the SCI subgroup was significantly longer (see table 4). This need for a longer inpatient rehabilitation period for SCI patients is well known because of the nature of the injury and its longer rehabilitation processes.32 The LOS in rehabilitation departments of our SCI terrorist victims, 264 days, was similar to the LOS of all traumatic SCI patients in Israel.32 The inpatient and the overall LOS in rehabilitation of our terror TBI subgroup were longer than the MT subgroup but did not reach statistical significance. Similarly, there was no prolonged LOS in rehabilitation reported in other studies that compared TBI patients with patients with other injuries.33, 34 Even in patients with comorbidity of SCI and TBI, there was no prolonged LOS.35 Our 3 subgroups started the rehabilitation period with similar functional abilities, according to their initial FIM values, and improved significantly during rehabilitation. The ΔFIM of the SCI subgroup, however, was lower than the ΔFIMs of the MT and TBI subgroups, which is similar to the ΔFIMs of nontraumatic SCI patients found in other studies.36, 37 The ΔFIM values of all our TBI patients were similar to those reported in previous studies.37 Unique Rehabilitation Progress of Terror Victims Terror victims started rehabilitation later because they were in acute care longer as a result of their more severe injuries. The severity of their injuries and their extended stay in acute care departments contributed to their lower levels of function, as measured by their lower FIM values, at the start of their rehabilitation. This delay in beginning rehabilitation, however, did not influence their rehabilitation outcome. On the contrary, as inpatients they gained a significantly higher ΔFIM in the same period of time. The reason for this marked improvement is not clear, because they received the same quantitative treatment by the same treating personnel as did the nonterror group. One possible explanation is the floor effect: terror victims improved more because they started with lower FIM values. Being terror victims in Israel, however, means that they were supported by many public and volunteer organizations. From the outset, they were treated by psychologists and social workers and had the close support of their families and relatives. We also think that given the sensitivity of Israeli citizens to the problem of terrorism, even our teams subconsciously pay more attention to terror victims and give them more quality treatment. The LOS was similar between the 2 groups as inpatients, but terrorist victims spent a significantly longer time in rehabilitation as outpatients. One of the reasons is that Israel’s National Insurance Institute finances the treatment of terror victims, which makes possible an adequate period of rehabilitation treatment. This prolonged stay enabled patients to attain their rehabilitation goals, including regaining almost normal function in ADLs (FIM 120) and a return to their previous occupations. Therefore, although they were severely injured, 53% of terror victims returned to their previous occupations, a percentage similar to that of the less injured nonterror victims, which is a reflection of Israel’s unique support system for terrorist victims. Psychologic and Occupational Outcome of Terror Victims A review of the literature indicates that PTSD is the most common psychiatric disorder after traumatic experiences, including those resulting in physical injuries. In previous studies, the prevalence of PTSD symptoms after regular trauma varied between 9% and 46%.38 Numerous studies12, 39, 40, 41, 42 of psychologic reactions to terrorist attacks were conducted in the United States and in Israel in recent years. These studies reported findings of acute PTSD and distress symptoms in many of the people exposed to those attacks. The rate of PTSD in survivors of the September 11, 2001, attacks on the United States varied between 7.5% in 1 study39 to 17% at 2 months and 5.8% at 6 months in the other.40 Terror victims have a higher risk of developing chronic psychologic disorders. According to a prospective study of post-traumatic stress in 70 victims of the terrorist attacks in a Paris subway in December 1996, 41% met PTSD criteria at 6 months; 34.4% still had PTSD after 18 months.43 In a prospective evaluation of the prevalence of PTSD in terror victims in Israel, 39 survivors had higher rates of PTSD than did 354 survivors of motor vehicle collisions (37.8% vs 18.7%).44 Similarly, in our study, 40.9% of 72 terror victims had PTSD symptoms compared with only 24.2% of the nonterror victims. We found no differences in the rates of PTSD in the 3 subgroups of terrorist victims. It is unknown how PTSD symptoms influence the rehabilitation outcome of victims of terror. In a study of survivors of the Oklahoma City bombing,45 people with PTSD reported widespread social and occupational dysfunction. For example, 52% of those with PTSD only and 87% of those with PTSD and a comorbid psychiatric diagnosis reported some type of functional interference, compared with 27% of those with a non-PTSD diagnosis and 16% of those with no psychiatric diagnosis.45 Surprisingly, in our study the presence of PTSD symptoms did not have a negative impact on functional outcome as measured by the FIM or on occupational outcome. One reason is that most of our patients had only a partial form of PTSD, according to Solomon criteria,28 and therefore it did not affect their functional abilities. Another reason is that psychologists and social workers closely followed these patients, beginning with the very early stages of their injuries. Patients with PTSD spent a significantly longer period in outpatient rehabilitation facilities. The continuing psychologic support required for a gradual return to previous occupations was partly responsible for this prolonged period. In our study, the rate of return to a previous occupation was similar between all terror victims and nonterror patients. Only the control TBI subgroup showed a lower rate of return to previous occupation (15.7%). This rate is similar to rates found in other studies46 that showed that less than 30% of TBI patients returned to work. The unexpected and encouraging finding in our study was the high rate (47.3%) of terrorist victims in the TBI subgroup who returned to their previous occupations. We speculate that this result was achieved because of the special attention given to social and psychologic issues in the rehabilitation of terror victims and to the prolonged treatment in the rehabilitation outpatient facility. During this period they were already being supported by representatives of the National Insurance Institute, who helped them to return to their previous occupations, even if only on a part-time basis. Conclusions Terror victims usually recovered from their injury after a long rehabilitation period. They regained most ADL functions and more than 50% returned to their previous occupations, probably because of the multidisciplinary rehabilitation approach that included intensive psychologic and social support. Our study emphasizes the importance of a multidisciplinary approach to the rehabilitation of victims of terror and of allowing an adequate period for recovery. Our study included only patients hospitalized in 1 institution in Israel. We did not measure quality of life or patient satisfaction and we lack follow-up data for periods longer than 1 or 2 years after injury. There is a need for further studies that would include national survey data for longer periods of time, including measures of quality of life and additional psychologic follow-up. Terror attacks have a severe impact on the lives of the injured, their families, and the whole of society. 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46. 46Yasuda S, Wehman P, Targett P, Cifu DX, West M. Return to work after spinal cord injury: a review of recent research. NeuroRehabilitation. 2002;17:177–186. MEDLINE a Department of Physical Medicine and Rehabilitation, Hadassah University Hospital, Jerusalem, Israel b Physical Therapy Department, School of Health Professions, Tel-Aviv University, Ramat-Aviv, Israel.  Correspondence to Zeev Meiner, MD, Dept of Physical Medicine and Rehabilitation, Hadassah University Hospital, POB 24035, Mount Scopus, Jerusalem, 91420, Israel
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 author(s) or upon any organization with which the author(s) is/are associated. Reprints are not available from the author. PII: S0003-9993(07)00002-0 doi:10.1016/j.apmr.2007.01.001 © 2007 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved. | |
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