Characteristics and Rehabilitation Outcomes Among Patients With Blast and Other Injuries Sustained During the Global War on Terror

Article Outline

• Abstract
• Methods
  • Sample
  • Measures
  • Statistical Analyses
• Results
  • Descriptive Findings
  • Improvement in Cognitive and Motor Functioning
  • LOS and FIM Efficiency
  • Mortality
• Discussion
  • Study Limitations
• Conclusions
• Acknowledgment
• References
• Copyright

Abstract 

Sayer NA, Chiros CE, Sigford B, Scott S, Clothier B, Pickett T, Lew HL. Characteristics and rehabilitation outcomes among patients with blast and other injuries sustained during the Global War on Terror.

Objective

To describe characteristics and rehabilitation outcomes among patients who received inpatient rehabilitation for blast and other injuries sustained in Iraq and Afghanistan during the Global War on Terror.

Design

Observational study based on chart review and Department of Veterans Affairs (VA) administrative data.

Setting

The 4 VA polytrauma rehabilitation centers (PRCs).

Participants

Service members (N=188) admitted to a PRC during the first 4 years of the Global War on Terror for injuries sustained during Operation Iraqi Freedom or Operation Enduring Freedom.

Intervention

Multidisciplinary comprehensive rehabilitation program.

Main Outcomes Measures

Cognitive and motor FIM instrument gain scores and length of stay (LOS).

Results

Most war-injured patients had traumatic brain injury, injuries to several other body systems and organs, and associated pain. Fifty-six percent had blast-related injuries, and the pattern of injuries was unique among those with injuries secondary to blasts. Soft tissue, eye, oral and maxillofacial, otologic, penetrating brain injuries, symptoms of post-traumatic stress disorder, and auditory impairments were more common in blast-injured patients than in those with war injuries of other etiologies. The mechanism of the injury did not predict functional outcomes. LOS was variable, particularly for those with blast injuries. Patients with low levels of independence at admissions made the most progress but remained more dependent at discharge compared with other PRC patients. The rate of gain was slower in this low-functioning group.

Conclusions

Blasts produce a unique constellation of injuries but do not make a unique contribution to functional gain scores. Findings underscore the need for assessment and treatment of pain and mental health problems among patients with polytrauma and blast-related injuries. Patients with polytrauma have lifelong needs, and future research should examine needs over time after community re-entry.

Key Words: Brain injuries, Length of stay, Outcome assessment (health care), Rehabilitation

AMERICA’S ARMED FORCES are sustaining new and complex patterns of injuries during the Global War on Terror.¹, ², ³ As of July 6, 2007, 27,919 service members had sustained nonmortal injuries during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) (in and around Afghanistan), and 12,772 (46%) of these soldiers did not return to duty within 72 hours, presumably because of the severity of their injuries.⁴ In this era of modern warfare, the majority of combat injuries are blast related.⁵, ⁶, ⁷ In combat, sources of blast injury include artillery, rocket and mortar shells, mines, booby traps, aerial bombs, improvised explosive devices (IEDs), and rocket-propelled grenades (RPGs). The severity and pattern of blast injuries depends on the explosive composition and amount of material involved, surrounding environment, delivery method, distance between the victim and the blast, and presence of intervening protective barriers or environmental hazards.⁸ More soldiers are surviving beyond the acute phase of blast injuries because of improvements in body armor and acute trauma care.², ⁹ Consequently, the Department of Defense and Department of Veterans Affairs (VA) are providing medical care to soldiers with combat injuries who may have died in previous wars.

The 4 basic mechanisms of blast injury are termed primary, secondary, tertiary, and quaternary.³ Primary injuries occur secondary to a high-order overpressurization shock wave moving through the body. This wave affects gas-filled organs such as the lungs, gastrointestinal tract, and middle ear. These injuries are not necessarily obvious. Secondary injuries are caused by bomb fragments and other objects propelled by the explosion. These result in penetrating injuries. Tertiary injuries result from the blast wind (not the overpressurization shock wave) throwing the victim and can include bone fractures and traumatic amputation. Quaternary injuries are those not included in the first 3 classes, such as burns, crushing injuries, and respiratory injuries. It is not surprising that blast injuries are often polytraumatic, meaning that they impact more than 1 body system or organ, given the various mechanisms of injury.¹⁰

It has been estimated that over 60% of blast injuries result in traumatic brain injury (TBI),¹, ¹¹ and, for this reason, TBI is often referred to as the “signature injury” in the Global War on Terror.¹² Recognizing that new systems of care are needed to meet the rehabilitation needs and to optimize functional outcomes among service members with TBI in the context of polytraumatic injuries, the U.S. Congress passed public laws number 108-422 (§302) and 108-447 and the secretary of the VA designated 4 polytrauma rehabilitation centers (PRCs) (located in Minneapolis, MN; Palo Alto, CA; Richmond, VA; Tampa, FL) to provide specialized rehabilitation treatment and expand clinical expertise in polytrauma throughout the VA.¹³, ¹⁴ The majority of the war injured do not require the level of specialized inpatient treatment PRCs provide. However, to meet the needs of the war-injured patients who do present with polytrauma and TBI, clinicians and policy-makers within and outside the VA need evidence-based information about the PRC patient population.

There are no prior published studies that have examined health service use or needs of war-injured service members, let alone those whose injuries are severe enough to warrant intensive inpatient rehabilitation at a PRC. This study helps to fill this knowledge gap. Specifically, the purpose of this study was to describe the characteristics and rehabilitation outcomes of patients treated for TBI with polytrauma and other combat injuries in the VA’s 4 PRCs. Prior research based on samples of people who endured TBI as part of civilian life have identified factors associated with favorable outcomes, including younger age,¹⁵, ¹⁶, ¹⁷, ¹⁸ higher functional status at admission,¹⁸ higher preinjury education,¹⁹, ²⁰ and a shorter injury to treatment interval.¹⁸, ²¹ In contrast, TBI of violent etiology,²² nonwhite race,²³ preinjury substance use,²⁴ post-TBI mood disorders,²⁵ and the presence of comorbid conditions²⁶ are negatively associated with outcome. Many of these same factors have been associated with the length of stay (LOS) in prior studies, including functional status at admissions, age, days from injury to admissions,¹⁸ and nonwhite race.²⁷ Additionally, it is well known that rehabilitation processes and outcomes vary by facility.¹⁸ Two important questions are (1) whether these same factors are predictive of rehabilitation outcomes among OIF and OEF combat injured, and (2) whether those with blast-related combat injuries have similar or different outcomes compared with those with non–blast-related combat injuries. This retrospective observational study addresses the following specific questions: (1) What are the sociodemographic characteristics of PRC patients who sustained injures during the Global War on Terror? (2) Do blasts produce a unique constellation of injuries and impairments relative to other mechanisms of injury? (3) What are the levels of recovery in functioning among those injured during OIF or OEF? Do levels of recovery vary by mechanism of injury? (4) What is the average LOS among PRC patients injured during the Global War on Terror? Does LOS vary by mechanism of injury? and (5) What is the rate of mortality among PRC patients injured during the Global War on Terror? Does mortality vary by mechanism of injury?

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Methods 

We obtained institutional review board (IRB) approval for this study from the VA and university IRBs associated with each PRC.

Sample 

The sample consists of all service members injured as part of OEF or OIF who received VA inpatient rehabilitation services at a PRC during the first 4 years of the Global War on Terror (October 2001 through January 2006). The PRCs treated 566 post–Vietnam era patients during this time period, the vast majority of whom were active duty. Chart review of each of these cases revealed that 188 patients were injured in the Iraq or Afghanistan war zone and hence were included in this study. The other patients had sustained injuries after deployment in Iraq or Afghanistan or during other active duty assignments.

Measures 

Trained master’s and doctoral-level chart reviewers extracted from the VA electronic medical records patient sociodemographic characteristics, injury date, etiology and types, pre-VA hospitalization surgeries including craniotomies and craniectomies, and impairment and treatment information by using a structured chart extraction form. The chart reviewers read all notes for each case to obtain the required data elements. Impairments in body structures and organs were categorized according to the classifications used by the International Classification of Functioning, Disability and Health of the World Health Organization.²⁸ Accordingly, pain and psychiatric symptoms were classified as functional impairments. Psychiatric symptoms abstracted from the medical records included post-traumatic stress disorder (PTSD), anxiety disorders other than PTSD, depression, and psychosis. Patients with psychiatric symptoms were grouped together for the purpose of the analyses presented later. Because the study goals included comparing the effects of blast-related injuries to the effects of other mechanisms of injury, we created 2 groupings of injury etiology: blast and other. Blast-related injuries were those injuries related to explosions including IEDs, RPGs, hand grenades, mortar, and bombs. Other mechanisms of injury included vehicular, bullet, and falls (table 1).

Table 1. Characteristics of PRC Patients Injured During the Global War on Terror

Background Characteristics	Values
Age (y)
Mean ± SD	28±9
Median	25
Minimum	19
Maximum	64
Sex, n (%)
Women	6(3)
Race, n (%)
Nonwhite⁎	56(30)
Education, n (%)
High school or equivalent	96(53)
Some college	60(33)
Associates degree or greater	25(14)
Marital status at admission, n (%)
Single never married	85(45)
Married	93(49)
Divorced/separated/widowed	10(5)
Military branch, n (%)
Army	120(64)
Marines	53(28)
Air Force/Navy	15(8)
Military component, n (%)
Active duty	139(74)
Reserves/National Guard	49(26)
Deployment location, n (%)
Iraq	182(97)
Afghanistan	6(3)
Mechanism of Injury, n (%)
Blast†	106(56)
Other‡	82(44)
Surgeries before VA admission	172(92)
Craniotomy or craniectomy	105(56)
Characteristics of PRC stay
Admissions source, n (%)
MTF	159(85)
Other	29(15)
Injury to VA admissions time interval (d)
Mean ± SD	86.76±119.11
Median	45.50
Minimum	13
Maximum	730
LOS (d)
Mean ± SD	39.09±34.23
Median	29
Minimum	3
Maximum	230
Discharge disposition, n (%)
Home or military base	119(64)
Other inpatient programs§	26(14)
MTF	24(13)
Residential day program	12(6)
Nursing home	6(3)
FIM scores
Mean motor FIM ± SD
Admit	59.61±29.48
Discharge	75.43±24.40
Gain	15.82±18.18
Mean cognitive FIM ± SD
Admit	22.14±10.06
Discharge	27.90±8.41
Gain	5.73±5.87
Mean FIM total ± SD
Admit	81.75±37.81
Discharge	103.30±31.89
Gain	21.55±22.01

NOTE. N equals 188 except for education (n=181) because of missing data; LOS and discharge location (n=187) because of 1 death during the inpatient stay; FIM (n=179) because of 1 death and 8 patients having missing admissions and/or discharge FIM scores.

Abbreviations: MTF, military treatment facility; SD, standard deviation.

Function was measured with the FIM instrument, which is to be completed within 72 hours of admissions and discharge.²⁹ FIM data are stored within the Functional Status Outcomes Database (FSOD) for all VA rehabilitation patients. All VA rehabilitation clinicians, including PRC providers, submitting data to the VA Uniform Data System are credentialed in the use of the FIM. The FIM is a 2-dimensional instrument consisting of 13 motor items and 5 cognitive items.³⁰ The LOS was identified through the FSOD and verified through chart review. Mortality during the inpatient stay and after discharge was obtained from a VA administrative database, and the cause of death was obtained by chart review.

Statistical Analyses 

Pearson chi-square, Fisher exact, and Wilcoxon rank-sum tests were used to determine whether the injuries and impairments differed by mechanism of injury. To identify predictors of cognitive FIM gain, motor FIM gain, and LOS, we developed multiple regression models. First, based on our research goals and prior studies we identified predictors to force into the regression models. These variables were age, race (white, nonwhite), PRC site, and mechanism of injury (blast, other). Next, we conducted bivariate analyses to identify other potential predictors. Variables of interest for the cognitive and motor FIM gain models included the respective baseline FIM values, LOS, education (high school, some college, associate’s degree, or greater), number of injuries, days between injury and acute rehabilitation, psychiatric symptoms (yes, no), marital status (married, not married), and history of craniotomy or craniectomy (yes, no). Variables of interest for the LOS model were the same, except that we used the total FIM score as a predictor rather than cognitive and motor FIM scores as 2 individual predictors because these 2 variables correlated highly with each other in patients with TBI¹⁸ and that LOS was a dependent rather than an independent variable. Potential predictors were entered into the multiple regression models if they exhibited at least some (P<.20) association with the outcome (FIM cognitive gain, FIM motor gain, or LOS) in bivariate analyses. After selecting the pool of potential predictors, we used backward elimination to obtain more parsimonious models, retaining only those variables that exhibited an association of P less than .20 with the outcome and the 4 forced variables. We used this criterion (P≤.20) for variable selection because much of the bias in the significance testing algorithms used for variable selection can be prevented by increasing significance levels beyond conventional values.³¹ We used a likelihood ratio test to verify that our final model included the important independent variables.

The Tukey multiple-comparison procedure was used to compare least-square means when omnibus tests were significant. Because some cases had missing data, the N values for the final cognitive FIM gain, motor FIM gain, and LOS models were 172, 179, and 179, respectively. Additionally, we used a natural logarithm transformation of age, LOS, and days from injury to admission because the values were positively skewed.

The fit of the final model was evaluated by using standard diagnostic residual plots, and influential observation indicators such as leverage, Cook’s distance, and difference in fit standardized.

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Results 

Descriptive Findings 

Demographic and descriptive statistics for the sample are presented in table 1. The modal patient was a white male Army service member deployed to Iraq from active duty status and admitted to a PRC from a military treatment facility who had surgeries before his PRC admissions, of which craniotomy or craniectomy was the most common. Fifty-six percent of the 188 PRC patients had blast-related combat injuries. There was considerable variation in the time from injury to admissions and in the LOS. Most patients were discharged to their homes or back to a military base. Compared with those with other types of injuries, service members with blast injuries were more likely to have served in the Marines ( test=7.10, P=.029) and to be nonwhite ( test=4.45, P=.035). There were no other sociodemographic differences by mechanism of injury.

Table 2 lists the injured body structures or organs by mechanism of injury. Not surprisingly, given that the PRCs were established to provide comprehensive rehabilitation for service members with brain injuries, almost all PRC patients had primary brain injuries. The presence of lesions was confirmed for 156 of the 175 patients with structural imaging (eg, a computed tomography scan).

Table 2. Patterns of Injury by Injury Mechanism

Injured System or Structure	Mechanism of Injury		Significance of System or Structure Between-Group Difference
	Blast⁎ (n=106)	Other† (n=82)
Brain injury	102(96)	81(99)	NS
Type of brain injury			<.001
Closed	43(42)	57(70)
Penetrating	59(58)	24(30)
Shrapnel remaining in brain	25(25)	10(12)	<.05
Skin or soft tissue	79(75)	30(37)	<.001
Burns	14(13)	3(04)	<.05
Wounds	76(72)	27(33)	<.001
Orthopedic	59(56)	44(54)	NS
Fracture	48(45)	38(46)	NS
Amputation	10(09)	2(02)	<.10
Oral/maxillofacial	54(51)	27(33)	<.05
Eye	50(47)	21(26)	<.01
Otologic	49(46)	19(23)	<.01
Peripheral nerve	37(35)	25(31)	NS
Respiratory/pulmonary	22(21)	18(22)	NS
Cardiovascular	19(18)	15(18)	NS
Gastrointestinal	8(08)	5(06)	NS
Spinal cord injury	3(03)	4(05)	NS
Speech/voice	1(01)	0(0)	NS
Spleen	5(05)	3(04)	NS
Genitourinary	0(00)	4(05)	<.05
No. of injuries (/16)
Median	5	4	<.001
Mode	5	4
Minimum	1	1
Maximum	9	8

NOTE: Values are n (% of N) except for closed, penetrating, and shrapnel temaining, where the denominator is the number of patients with brain injuries.

Abbreviation: NS, not significant.

Most (n=169) of the 188 PRC patients sustained injuries to more than 1 body structure or system. Blasts impacted more body systems and/or organs than other mechanisms of injury. Soft-tissue, eye, oral and maxillofacial, otologic, and penetrating brain injuries were more common in blast-injured patients than in those with war injuries of other etiologies. Genitourinary injuries were less frequent in patients with blast-related injuries.

In table 3, impairments that were the focus of rehabilitation are listed in order of prevalence among patients with blast-related injuries. The median number of impairments across the sample was 6. There was a trend for patients with blast injuries to have more impairments than patients with injuries of other etiologies (Wilcoxon z=1.85, P=.06). Pain was the second most common impairment. Psychiatric symptoms were documented in 57% of the sample. PTSD symptoms were more common among those with blast compared with injuries of other etiologies. Auditory impairments were more common in blast-injured patients.

Table 3. Patterns of Impairment by Injury Mechanism

Impairment‡	Mechanism of Injury		Significance of Between-Group Difference
	Blast⁎ (n=106)	Other† (n=82)
Cognition	93(88)	76(93)	NS
Pain	88(83)	65(80)	NS
Balance/equilibrium	72(68)	51(62)	NS
Motor functioning	66(62)	53(65)	NS
Sleep	64(60)	47(57)	NS
Seeing	61(58)	38(46)	NS
Auditory	59(56)	27(33)	<.01
Hearing loss	51(48)	27(33)	<.05
Tinnitus	28(26)	10(12)	<.05
Communication	53(50)	40(49)	NS
Mental health symptoms	65(61)	43(52)	NS
Depressive symptoms	39(37)	29(36)	NS
PTSD symptoms	45(42)	20(24)	<.01
Other anxiety symptoms	28(26)	20(24)	NS
Psychotic symptoms	4(4)	3(4)	NS
Swallowing/chewing	34(32)	22(27)	NS
Bowel/bladder	29(27)	22(27)	NS
Behavior	28(26)	18(22)	NS
No. of impairments (/12)			<.10
Median	6	5.5
Mode	8	6
Minimum	2	1
Maximum	11	10

Improvement in Cognitive and Motor Functioning 

The final model predicting cognitive FIM gain had an F value of 10.36 (P<.001), with an R² of .44. Predictors included in the cognitive FIM gain model were admissions cognitive FIM, LOS (logged), days from injury to admissions (logged), education, the presence of psychiatric symptoms, and the forced variables (age [logged], race, PRC site, mechanism of injury). Greater cognitive independence at admissions was associated with less improvement (F_1,159=21.75, P<.001). This variable made the greatest contribution to the explained variance in the outcome (R²=.32). Earlier acute rehabilitation intervention, higher education, and, surprisingly, the presence of psychiatric symptoms were positively associated with cognitive FIM gain scores (all P<.05). The other predictors were not associated with this outcome after adjusting for the other variables in the model.

The final model predicting motor FIM gain had an F value of 10.51 (P<.001), with an R² of .38. Admissions motor FIM, days from injury to admissions (logged), LOS (logged), psychiatric symptoms, and the 4 forced variables were included in the final multiple regression model. However, only motor independence at admissions, psychiatric symptoms, and earlier acute rehabilitation intervention were significantly associated with motor FIM gain. Higher admissions motor FIM scores were associated with less improvement in motor functioning (F_1,168=20.32, P<.001). This variable accounted for the majority of the explained variance in motor FIM gain (R²=.31). Earlier acute rehabilitation and, consistent with the previously described model predicting cognitive FIM gain, the presence of psychiatric symptoms were associated with greater improvement in motor functioning (all P≤.05).

As mentioned earlier, for both FIM gain models, admissions scores made the greatest contribution to gain scores. To understand this effect more fully, we divided the sample into 3 groups based on the distribution of the admissions FIM scores: patients in the low group had admissions FIM scores below the 25th percentile, patients in the middle group had admissions FIM scores within the interquartile range (25th through 75th percentile), and patients in the high group had admissions FIM scores above the 75th percentile. Table 4 presents unadjusted mean ± standard deviations for cognitive and motor FIM discharge and gain scores among patients in each admit FIM group. As can be seen, although patients in the low groups made the greatest functional gains, their discharge FIM scores were lower than those in the middle and high admission FIM groups (ie, although they improved the most over the course of rehabilitation, at discharge they were still more functionally dependent).

Table 4. Means of Cognitive and Motor FIM Discharge and Gain Scores by Admission FIM Groupings

FIM Scores	Mean ± SD			n
	Low	Middle	High	Low	Middle	High
Cognitive FIM				46	78	48
Discharge	17.93±9.61*	30.56±3.35†	33.75±1.34‡
Gain	9.78±7.48*	6.55±4.24†	0.75±1.34‡
Motor FIM				44	90	45
Discharge	41.25±27.76*	84.40±6.81†	90.80±00.46‡
Gain	24.66±24.41*	18.68±14.10*	0.66±1.13†

NOTE. N equals 172 for cognitive FIM and 179 for motor FIM values. Patients in the low, middle, and high groups had admissions scores below the 25th percentile, within the interquartile range (25th through 75th percentile), and above the 75th percentile, respectively. Means with different superscripts per row (*, †, ‡) are significantly different at P<.05 using the Tukey Studentized range statistic.

LOS and FIM Efficiency 

The final model predicting LOS (logged) had an F value of 42.10 (P<.001), with an R² of .66. Admissions total FIM, marital status, and the 4 forced variables were included in the final multiple regression model. Greater functional independence at admissions was associated with shorter LOS (F_1,170=309.33, P<.001). This variable accounted for the majority of the explained variance in LOS (R²=.57). Additionally, injury agent and PRC site were associated with LOS (all P<.05). Patients with blast-related injuries had a shorter LOS. Across the 4 sites, the unlogged LOS least-square means ranged from 22.5 to 33.4 days. Adjusting for multiple comparisons, we found that the average adjusted LOS was significantly smaller at 1 site compared with that at the other 3 sites (all P<.05), which had comparable average-adjusted LOS. Marital status and race were not significant predictors of LOS. There was also a trend for younger patients to have a longer LOS (P<.10).

Figure 1 presents boxplots of the predicted LOS (unlogged) by mechanism of injury. As can be seen, the median number of days in rehabilitation was smaller for those with blast injuries compared with those who had other war injuries (20.62d vs 25.71d). However, more patients with blast injuries have an extremely long LOS compared with patients with injuries of other etiologies. The variability in LOS was marginally greater among those with blast injuries (asymptotic Kolmogorov-Smirnov statistic, 1.30; P<.07).

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• Fig 1. 

  A boxplot of the predicted LOS in days. The box represents the interquartile range (IQR). The edges of each box represent the 1st and 3rd quartiles. The horizontal lines within boxes are the medians; “+” represents the mean. The maximum length of each whisker is 1.5 times the IQR. Circles are outliers according to the 1.5 times the IQR criterion.

To further explore the association between FIM scores and LOS, we divided the sample into 3 groups based on the distribution of their admissions FIM total scores. Patients in the low group had total FIM scores below the 25th percentile at admissions, patients in the middle group had total FIM scores within the interquartile range (25th through 75th percentile) at admissions, and patients in the high group had total FIM scores above the 75th percentile at admissions. Next, we examined FIM efficiency in each group, defined as FIM gain divided by LOS. FIM efficiency reflects the mean change in scores per day. Table 5 presents results. As can be seen, FIM efficiency was not consistent across the 3 groups, with the middle group making the greatest gain in FIM scores per day. The low efficiency in the group of patients who began inpatient rehabilitation with relatively high FIM scores (the high group) is not surprising given the fact that gain scores were small for this group.

Table 5. Means of FIM Efficiency by Admission FIM Groupings

NOTE. N equals 172 for cognitive FIM and 179 for motor FIM values. Patients in the low, middle, and high groups had admissions scores below the 25th percentile, within the interquartile range (25th through 75th percentile), and above the 75th percentile, respectively. Means with different superscripts per row (*, †, ‡) are significantly different at P<.05 using the Tukey Studentized range statistic.

Mortality 

Four (2%) of the 188 patients had died as of December 2006. One died during his inpatient stay and 3 died within the following 27 months. The causes of death were the removal of the feeding tube in a minimally conscious patient (n=1), complications subsequent to persistent vegetative state (n=2), and cardiopulmonary arrest with subsequent anoxic brain death (n=1). Three of these patients had blast-related combat injuries. The difference in the rate of mortality by injury agent was not significant (Fisher exact test, P=.63).

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Discussion 

This is the first study to describe characteristics and outcomes among patients who receive inpatient rehabilitation for injuries sustained during OIF and OEF through the VA’s 4 PRCs. Findings confirm the clinical complexity of the patients for whom the PRCs were developed. The frequency of pain is particularly remarkable and supports the development of pain-management protocols for patients with polytraumatic combat injuries.

Findings indicate that war-related explosions produce a unique constellation of injuries. There was some indication that LOS was more variable among those with blast injuries. This suggests that blast injuries can vary in their impact on patients’ rehabilitation needs. However, blasts did not make a unique contribution to functional improvement as measured by the FIM. More research with a larger sample would be needed to more definitively determine whether mortality differs by injury agent.

Consistent with prior studies,¹⁸ we found that baseline functioning was the strongest predictor of FIM gain and LOS. It is not surprising that those who begin rehabilitation with high FIM scores end rehabilitation with high FIM scores and, because of ceiling effects, do not exhibit much functional gain over the course of treatment. Other investigators³² have reported ceiling effects with the FIM by discharge from inpatient rehabilitation. In this sample, by discharge, 13% of the patients had achieved maximum cognitive FIM scores and 31% had achieved maximum motor FIM scores. Measures other than the FIM are needed to examine outcomes among patients who begin treatment at a high functional level and to monitor functional improvements after discharge.

Importantly, our data indicate that although patients at low levels of functioning at admissions do not become as functionally independent as those who begin rehabilitation at a higher functional level, they make considerable progress over the course of the hospitalization. In general, they improved more in functional independence than patients who were at a higher level of functional independence at admissions. This finding of significant progress over the inpatient rehabilitation stay in those who are relatively dependent at admissions is consistent with prior research³³ and may be of comfort to friends and family members of those with severely disabling injuries. FIM efficiency scores suggest that the rate of gain among those who are at low functional levels at admissions may be slower than those in the middle range of functioning on admissions. This information may help providers to shape appropriate expectations for the course of recovery in patients with more severe injuries.

The finding that shorter time from injury to admissions was associated with greater functional improvement is also consistent with prior research.¹⁸ This finding reinforces the importance of prompt admissions of combat-injured service members to inpatient rehabilitation. The positive association between education and cognitive FIM gain as well as the inverse association between age and LOS are consistent with prior research.¹⁸, ¹⁹, ²⁰

The relation between the charted psychiatric symptoms and FIM gain scores was surprising and difficult to interpret. Psychiatric symptoms are known to dampen cognitive functioning,³⁴ and prior research²⁵ suggests that mood disorders are associated with worse TBI rehabilitation outcomes. Our findings would be more interpretable if we had data on change in mental health symptom levels over the LOS. The majority (73%) of those with psychiatric symptoms received therapy and/or psychiatric medications for these problems as a PRC patient. It would be important to evaluate the effect of that adjunctive treatment and to determine whether improvement in psychiatric functioning contributed to or accompanied changes in functional independence. Although it is recognized that patients with TBI are at a greater risk for mood disorders,³⁵ more research is needed to determine whether mental health interventions improve not only mental health symptoms but also cognitive and motor functional independence in patients with TBI.

Study Limitations 

This study was based on retrospective data, including chart notes. Omissions and inaccuracies in the charting may have biased our results. A related limitation is that we were not able to obtain a good indicator of injury severity from the medical records. Glasgow Coma Scale scores at the time of injury were charted for only 73 of the patients and therefore were not included. Injury Severity Scores were not charted at all. Prior studies¹⁶, ¹⁹ show that indicators of injury severity are predictive of functional status. Research on TBI outcomes among VA patients would be improved if information on injury severity was documented consistently in VA medical charts and/or rehabilitation databases.

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Conclusions 

This study characterized the complexity, diversity, and outcomes of war-injured PRC patients. Penetrating brain, eye, otologic, skin and soft-tissue, oral and maxillofacial injuries, auditory impairments, and PTSD symptoms are more common among those exposed to blasts relative to other sources of injury in a war zone. Findings also indicate that rehabilitation of the combat injured should include a focus on pain and psychiatric symptoms. Better documentation of injury severity and the use of instruments other than the FIM to measure change at higher levels of functioning is needed. Importantly, the PRC stay is only a part of the continuum of care needed to address the lifelong needs of these complex patients. Future research should examine outcomes postdischarge from acute rehabilitation. The identification of modifiable factors (including treatment barriers) that influence outcomes is particularly important as the VA continues development of its polytrauma system of care.

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Acknowledgment 

The opinions expressed in this study do not necessarily represent those of the Department of Veterans Affairs.

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References 

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