Original research| Volume 100, ISSUE 10, P1801-1809, October 2019

Family Involvement in Traumatic Brain Injury Inpatient Rehabilitation: A Propensity Score Analysis of Effects on Outcomes During the First Year After Discharge



      To evaluate the effect of family attendance at inpatient rehabilitation therapy sessions on traumatic brain injury (TBI) patient outcomes at discharge and up to 9 months postdischarge.


      Propensity score methods are applied to the TBI Practice-Based Evidence database, a database consisting of multisite, prospective, longitudinal, and observational data.


      Nine inpatient rehabilitation centers in the United States.


      Patients (N=1835) admitted for first inpatient rehabilitation after an index TBI.


      Family attendance during therapy sessions.

      Main Outcome Measures

      Participation Assessment for Recombined Tools-Objective-17 (Total scores and subdomain scores of Productivity, Out and About, and Social Relations), Functional Independence Measure, Satisfaction with Life Scale, and Patient Health Questionnaire-9.


      Participants whose families were in attendance for at least 10% of the treatment time were more out and about in their communities at 3 and 9 months postdischarge than participants whose families attended treatment less than 10% of the time. Although findings varied by propensity score method, improved functional independence in the cognitive area at 9 months was also associated with increased family attendance.


      Family involvement during inpatient rehabilitation may improve community participation and cognitive functioning up to 9 months after discharge. Rehabilitation teams should engage patients’ families in the rehabilitation process to maximize outcomes.


      List of abbreviations:

      95% CI (95% confidence interval), ASD (absolute standardized difference), CSI (Comprehensive Severity Index), FI (family involvement), PART-O (Participation Assessment with Recombined Tools-Objective), PHQ-9 (Patient Health Questionnaire-9), POC (point of care), TBI (traumatic brain injury), TBI-PBE (Traumatic Brain Injury Practice-Based Evidence study)
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        • Bogner J.
        • Dijkers M.
        • Hade E.M.
        • et al.
        Contextualized treatment in traumatic brain injury inpatient rehabilitation: effects on outcomes during the first year after discharge.
        Arch Phys Med Rehabil. 2019; 100: 1810-1817
        • Foster A.M.
        • Armstrong J.
        • Buckley A.
        • et al.
        Encouraging family engagement in the rehabilitation process: a rehabilitation provider’s development of support strategies for family members of people with traumatic brain injury.
        Disabil Rehabil. 2012; 34: 1855-1862
        • Keenan A.
        • Joseph L.
        The needs of family members of severe traumatic brain injured patients during critical and acute care: a qualitative study.
        Can J Neurosci Nurs. 2010; 32: 25-35
        • Brown F.L.
        • Whittingham K.
        • Boyd R.
        • Sofronoff K.
        A systematic review of parenting interventions for traumatic brain injury: child and parent outcomes.
        J Head Trauma Rehabil. 2013; 28: 349-360
        • Wade S.L.
        • Walz N.C.
        • Carey J.C.
        • Williams K.M.
        Preliminary efficacy of a web-based family problem-solving treatment program for adolescents with traumatic brain injury.
        J Head Trauma Rehabil. 2008; 23: 369-377
        • Sherer M.
        • Evans C.C.
        • Leverenz J.
        • et al.
        Therapeutic alliance in post-acute brain injury rehabilitation: predictors of strength of alliance and impact of alliance on outcome.
        Brain Inj. 2007; 21: 663-672
        • Riley G.A.
        • Hough A.
        • Meader L.M.
        • Brennan A.J.
        The course and impact of family optimism in the post-acute period after acquired brain injury.
        Brain Inj. 2015; 29: 804-812
        • Kreutzer J.S.
        • Stejskal T.M.
        • Godwin E.E.
        • Powell V.D.
        • Arango-Lasprilla J.C.
        A mixed methods evaluation of the brain injury family intervention.
        NeuroRehabilitation. 2010; 27: 19-29
      1. McElroy E, Dijkers MP. Inpatient rehabilitation for traumatic brain injury: does family presence during speech-language therapy sessions influence length of stay and cognitive-communicative functional gain? Platform presentation at AAP annual meeting, 2014 AAP Annual Meeting, February 25–March 1, 2014, Nashville, TN.

        • Horn S.D.
        • Corrigan J.D.
        • Bogner J.
        • et al.
        Traumatic brain injury practice-based evidence study: design and patients, centers, treatments, and outcomes.
        Arch Phys Med Rehabil. 2015; 96: S178-S196
        • Beaulieu C.L.
        • Dijkers M.P.
        • Barrett R.S.
        • et al.
        Occupational, physical, and speech therapy treatment activities during inpatient rehabilitation for traumatic brain injury.
        Arch Phys Med Rehabil. 2015; 96 (e17): S222-S234
        • Keith R.A.
        • Granger C.V.
        • Hamilton B.B.
        • Sherwin F.S.
        The Functional Independence Measure: a new tool for rehabilitation.
        Adv Clin Rehabil. 1987; 1: 6-18
        • Whiteneck G.G.
        • Dijkers M.P.
        • Heinemann A.W.
        • et al.
        Development of the participation assessment with recombined tools-objective for use after traumatic brain injury.
        Arch Phys Med Rehabil. 2011; 92: 542-551
        • Sander A.M.
        • Maestas K.L.
        • Nick T.G.
        • et al.
        Predictors of sexual functioning and satisfaction 1 year following traumatic brain injury: a TBI model systems multicenter study.
        J Head Trauma Rehabil. 2013; 28: 186-194
        • Bogner J.A.
        • Whiteneck G.G.
        • Corrigan J.D.
        • Lai J.S.
        • Dijkers M.P.
        • Heinemann A.W.
        Comparison of scoring methods for the participation assessment with recombined tools-objective.
        Arch Phys Med Rehabil. 2011; 92: 552-563
        • Chung P.
        • Yun S.J.
        • Khan F.
        A comparison of partcipation outcome measures and the international classification of functioning, disability and health core sets for traumatic brain injury.
        J Rehabil Med. 2014; 46: 108-116
        • Wilde E.A.
        • Whiteneck G.G.
        • Bogner J.
        • et al.
        Recommendations for the use of common outcome measures in traumatic brain injury research.
        Arch Phys Med Rehabil. 2010; 91: 1650-1660
        • Granger C.V.
        • Hamilton B.B.
        • Linacre J.M.
        • Heinemann A.W.
        • Wright B.D.
        Performance profiles of the Functional Independence Measure.
        Am J Phys Med Rehabil. 1993; 72: 84-89
        • Hamilton B.B.
        • Laughlin J.A.
        • Fiedler R.C.
        • Granger C.V.
        Interrater reliability of the 7-level Functional Independence Measure (FIM).
        Scand J Rehabil Med. 1994; 26: 115-119
        • Heinemann A.W.
        • Linacre J.M.
        • Wright B.D.
        • Hamilton B.B.
        • Granger C.
        Prediction of rehabilitation outcomes with disability measures.
        Arch Phys Med Rehabil. 1994; 75: 133-143
        • Heinemann A.W.
        • Linacre J.M.
        • Wright B.D.
        • Hamilton B.B.
        • Granger C.
        Relationships between impairment and physical disability as measured by the Functional Independence Measure.
        Arch Phys Med Rehabil. 1993; 74: 566-573
        • Linacre J.M.
        • Heinemann A.W.
        • Wright B.D.
        • Granger C.V.
        • Hamilton B.B.
        The structure and stability of the Functional Independence Measure.
        Arch Phys Med Rehabil. 1994; 75: 127-132
        • Diener E.
        • Emmons R.A.
        • Larsen R.J.
        • Griffin S.
        The Satisfaction with Life Scale.
        J Pers Assess. 1985; 49: 71-75
        • Kroenke K.
        • Spitzer R.L.
        • Williams J.B.
        The PHQ-9: validity of a brief depression severity measure.
        J Gen Intern Med. 2001; 16: 606-613
        • Pavot W.
        • Diener E.
        • Colvin C.R.
        • Sandvik E.
        Further validation of the Satisfaction with Life Scale: evidence for the cross-method convergence of well-being measures.
        J Pers Assess. 1991; 57: 149-161
        • Fann J.R.
        • Bombardier C.H.
        • Dikmen S.
        • et al.
        Validity of the Patient Health Questionnaire-9 in assessing depression following traumatic brain injury.
        J Head Trauma Rehabil. 2005; 20: 501-511
        • Bombardier C.H.
        • Fann J.R.
        • Temkin N.R.
        • Esselman P.C.
        • Barber J.
        • Dikmen S.S.
        Rates of major depressive disorder and clinical outcomes following traumatic brain injury.
        JAMA. 2010; 303: 1938-1945
        • Corrigan J.D.
        • Bogner J.A.
        • Mysiw W.J.
        • Clinchot D.
        • Fugate L.
        Life satisfaction after traumatic brain injury.
        J Head Trauma Rehabil. 2001; 16: 543-555
        • Malec J.F.
        • Whiteneck G.G.
        • Bogner J.A.
        Another look at the PART-O using the Traumatic Brain Injury Model Systems national database: scoring to optimize psychometrics.
        Arch Phys Med Rehabil. 2016; 97: 211-217
        • Horn S.D.
        • Gassaway J.
        Practice based evidence: incorporating clinical heterogeneity and patient-reported outcomes for comparative effectiveness research.
        Med Care. 2010; 48: S17-S22
        • Austin P.C.
        • Stuart E.A.
        Moving towards best practice when using inverese probabilty of treatment weighting (IPTW) using the propensity score to estimate causal treatment effects in observaional studies.
        Stat Med. 2015; 34: 3661-3679
        • Austin P.C.
        An introduction to propensity score methods for reducing the effects of confounding in observational studies.
        Multivariate Behav Res. 2011; 46: 399-424
        • Leung J.
        • Fereday S.
        • Sticpewich B.
        • Hanna J.
        Extra practice outside therapy sessions to maximize training opportunity during inpatient rehabilitation after traumatic brain injury.
        Brain Inj. 2018; 32: 915-925
        • Holland J.N.
        • Schmidt A.T.
        Static and dynamic factors promoting resilience following traumatic brain injury: a brief review.
        Neural Plast. 2015; 2015: 902802
        • Sherer M.
        • Davis L.C.
        • Sander A.M.
        • Caroselli J.S.
        • Clark A.N.
        • Pastorek N.J.
        Prognostic importance of self-reported traits/problems/strengths and environmental barriers/facilitators for predicting participation outcomes in persons with traumatic brain injury: a systematic review.
        Arch Phys Med Rehabil. 2014; 95: 1162-1173
        • Fisher A.
        • Bellon M.
        • Lawn S.
        • Lennon S.
        • Sohlberg M.
        Family-directed approach to brain injury (FAB) model: a preliminary framework to guide family-directed intervention for individuals with brain injury.
        Disabil Rehabil. 2019; 41: 854-860