Authors: Lisandro Olmos, MD1; Mauricio F. Farez MD, MPH1; María Eugenia Barbieri, PhD2; Zulma Ortiz, MD3; Melania Ron, OT1; Lucila De La Serna, PhD4; Alejandra Cucien, PhD4; Laura Bosque, MD2.
1FLENI Rehabilitation Institute, Escobar, Buenos Aires, Argentina.
2Sociedad Argentina de Medicina y Cirugía del Trauma, Buenos Aires, Argentina.
3Academia Nacional de Medicina, Buenos Aires, Argentina.
4Familiares y Amigos de la Tragedia de Santa Fé, Santa Fe, Argentina
Background. Trauma disease is associated with considerable impairment in personal, social and professional life, with a wide range of associated costs. We aimed to investigate the clinical and social outcomes of patients affected with trauma in the largest rehabilitation center of Argentina.
Methods. We performed a retrospective cohort study in FLENI Rehabilitation Institute, including physical examination and questionnaires aimed to determine the social impact of their disease. We analyzed in particular the Brain Injury outcomes related to motor vehicle accidents.
Results. 105 patients aged 14 to 88 years were included. Most of patients were male. The mean age at the time of injury was 33.9 ± 15 years old. The majority of patients (84%) showed brain injury. Patients with trauma associated to motor vehicle accidents have lower levels of recovery than patients with other causes of injury. Most of patients (89%) returned at home after the rehabilitation program. A professional decline was analyzed in case of severe TBI resulting in significant loss of salary.
Conclusions. The severity of Trauma Disease and Brain Injury significantly influenced the subjective social and living conditions. Subjective mental and physical outcome as well as professional life depended on the severity of Traumatic Brain Injury one year after the discharge from the rehabilitation facility.
Traumatic Brain Injury (TBI) is worldwide known as a major public health concern potentially resulting in death or neurological impairment [1,2]. The incidence of TBI is about 300 per 100,000 inhabitants  with almost 50% related to traffic accidents in the Western civilization .
Due to improvements in clinical experience, overall mortality decreased during the last twenty years in traumatized patients . Thus, research also focused on long-term outcome after major trauma including TBI. However, despite this increasing interest in research on long-term outcome following trauma in general, patients with TBI were frequently omitted from study populations due to the known impact on mortality .
Furthermore, many long-term outcome studies including patients with TBI exhibit potential limitations. Limited information on long term recovery and morbidity are available [3, 7-9] particularly in countries from South America. Consequently, more comprehensive long-term outcome studies after Trauma with TBI are required in order to document potential prognosis and to prepare life plans for survivors, families and clinicians . In the present study we aimed to verify medical, economical, social as well as vocational long-term outcome results after Trauma and severe TBI in one of the largest long-term outcome study populations in Argentina.
MATERIALS AND METHODS
The study was approved by the institutional Ethic Comitee of the Raul Carrea Center for Neurological Research. Written informed consent was obtained for all patients. Questionnaire was taken in presence of relatives or caregiver.
The current investigation represents a retrospective cohort study at a multiple levels from trauma center to community rehabilitation.
Patients were analyzed by our databank and included in the study if the following criteria were fulfilled: Only traumatized patients who have sustained TBI (GCS 3 - 9 points) or other type of injury were included. Minimum follow-up was at least 1 year after discharge from inpatient rehabilitation Institute. Patients admitted at FLENI Rehabilitation Institute from January 2003 to December 2008 were evaluated. 105 patients from 146 admissions were selected. The analysis included from the acute admission at Intensive Care Unit (ICU) to 12 months after discharge from rehabilitation Institute. We excluded patients with previous TBI, mental handicaps and missed after discharge from rehabilitation facility.
Patients were recruited according to an established recruitment process: a standardized protocol was followed-up. Patients’ phones numbers were gathered from the data bank. The patients were contacted by phone up to three times. If none of these attempts was successful or three appointments were missed, patients were documented as “not available” to follow-up.
Patients with severe TBI were evaluated by an experienced occupational therapist. For reexamination a self-administered patient questionnaire and a standardized physical examination were used. The following measures and outcome parameters were raised by this study: vocational, social, and monetary outcomes at 6 months and a year. We investigated the cause of lesion, severity, Functional Independence Measure (FIM) [10, 11]at admission and discharge from the rehabilitation unit, length of treatment from ICU to rehabilitation discharge, cost of treatment, destination at discharge time, grade of return to the community, economical impact and subjective social impairments of patients one year after trauma.
Differences between groups were evaluated with χ2 or Fisher exact´s test for categorical data and Wilcoxon sign rank sum test or Student´s t test for continuous variables according to their distribution. Variables compared before and after trauma were analyzed using paired t test. A two sided p-value < 0.05 was considered to be significant. Data was analyzed with STATA version 12.1 (Statacorp, Texas, USA).
Clinical and demographic characteristics of the participants.
Of the included 105 patients, 83 suffered vehicular related trauma, whereas the other 22 suffered other cause of trauma, including sport related (n=9) and fall or violence related (n=13). The mean age at the time of the injury of the enrolled population was 33.9 ± 15, with no differences between those suffering vehicular trauma and all other injuries (P=0.7). Seventy nine percent of the population were males, with no significant differences in gender distribution between the groups compared (P=0.6). The majority of patients presented with brain injury (84.8%), followed by spinal cord injury (12.4%) and multiple trauma in 2.9%, with no significant differences between groups (P=0.7). Table 1 summarizes the clinical and demographic characteristics of the study population.
Patients affected with trauma stayed on average 30.6 ± 26, 4.9 ± 11, 25.5 ± 38, 65.6 ± 45 day in ICU, intermediate care, general care and the rehabilitation center respectively. Although patients in whose trauma was due to vehicular collision tended to stay longer in rehabilitation (74.1 ± 47 versus 34.7 ± 19), this difference did not reach significance (P=0.1). Disability was measured using the Functional Independence Measure (FIM) with an average score of 40.6 ± 24 and 73.3 ± 34 at admission and discharge respectively. Patients with vehicular traumatic injury did not recover functional independence as well as patients with other injuries, with an average FIM score of 69.7 ± 34 compared to 87.1 ± 30, P=0.03. While patients with vehicular traumatic injury recovered on average 0.55 points per day, patients with other injuries recovered 1 point per day, but this difference did not reach significance (P=0.3). The majority of patients returned to their homes at discharge (93%), the rest being taken to a nursing care center (7%). Table 2 summarizes clinical outcomes of the study population.
Vocational, social, and monetary outcomes.
A significant professional or academic decline was observed, as 76% of patients were unable to return to their work or studies at 6 months. This seems to be worse for patients with vehicular related trauma, as 80% did not return to work or university compared to 60% of patients with other injuries, with no statistical significance (P=0.07). After 1 year, 46% of the patients were still unable to return to work or academic life, 37% returning to a modified place to work, and 17% were able to return it without adaptations.
Only 16% of the patients declare not to participate in any community activity, whereas 44% claim to have partial involvement and 40% declare complete participation.
Of those patients who returned to work or university, they did it with a significant decline in the number of hours spent working or studying, with a reduction from 38.9 ± 23 hours per week before trauma to 13.4 ± 18 hours per week after the trauma (P<0.001) In addition to this, relatives had to reduce their working time an average of 8.9 ± 22 hours per week.
The average cost of care for trauma patients was US$ 56,064.73, with considerable more costs associated with vehicular trauma (US$ 64,082.35 ± 73,797) as compared to other injuries (US$ 24,662.4 ± 21,672, P=0.05). At discharge 44% of the families took financial care of the patient spending monthly an average of US$ 574.7.
The current paper presents first results of one of the largest long-term outcome studies after Trauma Disease and TBI in Argentina. Because traumatic vehicle accidents are one of the main causes of TBI in Argentina, with its socio-economic implications, we have focused on this trauma subtype. With the intention to verify medical, social as well as vocational long-term deficits following TBI in survivors our results can be summarized as follows:
Patients with severe Trauma Disease and TBI were more often of male gender. A significantly worse outcome according to the FIM, a higher decline of productivity (return to work as well as academic activities) was found after severe TBI associated to MVA. The cost of care of trauma associated to MVA, in particular the TBI, was significant higher than other types of injuries. Severe TBI significantly impacts vocational situation due to an occupational decline resulting in loss of regular income. Only 50% returned to work or academic activities and 35 % needed adaptations. The families gave economical support and reduce their working time in 44% of cases. The reason why MVA-related TBI is significantly worse than other types of injuries is not well established, but some potential explanation could be that MVA are usually associated with multiple injuries beside TBI that may compromise overall health and recovery.
Outcome after TBI has been investigated in different settings [3, 7-9,12,13]. However, knowledge of the influence of Trauma associated with TBI on long-term outcome remains sparse due to several reasons. First, the studies varied considerably according to the definition of “long term” with a posttraumatic observation period between 5 and 15 years [7,12,13].
Furthermore, some studies focused either only on the impact of mild TBI [3,7] or on the combination of moderate and severe TBI [8,12], whereas others verified outcome results only in multiple traumatized patients . Third, due to the high mortality after severe TBI even 10 years after trauma  and the reduced probability of severe isolated head injuries after high energy trauma [4,14], included study populations used to be relatively small.
In the presented study we were faced with the following problem: Almost 28% of the overall study population had to be excluded initially mainly because of missing follow-up.
For instance, Cameron et al. analyzed the 10-year outcome after TBI excluding not explicitly further injuries . Identifying an overall potential population of 21,032 patients based upon a Canadian state registry, finally 1,290 took part in the reexamination (6.1%) . In addition, Andersson and colleagues analyzed 198 patients evaluated from a main population of 1,719 patients with mild TBI (11.5%) .
According to the demonstrated demographic results, patients suffering severe TBI were more often male gender. One explanation for the increased incidence of severe injuries in these patients might be argued by the relatively high frequency of traffic accidents  as especially young male patients are known to be involved in high energy trauma . In this context, MVA have been found responsible for up to 80% of TBI patients .
The living situation after TBI is suspected to be a critical factor for quality of life and daily living activities. The majority of patients returned to their homes at discharge and received support from the family. For cultural reasons, the South American families give most support at their homes than in other parts of the world. The absence of a good chronic care medical system could be part of the reason. Living alone may be a sign of social isolation, but it may also reflect independence [8,12]. Nevertheless, it seems unlikely to expect that patients surviving severe TBI would be more capable of independent living than those with minor head injuries .
Focusing on long-term outcome measurements, the presented data indicates that survivors of severe TBI had significant impairments: a significant professional or academic decline was observed. Unemployment is known as a significant problem following TBI [3,7]. According to the presented results, severe TBI resulted in a significant occupational decline followed by loss of salary. Grauwmeijer et al. revealed that patients after moderate and severe TBI with impaired cognitive functioning at hospital discharge were at high risk of long-term unemployment three years later .
To the best of our knowledge, this is the first report about TBI in an Argentinean cohort. We found some differences when compared to other international reports [16, 17], of note, the prevalence of MVA is higher in our sample as compared to a large cohort form United States (79% as compared to 37.9%), and that injured patients seem to be younger (33.9 years mean versus 55.4 years).
The presented study has several limitations. Due to the follow-up period of one year, many critical events might have occurred in a persons’ life potentially affecting outcome. Although the participating patients have been asked for life-changing events between the TBI and follow-up, this aspect has to be considered as a potential limitation when interpreting the results. Mainly pre-existing psychological and behavioural disorders might be missed by this study, because none of the traumatized patients was assessed by specific psychological tests before the admission. We excluded patients with mental handicaps previous to TBI, but minor psychological problems were potentially missed by this study. As these problems might interfere with the presented outcome results, this aspect should be taken into account when interpreting the presented results.
Another major limitation is to be mentioned by including pediatric trauma patients to the study population. Pediatric TBI is known to have a better physical outcome compared to adult patients due to the plasticity of the immature brain [9,13]. Although this aspect is not proven in the literature without remaining criticism [9,13], this study could have been biased considerably. The results should be interpreted carefully due to this limiting factor. Furthermore, the length of follow-up and data collection at a single center and its retrospective design might be a limitation and it is likely that the presented findings cannot reflect the advances made in acute care as well as rehabilitation during the last decades.
Additionally, one might be aware of a potential selection bias due to the large number of excluded patients which is a known limiting aspect of long-term outcome studies discussed previously.
According to the presented results, patients after Trauma are confronted with social living, vocational and outcome restrictions.
Subjective mental and physical outcome as well as professional life depended on the grade recovery of Traumatic Brain Injury.
Knowledge of these impairments might change life plans of TBI relatives in order to create more supportive living environments. Furthermore, occupational rehabilitation or financial insurance support might be aspects that could limit the financial burden following the occupational decline after severe TBI.
The authors thank Dr. Jorge Neira and Dr. Ramón Leiguarda for supervising the study in the early phase.
This study was supported by funding from the Raúl Carrea Institute for Neurological Research.
Mauricio F. Farez received honoraria and professional travel/accommodations stipends from Merck-Serono Argentina.
Lisandro Olmos, MD.
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