Rehabilitation

Developing More Effective Rehabilitation Strategies by Identifying Injury-Related Disability and Its Long-Term Consequences

When successful trauma care ends, rehabilitation begins. As more and more patients survive once-fatal injuries, new challenges arise in helping them achieve the most independent and self-sustaining lives possible. The Rehabilitation Section of the Harborview Injury Prevention and Research Center has been working since 1985 to meet these challenges. Research in the Rehabilitation Section is dedicated to providing the best possible functional outcome for trauma survivors, many of whom sustain long-term injury effects with devastating physical, psychological and social consequences. The HIPRC researchers have worked to better identify the patients likely to suffer short- and long-term disabilities resulting from their injuries, and to minimize these after-effects by developing more appropriate and comprehensive rehabilitation programs.

The impact of traumatic brain injury

Traumatic brain injury is the leading cause of death and long-term disability in childhood. Although more than 100,000 children are hospitalized for head trauma each year in the United States, the long-term impact of this problem is not well understood. In 1988, HIPRC researchers began the first controlled prospective study in the country to examine the effects over time of traumatic brain injury in children ages 6 to 16. A group of 98 injured children were matched with a group of healthy children of similar age, educational performance, and economic and social background. The intellectual and cognitive capabilities, educational performance, and health of family and interpersonal relationships of the two groups were tested at three weeks, one year and three years post-injury.

The results have wide-ranging applications across many disciplines. The HIPRC researchers confirmed the assumption that mildly injured children - who comprise nearly 90 percent of those with traumatic brain injury - recovered rapidly and showed few long-term, injury-related problems in learning, behavior or social skills. With this knowledge, rehabilitation specialists have continued to expand their efforts on behalf of moderately and severely brain-injured children who, the study proved, do not fully recover.

At the three-year mark, these children demonstrated impairment across a spectrum of capabilities needed for school success. Although they were able to regain many previously learned skills in the first year after injury, their learning rate slowed in the second and third years, disrupting their development, leaving them substantially behind their uninjured peers, and suggesting they may never be able to catch up.

This is important information for educators, physicians, legislators and families as they attempt to provide effective services for brain-injured children at school and at home. Moderately and severely brain-injured children and those injured as preschoolers are at greatest risk for school failure. The research revealed that these children often are left with few areas of academic or cognitive strength, indicating a need for detailed analyses of their intellectual, academic and behavioral strengths and weaknesses before careful reintegration to school. The needs of each head-injured child are unique, so programs must be individually designed to offer academic success.

The challenge of brain injury on families

The HIPRC researchers also have studied the effects on families three years after a child's traumatic brain injury, and the role of family functioning in predicting how well the child does. They found that the most important factor influencing how well the family fares is the pre-existing strength of its relationships, cohesion, communication, problem-solving skills and social support. Nevertheless, families of severely injured children showed the most stress and deterioration in family relationships and coping resources, but were consistently better able to cope if they had open communication and the flexibility to respond to the injury's demands. The researchers also discovered that the family's existing strength was more important than injury severity in predicting behavior problems in brain-injured children, but that injury severity better predicted the injured child's school performance.

Defining the cost of brain injury

Despite its incidence, little was known about the economic impact of traumatic brain injury in children. The HIPRC collected data to help determine costs in relation to injury cause and severity. Using hospital charges for acute care and acute rehabilitation - which excludes indirect costs, such as lost work time, and long-term costs, such as therapy - researchers calculated an average cost of $598 per case to treat mild traumatic brain injury, rising to $12,020 for moderate injuries, and to $53,330 for severe injuries. The most costly categories of injury involved victims of motor-vehicle crashes, whether as passengers, pedestrians or bicyclists. These findings reaffirm the need for legislative, educational, and product safety efforts in these areas, and give an indication of the economic savings offered by effective prevention measures.

Vehicle-crash consequences

A separate, ongoing HIPRC research project is investigating whether drivers who have had a traumatic brain injury, whether from stroke or trauma, are more at risk for car crashes, driving violations and related injuries than uninjured drivers. The study compares crash data, hospitalization records and driving records of drivers across Washington state.

Another crash-related study is a collaborative effort among the HIPRC Rehabilitation Section, the Harborview Department of Surgery, and Johns Hopkins University to examine recovery trends among patients who sustain lower-extremity fractures in car crashes. Follow-up evaluations of nearly 400 patients at three Level I trauma centers showed that at six months post-injury, only 49 percent of employed patients had returned to work, and most patients reported that their injuries still interfered with walking, sleeping, household tasks, recreation, and emotional well-being. However, the degree of impairment did not consistently predict the extent of activity interruption, particularly in returning to work. These results suggest that factors beyond physical impairment influence broader disability issues, and need to be defined so that rehabilitation specialists can effectively intervene with at-risk patients. The HIPRC Rehabilitation Section is dedicated to research such as this, which strives to improve the lives of injured patients, especially those most likely to be disabled, through appropriate, comprehensive rehabilitation.

Surgical Critical Care Fellowship

Washington's status as a national leader in statewide trauma system development is reflected in a unique training program for general surgeons interested in a career in trauma/critical care and trauma systems implementation. In 1987, the University of Washington (UW) Department of Surgery and the HIPRC established a two-year fellowship in surgical critical care designed to enable well trained general surgeons to pursue an academic career in trauma and critical care. The program offers in-depth training in clinical and epidemiological investigation, as well as such background sciences as epidemiology and biostatistics, through the master's degree program in public health at the UW School of Public Health and Community Medicine. The Accreditation Council for Graduate Medical Education accredited the program in 1995.

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