The Indian Journal of Occupational Therapy

: 2021  |  Volume : 53  |  Issue : 1  |  Page : 31--38

Rehabilitation outcomes of persons with severe traumatic brain injury: A cross-sectional survey

CatherineJudithHossanna1, Selvaraj Samuelkamaleshkumar1, Ranjan Aruna1, Suresh Annpatriciacatherine1, Stephen Reethajanetsurekha2, Arumugam Elango1,  
1 Occupational Therapy, Christian Medical College, Vellore, Tamil Nadu, India
2 Hamad Medical Center, Qatar

Correspondence Address:
Selvaraj Samuelkamaleshkumar
Christian Medical College, Vellore - 632 002, Tamil Nadu


Background: The recent literature regarding functional outcomes and the effectiveness of rehabilitation for persons with severe traumatic brain injury (TBI) suggests that these patients are capable of significant functional recovery over a period of months to years after injury. However, the researches concerning this are very limited. Therefore, this study has been conducted to study the rehabilitation outcomes in persons with severe TBI. Objective: To study the rehabilitation outcomes of persons with severe TBI who have completed 8–16 weeks of residential, postacute rehabilitation. Study Design: A cross-sectional survey study design was chosen. Methods: This study was done in Rehabilitation center of Christian Medical College, Vellore. Forty-two patients with severe TBI who completed rehabilitation from January 2014 to November 2016 were selected for this study. Usual care was provided to the participants in a transdisciplinary service delivery model. The Wessex Head Injury Matrix (WHIM), Coma Recovery Scale Revised (CRS-R), Addenbrooke's Cognitive Examination-III (ACE-III), Modified Barthel Index (MBI), Disability Rating Scale, and Community reintegration Questionnaire (CIQ) were used based on the International Classification of Functioning framework to assess the functional gains achieved during and after the rehabilitation process that include admission, discharge, and follow-up. Results: Significant improvements in CRS-R (confidence interval [CI]: −2.879 to − 0.741; P = 0.000), WHIM (CI: −10.42 to − 2.96; P = 0.000), ACE-III (CI: −8.23 to − 26.15; P = 0.000), and MBI (CI: −15.32 to − 39.18; P = 0.000) were found from admission to discharge. A significant change in disability was observed at discharge (CI: 3.79–6.07; P = 0.000) and at follow-up (CI: 0.87–1.75; P = 0.000). Marital status was influencing the CRS-R (CI: −0.82–6.79; P = 0.011) and the WHIM scores (CI: −0.619–14.12; P = 0.047). The mean follow-up CIQ score was 9.77 (standard deviation = 7.01). Only socioeconomic status was influencing CIQ (CI: 2.90–12.98; P = 0.003). Conclusion: Participants showed significant functional gains after the residential, post-acute rehabilitation program. These functional gains were not reflected in their community reintegration.

How to cite this article:
CatherineJudithHossanna, Samuelkamaleshkumar S, Aruna R, Annpatriciacatherine S, Reethajanetsurekha S, Elango A. Rehabilitation outcomes of persons with severe traumatic brain injury: A cross-sectional survey.Indian J Occup Ther 2021;53:31-38

How to cite this URL:
CatherineJudithHossanna, Samuelkamaleshkumar S, Aruna R, Annpatriciacatherine S, Reethajanetsurekha S, Elango A. Rehabilitation outcomes of persons with severe traumatic brain injury: A cross-sectional survey. Indian J Occup Ther [serial online] 2021 [cited 2021 Sep 22 ];53:31-38
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Full Text


Traumatic brain injury (TBI) is a major worldwide health problem and one of the significant causes of morbidity and mortality in India with high incidence rates among young males.[1],[2] The probability of a person having a permanent disability depends upon the severity of TBI.[3] It is estimated that around 10% of the individuals sustain a severe TBI with a mortality rate of 30%–50%.[3],[4],[5] The individuals who survive a severe TBI require long-term care and hospitalization due to impairments in cognitive, emotional, and physical functioning.[6],[7],[8]

The advancement in the rehabilitation process and modern interventions had led to the development of various models worldwide to manage persons with severe TBI.[9],[10] These models follow different care pathways and are said to have a strong impact on the functional outcome of an individual. The pathways defined in the literature majorly include acute and rehabilitation services both of which follow separate pathways without any continuity.[10],[11] More than one-third of the persons with severe TBI are not referred to rehabilitation services and are discharged directly from the acute care due to varied reasons such as nonavailability of medical insurance and lack of rehabilitation facilities.[9] Persons with severe TBI who underwent a well-defined continuous line of care which comprises intensive care to inpatient rehabilitation that includes both acute and long-term rehabilitation services to discharge have been observed to improve functional outcomes and reduced medical expenses.[9],[10] These models and care pathways lack uniformity in different geographical locations and clarity in the line of care. However, the care pathways for manging patients with TBI are not well documented in India.

Hence, this study examines whether persons with severe TBI who completed an 8–12 weeks of inpatient rehabilitation in the rehabilitation center achieved significant functional gains and to find the gains achieved through continued rehabilitation result in higher community reintegration during follow-up.



The 100-bed rehabilitation center is attached with Christian Medical College, Vellore, India, and has offered comprehensive rehabilitation for spinal cord injury since 1966, for acquired brain injury since 2005 and other acute injuries/disabilities. TBI rehabilitation is an 8–16 weeks residential, post-acute rehabilitation program initiated after the injured person is medically stable with at least one family member staying with the patient throughout the hospitalization phase. Immediate postdischarge progress is followed up at the transdisciplinary brain injury clinic conducted weekly. Home visits at least once a year in and around 100 km radius, a monthly support group at the rehabilitation center and an annual follow-up called “Rehab mela” are key follow-up strategies that help the rehabilitation team to evaluate and improve the quality of services.

Study Design and Ethics

A cross-sectional survey study was conducted. The Institutional Review Board (IRB) and the ethics committee of Christian Medical College, Vellore (IRB minute no: 10443 dated: December 05, 2016) approved the research proposal. All applicable institutional and governmental regulations concerning the ethical use of identifiable data during this research were followed.


Persons with severe TBI, who were in vegetative and minimally conscious state with initial Glasgow Coma Scale (GCS) score ≤8, duration of loss of consciousness ≥24 h, a minimum of 1-year postinjury, over 18 years old, and had completed a minimum of 8 weeks of the in-patient rehabilitation program in the rehabilitation center from January 2014 to November 2016 were included. All patients admitted for inpatient care were identified from the hospital data.

Intervention at the Rehabilitation Center

The salient features of this program are as follows: a holistic approach, a transdisciplinary team-based model, integrated care, caregiver training, therapeutic recreation, follow-up strategies, and the therapeutic mileu at the rehabilitation center. The occupational therapists take the main lead in co-ordinating the therapy services for persons with TBI. The approximate cost for this program is 30,000 INR which is often self-paid, as no government funds are available for the rehabilitation in the country [Supplementary material for details of intervention].

Outcome Measures

The rehabilitation outcome measures were selected based on the International Classification of Functioning, Disability, and Health framework.[12],[13] The Coma Recovery Scale-Revised (CRS-R), Wessex Head Injury Matrix (WHIM), and Addenbrooke's Cognitive Examination-III (ACE III) were used to assess impairments in body function and structure domains during admission and at discharge; Modified Barthel Index (MBI) was used to assess the activity limitation during admission and at discharge, and Disability Rating Scale (DRS) was a multidimensional scale encompassing both the body functions and activities/participation components and was used during admission, discharge, and at follow-up. Community Reintegration Questionnaire (CIQ) was used to assess participation restriction at follow-up. As occupational therapists coordinates the therapy services for people with TBI, all of these measures were administered by them.

The patients' demographic and clinical data that included the admission and discharge scores of WHIM, CRS-R, ACE III, MBI, and DRS were retrieved from the TBI database. The patients' current disability (DRS) and the community reintegration status (CIQ) were assessed either in person during the annual follow-up event or through a telephonic interview for those who were residing outside the follow-up area.

JFK CRS-R (2004) is a 23-item scale to assess the disorders of consciousness and has six subscales addressing auditory, visual, motor, oro-motor, communication, and arousal functions. The lowest item on each subscale represents reflexive activity while the highest item represents cognitively mediated behaviors. The minimum score a person can get is 0 and the maximum is 23. The scale has excellent concurrent validity with the original CRS (Spearman rho = 0.97) and DRS (Spearmen rho = 0.90).[14]

WHIM is a 62-item observational matrix used to assess patients in and emerging from coma and patients in the vegetative and minimally conscious states. It collects the data by observation and by testing tasks used in everyday life; it picks up minute indices demonstrating recovery, providing objective evidence for realistic prediction. The scale has good psychometric properties.[15]

Addenbrooke's Cognitive Examination-III assesses the participants' cognitive functioning in five domains such as visuospatial memory, visuospatial skills, attention, and verbal fluency. Participants' scores were calculated for each domain to provide a cognitive profile, which is added together to provide a total score out of 100 with higher scores indicating better cognitive functioning. The scale was found to have good validity.[16]

MBI is a 10-item scale that assesses the individual's ability in the following areas: feeding, bathing, grooming, dressing, bowel control, bladder control, toileting, chair transfer, ambulation, and stair climbing. Items were rated based on the amount of assistance required to complete each activity. This scale has good internal consistency, Cronbach's alpha = 0.89, and good concurrent validity.[17]

CIQ is a 15-item scale assessing community reintegration across three domains home integration (e.g. meal preparation, housework, and child care), social integration (e.g. shopping, visiting friends, and leisure activities), and productive activity (e.g. full versus part-time work and school). Total scores ranging from 0 to 29 points and high scores represent greater independence and community reintegration. The scale has excellent internal consistency, Cronbach's alpha = 0.76, and the criterion validity for all three subscales (home, social, and productivity) demonstrated excellent to moderate correlation to total CIQ respectively (0.82, 0.80, and 0.56).[18]

DRS evaluates eight areas of functioning in four categories: consciousness (eye-opening, verbal response, and motor response), cognitive ability (feeding, toileting, and grooming), dependence on others, and employability. Each area of functioning is rated on a scale of 0 to either 3 or 5, with the highest scores representing the higher level of disability. This scale has excellent psychometric properties.[19]

Data Analysis

The Statistical analysis was performed using IBM Corp. Released 2010. IBM SPSS Statistics for Windows, Version 19.0. Armonk, New York. The categorical variables such as age, gender, marital status, socioeconomic staus, and seizures were presented as frequencies and percentages. The age was catagorized as <40 and >40 to find the difference in the outcomes between young and old patients with TBI. The Paired t-test was used to compare the admission and discharge scores of CRS-R, WHIM, ACE-III, and MBI scales. The ANOVA test was used to compare more than two-level variables such as DRS of admission, discharge, and follow-up scores. The comparison of age, gender, marital status, and Socioeconomic status (SES) with the outcomes were compared using the ANOVA test. The level of significance set at the outset of the study was P < 0.05, and 95% confidence interval (CI) values were computed.


A total of 120 patients with severe TBI who have been rehabilitated from the center from January 2014 to December 2016 have been identified from the hospital data. Thirty-six patients were lost to follow-up and 32 patients' data were incomplete (24 did not complete 8 weeks of inpatient rehabilitation due to complications and family issues, eight patients died). Of the 52 patients contacted, 10 refused to participate. Forty-two patients consented through the mail and postal letters. The participants' demographic and clinical characteristics are presented in [Table 1]. The mean GCS score of participants' within the first 24 h after injury was 7.8 (standard deviation [SD] = 1.4). Ten patients were in a vegetative or minimally conscious state during the time of initial assessment.{Table 1}

The CRS-R, WHIM, ACE-III, and MBI mean scores after inpatient rehabilitation was significant when compared to the admission scores (P = 0.000 for all the measures). A significant change in disability status was observed from the admission to discharge (P = 0.000) after the inpatient rehabilitation program and at follow-up (P = 0.000) [Table 2]. Nineteen (45%) of them fall under the moderate disability category, 14 (33%) were under the severe disability category, and 9 (21%) were under the vegetative category during the follow-up period [Figure 1]. The follow-up score of community reintegration was 9.77 (SD = 7.01).{Table 2}{Figure 1}

The mean difference scores of ACE-III, WHIM, CRS-R, and MBI did not show any significant change based on demographic variables except for marital status on CRS-R (Mean difference = −2.6; t = 1.31; confidence interval [CI] = −0.82–6.79; P = 0.011) and WHIM scores (mean difference = −6.8; t = 1.851; CI = −0.619–14.12; P = 0.047). The participants whose socioeconomic status were above the poverty line showed better community reintegration as compared to those who were below the poverty line (P = 0.003) [Table 3].{Table 3}


This cross-sectional survey examined the rehabilitation outcomes of 42 persons with severe TBI, who completed a comprehensive rehabilitation program. The participants showed significant changes in their impairment and activity levels postinpatient rehabilitation as seen in the scores of CRS-R, WHIM, ACE-III, and MBI. This finding is analogous to previous studies which also reported that severe TBI patients continue to show functional improvements and earlier gains when provided with a continuous line of care from acute to inpatient rehabilitation.[20],[21],[22],[23],[24],[25] Multidisciplinary and intensive rehabilitation is very important for persons with severe TBI because of the varied dimensions of disability experienced by the person which cannot be addressed by a single discipline and needs a combination of interventions.[20],[21] These findings highlighted that the well coordinated, seamless line of care from the intensive care unit to acute care to long-term care following severe TBI could warrant benefit.

A significant reduction in the disability status was observed after the inpatient rehabilitation program and during follow-up based on the DRS scores. These findings were in agreement with previous studies that observed a similar pattern of recovery in patients with severe TBI.[21],[26],[27] Although significant recovery was observed in their functional status from admission to follow-up, many patients were dependent on various functional activities as reflected by the mean DRS score (11 ± 9) during follow-up. However, the findings showed that at admission 14 (33%) patients were under vegetative and 27 (64%) were in a severe category and only one patient was under the moderate disability category. Whereas during follow-up, only 9 (21%) patients were in a vegetative state and 14 (33%) patients were in the severe disability category. Nineteen (45%) patients have moved to the moderate disability category [Figure 1]. This finding suggests that persons with severe TBI continue to show recovery over time.

The community reintegration scores of the participants during follow-up show a low level of reintegration into the community. These low scores in CIQ indicated that though patients with severe TBI showed a difference in the functional independence status after the inpatient rehabilitation, it was not reflecting on their community reintegration level. This can be attributed to the fact that a major portion of persons surviving a severe brain injury experience residual deficits even after the rehabilitation program which makes them still dependent on their families or caregivers, thereby preventing them to reintegrate back into the community and resuming to their previous roles and is supported by the follow-up mean DRS score (11 ± 9). These findings are in concordance with the previous studies which also have reported low community reintegration outcomes in their subjects.[21],[28] However, these results should be interpreted with caution as previous reports clearly stated that the community reintegration will change over time post-TBI.[28],[29] Hence, the measurement of community reintegration should be done on a different point in time to find its actual course. More robust study designs such as longitudinal investigations are needed to verify this outcome.

No significant difference in rehabilitation outcomes could be obtained based on most of the demographic variables except marital status with WHIM and CRS. These findings are in conjunction with previous studies that reported no significant association between either age or gender and functional outcomes.[30],[31],[32] The married participants have shown better CRS-R and WHIM scores as compared to the unmarried participants. The presence of a significant primary caregiver may provide essential physical, emotional, and economic support to the person with severe TBI. However, the impact of marital status on TBI outcomes needs to be explored.


The major limitation of this study was the lack of a comparison group that did not undergo inpatient rehabilitation, limiting the generalizability of these findings. The second important limitation of this study was related to the design. This was a single-center, cross-sectional survey. Another limitation of this study was that all the outcome measures administered during the inpatient rehabilitation were not used during the follow-up. The DRS and CIQ scales were only used during follow-up. The telephonic interview method limited the use of all the other outcome measures. All the scales used in this study were not validated for Indian population; hence, the results should be interpreted with caution.

Future Suggestions

In future, a case–control study could be planned to compare the patients who receive inpatient rehabilitation with patients who are not receiving specialized rehabilitation care. A study also could be planned to compare patients who receive early, continuous rehabilitation with those who receive delayed rehabilitation.


Patients with severe TBI who completed intensive, inpatient rehabilitation showed improvements in their consciousness, cognitive, physical, and functional outcomes. Persons with severe TBI continue to show a positive trend toward a reduction in their disability over time. However, these functional gains did not reflect on the community reintegration during follow-up. The well-coordinated, seamless line of care from the intensive care unit to acute care to long-term care following severe TBI could warrant benefit.

Financial Support and Sponsorship


Conflicts of Interest

There are no conflicts of interest.

 Supplementary Materials

Details of the Intervention Provided at the Rehabilitation Center

 Holistic Approach

Our program addresses the physical, emotional, psychological, behavioral, social, spiritual, and environmental imbalance that results from brain injury without attaching time intervals for each to be addressed.

 Trans-Disciplinary Team-Based Model

Goal-based rehabilitation, relevant to the person's social situation and strategies to accomplish them, are decided by the team members on a case-by-case basis and form the basis for the training program. Regular inhouse training is organized to familiarize the staff with the principles of treatment from other disciplines.

 Integrated Care

Therapy interventions include multisensory stimulation, functional mobility, cognitive retraining, behavioral management, caregiver training, health education, therapeutic group activities, vocational guidance and counseling, and outpatient and/or community and/or annual follow-up after discharge.

 Team Composition

For efficient service, a team is formed for each patient and comprises a physiatrist, neuropsychiatrist, physiotherapist, an occupational therapist, speech and language pathologist, nurse, and social worker.

 Team Meetings

The team meets formally with the patient and family once a week and also daily informal interactions. These meetings serve to set and modify goals, if need, plan training and discharge, and is an opportunity for patients and family to discuss their doubts, fears and dos and don'ts. A predischarge assessment verifies the patient's readiness to go home.

 Caregiver Training

The program emphasizes caregiver training and the enabling of family members to become cotherapists through their active involvement in therapy daily under the supervision of the therapist. This approach facilitates recovery at every stage and helps ensure that strategies initiated during the therapy consistently followed during the rest of the day and weekends. Families maintain the Antecedent Behavior Consequences (ABC) chart of the patient that is periodically analyzed and strategies devised to ameliorate behavioral issues with the active involvement of the family. This way the family is equipped to provide support once the patient goes home.

 Health Education

A structured health education program delivered every week in groups as well as individualized formats. Group interaction addresses common concerns and challenges and helps develop coping and communication skills. A daily interaction with therapists orients the patient and family to all aspects of dealing with TBI and relevant management mechanisms.

 Group Therapy

Language-based support groups formed for patients and their family members. This group conducted every week to discuss issues such as stress, anger, anxiety, change of roles, vocational resettlement, and community reintegration. This support group helps the patient and family to gain sufficient self-reliance. Activity group sessions help improve cognitive skills.


Counseling by the psychologist, social worker and peers help in dealing with emotional and behavioral problems as well as building acceptance and social skills.

 Medical Management

Physiatrists and visiting neuro-psychiatrists help evaluate and review medical management.

 Therapeutic Recreation

Patients are encouraged to participate in activities that help improve health and well-being. Games are conducted thrice a week and monthly events are conducted to help patients exhibit their talents and skills.

 Community Ambulation and Integration

Therapeutic community exposure in the form of shopping, picnics, watching movies at the theater and visits to various events such as the circus are also organized periodically to prepare the patients and family for challenges in community reintegration.

 Vocational Guidance and Training

Occupational Therapists, social workers offer guidance on the importance of vocation for self-esteem and recognition in society, survival with dignity and enhanced quality of life. This guidance begins as early as possible with a focus on strengths and weakness of the patient, suitability of pre-injury employment or vocation, adaptation if needed, experience sharing by role models and alternative options are explored, that may be available on returning home, if preinjury vocation is not possible. Job specific skill training, adaptations, and are provided whenever needed.

 Home Program

A discharge summary is given to help patients recall prescribed drugs and the important medical and therapy details. Every patient sends home with a custom-made home program that emphasizes skills and functional independence in practical day-to-day tasks. Essential environmental modifications are also suggested. The home-based programs, caregiver training, and communication through calls and email assume significance as access to comprehensive rehabilitation services is mostly not available back home.

 Follow up Strategies

Immediate postdischarge progress is followed up at the transdisciplinary brain injury clinic conducted weekly. Predischarge home visits, ongoing home visits at least once a year in and around 100 km radius, a monthly support group at the rehabilitation center and Rehab Mela are key follow-up strategies that help the rehabilitation team to evaluate and improve the quality of services. Home programs and treatment strategies are modified based on feedback.

 Rehab Mela

An annual follow-up of previously rehabilitated TBI patients residing in and around 100 km radius from the rehabilitation center. This follow-up has conducted to review neurological status, recreation and sports, peer interaction, spiritual and motivational aspects for the patient and family. This service is provided free of charge to the patients.

 Atmosphere at the Rehabilitation Centre

Patients come from across India and usually stay for 8–16 weeks. Many patients admitted for rehabilitation are displaced from their community and arrive with the perception of having to adjust in an 'alien environment'. Not only because they are in hospital, but, they are also in a different state, that speaks a different language and eats different food. However, the rehabilitation center functions like a “home away from home” with common cooking areas, so families can cook their own meals, chapel services, recreation services, gardens, and parks for patients and their families. These facilitate interaction and building of friendships between patients' and families and enhance the ambience and atmosphere of the center.


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