Does participation mediate the prospective relationships of impairment,injury severity,and pain to quality of life following burn injury?

Abstract

We examined the prospective impact of injury severity, functional impairment, and pain on participation in the community and subsequently on life satisfaction and self-rated health of 260 burn survivors 5 years post-discharge. Predictor variables include injury severity and total body surface area burned (assessed during acute care), functional independence (assessed at 12 months post-discharge), pain (assessed at the 24th month), and participation (assessed at the 48th month). Participation predicted life satisfaction and self-rated health. Functional independence and injury severity had significant indirect influences on adjustment via their influence on participation. Pain predicted both outcome variables. Clinical and research implications are discussed.

Keywords

burns functional impairment life satisfaction pain participation quality of life self-rated health

Depression, post-traumatic stress, poor body image, and other indicators of emotional maladjustment are routinely discussed in reviews of quality of life (QoL) following burn injury (Stavrou et al., 2014; Wiechman, 2011). Indicators of positive emotional adjustment (e.g. life satisfaction) are conspicuously absent in these reviews. There is an increasing emphasis on community integration and participation as QoL outcomes (Corry et al., 2009; Falder et al., 2009), congruent with the premium the World Health Organization places on involvement in valued life situations following disability (World Health Organization, 2001). Certain aspects of participation, such as mobility, are associated with optimal occupational outcomes (Öster et al., 2011) and self-rated health (SRH) (Moi and Nilsen, 2012) following burns.

Optimal adjustment following traumatic injury is influenced by an array of dynamic relationships between personal and environmental characteristics over time (Elliott and Warren, 2007). Functional impairments, injury severity, and other aspects of an injury may not directly predict life satisfaction over time, but these factors can limit and disrupt the pursuit of and engagement in meaningful, goal-directed, and personally rewarding activities. Engagement in intentional activities—behavioral, cognitive, and volitional—is a significant factor in life satisfaction, and its influence is greater than genetic or circumstantial (e.g. marital status) characteristics among people in general (Lyubomirsky et al., 2005). Participation in personally meaningful activities increases the probability of positive affect, rewarding social interactions, personal resilience, and life satisfaction among persons with acquired disabilities.

Consistent with a dynamic model of adjustment following disability (Elliott and Warren, 2007), the prospective relationships of functional abilities and pain to participation and life satisfaction and QoL are best examined in contextual analyses that take into account associations between predictor and mediating variables. Previous studies utilizing structural equation modeling demonstrate that the effects of functional independence and injury severity on optimal adjustment over time may be best understood in the context of participation in meaningful, productive activities over the first 5 years of spinal cord injury (Erosa et al., 2014) and traumatic brain injury (Kalpinski et al., 2013). Similarly, Moi and Nilsen (2012) used structural equation modeling to predict SRH in a study of 95 burn survivors in a cross-sectional study.

We report a contextual analysis of the prospective relationships of injury severity, functional impairment, and pain to participation and then to two indicators of QoL assessed over 5 years after a burn injury. We expected injury severity and total burn surface area (assessed during inpatient treatment) would predict functional impairment assessed 1 year post-discharge and the presence of pain (assessed 24 months post-discharge). Greater impairment and the presence of pain would then predict lower participation in desired activities 48 months post-discharge. In turn, greater participation would significantly predict life satisfaction and self-reported health status assessed 12 months later.

Method

Procedure

Participants were part of a larger longitudinal study of adjustment following disability by the Injury Control Research Center (ICRC) at the University of Alabama at Birmingham. The larger project followed individuals with one of four disabling injuries (burn, brain injury, spinal cord injury, or intra-articular fractures of the lower extremities) discharged from hospitals in north-central Alabama. Prospective participants were identified from acute care medical records and contacted at 12 months post-discharge. Eligibility criteria included the following: (1) acute care length of stay of three or more days, (2) residence (and injury) in Alabama, (3) discharged from an acute care hospital between 1 October 1989 and 30 September 1992, (4) 18 years or older when injured, and (5) could be contacted at pre-specified intervals after discharge.

Eligible individuals were initially contacted by mail 12 months post-discharge. The letter explained the study and included a pre-addressed consent to contact postcard. Individuals who did not reply via mail were contacted by phone to attempt to obtain consent. Following consent, a trained interviewer contacted participants. Spouses, caretakers, or close relatives were interviewed if the participant could not answer the questions over the phone. Demographic information was obtained from acute care hospital records. Measures were administered in telephone interviews and mailed self-report questionnaires at 12, 24, 48, and 60 months post-discharge. Measures were selected to assess variables theoretically and clinically relevant to all disability groups. For this study, data from a subset of these measures were analyzed.

Participants

A total of 260 individuals (209 men, 51 women) with burn injuries consented to participate. Participant age ranged from 18 to 96 years (M = 39.8 years, standard deviation (SD) = 16.97 years). The majority identified as Caucasian (n = 181, 69.6%); 73 participants identified as African American (28.1%). Injury severity scores indicated that 16.5 percent had an injury rating of “minor,” 43.2 percent were “moderate,” 25 percent were “serious,” 2.7 percent were “severe,” 6.5 percent were “critical,” and 1 participant had maximum severity during acute care. Measures of participants’ total percentage of body surface area burned (total body surface area (TBSA) ranged from 1 to 85 % the median TBSA was 13 percent and the mean was 16.9 percent (SD = 15.2%). Only 5 (2%) of the participants reported having inpatient rehabilitation (“Did you go to a rehabilitation center where you had to stay for a while?”). Of those who did not receive inpatient rehabilitation, 56.3 percent reported that no one suggested it to them, 32 percent reported that their injuries were not severe enough, 2.5 percent said they did not think it would have helped, and 2 percent said that they did not have the right insurance or otherwise could not pay; 7 percent did not know or gave other reasons. Of the 260 participants, 153 (60%) reported receiving some form of outpatient rehabilitation after leaving the hospital or rehabilitation center (“Did you receive any more rehabilitation help?”). The most common types of outpatient rehabilitation received were physical therapy (52%) and occupational therapy (6.5%). Of those who did not receive outpatient rehabilitation, most reported that no one suggested it (46.5%) or that their injuries were not severe enough (42.6%).

Measures

Injury severity (Abbreviated Injury Scale)

The Abbreviated Injury Scale (AIS) (Committee on Injury Scaling, 1985) assessed injury severity. The AIS provides an anatomical description of injury severity for six body regions based on ordinal values ranging from minor injury (1) to maximum injury or virtually unsurvivable (6) (Committee on Injury Scaling, 1985). Trained raters completed the AIS from information contained in the acute care medical record. To facilitate interpretation of correlational analyses in this study, the AIS was reverse scored so that higher scores reflect lower injury levels.

TBSA

TBSA documents the total percentage of body surface area (BSA) burned and the severity of the burns in degrees. TBSA is calculated by adding up percentage of second-degree burns and percentage of third-degree burns. Higher scores indicate a higher percentage of BSA affected by burns.

Functional Independence Measure

The Functional Independence Measure (FIM) (Keith et al., 1987) was administered via telephone at 12 months post-discharge. The FIM has 18 items that are rated on Likert-type scale ranging from 1 (total assistance) to 7 (complete independence). Functional abilities rated on the Motor subscale include eating, grooming, bathing, dressing upper body, dressing lower body, toileting, bladder management, bowel management, transfers to bed or chair, transfers to toilet, transfer to bath, locomotion, and locomotion of stairs. The Cognitive subscale includes ratings of comprehension, expression, social interaction, problem solving, and memory. Scores from each subscale are summed to obtain a total score. Total scores range from 18 to 126. Higher scores indicate greater functional independence.

The FIM is often included as an outcome measure in trauma registries because of its relevance across traumatic injuries (Gabbe et al., 2005). It has been used with burn survivors to assess functional independence (Gerrard et al., 2013). There is some evidence that slightly lower estimates of impairment occur with the telephone version of the FIM in comparisons with clinical observations (McDowell, 2006). FIM scores were linearized utilizing Rasch scaling procedures to increase measure variability and to ensure item quality and reliability (labeled as FIMR; Linacre, 2003).

Pain

A single item assessed the presence of pain among all participants in the larger project at the 24th month post-discharge: “Have you ever been told by a doctor that you have pain as a result of your injury?” Responses were coded as yes (0) or no (1). The item was considered sufficient to determine the presence of pain attributable to the injury. The use of a single pain item has been used in studies of burn survivors to understand possible differences in QoL between individuals with and without pain (Öster et al., 2011). Of 221 participants assessed for pain at 24 months, 88 (40%) responded “yes” to the item.

Participation

The Craig Hospital Assessment and Reporting Technique (CHART; Walker et al., 2003; Whiteneck et al., 1992) was administered by telephone at 48 months post-discharge to assess the mediating variables of participation. The CHART was developed to measure participation following disability as conceptualized by the World Health Organization, and it is appropriate for use with burn survivors (Falder et al., 2009). The Social Integration (SOC), Mobility (MOB), and Occupation (OCC) subscales were used in this study. Scores on each range from 0 to 100; higher scores reflect greater participation.

The Social Integration (SOC) scale contains six items to assess a person’s interactions with others in the community and at home. Questions on the Social Integration scale include “Do you live alone?” and “How many friends (nonrelatives contacted outside business or organizational settings) do you visit, phone, or write to at least once a month?”

The Mobility (MOB) scale contains nine items to assess a person’s ability to move around in and outside of their home. Questions on the Mobility scale include “On a typical day, how many hours are you out of bed?” and “Can you enter and exit your home without any assistance from someone?”

The Occupation (OCC) scale contains seven items to assess a person’s activity in and outside of their home. Questions on the Occupation scale include “How many hours per week do you spend working a job for which you get paid?” and “How many hours per week do you spend in active homemaking including parenting, housekeeping, and food preparation?”

Life satisfaction

The Life Satisfaction Index–A (LSI; Neugarten et al., 1961) was administered at 60 months post-discharge from hospital to assess for QoL. The LSI has 20 items to assess well-being, positive mood, and zest for life. Participants respond by either Agree or Disagree on each item. Higher scores on the LSI indicate greater life satisfaction.

SRH status

SRH status was measured by one item at 60 months post-discharge, “In general, how would you rate your health at the present time?” (Speake et al., 1989). The item has a Likert-type response scale: 1 = Excellent (no health problems), 2 = Good (no major health problems), 3 = Fair (several minor health problems), and 4 = Poor (major health problems affecting me daily). The use of a single item to assess for SRH status is common in health research with community samples, generally (Reyes-Gibby et al., 2002), and with burn survivors, specifically (Öster et al., 2011). To facilitate interpretation of correlational analyses, items were reverse scored so that higher scores indicate better health status.

Data analysis

Descriptive statistics and Pearson correlations were conducted using IBM SPSS version 22 (IBM^® SPSS^® Statistics, Chicago, IL, USA). The Mplus 5.21 program (Muthén and Muthén, 2007) was used to test longitudinal structural equation models (SEMs) for the direct and indirect effects of injury variables, functional independence, pain, and participation on the two distal outcome variables (SRH status and life satisfaction).

The a priori, theory-driven contextual model for analysis is available in supplemental materials. Injury severity (AIS) and TBSA at acute care were exogenous variables. Both of these injury variables were hypothesized to have causal effects on subsequent functional independence (FIMR), assessed at 12 months post-discharge, and pain (PAIN), assessed at 24 months post-discharge (residuals of FIMR and PAIN were assumed to be correlated; not shown in the figure). Functional independence and pain were modeled to have direct effects on participation at 48 months post-discharge. In our model, a latent participation factor was created from the measures of social integration (SOC), occupational activity (OCC), and mobility (MOB) assessed at 48 months post-discharge. This decision was based on the conceptual overlap and moderately high correlations among these three variables. Finally, the participation factor was modeled to have direct effects on both QoL outcomes, that is, SRH status and life satisfaction (LSI) assessed at 60 months post-discharge (residuals of these outcomes were allowed to covary). Our a priori SEM, therefore, is a strong mediation model with injury variables affecting participation strictly via FIM and pain, and FIM and pain affecting distal outcomes strictly via participation. After testing the initial model, modification indices were examined to determine whether additional parameters (e.g. direct effects) would improve model fit.

Parameter estimates were based on full information maximum likelihood estimation (ESTIMATOR = ML in MPLUS), which incorporates all available data into the estimation process, an advantage in longitudinal research in which dropouts and intermittent missing data occur. Overall model fit was assessed using the following fit indices: (a) χ² test of model fit, (b) comparative fit index (CFI), (c) root mean square error of approximation (RMSEA), and (d) standardized root mean square residual (SRMR). A nonsignificant χ² (p > .05) provides evidence of acceptable fit, at least when sample sizes are not large (Tanaka, 1987). CFI was used to measure incremental fit, and RMSEA and SRMR were used to measure absolute fit (Kline, 2011). CFI values above .90 are typically categorized as having adequate fit and categorized as having good fit if above .95 (Kline, 2011). RMSEA and SRMR scores below .08 are typically categorized as having adequate fit and categorized as having good fit if scores fall below .05 (Kline, 2011). For assessing indirect effects of predictors on outcomes (via mediators), bias-corrected 95 percent confidence intervals (CIs) (Preacher and Hayes, 2008) were computed using the BCBOOTSTRAP command in MPLUS (with 2000 replications). CIs that did not include 0 were interpreted as evidence of significant indirect effects of predictors on outcomes.

Results

Descriptive statistics and correlational analysis

A table containing Pearson correlations between all major study variables and descriptive statistics for each variable is available in supplemental materials. When interpreting the correlations, recall that injury severity (AIS), pain, and self-reported health status are scored such that higher scores reflect more favorable outcomes. With only two exceptions, the signs of the zero-order correlations were as expected.

Model evaluation

The results of our a priori model revealed a marginal fit to the data, χ²(22) = 45.3, p < .01, CFI = 0.92, RMSEA = .064, SRMR = .064. We used modification indices to explore the possibility of improving model fit. Modification indices indicate the reduction in the χ² value that would result from freely estimating a particular parameter. A modification index value of 3.84 or greater is commonly used to determine potentially important paths to estimate. Based on our examination of these indices, we added direct effects from the pain variable to both distal outcomes (life satisfaction and SRH status). Although residuals of the three participation variables were originally treated as independent, the modification indices suggested improved model fit by allowing errors of the mobility (MOB) indicator to correlate with errors of occupational activity (OCC) and social integration (SOC). With these modifications made to the original model, overall model fit improved substantially: χ²(18) = 14.5, p = .70, CFI = 1.00, RMSEA < .001, and SRMR = .034; these statistics indicate an excellent fit to the data. The extended model, along with standardized coefficients, is depicted in Figure 1.

Figure 1.

Final extended structural equation model with standardized coefficients. Not shown in the figure are standardized coefficients for the residual correlations between functional independence and pain (.36), mobility and occupational activity (.31), and mobility and social inclusion (.31).

Direct effects

Unstandardized parameter estimates of the direct effects for the extended model are displayed in Table 1. Mobility, social integration, and occupational activity all loaded moderately on the latent participation factor. The participation factor was significantly related to both distal QoL outcomes (both ps < .001). As hypothesized, functional independence significantly predicted participation (p < .001). However, pain did not significantly predict participation (p = .21). Pain had small but statistically significant direct effects on both life satisfaction (p < .05) and health status (p < .01). Injury severity at hospitalization significantly predicted functional independence at 12 months post-discharge and pain at 24 months post-discharge. But burn surface area did not significantly predict either subsequent functional independence or pain. The final model accounted for 44 percent of the variance in life satisfaction (R² = 0.437) and 33 percent of the variance in self-rated heath.

Table 1.

Unstandardized parameter estimates of mediation model predicting life satisfaction and self-rated health status.

Indicator	Latent variable	Estimate	SE	t
Mobility	←Participation	1.00	–	–
Social integration	←Participation	0.55	0.10	5.29***
Occupational activity	←Participation	1.86	0.22	8.28***
Life satisfaction	←Participation	0.24	0.05	5.01***
Life satisfaction	←Pain	2.09	0.85	2.47*
Self-rated health	←Participation	0.03	0.01	4.32***
Self-rated health	←Pain	0.48	0.15	3.13**
Participation	←FIMR	6.19	0.90	6.87***
Participation	←Pain	−3.14	2.53	−1.24
FIMR	←AIS	0.26	0.12	2.18*
FIMR	←TBSA	−0.01	0.01	−1.11
Pain	←AIS	0.09	0.04	2.32*
Pain	←TBSA	0.01	0.01	0.55
Occupational activity ↔ Mobility		115.79	51.15	2.26*
Social integration ↔ Mobility		82.03	22.83	3.59***
FIMR ↔ Pain		0.28	0.06	4.90***
Life satisfaction ↔ Self-rated health		0.53	0.37	1.44

SE: standard error; AIS: Abbreviated Injury Scale (injury severity score); TBSA: total body surface area; FIMR: Rasch scores of Functional Independence Measure.

p < .05; **p < .01; ***p < .001.

Indirect effects

All possible indirect effects on LSI and SRH at 60 months post-discharge were tested with bias-corrected bootstrap analysis. The bootstrap method constructed 95 percent CIs of indirect effects to test for statistical significance (see Table 2). Functional independence had significant indirect effects (positive lower bounds of CI) on both distal outcomes via participation as a mediator. Injury severity (AIS) also had significant indirect effects on both distal outcomes via paths through FIMR and participation. However, pain did not have significant indirect effects on either outcome variable. TBSA had no significant indirect effects on either outcome.

Table 2.

Specific indirect effects from predictors to distal outcomes via mediators.

Outcome	Mediator	Predictor	Est.	95% CI
Life satisfaction	←Participation	←FIMR	1.463^a	0.793, 2.111
Life satisfaction	←Participation	←Pain	−0.742	−2.352, 0.228
Life satisfaction	←Participation ←FIMR	←AIS	0.377^a	0.072, 0.809
Life satisfaction	←Participation ←Pain	←AIS	−0.064	−0.284, 0.008
Life satisfaction	←Participation ←FIMR	←TBSA	−0.001	−0.041, 0.006
Life satisfaction	←Participation ←Pain	←TBSA	−0.013	−0.010, 0.002
Self-reported health	←Participation	←FIMR	0.208^a	0.105, 0.314
Self-reported health	←Participation	←Pain	−0.105	−0.308, 0.033
Self-reported health	←Participation ←FIMR	←AIS	0.054^a	0.012, 0.119
Self-reported health	←Participation ←Pain	←AIS	−0.009	−0.037, 0.001
Self-reported health	←Participation ←FIMR	←TBSA	−0.002	−0.006, 0.001
Self-reported health	←Participation ←Pain	←TBSA	−0.001	−0.001, 0.001

AIS: Abbreviated Injury Scale (injury severity score); TBSA: total body surface area; FIMR: Rasch scores of Functional Independence Measure; Est.: unstandardized estimate of indirect effect; CI: bias-corrected bootstrapped confidence interval (lower bound, upper bound) based on 2000 samples.

95% CI does not contain 0.

Comparisons between completers and incompleters

The full likelihood model maximized all available data from participants. Missing data and attrition often typify longitudinal studies of persons with traumatic injuries. Of 260 initial participants, 252 provided FIM data at 12 months, 221 provided pain data at 24 months, 175 provided participation data at 48 months, and 147 had 5-year follow-up data. Comparing dropouts to completers, there were no significant differences in sex, ethnicity, or age, and no differences in injury severity, body burn percentage, FIM, or pain. There was no difference in mobility or occupational activity, but the dropouts were lower in social integration than the completers (p < .05).

Discussion

We proposed that a greater capacity to engage in intentional activities, as measured by the FIMR, would directly predict greater community participation (involving social integration, occupational activity, and mobility) and through this influence on participation would predict greater QoL over time. The SEM results supported this basic premise. Also as expected, injury severity during acute care affected QoL through its effect on functional independence and participation. Pain was not associated with participation, but it did have small (but significant) direct effects on later QoL. Total burn surface area was not significantly associated with any endogenous variable in the model.

The FIM has been considered an index of the burden of care required for a burn survivor, but it can lack sensitivity to the specific concomitants of a burn injury that require rehabilitation attention (e.g. scars, TBSA, burn thickness). Proponents of the FIM argue that it can be valuable tool in burn rehabilitation in distinguishing between patients who require inpatient rehabilitation and those who may be discharged home following acute care (Choo et al., 2006). The FIM may also be an indicator of subsequent participation, life satisfaction, and SRH.

The positive contribution of participation, including the occupational activity variable, is consistent with other studies linking work status and employment to health-related QoL (Dyster-Aas et al., 2007) and to SRH status, specifically, following burn injury (Öster et al., 2011). However, the CHART Occupational Activity scale does not measure actual employment. Items on this scale assess participation in personally meaningful educational, leisure, volunteer, and work-related pursuits (including homemaking and maintenance). Consequently, the scale may best reflect a purposeful productivity that appears to benefit a burn survivor’s sense of overall health. The subjective self-report nature of the CHART comports with the International Classification of Functioning, Disability and Health (ICF) position that participation should be assessed from the perspective of the individual to respect their life context, circumstance, and subjective experience in the lived environment (Reed et al., 2005).

Participation in desired activities, generally, has been associated with health-related QoL in previous research of burn survivors 12 months after injury (Cromes et al., 2002). This work indicates that participation 4 years post-discharge may be best understood in the context of initial injury severity and its effects on functional impairments reported by the survivor 2 years post-discharge. These findings converge with other recent research supporting the use of contextual analyses to understand the precursors of participation in community and the subsequent, cumulative influence on QoL and positive adjustment in the years following traumatic disability (Erosa et al., 2014; Kalpinski et al., 2013). Early involvement in desired activities following return to the community may be critical to subsequent QoL among persons who incur traumatic burn injuries (Stavrou et al., 2014).

The presence of pain appears to place individuals at risk of compromised QoL in the years following discharge for burn injury. Although we do not have information about pain intensity or pain behaviors, the present findings reinforce the need for continued interventions and services for individuals in the community who live with pain associated with burn injuries. Other research has found no relationship between burn severity (reflected in the total burn surface area) and subsequent psychological adjustment (e.g. Willebrand et al., 2004). The site and complications of burn injuries (e.g. over a joint, contractures) may be more important than total burn surface area.

Earlier we found participants with burn injuries had significantly less severe injuries (as measured by the AIS) and less impairment (as measured by the FIM) than participants with other traumatic injuries in the larger project (McCord et al., in press). However, the present model accounted for a greater percentage of variance in life satisfaction (43%) than observed in the similar predictive models with persons with spinal cord injuries (34%; Erosa et al., 2014) and traumatic brain injuries (21%; Kalpinski et al., 2013). The inclusion of burn-specific information (TBSA) in this study may have contributed to larger degree of variance accounted for in the model.

Clinical strategies that address activity restrictions and promote participation following burn injury are warranted. Behavioral activation emphasizes re-engagement in activities that increase the likelihood of pleasurable experiences and positive reinforcement (Mazzucchelli et al., 2009). This might benefit individuals living with disabling conditions (Mausbach et al., 2011). Preliminary evidence indicates that a manualized treatment including elements of behavioral activation may facilitate community integration among burn survivors (Cukor et al., 2014).

Although our sample size was larger than the 200 participants minimum often recommended for SEM analyses (Kline, 2011), sample size calculations for the overall model suggest the study might have been under-powered for strong model fit. For power of .80 in our initial model, a sample size of at least 175 is suggested for obtaining an adequate model fit (RMSEA = .08), but a sample size greater than 380 would be required for good fit (RMSEA = .05; Preacher and Coffman, 2006). Nonetheless, the presence of very good model fit and statistically significant direct and indirect effects in this study suggest that estimates in our final model were stable.

The project concluded almost 20 years ago. The degree to which our results pertain to contemporary burn care and rehabilitation outcomes is unknown. More contemporary and sophisticated measures of pain, community reintegration, and participation would likely provide more information about the relationships examined in the model. Cohort effects and measurement issues often limit prospective studies of long-term adjustment. Measures of function specific to burn injuries may provide greater detail about the prospective relationship of functional capacity to participation and QoL post-discharge. Studies using contemporary measures will further our understanding of functional impairment and pain to QoL following burns.

Footnotes

Funding

This research was supported in part by grant No. R49-CE000191 from the U.S. Department of Health and Human Services Center for Disease Control and Prevention and the National Center for Injury Prevention and Control to University of Alabama at Birmingham’s Injury Control Research Center.

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