Comparison of TBI and CVA outcomes: Durability of gains following post-hospital neurological rehabilitation

Abstract

BACKGROUND:

With the effectiveness of post-hospital brain injury rehabilitation clearly demonstrated, research focus has shifted to durability of treatment gains over time.

OBJECTIVE:

Study objectives were threefold: (1) examined the stability of outcomes following post-hospital rehabilitation for persons with acquired brain injury, (2) compare differences in short and long-term outcome for TBI and CVA groups, and (3) identify predictors of long-term outcomes.

METHODS:

Subjects (n = 108) were selected from 2,177 neurologically impaired adults with consecutive discharges from 18 post-hospital programs in 12 states from 2011 through 2019. The study sample included TBI, CVA, and Mixed neurological groups. All persons were evaluated using the Mayo Portland Adaptability Inventory –4 Participation Index at four assessment intervals: admission, discharge, and 3 and 12 month follow-up. Additional analyses included repeated measures 2x4 design addressing TBI and CVA by the four measurement periods, and hierarchical multiple regression to identify outcome predictors.

RESULTS:

The total sample demonstrated a reduction in Participation T-scores (indicating less disability) from admission to discharge. Reductions in disability were maintained at the 3 and 12 month follow-up assessments (Greenhouse-Geisser F (2.37) = 76.87, p < 0.001, partial eta2 = 0.418, power to detect = 0.99). The CVA group demonstrated greater disability at each assessment interval, however, those differences were not statistically significant. Significant predictors of outcome at 12 months post-discharge were length of stay in program and type of injury. TBIs with longer length of stay experienced better outcome at 12 months than non-TBIs with shorter length of stays (hierarchical multiple regression adjusted R² = 0.085, p < 0.05).

CONCLUSION:

Post-hospital residential neurorehabilitation programs provide a return on investment. Gains are realized from admission to discharge, and maintained one year following discharge from rehabilitation.

Keywords

TBI CVA post-hospital rehabilitation long-term outcome MPAI-4

1 Introduction

Recovery from severe acquired brain injury has no end point (Lorenz & Doonan, 2021), yet the course of that recovery is slow and deficits may persist for a lifetime (Center for Disease Control, 2021). Numerous outcome studies have been published on the effectiveness of post-hospital brain injury rehabilitation (Cope, 1995; Curran, Ponsford & Crowe, 2000; Lewis & Horn, 2015; Malec, 2001; Nelson 2006; Samuelkamaleshkumar, Reethajanetsureka, Elango, Padankatti, John, et al. 2022; Turner-Stokes 2008). In general, this research has shown that persons afforded comprehensive post-hospital rehabilitation can realize functional improvements long after the onset of injury (Cope, 1995; Lewis & Horn, 2015; Malec & Bransford, 1996). With the effectiveness post-hospital rehabilitation demonstrated, researchers have focused on the durability of gains realized during treatment (Ayon, 2019; Lannoo, Brusselmans, Eynde, et al. 2004; Sander, Roebuck, Struchen et al. 2001).

With a few exceptions, the majority of long-term outcome studies examining the effectiveness of post-hospital brain injury rehabilitation programs have been conducted with predominately TBI populations (Georgakis, Duering, Wardlaw & Dichgans, 2019; Haake, Althaus, Spottke, Siebert, et al. 2006; Sennfailt, Pihlsgard, Norrving & Ullberg, 2020). More recently, Duncan and her colleagues have emphasized the need to study long-term CVA outcomes following acute inpatient rehabilitation to better understand the course of full recovery with the current aging population and to prevent rehospitalizations (Duncan, Bushnell, Sissine, Coleman, Lutz, et al. 2021). Whether TBI or CVA, researchers conducting long-term outcome studies face a significant challenge to identify measures that can be applied consistently overtime and that are sensitive to detecting meaningful change. Numerous studies have employed various cognitive measures assessing skills from admission to several months post-discharge (Dikmen, Corrigan, Levin, et al. 2009; Wilson, Vizor, & Bryant, 1991). Often these studies report minimal change in specific cognitive skills such as processing speed, attention/concentration and memory (Dikmen et al. 2009). Natural aging processes tend to depress progress made in these areas distorting the benefits of prior acute comprehensive treatment. Other studies have employed objective measures of return to work or school (Johnstone, Reid-Arndt, Franklin & Harper, 2006; Saltychev, Eskola, Tenovuo & Laimi, 2013). These studies often show less than encouraging results, not due to an individual’s capability, but due to extraneous factors such as employment rates within a community, financial disincentives to work, age, or premorbid lack of interest in school.

An alternative approach to micro (cognitive test batteries) or macro (employment/return to school) outcome measures is to evaluate individuals’ functional capability for engagement in societal activities and roles. Such measures are free of non-person factors effecting outcome and also account for compensatory skills not detected on cognitive test batteries. In addition, measures must be both sufficiently sensitive to detect change and broad enough in scope to identify areas where functional improvement may be realized. The Mayo Portland Adaptability Inventory –4 (MPAI -4) meets these criteria. (Malec, 2004). The MPAI-4 consists of 29 functional items rated from 0 to 4 on a 5-point scale, where 0 represents no limitations and 4 represents a severe problem interfering with activity more than 75% of the time. Raw scores on the 29 items are converted to T-scores within three subscales: Abilities Index (physical, communication, and cognitive skills), Adjustment Index (emotional and behavioral skills), and Participation Index (contextual skill application). T-scores have a mean of 50 and a standard deviation of 10. Higher T-scores indicate greater disability. The Participation Index (M2PI; an abbreviated measure extracted from the full MPAI-4) was developed to provide an efficient measure of the final common outcome aim –societal participation (Malec, 2004). In the current trend of healthcare where brevity, sensitivity and remote access are essential, the M2PI provides a useful tool to evaluate long-term outcome following acquired brain injury for a wide range of diagnoses.

The purpose of this study was to investigate outcomes following post-hospital rehabilitation at three and twelve months post-discharge time periods. Specifically, the focus of this paper was to determine if these programs produce lasting improvements in participants and to identify predictors of long term outcome. Finally, given that acquired brain-injury in general includes a heterogeneous group of individuals, this study also sought to examine differences in functional outcomes between persons sustaining traumatic brain injury and persons surviving cerebral vascular accidents.

2 Methods

2.1 Participants

Individuals were selected from 2,177 neurologically impaired adults with consecutive discharges from 18 post-hospital programs in 12 states from 2011 through 2019. Inclusion criteria were as follows: between the ages of 18 and 75, sustained an acquired brain injury, participated in a post-hospital residential neurorehabilitation program for at least 7 days and had MPAI-4 Participation indices completed at admission, discharge, three month follow-up and twelve month follow-up. Exclusion criteria included persons younger than 18 or older than 75, diagnosed with a congenital neurological disorder, treated in residential neurorehabilitation for less than 7 days, or were unable to be reached for three and twelve month follow-ups. Applying these criteria left a study sample of 108 individuals. Demographic data for the sample is displayed in Table 1.

Table 1
Demographics by injury type

Injury type

TBI CVA Mixed

(n = 63) (n = 36) neurologic

injury

(n = 9)

Age

Mean 41.7 52.3 47.7

SD 15.7 12.6 12.4

Gender

Male 97% 61% 67%

Female 3% 39% 33%

Race

African American 8% 19% 44%

Caucasian 88% 81% 56%

Hispanic 2% 0% 0%

Asian 2% 0% 0%

Onset to admission (days)

Mean 785.7 99.3 244.8

SD 2450 113.9 276.4

Length of stay (days)

Mean 166.7 71.8 126.9

SD 267.7 39.9 182.4

	Injury type
Age
Mean	41.7	52.3	47.7
SD	15.7	12.6	12.4
Gender
Male	97%	61%	67%
Female	3%	39%	33%
Race
African American	8%	19%	44%
Caucasian	88%	81%	56%
Hispanic	2%	0%	0%
Asian	2%	0%	0%
Onset to admission (days)
Mean	785.7	99.3	244.8
SD	2450	113.9	276.4
Length of stay (days)
Mean	166.7	71.8	126.9
SD	267.7	39.9	182.4

Table 1 shows that the majority (58%) of the sample sustained a TBI (63/108 individuals). CVA comprised 33% of the sample (36/108 individuals), with mixed acquired neurological conditions making up 8% of the sample (9/108 individuals). Diagnoses for the mixed acquired neurological sample included 4 persons diagnosed with anoxia/hypoxia, 3 persons diagnosed with encephalopathy, and 2 persons diagnosed with combined traumatic brain and spinal cord injury.

As is common for persons treated in post-hospital brain injury rehabilitation programs, the TBI group was the most chronic with an average onset of injury to admission of just over 2 years and a standard deviation of 6 years. Research on post-hospital rehabilitation outcomes has shown that persons with TBI treated within 9 months of injury at this level of programming achieve greater gains in less time than those whose treatment begins beyond 9 months post-injury (Hayden, et. al. 2013; Lewis & Horn, 2015; Lewis, Horn & Russell, 2017). The chronicity of this group provides further evidence of the severity and level of disability at the time of admission.

2.2 Dependent measure

The dependent measure was the MPAI-4 Participation Index (M2PI). This measure assesses the amount of limitation experienced in 8 areas of function critical for societal participation: initiation of activity, social contact, leisure skills, self-care skills, residential skills (taking care of one’s living environment), transportation use/access, money management, and productive activity (e.g., work, volunteering, etc.).

2.3 Rehabilitation treatment

Each individual treated in neurorehabilitation programs received physical therapy, occupational therapy, speech therapy, recreation, counseling (based on need), case management, and medical management provided by nursing and physicians specializing in physical medicine and rehabilitation. Behavioral analysis was also provided for individuals requiring more extensive modification to reduce inappropriate behaviors and increase positive replacement behaviors.

2.4 Procedure

Individuals were evaluated upon admission by each program’s multidisciplinary treatment team members. Once discipline assessments were completed, each individual was then evaluated using the MPAI-4 (including the M2PI) by treatment team consensus. Discharge MPAI-4 data was completed in a similar fashion within the final week of the individual’s treatment. Three and twelve month follow-ups were conducted using the M2PI only. Post-discharge interviews were conducted via telephone by a trained coordinator. Primary respondents were family members accounting for 80% of the follow up cases, and 20% were from the brain injured respondent. The results of all evaluations were compiled into a national database and combined with individual demographic data.

WinSteps version 3.81 was used to conduct Rasch reliability analyses. All other analyses were performed using SPSS version 2.

2.5 MPAI-4 Participation index reliability statistics

Rasch analysis was used to determine the reliability of the Participation Index completed at the four assessment periods. Rasch analysis yields two important reliability statistics for functional assessment instruments: person reliability and item reliability. Person reliability reveals how well a measure identifies those exhibiting a lot or a little of the construct being measured (i.e. disability). Item reliability refers to whether test items uniquely contribute to describing the characteristics of a disparate group of individuals. A coefficient of 0.80 or greater is considered acceptable for person reliability, while a coefficient of at least 0.90 is optimal for item reliability (Wright, Linacre, & Gustafson, 1994). Person reliability at admission was the only value below the threshold. However, this result was due to an uneven distribution of disability levels at admission. The sample, as would be expected for persons entering post-hospital rehabilitation, was skewed to the moderate to severe end of the disability spectrum with very few in the mild disability category. Person reliability values for each assessment were 0.68 (admission), 0.85 (discharge), 0.88 (3 month) and 0.90 (12 month). Item reliability values were 0.94 (admission), 0.96 (discharge), 0.97 (3 month) and 0.95 (12 month).

3 Results

3.1 Full sample

To assess the durability of individuals’ functional improvements observed while in program, a one-way repeated measures ANOVA (1 x 4) was performed on MPAI –4 Participation T-scores for assessments taken during program at admission and at discharge, and post-discharge at 3 months and 12 months. This analysis revealed a significant main effect for time of testing, Greenhouse-Geisser F (2.37) = 76.87, p < 0.001, partial eta² = 0.418, power to detect = 0.99. Results of Bonferroni pairwise comparisons are presented in Table 2.

Table 2
Bonferroni pairwise comparison for differences in participation scores

Assessment Admission Discharge 3 months 12 months

period

Admission – 10.0^* 15.1^* 15.1^*

Discharge – – 5.1^* 5.1^*

3 months follow up – – – 0.02

Assessment	Admission	Discharge	3 months	12 months
Admission	–	10.0^*	15.1^*	15.1^*
Discharge	–	–	5.1^*	5.1^*
3 months follow up	–	–	–	0.02

^*p < 0.001.

Admission participation scores were significantly greater (more disability) than those obtained at discharge, and at the 3 and 12 month follow-up (p < 0.001). Discharge participation scores were also significantly greater (more disability) than those obtained at 3 months and 12 months post-discharge (p < 0.001). The 3 and 12 month scores did not differ significantly from each other indicating maintenance of improvements over a one year period. Figure 1 illustrates mean improvement in Participation T scores across assessment periods.

Fig. 1

Mean MPAI-4 Participation scores across assessment periods.

Follow-up Wilcoxon Z comparisons were performed to examine the number of persons improving, remaining the same or declining across assessment periods. Table 3 shows the results and p-values for these analyses.

Table 3

Number improving, remaining the same and declining across assessment periods as measured by the Participation Index

Time of assessment	Improved	Same	Decline	Wilcoxon Z	P value
Admission to discharge	96	11	1	8.5	0.001
Admission to 3 months	98	5	5	8.6	0.001
Admission to 1 year	96	4	8	8.6	0.001
Discharge to 3 months	72	13	23	5.1	0.001
Discharge to 1 year	65	10	33	4.2	0.001
3 months to 1 year	44	14	50	0.39	0.69

A noteworthy finding was that 89% of the sample experienced an overall reduction in disability from admission to one year post-discharge. Of those individuals that improved, 93% experienced a statistically (p < .05) and clinically significant 5 point gain or better on the Participation Index. Table 3 shows that the majority of individuals improved or maintained from 3 to 12 months. However, the data also revealed that 50 individuals within the total sample of 108 demonstrated a decline in total score during that follow up period. Investigating further, post hoc Wilcoxon Z tests were performed on Participation Index items (e.g., initiation, social contact, leisure development, self-care, home management, use of transportation, and money management) for the fifty decliners to determine which items were most problematic during that time period. The number declining ranged from 18 individuals on transportation to 29 individuals on initiation. Table 4 presents the Wilcoxon Z and p values for each comparison along with the number improving, declining and remaining the same.

Table 4

Item analysis for 50 persons who declined on Participation Index from 3 to 12 months

Item	Improved	Remained same	Decline	Wilcoxon Z	P value
Initiation	1	20	29	–4.72	0.001
Social contact	3	19	28	–4.10	0.001
Leisure	1	25	24	–4.33	0.001
Self-care	2	24	24	–3.81	0.001
Residential skills	2	23	25	–4.26	0.001
Transportation	4	28	18	–3.07	0.01
Money management	3	26	21	–2.91	0.01

The 50 decliners included 31 TBIs, 16 CVAs, and 3 with mixed diagnoses. Within the TBI group, residential skills, social contact and initiation were the areas with the greatest number of persons declining; 19, 18, and 17 respectively. For the CVA group, these areas were initiation (10 decliners) and self-care (9 decliners). Each of the mixed diagnostic cases showed a decline in self-care.

3.2 Comparison of TBI and CVA outcomes

A Repeated Measures mixed ANOVA (2 x 4) was performed to determine if outcomes for TBI and CVA individuals differed over assessment periods. This analysis revealed a main effect of time, Greenhouse-Geisser F(2.4) = 67.93, p < 0.001, partial eta² = 0.41, power to detect = 0.99. The interaction of diagnostic group by time was not significant p > 0.433. Results of Bonferroni post-hoc comparisons for differences between scores by assessment period are presented in Table 5.

Table 5
Change in Participation T-scores for TBI and CVA groups across assessment periods: Bonferroni post hoc comparisons

Group Admission Discharge 3 months 12 months

TBI

Admission –– 8.5^* 14.9^* 14.7^*

Discharge 8.5^* –– 6.4^* 6.2^*

3 months 14.9^* 6.4^* –– 0.30

12 months 14.7^* 6.2^* 0.30 ––

CVA

Admission –– 12.2^* 15.6^* 15.8^*

Discharge 12.2^* –– 3.4 3.6^*

3 months 15.6^* 3.4 –– 0.17

12 months 15.8^* 3.6^* 0.17 ––

Group	Admission	Discharge	3 months	12 months
TBI
Admission	––	8.5^*	14.9^*	14.7^*
Discharge	8.5^*	––	6.4^*	6.2^*
3 months	14.9^*	6.4^*	––	0.30
12 months	14.7^*	6.2^*	0.30	––
CVA
Admission	––	12.2^*	15.6^*	15.8^*
Discharge	12.2^*	––	3.4	3.6^*
3 months	15.6^*	3.4	––	0.17
12 months	15.8^*	3.6^*	0.17	––

^* P < 0.05.

For the CVA group, admission participation scores were significantly greater (more disability) than those obtained at each of the other assessment periods (p < 0.001). Discharge participation scores approached significance (p < 0.11, Bonferroni correction) when compared with 3 month outcome. When comparing the discharge participation scores to the 12 month follow up, the discharge scores were significantly (p < 0.05) greater (more disability) than those observed at the 12 month follow up.

For the TBI group, admission scores were significantly greater (more disability) than those at discharge, 3 months, and 12 months post discharge (p < 0.001). Discharge scores were also greater than those obtained at 3 and 12 months (p < 0.01). Again there were no statistically significant differences between the 3 month and 12 month scores, indicating maintenance of gains made in program.

The Repeated Measures mixed ANOVA (2×4) analysis also revealed a group main effect F(1, 97) = 4.18, p < 0.41, partial eta² = 0.041, power to detect = 0.525. Follow-up independent sample T- test found that the CVA group had significantly greater Participation scores at admission than the TBI group t(97) = 2.718, p < 0.01 (two-tailed), Cohen’s d = 0.568. Between groups comparisons at the other assessment periods were not significant, although the TBI group experienced less disability at each assessment period. Figure 2 illustrates TBI and CVA individuals’ mean scores across assessments.

Fig. 2

TBI and CVA participation T-scores admission through 12 months.

For both groups, performance improved following participation in post-hospital residential rehabilitation. Performance continued to improve at 3 months and for most was maintained at 12 months post discharge. Tables 6 7 present the number of persons improving, remaining the same, and declining along with Wilcoxon Z and p values for CVA and TBI respectively.

Table 6

CVA Wilcoxon Z and p values

Assessment period	Improved	Remained same	Decline	Wilcoxon Z	P value
Admission to discharge	34	2	0	5.1	0.001
Admission to 3 months	32	1	3	5.0	0.001
Admission to 12 months	34	0	2	5.1	0.001
Discharge to 3 months	23	3	10	2.4	0.17
Discharge to 12 months	22	2	12	2.7	0.01
3 months to 12 months	17	3	16	0.12	0.90

Table 7

TBI Wilcoxon Z and p values

Assessment period	Improved	Remained same	Decline	Wilcoxon Z	P value
Admission to discharge	53	9	1	6.2	0.001
Admission to 3 months	58	4	1	6.7	0.001
Admission to 12 months	56	4	3	6.6	0.001
Discharge to 3 months	46	7	10	4.7	0.001
Discharge to 12 months	40	6	17	3.5	0.001
3 months to 12 months	24	8	31	0.54	0.59

Due to the small sample size (9 persons), the mixed diagnostic group was not included in the between groups analysis of outcomes. However, it is noteworthy that this group also showed improvement from admission to discharge and most were able to maintain their gains at the 3 and 12 month follow-up periods. Mean participation T-scores for this group were: admission = 57.6, discharge = 46.1, three month = 44.1, and twelve month = 42.7. At the 12 month follow-up, 5 of the 9 maintained or improved upon gains made at discharge.

3.3 Predictive findings

To predict a participation score at 12 months post-discharge, length of stay, age, and chronicity (onset of injury to rehabilitation admission) were entered into the first hierarchical block by step-wise inclusion. Of these variables, length of stay predicted 0.06 of the variance of participation score at one year (0.05 of adjusted variance). Injury type (TBI, CVA) was selected for the second block. This variable increased the multiple R to its final level of 0.10 (adjusted R² = 0.085). These findings reveal that individuals with a TBI tended to have modestly better outcomes than those with a CVA. For both diagnoses, longer residential stays were associated with improved outcomes. Age and chronicity did not significantly improve prediction. Table 8 presents the results of the regression analysis.

Table 8
Predictors of MPAI-4 participation score at one-year follow-up

Block number and predictor Pearson r R² added Cumulative R² Final beta

Block 1: Length of stay 0.242^** 0.06^* 0.06^* 0.295^

Block 2: Injury type 0.154 0.045^ 0.105^* 0.219^*

Block number and predictor	Pearson r	R² added	Cumulative R²	Final beta
Block 1: Length of stay	0.242^**	0.06^*	0.06^*	0.295^**
Block 2: Injury type	0.154	0.045^**	0.105^*	0.219^*

p < 0.05^*; p < 0.01^**.

4 Discussion

The purpose of this study was to evaluate the effectiveness of post-hospital residential rehabilitation programming for individuals with traumatic brain injury, cerebrovascular accident, and mixed neurological impairments. The results demonstrate the efficacy of treatment overall as evidenced by reduced disability from admission to discharge. These results further support prior research indicating the same trend showing that rehabilitation gains can continue well beyond acute care and acute inpatient rehabilitation.

The second purpose was to examine differences between TBI and CVA within outcomes following acute care. The results revealed that CVA individuals had more disability at the time of admission and this carried through to the end of their post-hospital residential rehabilitation programming. This was unexpected since CVA effects tend to be more focal vs. TBI effects tends to be more diffuse and therefore impacting more skills. Although the trend for CVA having higher disability was evident, statistically the data revealed differences at the beginning of care but not by the time care was completed for both groups. Therefore, treatment at the post hospital level may lead to a final common outcome suggesting that post hospital care provides improvement to a point, and then additional care at the community level (outpatient, home and community therapy) becomes appropriate to continue this downward trend of reduced disability. As expected, the results clearly demonstrate that rehabilitation efforts from such significant neurological injury and impairment requires a continuum of care rather than one effort at the beginning of recovery only.

The third purpose was to determine if there were any predictors that could provide further insight into this level of care to enhance an individual’s recovery. The strongest predictor that was evident was the length of stay. This finding may be contrary to today’s healthcare model, but provides evidence that at certain points in time along the continuum, greater length of stay may reduce disability to a greater degree allowing one to be more functional. In fact, in a true continuum of care, the model may reveal shorter lengths of stay at the beginning of care and lengthen as the acuity subsides with functional skills remaining impaired. Therefore, when considering a model of care, length of stay in ICU and Acute care for TBI and CVA revealed an ICU stay of 0 days resulted in acute care management of 3.2 days, while an average ICU stay of 1.2 days resulted in 7.3 days in acute care management (Levant, Chari, DeFrances, 2016). Inpatient rehabilitation course may range from 1–3 weeks for TBI and 1–2 weeks for CVA but constant supervision is required at the time of hospital discharge. At the time of post-hospital care, 24 hour supervision remains necessary initially but is gradually reduced over a 4–5 month period thereby only requiring intermittent supervision once a person transitions to the community level. At the community level, supervision is reduced dramatically and in many cases is no longer necessary at the end of community based rehabilitation. However, community based rehabilitation may be required over many months or greater. In this continuum, however, the cost consistently reduces despite greater length of stay in each level of care after the hospital. With the gains being held for most individuals at 12 months post discharge from a residential rehabilitation program, the return on investment is evident even if the person does not receive additional therapy following residential care. The return is also evident as costs reduce with each subsequent level of care yet gains are maintained, or continue with improvement of functional skills.

5 Conclusion

Neurological injuries are difficult and require the concept of lifetime care. The goal of post-hospital residential rehabilitation care is skills acquisition and maintenance, skills generalization in the home and community setting, and reduced supervision all providing the context for reduced disability. The present study demonstrated that individuals benefit greatly from post hospital rehabilitation even after lengthy delays in receiving services.

Conflict of interest

The authors have no conflicts to disclose.

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	Injury type
	TBI	CVA	Mixed
	(n = 63)	(n = 36)	neurologic
			injury
			(n = 9)
Age
Mean	41.7	52.3	47.7
SD	15.7	12.6	12.4
Gender
Male	97%	61%	67%
Female	3%	39%	33%
Race
African American	8%	19%	44%
Caucasian	88%	81%	56%
Hispanic	2%	0%	0%
Asian	2%	0%	0%
Onset to admission (days)
Mean	785.7	99.3	244.8
SD	2450	113.9	276.4
Length of stay (days)
Mean	166.7	71.8	126.9
SD	267.7	39.9	182.4

Comparison of TBI and CVA outcomes: Durability of gains following post-hospital neurological rehabilitation

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1 Introduction

2 Methods

2.1 Participants

2.3 Rehabilitation treatment

2.4 Procedure

2.5 MPAI-4 Participation index reliability statistics

3 Results

3.1 Full sample

Table 2 Bonferroni pairwise comparison for differences in participation scores Assessment Admission Discharge 3 months 12 months period Admission – 10.0* 15.1* 15.1* Discharge – – 5.1* 5.1* 3 months follow up – – – 0.02

Table 8 Predictors of MPAI-4 participation score at one-year follow-up Block number and predictor Pearson r R2 added Cumulative R2 Final beta Block 1: Length of stay 0.242** 0.06* 0.06* 0.295** Block 2: Injury type 0.154 0.045** 0.105* 0.219*

5 Conclusion

Conflict of interest

References

Table 2
Bonferroni pairwise comparison for differences in participation scores

Assessment Admission Discharge 3 months 12 months

period

Admission – 10.0^* 15.1^* 15.1^*

Discharge – – 5.1^* 5.1^*

3 months follow up – – – 0.02

Table 8
Predictors of MPAI-4 participation score at one-year follow-up

Block number and predictor Pearson r R² added Cumulative R² Final beta

Block 1: Length of stay 0.242^** 0.06^* 0.06^* 0.295^

Block 2: Injury type 0.154 0.045^ 0.105^* 0.219^*