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Researchers recently discovered a surprising fact about people who have suffered from a traumatic brain injury (TBI): Patients who were injured as a result of violence have just as good a chance for recovery as patients who were injured by some other cause.
Less of a surprise was the finding that TBI patients who have a history of substance abuse have greater difficulty benefiting from rehab care, according to findings published in the Archives of Physical Medicine and Rehabilitation.
"The fact that substance abuse has a strong association with outcomes is not surprising; that’s something we’ve suspected for a while," says Jennifer Bogner, PhD, associate professor of physical medicine and rehabilitation at The Ohio State University in Columbus. Bogner was a co-author of the study.
"That we didn’t find a strong relationship between violence and the outcomes we looked at was somewhat surprising," Bogner adds. "I have a feeling that violence does affect adjustment, but we didn’t specifically look at that type of outcome."
Investigators measured how TBI patients measured on these outcomes: community integration, ability to return to work, taking care of one’s self at home, life satisfaction in general, and social integration.
Specifically, the study compared TBI patients who were injured by either an assault or a gunshot wound with those who were injured by some other means. All participants were screened for substance abuse, following criteria from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).1
The study found that individuals who had suffered a TBI due to violence were more likely to have a history of substance abuse; 79% of TBI patients with violent etiology had a history of substance abuse, compared with 55% of TBI patients whose injuries were not violent. The study included adjustments for this difference when determining how well TBI patients who had a violent injury adjusted after discharge.
A year after discharge from rehabilitation, investigators called TBI patients to ask them to complete telephone and mail surveys. In some cases, family members might have completed objective portions of the survey and assisted with communication. The outcomes measured included the patient’s life satisfaction as measured by the Satisfaction with Life Scale; home competency as measured by the subscale score on the Community Integration Questionnaire; objective analyses of whether the patient was living independently, including living with a family; and whether the patient was productive as defined by working, attending school, or volunteering.
Researchers found that TBI patients participating in the study demonstrated less satisfaction with life if they also had a substance abuse history. That was not the case for victims of violence.
"The significance of this study is showing how important substance abuse is in predicting outcomes," Bogner says. "But I don’t want folks to overlook the fact that violence is a significant source of TBI and is a significant concern with regards to prevention of TBI."
Nonetheless, rehabilitation facilities may want to incorporate substance abuse screening, referral, and/or treatment into their services, Bogner suggests.
"Rehab professionals should be prepared to screen for a history of substance abuse with all the folks who have had a traumatic brain injury," Bogner says. "And when screening, they should look at how much the patient used alcohol and other drugs before the injury."
For example, clinicians can find out if the patient had a high blood alcohol level at the time of injury and whether the patient previously had experienced use-related consequences, such as losing a job or a driving under the influence charge.
"What were the patient’s social activities that involved substances?" Bogner recommends asking. "Does the patient’s environment encourage substance abuse with other family members using substances, for example?"
Bogner suggests that rehab providers screen all TBI patients for substance abuse and make appropriate referrals based on their risk for continued abuse.
Ohio State’s outpatient rehabilitation program includes a case management program called TBI Network, which is designed specifically for patients who have a history of substance abuse. The rehab team makes referrals to TBI Network when appropriate.
Launched in 1992 with a grant from the Ohio Department of Rehabilitation Services and the Ohio Department of Drug and Alcohol Services, TBI Network is certified to provide alcohol and drug treatment to people who have had a traumatic brain injury, says Marty Wolfe, LISW, program manager.
TBI Network has evolved into a multidisciplinary fee-for-service program that has a staff of 11 and is accredited by CARF The Rehabilitation Accreditation Commission in Tucson, AZ.
The university’s rehabilitation program is designed to address a patient’s psychosocial needs holistically. Its staff include Bogner, a social worker, and two case managers, who together work with TBI patients at discharge from rehab in assessing their needs. The team evaluates each patient’s financial situation, psychosocial difficulties with adjustment, school re-entry, medical needs, family needs, and any other concerns the patient may have, Bogner says.
Patients and their families meet with a psychologist case manager and a physician at times when they already have other appointments in the rehab facility.
"Then we provide telephone follow-up to make sure they get the services they need," Bogner says.
Through a computerized resource tracking system, case managers can make certain a patient has met with TBI Network. A month after the referral was made, the system will give the case manager a computer message to check on the patient, Bogner says.
1. Bogner JA, Corrigan JD, Mysiw WJ, et al. A comparison of substance abuse and violence in the prediction of long-term rehabilitation outcomes after traumatic brain injury. Arch Phys Med Rehabil 2001; 82:571-577.