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ommunity Integration and Satisfaction With Functioningfter Intensive Cognitive Rehabilitation

or Traumatic Brain Injury
eith D. Cicerone, PhD, Tasha Mott, PhD, Joanne Azulay, PhD, John C. Friel, PsyD
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ABSTRACT. Cicerone KD, Mott T, Azulay J, Friel JC.ommunity integration and satisfaction with functioning after

ntensive cognitive rehabilitation for traumatic brain injury.rch Phys Med Rehabil 2004;85:943-50.

Objective: To evaluate the effectiveness of an intensiveognitive rehabilitation program (ICRP) compared with stan-ard neurorehabilitation (SRP) for persons with traumatic brainnjury (TBI).

Design: Nonrandomized controlled intervention trial.Setting: Community-based, postacute outpatient brain in-

ury rehabilitation program.Participants: Fifty-six persons with TBI.Interventions: Participants in ICRP (n�27) received an

ntensive, highly structured program of integrated cognitivend psychosocial interventions based on principles of holisticeuropsychologic rehabilitation. Participants in SRP (n�29)eceived comprehensive neurorehabilitation consisting primar-ly of physical therapy, occupational therapy, speech therapy,nd neuropsychologic treatment. Duration of treatment waspproximately 4 months for both interventions.

Main Outcome Measures: Community Integration Ques-ionnaire (CIQ); and Quality of Community Integration Ques-ionnaire assessing satisfaction with community functioningnd satisfaction with cognitive functioning. Neuropsychologicunctioning was evaluated for the ICRP participants.

Results: Both groups showed significant improvement onhe CIQ, with the ICRP group exhibiting a significant treatmentffect compared with the SRP group. Analysis of clinicallyignificant improvement indicated that ICRP participants werever twice as likely to show clinical benefit on the CIQ (oddsatio�2.41; 95% confidence interval, 0.8–7.2). ICRP partici-ants showed significant improvement in overall neuropsycho-ogic functioning; participants with clinically significant im-rovement on the CIQ also showed greater improvement ofeuropsychologic functioning. Satisfaction with communityunctioning was not related to community integration afterreatment. Satisfaction with cognitive functioning made a sig-ificant contribution to posttreatment community integration;his finding may reflect the mediating effects of perceivedelf-efficacy on functional outcome.

Conclusions: Intensive, holistic, cognitive rehabilitation isn effective form of rehabilitation, particularly for persons withBI who have previously been unable to resume community

From the Cognitive Rehabilitation Department, JFK-Johnson Rehabilitation Insti-ute, Edison, NJ.

Supported by the National Institute on Disability and Rehabilitation Researchgrant no. H133A020518).

No commercial party having a direct financial interest in the results of the researchupporting this article has or will confer a benefit on the author(s) or on anyrganization with which the author(s) is/are associated.Reprint requests to Keith D. Cicerone, PhD, JFK-Johnson Rehabilitation Institute,

048 Oak Tree Rd, Edison, NJ 08820, e-mail: [email protected]/04/8506-8427$30.00/0doi:10.1016/j.apmr.2003.07.019

unctioning. Perceived self-efficacy may have significant im-act on functional outcomes after TBI rehabilitation. Measuresf social participation and subjective well-being appear toepresent distinct and separable rehabilitation outcomes afterBI.Key Words: Brain injuries; Outcome and process assess-ent (health care); Quality of life; Rehabilitation.© 2004 by the American Congress of Rehabilitation Medi-

ine and the American Academy of Physical Medicine andehabilitation

T IS GENERALLY well recognized that the cognitive andpsychosocial impairments after traumatic brain injury (TBI)

ontribute to chronic disability, and therefore, rehabilitationust address these aspects of a person’s functioning to be

ffective. Neuropsychologic rehabilitation of persons with TBIay best be achieved through a comprehensive, holistic ap-

roach to the treatment of cognitive, emotional, and functionalmpairments and disability. In their review of postacute, out-atient brain injury rehabilitation, Malec and Basford1 notedhat comprehensive integrated treatment for persons with TBIncludes a neuropsychologic focus that addresses cognitive,nterpersonal, and affective concerns; group interventions thatddress awareness, acceptance, and social skills; involvementf significant others; and therapeutic trials to enhance voca-ional functioning and independent living skills. These pro-rams are typically centered on the goals of fostering partici-ants’ awareness of their functional potential; improvingersonal organization and social skills; developing compensa-ions for residual cognitive limitations; developing psychologicoping skills for emotional and behavioral self-management;articipating in social, work, and leisure activities; and adapt-ng to the chronic limitations imposed by their injury, tolleviate disability in everyday activities and facilitate socialole functioning. Malec et al2 made explicit the distinctionetween remedial interventions, which are intended to be re-torative of cognitive abilities, and interventions designed toevelop alternative or compensatory behaviors to accomplishhe same goals through different means. Although treatmentay initially attempt to restore dysfunctional cognitive sys-

ems—an approach that can increase awareness of disabilitiesnd produce small changes in cognitive impairments—the em-hasis on compensatory behavior and environmental restruc-uring for residual cognitive limitations increases over theourse of treatment.

In their discussion of the rationale for the holistic approacho neuropsychologic rehabilitation, Ben-Yishay and Gold3 em-hasized that the neurobehavioral manifestations after TBI areynamic and multidetermined. They stated that effective reha-ilitation must systematically integrate interventions directed athe remediation of cognitive deficits, functional skills, andnterpersonal functions. Improvements in functioning are typ-cally accomplished by an improvement in the effective func-ional application of residual cognitive abilities rather thanestoration of the underlying cognitive deficits per se. Evidence

Arch Phys Med Rehabil Vol 85, June 2004

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944 INTENSIVE COGNITIVE REHABILITATION FOR TBI, Cicerone

A

xists that holistic, integrated rehabilitation that includes bothndividualized cognitive and psychosocial-interpersonal thera-ies produces the greatest overall improvements in functioningy persons with TBI.4,5

Few studies of comprehensive integrated TBI rehabilitationave assessed treatment effectiveness at the level of commu-ity integration and social participation. Malec6 reported im-rovements in social participation after comprehensive TBIehabilitation, assessed with the Mayo Portland Adaptabilitynventory, despite the fact that primary cognitive functions ofttention, memory, and novel problem solving improved leastrequently over the course of treatment. Sander et al,7 using theommunity Integration Questionnaire (CIQ), evaluated treat-ent effects for 24 persons with TBI who were admitted for

omprehensive integrated, postacute rehabilitation within 8onths of injury. They found significant improvements after an

verage of 4 months of treatment on the CIQ total score and onhe 3 subscales measuring home integration, social integration,nd productivity. A subsequent analysis of 71 persons with TBIho participated in this program again showed significant

mprovements on all of the CIQ subscales.8 Participants whoere admitted for treatment less than 1 year after injury

howed greater improvement on the total CIQ and productivityubscale but not the home integration or social integrationubscales, compared with participants admitted to treatment 1o 5 years after injury. In addition to group analyses, individualariability in response to rehabilitation was evaluated usingeliable change methodology. The analysis of clinically signif-cant change for individual participants indicated that 46% ofhe total sample improved on total CIQ scores from pretreat-ent to posttreatment, 49% did not make significant change,

nd 4% showed clinically significant worsening. The partici-ants who were less than 1 year after injury were more likelyo make clinically significant improvement on total CIQ (59%s 36%) and productivity (59% vs 23%) scores, consistent withroup analyses.None of these studies included a comparison group, limiting

he interpretation of results. Further, measures of participationike the CIQ assess neither effectiveness of functioning8 norersons’ satisfaction with their community functioning.9 In hiseview of the CIQ as a measure of long-term outcomes afterBI, Dijkers10 noted a particular need for research both tossess CIQ change that occurs after interventions to improveommunity functioning and to relate objective assessment ofommunity functioning with the CIQ to subjective quality ofife (QOL).

Several studies have found little relation between QOL afterBI and injury-related variables,11-13 physical indepen-ence,14-17 or cognitive functioning.13,17,18 Several studies havexamined the relationship between subjective well-being andhe CIQ score.13,19-21 Heinemann and Whiteneck19 includedeasures of impairment, disability, handicap, and life satisfac-

ion among 758 individuals with TBI an average of 5 yearsfter injury. Global perception of life satisfaction was posi-ively related to social integration and productivity (but notome integration) on the CIQ. Corrigan et al13 also found aelation between life satisfaction and CIQ social integration for14 persons with TBI who were 2 years after injury (but not 1yfter injury). Life satisfaction was only modestly associatedith factors predictive of other aspects of outcome after TBI.urleigh et al20 examined the relation between global life

atisfaction and components of community integration on theIQ for 30 persons with TBI who were living in the commu-ity and were at least 8 years after injury. They found only aarginal relation between life satisfaction and social integra-

ion and no relation with home integration, productivity, or

rch Phys Med Rehabil Vol 85, June 2004

verall community integration scores. However, Smith et al21

ailed to find a significant relation between life satisfaction andotal CIQ score on any of the subscale scores among 43 adultsith TBI who were living in the community an average of 7ears after injury. Overall, the studies that evaluated bothommunity integration and QOL several years after TBI found

marginal relation, suggesting that these represent distinctspects of participants’ experience and separable aspects ofong-term outcome after rehabilitation for TBI.

Prior studies14,15,17 have emphasized the importance of un-erstanding a person’s perceptions of well-being, values, andeliefs for providing effective, holistic rehabilitation. Althougheveral studies that examined life satisfaction after TBI in-luded subjects who had received rehabilitation, we did notdentify a single study that directly assessed life satisfaction asn outcome of TBI rehabilitation.

The purpose of our study was to compare the effectivenesselative to community integration of a program of holistic,ntensive, cognitive rehabilitation with a more conventionalehabilitation program for persons with TBI. We also assessedarticipants’ satisfaction with their functioning after treatmentnd examined the relations among neuropsychologic function-ng, community integration, satisfaction with community func-ioning, and satisfaction with cognitive functioning.

METHODS

articipantsWe examined treatment effectiveness for people with TBI

ho participated in a comprehensive, postacute, outpatient,rain injury rehabilitation program. Criteria for participation inhis program include being medically stable at the time ofdmission; independent in basic self-care skills, such as feed-ng and toileting; and having the cognitive ability to participaten treatment. Additional inclusion criteria for participants in theurrent study included medical documentation of TBI, age of8 years or older, and having adequate language expressionnd comprehension to participate in verbally based interven-ions (ie, participants had to speak English and could not beeverely aphasic). Participants with a history of substancebuse or psychiatric history were not excluded, although pa-ients identified with current substance use or psychiatric dis-urbance that would preclude effective treatment for their cog-itive deficits were not admitted to the postacute rehabilitationrogram. Participants also had to have a family member orerson who could participate in treatment planning conferencesnd support implementation of the treatment plan. Participantsrovided informed consent to participate in treatment.The participants in our study were 56 persons with TBI who

ere admitted for treatment within a 2-year period from Jan-ary 1997 through December 1998. We conducted a prospec-ive analysis of 2 different intervention programs over thisime. The majority of participants (89%) had sustained mod-rate to severe TBI, with the remainder sustaining mild inju-ies. One group of 27 participants had been screened andelected for an intensive cognitive rehabilitation programICRP). These participants typically exhibited significant cog-itive limitations and had been unable to resume their preinjuryctivity levels and/or employment. Although these participantsere, in principle, considered to have some capacity to developrealistic awareness of their strengths and weaknesses, partic-

pants with significant impairments of self-awareness wereypically referred for the ICRP as the most likely means ofmproving their functional abilities. Impaired self-awarenessas determined by the judgment of clinicians involved in theatient’s care, typically based on a combination of clinical

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945INTENSIVE COGNITIVE REHABILITATION FOR TBI, Cicerone

nterview, discrepancies between the patient’s subjective reportnd results of neuropsychologic evaluation, and responses toeedback regarding the presence of cognitive deficits. Thereere 29 participants who participated in a standard rehabilita-

ion program (SRP) for brain injury. The 2 groups were equiv-lent with regard to age, education, and gender (table 1). Mostarticipants in both groups were productive before their injury,ith most engaged in full-time, competitive employment (table 1).A systematic bias existed in the selection of participants,

ased on time from injury at the admission to treatment.articipants who were further postinjury and had chronic dis-bility (including participants who had received prior postacuteehabilitation and/or been unsuccessful in their attempts toesume functioning) were more likely to be admitted to ICRP.articipants who were admitted to the postacute rehabilitationrogram relatively earlier after injury and who were consideredore likely to exhibit active neurologic recovery over the

ourse of treatment were more likely to receive SRP. As aesult, participants in SRP were significantly earlier postinjuryhan participants in ICRP (see table 1). Twenty-eight of 2997%) of the SRP participants were 1 year or less after injury,ith 20 of 29 (69%) 3 months or less after injury. In contrast,4 of the 27 (52%) ICRP participants were 1 year or less afternjury, and none were less than 4 months after injury.

One of the ICRP participants left treatment to enter a voca-ional training program 2 weeks before the completion of thelanned intervention. This patient returned to complete theosttreatment evaluation as originally scheduled and is in-luded in the current analysis. No SRP participants discontin-ed treatment, although the length of treatment could varyased on therapists’ recommendations and participants’ pref-rences.

nterventionsThe ICRP is a highly structured and integrated program

asting 16 weeks. It is provided to small groups of 5 to 8articipants at a given time. The ICRP consisted of individualnd group cognitive remediation with an emphasis on increas-ng awareness and developing compensations for cognitiveeficits, small-group treatment for interpersonal and pragmaticommunication skills, individual and/or group psychotherapy,amily support, and therapeutic work trials and placement toacilitate educational or vocational readiness. Some partici-ants received a limited amount of physical or occupationalherapy for sensorimotor deficits, if necessary. Within the

Table 1: Demographic Characteristics

ICRP SRP

n 27 29Mean age � SD (y) 37.8�10.6 37.1�12.0Mean education � SD (y) 13.2�1.7 13.0�2.2Gender, n (%)

Men 17 (63) 23 (79)Women 10 (37) 6 (21)

Preinjury employment status, n (%)Competitively employed 25 (92.6) 25 (86.2)Student 1 (3.7) 3 (10.3)Unemployed 1 (3.7) 1 (3.5)

Moderate to severe injury (%) 88.9 89.6Mean time after injury � SD (mo) 33.9�4.8 4.8�9.5*Mean treatment length � SD (mo) 3.8�0.4 3.9�2.5

bbreviation: SD, standard deviation.P�.05.

CRP, participants are expected to accept and to provide feed-ack to others, and interpersonal group process is emphasizedhroughout all of the treatment components. The core treatmentrogram was conducted 4 days a week, 5 hours a day. All ICRParticipants received cognitive group treatment for 2 hours aay, 3 days a week. Cognitive group treatment used a varietyf functional activities, with an emphasis on executive func-ioning (eg, planning, problem solving, adapting to unexpectedituations), metacognitive functioning (eg, self-monitoring,ognitive self-appraisal, affect regulation), and interpersonalroup process (eg, giving and receiving feedback, achievingonsensual agreement). The final 20 to 30 minutes of cognitiveroup treatment was devoted to reviewing the group process,ummarizing the activities of the group, and highlighting par-icipants’ individual problems and progress. After each cogni-ive group, participants received 1 hour of individual cognitiveemediation directed toward their specific areas of impairedognitive functioning. An active effort was made to relate theontent of individual cognitive interventions to the areas ofognitive difficulty observed in group treatments, as well as toake explicit the relation between individual cognitive treat-ents and the participant’s everyday functioning. These ses-

ions were also used to ensure participants’ agreement with theoals of their treatment, to obtain their recommendations re-arding appropriate treatment content, and to address any ad-itional concerns. Group treatment of communication and in-erpersonal skills was conducted for an additional 3 hours aeek, to address participants’ pragmatic language skills, inter-ersonal communication style, perspective taking, and socialehavior. The interpersonal communication interventions in-orporated role playing in varied functional and interpersonalcenarios. It also incorporated interpersonal and videotapedeedback, review of each participant’s communication stylend intent, and analysis of social interactions and interpersonalnteractions. Performance feedback and active self-appraisalere encouraged throughout the group process. Participants

lso received group treatment 1 hour a week to facilitate thepplication of therapeutic gains in their daily lives. Althoughhe specific focus and methods of this group varied at differentimes, typically reflecting the needs of different groups ofarticipants, the application of life skills (eg, note-taking),elf-management of emotional reactions that adversely im-acted functioning, and instruction and modeling to facilitateeneralization of compensatory strategies were consistentlyddressed. Participants received additional therapies within theore program determined by their individual needs. ICRP par-icipants typically received 15 hours a week of therapies in thereatments described above.

In addition to these treatments, 1 day a week of the coreCRP program was devoted to participation in individuallyesigned therapeutic work trials within the hospital or commu-ity. These trials were under the supervision of a vocationalherapist who could also provide on-site job coaching. Forarticipants expecting to return to school, this aspect of treat-ent was directed at reestablishing functional academic skills

nd participating in structured coursework or educational train-ng. Participants without active goals of returning to work orchool received treatment relevant to their discharge destina-ion, such as management of home responsibilities or providingolunteer services. The therapeutic work trials and relatedctivities provided an opportunity for participants to identifyheir deficits, to practice compensatory strategies, and to im-rove their interpersonal communication skills in a realisticnvironment. Throughout the program, families were sched-led to participate in a typical treatment day along with thearticipants, to establish an ongoing connection among the


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oals of the program, participants’ progress, observation ofamily members and significant others, and reinforcement ofhe use of compensatory strategies in the home and community.

The SRP consisted primarily of physical, occupational,peech, and neuropsychologic therapies. Each participant’sreatment content and duration were clinically determined inccordance with participants’ individual needs, medically pre-cribed treatments, and the treatment team’s clinical recom-endations. Specific interventions directed at their cognitive

eficits were typically included within these therapies, accord-ng to the therapists’ individual assessments and treatmentlans, and all participants continued to be monitored by a staffeuropsychologist throughout the course of their treatment.articipants in SRP could also receive recreational therapy,ocational or educational interventions, and psychologic coun-eling based on their individual needs. The SRP was deliveredithin the same postacute brain injury rehabilitation setting as

he ICRP and incorporated many of the principles of compre-ensive neuropsychologic rehabilitation,22 but the delivery ofreatment was less intensive and less structured. Participants inhe SRP were initially admitted for 15 hours a week of treat-ent; this was adjusted over the course of treatment to reflect

urrent needs and typically varied between 12 and 24 hours ofreatment a week for all of the SRP participants. Both groupseceived approximately 4 months of treatment (see table 1).

utcome MeasuresThe primary measure of the effectiveness of treatment was

mprovement in community integration from before to afterreatment. QOL, based on a new measure of participants’atisfaction with their functioning, was also assessed at theompletion of treatment. For participants receiving ICRP, welso evaluated changes in neuropsychologic functioning fromefore to after treatment.Community integration. Community integration was as-

essed with the CIQ, which was administered and scoredccording to the original procedures.9 The primary measure ofnterest was total CIQ score, although changes in home inte-ration, social integration, and productivity subscales were alsoxamined. Effect sizes (ESs) were determined using the Cohenstatistic, based on the pooled variance from pretreatment CIQ

cores.23 To evaluate the incidence of clinically significanthanges in community integration for individual participants,e derived a reliable change index24 (RCI) for the total CIQ

core from the psychometric information for 341 persons withBI.9 Participants were classified as showing positive change,o change, or negative change based on reliable change scoresxceeding the 90% confidence interval (CI) (5% in eitherirection). Using this method to determine the 90% RCI re-ulted in a value of 4.2 for the total CIQ score, which isssentially the same as the value derived by Seale et al.8

Satisfaction with functioning. No consensus exists on these of instruments to measure health-related QOL in a mannerhat is relevant to persons with TBI.25,26 To evaluate partici-ants’ satisfaction with their functioning after cognitive reha-ilitation, we took a practical approach and developed a mea-ure that complemented the CIQ. This instrument, which weave referred to as the Quality of Community Integrationuestionnaire (QCIQ) queries 2 types of satisfaction: (1) indi-iduals’ subjective satisfaction with their level of communityntegration and (2) individuals’ satisfaction with their currentevel of cognitive functioning as it affects their ability tounction in specific areas of their lives.

The initial portion of the QCIQ corresponds to the assess-ent of community integration with the CIQ, and consists of

uestions related to the individual’s satisfaction with commu-


ity functioning (QCI scale). The home integration sectionncludes a satisfaction question for each of the 6 CIQ items; forxample, the CIQ question “Who usually looks after yourersonal finances, such as banking or paying bills?” was ac-ompanied by the question “How satisfied are you with the wayn which your personal finances are managed?” The socialntegration section of the QCIQ incorporates 2 satisfactionuestions related to participants’ satisfaction with their leisureife and satisfaction with their ability to get along with others.he productivity section of the QCIQ included an additionaluestion related to satisfaction with current work situation,chool situation, and/or volunteer activities. Each of the satis-action questions is rated on a 4-point scale (range: 1, veryissatisfied to 4, very satisfied). Total possible scores on theCI scale range from 9 to 36.We believe that an important aspect of QOL for persons

ith TBI receiving cognitive rehabilitation is their satisfac-ion with their cognitive functioning. Therefore, the final sec-ion of the QCIQ addresses participants’ satisfaction with cog-itive functioning (QCOG scale). Subjects are initially asked toate how important they consider their cognitive functioning toheir happiness, with responses ranging from “not important”o “very important.” There are 6 subsequent questions askingespondents, “How satisfied are you with your cognitive func-ioning (1) as it affects your ability to carry out daily householdesponsibilities (eg shopping, meal preparation, housework,hild care, personal financial management); (2) as means ofnabling you to be a contributing member of your family; (3)s it enables you to engage in leisure activities; (4) as it impactsn your ability to get along with others; (5) as it impacts onour ability to be productive (being able to accomplish thingshat are important to you in your everyday life); and (6) as aource of feeling good about yourself?” Each of the 6 questionslso was rated on a 4-point scale (range: 1, very dissatisfied to, very satisfied). Total possible scores on the QCOG rangerom 6 to 24.

Properties of the QCIQ were evaluated in a sample of 80atients with neurologic injury or illness on admission forehabilitation. This sample included the 56 patients with TBIeported in our study, 16 stroke patients, and 8 patients withther neurologic illnesses. Principal components analysis sup-orted the interpretation of the QCI and QCOG scales asiscrete factors. Use of the QCIQ with this sample indicatedood internal reliability for both the scales measuring satisfac-ion with community functioning (Cronbach ��.85) and sat-sfaction with cognitive functioning (��.93).

Neuropsychologic functioning. Before they began treat-ent, most participants underwent comprehensive baseline

valuation that included neuropsychologic assessments as partf their clinical evaluation. Neuropsychologic assessmentsere readministered at the completion of treatment for all

CRP participants. Complete pretreatment and posttreatmenteuropsychologic data were obtained on only 12 of the 29 SRParticipants. Neuropsychologic data were, therefore, only ana-yzed for ICRP participants. The primary variable of interestas a composite index derived from 6 neuropsychologic mea-

ures. Attention and processing speed was evaluated withrail-Making Test27 Parts A (TMT-A) and B (TMT-B). Mem-ry functioning was evaluated with the total acquisition scorerom the California Verbal Learning Test28 (CVLT) and im-ediate-recall score from the Rey Complex Figure (RCF).29

igher cognitive functioning was assessed with the Controlledral Word Association Test30 (COWAT) and Category Test.27

ll raw scores were converted to T scores that were demo-raphically corrected for age (CVLT, RCF), or age and edu-ation (TMT-A, TMT-B, COWAT, Category Test). A compos-

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te score reflecting overall neuropsychologic functioning wasased on the mean T score. Five participants were missing 1europsychologic data point; for these participants, the meanalue from each participant’s respective pretreatment or post-reatment measures was imputed for the missing values fornalysis of overall neuropsychologic functioning. For the anal-sis of individual neuropsychologic measures, cases with miss-ng data were dropped from the analysis of that variable.

Analysis of change on the CIQ was evaluated with repeated-easures analyses of variance (ANOVAs) with program (ICRP

s SRP) as a between-subjects factor and time (pretreatment vsosttreatment) as a within-subjects factor. The difference be-ween groups on the QCIQ scales after treatment was analyzedith the Mann-Whitney U test. Spearman correlations werebtained to evaluate the relations among measures. Lineartepwise regression with probability equal to .05 or less to enterariables and equal to .10 or greater to remove variables wassed to evaluate predictors and indicators of total CIQ and QCInd QCOG scores at completion of treatment.

RESULTS

ffectiveness of InterventionWe found a significant main effect for time on total CIQ

cores (F1,54�40.49, P�.001) with both ICRP and SRP groupsmproving from before to after treatment (table 2). There waslso a significant program by time interaction effectF1,54�5.66, P�.021), suggesting that the participants in theCRP showed greater improvement from before to after treat-ent (table 3). The ICRP group exhibited over twice theagnitude of treatment effect on total CIQ than the participants

eceiving SRP did (ES, 1.20 vs 0.49).Analysis of CIQ subscales showed significant pretreatment

ersus posttreatment main effects for home integration

Table 2: CIQ, QCIQ, an

IC

Before

Community integrationCIQ 11.6�4.6Home integration 3.1�2.7Social integration 7.0�2.3Productivity 1.4�0.9

Satisfaction with functioningQCI —QCOG —

Neuropsychologic functioningOverall T score 35.5�8.7

OTE. Values are mean � SD.Significant difference between groups, before versus after treatmeSignificant difference between groups, before versus after treatmeSignificant difference between groups (P�.01)Significant difference before versus after treatment (P�.01)

Table 3: ANOVA for Type of Treatment Programand Before and After Treatment CIQ Scores

SourceSum ofSquares df

MeanSquare F Significance �2

CIQ 412.67 1 412.67 40.49 .000 .43Program 15.76 1 15.76 0.47 .497 .01CIQ by program 57.69 1 57.69 5.66 .021 .10

F1,54�3.44, P�.001), social integration (F1,54�18.81,�.001), and productivity (F1,54�12.51, P�.001). Significantrogram by time interaction effects were found for homentegration (F1,54�4.08, P�.048) and productivity (F1,54�8.29,�.006) but not for social integration.Among the participants receiving ICRP, 52% showed clin-

cally significant improvement on the CIQ compared with 31%f participants receiving SRP. Among SRP participants, 7%howed clinically significant decline on the CIQ, whereas nonef the ICRP participants exhibited significant decline. Usinglinically significant improvement on the CIQ as the index ofpositive outcome, the ICRP treatment represents a relative

enefit of 68% and an odds ratio of 2.41 (95% CI, 0.8–7.2); inther words, ICRP participants were almost 2.5 times moreikely than SRP participants to achieve a positive outcome.

Satisfaction with functioning after treatment. At comple-ion of treatment, SRP participants expressed greater satisfac-ion with their community functioning than did ICRP partici-ants (see table 2). There was a notable tendency for more SRParticipants to indicate that they were “very satisfied” with allspects of their community functioning; this was true of 6 SRParticipants (21%) but only 1 ICRP participant (4%). Theverall difference between groups on the QCI was statisticallyignificant (Mann-Whitney U�240, P�.03; ES�.57). TheRP participants also tended to report greater satisfaction with

heir cognitive functioning (see table 2), but the overall dif-erence between groups on the QCOG was not significantES�.38).

Neither total CIQ nor any of the CIQ subscales were relatedo the QCI. However, the QCOG was significantly related toosttreatment total CIQ (Spearman ��.42, P�.001), homentegration (��.41, P�.002), and social integration (��.36,�.007), although not to productivity (��.06). The relationetween posttreatment CIQ and QCOG scores was particularlypparent for ICRP participants (��.55, P�.005) comparedith SRP participants (��.36, P�.051).To evaluate what other factors were related to CIQ and

CIQ outcomes, we conducted stepwise linear regressionsith pretreatment CIQ total score, age, education, gender, timeostinjury, and type of treatment as predictor variables andosttreatment CIQ, QCI, and QCOG as concurrent indicatorariables. The CIQ outcome was best predicted by the QCOGP�.001), initial CIQ (P�.001), and treatment programP�.02), with this model accounting for slightly more than one

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hird of the variance associated with CIQ outcomes (adjusted2�.39). Satisfaction with community functioning (QCI) wasest predicted by time after injury in addition to QCOG scoreadjusted R2�.32, P�.001). A negative � coefficient (–.31)xisted between time after injury and QCI score, indicating thatore recent injury was associated with greater satisfaction with

ommunity functioning. No additional variables contributed tohe prediction of satisfaction with cognitive functioningQCOG) after taking into consideration the significant relationetween the QCOG and the CIQ and QCI measures (adjusted2�.36, P�.001).Neuropsychologic functioning for participants receiving

CRP. Change in neuropsychologic functioning from beforeo after treatment was evaluated for ICRP participants withepeated-measures ANOVA, with significant CIQ change as aetween-subjects factor. Participants who received ICRPhowed significant improvement of their overall neuropsycho-ogic functioning from before to after treatment (F�48.39,�.001; ES�.60) (see table 2). Post hoc analyses of individualeasures were conducted using Bonferroni adjustments to

djust the level of significance to P less than .008. Thesenalyses indicated significant improvements on the TMT-AP�.002), CVLT (P�.007), and RCF (P�.002).

Improvement on overall neuropsychologic functioning (dif-erences between pretreatment and posttreatment T scores) wasssociated with improvement on total CIQ raw scores (��.42,�.03). We found a significant interaction between pretreat-ent and posttreatment neuropsychologic functioning and clin-

cally significant CIQ change, with participants who showedlinically significant improvement on the CIQ showing greatermprovement on overall neuropsychologic functioningF�4.47, P�.045) and TMT-B (F�12.89, P�.001).

Neither overall neuropsychologic functioning T score��–.15) nor change in neuropsychologic functioning T score��.03) were related to participants’ subjective report of sat-sfaction with cognitive functioning.

DISCUSSIONResults of this prospective, observational study support the

ffectiveness of an intensive, holistic, postacute program ofognitive rehabilitation compared with an alternative programf neurorehabilitation for persons with TBI. Although bothroups improved with treatment, the participants receivingCRP showed significantly greater improvements in commu-ity integration than participants receiving standard rehabilita-ion. Over half the ICRP participants showed clinically signif-cant improvement in their community functioning, comparedith about one third of those who received standard neurore-abilitation. Those receiving ICRP were over twice as likely toxhibit clinically significant improvement as those receivingRP. Participants receiving ICRP also showed significant im-rovement in their overall neuropsychologic functioning, par-icularly in the areas of attention and processing speed andmmediate-memory recall. Improvements in neuropsychologicunctioning were greater for those participants who showedlinically significant improvement in their community integra-ion over the course of treatment. Improvement on a measure ofomplex attention and executive functioning was most directlyelated to improvement in community integration, a relation-hip that has been suggested previously.31,32 The differentialenefit of ICRP on community integration was evident, despiteCRP participants being further after injury and having lowerunctioning before treatment. These 2 factors appear to beotentially negative prognostic influences8,33 and might haveeen expected to reduce the probability of finding a significantreatment effect for the persons receiving ICRP.


Despite making greater improvements in community inte-ration, participants who received ICRP did not report greateratisfaction with their community functioning. In fact, thereas a tendency for SRP participants to report greater satisfac-

ion, although this may be related to the fact that they werearlier after injury. Many of the patients in the SRP were onlyeveral months after injury and had limited experience resum-ng their preinjury responsibilities. In contrast, the persons inhe ICRP program were significantly further after injury, and

any had already experienced difficulty with their attempts toesume functioning in their communities. During the acuteeriod of rehabilitation and recovery, patients with TBI areore likely to recognize physical impairments than cognitive

mpairments,34,35 and poorer awareness of impairments is as-ociated with reports of greater life satisfaction.36 Thus, thereay be a general tendency for persons who are earlier after

njury, who have not fully experienced difficulties associatedith their impairments, to feel more satisfied with their level of

ommunity functioning. Although self-reported cognitive dif-culties are minimal initially after injury, they may increaseignificantly over the first year of recovery from TBI as peopleecome more aware of their cognitive impairments.34

The relation between community functioning and satisfac-ion appears to become more complex over the postacuteourse of recovery from TBI. Our results are consistent withrevious studies that have found a marginal relationship be-ween community integration and QOL after TBI.13,19-21 Theissociation between functional outcomes and subjective well-eing has been noted, in particular, for persons with TBI whore many years after injury.14,15 These findings again suggesthat community functioning and satisfaction with functioningre distinct and separable aspects of participants’ experiencehat must be considered in the design and evaluation of reha-ilitation programs for persons with TBI.Satisfaction with cognitive functioning was strongly related

o participants’ level of community integration after treatment,nd this relationship was most apparent for those who receivedhe ICRP. The relation between satisfaction with cognitiveunctioning and community integration may reflect partici-ant’s perceived self-efficacy regarding their functioning. Per-eived self-efficacy refers to the individual’s belief and judg-ents of his/her capability to accomplish a specific task or to

ttain a designated level of performance and is mediatedhrough the process of cognitive self-appraisal.37 Both greatererceived self-efficacy and greater subjective well-being ap-ear to reflect the congruence of one’s expectations andchievements.38,39 Among patients with physical disease, func-ional disability is better predicted by perceived self-efficacyhan by the degree of actual physical impairment or duration ofllness.37,40-44 Perceived self-efficacy regarding cognitive abil-ties is also predictive of actual cognitive performance,45,46

ncluding the degree of improvement in cognitive functioningfter training in compensatory strategies.47,48 In the currenttudy, improvements in neuropsychologic functioning and sat-sfaction with cognitive functioning were not related to eachther, but each contributed positively to community integrationfter intensive cognitive rehabilitation. This finding again sug-ests that the relation between objective indices of severity ofBI or impairments, functional outcomes, and QOL are mod-rated by the subjective meanings and values assigned byatients. To be effective, rehabilitation after TBI must addressatients’ attitudes and beliefs in addition to their cognitivebilities; remediation of cognitive abilities may have moreeneralized effects if it increases self-efficacy beliefs as well asrains cognitive skills.49 Perceived self-efficacy may be en-anced by interventions that facilitate an understanding of

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nvironmental and task demands, provide training that im-roves individuals’ understanding of how to use their abilitiesuccessfully, and provide feedback to correct inaccurate per-onal or causal attributions.50 The impact of self-efficacy be-iefs on health-related outcomes is also mediated by self-egulatory processes—self monitoring, goal setting, cognitiveelf-appraisal, and affective self-evaluation.51 These are inte-ral components of ICRP.Our study has several limitations in its methods. The stan-

ard treatment condition in our study consisted of relativelyomprehensive, multidisciplinary, neuropsychologic rehabilita-ion. Therefore, our findings are likely to underestimate theifference that would be found if we were to compare ICRPith the type of services that may actually be available forany persons with TBI. The interpretation and generalization

f results is also tempered by sampling limitations: specifically,he confounding of time after injury with treatment condition.hat is, there was a systematic selection bias in enrolling, into

he more intensive, holistic treatment program, participantsho were further after injury with persistent disability, whereasarticipants who were more recently injured and were expectedo make additional recovery received the more limited treat-ent regimen. The ICRP participants also exhibited slightlyorse community integration before treatment, but this differ-

nce was no longer apparent after treatment. Although theifference in pretreatment CIQ scores was not significant, itay have contributed to the finding of a differential treatment

ffect in the ICRP group. As recently noted, time since injurynd level of disability appear to be important characteristics inetermining the appropriate form of postacute brain injuryehabilitation.33 Although these differences limit the ability toeneralize our results, it is notable that this selection bias mighte expected to reduce the probability of observing a differentialenefit for those persons with TBI who received the ICRP. Theresent findings suggest, at least, that persons with TBI who areess recently injured and have experienced persisting disabilityan be successfully treated, even many years after injury, withmore intensive and holistic approach to cognitive rehabilita-

ion.The relation among neurocognitive impairment, functional

isability, and QOL after rehabilitation for TBI merits addi-ional investigation. There is a need to validate measures ofOL for persons with TBI and, specifically, to develop mea-

ures that are sensitive to the participants’ views of changes inubjective well-being as a result of treatment. We did notbtain systematic follow-up information as part of our study. Inhe future, it will be important to assess the maintenance andtability of community integration and QOL after TBI rehabil-tation.7

CONCLUSIONSThe results of our controlled, observational study indicate

ignificant clinical benefit of ICRP for persons with TBI.lthough both groups improved, the participants receiving

CRP were over twice as likely to show clinically significantmprovement in community integration as those receiving SRP,espite being longer after injury and having slightly worseommunity functioning before treatment. Participants’ QOL,ssessed by their satisfaction with community functioning, wasot related to level of community integration. Satisfaction withognitive functioning did not differ between groups but didake a significant contribution to community integration, par-

icularly for those participants receiving ICRP. The constructf perceived self-efficacy has received limited attention inelation to brain injury rehabilitation and may have consider-ble heuristic and explanatory value for understanding the

ffective ingredients of interventions. Prospective controlledtudies are needed to compare the effectiveness of differentorms of cognitive rehabilitation and to assess the patientharacteristics and treatment ingredients that contribute to pos-tive outcomes. Future efforts to assess cognitive functioningnd social participation after TBI rehabilitation also must con-ider that functional disability and subjective well-being rep-esent distinct rehabilitation outcomes.

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