Retrospective assessment of rehabilitation outcome after traumatic brain injury: Development and utility of the functional independence level

Objective: To develop a measure suitable for retrospective analysis of qualitative brain injury outcome data, the Functional Independence Level (FIL), and document its reliability, validity, and utility. Design: Retrospective analysis of existing records, with inclusion based on availability of records, and quantitative or qualitative documentation of functional status at a minimum of 1.5 years after injury. Setting: Statewide acute and postacute rehabilitation facilities, as part of a State Head Injury Program. Participants: A total of 338 individuals, with documented moderate to severe traumatic brain injury; primarily males ages 16 to 45. Main Outcome Measures: Disability Rating Scale (DRS) at discharge from primary rehabilitation, Living Situation and Functional Independence Level coded from information in postacute rehabilitation reports, at an average of approximately 6 years after injury. Results: Inter-rater reliability coefficients for FIL ratings extracted from rehabilitation records, and between retrospective and in vivo assessments were highly significant. DRS scores at discharge from primary rehabilitation predicted a significant amount of variance in FIL scores at an average of 5 years after injury, and DRS scores remained a stable and significant predictor of FIL scores as the time period between discharge from rehabilitation and outcome ratings increased to 10 years after injury. FIL ratings were significantly lower for individuals living in residential facilities than those living with their families, as compared to living alone. Conclusions: The FIL is a reliable and useful tool for retrospective and prospective assessments of rehabilitation outcome. Gains made during primary rehabilitation by people with severe traumatic brain injury are generally maintained at long-term follow up. Retrospective ratings using the DRS and FIL can help guide postacute rehabilitation planning within state or regional head injury programs.