Authors:Marie-Josee Sirois, PhDClermont E. Dionne, PhDAndre Lavoie, PhD

Affiliations:From the Research Center of the“Centre hospitalier affilieuniversitaire de Quebec” (M-JS, CED,AL); Occupational Therapy Programat Universite du Quebec a Trois-Rivieres (M-JS); and Departments ofSocial and Preventive Medicine (AL)and Rehabilitation (CED), LavalUniversity, Quebec City, Canada.

Correspondence:All correspondence and requests forreprints should be addressed toMarie-Josee Sirois, PhD, CHAUQ,Pavillon Enfant-Jesus, Unite derecherche en Traumatologie, roomH-044, 1401-18ieme Rue, Quebec,QUE G1J 1Z4, Canada.

Disclosures:Supported by the Canadian Institutesfor Health Research (CIHR, grant no.MOP-62873) and the Quebec HealthResearch Funds (FRSQ, grant no.3255).

0894-9115/09/8805-0387/0American Journal of PhysicalMedicine & RehabilitationCopyright © 2009 by LippincottWilliams & Wilkins

DOI: 10.1097/PHM.0b013e31819c592f

Regional Differences inRehabilitation Needs, RehabilitationAccess, and Physical OutcomesAmong Multiple Trauma Survivors

ABSTRACT

Sirois M-J, Dionne CE, Lavoie A: Regional differences in rehabilitation needs,rehabilitation access, and physical outcomes among multiple trauma survivors.Am J Phys Med Rehabil 2009;88:387–398.

Objectives: The aims of this study were to compare regional differ-ences in perceived needs for postacute rehabilitation services, perceivedbarriers to postacute rehabilitation services, and long-term functional andphysical health outcomes among multiple trauma survivors.

Design: A population-based cohort study with retrospective measuresof exposure and cross-sectional health outcomes measures was con-ducted in regions with different levels of rehabilitation services availabilityin the province of Quebec, Canada. The study included 435 participants,aged 18–65 yrs, admitted to level I or level II trauma centers in 2000–2001, who required rehabilitation services. The participants were inter-viewed by telephone 2–4 yrs postinjury. Needs for (yes/no) and per-ceived barriers (yes/no) to obtain 18 posttraumatic rehabilitation serviceswere assessed. Physical health was measured with the medical outcomestudy SF-12 and functional status with the functional independencemeasure.

Results: There were no significant regional differences in the propor-tions of perceived barriers to functional rehabilitation (39.4%), to social/vocational rehabilitation (52.2%), and to community integration services(46.5%). Adjusted-SF-12 and functional independence measure scoreswere similar across regions.

Conclusion: Contrary to expectations, there were no regional differ-ences in perceived barriers to rehabilitation services for multiple traumasurvivors. Rather, surprisingly high proportions of barriers were reportedacross the province.

Key Words: Multiple Trauma, Rehabilitation, Access to Services, Outcomes

www.ajpmr.com Regional Differences in Outcomes 387

ORIGINAL RESEARCH ARTICLE

Outcomes

After trauma, regional differences in the acces-sibility to early rescue and critical care are recog-nized as important risk factors of trauma mortality,the latter being much higher in remote regionsthan in urban centers.1–3 For trauma survivors,access to a vast array of rehabilitation services isconsidered an important determinant of posttrau-matic health. Although access to rehabilitation ser-vices seems more limited in distant regions, thereare a limited number of studies that have examinedthe impact of regional differences in accessibilityto rehabilitation services on posttraumatic healthoutcomes.

The scarcity of rehabilitation facilities and ser-vices for traumatic brain injury (TBI) patients hasbeen described in rural regions of Missouri4 andColorado.5 In these studies, authors4,5 have sug-gested that the shortage of services in rural regionscould have a negative effect on post-TBI healthoutcomes, but no formal measure of this possibleassociation was undertaken. Nonetheless, barriersto some rehabilitation services seem to be associ-ated with lower health outcomes, reduced mobility,less cognitive independence,6 worse medical healthand psychological well-being in TBI patients,7 andwith less mobility and life satisfaction in patientswith spinal cord injury.6

To this day, only Schootman and Fuortes8 inIowa examined simultaneously self-reported acc-essibility to services after TBI and self-reportedhealth measures from a regional perspective. Theyfound that rural TBI survivors were more likely tobe functionally dependent and in poorer health at18 mos postinjury, although they did not reportmore barriers to postacute rehabilitation services.8

In two recent studies, post-TBI outcomes wereexamined from a regional perspective without di-rectly measuring availability or accessibility to re-habilitation services. In Australia, Harradine et al.9

used a regional definition based on accessibility togoods, services, and social interactions and foundno differences in clinician-rated functional out-comes between 109 rural and 35 urban TBI survi-vors at 18 mos postinjury. In a study of 111consecutive TBI patients, Gontkovsky et al.10 inMississippi found no association between an ur-banicity index, based on population density, andself-reported disability rating scale scores at 1 yrpostinjury.

In the province of Quebec (Canada), two smallsurveys conducted in the late 1990s among personswith various disabilities11 and rehabilitation pro-fessionals12 revealed important barriers to rehabil-itation services in some remote regions. Duringthe same period, the Quebec Association of Reha-bilitation Centers (AERDPQ) published an inven-tory of available rehabilitation services in each

health region of the province.13 This report con-firmed the shortage of material and human reha-bilitation resources within the functional, ed-ucational/vocational, and community maintenancerehabilitation programs in regions outside large met-ropolitan regions.13 No study has yet been conductedin Quebec to examine how regional differences inbarriers to rehabilitation services impact on patients’functional and health outcomes.

In this study, we aimed to compare (1) per-ceived needs for postacute rehabilitation services,(2) perceived barriers to postacute rehabilitationservices, and (3) common functional and physicalhealth outcomes measures, 2–4 yrs postinjuryamong severe trauma survivors from regions withdifferent documented levels of availability of reha-bilitation services.

METHODSDesign

We conducted a population-based cohort studyof trauma survivors,14 aged 18 yrs and older (n �1092) injured between January 1, 2000 and Decem-ber 31, 2001, who required rehabilitation servicesat discharge from hospital.14 Measures of perceivedbarriers to rehabilitation services were retrospec-tive. Measures of functional status and physicalhealth outcomes were cross sectional. The presentstudy included only participants aged 18–65 yrsevaluated within the larger cohort study.14

Sampling Frame and SamplePotential study participants were identified in

trauma registries provided by two level I and eightlevel II trauma centers. Inclusion criteria in theregistries are standard across centers. The regis-tries contain prospectively collected informationon injury circumstances, all hospital events, anddischarge destinations. Unfortunately, in mostlevel II registries, discharge information was in-valid and unusable to directly identify participantsdischarged to rehabilitation settings.14 The sam-pling frame was thus determined with a predictivemodel of rehabilitation discharge, which presentedan excellent discrimination capacity (area underthe Roc curve � 0.83) and for which internalvalidity was ensured through a resampling stra-tegy.14 The sampling frame included severely in-jured survivors (around 70% of survivors presentedan injury severity score �ISS� above 9).14

Among the 690 potential participants, 48 diedafter discharge from acute care. From the remain-ing 642 who were eligible, 97 (15.1%) declinedparticipation, 79 (12.3%) were not located, and 31(4.8%) were legally incompetent participants with-out a proxy responder and were excluded. Fourhundred thirty-five (67.8%) participants responded

388 Sirois et al. Am. J. Phys. Med. Rehabil. ● Vol. 88, No. 5, May 2009

to the survey. None of these proportions differsignificantly between the regions described below.

Data CollectionBetween October 2003 and September 2004, a

structured telephone interview was conducted withall participants. It included 73 questions organizedinto six sections: (1) perceived needs for postacuterehabilitation services and perceived access to suchservices; (2) current general health; (3) currentfunctional status; (4) comorbidities; (5) demo-graphics; and (6) social support. The questionnairewas pretested over the phone among a group of 15volunteers recruited among health research assis-tants in the Quebec region, and people with minortrauma not included in the present study sample.Both French and English versions of the question-naire were used according to participants’ spokenlanguage. Telephone interviews were conducted byfour trained health research assistants. Weekly re-searchers-interviewers meetings ensured the qual-ity and standardization of the data collectionprocess.

Exposure Variable: Regional DefinitionsPhases of the Trauma RehabilitationProcess in Quebec

The provincial trauma rehabilitation system isorganized into four phases. Phase I: acute rehabil-itation during hospitalization. Phase II: inpati-ent or outpatient functional rehabilitation servicesaiming at optimizing of physical and cognitive ca-pacities to optimize function in activities of dailyliving such as mobility, hygiene, and communica-tion. Phase III: social/vocational rehabilitation aim-ing at resuming productive and social activitiessuch as domestic chores, work, education, and lei-sure. Theses services are typically provided in re-habilitation centers on an inpatient or outpatientbasis. Phase IV: community integration servicesgeared toward preserving trauma survivors in theirhomes and communities. Such services includecommunity association services, selective servicesfor wheelchair, prostheses/orthoses repair, and trans-portation. Specific services included in each phase arelisted in Appendix 1.

Classification of the RegionsIn this study, direct information about avail-

ability of rehabilitation services was obtainedthrough the above-mentioned AERDPQ report.13

Thus, each health region was classified based onavailability of services as follows: best availability ofrehabilitation services (BARS) indicating full avail-ability of rehabilitation services in phases II, III,and IV (3/17 health regions met this definition);partial availability of rehabilitation services indicat-

ing full availability of services in phase II, butlimited availability in phases III and IV (6/17 re-gions met this definition); limited availability ofrehabilitation services (LARS) indicating limitedavailability of services in phase II, and severelylimited availability or no service in phases III andIV (8/17 regions met this definition).

Because availability is only one dimension ofservices accessibility, which also encompasses fi-nancial resources, geographic access, and timelyaccess,15–17 participants were directly asked aboutall possible access barriers to examine if the cur-rent regional classification could be a better proxyfor posttraumatic rehabilitation services accessibil-ity than population-density based indices.

Outcome MeasuresNeeds for Rehabilitation Services

Perceived needs for the 18 services listed inAppendix 1 were measured through dichotomousvariables. For each service, participants were askedwhether (1) “they had needed” the service aftertheir hospitalization (yes/no) or if (2) “they wouldhave needed this service, had it been readily acces-sible” (yes/no).

Accessibility/Barriers to ServicesPerceived barriers to access the 18 services

were also dichotomized (yes/no). Participants whoreported needs for services were asked: “Did youencounter difficulties in obtaining this service?”Four types of barriers were described: nonavailabil-ity of the service, geographic barriers (long dis-tances preventing regular visits to service provid-ers), financial barriers (inability to afford theservice), and time barriers (waiting list: having towait and receiving the service later). Barriers torehabilitation services were positively coded if atleast one of the barriers was encountered. All par-ticipants who answered “yes” to the question“would you have needed the service, had it beenreadily accessible” were considered having encoun-tered barriers.

Physical HealthSelf-reported physical health was measured

with the second version of short-form medical out-comes survey using the SF-1218,19–22 physical sum-mary score and three of its components—physicalfunctioning, role limitations because of physicalproblems, and general health—all rescaled from 0to 100 points.

Functional StatusThe 13 physical items of the FIM were mea-

sured. The functional independence measure (FIM)has shown good interrater reliability,23 and its tele-

www.ajpmr.com Regional Differences in Outcomes 389

phone version (PHONE-FIM) has shown good con-struct validity24 and good correlation with face-to-face evaluations.25 However, during the pretestphase of the questionnaire, good discriminationbetween intermediate levels of the FIM rating scalewas difficult to achieve over the phone. This prob-lem was also reported by others in face-to-faceassessments.26 Moreover, different methods for re-coding the FIM have been proposed26–31 withoutany consensus yet. To address these discriminationdifficulties, we used a 4-level FIM scale collapsinglevels 1 and 2 (total and maximum assistance), levels3 and 4 (moderate and minimal assistance), levels 5and 6 (supervision and modified independence), andkept level 7 (complete independence) as such. Be-cause the FIM is known to challenge linear regressionassumptions, FIM scores were transformed usingRasch analysis23,32–34 and further rescaled on thecommonly used 0–100 linear scale.

CovariatesDemographics

Age at injury and gender were available in thetrauma center registries. Higher levels of formaleducation,35–37 being married,38 and being em-ployed35,37 seem associated with better posttrau-matic functional status and general health. Thesevariables were gathered using the demographicsection of the Quebec Health and Social Survey(QHSS98).39

Injury SeverityThe ISS40 is a measure of anatomic injury sever-

ity, which provides an overall score ranging from 1(minor injury) to 75 (lethal injury). Time since injurywas also considered a potential covariate.

Major in-hospital complications seem associ-ated with worse physical outcomes at 18 mospostinjury.41 Complications were abstracted fromthe trauma registries to construct a dichotomousvariable: presence or absence of complications dur-ing the hospitalization.

ComorbiditiesWhen this study was conducted, none of the

recently published methods42,43 correlating co-morbidities and health measures were available. Alist of 18 medical conditions was derived from theQHSS98 questionnaire (Appendix 2) to measure“comorbidities” by counts of self-reported condi-tions at the time of interviews. The simple count ofmedical conditions was shown to provide similarresults in terms of SF-36 explained variance ascompared with weighted counts (R2 � 0.28vs. 0.30).42

Social SupportBetter family support44 and social net-

works38,45,46 are associated with better general healthand function. We used the social support index ques-tions of the QHSS98.39,47 It includes 11 questionsabout both the quantity and the satisfaction withsupport from the person’s social network. Social sup-port index scores range from 13 to 100, higher scoresreflecting better social support.

InsurancesAdministrative13 and research information12,48

in our province suggests that victims of motorvehicle crashes insured by the public automobileinsurance society (SAAQ) might receive more re-habilitation services than other patients insuredeither only by the workmen compensation board(work-related injuries) or by the public health sys-tem (injuries not related to work or motor vehiclecrashes). It is unknown, however, whether SAAQcoverage is associated with better outcomes. Insur-ance types were available in trauma registries.

Statistical AnalysesUnivariate and bivariate procedures were used

to describe the samples. Analyses of variance andScheffe tests were conducted to test for significantdifferences in continuous variables among regions(BARS, partial availability of rehabilitation service,and LARS).

We hypothesized that equal proportions of par-ticipants would need rehabilitation services amongregions and that incremental barriers to rehabili-tation services would be reported from BARS toLARS regions. These were tested with the nonpara-metric Jonckheere-Terpstra test19 for trends be-tween independent samples.

The association between regions and healthoutcomes was examined through five sets of mul-tiple linear regression analyses performed with thefollowing five dependent variables: physical FIM,SF-12 aggregated physical score, SF-12 physicalfunctioning, physical role, and general healthscales. For each set of analyses, the regions werefirst entered as two dummy variables with theBARS regions as the reference group. Then, poten-tial confounders (demographics, ISS, comorbidi-ties, social support, and time since injury, etc.)were entered through a stepwise procedure. Onlyconfounders leading to at least 10% change in theregions’ regression coefficients (�) were kept in themodels.

Statistical PowerTo our knowledge, there is no published defi-

nition of the minimal clinically significant differ-ence for Rasch-transformed FIM or for SF-12

390 Sirois et al. Am. J. Phys. Med. Rehabil. ● Vol. 88, No. 5, May 2009

scores. Power calculation simulations by Holmanet al.49 showed that the number of patients pergroup required to detect an effect size of 0.2 (min-imum), 0.5 (medium), and 0.8 (large) on the SF-12at the 5% level with 80% power was 380, 75, and35, respectively. In the current study, the aboveeffect sizes approximately represented differencesbetween groups of 3.9, 9.9, and 15.8 FIM pointsand 4.1, 10.3, and 16.6 SF-12 aggregated physical scalescore points. Our sample sizes thus allowed detection ofmedium effect sizes at the alpha level � 0.05.

All statistical analyses were performed usingthe SAS software version 9.1 (SAS institute Inc,Cary, NC). Rasch analyses were performed with theWinsteps software (Winsteps, Chicago, IL).

This study was approved by the “Commissiond’acces a l’information du Quebec” (Quebec Infor-mation Access Board) and by the research EthicsCommittees of the trauma centers providing datafor the study.

RESULTSTable 1 compares responders and nonre-

sponders. There were 9% more men among non-responders (P � 0.03) and 7% more victims ofmotor vehicle crashes among responders (P �0.04). None of the nonresponders’ characteristicsdiffered significantly among regions.

Description of SamplesThe proportions of proxy responders did not

vary significantly by region (BARS: 5.8%, partialavailability of rehabilitation service: 6.9%, LARS:7.7%, P � 0.27) (Table 2).

Overall, responders were 41.1 � 15.1 yrs old atthe time of injury. There were no differencesamong groups with regard to preinjury variablesexcept for completed years of education and mari-tal status (Table 2).

Most responders (n � 402, 92.4%) sufferedfrom multiple trauma (mean number of injuries �8.4 � 5.3, range 1–25). A total of 259 (59.5%)responders experienced acute care complications(Table 2).

Interviews were conducted on average 3.3 �0.7 yrs postinjury. The participants suffered froman average of 3.9 coexisting medical conditions(range 0–13), a variable that did not vary amongregions. Participants reported equally good socialsupport (mean 76.8 � 20.1, range 14–100) acrossregions (Table 2).

The following unadjusted health measures didnot differ among regions: the FIM (across groupsmean: 76.8 � 20.2, range 0–100), the SF-12 phys-ical aggregated physical score (mean: 53.8 � 20.5,range 0–100), the SF-12 physical role (mean:46.2 � 26.9, range 0–100), and the general healthscore (mean: 49.2 � 24.9, range 0–100). The SF-12

physical function score was 7 significant pointslower in patients from LARS regions. As a whole,24.5% of participants were functionally indepen-dent (maximum FIM score) across regions.

Regional Differences in PerceivedRehabilitation Needs and Barriersto Rehabilitation Services

Table 3 shows the number and proportion ofresponders perceiving needs for services and barri-ers to access them. All responders but one (n �434, 99.8%) needed postacute rehabilitation ser-vices, 100% of them needed functional rehabilita-tion, 90.8% (n � 395) needed sociovocational ser-vices, and 96.8% (n � 421) needed communityintegration services. As expected, perceived needswere homogenous across regions.

Barriers to functional rehabilitation services(phase II) did not differ across regions (mean pro-portion 39.4%). A total of 206 responders (52.2%)experienced barriers to sociovocational services

TABLE 1 Comparison between respondersand nonresponders (n, %)

Responders(n � 435)

Nonresponders(n � 207) P

Age at injury,mean (SD)

41.1 (15.1) 41.2 (14.9) 0.98

Male, n (%) 279 (64.5) 152 (73.4) 0.03Causes of injuries

Motor vehicleaccident,n (%)

329 (76.2) 143 (69.1) 0.04

Falls,n (%)

80 (18.5) 48 (23.2)

Othercauses,n (%)

23 (5.3) 16 (7.7)

Injury severityscore, n (%)

1–8 5 (2.4) 11 (2.5) 0.169–15 53 (19.4) 101 (23.4)16–21 27 (13.1) 66 (15.3)22–29 67 (32.4) 146 (33.8)30–41 40 (19.6) 74 (17.1)42–75 15 (7.2) 34 (7.9)

No. injuries,mean (SD)

8.4 (5.3) 8.6 (6.2) 0.68

No. acutecomplications,mean (SD)

1.9 (2.7) 1.7 (2.2) 0.62

Acute care lengthof stay,mean (SD)

31.3 (23.5) 32.3 (28.3) 0.64

Spine injury, n (%) 154 (35.4) 133 (35.8) 0.93Brain injury, n (%) 264 (81.7) 119 (78.8) 0.45Multiple

extremityinjury,n (%)

340 (78.2) 141 (68.12) 0.70

www.ajpmr.com Regional Differences in Outcomes 391

(phase III) and 196 (46.5%) to community integra-tion services (phase IV). There was a slight nonsig-nificant increment in perceived barriers to phasesIII and IV rehabilitation services from BARS toLARS regions. The largest difference in regionalbarriers was small, approximately 10% betweenBARS and LARS regions.

Association Between Regionsand Health Outcomes

Table 4 shows the unadjusted linear regressioncoefficients of the “regions” variables and potential

covariates with the five outcome measures. Theexposure measure (regions) was not significantlyassociated with health outcomes, explaining a max-imum of 1.0% of their variance.

Multimorbidity explained more variance inhealth outcomes (17.6%–25.0%) than any othervariable. Each added morbidity was associated withunadjusted decreases of 4–6 points in health out-comes. Each added point on the social supportindex was associated with crude increases of 0.29–0.50 depending on the health outcome (8.0%–12.0%of explained variances). Age had a significant negative

TABLE 2 Selected characteristics of the study participants in each region (n � 435)

BARS (n � 121) PARS (n � 145) LARS (n � 169)

DemographicsAge (years) (mean, SD) 41.2 � 15.3 40.2 � 15.1 41.8 � 15.1Male, n (%) 74 (61.7) 95 (66.0) 110 (65.5)Education (years completed), n (%)

1–7 11 (9.2) 10 ( 7.0) 22 (13.1)8–12 55 (45.8) 82 (56.9) 84 (50.3)13–15 26 (21.7) 32 (22.2) 42 (25.2)More than 15 28 (23.3)a 20 (13.9)a 19 (11.4)a

Marital status at the time of injury,n (%)

Married/living with spouse 60 (50.0)a 81 (55.9)a 98 (58.0)a

Divorced/single 14 (11.6) 14 (9.7) 17 (10.0)Widow 3 (2.5) 3 (2.1) 5 (3.0)Single/never married 44 (36.4)a 46 (31.7)a 47 (27.8)a

Preinjury occupation, n (%)Active worker 86 (71.0) 103 (71.0) 117 (69.2)Student 8 (6.6) 12 (8.3) 15 (8.9)Home maker 3 (2.5) 2 (1.4) 5 (3.0)Retired 16 (13.2) 20 (13.8) 22 (13.0)Social security/unemployed 8 (6.6) 7 (4.8) 8 (4.7)

Injury characteristicsCause of injuries

Motor vehicle crash 87 (71.9) 114 (78.6) 128 (75.7)Falls 27 (22.5) 24 (16.7) 29 (17.3)

ISS (median) 24 22 22No. injuries (mean, SD) 9.0 � 5.5a 7.1 � 4.3a 9.0 � 5.6a

No. acute complications (mean, SD) 1.9 � 2.4a 0.9 � 1.6a 2.7 � 3.3a

Traumatic brain injury, n (%) 83 (68.8) 82 (56.6) 99 (58.6)Spine injury, n (%) 41 (33.9) 58 (40.0) 55 (33.0)Multiple extremity injury, n (%) 95 (78.5) 111 (76.6) 134 (79.2)

Postinjury characteristicsElapsed time since injury

(years), mean � SD3.2 � 0.6 3.3 � 0.8 3.3 � 0.7

Comorbidities count,mean � SD

3.9 � 2.4 3.8 � 2.3 4.0 � 2.6

Social support index,mean � SD

75.9 � 23.8 78.2 � 17.6 77.0 � 19.2

Health outcomesFIM scores, mean � SD 76.6 � 22.3 78.4 � 17.8 74.4 � 19.2

SF-12 scores, mean � SDAggregated physical score 55.8 � 21.1 55.4 � 20.0 52.0 � 21.1Physical role 47.7 � 28.0 47.8 � 25.1 43.8 � 27.6Physical function 57.9 � 35.2a 57.1 � 35.6a 50.1 � 35.3General health 47.5 � 25.4 51.3 � 23.8 48.6 � 25.6

BARS, best availability of rehabilitation services; PARS, partial availability of rehabilitation services; LARS, limited avail-ability of rehabilitation services; FIM, functional independence measure.

aSignificant difference among groups at the P � 0.05.

392 Sirois et al. Am. J. Phys. Med. Rehabil. ● Vol. 88, No. 5, May 2009

impact on outcomes (2.0%–8.0% of explained vari-ances). The ISS, sex, marital status, active preinjuryemployment status, and time since injury were notgenerally associated with health outcomes. Publicautomobile insurance society coverage (SAAQ) wasassociated with statistically significant but minimal

differences SF-12 aggregated scores and physicalroles (0.37–1.01 point, 1.2%–1.9% of variances).

Table 5 shows the adjusted regression coeffi-cients of the “regions” variables and health outcomes.In each case, only comorbidities, social support, andage confounded the associations. The regions were

TABLE 4 Regression coefficients (�) from simple regression analyses between health outcomes,exposure (regions), and other potentially associated variables (n � 434)

PhysicalFIM

Aggregated PhysicalScore

SF-12

Physical Function Physical Roles General Health

PARSa 1.84 �0.40 �0.78 0.12 3.75LARSa �2.12 �3.79 �7.70 �3.94 1.09Adj. R2 (0.7%) (0.7%) (0.6%) (0.1%) (0.0%)Age �0.36 �0.21 �0.33 �0.27 �0.23Adj. R2 (7.7%)b (2.3%)b (1.8%)b (2.0%)b (1.8%)b

Male 0.12 2.82 5.40 0.34 1.34Adj. R2 (0.0%) (0.2%) (0.5%) (0.0%) (0.1%)Educationc 4.51 2.64 3.24 5.20 3.44Adj. R2 (4.0%)b (0.5%) (0.0%) (1.5%)b (0.5%)Married/spouse 1.32 2.41 2.53 1.88 2.71Adj. R2 (0.0%) (1.5%) (1.8%) (1.0%) (1.5%)Active employment 6.85 2.44 4.51 1.47 0.87Adj. R2 (1.3%)b (0.1%) (0.3%) (0.1%) (0.0%)ISS �0.00 0.07 0.12 �0.07 �0.09Adj. R2 (0.0%) (0.0%) (0.0%) (0.0%) (0.0%)Acute care complications �5.51 �5.01 �9.09 �5.86 �4.66Adj. R2 (2.0%)b (1.2%) (1.6%)b (1.2%)b (0.6%)Time since injury 0.18 0.27 0.10 2.94 0.13Adj. R2 (0.0%) (0.0%) (0.0%) (0.4%) (0.0%)Comorbidities �4.06 �4.18 �6.06 �5.18 �5.07Adj. R2 (25.4%)b (24.1%)b (17.6%)b (22.4%)b (24.9%)b

Social support 0.29 0.30 0.50 0.41 0.42Adj. R2 (8.3%)b (8.0%)b (8.0%)b (9.4%)b (11.3%)b

SAAQ �0.38 0.67 0.37 1.01 0.75Adj. R2 (0.0%) (1.2%)b (0.1%) (1.7%)b (1.0%)

PARS, partial availability of rehabilitation services; LARS, limited availability of rehabilitation services; SAAQ, provincialautomobile insurances; Adj. R2, adjusted R2; FIM, functional independence measure.

aReference: BARS: best availability of rehabilitation services.bP � 0.05.cIn four categories: 1–7, 8–12, 13–15, 16 � years completed.

TABLE 3 Perceived rehabilitation needs and barriers to services by rehabilitation phase in eachregion (n � 434)

BARS PARS LARS P

Phase IIFunctional rehabilitation needs, n (%) 120 (100.0) 145 (100.0) 169 (100.0) 0.27

Barriers to services, n (%) 47 (39.2) 52 (35.9) 72 (42.6) 0.23Phase III

Social/vocational rehabilitation needs, n (%) 110 (90.1) 135 (93.1) 150 (88.8) 0.22Barriers to services, n (%) 50 (45.5) 74 (54.8) 82 (54.7) 0.09

Phase IVCommunity integration services needs,

n (%)116 (95.9) 142 (97.9) 163 (96.5) 0.58

Barriers to services, n (%) 48 (41.4) 66 (46.4) 82 (50.3) 0.07

BARS, best availability of rehabilitation services; PARS, partial availability of rehabilitation services; LARS, limited avail-ability of rehabilitation services.

www.ajpmr.com Regional Differences in Outcomes 393

generally not associated with outcomes, except forLARS participants who reported significantly lowerSF-12 physical function scores (8.3 points lower, P �0.05) compared with BARS participants.

DISCUSSIONThis is one of the rare studies simultaneously

examining needs for rehabilitation services and im-pacts of barriers to such services on health out-comes in a population of severe multiple injurysurvivors, from a regional perspective.

The results demonstrate that perceived needsand barriers to services were comparable acrossregions: functional rehabilitation, 100% of per-ceived needs and 39% of perceived barriers; so-ciovocational rehabilitation, 91% needs and 52%barriers; and community integration services, 97%needs and 47% barriers. Proportions of barriers toservices were unexpectedly high across the prov-ince. Adjusted functional and health outcomeswere also comparable between regions, except formodestly lower SF-12 physical function scores inresponders from regions with LARS.

Similar studies among other subpopulations oftrauma survivors (e.g., spinal cord and TBI) arerare, thus allowing few comparisons. Schootmanand Fuortes8 examined at 12–18 mos postinjury“services that should have been received but werenot,” functional dependence (measured with oneDisability Rating Scale question) and generalhealth (answer to “How is your health today?”) in292 Iowan mild TBI responders (70% were com-pletely independent) aged 18 and older. Nonurbanparticipants (less than 100 residents per squaremiles) had a 2.8 adjusted relative risk of beingdependent and in poorer health compared withpatients from more populated counties. However,this association was probably overestimated be-cause of the increased response rate by injury se-verity and rurality. In this study, unmet needs forrehabilitation services were associated with func-tional dependency and poorer health but were notaffected by location. These authors argued that

absence of an organized trauma care system inIowa might impact more those living in rural re-gions.

In Australia, Harradine et al.9 used a complexrural-urban index50 based on both population den-sity and access to goods and services in a studyamong severely injured TBI patients (25% werecompletely functionally independent) aged 16–65yrs admitted to 1 of 11 units of a statewide networkof brain injury rehabilitation programs. They foundno differences between urban and rural partici-pants with regard to functional status (DisabilityRating Scale) and SF-36 physical scores at 18 mospostinjury. However, the sample sizes (109 urbanand 35 rural) were small, no multivariate analyseswere conducted, and accessibility to services wasnot directly measured. Their prospective samplerepresented about 55% of eligible participants.However, no comparisons between responders andnonresponders were made precluding evaluation ofthis possible bias.

Finally, Gontkovsky et al.10 used an urbanicityindex based on population density, which did notaccount for accessibility of services. Their Mississippistudy included a consecutive series of 111 severeTBI participants (25% had a DRS �1 at 1 yr postin-jury), aged �16 yrs admitted to a TBI model systeminvolving treatment at level I trauma center withsubsequent admission to a rehabilitation center.Again, urbanicity was not associated with DRSscores 1 year postinjury.

The current study contributes to the existingliterature by its large sample size, its minimallybiased (with regard to known factors) response rate(67%), and its acute and postacute multicenterprovincial design. Our sample is representative ofthe general population of multiple injury survivors,and 25% of the participants were completely inde-pendent (FIM scores) when interviewed, whichcompares with the TBI studies of Harradine et al.9

and Gontkovsky et al.10 One other strength of thepresent study is the significant effort made at reduc-ing potential confounding effects of comorbidities.

TABLE 5 Results of multiple linear regression analyses on the associations between areas andhealth outcomes in survey participants (n � 434)

PhysicalFIM

Aggregated PhysicalScore

SF-12

Physical Function Physical Roles General Health

PARS areas �(P value)a

0.40 (0.84) �1.46 (0.48) �2.77 (0.49) �1.56 (0.60) 3.22 (0.39)

LARS areas �(P value)a

�2.51 (0.20) �3.50 (0.08) �8.13 (0.03) �4.34 (0.11) 1.13 (0.65)

aReference: BARS areas. �: regression coefficients adjusted for age, comorbidities, and social support.

394 Sirois et al. Am. J. Phys. Med. Rehabil. ● Vol. 88, No. 5, May 2009

One assumption underlying the use of urban/rural population density-based indices9,10 in reha-bilitation research is that they could be indirectmeasures (proxies) for availability or accessibilityof services. We also examined if a regional classifi-cation based on availability of rehabilitation ser-vices could be a better measure of rehabilitationaccessibility (data not shown). It was not the case.In fact, the current classification shares similaritieswith conventional population-based ones: BARS re-gions included highly populated metropolitan re-gions and the LARS regions included the mostremote and least densely populated locations.

This study also presents limitations. First,there were 9% more men among nonresponders ineach region. Responders could present slightly bet-ter FIM because men aged 18–65 yrs generallysustain more severe injuries, which are associatedwith worse functional status.6,36,38,51,52 In the totalsample (responders and nonresponders), men hadhigher ISS than women (24.4 vs. 21.6, P � 0.01).This small gender difference could slightly de-crease SF-12 scores as women tend to report worseposttraumatic general health than men53,54 al-though it was not the case in responders. Thissmall gender bias, being nondifferential, could thusmoderately underestimate the association betweenregions and outcomes.

Responses being neither associated with re-gions nor with known injury severity variables ren-ders the high probability for nonresponders’ andresponders’ postacute needs to be comparableacross regions. Individuals lost to follow-up in spi-nal cord injury 55 and TBI outcomes studies56 havebeen reported to be more socioeconomically disad-vantaged. If this bias occurred in this study, re-ported barriers to services would be underesti-mated and health outcomes overestimated giventhe known association between socioeconomic sta-tus and health.57

A recall bias may have lowered estimates be-cause participants might have forgotten earlyneeds or barriers to services at the time of inter-view, the latter taking place on average 3.3 yrspostinjury. This seems unlikely for needs, however,as their proportions were high (90%–100%). Therecall could be related to whether there were needsand whether they were met or not. The interview-ing strategy about needs and barriers was designedto, at least partially, correct this bias. Indeed, thefirst question “did you need (the service)” targetedfelt needs58: perceived wants for services, availableor not. The second question “would you haveneeded (the service), had it been readily accessible”was specifically added to trigger awareness aboutboth unfelt needs,58 i.e., services unknown to re-sponders because of unavailability, and unmetneeds (service not received58). Thus, in this study,

reported needs included both felt and unfelt needs.Barriers to services involved unmet services (forfelt or unfelt needs) and undermet services (for feltneeds) or insufficient services because of differentbarriers. Some recall bias might remain as 56% ofthe sample presented a TBI and possible cognitivedeficits. Nevertheless, there is evidence that TBIparticipants can provide valid responses to tele-phone surveys.59 Moreover, the current estimatesof perceived barriers are comparable with the fewothers reported 1 year postinjury.60,61

Recently, Pickelsimer et al.61 reported that themost frequently cited barriers to services in a studyof community-dwelling persons with TBI was“lack of awareness/advocacy/case management”and “help to obtain information on services.” Thistype of barrier reflects the difficulties for traumapatients to know about services, apply for them,and to navigate the system. We did not directlyaddress that type of situation, but if proven true,our estimates of barriers to services would be un-derestimated.

Despite our efforts to increase response rateand limit biases, our results did not support hy-potheses of regional differences in the perceptionsabout accessibility of rehabilitation services, func-tional status, and physical health outcomes. Onepartial explanation could be the mobility of partic-ipants who sought services in other regions. In thisstudy, 34 participants in partial availability of re-habilitation service and 79 participants in LARS(n � 113, 26% of responders) were transferred tometropolitan level I trauma centers and only half ofthem (n � 56) stayed there for inpatient rehabili-tation. Subsequently, 10% of responders receivedphase III rehabilitation services outside their ownregion. Yet, removing these participants from theanalyses did not change results.

It has been suggested10 that the different re-gional classifications could partially explain thelimited number of significant associations reportedto date. As proposed elsewhere,62 we would addthat previously used8–10 health region indicatorsand the one used in the present study remainspatial proxies for exposures to an array of ele-ments that fail to capture the heterogeneity ofsituations within and across regions as well asspecific environmental and populations contexts.

The nonassociation between regional locationsand physical outcomes seen in the present and inprevious studies9,10 may be because of the fact thatthese were conducted among severely injured pop-ulations within contexts of continued and coordi-nated care between level I trauma centers (andlevel II, in our case) and rehabilitation settings. Insuch systems, severe cases are priorities and re-ceive the highest and most extensive standardof care. Rehabilitation accessibility is augmented

www.ajpmr.com Regional Differences in Outcomes 395

through mechanisms, such as transfer of patients,which compensate for unavailable services in re-mote regions. In such contexts, various regionalindices might never prove to relate significantly tooutcomes. Schootman’s study might suggest thatthe situation of less severe patients in less orga-nized systems could be different.

On the one hand, the comparable outcomes inpatients from all regions are, in fact, reassuring.However, the high prevalence of perceived barriersto services in several phases of the rehabilitationcare continuum is surprising and demonstratesthat access is a provincewide issue. Besides, unpub-lished results of this study showed that, regardlessof regions, access to functional rehabilitation sig-nificantly explained 5% FIM scores variation andaccess to sociovocational rehabilitation signifi-cantly explained the same amount of variation inSF-12 measures. This demonstrates that in futurestudies direct measures of access to services shouldbe used instead of regional-spatial proxies.

The high prevalence of perceived barriers torehabilitation services might also illustrate that therehabilitation settings are underequipped to meetall the postacute care needs of trauma patients.Indeed, it has been reported that the Canadianhealth care value of providing services based on theneeds of populations15–17 has traditionally driventhe reinforcement of acute care hospitals.15 Devel-opments of new specialized rehabilitation serviceswere recently announced in the province. Hope-fully, this will help to better meet the broad post-acute needs of severe trauma survivors.

CONCLUSIONIn conclusion, this study shows that there

were no regional differences in perceived barriersto rehabilitation services, which were reported insimilar proportions across the province. Func-tional and physical health outcomes were alsocomparable across regions. Because barriers to ser-vices seem, nevertheless, associated with out-comes, we suggest that direct measures of rehabil-itation accessibility, rather than regional proxies ofit, would be more useful to understand its influ-ence on health outcomes in trauma survivors.

REFERENCES1. Rogers F, Shackford S, Osler TM, et al: Rural

trauma: The challenge for the next decade. J Trauma1999;47:802–21

2. Angus D, Albert T, Chenard D, et al: The EconomicBurden of Unintentional Injury in Canada. Ottawa,Smart Risk, 1998

3. Martinez J, Pampalon R, Hamel D, et al: Does livingin rural communities rather than cities really makea difference in people’s health and wellness? Mon-

treal, Quebec National Institute for Public Health,2004, pp 81

4. Johnstone B, Nossaman L, Schopp L, et al: Distribu-tion of services and supports for people with trau-matic brain injury in rural and urban Missouri.J Rural Health 2002;18:109–17

5. Sample P, Darragh A: Perception of cares access: theexperience of rural and urban women followingbrain injury. Brain Injury 1998;12:855–74

6. Witheneck G, Meade M, Dijkers M, et al: Environ-mental factors and their role in participation and lifesatisfaction after spinal cord injury. Arch Phys MedRehabil 2004;85:1793–803

7. Witheneck G, Gerhart K, Cusick C: Identifying en-vironment factors that influence the outcomes ofpeople with traumatic brain injury. J Head TraumaRehabil 2004;19:191–204

8. Schootman M, Fuortes L: Functional status follow-ing brain injuries: Population-based rural-urban dif-ferences. Brain Injury 1999;13:995–1004

9. Harradine P, Winstanly J, Tate R, et al: Severe trau-matic brain injury in the New South Wales: Compa-rable outcomes for rural and urban residents. Med JAust 2004;181:130–4

10. Gontkovsky S, Sherer M, Nick T, et al: Effect ofurbanicity of residence on TBI outcome at one yearpost-injury. Brain Injury 2006;20:701–9

11. Vincent C, Dumont C, Begin L, et al: La regionalisa-tion des services de readaptation, ce qu’en pensentles usagers dans le centre et l’est du Quebec. CanFam Physician 2001;47:1769–75

12. Dumont C, Vincent C, Beauregard L, et al: Etudedescriptive sur la regionalisation des services de re-adaptation en deficience physique dans le centre etl’est du Quebec. Ruptures revue transdisciplinaireen sante 2000;7:23–40

13. AERDPQ. En toute urgence. Association des etab-lissements en readaptation physique du Quebec,1999, pp 150.

14. Sirois M, Lavoie A, Dionne C: Predicting discharge oftrauma survivors to rehabilitation: A sampling solu-tion for a population-based trauma rehabilitationsurvey. Am J Phys Med Rehabil 2007;86:563–73

15. Sante Canada. “Certaines circonstances” equite etsensibilisation du systeme de soins de sante quantaux besoins des populations minoritaires et margin-alisees. Recueil de documents et de rapports preparepour Sante Canada. Ottawa, ON, 2001

16. Agence de sante publique du Canada. Qu’est-ce quidetermine la sante? Sante de la population. Ottawa,2003

17. Lewis S, Blundell W, Cashin R, et al: Canada HealthAction: Building on the Legacy-Volume II. Strikinga Balance Working Group Synthesis Report. Ottawa,Health Canada, 2003

18. Ware J, Kosinski M, Turner-Bowker D, et al: How toscore version 2 of the SF-12 Health Survey (with aSupplement Documenting Version 1). Lincoln, RI,QualityMetric Inc., 2002

396 Sirois et al. Am. J. Phys. Med. Rehabil. ● Vol. 88, No. 5, May 2009

19. Zelle B, Stalp M, Weighs C, et al: Validation of theHannover score for polytrauma outcome (HASPOC)in a sample of 170 polytrauma patients and a com-parison with the SF-12. Chirurg 2003;74:361–9

20. Zelle B, Panzica M, Voght M, et al: Influence ofworkers’ compensation eligibility upon functionalrecovery 10 to 28 years after polytrauma. Am J Surg2004;190:30–6

21. Hicken B, Putzke J, Richards J: Bladder manage-ment and quality of life after spinal cord injury. Am JPhys Med Rehabil 2001;80:916–22

22. Cusick C, Gerhart K, Mellick D, et al: Evaluation ofthe home community-based services brain injuryMEDICAID WAIVER PROGRAMME in Colorado.Brain Injury 2003;17:931–45

23. Linacre J, Heinemann A, Wright B, et al: The struc-ture and stability of the functional independencemeasure. Arch Phys Med Rehabil 1994;75:127–32

24. Chang W, Chan C, Slaughter S, et al: Evaluation ofthe FONE FIM. Part I. Construct validity and influ-encing factors. J Outcome Meas 1997;1:259–85

25. Smith P, Illig S, Fiedler R, et al: Intermodal agree-ment of follow-up telephone functional assessmentusing the functional independence measure in pa-tients with stroke. Arch Phys Med Rehabil 1996;77:431–5

26. Gosman-Hedstrom G, Blomstrand C: Evaluation of a5-level FIM in longitudinal study of elderly stroke.Disabil Rehabil 2004;26:410–8

27. Nilsson A, Sunnerhagen K, Grimby G: Scoring alter-natives for FIM in neurological disorders applyingRasch analysis. Acta Neurol Scand 2005;111:264–73

28. Gosman-Hedstrom G, Svensson E: Parallel reliabil-ity of the functional independence measure and theBarthel ADL index. Disabil Rehabil 2000;22:702–15

29. Heinemann A, Semik P, Bode R: Reducing StepDisorder in Multidisciplinary FIM Ratings. 1stWorld Congress of the International Society ofPhysical and Rehabilitation Medicine 2001. Bolo-gna, Italy, Monduzzi Editore, 2001

30. Tennant A, Penta M, Tesio L, et al: Assessing andadjusting for cross-cultural validity of impairmentand activity limitation scales through differentialitem functioning within the framework of the RaschModel. Med Care 2004;42:137–48

31. Lungren-Nilsson A, Grimby G, Ring H, et al: Cross-cultural validity of Functional Independence Mea-sure Items in Stroke: A study using Rasch analysis. JRehabil Med 2005;37:23–31

32. Heinemann A, Linacre J, Wright B, et al: Relation-ship between impairment and disability as measuredby the functional independent measure. Arch PhysMed Rehabil 1993;74:566–77

33. Wright B, Stone M: Best Test Design. Chicago, IL,Mesa Press, 1979

34. Bond T, Fox C: Applying the Rasch Model: Funda-mental Measurement in the Human Science. Mah-wah, NJ, Lawrence Erlbaum Associates, Inc., 2001

35. Dijkers M, Abela MB, Gans B, et al: The aftermath ofspinal cord injury, in Stover S, Delisa J, Whiteneck G(eds). Spinal Cord Injury. Gaithersburg, ML, Aspen,1995, pp 185–211

36. Wagner A, McConnel, Hammond F, et al: Use ofinjury severity variables in determining disabilityand community integration after traumatic braininjury. J Trauma 2000;49:411–19

37. Evans R: Predicting outcome following traumaticbrain injury. J Rehabil Outcomes Meas 1999;3:45–9

38. Holbrook T, Anderson J, William J, et al: Outcomeafter major trauma. J Trauma 1999;46:765–73

39. Daveluy C, Pica L, Audet N, et al. Enquete sociale etde sante 1998-Cahier technique et methodologique:documentation generale. 1 vol. Montreal, 2001

40. Copes W, Champion H, Sacco W, et al. The injuryseverity score revisited. J Trauma 1988:69–77

41. Holbrook T, Hoyt D, Anderson J: The impact ofmajor in-hospital complications on functional out-come and quality of life after trauma. J Trauma2000;50:91–5

42. Groll D, To T, Bombardier C, et al: The developmentof a comorbidity index with physical function as theoutcome. J Clin Epidemiol 2005;58:595–602

43. Fortin M, Bravo G, Lapointe L, et al: Relationshipbetween multimorbidity and health-related qualityof life of patients in primary care. Qual Life Res2006;15:83–91

44. Webb C, Wrigley M, Yoels W, et al: Explaining quality oflife for persons with traumatic brain injury 2years after injury. Arch Phys Med Rehabil 1995;76:1113–19

45. Elfstrom M, Ryden A, Kreutzer M, et al: Relationsbetween coping strategies and health-related qualityof life in patients with spinal cord lesion. J RehabilMed 2005;37:9–16

46. Lund M, Nordlund A, Nygard L, et al: Perceptions ofparticipation and predictors of perceived problemswith participation in persons with spinal cord injury.J Rehabil Med 2005;37:3–8

47. Audet N, Lemieux M, Cardin J: Enquete sociale et de sante1998-Cahier technique et methodologique: Definition etcomposition des indices. Vol 2. Montreal, 2001

48. Gervais M. La mise en place de reseaux deneurotraumatologie: lecons apprises d’experiences quebe-coises, inPUL (ed): Quebec, Universite Laval, 2000

49. Holman R, Glass C, Haan R: Power analysis in ran-domized clinical trial based on item response theory.Controlled Clinical Trials 2003;24:390–410

50. Measuring Remoteness: Accessibility/RemotenessIndex of Australia (ARIA). October 2001 revised edi-tion. Canberra: Commonwealth Department ofHealth and Aged Care; 2001

51. Ditunno J, Cohen M, Formal C, et al: FunctionalOutcomes, in Stover S, Delisa J, Whiteneck G (eds):Spinal Cord Injury. Gaithersburg, ML, Aspen, 1995,pp 170–84

52. Novack T, Bush B, Meythaler J, et al: Outcome after

www.ajpmr.com Regional Differences in Outcomes 397

brain injury: Pathway analysis of contribution frompremorbid, injury severity, and recovery variables.Arch Phys Med Rehabil 2001;82:300–5

53. Holbrook T, Hoyt D, Anderson J: The importance ofgender on outcome after major trauma: Functionaland psychological outcomes in women versus men.J Trauma 2001;50:270–3

54. Krause J, Broderick L: Outcome after spinal cordinjury: Comparisons as a function of gender, raceand ethnicity. Arch Phys Med Rehabil 2004;85:355–62

55. Lin H-Y, Chen Y, De Vivo M: Loss to follow-up ratesand characteristics in the spinal cord injury modelsystems database. Arch Phys Med Rehabil 2007;88:E13

56. Corrigan J, Harrison-Felix C, Bogner J, et al: Sys-tematic bias in traumatic brain injury outcomesstudies because of loss to follow-up. Arch Phys MedRehabil 2003;84:153–9

57. Pageau M, Choiniere R, Ferland M, et al: Le portraitde sante. Le Quebec et ses regions. Quebec, Publi-cations du Quebec, 2001

58. Heinemann A, Sokol K, Garvin L, et al: Measuringunmet needs and services among persons with trau-matic brain injury. Arch Phys Med Rehabil 2002;83:1052–9

59. Mackenzie E, McCarthy M, Ditunno J: Using theSF-36 for characterizing outcome after multipletrauma involving head injury. J Trauma 2002;52:527–34

60. Corrigan J, Whiteneck G, Mellik D: Perceived needsfollowing traumatic brain injury. J Head TraumaRehabil 2004;19:205–16

61. Pickelsimer E, Selassie A, Sample P, et al: Unmetservice needs of persons with traumatic brain injury.J Head Trauma Rehabil 2007;22:1–13

62. McDade T, Adair L: Defining the “urban” in urban-ization and health: A factor analysis approach. SocSci Med 2001;53:55–70

APPENDIX

APPENDIX 1 Type of services included in each rehabilitation phase

Phase II Phase III Phase IV

Physical therapy Psychology individual follow-up Support for instrumental activities of daily livingTraining in activities

of daily livingCouple and family follow-up General or specialized medical follow-up

Rehabilitation nursing Home modification services Day center servicesCognitive therapy Driving assessment and training Adapted transportationSpeech therapy Work/school integrationTraining with mobility

equipmentLeisure training

Special educationOutpatient or day hospital

services

APPENDIX 2 Comorbidities index

ItemsArthritis/osteoarthritisOther serious joints/bones problemsOther serious muscles or tendon problemsRespiratory diseases (asthma, COPD, chronic

bronchitis)Metabolic diseaseHeart diseaseCancerVisual impairmentHearing impairmentDepressionMigraineEpilepsyPeriod of important anxiety/irritabilityImportant confusion/memory lossGastrointestinal diseaseGenitourinary diseaseStroke sequelea/transient ischemic attacksAlzheimer disease (other than 14)Other

398 Sirois et al. Am. J. Phys. Med. Rehabil. ● Vol. 88, No. 5, May 2009