Submitted:
27 May 2026
Posted:
27 May 2026
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Abstract
Background and Objectives: Evidence guiding rehabilitation outcomes among medically complex traumatic brain injury (TBI) populations remains limited, particularly in long-term acute care hospital (LTACH) settings. Most prior studies have focused on inpatient rehabilitation facilities, leaving a limited understanding of factors influencing recovery during LTACH rehabilitation. This study examined the association between mechanism of injury, time from injury to LTACH admission, and functional rehabilitation outcomes in adults with moderate-to-severe TBI. Materials and Methods: This cross-sectional observational study included adults with moderate-to-severe TBI who received multidisciplinary rehabilitation in an LTACH between January 2017 and December 2024. Of 272 eligible patients, 239 met the inclusion criteria after exclusions for short length of stay, incomplete evaluations, duplicate records, death during rehabilitation, or full independence at admission. Functional improvement in mobility and activities of daily living (ADLs) was measured using CMS Section GG assessments and dichotomized as improvement versus no improvement. Logistic regression analyses examined associations between predictors and outcomes while adjusting for demographic covariates. Results: Longer time from injury to LTACH admission was associated with lower odds of functional improvement. Compared with admission within 30 days, admission at 31–60 days (OR=0.53; 95% CI, 0.28-0.99; p=.045) and beyond 60 days (OR=0.26; 95% CI, 0.10-0.69; p=.006) was associated with reduced odds of improvement. Mechanism of injury was not significantly associated with outcomes. Male gender was associated with higher odds of improvement (OR=2.18; 95% CI, 1.05-4.51; p=.036). No significant interaction effects were identified. Conclusions: Delayed LTACH admission was associated with lower odds of functional improvement following TBI rehabilitation, independent of injury mechanism and demographic factors. These findings support the importance of timely access to postacute rehabilitation among medically complex TBI populations.
Keywords:
traumatic brain injury
; rehabilitation
; long-term acute care hospital
; LTACH
; postacute care
; Section GG
; functional outcomes
; mobility
; activities of daily living
; neurorehabilitation
1. Introduction
Traumatic brain injury (TBI) is a major public health concern associated with substantial long-term disability, healthcare utilization, and socioeconomic burden worldwide [1,2,3]. Recent estimates indicate that approximately 55 million individuals live with the long-term effects of TBI globally, with moderate-to-severe injuries frequently resulting in persistent impairments in mobility, activities of daily living (ADLs), cognition, and psychosocial functioning that require prolonged multidisciplinary rehabilitation [2,3,4,5]. Early and coordinated rehabilitation has been associated with improved functional recovery, shorter length of stay, and reduced disability following TBI [6,7,8]. However, rehabilitation outcomes vary considerably across postacute care settings and patient populations.
Long-term acute care hospitals (LTACHs) represent a specialized phase of postacute care for medically complex patients who are not yet appropriate candidates for traditional inpatient rehabilitation facilities [9,10]. Patients admitted to LTACHs often require prolonged medical management, ventilatory support, and specialized interdisciplinary rehabilitation following severe neurological injury [11,12]. Recent studies have demonstrated that patients with TBI admitted to LTACHs are typically older, medically complex, and at increased risk for prolonged functional impairment and mortality [9,11]. Despite the important role of LTACHs within the rehabilitation continuum, evidence examining functional outcomes and predictors of recovery in this setting remains limited [13]. Most prior rehabilitation studies have focused on inpatient rehabilitation facilities, skilled nursing facilities, or acute care populations [14,15,16]. As a result, rehabilitation trajectories during the LTACH phase remain incompletely understood.
Mechanism of injury and timing of rehabilitation initiation are recognized as important factors influencing recovery after TBI [2,6,8]. Earlier rehabilitation has consistently been associated with improved functional outcomes, whereas delayed rehabilitation may contribute to poorer recovery trajectories and prolonged disability [7,8,17]. For example, Bae and Lee [17] reported substantially longer lengths of stay among patients with delayed rehabilitation initiation following TBI. However, evidence regarding these associations during LTACH rehabilitation remains scarce [13]. Previous studies have also reported inconsistent findings regarding the influence of demographic characteristics, including age, gender, and race/ethnicity, on rehabilitation outcomes following TBI [2,18,19]. Clarifying these relationships may support more targeted rehabilitation planning in medically complex populations.
Guided by the Social Ecological Model SEM, recovery was conceptualized as the result of interacting individual, interpersonal, organizational, and health-system factors [20,21,22]. The Social Ecological Model has also been widely applied to complex public health and rehabilitation contexts requiring coordinated systems-level approaches [23]. Our study addressed the limited evidence examining predictors of functional rehabilitation outcomes during the LTACH phase of recovery after TBI.I. Little is known regarding the influence of injury mechanism and rehabilitation timing on functional outcomes among medically complex patients receiving LTACH rehabilitation. We examined the association between mechanism of injury, time from injury to LTACH admission, and functional rehabilitation outcomes among adults with moderate-to-severe TBI receiving postacute rehabilitation in an LTACH setting. It was hypothesized that a longer time from injury to rehabilitation would be associated with lower odds of functional improvement. The findings demonstrated that delayed admission to LTACH rehabilitation was independently associated with reduced odds of functional improvement, whereas mechanism of injury was not significantly associated with outcomes.
2. Materials and Methods
2.1. Study Design and Setting
This cross-sectional observational study examined the association between mechanism of injury, time from injury to rehabilitation initiation, and functional rehabilitation outcomes among adults with TBI receiving postacute rehabilitation in a LTACH. The study was conducted using retrospective clinical rehabilitation data collected between January 2017 and December 2024.
2.2. Participants
Participants included adults aged ≥18 years with moderate-to-severe TBI who received multidisciplinary rehabilitation targeting mobility and activities of ADLs during LTACH hospitalization. Inclusion criteria required completion of both admission and discharge functional assessments. Exclusion criteria included length of stay <7 days, incomplete rehabilitation evaluations, duplicate records, death during rehabilitation, or full functional independence at admission.
A total of 272 patients met initial eligibility criteria. After exclusions, 239 participants were included in the final analysis.
2.3. Variables and Outcomes Measures
The primary independent variables were mechanism of injury and time from injury to LTACH admission. Mechanism of injury was categorized as motor vehicle accidents, falls, or violence-related injuries. Time from injury was categorized as ≤30 days, 31–60 days, or >60 days. Covariates included age, gender, and race/ethnicity.
The primary outcome was improvement in functional rehabilitation, as measured by CMS Section GG standardized functional assessments [24,25] of mobility and ADLs. Occupational and physical therapists completed Section GG assessments at admission and discharge as part of routine clinical care. Composite functional scores were calculated by combining mobility and ADL performance measures. Functional improvement was operationalized as the difference between discharge performance scores and admission goal scores (final − goal) and dichotomized as improvement (≥0) versus no improvement (<0).
2.4. Statistical Analysis
Descriptive statistics summarize demographic and clinical characteristics. Chi-square tests and Fisher–Freeman–Halton exact tests were used to examine unadjusted associations between categorical variables and functional outcomes. Binary logistic regression analyses were performed to estimate associations between predictors and functional improvement while adjusting for demographic covariates. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported. Interaction analyses examined whether demographic variables modified the association between time from injury and rehabilitation outcomes. Statistical significance was defined as P<.05. Analyses were conducted using SPSS version 30.0 (IBM Corp., Armonk, NY, USA).
2.5. Ethical Considerations
Institutional review board approval was obtained from Walden University and the participating LTACH before data collection (IRB No. 03-21-25-1169977). All data were de-identified before analysis in compliance with HIPAA regulations.
2.6. Data Availability
The data analyzed in this study were derived from de-identified clinical rehabilitation records and are not publicly available because of institutional and privacy restrictions. Additional methodological details may be available from the corresponding author upon reasonable request.
3. Results
3.1. Participant Characteristics
A total of 272 patients with TBI were screened for eligibility between January 2017 and December 2024. After applying exclusion criteria, 239 participants were included in the final analysis. The most common reasons for exclusion were length of stay < 7 days and incomplete rehabilitation evaluations. Motor vehicle accidents were the most common mechanism of injury (56.5%), followed by falls (36.4%) and violence-related injuries (7.1%) (Table 1). Functional improvement in mobility and/or activities of daily living (ADLs) was observed in 33.1% of participants. The overall rate of functional improvement observed in this cohort was lower than rates reported in CMS LTACH benchmarks and comparable rehabilitation populations.
3.2. Unadjusted Associations
In unadjusted analyses, time from injury to LTACH admission was significantly associated with functional improvement status, χ2(2, N = 239) = 9.34, p = .009. Participants admitted within 30 days of injury demonstrated the highest proportion of functional improvement. Mechanism of injury was not significantly associated with rehabilitation outcomes, χ2(2, N = 239) = 2.85, p = .241. Similarly, no significant unadjusted associations were observed between functional improvement and gender or race/ethnicity.
3.3. Logistic Regression Analysis
Binary logistic regression analyses examined associations between mechanism of injury, time from injury to rehabilitation initiation, and functional outcomes while adjusting for demographic covariates (Table 2). Compared with admission within 30 days of injury, admission at 31–60 days was associated with lower odds of functional improvement (OR = 0.53; 95% CI, 0.28–0.99; p = .045). Admission beyond 60 days demonstrated an even greater reduction in odds of improvement (OR = 0.26; 95% CI, 0.10–0.69; p = .006). Mechanism of injury was not significantly associated with functional outcomes. Male gender was independently associated with higher odds of functional improvement (OR = 2.18; 95% CI, 1.05–4.51; p = .036), whereas age and race/ethnicity were not significant predictors.
3.4. Interaction Analysis
Interaction analyses evaluated whether demographic variables modified the association between time from injury and functional rehabilitation outcomes. No statistically significant interaction effects were identified between time from injury and age, gender, or race/ethnicity (Table 3). These findings indicate that the association between delayed rehabilitation and lower functional improvement was generally consistent across demographic subgroups.
4. Discussion
To our knowledge, this study is among the first to examine the association between mechanism of injury, time from injury to LTACH admission, and functional rehabilitation outcomes among adults with moderate-to-severe TBI receiving postacute rehabilitation in an LTACH setting. The findings demonstrated that delayed admission to LTACH rehabilitation was independently associated with lower odds of functional improvement in mobility and ADLs. In contrast, mechanism of injury was not significantly associated with rehabilitation outcomes. These findings support the study hypothesis that longer delays between injury and rehabilitation initiation are associated with poorer functional recovery.
Time from injury emerged as the strongest predictor of rehabilitation outcomes in this cohort. Participants admitted more than 30 days after injury demonstrated significantly lower odds of improvement, with the greatest reduction observed among individuals admitted after 60 days. These findings are consistent with previous rehabilitation literature demonstrating that earlier rehabilitation initiation is associated with improved functional outcomes, shorter length of stay, and reduced disability following TBI [6,7,8,17]. Prior studies conducted in inpatient rehabilitation and acute care settings have similarly reported improved mobility and ADL outcomes among patients receiving earlier rehabilitation interventions [14,15,16]. Collectively, these findings reinforce the importance of timely access to postacute rehabilitation services during critical recovery phases after TBI.
The mechanism of injury was not significantly associated with functional outcomes in this study. Although motor vehicle accidents were the most common injury mechanism, rehabilitation outcomes did not differ significantly across injury categories. Previous studies have reported associations between injury mechanism, injury severity, and acute neurological outcomes [2,19,26]. However, the present findings suggest that within medically complex LTACH populations, rehabilitation timing and postacute clinical factors may have a greater influence on functional recovery than the initial cause of injury. This may reflect the shared medical complexity and prolonged recovery trajectories characteristic of LTACH patients.
The overall rate of functional improvement observed in this cohort was lower than rates commonly reported in inpatient rehabilitation populations [14,15,16]. This finding likely reflects the substantial medical complexity of LTACH patients, who frequently require prolonged medical management, ventilatory support, and other medical complexities that delay rehabilitation initiation [9,10,11,12,13]. Nevertheless, approximately one-third of participants achieved measurable functional improvement, supporting the clinical value of multidisciplinary rehabilitation in medically complex TBI populations.
Demographic variables did not significantly modify the relationship between time from injury and rehabilitation outcomes. These findings suggest that delayed rehabilitation may adversely affect recovery across demographic subgroups. Previous studies have reported inconsistent associations between demographic factors and TBI outcomes [2,18,19]. The present findings emphasize the broader importance of reducing delays in access to postacute rehabilitation services.
From a systems perspective, delayed admission to LTACH rehabilitation may reflect barriers related to referral processes, insurance authorization, medical instability, or limited availability of specialized postacute services. The findings, therefore, highlight the importance of coordinated care transitions and streamlined referral pathways to facilitate timely access to LTACH rehabilitation for medically complex patients with TBI.
4.1. Limitations
Several limitations should be considered. The retrospective cross-sectional design precludes causal inference, and the study was conducted within a single LTACH system, which may limit generalizability. Additionally, injury severity indices, rehabilitation intensity, and certain social determinants of health were not available within the dataset. Functional outcomes were also dichotomized, potentially reducing sensitivity to smaller, yet clinically meaningful, changes.
4.2. Recommendations
Future research should examine rehabilitation timing and functional recovery using longitudinal and multicenter designs. Studies incorporating measures of injury severity, rehabilitation intensity, medical complexity, and social determinants of health may further clarify factors influencing postacute TBI recovery in LTACH settings.
5. Conclusions
Delayed admission to LTACH rehabilitation following TBI was associated with lower odds of functional improvement in mobility and activities of daily living, independent of mechanism of injury and demographic characteristics. In contrast, the mechanism of injury was not significantly associated with rehabilitation outcomes in this medically complex population. These findings emphasize the importance of timely access to specialized postacute rehabilitation services following moderate-to-severe TBI. Within LTACH settings, system-level factors related to rehabilitation timing and care transitions may have greater influence on early functional recovery than injury etiology alone. Efforts to reduce delays in referrals and admission to postacute rehabilitation may help improve recovery trajectories among medically complex patients with TBI. Further multicenter and longitudinal studies are warranted to better characterize rehabilitation timing, medical complexity, and long-term functional outcomes across postacute care settings.
Author Contributions
Conceptualization, A.O. and S.B..; methodology, A.O. and S.B.; software, A.O.; validation, S.B. and T.O.; formal analysis, A.O. and S.B.; investigation, A.O.; resources, S.B. and T.O.; data curation, A.O., S.B., and T.O.; writing—original draft preparation, A.O., S.B., and T.O.; writing—review and editing, A.O., S.B., and T.O.; visualization, A.O.; supervision, S.B. and T.O.; project administration, A.O., S.B., and T.O. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Institutional Review Board Statement
We received ethical approval through the Walden University IRB (03-21-25-1169977).
Informed Consent Statement
Not applicable.
Data Availability Statement
The data presented in this study are available on request from the corresponding author due to institutional and privacy restrictions involving de-identified clinical rehabilitation data. Data may be available from the corresponding author upon reasonable request and with appropriate institutional approval.
Conflicts of Interest
The authors declare no conflicts of interest.
Abbreviations
The following abbreviations are used in this manuscript:
| ADLs | Activities of Daily Living |
| CDC | Centers for Disease Control and Prevention |
| CI | Confidence Interval |
| CMS | Centers for Medicare & Medicaid Services |
| HIPAA | Health Insurance Portability and Accountability Act |
| IMPACT Act | Improving Medicare Post-Acute Care Transformation Act |
| LTACH | Long-Term Acute Care Hospital |
| NASEM | National Academies of Sciences, Engineering, and Medicine |
| OR | Odds Ratio |
| SPSS | Statistical Package for the Social Sciences |
| TBI | Traumatic Brain Injury |
Appendix A
Functional Performance Coding for ADLs and Mobility (Section GG)
CMS Section GG coding scale used to assess functional performance in Activities of Daily Living (ADLs) and Mobility. Each item is rated from 0 to 6, reflecting the level of assistance required.
Coding Scale
| Code | Explanation |
| 0 | Activity Not Attempted – not performed due to safety or medical condition. |
| 1 | Dependent – complete assistance required. |
| 2 | Substantial/Maximal Assistance – patient performs <50% of effort. |
| 3 | Partial/Moderate Assistance – patient performs ≥50% of effort. |
| 4 | Supervision or Touching Assistance – needs supervision or light contact. |
| 5 | Setup or Clean-Up Assistance – needs only preparation or clean-up help. |
| 6 | Independent – no assistance needed. |
Per CMS directive, “activity not attempted” reasons (07=patient refused; 09=not applicable (patient did not perform the task before stroke); 10=not attempted because of environmental limitations; 88=not attempted because of medical condition or safety concerns) were scored “1”.16.
ADLs (Evaluated by Occupational Therapy)
- a)
- Eating
- b)
- Oral hygiene
- c)
- Toileting hygiene
- d)
- Showering/bathing self
- e)
- Washing lower body
- f)
- Upper body dressing
- g)
- Lower body dressing
- h)
- Toilet transfer (on/off)
- i)
- Bed/chair transfer
Mobility (Evaluated by Physical Therapy)
- a)
- Bed mobility (roll left/right/back)
- b)
- Sit to lie
- c)
- Lying to sitting
- d)
- Sit to stand
- e)
- Bed-to-chair/chair transfer
- f)
- Toilet transfer (on/off)
- g)
- Walking 10 feet
- h)
- Walking 50 feet with two turns
- i)
- Walking 150 feet
- j)
- Four steps
- k)
- Wheel 50 feet with two turns
- l)
- Wheel 150 feet
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Table 1.
Characteristics of the study participants.
| Characteristics | Full sample N = 239 (100%) |
Functional differential score | p value | |
|---|---|---|---|---|
| No improvement N = 160 (66.9%) |
Improvement N = 79 (33.1%) |
|||
| Mechanism of injury | .241 | |||
| MVA | 135 (56.5) | 92 (68.1) | 43 (31.9) | |
| Fall | 87 (36.4) | 54 (62.1) | 33 (37.9) | |
| Violence | 17 (7.1) | 14 (82.4) | 3 (17.6) | |
| Time from injury | .009 | |||
| ≤ 30 days | 111 (46.4) | 64 (57.7) | 47 (42.3) | |
| 31–60 days | 89 (37.2) | 64 (71.9) | 25 (28.1) | |
| > 60 days | 39 (16.3) | 32 (82.1) | 7 (17.9) | |
| Age (y), Mean (SD) | 48.93 (16.314) | |||
| Gender | .111 | |||
| Female | 54 (22.6) | 41 (75.9) | 13 (24.1) | |
| Male | 185 (77.4) | 119 (64.3) | 66 (35.7) | |
| Race/ethnicity | .637 | |||
| Black | 34 (14.2) | 23 (67.6) | 11 (32.4) | |
| White | 187 (78.2) | 125 (66.8) | 62 (33.2) | |
| Hispanic | 8 (3.3) | 4 (50.0) | 4 (50.0) | |
| Other | 10 (4.2) | 8 (80.0) | 2 (20.0) | |
Note: Abbreviations: MVA = Motor vehicle accident. Values represent frequencies and percentages of participants with functional improvement by mechanism of injury and time from injury to rehabilitation initiation. Statistical significance was set at p < .05. Statistical significance was determined at p < .05. 1 Fisher’s Feeman-Halton exact tests were used when expected cell counts were <5.
Table 2.
TBI. Mechanism of injury and time from injury on rehabilitation outcomes.
| Predictor (reference) | OR | 95% CI | p value |
|---|---|---|---|
| Mechanism of injury (ref.: MVA) | |||
| Falls vs MVA | 1.21 | [0.68, 2.16] | .513 |
| Violence vs MVA | 0.63 | [0.17, 2.38] | .493 |
| Time from injury (ref.: ≤ 30 days) | |||
| 31-60 days vs ≤ 30 days | 0.56 | [0.31, 1.03] | .062 |
| > 60 days vs ≤ 30 days | 0.33 | [0.13, 0.82] | .017 |
Note. Abbreviations: MVA = Motor vehicle accident. Outcome modeled as a binary rehabilitation outcome. Reference categories: mechanism of injury = motor vehicle accident; time from injury = ≤30 days.
Table 3.
Mechanism of injury, time from injury, and covariates on rehabilitation outcomes.
| Predictor (reference) | OR | 95% CI | p value |
|---|---|---|---|
| Mechanism of injury (ref.: MVA) | |||
| Fall vs MVA | 1.62 | [0.82, 3.17] | .163 |
| Violence vs MVA | 0.58 | [0.15, 2.29] | .435 |
| Time from injury (ref.: ≤ 30 days | |||
| 31-60 days vs ≤ 30 days | 0.53 | [0.28, 0.99] | .045 |
| > 60 days vs ≤ 30 days | 0.26 | [0.10, 0.69] | .006 |
| Age (per year) | 0.99 | [0.97, 1.01] | .241 |
| Gender (male vs female) | 2.18 | [1.05, 4.51] | .036 |
| Race/ethnicity (ref.: Black) | |||
| White vs Black | 0.68 | [0.28, 1.65] | .398 |
| Hispanic vs Black | 1.86 | [0.36, 9.60] | .461 |
| Other vs Black | 0.39 | [0.07, 2.30] | .296 |
Note. Abbreviations: MVA = Motor vehicle accident. Outcome modeled as a binary rehabilitation outcome. Reference categories: mechanism of injury = motor vehicle accident; time from injury = ≤30 days.
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