Submitted:
18 July 2026
Posted:
20 July 2026
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Abstract
Background and Objectives: Adults with moderate-to-severe traumatic brain injury (TBI) frequently experience medical complications during post-acute rehabilitation that may adversely affect recovery. Although falls and infections are common among medically complex rehabilitation populations, their relationship with functional outcomes in long-term acute care hospitals (LTACHs) has not been well characterized. This study evaluated whether hospitalization-related falls and infections were associated with functional rehabilitation outcomes among adults with moderate-to-severe TBI receiving LTACH rehabilitation. Materials and Methods: A retrospective cohort study was conducted using electronic medical record data from adults admitted to an LTACH between January 2017 and December 2024. Among 272 screened patients, 239 met the eligibility criteria. Functional rehabilitation outcomes were determined using Centers for Medicare & Medicaid Services (CMS) Section GG mobility and activities of daily living (ADL) assessments completed at admission and discharge. Hospitalization-related falls and infections were examined as predictor variables using logistic regression models adjusted for age, gender, and race/ethnicity. Results: Falls occurred in 11.3% of participants and infections in 15.9%, while 33.1% achieved functional improvement. After adjustment for demographic characteristics, hospitalization-related falls were associated with 69% lower odds of functional improvement (OR = 0.31; 95% CI, 0.10–0.98; p = .046), whereas infections were associated with a 62% lower odds of improvement (OR = 0.38; 95% CI, 0.15–0.97; p = .042). No significant demographic interaction effects were identified. Conclusions: Hospitalization-related falls and infections were independently associated with poorer functional rehabilitation outcomes among adults with moderate-to-severe TBI receiving LTACH care. These findings support the importance of multidisciplinary strategies aimed at preventing and promptly managing clinical complications throughout post-acute rehabilitation.
Keywords:
traumatic brain injury
; long-term acute care hospital
; LTACH
; post-acute rehabilitation
; Section GG
; falls
; infections
; functional recovery
; neurorehabilitation
; mobility
; activities of daily living (ADLs)
1. Introduction
Traumatic brain injury (TBI) remains a leading cause of mortality and long-term disability worldwide, frequently resulting in persistent physical, cognitive, and psychosocial impairments that require prolonged interdisciplinary rehabilitation [1,2,3,4]. 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 [2,3,5,6]. Recovery following moderate-to-severe TBI is highly variable and extends beyond the initial neurological injury, reflecting the combined influence of injury characteristics, medical complications, rehabilitation interventions, and patient-specific factors [5,6,7,8]. Identifying potentially modifiable factors that influence functional recovery is essential for optimizing rehabilitation outcomes in medically complex populations.
Long-term acute care hospitals (LTACHs) provide specialized post-acute care for medically complex patients who require ongoing medical management in conjunction with intensive rehabilitation [9,10,11,12]. Individuals with moderate-to-severe TBI admitted to LTACHs frequently present with multiple comorbidities, prolonged recovery needs, and an increased risk of secondary medical complications that may interfere with rehabilitation participation and functional progress [9,10,12,13,14]. Despite the expanding role of LTACHs within the continuum of neurorehabilitation, relatively few studies have examined factors associated with rehabilitation outcomes in this setting.
Falls and healthcare-associated infections represent two of the most frequent adverse events encountered during inpatient rehabilitation and are associated with increased morbidity, prolonged hospitalization, and higher healthcare utilization [15,16,17,18,19]. Among individuals recovering from TBI, these complications may interrupt rehabilitation, reduce therapy participation, and delay functional recovery through mechanisms including systemic inflammation, physical deconditioning, and increased medical instability [17,18,19,20,21,22]. Although each complication has been examined independently in selected rehabilitation populations, their contribution to functional rehabilitation outcomes among medically complex adults with TBI receiving LTACH care remains poorly understood.
Existing rehabilitation research has primarily focused on acute care hospitals, inpatient rehabilitation facilities, skilled nursing facilities, or outpatient settings, with comparatively little attention to the LTACH environment [9,10,23]. Consequently, the influence of hospitalization-related falls and infections on functional recovery during LTACH rehabilitation has not been well characterized. Improved understanding of these potentially modifiable complications may inform multidisciplinary prevention strategies and optimize rehabilitation outcomes.
Guided by the Social Ecological Model (SEM), this study conceptualized functional recovery as the result of dynamic interactions among patient characteristics, clinical events, rehabilitation processes, and healthcare system factors [24,25,26,27]. Within this framework, hospitalization-related falls and infections were considered modifiable clinical events that may influence rehabilitation trajectories. Accordingly, this study examined the association between hospitalization-related falls, infections, and functional rehabilitation outcomes among adults with moderate-to-severe TBI receiving post-acute rehabilitation in an LTACH. We hypothesized that both complications would be independently associated with lower odds of functional improvement.
Our study addressed the limited evidence examining the association between hospitalization-related falls and infections with functional rehabilitation outcomes during the LTACH phase of recovery after TBI. Specifically, this study examined the association between hospitalization-related falls, infections, and functional rehabilitation outcomes among adults with moderate-to-severe TBI receiving post-acute rehabilitation in an LTACH setting. We hypothesized that falls and infections during hospitalization would be independently associated with lower odds of functional improvement.
2. Materials and Methods
2.1. Study Design and Setting
This retrospective cohort study evaluated the association between hospitalization-related falls, infections, and functional rehabilitation outcomes among adults with moderate-to-severe TBI admitted to a long-term acute care hospital (LTACH). The study used de-identified electronic medical record data collected between January 2017 and December 2024. Functional outcomes were evaluated throughout each participant's LTACH rehabilitation episode, defined as the period from admission to discharge.
2.2. Study Population
Eligible participants were adults aged 18 years or older admitted to the LTACH with a diagnosis of moderate-to-severe TBI who underwent multidisciplinary rehabilitation. Patients were required to have complete clinical documentation, including CMS Section GG assessments at admission and discharge. Exclusion criteria included a rehabilitation length of stay of less than seven days, incomplete rehabilitation evaluations, duplicate records, death during the rehabilitation admission, and full functional independence at admission. After applying these criteria, 239 of 272 screened patients were included in the final analysis.
2.3. Variables and Outcomes Measures
Functional performance was routinely evaluated by occupational and physical therapists using the CMS Section GG standardized assessment of ADLs and mobility (Appendix A). Composite functional scores were generated by combining mobility and ADL items. Functional improvement was determined by comparing discharge performance with individualized rehabilitation goals established at admission (Section GG differential score: discharge performance − admission goal). This goal-oriented approach reflects patient-centered rehabilitation principles and is conceptually consistent with CMS functional outcome methodology, although admission-to-discharge change scores remain more commonly reported in rehabilitation research.
Hospitalization-related falls and infections served as the primary exposure variables and were analyzed as dichotomous measures (yes/no). Age was treated as a continuous variable, whereas gender and race/ethnicity were analyzed as categorical variables.
2.4. Statistical Analysis
Participant characteristics were summarized using descriptive statistics. Initial comparisons between categorical variables and functional rehabilitation outcomes were performed using chi-square or Fisher's exact tests, as appropriate. Logistic regression analyses were subsequently conducted to estimate the associations between hospitalization-related falls, infections, and functional improvement. Crude associations were examined first, followed by multivariable models adjusting for age, gender, and race/ethnicity. Additional interaction analyses evaluated whether demographic characteristics modified the associations between hospitalization-related complications and rehabilitation outcomes. Results are reported as odds ratios (ORs) with corresponding 95% confidence intervals (CIs). Statistical significance was defined as p < .05. All analyses were conducted using IBM SPSS Statistics Version 30 (IBM Corp., Armonk, NY, USA).
2.5. Ethical Statement
The study was approved by the Walden University Institutional Review Board (IRB No. 03-21-25-1169977) and the participating LTACH. The study used de-identified retrospective clinical data, involved no direct participant contact or intervention, and qualified for a waiver of informed consent in accordance with the approved protocol and institutional requirements.
2.6. Generative Artificial Intelligence
No generative artificial intelligence was used in the design of the study, data collection, statistical analyses, or interpretation of the findings. Artificial intelligence-assisted tools (ChatGPT-4o and Grammarly) were used only for editorial support during manuscript preparation. The authors assume full responsibility for the content of the manuscript.
3. Results
3.1. Participants Characteristics
A total of 272 adults with moderate-to-severe traumatic brain injury were screened for eligibility between January 2017 and December 2024. Following application of the predefined inclusion and exclusion criteria, 239 participants comprised the final study cohort. The most common reasons for exclusion were a rehabilitation length of stay of fewer than seven days and incomplete rehabilitation assessments. During LTACH hospitalization, falls occurred in 11.3% of participants and infections in 15.9%. Overall, functional improvement in mobility and/or ADLs was achieved by 33.1% of the cohort (Table 1).
3.2. Regression Analysis
Initial bivariate analyses demonstrated statistically significant associations between both hospitalization-related falls and infections and functional rehabilitation outcomes. No significant unadjusted associations were identified between functional improvement and demographic characteristics, including gender or race/ethnicity. Results of the unadjusted logistic regression analyses (Table 2) showed infection during hospitalization associated with lower odds of functional improvement (OR = 0.36, 95% CI: 0.14–0.90, p = .029). Likewise, falls were associated with lower odds of improvement, although this association did not reach statistical significance (OR = 0.36, 95% CI: 0.12–1.08, p = .067).
Multivariate logistic regression analyses adjusting for age, gender, and race/ethnicity (Table 3), showed that both falls and infections remained independently associated with lower odds of functional improvement. Falls were associated with a 69% reduction in the odds of improvement (OR = 0.31, 95% CI: 0.10–0.98, p = .046), while infections were associated with a 62% reduction (OR = 0.38, 95% CI: 0.15–0.97, p = .042). None of the demographic covariates were statistically significant.
3.3. Interaction Analyses
Interaction analyses were performed to determine whether demographic characteristics modified the association between hospitalization-related falls, infections, and functional rehabilitation outcomes. No statistically significant interaction effects were identified for age, gender, or race/ethnicity (Table 4). These findings suggest that the observed associations between hospitalization-related complications and functional recovery were generally consistent across demographic subgroups.
4. Discussion
To our knowledge, this study is among the first to evaluate the association of hospitalization-related falls and infections with functional rehabilitation outcomes among adults with moderate-to-severe TBI receiving post-acute rehabilitation in an LTACH. Consistent with the study hypothesis, both falls and infections were independently associated with lower odds of achieving functional improvement in mobility and ADLs. Prior studies have reported associations between healthcare-associated infections and poorer functional outcomes during rehabilitation [15,17,24]. Likewise, previous rehabilitation studies have shown that falls during rehabilitation were associated with adverse clinical consequences and interruptions in recovery processes, suggesting their potential influence on rehabilitation trajectories [19,20,28]. In contrast, demographic characteristics, including age, gender, and race/ethnicity, did not significantly modify these relationships. These findings suggest that preventable clinical complications may represent important barriers to rehabilitation progress during the LTACH phase of recovery after TBI.
The overall improvement rate observed in this cohort (33.1%) was lower than rates reported in broader post-acute rehabilitation populations, including approximately 48.7% reported in national CMS LTACH benchmarks and approximately 44% reported among Medicare beneficiaries receiving skilled nursing facility rehabilitation [29,30]. Community-based and inpatient rehabilitation programs have reported functional improvement rates exceeding 60% in selected TBI populations [31,32]. These differences likely reflect the substantial medical complexity of LTACH patients, who often require prolonged medical management, ventilatory support, and intensive interdisciplinary care before transitioning to traditional rehabilitation settings [9,10,33,34]. Within this context, the observed associations between clinical complications and rehabilitation outcomes are particularly relevant because they occur in a population already at elevated risk for delayed recovery.
Falls during hospitalization were associated with a 69% reduction in the odds of functional improvement after adjustment for demographic variables. This finding is consistent with previous studies demonstrating that falls can disrupt rehabilitation participation, increase morbidity, and delay recovery. Marshall et al.[28] reported that falls occurring during inpatient rehabilitation were associated with adverse clinical consequences and interruptions in rehabilitation activities. Similarly, Kinoshita et al.[20] identified reduced mobility and communication deficits as important predictors of rehabilitation-related falls, while Choo et al.[19] documented the persistent occurrence of falls in brain injury rehabilitation populations despite ongoing prevention efforts. Falls represent more than isolated safety events and may directly interfere with rehabilitation engagement, functional progression, and goal attainment.
Infections were also independently associated with poorer rehabilitation outcomes, reducing the odds of functional improvement by approximately 62%. These findings align with previous investigations demonstrating the adverse impact of infections on recovery after acquired brain injury. Bartolo et al.[15] reported that healthcare-associated infections were associated with reduced functional gains during inpatient rehabilitation, while Finotti et al.[17] identified infections as predictors of poorer functional recovery among patients with severe acquired brain injury. Castellani et al.[24] further demonstrated associations between healthcare-associated infections, antimicrobial resistance, and delayed rehabilitation outcomes. The biological mechanisms underlying these findings may include systemic inflammation, increased metabolic demands, interruptions in therapy participation, and prolonged hospitalization, all of which may negatively affect neuroplasticity and functional recovery [15,16,22,23,24,35]. Reducing infection-related disruptions may help maximize participation in rehabilitation and support functional recovery after TBI. Together, these findings underscore the importance of infection prevention and timely management as components of multidisciplinary rehabilitation for medically complex TBI patients.
No significant interaction effects were identified between demographic variables and either falls or infections. Although previous studies have reported inconsistent findings regarding the of age, sex, and race/ethnicity on TBI outcomes [36,37,38,39,40], the present findings suggest that the adverse effects of hospitalization-related falls and infections may be broadly consistent across demographic subgroups within LTACH rehabilitation populations. This does not imply that demographic disparities are absent. Rather, demographic influences may operate through differences in access to care, rehabilitation intensity, social support, or healthcare utilization, rather than through differential susceptibility to clinical complications.
These findings highlight the importance of multidisciplinary strategies to prevent hospitalization-related complications during LTACH rehabilitation. Early identification of patients at increased risk for falls and infections, together with standardized prevention protocols and prompt clinical management, may help maximize participation in rehabilitation participation and support functional recovery in medically complex populations. Falls and infections are potentially modifiable complications that may interfere with recovery during a critical period of neurological rehabilitation. LTACHs occupy a unique position within the continuum of care by providing both medical stabilization and rehabilitation services for medically complex patients. Consequently, interdisciplinary approaches emphasizing infection prevention, early surveillance, fall-risk assessment, mobility promotion, and coordinated rehabilitation planning may contribute to improving functional outcomes in this vulnerable population.
4.1. Limitations
Several limitations should be considered when interpreting these findings. First, the retrospective single-center cohort design limits causal inference and may reduce the generalizability of the results to other LTACHs or rehabilitation settings. Second, hospitalization-related falls and infections were analyzed as dichotomous variables without accounting for their timing, severity, recurrence, duration, or specific infection types, precluding evaluation of dose-response relationships. Third, important prognostic factors, including injury severity (e.g., Glasgow Coma Scale score, post-traumatic amnesia, neuroimaging findings, neurosurgical interventions), rehabilitation intensity, and medical complexity, were unavailable and therefore could not be incorporated into the adjusted analyses, leaving the possibility of residual confounding. Fourth, functional improvement was defined using dichotomized Section GG differential scores based on individualized rehabilitation goals. Although this patient-centered approach is conceptually consistent with CMS functional outcome methodology and goal-attainment models, it may reduce statistical power and limit direct comparison with studies using continuous admission-to-discharge change scores. Finally, rehabilitation outcomes were evaluated only during the LTACH admission, from admission through discharge, and therefore do not reflect longer-term functional recovery after transition to subsequent levels of care.
4.2. Recommendations
Future investigations should validate these findings in larger multicenter LTACH cohorts and evaluate the temporal relationship between hospitalization-related complications and functional recovery. Incorporating standardized measures of injury severity, rehabilitation intensity, medical complexity, and social determinants of health may further clarify factors influencing rehabilitation outcomes following moderate-to-severe TBI. Studies examining the frequency, severity, timing, and duration of falls and infections, together with continuous functional outcome measures and standardized follow-up intervals extending beyond LTACH discharge, may provide additional insight into recovery trajectories and identify opportunities for targeted preventive interventions.
5. Conclusions
Hospitalization-related falls and infections were independently associated with lower odds of functional improvement among adults with moderate-to-severe TBI receiving LTACH rehabilitation. These findings highlight the importance of preventing and promptly managing clinical complications during post-acute rehabilitation and support continued investigation in larger multicenter LTACH cohorts to determine whether prevention of hospitalization-related complications improves rehabilitation outcomes.
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 study site and 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.
Acknowledgments
During the preparation of this work, the authors used ChatGPT (Model GPT-4o) and Grammarly for language correction. After using these tools/services, the authors reviewed and edited the content as needed and therefore took full responsibility for the publication's content.
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 |
| 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
Appendix A.1. 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”.
Appendix A.2. 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
Appendix A.3. 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.
Participants Characteristics.
| Characteristics | Prevalence N = 239 (100%) |
Functional differential score | p value | |
|---|---|---|---|---|
| No improvement N=160 (66.9%) |
Improvement N=79 (33.1%) |
|||
| Falls | 27 (11.3) | 23 (85.2) | 4 (14.8) | .032 |
| Infections | 38 (15.9) | 32 (84.2) | 6 (15.8) | .014 |
| 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. Functional Differential Score = Final Score – Goal Score for functional rehabilitation outcomes (activities of daily living–ADLs–and mobility). Chi-square tests were reported when expected cell counts met assumptions. Statistical significance was determined at p < .05.
Table 2.
Unadjusted Logistic Regression Analysis of Falls and Infections on Functional Rehabilitation Outcomes.
Table 2.
Unadjusted Logistic Regression Analysis of Falls and Infections on Functional Rehabilitation Outcomes.
| Predictor (reference) | OR | 95% CI | p value | |
|---|---|---|---|---|
| Falls during hospitalization (yes vs no) | 0.36 | [0.12, 1.08] | .067 | |
| Infections during hospitalization (yes vs no) | 0.36 | [0.14, 0.90] | .029 |
Note: Dependent variable: rehabilitation outcomes (ADLs and mobility).
Table 3.
Adjusted Multivariable Logistic Regression Analysis of Falls, Infections, and Demographic Covariates on Functional Rehabilitation Outcomes.
Table 3.
Adjusted Multivariable Logistic Regression Analysis of Falls, Infections, and Demographic Covariates on Functional Rehabilitation Outcomes.
| Predictor | OR | 95% CI | p value | |
|---|---|---|---|---|
| Falls during hospitalization | 0.31 | [0.10, 0.98] | .046 | |
| Infections during hospitalization | 0.38 | [0.15, 0.97] | .042 | |
| Age (Years) | 1.00 | [0.98, 1.01] | .583 | |
| Gender (male gender vs female) | 1.96 | [0.96, 4.00] | .065 | |
| Race/ethnicity | ||||
| White vs Black | 1.09 | [0.48, 2.46] | .835 | |
| Hispanic vs Black | 2.42 | [0.46, 12.66] | .297 | |
| Other races vs Black | 0.49 | [0.09, 2.84] | .430 |
Note. Odds ratios (ORs) are from logistic regression models predicting functional improvement (improvement ≥ 0 vs no improvement < 0). Race/ethnicity was dummy coded with Black as the reference category. Models were adjusted for age, gender, and hospitalization-related falls and infections. Wide confidence intervals reflect sparse cell counts in some race/ethnicity categories and should be interpreted cautiously.
Table 4.
Interaction effects between falls and infections, and demographic variables on rehabilitation outcomes.
Table 4.
Interaction effects between falls and infections, and demographic variables on rehabilitation outcomes.
| Interaction Term | Δχ² | df | p value |
|---|---|---|---|
| Falls × age | 0.74 | 1 | .390 |
| Falls × gender | 2.51 | 1 | .113 |
| Falls × race/ethnicity | 3.83 | 3 | .281 |
| Infections × gender | 0.33 | 1 | .566 |
| Infections × age | 2.64 | 1 | .104 |
| Infections × race/ethnicity | 3.58 | 2 | .164 |
Note. Interaction effects were evaluated using likelihood-ratio χ² tests comparing models with and without interaction terms. None of the tested interactions significantly improved model fit. Estimates involving race/ethnicity should be interpreted cautiously due to sparse cell counts and convergence warnings.
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