Life Satisfaction After Traumatic Brain Injury

Corrigan, John D. PhD; Bogner, Jennifer A. PhD; Mysiw, W. Jerry MD;

Clinchot, Daniel MD; Fugate, Lisa MD, MS

Abstract

Objective: To investigate correlates of life satisfaction after traumatic brain injury (TBI).

Design: Prospective, longitudinal study of patients with TBI studied 1 and 2 years after injury.

Setting: A specialized inpatient TBI rehabilitation unit in a midwestern academic medical

center.

Subjects: Two hundred eighteen consecutive patients admitted for rehabilitation, at least 14
years of age, with a primary diagnosis of TBI, consented to participate, and interviewed 1
and/or 2 years after injury (112 interviewed both years, 58 at year 1 only, 48 at year 2 only).

Main Outcome Measures: Satisfaction With Life Scale.

Results: Stepwise multiple regressions accounted for statistically significant, but small,
proportions of variance. Not having a preinjury history of substance abuse and having gainful
employment at the time of follow-up were associated with higher life satisfaction both 1 and 2
years after injury. Motor independence at rehabilitation discharge was also associated at 1
year. Current social integration and the absence of depressed mood were associated at 2 years.
Life satisfaction was relatively stable between years. Change that did occur was associated
with marital status and depressed mood 2 years after injury.

Conclusions: Life satisfaction after TBI seems to be related to attaining healthy and
productive lifestyles. Future research should investigate other factors that affect life
satisfaction to increase prediction and appreciate all influences on subjective well being after
TBI.

FUHRER 1 asserted that regardless of the model of disablement used, evaluations of the
outcomes of medical rehabilitation are incomplete if they ignore the subjective well being of
the individual served. Consistent with concepts used in social sciences research, Fuhrer's
definition of subjective well-being emphasized individually held expectations rather than
externally defined criteria and involved both cognitive and emotional judgments of
discrepancies from these implicit standards. Dijkers 2 distinguished subjective quality of life
from both aggregate quality of life based on social indicators for large groups or populations
and objective quality of life that uses externally defined indices of an individual's life
situation. In his taxonomy of quality of life measurement, Dijkers 3 further distinguished
between measures of subjective quality of life and cognitive versus affective orientations. The
former have most often been referred to as measures of life satisfaction, whereas the latter
include constructs such as happiness, morale, and positive and negative affect. In this article,
the term “life satisfaction” refers to a cognitively oriented, subjective judgment of one's
current life situation in relation to one's own expectations.
Life satisfaction has been studied in many health conditions, especially individuals
experiencing chronic disease or disability. Studies of life satisfaction among persons with
disabilities have been more frequent in conditions affecting physical function than disability
caused by cognitive impairment. 1,2 Most notably, among persons with spinal cord injury,
higher life satisfaction has been associated with better perceived health, greater social support,
more social activity, and a greater sense of control over one's life. 4 Other researchers found
that life satisfaction was not related to the extent of impairment or disability but was
associated with several dimensions of societal participation. 5 These studies might be
interpreted as indicating that life satisfaction after spinal cord injury is associated with the
same types of intrapsychic and situational variables that affect satisfaction for the general
population. Disability-related indices of impairment and functional limitations seem less
related. Regression analyses of Spinal Cord Injury Model Systems data found gender, number
of rehospitalizations, years since injury, the Functional Independence Measure (FIM™)
Cognition score, and Craig Handicap Assessment and Reporting Technique (CHART)
mobility, occupation, and social integration subscales were all associated with life
satisfaction. 6 In contrast to earlier studies, these results suggested a relationship to disability-
specific issues. Because regression analyses are highly dependent on both sample
characteristics and the pool of predictor variables, these findings require independent
replication. However, studies in spinal cord injury raise a question about the extent to which
the experience of life satisfaction is affected by issues specific to the onset and/or ongoing
experience of living with a disability.

Life satisfaction among persons with cognitive impairments has been investigated in both
individuals with strokes and traumatic brain injury (TBI). Soderback and Ekholm 7 observed
that stroke patients who were working before but not after onset had decreased life
satisfaction, as did those who had experienced other changes in social roles. Inability to re-
enter work and changed social roles were also related to diminished intellectual functioning,
disrupted sleep, less independence in personal care, less activity in the home, and requiring
more rest during the day. Unfortunately, the design of the study did not allow direct testing of
a relationship between life satisfaction and these indices of impairment and functional
limitation. Astrom and colleagues 8 conducted serial testing on a prospective sample of stroke
patients 3 months to 3 years after onset. These authors found a marked temporal relationship,
with some subjects showing improvement in depression, leisure and social activity, and life
satisfaction between 3 and 12 months after their stroke. Those who showed improvement
maintained it over the subsequent 2 years, whereas those who did not continued to show
lower life satisfaction. These authors concluded that depressed mood, functional disability,
and restricted social networks were precipitating factors in lower life satisfaction after stroke;
however, their design did not allow investigation of cause and effect. 8 Segal and Schall 9
evaluated subjects 6 months after stroke and found life satisfaction was more closely
associated with disability as measured by the FIM™ than with community participation as
measured by the CHART. Although the limited research in spinal cord injury was equivocal in
terms of disability-specific determinants of life satisfaction, these studies of stroke patients
suggest a greater relationship, including a temporal association with recovery.

Warren and colleagues 10 compared life satisfaction 1 year after hospital discharge for
persons with either traumatic spinal cord injury or TBI. They found that closeness to family,
level of family activities, and perceived responsibility for the injury were associated with life
satisfaction among persons with spinal cord injury, whereas the satisfaction of persons with
TBI was associated with employment, marital status, functional memory capacity, bowel
independence, family satisfaction, and perceived responsibility for the injury. They suggested
that these differences were sufficient to necessitate these populations being considered as
distinct with regard to factors affecting life satisfaction. Heinemann and Whiteneck 11 found
that life satisfaction was associated with age, extent of disability, social integration, and
productivity among persons with TBI living in the community. In a sample of community-
dwelling individuals who were at least 8 years after injury, Burleigh, Farber, and Gillard 12
reported a significant relationship between life satisfaction and the Social Integration subscale
of the Community Integration Questionnaire (CIQ) but not the Total or other subscale scores.
12 They also observed that older age at time of injury was associated with higher life
satisfaction. Like studies of the general population, studies of persons with TBI have found
life satisfaction to be associated with societal participation, marital status, and employment.
However, additional disability-specific variables have included age at onset, functional
limitations, memory impairment, and perceived responsibility for the injury.

Corrigan, Smith-Knapp, and Granger 14,15 examined the validity of the FIM™ as a measure
of disability for persons with TBI, including its relationship to life satisfaction. Multiple
indices of impairment, disability, societal participation, affective functioning, and life
satisfaction were collected from a cross-sectional sample of subjects with moderate to severe
TBI who were 6 months to 5 years postdischarge from acute rehabilitation. Results of this
cross-sectional study indicated that functional independence was not correlated with life
satisfaction; however, depressed mood, income, and time after injury were highly related.
Social integration and extent of social activity were related but did not contribute substantially
to the prediction model. Results also indicated that age, race/ethnicity, and impairment
affected life satisfaction. Although depressed mood and income are highly correlated with life
satisfaction in the general population, time after injury was disability specific. Lower life
satisfaction was evident for those subjects 1 to 2 years postdischarge. Because this sample
was cross-sectional, no conclusion could be drawn about this difference being caused by
developmental dynamics or cohort differences.

There is considerable diversity in studies of life satisfaction in persons with disabilities. There
is certainly evidence that factors affecting life satisfaction in the general population (e.g.,
affective distress, economic status, productivity, marital status, family satisfaction, or societal
participation) also affect persons with disabilities. However, disability-specific factors may
have a role in determining life satisfaction. For persons who experience TBI these factors may
include cognitive and motor independence, adjustment to disability, age at onset, and time
after injury. If life satisfaction changes with time after injury, it would be of interest to
determine whether this is due to changes in factors that are determinants of life satisfaction or
whether the determinants themselves change. Thus, the purposes of this study were to (1)
investigate factors associated with life satisfaction at 1 and 2 years after injury and (2) identify
factors that correlate with changes between the first and second years.