health RelateD QUality OF liFe OF sURViVORs OF tRaUMa six MONths aFteR DischaRGe

Correspondence Author: Helena Van Aswegen Department of Physiotherapy Faculty of Health Sciences University of Witwatersrand 7 York Road, Parktown Johannesburg 2193 Email: Helena.vanaswegen@wits.ac.za AbstrACt: To investigate the health-related quality of life (hrQol) of survivors of major trauma at six months following discharge, using two popular hrQol tools. A cross-sectional study was done on adult trauma survivors in Johannesburg. Subjects completed the eQ-5D and Sf-36 hrQol questionnaires. Additional demo graphic and clinical data were collected. The majority of subjects reported some problems in usual activities and pain/ discomfort as measured with the eQ-5D at six months. The mean eQ-5D vAS was 68 (±26.1). lowest scores were reported in the role physical (44.6 ±41.6) and role emotional (44.1 ±45.4) domains of the Sf-36. mean Sf-36 physical component summary (PCS) score (62.1 ±27.8) was higher than mental component summary score (58.7 ±20.1). eQ-5D vAS was found to be moderately correlated with age (r=-0.4; p=0.05). A negative correlation was found between Sf-36 physical function score and iCu length of stay (loS), hospital LOS and age (r=-0.4 (p=0.03), -0.4 (p=0.03) and -0.6 (p=0.00) respectively). Statistical significance was observed in the correlation between age and Sf-36 general health domain (r=-0.4; p=0.02) as well as age and PCS score (r=-0.5; p=0.01). Trauma survivors in Johannesburg experience limitations in specific emotional and physical domains of HRQOL at six months after discharge. Age was associated with the level of self-rated health as well as limitations in general health and physical function. iCu and hospital loS were associated with limitations in physical function. There is a need for physical and psychological rehabilitation after discharge from trauma intensive care.

treated in the intensive care unit (ICU) with mechanical ventilation (MV) suffer from muscle weakness and dysfunction due to the effects of critical illness and immobility on the human body (Topp et al, 2002).
Much research has been conducted on the healthrelated quality of life (HRQOL) of survivors of critical ill ness after ICU discharge in other parts of the world (Hofhuis et al 2009;Ulvik et al 2008;Cuthbertson et al 2005;Granja et al 2002).Many of these reports highlighted limitations in HRQOL related to physical function ing and emotional health in survivors of critical illness.There is, however, little known about the HRQOL of critical care survivors following ICU discharge in the South African population (Karachi, Hanekom and Faure 2011;Van Aswegen et al 2010).Van Aswegen et al (2010), reported poor HRQOL outcomes in 40 iNtRODUctiON Road traffic fatality rates in South Africa are almost double the global average and pedestrians are involved in more than half of these fatalities.In contrast to worldwide statistics, road traffic injuries rank second to interpersonal violence in South Africa (Norman et al, 2007).It is important to consider the nonfatal aspect of these statistics as for each death there are several survivors with perma nent sequelae as a result of the injuries sustained.Patients with trauma who are survivors of penetrating trunk trauma in Johannesburg at six months follow ing discharge particularly in relation to physical functioning.Karachi et al (2011), reported poor HRQOL out comes in 46 surgical ICU survivors in Western Cape at 12 months following discharge also in relation to physical functioning.Due to obvious differences between African and European demographics, there is a need to further investigate the HRQOL of survivors of major trauma in South Africa specifically in order to come to relevant conclusions about the quality of life of these survivors and as to whether results from South African studies are comparable to that of the international trauma population.Although many HRQOL tools have been used worldwide, the EuroQoL (EQ)5D and Medical Outcomes Short Form36 (SF36) proved to be popular instru ments in the assessment of HRQOL in ICU populations (Orwelius et al 2010).In order to allow for comparisons to be made between HRQOL of South African survivors of critical illness and trauma and that reported on an international level, it becomes important to use uni versally accepted HRQOL tools.
In the South African population, the EQ5D has been used in measuring the HRQOL in nonICU populations (Jelsma et al 2004;Jelsma et al 2005;Louwagie et al 2007); no evidence of its use in the assessment of HRQOL of the South African ICU population could be found.The SF36 has been used to assess HRQOL in some nonICU popu lations in South Africa (Benitha and Tikly 2007;O'Keefe and Wood 1996).Only two groups have used the SF36 to assess HRQOL in critical care sur vivors in South Africa (Karachi, et al 2011;Van Aswegen et al 2011).
International reports confirm that survivors of critical illness experience delayed recovery of physical function at six months and even five years after discharge and emphasise the impor tance of rehabilitation interventions for such survivors to improve their HRQOL (Hough and Herridge 2012;Orwelius et al 2010;Ulvik et al 2008).Rehabilitation programmes exist in South Africa for people with chronic cardiac and/or pulmonary diseases, which have been shown to be effective in improving their ability to participate in cardiovascular exercises (improving ability to cope with work and activities of daily living [ADL]) and play a role in improving HRQOL.No rehabilitation programmes for survivors of critical illness in South Africa have been reported in the lite rature.Without knowledge of possible limitations in the HRQOL of survivors of major trauma, it is not known whether they too would benefit from a rehabili tation programme after discharge from the hospital.The aim of this study was to investigate the HRQOL of survivors of major trauma in Johannesburg six months after discharge using the EQ5D and SF36 (UK Version 1) HRQOL ques tionnaires.As the EQ5D question naire had not been utilised in the South African ICU population as yet, the suitability of the questionnaire for this population required investigation.also explained the aims of the study to the subject and excluded those not eli gible.Male and female subjects, aged 18 years and older who suffered major trauma, received intubation and MV at one of the two trauma centres and were discharged six months ago, were eligible for inclusion.Subjects were excluded if they had an ICU length of stay (LOS) <24 hours, MV <24 hours, severe communication problems, dimi nished mental capacity, suffered lesions affecting the central nervous system, terminal malignancy, lived outside of Johannesburg and surrounding areas or were imprisoned after discharge.Recruitment of subjects began in May 2009 and extended to October 2010.
Once permission was obtained from the subject, the researcher contacted him/ her telephonically.The study aims and procedure was explained to the subject in more detail to make sure that he/she understood what was expected of them.An appointment was arranged between the researcher and the subject, at the particular trauma centre that the subject frequented, at a time that suited both.The researcher attempted to arrange appointments with subjects on the day of their scheduled follow up appoint ment with the trauma surgeon in order to reduce transport costs.Those subjects who could not be seen by the researcher on the day of their appointment with the surgeon were given a separate appoint ment date.They were reimbursed for their additional travel expenses.On the day of the scheduled appointment with the researcher, written informed consent was obtained.The subject completed the English (UK) SF36 (version 1) and the English EQ5D questionnaires in a self administered fashion.The researcher was present to assist the subject with any questions that were unclear to him/ her but in no way attempted to influ ence the subject's responses.Generally one participant at a time was seen by the researcher.The same researcher obtained written consent and was pre sent while each participant completed the two HRQOL questionnaires.
Demographic information (age, gen der, admission diagnosis, Glasgow Coma Scale, vital signs, full blood count and arterial blood gas results, ICU and hos

MethODs
Permission was obtained from the University of the Witwatersrand Human Research Ethics Committee to conduct the study.Permission was obtained from the QualityMetric group to use the SF36 questionnaire (UK Version 1) and from the EuroQoL group to use the EQ5D questionnaire.The SF36 ques tionnaire comprises 36 questions con sisting of eight domains: physical func tioning (PF), social functioning (SF), role limitation due to physical problems (RP), role limitation due to emotional problems (RE), mental health (MH), vitality (VT), bodily pain (BP) and general health perceptions (GH).The domains are summarised in summary scores namely physical component sum mary (PCS) score and mental component summary (MCS) score (Hofhuis et al 2009).The EQ5D consists of two parts namely the EQvisual analogue scale (VAS) (20 centimetre vertical scale) used to assess overall selfrated health (range 0100) and a descriptive por tion whereby the participant depicts health problems according to five items: mobility, selfcare, usual activities, pain/ discomfort and anxiety/depression.The participant marks one of three levels of severity (1=no problems, 2=moderate problems and 3=severe problems) for each of the five items and can then be classified into any one of 243 possible health states.Each state is referred to in terms of a five digit code (Hofhuis et al 2009;Badia et al 2001).
Permission from the management of two trauma centres in Johannesburg was obtained to conduct the study and to gain access to the hospital database and sub ject files.A retrospective crosssectional study design was used for a cohort of adult subjects that survived trauma.In order to identify potential subjects for the study, the admission books and records of the respective ICUs were searched for those subjects who were discharged from ICU six months prior to the study.The subjects were contacted telephoni cally by the physiotherapist who was responsible for their care at the particu lar hospital and permission was sought from that person for the researcher to contact the subject regarding the study.The abovementioned physiotherapist pital LOS) was collected using the sub ject's hospital file and ICU charts.The Acute Physiology and Chronic Health Evaluation (APACHE) II score for each subject was calculated from this infor mation using a freely available online calculator as these scores were not readily documented on ICU charts or in medical files.The Injury Severity Score (ISS) was obtained from an administrator in the casualty department of the two trauma centres.statistical analysis SF36 questionnaires were scored with the SF Health Outcomes TM Scoring Software package (Release 1.0) to con vert raw scores into domain scores rang ing from 0 -100 (transformed scores).There were no missing data.Values for PCS and MCS scores (normbased scores) were obtained through merging of the domain scores.EQ5D scores were calculated using the standard SPSS syntax developed by the EuroQol group.Frequency, percentage and cross tabula tion were used to summarise categorical data pertaining to EQ5D items, gender and trauma type.Continuous variables such as age, LOS, injury severity, EQ5D VAS, SF36 domain and summary scores were summarised using means and standard deviations (SD).Trauma type and gender categories were compared with respect to continuous variables using Student's Ttest and oneway anal ysis of variance (ANOVA).In the latter, when necessary, pairwise comparisons between three trauma groups were done using the Bonferroni approach.Where homogeneity of variance between groups could not be assumed, the one way ANOVA for ranks was performed.EQ5D items, trauma type and gender categories were compared using Fisher's exact test.The EQ5D VAS, SF36 scores were assessed in relation to age, hospital and ICU LOS using Pearson's productmoment correlation coefficient.A pvalue of ≤0.05 was deemed statis tically significant.

ResUlts
A total of 200 patients were admit ted into the one trauma ICU in the six months prior to the study.Of these admissions, 31 deaths were recorded.The number of patients admitted into the second trauma ICU totalled 1115 and 65 deaths were recorded.The types of trauma seen at both centres varied between blunt and penetrating trauma and polytrauma.Not all admissions into the second trauma ICU presented with a diagnosis of trauma as this ICU also served as an overflow to the surgi cal and respiratory ICUs.Contact details were obtainable for 32 subjects at six months following ICU discharge.Of these, five subjects were excluded (not intubated and mechanically ventilated (n=3); ventilated <24 hours (n=1); para plegia (n=1)); hence 27 subjects (n=27) participated in the study.
Demographic characteristics are dis played in Table I.Missing data is owing to the lack of obtainable hospital records for some subjects.The vast majority of subjects were male (81.5%).More than half of the subjects were involved in polytrauma (51.8%) due to motor vehi cle or pedestrian vehicle accidents.The average LOS in ICU and in hospital for this group of subjects was longer than 20 days.
Subjects took approximately five mi nutes to complete the EQ5D ques tionnaire (range: 19 minutes).Extreme problems were reported in the pain/ discomfort (n=2) and anxiety/depression (n=2) items of the questionnaire for a small minority of subjects at six months following ICU discharge (Table II).The majority of subjects had some pro blems in usual activities (n=18) and pain/dis comfort (n=16) whilst a large number scores were reported in the GH domain (mean 65.7 (±27.7)).Lowest scoreswere reported in the RP (mean 44.6 (±41.6)) and RE (mean 44.1 (±45.4))domains indicating problems with work or other daily activities as a result of physical health and emotional problems respec tively.Mean PCS score was 62.1 (±27.8) and mean MCS score was 58.7 (±20.1).Mean PCS was higher than mean MCS score.
A comparison of the EQ5D items with the type of trauma and subject gender was done (Table III).More sub jects with blunt or polytrauma reported having some problems in the mobility item compared to those with penetrating trauma who reported having no pro blems with mobility.The majority of subjects with blunt and polytrauma reported some problems in the usual activities item as well as in the pain/discomfort item.An equal number of subjects with penetrating trauma reported no pro blems and some problems with usual activi ties.A small number of the penetrating (20%) and polytrauma (9.1%) subjects described extreme problems in pain/ discomfort.A small number of subjects in the blunt trauma (16.7%) and poly trauma (9.1%) groups reported extreme problems with anxiety/depression.Males with blunt trauma had the lowest mean EQVAS score at six months compared to those with polytrauma who had the highest score.The EQVAS was found to be moderately correlated with age (r=0.4;p=0.05); thus with an increase in age, a decrease in VAS was evident.
Table IV illustrates comparisons between EQ5D items and various out come measures assessed.Regarding mobility, mean ICU LOS was 14.5 days (±9.6) and 30.9 days (±18.7)respec tively for those reporting no problems and those reporting some problems on the EQ5D questionnaire; therefore a longer ICU LOS resulted in more prob lems with mobility (p=0.01).Those subjects who reported some problem in the mobility item of the EQ5D were found to have had a prolonged period of hospital stay compared to those subjects who reported no problem with mobility (p=0.04).Subjects who reported having some problems in the selfcare item of the EQ5D had a longer hospital LOS compared with those who reported no problems (p=0.04).
The SF36 PF score had a moder ately negative association with ICU and hospital LOS and a strongly negative association with age (correlation coef ficient (r) = 0.4 (p=0.03),0.4 (p=0.03) and 0.6 (p=0.00)respectively); there fore, an increase in ICU and hospital LOS and an increase in age resulted in a decrease in the PF score.Statistical significance was observed in the mode rately negative association between age and GH (r=0.4 (p=0.02)) and age and PCS (r=0.5 (p=0.01));hence, an increase in age was associated with a decrease in GH and PCS.Subjects reported that the EQ5D was more userfriendly and easier to understand than the SF36.They found the English language used in the SF36 questionnaire difficult to comprehend and required more assistance from the researcher in completing this question naire compared to the EQ5D ques tionnaire; however the SF36 provided a more detailed account of HRQOL.Due to the nature of data obtained from the SF36 (continuous) and EQ5D (cate gorical) questionnaires, a statistical comparison of results between the ques tionnaires could not be performed.

DiscUssiON
This study is one of a few that has investigated the HRQOL of survivors of major trauma in Johannesburg and South Africa.An important finding was that subjects presented with a reduc tion in specific emotional and physical domains of HRQOL at six months fol lowing ICU discharge.
Demographics related to gender and injury type in the current study are simi lar to that reported by other authors (Van Aswegen et al 2011;Ulvik et al 2008;Norman et al 2007).Subjects in this study had a prolonged ICU and hospi tal LOS which put them at risk for the development of physical debilitation.Bailey et al. (2007) Van Aswegen et al (2011) who reported on survivors of penetrating trunk trauma only.
Subjects were found to experience problems in all five items of the EQ5D at six months with some reporting extreme problems in the pain/discomfort and anxiety/depression items.The HRQOL reported in this study was reduced when compared to the subjects in the study by Granja et al. (2002) where HRQOL was measured using the EQ5D six months after ICU discharge; however, Granja et al. (2002) studied a mixed ICU popu lation where only four percent of the sample had a diagnosis of trauma.Since those that experience trauma are gene rally younger (<40 years) and in good health prior to the incident, it might be reasonable to assume that their expecta tions of HRQOL after the traumatic inci dent will be reported as poor.This could explain why the results from the current study showed reduced HRQOL as mea sured with the EQ5D.The EQVAS of the trauma population reported on by Granja et al. (2002) was 70 and in con gruence with that reported in this study.
Reported HRQOL as measured with the SF36 questionnaire showed that subjects in this study had not achieved optimal HRQOL in any of the domains nor with regard to the summary scores at six months.Lowest scores were found in the RP and RE domains.Subjects perceived having less physical limita tion to HRQOL than limitations due to emotional factors in their daily lives at six months after ICU discharge.During informal discussions with the parti cipants, it was found that less than half had returned to work.Arguably, the implication of this fact is that subjects struggled with a reduced sense of self worth and lack of integration into their community.This fact could translate into the low reported MCS scores; however, a limitation of this study is that return to work was not assessed objectively.
With the exception of GH and VT, all SF36 domain scores in the current study were decreased when compared with the domain scores reported by Orwelius et al. (2010).Their study sample was a mixed ICU population where 12% had a diagnosis of trauma.The current study did not investigate changes in HRQOL over time as did Orwelius et al. (2010).Orwelius et al. (2010) reported no con siderable change in HRQOL over time (636 months after ICU discharge), and thus the measurement of HRQOL at six months (current study) provided a fair depiction of the subject's current state of HRQOL.Van Aswegen et al. ( 2011) measured HRQOL at one, three and six months after hospital discharge in survivors of penetrating trunk trauma.They reported low PCS scores at six months for subjects who had prolonged MV whereas MCS scores were compa rable with that of a healthy group at six months.In the current study subjects reported higher mean PCS and MCS scores and also a higher PCS score than MCS score which is in contrast to that reported by Van Aswegen et al. (2011).These subjects however, suffered dif ferent types of trauma while the study by Van Aswegen et al. (2011) included only those with penetrating trunk trauma.The difference in type of trauma and the experience of such could bring about a difference in perception of HRQOL.
An association was found between age and EQVAS which is similar to the findings reported by Granja et al. (2002) who found age to be significant in the association with mobility, selfcare, usual activities and pain/discomfort.Significance was reached in the asso ciation between ICU and hospital LOS and the mobility item of the EQ5D in the current study and as well as between hospital LOS and the self care item; thus with an increase in time spent in ICU and in hospital, more limitation was found to be present in these items at six months following discharge.A mode rate association was observed between ICU and hospital LOS and PF domain of the SF36.Similarly, an increase in time spent in ICU and in hospital resulted in a decrease in the PF domain score.(Orwelius et al. (2010) described ICU LOS to have no association with HRQOL but hospital LOS was found to have a significant relationship with such.
It was reported that survivors of pene trating trunk trauma who were treated in ICU with MV, suffered from muscle weakness/dysfunction and limitations in exercise capacity up to six months fol lowing discharge due to the effects of critical illness and prolonged bed rest on the human body (Van Aswegen et al 2010).Exercise therapy has been shown to have beneficial effects on physical and psychological wellbeing and could potentially be a beneficial intervention strategy to improve HRQOL for sur vivors of major trauma after hospital discharge.Stathopoulou et al. (2006) conducted a metaanalysis investigat ing the effect of exercise intervention on mental health.It was hypothesized that the mechanism of action of the benefi cial effects of exercise can be attributed to both psychological and physiological factors.Physiological factors included changes in metabolism and availability of central neurotransmitters.Psychological effects of exercise included changes in coping strategies and the interruption of negative thoughts.(Jones et al. (2003) investigated the effectiveness of a reha bilitation programme on the recovery of survivors of critical illness after dis charge.They found that the SF36 PF score for subjects in the rehabilitation group was closer to normal and signifi cantly different from those in the control group.In light of the above it might be reasonable to suggest that exercise the rapy, commenced after discharge from the hospital, might have a beneficial effect on the physical and psychological recovery of survivors of major trauma.
Some limitations to the current study include the fact that hospital records for a portion of subjects could not be attained.This was problematic as data for the whole sample could not be retrieved for APACHE II and ISS and may have influenced the significance of the asso ciations of severity of illness with HRQOL.Subjects also found the English language used in the SF36 question naire (Version 1) difficult to comprehend at times.Furthermore, as the question naire spoke of 'miles' and 'yards', some found it difficult to place the questions in context.It is recommended that HRQOL for trauma victims be assessed on ICU admission through proxies; even though there are known limitations to the use of proxies in HRQOL assess ment, it may be possible to ascertain by how much HRQOL had deteriorated due to the traumatic insult as well as ICU and hospital LOS.
This study provides valuable baseline information on the HRQOL of survivors of various types of major trauma at six months after discharge and provides a platform for future research in this field in South Africa.cONclUsiON Survivors of major trauma experience limitations in emotional and physical HRQOL domains at six months after discharge.Age was associated with the level of selfrated health as well as limi tations in general health and physical function.ICU and hospital LOS were associated with limitations in physical functioning.The results of this study support the recommendation that reha bilitation, in the form of physical and psychological interventions, be offered for survivors of trauma after hospital discharge to adequately address the identified limitations in HRQOL.