Prescribed versus actual length of stay and inpatient neurorehabilitation outcome for brain dysfunctional patients

Effect of rehabilitation length of stay on outcomes in individuals with traumatic brain injury or spinal cord injury: a systematic review protocol

BACKGROUND

Rehabilitation interventions are a key component of the services required by individuals with neurotrauma to recover or compensate for altered abilities and achieve optimal social participation. Primary studies have produced evidence of the effect of rehabilitation length of stay on individuals with neurotrauma. However, to date no systematic review of this evidence has been performed. This makes it difficult for managers and clinicians to base their rehabilitation practices upon evidence.

METHOD

Supported by a committee of stakeholders, we will search electronic databases for research articles examining the association between length of stay or intensity of inpatient rehabilitation services and outcomes or the determinants of inpatient rehabilitation length of stay in adults with neurotrauma published after January 1990. Two researchers will independently screen the article titles and abstracts for inclusion. Two reviewers will independently extract the data. Primary outcomes of interest will be level of function, participation and return to work. If the data allow it, a meta-analysis of the studies will be performed.

DISCUSSION

The results of this systematic review will clarify the factors that influence length of stay and intensity of rehabilitation services for individuals with TBI and SCI. They will give clinicians indications for optimal length of stay in these patient populations, contributing to better quality of care and better functional results.

TRIAL REGISTRATION

This review protocol has been registered on the PROSPERO database (CRD42012003120) and is available at http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42012003120.

Rehabilitation outcome after traumatic brain injury

Rehabilitation goals after traumatic brain injury are improving function, increasing the level of independence as high as possible, preventing complications and providing an acceptable environment to the patient. Several complications can be encountered during the rehabilitation period which lead to physical, cognitive and neurobehavioral impairments that cause major delay in functional improvement. This prospective study was designed in order to investigate the complications and their relations with functional recovery in patients that were included in the acute phase of a rehabilitation program. Thirty traumatic brain injured patients admitted to the Intensive Care Units of Uludag University School of Medicine were included in the study. Rehabilitation program consisted in appropriate positioning, range of motion exercises, postural drainage and respiratory exercises. Complications that were encountered during intensive care rehabilitation program were recorded. All patients were evaluated by Functional Independence Measure, Disability Rating Scale and Ranchos Los Amigos Levels of Cognitive Function Scale at admission and discharge. Improvement was observed in patients in terms of functional outcome and disability levels. Pneumonia, athelectasis, anemia and meningitis were the most frequent complications. Deterioration in functional outcome and disability levels was noted as the number of these complications increased. In conclusion, rehabilitation has an important role in the management of traumatic brain injured patients. Reduction of frequency of complications and improvement in functional outcome and disability levels can be achieved through rehabilitation programs. Long-term controlled studies with large number of patients are needed in order to obtain accurate data on factors associated with rehabilitation outcomes.

The effect of poststroke cognitive impairment on rehabilitation process and functional outcome

OBJECTIVES

To determine whether cognitive impairment affects access to, or quality of, rehabilitation services, and to examine the effects of functional outcomes in stroke patients.

DESIGN

Secondary analysis of prospective cohort of stroke patients followed for 6 months after stroke.

SETTINGS

Eleven large-volume US Department of Veterans Affairs hospitals nationwide.

PARTICIPANTS

Stroke patients (N=272) who were candidates for rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Rehabilitation process variables were examined for patients assessed as cognitively impaired or unimpaired according to education-adjusted Mini-Mental State Examination score. Functional outcomes were performance of activities of daily living (ADLs), measured by the FonFIM, and instrumental activities of daily living (IADLs), measured by Lawton, at 6-month follow-up.

RESULTS

Compliance with guidelines and receipt of and interval to postacute treatment initiation did not differ between cognitively impaired and unimpaired patients. Although most cognition-related treatment elements were similar for both groups, cognitive goals were more frequently charted in impaired patients. Controlling for baseline function and rehabilitation process, cognitively impaired patients had worse IADL performance at 6 months than did unimpaired patients; cognition did not significantly influence ADL performance.

CONCLUSIONS

Quality of, and access to, rehabilitative care was equivalent for patients with and without cognitive impairment. Despite a similar rehabilitation process, cognitively impaired stroke patients experienced worse recovery of IADLs.

The 'preliminary neuropsychological battery'. An instrument to grade the cognitive level of minimally responsive patients

An early, formalized cognitive evaluation of'minimally responsive' patients could be important in the planning of their care and rehabilitation as well as in providing a realistic prognosis and studying the modality of the cognitive recovery. A short, bedside, neuropsychologically-oriented test-battery, the Preliminary Neuropsychological Battery, a psychometric tool which enables the cognitive evaluation of these patients and of patients unable to give verbal or complex motor answers, has been devised. The BNP was administered to a sample of 40 head-injured patients and to a sample of 34 healthy subjects. The aim was (i) to evaluate its usefulness, and (ii) to study its correlation with cortical functions as assessed by a more extensive battery. The findings suggest that the BNP is useful for assessing the general cognitive level of head-injured post-comatose patients. It was able to detect patients deserving a wider, analytic, neuropsychological assessment. Attentional defects emerged as an important variable determining the BNP score.

Cognitive and affective improvement in brain dysfunctional patients who achieve inpatient rehabilitation goals

OBJECTIVE

To evaluate whether improvements in specific cognitive and affective functions are associated with achieving inpatient rehabilitation goals after the acute onset of brain dysfunction.

DESIGN

Retrospective analysis of data obtained in a prospective inception cohort study.

STUDY SETTING

Medical center and neurological institute.

SUBJECTS

Ninety-five heterogeneous brain dysfunctional patients who participated in an interdisciplinary inpatient neurorehabilitation program. Subjects were classified as having achieved their rehabilitation goals (Group 1) or not (Group 2) at time of discharge.

MAIN OUTCOME MEASURE

Number of treatment goals attained.

RESULTS

Although overall level of performance on the BNI Screen (BNIS) for Higher Cerebral Functions distinguished patients who later achieved their inpatient rehabilitation goals, on admission only performance on the visual spatial subtest was associated with later goal attainment. In contrast, at discharge, patients who showed greater improvement in awareness, affect, visual spatial skills, memory, and attention/concentration were likely to obtain their rehabilitation goals. This was true when the initial level of performance was taken into account.

CONCLUSIONS

Measurement of overall neuropsychological status and specific visual spatial abilities at time of admission may help determine which brain dysfunctional patients will obtain inpatient rehabilitation goals. Improvement in a variety of cognitive and affective functions was associated with goal attainment. Early cognitive rehabilitation should focus on both cognitive and affective disturbances to facilitate recovery and rehabilitation outcome.

Speed of finger tapping and goal attainment after unilateral cerebral vascular accident

OBJECTIVE

To determine (1) if speed of finger tapping is bilaterally slow after an acute unilateral cerebral vascular accident (CVA) and (2) if speed of finger tapping and grip strength are related to achieving rehabilitation goals during the first few weeks after stroke.

DESIGN

Prospective inception cohort study.

STUDY SETTING

Medical center and neurological institute.

PARTICIPANTS

Fifty-one patients with unilateral CVAs.

MAIN OUTCOME MEASURES

Documentation of goal attainment at discharge and bilateral measures of speed of finger tapping and grip strength.

RESULTS

Speed of finger tapping and grip strength were often bilaterally below normal limits after an acute unilateral CVA, with the contralateral hand most affected. Speed of finger tapping, but not grip strength, in the ipsilateral hand was associated with achieving rehabilitation goals. Speed of finger tapping in the contralateral hand as well as bilateral grip strength was not related to achievement of rehabilitation goals.

CONCLUSIONS

Motor findings suggest that bilateral cerebral dysfunction may be common after an acute unilateral CVA. The speed of finger movement in the hand ipsilateral to the lesion may reflect the degree to which the so-called "unaffected" cerebral hemisphere has in fact maintained its functional integrity. As such, it may be a useful behavioral marker for predicting goal attainment during early stages of neurorehabilitation.