The Early Rehabilitation Barthel Index (ERBI)

The Impact of Concurrent Chronic Heart Failure and Chronic Kidney Dysfunction on Post-Stroke Rehabilitation Outcomes

Background/Objectives: The aim of this study was to evaluate the impact of chronic heart failure (CHF), chronic kidney dysfunction (CKD), and the combined CHF-CKD comorbidity on the outcomes of rehabilitation in stroke patients. Methods: A total of 586 patients who had suffered a stroke (mean age, 70 ± 13; 47.6% female; 72.4% ischemic and 27.6% hemorrhagic strokes) and who were admitted immediately after acute stroke care to a rehabilitation center were included in this cohort study and followed up with until their death or discharge from the rehabilitation center. The clinical characteristics of the patients were obtained from their medical records. The relationship between the background comorbidities (CHF, CKD, and concurrent CHF-CKD) and fatal and non-fatal unfavorable outcomes (emergency readmission to a primary hospital or transfer to a long-term care facility in a vegetative or minimally conscious state) were investigated. Results: Unfavorable outcomes were more common in the groups with background CHF and/or CKD. From the Cox multivariate analysis, both CHF and CKD were independent prognostic factors for the occurrence of unfavorable outcomes, with a hazard ratio (HR) of 2.28 (95% CI = 1.2-4.29; p-value = 0.01) and 2.19 (95% CI = 1.24-3.87; p-value = 0.007), respectively. Moreover, the combined CHF-CKD comorbidity showed a more than 5-fold increased risk of an adverse post-stroke outcome (HR of 5.8; 95% CI = 2.5-13.44; p-value < 0.001). Conclusions: The combined CHF-CKD comorbidity is an important independent complicating factor that, along with other known influencing factors, can affect unfavorable post-stroke outcomes more than CHF or CKD alone, and necessitates critical attention to its diagnosis and management as a separate mixed syndrome.

Comprehensive assessment and progression of health status during neurorehabilitation in survivors of critical illness: a prospective cohort study

BACKGROUND

Critical illness survivors frequently suffer from long-term impairments, often described as post-intensive care syndrome (PICS). PICS encompasses physical, cognitive, and mental impairments. Additionally, the term intensive care unit (ICU)-acquired weakness (ICUAW) was coined for muscle weakness after critical illness. Research on the progression and outcome of individuals affected by PICS and ICUAW is scant. Thus we aimed to assess the health status and its progression during neurorehabilitation in critically ill patients using comprehensive outcome measures, describe the prevalence of PICS, and evaluate factors associated with rehabilitation outcomes.

METHODS

Patients with mixed reasons for critical illness who received ≥ 5 days of mechanical ventilation on the ICU and who were admitted to neurorehabilitation, were eligible to be included in this prospective cohort study. A number of outcomes (patient-reported, clinician-reported, and performance) were assessed after discharge from the ICU (V1) and shortly before discharge from inpatient neurorehabilitation (V2). The prevalence of PICS, defined as having at least one impairment in any PICS dimension), was calculated at V1 and V2. Multiple logistic regressions were conducted to identify factors associated with rehabilitation outcome (poor outcome = modified Rankin Scale > 2) and ICUAW at V2 (MRC sum score < 48).

RESULTS

In total, 250 critical illness survivors (62 ± 14 years, 34% female, median stay on ICU 55 days, median inpatient rehabilitation 65 days) were included. 11 participants (4.4%) died before V2. All outcomes improved significantly during rehabilitation except sensory impairment and pain. PICS was present in 96% at V1 and in 85% at V2, whereby mainly the physical domain (V1: 87%, V2: 66%; ICUAW with MRC sum score < 48) and the cognitive domain (V1:65%, V2:55%; Montreal Cognitive Assessment < 26) were affected. Mental impairment was lower (V1:48%, V2:29%; Hospital Anxiety and Depression Scale > 7), but still affected a considerable number of participants. Accordingly, health-related quality of life was rather low at discharge (0.64 ± 0.28, index value of EQ-5D-5L). MRC sum score at V1, duration of mechanical ventilation, and female gender were significantly associated with a poor rehabilitation outcome. Grip strength in % of reference at V1, age, female gender, and comorbidities were significantly associated with persistent ICUAW at discharge.

CONCLUSIONS

Despite significant improvements during rehabilitation, survivors after critical illness experience a substantial burden of PICS and ICUAW at discharge from rehabilitation care. Survivors of critical illness require long-term follow-up, supportive structures, and tailored long-term multi-disciplinary therapies even after intensive rehabilitation.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00021753. Registered 03 September, 2020. https://drks.de/search/en/trial/DRKS00021753 .

Link between post-stroke psychopathology and scope-of-action awareness

Background

Epidemiological research has failed to confirm laterality of lesion site as a neurobiological source of post-stroke psychopathology. However, acquired communication disorders have proved to be a key risk factor for depression, apart from established parameters such as pre-stroke psychopathology and physical immobility.

Objectives

The present work examines a new predictor of post-stroke psychopathology: psychological flexibility. This concept describes an accepting attitude toward irreversible loss following stroke while using remaining agency.

Design

Overall, 70 individuals engaged in a cross-sectional study conducted in the subacute stage after an ischemic or hemorrhagic event, a period with elevated prevalence of mental-health problems (2 weeks to 6 months after stroke).

Methods

Outcomes included standardized self-report and clinician-rated measures of depression, anxiety disorders, and general psychopathology (Beck Depression Inventory; Hospital Anxiety and Depression Scale; ICD-10 Symptom Rating; Hamilton Depression Rating Scale) alongside lack of psychological flexibility (Acceptance and Action Questionnaire II). The study design controlled for pre-stroke psychopathology and physical immobility (Barthel Index).

Results

Partial correlation analyses revealed a significant medium-to-large association between the entire set of clinical outcomes and lack of psychological flexibility (r ⩽ 0.62, p < 0.001). In moderator analyses, the magnitude of this association did not vary significantly with diagnosis of acquired communication disorders (i.e., aphasia, apraxia of speech or dysarthria; separately or combined).

Conclusion

The current results demonstrate a substantial link between post-stroke psychopathology and psychological flexibility. This finding opens new avenues for research on depression and other mental-health problems in stroke survivors with and without acquired communication disorders.

Registration

www.drks.de; identifier: DRKS00031204.

Early Boost of Linguistic Skills? Individualized Non-Invasive Brain Stimulation in Early Postacute Aphasia

Non-invasive brain stimulation, such as transcranial direct current stimulation (tDCS), has been shown to increase the outcome of speech and language therapy (SLT) in chronic aphasia. Only a few studies have investigated the effect of add-on tDCS on SLT in the early stage of aphasia; this may be due to methodological reasons, in particular the influence of spontaneous remission and the difficulty of establishing stimulation protocols in clinical routines. Thirty-seven participants with subacute aphasia (PwA) after stroke (23 men, 14 women; mean age 62 ± 12 years; mean duration 49 ± 28 days) were included in two consecutive periods of treatment lasting two weeks each. During the first period (P1) the participants received 10 sessions of SLT, during the second period (P2) the aphasia therapy was supplemented by anodal left hemispheric 2 mA tDCS over the left hemisphere. Severity-specific language tests (Aachen Aphasia Test (AAT), n = 27 and Bielefeld Aphasia Screening-Reha (BIAS-R), n = 10) were administered before P1, between P1 and P2, and after P2. Where information was available, the results were corrected for spontaneous remission (AAT sample), and the therapy outcomes of P1 and P2 were compared. Participants' overall language abilities improved significantly during P1 and P2. However, improvement-as measured by the AAT profile level or the BIAS-R mean percentage value-during P2 (with tDCS) was significantly higher than during P1 (p < 0.001; AAT sample and p = 0.005; BIAS-R sample). Thus, tDCS protocols can be implemented in early aphasia rehabilitation. Despite the limitations of the research design, which are also discussed from an implementation science perspective, this is preliminary evidence that an individually tailored anodal tDCS can have a significant add-on effect on the outcome of behavioral aphasia therapy in subacute aphasia.

Evolution of Severe Closed Head Injury: Assessing Ventricular Volume and Behavioral Measures at 30 and 90 Days Post-Injury

Background: Assessing functional outcomes in Severe Closed Head Injury (SCHI) is complex due to brain parenchymal changes. This study examines the Ventricles to Intracranial Volume Ratio (VBR) as a metric for these changes and its correlation with behavioral scales. Methods: Thirty-one SCHI patients were included. VBR was derived from CT scans at 3, 30, and 90 days post-injury and compared with Levels of Cognitive Functioning (LCF), Disability Rating Scale (DRS), and Early Rehabilitation Barthel Index (ERBI) assessments at 30 and 90 days. Results: Ten patients were excluded post-decompressive craniectomy or ventriculoperitoneal shunt. Findings indicated a VBR decrease at 3 days, suggesting acute phase compression, followed by an increase from 30 to 90 days, indicative of post-acute brain atrophy. VBR correlated positively with the Marshall score in the initial 72 h, positioning it as an early indicator of subsequent brain atrophy. Nevertheless, in contrast to the Marshall score, VBR had stronger associations with DRS and ERBI at 90 days. Conclusions: VBR, alongside behavioral assessments, presents a robust framework for evaluating SCHI progression. It supports early functional outcome correlations informing therapeutic approaches. VBR's reliability underscores its utility in neurorehabilitation for ongoing SCHI assessment and aiding clinical decisions.

Effectiveness of Proprioceptive Body Vibration Rehabilitation on Motor Function and Activities of Daily Living in Stroke Patients with Impaired Sensory Function

Stroke patients experience impaired sensory and motor functions, which impact their activities of daily living (ADL). The current study was designed to determine the best neurorehabilitation method to improve clinical outcomes, including the trunk-impairment scale (TIS), Berg balance scale (BBS), Fugl-Meyer assessment (FMA), and modified Barthel index (MBI), in stroke patients with impaired sensory function. Forty-four stroke survivors consistently underwent proprioceptive body vibration rehabilitation training (PBVT) or conventional physical therapy (CPT) for 30 min/session, 5 days a week for 8 weeks. Four clinical outcome variables-the FMA, TIS, BBS, and MBI-were examined pre- and post-intervention. We observed significant differences in the FMA, BBS, and MBI scores between the PBVT and CPT groups. PBVT and CPT showed significant improvements in FMA, BBS, TIS, and MBI scores. However, PVBT elicited more favorable results than CPT in patients with stroke and impaired sensory function. Collectively, this study provides the first clinical evidence of optimal neurorehabilitation in stroke patients with impaired sensory function.

Neuroanatomy of post-stroke depression: the association between symptom clusters and lesion location

Post-stroke depression affects about 30% of stroke patients and often hampers functional recovery. The diagnosis of depression encompasses heterogeneous symptoms at emotional, motivational, cognitive, behavioural or somatic levels. Evidence indicates that depression is caused by disruption of bio-aminergic fibre tracts between prefrontal and limbic or striatal brain regions comprising different functional networks. Voxel-based lesion-symptom mapping studies reported discrepant findings regarding the association between infarct locations and depression. Inconsistencies may be due to the usage of sum scores, thereby mixing different symptoms of depression. In this cross-sectional study, we used multivariate support vector regression for lesion-symptom mapping to identify regions significantly involved in distinct depressive symptom domains and global depression. MRI lesion data were included from 200 patients with acute first-ever ischaemic stroke (mean 0.9 ± 1.5 days of post-stroke). The Montgomery-Åsberg Depression Rating interview assessed depression severity in five symptom domains encompassing motivational, emotional and cognitive symptoms deficits, anxiety and somatic symptoms and was examined 8.4 days of post-stroke (±4.3). We found that global depression severity, irrespective of individual symptom domains, was primarily linked to right hemispheric lesions in the dorsolateral prefrontal cortex and inferior frontal gyrus. In contrast, when considering distinct symptom domains individually, the analyses yielded much more sensitive results in regions where the correlations with the global depression score yielded no effects. Accordingly, motivational deficits were associated with lesions in orbitofrontal cortex, dorsolateral prefrontal cortex, pre- and post-central gyri and basal ganglia, including putamen and pallidum. Lesions affecting the dorsal thalamus, anterior insula and somatosensory cortex were significantly associated with emotional symptoms such as sadness. Damage to the dorsolateral prefrontal cortex was associated with concentration deficits, cognitive symptoms of guilt and self-reproach. Furthermore, somatic symptoms, including loss of appetite and sleep disturbances, were linked to the insula, parietal operculum and amygdala lesions. Likewise, anxiety was associated with lesions impacting the central operculum, insula and inferior frontal gyrus. Interestingly, symptoms of anxiety were exclusively left hemispheric, whereas the lesion-symptom associations of the other domains were lateralized to the right hemisphere. In conclusion, this large-scale study shows that in acute stroke patients, differential post-stroke depression symptom domains are associated with specific structural correlates. Our findings extend existing concepts on the neural underpinnings of depressive symptoms, indicating that differential lesion patterns lead to distinct depressive symptoms in the first weeks of post-stroke. These findings may facilitate the development of personalized treatments to improve post-stroke rehabilitation.

The structure of the Early Rehabilitation Barthel Index (ERBI) should be modified: evidence from a Rasch analysis study

BACKGROUND

The Early Rehabilitation Barthel Index (ERBI) comprises seven items of the Early Rehabilitation Index and ten items of the Barthel Index. The ERBI is usually used to measure functional changes in patients with severe acquired brain injury (sABI), but its measurement properties have yet to be extensively assessed.

AIM

To study the unidimensionality and internal construct validity (ICV) of the ERBI through Confirmatory Factor Analysis (CFA), Mokken Analysis (MA), and Rasch Analysis (RA).

DESIGN

Multicenter prospective study.

SETTING

Inpatients from five intensive rehabilitation centers.

POPULATION

Two hundred and forty-seven subjects with sABI.

METHODS

ERBI was administered on admission and discharge to study its unidimensionality through CFA and MA and its ICV, reliability, and targeting through RA.

RESULTS

The preliminary analyses showed a lack of unidimensionality (RMSEA=0.460 >0.06; SRMR=0.176 >0.06; CFI=1.000 >0.950; TLI=1.000 >0.950). According to CFA, "Confusional state" and "Behavioral disturbance" items showed low factor loadings (<0.40), whereas these two items composed a separate scale within the MA. Furthermore, the baseline RA showed that three items misfitted ("Mechanical ventilation," "Confusional state," "Behavioral disturbances") and a lack of conformity of several ICV requirements. After deletion of three misfitting items and further non-structural modifications (i.e., testlets creation to absorb local dependence between items and item misfit), the solution obtained showed adequate ICV, adequate reliability for measurements at the individual level (PSI>0.85), although with a frank floor effect. This final solution was successfully replicated in a total sample of the subjects. After post-hoc modifications of the score structure of two out of three misfitting items, the subsequent CFA (RMSEA=0.044 <0.06; SRMR=0.056 <0.06; CFI=1.000 >0.950 TLI=1.000 >0.950) and MA showed the resolution of the unidimensional issues.

CONCLUSIONS

Although the ERBI is a potentially valuable tool for measuring functioning in the coma-to-community continuum, our analyses suggested its lack of ICV, partly due to an incorrect scoring design of some items. A new perspective multicenter study is proposed to validate a modified version of the ERBI that overcomes the problems highlighted in this analysis.

CLINICAL REHABILITATION IMPACT

Our results do not support the use of the original structure of the ERBI in clinical practice and research, as a lack of ICV was highlighted.

Plasma bioactive adrenomedullin predicts outcome after acute stroke in early rehabilitation

An early and reliable prediction of outcomes after stroke is important for early effective stroke management and the adequate optimal planning of post-stroke rehabilitation and long-term care. Bioactive adrenomedullin (bio-ADM) is a 52-amino acid peptide that is an important peptide hormone in nervous system diseases. The aim of this study was to investigate the prognostic value of bio-ADM on outcomes after rehabilitation in patients with stroke. A total of 557 consecutive patients with a primary diagnosis of ischemic or hemorrhagic stroke (age 69.6-12.9 years, male 51.3%, ischemic stroke 72.5%), who were admitted to an in-patient early rehabilitation center directly after discharge from acute stroke hospital care, were enrolled in this prospective observational study. Plasma concentrations of bio-ADM were determined by using a chemiluminescence immunoassay (functional assay sensitivity 8 pg/ml). The early rehabilitation barthel index (ERBI) was used for the neurological assessment of the patients. The plasma bio-ADM level was analyzed in association with 6-month all-cause mortality as well as a composite outcome of all-cause mortality, unscheduled re-hospitalization, or transfer to a long-term care facility in a vegetative or minimally conscious state. Bio-ADM levels significantly increased in patients with ischemic stroke who died compared to surviving patients (40.4 pg/ml vs. 23.8 pg/ml, p < 0.001) or in those with composite outcomes compared to those with no events (36.9 pg/ml vs. 23.5 pg/ml, p < 0.001). Six-month all-cause mortality was higher in all patients with bio-ADM levels > 70 pg/ml (HR 4.83 [CI 2.28-10.2]). Patients with bio-ADM levels > 70 pg/ml also had higher rates of 6-month composite outcomes (HR 3.82 [CI 2.08-7.01]). Bio-ADM was an independent predictor of all-cause mortality and 6-month composite outcomes after adjusting for age, gender, and ERBI (adjusted OR 1.5; 95% CI 1.0-2.1; p = 0.047 and adjusted OR 1.48; 95% CI 1.1-2.0; p = 0.01, respectively). Bio-ADM may be a suitable novel biomarker to assess the outcomes of patients in rehabilitation after acute stroke. Elevated bio-ADM concentrations may have prognostic value for fatal and nonfatal events in patients with ischemic stroke during early rehabilitation.

Rates and predictors of mental health care utilisation in patients following a prolonged stay on intensive care unit: a prospective cohort study

OBJECTIVES

An acute critical illness and secondary complications may necessitate a prolonged treatment on an intensive care unit (ICU). As long-term consequences, ICU survivors may suffer from both physical and psychological sequelae. To improve the aftercare of these patients, the present study aimed to assess the use of mental healthcare and associated factors following prolonged ICU stay.

METHODS

N=197 patients with a primary diagnosis of critical illness polyneuropathy/myopathy were enrolled within 4 weeks (T1) and interviewed three (T2) and six (T3) months following the transfer from acute-care to postacute ICU. Symptoms and a current diagnosis of major depression/post-traumatic stress disorder (PTSD) were assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders. The potential need for mental healthcare, its current and past use and reasons for non-use were raised.

RESULTS

Full syndromal and subsyndromal major depression/PTSD were diagnosed in 8.3%/15.6% at T2, 12.2%/23.5% at T3. About 29% of the patients reported mental healthcare utilisation. Considering somatic complaints, more important was a common reason for the non-use of mental healthcare. Female gender, previous mental healthcare, number of sepsis episodes and pension receipt increased the chance for mental healthcare utilisation, a pre-existing mental disorder decreased it.

CONCLUSION

Every fourth patient surviving prolonged ICU treatement makes use of mental healthcare . Particularly male patients with pre-existing mental disorders should be targeted preventively, receiving specific psychoeducation about psychological long-term sequelae and mental healthcare options post-ICU.Trial registration numberDRKS00003386.

Critical COVID-19 disease: Clinical course and rehabilitation of neurological deficits

BACKGROUND

The COVID-19 disease frequently causes neurological symptoms. Critically ill patients often require neurorehabilitation for manifestations like intensive care unit (ICU) acquired weakness or encephalopathy. The outcome of these patients, however, is largely unknown. Here we report the clinical course of critical affected COVID-19 patients from hospital admission to discharge from inpatient neurorehabilitation.

METHODS

Prospective cohort study. COVID-19 patients admitted to neurorehabilitation were included based on a laboratory-confirmed SARS-CoV-2 infection. Assessments [modified Rankin Scale (mRS), Barthel-Index, Fatigue-Severity-Scale-7 and health-related quality of life (EQ-5D-5L)] were conducted at admission and before discharge from inpatient care. Data were compared to the preclinical health status.

RESULTS

Sixty-one patients (62 ± 13 years, 16 female) were included in the analysis. Most patients had been treated on ICU (n = 58; 57 ± 23 days) and had received invasive ventilation (n = 57; 46 ± 21 days). After discharge from ICU, patients spent on average 57 ± 26 days in neurorehabilitation. The most frequent neurological diagnoses were ICU-acquired weakness (n = 56) and encephalopathy (n = 23). During rehabilitation overall disability improved [mRS median (IQR) 4.0 (1.0) at inclusion and 2.0 (1.0) at discharge]. However, the preclinical health state [mRS 0.0 (0.0)] was not regained (p < 0.001). This was also reflected by the Barthel-Index [preclinical 100.0 (0.0), at inclusion 42.5 (35.0), at discharge 65.0 (7.5); p < 0.001]. Patients had only minor fatigue during inpatient care. Quality of life generally improved but was still low at discharge from hospital.

CONCLUSION

Patients with neurological sequelae after critical COVID-19 disease showed substantial deficits at discharge from inpatient care up to 4 months after the initial infection. They were restricted in activities of daily living and had reduced health-related quality of life. All patients needed continued medical support and physical treatment.

The Impact of Cerebral Amyloid Angiopathy on Functional Outcome of Patients Affected by Spontaneous Intracerebral Hemorrhage Discharged from Intensive Inpatient Rehabilitation: A Cohort Study

Background: Sporadic CAA is recognized as a major cause of sICH and sABI. Even if intensive rehabilitation is recommended to maximize functional recovery after sICH, no data are available on whether CAA may affect rehabilitation outcomes. In this observational prospective study, to explore the impact of CAA on rehabilitation results, functional outcomes after intensive rehabilitation have been compared between patients affected by sICH with and without a diagnosis of CAA. Methods: All adults affected by sABI due to sICH and admitted to the IRU of IRCCS-Don-Gnocchi-Foundation were consecutively enrolled for 12 months. Demographic and clinical data were recorded upon admission and discharge. Results: Among 102 sICH patients (age: 66 (IQR = 16), 53% female), 13% were diagnosed as probable/possible-CAA. TPO and functional assessment were comparable upon admission, but CAA patients were significantly older (p = 0.001). After a comparable LOS, CAA patients presented higher care burden (ERBI: p = 0.025), poorer functional recovery (FIM: p = 0.02) and lower levels of global independence (GOSE > 4: p = 0.03). In multivariate analysis, CAA was significantly correlated with a lower FIM (p = 0.019) and a lower likelihood of reaching GOS-E > 4, (p = 0.041) at discharge, independently from age. Conclusions: CAA seems to be independently associated with poorer rehabilitation outcomes, suggesting the importance of improving knowledge about CAA to better predict rehabilitation outcomes.

Connectivity in deep brain stimulation for self-injurious behavior: multiple targets for a common network?

Self-injurious behavior (SIB) is associated with diverse psychiatric conditions. Sometimes (e.g., in patients with autism spectrum disorder or acquired brain injuries), SIB is the most dominant symptom, severely restricting the psychosocial functioning and quality of life of the patients and inhibiting appropriate patient care. In severe cases, it can lead to permanent physical injuries or even death. Primary therapy consists of medical treatment and if implementable, behavioral therapy. For patients with severe SIB refractory to conventional therapy, neuromodulation can be considered as a last recourse. In scientific literature, several successful lesioning and deep brain stimulation targets have been described that can indicate a common underlying neuronal pathway. The objectives of this study were to evaluate the short- and long-term clinical outcome of patients with severe, therapy refractory SIB who underwent DBS with diverse underlying psychiatric disorders and to correlate these outcomes with the activated connectivity networks. We retrospectively analyzed 10 patients with SIB who underwent DBS surgery with diverse psychiatric conditions including autism spectrum disorder, organic personality disorder after hypoxic or traumatic brain injury or Tourette syndrome. DBS targets were chosen according to the underlying disorder, patients were either stimulated in the nucleus accumbens, amygdala, posterior hypothalamus, medial thalamus or ventrolateral thalamus. Clinical outcome was measured 6 months after surgery and at long-term follow-up after 10 or more years using the Early Rehabilitation Barthel index (ERBI) and time of restraint. Connectivity patterns were analyzed using normative connectome. Based on previous literature the orbitofrontal cortex, superior frontal gyrus, the anterior cingulate cortex, the amygdala and the hippocampus were chosen as regions of interest. This analysis showed a significant improvement in the functionality of the patients with DBS in the short- and long-term follow-up. Good clinical outcome correlated with higher connectivity to the amygdala and hippocampus. These findings may suggest a common pathway, which can be relevant when planning a surgical procedure in patients with SIB.

Iron deficiency is related to low functional outcome in patients at early rehabilitation after acute stroke

BACKGROUND

Iron deficiency (ID) is a common co-morbidity in patients with cardiovascular disease and contributes to impaired functional capacity. The relevance of ID in patients in recovery after acute stroke is not known. We assessed the prevalence of ID and anaemia in relation to functional capacity and to recovery during early rehabilitation after stroke.

METHODS

This observational study enrolled consecutively 746 patients with ischaemic or haemorrhagic stroke at in-patient early rehabilitation (age 68 ± 13 years, female 47%, ischaemic stroke 87%). Functional capacity was assessed before and after rehabilitation using Barthel index (reha-BI), motricity index (MI), trunk control test (TCT), and functional ambulatory category (FAC). ID was defined as ferritin <100 μg/L or as transferrin saturation (TSAT) < 20% if ferritin was 100- < 300 μg/L or if CrP > 5 mg/L. Anaemia was defined as Hb < 12 g/dL (women) and <13 g/dL (men).

RESULTS

The prevalence of ID and anaemia before rehabilitation were 45% and 46%, respectively, and remained high at discharge (after 27 ± 17 days) at 40% and 48%, respectively. Patients with ID had lower functional capacity compared with patients without ID (reha-BI 20 [±86] vs. 40 [±80], MI 64 [±66] vs. 77 [±41], TCT 61 [±76] vs. 100 [±39], FAC 1 [±4] vs. 4 [±4]; median [IQR], all P < 0.001). ID was related to inflammation (OR 2.68 [95% CI 1.98-3.63], P < 0.001), female sex (OR 2.13 [95% CI 1.59-2.85], P < 0.001), haemorrhagic stroke (OR 1.70 [95% CI 1.11-2.61], P = 0.015), initial treatment on stroke unit (OR 3.59 [95% CI 1.08-11.89], P < 0.001), and anaemia (OR 2.94 [95% CI 2.18-3.96], P < 0.001), while age, BMI, and renal function were not related to ID. In adjusted analysis, ID was associated with low functional capacity in all functional scores: reha-BI (OR 1.66 [95% CI 1.08-2.54], P = 0.02), motricity index (OR 1.94 [95% CI 1.36-2.76], P < 0.001), trunk control test (OR 2.34 [95% CI] 1.64-3.32, P < 0.001) and functional ambulatory category (OR 1.77 [95% CI 1.2-2.63], P < 0.02). Functional capacity improved during rehabilitation regardless of presence of ID, but functional outcome remained significantly lower in patients with ID at the end of rehabilitation (rehab BI and MI, both P < 0.001).

CONCLUSIONS

Iron deficiency and anaemia are common and persistent findings in patients after acute stroke. ID and anaemia are independently related to lower functional capacity after acute stroke and to poor functional outcome after rehabilitation. Regular assessment of iron status may identify patients at risk of low functional recovery.

[Study of the effectiveness of neuroprotective therapy in restoring motor function in patients during the acute period of ischemic stroke]

OBJECTIVE

The purpose of the work was to study the effect of neuroprotective therapy with Cellex on the features of recovery of movement disorders in patients in the acute period of ischemic stroke.

MATERIAL AND METHODS

A single-center randomized study was conducted to assess the efficacy and safety of the use of neuroprotective therapy with Cellex in patients in the acute period of ischemic stroke. The study included 60 patients with a stroke duration of no more than 3 days in the middle cerebral artery area and vertebrobasillar area with moderate and severe central hemiparesis. Patients of the study group received 1 ml of Cellex. subcutaneously 1 time per day for 10 days. All patients received drug therapy and rehabilitation measures within the framework of the standard of care for patients with ischemic stroke.

RESULTS

Against the background of the therapy, by the end of the study on days 14-21, the study and control groups showed a significant improvement according to clinical scales: NIHSS, mRS, RMI. The patients of the study group showed a more pronounced recovery of motor function, relative to the comparison group, according to motor scales: «A-D» FMA (54 [53; 62] and 42 [34; 51], p=0.03), «E-F» FMA (29 [28; 33] and 25 [18; 27], p=0.03), ARAT (47 [48; 57], 32 [24; 48], p=0.046). Among the patients of the study group, by the end of the study, the severity of mild stroke was 67%, relative to the comparison group 11% (χ²_1df=6.48; p=0.01). The use of neuroprotective therapy in the form of Cellex had a positive effect on both the prognostic score and the long-term assessment according to the SSS scale, due to the regression of motor disorders of the upper and lower extremities.

CONCLUSION

The study has demonstrated the effectiveness of the use of neuroprotective therapy in the treatment of movement disorders in patients in the acute period of ischemic stroke. Therapy with Cellex helped to reduce the severity of stroke, and had a positive effect on the prognosis of the disease.

Comparison of content and psychometric properties for assessment tools used for brain tumor patients: a scoping review

AIMS

To determine the most frequently utilized functional status assessment instruments for patients with brain tumors, compare their contents, using the International Classification of Functioning, Disability and Health (ICF), and their psychometric properties.

METHODS

A scoping review was conducted to explore possible assessment instruments and summarize the evidence. A systematic literature search was performed for identification of the frequently used functional assessment tool in clinical trials in PubMed, ScienceDirect, and ProQuest databases. The content of most used instruments was linked to the ICF categories. The psychometric qualities of these assessment tools were systematically searched and analyzed.

RESULTS

Nine most used assessment tools in clinical trials were identified. The most frequently used assessment instrument is the Karnofsky Performance Scale, which is developed for a general assessment of oncological patients. Out of four self-assessment tools, two were disease-specific (EORTC QLQ-BN20 and FACT-Br), EORTC QLQ-C30 has been shown good psychometric properties in patients with brain tumors as well as in patients with various oncological diseases, similar to the SF-36, it is used in patients with brain tumors as well as in patients with various diseases. The Functional Independence Measure and the Barthel Index were two objective assessment tools that described functioning, but two were neuropsychological tests (MMSE and Trial Making Test). Two hundred eighty-three meaningful concepts were identified and linked to 102 most relevant second-level categories covering all components of the ICF. Forty-nine studies reporting psychometric properties of those nine assessment tools were identified, indicating good reliability and validity for all the instruments.

CONCLUSION

Nine most frequently utilized functional status assessment instruments for patients with brain tumors represent all components of the ICF and have good psychometric properties. However, the choice of the tool depends on the clinical question posed and the aim of its use.

Early Rehabilitation Index: translation and cross-cultural adaptation to Brazilian Portuguese; and Early Rehabilitation Barthel Index: validation for use in the intensive care unit

Objetivo

Traduzir, adaptar transculturalmente para o português do Brasil o instrumento Early Rehabilitation Index e validar para uso na unidade de terapia intensiva o instrumento Early Rehabilitation Barthel Index, para avaliação do estado funcional.

Métodos

Foram executadas as seguintes etapas: preparação, tradução, reconciliação, tradução reversa, revisão, harmonização, pré-teste e avaliação psicométrica. Após esse processo inicial, a versão em português foi aplicada por dois avaliadores em pacientes que permaneciam pelo menos 48 horas internados na unidade de terapia intensiva. Verificou-se a confiabilidade da escala por meio da consistência interna, da confiabilidade entre avaliadores e do efeito piso e teto. Para a validade de constructo, correlacionou-se o Early Rehabilitation Barthel Index com instrumentos que usualmente são utilizados para avaliação do estado funcional na unidade de terapia intensiva.

Resultados

Participaram 122 pacientes com mediana de idade de 56 [46,8 - 66] anos. O Early Rehabilitation Barthel Index teve confiabilidade adequada com coeficiente alfa de Cronbach de 0,65. A confiabilidade entre avaliadores foi excelente, com coeficiente de correlação intraclasse de 0,94 (IC95% 0,92 - 0,96) e moderado a excelente com índice de concordância de kappa de 0,54 a 1,0. Os efeitos piso e teto foram mínimos. Observou-se a validade do Early Rehabilitation Barthel Index por meio das correlações com o escore total do Perme Escore (rô = 0,72), da Escala de Estado Funcional em UTI (rô = 0,77), do Physical Function in Intensive Care Test-score (rô = 0,69), do Medical Research Council sum score (rô = 0,58), além das dinamometrias de preensão palmar (rô = 0,58) e manual de coxa (rô = 0,55), todos com p < 0,001.

Conclusão

A versão adaptada do Early Rehabilitation Index para o português brasileiro e na sua totalidade, Early Rehabilitation Barthel Index é confiável e válida para avaliação do estado funcional dos pacientes na alta da unidade de terapia intensiva.

A precision neurorehabilitation using SSEP for early detection of sensory deficit and restoration of the motor recovery in balance, gait and activities of daily living in acute stroke

BACKGROUND:

Impaired sensory in acute stroke patients results in dynamic balance, gait and activities of daily living (ADL) impairment.

OBJECTIVE:

The aim of present study was to examine the correlation between somatosensory-evoked potential (SSEP) parameters and motor recovery in balance, gait and ADL performance in hemiparetic stroke survivors.

METHODS:

One hundred and one participants with hemiparetic stroke (43 males, 58 females; mean age, 6538 ± 1222 years; post-stroke duration, 199 ± 0.74 month) participated in this study. The Electro Synergy system (Viasys Healthcare; San Diego, CA, USA) was applied to measure SSEP measurement. The 101 stroke survivors were divided into three groups consistent with their SSEP results: sensory normal group; sensory impaired group; sensory absent group. All the subject participated the inpatient rehabilitation intervention for 4 weeks. Analyses of variance (ANOVA) were used to verify the group difference among the three groups after the treatment.

RESULTS:

ANOVA revealed the significant difference (p< 0.01). The Scheffe test demonstrated that the sensory normal group showed greater increasement in Modified Barthel Index (MBI), Fugl-Myer Assessment (FMA), Trunk Impairment Scale (TIS), Berg Balance Scale (BBS) and Functional Ambulation Category (FAC) scores than the sensory impaired and absent group (p< 0.05).

CONCLUSIONS:

Our research provides therapeutic evidence that correlation of somatosensory functions on motor recovery, balance, gait, and ADL in patients with hemiplegic stroke.

The influence of the CRS-R score on functional outcome in patients with severe brain injury receiving early rehabilitation

Background

The aim of the study was to determine the role of the Coma Recovery Scale-Revised (CRS-R) in the prediction of functional status at the end of neurological early rehabilitative treatment.

Methods

Patients consecutively admitted to intensive or intermediate care units of a neurological rehabilitation center were enrolled in the study. Consciousness and functional status were assessed with the Coma Recovery Scale-Revised (CRS-R) and the Early Rehabilitation Barthel Index (ERBI), respectively. Both assessments were carried out weekly within the first month and at the end of early rehabilitation. Patient and clinical data were entered into a binary logistic regression model to predict functional status at discharge.

Results

327 patients (112 females, 215 males) with a median age of 63 years (IQR = 53–75) and a median disease duration of 18 days (IQR = 12–28) were included. Most patients suffered from stroke (59 %), followed by traumatic brain injury (31 %), and hypoxic ischemic encephalopathy (10 %). Upon admission, 12 % were diagnosed as comatose, 31 % as unresponsive wakefulness syndrome (UWS), 35 % as minimally conscious state (MCS) and 22 % already emerged from MCS (eMCS). Of all patients undergoing complete early rehabilitative treatment (n = 180), 72 % showed improvements in level of consciousness (LOC). In this group, age, initial CRS-R score and gains in CRS-R score after four weeks independently predicted functional outcome at discharge.

Conclusions

The study confirms the relevance of the CRS-R score for functional outcome prediction. High CRS-R scores and young age facilitate functional improvements and increase the probability to continue treatment in subsequent rehabilitation phases. Moreover, results indicate that recovery might occur over a period of time that extends beyond acute care.

Single assessment of delirium severity during postacute intensive care of chronically critically ill patients and its associated factors: post hoc analysis of a prospective cohort study in Germany

OBJECTIVES

To assess the delirium severity (DS), its risk factors and association with adverse patient outcomes in chronically critically ill (CCI) patients.

DESIGN

A prospective cohort study.

SETTING

A tertiary care hospital with postacute intensive care units (ICUs) in Germany.

PARTICIPANTS

N=267 CCI patients with critical illness polyneuropathy and/or critical illness myopathy, aged 18-75 years, who had undergone elective tracheotomy for weaning failure.

INTERVENTIONS

None.

MEASURES

Primary outcomes: DS was assessed using the Confusion Assessment Method for the Intensive Care Unit-7 delirium severity score, within 4 weeks (t1) after the transfer to a tertiary care hospital. In post hoc analyses, univariate linear regressions were employed, examining the relationship of DS with clinical, sociodemographic and psychological variables. Secondary outcomes: additionally, correlations of DS with fatigue (using the Multidimensional Fatigue Inventory-20), quality of life (using the Euro-Quality of Life) and institutionalisation/mortality at 3 (t2) and 6 (t3) months follow-up were computed.

RESULTS

Of the N=267 patients analysed, 9.4% showed severe or most severe delirium symptoms. 4.1% had a full-syndromal delirium. DS was significantly associated with the severity of illness (p=0.016, 95% CI -0.1 to -0.3), number of medical comorbidities (p<0.001, 95% CI .1 to .3) and sepsis (p<0.001, 95% CI .3 to 1.0). Patients with a higher DS at postacute ICU (t1), showed a higher mental fatigue at t2 (p=0.008, 95% CI .13 to .37) and an increased risk for institutionalisation/mortality (p=0.043, 95% CI 1.1 to 28.9/p=0.015, 95% CI 1.5 to 43.2).

CONCLUSIONS

Illness severity is positively associated with DS during postacute care in CCI patients. An adequate management of delirium is essential in order to mitigate functional and cognitive long-term sequelae following ICU.

TRIAL REGISTRATION NUMBER

DRKS00003386.

Clinical questions on rehabilitation in cancer patients with skeletal metastasis: a content analysis of the multidisciplinary tumor board records

PURPOSE

Cancer rehabilitation addresses the functional needs of patients who have various impairments. Disease control is a critical oncological consideration, while physical intervention increased weights of importance in several situations. To identify the clinical status that necessitates active physical intervention in cancer patients with skeletal metastasis, we performed a content analysis in the multidisciplinary tumor board (MDTB) records.

METHODS

From January 2017 to September 2019, the MDTB discussed 168 consecutive patients with skeletal metastasis. We reviewed the MDTB records and asked responsible physicians to frame clinical questions. Based on these data, we identified the predictor valuables with the association to rehabilitation-related clinical questions using univariate and multivariate analyses. Moreover, we investigated a predictor of the change in Barthel index (BI) scores using univariate analyses.

RESULTS

Rehabilitation-related questions arose more frequently in older patients (p = 0.011), in patients with slow-growth vs. rapid-growth tumor (p = 0.002), and in patients with skeletal-related events (p = 0.001) at MDTB. The tumor growth speed was associated with the change in BI scores, as slower-growth tumors had the benefit of BI gains (p = 0.017).

CONCLUSIONS

Regarding rehabilitation in patients with skeletal metastasis, we should pay attention to three parameters: occurrence of skeletal events, patient age, and growth speed of tumors. Rehabilitation-related questions may reflect patients' functional needs that occur more frequently in patients with pathological fractures or neurological symptoms, older patients, and patients with slow-growth tumors.

The effect of stem cell therapy and comprehensive physical therapy in motor and non-motor symptoms in patients with multiple sclerosis: A comparative study

INTRODUCTION

People with multiple sclerosis (PwMS) experience a wide range of disabilities which negatively impact their quality of life (QOL). Several interventions have been used in PwMS such as medication, physical therapy exercises and stem cell therapy to improve their QOL. However, there is a limited evidence on the benefits of combining interventions. The purpose of this study is to explore the effect of combining physical therapy exercises (PTE) and Wharton Jelly mesenchymal stem cell (WJ-MSCs) injections on motor and non-motor symptoms versus each intervention alone in PwMS.

METHODS

Sixty PwMS will be allocated to either PTE, WJ-MSCs, or a combined group, followed up for 12 months and examined using a comprehensive battery of measures. Participants in the PTE group will receive 2 sessions per week of a supervised exercise program for 6 months followed by a home exercise program for another 6 months. The WJ-MSCs group will receive 3 WJ-MSCs injections in the first 6 months then they will be encouraged to follow an active life style. The third group will receive both interventions.

DISCUSSION

This study will aid in a better understanding of the combined effect of physical therapy and mesenchymal stem cell therapy. The results from this proposed study may reduce disability, improve QOL in PwMS, and consequently, reduce the cost associated with the life-time care of these individuals worldwide.

TRIAL REGISTRATION NUMBER

NCT03326505.

Impairment-driven cancer rehabilitation in patients with neoplastic spinal cord compression using minimally invasive spine stabilization

BACKGROUND

Neoplastic spinal cord compression is a cause of severe disability in cancer patients. To prevent irreversible paraplegia, a structured strategy is required to address the various impairments present in cancer patients. In this study, we aimed to identify the status where rehabilitation with minimally invasive spine stabilization (MISt) effectively improves ADL.

METHODS

We retrospectively reviewed 27 consecutive patients with neoplastic spinal compression who were treated with MISt. We classified the impairments of patients through our multidisciplinary tumor board based on spine-specific factors, skeletal instability, and tumor growth. The neurological deficits, progress of pathological fracture, incidence of vertebral collapse, and postoperative implant failure were examined. Changes of the Barthel index (BI) scores before and after surgery were investigated throughout the clinical courses.

RESULTS

The average duration to ambulation was 7.19 ± 11 days, and we observed no collapse or progression of paralysis except in four cases of complete motor paraplegia before the surgery. Neurological deficiency was improved to or maintained at Frankel's grade E in 16 patients, remained unchanged in 6 patients (in grades B, C, D), and worsened in 5 patients. BI score comparisons before and after surgery in all patients showed statistically significant increments (p < 0.05). On further analysis, we noted good functional prognosis in patients capable of ambulation within 7 days (p < 0.05) and in patients who could survive longer than 3 months after the surgery (p < 0.05).

CONCLUSIONS

In various cancer patients with neoplastic spinal cord compression, skeletal instability as the primary impairment is a good indication for MISt, as the patients showed early ambulation with improved BI scores.

Recovery in cognitive motor dissociation after severe brain injury: A cohort study

OBJECTIVE

To investigate the functional and cognitive outcomes during early intensive neurorehabilitation and to compare the recovery patterns of patients presenting with cognitive motor dissociation (CMD), disorders of consciousness (DOC) and non-DOC.

METHODS

We conducted a single center observational cohort study of 141 patients with severe acquired brain injury, consecutively admitted to an acute neurorehabilitation unit. We divided patients into three groups according to initial neurobehavioral diagnosis at admission using the Coma Recovery Scale-Revised (CRS-R) and the Motor Behavior Tool (MBT): potential clinical CMD, [N = 105]; DOC [N = 19]; non-DOC [N = 17]). Functional and cognitive outcomes were assessed at admission and discharge using the Glasgow Outcome Scale, the Early Rehabilitation Barthel Index, the Disability Rating Scale, the Rancho Los Amigos Levels of Cognitive Functioning, the Functional Ambulation Classification Scale and the modified Rankin Scale. Confirmed recovery of conscious awareness was based on CRS-R criteria.

RESULTS

CMD patients were significantly associated with better functional outcomes and potential for improvement than DOC. Furthermore, outcomes of CMD patients did not differ significantly from those of non-DOC. Using the CRS-R scale only; approximatively 30% of CMD patients did not recover consciousness at discharge.

INTERPRETATION

Our findings support the fact that patients presenting with CMD condition constitute a separate category, with different potential for improvement and functional outcomes than patients suffering from DOC. This reinforces the need for CMD to be urgently recognized, as it may directly affect patient care, influencing life-or-death decisions.

Efficacy and safety of cerebrolysin in neurorecovery after moderate-severe traumatic brain injury: results from the CAPTAIN II trial

INTRODUCTION

The objective of this trial was to evaluate the efficacy and safety of Cerebrolysin in treating patients after moderate to severe traumatic brain injury (TBI) as an adjunct to standard care protocols. The trial was designed to investigate the clinical effects of Cerebrolysin in the acute (neuroprotective) stage and during early and long-term recovery as part of a neurorestorative strategy.

MATERIALS AND METHODS

The study was a phase IIIb/IV single-center, prospective, randomized, double-blind, placebo-controlled clinical trial. Eligible patients with a Glasgow Coma Score (GCS) between 7 and 12 received study medication (50 ml of Cerebrolysin or physiological saline solution per day for 10 days, followed by two additional treatment cycles with 10 ml per day for 10 days) in addition to standard care. We tested ensembles of efficacy criteria for 90, 30, and 10 days after TBI with a priori ordered hypotheses using a multivariate, directional test, to reflect the global status of patients after TBI.

RESULTS

The study enrolled 142 patients, of which 139 underwent formal analysis (mean age = 47.4, mean admission GCS = 10.4, and mean Baseline Prognostic Risk Score = 2.6). The primary endpoint, a multidimensional ensemble of 13 outcome scales, indicated a "small-to-medium"-sized effect in favor of Cerebrolysin, statistically significant at day 90 (MW_combined = 0.59, 95% CI 0.52 to 0.66, P = 0.0119). Safety and tolerability observations were comparable between treatment groups.

CONCLUSION

Our trial confirms previous beneficial effects of the multimodal, biological agent Cerebrolysin for overall outcome after moderate to severe TBI, as measured by a multidimensional approach. Study findings must be appraised and aggregated in conjunction with existing literature, as to improve the overall level of insight regarding therapeutic options for TBI patients. The widely used pharmacologic intervention may benefit from a large-scale observational study to map its use and to establish comparative effectiveness in real-world clinical settings.

Alien limb phenomenon following posterior cerebral artery stroke: a distinct clinical entity

Alien limb syndrome following stroke within the territory of the posterior cerebral artery is exceedingly rare. A right-handed female experienced left homonymous hemianopia, visuospatial neglect, and proprioceptive loss of her left hemi-body. She experienced unintended, involuntary movements of her left arm and hand, which interfered with and disturbed motor actions of daily life performed with her right upper limb. There was no denial of ownership, but she interpreted movements of her left upper limb to be annoying, out of her will and unwanted. The alien limb phenomenon improved in parallel with improvement of proprioceptive loss over a 12-week of in-patient rehabilitation. A recently proposed theoretical concept of the alien limb phenomenon after posterior artery stroke is discussed.

Impact of post-traumatic stress symptoms on the health-related quality of life in a cohort study with chronically critically ill patients and their partners: age matters

Background

Survivors of an acute critical illness with continuing organ dysfunction and uncontrolled inflammatory responses are prone to become chronically critically ill. As mental sequelae, a post-traumatic stress disorder and an associated decrease in the health-related quality of life (QoL) may occur, not only in the patients but also in their partners. Currently, research on long-term mental distress in chronically critically ill patient-partner dyads, using appropriate dyadic analysis strategies (patients and partners being measured and linked on the same variables) and controlling for contextual factors, is lacking.

Methods

The present study investigates the interdependence of post-traumatic stress symptoms (PTSS) and the health-related QoL in n = 70 dyads of chronically critically ill patients and their partners, using the Actor-Partner-Interdependence Model (APIM) under consideration of contextual factors (age, gender, length of partnership). The Post-traumatic Stress Scale (PTSS-10) and Euro-Quality of Life (EQ-5D-3L) were applied in both the patients and their partners, within up to 6 months after the transfer from acute care ICU to post-acute ICU.

Results

Clinically relevant post-traumatic stress symptoms were reported by 17.1% of the patients and 18.6% of the partners. Both the chronically critically ill patients and their partners with more severe post-traumatic stress symptoms also showed a decreased health-related QoL. The latter was more pronounced in male partners compared to female partners or female patients. In younger partners (≤ 57 years), higher values of post-traumatic stress symptoms were associated with a decreased QoL in the patients.

Conclusions

Mental health screening and psychotherapeutic treatment options should be offered to both the chronically critically ill patients and their partners. Future research is required to address the special needs of younger patient-partner dyads, following protracted ICU treatment.

Trial registration

German Clinical Trials Register No. DRKS00003386. Registered 13 November 2011

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2321-0) contains supplementary material, which is available to authorized users.

The culturally adapted Italian version of the Barthel Index (IcaBI): assessment of structural validity, inter-rater reliability and responsiveness to clinically relevant improvements in patients admitted to inpatient rehabilitation centers

The Barthel Index (BI) is widely used to determine eligibility criteria for inpatient rehabilitation and to monitor patients' recovery, irrespective of the illnesses that affect them. The culturally adapted Italian version of the Barthel Index (IcaBI) was recently validated. This paper reports the structural validity and inter-rater reliability of the IcaBI and its responsiveness to the results of inpatient rehabilitation. The IcaBI was administered to a cohort of 264 patients hospitalized in two rehabilitation centers in Rome, Italy. Factor analysis using principal component analysis revealed a monofactorial structure for neurological patients and, after removal of item 1 "feeding", also for orthopedic patients. Substantial to optimal inter-rater reliability was found (0.74 > intraclass correlation coefficient < 0.96). The IcaBI was found to be accurate (area under the curve= 0.72) with a minimal clinically important change score of 35 points. This work confirms that IcaBI is a useful tool for measuring disability in health and social care settings along the continuum of care. Further studies are needed to assess its criterion validity, interpretability and responsiveness in other specific disease conditions.

Predictors of Major Depressive Disorder following Intensive Care of Chronically Critically Ill Patients

OBJECTIVE

Major depressive disorder (MDD) is a common condition following treatment in the Intensive Care Unit (ICU). Long-term data on MDD in chronically critically ill (CCI) patients are scarce. Hence, the primary aim of the present study was to investigate the frequency and predictors of MDD after intensive care of CCI patients.

MATERIALS AND METHODS

In a prospective cohort study, patients with long-term mechanical ventilation requirements (n=131) were assessed with respect to a diagnosis of MDD, using the Structured Clinical Interview for DSM-IV, three and six months after the transfer from acute ICU to post-acute ICU. Sociodemographic, psychological, and clinical risk factors with p values ≤ 0.1 were identified in a univariate logistic regression analysis and entered in a multivariable logistic regression model. A mediator analysis was run using the bootstrapping method, testing the mediating effect of perceived helplessness during the ICU stay, between the recalled traumatic experience from the ICU and a post-ICU MDD.

RESULTS

17.6% (n=23) of the patients showed a full- or subsyndromal MDD. Perceived helplessness, recalled experiences of a traumatic event from the ICU, symptoms of acute stress disorder, and the diagnosis of posttraumatic stress disorder (PTSD) after ICU could be identified as significant predictors of MDD. In a mediator analysis, perceived helplessness could be proved as a mediator.

CONCLUSIONS

Every fifth CCI patient suffers from MDD up to six months after being discharged from ICU. Particularly, perceived helplessness during the ICU stay seems to mainly affect the long-term evolvement of MDD. CCI patients with symptoms of acute stress disorder/PTSD should also be screened for MDD.

Self-reported fatigue following intensive care of chronically critically ill patients: a prospective cohort study

Background

Protracted treatment on intensive care unit (ICU) sets the patients at increased risk for the development of chronic critical illness (CCI). Muscular and cardio-respiratory deconditioning are common long-term sequelae, going along with a state of chronic fatigue. At present, findings regarding the frequency, long-term course, and associated factors of self-reported fatigue following ICU treatment of CCI patients are lacking.

Methods

CCI patients with the diagnosis of critical illness polyneuropathy/myopathy (CIP/CIM) were assessed at three time points. Four weeks following the discharge from ICU at acute care hospital (t1), eligibility for study participation was asserted. Self-reported fatigue was measured using the Multidimensional Fatigue Inventory (MFI-20) via telephone contact at 3 (t2, n = 113) and 6 months (t3, n = 91) following discharge from ICU at acute care hospital.

Results

At both 3 and 6 months, nearly every second CCI patient showed clinically relevant fatigue symptoms (t2/t3: n = 53/n = 51, point prevalence rates: 46.9%/45.1%). While total fatigue scores remained stable in the whole sample, female patients showed a decrease from 3 to 6 months. The presence of a coronary heart disease, the perceived fear of dying at acute care ICU, a diagnosis of major depression, and the perceived social support were confirmed as significant correlates of fatigue at 3 months. At 6 months, male gender, the number of medical comorbidities, a diagnosis of major depression, and a prior history of anxiety disorder could be identified. A negative impact of fatigue on the perceived health-related quality of life could be ascertained.

Conclusions

Nearly every second CCI patient showed fatigue symptoms up to 6 months post-ICU. Patients at risk should be informed about fatigue, and appropriate treatment options should be offered to them.

Trial registration

The present study was registered retrospectively at the German Clinical Trials Register (date of registration: 13th of December 2011; registration number: DRKS00003386). Date of enrolment of the first participant to the present trial: 09th of November 2011.

Electroacupuncture for poststroke spasticity (EAPSS): protocol for a randomised controlled trial

INTRODUCTION

Spasticity is a common complication of stroke. Current therapies for poststroke spasticity (PSS) have been reported to be associated with high costs, lack of long-term benefit and unwanted adverse events (AEs). Electroacupuncture (EA) has been used for PSS, however, its efficacy and safety is yet to be confirmed by high-quality clinical studies. This study is designed to evaluate the add-on effects and safety profile of EA when used in combination with usual care (UC).

METHODS AND ANALYSIS

This study is a parallel group randomised controlled trial. A total of 136 participants will be included and randomly assigned to either the treatment group (EA plus UC) or the control group (UC alone). Prior to the main trial, a pilot study involving 30 participants will be conducted to assess the feasibility of the trial protocol. EA will be administered by registered acupuncturists for 20min to 30 min, three times per week for 4 weeks. The primary outcome measure (Modified Ashworth Scale) and secondary outcome measures (Fugl-Meyer Assessment and Barthel Index) will be evaluated at baseline, the end of treatment (week 4) and the end of follow-up (week 8). AEs will be monitored, recorded and reported, and their causality will be explored.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the ethics committees of Guangdong Provincial Hospital of Chinese Medicine and RMIT University in December 2016. The results will be disseminated in a peer-reviewed journal, and PhD theses and might be presented at international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR-IOR-16010283; Pre-results.

The effect of a natural food based tube feeding in minimizing diarrhea in critically ill neurological patients

BACKGROUND & AIMS

Diarrhea has negative consequences for patients, health care staff and health care costs when neurological patients are fed enterally over long periods. We examined the effect of tube feeding with natural foods in reducing the number of fluid stool evacuations and diarrhea in critically ill neurological patients.

METHODS

A multicenter, prospective, open-label and randomized controlled trial (RCT) was conducted at facilities in Germany specializing in early rehabilitation after neurological damage. Patients of the INTERVENTION group were fed by tube using a commercially available product based on real foods such as milk, meat, carrots, whereas CONTROL patients received a standard tube-feed made of powdered raw materials. All received enteral nutrition over a maximum of 30 days. The number of defecations and the consistency of each stool according to the Bristol Stool Chart (BSC) were monitored. In addition, daily calories, liquids and antibiotic-use were recorded.

RESULTS

118 Patients who had suffered ischemic stroke, intracerebral hemorrhage, traumatic brain injury or hypoxic brain damage and requiring enteral nutrition were enrolled; 59 were randomized to receive the intervention and 59 control feed. There were no significant differences in clinical screening data, age, sex, observation period or days under enteral nutrition between the groups. Patients in both groups received equivalent amount of calories and fluids. In both groups antibiotics were frequently prescribed (69.5% in the INTERVENTION group and 75.7% in the CONTROL group) for 10-11 days on average. In comparison to the CONTROL group, patients in the INTERVENTION group had a significant reduction of the number of watery stool evacuations (type 7 BSC) (minus 61%, IRR = 0.39, p < 0.001). Further statistical evaluations using the following corrections: major diarrhea-associated confounders (number and duration of antibiotics); shorter observation period of 15 days; excluding patients with Clostridium difficile associated diarrhea (CDAD) and the Per Protocol Population, confirmed the primary hypothesis. The number of days with diarrhea was significantly lower in the INTERVENTION group (0.8 ± 1.60 days versus 2.0 ± 3.46 days).

CONCLUSIONS

Tube feeding with natural based food was effective in reducing the number of watery defecations and diarrhea in long term tube-fed critically ill neurological patients, compared to those fed with standard tube feeding.

Risk Factors of Delayed Onset Posttraumatic Stress Disorder in Chronically Critically Ill Patients

The main aim of this study was to investigate factors associated with a delayed-onset posttraumatic stress disorder (PTSD) after the intensive care unit (ICU) treatment of patients with a chronic critical illness (CCI). Patients (n = 97) with critical illness polyneuropathy or critical illness myopathy were interviewed via the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. The diagnosis of the acute stress disorder was assessed within 1 month (t1), the diagnosis of PTSD at 3 (t2) and 6 (t3) months after transfer from the acute care ICU to the post-acute ICU. Patients showing a delayed-onset or persistent course of PTSD were subsumed in one group; 24.7% (n = 24) showed a delayed-onset PTSD. Significant risk factors were as follows: the severity of the medical illness, the perceived fear of dying at the ICU, the number of traumatic memories from the ICU, and the presence of a coronary heart disease. Every fourth patient with CCI showed a delayed-onset PTSD up to 6 months after the ICU treatment. Markers for a delayed-onset PTSD should already be assessed at the time of discharge from the ICU.

Impact of Thyroid Hormone Levels on Functional Outcome in Neurological and Neurosurgical Early Rehabilitation Patients

Background

Neurological and neurosurgical early rehabilitation (NNER) is a specialized treatment option for patients with severe neurological disorders. The present study investigated whether thyroid hormone levels on admission have an impact on the outcome of NNER patients.

Method

The study included 500 NNER patients who were admitted to the BDH-Clinic Hessisch Oldendorf between 2009 and 2010. Data such as age, sex, diagnoses, comorbidities, Glasgow Coma Scale score, length of stay, and thyroid hormone levels (obtained as part of clinical routine care) were analyzed retrospectively. Improvement in the Early Rehabilitation Barthel Index (ERBI) at the end of the NNER treatment was defined as outcome parameter.

Results

Most patients made functional progress during treatment, as reflected in significant enhancements of the ERBI. Approximately half of the patients were transferred to further rehabilitation treatment. Young age, early onset of NNER treatment, low functional impairment on admission, and, in particular, low total T3 levels were independently associated with a good outcome.

Conclusion

Age, severity of disease, and time between injury and admission are known to predict outcome. The present study confirms the influence of these general factors. In addition, an association between thyroid hormones and functional outcome was demonstrated for NNER patients.

Outcome of neurological early rehabilitation patients carrying multi-drug resistant bacteria: results from a German multi-center study

BACKGROUND

Colonization or infection with multi-drug resistant (MDR) bacteria is considered detrimental to the outcome of neurological and neurosurgical early rehabilitation patients.

METHODS

In a German multi-center study, 754 neurological early rehabilitation patients were enrolled and and reviewed in respect to MDR status, length of stay (LOS) and the following outcome variables: Barthel Index (BI), Early Rehabilitation Index (ERI), Glasgow Outcome Score Extended (GOSE), Coma Remission Scale (CRS), Functional Ambulation Categories (FAC).

RESULTS

The mean age of the study population was 68.0 ± 14.8 years. Upon admission, the following prevalence for MDRs was observed: MRSA (methicillin resistant staphylococcus aureus) 7.0% (53/754), ESBL- (extended spectrum beta-lactamase) producing bacteria strains 12.6% (95/754), VRE (vancomycin resistant enterococci) 2.8% (21/754). Patients colonized or infected with MDR bacteria (MDR+) were significantly more frequently diagnosed with a critical illness polyneuropathy - CIP - than non-colonized (MDR-) patients: 29.0% vs. 14.8%. In addition, they were more frequently mechanically ventilated (MDR+: 55/138, 39.9%; MDR- 137/616, 22.2%). MDR+ patients were referred to rehabilitation earlier, had a longer LOS in early rehabilitation, lower BI on admission and at discharge, lower ERI on admission and lower CRS at discharge than MDR- patients. There was a highly significant correlation of the BI upon admission with the BI at discharge (rs = 0.492, p < 0.001). GOSE at discharge differed significantly between both groups (χ 2-test, p < 0.01). Perhaps of greatest importance, mortality among MDR+ was higher in comparison to MDR- (18.1% vs. 7.6%).

CONCLUSIONS

The outcome of neurological early rehabilitation patients colonized or infected with MDR bacteria including MRSA or ESBL producing strains is significantly poorer than by non-colonized patients. There is some evidence that the poor outcome could be related to the higher morbidity and lower functional status upon admission.

Does the APACHE II score predict performance of activities of daily living in patients discharged from a weaning center?

INTRODUCTION

Data regarding the functional status of patients after prolonged mechanical ventilation are scarce, and little is known about its clinical predictors.

AIM

To investigate whether the Acute Physiology and Chronic Health Evaluation (APACHE) II score on admission may predict performance in activities of daily living on discharge from a weaning center.

MATERIAL AND METHODS

All consecutive patients admitted between January 1, 2012 and December 31, 2013 were enrolled (n = 130). During this period, 15 subjects died, and 115 were successfully discharged (34 women; 81 men). APACHE II was calculated based on the worst values taken during the first 24 hours after admission. On discharge, the Barthel Index (BI) and its extended version, the Early Rehabilitation Barthel Index (ERBI), were assessed.

RESULTS

Median BI was 20 points (IQR 5; 40), and ERBI was 20 points (-50; 40). There was no correlation between APACHE II and either BI (R = -0.07; p = 0.47) or ERBI (R = -0.07; p = 0.44). APACHE II predicted the need for assistance with bathing (AUROC = 0.833; p < 0.001), grooming (AUROC = 0.823; p < 0.001), toilet use (AUROC = 0.887; p < 0.001), and urination (AUROC = 0.658; p = 0.04). APACHE II had no impact on any ERBI items associated with ventilator weaning, including the need of further mechanical ventilation (AUROC = 0.534; p = 0.65) or tracheostomy (AUROC = 0.544; p = 0.42).

CONCLUSIONS

Although APACHE II cannot predict the overall functional status in patients discharged from a weaning center, it helps identify subjects who will need support with bathing, grooming, and toilet use. The APACHE II score is inadequate to predict performance in activities associated with further respiratory support.

Criterion validity and sensitivity to change of the Early Rehabilitation Index (ERI): results from a German multi-center study

BACKGROUND

Evaluation of functional status is difficult in neurological and neurosurgical early rehabilitation patients. The Early Rehabilitation Index (ERI) was introduced in Germany over 20 years ago, but since then validation studies are lacking. The ERI (range -325 to 0 points) includes highly relevant items including the necessity of intermittent mechanical ventilation or tracheostomy.

METHODS

The present paper analyzed data from a German multi-center study, enrolling 754 neurological early rehabilitation patients. Together with ERI, Barthel Index (BI), Glasgow Coma Scale (GCS), Glasgow Outcome Score Extended, Coma Remission Scale (CRS), Functional Ambulation Categories and length of stay were obtained.

RESULTS

ERI showed significant improvements from admission to discharge (p < 0.001). In addition, there were significant correlations of the ERI upon admission and at discharge with BI, CRS and GCS.

CONCLUSIONS

Evaluation of our study data suggest that the ERI may be used as a valid assessment instrument for neurological and neurosurgical early rehabilitation patients.

Predictors of posttraumatic stress and quality of life in family members of chronically critically ill patients after intensive care

Background

Prolonged mechanical ventilation for acute medical conditions increases the risk of chronic critical illness (CCI). Close family members are confronted with the life-threatening condition of the CCI patients and are prone to develop posttraumatic stress disorder affecting their health-related quality of life (HRQL). Main aim of the present study was to investigate patient- and family-related risk factors for posttraumatic stress and decreased HRQL in family members of CCI patients.

Methods

In a cross-sectional design nested within a prospective longitudinal cohort study, posttraumatic stress symptoms and quality of life were assessed in family members of CCI patients (n = 83, aged between 18 and 72 years) up to 6 months after transfer from ICU at acute care hospital to post-acute rehabilitation. Patients admitted a large rehabilitation hospital for ventilator weaning. The Posttraumatic Stress Scale-10 and the Euro-Quality of life-5D-3L were applied in both patients and their family members via telephone interview.

Results

A significant proportion of CCI patients and their family members (14.5 and 15.7 %, respectively) showed clinically relevant scores of posttraumatic stress. Both CCI patients and family members reported poorer HRQL than a normative sample. Factors independently associated with posttraumatic stress in family members were the time following ICU discharge (β = .256, 95 % confidence interval .053–.470) and the patients’ diagnosis of PTSD (β = .264, 95 % confidence interval .045–.453). Perceived satisfaction with the relationship turned out to be a protective factor for posttraumatic stress in family members of CCI patients (β = −.231, 95 % confidence interval −.423 to −.015). Regarding HRQL in family members, patients’ acute posttraumatic stress at ICU (β = −.290, 95 % confidence interval −.360 to −.088) and their own posttraumatic stress 3 to 6 months post-transfer (β = −.622, 95 % confidence interval −.640 to −.358) turned out to be significant predictors.

Conclusions

Posttraumatic stress and HRQL should be routinely assessed in family members of CCI patients at regular intervals starting early at ICU. Preventive family-centered interventions are needed to improve posttraumatic stress and HRQL in both patients and their family members.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-016-0174-0) contains supplementary material, which is available to authorized users.

First results about recovery of walking function in patients with intensive care unit-acquired muscle weakness from the General Weakness Syndrome Therapy (GymNAST) cohort study

OBJECTIVES

To describe the time course of recovery of walking function and other activities of daily living in patients with intensive care unit (ICU)-acquired muscle weakness.

DESIGN

This is a cohort study.

PARTICIPANTS

We included critically ill patients with ICU-acquired muscle weakness.

SETTING

Post-acute ICU and rehabilitation units in Germany.

MEASURES

We measured walking function, muscle strength, activities in daily living, motor and cognitive function.

RESULTS

We recruited 150 patients (30% female) who fulfilled our inclusion and exclusion criteria. The primary outcome recovery of walking function was achieved after a median of 28.5 days (IQR=45) after rehabilitation onset and after a median of 81.5 days (IQR=64) after onset of illness. Our final multivariate model for recovery of walking function included two clinical variables from baseline: the Functional Status Score ICU (adjusted HR=1.07 (95% CI 1.03 to 1.12) and the ability to reach forward in cm (adjusted HR=1.02 (95% CI 1.00 to 1.04). All secondary outcomes but not pain improved significantly in the first 8 weeks after study onset.

CONCLUSIONS

We found good recovery of walking function for most patients and described the recovery of walking function of people with ICU-acquired muscle weakness.

TRIALS REGISTRATIONS NUMBER

Sächsische Landesärztekammer EK-BR-32/13-1; DRKS00007181, German Register of Clinical Trials.

May clinical neurophysiology help to predict the recovery of neurological early rehabilitation patients?

BACKGROUND

So far, the role of clinical neurophysiology in the prediction of outcome from neurological and neurosurgical early rehabilitation is unclear.

METHODS

Clinical and neurophysiological data of a large sample of 803 early rehabilitation cases of the BDH-Clinic Hessisch Oldendorf in Northern Germany have been carefully reviewed. Most patients (43.5%) were transferred to rehabilitation after stroke, mean age was 66.6 (15.5) years. Median somatosensory (SEP), auditory (AEP) and visual evoked potentials (VEP) along with EEG recordings took place within the first two weeks after admission. Length of stay (LOS) in early rehabilitation was 38.3 (37.2) days.

RESULTS

Absence of SEP on one or both sides was associated with poor outcome, χ2 = 12.98 (p = 0.005); only 12.5% had a good outcome (defined as Barthel index, BI ≥50) when SEP were missing on both sides. In AEP, significantly longer bilateral latencies III were observed in the poor outcome group (p < 0.05). Flash VEP showed that patients in the poor outcome group had a significantly longer latency III on both sides (p < 0.05). The longer latency III, the smaller BI changes (BI discharge minus admission) were observed (latency III right r = -0.145, p < 0.01; left r = -0.206, p < 0.001). While about half of the patients with alpha EEG activity belonged to the good outcome group (80/159, 50.3%), only 39/125 (31.2%) with theta and 5/41 (12.2%) with delta rhythm had a favourable outcome, χ2 = 24.2, p < 0.001.

CONCLUSIONS

Results from this study suggest that loss of median SEP, prolongation of wave III in AEP and flash-VEP as well as theta or delta rhythms in EEG are associated with poor outcome from neurological early rehabilitation. Further studies on this topic are strongly encouraged.

The Early Functional Abilities (EFA) scale to assess neurological and neurosurgical early rehabilitation patients

Background

It is difficult to assess neurological and neurosurgical early rehabilitation patients comprehensively. Available scales focus on activities of daily living (Barthel (BI) and Early Rehabilitation Barthel Index (ERBI)) or wakefulness (Glasgow Coma Scale (GCS), Coma Remission Scale (CRS)) while cognitive items are missing.

Methods

The Early Functional Abilities (EFA) scale comprises 20 items referring to activities of daily living (ADL), wakefulness and cognitive abilities. To evaluate its validity, n = 623 early neurological and neurosurgical rehabilitation patients (most of them after ischemic stroke or cerebral bleeding) were assessed on admission using the EFA, ERBI, GCS, CRS and measures of morbidity (co-diagnoses).

Results

The more co-diagnoses the lower EFA sum scores were obtained (Spearman-Rho r_s = -0.509, p < 0.001). EFA predicted length of stay (LOS, r_s = -0.565, p < 0.001) and BI at discharge (r_s = 0.571, p < 0.001).

Conclusions

The results suggest that EFA is a valid instrument to assess critically ill neurological and neurosurgical early rehabilitation patients. It may be used as a measure of morbidity and a predictor of LOS and outcome. Further studies are strongly encouraged.

Factors Associated with the Risk of Falls of Nursing Home Residents Aged 80 or Older

BACKGROUND

Falls are the leading cause of mortality and morbidity in older and represents one of the major and most costly public health problems worldwide.

PURPOSE

Evaluate the influences of lower limb muscle performance, static balance, functional independence and quality of life on fall risk as assessed with the timed up and go (TUG) test.

DESIGN

Cross-sectional study.

METHODS

Fifty-two residents aged 80 or older were assessed and distributed in one of the two study groups (no risk of falls; risk of falls) according to the time to complete the TUG test. A Kistler force platform and linear transducer was used to determinate lower limb muscle performance. Postural Stability (static balance) was measured by recording the center of pressure. The EuroQol-5 dimension was used to assess Health-related quality of life and the Barthel index was used to examine functional status. Student's t-test was performed to evaluate the differences between groups. Correlations between variables were analyzed using Spearman or Pearson coefficient. ROC (receiver operating charasteristic) analysis was used to determine the cut-off points related to a decrease in the risk of a fall.

FINDINGS

Participants of no-fall risk group showed better lower limb performance, quality of life, and functional status. Cut-off points were determined for each outcome.

CONCLUSIONS

Risk of falls in nursing home residents over the age of 80 is associated with lower limb muscle performance, functional status, and quality of Life.

CLINICAL RELEVANCE

Cut-off points can be used by clinicians when working toward fall prevention and could help in determining the optimal lower limb muscle performance level for preventing falls.

Test-Retest Reliability and Validity of the Malay Version Life Habits Assessment (LIFE-H 3.1) to Measure Social Participation in Adults With Physical Disabilities

BACKGROUND AND PURPOSE

Social participation restriction is a common barrier encountered by older adults and individuals with physical disabilities. To best direct the limited resource to support social services for individuals with disability, there is a need to objectively measure social participation restriction. A number of tools to measure levels of social participation are available, but none of them has been translated into the Malay language. This cross-sectional study examined the test-retest reliability and concurrent validity of the Life Habits Assessment (LIFE-H 3.1) that had been translated and culturally adapted to the Malay language.

METHODS

Seventy-five individuals with physical disabilities (age, mean [standard deviation] = 58 [10] years; 49 males) participated in this study. Participants were interviewed twice with the Malay version LIFE-H 3.1, approximately 1 week apart. The Barthel Index (BI) and the World Health Organization Assessment of Quality of Life-Brief version (WHOQoL-BREF) were administered in the first interview as well. Intraclass correlation coefficients and the Bland-Altman Bias D were used to examine test-retest reliability. The Spearman correlation coefficients were computed to quantify the correlation between the Malay version LIFE-H 3.1 and the BI and the WHOQoL-BREF, respectively, to examine the concurrent validity of the Malay version LIFE-H 3.1. Furthermore, standard error of measurement and minimal detectable change were calculated.

RESULTS

The Malay version LIFE-H 3.1 had excellent test-retest reliability as evidenced by good to excellent intraclass correlation coefficients (0.71-0.95) and minimal Bland-Altman biases (0.01-0.12). The correlations between the Malay version LIFE-H 3.1 and the BI were fair to good (r = 0.28-0.69). The correlations between the Malay version LIFE-H 3.1 and the WHOQoL-BREF were weak to fair, ranging from 0.02 to 0.57.

CONCLUSIONS

The Malay version LIFE-H 3.1 demonstrates excellent test-retest reliability and satisfactory validity. This questionnaire is an appropriate tool to assess social participation in rehabilitation for native Malay language speakers.

Stress disorders following prolonged critical illness in survivors of severe sepsis

OBJECTIVES

To examine the frequency of acute stress disorder and posttraumatic stress disorder in chronically critically ill patients with a specific focus on severe sepsis, to classify different courses of stress disorders from 4 weeks to 6 months after transfer from acute care hospital to postacute rehabilitation, and to identify patients at risk by examining the relationship between clinical, demographic, and psychological variables and stress disorder symptoms.

DESIGN

Prospective longitudinal cohort study, three assessment times within 4 weeks, 3 months, and 6 months after transfer to postacute rehabilitation.

SETTING

Patients were consecutively enrolled in a large rehabilitation hospital (Clinic Bavaria, Kreischa, Germany) admitted for ventilator weaning from acute care hospitals.

PATIENTS

We included 90 patients with admission diagnosis critical illness polyneuropathy or critical illness myopathy with or without severe sepsis, age between 18 and 70 years with a length of ICU stay greater than 5 days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Acute stress disorder and posttraumatic stress disorder were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, criteria by a trained and experienced clinical psychologist using a semistructured clinical interview for Diagnostic and Statistical Manual of Mental Disorders. We further administered the Acute Stress Disorder Scale and the Posttraumatic Symptom Scale-10 to assess symptoms of acute stress disorder and posttraumatic stress disorder. Three percent of the patients had an acute stress disorder diagnosis 4 weeks after transfer to postacute rehabilitation. Posttraumatic stress disorder was found in 7% of the patients at 3-month follow-up and in 12% after 6 months, respectively. Eighteen percent of the patients showed a delayed onset of posttraumatic stress disorder. Sepsis turned out to be a significant predictor of posttraumatic stress disorder symptoms at 3-month follow-up.

CONCLUSIONS

A regular screening of post-ICU patients after discharge from hospital should be an integral part of aftercare management. The underlying mechanisms of severe sepsis in the development of posttraumatic stress disorder need further examination.

Outcome and prognosis of hypoxic brain damage patients undergoing neurological early rehabilitation

BACKGROUND

The prevalence of patients suffering from hypoxic brain damage is increasing. Long-term outcome data and prognostic factors for either poor or good outcome are lacking.

METHODS

This retrospective study included 93 patients with hypoxic brain damage undergoing neurological early rehabilitation [length of stay: 108.5 (81.9) days]. Clinical data, validated outcome scales (e.g. Barthel Index-BI, Early Rehabilitation Index-ERI, Glasgow Coma Scale-GCS, Coma Remission Scale-CRS), neuroimaging data, electroencephalography (EEG) and evoked potentials were analyzed.

RESULTS

75.3% had a poor outcome (defined as BI <50). 38 (40.9%) patients were discharged to a nursing care facility, 21 (22.6%) to subsequent rehabilitation, 17 (18.3%) returned home, 9 (9.7%) needed further acute-care hospital treatment and 8 (8.6%) died. Barthel Index on admission as well as coma length were strong predictors of outcome from hypoxic brain damage. In addition, duration of vegetative instability, prolongation of wave III in visual evoked potentials (flash VEP), theta and delta rhythm in EEG, ERI, GCS and CRS on admission were related to poor outcome. All patients with bilateral hypodensities of the basal ganglia belonged to the poor outcome group. Age had no independent influence on functional status at discharge.

CONCLUSIONS

As with other studies on neurological rehabilitation, functional status on admission turned out to be a strong predictor of outcome from hypoxic brain damage.