Does intensive rehabilitation improve the functional outcome of patients with traumatic brain injury? Interim result of a randomized controlled trial

Exploring the measurement of pediatric cognitive-communication disorders in traumatic brain injury research: A scoping review

OBJECTIVE

To synthesize information about the constructs measured, measurement instruments used, and the timing of assessment of cognitive-communication disorders (CCDs) in pediatric traumatic brain injury (TBI) research.

METHODS AND PROCEDURES

Scoping review conducted in alignment with Arksey and O'Malley's five-stage methodological framework and reported per the PRISMA extension for Scoping Reviews. Inclusion criteria: (a) cohort description, case-control, and treatment studies; (b) participants with TBI aged 5-18 years; (c) communication or psychosocial outcomes; and (d) English full-text journal articles. The first author reviewed all titles, abstracts, and full-text articles; 10% were independently reviewed.

OUTCOMES AND RESULTS

Following screening, a total of 687 articles were included and 919 measurement instruments, measuring 2134 unique constructs, were extracted. The Child Behavior Checklist was the most used measurement instrument and 'Global Outcomes/Recovery' was the construct most frequently measured. The length of longitudinal monitoring ranged between ≤3 months and 16 years.

CONCLUSIONS AND IMPLICATIONS

We found considerable heterogeneity in the constructs measured, the measurement instruments used, and the timing of CCD assessment in pediatric TBI research. A consistent approach to measurement may support clinical decision-making and the efficient use of data beyond individual studies in systematic reviews and meta-analyses.

The Outcome of Neurorehabilitation Efficacy and Management of Traumatic Brain Injury

For public health professionals, traumatic brain injury (TBI) and its possible protracted repercussions are a significant source of worry. In opposed to patient neurorehabilitation with developed brain abnormalities of different etiologies, neurorehabilitation of affected persons has several distinct features. The clinical repercussions of the various types of TBI injuries will be discussed in detail in this paper. During severe TBI, the medical course frequently follows a familiar first sequence of coma, accompanied by disordered awareness, followed by agitation and forgetfulness, followed by return of function. Clinicians must be aware of common medical issues that might occur throughout the various stages of neurorehabilitation, for example, posttraumatic hydrocephalus, paroxysmal sympathetic hyperactivity and posttraumatic neuroendocrine disorders, at each step of the process. Furthermore, we address problems about the scheduling of various rehabilitation programs as well as the availability of current data for comprehensive rehabilitative neuropsychology techniques.

Early Intensified Rehabilitation Training with Hyperbaric Oxygen Therapy Improves Functional Disorders and Prognosis of Patients with Traumatic Brain Injury

Objective: Traumatic brain injury (TBI) is a global public health problem. Hyperbaric oxygen (HBO) therapy may be beneficial for TBI because it improves cerebral blood flow into tissues exhibiting low blood flow. This was done to observe the clinical therapeutic effect of different intensities of rehabilitation training and HBO therapy in early stages of TBI.

Approach: In this multicenter, randomized, stratified case-controlled prospective clinical trial, we selected 158 patients with moderate-severe TBI and assigned them into (1) a control group receiving routine once-daily (1/d) rehabilitation training without HBO, (2) study group A receiving routine 1/d rehabilitation training with HBO, (3) study group B receiving twice-daily (2/d) intensified rehabilitation training with HBO, and (4) study group C receiving 2/d intensified rehabilitation training without HBO, all for 3 months. The cognitive ability, activities of daily life (ADL), and movement ability were assessed before and after training with the Fugl-Meyer Assessment (FMA), Functional Independence Measure (FIM), Modified Barthel Index (MBI), and Mini-Mental State Examination (MMSE).

Results: FIM, FMA, MBI, and MMSE scores were improved significantly after 1-, 2-, and 3-month rehabilitation training in all TBI patients (p < 0.01), and this improvement was especially remarkable in patients who received 2/d intensified rehabilitation training with HBO (p < 0.01).

Innovation: With extensive and intensive research on TBI rehabilitation, it was proved that TBI rehabilitation intervention should be initiated as early as possible.

Conclusion: Early intensified rehabilitation training in combination with HBO is more beneficial to the recovery of cognitive, ADL, and movement abilities of TBI patients.

Neurorehabilitation of Traumatic Brain Injury (TBI): A Clinical Review

Traumatic brain injury (TBI) and its potential long-term consequences are of major concern for public health. Neurorehabilitation of affected individuals has some specific characteristics in contrast to neurorehabilitation of patients with acquired brain lesions of other aetiology. This review will deal with the clinical consequences of the distinct lesions of TBI. In severe TBI, clinical course often follows a typical initial sequence of coma; followed by disturbed consciousness; later, post-traumatic agitation and amnesia; and finally, recovery of function occurs. In the different phases of neurorehabilitation, physicians should be aware of typical medical complications such as paroxysmal sympathetic hyperactivity, posttraumatic hydrocephalus, and posttraumatic neuroendocrine dysfunctions. Furthermore, we address questions on timing and on existing evidence for different rehabilitation programmes and for holistic neuropsychological rehabilitation approaches.

Predicting length of stay in specialist neurological rehabilitation

AIMS

A retrospective case series was performed to determine which measures of complexity, dependency and function most accurately predict inpatient neurorehabilitation length of stay for individuals with post-acute neurological disorders.

METHODS

Sociodemographic, medical and functional variables were extracted from data submitted to the UK Rehabilitation Outcomes Collaborative. Length of stay was calculated as the total number of inpatient days, functional status was measured using Barthel Index, rehabilitation complexity was measured using Extended Rehabilitation Complexity Scale, and nursing dependency was measured using the Northwick Park Dependency Scale.

RESULTS

The mean rehabilitation length of stay was 70.9 days, with length of stay being 35.1 days higher in inpatients with acquired brain injury than inpatients with spinal cord injury. Diagnostic category, Barthel Index scores, Extended Rehabilitation Complexity Scale scores and Northwick Park Dependency Scale scores at admission independently predicted length of stay. Multiple regressions including diagnostic group, Barthel Index, Extended Rehabilitation Complexity Scale and Northwick Park Dependency Scale statistically significantly predicted 37.9% of the variability in length of stay (p < 0.005). Northwick Park Dependency Scale on admission was most closely correlated with inpatient length of stay.

CONCLUSIONS

In conclusion, inpatient length of stay is predicted by diagnostic category, Extended Rehabilitation Complexity Scale, Northwick Park Dependency Scale and Barthel Index. The most influential predictor of rehabilitation length of stay was Northwick Park Dependency Scale score at admission. These results may help facilitate rehabilitation resource planning and implementation of effective commissioning plans. Implications for Rehabilitation The most accurate predicting variable for length of stay in inpatient neurological rehabilitation was nursing need as measured by the Northwick Park Dependency Scale score on admission. Service users and commissioners can be provided with more realistic predictions of length of stay derived from admission variables that can be used in planning inpatient rehabilitation. Age and gender do not seem to have an effect on the total length of stay in rehabilitation.

Multi-disciplinary rehabilitation for acquired brain injury in adults of working age

BACKGROUND

Evidence from systematic reviews demonstrates that multi-disciplinary rehabilitation is effective in the stroke population, in which older adults predominate. However, the evidence base for the effectiveness of rehabilitation following acquired brain injury (ABI) in younger adults has not been established, perhaps because this scenario presents different methodological challenges in research.

OBJECTIVES

To assess the effects of multi-disciplinary rehabilitation following ABI in adults 16 to 65 years of age.

SEARCH METHODS

We ran the most recent search on 14 September 2015. We searched the Cochrane Injuries Group Specialised Register, The Cochrane Library, Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic+Embase (OvidSP), Web of Science (ISI WOS) databases, clinical trials registers, and we screened reference lists.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing multi-disciplinary rehabilitation versus routinely available local services or lower levels of intervention; or trials comparing an intervention in different settings, of different intensities or of different timing of onset. Controlled clinical trials were included, provided they met pre-defined methodological criteria.

DATA COLLECTION AND ANALYSIS

Three review authors independently selected trials and rated their methodological quality. A fourth review author would have arbitrated if consensus could not be reached by discussion, but in fact, this did not occur. As in previous versions of this review, we used the method described by Van Tulder 1997 to rate the quality of trials and to perform a 'best evidence' synthesis by attributing levels of evidence on the basis of methodological quality. Risk of bias assessments were performed in parallel using standard Cochrane methodology. However, the Van Tulder system provided a more discriminative evaluation of rehabilitation trials, so we have continued to use it for our primary synthesis of evidence. We subdivided trials in terms of severity of brain injury, setting and type and timing of rehabilitation offered.

MAIN RESULTS

We identified a total of 19 studies involving 3480 people. Twelve studies were of good methodological quality and seven were of lower quality, according to the van Tulder scoring system. Within the subgroup of predominantly mild brain injury, 'strong evidence' suggested that most individuals made a good recovery when appropriate information was provided, without the need for additional specific interventions. For moderate to severe injury, 'strong evidence' showed benefit from formal intervention, and 'limited evidence' indicated that commencing rehabilitation early after injury results in better outcomes. For participants with moderate to severe ABI already in rehabilitation, 'strong evidence' revealed that more intensive programmes are associated with earlier functional gains, and 'moderate evidence' suggested that continued outpatient therapy could help to sustain gains made in early post-acute rehabilitation. The context of multi-disciplinary rehabilitation appears to influence outcomes. 'Strong evidence' supports the use of a milieu-oriented model for patients with severe brain injury, in which comprehensive cognitive rehabilitation takes place in a therapeutic environment and involves a peer group of patients. 'Limited evidence' shows that specialist in-patient rehabilitation and specialist multi-disciplinary community rehabilitation may provide additional functional gains, but studies serve to highlight the particular practical and ethical restraints imposed on randomisation of severely affected individuals for whom no realistic alternatives to specialist intervention are available.

AUTHORS' CONCLUSIONS

Problems following ABI vary. Consequently, different interventions and combinations of interventions are required to meet the needs of patients with different problems. Patients who present acutely to hospital with mild brain injury benefit from follow-up and appropriate information and advice. Those with moderate to severe brain injury benefit from routine follow-up so their needs for rehabilitation can be assessed. Intensive intervention appears to lead to earlier gains, and earlier intervention whilst still in emergency and acute care has been supported by limited evidence. The balance between intensity and cost-effectiveness has yet to be determined. Patients discharged from in-patient rehabilitation benefit from access to out-patient or community-based services appropriate to their needs. Group-based rehabilitation in a therapeutic milieu (where patients undergo neuropsychological rehabilitation in a therapeutic environment with a peer group of individuals facing similar challenges) represents an effective approach for patients requiring neuropsychological rehabilitation following severe brain injury. Not all questions in rehabilitation can be addressed by randomised controlled trials or other experimental approaches. For example, trial-based literature does not tell us which treatments work best for which patients over the long term, and which models of service represent value for money in the context of life-long care. In the future, such questions will need to be considered alongside practice-based evidence gathered from large systematic longitudinal cohort studies conducted in the context of routine clinical practice.

Longitudinal changes in functioning and disability in patients with disorders of consciousness: the importance of environmental factors

Disorders of consciousness are neurological conditions associated with low levels of functioning which pose a serious challenge to public health systems. The current study aimed to examine longitudinal changes in functioning in patients with disorders of consciousness and to identify associated biopsychosocial factors using the International Classification of Functioning, Disability, and Health. An Italian sample of 248 patients was assessed longitudinally. Differences in relative variability (an index of change that controls for baseline levels) between acute and chronic patients and predictors of relative variability in "Activities &amp; Participation" were examined. Results showed that there were subgroups of patients whose functioning improved over time. The number of problems in "Activities &amp; Participation" decreased in acute patients over time, whereas in chronic patients, an increase was found. The significant difference in relative variability for the environmental factor "support and relationships" reflects the increase in facilitators in acute patients, whereas the number of facilitators in chronic patients remained unchanged over time. Age at event, time from event, and relative variability in "Environmental Factors" were significant predictors of relative variability in "Activities &amp; Participation". It is of clinical relevance that patients with disorders of consciousness are kept in a supportive and facilitative environment, in order to prevent a decline in their functioning. Moreover, caregivers should receive tailored support in order to enhance and facilitate appropriate care of patients with disorders of consciousness.

Environmental enrichment and the sensory brain: the role of enrichment in remediating brain injury

The brain's life-long capacity for experience-dependent plasticity allows adaptation to new environments or to changes in the environment, and to changes in internal brain states such as occurs in brain damage. Since the initial discovery by Hebb (1947) that environmental enrichment (EE) was able to confer improvements in cognitive behavior, EE has been investigated as a powerful form of experience-dependent plasticity. Animal studies have shown that exposure to EE results in a number of molecular and morphological alterations, which are thought to underpin changes in neuronal function and ultimately, behavior. These consequences of EE make it ideally suited for investigation into its use as a potential therapy after neurological disorders, such as traumatic brain injury (TBI). In this review, we aim to first briefly discuss the effects of EE on behavior and neuronal function, followed by a review of the underlying molecular and structural changes that account for EE-dependent plasticity in the normal (uninjured) adult brain. We then extend this review to specifically address the role of EE in the treatment of experimental TBI, where we will discuss the demonstrated sensorimotor and cognitive benefits associated with exposure to EE, and their possible mechanisms. Finally, we will explore the use of EE-based rehabilitation in the treatment of human TBI patients, highlighting the remaining questions regarding the effects of EE.

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 of children with traumatic brain injury: a critical review

The purpose of this critical review of the English literature published between 1975 and 2009 was to assess the quality of the evidence for the efficacy of rehabilitation intervention after traumatic brain injury in children. "Evidence for intervention studies" was used to classify the research strength of design and report. Only a minority (16/439) of the published studies has been related to traumatic brain injury in children and has used a scientific or quasiscientific design. Only one study met the criteria of class I "evidence for intervention" studies. However, this study included adults, as well as children. The other 15 studies, although reporting positive results, had many methodologic deficiencies, and consequently their validity is questionable. Although the methodologic and ethical difficulties involved are acknowleged, a multicenter approach is required to achieve valid conclusions. Use of designs such as comparative effectiveness research might prove to be a practical solution. High-quality intervention research would facilitate stronger evidence-based counseling for children and families requiring posttraumatic brain injury intervention and to policy makers.

Traumatic brain injury and post-acute decline: what role does environmental enrichment play? A scoping review

Objectives: While a growing number of studies provide evidence of neural and cognitive decline in traumatic brain injury (TBI) survivors during the post-acute stages of injury, there is limited research as of yet on environmental factors that may influence this decline. The purposes of this paper, therefore, are to (1) examine evidence that environmental enrichment (EE) can influence long-term outcome following TBI, and (2) examine the nature of post-acute environments, whether they vary in degree of EE, and what impact these variations have on outcomes.

Methods: We conducted a scoping review to identify studies on EE in animals and humans, and post-discharge experiences that relate to barriers to recovery.

Results: One hundred and twenty-three articles that met inclusion criteria demonstrated the benefits of EE on brain and behavior in healthy and brain-injured animals and humans. Nineteen papers on post-discharge experiences revealed that variables such as insurance coverage, financial, and social support, home therapy, and transition from hospital to home, can have an impact on clinical outcomes.

Conclusion: There is evidence to suggest that lack of EE, whether from lack of resources or limited ability to engage in such environments, may play a role in post-acute cognitive and neural decline. Maximizing EE in the post-acute stages of TBI may improve long-term outcomes for the individual, their family and society.

Effectiveness of physiotherapy and occupational therapy after traumatic brain injury in the intensive care unit

Physiotherapy and occupational therapy are frequently administered in intensive care units (ICUs) after traumatic brain injury (TBI) to promote recovery. The increasing economic pressure and the growing need for evidence of therapeutic effectiveness are reasons for reviewing the currently available scientific data. The databases of OTseeker, PEDro, Medline, and Cochrane were searched for studies on frequently applied therapeutic procedures in the ICU following a TBI. It becomes evident that the currently available data on physiotherapy and occupational therapy are very limited. Consequently, it is not possible to give conclusive recommendations within an evidence-based context. Studies of other neurological disorders indicate that early mobilisation positively influences outcome parameters such as the ability to walk. It can be concluded from three studies that physiotherapy for the prevention or treatment of ventilator-associated pneumonia is not effective. The proof of effectiveness for other physiotherapeutic and occupational therapy interventions must still be demonstrated.

Evaluation of the Evidence for Rehabilitation Following Acquired Brain Injury

This article represents a summary of the George Burniston Oration of the Australian Faculty of Rehabilitation Medicine, which was given as a keynote address at the 6th World Congress on Brain Injury, Melbourne, May 2005. The paper concerns evaluation of the evidence for effectiveness of rehabilitation following acquired brain injury (ABI). It explores the current evidence available, and discusses a number of different review strategies which may be used to overcome the challenges of assimilating research evidence in this context.

Does intensive rehabilitation improve the functional outcome of patients with traumatic brain injury (TBI)? A randomized controlled trial

OBJECTIVE

To evaluate the effects of an increase in the intensity of rehabilitation on the functional outcome of patients with traumatic brain injury (TBI).

DESIGN AND METHODS

Sixty-eight patients (age 12-65 years) with moderate-to-severe TBI were included. They were randomized into high (4-hour/day) or control (2-hour/day) intensity rehabilitation programmes at an average of 20 days after the injury. The programmes ended when the patients achieved independence in daily activities or when 6 months had passed.

OUTCOME AND RESULTS

No significant differences were found in the Functional Independence Measure (FIM) (primary outcome) and Neurobehavioural Cognitive Status Examination (NCSE) total scores between the two groups. There were significantly more patients in the high intensity group than in the control group who achieved a maximum FIM total score at the third month (47% vs. 19%, p = 0.015) and a maximum Glasgow Outcome Scale (GOS) score at the second (28% vs. 8%, p = 0.034) and third months (34% vs. 14%, p = 0.044).

CONCLUSIONS

Early intensive rehabilitation may improve the functional outcome of patients with TBI in the early months post-injury and hence increase the chance of their returning to work early. Intensive rehabilitation in this study speeded up recovery rather than changed the final outcome.

The efficacy of acquired brain injury rehabilitation

OBJECTIVE

The purpose of this review was to investigate the efficacy of rehabilitation interventions in acquired brain injury (ABI) rehabilitation to provide guidance for clinical practice based on the best available evidence.

METHODS AND MAIN OUTCOMES

A systematic review of the literature from 1980-2005 was conducted focusing on rehabilitation interventions for ABI. The efficacy of a given intervention was classified as strong (supported by at least two randomized controlled trials (RCTs)), moderate (supported by a single RCT), or limited (supported by other types of studies in the absence of RCTs).

RESULTS

The majority of interventions were only supported by limited evidence. However, there is moderate evidence that inpatient rehabilitation results in successful return to work and return to duty for the majority of military service members, increasing the intensity of rehabilitation reduces length of stay and improves short-term functional outcomes, and that direct patient involvement in neurorehabilitation goal setting results in significant improvements in reaching and maintaining those goals.

CONCLUSIONS

There is a need for studies of improved methodological quality into ABI rehabilitation.

Natural history of recovery from brain injury after prolonged disorders of consciousness: outcome of patients admitted to inpatient rehabilitation with 1-4 year follow-up

The natural history of recovery from brain injury typically consists of a period of impaired consciousness, a subsequent period of confusion and amnesia, followed by a period of post-confusional recovery of function. Patients with more severe injuries may have more prolonged episodes of unconsciousness or minimal consciousness and may not fully evolve through this continuum of recovery. There is limited information on the course of recovery and long-term outcome of patients with prolonged unconsciousness, particularly those with extended periods in the minimally conscious state. Further, patients with impaired consciousness are frequently denied access to hospital-based rehabilitation services because of uncertain prognosis and a perceived lack of benefit from rehabilitative interventions.

METHODS

A consecutive series of 36 patients with traumatic (TBI) and non-traumatic brain injury (nonTBI) in a vegetative state (VS) or minimally conscious state (MCS) on admission to a specialized, slow-to-recover brain injury program in an acute rehabilitation hospital was retrospectively reviewed to evaluate course of recovery during rehabilitation hospitalization and in follow-up, 1-4 years post-injury. Independent variables included: time to resolution of VS, MCS and confusional state/posttraumatic amnesia (CS/PTA), based on Aspen criteria, Coma Recovery Scale-Revised (CRS-R) and Galveston Orientation and Amnesia Test (GOAT) scores. Outcome measures (calculated separately for TBI, nonTBI, VS, or MCS on admission subgroups) included: proportion of patients who recover and recovery time to MCS, CS/PTA stages, household independence, and return to school or work, as well as Disability Rating Scale (DRS) scores at 1, 2, 3, and 4 years post-injury.

RESULTS

The majority emerged from MCS (72%) and CS/PTA (58%) by latest follow-up. It took significantly longer for patients admitted in VS (means: MCS, 16.43 weeks; CS/PTA, 30.1 weeks) than MCS (means: MCS, 7.36 weeks; CS/PTA, 11.5 weeks) to reach both milestones. Almost all who failed to clear CS/PTA by latest follow-up were patients with nonTBI or TBI with VS lasting over 8 weeks. Duration of MCS was a strong predictor of duration CS/PTA after emergence from MCS, accounting for 57% of the variance. Nearly half the patients followed at least 1 year achieved recovery to, at least, daytime independence at home and 22% returned to work or school, 17% at or near pre-injury levels. Discharge FIM score or duration of MCS, along with age, were best predictors of DRS in outcome models. DRS scores continued to improve after 2 and 3 years post-injury.

CONCLUSIONS

Patients in VS whose transition to MCS occurred within 8 weeks of onset are likely to continue recovering to higher levels of functioning, a substantial proportion to household independence, and productive pursuits. Patients with TBI are more likely to progress than patients with nonTBI, though significant improvement in the nonTBI group is still possible. Active, higher intensity, rehabilitation should be strongly considered for patients with severely impaired consciousness after brain injury, especially for patients with TBI who have signs of progression to the MCS.

Motor recover during the acute period of craniocerebral trauma using kinetotherapy

The aim of the present work was to assess the influences of age, gender, and the severity of brain trauma on recovery of motor function using kinetotherapy. The study included 131 patients (99 men and 32 women) investigated during the acute phase of trauma in the Department of Brain Trauma, Clinical Hospital, Kaunas Medical University. After stabilization, 80 patients were transferred to the neurorehabilitation clinic and 51 were transferred to other rehabilitation centers. Motor function in the patients was assessed using the Clinical Outcomes Variable Scale (COVS) at the beginning and end of the acute trauma period and during early rehabilitation, i.e., at the beginning, 25 days later, and on completion. During the acute trauma period, patients had impairments to the abilities to turn over, sit, maintain balance while sitting, to move horizontally and vertically, walk, and use mobility aids, along with reductions in walking duration and speed, and difficulty in wheelchair mobility and hand functions. Kinetotherapy yielded high or intermediate levels of efficacy in 90% of the patients. The efficacy of kinetotherapy was significantly greater in young patients than in elderly and old patients (p < 0.05). Gender and trauma severity had no statistically significant effects on the efficacy of kinetotherapy (p > 0.05).

Physiotherapy after traumatic brain injury: a systematic review of the literature

PRIMARY OBJECTIVES

At present there are no standardized recommendations concerning physiotherapy of individuals with traumatic brain injury (TBI) resulting in a high variability of methods and intensity. The aim of this literature review is to develop recommendations concerning physiotherapy in the post-acute phase after TBI on the basis of scientific evidence.

METHOD

literature review: data bases: PubMed, PEDro, OT-Seeker, Cochrane and Cinahl.

KEYWORDS

brain injury (in PEDro, OT-Seeker, Cochrane), brain injury AND physical therapy (in PubMed and Cinahl).

RESULTS

Fourteen studies met the inclusion criteria and were grouped into sub-groups: sensory stimulation, therapy intensity, casting/splinting, exercise or aerobic training and functional skill training. While for sensory stimulation evidence could not be proven, a strong evidence exists that more intensive rehabilitation programmes lead to earlier functional abilities. The recommendation due to casting for the improvement of passive range of motion is a grade B, while only a C recommendation is appropriate concerning tonus reduction. Strong evidence exists that intensive task-orientated rehabilitation programmes lead to earlier and better functional abilities.

CONCLUSION

Although some recommendations for the effectiveness of physical therapy interventions could be expressed, there are many questions concerning the treatment of humans with TBI which have not been investigated so far. Especially on the level of activity and participation only a few studies exist.

Psychosocial factors associated with lifetime experience of serious unintentional injury in South Korea

PURPOSE

The purpose of this study was to determine the prevalence of lifetime unintentional-injury experience and evaluate the quality of life of unintentional-injury victims, to provide useful data for the development of interventions aimed at decreasing the incidence of unintentional injuries. DESIGN, SAMPLE, AND METHODS: This study utilized data obtained from cross-sectional surveys of 24,327 Korean individuals aged 19-65 years, performed using face-to-face interviews. Demographic characteristics, unintentional-injury experience, attributes of health behavior, and health-related quality of life (HRQoL) questions were included in the study instruments.

RESULTS

About 11.8% of the subjects had experienced an unintentional injury that required hospitalization at least once in their lifetime. Being older, being male, having less education and lower income, working in a blue-collar job, and being enrolled in medical aid programs were associated with increased likelihood of having an unintentional injury. Among the HRQoL and risk-taking behavior variables, limitations in daily activities, suicide ideation, and binge drinking were significantly associated with injury experience.

CONCLUSION

Public health efforts to prevent unintentional injuries should target high-risk populations such as males, those with low incomes and education levels, and binge drinkers. Efforts should also be made to enhance the HRQoL of injury victims.

Multi-disciplinary rehabilitation for acquired brain injury in adults of working age

BACKGROUND

Evidence from systematic reviews demonstrates that multi-disciplinary rehabilitation is effective in the stroke population, where older adults predominate. However, the evidence base for the effectiveness of rehabilitation following acquired brain injury (ABI) in younger adults is not yet established, perhaps because there are different methodological challenges.

OBJECTIVES

To assess the effects of multi-disciplinary rehabilitation following ABI in adults, 16 to 65 years. To explore approaches that are effective in different settings and the outcomes that are affected.

SEARCH STRATEGY

We used a wide range of sources including: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966-2004), EMBASE (1988-2004), CINAHL (1983-2004), PsycLIT (1967-2004), AMED, the National Research Register 2004 and ISI Science Citation Index (1981-2004).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing multi-disciplinary rehabilitation with either routinely available local services or lower levels of intervention; or trials comparing intervention in different settings or at different levels of intensity. Quasi-randomised and quasi-experimental designs were also included, providing they met pre-defined methodological criteria.

DATA COLLECTION AND ANALYSIS

Trials were selected by two authors independently, and their methodological quality rated, again by two independent authors. A third reviewer arbitrated when disagreements could not be resolved by discussion. A 'best evidence' synthesis was performed by attributing levels of evidence, based on methodological quality. Trials were sub-divided in terms of severity of ABI and the setting and type of rehabilitation offered.

MAIN RESULTS

Ten trials were identified of good methodological quality and four of lower quality. Within the subgroup of predominantly mild brain injury, 'strong evidence' suggested that most patients make a good recovery with provision of appropriate information, without additional specific intervention. For moderate to severe injury, there is 'strong evidence' of benefit from formal intervention. For patients with moderate to severe ABI already in rehabilitation, there is strong evidence that more intensive programmes are associated with earlier functional gains, and 'moderate evidence' that continued outpatient therapy can help to sustain gains made in early post-acute rehabilitation. There is 'limited evidence' that specialist in-patient rehabilitation and specialist multi-disciplinary community rehabilitation may provide additional functional gains, but the studies serve to highlight the particular practical and ethical restraints on randomisation of severely affected individuals for whom there are no realistic alternatives to specialist intervention.

AUTHORS' CONCLUSIONS

Problems following ABI vary; different services are required to suit the needs of patients with different problems. Patients presenting acutely to hospital with moderate to severe brain injury should be routinely followed up to assess their need for rehabilitation. Intensive intervention appears to lead to earlier gains. The balance between intensity and cost-effectiveness has yet to be determined. Patients discharged from in-patient rehabilitation should have access to out-patient or community-based services appropriate to their needs. Those with milder brain injury benefit from follow-up, and appropriate information and advice. Not all questions in rehabilitation can be addressed by traditional research methodologies. There are important questions still to be answered and future research should employ the most appropriate methodology.

Rehabilitation interventions for vegetative and minimally conscious patients

Brain injury rehabilitation is a complex and challenging task for all members of the multidisciplinary team. Medical advances have allowed more severely impaired patients to survive and consequently the number of patients in the vegetative and minimally conscious states have proportionately increased. Thus, the need for evidence-based practice and further research demonstrating the effects of specific rehabilitation interventions is required. This article reviews the current research and consensus on rehabilitation for patients in the vegetative and minimally conscious states.

Beneficial effect of cerebrolysin on moderate and severe head injury patients: result of a cohort study

Cerebrolysin is used as a neurotrophic agent for the treatment of ischemic stroke and Alzheimer's Disease. Exploratory studies in patients with post-acute traumatic brain injury have shown that this treatment might help improve recovery. Aim of this study was to investigate whether addition of Cerebrolysin to the initial treatment regimen of moderate and severe head injury patients would improve their outcome. At 6 months, 67% of the patients (Cerebrolysin group) attained good outcome (GOS 3-5). The study group was compared with the historical cohort of patients from the hospital trauma data bank, with age, sex and admitting GCS matching. More patients tended to a good outcome in the Cerebrolysin group (P = 0.065). No significant side-effect requiring cessation of Cerebrolysin was noted. It can be concluded that the use of Cerebrolysin as part of the initial management of moderate and severe head injury is safe and well tolerated. The results suggest that Cerebrolysin is beneficial in regard to the outcome in these patients, especially in elderly patients.

Predicting one year clinical outcome in traumatic brain injury (TBI) at the beginning of rehabilitation

Predicting long-term clinical outcome for patients with traumatic brain injury (TBI) at the beginning of rehabilitation provides essential information for counseling of the family and priority-setting for the limited resources in intensive rehabilitation. The objective of this study is to work out the probability of the one-year outcome at the beginning of rehabilitation. Sixty-eight patients with moderate-to-severe TBI and known one-year outcome were employed for outcome prediction using the logistic regression model. A large number of prospectively collected data at admission (age, Glasgow Coma Scale [GCS] Score, papillary response), during intensive care unit (ICU) management (duration of coma, intracranial pressure [ICP] and its progress) and at the beginning of rehabilitation (baseline Functional Independence Measure [FIM], Neuro-behavioral Cognitive Status Examination [NCSE] and Functional Movement Assessment [FMA]) were available for preliminary screening by univariate analysis. Six prognostic factors (age, GCS, duration of coma, baseline FIM, NCSC and FMA) were utilized for the final logistic regression model. Age, GCS and baseline FIM at the beginning of rehabilitation have been found to be independent predictors for one-year outcome. The accuracy of prediction for a good Glasgow Outcome Score is 68% and an outcome for disability (either moderate or severe) is 83%. Validation of this model using a new set of data is required.

Measuring High-Level Mobility After Traumatic Brain Injury

High-level mobility is important for participation in many pre-accident activities after traumatic brain injury (TBI). This review examined which measures are used to quantify physical status and mobility after TBI to determine their appropriateness for measuring high-level mobility. Electronic databases, hand searching of several TBI journals, and citation tracking from retrieved articles were used to identify all TBI outcome studies from 1990 through to May 2004. Preliminary screening identified articles that either reported on physical outcome or mobility after TBI or utilized measurement tools with a physical component. Studies were selected for detailed analysis if they reported on mobility or physical outcomes after TBI. The search identified 175 studies that met the inclusion criteria for further analysis. The FIM instrument is the most frequently used outcome measure, highlighting a trend toward using inpatient measures to evaluate long-term outcomes. Only one study used a measurement tool that incorporated a mobility item beyond independent walking and stairs. High-level mobility is seldom measured using standardized outcome measures after TBI, despite independent mobility being one of the major goals of rehabilitation. A high-level mobility scale is needed to address the ceiling effect of outcome scales currently used in TBI rehabilitation and to extend mobility to age-appropriate levels for return to leisure and sporting activities.

Pediatric trauma systems

The origins of trauma systems in the United States date to the 1960s when physicians returning from wars abroad realized that lessons learned from managing military casualties could be applied to civilian traumatic injury. Over the next several decades, trauma centers and then trauma systems began to be developed in an attempt to improve prehospital and acute care for these patients. Although studies of trauma system effectiveness are fraught with methodologic difficulties, several types of studies (panel reviews of preventable deaths, registry studies, and population-based studies), suggest that there may be improvements in mortality when trauma systems are established. Further study needs to focus on other outcomes than mortality, such as return to function after rehabilitation. Pediatric trauma systems have by necessity developed within the "adult" systems in place. The history of pediatric system development and studies assessing outcomes are also discussed. Continued system development, assessment, and educational efforts about how childhood injuries are different are essential to combat this leading killer of children.