Does an early onset and continuous chain of rehabilitation improve the long-term functional outcome of patients with severe traumatic brain injury?

Published version of an article published in the journal: Journal of Neurotrauma. Also available from the publisher at: http://dx.doi.org/10.1089/neu.2011.1811There are currently no international guidelines regarding treatment in the early rehabilitation phase for persons with severe traumatic brain injury (TBI), and only a few studies have investigated the effect of integrating rehabilitation into acute TBI care. The aim of the study was to evaluate whether a continuous chain of rehabilitation that begins with the acute phase could improve the functional outcome of severe TBI patients, compared to a broken chain of rehabilitation that starts in the sub-acute phase of TBI. A total of 61 surviving patients with severe TBI were included in a quasi-experimental study conducted at the Level I trauma center in Eastern Norway. In the study, 31 patients were in the early rehabilitation group (Group A) and 30 patients were in the delayed rehabilitation group (Group B). The functional outcomes were assessed 12 months post-injury with the Glasgow Outcome Scale Extended (GOSE) and the Disability Rating Scale (DRS). A favorable outcome (GOSE 6-8) occurred in 71 % of the patients from Group A versus 37 % in Group B (p=0.007). The DRS score was significantly better in Group A (p=0.03). The ordinal logistic regression analysis was used to quantify the relationship between the type of rehabilitation chain and the GOSE. A better GOSE outcome was found in patients from Group A (unadjusted OR 3.25 and adjusted OR 2.78, respectively). These results support the hypothesis that better functional outcome occurs in patients who receive early onset and a continuous chain of rehabilitation

Functional level after Traumatic Brain Injury

Objectives: The objectives of the thesis were to describe the functional level (papers I and II) and self awareness of functional deficits (paper III) after moderate and severe Traumatic Brain Injury (TBI), and to evaluate the predictive impact of pre-injury and injury-related factors on functional level (papers I, II) and awareness of functional deficits (paper III). Material and methods: Papers I-II were cohort studies of 55 TBI patients (moderate = 21, severe = 34) and 65 TBI patients (moderate = 21, severe = 44). Their functional level was assessed by FIM (Functional Independence Measure) at admission and discharge from in-hospital sub-acute rehabilitation (paper I), and by FIM and GOSE (Glasgow Outcome Scale Extended) 12 months after injury (paper II). Possible predictors of FIM at discharge (paper I) and at 12 months (paper II) were analyzed in a regression model. Paper III was a cohort study of 50 TBI patients (moderate = 17, severe = 33) assessed by Patient Competence Rating Scale (PCRS) 12 months after injury. Awareness of functional deficits was investigated by subtracting PCRS relative ratings (PCRS-R) from PCRS patient ratings (PCRS-P). Predictors of PCRS-P ratings and differences between patient and relative ratings were analyzed in a regression model. Results: At discharge from sub-acute rehabilitation, on average 53 (± 24) days post-injury, the FIM motor and cognitive scores had improved in both moderate and severe TBI patients, but 57% of those with moderate TBI and 91% of those with severe TBI still had impaired motor and cognitive function with a FIM score < 126 (paper I). The activity limitations were mild (FIM109-126 = functionally independent) in 95% of moderate TBI patients and in 62% of severe TBI patients. During the period from discharge to 12 months after injury, the FIM motor score improved in severe TBI but not in moderate TBI patients, and the FIM cognitive score did not improve in any of the groups (paper II). At 12 months, 19% of moderate TBI patients and 40% of severe TBI patients still had impaired motor and cognitive function as assessed by FIM. The activity limitations were mild (FIM 109-126) in 95% with moderate and in 74% with severe TBI (paper II). Functional global outcome as assessed by GOSE showed “good recovery” in 52% with moderate TBI versus 33% in severe TBI, “moderate disability” in 33% with moderate TBI versus 31% in severe TBI, and “severe disability” in 14% with moderate TBI versus 36% in severe TBI. Longer stays at the rehabilitation unit, a short PTA period and a high GCS score at admission to rehabilitation were positive predictors of functional level (FIM) at discharge and 12 months follow-up (papers I and II). Self-perceived function 12 months after injury was assessed by PCRS–P and compared to relative-perceived function (PCRS-R) with mean scores of 122/150 (95% CI = 115; 129) and 117/150 (95% CI = 110; 125), p = 0.93. The patients scored themselves slightly higher than their relatives in the domains of Activities of Daily Living (ADL) and cognitive function, but not in the domains of interpersonal and emotional function. The strongest predictor of PCRSP was GCS at admission to rehabilitation (GCS rehab) (B = 3.314, p = 0.008), while others were GCS acute (admission acute hospital) (B = -1.771, p = 0.044), age (B = 0.510, p = 0.002), and PTA duration (B = -0.330, p < 0.001). Predictors of differences in PCRS-P and PCRS-R (overestimation of own function) were GCS acute (B = -3.530, p = 0.001), age (B = 0.304, p = 0.036), and PTA (B = -0.160, p = 0.020). Analyses of predictors in different domains showed that lower GCS rehabilitation predicted overestimation of ADL functioning (B = -0.526, p = 0.037), lower GCS acute was the strongest predictor of overestimation of cognition (B = -0.851, p = 0.001), and of emotional regulation (B = -1.042, p = 0.042) while being married (12 months post-injury) was the strongest negative predictor of overestimation of interpersonal functioning (B = -3.622, p = 0.015). Conclusions: The greatest improvement after moderate and severe TBI was in the sub-acute phase during the stay in a specialised rehabilitation unit. A short PTA period, a high GCS score and FIM score at admission to rehabilitation, and a longer stay in the rehabilitation unit were positive predictors of functional level at discharge and 12 months after injury. Residual disability was reported in 48% of moderate TBI patients measured by GOSE 12 months post injury. A slight lack of awareness of dysfunction in the domains of ADL and cognitive function were reported 12 months after injury. Higher age was a predictor of more severe awareness deficits 12 months after injury. More severe injury (longer PTA) was a predictor of low self-perceived function though negatively associated with degree of awareness deficits 12 months after injury

Functional Level During the First Year After Moderate and Severe Traumatic Brain Injury: Course and Predictors of Outcome

Background: The objective of this study was to describe the functional level during the first year after moderate and severe traumatic brain injury (TBI), and to evaluate the predictive impact of pre-injury and injury-related factors. Methods: A cohort of 65 patients with moderate (N = 21) or severe (N = 44) TBI were examined with FIM (Functional Independence Measure) at admission and discharge from the rehabilitation clinic (on average two months after injury) and at 12 months, and with GOSE (Glasgow Outcome Scale Extended) at 12 months after injury. Possible predictors were analyzed in a regression model using FIM total score at 12 months as outcome. Results: All mean FIM scores improved significantly from injury to discharge from sub-acute rehabilitation. In the later period from discharge to 12 months after injury, the mean FIM motor score improved in severe TBI but not in moderate TBI patients. The mean FIM cognitive scores did not improve in any of the groups. At 12 months, 95% with moderate TBI had a FIM score from 109 - 126 (functionally independent) compared to 74% with severe TBI. Functional global outcome as assessed by GOSE was “good recovery” in 52% with moderate TBI versus 33% in severe TBI, “moderate disability” in 33% with moderate TBI versus 31% in severe TBI, and “severe disability” in 14% with moderate TBI versus 36% in severe TBI. Predictors such as PTA duration (B = -0.209), GCS admission rehabilitation (B = 5.058) and LOS rehabilitation (B = 0.458) explained 47% of the FIM variance 12 months post injury. Conclusions: The greatest improvement after moderate and severe TBI was in the sub-acute phase during the stay in a specialized rehabilitation unit. Residual disability was reported in 47% of moderate TBI patients as measured by GOSE at 12 months post injury indicating the importance of post-acute rehabilitation for these patients. Longer stays at the rehabilitation unit, a short PTA period and a high GCS score at admission to rehabilitation were positive predictors of functional level (FIM) at 12 months follow-up demonstrating that these factors are common predictors of early and late TBI phases

Children’s, parents’, and teachers’ experiences of the feasibility of a telerehabilitation intervention for children with acquired brain injury in the chronic phase – a qualitative study of acceptability and participation in the Child In Context Intervention (CICI)

Abstract Background This is a qualitative feasibility study of the Child in Context Intervention (CICI). The CICI is an individualized, goal-oriented and home-based tele-rehabilitation intervention which targets everyday functioning of children (6–16 years) with acquired brain injury in the chronic stage, and their families, one year or more after insult, who have ongoing challenges (physical, cognitive, behavioral, social and/or psychological). The aim of this study is to better understand how children, parents and teachers experienced participation and acceptability; to develop knowledge about the mechanisms of change, and to explore how the CICI was tailored to the context. Methods Six families and schools participated in the intervention, which comprised seven tele-rehabilitation sessions in which the child and parent participated, one in-person parent seminar and four digital school meetings. A multidisciplinary team delivered the intervention to 23 participants over a 4- to 5-month period. The intervention involved psychoeducation about targeted acquired brain injury-related problems, such as fatigue, pain, or social challenges. All but one consented to participate in the current digital interview study. The data were analyzed using content analysis. Results The experience of participation and acceptability varied among the children. Attendance was consistently high; the child participants felt mostly listened to and could influence goal setting and strategies. However, engaging and motivating the child participants proved somewhat challenging. The parents found the CICI rewarding, useful and relevant. However, they had different experiences regarding which intervention component they perceived as most helpful. Some argued in favor of the ‘whole intervention’, while others highlighted new knowledge, SMART goals or the school collaboration. The teachers found the intervention acceptable and useful but wanted a better meeting plan. They had difficulties in finding time for meetings, emphasized the involvement of school leaders, and appreciated the digital format. Conclusions Overall, the intervention was perceived as acceptable, and the participants felt that the various intervention components contributed to improvements. The CICI’s flexibility facilitated tailoring to different contexts based on the children’s functional level. The digital format saved time and provided flexibility regarding the amount of attendance but limited full participation from children with more severe cognitive impairments. Trial registration ClinicalTrials.gov Identifier: NCT04186182

Rehabilitation for children with chronic acquired brain injury in the Child in Context Intervention (CICI) study: study protocol for a randomized controlled trial

Background: Pediatric acquired brain injury (pABI) is associated with long-term cognitive, behavioral, social, and emotional problems, which may affect the quality of life, school, and family functioning. Yet, there is a lack of evidence-based community-centered rehabilitation programs for chronic pABI and these children do not systematically receive comprehensive rehabilitation. The Child In Context Intervention (CICI) study is a pragmatic randomized controlled trial (RCT) for children with chronic pABI, which aims to evaluate the effectiveness of an individualized and goal-oriented intervention targeting everyday functioning of the child and family. Methods: Children aged 6–16 years with MRI/CT-verified intracranial abnormalities will be included in the CICI study if they have persistent self- or parent-reported cognitive, emotional, and/or behavioral challenges 1 year or more after insult and attend school regularly. A total of 70 families will be randomized 1:1 to an intervention or a control group. The intervention consists of seven family sessions, one parent seminar, and four school sessions delivered over approximately 6 months. The parent seminar will be held in person, and the other sessions will mainly be video based. The children’s and families’ self-reported major challenges in everyday life will be targeted using SMART goals. Evidence-based strategies, when available, will be applied to achieve the goals, combined with psychoeducation. Goal attainment scaling (GAS) will be used to evaluate goal attainment. Data is collected at baseline and after approximately 6 and 9 months. External assessors are blinded to group allocation. Primary outcomes are parent-reported brain injury symptoms in children and parenting self-efficacy at 9 months of follow-up. Secondary outcomes include child-reported brain injury symptoms, quality of life, executive functioning in daily life, parent emotional symptoms, family functioning, and unmet family health care needs. A process evaluation will be conducted. Discussion: The current study provides an innovative approach to rehabilitation for children in the chronic phase of ABI and their families. This complex intervention may contribute to the development of evidence-based, high-quality rehabilitation for a large patient group, which is underrepresented in clinical research. It may also improve collaboration between specialized rehabilitation facilities, schools, and local health care services. Inclusion for the trial started in April 2021

Rehabilitation for children with chronic acquired brain injury in the Child in Context Intervention (CICI) study: study protocol for a randomized controlled trial

Background Pediatric acquired brain injury (pABI) is associated with long-term cognitive, behavioral, social, and emotional problems, which may affect the quality of life, school, and family functioning. Yet, there is a lack of evidence-based community-centered rehabilitation programs for chronic pABI and these children do not systematically receive comprehensive rehabilitation. The Child In Context Intervention (CICI) study is a pragmatic randomized controlled trial (RCT) for children with chronic pABI, which aims to evaluate the effectiveness of an individualized and goal-oriented intervention targeting everyday functioning of the child and family. Methods Children aged 6–16 years with MRI/CT-verified intracranial abnormalities will be included in the CICI study if they have persistent self- or parent-reported cognitive, emotional, and/or behavioral challenges 1 year or more after insult and attend school regularly. A total of 70 families will be randomized 1:1 to an intervention or a control group. The intervention consists of seven family sessions, one parent seminar, and four school sessions delivered over approximately 6 months. The parent seminar will be held in person, and the other sessions will mainly be video based. The children’s and families’ self-reported major challenges in everyday life will be targeted using SMART goals. Evidence-based strategies, when available, will be applied to achieve the goals, combined with psychoeducation. Goal attainment scaling (GAS) will be used to evaluate goal attainment. Data is collected at baseline and after approximately 6 and 9 months. External assessors are blinded to group allocation. Primary outcomes are parent-reported brain injury symptoms in children and parenting self-efficacy at 9 months of follow-up. Secondary outcomes include child-reported brain injury symptoms, quality of life, executive functioning in daily life, parent emotional symptoms, family functioning, and unmet family health care needs. A process evaluation will be conducted. Discussion The current study provides an innovative approach to rehabilitation for children in the chronic phase of ABI and their families. This complex intervention may contribute to the development of evidence-based, high-quality rehabilitation for a large patient group, which is underrepresented in clinical research. It may also improve collaboration between specialized rehabilitation facilities, schools, and local health care services. Inclusion for the trial started in April 2021. Trial registration ClinicalTrials.gov NCT04798859 . Registered on March 15, 202