Functional recovery following traumatic vs non-traumatic brain injury: A case-controlled study

Long-term quality of survival after pediatric low-grade glioma

BACKGROUND

Low-grade glioma is the most common brain tumor in children with different modes of treatment and a high overall survival. Low-grade glioma is considered a chronic disease, since residual tumor is present in many children. The tumor and its treatment lead to acquired brain injury with diverse consequences for later life based on factors like the diverse tumor locations, treatment(s) applied, neurofibromatosis type 1, and age at diagnosis.

METHODS

An overview of affected domains is provided based upon cohort studies from literature and partially based on clinical experience with a practical approach regarding each domain of functioning in order to provide insight in the requirements for long-term care assistance after childhood low-grade glioma.

RESULTS

The diverse domains that can potentially be affected are described as follows: motor function, speech, eating and swallowing, sensory functions, seizures, neuropathy, organ function after systemic treatment, late effects due to cranial radiation (vascular changes and secondary tumors, endocrine and hypothalamic function, sleep and energy, neuro-cognition and education, psychosocial effects, and quality of life.

CONCLUSION

Insight in affected domains guides advices for medical follow-up, diagnostics, supportive instructions, and assistive measures per domain of functioning and provide insight in the requirements for long-term care assistance after childhood low-grade glioma.

Assessment and theoretical interpretation of spoken discourse and cognitive skills in two adolescents with acquired brain injury

PURPOSE

Although discourse assessment is recommended, few tools exist for adolescent acquired brain injury (ABI) and few theories describe the contribution of cognition to discourse impairment. This study explored whether a novel discourse protocol can identify difficulties following ABI and whether a discourse processing model provides a useful account of impairment.

METHOD

Using a case-control design, two adolescent males with moderate ABI (12 and 14 years) were compared to a neurotypical sample on a range of language and cognitive assessments. Patterns in performance were interpreted using a theoretical model. Participants completed a standardised omnibus language assessment, discourse assessment, and battery of cognitive tasks.

RESULT

Analyses revealed significant differences in discourse and cognition between adolescents with and without ABI. No impairment was detected on a standardised language assessment. Patterns in discourse and cognition aligned with a contemporary model of discourse processing.

CONCLUSION

Participants with ABI demonstrated discourse deficits relative to the neurotypical reference sample. The findings demonstrate the value of discourse sampling across multiple genres and analysis of microlinguistic to superstructural features. A structure-building framework (SBF) model, originating in schizophrenia, provides a promising theory with which to interpret discourse impairment and has the potential to inform intervention for discourse in ABI.

Long-Term Effects of Intensive Rehabilitation on Memory Functions in Acquired Brain-Damaged Patients

OBJECTIVE

Memory difficulties after brain injury are a frequent and concerning outcome, affecting a wide range of daily activities, employment, and social reintegration. Despite the importance of functional memory capacities throughout life, most studies examined the short-term effects of memory interventions in brain-damaged patients who underwent a rehabilitation program. In the present study, we investigated the long-term outcomes and intensity of memory interventions in acquired (traumatic brain injury [TBI] and non-TBI) brain-damaged patients who participated in an intensive cognitive rehabilitation program and either suffered or did not suffer from memory impairments.

METHOD

We measured pre-post-treatment memory performance of patiients (N = 24) suffering from memory deficits in four common and validated memory tasks (e.g. ROCFT). We compared them to other acquired brain injury patients treated at the same rehabilitation facility who did not suffer from memory impairments (N = 16).

RESULTS

Patients with memory deficits showed long-term improvements in three out of four tasks, while patients without memory deficits showed memory enhancements in only one task. In addition, rehabilitation intensity and type of brain damage predicted the extent of the memory change over time.

DISCUSSION

Long-term improvements in objective memory measures can be observed in patients suffering from brain injury. These improvements can be enhanced by intensifying the treatment program. Findings also suggest that these memory improvements are more pronounced in non-TBI than TBI patients. We discuss the implications of these results in designing optimal memory rehabilitation interventions.

Case identification of non-traumatic brain injury in youth using linked population data

BACKGROUND

Population-level administrative data provides a cost-effective means of monitoring health outcomes and service needs of clinical populations. This study aimed to present a method for case identification of non-traumatic brain injury in population-level data and to examine the association with sociodemographic factors.

METHODS

An estimated resident population of youth aged 0-24 years was constructed using population-level datasets within the New Zealand Integrated Data Infrastructure. A clinical consensus committee reviewed the International Classification of Diseases Ninth and Tenth Editions codes and Read codes for inclusion in a case definition. Cases were those with at least one non-traumatic brain injury code present in the five years up until 30 June 2018 in one of four databases in the Integrated Data Infrastructure. Rates of non-traumatic brain injury were examined, both including and excluding birth injury codes and across age, sex, ethnicity, and socioeconomic deprivation groups.

RESULTS

Of the 1 579 089 youth aged 0-24 years on 30 June 2018, 8154 (0.52%) were identified as having one of the brain injury codes in the five-years to 30 June 2018. Rates of non-traumatic brain injury were higher in males, children aged 0-4 years, Māori and Pacific young people, and youth living with high levels of social deprivation.

CONCLUSION

This study presents a comprehensive method for case identification of non-traumatic brain injury using national population-level administrative data.

The effect of self-reported balance confidence on community integration after brain injury: an observational study

OBJECTIVE

To evaluate the correlation between self-reported balance confidence and community integration related to home management for community-dwelling adults with acquired brain injury (ABI).

METHODS

This is a study of 141 participants over the age of 18 with a history of ABI, living in the community, who completed an online survey. The survey included a series of demographic questions followed by the Activities-Specific Balance Confidence Scale (ABC) and the Home Integration subscale of the Community Integration Questionnaire (CIQ-H).

RESULTS

Data from 119 completed surveys were included in the analysis. Significant positive correlations were found between the ABC and the CIQ-H total scores (rs = 0.241, p = 0.008). There was no significant difference between CIQ-H total scores in individuals by injury type (traumatic vs non-traumatic) or by level of severity (mild, moderate, severe) (p > 0.05). There was no significant difference between ABC total scores by injury type (p > 0.05).

CONCLUSIONS

Higher levels of balance confidence may be associated with improved community integration related to home management for individuals with traumatic and non-traumatic BI. This study's results support future research to evaluate the integration of strategies to improve balance confidence as a component of interdisciplinary assessment and rehabilitation to maximize community integration in community-dwelling adults with ABI.

Cognitive chicken or the emotional egg? How reconceptualizing decision-making by integrating cognition and emotion can improve task psychometrics and clinical utility

Decision-making is an executive function, tapping into cognitive, emotional, and personality-based components. This complexity, and the varying operational definitions of the construct, is reflected in the rich array of behavioral decision-making tasks available for use in research and clinical settings. In many cases, these tasks are "subfield-specific," with tasks developed by cognitive psychologists focusing on cognitive aspects of decision-making and tasks developed by clinical psychologists focusing on interactions between emotional and cognitive aspects. Critically, performance across different tasks does not consistently correlate, obfuscating the ability to compare scores between measures and detect changes over time. Differing theories as to what cognitive and/or emotional aspects affect decision-making likely contribute to this lack of consistency across measures. The low criterion-related validity among decision-making tasks and lack of consistent measurement of the construct presents challenges for emotion and decision-making scholars. In this perspective, we provide several recommendations for the field: (a) assess decision-making as a specific cognitive ability versus a taxonomy of cognitive abilities; (b) a renewed focus on convergent validity across tasks; (c) further assessment of test-retest reliability versus practice effects on tasks; and (d) reimagine future decision-making research to consider the research versus clinical implications. We discuss one example of decision-making research applied to clinical settings, acquired brain injury recovery, to demonstrate how some of these concerns and recommendations can affect the ability to track changes in decision-making across time.

Developing behavioural activation for people with acquired brain injury: a qualitative interpretive description study of barriers and facilitators to activity engagement

BACKGROUND

Acquired brain injuries (ABI) from stroke, head injury, or resected brain tumours are associated with poor emotional wellbeing and heightened risk of mood disorder. Common sequalae of ABI, such as poor attention and memory, can create barriers to the efficacy of cognitively demanding mood interventions, such as Cognitive Behavioural Therapy (CBT). Behavioural Activation (BA), where individuals plan and engage in reinforcing activities, is a promising alternative due to lower cognitive demands. However, BA was initially developed in clinical populations without ABI where the primary barriers to activity engagement were low mood and anxious avoidance. Additionally, BA can incorporate a range of techniques (e.g., mood monitoring, activity scheduling, targeting avoidance, contingency management) and psychoeducational topics (e.g., mindfulness, managing uncertainty; social/communication skills). Exploring barriers and facilitators to adopting specific BA components in ABI is an important aim.

METHODS

Semi-structured interviews were conducted with purposively selected ABI survivors (N = 16) with both low and high depressive symptoms, and family members (N = 7). Questions focused on routine and enjoyable activities, and feedback on 10 different BA techniques and associated psychoeducational topics. Transcripts were analysed using an interpretive description framework. Analysis was informed by field notes, reflexivity diaries, and peer debriefing.

RESULTS

The final constructed framework, Creating Sustainable Engagement, comprises a two-tier hierarchy. Higher-level themes concerned core perspectives of BA, regardless of BA component discussed. This included identifying optimal time windows for different BA components (Right Tool at the Right Time), that BA components should, at least initially, not be burdensome or fatiguing (Perceived Effort), that emotional readiness to confront activity-mood relationships should be addressed (Emotional Impact), and that planned BA activities be consistent with individual values (Relation to Values). Lower-level themes concerned specific BA components: Of these, activity scheduling, procedures targeting avoidance, managing uncertainty and social/communication skills were generally well-received, while mood monitoring, contingency management, and mindfulness had mixed feedback.

CONCLUSIONS

BA is a widely scalable intervention that can be adapted for ABI. This study provides a novel framework on implementing a range of BA components in ABI and adds to the limited evidence on which components may be particularly suitable.

Retrospective case-control study to compare exoskeleton-assisted walking with standard care in subacute non-traumatic brain injury patients

BACKGROUND

Advanced technologies are increasingly used to address impaired mobility after neurological insults, with growing evidence of their benefits for various populations. However, certain robotic devices have not been extensively investigated in specific conditions, limiting knowledge about optimal application for healthcare.

OBJECTIVE

To compare effectiveness of conventional gait training with exoskeleton-assisted walking for non-traumatic brain injury during early stage rehabilitation.

METHODS

Clinical evaluation data at admission and discharge were obtained in a retrospective case-control design. Patients received standard of care physical therapy either using Ekso GT or not. Within- or between-group statistical tests were performed to determine change over time and interventional differences.

RESULTS

This study analyzed forty-nine individuals (33% female), 20 controls and 29 Ekso participants who were equivalent at baseline. Both groups improved in Functional Independence Measure scores and ambulation ability (p < .00001 and p < .001, respectively). Control subjects demonstrated significantly different distance walked and assistance level values at discharge from those who were treated with the exoskeleton (p < .01).

CONCLUSION

Robotic locomotion is non-inferior for subacute functional recovery after non-traumatic brain injury. Conventional therapy produced larger gait performance gains during hospitalization. Further research is needed to understand specific factors influencing efficacy and the long-term implications after rehabilitation.

Prognostic Factors for Tracheal Restenosis after Stent Removal in Patients with Post-Intubation and Post-Tracheostomy Tracheal Stenosis

PURPOSE

Long-term tracheal stent placement can increase the risk of stent-related complications; hence, removal of the stent after stabilization is attempted. However, little evidence has been established regarding the risk factors for tracheal restenosis. We aimed to identify the risk factors for tracheal restenosis in patients with post-intubation tracheal stenosis (PITS) and post-tracheostomy tracheal stenosis (PTTS).

MATERIALS AND METHODS

We retrospectively analyzed patients with PITS and PTTS between January 2004 and December 2019. Patients were classified into a success or failure group according to treatment outcomes. Patients with successful stent removal were defined as patients who did not require additional intervention after stent removal during the follow-up period. Multiple logistic regression analysis was performed to identify the factors associated with tracheal restenosis.

RESULTS

Among 269 stented patients, 130 patients who had removed the stent were enrolled in this study. During the follow-up period, 73 (56.2%) patients had a stable clinical course; however, 57 (43.8%) patients had restenosis. The proportion of trauma-induced intubation was higher in the success group than in the failure group (p=0.026), and the median stent length was shorter in the success group (45 mm) than in the failure group (50 mm, p=0.001). On multivariate analysis, trauma-induced intubation [adjusted odds ratio (aOR), 0.329; 95% confidence interval (CI), 0.117-0.927; p=0.036], and stent length <50 mm (aOR, 0.274; 95% CI, 0.130-0.578; p=0.001) were associated with a decreased risk of restenosis.

CONCLUSION

Trauma-induced intubation and stent length were associated with successful stent removal.

Factors Influencing Functional Recovery during Rehabilitation after Severe Acquired Brain Injuries: A Retrospective Analysis

Severe acquired brain injuries (sABI) represent one of the main causes of disability and limitation in social life participation that need an intensive rehabilitation approach. The purpose of this study was to identify a possible correlation between different supposed conditioning factors and the efficiency of rehabilitation interventions. In this retrospective study, data were processed regarding 44 patients admitted to a neurorehabilitation department after sABI. A significant correlation with the efficiency of the rehabilitation intervention (expressed as the variation of the Barthel score between discharge and admittance in relation to the duration of the rehabilitative hospitalization) was found for both the etiology of the brain injury (p = 0.023), the precocity of the rehabilitation treatment (p = 0.0475), the presence of a tracheal cannula (p = 0.0084) and forms of nutrition other than oral (p < 0.0001). The results of this study suggest that improving the management of the respiratory system, swallowing and nutritional aspects, and favoring an early and personalized rehabilitation treatment, can help to optimize the overall care of patients suffering from sABI, thus allowing a reduction in complications, improvement in functional recovery and ensuring a better management of economic, social and health resources.

Determinants of Discharge Disposition From Acute Care for Survivors of Hypoxic-Ischemic Brain Injury: Results From a Large Population-Based Cohort Data Set

OBJECTIVE

To identify determinants of discharge disposition from acute care among survivors of hypoxic-ischemic brain injury (HIBI), stratified by sex.

DESIGN

Population-based retrospective cohort study using provincial data in Ontario, Canada. The determinants were grouped into predisposing, need, and enabling factors using the Anderson Behavioral Model.

SETTING

Acute care.

PARTICIPANTS

Survivors of HIBI aged ≥20 years at the time of hospitalization and discharged alive from acute care between April 1, 2002, and March 31, 2017. There were 7492 patients with HIBI, of whom 28% (N=2077) survived their acute care episode.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Discharge disposition from acute care, categorized as complex continuing care (CCC), long-term care (LTC), inpatient rehabilitation (IR), home with support, home without support, and transferred to another acute care.

RESULTS

The discharge dispositions for the 2077 survivors were IR 23.4% (n=487), CCC 19.5% (n=404), LTC 6.2% (n=128), home without support 31.2% (n=647), home with support 15.1% (n=314), and other 4.6%. Multinomial multivariable logistic regression analysis using home without support as the reference category revealed that female patients were significantly more likely than male patients to be discharged to LTC/CCC. Those who were older, were frail, and had longer stay in acute care or special care unit (SCU) were more likely to be discharged to LTC/CCC. The only significant determinant for IR was longer stay in acute care. Survivors with cardiac-related injury were less likely to be discharged to LTC/CCC. Income was a significant factor for male patients but not for female patients in the sex-stratified analysis. The following variables were investigated but were not significant determinants in this study: need factors (comorbidity score, prior psychiatric disorders, health care utilization) and enabling factors (income quintile, rural area of residence).

CONCLUSIONS

Predisposing (age, sex) and need factors (frailty, acute care days, SCU days, type of injury) were significant determinants of discharge disposition from acute care after HIBI. In spite of a system with universal coverage, sex differences were found, with more female patients being discharged to CCC/LTC rather than IR, controlling for age and other confounders. These findings should be considered in appropriate discharge planning from acute care for survivors of HIBI.

Comorbid Conditions Differentiate Rehabilitation Profiles in Traumatic Versus Nontraumatic Brain Injury: A Retrospective Analysis Using a Medical Database

PURPOSE

We examined the relationship between comorbid medical conditions and changes in cognition over the course of rehabilitation following acquired brain injury. In particular, we compared outcomes between traumatic brain injury (TBI) and non-TBI using a retrospective inpatient rehabilitation dataset. We hypothesized that differences by diagnosis would be minimized among subgroups of patients with common comorbid medical conditions.

MATERIALS AND METHODS

We used the Functional Independence Measure (FIM)-cognition subscale to index changes in cognition over rehabilitation. A decision tree classifier determined the top 10 comorbid conditions that maximally differentiated TBI and non-TBI. Ten subsets of patients were identified by matching on these conditions, in rank order. Data from these subsets were submitted to repeated-measures logistic regression to establish the minimum degree of commonality in comorbid conditions that would produce similar cognitive rehabilitation, regardless of etiology.

RESULTS

The TBI group demonstrated a greater increase in ordinal scores over time relative to non-TBI, across all subscales of the FIM-cognition. When both groups were matched on the top 3 symptoms, there were no significant group differences in rehabilitation trajectory in problem-solving and memory domains (Cohen's d range: 0.2-0.4).

CONCLUSION

Comorbid medical conditions explain differences in cognitive rehabilitation trajectories following acquired brain injury beyond etiology.

Factors Associated With Gains in Performance During Rehabilitation After Pediatric Brain Injury: Growth Curve Analysis

OBJECTIVE

Predicting recovery of functional performance within pediatric rehabilitation after brain injury is important for health professionals and families, but information regarding factors associated with change in functional skills ("what the child can do") and functional independence ("what the child does") is limited. The aim of the study was to examine change in functional skills and independence over time in children with moderate-severe brain injury during prolonged inpatient rehabilitation.

DESIGN

This study used a retrospective cohort design. Longitudinal data from 139 children (age 1.6-20.6 yrs), hospitalized for 115.4 ± 72 days, were examined. Growth curve analysis was used to examine factors associated with change in the Pediatric Evaluation of Disability Inventory (functional skills and caregiver assistance, ie, functional independence) in mobility and self-care. Typical estimates for change per hospitalization day were obtained.

RESULTS

Traumatic brain injury and older age at injury, but not sex, were associated with faster recovery. Length of stay was associated with rate of change in functional skills but not in functional independence, suggesting that improvement in functional independence during rehabilitation may be associated with other factors.

CONCLUSIONS

Identifying the factors associated with individual profiles of functional improvement can provide valuable information for clinicians and decision-makers to optimize performance after prolonged inpatient rehabilitation.

Prognosis of severe acquired brain injury: Short and long-term outcome determinants and their potential clinical relevance after rehabilitation. A comprehensive approach to analyze cohort studies

Background

Accurate prognostic evaluation is a key factor in the clinical management of patients affected by severe acute brain injury (ABI) and helps planning focused therapies, better caregiver’s support and allocation of resources. Aim of the study was to assess factors independently associated with both the short and long-term outcomes after rehabilitation in patients affected by ABI in the setting of a single Rehabilitation Unit specifically allocated to these patients.

Methods and findings

In all patients (567) with age ≥ 18 years discharged from the Unit in the period 2006/2015 demographic, etiologic, comorbidity indicators, and descriptors of the disability burden (at hospital admission and discharge) were evaluated as potential prognostic factors of both short-term (4 classes of disability status at discharge) and long-term (mortality) outcomes. A comprehensive analytical method was adopted to combine several tasks. Select the factors with a significant independent association with the outcome, assess the relative weights and the “stability” (by bootstrap resampling) of them and estimate the role of the prognostic models in the clinical framework considering “cost” and “benefits”. The generalized ordered logistic model for ordinal dependent variables was used for the short-term outcome while the Cox proportional hazard model was used for the long-term outcome. The final short-term model identified 7 factors that independently account for 37% of the outcome variability as shown by pseudo R² (pR²) = 0.37. The disability status descriptors show the strongest association since they account for more than 60% of the pR², followed by age (14.8%), the presence of percutaneous endoscopic gastrostomy or nasogastric intubation (14.4%), a longer stay in the acute ward (5.9%) and concomitant coronary disease (1.3%). The final multivariable Cox model identified 4 factors that independently account for 52% of the outcome variability (R² = 0.52). The disability extent and the disability recovered lead the long-term mortality since they account for the 53% of the global R². The relevant effect of age (42%) is appreciable only after 2 years given the significant interaction with time. A longer stay in the acute ward explains the remaining fraction (5%). Considering ‘cost and benefits’, the decision curve analysis shows that the clinical benefit achieved by using both prognostic models is greater than the other possible action strategies, namely ‘treat all’ and ‘treat none. Several less obvious characteristics of the prognostic models are appreciated by integrating the results of multiple analytical methods.

Conclusion

The comprehensive analytical tool aimed to integrate statistical significance, weight, “stability” and clinical “net” benefit, gives back a prognostic framework explaining a relevant portion of both outcomes’ variability in which the strong association of the disability status with both outcomes is comparable to and followed by a time modulated role of age. Our data do not support a differentiated association of traumatic vs non-traumatic etiology. The results encourage the use of integrated approach to analyze cohort data.

Readmission following hypoxic ischemic brain injury: a population-based cohort study

BACKGROUND

Readmission to acute care is common and is associated with indicators of suboptimal care and health system inefficiencies. The objective of this study was to identify independent determinants of readmission following survival of hypoxic ischemic brain injury.

METHODS

We conducted a population-based retrospective cohort study using Ontario's administrative health data. Survivors of hypoxic ischemic brain injury aged 20 years or more discharged from acute care between fiscal years 2002/03 and 2010/11 were included. Multivariable negative binomial regression was used to identify independent determinants of both number of readmissions and cumulative duration of hospital stay(s) within 1 year after the index discharge.

RESULTS

Of the 593 patients with hypoxic ischemic brain injury, 233 (39.3%) were readmitted within 1 year of the index acute care discharge. The number of readmissions was associated with age (35-49 yr v. 65-79 yr: rate ratio [RR] 0.57, 95% confidence interval [CI] 0.38-0.85; ≥ 80 yr v. 65-79 yr: RR 0.58, 95% CI 0.34-0.97) and higher comorbidity score (Johns Hopkins Aggregated Diagnosis Groups score > 30 v. < 10: RR 1.60, 95% CI 1.11-2.31). Cumulative readmission stay was associated with increased index acute care length of stay (31-90 d v. ≥ 90 d: RR 4.17, 95% CI 1.38-12.64), prior use of health care services (minimal v. very high: RR 0.15, 95% CI 0.05-0.49) and discharge disposition (home v. continuing/long-term care: RR 0.44, 95% CI 0.21-0.91).

INTERPRETATION

The findings indicate a high readmission rate in the first year after the index acute care admission for survivors of hypoxic ischemic brain injury, reflecting care gaps and system inefficiencies. This suggests that bolstered discharge and home care planning and support are needed to address the specific needs of those with hypoxic ischemic brain injury.

The Role of Emotional Intelligence in Community Integration and Return to Work After Acquired Brain Injury

OBJECTIVE

To investigate whether emotional intelligence (EI) skills measured via the Perceiving, Understanding, and Managing Emotions branches of the Mayer-Salovey-Caruso Emotional Intelligence Test V2.0 are associated with community integration (CI) and return to work (RTW) after moderate-to-severe acquired brain injury (ABI), after accounting for other established predictors.

DESIGN

Retrospective cohort study.

SETTING

Outpatient follow-up services within 2 specialist ABI rehabilitation centers in Melbourne, Australia.

PARTICIPANTS

Individuals (N=82) with moderate-to-severe ABI discharged from inpatient rehabilitation and living in the community (2mo to 7y postinjury).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Community Integration Questionnaire scores for the total sample (N=82; age range 18-80) and RTW status (employed vs not employed) for the subset of participants employed prior to ABI (n=71; age range 19-66).

RESULTS

Hierarchical logistic and multiple regression analyses were used to examine the unique contribution of Perceiving, Understanding, and Managing Emotions scores to RTW and CI, after controlling for demographic, injury-related, psychological, and cognitive predictors. As a set, the 3 EI variables did not explain incremental variance in outcomes. However, individually, Understanding Emotions predicted RTW (adjusted odds ratio=3.10, P=.03), χ² (12)=35.52, P<.001, and Managing Emotions predicted CI (β=0.23, P=.036), F_12,69=5.14, P<.001.

CONCLUSION

Although the EI constructs in combination did not improve prediction beyond the effects of established variables, individual components of strategic EI may be important for specific participation outcomes after ABI.

Interrater Reliability of Three Versions of the Chedoke Arm and Hand Activity Inventory

Purpose: The purpose of this study was to estimate the interrater reliability of three shortened versions of the Chedoke Arm and Hand Activity Inventory (CAHAI-7, CAHAI-8, CAHAI-9) when used with persons with acquired brain injury (ABI). The CAHAI is an assessment of upper limb function with high reliability in the stroke and ABI populations. In the stroke population, three shortened versions of the measure have established reliability. Clinicians report time constraints as a barrier to using standardized assessments; thus, establishing the reliability of the shortened versions of the CAHAI in the ABI population may increase the use of this measure. Method: This was an observational, parameter estimation study. The participants were recruited from an in-patient ABI rehabilitation programme. The administration of the CAHAI to six persons with ABI was video recorded, and the video recordings were assessed by six clinicians to estimate interrater reliability. A Latin square design was used to balance the order in which the raters evaluated the videos. A repeated-measures analysis of variance was performed, and the variance components were used to calculate an intra-class correlation coefficient (ICC) and standard error of measurement (SEM) with 95% confidence limits (CLs) for each of the shortened versions. Results: Interrater reliability was high for all three versions: CAHAI-7, ICC=0.96 (95% CL: 0.89, 0.99; SEM 2.65); CAHAI-8, ICC=0.96 (95% CL: 0.90, 0.99; SEM 2.72); and CAHAI-9, ICC=0.95 (95% CL: 0.85, 0.99; SEM 3.49). Conclusions: These results suggest that the three shortened versions of the CAHAI demonstrate high reliability in the ABI population. These versions may be particularly useful when time constraints or patient tolerance are an issue.

Prognostic factors in childhood-acquired brain injury

BACKGROUND

A long-term follow-up study comparing children after anoxic brain injury (AnBI) with those after traumatic brain injury (TBI) was conducted, and prognostic factors were mapped.

METHODS

A prospective historical study following long-term functional outcome after childhood brain injury was conducted in two phases. The first phase included patients suffering from moderate-severe TBI. The second phase assessed children after AnBI, and the results were compared. Functional outcome was recorded and factors influencing prognosis were outlined.

RESULTS

On admission vegetative state (VS) was twice as prevalent in the AnBI subgroup. Approximately 90% of children with TBI and 60% of patients with AnBI gained independency in activities of daily living (ADL) and mobility. Long-term positive outcome, i.e., return to school and open-market employment, were higher in patients with TBI when compared with AnBI (61% and 48.1%, respectively). Significant outcome-predicting factors were VS at admission to rehabilitation, length of loss of consciousness (LOC) up to 11 days and functional independence measure (FIM) score at admission and discharge. Aetiology was not found to be a predicting factor.

CONCLUSIONS

Duration of unconsciousness is the main long-term negative prognostic outcome factor. Anoxic brain damage, associated with longer periods of unconsciousness also heralds a less favourable outcome.

Children and youth with non-traumatic brain injury: a population based perspective

BACKGROUND

Children and youth with non-traumatic brain injury (nTBI) are often overlooked in regard to the need for post-injury health services. This study provided population-based data on their burden on healthcare services, including data by subtypes of nTBI, to provide the foundation for future research to inform resource allocation and healthcare planning for this population.

METHODS

A retrospective cohort study design was used. Children and youth with nTBI in population-based healthcare data were identified using International Classification of Diseases Version 10 codes. The rate of nTBI episodes of care, demographic and clinical characteristics, and discharge destinations from acute care and by type of nTBI were identified.

RESULTS

The rate of pediatric nTBI episodes of care was 82.3 per 100,000 (N = 17,977); the average stay in acute care was 13.4 days (SD = 25.6 days) and 35% were in intensive care units. Approximately 15% were transferred to another inpatient setting and 6% died in acute care. By subtypes of nTBI, the highest rates were among those with a diagnosis of toxic effect of substances (22.7 per 100,000), brain tumours (18.4 per 100,000), and meningitis (15.4 per 100,000). Clinical characteristics and discharge destinations from the acute care setting varied by subtype of nTBI; the proportion of patients that spent at least one day in intensive care units and the proportion discharged home ranged from 25.9% to 58.2% and from 50.6% to 76.4%, respectively.

CONCLUSIONS

Children and youth with nTBI currently put an increased demand on the healthcare system. Active surveillance of and in-depth research on nTBI, including subtypes of nTBI, is needed to ensure that timely, appropriate, and targeted care is available for this pediatric population.

Determinants of Admission to Inpatient Rehabilitation Among Acute Care Survivors of Hypoxic-Ischemic Brain Injury: A Prospective Population-Wide Cohort Study

OBJECTIVE

To investigate demographic and acute care clinical determinants of admission to inpatient rehabilitation (IR) among patients with hypoxic-ischemic brain injury (HIBI) who survive the initial acute care episode.

DESIGN

Population-wide prospective cohort study using Canadian Institutes for Health Information administrative health data from Ontario, Canada. All patients who survived their HIBI acute care episode during the study period remained eligible for the outcome, admission to IR, for 1 year postacute care discharge.

SETTING

Inpatient rehabilitation.

PARTICIPANTS

We included all patients with HIBI using International Classification of Diseases, Tenth Revision, Canadian Enhancement codes recorded at acute care admission who were ≥20 years old (N=599) and discharged from acute care between the 2002 and 2010 fiscal years, inclusive. Six patients were excluded from analyses because of missing data.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Admission to IR.

RESULTS

Of HIBI survivors admitted to IR within 1 year of acute care discharge (n=169), most (56.2%) had an IR admitting diagnosis indicating anoxic brain damage. Younger age, being a man, lower comorbidity burden, longer length of stay of preceding acute care episode, and shorter duration in special care were most predictive of admission to IR in multivariable regression models. Women had an almost 2-fold lower incidence of admission to IR (risk ratio, .62; 95% confidence interval, .46-.84).

CONCLUSIONS

Older age, higher comorbidity burden, and shorter lengths of stay and delayed discharge from acute care are associated with lower incidence of IR admission for patients with HIBI. That women are almost 2-fold less likely to receive rehabilitation requires further investigation.

A note on survival after anoxic brain injury in adolescents and young adults

BACKGROUND

Much is known about survival after traumatic brain injury (TBI), yet relatively little about survival after anoxic brain injury (ABI).

OBJECTIVE

To determine whether long-term survival after ABI is comparable to that after TBI.

METHODS

We identified 237 patients with ABI and 1,620 with TBI in California who were aged 15 to 35, survived at least 1 year post injury, and were injured in 1986 or later. We analyzed the long-term follow-up data using the Cox Proportional Hazards Regression Model, controlling for age, sex, and severity of disability.

RESULTS

After adjustment for risk factors, no significant differences in long-term survival between ABI and TBI were found (hazard ratio = 0.97; 95% c.i. 0.57-1.65).

CONCLUSIONS

In adolescents and young adults, long-term survival after ABI appears to be similar to that after TBI.

Comparative effectiveness of traumatic brain injury rehabilitation: differential outcomes across TBI model systems centers

OBJECTIVE

To measure patient functional outcomes across rehabilitation centers.

SETTING

Traumatic Brain Injury Model System (TBIMS) centers.

PARTICIPANTS

Patients with traumatic brain injury (TBI) admitted to 21 TBIMS rehabilitation centers (N = 6975, during 1999-2008).

DESIGN

Retrospective analysis of prospectively collected data.

MAIN MEASURES

Center-specific functional outcomes of TBI patients using Functional Independence Measure, Disability Rating Scale, and Glasgow Outcome Scale-Extended.

RESULTS

There were large differences in patient characteristics across centers (demographics, TBI severity, and functional deficits at admission to rehabilitation). However, even after taking those factors into account, there were significant differences in functional outcomes of patients treated at different TBIMS centers.

CONCLUSION

There are significant differences in functional outcomes of TBI patients across rehabilitation centers.

Older adults with acquired brain injury: outcomes after inpatient rehabilitation

This study examined a population-based profile of older adults with acquired brain injury, and their functional outcomes, in in-patient rehabilitation. Older adults aged 65 and older admitted to in-patient rehabilitation from acute care with traumatic brain injury (TBI) (n = 1214) or non-traumatic brain injury (nTBI) (n = 1,530) from 2003/04 to 2009/10 in Ontario were identified. Demographic and clinical characteristics and the total function score from the FIM(™) Instrument were examined. The Discharge Abstract Database and National Rehabilitation Reporting System were used. Results indicated that older adults with TBI had significantly higher total function scores than those with nTBI at admission and at discharge (p < .001). However, both groups made significant (p < .001) and similar gains (p > .05) in total function scores. We conclude that older adults with TBI and nTBI make similar in-patient rehabilitation gains. Lower initial functional ability of nTBI patients on admission and patients' different clinical profiles have implications for clinical care and resources.

Cognitive correlates with functional outcomes after anoxic brain injury: a case-controlled comparison with traumatic brain injury

OBJECTIVES

To assess the effectiveness of inpatient rehabilitation in adults who have sustained an anoxic brain injury (AnBI). Secondly, to identify areas of cognition that predict functional outcomes at discharge.

DESIGN

Retrospective, matched case-controlled study.

METHODS

Ten patients with moderate-to-severe AnBI and 10 patients with traumatic brain injury (TBI), treated in an inpatient neurorehabilitation programme, were matched on age, acute care length of stay and admission Functional Independence Measure (FIM). Functional outcome was assessed using the FIM and Disability Rating Scale (DRS).

RESULTS

Patients with AnBI performed worse on all measures of functional outcome relative to patients with TBI. Patients with AnBI achieved significantly lower FIM motor and cognitive gain compared with patients with TBI (11.5, SD 13.6 vs. 31.0, SD 19.7 and 2.4, SD 3.9 vs. 7.5, SD 4.2, respectively (p < 0.02)). DRS data showed similar trends of functional improvement between the groups. Several neuropsychometric tests correlated with functional outcome (p < 0.01).

CONCLUSIONS

Patients with AnBI had worse functional outcomes following rehabilitation than patients with TBI, confirming the results of previous reports. Poor cognitive function predicted poor functional outcomes on the FIM and somewhat on the DRS. Research is needed to assess why these differences occur and to improve or develop new effective rehabilitation treatments for AnBI.