Functional outcomes following post-acute rehabilitation for moderate-to-severe traumatic brain injury

Disinhibition, rather than moderate-to-severe traumatic brain injury, moderates the impact of anger provocation on subjective emotional experience

OBJECTIVE

Altered reactivity to emotional stimuli is common after traumatic brain injury (TBI), which is suggested to reflect difficulties with emotion regulation. While disinhibition is common after moderate-to-severe TBI, limited research has investigated the link between disinhibition and emotional reactivity in this clinical group. The aim of this research, therefore, was to investigate the relationship between disinhibition and TBI to anger provocation.

METHOD

Thirty-five individuals with moderate-to-severe TBI and thirty-one controls completed an anger induction task. Participants rated their experience of emotions and subjective arousal before and after the induction. Heart rate, respiration and skin conductance were also measured. Disinhibition was measured using the Frontal Systems Behavior Scale.

RESULTS

In the full sample, the mood induction led to increased skin conductance, respiration, and self-reported anger, tension, arousal and negative mood. There were no differences between those with TBI and controls. Disinhibition interacted with the impact of anger provocation on subjective, but not objective, outcomes such that those elevated in disinhibition reported increased feelings of anger and tension in response to the mood induction. Disinhibition did not interact with TBI across any subjective and objective emotional measures examined in response to mood induction.

CONCLUSIONS

While anger causes emotional changes for all individuals, these changes are particularly pronounced among those who are disinhibited, irrespective of whether an individual has sustained a TBI. This is an important consideration when examining emotional regulation post-TBI as the degree of disinhibition appears to alter subjective interpretations of emotional events, which could lead to emotion dysregulation.

Cross-cultural adaptation and validation of the Arabic Project for the Epidemiological Analysis of Critical Care Patients (PAEEC) scale in individuals with traumatic brain injury in Lebanon

The aim of this study is to cross-culturally adapt the Project for the Epidemiological Analysis of Critical Care Patients (PAEEC) Quality of Life (QoL) scale into the Arabic language and to examine its clinimetric properties, including validity and reliability among Lebanese native speaker with traumatic brain injury (TBI). This is a cross-sectional study including 49 men with TBI aged between 20 and 59 years. The Arabic version of the PAEEC (PAEEC-A) was administered to the subjects or their primary caregiver as well as the Short Form Health Survey 36 (SF-36). The internal consistency, test-retest reliability, content, construct and convergent validity were evaluated. The PAEEC-A displayed high internal consistency (Chronbach's alpha = 0.916) and test-retest reliability (Intraclass Correlation coefficient = 0.966). Exploratory factor analysis extracted a 3-factor model that explained 68.48% of the total variance. As for the convergent validity, Spearman correlations between the PAEEC-A total score and the physical and mental components of the SF-36 were -0.788 and -0.794, respectively (p-value < 0.0001 for both). The findings indicate that the PAEEC-A has robust clinimetric properties and is a valid and reliable quality of life measure among Lebanese men with traumatic brain injury.

Biopsychosocial factors of quality of life in individuals with moderate to severe traumatic brain injury: a scoping review

PURPOSE

Individuals with moderate to severe traumatic brain injury (TBI) experience changes in their quality-of-life (QOL) post-injury. Given the vast literature that exists about QOL after TBI, a scoping review was performed to identify the different biopsychosocial factors that affect a person's QOL after a moderate to severe TBI.

METHODS

A scoping review was conducted using the following electronic databases: MEDLINE, CINAHL, Embase, and PsycINFO. Terms relating to TBI and QOL were used.

RESULTS

There were 7576 articles obtained from the databases, resulting in 535 full-text articles. Ultimately, 52 articles were extracted, which consisted of biopsychosocial QOL factors after TBI. The biopsychosocial factors of QOL after TBI included 19 biological factors (i.e., sex, TBI severity, cognition), 16 psychological factors (i.e., depression, self-efficacy, coping styles), and 19 social factors (i.e., employment, social participation, social support). Factors such as fatigue, self-awareness, transition, and discharge from hospitals are known issues in TBI literature but were minimally reported in studies in this review, identifying them as potential gaps in research.

CONCLUSION

Identifying biopsychosocial factors relating to QOL after TBI can enable health services to develop targeted rehabilitation programs for individuals with TBI.

Computed tomography findings as early predictors of long-term language impairment in patients with traumatic brain injury

This study aims to assess the relationship between computed tomography (CT) findings, during the acute phase of hospitalization, and long-term language impairment in people with traumatic brain injury (TBI). Another aim was to assess the receptive and expressive abilities of subjects with TBI based on the location of the injury. This is a retrospective observational study including 49 participants with TBI due to war injuries. The Arabic Diagnostic Aphasia Battery (A-DAB-1) was administered to the participants and the Helsinki CT score was computed to quantify brain damage. The results showed that the Helsinki CT score was negatively correlated with the total score of the A-DAB-1 (r = -0.544, p-value < 0.0001). Simple linear regression supported such findings and reflected an inversely proportional relationship between both variables (p-value < 0.0001). When compared with subjects having right hemisphere damage, subjects with left hemisphere and bilateral brain damage performed more poorly on language tasks respectively as follows: A-DAB-1 overall score (92.08-66.08-70.28, p-value = 0.021), Content of descriptive speech (9.57-6.69-7.22, p-value = 0.034), Verbal fluency (6.57-3.54-3.89, p-value = 0.002), Auditory comprehension (9.71-7.54-7.78, p-value = 0.039), Complex auditory commands (9.71-7.65-7.56, p-value = 0.043), Repetition (9.75-7.08-7.61, p-value = 0.036), Naming (9.93-7.15-8.11, p-value = 0.046). Following TBI, CT findings on admission can significantly predict long-term language abilities, with left side lesions inducing poorer outcomes.

Post-Acute Care for Traumatic Brain Injury Patients in Taiwan

Background

Traumatic brain injury (TBI) can result in functional impairments. Many patients with TBI require post-acute care to improve their functional skills and allow for greater self-independence and a better quality of life. Taiwan's National Health Insurance proposed a nationwide post-acute care program in 2017 for patients with traumatic brain injury. The program's goal was to maximize patients' functional recovery and make it possible for them to return to their homes and communities. This study aimed to explore the effectiveness of such programs in Taiwan.

Methods

This pilot study retrospectively evaluated a de-identified database that contained the scores of various assessments evaluated at admission and discharge. It used the data to determine the functional improvement of patients with traumatic brain injury after participating in post-acute care programs.

Results

This study collected complete data from 27 patients. After an average of 45.11 days in the program, the patients showed significant improvement in the Barthel Activity Daily Living Index, the Lawton-Brody Instrumental Activity Daily Living Scale, the Mini Nutrition Assessment, the EuroQol Five Dimensions Questionnaire, the Berg Balance Scale, the Galveston Orientation and Amnesia Test, the Rancho Los Amigos Scale, the Concise Chinese Aphasia Test, and the Mini Mental State Examination. After discharge, 96% of the patients could return to their community.

Conclusion

This pilot study concluded that the program significantly promoted functional recovery for patients and could help patients with traumatic brain injury return to their communities and reduce the risk of institutionalization. Thus, patients with the potential for functional recovery could receive post-acute care in regional or community hospitals immediately after being discharged from acute wards. In the future randomized controlled trials are needed to further confirm the clinical impact of this program.

Use of person-centered goals to direct interdisciplinary care for military service members and Veterans with chronic mTBI and co-occurring psychological conditions

OBJECTIVE

To explore the use of person-centered goals (PCGs) to direct interdisciplinary care to support PCG attainment in military service members and Veterans (SM/Vs) with chronic mild traumatic brain injury (mTBI) and co-occurring psychological conditions.

METHODS

A retrospective chart review was completed for 146 United States military SM/Vs reporting chronic symptoms following mTBI and co-occurring psychological conditions who received care in the SHARE Military Initiative intensive outpatient program, a donor-funded program administered by a not-for-profit hospital, between April 1, 2015 and March 31, 2019. PCGs were used to direct care consisting of individual and group-based interventions and therapies delivered by an interdisciplinary, co-located team including behavioral health, case management, neurology or physiatry, nursing, occupational therapy, physical therapy, recreation therapy, speech-language pathology, and transition support. The primary outcome measure was PCG attainment measured via goal attainment scaling.

RESULTS

Increased PCG attainment was demonstrated at program discharge and throughout the first year following program discharge. Predictors of goal attainment at discharge included longer participation in treatment, greater reduction in depressive symptoms and greater improvement in adjustment at discharge, male gender, and higher cognitive and physical abilities on admission.

CONCLUSIONS

This sample of military SM/Vs with mTBI and co-occurring psychological conditions who received intensive, interdisciplinary, PCG directed care demonstrated increased PCG attainment at program discharge which further increased with transition support over the year post-discharge. Results suggest PGC goal directed care is a feasible, promising methodology of individualizing treatment in this population. This exploratory study lays a foundation for future prospective, controlled, comparative effectiveness research that will further understanding of the effectiveness of intensive, interdisciplinary, PCG directed care.

Predictive Factors of Return Home and Return to Work for Intensive Care Unit Survivors after Traumatic Brain Injury with a Follow-up Period of 2 Years

Intensive care unit (ICU) survivors after traumatic brain injury (TBI) frequently have serious disabilities with subsequent difficulty in reintegration into society. We aimed to investigate outcomes for ICU survivors after moderate to severe TBI (msTBI) and to identify predictive factors of return home (RH) and return to work (RTW). This single-center retrospective cohort study was conducted on all trauma patients admitted to the emergency ICU of our hospital between 2013 and 2017. Of these patients, adult (age ≥ 18 years) msTBI patients with head Abbreviated Injury Scale ≥ 3 were extracted. We performed univariate/multivariate logistic regression analyses to explore the predictive factors of RH and RTW. Among a total of 146 ICU survivors after msTBI, 107 were included (median follow-up period: 26 months). The RH and RTW rates were 78% and 35%, respectively. Multivariate analyses revealed that the predictive factors of RH were age < 65 years (P < 0.001), HR < 76 bpm (P = 0.015), platelet count ≥ 19 × 10⁴/μL (P = 0.0037), D-dimer < 26 μg/mL (P = 0.034), and Glasgow Coma Scale (GCS) score > 8 (P = 0.0015). Similarly, the predictive factors of RTW were age < 65 years (P < 0.001) and GCS score > 8 (P = 0.0039). This study revealed that “age” and “GCS score on admission” affected RH and RTW for ICU survivors after msTBI.

Variations in Discharge Destination Following Severe Traumatic Brain Injury across the United States

BACKGROUND

Discharge destination after traumatic brain injury (TBI) may be influenced by non-patient factors such as regional or institutional practice patterns. We hypothesized that non-patient factors would be associated with discharge destination in severe TBI patients.

METHODS

All patients in the ACS Trauma Quality Improvement Program 2016 data set with severe TBI, defined as head Abbreviated Injury Scale ≥3, were categorized by discharge destination. Logistic regression was used to assess factors associated with each destination; odds ratios and 95% confidence level are reported. Regressions were adjusted for age, gender, race, insurance, GCS, ISS, polytrauma, mechanism, neurosurgical procedure, geographic region, teaching status, trauma center level, hospital size, and neurosurgeon group size.

RESULTS

75,690 patients met inclusion criteria. 51% were discharged to home, 16% to rehab, 14% to SNF, and 11% deceased. Mortality was similar across geographic region, teaching status, and hospital size. Southern patients were more likely to be discharged to home while Northeastern patients were more likely to be discharged to rehab. Treatment by groups of 3 or more neurosurgeons was associated with SNF discharge as was treatment at community or non-teaching hospitals. Patients treated at larger hospitals were less likely to be discharged to rehab and more likely to go to SNF.

CONCLUSIONS

Geographic region, neurosurgeon group size, teaching status, and hospital size are significantly associated with variation in discharge destination following severe TBI. Regional and institutional variation in practice patterns may play important roles in recovery for some patients with severe TBI.

Recovery of Cognitive and Behavioural Function During Long-term Inpatient Rehabilitation in Patients with Moderate-To-Severe Traumatic Brain Injury: Evaluation of a Retrospective Case Series

OBJECTIVE

To elucidate the characteristics of recovery progression during long-term rehabilitation after moderate-to-severe traumatic brain injury.

METHODS

Longitudinal changes in consciousness, swallowing disorders, activities of daily living, and psychological and behavioural status were studied in 7 patients with moderateto-severe traumatic brain injury, using scores of the National Agency for Automotive Safety & Victim's Aid (NASVA score), Glasgow Coma Scale (GCS), Dysphagia Severity Scale (DSS), Eating Status Scale (ESS), Functional Independence Measure (FIM), Cognitive-related Behavioural Assessment (CBA), and Neuropsychiatric Inventory (NPI). Scores were collected every month until discharge (median 359 days after injury), or until the study end date for those patients who remained hospitalized (432 days).

RESULTS

Patients were qualitatively classified into those who improved well in the early phase, in terms of consciousness, swallowing, and activities of daily living, and those with less or delayed improvement. Psychological and behavioural difficulties appeared to remain less improved than the other functions for longer periods in many patients. Statistical comparisons that included all 7 patients revealed a significant improvement in NASVA score, GCS, DSS, and ESS, but not in FIM, CBA, and NPI at discharge/at the last measurement compared with scores at admission.

CONCLUSION

Swallowing function is more responsive to long-term rehabilitation in patients with moderate-to-severe traumatic brain injury, while neuropsychiatric and behavioural difficulties tend to persist for longer periods.

Secreted Peptides for Diagnostic Trajectory Assessments in Brain Injury Rehabilitation

BACKGROUND

Rehabilitation following traumatic brain injury (TBI) significantly improves outcomes; yet TBI heterogeneity raises the need for molecular evidence of brain recovery processes to better track patient progress, evaluate therapeutic efficacy, and provide prognostication.

OBJECTIVE

Here, we assessed whether the trajectory of TBI-responsive peptides secreted into urine can produce a predictive model of functional recovery during TBI rehabilitation.

METHODS

The multivariate urinary peptidome of 12 individuals with TBI was examined using quantitative peptidomics. Measures were assessed upon admission and discharge from inpatient rehabilitation. A combination of Pavlidis template matching and partial least-squares discriminant analysis was used to build models on Disability Rating Scale (DRS) and Functional Independence Measure (FIM) scores, with participants bifurcated into more or less functional improvement groups.

RESULTS

The produced models exhibited high sensitivity and specificity with the area under the receiver operator curve being 0.99 for DRS- and 0.95 for FIM-based models using the top 20 discriminant peptides. Predictive ability for each model was assessed using robust leave-one-out cross-validation with Q² statistics of 0.64 (P = .00012) and 0.62 (P = .011) for DRS- and FIM-based models, respectively, both with a high predictive accuracy of 0.875. Identified peptides that discriminated improved functional recovery reflected heightened neuroplasticity and synaptic refinement and diminished cell death and neuroinflammation, consistent with postacute TBI pathobiology.

CONCLUSIONS

Produced models of urine-based peptide measures reflective of ongoing recovery pathobiology can inform on rehabilitation progress after TBI, warranting further study to assess refined stratification across a larger population and efficacy in assessing therapeutic interventions.

The effect of access to a designated interdisciplinary post-acute rehabilitation service on participant outcomes after brain injury

OBJECTIVE

This study aimed to determine the influence of participation in a designated acquired brain injury (ABI) transitional rehabilitation service (ABI TRS) on outcome, in the context of a historical comparison group (HIST). Design: A cohort study, with retrospective comparison. Participants: 187 persons with ABI. Measures: The Depression, Anxiety and Stress Scale (DASS-21), Mayo-Portland Adaptability Index (MPAI-4) and Sydney Psychosocial and Reintegration Scale (SPRS) were completed at discharge and 3 months after discharge. Participation in the ABI TRS involved interdisciplinary rehabilitation, 2-4 times per week, for 3 months after hospital discharge. Results: There was evidence that at 3 months, participants with ABI TRS showed stabilized psychological wellbeing, and improvements in MPAI-4 ability and participation scores; in addition to improvements in SPRS occupational activity and living skills scores. Conclusion: A designated ABI TRS may improve the transition from hospital to home, and could form an important part of the brain injury rehabilitation continuum, between the inpatient and community setting.

Time between acquired brain injury and admission to community-based rehabilitation: differences in cognitive and functional gains

OBJECTIVE

To determine differences in rehabilitation gains made by people with an acquired brain injury undergoing staged community-based brain injury rehabilitation (SCBIR) at different times between injury and admission.

METHOD

Retrospective cohort analysis of routinely collected demographic and rehabilitation data from clients admitted to SCBIR service 2011-2017 (n=92). Outcome measures: Mayo-Portland Adaptability Inventory-4 (MPAI-4) and UK Functional Assessment Measure (UK FIM+FAM) collected on admission and annually thereafter until discharge. Analysis was stratified by time since injury on admission: 'Early' (<1 year (n=36)), 'Middle' (1-2 years (n=34)) and 'Late' (>2 years (n=22)). Between-group differences were tested using bootstrapped one-way ANOVA. Within-group differences were tested using paired T tests.

RESULTS

Total cohort made significant gains in MPAI-4 and UK FIM+FAM total and all subscales (p = .001). Early group made greatest change in all subscales of both outcome measures (p < .01). Middle cohort improved significantly in all subscales (p < .02) excluding MPAI-4 Adjustment. Late cohort still made statistically significant gains in all UK FIM+FAM subscales (p < .05) and MPAI-4 Participation (p < .01). Item level changes are presented.

CONCLUSION

More than 2 years after injury, people are able to make improvements in participation and functional independence following SCBIR.