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Perrin PB, Haun JN, Klyce DW, Melillo C, Nakase-Richardson R, Seel RT, Martindale-Adams J, Nichols LO, Perera RA, Xia B, Hahm B, Zuber J. Efficacy and Implementation Planning Across the Veterans Affairs Polytrauma System of Care: Protocol for the REACH Intervention for Caregivers of Veterans and Service Members With Traumatic Brain Injury. JMIR Res Protoc 2024; 13:e57692. [PMID: 39145996 PMCID: PMC11362706 DOI: 10.2196/57692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 05/22/2024] [Accepted: 06/14/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND The responsibility of care for Veterans and Service Members (V/SMs) with traumatic brain injury (TBI) often defaults to informal family caregivers. Caregiving demands considerable knowledge, skill, and support to facilitate the health and well-being of V/SMs and themselves. Persistent and common TBI caregiver issues include strain, depression, and anxiety. While evidence-based, brief interventions have been developed and implemented for family caregivers in Veteran neurodegenerative populations, few interventions have been developed, adapted, or tested to support the unique needs of caregivers of V/SMs with TBI. OBJECTIVE This study will adapt and test an evidence-based, personalized, 6-session telehealth caregiver intervention, "Resources for Enhancing All Caregivers' Health" (REACH), to meet the unique needs of caregivers of V/SMs with TBI. If successful, a community-based participatory research team will develop an implementation plan to roll out REACH TBI across the national Veterans Affairs Polytrauma System of Care. METHODS This mixed methods, crossover waitlist control clinical trial will use a Type 1 Hybrid Effectiveness-Implementation approach to adapt and then test the effects of REACH TBI on key TBI caregiver outcomes. RESULTS This study was funded by the Department of Defense in September 2023. Participant enrollment and data collection will begin in 2024. CONCLUSIONS If effective, REACH TBI will be the first evidence-based intervention for caregivers of V/SMs with TBI that can be scaled to implement across the Veterans Affairs Polytrauma System of Care and fill a notable gap in clinical services. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/57692.
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Affiliation(s)
- Paul B Perrin
- School of Data Science, University of Virginia, Charlottesville, VA, United States
- Central Virginia Veterans Affairs Health Care System, Richmond, VA, United States
| | - Jolie N Haun
- Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, UT, United States
- James A. Haley Veterans' Hospital, Tampa, FL, United States
| | - Daniel W Klyce
- Central Virginia Veterans Affairs Health Care System, Richmond, VA, United States
- Department of Physical Medicine & Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, VA, United States
- Sheltering Arms Institute, Richmond, VA, United States
| | - Christine Melillo
- Seattle-Denver Center of Innovation, Rocky Mountain Regional VA Medical Center, Aurora, VA, United States
| | - Risa Nakase-Richardson
- James A. Haley Veterans' Hospital, Tampa, FL, United States
- Division of Pulmonary and Sleep Medicine, Department of Internal Medicine, University of South Florida, Tampa, FL, United States
| | - Ronald T Seel
- Department of Physical Medicine & Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Jennifer Martindale-Adams
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
- Lt. Col. Luke Weathers, Jr. Veterans Affairs Medical Center, Memphis, TN, United States
| | - Linda O Nichols
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
- Lt. Col. Luke Weathers, Jr. Veterans Affairs Medical Center, Memphis, TN, United States
| | - Robert A Perera
- Department of Biostatistics, School of Public Health, Virginia Commonwealth University, Richmond, VA, United States
| | - Bridget Xia
- School of Data Science, University of Virginia, Charlottesville, VA, United States
- Central Virginia Veterans Affairs Health Care System, Richmond, VA, United States
| | - Bridget Hahm
- Edward Hines, Jr. VA Hospital, Hines, IL, United States
| | - Jeffrey Zuber
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
- Lt. Col. Luke Weathers, Jr. Veterans Affairs Medical Center, Memphis, TN, United States
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Perrin PB, Rodriguez-Agudelo Y, Plaza SLO, Quijano-Martinez MC, Trujillo MA, Smith ER, Cariello AN, Arango-Lasprilla JC. Multi-site, multi-country randomized clinical trial of an acute traumatic brain injury caregiver transition assistance program in Latin America. NeuroRehabilitation 2023; 52:137-147. [PMID: 36617755 DOI: 10.3233/nre-220121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Individuals with traumatic brain injury (TBI) in Latin America experience high levels of disability and extremely poor functional outcomes, and their informal caregivers play a key role in their rehabilitation and care. OBJECTIVE To improve TBI rehabilitation through stronger informal caregiving, this study developed and evaluated an evidence-based and culturally appropriate Transition Assistance Program (TAP) for informal caregivers of individuals with TBI in Latin America, specifically targeting the time period before and after the transition from hospital to home. METHODS A sample of 89 people with a new TBI and their primary informal caregiver (n = 178) was recruited from two hospitals in Mexico City, Mexico, and in Cali, Colombia. Caregivers were randomly assigned to either the TAP group or to a control group receiving the standard care provided by the hospital. Caregivers completed measures of depression and burden, and individuals with TBI completed measures of depression and self-perceived burden on caregivers before hospital discharge and at 2- and 4-month follow ups. RESULTS Caregivers in the TAP group reported significantly lower burden than those in the control group and marginally lower depression. Individuals with TBI whose caregivers had been in the TAP group reported significantly lower depression than those whose caregivers had been in the control group, and a non-significant but lower self-perceived burden on their caregivers. CONCLUSION The results suggest that the TAP has strong potential to benefit both TBI caregivers and individuals with TBI during the transition from acute TBI hospitalization to home in Latin America, generally showing small-or medium-sized effects on key outcomes.
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Affiliation(s)
- Paul B Perrin
- University of Virginia, Charlottesville, VA, USA.,Central Virginia Veterans Affairs Health Care System, Richmond, VA, USA
| | - Yaneth Rodriguez-Agudelo
- Neuropsychology Department, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | | | | | | | - Erin R Smith
- Virginia Commonwealth University, Richmond, VA, USA
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Mascialino G, Cañadas V, Valdiviezo-Oña J, Rodríguez-Lorenzana A, Arango-Lasprilla JC, Paz C. Self-concept 6 months after traumatic brain injury and its relationship with emotional functioning. Front Psychol 2022; 13:995436. [DOI: 10.3389/fpsyg.2022.995436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022] Open
Abstract
This is an observational exploratory study assessing self-concept and its association with depression, anxiety, satisfaction with life, and quality of life 6 months after experiencing a traumatic brain injury. Participants were 33 patients who suffered a traumatic brain injury 6 months before the assessment. The measures used in this study were the Repertory Grid Technique, Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, Satisfaction With Life Scale, and the Quality of Life after Brain Injury. We calculated Euclidean distances to assess differences in pre-and post-injury self-perception, as well as the proportion of opposed pole construct rating and polarization to understand how they are associated with the scores of the other offered measures. We found that the distance between the present and ideal self, as well as the distance between the present self and the self before the lesion showed moderate positive correlations with depression, and negative correlations with satisfaction with life and quality of life. Also, for the present and self before the lesion, the proportion of opposed pole ratings was correlated with depression symptoms, quality, and satisfaction with life, while for the present self and the ideal self this proportion was correlated with all the measures. The proportion of polarization of the present self and the total polarization was negatively correlated with symptom measures. The repertory grid might facilitate a greater understanding of self-concept after traumatic brain injury. This information could be used to guide treatments that address the emotions related to distances observed in the perception of the self.
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Allen N, Hevey D, Carton S, O'Keeffe F. Life is about "constant evolution": the experience of living with an acquired brain injury in individuals who report higher or lower posttraumatic growth. Disabil Rehabil 2021; 44:3479-3492. [PMID: 33459069 DOI: 10.1080/09638288.2020.1867654] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To explore the experience of living with an Acquired Brain Injury (ABI) in individuals who report higher or lower posttraumatic growth (PTG). METHOD A multi-method design was employed. Participant scores on the Posttraumatic Growth Inventory (PTGI) were used to identify groups for qualitative comparative analysis. Individual semi-structured interviews were conducted with fourteen individuals with ABI. Data were analysed thematically. RESULTS Four themes emerged. The first two themes: "In my mind I was fine" surviving in aftermath of acquiring a brain injury and The everyday as "derailing" capture the transition process from an initial rehabilitation state characterised by neuropsychological and avoidance coping, towards active rebuilding for PTG. Internal building blocks for PTG and Growing in the social world: "you need to have that social connection" elaborate on the internal (e.g., acceptance, integration of the pre and post-injury self) and external (e.g., social relationships) factors seen to facilitate or obstruct PTG. CONCLUSIONS Under certain conditions, individuals living with ABI may construe positive growth from their experiences. Practitioners can support PTG development by providing individual and family-based supports aimed at increasing acceptance, the integration of self, and social connection throughout all stages of ABI rehabilitation.IMPLICATIONS FOR REHABILITATIONInternal factors such as having a flexible and positive mindset and external factors such as one's social environment can affect how individuals living with an ABI construe positive growth.Individuals with ABI and their families require access to individualised longitudinal support for neuropsychological and social challenges that can result in increased distress and obstruct the development of PTG.Efforts to facilitate acceptance and support the integration of the pre and post-injury self through recognition of continuity of self and processing of new schematic beliefs can benefit PTG development.Rehabilitation providers should support individuals with ABI to develop or maintain a positive social identity within new or existing social groups.
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Affiliation(s)
- Niamh Allen
- School of Psychology, Trinity College Dublin, Dublin, Ireland
| | - David Hevey
- School of Psychology, Trinity College Dublin, Dublin, Ireland
| | - Simone Carton
- National Rehabilitation Hospital, Dún Laoghaire, Dublin, Ireland
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Taylor JE, Seebeck RF. Preinjury Psychological Factors and Case Formulation in Mild Traumatic Brain Injury Rehabilitation: A Case Report. REHABILITATION COUNSELING BULLETIN 2019. [DOI: 10.1177/0034355219878500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Mild traumatic brain injury (TBI) accounts for the majority of TBIs. Most cases recover within 3 months and usual medical advice covers physical and cognitive rest, activity and fatigue management, and education. However, in some cases, symptoms can persist and there may be ongoing postconcussion difficulties. It is well established that pre- and postinjury psychological factors can contribute to cases of persistent postconcussion symptoms. However, there are few illustrative case examples in the published literature on mild TBI. This case example demonstrates the pivotal role that preinjury psychological factors can play in recovery from mild TBI, using an example of a 35-year-old woman with persistent mild TBI symptoms who had a limited response to previous brief treatment through a Concussion Clinic. Through the process of assessment and development of a psychological case formulation, preinjury psychological factors that had been barriers to recovery and prior rehabilitation efforts were identified. Rehabilitation counselors are equipped to (1) identify and address such barriers, (2) communicate this information to other rehabilitation professionals in the treatment team to facilitate a shared understanding of how factors might affect the client’s functioning and (3) contribute to team case formulation.
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Forslund MV, Roe C, Perrin PB, Sigurdardottir S, Lu J, Berntsen S, Andelic N. The trajectories of overall disability in the first 5 years after moderate and severe traumatic brain injury. Brain Inj 2017; 31:329-335. [PMID: 28095032 DOI: 10.1080/02699052.2016.1255778] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PRIMARY OBJECTIVES To assess longitudinal trajectories of overall disability after moderate-to-severe traumatic brain injury (TBI) and to examine whether those trajectories could be predicted by socio-demographic and injury characteristics. METHODS Demographics and injury characteristics of 105 individuals with moderate-to-severe TBI were extracted from medical records. At the 1-, 2-, and 5-year follow-ups, TBI-related disability was assessed by the GOSE. A hierarchical linear model (HLM) was used to examine functional outcomes up to 5 years following injury and whether those outcomes could be predicted by: time, gender, age, relationship, education, employment pre-injury, occupation, GCS, cause of injury, length of post-traumatic amnesia (PTA), CT findings and injury severity score, as well as the interactions between each of these predictors and time. RESULTS Higher GOSE trajectories (lower disability) were predicted by younger age at injury and shorter PTA, as well as by the interaction terms of time*PTA and time*employment. Those who had been employed at injury decreased in disability over time, while those who had been unemployed increased in disability. CONCLUSION The study results support the view that individual factors generally outweigh injury-related factors as predictors of disability after TBI, except for PTA.
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Affiliation(s)
- Marit V Forslund
- a Department of Physical Medicine and Rehabilitation , Oslo University Hospital , Oslo , Norway
| | - Cecilie Roe
- a Department of Physical Medicine and Rehabilitation , Oslo University Hospital , Oslo , Norway.,b Faculty of Medicine , University of Oslo , Oslo , Norway
| | - Paul B Perrin
- c Department of Psychology , Virginia Commonwealth University , Richmond , VA , USA
| | - Solrun Sigurdardottir
- d CHARM (Research Centre for Habilitation and Rehabilitation Models and Services), Faculty of Medicine , University of Oslo , Oslo , Norway.,e Department of Research , Sunnaas Rehabilitation Hospital , Nesoddtangen , Norway
| | - Juan Lu
- f Department of Epidemiology and Community Health , Virginia Commonwealth University , Richmond , VA , USA
| | - Svein Berntsen
- g Department of Physical Medicine and Rehabilitation , Sørlandet Hospital , Kristiansand , Norway
| | - Nada Andelic
- a Department of Physical Medicine and Rehabilitation , Oslo University Hospital , Oslo , Norway.,d CHARM (Research Centre for Habilitation and Rehabilitation Models and Services), Faculty of Medicine , University of Oslo , Oslo , Norway
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Mathias JL, Wheaton P. Contribution of brain or biological reserve and cognitive or neural reserve to outcome after TBI: A meta-analysis (prior to 2015). Neurosci Biobehav Rev 2015; 55:573-93. [PMID: 26054792 DOI: 10.1016/j.neubiorev.2015.06.001] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 05/22/2015] [Accepted: 06/02/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Jane L Mathias
- School of Psychology, University of Adelaide, Adelaide, South Australia, Australia.
| | - Patricia Wheaton
- School of Psychology, University of Adelaide, Adelaide, South Australia, Australia
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Ulfarsson T, Lundgren-Nilsson Å, Blomstrand C, Jakobsson KE, Odén A, Nilsson M, Rosén T. Ten-year mortality after severe traumatic brain injury in western Sweden: A case control study. Brain Inj 2014; 28:1675-81. [DOI: 10.3109/02699052.2014.947625] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Ulfarsson T, Lundgren-Nilsson Å, Blomstrand C, Nilsson M. A history of unemployment or sick leave influences long-term functioning and health-related quality-of-life after severe traumatic brain injury. Brain Inj 2013; 28:328-35. [DOI: 10.3109/02699052.2013.865274] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Norman RS, Jaramillo CA, Amuan M, Wells MA, Eapen BC, Pugh MJ. Traumatic brain injury in veterans of the wars in Iraq and Afghanistan: Communication disorders stratified by severity of brain injury. Brain Inj 2013; 27:1623-30. [DOI: 10.3109/02699052.2013.834380] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Ulfarsson T, Arnar Gudnason G, Rosén T, Blomstrand C, Sunnerhagen KS, Lundgren-Nilsson A, Nilsson M. Pituitary function and functional outcome in adults after severe traumatic brain injury: the long-term perspective. J Neurotrauma 2013; 30:271-80. [PMID: 23121499 DOI: 10.1089/neu.2012.2494] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Post-traumatic hypopituitarism (PTHP) has been linked to disability and decreased quality of life. However, no studies have addressed the long-term consequences of PTHP in adults with severe traumatic brain injury (TBI) only. In this study, we evaluated the relationship between pituitary function, quality of life, and functioning in 51 patients (16-65 years of age) with severe TBI who were admitted to Sahlgrenska University Hospital, Gothenburg from 1999 to 2002. The patients were assessed once, 2-10 years after trauma. Data from the time of injury were collected retrospectively to adjust for injury severity. Outcome measures included hormonal testing, the Short Form-36 Health Survey, the Glasgow outcome scale-extended, and a self-report questionnaire specifically designed for this study and based on the International Classification of Functioning, Disability and Health. Of 51 patients, 14 (27.5%) presented with PTHP, and 11 (21.6%) had isolated growth hormone deficiency. Patients with PTHP were more often overweight at follow-up (p=0.01); the higher body mass index was partially explained by PTHP (R2 change=0.07, p=0.001). Otherwise no significant correlation was found among PTHP, functioning, or patient-reported quality of life. This study-which is unique in the homogeneity of the patients, the long follow-up time, and the use of injury severity as an outcome predictor-did not confirm results from previous studies linking PTHP to a worse outcome. Therefore, screening for PTHP might be restricted to specific subgroups such as overweight patients, indicating growth hormone deficiency.
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Affiliation(s)
- Trandur Ulfarsson
- Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.
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Shi HY, Hwang SL, Lee KT, Lin CL. Temporal trends and volume-outcome associations after traumatic brain injury: a 12-year study in Taiwan. J Neurosurg 2013; 118:732-8. [PMID: 23350773 DOI: 10.3171/2012.12.jns12693] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The purpose of this study was to evaluate temporal trends in traumatic brain injury (TBI); the impact of hospital volume and surgeon volume on length of stay (LOS), hospitalization cost, and in-hospital mortality rate; and to explore predictors of these outcomes in a nationwide population in Taiwan. METHODS This population-based patient cohort study retrospectively analyzed 16,956 patients who had received surgical treatment for TBI between 1998 and 2009. Bootstrap estimation was used to derive 95% confidence intervals for differences in effect sizes. Hierarchical linear regression models were used to predict outcomes. RESULTS Patients treated in very-high-volume hospitals were more responsive than those treated in low-volume hospitals in terms of LOS (-0.11; 95% CI -0.20 to -0.03) and hospitalization cost (-0.28; 95% CI -0.49 to -0.06). Patients treated by high-volume surgeons were also more responsive than those treated by low-volume surgeons in terms of LOS (-0.19; 95% CI -0.37 to -0.01) and hospitalization cost (-0.43; 95% CI -0.81 to -0.05). The mean LOS was 24.3 days and the average LOS for very-high-volume hospitals and surgeons was 61% and 64% shorter, respectively, than that for low-volume hospitals and surgeons. The mean hospitalization cost was US $7,292.10, and the average hospitalization cost for very-high-volume hospitals and surgeons was 19% and 22% lower, respectively, than that for low-volume hospitals and surgeons. Advanced age, male sex, high Charlson Comorbidity Index score, treatment in a low-volume hospital, and treatment by a low-volume surgeon were significantly associated with adverse outcomes (p < 0.001). CONCLUSIONS The data suggest that annual surgical volume is the key factor in surgical outcomes in patients with TBI. The results improve the understanding of medical resource allocation for this surgical procedure, and can help to formulate public health policies for optimizing hospital resource utilization for related diseases.
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Affiliation(s)
- Hon-Yi Shi
- Department of Health Care Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan, Republic of China
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Gupta A, Taly AB. Functional outcome following rehabilitation in chronic severe traumatic brain injury patients: A prospective study. Ann Indian Acad Neurol 2012; 15:120-4. [PMID: 22566725 PMCID: PMC3345588 DOI: 10.4103/0972-2327.94995] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 01/26/2012] [Accepted: 02/03/2012] [Indexed: 11/05/2022] Open
Abstract
Objective: The objective was to assess functional outcome of rehabilitation in chronic severe traumatic brain injury (TBI) in-patients. Setting: The study was performed at university tertiary research hospital. Study Design: A prospective cross-sectional study Materials and Methods: Forty patients (34 men) with mean age of 30.1 years (range 6--60, SD 10.8), severe TBI (Glasgow coma scale 3--8, duration of coma > 6 hours, post-traumatic amnesia> 1 day postinjury) were admitted in rehabilitation unit minimum 3 months (mean 7.7±4.6 months, range 3--22 months) following injury falling in Glasgow outcome scale (GOS) of 3. Functional recovery was assessed using the Barthel Index (BI) score and disability rating scores (DRS). Data Analysis: Paired Student's t-test was used for the assessment of functional recovery using mean BI scores at admission and discharge. The Wilcoxon nonparametric test was used for the assessment of functional recovery by comparing admission and discharge DRS scores. Results: Mean duration of stay was 30.8 days (range 18--91, SD15.6). Significant functional recovery observed in patients comparing BI and DRS scores at admission and discharge (mean BI admission 50.5±25.4, range 0--85 vs. mean discharge BI score 61.1±25.3, range 0--95, P<0.001, mean DRS admission score 7.57±4.1, range 2.5--21.0 vs. mean discharge DRS score 6.36±4.3, range 1.0-21.0, P<0.001). Conclusion: Patients with severe TBI continue to show functional recovery even in chronic phase with rehabilitation. They are left with significant residual physical and cognitive deficits and would require long-term care and assistance from care givers for the daily activities, as suggested by the mean DRS score at discharge.
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Affiliation(s)
- Anupam Gupta
- Neurological Rehabilitation Division, Department of Psychiatric and Neurological Rehabilitation, National Institute of Mental Health and Neuro Sciences, Bangalore, India
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