Severe traumatic brain injury in New South Wales: comparable outcomes for rural and urban residents

Epidemiology and outcomes of brain trauma in rural and urban populations: a systematic review and meta-analysis

OBJECTIVE

To identify and describe differences in demographics, injury characteristics, and outcomes between rural and urban patients suffering brain injury.

DATA SOURCES

CINAHL, Emcare, MEDLINE, and Scopus.

REVIEW METHODS

A systematic review and meta-analysis of studies comparing epidemiology and outcomes of rural and urban brain trauma was conducted in accordance with PRISMA and MOOSE guidelines.

RESULTS

36 studies with ~ 2.5-million patients were included. Incidence of brain injury was higher in males, regardless of location. Rates of transport-related brain injuries, particularly involving motorized vehicles other than cars, were significantly higher in rural populations (OR:3.63, 95% CI[1.58,8.35], p = 0.002), whereas urban residents had more fall-induced brain trauma (OR:0.73, 95% CI[0.66,0.81], p < 0.00001). Rural patients were 28% more likely to suffer severe injury, indicated by Glasgow Coma Scale (GCS)≤8 (OR:1.28, 95% CI[1.04,1.58], p = 0.02). There was no difference in mortality (OR:1.09, 95% CI[0.73,1.61], p = 0.067), however, urban patients were twice as likely to be discharged with a good outcome (OR:0.52, 95% CI[0.41,0.67], p < 0.00001).

CONCLUSIONS

Rurality is associated with greater severity and poorer outcomes of traumatic brain injury. Transport accidents disproportionally affect those traveling on rural roads. Future research recommendations include addition of prehospital data, adequate follow-up, standardized measures, and sub-group analyses of high-risk groups, e.g. Indigenous populations.

Return to Work One Year after Moderate to Severe Traumatic Injury in a Working Age Population

Background/Objectives: Physical trauma may cause long-term disabilities. The importance of place of residence in the return to work after injuries is little researched. The primary aims of this study were to describe return to work or school (RTW) at 6 and 12 months after moderate to severe traumatic injury and to investigate demographic and injury-related predictors for RTW with an initial focus on geographic centrality of residency. The secondary aim was to investigate the association between RTW and functioning. Methods: A prospective cohort study conducted at two Norwegian trauma centres. Inclusion criteria: age 18 to 70 years, at least a two-day hospital stay and a New Injury Severity Score > 9. Information about centrality, demographics, injuries, and return to work were collected. Associations between possible predictors and RTW were assessed using binary logistic regression. Results: Of the 223 participants, 68% had returned to work after 6 months and 77% after 12 months. Twelve-month RTW was 89% after thorax/abdomen injuries, 78% after extremity/spine injuries and 73% after head injuries. More central residency was a significant predictor for RTW in univariable but only within the extremity/spine injury subgroup in multivariable analysis. Negative factors were age, having a blue-collar job, number of injuries and rehabilitation complexity. Function 12 months post-injury was associated with RTW in the multivariable model. Conclusions: RTW after one year was high in all major trauma groups. Demographic and injury-related factors were more important predictors of RTW than centrality of residency. Blue-collar workers and patients with multiple injuries and high rehabilitation complexity should be given special attention to support RTW.

Building resilience among families supporting relatives with ABI in rural NSW: testing the feasibility of telephone delivery of Strength2Strength program

BACKGROUND

Strength2Strength (S2S) is a group psychoeducational program aiming to build resilience among families supporting relatives after traumatic injury.

OBJECTIVE

To test the feasibility, acceptability and outcomes of teleconference delivery of a 5 hour S2S program in rural New South Wales.

METHODS

A mixed methods design investigated the (i) convenience of telephone-based delivery; and (ii) acceptability of the program material (purpose-designed survey and the Narrative Evaluation of Intervention Interview). Program efficacy was measured with the Resilience Scale (RS) and Connor-Davidson Resilience Scale (CD-RISC); the Positive and Negative Affect Scale (PANAS); Depression, Anxiety and Stress Scale - 21 (DASS-21); Carer Assessment of Managing Index (CAMI); and Caregiver Burden Scale (CBS). Participant outcome data were collected at baseline, post program and 3 months follow-up.

RESULTS

11 participants supporting adult relatives with severe brain injury completed the program. All participants and facilitators commented positively about the cost, ease of use and quality of the teleconference facility. Statistically significant gains were found between pre-program and follow-up scores on the RS, CD-RISC, PANAS-Positive, and CAMI, with statistically significant reductions found on the DASS-21 Depression Scale and CBS scores.

CONCLUSION

The study provides preliminary evidence for the efficacy of telephone-based delivery of S2S to family participants.

Social and community participation following traumatic lower limb amputation: an exploratory qualitative study

PURPOSE

To explore barriers and facilitators to social and community participation experienced by people following traumatic lower limb amputation (LLA).

METHODS

An exploratory qualitative study was conducted with nine adults with traumatic LLA in Victoria, Australia. Participants were a minimum of 18 months post amputation. Interview data was analysed using thematic analysis.

RESULTS

Participants referenced the inaccessibility of the built environment and physical challenges associated with prosthetic mobility as barriers to participation. Chronic and complex health concerns due to their injuries resulted in physical and emotional distress for some, further limiting their social and community engagement. Participants highlighted the benefit of peer-support networks and the value of supportive community groups in assisting the transition to their pre-amputation family, work and social roles. Participants also felt that a strong, positive attitude and being self-motivated were important to aid in their return to social and community participation.

CONCLUSION

People following traumatic LLA experience a number of physical, psychological and environmental challenges to participation. The role of peer-support networks, community groups and personal attitudes are important facilitators to assist a return to family, work and life roles. The findings of this study have informed the development of recommendations to guide clinical practice.IMPLICATIONS FOR REHABILITATIONPeer-support groups for people following traumatic lower limb amputation (LLA) may assist to improve their long-term adjustment to disability and community participationRetraining skills in an individual's own community should be considered when planning community-based therapy services for people following traumatic LLA.Ongoing psychosocial support including strategies to develop self-efficacy and positive mindset may improve social and community participationRegular medical and allied health reviews can be beneficial to promote early intervention for any complications that arise to minimise time off prosthesis.

Increased distance or time from a major trauma centre in South Australia is not associated with worse outcomes after moderate to severe traumatic brain injury

OBJECTIVE

Considerations in traumatic brain injury (TBI) management include time to critical interventions and neurosurgical care, which can be influenced by the geographical location of injury. In Australia, these distances can be vast with varying degrees of first-responder experience. The present study aimed to evaluate the association that distance and/or time to a major trauma centre (MTC) had on patient outcomes with moderate to severe TBI.

METHODS

A retrospective cohort study was conducted using data from the Royal Adelaide Hospital's (RAH) Trauma Registry over a 3-year period (1 January 2018 to 31 December 2020). All patients with a moderate to severe TBI (Glasgow Coma Scale [GCS] ≤13 and abbreviated injury score head of ≥2) were included. The association of distance and time to the RAH and patient outcomes were compared by calculating the odds ratio utilising a logistic regression model.

RESULTS

A total of 378 patients were identified; of these, 226 met inclusion criteria and comprised our study cohort. Most patients were male (79%), injured in a major city (55%), with median age of 38 years old and median injury severity score (ISS) of 25. After controlling for age, ISS, ED GCS on arrival and pre-MTC intubation, increasing distance or time from injury site to the RAH was not shown to be associated with mortality or discharge destination in any of the models investigated.

CONCLUSION

Our analysis revealed that increasing distance or time from injury site to a MTC for patients with moderate to severe TBI was not significantly associated with adverse patient outcomes.

Quality of life, community integration, service needs and clinical outcomes of people with traumatic brain injury in urban, regional and remote areas of Queensland, Australia

OBJECTIVE

To understand and explore the traumatic brain injury (TBI) outcomes for people returning to urban versus rural communities post-injury, and if geographical location plays a role in those outcomes.

DESIGN

Cross-sectional mail-out survey of TBI patients, using standardised, quantitative measures.

SETTING

Data were drawn from three Accessibility Remoteness Index of Australia (ARIA) areas in Queensland to model the contribution of these areas and other factors to TBI outcomes.

PARTICIPANTS

Using hospital records, 662 people with mild to severe TBI were identified. These people were sent a survey, postdischarge. Usable surveys were returned by 91 individuals, 6- to 18-months post-injury. Location was coded using the ARIA (urban n = 22, rural n = 43, remote n = 26).

MAIN OUTCOME MEASURES

TBI-related symptoms, quality of life, service obstacles, unmet needs, mental health and community integration.

RESULTS

No group differences in TBI outcomes due to location were found. While the participant's gender, age, and injury severity were significant independent predictors of five of the six outcomes, location did not play a role.

CONCLUSION

Consistent with previous findings, geographical remoteness did not affect self-reported TBI outcomes. Older people, women and those with severe TBI had worse outcomes and required additional supports, and men require community integration assistance. An Australia-wide study with regular follow-ups is strongly recommended to support direct regional comparisons and improve service planning.

Caring for people with serious injuries in urban and regional communities: a qualitative investigation of healthcare providers' perceptions

Purpose: To understand the factors that affect the management of people after serious injury in urban and regional settings, beyond hospital discharge from the perspectives of allied health professionals (AHPs).Materials and methods: An exploratory qualitative study of AHPs caring for people with serious injuries post-hospital discharge in urban and regional areas of Victoria, Australia was completed. Twenty-five semi-structured interviews were undertaken with AHPs and thematically analysed.Results: Allied health professionals in urban and regional settings reported the benefits of a multi-disciplinary team to deliver high-quality care. However, a number of barriers to service delivery were identified that impacted on their ability to meet the needs of patients. These included insufficient psychological services, a shortage of available carers and an unmet need for external clinical support in regional areas. Communication between AHPs and other services, and care co-ordination of post-discharge services, was also highlighted as key areas to improve for optimal patient care.Conclusions: Factors that influenced optimal patient management included the availability of psychological and carer services, communication between health professionals and coordination of post-discharge care. The experiences of AHPs can offer practical suggestions to optimise service delivery and post-discharge care for people with serious injuries.Implications for RehabilitationAllied health professionals (AHPs) face a number of challenges in the provision of optimal care to people with serious injuries.Improving the availability of psychological support and attendant carers is needed in regional areas.A designated care coordinator role may assist people with serious injuries transitioning between hospital and home to engage with necessary services and reduce administrative burden for AHPs.Telehealth may provide facilitate improved communication between health professionals and support regional clinicians caring for people with complex injuries.

The Importance of Place of Residence on Hospitalized Outcomes for Severely Injured Trauma Patients: A Trauma Registry Analysis

PURPOSE

Socioecological factors are understudied in relation to trauma patients' outcomes. This study investigated the association of neighborhood socioeconomic disadvantage (SED) and remoteness of residence on acute length of hospital stay days (ALSD) and inpatient mortality.

METHODS

A retrospective cohort study was conducted on adults hospitalized for major trauma in a Level 1 trauma center in southeast Queensland from 2014 to 2017. Neighborhood SED and remoteness indices were linked to individual patient variables. Step-wise multivariable negative binomial regression and proportional hazards regression analyses were undertaken, adjusting for injury and patient factors. Outcomes were ALSD and inpatient mortality.

FINDINGS

We analyzed 1,025 patients. Statistically significant increased hazard of inpatient mortality was found for older age (HR 3.53, 95% CI: 1.77-7.11), injury severity (HR 5.27, 95% CI: 2.78-10.02), remoteness of injury location (HR 1.75, 95% CI: 1.06-2.09), and mechanisms related to intentional self-harm or assault (HR 2.72, 95% CI: 1.48-5.03,). Excess mortality risk was apparent for rural patients sustaining less severe injuries (HR 4.20, 95% CI: 1.35-13.10). Increased risk for longer ALSD was evident for older age (RR 1.35, 95% CI: 1.07-1.71), head injury (RR 1.39, 95% CI: 1.19-1.62), extremity injuries (RR 1.82, 95% CI: 1.55-2.14), and higher injury severity scores (ISS) (RR 1.51, 95%: CI: 1.29-1.76).

CONCLUSIONS

Severely injured rural trauma patients are more likely to be socioeconomically disadvantaged and sustain injuries predisposing them to worse hospital outcomes. Further research is needed to understand more about care pathways and factors influencing the severity, mechanism and clinical consequences of rural-based traumatic injuries.

The relationship between geographic location and outcomes following injury: A scoping review

INTRODUCTION

Globally, injury incidence and injury-fatality rates are higher in regional and remote areas. Recovery following serious injury is complex and requires a multi-disciplinary approach to management and community re-integration to optimise outcomes. A significant knowledge gap exists in understanding the regional variations in hospital and post-discharge outcomes following serious injury. The aim of this study was to review the evidence exploring the association between the geographic location, including both location of the event and place of residence, and outcomes following injury.

MATERIALS AND METHODS

A scoping review was used to investigate this topic and provide insight into geographic variation in outcomes following traumatic injury. Seven electronic databases and reference lists of relevant articles were searched from inception to October 2018. Studies were included if they measured injury-related mortality, outcomes associated with hospital admission, post-injury physical or psychological function and analysed these outcomes in relation to geographic location.

RESULTS

Of the 2,213 studies identified, 47 studies were included revealing three key groups of outcomes: mortality (n = 35), other in-hospital outcomes (n = 8); and recovery-focused outcomes (n = 12). A variety of measures were used to classify rurality across studies with inconsistent definitions of rurality/remoteness. Of the studies reporting injury-related mortality, findings suggest that there is a greater risk of fatality in rural areas overall and in the pre-hospital phase. For those patients that survived to hospital, the majority of studies included identified no difference in mortality between rural and urban patient groups. In the small number of studies that reported other in-hospital and recovery outcomes no consistent trends were identified.

CONCLUSION

Rural patients had a higher overall and pre-hospital mortality following injury. However, once admitted to hospital, there was no significant difference in mortality. Inconsistencies were noted across measures of rurality measures highlighting the need for more specific and consistent international classification methods. Given the paucity of data on the impact of geography on non-mortality outcomes, there is a clear need to develop a larger evidence base on regional variation in recovery following injury to inform the optimisation of post-discharge care services.

Long-Term Follow-Up of Disability, Cognitive, and Emotional Impairments after Severe Traumatic Brain Injury

Aim

To assess the clinical course of disability, cognitive, and emotional impairments in patients with severe TBI (s-TBI) from 3 months to up to 7 years post trauma.

Methods

A prospective cohort study of s-TBI in northern Sweden was conducted. Patients aged 18-65 years with acute Glasgow Coma Scale 3-8 were assessed with the Glasgow Outcome Scale Extended (GOSE), the Hospital Anxiety and Depression Scale (HADS), and the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) at 3 months, 1 year, and 7 years after the injury.

Results

The scores on both GOSE and BNIS improved significantly from 3 months (GOSE mean: 4.4 ± 2.3, BNIS mean: 31.5 ± 7.0) to 1 year (GOSE mean: 5.5 ± 2.7, p = 0.003, BNIS mean: 33.2 ± 6.3, p = 0.04), but no significant improvement was found from 1 year to 7 years (GOSE mean: 4.7 ± 2.8, p = 0.13, BNIS mean: 33.5 ± 3.9, p = 0.424) after the injury. The BNIS subscale “speech/language” at 1 year was significantly associated with favourable outcomes on the GOSE at 7 years (OR = 2.115, CI: 1.004-4.456, p = 0.049).

Conclusions

These findings indicate that disability and cognition seem to improve over time after s-TBI and appear to be relatively stable from 1 year to 7 years. Since cognitive function on some of the BNIS subscales was associated with outcome on the GOSE, these results indicate that both screening and follow-up of cognitive function could be of importance for the rehabilitation of persons with s-TBI.

Navigating Employment Pathways and Supports Following Brain Injury in Australia: Client Perspectives

This study investigated the vocational rehabilitation experiences of 29 clients, up to 14 years post brain injury. Data obtained from participant interviews were thematically analysed by employment pathway (‘return to pre-injury employment’, ‘job seeking’ and ‘not worked since injury’). A total of nine themes were identified. Across all pathways, participants identified the importance of working, impact of injury and their own determination. The content for the remaining themes (understanding, adjustment, access, support, disclosure of injury, intervention) varied by pathway, reflecting the differing perspectives arising from integrating back into a familiar workplace versus seeking new employment. In conclusion, programme approaches to vocational rehabilitation need to be tailored to the individual circumstances, opportunities and support needs of people with brain injury pursuing these different pathways.

Psychological impact of injuries sustained in motor vehicle crashes: systematic review and meta-analysis

OBJECTIVE

The aim of this meta-analysis was to determine the psychological impact associated with motor vehicle crash (MVC)-related physical injuries.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Multiple search engines included MEDLINE (via OVID), PsycINFO and Embase, and studies were sourced from scientific journals, conference papers and doctoral theses.

STUDY SELECTION

A high-yield search strategy was employed. Terms like 'psychological distress', 'depression', 'PTSD' and 'motor vehicle accident' were employed. These key words were run primarily and secondary searches were then conducted in association with the major injury types. Studies needed to compare psychological distress in people injured in an MVC with uninjured controls who had not recently experienced an MVC.

DATA EXTRACTION

Searches resulted in the identification of 2537 articles, and after eliminating duplicates and studies not meeting inclusion criteria, 24 studies were selected involving 4502 injured participants. These studies were entered into separate meta-analyses for mild to moderate traumatic brain injury (mTBI), whiplash-associated disorder (WAD) and spinal cord injury (SCI).

RESULTS

Elevated psychological distress was associated with MVC-related injuries with a large summary effect size in WAD (0.90), medium to large effect size in SCI (0.69) and small to medium effect size in mTBI (0.23). No studies meeting inclusion criteria were found for burns, fractures and low back injury. Increased psychological distress remains elevated in SCI, mTBI and WAD for at least 3 years post-MVC.

CONCLUSIONS

Rehabilitation strategies are needed to minimise distress subsequent to MVC-related physical injuries and the scientific robustness of studies requires improvement.

Cognitive Impairment after Severe Traumatic Brain Injury, Clinical Course and Impact on Outcome: A Swedish-Icelandic Study

OBJECTIVE

To assess the clinical course of cognitive and emotional impairments in patients with severe TBI (sTBI) from 3 weeks to 1 year after trauma and to study associations with outcomes at 1 year.

METHODS

Prospective, multicenter, observational study of sTBI in Sweden and Iceland. Patients aged 18-65 years with acute Glasgow Coma Scale 3-8 were assessed with the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) and the Hospital Anxiety and Depression Scale (HADS). Outcome measures were Glasgow Outcome Scale Extended (GOSE) and Rancho Los Amigos Cognitive Scale-Revised (RLAS-R).

RESULTS

Cognition was assessed with the BNIS assessed for 42 patients out of 100 at 3 weeks, 75 patients at 3 months, and 78 patients at 1 year. Cognition improved over time, especially from 3 weeks to 3 months. The BNIS subscales "orientation" and "visuospatial and visual problem solving" were associated with the GOSE and RLAS-R at 1 year.

CONCLUSION

Cognition seemed to improve over time after sTBI and appeared to be rather stable from 3 months to 1 year. Since cognitive function was associated with outcomes, these results indicate that early screening of cognitive function could be of importance for rehabilitation planning in a clinical setting.

We Finally Learnt to Demand: Consumers’ Access to Rehabilitation Following Traumatic Brain Injury

Clinical care guidelines exist internationally recommending the appropriate standards of care for adults following brain injury. These guidelines recommend a care pathway including acute, inpatient and outpatient rehabilitation and community-based care. However, if and how these guidelines are implemented is largely unknown. The aim of this study was to explore the recollected continuum of care experienced by 202 adults with moderate to severe traumatic brain injury (TBI) in Victoria, Australia. The experiences of participants in this study were investigated using a mixed methods research approach (surveys and in-depth interviews). The results indicated that only 20% of participants in this study recollected receiving care in line with recommendations made in clinical care guidelines. Reasons they identified for their problematic access to services included: a lack of information about the services available, the absence of an advocate and services being restricted by limited funding. The findings of this study indicate that while guidelines provide recommendations regarding standards of care and can serve as a benchmark to improve the quality of services, they do not ensure the equitable delivery of services. Clinicians using these guidelines need to be aware of the factors that restrict clients’ access to services and take these into account when planning the delivery of services.

Late mortality after severe traumatic brain injury in New South Wales: a multicentre study

OBJECTIVES

To determine the long-term mortality pattern of adults with severe traumatic brain injury (TBI), and to identify the risk factors associated with death in this group.

DESIGN, PATIENTS AND SETTING

Inception cohort study of 2545 adults consecutively discharged from one of three metropolitan tertiary, post-acute inpatient rehabilitation services of the New South Wales Brain Injury Rehabilitation Program from 1 January 1990 to 1 October 2007 after inpatient rehabilitation for primary TBI.

MAIN OUTCOME MEASURE

Survival status at 1 October 2009.

RESULTS

258 deaths were recorded in this sample, yielding a standardised mortality ratio of 3.19 (95% CI, 2.80-3.60). Risk of death remained elevated above societal norms for at least 8 years after discharge from rehabilitation. Mortality risk was increased by: functional dependence at discharge; age at injury; pre-injury drug and alcohol misuse; pre-injury epilepsy; and discharge to an aged care facility. The risk of death from external causes, and respiratory system and nervous system disorders was six to seven times higher, and the risk of death from disorders of the digestive system, and mental and behavioural disorders was five times higher in adults with severe TBI than in the general population.

CONCLUSIONS

People who survive to discharge from inpatient rehabilitation following a severe TBI were found to have a sustained increase in risk of death for eight years post discharge. Various demographic and injury-related variables selectively increase mortality risk and may be modifiable in order to reduce the observed increase in mortality.

Two-Year Outcome Following Traumatic Brain Injury and Rehabilitation: A Comparison of Patients From Metropolitan Melbourne and Those Residing in Regional Victoria

Background and Objective:Victoria's trauma management system provides acute care and rehabilitation following traumatic brain injury (TBI), with care of more complex injuries generally provided in specialist centres in metropolitan Melbourne. Little is known about how the outcomes of TBI survivors living in metropolitan Melbourne compare to those who reside in regional Victoria once they return to their community, where support services may be less available. The aim of the present study was to compare, in TBI individuals who have been treated at an inner-city rehabilitation centre in Melbourne, the long-term outcomes of those who live in metropolitan Melbourne (termed ‘Metro’) with those who reside in regional Victoria, termed ‘Regional.’Design and participants:Comparative study with quantitative outcome measures. A total of 959 patients, of whom 645 were designated ‘metro’ and 314 ‘regional’, were followed-up routinely at 2 years post-injury.Outcome measures:Structured Outcome Questionnaire, Glasgow Outcome Scale — Extended, Sickness Impact Profile, Craig Handicap Assessment and Reporting Technique, Hospital Anxiety and Depression Scale, Alcohol Use Disorders Identification Test and Drug Abuse Screening Test.Results:Few differences in outcomes were found between groups. However, after controlling for group differences in age and injury severity, some non-significant trends were suggestive of better outcomes in terms of less social isolation and anxiety and fewer dysexecutive behaviours in regional dwellers.Conclusions:These findings suggest that outcomes in patients from regional areas are at least as good as those from metropolitan Melbourne.

Outcomes of participation objective, participation subjective (POPS) measure following traumatic brain injury

PRIMARY OBJECTIVE

To investigate the participation of adults living with traumatic brain injury in regional and rural NSW as measured by the Participation Objective Participation Subjective (POPS) measure.

RESEARCH DESIGN

A quantitative survey of a single cohort as the first of a two phase mixed methods study.

METHODS AND PROCEDURES

One hundred and thirty-one adults with a TBI were recruited through eight rural brain injury rehabilitation programmes in NSW. These adults completed a range of survey instruments, including the POPS.

MAIN OUTCOMES AND RESULTS

The POPS measure supported findings from other research that identified varying impacts of TBI. However, in contrast to other studies, there was no correlation between participation scores and age, gender, time since injury and severity of injury.

CONCLUSIONS

The findings from this study suggest that the issue of participation of adults with TBI living in non-metropolitan areas needs to be further researched.

Traumatic brain injury, participation, and rural identity

In this article we focus on participation following traumatic brain injury (TBI) in rural and regional Australian contexts, asking how aspects of rurality, such as place identity and rural belonging, impact on participation for the individual living with TBI. We found a preference for country living, despite disadvantages including distance from services and lack of anonymity. A rural identity provides access to an enabling narrative, the "rural idyll," which allows people with TBI to inhabit the realm of social normality. A rural identity is enabling in this regard, because it cooperates with TBI-based preferences for social isolation and a relaxed pace that accommodates fatigue. Thus, people living in rural areas report satisfaction with their quality of life despite restricted access to resources and reduced social participation.

Return to work following traumatic brain injury: Trends and challenges

PURPOSE

The aim of this paper is to present the current knowledge regarding return to work (RTW) following traumatic brain injury (TBI).

METHOD

Based on a Medline search, the authors reviewed the current TBI rehabilitation literature regarding (a) predictive factors for successful RTW, and (b) current concepts in rehabilitative strategies for successful RTW.

RESULTS

The functional consequences to the victim of traumatic brain injury (TBI) can be severe. Intensive rehabilitative efforts typically emphasize the early phase and address mainly the accompanying functional deficits in the realm of basic activities of daily living and mobility. An otherwise successful medical rehabilitation may end unsuccessfully because of the failure to return to work, with profound consequences to the individual and family, both economic and psychosocial. Even mild TBI may cause lasting problems in tasks calling for sustained attention. There appears to be a complex interaction between pre-morbid characteristics, injury factors, post injury impairments, personal and environmental factors in TBI patients, which influences RTW outcomes in ways that make prediction difficult. Injury severity and lack of self-awareness appear to be the most significant indicators of failure to RTW. Several medical, psychosocial and rehabilitative therapies are currently being implemented in rehabilitation settings which improve the chances of returning to work.

CONCLUSION

Accurate prediction of whether a particular TBI patient will successfully return to work is not feasible, with RTW rates in the 12 - 70% range. A significant proportion of TBI patients, including those who are severely injured, are able to return to productive employment if sufficient and appropriate effort is invested. A comprehensive approach - medical and psychosocial - eventually entailing adequate vocational rehabilitation with supported employment can improve outcomes.

Neurological disorders in a rural Western Australian population

BACKGROUND

There is limited information on the causes of neurological disorders in an Australian rural setting.

METHODS

This study reports on a prospective cohort of 160 patients (95 women and 65 men) with a mean age of 55.1 years (standard deviation 19.78 years, range 12-92 years) receiving a neurological work-up from one neurologist attending the Geraldton and Midwest region of Western Australia over a 12-month period.

RESULTS

Patients were divided into 15 diagnostic classifications. Movement disorders were the most common diagnostic classification (38 of 160 or 23.75%) and Parkinson's disease was the most common movement disorder (30 of 38 or 78.95%) with an estimated period of prevalence of 187.5 persons per 1000. Of the other neurological disorder diagnosis classifications the following number of patients per group was observed: epilepsy (27 or 16.87%); neuromuscular disorders (22 or 13.75%); multiple sclerosis (12 or 7.5%); cerebrovascular disease (10 or 6.25%); headaches (7 or 4.37%); neurodegenerative (7 or 4.37%); dementias (6 or 3.75%); memory dysfunction (6 or 3.75%); gait disorders (4 or 2.5%); vestibular syndrome (3 or 1.87%); pain syndrome (3 or 1.87%); sensory syndrome (2 or 1.25%); brain injury (1 or 0.62%) and miscellaneous (12 or 7.5%). A high number of persons having Parkinson's disease was found.

CONCLUSION

Possible risk factors for Parkinson's disease for individuals living in Geraldton and Midwest region need to be investigated. This study raises issues pertaining to the provision of services and allocation of resources in rural areas, especially for patients with Parkinson's disease.

Neighborhood characteristics and outcomes after traumatic brain injury

OBJECTIVE

To determine the extent to which characteristics of a person's neighborhood contribute to outcomes after traumatic brain injury (TBI).

DESIGN

Prospective cohort.

SETTING

A specialized brain injury unit providing acute rehabilitation care.

PARTICIPANTS

A consecutive sample of participants (N=200) in the Traumatic Brain Injury Model Systems (TBIMS) longitudinal study: 100 participants were 2 years postinjury, and 100 participants were 5 years postinjury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

U.S. Census Bureau block group descriptors of economic and social characteristics and initial and follow-up data from the TBIMS national dataset including the Glasgow Outcome Scale-Extended (GOS-E) and Satisfaction With Life Scale (SWLS).

RESULTS

Economic and social characteristics of a person's neighborhood accounted for additional variance in outcomes beyond what could be accounted for by individual characteristics, including demographic, premorbid, and injury-related measures; concurrent measures of functioning; and the persons's perception of environmental influences. Individual characteristics predicted a substantial proportion of the variance in the GOS-E (69%); neighborhood characteristics contributed an additional 1.5%. Individual characteristics predicted 33.3% of the variance in SWLS, with neighborhood characteristics accounting for an additional 6.9%.

CONCLUSIONS

For both outcomes, a small but important proportion of the variance accounted for by neighborhood indices was unique to these environmental influences and was not accounted for by individual indices, including concurrent measures of functioning and the individual's perception of environmental influences. Further investigations of how neighborhood factors affect outcomes after TBI are warranted.

Building sustainable rural research capacity: The experiences of a brain injury rehabilitation service

There is an emerging recognition of the need for health research that is conducted by and for rural people. Rural research promotes excellence in clinical practice and can improve staff recruitment and retention. A group of clinicians from a regional brain injury service collaborated with academics at their local university to form the Rural Rehabilitation Research on Brain Injury initiative. This initiative has funded four peer-reviewed research projects, secured an Australian Research Council grant and established the beginnings of a state-wide rural research collective involving all Brain Injury Rehabilitation Programs in New South Wales. Sustainable research enterprises such as this have significant potential as a 'prototype' for building research capacity in other rural health sectors. Governments and funding bodies should support these initiatives.

Centralized rehabilitation after severe traumatic brain injury--a population-based study

OBJECTIVES

To present results from the first 3 years of centralized subacute rehabilitation after very severe traumatic brain injury (TBI), and to compare results of centralized versus decentralized rehabilitation.

MATERIAL AND METHODS

Prospectively, the most severely injured group of adults from an uptake area of 2.4 million in Denmark were included at admission to a regional brain injury unit (BIU), on average 19 days after injury. Patients in the retrospective study used for comparison were randomly chosen from the national hospital register.

RESULTS AND CONCLUSIONS

Out of 117 patients in the prospective study, six died, and 92 (1.27 per 100,000 population per year) survived after a post-traumatic amnesia (PTA) period of at least 28 days. All 19 patients with PTA 7-27 days and 48% of survivors with PTA at least 4 weeks were discharged directly home. The incidence of patients vegetative at 1 month post-trauma was 0.29, and at 1 year 0.055 per 100,000 population. By comparison of 39 patients from the centralized unit injured in 2000-2003 with 21 patients injured in 1982, 1987 or 1992 and with similar PTA- and age distributions and male/female ratio, Glasgow Outcome Scale score at discharge was significantly better for the former group.