Sub-symptom threshold aerobic exercise for patients with persisting post-concussion symptoms and exercise intolerance after mild traumatic brain injury - a study protocol with a nested feasibility study for a randomized controlled trial

BACKGROUND

Persistent post-concussion symptoms (PPCS) affect between 34 and 46% after a mild traumatic brain injury (mTBI). Many also experience exercise intolerance. Sub-symptom threshold aerobic exercise, SSTAE (exercise at an intensity level that does not increase symptoms) is proposed as a treatment to both reduce the symptom burden and increase the exercise tolerance after the injury. It is unclear if this also applies in a more chronic phase after mTBI.

MAIN PURPOSE

The main purpose of this study is to evaluate whether SSTAE in addition to ordinary rehabilitation will lead to clinically meaningful improvement of symptom burden, normalize exercise tolerance, increase physical activity, improve health-related quality of life, and reduce patient-specific activity limitations compared to a control group that only receives ordinary rehabilitation.

DESIGN

Randomized, controlled, single-blind parallel-group study with three measurement times; T0 at baseline, T1 after the intervention and T2 six months after T1.

METHODS

Patients between the ages of 18 and 60 with exercise intolerance and persistent PPCS (> 3 months) will be recruited to the study and randomized to two groups. All patients will receive follow-up at the outpatient TBI clinic. The intervention group will in addition receive SSTAE for 12 weeks with exercise diaries and a retest every 3 weeks for optimal dosage and progression. The Rivermead post-concussion symptoms questionnaire will be the main outcome measure. The secondary outcome measure will be a test of exercise tolerance-the Buffalo Concussion Treadmill Test. Other outcome measures include the patient-specific functional scale that measures patient-specific activity limitations, as well as outcome measures for diagnosis-specific health-related quality of life, anxiety and depression, specific symptoms such as dizziness, headache and fatigue, and physical activity.

DISCUSSION

This study will add knowledge about the effect of SSTAE and whether it should be implemented in rehabilitation for the adult population with persistent PPCS after mTBI. The nested feasibility trial showed that the SSTAE intervention was safe and that the study procedures and delivery of the intervention overall were feasible. However, minor amendments to the study protocol were made prior to the commencement of the RCT.

TRIAL REGISTRATION

Clinical Trials.gov, NCT05086419. Registered on September 5th, 2021.

Associations between protective resources and family functioning after traumatic brain injury: A cross-sectional study using a structural equation modeling approach

BACKGROUND

A strength-based approach in the rehabilitation after traumatic brain injury (TBI) is recommended for patients and their families. However, further exploration of the complexity of individual and family factors is needed.

OBJECTIVE

To explore the associations between individual protective resources in patients and family members and the overall family functioning using a strength-based approach.

METHODS

Secondary analysis of data collected at baseline in a randomized controlled trial. Structural equation modeling with two latent constructs and six observed variables was performed. Outcome measures included the Resilience Scale for Adults, the Mental Component Summary (SF-36), the General Self-Efficacy Scale, and the Family Adaptability and Cohesion Evaluation Scale-IV.

RESULTS

Hundred and twenty-two participants (60 patients, 62 family members) with a mean age of 43 years were included at a median of 11 months post-injury. The final model demonstrated a strong covariance (coefficient = 0.61) between the latent Protective construct and Family functioning. Model-fit statistics indicated an acceptable fit to the data.

CONCLUSION

Higher levels of protective resources (resilience, self-efficacy, and mental HRQL) were positively associated with family functioning. These resources should be further assessed in patients and their families, to identify factors that can be strengthened through TBI rehabilitation intervention.

The development of a minimum reporting set of contextual factors for rehabilitation studies

Objective

To identify the most important categories of the International Classification of Service Organization in Rehabilitation (ICSO-R 2.0) for a minimum reporting data set.

Methods

A 2-step Delphi survey was used. Rehabilitation experts from all world regions including physicians, nurses, neuropsychologists, physiotherapists, and others, were invited to participate. In the first round, all participants were asked to rate the categories and subcategories of the ICSO-R 2.0 with the following criteria: Being relevant for study outcomes; Being distinctive among different rehabilitation settings; Being feasible to use and reported by objective figures or other clear characterization. All categories that were rated relevant, distinctive and feasible by more than 60% of respondents from the first round were included in the second round.

Results

The most important and relevant factors for the minimum reporting set in rehabilitation services regarding the provider were: human resources, context, technical resources, quality assurance and management, location of provider, and ownership. Regarding the service delivery, the most important and relevant factors were: target group, rehabilitation team, aspect of time and intensity, setting, location of service delivery, modes of referral, facility and reporting and documentation.

Conclusion

Several categories were identified, and reduction in these through discussions and iterative voting at workshops and consensus conferences is needed before finalizing the reporting set.

Rehabilitation Goals and Effects of Goal Achievement on Outcome Following an Adapted Physical Activity-Based Rehabilitation Intervention

PURPOSE

To explore the goal-setting process carried out at a rehabilitation facility providing adapted physical activity, by 1) identifying goals set by individuals with chronic disabilities, 2) comparing these goals to the negotiated goals set in collaboration with the rehabilitation team and 3) assessing goal achievement and its association with self-reported functioning after 12 months.

METHODS

A prospective observational study where adults (18-67 years) admitted to Beitostølen Healthsports Centre (n=151) reported mental and physical functioning measured by the Medical Outcomes Study 12-item Short-Form Health Survey (SF-12) administered at baseline (eight weeks before rehabilitation), admission, discharge and follow-up 12 months after rehabilitation. The participants provided their individual goals for rehabilitation in the admission questionnaire. Individual goals were compared to negotiated goals set by the participants and the rehabilitation team together as part of the goal-setting process at the facility. The goals were linked to The International Classification of Functioning, Disability and Health (ICF) for comparison. Goal achievement was assessed on a 10-point numeric rating scale (NRS) in the discharge questionnaire. The association between SF-12 physical and mental functioning at long-term follow-up and goal achievement was explored.

RESULTS

The 293 individual goals and the 407 negotiated goals were most frequently linked to the ICF-component Body Functions. When comparing negotiated to individual goals, negotiated goals were more frequently linked to activities and participation. Goals to wide to be linked to the ICF were less frequent. For 76% of the participants, content of individual goals was captured in negotiated goals. Goal achievement with NRS scores ≥9 points was reported by 66% of the included participants. Goal achievement was a significant predictor for long-term mental functioning (p=0.04).

CONCLUSION

Collaboration between participants and health professionals resulted in more specific goals directed towards the activities and participation component. Goal achievement predicted long-term mental functioning following rehabilitation.

The effectiveness of a family-centred intervention after traumatic brain injury: A pragmatic randomised controlled trial

Objectives:

To determine the effectiveness of a family-centred intervention for patients with traumatic brain injury and family members.

Design:

Open-labelled, two-armed randomised controlled trial.

Settings:

Outpatient clinic and family residences.

Participants:

Sixty-one patients (33 women) with traumatic brain injury, with mean (SD) age 43.8 (12.2), and 63 family members (33 women), with mean (SD) age 42.6 (11.3), were assign to intervention (n = 30 families) and control group (n = 31 families).

Intervention:

An eight-session single-family intervention to improve individual and family functioning.

Outcome measures:

Self-reported questionnaires at start-of-treatment, median (IQR) 11.4 (8.4, 15.9) months post-injury, and at two follow-ups, 2.7 (2.3, 3.8) and 9.2 (8.2, 9.9) months after start-of-treatment. Primary outcome measures were the SF-36 Mental Component Summary (MCS) and Caregiver Burden Scale (CGB). Secondary outcome measures were the Family Adaptability and Cohesion Evaluation Scale (FACES) and Quality of Life after Brain Injury Questionnaire (QOLIBRI). Group differences were analysed with linear mixed-model analysis for repeated measurements.

Results:

No significant between-group differences were found. The intervention group significantly improved on the MCS, the CGB and FACES in the treatment period, whereas the controls did not. The mean (SD) MCS change in the treatment period was 2.4 (1.1) points P = 0.028 in the intervention group. Mean (SE) MCS scores were 47.9 (1.26) and 47.3 (1.27) in the intervention and control group at last follow-up.

Conclusions:

Receiving an eight-session family intervention, in addition to specialised rehabilitation for the patients, was not superior to rehabilitation at a specialised traumatic brain injury outpatient clinic.

Dizziness-related disability following mild-moderate traumatic brain injury

OBJECTIVE

To investigate the associations between dizziness-related disability after mild- moderate Traumatic Brain Injury (TBI) and personal factors, injury-related factors and post-injury functioning using the International Classification of Functioning, Disability and Health (ICF) as a framework.

METHODS

Baseline assessments for a Randomised Controlled Trial (RCT) were obtained for 65 patients (mean age 39.2 years; SD 12.9 years; 70.8% women) who had dizziness and reduced balance 2-6 months after injury. The severity of the brain injury, physical and psychological self-reported symptoms and results from the performance based tests were used as independent variables. The main outcome measure (dependent variable) was the Dizziness Handicap Inventory (DHI).

RESULTS

Multivariate analyses showed that, the dizziness-related disability was predicted by pre-injury comorbidities (p ≤ 0.05) and was associated with self-reported vertigo symptoms (p < 0.001), reduced performance-based balance (p ≤ 0.05) and psychological distress (p ≤ 0.05). These factors accounted for 62% of the variance in DHI.

CONCLUSION

Dizziness and balance problems after mild-moderate TBI appear to be complex biopsychosocial phenomena. Assessments linked to the ICF domains of functioning might contribute to a broader understanding of the needs of these patients. Further, prospective clinical studies with non-dizzy control groups are needed to investigate dizziness-related disability after TBI.

One year results of a randomized controlled trial on radial Extracorporeal Shock Wave Treatment, with predictors of pain, disability and return to work in patients with subacromial pain syndrome

BACKGROUND

Radial Extracorporeal Shock Wave Therapy (rESWT) is increasingly used to treat patients with subacromial pain syndrome despite conflicting evidence of its effectiveness. Better knowledge regarding prognostic factors may contribute to the improvement in treatment and prognosis for the patients.

AIM

The first aim of this study was to evaluate the effect of rESWT in addition to supervised exercises in patients with subacromial pain syndrome after one year. The second aim was to identify predictors of pain and disability and work status after one year in this patient group.

DESIGN

A randomized, double-blind, sham-controlled trial.

SETTING

An outpatient shoulder clinic of a University hospital.

METHODS

Patients aged 25 to 70 years, with subacromial pain syndrome lasting at least three months were included and randomly assigned to receive either rESWT and supervised exercises or sham rESWT and supervised exercises. The Shoulder Pain and Disability Index (SPADI) and work status were assessed after one year.

RESULTS

We screened 265 patients and enrolled 143; 74 were allocated to receive sham rESWT and exercises, and 69 were allocated to receive rESWT and exercises. After one year, no differences were found for the SPADI Score (mean difference -1.6, 95% confidence interval (CI) -10.2 to 7.0, P=0.71). Subgroup analysis of patients with calcification in the rotator cuff demonstrated no significant additional effect of rESWT to supervised exercises (mean difference -6.3, 95% CI -22.4 to 9.8, P=0.44). Marital status (single), frequent use of pain medication, not working at baseline, negative outcome expectations, low self-reported general health status and few supervised exercise sessions predicted a poor outcome on SPADI after one year.

CONCLUSIONS

Radial ESWT was not superior to sham rESWT in addition to supervised exercises in the long term for patients with subacromial pain syndrome. The identified predictors for pain, disability and work should be assessed in future studies and addressed by clinicians in order to improve the effectiveness of supervised exercises.

CLINICAL REHABILITATION IMPACT

Radial ESWT should not be recommended for patients with subacromial pain syndrome. Clinicians should assess patient`s outcome expectations, and if possible reduce the use of pain medication and sick leave in this patient group.

Predicting Outcome 12 Months after Mild Traumatic Brain Injury in Patients Admitted to a Neurosurgery Service

Objective

Accurate outcome prediction models for patients with mild traumatic brain injury (MTBI) are key for prognostic assessment and clinical decision-making. Using multivariate machine learning, we tested the unique and added predictive value of (1) magnetic resonance imaging (MRI)-based brain morphometric and volumetric characterization at 4-week postinjury and (2) demographic, preinjury, injury-related, and postinjury variables on 12-month outcomes, including global functioning level, postconcussion symptoms, and mental health in patients with MTBI.

Methods

A prospective, cohort study of patients (n = 147) aged 16–65 years with a 12-month follow-up. T1-weighted 3 T MRI data were processed in FreeSurfer, yielding accurate cortical reconstructions for surface-based analyses of cortical thickness, area, and volume, and brain segmentation for subcortical and global brain volumes. The 12-month outcome was defined as a composite score using a principal component analysis including the Glasgow Outcome Scale Extended, Rivermead Postconcussion Questionnaire, and Patient Health Questionnaire-9. Using leave-one-out cross-validation and permutation testing, we tested and compared three prediction models: (1) MRI model, (2) clinical model, and (3) MRI and clinical combined.

Results

We found a strong correlation between observed and predicted outcomes for the clinical model (r = 0.55, p < 0.001). The MRI model performed at the chance level (r = 0.03, p = 0.80) and the combined model (r = 0.45, p < 0.002) were slightly weaker than the clinical model. Univariate correlation analyses revealed the strongest association with outcome for postinjury factors of posttraumatic stress (Posttraumatic Symptom Scale-10, r = 0.61), psychological distress (Hospital Anxiety and Depression Scale, r = 0.52), and widespread pain (r = 0.43) assessed at 8 weeks.

Conclusion

We found no added predictive value of MRI-based measures of brain cortical morphometry and subcortical volumes over and above demographic and clinical features.

The One or the Many: Quantified Subjectivity and Aggregated Uniqueness in Qualitative Rehabilitation Research

This article aims to identify and critically assess qualitative intervention studies of rehabilitation processes that target young adults. By applying a meta-epistemological approach inspired by the works of Michel Foucault and Julia Kristeva, we examine how the included studies present qualitative knowledge and whether they adhere to their own stated principles of qualitative knowledge. Through their stated aims and theoretical framing, the articles draw attention to individual processes of meaning making. Nonetheless, we find that the articles to a great extent emphasize frequencies of the qualitative data they present. Individual processes and experiences are subject to subdivisions and categorization and transformed into manageable objects of knowledge. In conclusion, these studies, with one important exception, contribute to self-marginalization of the knowledge they themselves promote: They undermine the uniqueness of the qualitative knowledge they proclaim by focusing on frequency and the general patterns and categories encompassing the unique.

User involvement and experiential knowledge in interprofessional rehabilitation: a grounded theory study

Background

User involvement is increasingly important in developing relevant health care services. The aim of this study was to contribute to a deeper understanding of user involvement and patients’ experiential knowledge as recognized and incorporated into clinical practice by rehabilitation professionals.

Methods

A qualitative design using a grounded theory approach was applied. Data were collected by observations of the interprofessional meetings at two rehabilitation units treating patients with traumatic brain injury and multiple trauma and by individual semi-structured interviews with rehabilitation professionals.

Results

The professionals recognized and incorporated user involvement into clinical practice as formal or authentic. Formal user involvement was sometimes considered pro forma. Incorporating patient’ experiential knowledge was considered a part of authentic user involvement. Possible gaps between the patients’ experiential knowledge and professional expertise were recognized. Challenges included dealing with ‘artifacts’, sources of information external to the patients’ own experiences, and addressing the patients’ possibly reduced insight due to trauma.

Conclusion

Patients’ experiential knowledge was recognized as an essential component of the professionals’ knowledge base. The professionals considered user involvement and patients’ experiential knowledge as part of their clinical practice. Implementation of user involvement and contribution of patients’ experiential knowledge could be improved by understanding the issues raised in practice, such as possible negative consequences of user involvement in form of burdening or disempowering the patients. A better understanding of the characteristics and measures of user involvement is necessary in order to be able to offer its full benefits for both the patients and the professionals.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1808-5) contains supplementary material, which is available to authorized users.

Rehabilitation pathways and functional independence one year after severe traumatic brain injury

BACKGROUND

After severe traumatic brain injury (TBI) it is recommended that patients in need of rehabilitation be transferred directly from acute care to specialized rehabilitation. However, recent European cohort studies found a variety of care pathways and delays in admission to rehabilitation after severe TBI.

AIM

To study the pathways within rehabilitation services in a Norwegian national cohort with severe TBI and the association to functional independence 12 months post-injury.

DESIGN

Observational prospective multicenter study.

SETTING

Regional trauma centers.

POPULATION

A total of 163 adults, age 16-85 years, with severe TBI.

METHODS

The main variables were transfer between acute care and rehabilitation, type of rehabilitation services and functional independence.

RESULTS

75% of the patients had specialized TBI rehabilitation, 11% non-specialized and 14% no in-patient rehabilitation. In total, 48% were transferred directly to specialized rehabilitation from acute units in regional trauma centers. There were no differences in injury severity between patients transferred directly and non-directly, but the direct-transfer patients were younger. At 12 months post-injury, 71% were functionally independent and 90% lived in their home. Younger age, fewer days of ventilation and shorter post-traumatic amnesia were associated with independence. Among patients treated with specialized rehabilitation, direct transfer to rehabilitation was associated with functional independence (OR=4.3, P<0.01).

CONCLUSIONS

A direct clinical pathway including specialized rehabilitation in dedicated units was associated with functional independence.

CLINICAL REHABILITATION IMPACT

Direct pathways from acute care to sub-acute specialized rehabilitation might prove beneficial to functional status.

Minimum data set to measure rehabilitation needs and health outcome after major trauma: application of an international framework

BACKGROUND

Measurement of long term health outcome after trauma remains non-standardized and ambiguous which limits national and international comparison of burden of injuries. The World Health Organization (WHO) has recommended the application of the International Classification of Function, Disability and Health (ICF) to measure rehabilitation and health outcome worldwide. No previous poly-trauma studies have applied the ICF comprehensively to evaluate outcome after injury.

AIM

To apply the ICF categorization in patients with traumatic injuries to identify a minimum data set of important rehabilitation and health outcomes to enable national and international comparison of outcome data.

DESIGN

A mixed methods design of patient interviews and an on-line survey.

SETTING

An ethnically diverse urban major trauma center in London.

POPULATION

Adult patients with major traumatic injuries (poly-trauma) and international health care professionals (HCPs) working in acute and post-acute major trauma settings.

METHODS

Mixed methods investigated patients and health care professionals (HCPs) perspectives of important rehabilitation and health outcomes. Qualitative patient data and quantitative HCP data were linked to ICF categories. Combined data were refined to identify a minimum data set of important rehabilitation and health outcome categories.

RESULTS

Transcribed patient interview data (N.=32) were linked to 234 (64%) second level ICF categories. Two hundred and fourteen HCPs identified 121 from a possible 140 second level ICF categories (86%) as relevant and important. Patients and HCPs strongly agreed on ICF body structures and body functions categories which include temperament, energy and drive, memory, emotions, pain and repair function of the skin. Conversely, patients prioritised domestic tasks, recreation and work compared to HCP priorities of self-care and mobility. Twenty six environmental factors were identified. Patient and HCP data were refined to recommend a 109 possible ICF categories for a minimum data set.

CONCLUSIONS

The comprehensive measurement of health outcomes after trauma is important for patients, health professionals and trauma systems. An internationally applied ICF minimum data set will standardize the language used and concepts measured after major trauma to enable national and international comparison of outcome data.

CLINICAL REHABILITATION IMPACT

A minimum ICF data set for trauma will standardize rehabilitation language and provide a minimum dataset to capture outcome in trauma systems to enable comparison and service improvement.

Health outcome after major trauma: what are we measuring?

Importance

Trauma is a global disease and is among the leading causes of disability in the world. The importance of outcome beyond trauma survival has been recognised over the last decade. Despite this there is no internationally agreed approach for assessment of health outcome and rehabilitation of trauma patients.

Objective

To systematically examine to what extent outcomes measures evaluate health outcomes in patients with major trauma.

Data Sources

MEDLINE, EMBASE, and CINAHL (from 2006–2012) were searched for studies evaluating health outcome after traumatic injuries.

Study selection and data extraction

Studies of adult patients with injuries involving at least two body areas or organ systems were included. Information on study design, outcome measures used, sample size and outcomes were extracted. The World Health Organisation International Classification of Function, Disability and Health (ICF) were used to evaluate to what extent outcome measures captured health impacts.

Results

34 studies from 755 studies were included in the review. 38 outcome measures were identified. 21 outcome measures were used only once and only five were used in three or more studies. Only 6% of all possible health impacts were captured. Concepts related to activity and participation were the most represented but still only captured 12% of all possible concepts in this domain. Measures performed very poorly in capturing concepts related to body function (5%), functional activities (11%) and environmental factors (2%).

Conclusion

Outcome measures used in major trauma capture only a small proportion of health impacts. There is no inclusive classification for measuring disability or health outcome following trauma. The ICF may provide a useful framework for the development of a comprehensive health outcome measure for trauma care.

Self-perceived health care needs and delivery of health care services 5 years after moderate-to-severe traumatic brain injury

OBJECTIVE

To describe the self-perceived health care needs of patients with moderate-to-severe traumatic brain injury (TBI) and to assess the impact of the functional level at 1 year after injury on patients' unmet needs at the 5-year follow-up.

DESIGN

A prospective follow-up study.

SETTING

Clinical research.

PARTICIPANTS

A total of 93 patients participated in the 5-year follow-up.

METHODS

We registered demographic and injury-related data at the time of admission and the scores for the Disability Rating Scale, Glasgow Outcome Scale-Extended, and Short Form 36 subscales for physical functioning and mental health at 1 and 5 years. The patients' self-perceived health care needs and use of health care services at 5 years were the main outcome measurements.

RESULTS

At the 5-year follow-up, 70% of patients reported at least 1 perceived need. The self-perceived health care needs were met for 39% of the patients. The patients with unmet needs (n = 29 [31%]) reported frequent needs in emotional (65%), vocational (62%), and cognitive (58%) domains. These patients were significantly more likely to present a less severe disability on the Disability Rating Scale at the 1-year follow-up (odds ratio [OR] 0.11 [95% confidence interval {CI}, 0.02-0.7]; P = .02). Worse mental health at the 1-year follow-up and a younger age (16-29 years) largely predicted unmet needs at the 5-year follow-up (OR 3.28 [95% CI, 1.1-10.04], P = .04; and OR 4.93 [95% CI, 0.16-15.2], P = .005, respectively).

CONCLUSION

Gaps between self-perceived health care needs and health care services received at the 5-year follow-up were found. An important message to clinicians who provide health care services in the late TBI phase is that they should be aware of patients' long-term needs regarding cognitive and emotional difficulties. Of equal importance is an emphasis on long-term vocational rehabilitation services. To ensure the appropriateness of health care service delivery, health care services after TBI should be better targeted at less-severe TBI population as well.

Associations among self-reported balance problems, post-concussion symptoms and performance-based tests: a longitudinal follow-up study

PURPOSE

The main objectives of this study were to describe long-term self-reported balance problems and to explore their associations with post-concussion symptoms and performance-based tests.

METHOD

Prospective study of patients with mild traumatic brain injury (MTBI). Self-reported balance problems and post-concussion symptoms were measured with the Rivermead Post-concussion Symptoms Questionnaire at 1 and 4 years after injury. Performance-based tests were performed 4 years after injury and included posturography, the Dynamic Gait Index (DGI), walking speed tests, and the six-minute walk test.

RESULTS

Self-reported balance problems were reported in 31% of patients 4 years after injury and correlated significantly with post-concussion symptoms. The correlations with performance-based tests varied from ρ = 0.18 to ρ = 0.70 and were strongest for the maximum walking speed test (ρ = 0.70) and a dual-task test (ρ = 0.43). The DGI had a considerable ceiling effect.

CONCLUSIONS

Balance problems were long-term consequences of MTBI in one third of this study sample. Self-reported balance problems correlated with post-concussion symptoms and some of the performance-based tests. Future research needs to develop and evaluate appropriate rehabilitation strategies that also address the balance problems.