Rehabilitation and outcomes after complicated vs uncomplicated mild TBI: results from the CENTER-TBI study.

BACKGROUND: Despite existing guidelines for managing mild traumatic brain injury (mTBI), evidence-based treatments are still scarce and large-scale studies on the provision and impact of specific rehabilitation services are needed. This study aimed to describe the provision of rehabilitation to patients after complicated and uncomplicated mTBI and investigate factors associated with functional outcome, symptom burden, and TBI-specific health-related quality of life (HRQOL) up to six months after injury. METHODS: Patients (n = 1379) with mTBI from the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study who reported whether they received rehabilitation services during the first six months post-injury and who participated in outcome assessments were included. Functional outcome was measured with the Glasgow Outcome Scale - Extended (GOSE), symptom burden with the Rivermead Post Concussion Symptoms Questionnaire (RPQ), and HRQOL with the Quality of Life after Brain Injury - Overall Scale (QOLIBRI-OS). We examined whether transition of care (TOC) pathways, receiving rehabilitation services, sociodemographic (incl. geographic), premorbid, and injury-related factors were associated with outcomes using regression models. For easy comparison, we estimated ordinal regression models for all outcomes where the scores were classified based on quantiles. RESULTS: Overall, 43% of patients with complicated and 20% with uncomplicated mTBI reported receiving rehabilitation services, primarily in physical and cognitive domains. Patients with complicated mTBI had lower functional level, higher symptom burden, and lower HRQOL compared to uncomplicated mTBI. Rehabilitation services at three or six months and a higher number of TOC were associated with unfavorable outcomes in all models, in addition to pre-morbid psychiatric problems. Being male and having more than 13 years of education was associated with more favorable outcomes. Sustaining major trauma was associated with unfavorable GOSE outcome, whereas living in Southern and Eastern European regions was associated with lower HRQOL. CONCLUSIONS: Patients with complicated mTBI reported more unfavorable outcomes and received rehabilitation services more frequently. Receiving rehabilitation services and higher number of care transitions were indicators of injury severity and associated with unfavorable outcomes. The findings should be interpreted carefully and validated in future studies as we applied a novel analytic approach. TRIAL REGISTRATION: ClinicalTrials.gov NCT02210221.

Effect of vestibular rehabilitation on change in health-related quality of life in patients with dizziness and balance problems after traumatic brain injury: A randomized controlled trial.

OBJECTIVE: Secondary analysis, testing the effect on change in health-related quality of life of group-based vestibular rehabilitation in patients with mild-moderate traumatic brain injury, dizziness and -balance problems. DESIGN: A single-blind randomized controlled trial. SUBJECTS: A total of 65 patients aged 16-60 years with a Rivermead Post-concussion Symptoms Questionnaire dizziness score ≥2, and Dizziness Handicap Inventory score >15 points. Data collection was performed at baseline 3.5 (standard deviation (SD) 2.1) months post-injury, end of intervention, and 4.4 (SD 1.0) months after baseline. METHODS: Quality of Life after Brain Injury was the main outcome. Independent variables were demographic and injury variables, Hospital Anxiety and Depression Scale, changes on the Rivermead Post-concussion Symptoms Questionnaire (RPQ3 physical and RPQ13 psychological/cognitive), and Vertigo Symptom Scale-Short Form. RESULTS: Mean age of participants was 39.4 years (SD 13.0); 70.3% women. Predictors of change in the Quality of Life after Brain Injury were receiving the vestibular rehabilitation (p=0.049), baseline psychological distress (p=0.020), and change in RPQ3 physical (p=0.047) and RPQ13 psychological/cognitive (p=0.047). Adjusted R2 was 0.399, F=6.13, p<0.001. CONCLUSION: There was an effect in favour of the intervention group in improvement in health-related quality of life. Changes on the Rivermead Post-concussion Symptoms Questionnaire were also associated with change on the Quality of Life after Brain Injury.

Unmet Rehabilitation Needs after Traumatic Brain Injury across Europe: Results from the CENTER-TBI Study.

This study aims to assess rehabilitation needs and provision of rehabilitation services for individuals with moderate-to-severe disability and investigate factors influencing the probability of receiving rehabilitation within six months after traumatic brain injury (TBI). Overall, the analyses included 1206 individuals enrolled in the CENTER-TBI study with severe-to-moderate disability. Impairments in five outcome domains (daily life activities, physical, cognition, speech/language, and psychological) and the use of respective rehabilitation services (occupational therapy, physiotherapy, cognitive and speech therapies, and psychological counselling) were recorded. Sociodemographic and injury-related factors were used to investigate the probability of receiving rehabilitation. Physiotherapy was the most frequently provided rehabilitation service, followed by speech and occupational therapy. Psychological counselling was the least frequently accessed service. The probability of receiving a rehabilitative intervention increased for individuals with greater brain injury severity (odds ratio (OR) 1.75, CI 95%: 1.27-2.42), physical (OR 1.92, CI 95%: 1.21-3.05) and cognitive problems (OR 4.00, CI 95%: 2.34-6.83) but decreased for individuals reporting psychological problems (OR 0.57, CI 95%: 1.21-3.05). The study results emphasize the need for more extensive prescription of rehabilitation services for individuals with disability. Moreover, targeted rehabilitation programs, which aim to improve outcomes, should specifically involve psychological services to meet the needs of individuals recovering from TBI.

The effects of vestibular rehabilitation on dizziness and balance problems in patients after traumatic brain injury: a randomized controlled trial.

OBJECTIVE:: To investigate the effects of group-based vestibular rehabilitation in patients with traumatic brain injury. DESIGN:: A single-blind randomized controlled trial. SETTING:: University Hospital (recruitment and baseline assessments) and Metropolitan University (experimental intervention). SUBJECTS:: A total of 65 patients (45 women) with mild-to-moderate traumatic brain injury (mean age 39.4 ± 13.0 years) were randomly assigned to intervention ( n = 33) or control group ( n = 32). INTERVENTION:: Group-based vestibular rehabilitation for eight weeks. Participants were tested at baseline (3.5 ± 2.1 months after injury) and at two post-intervention follow-ups (2.7 ± 0.8 and 4.4 ± 1.0 months after baseline testing). MAIN MEASURES:: Primary outcome: Dizziness Handicap Inventory. Secondary outcome: High-Level Mobility Assessment Tool. Other outcomes: Vertigo Symptom Scale; Rivermead Post-concussion Symptoms Questionnaire; Hospital Anxiety and Depression Scale; and Balance Error Scoring System. Between-group differences were analyzed with a linear mixed-model analysis for repeated measurements. RESULTS:: At baseline, no group differences were revealed (personal factors, clinical characteristics and outcome measures). At the first follow-up, statistically significant mean differences in favor of the intervention were found in the primary (-8.7, 95% confidence interval (CI): -16.6 to -0.9) and secondary outcomes (3.7 points, 95% CI: 1.4-6.0). At the second follow-up, no significant between-group differences were found. No significant between-group differences in the other outcomes were found at the two follow-ups. CONCLUSION:: The intervention appeared to speed up recovery for patients with dizziness and balance problems after traumatic brain injury. However, the benefits had dissipated two months after the end of the intervention.

Vestibular Rehabilitation After Traumatic Brain Injury: Case Series.

BACKGROUND AND PURPOSE: There has been an increasing focus on vestibular rehabilitation (VR) after traumatic brain injury (TBI) in recent years. However, detailed descriptions of the content of and patient responses to VR after TBI are limited. The purposes of this case series are (1) to describe a modified, group-based VR intervention and (2) to examine changes in self-reported and performance-based outcome measures. CASE DESCRIPTION: Two women and 2 men (aged 24-45 years) with mild TBI, dizziness, and balance problems participated in an 8-week intervention consisting of group sessions with guidance, individually modified VR exercises, a home exercise program, and an exercise diary. Self-reported and performance-based outcome measures were applied to assess the impact of dizziness and balance problems on functions related to activity and participation. OUTCOMES: The intervention caused no adverse effects. Three of the 4 patients reported reduced self-perceived disability because of dizziness, diminished frequency and severity of dizziness, improved health-related quality of life, reduced psychological distress, and improved performance-based balance. The change scores exceeded the minimal detectable change, indicating a clinically significant change or improvement in the direction of age-related norms. The fourth patient did not change or improve in most outcome measures. DISCUSSION: A modified, group-based VR intervention was safe and appeared to be viable and beneficial when addressing dizziness and balance problems after TBI. However, concurrent physical and psychological symptoms, other neurological deficits, and musculoskeletal problems might influence the course of central nervous system compensation and recovery. The present case series may be useful for tailoring VR interventions to patients with TBI. Future randomized controlled trials are warranted to evaluate the short- and long-term effects of VR after TBI.

Measurement properties of the high-level mobility assessment tool for mild traumatic brain injury.

BACKGROUND: The High-Level Mobility Assessment Tool (HiMAT) was developed to quantify balance and mobility problems after traumatic brain injury (TBI). Measurement properties of the HiMAT have not been tested in the mild TBI (MTBI) population. OBJECTIVE: The aim of this study was to examine the reliability, validity, and responsiveness of the HiMAT in a sample of the MTBI population. DESIGN: A cohort, pretest-posttest, comparison study was conducted. METHODS: Ninety-two patients (69% men, 31% women) with a mean age of 37.1 years (SD=13.8) and a mean Glasgow Coma Scale score of 14.7 (SD=0.7) were recruited from Oslo University Hospital. All patients were tested with the HiMAT (range of scores=0 [worst] to 54 [best]) at 3 months postinjury. Fifty-one patients were retested at 6 months. A subgroup of 25 patients was selected for the reliability testing. Balance function reported on the Rivermead Post Concussion Symptoms Questionnaire was chosen as a criterion and anchor. Criterion-related validity was studied with correlation analysis. Intraclass correlation coefficients (ICCs) were used for assessing interrater and intrarater reliability. Minimal detectable change (MDC) for the HiMAT was estimated. Responsiveness was assessed with receiver operating characteristic curve analyses. RESULTS: The mean HiMAT sum score was 46.2 (95% confidence interval=44.4 to 48.1). The HiMAT had a ceiling effect of 22.8%. The correlation between HiMAT scores and self-reported balance problems was large (r=-.63, P<.001). Interrater and intrarater reliability of the HiMAT sum score was high (interrater ICC=.99, intrarater ICC=.95). The MDC was -3 to +4 points. Responsiveness was good, and the HiMAT discriminated well between patients with self-perceived improved balance function versus unchanged balance function (area under the curve=0.86). LIMITATIONS: The small sample size, a ceiling effect, and lack of a gold standard were limitations of the study. CONCLUSIONS: The HiMAT demonstrated satisfactory measurement properties for patients with MTBI. The HiMAT can be used as an outcome measure of balance and mobility problems in patients with MTBI.

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.