Rehabilitation of traumatic brain injury in Italy: a multi-centred study.

OBJECTIVES: The aims of this study were to analyse TBI rehabilitation in Italy, identifying the main factors conditioning motor and functional recovery and destination upon discharge of traumatic severe acquired brain injury (sABI) patients who had undergone intensive rehabilitative treatment. DESIGN: An observational prospective study of 863 consecutive patients admitted to 52 Rehabilitation Centres from January 2001 to December 2003. RESULTS: The main cause of trauma was road accidents (79.8%), the mean length of stay was 87.31 ± 77.26 days and 40.4% access to rehabilitation facilities after a month. Pressure sore rates fell from 26.1% to 6.6% during the rehabilitation programme. After discharge 615 patients returned home, whilst 212 were admitted to other health facilities. DISCUSSION: This study highlights some major criticisms of rehabilitation of TBI. The delay of admission and evitable complications such as pressure sores are correlated to a worse outcome. While LOS causes a problem of cost-effectiveness, the rate of home discharge is prevalent and very high compared with other studies.

Early rehabilitative treatment in patients with traumatic brain injuries: outcome at one-year follow-up.

AIM: The aim of this study was to analyze the outcome at one-year follow-up of patients with traumatic brain injuries (TBI) after 4 years of application of our organizing model and compare our results with the international data in terms of disability (functional independence measure [FIM], disability rating scale [DRS] scores) and social integration (community integration questionnaire [CIQ], work reentry) METHODS: We started a routine based on the presence of the physiatrist in the Intensive Care Unit (ICU) and Neurosurgery 3 times per week to evaluate all patients with TBI, program and control physiotherapeutic treatments and transfers to rehabilitative centers. Data were collected considering 80 TBI patients sequentially discharged from our department, from August 1999 to December 2003. The sample was composed of patients with severe brain injury evaluated at rehabilitation admission, rehabilitation discharge and one-year follow-up. We compared our data with those of the Traumatic Brain Injury Model System Data Base (TBI MSDB) and Gruppo Italiano per lo Studio delle Cerebrolesioni Acquisite Riabilitazione (GISCAR). RESULTS: Disability at one-year follow-up was better than at discharge: increase in FIM value, in DRS value. Social reintegration and return to work were not optimal: CIQ value was 16 and only 38% of patients returned to work at follow-up. Disability and social integration mean scores in our sample were similar to those obtained in TBI MSDB and so were the values of onset-admission interval (OAI) and length of stay (LOS). Differences were found with the Italian GISCAR database where mean OAI and LOS were higher than in our sample (55 and 86 days vs 18 and 37 days). CONCLUSIONS: Our data show that this kind of organizing model for the rehabilitative evolution of TBI patients can positively influence the cost-efficiency rate of rehabilitation process reducing care costs in terms of ICU and rehabilitation LOS without affecting outcome in terms of disability and reintegration.

Prolonged duodenal paralysis after PEG placement in a patient with traumatic brain injury: a case report.

Percutaneous endoscopic gastrostomy (PEG) has recently become a usual procedure for patients with prolonged disorders of consciousness after brain injuries. Despite a high rate of success and a very low procedure-related mortality, morbidity associated to PEG placement reaches 9.4% in a recent large meta-analysis. This case report describes an uncommon complication of PEG placement in a patient with vegetative state after traumatic brain injury: the development of prolonged duodenal paralysis. This patient was treated by placement of a transient jejunostomy until recovery of duodenal functional activity, to permit adequate nutrition. This procedure-related complication is previously unreported in scientific literature.

Rehabilitation in patients affected by different types of stroke. A one-year follow-up study.

AIM: Stroke is the third highest cause of death and the leading cause of chronic disability in adults in Italy. More than half of patients who survive the first month after a stroke will require specialised rehabilitation. Rehabilitation is, however, an expensive and limited resource, and its success depends on careful selection of patients. The aim of this study was to identify the functional ability at discharge and after one-year of follow-up in a large sample of first-time stroke patients from a rehabilitation hospital according to the stroke Oxfordshire Community Stroke Project (OCSP) criteria. METHODS: A multicenter observational study was conducted among 1023 first-time stroke patients who were admitted to 18 different Italian inpatient rehabilitation centres between February 1999 and November 2000. The study population consisted of 946 (92.4%) of the 1023 enrolled at baseline. Each patient has been first evaluated within 72 h after admission and, on a second occasion, within 72 h before discharge. From the 722 ischemic strokes evaluated at baseline, after one-year of follow-up 76 participants died. From the survived 646 patients, we had 513 (79.0%) participants both evaluated at baseline and after one-year of follow-up. Clinical data regarding stroke type and ischemic stroke clinical syndrome, according to the Oxfordshire Community Stroke Project (OCSP) criteria; the degree of impairment, both motor (assessed by Barthel Index [BI], Motricity Index, and Trunk Control Test) and neuropsychological (assessed by the Mini Mental State Examination, and the presence of aphasia or neglect); the extent of disability, as assessed by Functional Independence Scale (FIM) and the evidence of concomitant prespecified medical complications, as well as of dysphasia and of the need of indwelling urinary catheter. Other variables were taken into account, such as the time interval between stroke onset and admission to rehabilitation ward and the length of stay. To assess stroke outcome, two different indexes were selected: the frequency of home discharge and the extent of functional recovery. RESULTS: There were 722 (76.3%) ischemic and 224 (23.7%) hemorrhagic strokes. Among ischemic strokes, the partial anterior circulation infarct was the most frequent syndrome, accounting for the 33.2% of cases. The posterior circulation infarct syndrome was the less frequent (14.1%). Lacunar anterior circulation infarct was present for the 29.5% and finally, the total anterior circulation infarct (TACI) was present for the 23.2%. According to the OCSP criteria, the TACI syndrome received 76.1±52.9 (mean±SD) days of rehabilitation, which were statistically different from the other three types of stroke. At discharge, the BI and the FIM of patients affected by TACI was significantly lower and higher, respectively, from the other three type of stroke. However, this difference disappear after one-year of follow-up. CONCLUSION: The TACI subtype of stroke required higher days of rehabilitation from the other type of stroke according to the OCSP criteria. Rehabilitation program is efficacious for improving functional ability of patients affected by stroke although the program should be tailored according to the stroke type.