Selecting patients for early interdisciplinary rehabilitation during neurointensive care after moderate to severe traumatic brain injury.

BACKGROUND: Early interdisciplinary rehabilitation (EIR) in neurointensive care is a limited resource reserved for patients with moderate to severe traumatic brain injury (TBI) believed to profit from treatment. We evaluated how key parameters related to injury severity and patient characteristics were predictive of receiving EIR, and whether these parameters changed over time. METHODS: Among 1003 adult patients with moderate to severe TBI admitted over 72 h to neurointensive care unit during four time periods between 2005 and 2020, EIR was given to 578 and standard care to 425 patients. Ten selection criteria thought to best represent injury severity and patient benefit were evaluated (Glasgow Coma Scale, Head Abbreviated Injury Scale, New-Injury-Severity-Scale, intracranial pressure monitoring, neurosurgery, age, employment, Charlson Comorbidity Index, severe psychiatric disease, and chronic substance abuse). RESULTS: In multivariate regression analysis, patients who were employed (adjOR 1.99 [95% CI 1.41, 2.80]), had no/mild comorbidity (adjOR 3.15 [95% CI 1.72, 5.79]), needed neurosurgery, had increasing injury severity and were admitted by increasing time period were more likely to receive EIR, whereas receiving EIR was less likely with increasing age (adjOR 0.97 [95% CI 0.96, 0.98]) and chronic substance abuse. Overall predictive ability of the model was 71%. Median age and comorbidity increased while employment decreased from 2005 to 2020, indicating patient selection became less restrictive with time. CONCLUSION: Injury severity and need for neurosurgery remain important predictors for receiving EIR, but the importance of age, employment, and comorbidity have changed over time. Moderate prediction accuracy using current clinical criteria suggest unrecognized factors are important for patient selection.

Inter-rater reliability of the early functional abilities scale.

OBJECTIVE: To investigate the inter-rater reliability of the Early Functional Abilities (EFA) scale. DESIGN: An observational study of inter-rater reliability in an open cohort. PATIENTS: Twenty-four patients with traumatic brain injury in need of medical or surgical intervention in the early rehabilitation section of the intensive care unit. METHODS: The EFA was assessed by 4 different professions in the rehabilitation team. Inter-rater reliability was assessed using linear weighted kappa statistics. RESULTS: The overall weighted kappa values of the different EFA items varied from 0.27 to 0.60. The items in the sensorimotor functional area had the highest pairwise agreement,with a mean kappa range of 0.68­0.76. The vegetativest ability, position tolerance and wakefulness items had the lowest mean kappa values (0.49, 0.33 and 0.49, respectively). Agreement was good to excellent between the occupational therapist and physiotherapist across the majority of the items, whereas the physician and nurse agreed less with one another. CONCLUSION: The inter-rater reliability of the EFA scale was good for most items among all the raters. The scale maybe used by all members of the interdisciplinary team after training in administration and scoring. A reduction in the number of items in the vegetative functional domain is recommended.

Relationship between competency in activities, injury severity, and post-concussion symptoms after traumatic brain injury.

OBJECTIVE: To determine to what extent injury severity and post-concussion symptoms after 3 months predict ability in activities 12 months after traumatic brain injury (TBI) and assess the frequency of problems in daily activities. METHODS: A one-year cohort of 63 persons with mild to severe TBI was assessed on admission, after three and 12 months. Injury severity was assessed using the Glasgow Coma Scale, Abbreviated Injury Scale for the head and Injury Severity Score. Post-concussion symptoms were reported using the Rivermead Post Concussion Symptoms Questionnaire after three months. The Patient Competency Rating Scale (PCRS), a self-rating scale of ability in activities, was applied 12 months post-injury. The PCRS consists of the domains interpersonal/emotional and cognitive competency, and instrumental ADL. Multiple backward regression models were performed with the three subscales of PCRS as dependent variables. RESULTS: Activity problems at 12 months were related to perceived cognitive and interpersonal/emotional competency. Post-concussion symptoms reported at three-month follow-up were main predictors of cognitive and interpersonal/emotional competency at 12 months. Injury severity predicted only cognitive competency. CONCLUSION: Symptoms evolving after the trauma seem to be the strongest predictor of perceived ability in activities in this population. This underlines the need for follow-up after TBI to identify persons at risk of developing long-term activity limitations.

Post-concussion symptoms after mild traumatic brain injury: influence of demographic factors and injury severity in a 1-year cohort study.

PURPOSE: To assess the prevalence and variation of post-concussion symptoms within the first year after mild traumatic brain injury (TBI), and explore the association between injury severity, demographic factors and symptoms. METHODS: Prospective study of patients with mild TBI followed up at 3, 6 and 12 months (N= 96 included, n = 52 attending all follow-ups). Sociodemographic factors, injury mechanisms and impact of injury (Glasgow Coma Scale score, Abbreviated Injury Severity Score (AIS), Injury Severity Score) were recorded at inclusion. Symptoms were reported in the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) at the follow-ups. The sumscore of all symptoms in RPQ was calculated for each subject. Scores were also calculated separately for the cognitive, physical and behavioural symptoms. RESULTS: Twenty-nine subjects met the post-concussion syndrome criteria at 3 months, and 22 patients at 6 and 12 months. The cognitive symptoms were more prominent than the physical and behavioural symptoms. The cognitive and physical symptoms were associated with AIS for the head injury at 3 months, but not at 12 months. Considerable individual variability in the symptom pattern was found, and the subjects who attended only the 3-months follow-up reported a lower level of symptoms than those attending all follow-ups. CONCLUSIONS: Persistence of symptoms was a considerable problem even 1 year after the injury, with cognitive symptoms dominating. More severe AIS scores were associated with a higher level of cognitive and physical symptoms at 3 months, but not at later follow-ups. Strategies to prevent and treat these symptoms should be focussed in clinical practice.