Nutritional interventions and related efforts addressing undernutrition during rehabilitation after acquired brain injury: a scoping review protocol.

INTRODUCTION: Patients with an acquired brain injury (ABI) are at an increased risk of undernutrition due to the disease-related inflammation and other numerous symptoms that impact their nutrition. Unfortunately, recommendations related to nutritional interventions and related efforts vary. The objective of this scoping review is to map the body of literature on nutritional interventions and related efforts provided by health professionals, such as screening or assessments, addressing undernutrition in adults with a moderate to severe ABI during the subacute rehabilitation pathway. METHODS AND ANALYSIS: The review follows the Joanna Briggs Institute methodology for scoping reviews. The librarian-assisted search strategy will be conducted in the bibliographical databases: MEDLINE (PubMed), Embase, CINAHL, Web of Science and OpenGrey. Indexed and grey literature in English, German or Scandinavian languages from January 2010 will be considered for inclusion. Two independent reviewers will conduct the iterative process of screening the identified literature, paper selection and data extraction. Disagreements will be resolved by discussion until a consensus is reached. A template will be used to guide the data extraction. This scoping review will include research articles, methodological papers and clinical guidelines reporting on nutritional interventions or related efforts to prevent or address undernutrition in adult patients (≥18 years) with moderate to severe ABI within the first year after admission to rehabilitation hospital. We will map all kinds of nutritional efforts provided by professionals in different settings within high-income countries, including interventions targeting relatives. ETHICS AND DISSEMINATION: This review will involve the collection and analysis of secondary sources that have been published and/or are publicly available. Therefore, ethics approval is not required. The results will be published in an international peer-reviewed journal, presented at scientific conferences and disseminated through digital science communication platforms. STUDY REGISTRATION: Open Science Framework: https://doi.org/10.17605/OSF.IO/H5GJX.

Characteristics of constipation screening and assessment tools: a scoping review protocol.

INTRODUCTION: Constipation is a common and significant burden on individuals and healthcare systems. Accurate assessment of constipation severity and symptom improvement are vital aspects of caring for patients with constipation. Therefore, nurses and allied healthcare professionals should possess knowledge regarding the characteristics of constipation assessment tools (ie, aim, scope, definition of constipation, content, structure, mode, administration time and context of use). However, existing reviews summarising characteristics of tools have been restricted to chronic constipation and self-reported measures. Furthermore, they have not included literature published after 2011. This scoping review aims to identify and comprehensibly map the characteristics of available tools for screening and assessment of constipation in order to manage the nursing care need related to constipation within any healthcare or research context and any patient group. METHODS AND ANALYSIS: This review will include primary research articles, methodological papers and clinical guidelines using tools for constipation screening and assessment, pertinent to nursing care management. It is not limited to a specific population or healthcare setting. Databases to be searched include PubMed, Embase, CINAHL, ProQuest, ClinicalKey and Google Scholar. To identify grey literature, national health services in selected countries will be searched. Papers written in English, Nordic language or German will be included. The reviewers will independently review the retrieved citations against the inclusion criteria, and data from included papers will be extracted using a data extraction form developed for this review. The scoping review will be conducted following the Joanna Briggs Institute Guidelines. The results will be presented in a table accompanied by a narrative summary. ETHICS AND DISSEMINATION: Ethical approval is not required, as no individual patient data are included. Findings will be shared and discussed with relevant stakeholders and disseminated through peer-reviewed publications and conference presentations. The protocol is registered on Open Science Framework (registration number: osf.io/h2vzd).

Convergence insufficiency in patients with post-concussion syndrome is accompanied by a higher symptom load: a cross-sectional study.

OBJECTIVE: To estimate the prevalence of convergence insufficiency (CI) in adult patients with post-concussion syndrome and determine the impact of CI on symptom load. METHODS: Cross-sectional study of 103 patients with neurological symptoms 2-6 months after a concussion. Symptoms were assessed with the Rivermead Post Concussion Symptoms Questionnaire (RPQ), and CI was diagnosed using near point of convergence, vergence facility, and the Convergence Insufficiency Symptom Survey. The RPQ score for patients with and without CI was compared, and sensitivity, specificity, and area under the receiver operating characteristic curve for the two visually related RPQ questions as indicators of CI were calculated. RESULTS: The proportion of patients diagnosed with symptomatic CI was 20.4% (95% confidence interval: 13.1-29.5%). The RPQ score was significantly higher for patients with symptomatic CI both before (p = .01) and after removal of the two visually related questions in the RPQ-questionnaire (p = .03). The two visually related RPQ questions were unable to detect CI. CONCLUSION: In patients with post-concussion syndrome, the load of nonvisual symptoms is higher in the presence of CI. A prospective interventional study on CI is required to study the relationship between CI and other post-concussion symptoms.

Malnutrition in Patients With Moderate to Severe Acquired Brain Injury: Prevalence During 4 Weeks of Subacute Rehabilitation.

ABSTRACT: BACKGROUND: Malnutrition is associated with high rates of complication, longer hospital stays, and increased morbidity and mortality. Malnutrition defined as undernutrition is common in patients with acquired brain injury (ABI); however, estimates vary remarkably. This study aimed to describe malnutrition at admission and after 4 weeks of subacute inpatient neurorehabilitation in patients with ABI using the new global consensus definition of malnutrition. METHODS: One hundred thirty-three patients with moderate to severe ABI consecutively admitted to a specialized neurorehabilitation hospital within a period of 4 months were screened for inclusion, of which 92 were included. Malnutrition was defined as at least 1 phenotypic criterion (weight loss, low body mass index, low muscle mass) and at least 1 etiologic criterion (reduced food intake, inflammation). Malnutrition on admission and after 4 weeks was compared using the McNemar test. RESULTS: The proportion of patients with malnutrition at admission was 42%, with more men (46%) than women (36%) fulfilling the criteria for malnutrition. The most frequent phenotypic and etiologic criteria were weight loss (56%) and inflammation (74%), respectively. During the 4 weeks of rehabilitation, the proportion of male patients fulfilling the individual criteria "weight loss" (difference, -21.4%) and "inflammation" (difference, -18.9%) decreased significantly; "low muscle mass" decreased borderline significant (difference, -8.9%), whereas "low body mass index" did not change. The proportion of female patients fulfilling individual criteria for malnutrition was stable or increased nonsignificantly. CONCLUSION: Malnutrition was common at admission to neurorehabilitation in patients with moderate to severe ABI, with more men than women fulfilling the criteria for malnutrition. The nutritional status improved after 4 weeks of rehabilitation in male patients, whereas it was largely unchanged in female patients. The results provide the basis for monitoring high-quality nutritional nursing care.

Nursing representatives in clinical quality databases and the presence of nursing-sensitive indicators of fundamental nursing care.

AIM: To identify and describe nursing-sensitive indicators in Danish clinical quality databases and to examine the association between nurse representation on database steering committees and the presence of indicators related to aspects of fundamental care. DESIGN: This was a cross-sectional study. The STROBE checklist was employed to ensure reporting quality. METHODS: We reviewed data from the latest annual report of 71 clinical quality databases in April 2021. Aspects of fundamental care were defined as the 12 nursing domains defined in the Danish Minimum Nursing Data framework. For each database, we recorded the number and type of indicators and identified indicators measuring fundamental care aspects. We used the prevalence ratio to estimate the likelihood of indicators related to aspects of fundamental care in databases with nurse representation on the steering committee. RESULTS: One-third of the databases included indicators related to aspects of fundamental care. The most common aspects were Respiration and circulation, Nutrition and Psychosocial conditions, whereas Skin and mucous membranes, Elimination and Pain were rarely measured. Nurse representation on the steering committee of a quality database increased the likelihood of having indicators related to aspects of fundamental care three-fold (prevalence ratio 3.25). CONCLUSION: Fundamental care was rarely monitored in Danish clinical quality databases, but databases with nurse representation on the steering committee had a higher likelihood of monitoring fundamental care. IMPACT: This study addressed the knowledge gap of how fundamental nursing care is measured in clinical quality databases. It introduces nurses to the measurement of fundamental care as a first step toward performing nursing intervention studies and investigating associations with patient outcomes. The increased likelihood of fundamental care monitoring in clinical databases with nurse representation on the steering committee indicates a feasible way for decision makers and nurse leaders to ensure a stronger focus on fundamental care to the patients' benefit.

Interdisciplinary intervention (GAIN) for adults with post-concussion symptoms: a study protocol for a stepped-wedge cluster randomised trial.

BACKGROUND: Persistent post-concussion symptoms (PCS) are associated with prolonged disability, reduced health-related quality of life and reduced workability. At present, no strong evidence for treatments for people with persistent PCS exists. Our research group developed a novel intervention, "Get going After concussIoN (GAIN)", that incorporates multiple evidence-based strategies including prescribed exercise, cognitive behavioural therapy, and gradual return to activity advice. In a previous randomised trial, GAIN provided in a hospital setting was effective in reducing symptoms in 15-30-year-olds with PCS 2-6 months post-injury. In the current study, we describe the protocol for a trial designed to test the effectiveness of GAIN in a larger municipality setting. Additionally, we test the intervention within a broader age group and evaluate a broader range of outcomes. The primary hypothesis is that participants allocated to enhanced usual care plus GAIN report a higher reduction in PCS 3 months post-intervention compared to participants allocated to enhanced usual care only. METHODS: The study is a stepped-wedge cluster-randomised trial with five clusters. The 8-week interdisciplinary GAIN program will be rolled out to clusters in 3-month intervals. Power calculation yield at least 180 participants to be enrolled. Primary outcome is mean change in PCS measured by the Rivermead Post-Concussion Symptoms Questionnaire from enrolment to 3 months after end of treatment. Secondary outcomes include participation in and satisfaction with everyday activities, labour market attachment and other behavioural measures. Self-reported outcomes are measured at baseline, by end of treatment and at 3, 6, and 18 months after end of treatment. Registry-based outcomes are measured up to 36 months after concussion. DISCUSSION: The trial will provide important information concerning the effectiveness of the GAIN intervention in a municipality setting. Furthermore, it will provide knowledge of possible barriers and facilitators that may be relevant for future implementation of GAIN in different settings. TRIAL REGISTRATION: The current GAIN trial is registered in ClinicalTrials.gov (study identifier: NCT04798885 ) on 20 October 2020.

Body composition measures may help target fundamental nutritional nursing efforts in rehabilitating patients with acquired brain injury.

AIM: To illuminate using body composition measurements for malnutrition measured by Bio Impedance Analysis (BIA), as opposed to body mass index (BMI), and discuss benefits and burdens for fundamental nursing care. DESIGN: A second analysis of a prospective, descriptive cohort study, targeting fundamental nursing care elements. METHODS: This postevaluation study explored data from a prospective, descriptive cohort study, which consecutively included 92 patients admitted for neurorehabilitation care. Measures of nutritional status were BMI and FFMI. Chi-Square test and Multivariable logistic regression were used. RESULTS: Body composition measures rather than BMI contributed to target individual nutritional nursing care as this measure detected more patients at potential risk of malnutrition and indicated minor changes in the nutritional state. Transitions from being malnourished to a normal nutritional status occurred in 29% using the BMI definition while it was the case in 40% of individuals with malnutrition defined by the body composition.

Epilepsy after severe traumatic brain injury: frequency and injury severity.

Objective: To estimate national frequency of posttraumatic epilepsy (PTE) after severe traumatic brain injury (TBI) and assess injury severity (Glasgow Coma Scale (GCS) and posttraumatic amnesia (PTA)) as prognostic factors for PTE. METHODS: Data on patients ≥18 years surviving severe TBI 2004-2016 were retrieved from the Danish Head Trauma Database (n = 1010). The cumulative incidence proportion (CIP) was estimated using death as competing event. The association between injury severity and PTE was assessed using multivariable competing risk regressions. RESULTS: CIP of PTE 28 days and one year post-TBI was 6.8% (95% confidence interval (CI) 5.4-8.5) and 18.5% (95% CI 16.1-21.1%), respectively. Injury severity was not associated with PTE within 28 days post-TBI but indicated higher PTE-rates in less severely injured patients. PTA-duration >70 days was associated with PTE 29-365 days post-TBI (Adjusted sub-hazard ratio 4.23 (95% CI 1.79-9.99)). GCS was not associated with PTE 29-365 days post-TBI. CONCLUSION: The PTE frequency was higher compared to previous estimates. Increasing injury severity was associated with PTE 29-365 days post-TBI when measured with PTA, but not with GCS. Though nonsignificant, the increased PTE-risk within 28 days in lower severity suggests an underdiagnosing of PTE.

Using clinical quality databases to monitor the quality of fundamental care: Example with weight status after severe traumatic brain injury.

AIMS AND OBJECTIVES: To determine weight status and risk of overweight up to 1 year after severe traumatic brain injury (TBI) as basis for defining nursing-sensitive indicators of fundamental nutritional nursing care in a clinical quality database. BACKGROUND: Patients' nutritional needs are recognised as fundamental care during hospitalisation, but less attention has been given to nutritional status after discharge. DESIGN: Nationwide cohort study. The STROBE checklist was used to ensure reporting quality. METHODS: Data were retrieved from the Danish Head Trauma Database, a clinical quality database aiming at improving the quality of neurorehabilitation. Individuals aged ≥ 15 years with severe TBI 2011-2015 (N = 424) were included. Normal weight, underweight and overweight were described according to the body mass index (BMI) at admission to subacute rehabilitation, at discharge and at 1 year postinjury. The probability of transition between weight groups from admission to 1 year postinjury was calculated. Multivariable binominal regression analyses compared risk of overweight between age groups. RESULTS: The prevalence of underweight decreased from 13% at admission to 6% and 3% at discharge and 1 year postinjury, respectively. The prevalence of overweight was stable at 26%-27% at admission and discharge and increased to 44% at 1 year postinjury. Of the individuals not overweight at admission, 28% became overweight by 1 year postinjury. Overweight was significantly more prevalent in older compared to younger individuals. The risk of becoming overweight among those not overweight at admission did not differ between age groups. CONCLUSION: Underweight individuals achieved normal weight during inpatient rehabilitation. By 1 year postinjury, individuals were increasingly overweight. RELEVANCE TO CLINICAL PRACTICE: Weight status has potential as nursing-sensitive indicators that may be included in clinical quality databases to inform the organisational and policy level on the state of fundamental nutritional nursing care. The inclusion emphasise requested responsibilities of nursing care. This facilitates health economic attention and influences nursing professional execution.

Incidence of Free of Charge Physiotherapy in a Danish National Cohort of Stroke, Parkinson's Disease, Multiple Sclerosis and Rheumatoid Arthritis Patients.

BACKGROUND: Denmark is a welfare state with a publically funded healthcare system that includes the right to free of charge physiotherapy (FCP) for patients with chronic or progressive disease who fulfill strict criteria. The aim of this study was to investigate the incidence of referral to FCP in patients with a hospital diagnosis of stroke, multiple sclerosis (MS), Parkinson's disease (PD) and rheumatoid arthritis (RA) between 2007 and 2016. METHODS: The study was register-based and included data from The Danish National Patient Registry and The National Health Service Registry. The study population included the four largest disease groups receiving FCP in Denmark. The incidence of receiving FCP was reported as the cumulated incidence proportion (CIP). RESULTS: The study showed that FCP was mainly initiated within the first 2 years after diagnosis. The 2-year CIP was 8% for stroke patients, 53% for PD patients, 49% for MS patients, and 16% for RA patients. The proportion of patients referred to FCP generally increased over the period of the study due to more patients being referred from medical specialists in primary care. CONCLUSION: This study found substantial differences in the incidence of referral to FCP in a Danish population of stroke, PD, MS and RA patients.

Survey of oral nursing care attitudes, knowledge and practices in a neurorehabilitation setting.

The provision of oral care is an important fundamental nursing activity. The purpose of the study was to gain knowledge on nursing care professionals´ attitude, belief, knowledge and practice towards oral care in a neurorehabilitation setting. Nursing care professionals (n = 260, response rate: 60%) at neurorehabilitation hospital took part in cross-sectional web-based 59-items survey. Attitudes were cross-tabulated and compared using Fisher's exact test. Oral care product frequencies were compared between patients with/without eating difficulties using McNemar's test. Most professionals agreed that oral health impacts general health (93%) and poor oral health can cause pneumonia (85%). 41% professionals found it difficult to clean the oral cavity and 12% found it unpleasant. 40% indicated that time allocated for oral hygiene was insufficient, 27% indicated a need for broader range of oral care supplies and >80% would like continuing oral care education. Manual toothbrush and toothpaste were used more than once per shift by >75% in all patients. Swabs, premixed mouth rinse, carbonated water and lip moisturiser were more frequently used in patients with eating difficulties compared to with no eating difficulties. Oral care is perceived as an essential component of care in neurorehabilitation. However, professionals indicated lack of time, need for better supplies and oral care training. The differentiated use of oral care products shows that professionals were aware that patients with eating difficulties have different requirements; however, some oral care practices were inappropriate. The results should be considered while designing oral care guidelines and training.

Nursing Sensitive Outcomes After Severe Traumatic Brain Injury: A Nationwide Study.

BACKGROUND: Complications such as infections and conditions after immobilization are frequent after severe traumatic brain injury (TBI) due to compromised bodily functions. Traditionally, bodily functions are core elements in nursing, and therefore nurses in the rehabilitation departments are pivotal in the prevention of complications. Hence, the frequency of complications is an indicator of nursing care quality, which can be included in nursing-sensitive outcome indicators. To do so, it is necessary to know the frequency of the selected complications. OBJECTIVE: The aim of this study was to quantify complications during the first year after severe TBI. PARTICIPANTS: This study included patients 15 years or older who received subacute neurorehabilitation after severe TBI from 2011 to 2015 (N = 469). DESIGN: This is a register-based follow-up study using data from the Danish Head Trauma Database, a national clinical quality database aimed at monitoring and improving the quality of rehabilitation for patients with severe TBI. MAIN MEASURES: The following complications were assessed: urinary tract infection, pneumonia, pressure ulcers, joint contractures, and deep venous thrombosis. The prevalence of each complication was calculated at admission, discharge, and 1 year postinjury and for the period from admission and during subacute rehabilitation. In addition, the frequency of complications that certainly developed during subacute rehabilitation was calculated. Complications were compared between age-specific subgroups using multivariable binominal regression analyses. RESULTS: Urinary tract infections (53%) and pneumonia (32%) were the most common complications in the period from admission and during subacute rehabilitation. Pressure ulcers (18%), joint contractures (18%), and deep venous thrombosis (4%) were less frequent. At discharge and 1 year postinjury, the prevalence was less than 4% for all complications, except for joint contractures (16% and 13% at discharge and 1 year postinjury, respectively). CONCLUSION: The prevalence of complications was high. The findings are important for future quality improvement of the rehabilitation trajectory and for further studies that explore the high frequency of complications.

Prevalence and association of oral candidiasis with dysphagia in individuals with acquired brain injury.

OBJECTIVE: To describe the prevalence of oral candidiasis (OC) in individuals with acquired brain injury (ABI) and to evaluate the association of OC with improvement in dysphagia. DESIGN: Longitudinal observational study. METHODS: Individuals with ABI admitted to rehabilitation were recruited over a one-year period (n = 206 (59% with dysphagia)). OC-data were collected by clinical examinations and verified by cultivation/microscopy in every 3 weeks during first 10 weeks of admission. Dysphagia improvement was defined by: 1) first positive change in food consistency, 2) initiation of at least soft food consistency. Individuals with/without OC were compared using multivariable Cox proportional hazards regression. RESULTS: The overall OC prevalence in all individuals, in individuals with dysphagia and in individuals not treated with antifungal agents were 32.5%, 43.4% and 29.7%, respectively. The OC prevalence was 24.8% at one week after admission and reduced to 10.1% ten weeks after admission. Adjusted hazard ratios for improvement in dysphagia were 0.64-0.77 in OC compared to without OC, though not statistically significant. CONCLUSION: Prevalence of OC was high at admission but reduced during rehabilitation. Though non-significant, the negative trend between OC and improvement in dysphagia suggest that OC may delay rehabilitation of dysphagia.

Alternative measures reveal different but low estimates of labour market attachment after severe traumatic brain injury: A nationwide cohort study.

OBJECTIVE: To explore if the definition of labour market attachment (LMA) changes LMA proportions after severe traumatic brain injury (TBI). DESIGN: Cohort study with 5-year follow-up. PARTICIPANTS: Patients aged 18-64 years with severe TBI from 2004 to 2012 (n = 637) and matched controls (n = 2497). METHODS: LMA was defined in three ways. All definitions included patients working with no government benefits. Definition 2 included patients receiving unemployment benefits (LMA-unemployment benefits). Definition 3 included patients receiving supplemental benefits/services such as patients involved in work-activation schemes (LMA supplementary benefits). First week of return to work (RTW), stable LMA first year after RTW and weekly LMA prevalence were calculated. Patients and controls were compared using multivariable conditional logistic regression. RESULTS: LMA unemployment benefits had similar proportions to LMA with no benefits. These estimates were lower than LMA supplemental benefits where 52% attempted to RTW and 31% achieved stable LMA within 2 years. The maximal LMA prevalence (LMA supplementary benefits) decreased from 33 to 30% from years 2 to 5. Adjusted odds ratios were 0.05 and 0.06 for years 1 and 2, and 0.07 for stable LMA in patients compared to controls. CONCLUSION: LMA proportions differed depending on the definition. Regardless of definition, LMA proportions following severe TBI were low in Denmark.

Return to Work After Severe Traumatic Brain Injury: A Nationwide Follow-up Study.

OBJECTIVE: To determine return to work (RTW) after severe traumatic brain injury (TBI) and to compare long-term labor market attachment (LMA) with the general population. PARTICIPANTS: All persons aged 18 to 64 years who received highly specialized neurorehabilitation after severe TBI between 2004 and 2012 (n = 637) were matched to general population controls on age, sex, preinjury employment status, educational level, and residence (n = 2497). DESIGN: Nationwide follow-up study using weekly records on public assistance benefits. MAIN MEASURES: Both RTW and LMA were defined as having no public assistance benefits except education grants/leave. Stable LMA was defined as weeks with LMA of 75% or more. LMA among persons with severe TBI and controls was compared using multivariable conditional logistic regression. RESULTS: RTW mainly occurred within first 2 years after severe TBI, with 30% of the people attempting RTW and 16% achieving stable LMA within 2 years. The prevalence of people with LMA decreased to 11% from 2½ years to 5 years postinjury. Adjusted odds ratios were 0.01 for LMA up to 2 years postinjury and 0.05 for stable LMA for persons with severe TBI compared with the general population. CONCLUSION: Both RTW and long-term LMA after severe TBI were low in Denmark when compared with the general population and other countries.

Surviving severe traumatic brain injury in Denmark: incidence and predictors of highly specialized rehabilitation.

PURPOSE: To identify all hospitalized patients surviving severe traumatic brain injury (TBI) in Denmark and to compare these patients to TBI patients admitted to highly specialized rehabilitation (HS-rehabilitation). PATIENTS AND METHODS: Patients surviving severe TBI were identified from The Danish National Patient Registry and The Danish Head Trauma Database. Overall incidence rates of surviving severe TBI and incidence rates of admission to HS-rehabilitation after severe TBI were estimated and compared. Patient-related predictors of no admission to HS-rehabilitation among patients surviving severe TBI were identified using multivariable logistic regression. RESULTS: The average incidence rate of surviving severe TBI was 2.3 per 100,000 person years. Incidence rates of HS-rehabilitation were generally stable around 2.0 per 100,000 person years. Overall, 84% of all patients surviving severe TBI were admitted to HS-rehabilitation. Female sex, older age, and non-working status pre-injury were independent predictors of no HS-rehabilitation among patients surviving severe TBI. CONCLUSION: The incidence rate of hospitalized patients surviving severe TBI was stable in Denmark and the majority of the patients were admitted to HS-rehabilitation. However, potential inequity in access to HS-rehabilitation may still be present despite a health care system based on equal access for all citizens.