Long-Term Functional and Psychosocial Outcomes After Hypoxic-Ischemic Brain Injury: A Case-Controlled Comparison to Traumatic Brain Injury.

BACKGROUND: Despite the increasing rate of survival from hypoxic-ischemic brain injury (HIBI), there is a paucity of evidence on the long-term functional outcomes after inpatient rehabilitation among these nontrauma patients compared to patients with traumatic brain injury (TBI). OBJECTIVES: To compare functional and psychosocial outcomes of patients with HIBI to those of case-matched patients with TBI 4-11 years after brain insult. DESIGN: Retrospective, matched case-controlled study. METHODS: Data at the time of rehabilitation admission and discharge were collected as part of a larger acquired brain injury (ABI) database at Toronto Rehabilitation Institute (TRI) between 1999 and 2009. This study consisted of 11 patients with HIBI and 11 patients with TBI that attended the neuro-rehabilitation day program at TRI during a similar time frame and were matched on age, admission Functional Independence Measure (FIM) scores, and acute care length of stay (ALOS). At 4-11 years following brain insult, patients were reassessed using the FIM, Disability Rating Scale (DRS), Personal Health Questionnaire Depression Scale (PHQ-9), and the Mayo-Portland Adaptability Inventory 4 (MPAI-4). RESULTS: At follow-up, patients with HIBI had significantly lower FIM motor and cognitive scores than patients with TBI (75.3 ± 20.6 versus 88.1 ± 4.78, P < .05, and 25.5 ± 5.80 versus 32.7 ± 2.54, P <.05, respectively) despite having a similar time frame postinsult (ie, 4-11 years). In addition, there were significant differences in motor and total FIM change from admission to follow-up between HIBI and TBI patients (P < .05). Patients with HIBI also had significantly lower scores on the DRS, PHQ-9, and total MPAI-4 at follow-up (P < .05). CONCLUSIONS: The study results suggest that patients with HIBI achieve less long-term functional improvements compared to patients with TBI. Further research is warranted to compare the components of inpatient rehabilitation while adjusting for demographics and clinical characteristics between these 2 groups of patients. LEVEL OF EVIDENCE: III.

Conducting systematic evidence reviews: core concepts and lessons learned.

A systematic review (SR) is an essential component of evidence-based practice, because it synthesizes information on a particular topic that is necessary to inform health-related decision making. The purpose of this article is to document the process of producing a high-quality SR within the field of rehabilitation in contrast to other fields (eg, pharmaceutic research). We describe the notable methodologic challenges to producing high-quality SRs for rehabilitation researchers. Broadly, we outline how the quality of SRs is evaluated and suggest mechanisms for researchers to address potential pitfalls. Because meaningful SRs can and should be conducted in this field, we provide practical guidance regarding how to conduct such an SR. We outline a series of 8 important steps in the production of an SR: forming a committee, creating a development plan, conducting a literature review, selecting articles for inclusion, extracting data, preparing tables of evidence, facilitating external review and publication, and forming conclusions and recommendations. For each step of the SR process, we provide detailed description about the methodologic decisions involved and recommended strategies that researchers can implement to produce a high-quality SR. Using these preestablished steps and procedures as a guideline will not only help to increase the efficiency of the SR process, but also to improve the quality. The availability of high-quality SRs with plain language summaries promotes access to the best quality information for all involved in decision making.

Cognitive correlates with functional outcomes after anoxic brain injury: a case-controlled comparison with traumatic brain injury.

OBJECTIVES: To assess the effectiveness of inpatient rehabilitation in adults who have sustained an anoxic brain injury (AnBI). Secondly, to identify areas of cognition that predict functional outcomes at discharge. DESIGN: Retrospective, matched case-controlled study. METHODS: Ten patients with moderate-to-severe AnBI and 10 patients with traumatic brain injury (TBI), treated in an inpatient neurorehabilitation programme, were matched on age, acute care length of stay and admission Functional Independence Measure (FIM). Functional outcome was assessed using the FIM and Disability Rating Scale (DRS). RESULTS: Patients with AnBI performed worse on all measures of functional outcome relative to patients with TBI. Patients with AnBI achieved significantly lower FIM motor and cognitive gain compared with patients with TBI (11.5, SD 13.6 vs. 31.0, SD 19.7 and 2.4, SD 3.9 vs. 7.5, SD 4.2, respectively (p < 0.02)). DRS data showed similar trends of functional improvement between the groups. Several neuropsychometric tests correlated with functional outcome (p < 0.01). CONCLUSIONS: Patients with AnBI had worse functional outcomes following rehabilitation than patients with TBI, confirming the results of previous reports. Poor cognitive function predicted poor functional outcomes on the FIM and somewhat on the DRS. Research is needed to assess why these differences occur and to improve or develop new effective rehabilitation treatments for AnBI.

Early neuropsychological tests as correlates of productivity 1 year after traumatic brain injury: a preliminary matched case-control study.

This study explored the relative strength of five neuropsychological tests in correlating with productivity 1 year after traumatic brain injury (TBI). Six moderate-to-severe TBI patients who returned to work at 1-year post-injury were matched with six controls who were unemployed after 1 year based on age, severity of injury, and Functional Independence Measure scores. Five neuropsychological tests were administered to patients during inpatient rehabilitation. Two of the five tests (Symbol Digit and Block Design) discriminated TBI patients based on employment outcome. Symbol Digit and Rey Auditory Verbal Learning Test were significantly correlated with follow-up Functional Independence Measure scores. Results indicate that neuropsychological measures of visual perception (Block Design), and attention and mental speed (Symbol Digit) may be useful predictors of employment productivity after TBI; whereas attention and mental speed, learning and memory ability (Symbol Digit and Rey Auditory Verbal Learning Test) may predict functional outcomes.

Rehabilitation outcomes after anoxic brain injury: a case-controlled comparison with traumatic brain injury.

OBJECTIVE: To investigate the functional outcomes of patients with anoxic brain injury (AnBI) compared with control patients with traumatic brain injury (TBI) during inpatient rehabilitation. DESIGN: Matched case-controlled design. SETTING: Inpatient neurorehabilitation program. PARTICIPANTS: Fifteen patients with AnBI and 15 patients with TBI. METHODS: Data of 15 patients with a primary diagnosis of AnBI were retrospectively reviewed and matched to 15 patients with TBI admitted within the same time frame on age, acute care length of stay, and functional status at admission. MAIN OUTCOME MEASURE: Functional outcome was assessed by the use of the Functional Independence Measure (FIM). RESULTS: Compared with the control patients with TBI, patients with AnBI achieved significantly lower FIM motor gain (16.3+/-15.6 versus 5.7+/-10.7, respectively) and efficiency scores (0.27+/-0.28 versus 0.06+/-0.13), discharge FIM cognition scores (25.9+/-5.9 versus 21.7+/-7.3), total FIM gain (22.5+/-19.6 versus 9.1+/-12.1), and total FIM efficiency scores (0.39+/-0.38 versus 0.10+/-0.16; all P<.05). CONCLUSIONS: Results suggest a slower rate of recovery for patients with AnBI compared with TBI, with physical recovery being slower than cognitive recovery as measured by the FIM during inpatient rehabilitation when matched according to preinjury characteristics and functional status at rehabilitation admission. Future studies on larger samples of patients with AnBI and TBI that use a case-controlled design and longer-term outcome measurement are warranted to further clarify the differences in functional outcomes between these groups and to assess whether optimal rehabilitation interventions differ for these groups.

Functional recovery following traumatic vs non-traumatic brain injury: a case-controlled study.

PRIMARY OBJECTIVE: To explore differences in rate of recovery and functional outcome in case-matched patients with traumatic (TBI) vs non-traumatic brain injury (non-TBI) during inpatient rehabilitation and 1 year post-insult. RESEARCH DESIGN: Retrospective comparison study and case-controlled design. METHODS AND PROCEDURES: Demographic data, severity of injury, functional outcome measures and outcomes at 1 year follow-up were collected on 573 patients (404 TBI; 169 non-TBI) admitted to a multidisciplinary neurorehabilitation programme. After general cohort comparisons, 86 TBI and 86 non-TBI patients were matched on age, severity of injury and functional outcome scores. MAIN OUTCOMES AND RESULTS: In the general cohort analyses, TBI patients demonstrated better outcomes at discharge as indicated by lower Disability Rating Scale (DRS) scores and higher gain and efficiency scores on both motor and cognitive sub-scales of the Functional Independence Measure (FIM). After matching patients, TBI patients showed greater functional improvement throughout their rehabilitation stay. Outcomes at 1 year follow-up were mixed; TBI patients showed better outcomes compared to non-TBI patients on DRS scores; however, FIM scores were not significantly different. CONCLUSIONS: Results from the present study support the hypothesis that TBI patients achieve greater functional improvements compared to non-TBI patients when matched according to injury and demographic characteristics.

A preliminary study of the efficacy of ondansetron in the treatment of ataxia, poor balance and incoordination from brain injury.

BACKGROUND: Ataxia is caused by a variety of conditions leading to imbalance, incoordination and other disabilities. Current treatment is largely symptomatic. Ondansetron (a 5-HT3 antagonist) has been established as an anti-emetic in cancer patients, but has recently been shown to improve vertigo and cerebellar tremor in some patients. HYPOTHESIS: Ondansetron can improve symptoms of ataxia, imbalance and incoordination in four brain-injured patients. DESIGN: Placebo-controlled, double blind, crossover, 'n of 1' study, A-B-A design. SUBJECTS: Four patients with ataxia from traumatic brain injury. METHODS: Four patients underwent five separate tests of ataxia under three different conditions in a double blind fashion. RESULTS: For all subjects, there was little difference in scores in the five areas tested, with some improvement in tests of lower limb ataxia (10.4% for 4 mg and 10.7% for 8 mg ondansetron vs baseline). CONCLUSION: Ondansetron use showed a trend towards improvement in tests of lower extremity ataxia but did not consistently improve scores in four patients.