Brain Injury Program Research Articles

A Look at Traumatic Brain Injury Community Programs in British Columbia: Barriers and facilitators of implementation

ABSTRACT Research Objectives 1) Characterize the delivery of programs that support acceptance and resiliency for people with brain injury in the healthcare sector; 2) Understand the barriers and facilitators in implementation of programs to support self-acceptance and resiliency for people with brain injury Design Participatory focus groups were used to explore experiences of conducting brain injury programs and knowledge of the barriers and facilitators to their implementation. Focus group data were analyzed with manifest content analysis to minimally deviate from broad and structural information provided by participants. Setting Four focus group sessions were conducted online through a video calling platform. Participants 22 individuals from community associations conducting programs for people with brain injury. Participants were recruited from a public brain injury organization database. Results Systemic challenges such as access to and allocation of funding require navigation support. Resource consistency and availability, including stable program leaders and a welcoming atmosphere, are important for program implementation and sustainability. Shared experiences promote connection with the community and personal development. Conclusions This study informs individual- and community-level approaches to promote meaningful life after brain injury. Findings highlight existing resources and support future programming for people with brain injury.

Six-month post-release outcomes for inmates with traumatic brain injury in supported community programming

ABSTRACT Objective: The goal of this study is to examine the effectiveness of case management services for a population of justice-involved individuals with TBI history. Methods: Two thousand three hundred and eighty-nine records from statewide behavioral health and brain injury program databases were used in two studies. Results: Participants with a reported TBI history were more likely to have experienced trauma and to have a behavioral health diagnosis relative to incarcerated persons without TBI. Six months after release, 56.8% of participants with a history of TBI were still receiving community treatment, 27.8% were not in treatment, and 3.4% had completed treatment. There was a high attrition rate; 70% of people referred for case management failed to maintain contact. Conclusions: For those that did receive services, these data suggest that it prevented an escalation of psychosocial needs. There were no differences in community participation as measured by the Mayo Portland Adaptability Index’s Participation Index (M2PI) scores (t24 = .497, p = 0.624) at intake and after 6 months of case management. This study confirms that case management confers a benefit to persons with TBI who are released from the criminal justice system. Further, recidivism rates for this vulnerable group were no different from the larger population of returning citizens.

Poster (Clinical/Best Practice Implementation) ID 1985003

Background Sexual health is an important component of overall health. Yet, sexuality is often neglected in rehabilitation. Studies indicate that typically clinicians do not address the sexual health concerns of patients because of lack of adequate training, comfort, and knowledge in this area. Objectives The purpose of this initiative was to develop and implement an e-learning module to address the current gap in rehabilitation practice. Methods In 2021, an interdisciplinary team of rehab clinicians worked with an Instructional Designer based at Parkwood Institute to develop e-Learning modules aimed to introduce rehab teams to sexual health rehab and application to practice. The modules were launched at Parkwood Institute in January 2022 and were compulsory education for all rehabilitation staff in Spinal Cord, Acquired Brain Injury and Stroke programs. They were subsequently launched more broadly at Vancouver Coastal Health in March 2022. Surveys were conducted to assess the impact of the modules on clinical application. Results To date,186/209 (89%) of rehabilitation staff at Parkwood Institute and a total of 55 clinicians from Vancouver Coastal Health have completed the modules. Preliminary results show improvement in confidence, knowledge, and ability to address the sexual health needs of rehabilitation patients. Conclusions The e-Learning modules help fill the current practice gap and facilitate sustainability of sexual health practice in clinical settings. Accessible educational opportunities such as the e-modules are valuable tools in enhancing self-efficacy of staff when addressing sexual health concerns of patients.

Iterative Development of the Caregiver Wellness After Traumatic Brain Injury Program (CG-Well).

(1) To iteratively design a web/phone-based intervention to support caregivers of adults acutely following traumatic brain injury (TBI), Caregiver Wellness (CG-Well), and (2) to obtain qualitative and quantitative feedback on CG-Well from experts and caregivers to refine the intervention. A level I trauma and tertiary medical center. Convenience sample of a total of 19 caregivers and 25 experts. Multistep prospective study with iterative changes to CG-Well: (1) developed intervention content based on qualitative feedback from a prior study and literature review; (2) obtained qualitative feedback from 10 experts; (3) refined content using a modified Delphi approach involving 4 caregivers and 6 experts followed by qualitative interviews with 9 caregivers; (4) designed CG-Well website and videos; and (5) obtained feedback on program acceptability, appropriateness, and feasibility from 6 caregivers and 9 experts. CG-Well included content on TBI, self-care and support, and skill-building strategies delivered through a website and telephone calls. Qualitative data were analyzed using content analysis. Caregivers and experts completed Likert-type scales to rate module relevance, clarity, accuracy, utility and website acceptability, appropriateness, and feasibility (1 = strongly disagree to 5 = strongly agree). Means and standard deviations (SD) characterized ratings. Qualitative findings were instrumental in designing and refining CG-Well. Ratings were positive for modules (means and SD for relevant [4.9, 0.33], clear [4.6, 0.53], accurate [4.9, 0.33], and useful [5, 0]) and the website (means and SD for acceptable [4.8, 0.36], appropriate [4.8, 0.35], and feasible [4.8, 0.36]). The iterative design process for CG-Well resulted in a highly acceptable program. An early-stage randomized controlled trial is underway to estimate treatment effects for a future well-powered clinical trial.

Alcy R. Torres, MD

Dr Alcy Torres is a pediatric neurologist who specializes in traumatic brain injury. Much of his clinical work takes place around the Pediatric Concussion Program at Boston Medical Center; a multidisciplinary center coordinating care between the Emergency Room, the inpatient and outpatient services but also the common referrals to Physical, Vestibular, Ocular, Speech therapies and Neuropsychology services. His aim is to provide the highest level of care to children and adolescents who have sustained a brain injury by understanding the pathophysiology of the pediatric patient through research and enhancing the health and well-being of patients, minimizing distress, and preventing longer-term difficulties.In order to achieve this goal, he has developed a Standardized Clinical Assessment and Management Plans, now adopted by the Adult Concussion Clinic at Boston University to continuously review individual patient data for areas in our practice that need improvement, thus ensuring that the Brain Injury program always provides the best, most cost-effective care for our patients. Another goal of the center is access to acute and follow-up care, to which end we began developing an open access clinic in 2013 to provide services at Boston Medical Center, our satellites and across different different specialties.

Enabling Meaning after Brain injury through Acceptance and Resiliency Construction (EMBARC)

<h3>Research Objectives</h3> 1) Explore community services that foster acceptance, resiliency, and meaning after brain injury; 2) Understand the barriers and facilitators to implementation of these programs for people with brain injury; and 3) Identify implementation and service adaptation priorities in brain injury programming. <h3>Design</h3> A participatory focus group design with patient partnership was used to explore experiences of conducting brain injury programs and knowledge of the barriers and facilitators to their implementation (Krueger & Casey, 2014; Thorne, 2016; Visser et al., 2021). Using a manifest content analysis approach, focus group data was analyzed while minimally deviating from broad and structural information provided by participants (Bengtsson, 2016; Graneheim et al., 2017; Kleinheksel et al., 2020). <h3>Setting</h3> Focus groups were conducted online through Zoom, a video calling platform. <h3>Participants</h3> 22 individuals from community associations conducting programs for people with brain injury were included. Participants were recruited from a public brain injury organization database using convenience sampling methods. <h3>Results</h3> Preliminary results indicate that programs and services promoting engagement, life reconstruction, and connection to the community are particularly meaningful for people with brain injury. External systems or factors such as public policy, use of technology, and systems processes can act as both barriers and facilitators to program success. These findings highlight existing brain injury resources, reveal program barriers and facilitators, and suggest priorities for adapting existing services or developing future community programs. <h3>Conclusions</h3> This study informs individual- and community-level approaches to promote meaningful life after brain injury. Overall, findings contribute knowledge to the rehabilitation field, supporting future research to guide successful programming for people with brain injury. <h3>Author(s) Disclosures</h3> Not applicable.

Iterative Development of the Caregiver Wellness after Traumatic Brain Injury Program (CG-Well)

<h3>Research Objectives</h3> Main Objective: To iteratively design a web/phone-based intervention for caregivers of adults with traumatic brain injury (TBI), Caregiver Wellness (CG-Well) Secondary Objective: To obtain qualitative and quantitative feedback on CG-Well from experts and caregivers. <h3>Design</h3> Multi-step prospective study with iterative changes to CG-Well: 1) Developed intervention content based on qualitative feedback from 18 family caregivers; 2) obtained qualitative feedback from 10 experts; 3) refined content using a modified Delphi approach involving 4 caregivers and 6 experts; 4) designed CG-Well website and videos; 5) obtained feedback on program acceptability, appropriateness and feasibility from 6 caregivers and 9 experts. <h3>Setting</h3> A level-I trauma and tertiary medical center, focused on acute and sub-acute timeframes. <h3>Participants</h3> A convenience sample of caregivers and experts including healthcare providers with five years of TBI experience, or researchers with a record of TBI publications. <h3>Interventions</h3> The CG-Well intervention was designed with content in education, support, and skill-building delivered through a website with videos and telephone calls with an intervener. <h3>Main Outcome Measures</h3> Qualitative data were analyzed using content analysis. Caregivers and experts completed a survey using Likert-type scales to rate if modules were relevant, clear, accurate, and useful and if the website was acceptable, appropriate, and feasible for TBI caregivers (1 = strongly disagree to 5 = strongly agree). Means and standard deviations (SD) were used to characterize ratings. <h3>Results</h3> Qualitative findings were instrumental in designing and refining the CG-Well intervention. Ratings were positive for the modules [means and SD for relevant (4.9, 0.33), clear (4.6, 0.53), accurate (4.9, 0.33) useful (5, 0)] and for the website [means and SD for acceptable (4.8, 0.36), appropriate (4.8, 0.35), and feasible (4.8, 0.36)]. <h3>Conclusions</h3> The iterative design process for CG-Well resulted in a highly acceptable program. A randomized controlled trial to test feasibility of CG-Well compared with an attention control group is underway to generate data trends for a future well-powered clinical trial. <h3>Author(s) Disclosures</h3> No relevant disclosures.

Aggression in Military Members With Mild Traumatic Brain Injury and Post-Traumatic Stress Disorder Is Associated With Intimate Partner Health-Related Quality of Life.

We aimed to examine the relationship between service member/veteran (SMV) aggression and health-related quality of life (HRQOL) in their intimate partners. This prospective cohort study included 201 female intimate partner caregivers of post-9/11 male SMVs with a diagnosis of uncomplicated mild traumatic brain injury and post-traumatic stress disorder from a military treatment facility. Caregivers completed 17 HRQOL measures and rated the level the SMV experiences problems with verbal or physical expressions of irritability, anger, or aggression on the Mayo-Portland Adaptability Inventory, 4th edition. Caregivers were classified into three SMV Aggression groups: i) none or very mild (n=53); ii) mild (n=47); and iii) moderate or severe (n=101). HRQOL scores were classified as clinically elevated using a cutoff of 60T or higher. Using χ2 analysis, the moderate or severe group had a significantly higher proportion of clinically elevated scores on 15 HRQOL measures compared with the none or very mild group, and six measures compared with the mild group. The mild group had higher scores on two measures compared with the none or very mild group. Using analysis of covariance (and controlling for caregiver strain), the moderate or severe group had significantly higher scores on 11 HRQOL measures compared with the none or very mild group, and two measures compared with the mild group. The mild group had higher scores on five measures compared with the none or very mild group. Many caregivers who report moderate to severe SMV aggression after a traumatic brain injury report poor HRQOL beyond the strain of care provision. Traumatic brain injury and post-traumatic stress disorder programs should screen for and treat SMV aggression and attend to the health needs of SMVs' caregivers.

Comparing Outcomes of the Veterans Health Administration's Traumatic Brain Injury and Mental Health Screening Programs: Types and Frequency of Specialty Services Used.

The Veterans Health Administration (VHA) screens veterans who deployed in support of the wars in Afghanistan and Iraq for traumatic brain injury (TBI) and mental health (MH) disorders. Chronic symptoms after mild TBI overlap with MH symptoms, for which there are already established screens within the VHA. It is unclear whether the TBI screen facilitates treatment for appropriate specialty care over and beyond the MH screens. Our primary objective was to determine whether TBI screening is associated with different types (MH, Physical Medicine & Rehabilitation [PM&R], and Neurology) and frequency of specialty services compared with the MH screens. A retrospective cohort design examined veterans receiving VHA care who were screened for both TBI and MH disorders between Fiscal Year (FY) 2007 and FY 2018 (N = 241,136). We calculated service utilization counts in MH, PM&R, and Neurology in the six months after the screens. Zero-inflated negative binomial regression models of encounters (counts) were fit separately by specialty care type and for a total count of specialty services. We found that screening positive for TBI resulted in 2.38 times more specialty service encounters than screening negative for TBI. Compared with screening positive for MH only, screening positive for both MH and TBI resulted in 1.78 times more specialty service encounters and 1.33 times more MH encounters. The TBI screen appears to increase use of MH, PM&R, and Neurology services for veterans with post-deployment health concerns, even in those also identified as having a possible MH disorder.

Do state supports for persons with brain injury affect outcomes in the 5Years following acute rehabilitation?

While a substantial literature has examined the effects of individual and family-level factors on outcomes following traumatic brain injury (TBI), minimal attention has been directed to the potential influence of the larger environmental context on outcomes. The purpose of the current study was to investigate the effects of state-level resources and supports as an environmental factor influencing long-term outcomes from TBI using data from the TBI Model Systems. We examined the effects of U.S. state supports that specifically target people with TBI (federal funding for state brain injury programs, per capita revenue generated by brain injury trust funds, and expenditures for brain injury specific Medicaid waivers) and one measure of the relative quality of a state's Long-Term Services and Supports (LTSS) for all people with disabilities. The primary hypothesis was that community participation, global functioning, and life satisfaction will be higher on average among people with TBI living in states with more brain injury specific programs and resources and better LTSS. The results of multilevel and fixed-effects modeling indicated that state supports have a small but significant impact on participation and life satisfaction. The most consistent finding indicated that states with better LTSS had higher levels of community participation and life satisfaction on average for people with TBI over and above individual-level differences and fluctuations in these outcomes over time. There was some indication that more brain injury specific supports also result in better participation in the community. These findings deserve replication and extension to include other environmental factors, particularly community level characteristics, that might affect outcomes from TBI.

Caring for Our Caregivers: a feasibility study of caregiver preparedness training within inpatient brain injury rehabilitation

Background/aims Evidence-based inpatient caregiver training may ensure that caregiver needs are met and hospital readmission costs reduced. The aim of this study was to evaluate the feasibility of implementing a caregiver education model, Caring for Our Caregivers, within an inpatient brain injury programme. Methods A total of 32 adults were admitted to inpatient neurorehabilitation during the 7-week feasibility trial. The three-step Caring for Our Caregivers programme included evidence-based recommendations following a caregiver needs assessment, goal setting and hands-on training. Satisfaction levels and caregiver preparedness were assessed via a survey. Results The caregiver needs assessment and goal collaboration was completed within 5 days 66% of the time. Results indicated an even distribution of hands-on (47%) and discussion-based (53%) education. Caregivers and staff identified high levels of satisfaction with the programme. Conclusions Early engagement, collaborative goals and hands-on training of the family caregiver of a client with acquired brain injury during inpatient rehabilitation demonstrated initial feasibility with positive implications for caregiver satisfaction and community discharge.

A Multicenter Look at Multidisciplinary Youth Concussion/Mild Traumatic Brain Injury Programs: The Four Corners Youth Consortium (4CYC)

Abstract Introduction A 2013 Institute of Medicine report revealed a striking lack of data on youth concussion. The 4CYC is a group of self-funded centers committed to working together to better understand youth sports and brain health. Objectives The goal is to create a collaborative, multi-institutional partnership amongst academic centers with expertise in youth concussion care, research, and education. Methods Six sites provided baseline and clinical data, collected October 2014- September 2015. Subjects included pediatric (5-18.99 years) patients and athletes seen in outpatient treatment for concussion or preseason baseline assessments. The demographic data followed the NIH Common Data Elements (CDE) for pediatric TBI. Results We collected data from 687 baseline-testing encounters, 2803 new clinic encounters for concussion and 1672 follow-up visits. The types of encounters varied among the sites. Conclusions This paper demonstrates the feasibility for multiple academic, multidisciplinary concussion centers to combine clinical data on youth mTBI.

Growing Academic Physiatry: The Impact of the Baruch's Grants on Harvard Medical School and Columbia College of Physicians and Surgeons. Part II.

Growing Academic Physiatry: The Impact of the Baruch's Grants on Harvard Medical School and Columbia College of Physicians and Surgeons. Part II.

A Study of Impaired Self-awareness and Behavioral Change in A Patient with Higher Brain Dysfunction Who Undertook The Understanding Brain Injury (UBI) Program

A Study of Impaired Self-awareness and Behavioral Change in A Patient with Higher Brain Dysfunction Who Undertook The Understanding Brain Injury (UBI) Program

A Participatory Action Workshop on Integrating Services for Traumatic Brain Injury, Mental Health, and Addictions

This presentation will describe results from a one-day participatory action meeting that was held at the beginning of the ‘Integrating Brain Injury, Mental Health, and Addictions Research Program’, aimed at identifying emerging/ongoing gaps and further refining the research methodology for this program.

The Validity of the Montreal Cognitive Assessment for Moderate to Severe Traumatic Brain Injury Patients: A Pilot Study.

The aim of the study was to pilot the use of Montreal Cognitive Assessment as a quick clinical screen for cognitive assessment in traumatic brain injury patients. The study recruited 61 participants with moderate to severe traumatic brain injury presenting to a tertiary rehabilitation center under the Brain Injury Program. A Montreal Cognitive Assessment questionnaire and neuropsychological battery (Repeatable Battery for the Assessment of Neuropsychological Status and Color Trails Test) were administered to participants who had completed inpatient rehabilitation. Receiver operating characteristic analysis for the Montreal Cognitive Assessment revealed an optimal balance of sensitivity and specificity at 24/25 to discriminate participants who were classified as less than 5th centile on the Total Scale Index on the Repeatable Battery for the Assessment of Neuropsychological Status. This achieved a sensitivity, specificity, PPV, and NPV of 73.9%, 86.5%, 77.3%, and 84.2%, respectively. Receiver operating characteristic analysis for the trail making subtest of the Montreal Cognitive Assessment achieved a sensitivity, specificity, PPV, and NPV of 79.4%, 74.1%, 79.4%, and 74.1% in identifying patients classified as less than 5th centile on Color Trail Test part 2. The use of Montreal Cognitive Assessment displayed good validity in identifying patients with clinically significant impairment on a standard neuropsychological assessment battery in the study population. However, it may lack sensitivity for estimating mild levels of impairment.

Predictors of Successful Outcome Following mTBI

To investigate predictors of neurobehavioral symptom outcome following treatment within a military traumatic brain injury (TBI) program.

An Interdisciplinary Resource Pack for working with Child Relatives of Adults with Brain Injury

Introduction and Description: In the NRH brain injury rehabilitation programme, an interdisciplinary team works with persons with acquired brain injury and helps them to achieve goals in order to improve their quality of life. While some consideration is given to child relatives, the process has been largely client and carer centred. Many injured persons have young children, and there has been an inconsistent approach across the service in terms of helping children cope with and adjust to their brain injured parent or relative. A resource pack for all members of the inter-disciplinary team in the NRH brain injury programme was designed and provided to all staff, in order to offer guidance and advice on working with child relatives and including them in the rehabilitation process. Work on developing the pack was funded through the Dr Tom Gregg Bursary Fund. Aim and theory of change: There has been a new emphasis in recent years on the importance of family focussed rehabilitation, with the UK’s ‘Think Family’ policy, as well as research from various authors, such as Audrey Daisley. To date in Ireland, rehabilitation has been more client and carer focussed, so the aim of the resource pack was to strengthen the family approach to rehabilitation. The objective of the pack was to support staff to be more inclusive of child relatives; and to help them see the importance of including child relatives when working with adults with an acquired brain injury. It was also hoped that the resource pack would provide staff with the tools and confidence to work with children. The majority of staff in the adult brain injury programme had experience of working with adults only, and lacked the confidence to work with children. The aim of the pack was to serve as a tool kit with suggestions and ideas on how to work with children, as well as provide information on the developmental stages of children and how they are impacted by brain injury. Targeted population and stakeholders: The resource pack was for all members of the Brain Injury Programme interdisciplinary team in the NRH, both inpatient and outpatient. There are 4 brain injury wards in the NRH, which adds up to 57 patients at any one time. The number of physios, occupational therapists, speech and language therapists, social workers and nursing staff averages 70. The resource pack also included fact sheets to be administered to patients and their families. Timeline: The timeline for the production of the pack was 5 months, with a review of outcomes scheduled for 6 months following its distribution. Highlights: Research has shown that children with brain injured parents can have significantly more emotional and behavioural problems than children in the general population. Involving child relatives in the rehabilitation process impacts on their adjustment and consequently has a positive impact on the whole family. Including child and family centred goals in a rehabilitation programme can help an injured parent’s programme to be more helpful on a practical level as well as helping the non-injured parent learn how to deal with their child’s adjustment to the brain injury. Following a pilot release of the resource pack, outcomes will be measured in autumn 2017, with a view to making any changes necessary. Sustainability: Although a review of the effectiveness of the pack has yet to be undertaken, the notion of helping staff to be more family focussed has been evidenced in the literature as having positive outcomes for patients and therefore is a focus which should be encouraged and maintained in the NRH brain injury programme. Transferability: It is hoped that while this resource pack was initially targeted towards NRH staff on the brain injury programme, it could be transferable to brain injury rehabilitation teams across Ireland. It is also hoped that in the future the pack could be adapted for the spinal injury programme. Conclusions: The resource pack represents a move toward child and family focussed rehabilitation, which has been shown to have a positive impact on both patients and families. It is also a useful tool for members of the interdisciplinary team, enhancing their skills and confidence when working with child relatives. Discussions: The recognition of the impact of brain injury on child relatives will have benefits in supporting families as a whole and should help to reduce the negative impact of brain injury on children. Lessons learned: A review of the impact of the resource pack will be important to ascertain its benefits and problems, and if it should be adapted or adjusted. The importance of including this neglected population of children is a welcome development within the NRH.

Cost effectiveness of integrated care in patients with acquired brain injury

Introduction : Integrated care and Rehabilitation following acquired brain injury improves health outcomes, reduces disability, and improves quality of life. We assessed the cost effectiveness of inpatient rehabilitation after brain injury in individuals with brain injury admitted to the Irish national tertiary specialist rehabilitation centre in 2011. The brain injury team – which consists of a specialist multidisciplinary team including Doctors, nurses, physiotherapists, occupational therapists, speech and language therapists, psychologists, clinical nutritionists, pharmacists and medical social workers – work with patients and their families and carers to achieve the best possible outcome for the patient with a person centred inpatient programme tailored to meet each patient's individual needs. Methods : The study included all patients discharged between 1 January 2011 and 31 December 2011 from the NRH Brain Injury Programme under one of the NRH rehabilitation consultants(AC).Patients’ score on the Disability Rating Scale (DRS) was recorded on admission and at discharge after intensive inpatient rehabilitation. Cost savings attributed to the rehabilitation programme were calculated as the difference between direct care costs on admission and discharge. Direct costs of care were calculated as the weekly cost of the care-assistant hours required to care for patients on the basis of their level of disability or daily nursing-home bed cost when this was required. Results : Of 63 patients, complete DRS information for admission and discharge was available for 41. DRS scores, and therefore average levels of functioning, differed significantly at admission (2.3, between mildly and moderately dependent) and discharge (1.1, independent in special environments, p Average weekly care costs fell from €629 to €242, with costs recouped within 30 months. Discussion : Although the cost of inpatient rehabilitation in this group is expensive initially, in the medium term these costs are covered by the savings in care costs. Ceiling and floor effects of dependency scales can result in underestimation of cost-effectiveness of rehabilitation.Thus, substantial savings result from inpatient rehabilitation, and these savings could have been greater had we considered also the economic benefit of enabling patients to return to employment. Limitations : A randomised controlled trial of rehabilitation versus no rehabilitation would provide more information but would generate an ethical dilemma, in that it would necessitate denying treatment, which is considered standard and has sufficient evidence to support its use, to a group of individuals. We have looked only at financial savings in this study. An analysis of gains in quality of life would clearly provide a more accurate reflection of the value of inpatient rehabilitation. Conclusion : This is the first analysis of the cost effectiveness of inpatient rehabilitation in an Irish setting. We have shown that, on average, the cost of inpatient rehabilitation is covered by the savings resulting from reductions in dependency within 30 months. Inpatient rehabilitation seems to be most cost effective in individuals with brain injury who are markedly dependent on admission, with only 15.6 months required to cover the inpatient cost in this group. After this time, calculated savings of over €50,000 per patient annually can be expected.

Recovery from vegetative state of patients with a severe brain injury: a 4-year real-practice prospective cohort study.

Patients who have suffered severe traumatic or nontraumatic brain injuries can show a progressive recovery, transitioning through a range of clinical conditions. They may progress from coma to a vegetative state (VS) and/or a minimally conscious state (MCS). A longer duration of the VS is known to be related to a lower probability of emergence from it; furthermore, the literature seems to lack evidence of late improvements in these patients. This real-practice prospective cohort study was conducted in inpatients in a VS following a severe brain injury, consecutively admitted to a vegetative state unit (VSU). The aim of the study was to assess their recovery in order to identify variables that might increase the probability of a VS patient transitioning to MCS. Rehabilitation treatment included passive joint mobilisation and helping/placing patients into an upright sitting position on a tilt table. All the patients underwent a specific assessment protocol every month to identify any emergence, however late, from the VS. Over a 4-year period, 194 patients suffering sequelae of a severe brain injury, consecutively seen, had an initial Glasgow Coma Scale score ≤ 8. Of these, 63 (32.5%) were in a VS, 84 (43.3%) in a MCS, and 47 (24.2%) in a coma; of the 63 patients admitted in a VS, 49 (57.1% males and 42.9% females, mean age 25.34 ± 19.12 years) were transferred to a specialist VSU and put on a slow-to-recover brain injury programme. Ten of these 49 patients were still in a VS after 36 months; of these 10, 3 recovered consciousness, transitioning to a MCS, 2 died, and 5 remained in a VS during the last 12 months of the observation. Univariate analysis identified male sex, youth, a shorter time from onset of the VS, diffuse brain injury, and the presence of status epilepticus as variables increasing the likelihood of transition to a MCS. Long-term monitoring of patients with chronic disorders of consciousness should be adequately implemented in order to optimise their access to rehabilitation services.