Neurological Rehabilitation Patients Research Articles

One-year outcome of brain injured patients undergoing early neurological rehabilitation: a prospective observational study

BackgroundThe present study intended to analyze the outcome of patients with severe brain injury one-year after discharge from early rehabilitation.MethodsEarly neurological rehabilitation patients admitted to intensive or intermediate care units and discharged between June 2018 and May 2020 were screened for eligibility. The level of consciousness was evaluated using the Coma Recovery Scale-Revised (CRS-R) upon admission and at discharge. At one-year follow-up, the outcome was assessed with the Glasgow Outcome Scale-extended (GOSE). Demographical and clinical data collected during inpatient rehabilitation were used to predict the outcome 1 year after discharge.ResultsTwo hundred sixty-four patients (174 males, 90 females) with a median age of 62 years (IQR = 51–75) and a median duration of their disease of 18 days (IQR = 12–28) were included in the study. At follow-up, the mortality rate was 27% (n = 71). Age and discharge CRS-R total score were independent predictors in a Cox proportional hazards model with death (yes/no) as the dependent variable. According to the GOSE interviews, most patients were either dead (n = 71; 27%), in a vegetative state (n = 28; 11%) or had a severe disability (n = 124; 47%), whereas only a few patients showed a moderate disability (n = 18; 7%) or a good recovery (n = 23; 9%) 1 year after discharge. Age, non-traumatic etiology, discharge CRS-R total score and length of stay independently predicted whether the outcome was good or poor at follow-up.ConclusionAge was an important predictor for outcome at one-year follow-up, which might be due to altered brain plasticity and more comorbidities in elderly subjects. In addition, the present study demonstrated that the CRS-R total score at discharge might be more important for the prediction of one-year outcome than the initial assessment upon admission.

Evaluation of the predictive validity of the Hessisch Oldendorf Risk of Falling Scale (HOSS)

Objective: This study aims to further validate the Hessisch Oldendorf Risk of Falling Scale (HOSS) for neurological rehabilitation patients. Design: The overall scale performance and fall rate was calculated in a retrospective data analysis. Setting: The study was performed in a subacute care facility during inpatient neurological rehabilitation. Subjects: The study population (n = 512) included neurological and neurosurgical patients with heterogeneous levels of disability. Main measures: The HOSS total score and the suspected risk of falling were compared with the number of falls. Characteristics of fallers and non-fallers were compared using non-parametric group comparisons. Overall scale performance was assessed by calculating the area under the receiver operating characteristic curve of the HOSS as well as by calculating the sensitivity and specificity. Results: A total of 82 (16%) patients experienced at least one fall. Fallers were characterized by an older age, a longer length of stay, a more severe impairment in the activities of daily living upon admission, a hemiparesis, an orientation disorder, a need of a walking aid device and an urinary incontinence. The number of falls was associated with the HOSS total score. Sixty-four fallers and two hundred seventy-four non-fallers were correctly categorized leading to a sensitivity of 78.0% and a specificity of 63.7%. The area under the receiver operating characteristic curve of the HOSS was 0.778 ± 0.25 (CI = 0.729–0.828, P < 0.001). Conclusion: The scale performance of the HOSS showed a good sensitivity and an adequate specificity to identify neurological patients who are at high risk of falling during inpatient rehabilitation.

(Neuro)psychological Rehabilitation after Stroke: a National Survey of Structures and Practice in Inpatient and Outpatient Neurological Rehabilitation

Structures and practice of psychological units in neurological rehabilitation centres treating post-stroke patients are described. A nationwide survey of psychological services in neurological rehabilitation centres was conducted. Psychologist-patient ratios differed greatly among rehabilitation centres. Post-stroke patients showed a variety of complex problems. Psychological interventions mainly comprised diagnostic evaluation as well as individual interventions and cognitive training. The complex and manifold problems of patients in neurological rehabilitation require a comprehensive knowledge of (neuro)psychological functioning. In order to support appropriate and individual treatment decisions, practice guidelines for psychological interventions in the rehabilitation of post-stroke patients are necessary. The present survey constitutes the basis for developing such practice guidelines.

Outcome of Early Neurological Rehabilitation Patients Colonized with Extended-Spectrum Beta-Lactamase (ESBL) Producing Bacteria

Colonization with multidrug-resistant germs, in particular methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum betalactamase producing bacteria (ESBL), is an emerging threat in early neurological rehabilitation. This study examined whether colonization with ESBL bacteria had deteriorating effects on neurological rehabilitation patients because of contact precautions (CP). Medical records have been carefully reviewed with respect to colonization with ESBL, outcome variables (functional independence), morbidity, and length of stay (LOS). 148/643 (23.0%) patients were ESBL positive on admission. ESBL carriers had a significantly longer LOS in early neurological rehabilitation (67.5 (42.0) vs. 25.8 (24.5), p < 0.001), worse functional status on admission (Barthel Index (BI) 13.0 (5.8) vs. 25.6 (24.1), p < 0.001), worse Glasgow Coma Scale (9.7 (3.8) vs. 12.0 (3.3), p < 0.001), worse Coma Remission Scale (9.5 (6.4) vs. 14.0 (6.8), p = 0.001), more codiagnoses (18.8 (5.1) vs. 13.3 (5.5), p < 0.001), and higher Patient Clinical Complexity Levels (PCCL). The outcome was significantly worse among ESBL positive patients (BI 28.2 (21.7) vs. 47.4 (31.0), p < 0.001; Early Rehabilitation Index -43.0 (51.7) vs. -26.0 (35.4), p < 0.001). ESBL patients had the same amount of therapy per day (136.2 (20.2) vs. 140.2 (18.7) min/day, n.s.), but the overall sum was significantly larger in the ESBL group due to longer LOS (p < 0.001). Mortality of both groups was comparable (3.8% vs. 4.1%). 54.3% of ESBL negative patients were discharged to home, but only 34.5% of ESBL colonized. 48% of ESBL positive patients were discharged to a nursing home, but only 25.1% of the ESBL free patients. Functional recovery of ESBL carriers undergoing neurological early rehabilitation is worse than that of patients without multidrug-resistant germs. Poorer outcome is not resulting from less therapy due to CP, but from functional status and higher morbidity on admission.

Outcome of MRSA carriers in neurological early rehabilitation

BackgroundColonization with MRSA is believed to have deteriorating effects on neurological rehabilitation patients because MRSA carriers need to be isolated.MethodsMedical records of neurological early rehabilitation patients (most of them after stroke) admitted to a large rehabilitation facility in Northern Germany in 2010 have been carefully reviewed with respect to MRSA status, outcome variables (functional independence), morbidity, and length of stay (LOS).Results74/569 (13.0%) patients were MRSA positive on admission. MRSA carriers had a significantly longer LOS in early neurological rehabilitation (63.7 (37.1) vs. 25.8 (24.5) days, p < 0.001), worse functional status on admission (Barthel index (BI) 13.6 (9.9) vs. 25.6 (24.1), p < 0.001), worse Glasgow Coma Scale (9.5 (3.2) vs. 12.0 (3.3), p < 0.001), more co-diagnoses (20.5 (5.1) vs. 13.3 (5.5), p < 0.001), and higher Patient Clinical Complexity Levels (PCCL). The outcome was significantly worse among MRSA positive patients (BI 25.5 (21.2) vs. 47.4 (31.0), p < 0.001; Early Rehabilitation Index −47.3 (51.4) vs. -26.0 (35.4), p < 0.001). Isolated patients had slightly less therapy per day (131.6 (16.6) vs. 140.2 (18.7) min/day, p < 0.001), but the overall sum of therapy was significantly larger in the MRSA positive group due to longer LOS.ConclusionsFunctional recovery of MRSA carriers in early neurological rehabilitation is worse than in MRSA negative patients. Poorer outcome is not resulting from isolation (less therapy) but from functional status and higher morbidity on admission.

Activity coaching to improve walking is liked by rehabilitation patients but physiotherapists have concerns: a qualitative study

Does activity coaching add value to physiotherapy from the perspective of physiotherapists and patients in neurological rehabilitation? Is the use of activity coaching to promote walking and physical activity considered feasible by these physiotherapists and patients? Qualitative study using interviews. Five pairs of physiotherapists and their patients with neurological conditions. A research physiotherapist trained in health coaching delivered an activity coaching intervention. This was provided in addition to standard physiotherapy. The treating physiotherapists observed the activity coaching session undertaken by their patients. Observing the coaching interview was valuable for the treating physiotherapists in that it provided a way to refocus, step back, gain insight, and facilitate more active involvement for their patients in the rehabilitation process. Similarly patients valued the opportunity to focus on what was important and put into action their rehabilitation goals. Contrasting perceptions were evident, which limits the practical usefulness of this intervention due to the concerns voiced by some of the physiotherapists. The activity coaching was perceived as providing a valuable addition to standard practice and was acceptable to patients but the mixed responses of physiotherapists limit the feasibility of this approach. Use of strategies and specific training for physiotherapists may be needed before approaches like activity coaching can be adopted successfully.

The Early Rehabilitation Barthel Index (ERBI)

An extended version of the Barthel index, the so-called "Early Rehabilitation Barthel Index", or ERBI, is widely used in German early neurological rehabilitation centres and even was used in defining early rehabilitation procedures in the German DRG system. It contains highly relevant items like mechanical ventilation, tracheostomy, or dysphagia. This study presents an English version of the ERBI and examines its validity and reliability. Two samples of early neurological rehabilitation patients have been analyzed. In one sample (n=1,669), measures of morbidity and length of stay (LOS) have been compared between certain ERBI categories. In a second sample (n=273), inter-rater reliability (nurses vs. physicians) has been examined. Patients with low ERBI had a significantly longer LOS than those with high ERBI values (p<0.001). Further, parameters of morbidity (patient clinical complexity level, number of co-diagnoses) were significantly higher in a low ERBI subgroup. Inter-rater reliability was r=0.849 (p<0.001). The findings suggest that the ERBI is a reliable and valid scale to assess early neurological rehabilitation patients.

Berufliche Teilhabe von neurologischen Rehabilitanden - Langzeitergebnisse eines medizinisch-beruflichen Rehabilitationszentrums (Phase II)

Occupational rehabilitation in Germany is done in specialized centres (so-called "Phase II" centres). In the present study, long-term outcome data of 237 neurological rehabilitation patients (mean age 38.3 years) were analyzed. Most of the patients had suffered brain injuries. The examination took place some 7 years after the end of occupational rehabilitation and approximately 10 years after the injury. About 60% of patients returned to work (35% worked, 9.3% were seeking a job, 13.5% underwent training). Positive predictors for return to work were lower age and high educational level. The results from this study suggest that occupational rehabilitation is effective. Controlled and multi-centre studies should be carried out.

Pellegrini–Stieda Disease in Traumatic Brain Injury Rehabilitation

Pellegrini–Stieda disease (PSD) is posttraumatic ossification of the proximal attachment of the medial collateral ligament of the knee, diagnosed by radiography.1 Antecedent traumas include direct and indirect injury to the medial side of the knee. Repeated microtraumas, including therapeutic manipulation of a stiff joint and postsurgical rehabilitation, have also been reported.2 Because PSD is rarely diagnosed in neurologic rehabilitation patients, only one case of spinal cord injury having this disease was reported.3 We describe a traumatic brain injury patient with clinical and radiologic findings of PSD. Our aim in this report is to show that this entity can be seen in neurological rehabilitation patients during the course of exercise treatment and must be taken into account in differential diagnosis of knee pain, swelling, and range-of-motion limitation. A 22-yr-old man, with contusion lesions determined by cranial computerized tomography secondary to a motorcycle accident, attended our clinic for rehabilitation. The patient had a history of 3 mos of hospitalization in the intensive care unit and anesthesia clinic in another hospital for multiple traumas. The patient did not describe any known injury or trauma to the knee in the motorcycle accident. On examination, the patient was found to have range-of-motion limitation with swelling and complaint of pain in his left knee. The patient had no history of systemic diseases such as gout, rheumatoid arthritis, systemic sclerosis, sarcoidosis, or hyperparathyroidism. On physical examination, the left knee was limited at 60 degrees of flexion, extension was at a normal range, and the knee joint was stable. Serum calcium, phosphate, and alkaline phosphatase levels were within normal ranges. The plain radiographs demonstrated a characteristic bony formation, calcification medial to the femoral condyle (Fig. 1). Because of the characteristic radiographic findings and the clinical course, the diagnosis of PSD was considered.FIGURE 1: Anteroposterior radiogram reveals a massive bony tissue (arrows) medial to the femoral condyle.PSD manifests radiographically, with ossification arising from the epicondylar portion of the medial femoral condyle.1 In the etiology of neurogenic ectopic bone formation, humoral, neural, and local factors, including tissue hypoxia, hypercalcemia, changes in sympathetic nerve activity, prolonged immobilization, and mobilization with frequent periods of exercising after prolonged immobilization, play a role. In traumatic brain injury patients, neurogenic heterotopic ossification can result in accelerated fracture healing. Reduced collagen degradation in polytraumas with traumatic brain injury causes enhanced osteogenesis.4 Radiographically, the ossification is seen as a thin crescent or curvilinear line of a few millimeters from the femoral condyle. This feature is crucial for ruling out other lesions including fracture of the femoral condyle, periostitis, and osteoma.1 In conclusion, PSD can be seen in neurologic rehabilitation patients during the course of exercise treatment, and it must be taken into account in the differential diagnosis of knee pain, swelling, and range-of-motion limitation.

Psychometric properties of an International Classification of Functioning, Disability and Health (ICF)-oriented, adaptive questionnaire for the assessment of mobility, self-care and domestic life

Development of an adaptive, International Classification of Functioning, Disability and Health (ICF)-oriented patient questionnaire on mobility and self-care based on an item response theory model (MOSES questionnaire). Using item reconstruction rules, items were developed for the ICF chapters "mobility", "self-care" and "domestic life". The resulting instrument, together with other instruments (SF-36, Short Musculoskeletal Function Assessment Questionnaire (SMFA), MacNew, Functional Independence Measure (FIM), Barthel) was presented to 549 patients with musculoskeletal disease, 212 patients with cardiac disease and 258 neurological rehabilitation patients in rehabilitation clinics in Germany. The MOSES questionnaire includes 58 items on 12 scales and fulfills the requirements of the 1-parameter item response theory model (Rasch model). The results indicate good reliability and high construct validity and sensitivity to change of the instrument. In the construction and selection of items, ICF contents that include complex processes of evaluation, and which presuppose skills that are not acquired prior to the individual learning process, were omitted due to a lack of unidimensionality. The successful implementation of the concept of applying rules to ICF categories in formulating the items of a patient questionnaire showed that the goal of a theory-driven measurement of activities using the ICF is feasible. The results of the project also raise questions as to the homogeneity of the contents of some ICF categories.

Empowerment, quality of life and participation in neurological rehabilitation: Empirical study with stroke patients and their relatives

The active role (participation) that patients with chronic conditions are able to achieve has increasingly been recognised as a measure for the effectiveness of prevention- and rehabilitation strategies. An empowerment scale is an especially effective instrument for measuring social participation, and was applied to stroke patients in neurological rehabilitation for the first time. 26 stroke survivors and 26 informal carers, who participated in self-help groups in Lower Austria, were surveyed. The mean age was 63.9 (+/- 10.4) (stroke survivors) and 61.9 (+/- 9.6) years (informal carers). The mean duration of disease was 7.3 (+/- 3.2) years and the mean length of self-help group participation approximately 4 years. Every other stroke survivor and every fifth informal carer had to give up their professional life because of the stroke. Financial burden, reduction of vacations and social activities was found for both groups. Informal carers more frequently reported an increased fear of a relapse and generally of the future. One third of the stroke survivors had insomnia, depression, and nervousness. Reduced mobility, memory impairment, and increased sensitivity to temperature-changes were seen as the largest burdens. In spite of the large overlap in many domains of empowerment- and quality-of-life measures, empowerment measures also seem to reflect aspects of social participation. Therefore, measures of empowerment should be included in long-term outcome measurements following stroke.

Effects of anticonvulsant therapy on recovery and rehabilitation

Antiepileptic drugs (AEDs) are used in rehabilitation patients with injury to the nervous system for control of clinical seizures, prophylaxis against the development of a seizure disorder, and treatment of secondary mania. Although most AEDs can produce mild cognitive side effects, the benefits of treatment with AEDs in rehabilitation patients with seizure disorders typically outweigh these minor risks, Bromide, phenobarbital, and benzodiazepines may have more severe cognitive side effects than other AEDs. However, there is no convincing evidence of clinically significant differences in cognitive adverse effects among the other established AEDs. Furthermore, cognitive side effects are usually modest with mono therapy and anticonvulsant blood levels within standard therapeutic ranges. With regard to prophylaxis against future seizures, there is no significant data indicating that AED administration can prevent or retard the process of epileptogenesis, Therefore, the use of AEDs to prevent the development of a seizure disorder is not warranted at this time. Finally, although there is little information about the behavioral effects of anticonvulsants in neurological rehabilitation patients, the efficacy of carbamazepine, and perhaps valproate, in the treatment of primary mania suggests that these AEDs may be beneficial in mania secondary to brain injury. The role of AEDs in the treatment of other psychiatric disorders, such as post-traumatic stress disorder and episodic dyscontrol, remains unclear.