Post-acute Neurorehabilitation Research Articles

Post-acute Neurorehabilitation for Stroke as a Community Effort (P8-11.020)

Post-acute Neurorehabilitation for Stroke as a Community Effort (P8-11.020)

Effects of transsectoral long-term neurorehabilitation

BackgroundAcquired brain injuries are among the most common causes of disability in adulthood. An intensive rehabilitation phase is crucial for recovery. However, there is a lack of concepts to further expand the therapeutic success after the standard rehabilitation period. Hereafter, the characteristics of a transsectoral, multiprofessional long-term neurorehabilitation concept and its effects on outcome at different ICF levels are described.MethodsThe P.A.N. Center for Post-Acute Neurorehabilitation combines living with 24/7 support of pedagogical staff with on-site outpatient therapy and medical care. A secondary data analysis was conducted on the records of all patients with completeted P.A.N. treatment between 01.01.2015 and 09.04.2022. Outcome parameters included demographic characteristics, diagnostics, Barthel Index (BI), the German scale „Hilfebedarf von Menschen mit Behinderung für den Lebensbereich Wohnen “ (HMBW), the Canadian Occupational Performance Measure (COPM) and the destination after discharge. For BI and discharge destination, potential determinants of therapy success are evaluated.Results168 patients were enrolled in the analyses. Significant improvements were observed in the BI (p < .001), with median values increasing from 55 to 80 points. The HMBW showed a significant decrease in the need for assistance in everyday living (p < .001), individual basic care (p < .001), shaping social relationship (p = .003) and communication (p < .001). Significant improvements were reported in the COPM total score for performance (p < .001) and satisfaction (p < .001). 72% of the patients were able to move in a community living arrangement with moderate need for support. Main predictive factor for discharge destination was the initial cognitive deficit. The comparison of the third-person scales BI and HMBW with the self-reported COPM showed that individually formulated patient goals are only insufficiently reflected in these global scales.DiscussionThe data show that a highly coordinated, trans-sectoral 24/7 approach of goal-oriented practice as pursued at P.A.N. is feasible and effective. We assume that the success of the intervention is due to the high intensity of therapies delivered over a long time and its interlink with real world practice. For a comprehensive analysis of rehabilitation success, it is necessary to record and evaluate individual patient goals, as these are not always reflected in the commonly used global scales.

A - 164 Executive Functioning Predicts Comparable Autobiographical Memory Accuracy in Severe TBI Adults and Controls.

The present study investigated the association between executive functioning (EF) and cognitive script accuracy for autobiographical events in adults with severe traumatic brain injury (sTBI). Sequelae of sTBI commonly disrupt brain areas responsible for EF and retrieval of autobiographical knowledge, but script impairments are not consistently found, likely due to protocol differences, sample heterogeneity, and failure to assess for event exposure pre-injury. The present study remedied these issues obtaining a realistic assessment of script knowledge and its relation to EF. Twenty sTBI adults and 20 healthy controls recruited from a post-acute neurorehabilitation facility completed tasks evaluating autobiographical knowledge (central actions [CAs], trivial actions [TAs]) for three common events using multiple memory measures (recall, prediction, recognition). EF was assessed with standardized neuropsychological tasks of verbal fluency and social judgment. Controls performed better than sTBI adults on all EF measures (p < 0.001), and recalled a greater proportion of CAs (F[2,19] = 4.63, p < 0.05) but similar proportions of TAs (p = 0.952). Groups did not differ in predicting (p = 0.989) or recognizing (p = 0.202) autobiographical events. EF predicted CAs (R2 = 0.425, F[2,37] = 13.66, p < 0.001) and TAs (R2 = 0.201,F[2,37] = 4.66, p < 0.05) in both groups after controlling for estimated premorbid functioning. Severe TBI adults are fairly knowledgeable about common events. Executive dysfunction may inhibit successful initiation and completion of such events. Errors rarely occurred with these familiar events and within easier memory paradigms. Thus, development of therapies introducing a graded integration into novel events is a realistic goal. Because results are based on confirmed autobiographical events, these conclusions elicit greater confidence than ever before.

Sex/gender differences in service use patterns, clinical outcomes and mortality risk for adults with acquired brain injury: a retrospective cohort study (ABI-RESTART).

To identify sex/gender differences in functional, psychosocial and service use patterns in community-based post-acute care for acquired brain injury. Design: Retrospective cohort study. Adults with acquired brain injury enrolled in post-acute neurorehabilitation and disability support in Western Australia (n = 1,011). UK Functional Independence Measure and Functional Assessment Measure (FIM + FAM), Mayo-Portland Adaptability Inventory-4, goal attainment, length of stay (LOS), number of episodes of care and deaths were evaluated using routinely collected clinical and linked administrative data. At admission, women were older (p < 0.001) and displayed poorer functional independence (FIM + FAM; p < 0.05) compared with men. At discharge, there were no differences in goal attainment, psychosocial function or functional independence between men and women. Both groups demonstrated functional gains; however, women demonstrated clinically significant gains (+ 15.1, p < 0.001) and men did not (+ 13.7, p < 0.001). Women and men had equivalent LOS (p = 0.205). Aboriginal and/or Torres Strait Islander status predicted longer LOS for women but not for men. Being partnered predicted reduced LOS for women but not men. Women had a higher risk of multiple episodes of care (p < 0.001), but not death (p = 0.409), compared with that of men. At admission to rehabilitation and disability support services for acquired brain injury, women have poorer functional independence and higher risk of multiple episodes of care, compared with men, suggesting greater disability in the community. By the time of discharge from these services, women and men make equivalent functional and psychosocial gains. The higher risk of multiple episodes of care for women relative to men suggestwomen may need additional post-discharge support, to avoid readmission.

Effects of comorbidity on post-acute outcomes in acquired brain injury: ABI-RESTaRT 1991-2020.

Current understanding of comorbidities associated with acquired brain injury (ABI) and the effects on post-acute ABI outcomes is poor. To describe the prevalence, severity and patterns of comorbidity for the pre-injury, acute and post-acute phases, and to examine the effects of post-acute comorbidities on functional independence and length of stay (LOS) at discharge from post-acute care. Retrospective whole-population cohort study of n=1,011 individuals with traumatic (TBI) or non-traumatic brain injury (NTBI), or eligible neurologic conditions admitted to a post-acute neurorehabilitation and disability support service in Western Australia (WA) between 1991 and 2020. Comorbidities were ascertained from internal electronic medical records and linked hospital and emergency department data from the WA Data Linkage System. We measured comorbidities across 14 body systems using the Cumulative Illness Rating Scale (CIRS) and Elixhauser Comorbidity Index (ECI), and functional independence with the UK Functional Independence Measure and Functional Assessment Measure (UK FIM+FAM). We used multilevel mixed-effect regression models to determine the effects of comorbidity on post-acute outcomes. NTBI was the most common diagnosis (54%), followed by TBI (34%) and neurologic conditions (10%). Pre-injury comorbidities were present in over half the cohort. Comorbidity prevalence increased significantly from 57% to 84% (∆+27%) and severity (mean ECI score) increased significantly from 2.1 to 13.8 (∆+11.7) between pre-injury and the acute phase and remained elevated at admission to post-acute services (82%, mean ECI score 7.3). Psychiatric comorbidity was the most prevalent (56%) and was associated with significantly poorer functional outcomes at discharge and an increase in LOS of 6.5 months. Genitourinary, musculoskeletal, eye, ear nose and throat, and renal comorbidities also had significant effects on post-acute outcomes. ABI has a long-term impact on multiple body systems. Identification and management of comorbidities is critical to maximize functional outcomes and reduce the cost of post-acute care.

Using therapy outcome measures to identify the speech and language therapy needs of children and young people with severe acquired brain injury

Background/Aims Children and young people often require speech and language therapy input following severe acquired brain injury. However, there is limited understanding of the impact of post-acute neurorehabilitation on children and young people's communication and swallowing, and how to measure this. The aim of this study was to evaluate the initial and ongoing speech and language therapy needs of children and young people in one specialist paediatric neurorehabilitation centre, and to determine the usefulness of therapy outcome measures for this population. Methods A retrospective review was performed of routinely collected data, including therapy outcome measures for children and young people admitted to the centre. Descriptive analysis was completed for all therapy outcome measures data, and statistical significance of change during rehabilitation was determined on those with sufficient data using Wilcoxon signed-rank tests. Results A total of 165 records of children and young people aged between 1 and 17 years were reviewed. The average length of stay at the centre was 19.7 weeks. The most prevalent therapy outcome measures were cognition and dysphagia. Highly significant differences were found between admission and discharge in all therapy outcome measures scores, including participation (Wilcoxon Z=-9.523, P&lt;0.001) and wellbeing (Wilcoxon Z=-7.656, P&lt;0.001). Median discharge scores did not exceed 4 (from a maximum of 5) for any scales. Conclusions Therapy outcome measures were able to capture the complex profiles of these children and young people and could measure changes during post-acute neurorehabilitation. Children and young people presented with a range of speech and language therapy needs following severe acquired brain injury. They made significant improvements in impairment, activity, participation and wellbeing scales during rehabilitation. Children and young people left with ongoing speech and language therapy needs in all areas, which require input from community services.

The impact of early surgical treatment of tracheal stenosis on neurorehabilitation outcome in patients with severe acquired brain injury

ABSTRACT Introduction Acquired tracheal stenosis (TS) is a potentially life-threatening condition following prolonged intubation and/or tracheostomy in adult patients with severe Acquired Brain Injury (sABI), requiring a tracheal resection and reconstruction. Methods We included 38 sABI adult patients with TS, admitted at a post-acute Neurorehabilitation Hospital. Disability Rating Scale (DRS) and other functional assessment measures were recorded at admission (t1), before TS surgical treatment (t2), and at discharge (t3). Patients were defined as ‘improved’ when they changed from a more severe to a less severe disability, between time t2 and time t3, and as “not improved” when they did not show any further improvement between t2 and t3, or they already exhibited a disability improvement since time interval t1-t2. Results Time interval between the injury onset and TS surgical treatment (t2-t0) was associated with the patient’s disability improvement, suggesting the t2-t0 time interval ≤ 115 days as a cutoff value for a possible functional recovery. A t2-t0 time interval ≤ 170 days is also associated to absence of persistent dysphagia. Conclusions Early TS surgical treatment within 115 days from the injury onset contributes to the improvement of the disability level in patients with sABI, optimizing their functional outcomes and recovery potential.

The effects of aquatic therapy during post-acute neurorehabilitation in patients with severe traumatic brain injury: a preliminary randomized controlled trial

ABSTRACT Objective The primary aim is to verify the effectiveness of an aquatic training (AT) in inpatients with severe Traumatic Brain Injury (sTBI) on balance. The secondary aims are to explore the effects on gait, activities of daily living, and quality of life, comparing to a land-based conventional protocol. Methods Two-arm, randomized controlled trial. Twenty inpatients with sTBI, Glasgow Coma Scale score ≤8, and Level of Cognitive Functioning ≥7 were recruited and randomly assigned to the aquatic therapy group (ATG) or to the Conventional Training Group (CTG). Patients underwent 12 individual rehabilitation sessions (3 days/week, 4 weeks), in a rehabilitation pool during the post-acute intensive neurorehabilitation. The primary outcome measure was the Berg Balance Scale (BBS). Secondary outcome measures were the Modified Barthel Index (MBI), Disability Rating Scale (DRS), Tinetti Gait Balance Scale (TBG) and Quality of Life After Brain Injury (QOLIBRI). All the evaluations were performed at the baseline and after 4 weeks of training. Results The within-subjects analysis showed a significant improvement both in ATG and CTG in MBI, BBS, TBG, and QOLIBRI. Conclusion Our results may support the use of AT during post-acute phase to improve motor functions and quality of life in patients with sTBI.

Measuring outcomes of a peer-led social communication skills intervention for adults with acquired brain injury: A pilot investigation

ABSTRACT Reduced social competence following severe acquired brain injury (ABI) is well-documented. This pilot study investigated a peer-led group intervention based on the claim that peer models may be a more effective mechanism for behaviour change than clinician-led approaches. Twelve participants with severe ABI were recruited from a post-acute neurorehabilitation setting and randomly assigned to either a peer-led intervention or a staff-led activity group (usual care) (Clinicaltrials.gov: NCT02211339). The groups met twice a week for 8 weeks. A peer was trained separately to facilitate interaction in the intervention group. Training comprised 16 individual sessions over 4 weeks. Group behaviour was measured twice at baseline, after intervention and at maintenance (4 weeks), using the Adapted Measure of Participation in Conversation (MPC) and the Interactional Network Tool (INT), a newly devised measure of group conversational interaction. Outcome measures showed differential sensitivity. The groups did not differ in baseline behaviour. Findings showed a significant improvement in the treated group on the MPC transaction scale post-intervention (p = .02). The intervention group showed more balanced interaction post-intervention on the INT and at follow-up. Findings show preliminary evidence of the advantage for peer-led groups. The INT shows promise as a method to detect a change in group communication behaviour. Trial registration: ClinicalTrials.gov identifier: NCT02211339.

Second look Holter ECG in neurorehabilitation

BackgroundMany stroke survivors suffer recurrent stroke because paroxysmal atrial fibrillation (AF) was missed and no preventive anticoagulation initiated. This prospective cohort study determined the added diagnostic yield of second-look 24-h electrocardiographic recording (ECG) in a population at high risk for AF: patients who suffered a stroke of such severity that they require inpatient neurorehabilitation.MethodsWe enrolled 508 patients with ischemic stroke admitted to post-acute inpatient neurorehabilitation and determined whether AF was detected during acute care at the referring hospital. Second-look baseline and 24-h Holter ECG were then conducted during neurorehabilitation. Primary outcome was number of newly detected AF with duration of > 30 s; secondary outcomes were number of newly detected absolute arrhythmia of 10–30 s and < 10 s duration. For comparison, we further enrolled 100 patients with hemorrhagic stroke without history of AF (age = 72 + 11 years, 51% female).ResultsIn 206 of the 508 ischemic stroke patients, AF had been detected during acute phase work-up (age = 78 + 10 years, 55% female). For the remaining 302 ischemic stroke patients, no AF was detected during acute phase work-up (age = 74 + 9 years; 47% female). Second-look 24-h ECG showed previously missed AF of > 30 s in 20 of these patients, i.e. 6.6% of the sample, and shorter absolute arrhythmia in 50 patients (i.e. 16.5%).ConclusionsSecond-look 24-Hour ECG performed during post-acute inpatient neurorehabilitation has a high diagnostic yield and should become a standard component of recurrent stroke prevention.

Neuropsychoanalytically informed psychotherapy approaches to rehabilitation: The North Wales Brain Injury Service – Bangor University experience 1998–2018

ABSTRACTThe North Wales Brain Injury Service was developed 20 years ago, to provide multi-disciplinary community-based neuropsychological rehabilitation to the residents of North Wales. The theoretical underpinning of clinical service delivery is an adapted, slow-stream Holistic Neuropsychological Rehabilitation model. Some of its key aspects include the provision of long-term psychotherapeutic follow-up, to facilitate psychological adjustment, self-awareness, and encourage self-management over time. While financial realities undeniably influenced the way this model was developed (the North Wales Brain Injury Service is a publically funded NHS service), an equally influential factor was a recognition of the central role that neuropsychoanalytically informed psychotherapy can play in post-acute neuro-rehabilitation. In post-acute rehabilitation settings, where working psychotherapeutically with problems of self-awareness towards psychological adjustment is central to the clinical model, the relevance of time over intensity of intervention is very important. Over the past two decades the service has evolved in several areas. While the service is multi-professional, this paper mainly reports on the nature of program developments as regards psychotherapy, resulting from the close collaboration of the North Wales Brain Injury Service with its local academic partner, Bangor University. In this context, five distinctive but inter-related themes of neuropsychoanalytically-informed approaches used in the service are discussed.

Rupture of a non-traumatic anterior communicating artery aneurysm: Does location of aneurysm associate with functional independence following post-acute in-patient neurorehabilitation?

Objective: Patients with non-traumatic rupture of an aneurysm located at the anterior communicating artery (ACoA) often experience cognitive disabilities. It is unknown whether location of aneurysm also affects the possibility for improvement in functional independence compared to patients with an aneurysmal subarachnoid hemorrhage (a-SAH) located elsewhere. The aim was to explore the association between location of aneurysm (ACoA versus other) and level of functional independence, measured by Functional Independence Measure (FIM), at discharge from rehabilitation. Additionally, age and FIM at admission were explored.Method: Historical cohort study among 107 patients with a-SAH based on data from a clinical database and a population-based register. Data were analyzed using multivariable logistic regression.Results: Patients with ACoA were admitted with poorer cognitive FIM (median 6 (IQR 5–14) compared to patients with aneurysms located elsewhere (median 12 (IQR 6–23) (p = 0.0129); no difference at discharge. No association between aneurysm location and functional independence was observed. Higher age was associated with poorer outcome in bowel management OR 0.54 (95% CI 0.31–0.92), bladder management OR 0.59 (95% CI 0.35–0.98), comprehension OR 0.53 (95% CI 0.30–0.94), and memory OR 0.48 (95% CI 0.25–0.93). Overall, FIM at admission was associated with functional independence at discharge with the exception of stair walking and bladder management which did not reach statistical significance.Conclusion: ACoA was not associated with poorer level of functional independence compared to patients with a-SAH located elsewhere. Higher age was associated with poorer outcome in continence, comprehension, and memory, whereas higher FIM was associated with better functional independence across items at discharge.

Using reliability of change analysis to evaluate post-acute neuro-rehabilitation.

It is important to evaluate change in order to re-assure commissioners, staff and patients of the effectiveness of interventions, but also in order to identify areas for improvement. To consider whether analysis of improvement at the level of the individual, taking into account measurement error, may offer a further valuable way to assess change and inform service development over considering change at the group level in a post-acute neuro-rehabilitation unit. Pre and post intervention Scores on the FIM+FAM Full Scale and Cognitive and Motor subscales were considered for eighteen patients aged between 35 and 81 with mixed diagnoses who attended a post-acute inpatient neuro-rehabilitation unit for treatment. Statistically significant improvements were achieved on the FIM+FAM Full Scale and Cognitive and Motor subscales in a whole group analysis. Reliable change analyses for each patient within each subscale however identified only half of the sample achieved reliable improvement within the Motor domain and just one person within the Cognitive domain (5.6%). Findings are consistent with the emphasis of the rehabilitation unit on physical/motor function, and unsurprising as many of those assessed had multiple sclerosis, an often deteriorative condition. Use of reliable change analysis allowed a more detailed understanding of intervention impact, potentially identifying what services reliably work for whom, thereby informing future planning.

Changes in aspects of social functioning depend upon prior changes in neurodisability in people with acquired brain injury undergoing post-acute neurorehabilitation.

Post-acute community-based rehabilitation is effective in reducing disability. However, while social participation and quality of life are valued as distal outcomes of neurorehabilitation, it is often not possible to observe improvements on these outcomes within the limited time-frames used in most investigations of rehabilitation. The aim of the current study was to examine differences in the sequence of attainments for people with acquired brain injury (ABI) undergoing longer term post-acute neurorehabilitation. Participants with ABI who were referred to comprehensive home and community-based neurorehabilitation were assessed at induction to service, at 6 months and again at 1.5 years while still in service on the Mayo-Portland Adaptability Index (MPAI-4), Community Integration Questionnaire, Hospital Anxiety and Depression Scale, and World Health Organisation Quality of Life measure. At 6 months post-induction to service, significant differences were evident in MPAI abilities, adjustment, and total neurodisability; and in anxiety and depression. By contrast, there was no significant effect at 6 months on more socially oriented features of experience namely quality of life (QoL), Community Integration and Participation. Eighteen month follow-up showed continuation of the significant positive effects with the addition of QoL-related to physical health, Psychological health, Social aspects of QoL and Participation at this later time point. Regression analyses demonstrated that change in QoL and Participation were dependent upon prior changes in aspects of neurodisability. Age, severity or type of brain injury did not significantly affect outcome. Results suggest that different constructs may respond to neurorehabilitation at different time points in a dose effect manner, and that change in social aspects of experience may be dependent upon the specific nature of prior neurorehabilitation attainments.

It Takes Two: Noninvasive Brain Stimulation Combined With Neurorehabilitation

The goal of postacute neurorehabilitation is to maximize patient function, ideally by using surviving brain and central nervous system tissue when possible. However, the structures incorporated into neurorehabilitative approaches often differ from this target, which may explain why the efficacy of conventional clinical treatments targeting neurologic impairment varies widely. Noninvasive brain stimulation (eg, transcranial magnetic stimulation [TMS], transcranial direct current stimulation [tDCS]) offers the possibility of directly targeting brain structures to facilitate or inhibit their activity to steer neural plasticity in recovery and measure neuronal output and interactions for evaluating progress. The latest advances as stereotactic navigation and electric field modeling are enabling more precise targeting of patient's residual structures in diagnosis and therapy. Given its promise, this supplement illustrates the wide-ranging significance of TMS and tDCS in neurorehabilitation, including in stroke, pediatrics, traumatic brain injury, focal hand dystonia, neuropathic pain, and spinal cord injury. TMS and tDCS are still not widely used and remain poorly understood in neurorehabilitation. Therefore, the present supplement includes articles that highlight ready clinical application of these technologies, including their comparative diagnostic capabilities relative to neuroimaging, their therapeutic benefit, their optimal delivery, the stratification of likely responders, and the variable benefits associated with their clinical use because of interactions between pathophysiology and the innate reorganization of the patient's brain. Overall, the supplement concludes that whether provided in isolation or in combination, noninvasive brain stimulation and neurorehabilitation are synergistic in the potential to transform clinical practice.

Mauritius Calling: Medical Care and Neurorehabilitation Needs in an Oceanic Idyll

Soopramanien A. Mauritius calling: medical care and neurorehabilitation needs in an oceanic idyll.The tropical island of Mauritius, located off the coast of Southern Africa, has greatly improved its health care system, especially for frontline services and procedures such as cardiac surgery. But the post–acute neurorehabilitation care is still problematic, much to the detriment of disabled patients, their families, and Mauritian society overall. Comparisons with neurorehabilitation care in the United Kingdom suggest the scale of the problem in terms of uncoordinated medical teams, limited follow-ups, lack of expertise, and cultural stigma. This article assesses the needs of the neurologic rehabilitation segment in Mauritian health care and submits a set of policy recommendations addressing what medical professionals, hospitals, government officials, and other organizations can do to improve the neurologic rehabilitation infrastructure for Mauritian patients.

FMRI Activation with an “Affective Speech” Paradigm in Vegetative and Minimally Conscious States: Applicability and Prognostic Value

Vegetative state (VS) and minimally conscious state (MCS) are considered different clinical entities but their differential diagnosis remains challenging. Some VS patients can show an MCS-like activation in functional magnetic resonance imaging (fMRI) studies that seems to predict recovery from VS. We studied fMRI activation with an affective speech paradigm in a cohort of non-communicative brain-injured individuals consecutively admitted to a post-acute neurorehabilitation facility in five years. Among 93 eligible subjects, 65 met the clinical criteria for VS and 28 for MCS. Because of exclusion criteria, activation studies were performed in only 30 cases out of 93 and analysed in only 24 (about ¼ of the eligible cases): 19 VS and five MCS patients. The passive acoustic stimulus consisted in a familiar voice narrating a significant episode in the patient's life, administered by nonmagnetic earphones. All the MCS patients showed an activation spread to secondary associative cortices but also 52.7% of the VS patients displayed an "atypical" large-scale activation pattern. Regarding the clinical outcome, 80% of the patients with large-scale network activation (LSNA) had some recovery of consciousness. Our results confirm that the VS patients with LSNA at fMRI study have potential for further recovery of consciousness, whereas no patient without activation or only typical activation improved. fMRI study with an affective speech paradigm, when applicable, seems to have a valuable prognostic value in VS patients, even if there are major limitations in terms of applicability.

Development of a clinical screening tool to differentiate levels of challenging patient behaviour

Aims This article describes the design of a systematic interdisciplinary clinical tool developed to differentiate levels of challenging behaviour (CB) in patients following a traumatic or acquired brain injury in order to facilitate decisions regarding rehabilitation and management needs. Methods A ‘top-down and bottom-up’ approach was used, based on clinical case examples and adaptations from the Overt Aggression Scale – Modified for Neurorehabilitation (OAS-MNR) (Alderman et al, 1997). Inter-rater reliability, face and content validity were tested through opportunistic sampling and blind re-screening of 20 patients on a post-acute neurorehabilitation ward. Findings Inter-rater reliability for overall decision on suitability for inpatient neurorehabilitation referral was significant (V = 0.84; P = 0.03); with significant inter-rater reliability within CB ratings. Ninety-three percent of staff were able to make an agreed decision regarding overall level of CB; there was a 95% concordance between staff using the tool; 90% of expert neurorehabilitation staff agreed with the decision from the tool, indicating a high degree of feasibility and clinical utility. Conclusions Changes were made to improve the tool's overall clinical usefulness. Findings indicate it is accessible for ward staff, and appropriate for use as a decision and management aid for patients presenting with a range of CBs. Further exploration of psychometric properties across settings and aetiology of CB is recommended.

Outcomes of post-acute rehabilitation for persons with brain injury

Objectives: To examine the impact of multifaceted rehabilitation services on functional outcomes after traumatic brain injury (TBI) for individuals with significant physical and cognitive difficulties, as well as those with added behavioural complications.Design: Cohort, non-randomized, intervention study with a pre-test–post-test, follow-up design.Setting: Community integrated post-acute rehabilitation centre.Participants: Individuals with primarily severe TBI receiving post-acute neurorehabilitation services (NR, n = 129) as well as similarly impaired individuals with additional antagonistic/disruptive behaviours receiving neurobehavioural services (NB, n = 76).Interventions: Multi-faceted behavioural and cognitive therapy methods delivered individually and in groups.Main outcome measure: The Functional Area Outcome Menu (FAOM), a behaviourally anchored 5-step scale rated by rehabilitation teams at three time periods.Conclusions: The rehabilitation treatment model achieved significant functional gains of ∼1.5 levels for neuropsychologically-impaired adults with and without associated behavioural and substance problems.

Analysis of Wessex Head Injury Matrix (WHIM) scores in consecutive vegetative and minimally conscious state patients

Consensus guidelines defining minimally conscious state (MCS) have been available for some years. However, to date, few measures have been developed that are particularly suited to monitoring MCS patients and there are limited clinical outcome data. The objective of the study was to determine the value of serial repeated assessments using the Wessex Head Injury Matrix (WHIM) to identify changes in vegetative state (VS) and MCS patients. Twenty consecutive VS/MCS patients admitted to a post-acute regional neurorehabilitation unit were assessed using WHIM. Significant differences in both total number of behaviours observed (p < .001) and highest rank behaviour were observed (p = .001) between initial and final WHIM assessments. Preliminary findings suggest that the WHIM is a sensitive measure of subtle changes in VS and MCS patients.