Functional Level During the First Year After Moderate and Severe Traumatic Brain Injury: Course and Predictors of Outcome

(1)

Original Article

Articles © The authors | Journal compilation © J Neurol Res and Elmer Press™ | www.neurores.org

Functional Level During the First Year After Moderate and Severe Traumatic Brain Injury: Course and

Predictors of Outcome

Maria Sandhaug^{a, b, e}, Nada Andelic^c, Svein A Berntsen^b, Stephen Seiler^a, Aase Mygland^{a, b, d}

Abstract

Background: The objective of this study was to describe the func- injury and injury-related factors.

Methods:!"# $ %&'(

%&))$ * $+/+

/ $ (' $ 01230$1 2 3* (' - 45 $ 6 +/ (' 4

Results:! +/

4 (' +/ - 4 +/ 4!(' 7#8$ +/ (97('"

:)8 $ 4 + 0123$; - <#'8$ ==8 ;- <==8$ =(8

; <()8$ ="8 45 5!&94'970>2

&#49#?@12 &

94)#? * ):8 +/ ('4 Conclusions:

TBI was in the sub-acute phase during the stay in a specialized 4C $ ):8- 0123(' - 4 @ 5!

0>2 $ +/('$ - late TBI phases.

Keywords: @ D 0 D C D

Introduction

+ $ - E(F4 G H $ - E'F45 $ * E'F4

Several factors are reported to correlate with recovery J- 5!E(F0$>2 0>2 E=F @1>E=F E(F4 5! E(=F4

5 E(=F4 In a previous study of functional level during sub-acute rehabilitation, we found that a considerable portion of patients

$ E)F4 $

$ $

/ /':'9((

a+K 2! L O%$

b>C 2 KO%$

cG 5/ 1L KL %$

d >/ L %$

e> J/2+K 2

! L 2 *)'')"9)O%$4 3J4P4

J(94)9'(Q'9$

)?

(2)

(' 4 $ $ $ 4 In general, there are several recently published retrospective E#:F4 - E?7F42 R ; regional, national and international differences and needs in <E(9F4

The purpose of this study was to describe the course of (' - + / +/ * (' 0$1 2 3*

01234U $ * H +/ ('4

Materials and Methods

Subjects

We considered for inclusion consecutive patients with TBI >

C O G '99#% '99?4

G '99#$ - 2 K - $ 43* $ V("

! >

C / !>C/ E((F (no response indicative of consciousness during the rehabili- $ $ $ as associated spinal cord injuries, previously diagnosed se- Q 4Y - $ * C > / C 3 $ - $ 45 $ 2 K $ - cations in Southern Norway) where they, after intensive care, % =(

2 (? 4 $ @ ( 1L KL 4

U (= - 1L KL @ 4 $ 3 %-

$$ * $ 4+

(= 4U

$ 4 C >-

tee for Medical Research Ethics approved the study. Our re- $ at the institution in which the study was conducted and in $ G U / !- sociation.

Sub-acute rehabilitation

All patients received interdisciplinary brain injury rehabilita- 6 J nurse, physiotherapist, occupational therapist, speech therapist, psychologist, neuropsychologist and social worker.

$ 6 - - R 4 $ $ achieved their functional goals.

Post-acute rehabilitation

! 6

>C 4K

$ >

4+$

acute rehabilitation.

Follow-up

K +/0123 $ (' 4 R

$ 6 $ 4 + $ $ (=

@ ( 4 Independent variables

$ $ - J Q $ -

^('Q_(' Q Q Q ( QQ 6 * > Q E('F Q Q_( Q_(Q H Q @12 @12 5! 0$ > 2 0>2 6 0>2 0>2 0>2 4

)7

(3)

Predictor N (%) FIM 12 months (SD) Corr* P-value

Place of acute care

Regional hospital )?:" ((=m'" 94''7

@ ( (#') ((7m'(

C Q #9:7Q(='( (('m'?Q('#m) 94(9(

0 /Q+ )?:"Q(#') ((#m'=Q(((m=' 94'?9

Age "=(99 949:' 94#:#

> Q $ =9)?Q='#' ((:m(7Q(('m=9 94":9 3^('Q_(' ')#'Q'')? (("m'#Q(''m(: 947)=

!Q Q (:("Q)='" ('9m("Q((=m'" 94()9 1 Q_( =?"9Q'#)9 ('(m("Q((9m'7 949":

> Q_( (#'7Q=::( ((:m(7Q(9"m=" 949(#

Injury severity

Moderate TBI '(== ('=m(= ^9499(

Severe TBI )'"" ((9m'7

='#( (()m'? 94)')

+ '==: (('m'#

Y ?(= ('"m(

Injury localization

+ (:'? ((#m'# 94"77

Non-frontal )=:' (("m'=

PTA duration (days) "=(99 94#(' ^9499(

@12 "=(99 94=#: ^9499)

@12 "=(99 94=7: ^9499(

0>2 "'(99 94=:: ^9499'

0>2 "=(99 94#=" ^9499(

+/ "=(99 94#?? ^9499(

+/ "=(99 94:9? ^9499(

Table 1. Pre-Analyses of Patient Characteristics in Relation to FIM 12 Months After Injury

Numbers are given as mean values if not otherwise indicated. M/F: Male/Female; PTA: Post-Traumatic Amnesia; LOS acute:

Length of Stay acute hospitalization; LOS rehab: Length of Stay in rehabilitation hospital; GCS acute: Glasgow Coma Scale acute hospitalization; GCS rehab: Glasgow Coma Scale in rehabilitation hospital; FIM Adm/Disch: Functional Independence Measure Admission/Discharge. * Spearman’s Rank Order Correlation. N = 63 due to missing FIM values in 2 out of 65 subjects. Missing 17 responses in the education predictor. Missing 11 responses in the complication predictor.

#9

(4)

U $ * $4/$

0>2(=(# $ @1>@1>=9 5!

') !>C/E((F4/

$ 0>27('@1> =9- utes, but less than 6 hours. Patients with clinical features of $ > $ - 4 2 $ 0>2 V?@1> "4! $ "

$>)

$ * @1>

0>24U $ 0>2 in one of the patients.

5!$ $

;< 0 1- ! 01!E(=F4 01!(9 and person) and the ability of the patient to recall personal $4

! 01!

$ x 4!

:"(99 $ "# E(=F4 In-between scores are considered borderline. GOAT assess- $ 4

Outcome variables

+/$

$ (' 4 +/ (?

$ - E()F4 3 ( : E(#F4 +/ $ +/ / +// +/ > +/

>104 +// (=

(= 7( +/>10 # $ #=#- +/ (? ('"4! +/

+// +/>10 V (9?

$ (97 ('" 4 +/ $ - E("F4 +/$

- $ x

$ x ('$4+

' +/$

E(:F4

0123 $ x (?J ?& :&

$

" & $x $ # & $x

$ )&

=& - '

& (& E(?F4 0123 E(7F4 0123-

$ $ - (' 4

Statistical analysis

+/

$ /* / ! +

Table 2. Results of Multiple Regression Analysis With FIM

Adjusted R Square for the model: 0.474.

*Number of patients, N = 63.

Variable P-value

> ='4(7#:4":=:'49"' 94(((

Gender ?49(=(74=(==4'?" 94("(

PTA duration 94'((94=7(949=( 949''

@12 94)(7949#794::? 949'=

0>2 #4'=)'4):":477= ^9499(

+/ 94(?9949?'94))( 94(:)

#(

(5)

$ - E'9F4 0123 $

>R 4

The dependent variable in our regression analysis was +/(' 4 - sidered for use as independent variables are shown in Table (4 $ +/ (' 2 | Cx 1 >- OxU /U L - 2 !%1Y!4 subjects were divided into two groups of either acute treat- )?

(# 4 +/

$ as a covariate to adjust for the baseline level. Independent $ 5 ^ 949#

$ - R +/- 4(( 5^949#

$ Q 5!@12 @12 0>2 0>2 +/ 4

>$

(( 4G -

$ (9&"'

" $$ 5 $ '4

Y $ }94:$ * 4 $ - Y+

H $ * >x| 4 $ 4%

$ (9 4!$ - 2522 (#49 $ 5^949# 4

Results

2* '( $ )) $

$ 41 $ * - 4% $ * Q (:

$ H Q - 4 +/0123 (' - $ "=

two patients.

Demographics and severity of TBI

1"# )(m(? #9::8$

(#'=8 45 $ - Adm rehab. (± SD) Disch rehab. (± SD) 12 months (± SD) P-value

/ &'(

+/ (97m'( (')m= ('=m(=

9499#~~

94997~~~

(4999~~~~

+// ?'m(# 7(m7 ?7m7

949(?~~

949?=~~~

(4999~~~~

+/>10 ':m? ==m= =)m)

^9499(~~

^9499(~~~

(4999~~~~

2 &))~

+/ ?(m# (9(m# ((=m'7

^9499(~~

^9499(~~~

9499#~~~~

+// "9m) :#m) ?=m)

^9499(~~

^9499(~~~

949#9~~~~

+/>10 ''m' '?m' '7m'

9499#~~

^9499(~~~

(4999~~~~

Table 3. Functional Measures at Admission, Discharge and 12 Months After Moderate or Severe TBI

!"#$

% % &#$%'()'% +8#9%

Bonferroni correction. * N = 42 at 12 months follow-up. ** P-value between adm rehab and disch rehab. *** P-value between adm rehab and 12 months follow-up. **** P-value between disch rehab and 12 months follow-up.

#'

(6)

$ 5&94='?

5&94#?#4+ )?8 - =)8 5&94)"#4 =?8

#)8 5 & 94)"# ()8 ((85&94)"# 4 - $ '98 ='8 5&94)'((#8 - )"8 5&94(?: ()8 ='8 5 & 947(7 ((8 ()85&94)(= ?8 ('85&

94"7: #8 (:85&94#97 *9 ((85&949=#4!

# $- $ 5! ("8 $ 5&949'94/ 5!$((m () ))m))5^9499(4

Length of stays and discharge place

Transfer to the specialized rehabilitation unit took place, '?m') =('"4/

$'?m'=

)7"4 - $ $ 5 ^ 9499( 5 & 9499#4!

$ (998$

4 ! $ "(8 $ - ':8 Q ((8 4

Measurements of functional recovery

/ +/

(' $ =4 ! +/

(' 4 +/

=' () 5^9499(4

! +/

4 K$ -

$ (' - $ +/

4 2 +/+//+/>104

+/ - $ + (4 - (' $ were unchanged and two patients (one with severe and one

$ +4(4!('

$7#8 +/

(97('" - :)8 $ 4 - +//

?"8 R +/>10 score. Twelve percent of the severe TBI patients had a score

^:' 4

Figure 1. Individual FIM scores in moderate and severe TBI patients.

#=

(7)

+ $ - 0123('$; <)98

; <='8; <'784 0123

$ + '4! * -

$ $ 5^949#4 $ ; < ((Q'( #'8 $ ()Q)'==8 ;

< :Q'( ==8 $ (=Q)'

=(8 ; <=Q'(()8

$ (#Q)'="8 4 Predictors of functional recovery (FIM total score) 12 months after injury

H - $ '4 U $ +/

(' J0>2 - 5!@12 4 CR $94): 5!

0>2 @12 * +/ (' 4 $ 0>2 @12 - 5! 0>2- 5!

R (' 4 0>2 H

&#49#?$ @12 &94)#?5!

&94'974

Discussion

$ R -

"= $ %&'( %&)'4 +/ - (' 4 $ $ 4 * E'(F4 5 - - # $ *:E''F4 G (' $ +/ - ate TBI patients. Mean scores of cognitive function did not 4 x- +/

$ +4(4! +/$

developed to track progress in functional status during inpa- tient rehabilitation and has a ceiling effect at one-year post E'=F4@x +/

sensitive enough to detect changes in either upper functional E'(F4

Most previous studies on post-TBI prognosis focus on 4/ $ - pitals. We have previously shown that a considerable portion E)F4 $ $ 0123(' after injury. The proportion of severe disability is in accor-

Figure 2. The distribution of GOSE outcome in moderate and severe TBI patients.

#)

(8)

$ U 4 '99" E')F4 K$- ever, in a recent Norwegian study on neuropsychological and (' 4 fact that patients that were not able to be tested sub-acutely 5!$ * E7F4

x - H +/>10 4K$ R

$ $$

is needed during the post-acute phases after TBI. After dis- $ - 6 6 (' 4 were offered visits, telephone contact, assistance and educa- - tutional settings when considered necessary. It is a question

$ 6 (' 4

We have recently shown that longer stays in the rehabili- 5! 0>2 - E)F4

$ (' 40>2 - &#49#?4 0>2 - to PTA which has been reported as the strongest predictor in E(=F4

0>2 $ E'#F40>2 E'#'7F4 0>2 E=( ='F4

$0>2 0>2 E'#='F4

5!

E=F4 5!

duration turned out to be a weak predictor of functional level & 94'97 (' 4 others have found PTA duration to be the strongest predic- 0>2 E===#F42 - - E'=)=")9F42 4'99?$

5!)?$ x threshold points that should aid prognosis accuracy after TBI

E=F4

A longer stay in the rehabilitation unit was associated

$ &

94)#?4 $ >$ 4(77#

$ @12$- $ +//

+/>10 E)(F4!

$ -

$ 4 $ @12 - pendent predictor of functional level. Overall, a longer stay E)F4

0123 +/ 0123 $ +/

x4 $ -

$ $ 0123+/(' $ 4 0123 $ ):8 $ (' $ +/ - ')8 ()84 + 7#8 +/

$ #'8 0123 ('4

U xx 4 + (7?9 $ = " 4 +$

xE)'F4!

E)'F41 $ $ $ E7(?)')=F4+

0>2 5!

E))F4

1 $ 6 4 K$ $ $ 4! - * $ - $ +/4 % would have been preferable for a better description of cognitive functional recovery after TBI. One should be careful in generalizing our results with the overall TBI population

$ 6 4/$

##

(9)

need of further follow-up.

Conclusion

+ +/ - 4 $ in the sub-acute phase during the stay in a specialized reha- 4 $ - - +/

4 C $ ):8 0123('

$ 4@

5! 0>2 $ +/ (' $4 1 - and rehabilitation overall in the post-acute TBI phase. The x R - bilitation after TBI.

Acknowledgement

U $x x! K51 L K - 3 01!

$ @1 % C O >C 2 KO collection.

Disclosures

$ 3C!

%$ +K C - 4 % *4

References

(4 Ux U>O //$6K> K- + 2 / / 4 ! - 4 % % 5 '9(9D?((J?:?74

'4 $!U/ +/> C@G %%3- > G4 > - J -

4

% '99#D''(9J(9)9(9#(4

=4 2 / 2 /! 2! U %x 04 >

J 0$ > 2 4% % 5 '99?D:7"J":?"?#4

)4 2 / ! % Y ! 2 2 /

!4 + - J - 4'9(9D')#J:)9:):4

#4 2!O R / 3 / C 4 5

# 4 C C '997D=''J(=7():4

"4 2!2x !@/02O3- !U K / 5 1 4 @ $ J$

4% '997D))(J(?4 :4 3 !U U4 5 -

$J - $4'99)D(?"J#==#)#4

?4 ! % 2 2 2x !O 2x @ 2 LC >4G ( 4GC - '9(9D='(=J((''((=(4

74 22! %C >2x !O4>- ( 4% 2 '997D(##J:)9:#94

(94 ! O > > 2 L R

@4 >+J! UK1 of functioning, disability and health to brain injury reha- 4% C '99=D(?=J'=7'#94 ((4 CC/ 0@22 xGO4

C J%! % - 4!>% '997D')(J=(94 ('4 @ 22 !/2x >3

K K U 4 % $ J 4 '99#D(7)J'=7'#"4

(=4 @ K21|G Y/0C04 0 - 1 ! 4 ! 4 % / G (7:7D(":((J":#"?)4

()4 0000C /2 O2 2Y 1 /@4 2$ J * - 4 2 C / (77"D'?'J#("'4

(#4 0 >Y K @ / K

#"

(10)

!U U G4 5 - 4!5/ C (77=D:''J?)?74

("4 > G 2O O 0 >Y4 Y-

$ 4 ! 5 / C (77:D:??J?'??=)4

(:4 G ! 0 >Y K !U + C>

G 0O C@1 O 45x J rehabilitation facilities and subacute rehabilitation pro- 42x '99"D=:"J()::()?'4

(?4 U5 $@3 0/42 - $ 0$1 2 * 0$1 2 J 4% - (77?D(#?J#:=#?#4

(74 % !K2 U/ -

/41 J - $x4%

% 5(777D""'J'9:'(=4

'94 K !U @ / U G K- 0 >4 C $ - - 4! 5 / C (77=D:)"J#""#:=4

'(4 Ox >@ +$ @ O6 4 -

$ 4 ! 5 / C '99"D?:('J(#79(#7"4

''4 > O> 3K G/

G, Bayley M, Green RE. Recovery of cognitive func- J

> 4!5/ C '99?D?7('2J2=(#4

'=4 > /3/C4 4!5/ C - '999D?(('2'J2'('74

')4 U@////0G 0/4 G J

#: $ 4% -

% 5'99"D::#J")9")#4 '#4 +4 ! !-

% 2 4 2

% > > 4 0$

4% '999D(:":J#"=#:(4

'"4 / > K K / K >

OKO K>! 45- 2J )=: 4'99)D#:'J'##'"(4

':4 / 0G 0/ x C > + G / + O! 4 3 > 4!

% U (777D()(=J''='="4

'?4 C!O24>

4%

'99)D'(:J??"?7=4

'74 2 G+ ! $ 5 5! U$ /

/ G45 - J 4 %

% 5(777D""(J'9'#4

=94 > G O / @ @ 6 3 U 5 O 6 23 KU4!

$x ( J 4! 5 / C (77:D:?'J('#(=(4

=(4 Gx 22C@/ 3 x%C41 4% - 2(77#D((J":::4

='4 2 %5+>3> O @

> 0>/ 4 4 % '99)D'(7J((=((()94

==4 !6///5/!R >0!

!22R4H * - 4% '99)D'(:J?")?:"4

=)4 O6G! * /5445 - - 4!% (77)D#(:J""(":94

=#4 2 /2 !/%x0KU/4/

+ C /4 3 - J 4! 5 / C '99'D?='J(?=(7'4

="4 2% 5 +/ 0 K5 O C04 5 0$ > 2 - of patients with severe closed-head injury. Brain Inj (77'D")J=:==?94

=:4 3 K @ K2 2 >4 5

! 4 5 4 ! % (77"D#=?J:?':7(4

=?4 !x O /2245 $ - J#9?+

# 4 (77?D(''J7#

(9:4

=74 K $ GC5 4> - $ - 4(777D(=:J)?7#9)4 )94 / >6x / > G! 2 @!

2 3! 2 $x 5 / 4 5 0$>2 J 4% % 5-

#:

(11)

'99)D:#(J("(("'4

)(4 >$ G / / G Y / >2 =

@ $ %x !4 H - sure scores and rehabilitation length of stay and charges.

!5/ C (77#D:"7J:7:?9=4

)'4 K 6K2G2 @@C/4K$

x

% (7??D''#J?#=?#?4

)=4 Gx 2 /@ ! x %4 % R 4

% % 5(7?"D)7((J('':('='4 ))4 O / @ >4 / J

4(77"D(9=J(#7(?"4

#?