Impact of Medicare prospective payment system on acute rehabilitation outcomes of patients with spinal cord injury

Qu H, Shewchuk RM, Chen Y, Deutsch A. Impact of Medicare prospective payment system on acute rehabilitation outcomes of patients with spinal cord injury.

Objective

To examine the impact of Medicare's inpatient rehabilitation facility (IRF) prospective payment system (PPS) on inpatient rehabilitation outcomes for patients with traumatic spinal cord injury (SCI).

Design

Retrospective study.

Setting

Twelve SCI Model Systems.

Participants

A sample of Medicare (n=296) and non-Medicare (n=3110) patients was selected from the National SCI Statistical Center Database from 1996 to 2006.

Interventions

Not applicable.

Main Outcome Measures

Motor FIM score change and length of stay (LOS).

Results

LOS decreased by about 5.8 days a year (P<.001) for Medicare patients and about 1.3 days a year (P=.031) for non-Medicare patients after PPS implementation. However, for both groups, FIM score gains were not significantly different in the pre-PPS and PPS periods.

Conclusions

Although significant decreases in LOS were observed for Medicare patients after IRF PPS implementation, Medicare patients' improvements in motor function did not decrease. Non-Medicare patients with SCI also experienced shortened stays after Medicare IRF PPS implementation, but had equivalent FIM score gains compared with their counterparts who received inpatient rehabilitation care before PPS implementation. IRF PPS implementation was associated with shorter stays, but was not associated with lower functional improvement.     

Relationships among premorbid alcohol use, acute intoxication, and early functional status after traumatic brain injury

Vickery CD, Sherer M, Nick TG, Nakase-Richardson R, Corrigan JD, Hammond F, Macciocchi S, Ripley DL, Sander A. Relationships among premorbid alcohol use, acute intoxication, and early functional status after traumatic brain injury.

Objective

To investigate the relationships among intoxication at time of injury, preinjury history of problem drinking, and early functional status in patients with traumatic brain injury (TBI).

Design

Prospective cohort study.

Setting

Acute inpatient TBI rehabilitation.

Participants

Participants were 1748 persons with TBI.

Interventions

Not applicable.

Main Outcome Measures

Blood alcohol levels (BALs) were obtained at admission to the emergency department, and a history of problem drinking was obtained through interview. Study outcomes, Disability Rating Scale (DRS), and FIM instrument scores were gathered at admission to inpatient rehabilitation.

Results

Multivariate regression analysis revealed that BAL and a history of binge drinking were predictive of DRS, but not FIM, scores. A higher BAL was associated with poorer functional status on the DRS. Paradoxically, a history of binge drinking was associated with more intact functional status on the DRS.

Conclusions

The relationships among intoxication at time of injury, history of problem drinking, and early outcome after TBI were modest. Injury severity had a more significant association with TBI functional status.     

Current trends in venous thromboembolism among persons hospitalized with acute traumatic spinal cord injury: does early access to rehabilitation matter?

Selassie AW, Varma A, Saunders LL. Current trends in venous thromboembolism among persons hospitalized with acute traumatic spinal cord injury: does early access to rehabilitation matter?

Objective

To determine the incidence of venous thromboembolism (VTE) among patients with traumatic spinal cord injury (TSCI) in acute care settings that is attributable to extended length of stay (LOS), insurance status, and access to rehabilitation.

Design

Population-based, retrospective cohort study.

Setting

Levels I through III and undesignated trauma centers.

Participants

Patients with acute TSCI (N=3389) discharged from all acute care hospitals in South Carolina from 1998 through 2009, and a representative sample of patients with TSCI (n=186) interviewed 1 year later.

Interventions

Not applicable.

Main Outcome Measure

VTE while in acute care.

Results

Annual incidence of TSCI is 67.2 per million in the state of South Carolina, while the cumulative incidence of VTE is 4.1%. Patients with TSCI who developed VTE were nearly 4 times more likely (odds ratio [OR], 3.98; 95% confidence interval [CI], 2.57–6.17) to have been those who stayed 12 days or longer in acute care after adjusting for covariates. The adjusted mean LOS in acute care was 32.0 days (95% CI, 27.7–37.2) for patients with TSCI who had indigent insurance versus 11.3 days (95% CI, 4.9–17.6) for Medicare, and 18.5 days (95% CI, 14.5–22.5) for commercial insurance after adjusting for VTE, disposition, and year of discharge. Only 20% of the persons under indigent care received rehabilitation from accredited rehabilitation facilities in contrast to 60% under commercial insurance.

Conclusions

Fewer patients with TSCI under indigent care received postacute rehabilitation compared with Medicare or commercial insurance. Insurance status remains a major barrier to timely transfer to rehabilitation, leading to protracted LOS in acute care with increased risk of VTE.     

Factors that predict acute hospitalization discharge disposition for adults with moderate to severe traumatic brain injury

Cuthbert JP, Corrigan JD, Harrison-Felix C, Coronado V, Dijkers MP, Heinemann AW, Whiteneck GG. Factors that predict acute hospitalization discharge disposition for adults with moderate to severe traumatic brain injury.

Objective

To identify factors predicting acute hospital discharge disposition after moderate to severe traumatic brain injury (TBI).

Design

Secondary analysis of existing datasets.

Setting

Acute care hospitals.

Participants

Adults hospitalized with moderate to severe TBI included in 3 large sets of archival data: (1) Centers for Disease Control and Prevention Central Nervous System Injury Surveillance database (n=15,646); (2) the National Trauma Data Bank (n=52,012); and (3) the National Study on the Costs and Outcomes of Trauma (n=1286).

Interventions

None.

Main Outcome Measure

Discharge disposition from acute hospitalization to 1 of 3 postacute settings: (1) home, (2) inpatient rehabilitation, or (3) subacute settings, including nursing homes and similar facilities.

Results

The Glasgow Coma Scale (GCS) score and length of acute hospital length of stay (LOS) accounted for 35% to 44% of the variance in discharges to home versus not home, while age and sex added from 5% to 8%, and race/ethnicity and hospitalization payment source added another 2% to 5%. When predicting discharge to rehabilitation versus subacute care for those not going home, GCS and LOS accounted for 2% to 4% of the variance, while age and sex added 7% to 31%, and race/ethnicity and payment source added 4% to 5%. Across the datasets, longer LOS, older age, and white race increased the likelihood of not being discharged home; the most consistent predictor of discharge to rehabilitation was younger age.

Conclusions

The decision to discharge to home a person with moderate to severe TBI appears to be based primarily on severity-related factors. In contrast, the decision to discharge to rehabilitation rather than to subacute care appears to reflect sociobiologic and socioeconomic factors; however, generalizability of these results is limited by the restricted range of potentially important variables available for analysis.     

Spinal cord injury and co-occurring traumatic brain injury: assessment and incidence

Macciocchi S, Seel RT, Thompson N, Byams R, Bowman B. Spinal cord injury and co-occurring traumatic brain injury: assessment and incidence.

Objectives

To examine prospectively the incidence and severity of co-occurring traumatic brain injury (TBI) in persons with traumatic spinal cord injury (SCI) and to describe a TBI assessment process for SCI rehabilitation professionals.

Design

A prospective, cohort design to collect and analyze clinical variables relevant for diagnosing co-occurring TBI.

Setting

An urban, single-center National Institute of Disability and Rehabilitation Research Model Spinal Cord Injury System in the Southeastern United States.

Participants

People (N=198) who met inclusion criteria and provided consent within an 18-month recruitment window.

Interventions

Not applicable.

Main Outcome Measure

FIM cognitive scale.

Results

Based on participants' presence and duration of posttraumatic amnesia, initial Glasgow Coma Scale total score, and presence of cerebral lesion documented by neuroimaging, 60% of our traumatic SCI sample also sustained a TBI (n=118). Most co-occurring TBIs were mild (34%). Co-occurring mild complicated (10%), moderate (6%), and severe TBI (10%) were less common but still occurred in a significant percentage (26%) of persons with traumatic SCI. Persons with traumatic SCI who were injured in motor vehicle collisions and falls were more likely to sustain a co-occurring TBI. Cervical level traumatic SCI was associated with greater rates of TBI but not more severe injuries. Tree analyses established a practical algorithm for classifying TBI severity associated with traumatic SCI. Analysis of variance established criterion validity for the algorithm's TBI severity classifications.

Conclusions

Findings from our prospective study provide strong support that TBI is a common co-occurring injury with traumatic SCI. Incomplete acute care medical record documentation of TBI in the traumatic SCI population remains a considerable issue, and there is a significant need to educate emergency department and acute care personnel on the TBI clinical data needs of acute rehabilitation providers. A systematic algorithm for reviewing acute care medical records can yield valid estimates of TBI severity in the traumatic SCI population.     

Paraplegia after aortic aneurysm repair versus traumatic spinal cord injury: functional outcome, complications, and therapy intensity of inpatient rehabilitation

Yokoyama O, Sakuma F, Itoh R, Sashika H. Paraplegia after aortic aneurysm repair versus traumatic spinal cord injury: functional outcome, complications, and therapy intensity of inpatient rehabilitation.

Objective

To compare outcomes, complications, and therapy intensity of inpatient rehabilitation in patients with paraplegia caused by spinal cord injury associated with aortic aneurysm repair (SCI-AA) versus patients with traumatic spinal cord injury (SCI).

Design

Case-controlled study.

Setting

SCI unit in a rehabilitation center.

Participants

Seventeen patients with SCI-AA and 17 patients with traumatic SCI.

Intervention

Standard rehabilitation therapy for SCI.

Main Outcome Measures

Length of stay (LOS) in acute and rehabilitation hospitals; FIM instrument scores; FIM change; FIM efficiency; complications; therapy intensity; and ambulatory state and return to community at discharge.

Results

No significant differences were noted in acute and rehabilitation LOS and admission FIM scores. Discharge FIM scores, FIM change, and FIM efficiencies were significantly lower in the SCI-AA group, which had many complications related to AA and SCI. Intensity of rehabilitation sports therapy in the SCI-AA group was significantly lower than that of the traumatic SCI group, but total therapy intensity did not differ significantly. Both had similar rates of return to ambulatory state and discharge to the community.

Conclusions

SCI-AA patients had many complications that interfered with rehabilitation therapy, and could not achieve functional gains comparable to those with traumatic SCI. However, both groups achieved comparable success with return to ambulatory state and discharge to the community.     

Functional oral intake and time to reach unrestricted dieting for patients with traumatic brain injury

Hansen TS, Engberg AW, Larsen K. Functional oral intake and time to reach unrestricted dieting for patients with traumatic brain injury.

Objectives

To investigate the status of functional oral intake for patients with severe traumatic brain injury (TBI) and time to return to unrestricted dieting; and to investigate whether severity of brain injury is a predictor for unrestricted dieting.

Design

Observational retrospective cohort study.

Setting

Subacute rehabilitation department, university hospital.

Participants

Patients age 16 to 65 years (N=173) with severe TBI (posttraumatic amnesia from 7d to >6mo) admitted over a 5-year period. Patients are transferred to the brain injury unit as soon as they ventilate spontaneously.

Intervention

Facial oral tract therapy.

Main Outcome Measure

Unrestricted dieting assessed by the Functional Oral Intake Scale (FOIS).

Results

We found that 93% of all patients had problems with functional oral intake at admission. Within 126 days of rehabilitation, 64% recovered to unrestricted dieting before discharge. The chance of returning to total oral diet depends on the severity of the brain injury and can be predicted by Glasgow Coma Scale (GCS; measured the day after cessation of sedation; Wald χ²=42.78, P<.01), Rancho Los Amigos Scale (RLAS) level (Wald χ²=11.84, P=.01), FIM instrument (Wald χ²=44.40, P<.01), and FOIS score at admission (Wald χ²=82.93, P<.01).

Conclusions

Impairment in functional oral intake was found to be very common for patients with severe TBI admitted to a subacute rehabilitation department. For those who recovered during hospital rehabilitation, return to unrestricted dieting happened within 126 days of rehabilitation. The chance of returning to unrestricted dieting depends on the severity of the brain injury and can be predicted by GCS score, RLAS level, FIM score, and functional oral intake at admission. These results are important when planning rehabilitation, giving information to patients and relatives, and designing efficacy studies of facial oral tract therapy, which are highly recommended.     

Predictors of Extended Rehabilitation Length of Stay After Traumatic Brain Injury

Arango-Lasprilla JC, Ketchum JM, Cifu D, Hammond F, Castillo C, Nicholls E, Watanabe T, Lequerica A, Deng X. Predictors of extended rehabilitation length of stay after traumatic brain injury.

Objective

To develop a prediction rule for acutely identifying patients at risk for extended rehabilitation length of stay (LOS) after traumatic brain injury (TBI) by using demographic and injury characteristics.

Design

Retrospective cohort study.

Setting

Traumatic Brain Injury Model Systems.

Participants

Sample of TBI survivors (N=7284) with injuries occurring between 1999 and 2009.

Interventions

Not applicable.

Main Outcome Measures

Extended rehabilitation LOS defined as 67 days or longer.

Results

A multivariable model was built containing FIM motor and cognitive scores at admission, preinjury level of education, cause of injury, punctate/petechial hemorrhage, acute-care LOS, and primary payor source. The model had good calibration, excellent discrimination (area under the receiver operating characteristic curve = .875), and validated well. Based on this model, a formula for determining the probability of extended rehabilitation LOS and a prediction rule that classifies patients with predicted probabilities greater than 4.9% as at risk for extended rehabilitation LOS were developed.

Conclusions

The current predictor model for TBI survivors who require extended inpatient rehabilitation may allow for enhanced rehabilitation team planning, improved patient and family education, and better use of health care resources. Cross-validation of this model with other TBI populations is recommended.     

The Moss Attention Rating Scale for traumatic brain injury: further explorations of reliability and sensitivity to change

Whyte J, Hart T, Ellis CA, Chervoneva I. The Moss Attention Rating Scale for traumatic brain injury: further explorations of reliability and sensitivity to change.

Objective

To examine the interrater agreement and responsiveness to change of the Moss Attention Rating Scale (MARS), 22-item version, during acute inpatient rehabilitation after traumatic brain injury (TBI).

Design

Observational study of clinician ratings (physical therapy [PT], occupational therapy [OT], speech-language pathology [SLP], nursing) of each patient's attentional function at 2 points in time, near the time of admission and near the time of discharge from inpatient rehabilitation.

Setting

Dedicated acute inpatient brain injury rehabilitation program.

Participants

Inpatients (N=149) with moderate to severe TBI (58% enrolled in the National Institute on Disability Rehabilitation Research−funded Traumatic Brain Injury Model System); age 16 years or older; receiving OT, PT, SLP, and nursing care on the inpatient TBI rehabilitation unit; and having Rancho Los Amigos Levels of Cognitive Functioning Scale scores of IV (confused/agitated) or higher at enrollment. Patients were excluded if they had premorbid history of attention-deficit hyperactivity disorder, major psychiatric disorder (eg, bipolar), or neurologic impairment (eg, stroke).

Interventions

Not applicable.

Main Outcome Measure

Scores on the MARS (22-item version) and its 3 factor scores.

Results

Intraclass correlations among ratings from PT, OT, and SLP ranged from .69 to .78 at the initial assessment and .67 to .72 at the follow-up assessment. Agreement between nursing and the other disciplines was somewhat lower (at initial assessment, .59-.68; at follow-up, .48-.59), although still substantial. Agreement for 2 of the factor scores (restlessness and/or distractibility, initiation) was similar but agreement for the third factor (consistent and/or sustained attention) was lower (.25-.27). The total MARS scores were highly significantly improved (P<.001) at follow-up compared with initial assessment (mean, 27.6d between ratings; median, 21d; range, 4-125d) for each of the rating disciplines, with change scores ranging from 7.8 points (OT) to 13.1 points (nursing). Factor scores also improved significantly during the same interval. When different occupational therapists provided the initial and follow-up OT ratings, these follow-up ratings were significantly lower, but this pattern was not seen among other rating disciplines.

Conclusions

The 22-item MARS showed good interrater agreement among PT, OT, and SLP and lower but still acceptable agreement between nursing and the other disciplines. Two of the 3 factor scores also showed good agreement. The 22-item total score and all 3 factor scores were highly sensitive to change occurring during inpatient rehabilitation. These results show that the 22-item MARS is a reliable instrument for the observational rating of attentiveness in an acute TBI rehabilitation sample. Lower agreement between nursing and the other disciplines suggests that the less structured environment of the nursing unit compared with therapy sessions reduces interrater agreement. The utility of the factor scores, particularly the least reliable sustained and/or consistent attention factor, requires additional investigation. Further research on construct validity and impact of the use of the MARS on clinical practice are warranted.     

Efficacy of cognitive-behavioral therapy for insomnia associated with traumatic brain injury: a single-case experimental design

Ouellet M-C, Morin CM. Efficacy of cognitive-behavioral therapy for insomnia associated with traumatic brain injury: a single-case experimental design.

Objective

To test the efficacy of a cognitive-behavioral therapy (CBT) for insomnia in persons having sustained traumatic brain injury (TBI).

Design

Single-case design with multiple baselines across participants.

Setting

Outpatient rehabilitation center.

Participants

Eleven subjects having sustained mild to severe TBI who developed insomnia after the injury.

Intervention

Eight-week CBT for insomnia including stimulus control, sleep restriction, cognitive restructuring, sleep hygiene education, and fatigue management.

Main Outcome Measures

Total wake time, sleep efficiency, and diagnostic criteria.

Results

Visual analyses, corroborated by intervention time series analyses and t tests, revealed clinically and statistically significant reductions in total wake time and sleep efficiency for 8 (73%) of 11 participants. An average reduction of 53.9% in total wake time was observed across participants from pre- to post-treatment. Progress was in general well maintained at the 1-month and 3-month follow-ups. The average sleep efficiency augmented significantly from pretreatment (77.2%) to post-treatment (87.9%), and also by the 3-month follow-up (90.9%). Improvements in sleep were accompanied by a reduction in symptoms of general and physical fatigue.

Conclusions

The results of this study show that psychologic interventions for insomnia are a promising therapeutic avenue for TBI survivors.     

Apparent Changes in Inpatient Rehabilitation Facility Outcomes Due to a Change in the Definition of Program Interruption

Deutsch A, Granger CV, Russell C, Heinemann AW, Ottenbacher KJ. Apparent changes in inpatient rehabilitation facility outcomes due to a change in the definition of program interruption.

Objective

To describe changes in inpatient rehabilitation facility (IRF) outcomes due to the program interruption definitional change, from 30 days to 3 days, in 2002.

Design

Secondary data analysis of the Uniform Data System for Medical Rehabilitation (UDSMR) database.

Setting

Four hundred eleven IRFs that submitted data to the UDSMR database in each of the years 1998 through 2003.

Participants

Patient assessment data for 772,584 Medicare fee-for-service beneficiaries.

Interventions

None.

Main Outcome Measures

The number of IRF patient discharges, percent of IRF patients discharged to the community, percent of IRF patients discharged to acute care, percent of IRF patients with program interruptions, percent of IRF inpatient deaths, and average IRF length of stay (LOS).

Results

IRF outcomes appeared to change because of the program interruption redefinition, with changes varying by impairment group. The largest changes due to the redefinition occurred for patients with traumatic spinal cord injury, including the largest percentage increase in patients (5.16%), the largest decrease in program interruptions (5.14%), the largest increase in acute care discharges (5.04%), and the largest mean decrease in LOS (1.27d). Community discharge showed the largest decrease for patients with Guillain-Barré syndrome (4.03%).

Conclusion

The change in the definition of program interruptions creates the appearance of changes in IRF performance and is important to consider when comparing the preprospective payment system (PPS) and PPS assessment data.     

Neuropsychologic and functional outcome after complicated mild traumatic brain injury

Kashluba S, Hanks RA, Casey JE, Millis SR. Neuropsychologic and functional outcome after complicated mild traumatic brain injury.

Objective

To investigate the extent to which neuropsychologic and functional outcome after complicated mild traumatic brain injury (TBI) parallels that of moderate TBI recovery.

Design

A longitudinal study comparing neuropsychologic and functional status of persons with complicated mild TBI and moderate TBI at discharge from inpatient rehabilitation and at 1 year postinjury.

Setting

Rehabilitation hospital with a Traumatic Brain Injury Model System.

Participants

Persons with complicated mild TBI (n=102), each with an intracranial brain lesion documented through neuroimaging and a highest Glasgow Coma Scale (GCS) score in the emergency department between 13 and 15, and 127 persons with moderate TBI.

Interventions

Not applicable.

Main Outcome Measures

FIM instrument, Disability Rating Scale, Community Integration Questionnaire, Wechsler Memory Scale logical memory I and II, Rey Auditory Verbal Learning Test, Trail-Making Test, Controlled Oral Word Association Test, Symbol Digit Modalities Test, Wisconsin Card Sorting Test, and block design.

Results

Few differences in neuropsychologic performance existed between the TBI groups. Less severely impaired information processing speed and verbal learning were seen in the complicated mild TBI group at rehabilitation discharge and 1 year postinjury. Despite overall improvement across cognitive domains within the complicated mild TBI group, some degree of impairment remained at 1 year postinjury on those measures that had identified participants as impaired soon after injury. No differences on functional ability measures were found between the TBI groups at either time period postinjury, with both groups exhibiting incomplete recovery of functional status at the 1-year follow-up.

Conclusions

When classifying severity of TBI based on GCS scores, consideration of a moderate injury designation should be given to persons with an intracranial bleed and a GCS score between 13 and 15.     

Ethnic differences in discharge destination among older patients with traumatic brain injury

Chang P-F, Ostir GV, Kuo Y-F, Granger CV, Ottenbacher KJ. Ethnic differences in discharge destination among older patients with traumatic brain injury.

Objective

To estimate the association between ethnicity and discharge destination in older patients with traumatic brain injury (TBI).

Design

A retrospective analysis.

Setting

Nationally representative sample of older patients from the Uniform Data System for Medical Rehabilitation in 2002 and 2003.

Participants

Patients (N=9240) aged 65 years or older who received inpatient rehabilitation services for TBI.

Interventions

Not applicable.

Main Outcome Measures

Discharge destination (home, assisted living facility, institution) and ethnicity (white, black, Hispanic).

Results

Multinomial logit models showed that older Hispanics (odds ratio [OR]=2.24; 95% confidence interval [CI], 1.66-3.02) and older blacks (OR=2; 95% CI, 1.55-2.59) with TBI were significantly more likely to be discharged home than older whites with TBI, after adjusting for relevant risk factors. Older blacks were also 78% less likely (OR=.22; 95% CI, .08-.60) to be discharged to an assisted living facility than whites after adjusting for relevant risk factors.

Conclusions

Our findings indicate that older minority patients with TBI were significantly more likely to be discharged home than white patients with TBI. Studies are needed to investigate underlying factors associated with this ethnic difference.     

Feasibility of a brief neuropsychologic test battery during acute inpatient rehabilitation after traumatic brain injury

Kalmar K, Novack TA, Nakase-Richardson R, Sherer M, Frol AB, Gordon WA, Hanks RA, Giacino JT, Ricker JH. Feasibility of a brief neuropsychologic test battery during acute inpatient rehabilitation after traumatic brain injury.

Objectives

To determine (1) if more than 50% of patients with moderate to severe traumatic brain injury (TBI) who met study criteria can complete a battery of neuropsychologic tests in less than 75 minutes 2 to 6 weeks after injury regardless of posttraumatic amnesia (PTA) status; (2) which tests are most likely to be completed; and (3) range of scores obtained.

Design

Prospective multicenter observational study.

Setting

Acute inpatient neurorehabilitation hospitals.

Participants

Screened 543 Traumatic Brain Injury Model System patients with moderate to severe TBI; 354 were tested at 2 to 6 weeks postinjury.

Interventions

Not applicable.

Main Outcome Measure

Percentage of patients able to complete the neuropsychologic tests in less than 75 minutes.

Results

Two hundred eighteen (62%) patients completed the battery in 66 minutes on average. Mean interval from injury to testing was 28.3±7.1 days. Tests completed with the highest frequency were California Verbal Learning Test−II, FAS, and animal naming. Performance was less impaired (P<.001) on all measures for patients who had emerged from PTA.

Conclusions

Approximately two thirds of screened patients were able to complete a brief neuropsychologic test battery at 2 to 6 weeks postinjury, regardless of PTA status. Although patients out of PTA were less impaired on all test measures, confusion did not preclude participation in the test battery or prohibit assignment of test scores. Early neuropsychologic assessment after TBI is feasible even for many patients who are still in PTA.     

Obesity and inpatient rehabilitation outcomes for patients with a traumatic spinal cord injury

Stenson KW, Deutsch A, Heinemann AW, Chen D. Obesity and inpatient rehabilitation outcomes for patients with a traumatic spinal cord injury.

Objective

To examine the effect of obesity on change in FIM self-care and mobility ratings and community discharge for patients with traumatic spinal cord injury (SCI).

Design

Retrospective cohort study analyzing National Model Systems SCI Database data.

Setting

Fourteen Model Systems SCI programs.

Participants

Patients (N=1524) with a new traumatic SCI discharged from Model Systems rehabilitation centers between October 2006 and October 2009.

Interventions

None.

Main Outcome Measures

Change in FIM self-care and mobility ratings, discharge destination. Separate analyses were conducted by neurologic category: paraplegia incomplete, paraplegia complete, tetraplegia incomplete, and tetraplegia complete.

Results

Of all patients with traumatic SCI, approximately 25% were obese at admission. Patients who were obese were more likely to be married and slightly older than nonobese patients. In patients with paraplegia incomplete, obese patients had lower FIM self-care (−1.9; 95% confidence interval [CI], −3.4 to −.4) and mobility score gains (−1.5; 95% CI, −2.9 to −.1) than normal-weight patients. For patients with paraplegia complete, obese patients had significantly lower self-care (−2.2; 95% CI, −3.5 to −.8) and mobility score gains (−2.7; 95% CI, −3.9 to −1.5). For patients with tetraplegia incomplete and tetraplegia complete, FIM self-care and mobility ratings for obese patients were not significantly different from ratings for normal-weight patients. Within each neurologic category, the percentage of patients discharged to the community was not significantly different for nonobese and obese patients.

Conclusions

Obesity appears to be a barrier to meeting self-care and mobility functional goals for patients with paraplegia in inpatient SCI rehabilitation.     

Major and minor depression after traumatic brain injury

Hart T, Brenner L, Clark AN, Bogner JA, Novack TA, Chervoneva I, Nakase-Richardson R, Arango-Lasprilla JC. Major and minor depression after traumatic brain injury.

Objective

To examine minor as well as major depression at 1 year posttraumatic brain injury (TBI), with particular attention to the contribution of depression severity to levels of societal participation.

Design

Observational prospective study with a 2-wave longitudinal component.

Setting

Inpatient rehabilitation centers, with 1-year follow up conducted primarily by telephone.

Participants

Persons with TBI (N=1570) enrolled in the TBI Model System database and followed up at 1-year postinjury.

Interventions

Not applicable.

Main Outcome Measures

FIM, Patient Health Questionnaire-9, Participation Assessment with Recombined Tools-Objective, Glasgow Outcome Scale-Extended, and the Satisfaction With Life Scale.

Results

Twenty-two percent of the sample reported minor depression, and 26% reported major depression at 1-year post-TBI. Both levels of depression were associated with sex (women), age (younger), preinjury mental health treatment and substance abuse, and cause of injury (intentional). There was a monotonic dose-response relationship between severity of depression and all 1-year outcomes studied, including level of cognitive and physical disability, global outcome, and satisfaction with life. With other predictors controlled, depression severity remained significantly associated with the level of societal participation at 1-year post-TBI.

Conclusions

Minor depression may be as common as major depression after TBI and should be taken seriously for its association to negative outcomes related to participation and quality of life. Findings suggest that, as in other populations, minor and major depression are not separate entities, but exist on a continuum. Further research should determine whether people with TBI traverse between the 2 diagnoses as in other patient groups.     

Inpatient and postdischarge rehabilitation services provided in the first year after spinal cord injury: findings from the SCIRehab Study

Whiteneck GG, Gassaway J, Dijkers MP, Lammertse DP, Hammond F, Heinemann AW, Backus D, Charlifue S, Ballard PH, Zanca JM. Inpatient and postdischarge rehabilitation services provided in the first year after spinal cord injury: findings from the SCIRehab study.

Objective

To examine the amount and type of therapy services received in inpatient and postdischarge settings during the first year after spinal cord injury (SCI).

Design

Prospective observational longitudinal cohort design. Data were obtained from systematic recording of interventions by clinicians and from patient interview.

Setting

Inpatient and postdischarge rehabilitation programs.

Participants

Patients (N=493) with traumatic SCI admitted to 6 rehabilitation centers participating in the SCIRehab study.

Interventions

Not applicable.

Main Outcome Measures

Hours of therapy by physical therapy (PT), occupational therapy (OT), speech therapy, recreation therapy, psychology, social work/case management, and nursing education during initial inpatient rehabilitation and postdischarge up to the first anniversary of injury. Inpatient data were collected prospectively by the treating clinicians; postdischarge service data were collected by patient self-report during follow-up interviews.

Results

Of the total hours spent on these rehabilitation interventions during the first year after injury, 44% occurred after discharge from inpatient rehabilitation. Participants received 56% of their PT hours after discharge and 52% of their OT hours, but only a minority received any postdischarge services from other rehabilitation disciplines. While wide variation was found in the total hours of inpatient treatment across all disciplines, the variation in the total hours of postdischarge services was greater, with the interquartile range of postdischarge services being twice that of the inpatient services.

Conclusions

SCI rehabilitation is often given in a care continuum, with inpatient rehabilitation being only the beginning. Reductions in inpatient SCI rehabilitation length of stay are well documented, but the postdischarge services that may replace some inpatient treatment appear to be greater than previously reported. The availability and impact of postdischarge care should be studied in greater detail to capture the wide array of postdischarge services and outcomes.     

Rehabilitation of Traumatic Brain Injury in Active Duty Military Personnel and Veterans: Defense and Veterans Brain Injury Center Randomized Controlled Trial of Two Rehabilitation Approaches

Vanderploeg RD, Schwab K, Walker WC, Fraser JA, Sigford BJ, Date ES, Scott SG, Curtiss G, Salazar AM, Warden DL, for the Defense and Veterans Brain Injury Center Study Group. Rehabilitation of traumatic brain injury in active duty military personnel and veterans: Defense and Veterans Brain Injury Center randomized controlled trial of two rehabilitation approaches.

Objectives

To determine the relative efficacy of 2 different acute traumatic brain injury (TBI) rehabilitation approaches: cognitive didactic versus functional-experiential, and secondarily to determine relative efficacy for different patient subpopulations.

Design

Randomized, controlled, intent-to-treat trial comparing 2 alternative TBI treatment approaches.

Setting

Four Veterans Administration acute inpatient TBI rehabilitation programs.

Participants

Adult veterans or active duty military service members (N=360) with moderate to severe TBI.

Interventions

One and a half to 2.5 hours of protocol-specific cognitive-didactic versus functional-experiential rehabilitation therapy integrated into interdisciplinary acute Commission for Accreditation of Rehabilitation Facilities–accredited inpatient TBI rehabilitation programs with another 2 to 2.5 hours daily of occupational and physical therapy. Duration of protocol treatment varied from 20 to 60 days depending on the clinical needs and progress of each participant.

Main Outcome Measures

The 2 primary outcome measures were functional independence in living and return to work and/or school assessed by independent evaluators at 1-year follow-up. Secondary outcome measures consisted of the FIM, Disability Rating Scale score, and items from the Present State Exam, Apathy Evaluation Scale, and Neurobehavioral Rating Scale.

Results

The cognitive-didactic and functional-experiential treatments did not result in overall group differences in the broad 1-year primary outcomes. However, analysis of secondary outcomes found differentially better immediate posttreatment cognitive function (mean ± SD cognitive FIM) in participants randomized to cognitive-didactic treatment (27.3±6.2) than to functional treatment (25.6±6.0, t₃₃₂=2.56, P=.01). Exploratory subgroup analyses found that younger participants in the cognitive arm had a higher rate of returning to work or school than younger patients in the functional arm, whereas participants older than 30 years and those with more years of education in the functional arm had higher rates of independent living status at 1 year posttreatment than similar patients in the cognitive arm.

Conclusions

Results from this large multicenter randomized controlled trial comparing cognitive-didactic and functional-experiential approaches to brain injury rehabilitation indicated improved but similar long-term global functional outcome. Participants in the cognitive treatment arm achieved better short-term functional cognitive performance than patients in the functional treatment arm. The current increase in war-related brain injuries provides added urgency for rigorous study of rehabilitation treatments. (http://ClinicalTrials.gov ID# NCT00540020.)     

Urologic dysfunction and neurologic outcome in coma survivors after severe traumatic brain injury in the postacute and chronic phase

Giannantoni A, Silvestro D, Siracusano S, Azicnuda E, D'Ippolito M, Rigon J, Sabatini U, Bini V, Formisano R. Urologic dysfunction and neurologic outcome in coma survivors after severe traumatic brain injury in the postacute and chronic phase.

Objectives

To investigate voiding dysfunction and upper urinary tract status in survivors of coma resulting from traumatic brain injury (TBI), and to compare clinical and urodynamic results with neurologic and psychological features as well as functional outcomes.

Design

Observational study focused on urologic dysfunction and neurologic outcome in coma survivors after traumatic brain injury in the postacute and chronic phase.

Setting

A postcoma unit in a rehabilitation hospital.

Participants

Consecutive patients (N=57) who recovered from coma of traumatic etiology and who were admitted during a 1-year period to a postcoma unit of a rehabilitation hospital.

Interventions

Patients underwent clinical urologic assessment, urodynamics with the assessment of the Schafer nomogram and the projected isovolumetric detrusor pressure to evaluate detrusor contractility, ultrasound assessment of the lower and upper urinary tract and voiding cystourethrography, routinely performed, according to the International Continence Society Standards. Neurologic variables assessed were brain injury and disability severity, and neuropsychological status. Neuroimaging identified the site of cerebral lesions.

Main Outcome Measures

Urinary symptoms, disability by means of the Glasgow Outcome Scale (GOS), and neuropsychological status by means of the Neurobehavioral Rating Scale (NBRS), and the relationships among them.

Results

Of the 57 patients studied, 30 had overactive bladder (urge incontinence) symptoms, 28 had detrusor overactivity, and 18 had detrusor underactivity with associated pseudodyssynergia in 15 of these patients. Eleven patients had hypertrophic bladder; 3, bilateral pyelectasia; and 2, vesicoureteral reflux. Disability measured by GOS was severe in 8 patients and moderate in 27, while recovery was good in 22 patients. The mean NBRS total score indicated a mild cognitive impairment. Neuroimaging showed diffuse brain injury in all patients. Statistically significant relationships were found between urge incontinence, detrusor overactivity, and poor neurologic functional outcome, between detrusor overactivity and right hemisphere damage (P=.0001), and between impaired detrusor contractility and left hemisphere injuries (P=.0001).

Conclusions

Most patients who recovered from coma resulting from TBI have symptoms of overactive bladder syndrome and voiding difficulties. These urinary problems correlate with cerebral involvement and neurologic functional outcome.