Traumatic brain injury rehabilitation: case management and insurance-related issues

Traumatic brain injury (TBI) cases are medically complex, involving the physical, cognitive, behavioral, social, and emotional aspects of the survivor. Often catastrophic, these cases require substantial financial resources not only for the patient's survival but to achieve the optimal outcome of a functional life with return to family and work responsibilities for the long term. TBI cases involve the injured person, the family, medical professionals such as treating physicians, therapists, attorneys, the employer, community resources, and the funding source, usually an insurance company. Case management is required to facilitate achievement of an optimal result by collaborating with all parties involved, assessing priorities and options, coordinating services, and educating and communicating with all concerned.     

Traumatic amputation. Mechanisms of injury, treatment, and rehabilitation

Traumatic amputations are one of many injuries that can occur to the body's musculoskeletal systems. Degloving, partial and total amputations are common types of traumatic injuries. Since traumatic amputations are very life threatening, emergency treatment must be initiated quickly and directed toward profuse blood loss and potential hypovolemia. Not only do traumatic amputees undergo extreme physiological changes, but they must also encounter the psychological trauma of an amputation. Due to a loss of body part(s) and alteration in body image, the amputee often experiences the stages of grieving which may take months and years to resolve. Extensive rehabilitation with the use of an interdisciplinary team approach is one of the most successful ways to return the amputee to the work place. A combination of occupational therapy, physical therapy, vocational rehabilitation and psychological support generally promote a sense of well being and return the traumatic amputee to a level of independence.     

集束化管理策略在重型颅脑损伤患者早期康复护理中的应用

目的 探讨集束化管理策略在重型颅脑损伤(STBI)患者早期康复护理中的应用效果.方法 选择2019年1月—2020年12月医院重症医学科收治的86例STBI患者作为研究对象,按照组间基本特征匹配的原则分为对照组与观察组,每组43例.对照组采用常规疗护方法,观察组采取集束化管理策略,比较两组护理效果.结果 护理管理3个月...     

Traumatic brain injury and pain

The co-occurrence of traumatic brain injury (TBI) and pain is quite frequent and presents a number of challenges to the medical practitioner. The distinct nature and extent of these challenges calls for considering the co-existence of TBI and pain a unique medical entity. Clearly, from a research standpoint, the area is in its infancy. The clinician is often left with adapting standard techniques effective for evaluating and treating pain in patients without TBI. Such adaptations require a readiness to recognize how pain affects the presence and course of TBI-related symptoms and, in turn, how TBI symptoms affect the presence and course of pain. Given the myriad factors that can affect outcome, effective evaluation and treatment of this co-occurring problem need to rely on a biopsychosocial model, which encourages consideration of a broad perspective of possible causes and care approaches as well as use of multiple disciplines.     

Traumatic brain injury resiliency model: a conceptual model to guide rehabilitation research and practice

Abstract

There is a growing trend in traumatic brain injury (TBI) rehabilitation, and research, to focus on the processes of adaptation following the injury. Resiliency is an umbrella term describing the range of personal protective factors, environmental supports and resources, as well as self-regulatory processes, engaged in response to adversity. An affective, cognitive, and behavioural self-regulatory process model of resiliency in the workplace was adapted to suit the TBI context. Through a narrative review of the literature pertaining to brain injury rehabilitation, participation, and resilience, we substantiated the model, and explained how resiliency can frame research on life experiences following the injury. TBI represents a cascading adversity as the injury and subsequent life experiences (e.g., job loss) shape adaptation. Resiliency is shaped by: personal characteristics (e.g., hope, social functioning, self-awareness, memory, spirituality, coping, and self-efficacy), environmental resources/supports (e.g., services and social support), and self-regulatory processes that lead to the resiliency-related outcomes, which we suggest involve re-engaging in activities, adapting participation, and reconstructing identity. This conceptual model outlines and defines the factors and processes operating and contributing to resiliency following TBI. Recommendations for future research are outlined.

• Implications for rehabilitation

• Investigating resiliency processes can move the traumatic brain injury field beyond examining individual traits and protective factors, to transactional processes that influence participation experiences and opportunities over time.

• The Traumatic Brain Injury Resiliency Model can be used to frame the targets and desired outcomes of rehabilitation interventions, such as self-regulatory processes or environmental supports known to enhance resiliency.

• Studying resiliency will help to shift the paradigms of traumatic brain injury research, and rehabilitation practice, to a focus on life experiences and adaptation, helping individuals, clinicians, and families consider processes of positive change, rather than focusing solely on adversity.

     

Progress assessed with the Mayo-Portland Adaptability Inventory in 604 participants in 4 types of post-inpatient rehabilitation brain injury programs

Eicher V, Murphy MP, Murphy TF, Malec JF. Progress assessed with the Mayo-Portland Adaptability Inventory in 604 participants in 4 types of post–inpatient rehabilitation brain injury programs.ObjectiveTo compare progress in 4 types of post–inpatient rehabilitation brain injury programs.DesignQuasiexperimental observational cohort study.SettingCommunity and residential.ParticipantsIndividuals (N=604) with acquired brain injury.InterventionsFour program types within the Pennsylvania Association of Rehabilitation Facilities were compared: intensive outpatient and community-based rehabilitation (IRC; n=235), intensive residential rehabilitation (IRR; n=78), long-term residential supported living (SLR; n=246), and long-term community-based supported living (SLC; n=45). With the use of a commercial web-based data management system developed with federal grant support, progress was examined on 2 consecutive assessments.Main Outcome MeasureMayo-Portland Adaptability Inventory (MPAI-4).ResultsProgram types differed in participant age (F=10.69, P<.001), sex (χ²=22.38, P<.001), time from first to second assessment (F=20.71, P<.001), initial MPAI-4 score (F=6.89, P<.001), and chronicity (F=13.43, P<.001). However, only initial MPAI-4 score and chronicity were significantly associated with the second MPAI-4 rating. On average, SLR participants were 9.1 years postinjury compared with 5.1 years for IRR, 6.0 years for IRC, and 6.8 years for SLC programs. IRR participants were more severely disabled per MPAI-4 total score on admission than the other groups. Controlling for these variables, program types varied significantly on second MPAI-4 total score (F=5.14, P=.002). Both the IRR and IRC programs resulted in significant functional improvement across assessments. In contrast, both the SLR and SLC programs demonstrated relatively stable MPAI-4 scores.ConclusionsResults are consistent with stated goals of the programs; that is, intensive programs resulted in functional improvements, whereas supported living programs produced stable functioning. Further studies using data from this large, multiprovider measurement collaboration will potentially provide the foundation for developing outcome expectations for various types of postacute brain injury programs.     

创伤性脑损伤的临床康复

创伤性脑损伤(traumaticbraininjury,TBI)在欧美发病率较高,初步统计是创伤性脊髓损伤的30～40倍,在某些方面,接近于脑卒中的发病率。病因多为交通事故、体育活动、工伤和暴力袭击。患者主要为青年男性,美国统计,15～24岁青年男性的发病率≥550人/100000人口。严重TBI的良好结局依赖于长期的综合性康复治疗,大多数患者的社会生活能力较差,家庭和社会为此负担较大。     

Assessing organizational performance in intensive care units: a French experience

OBJECTIVE: The objective of the study was to assess and to explain variation of organizational performance in intensive care units (ICUs). DESIGN: This was a prospective multicenter study. SETTING: The study involved 26 ICUs located in the Paris area, France, participating in a regional database. METHODS: Data were collected through answers of 1000 ICU personnel to the Culture, Organization, and Management in Intensive Care questionnaire and from the database. Organizational performance was assessed through a composite score related to 5 dimensions: coordination and adaptation to uncertainty, communication, conflict management, organizational change, and organizational learning, Skills developed in relationship with patients and their families. Statistical comparisons between ICUs were performed by analysis of variance with a Scheffé pairwise procedure. A multilevel regression model was used to analyze both individual and structural variables explaining differences of ICU's organizational performance. RESULTS: The organizational performance score differed among ICUs. Some cultural values were negatively correlated with a high level of organizational performance, suggesting improvement potential. Several individual and structural factors were also related to the quality of ICU organization, including absence of burnout, older staff, satisfaction to work, and high workload (P < .02 for each). CONCLUSIONS: A benchmarking approach can be used by ICU managers to assess the organizational performance of their ICU based on a validated questionnaire. Differences are mainly explained by cultural values and individual well-being factors, introducing new requirements for managing human resources in ICUs.     

颅脑损伤术后再出血临床分析

目的:探讨颅脑损伤颅内血肿术后再手术原因,减少再次手术,提高颅脑损伤救治成功率。方法:回顾性分析我院55例颅脑损伤颅内血肿清除术后再手术的原因及其导致再手术影响因素。结果:再手术的原因为迟发性血肿21例(36%)、止血不彻底10例(18%)、术中低血压7例(12%)、凝血障碍6例(11%)、骨窗过小5例(9%)、脑梗死5例(9%)。结论:广泛性脑挫裂伤伴颅骨折为术后颅内再出血手术的高危因素,而首次手术要彻底清除挫碎失活脑组织、直视下彻底止血、术中维持正常血压、对凝血障碍患者术中及时输入新鲜血浆、冷沉淀、血小板及时补充凝血因子可以减少再手术的可能。     

Comprehensive rehabilitation of closed injury of brain

Objective:To observe the effect of physical factors and promotion canalization on closed injury of brain,Method:68 cases of closed injury of brain were given the comprehensive rehabilitation therapy with many physical factors and promoting canalization technique,Result:The patients‘ consciousnesses were significantly improved after treatment.The motorial function of hemiplegic limbs was distinctly improved(P&;lt;0.05).The balance functions were distinctly improved (P&;lt;0.001).The activities of daily living abilities were significantly improved (P&;lt;0.05).Conclusion:The physical factors and promoting canalization treatment on the closed injury of brain are functionally effective.     

Pushing the frames of reference in traumatic brain injury rehabilitation

Cognitive rehabilitation is an empirically based field driven by multiple sources of activities and knowledge bases. Drawing on frames of reference provided by rehabilitation, neuropsychology, and rehabilitation psychology, cognitive rehabilitation has evolved to a point where studies have been generated to qualify for consideration in tables of evidence. At the center of cognitive rehabilitation is the effort to teach people to overcome or adapt to limitations. While rehabilitation has traditionally been focused on activity, a recent trend in the literature is to incorporate the individuals experience into a frame of reference for rehabilitation. Emphasizing the experience of the person in the situation fits into cognitive rehabilitation and raises the bar for rehabilitation not only in viewing rehabilitation as an activity to relieve burdens but also in terms of how rehabilitants come to grips with limitations. Dealing with limitations is an important indicator of mental health.     

Traumatic brain injury is under-diagnosed in patients with spinal cord injury.

OBJECTIVE: To investigate the occurrence and severity of traumatic brain injury in patients with traumatic spinal cord injury. DESIGN: Cross-sectional study with prospective neurological, neuropsychological and neuroradiological examinations and retrospective medical record review. PATIENTS: Thirty-one consecutive, traumatic spinal cord injury patients on their first post-acute rehabilitation period in a national rehabilitation centre. METHODS: The American Congress of Rehabilitation Medicine diagnostic criteria for mild traumatic brain injury were applied. Assessments were performed with neurological and neuropsychological examinations and magnetic resonance imaging 1.5T. RESULTS: Twenty-three of the 31 patients with spinal cord injury (74%) met the diagnostic criteria for traumatic brain injury. Nineteen patients had sustained a loss of consciousness or post-traumatic amnesia. Four patients had a focal neurological finding and 21 had neuropsychological findings apparently due to traumatic brain injury. Trauma-related magnetic resonance imaging abnormalities were detected in 10 patients. Traumatic brain injury was classified as moderate or severe in 17 patients and mild in 6 patients. CONCLUSION: The results suggest a high frequency of traumatic brain injury in patients with traumatic spinal cord injury, and stress a special diagnostic issue to be considered in this patient group.     

功能磁共振成像在脑损伤康复期演变中的应用

脑损伤患者在康复过程中会伴有不同程度的脑组织重塑和功能重组.功能磁共振成像(fMRI)能够获得脑组织的解剖学、生理学及病理学信息,并且在一定程度上反映各功能区间的相互联系.因此.fMRI技术能够反映脑损伤康复过程中脑组织发生的结构和功能变化,为临床开展有针对性的治疗提供有价值的信息.     

创伤性颅脑损伤康复治疗患者相关因素的回顾性分析

目的了解接受康复治疗的创伤性颅脑损伤(TBI)患者的一般情况、康复治疗时间、并发症等情况。方法回顾性分析北京博爱医院神经康复科1993年9月~2004年7月入院的所有TBI病例。结果共有280例TBI住院患者,平均发病年龄(33.1±11.4)岁,男女比为4.28∶1,职业构成以机关干部为主(占34.6%),报销方式也以公费医疗最多(占71.1%)。受伤原因以交通事故为主(占66.4%)。入院时距离受伤日期10 d~6年,平均288 d,在伤后3月内入院行康复治疗者占25.0%。继发癫痫者占15.7%,住院期间发现有脑积水者占18.9%。结论目前我国因TBI住院康复治疗的群体主要为城市男性居民、享受公费医疗待遇者;TBI急性期和亚急性期的康复流程体系也有待建立和完善。     

脑损伤修复与成体干细胞的可塑性

目的成体干细胞体在内外可分化为神经细胞而用于脑损伤修复,探讨成体干细胞用于脑损伤康复的可行性可为脑功能恢复的临床实践提供前瞻性依据.资料来源应用计算机检索Medline 1998-01/2004-04和PubMed1998-01/2004-04期间的相关文章,检索词"stem cell,cerebral injury,rehabilitation",并限定文章语言种类为English.同时计算机检索<中国临床康复>杂志1997-01/2004-04期间的相关文章,限定文章语言种类为中文,检索词"干细胞、脑损伤、康复".资料选择对资料进行初审,选取包括成体干细胞分化为神经细胞及其用于脑损伤治疗的实验和l临床研究文献,查找文献全文.资料提炼共收集到33篇关于成体干细胞可塑性分化及其用于脑损伤的研究文献.资料综合33篇文献证明了成体干细胞可分化为神经细胞及其可能的机制,并证明了成体干细胞移植治疗脑损伤的有效性.结论已有研究充分证明成体干细胞在体内外可分化为神经细胞,并可用于脑损伤的修复.