From Shunt to Recovery: A Multidisciplinary Approach to Hydrocephalus Treatment in Severe Acquired Brain Injury Rehabilitation

Background: Hydrocephalus among Severe Acquired Brain Injury (SABI) patients remains overlooked during rehabilitation. Methods: A retrospective cohort study was carried out of traumatic and non-traumatic SABI patients with hydrocephalus, consecutively admitted over 9 years in a tertiary referral specialized rehabilitation hospital. Patients were treated with ventriculoperitoneal shunt before or during inpatient rehabilitation and assessed using the Level of Cognitive Functioning Scale and Disability Rating Scale. Logistic regression models were used to identify predictors of post-surgical complications. Linear regression models were used to investigate predictors of hospital length of stay (LOS), disability, and cognitive function. Results: Of the 82 patients, 15 had post-surgical complications and 16 underwent cranioplasty. Shunt placement complication risk was higher when fixed vs. when programmable pressure valves were used. A total of 56.3% achieved functional improvement at discharge and 88.7% improved in cognitive function; of the 82 patients, 56% were discharged home. In multiple regression analyses, higher disability at discharge was related to cranioplasty and longer LOS, while poorer cognitive function was associated with cranioplasty. Increase in LOS was associated with increasing time to shunt and decreasing age. Conclusions: A significant improvement in cognitive and functional outcomes can be achieved. Cranioplasty increased LOS, and fixed pressure valves were related to poorer outcomes.

Scoping review to identify and map non-pharmacological, non-surgical treatments for dysphagia following moderate-to-severe acquired brain injury

IntroductionDysphagia is a common and critical consequence of acquired brain injury (ABI) and can cause severe complications. Dysphagia rehabilitation is transforming from mainly compensatory strategies to the retraining of swallowing function using principles from neuroscience. However, there are no studies that map interventions available to retrain swallowing function in patients with moderate-to-severe ABI.ObjectiveTo systematically map the accessible research literature to answer the research question: Which non-surgical, non-pharmacological interventions are used in the treatment of dysphagia in patients with moderate and severe ABI in the acute and subacute phase?DesignScoping review based on the methodology of Arksey and O’Malley and methodological advancement by Levac et al.Data sourcesMEDLINE, Embase, Cochrane Library, CINAHL, PsycINFO, Web of Science, OTseeker, speechBITE and PEDro were searched up until 14 March 2021.Eligibility criteriaAll studies reporting rehabilitative interventions within 6 months of injury for patients with moderate-to-severe ABI and dysphagia were included.Data extraction and synthesisData was extracted by two independent reviewers and studies were categorised based on treatment modality.ResultsA total of 21 396 records were retrieved, and a final of 26 studies were included. Interventions were categorised into cortical or non-cortical stimulation of the swallowing network. Cortical stimulation interventions were repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation. Non-cortical were complex swallowing interventions, neuromuscular electrical stimulation, pharyngeal electrical stimulation (PES), sensory stimulation, strengthening exercises and respiratory muscle training.ConclusionThis scoping review provides an overview of rehabilitative dysphagia interventions for patients with moderate and severe ABI, predominantly due to stroke, in the acute and subacute phase. Positive tendencies towards beneficial effects were found for rTMS, complex swallowing interventions, PES and cervical strengthening. Future studies could benefit from clear reporting of patient diagnosis and disease severity, the use of more standardised treatment protocols or algorithms and fewer but standardised outcome measures to enable comparison of effects across studies and interventions.

Value and Cost Savings From Access to Multi-disciplinary Rehabilitation Services After Severe Acquired Brain Injury

Acquired brain injury (ABI) is a major global public health problem and source of disability. A major contributor to disability after severe ABI is limited access to multidisciplinary rehabilitation, despite evidence of sustained functional gains, improved quality of life, increased return-to-work, and reduced need for long-term care. A societal model of value in rehabilitation matches patient and family expectations of outcomes and system expectations of value for money. A policy analysis of seven studies (2009–2019) exploring outcomes and cost-savings from access to multi-disciplinary rehabilitation identified average lifetime savings of $1.50M per person, with costs recouped within 18 months.Recommendations: Increase access to multi-disciplinary rehabilitation following severe ABI; strengthen prevention focus; increase access to case management; support return-to-work; and systematically collect outcome and cost data.

Revisiting the diagnostic criteria for emergence from the minimally conscious state: An empirical investigation

Objective: To determine whether consistent command-following (CCF) should be added to the diagnostic criteria for emergence from the minimally conscious state (MCS) Design: Retrospective cohort study Setting: Inpatient rehabilitation hospital Participants: Patients with severe acquired brain injury and disorders of consciousness (DoC) admitted to a specialized rehabilitation program Main Outcome Measure: Difference between time to recovery of CCF and time to recovery of functional object use [FOU] or functional communication [FC] (the two existing criteria for emergence from MCS) as measured by the Coma Recovery Scale-Revised [CRS-R]). Results: Of 214 patients (median [interquartile range] age: 53 [34, 66] years, male: 134 (62.6%), traumatic etiology: 115 (53.7%), admission CRS-R total score: 10 [7, 13]) admitted to rehabilitation without CCF, FO, or FC, 162 (75.7%) recovered CCF and FOU or FC during the eight-week observation period. On average, recovery of CCF, FOU, and FC was observed within one day of one another, approximately 46 [38.25, 58] days post-injury. One hundred and sixteen patients (71.6%) recovered FOU or FC prior to or at the same time as CCF. Conclusions: In patients recovering from DoC, CCF reemerges around the same time as FOU and FC. This finding likely reflects the shared dependency of these behaviors on cognitive procecess (e.g., language comprehension, attention, motor control) that are essential for effective interpersonal interaction and social participation. Our results support the addition of CCF to the existing diagnostic criteria for emergence from MCS.

Pictures and a thousand words: the experiences of significant others whose loved ones have a severe brain injury who are being discharged home

Purpose: To investigate the experiences of significant others when their loved one with a severe acquired brain injury (ABI) is being discharged from an ABI-specific rehabilitation unit. Participants: Significant others of loved ones with an ABI participated in interviews close to their loved ones being discharged from inpatient ABI rehabilitation. Methods: Semi-structured interviews were conducted, and thematic analysis applied. Additionally, the drawing method was also used which involved participants drawing what it was like for them as their loved one was going home. Image analysis was then combined with the interview data. Results: Eight significant others participated in interviews on discharge and completed a drawing describing their experience. Five themes were identified (Change, Mixed feelings, Support of family and friends, Journey and Staff interactions). Conclusion: The experience of having a loved one with a severe ABI in rehabilitation is an emotional event. Compassionate communication, consistency of information and thorough discharge planning practices were cornerstones to enhancing the experience of significant others, empowering them to undertake their new role.