Lawrence J. Horn

Longitudinal outcome of patients with disordered consciousness in the NIDRR TBI model systems programs

Few studies address the course of recovery from prolonged disorders of consciousness (DOC) after severe traumatic brain injury (TBI). This study examined acute and long-term outcomes of persons with DOC admitted to acute inpatient rehabilitation within the National Institute on Disability and Rehabilitation Research (NIDRR) TBI Model Systems Programs (TBIMS). Of 9028 persons enrolled from 1988 to 2009, 396 from 20 centers met study criteria. Participants were primarily male (73%), Caucasian (67%), injured in motor vehicle collision (66%), with a median age of 28, and emergency department Glasgow Coma Scale (GCS) score of 3. Participant status was evaluated at acute rehabilitation admission and discharge and at 1, 2, and 5 years post-injury. During inpatient rehabilitation, 268 of 396 (68%) regained consciousness and 91 (23%) emerged from post-traumatic amnesia (PTA). Participants demonstrated significant improvements on GCS (z=16.135, p≤0.001) and Functional Independence Measure (FIM) (z=15.584, p≤0.001) from rehabilitation admission (median GCS=9; FIM=18) to discharge (median GCS=14; FIM=43). Of 337 with at least one follow-up visit, 28 (8%) had died by 2.1 years (mean) after discharge. Among survivors, 66 (21%) improved to become capable of living without in-house supervision, and 63 demonstrated employment potential using the Disability Rating Scale (DRS). Participants with follow-up data at 1, 2, and 5 years post-injury (n=108) demonstrated significant improvement across all follow-up evaluations on the FIM Cognitive and Supervision Rating Scale (p<0.01). Significant improvements were observed on the DRS and FIM Motor at 1 and 2 years post-injury (p<0.01). Persons with DOC at the time of admission to inpatient rehabilitation showed functional improvement throughout early recovery and in years post-injury.

The effect of a Web-based stroke intervention on carers' well-being and survivors' use of healthcare services

Purpose. We hypothesised that carers of stroke survivors who participate in the Web-based intervention, Caring∼Web©, would have higher well-being than non-Web users. We also postulated that those survivors whose carers participated in Caring∼Web would use fewer healthcare services. Method. A randomised, two-group, repeated measures design was used. Subjects were recruited from four rehabilitation centres from which first-time stroke survivors were discharged to home in two Midwestern states. Of 144 carers screened, 103 carers of these survivors who were novice Internet users were assigned to a Web or non-Web user group. Seventy-three subjects completed the study. Intervention. Caring∼Web was a Web-based intervention of education and support provided to the Web user group for 1 year. A bi-monthly telephone survey collected data on all carers well-being (perceived depression, life satisfaction) and survivors healthcare service use (self-reported provider and emergency department visits, hospital re-admissions, nursing home placement). Results. No statistical differences were found between the groups in carers well-being or in the number of provider visits for survivors. There were significant differences in emergency department visits (p = 0.001) and hospital re-admissions (p = 0.0005) related to the health of survivors. Conclusions. This Web-based intervention helped new carers make informed decisions about healthcare needs of stroke survivors, thus reducing service use.

Functional Outcomes in Traumatic Disorders of Consciousness: 5-Year Outcomes From the National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems

OBJECTIVE To characterize the 5-year outcomes of patients with traumatic brain injury (TBI) not following commands when admitted to acute inpatient rehabilitation. DESIGN Secondary analysis of prospectively collected data from the National Institute on Disability and Rehabilitation Research-funded Traumatic Brain Injury Model Systems (TBIMS). SETTING Inpatient rehabilitation hospitals participating in the TBIMS program. PARTICIPANTS Patients (N=108) with TBI not following commands at admission to acute inpatient rehabilitation were divided into 2 groups (early recovery: followed commands before discharge [n=72]; late recovery: did not follow commands before discharge [n=36]). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES FIM items. RESULTS For the early recovery group, depending on the FIM item, 8% to 21% of patients were functioning independently at discharge, increasing to 56% to 85% by 5 years postinjury. The proportion functioning independently increased from discharge to 1 year, 1 to 2 years, and 2 to 5 years. In the late recovery group, depending on the FIM item, 19% to 36% of patients were functioning independently by 5 years postinjury. The proportion of independent patients increased significantly from discharge to 1 year and from 1 to 2 years, but not from 2 to 5 years. CONCLUSIONS Substantial proportions of patients admitted to acute inpatient rehabilitation before following commands recover independent functioning over as long as 5 years, particularly if they begin to follow commands before hospital discharge.

Do Rehospitalization Rates Differ Among Injury Severity Levels in the NIDRR Traumatic Brain Injury Model Systems Program

OBJECTIVE To compare the rate and nature of rehospitalization in a cohort of patients enrolled in the National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems (TBIMS) who have disorders of consciousness (DOC) at the time of rehabilitation admission with those in persons with moderate or severe traumatic brain injury (TBI) but without DOC at rehabilitation admission. DESIGN Prospective observational study. SETTING Inpatient rehabilitation within TBIMS with annual follow-up. PARTICIPANTS Of 9028 persons enrolled from 1988 to 2009 (N=9028), 366 from 20 centers met criteria for DOC at rehabilitation admission and follow-up data, and another 5132 individuals met criteria for moderate (n=769) or severe TBI (n=4363). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Participants and/or their family members completed follow-up data collection including questions about frequency and nature of rehospitalizations at 1 year postinjury. For the subset of participants with DOC, additional follow-up was conducted at 2 and 5 years postinjury. RESULTS The DOC group demonstrated an overall 2-fold increase in rehospitalization in the first year postinjury relative to those with moderate or severe TBI without DOC. Persons with DOC at rehabilitation admission have a higher rate of rehospitalization across several categories than persons with moderate or severe TBI. CONCLUSIONS Although the specific details of rehospitalization are unknown, greater injury severity resulting in DOC status on rehabilitation admission has long-term implications. Data highlight the need for a longitudinal approach to patient management.

Poster 446: Acute Deep Venous Thrombosis Associated With Botulinum Toxin Injection: A Case Report

Disclosures: H. Wang, None. Objective: To study the association of time to inpatient rehabilitation hospital (IRH) admission and functional outcomes of stroke patients. Design: A retrospective cohort study. Setting: A regional IRH. Participants: Moderately (n 614) and severely (n 1294) impaired stroke patients admitted to the facility between 2002 and 2006. Interventions: Not applicable. Main Outcome Measures: Changes of total, motor, and cognitive functional independence measures (FIM) between admission and discharge. Results: Time from stroke onset to IRH admission was significantly associated with functional gain of stroke patients, after controlling for patient social demographics and other medical conditions. Patients in the moderately impaired stroke group had a higher total FIM gain when admitted to IRH within 21 days of stroke. Patients in the severely impaired stroke group showed a gradient relationship between time to IRH admission and total FIM gain: patients admitted within 30 days of stroke had a statistically significant higher total FIM gain than those admitted after 30 days of stroke; patients admitted within 60 days of stroke had a statistically significant higher total FIM gain than those admitted after 60 days of stroke. Results of multiple regression analysis also showed that a younger age and prescription of certain medications were strong predictors for improvement of all functional outcomes under study; race/ethnicity, type and side of stroke, history of a previous stroke, functional measures at IRH admission, IRH length of stay (LOS) were associated with the corresponding total, motor, and cognitive FIM score changes. Conclusions: Earlier transfer to an IRH and medication prescription were significantly associated with the improvement of total, motor and cognitive functions for patients in both moderately and severely impaired stroke groups. Age, race/ethnicity, initial medical, and functional measures, and IRH LOS also contributed to the study outcomes.