Unni Sveen

Functional outcome and health-related quality of life 10 years after moderate-to-severe traumatic brain injury.

Objectives –  To describe the functional outcome and health‐related quality of life (HRQL) 10 years after moderate‐to‐severe traumatic brain injury (TBI).

Post-concussion symptoms after mild traumatic brain injury: influence of demographic factors and injury severity in a 1-year cohort study

Purpose. To assess the prevalence and variation of post-concussion symptoms within the first year after mild traumatic brain injury (TBI), and explore the association between injury severity, demographic factors and symptoms. Methods. Prospective study of patients with mild TBI followed up at 3, 6 and 12 months (N = 96 included, n = 52 attending all follow-ups). Sociodemographic factors, injury mechanisms and impact of injury (Glasgow Coma Scale score, Abbreviated Injury Severity Score (AIS), Injury Severity Score) were recorded at inclusion. Symptoms were reported in the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) at the follow-ups. The sumscore of all symptoms in RPQ was calculated for each subject. Scores were also calculated separately for the cognitive, physical and behavioural symptoms. Results. Twenty-nine subjects met the post-concussion syndrome criteria at 3 months, and 22 patients at 6 and 12 months. The cognitive symptoms were more prominent than the physical and behavioural symptoms. The cognitive and physical symptoms were associated with AIS for the head injury at 3 months, but not at 12 months. Considerable individual variability in the symptom pattern was found, and the subjects who attended only the 3-months follow-up reported a lower level of symptoms than those attending all follow-ups. Conclusions. Persistence of symptoms was a considerable problem even 1 year after the injury, with cognitive symptoms dominating. More severe AIS scores were associated with a higher level of cognitive and physical symptoms at 3 months, but not at later follow-ups. Strategies to prevent and treat these symptoms should be focussed in clinical practice.

Are there gender differences in functional outcome after stroke

Purpose: To study gender differences in functional outcome unexpectedly observed in a follow-up study of stroke patients. Design: Prospective study of hospitalized stroke patients, with evaluations in the subacute phase and after one year. Setting: Geriatric and general medical wards, and geriatric outpatient clinic of a university hospital serving as general hospital for a defined population. Subjects: All stroke patients admitted during a six-month period (n = 165) were considered for inclusion, of whom 87 could be assessed in the subacute phase and 65 after one year. Main outcome measures: Motor function assessed by the Sodring Motor Evaluation of Stroke Patients; cognitive function by the Assessment of Stroke and other Brain Damage; and activities of daily living (ADL) function by the Barthel Index. Nursing-home residency registered after one year. Results: Men achieved a significantly better score than women on most of the scales used. The age-adjusted odds for a man to have a higher Barthel score than a woman was 3.1 (95% confidence interval (CI) 1.3-7.0) in the subacute phase and 3.3 (95% CI 1.2-9.0) after one year. Differences of the same magnitude were seen on the subscales of the motor and cognitive tests. The same trend was observed on all items of the Barthel Index. The males had a lower likelihood to be permanent nursing-home residents after one year, the age-adjusted odds ratio for nursing-home residency for females versus males being 6.3 (95% CI 1.2-65.3). Conclusion: Women seem to be functionally more impaired by stroke than men.

Does an Early Onset and Continuous Chain of Rehabilitation Improve the Long-Term Functional Outcome of Patients with Severe Traumatic Brain Injury?

There are currently no international guidelines regarding treatment in the early rehabilitation phase for persons with severe traumatic brain injury (TBI), and only a few studies have investigated the effect of integrating rehabilitation into acute TBI care. The aim of the study was to evaluate whether a continuous chain of rehabilitation that begins with the acute phase could improve the functional outcome of severe TBI patients, compared to a broken chain of rehabilitation that starts in the sub-acute phase of TBI. A total of 61 surviving patients with severe TBI were included in a quasi-experimental study conducted at the Level I trauma center in Eastern Norway. In the study, 31 patients were in the early rehabilitation group (Group A) and 30 patients were in the delayed rehabilitation group (Group B). The functional outcomes were assessed 12 months post-injury with the Glasgow Outcome Scale Extended (GOSE) and the Disability Rating Scale (DRS). A favorable outcome (GOSE 6-8) occurred in 71% of the patients from Group A versus 37% in Group B (p=0.007). The DRS score was significantly better in Group A (p=0.03). The ordinal logistic regression analysis was used to quantify the relationship between the type of rehabilitation chain and the GOSE. A better GOSE outcome was found in patients from Group A (unadjusted OR 3.25 and adjusted OR 2.78, respectively). These results support the hypothesis that better functional outcome occurs in patients who receive early onset and a continuous chain of rehabilitation.

Well-being and instrumental activities of daily living after stroke

Objective: To explore the relationship between subjective well-being and competence in instrumental activities of daily living after stroke. Design: Cross-sectional with evaluation at six months post stroke. Subjects: Eighty-two patients admitted to an acute stroke unit, of whom 64 were seen at six months. The mean age was 77.5 years, 55% were females and 55% were living alone. Main outcome measures: The General Health Questionnaire (GHQ-20 version), a well-being scale, was factor analysed and yielded three dimensions, named ‘coping’, ‘anxiety’ and ‘satisfaction’ that served as main outcomes. Results: Explanatory variables were the four subscales of the Nottingham IADL scale, the Ullevaal Aphasia Screening test, urinary continence and demographics. Structural equation modelling showed that the GHQ dimension ‘satisfaction’ related significantly to the Nottingham subscale ‘leisure activities’ (β = -0.38, p= 0.01), whereas ‘coping’ was indirectly associated with ‘leisure activities’ by its correlation with ‘satisfaction’ (R= 0.26, p= 0.01). None of the outcomes were statistically associated with aphasia, continence or the background variables. Conclusion: ‘Leisure activities’ demonstrated the strongest association to subjective well-being as expressed by the ‘satisfaction’ dimension. In stroke rehabilitation leisure activities should be addressed when assessing function and planning intervention.

Disability, physical health and mental health 1 year after traumatic brain injury

Purpose. The purpose of this study was to assess disability and the physical and mental health status 1 year after traumatic brain injury (TBI), using the International Classification of Functioning, Disability and Health (ICF) as a conceptual model for understanding TBI disability. Methods. A prospective study of 85 patients with moderate-to-severe TBI (aged 16–55 years) due to injury occurring from May 2005 to May 2007 and hospitalised at the Trauma Referral Centre in Eastern Norway were included. The severity of structural brain damage and overall trauma were used as indices of body structure impairments. Activity limitations were measured by the Functional Independence Measure, and participation restrictions were assessed via the Community Integration Questionnaire. Physical and mental health dimensions as reported on the Medical Outcome Survey Short-Form were chosen as outcome measures. Results. Roughly one quarter of the patients reported disability requiring personal assistance. One Quarter had major problems with social integration, and 42% were not working. Nearly half of the patients reported poor physical health, and 37% reported poor mental health. Regression models, including demographics, impairments, activity limitations and participation restrictions, accounted for 50% of the variance in physical health and 35% of the variance in mental health. More severe impairments, fewer activity limitations and fewer participation restrictions equated to better overall health. Conclusions. The results demonstrated that a significant proportion of TBI survivors face substantial disability and impaired overall health 1 year after injury. To optimise health and well-being outcomes, clinicians need to ensure that health needs of patients with less severe TBI are identified and treated during the post-acute period.

Early supported discharge of patients with acute stroke: a randomized controlled trial

Purpose: To evaluate the feasibility and effectiveness of early supported discharge (ESD) following acute stroke. Method: An ESD scheme was compared to conventional rehabilitation in a randomized controlled trial. All patients admitted with acute stroke were considered for inclusion. Eighty-eight (20.2%) were found to be eligible and 82 were randomized either to early supported discharge (n=42) or conventional rehabilitation (n=40). The primary outcome measure was the Nottingham Extended Activities of Daily Living Scale. The General Health Questionnaire, the Montgomery Aasberg Depression Rating Scale, mortality, placement and patient and carer satisfaction served as secondary outcome measures. Results: Median length of stay was reduced from 31 days in the conventional hospital rehabilitation group to 22 days in the early supported discharge group (p=0.09). No differences were found regarding primary outcome. The General Health Questionnaire score showed a significant difference in favour of the early supported discharge group at three months (19.5/24, p =0.02), but not at six. At six months, the proportion of patients being dead or in institution showed a trend of being higher in the conventional rehabilitation group (OR 3.8, 95 % CI 0.8-23). Conclusions: Early supported discharge after stroke is feasible and it is possible that it has benefits compared with conventional rehabilitation.

Self-rated competency in activities predicts functioning and participation one year after traumatic brain injury

Objective: To investigate whether the Patient Competency Rating Scale at three months predicts global functioning and participation one year after traumatic brain injury. Design: Prospective cohort study with follow-up at 3 and 12 months post injury. The Patient Competency Rating Scale was analysed in a logistic regression model with the outcomes Community Integration Questionnaire, Glasgow Outcome Scale Extended and return to work/study. Setting: The neurosurgical department of a trauma referral centre in a metropolitan hospital. Subjects: A cohort of 70 patients with acute traumatic brain injury, ranging from mild to severe injury. Main measures: The Patient Competency Rating Scale, assessing competency in activities, was applied as a predictor. Outcomes describing community participation at 12 months were the Community Integration Questionnaire and return to work/study. Global functioning was evaluated by the Glasgow Outcome Scale Extended. Results: Factor analysis of the Patient Competency Rating Scale items yielded three domains: activities demanding cognition, interpersonal/emotional skills, and activities of daily living (ADL) competency. The first two of these domains significantly predicted return to work/study and community integration, whilst global functioning at one year was predicted by interpersonal/emotional competency. Conclusions: The Patient Competency Rating Scale at three months predicted functioning and participation one year after traumatic brain injury. This indicates that rehabilitation interventions should focus on cognitive and interpersonal competency in order to enhance participation after traumatic brain injury.

CONSTRUCT DIMENSIONALITY AND PROPERTIES OF THE CATEGORIES IN THE ICF CORE SET FOR LOW BACK PAIN

OBJECTIVE The aim of this study was to explore by Rasch analysis whether the Comprehensive International Classification of Functioning, Disability and Health (ICF) Core Set might represent a future clinical tool for measuring functioning of patients with low back pain. Material and methodsThe Comprehensive ICF Core Set for low back pain was scored by health professionals for 118 patients with low back pain. Qualifier levels, invariance, construct validity and ordering of the categories in the components of Body function, Body structure, Activities and participation and Environmental factors were explored by Rasch analysis. RESULTS The number of qualifier levels had to be reduced. Categories within Body functions and within Environmental factors reflected a single underlying construct. The categories within the component of Activities and Participation did not meet the requirements of a single underlying construct in the present population. Few categories covered the problems reported by patients with a relatively high level of function. CONCLUSION Rasch analysis indicated that the Comprehensive ICF Core Set for low back pain may be used with some modification of categories as a common tool for assessing problems within the components Body functions, and Activity and Participation. However, detecting ICF categories that reflect the higher functional levels in patients with low back pain, and revision of the qualifier levels may be necessary.

Problems in functioning after a mild traumatic brain injury within the ICF framework: the patient perspective using focus groups

Purpose: To describe problems in body functions, activities, and participation and the influence of environmental factors as experienced after mild traumatic brain injury (TBI), using the ICF framework. To compare our findings with the Brief and Comprehensive ICF Core Sets for TBI. Methods: Six focus-group interviews were performed with 17 participants (nine women, eight men, age ranged from 22 to 55 years) within the context of an outpatient rehabilitation programme for patients with mild TBI. The interviews were transcribed verbatim and analysed using the ICF. Results: One-hundred and eight second-level categories derived from the interview text, showing a large diversity of TBI-related problems in functioning. Problems in cognitive and emotional functions, energy and drive, and in carrying out daily routine and work, were frequently reported. All ICF categories reported with high-to-moderate frequencies were present in the Brief ICF Core Set and 84% in the Comprehensive ICF Core Set. The reported environmental factors mainly concerned aspects of health and social security systems, social network and attitudes towards the injured person. Conclusions: This study confirms the diversity of problems and the environmental factors that have an impact on post-injury functioning of patients with mild TBI. Implications for Rehabilitation Disabilities related to cognitive and emotional functions, energy and drive, and carrying out daily routine and work should be addressed in rehabilitation of people with mild traumatic brain injury (TBI). Attention should be given to environmental facilitators and barriers for activities and participation. Participation in everyday life after a mild TBI, including social- and work-participation, constitutes a challenge where multidisciplinary rehabilitation efforts should be considered. The Brief Core Set does not attain all frequently observed categories of functioning among people with mild TBI.