Long-term Rehabilitation in Patients With Acquired Brain Injury

Abstract

Background: Patients with acquired brain injury who have been discharged from inpatient neurological rehabilitation often continue to suffer from limited independence, participation, and quality of life. Participation-focused outpatient treatment (in German: teilhabeorientierte ambulan.

Methods: In a randomized, controlled trial, 53 patients who had sustained an acquired brain injury approximately four years earlier were allotted to two different sequences of treatment (26 TEAM/control, 27 control/TEAM). The primary endpoint was the achievement of an individual participation goal one month after the start of treatment. The secondary endpoints included independence in everyday activities, health-related quality of life, participation, and need for nursing care. The intervention was four weeks long and was carried out on an outpatient basis (19.4 ± 1.3 hours per week). Patients in the control group were treated in a manner resembling usual current care. All endpoints were evaluated in a per-protocol (PP) analysis of data from 47 patients. For confirmation, an intention-to-treat (ITT) analysis was also carried out for the primary endpoint and for independence in everyday activities.

Results: According to the PP analysis, TEAM patients achieved their individual participation goals at 1 month more frequently than control patients receiving standard treatment (61% vs. 21%; p = 0.008) and improved more with respect to independence in everyday activities. The difference between TEAM and standard treatment was +7.3 points on the FIM (Functional Independence Measure) scale (95% confidence interval [2.8; 11.8]; p = 0.0024). The superiority of TEAM was confirmed by the ITT analysis (achievement of the participation goal, TEAM vs. standard treatment: 54% vs. 19%, p = 0.0103). Moreover, improvements were seen at 12 months in quality of life, participation, and the need for nursing care.

Conclusion: The TEAM rehabilitation program can help patients in the chronic phase of acquired brain injury achieve participation goals that are relevant to everyday life. An adjustment of the care structure in Germany to include such intensive goal-oriented rehabilitation programs would lead to a more effective mobilization of these patients' potential for long-term rehabilitation.

Figure 1

Changes in various domains and outcomes during the one-year trial period. Significance data according to t-test for matched samples (2-tailed). For FIM, EQ-5D, and SF-36, an increase in score reflects an improvement between the beginning and end of the trial. For WHODAS and NAA, in contrast, a decrease in score reflects an improvement (reduced participation restriction or reduced care needs). EQ-5D, EuroQol Quality of Life questionnaire; FIM, Functional Independence Measure; NAA, New Appraisal Assessment: Nursing Care; SF-36, Short-Form 36 quality of life questionnaire; WHODAS, WHO Disability Assessment Schedule for activity limitation and participation restriction

Figure 2

Changes in FIM (?FIM) during trial, from initial value at beginning of trial, by treatment group. Significance data are from t-tests for independent samples (2-tailed) at each point in time. TEAM treatment was administered to the TEAM group between T1 and T2 and to the control group between T3 and T4. FIM, Functional Independence Measure; TEAM, participation-focused outpatient program

Figure 3

Attainment of independence and participation goals in daily life following acquired brain injury in relation to therapy and care structure a) Current care structure: in the rehabilitation phase model, there is a very dynamic increase in independence and attainment of individual participation goals in the first weeks and months. After rehabilitation ends, typical therapeutic practice leads to only small improvements, or even to a plateau. b) The addition of intensive therapy phases (e.g. TEAM) can always allow new individual participation goals to be attained, and there is a sustained improvement in independence.

eFigure 1

TEAM trial design and conduct TEAM: Participation-focused outpatient program

eFigure 2

CONSORT flow diagram showing details on trial enrolment, randomization to the two treatment orders, and patient flow

eFigure 3

Goal attainment (%) for individual participation goals at each visit, as percentages of the total trial population (n = 47)