The rehabilitation of patients with ABI involves a comprehensive effort by an interdisciplinary team including physicians, nurses, physical therapists, speech-language pathologists, occupational therapists, and social workers. Considering the incidence and consequences of ABI, it is important to understand the effectiveness of rehabilitation.
While many patients with ABI are discharged directly home or to a long term care facility, others are discharged to a dedicated inpatient rehabilitation service. These services vary from institution to institution but generally include some type of intensive therapy program for physical, social, behavioral and cognitive difficulties. Deciding who should receive inpatient rehabilitation remains a major challenge. Patient referral decisions are inherently complex and need to be understood as a dynamic phenomenon shaped by characteristics of the individual. However, they also rely on the interactions and interpretations of health professionals who operate within unique organizational and broader health care contexts (Foster & Tilse 2003). These decisions are also influenced by social and funding issues. For example, in the US patients insured by Medicaid or a Healthcare Maintenance Organization were more likely to go to a skilled nursing facility, rather than inpatient rehabilitation, relative to people with commercial fee-for-service plans (Chan et al. 2001). In Canada, patients aged 36 to 45 years old with more co-morbid conditions are more likely to receive rehabilitation than those older than 65, rural dwellers, non-English speaking people and individuals with mental health, alcohol and/or drug problems (Colantonio et al. 2004). The diversity of patient needs has also led to the formation of differing systems of rehabilitation. In Calgary, for instance, the Halvar Johnson Centre has established a slow stream rehabilitation program for individuals with TBI who may require slightly extended care.
Due to the unique challenges posed by ABI, the structure of inpatient rehabilitation is extremely diverse. Patients are generally rehabilitated in one of two centers: a general rehabilitation unit or a coordinated multidisciplinary neurorehabilitation unit. Some argue that an effective rehabilitation service requires a multidisciplinary team, which includes nursing care, physician monitoring, psychologist and social work intervention, physiotherapists, occupational therapists, and speech language pathologists, among other things (Cifu et al. 2003). In reality, differences in care often amount simply to the availability of neuro-rehabilitative beds and facilities. Limited resources mandate decisions regarding which patients will benefit most from inpatient rehabilitation compared to community-based programs.
Debate also exists about appropriate targets of rehabilitative care. Traditional rehabilitation models in other disciplines such as stroke, spinal cord, and polio have focused on orthopedic and neuromotor impairments (Cope et al. 2005). Brain Injury rehabilitation initially followed a similar path; however, an increased focus was then placed on cognitive and behavioral remediation (Mazaux & Richer 1998), as well as coma stimulation (Cope et al. 2005). Patients in need of skill application training are often discharged to community based services while inpatient rehabilitation has focused more on intensive, short term physical or cognitive rehabilitation (Evans 1997). Furthermore, some inpatient facilities have recognized the need to divide patients into different streams during rehabilitation. At the Toronto Rehabilitation Institute, for example, patients have been streamed into a Neurocognitive group and a Neurophysical group since 2002 (Cullen 2007). Patients in the Neurophysical stream showed similar Functional Independence Measure (FIM) gains compared to patients before the streaming began, although the neurophysical stream had significantly shorter LOS.
Inpatient rehabilitation typically begins when a patient is medically stable enough to be transferred out of acute care and into a dedicated rehabilitation unit for a defined period of interdisciplinary rehabilitation. There is a great deal of variability in the length, type, and intensity of services provided in programs throughout the world. As such, we delineate the evidence supporting the various aspects of treatment for inpatient care delivery.
Functional outcome after discharge from inpatient rehabilitation was evaluated in a number of studies. The FIM was the most frequently used assessment tool, with numerous studies showing a significant improvement for this measure during inpatient rehabilitation (Bender et al. 2014; Cullen et al. 2013; Gray & Burnham 2000; Kim & Colantonio 2013; Whitlock 1992; Whitlock & Hamilton 1995). Bender et al. (2014) reported an improvement in FIM scores during early rehabilitation, community care, and inpatient interval rehabilitation, with benefits that lasted up to one and a half years, despite the therapy only lasting six to seven weeks. Bender et al. (2014) also report that patients who entered the interval rehabilitation program demonstrated improvement-rate increases comparable to initial rehabilitation levels, where the greatest gains are said to be made, highlighting the benefit ofor additional rehabilitation at later stages of recovery. This point has been made by earlier studies as well. A study noted that 53% of patients readmitted to inpatient rehabilitation at more than 12 months post-injury showed statistically significant improvement (p=0.0001) on BI scores from readmission to discharge (Tuel et al. 1992).
Cullen et al. (2013) found some evidence for a streamed model of treatment depending on patient needs; patients in a neuro-physical group had a higher FIM efficiency than controls receiving traditional neurorehabilitation. However, the total FIM gains and total FIM efficiency was not significantly different between groups (Cullen et al. 2013). Two groups that did differ significantly in terms of FIM gains were those who discharged themselves against medical advice and patients who were given a regular discharge, the latter groups’ FIM gains being two times higher (Kim & Colantonio 2013). Not only do patients make physical gains from inpatient rehabilitation, but Whitlock and Hamilton (1995) revealed that motor and cognitive improvements run parallel to each other with only a small number of patients making gains in one and not the other.
One study found that 35% of subjects experienced good outcome or moderate disability at six months post-injury, as measured by GOS scores (Whitlock 1992). According to Cullen (2007), rehabilitation in Canada, on average, discharges 80% of patients home. However, patients who sustained a TBI caused by physical assault are less likely to be discharged home and demonstrate poorer functional gains at discharge from inpatient rehabilitation (Kim & Colantonio 2013).
There is Level 2 evidence that traditional rehabilitation and functionally based rehabilitation programs result in similar total Functional Independence Measures (FIM) gains; however, patients in a neuro-physical rehabilitation program have higher FIM motor efficiency than patients in traditional rehabilitation.
There is Level 3 evidence that patients discharged from rehabilitation make greater Functional Independence Measure gains than individuals discharged against medical advice.
There is Level 3 evidence that patients with ABI are able to make continued improvements in an inpatient interval rehabilitation program.
There is Level 2 evidence that individualized interdisciplinary rehabilitation results in functional improvements over the course of treatment.
There is Level 4 evidence that inpatient rehabilitation significantly improves functional outcome, as measured by the Functional Independence Measure.
Inpatient rehabilitation improves self-care and mobility and significantly improves functional outcome, social cognition and return to work in patients with ABI.
Readmission to inpatient rehabilitation at more than twelve months post-injury is related to statistically significant improvement in function.
Over a quarter of patients admitted to inpatient rehabilitation experience good outcome or moderate disability six months post-injury, as measured by the Glasgow Outcome Scale.
Intensity of Inpatient Rehabilitation
While patients are undergoing rehabilitation the amount of therapy provided to them is potentially an important factor in promoting neurological and functional recovery. We review the evidence for increased intensity in this section.
When investigating the efficacy of intensity within inpatient rehabilitation programs, the majority of studies use the FIM to analyze cognitive and motor gains. Two Randomized Controlled Trials (RCT) were conducted to assess the effects of intensity level on functional gains (Shiel et al. 2001; Zhu et al. 2001). In the study by Sheil et al. (2001) patients in the intervention group received additional therapy from a health care professional (a rehabilitation nurse at one center and an occupational therapist at the other) who provided these extra services as necessary. Shiel et al. (2001) found that patients receiving additional therapy made improvements at discharge on both the FIM and the Functional Assessment Measure; however, these improvements may be related to the size of the rehabilitation facility and the amount of staffing available to the patients. Despite that there was supposed to be an intense group and routine therapy group at each site, patients in the larger facility received more intensive therapy over a shorter period of time. Therefore, the results should be interpreted with caution. In the second RCT, conducted by Zhu et al. (2001), long-term functional gains were not improved or affected by treatment intensity. A greater number of subjects in the intensive therapy group, compared to controls, achieved full FIM scores and good GOS scores at two and three months post-injury; however, at the sixth month follow-up, despite initial improvements obtained in rehabilitation by the intervention group, the control group had made significant gains. The control group was said to be “catching up” and there were no significant difference in the motor or cognitive FIM scores between the two groups (Zhu et al. 2001). Both studies noted a trend towards improvements in functional gains with increased intensity but additional research is needed in this area.
A cohort study by Semlyen et al. (1998) compared coordinated multidisciplinary inpatient rehabilitation to single discipline therapy provided in a local district hospital. Patients treated in the multidisciplinary hospital showed greater improvement measured by BI, FIM and Newcastle Independence Assessment Form scores, with gains being maintained at two years (Semlyen et al. 1998). Unfortunately, this study has some methodological concerns. The groups were not made through randomization; consequently, the single discipline group had less severe injuries and a shorter LOS. This may have resulted in a ceiling effect for these patients that could have hindered their recovery gains.
Following from this, Cifu et al. (2003) examined the efficacy of rehabilitation intensity and functional gain in relation to the hospital LOS in a multicenter, prospective controlled trial. Rehabilitation intensity was found to predict motor functioning at discharge (p<0.001) but not cognitive gain (p<0.05) (Cifu et al. 2003). However, both cognitive and motor abilities at admission were significant predictors of LOS (p<0.01). LOS was significantly decreased (31%) for both acute care and coma groups with increased intensity (Blackerby 1990). Further, Spivack et al. (1992) conducted at study looking at the combined effects of rehabilitation intensity and inpatient rehabilitation LOS. In their comparison of patients who had a long LOS and received low-intensity or high-intensity rehabilitation, the latter group fared better on the Rancho Los Amigos Scale at discharge.
Despite the above discussion, not all studies of rehabilitation intensity focus solely on functional gains or LOS, others have investigated outcomes such as community reintegration. Intensive and structured cognitive rehabilitation therapy (group and individual) and standard neurorehabilitation therapy both resulted in improvements on the community integration questionnaire; however, the more intensive program participants made greater gains (Cicerone et al. 2004). The intensive rehabilitation program participants showed significant effects on their cognitive functioning as demonstrated on their improvement on standard neuropsychological tests (Cicerone et al. 2004).
Intuitively, it seems reasonable to assume that more therapy will result in more rapid and ultimately greater improvement in recovery from brain injury. Based on the available literature, greater intensity appears to result in a faster recovery and therefore shorter lengths of stay, but not necessarily better outcomes at six months. More studies are needed in this regard.
There is Level 1b evidence that intensive rehabilitation improves functional outcome, as measured by Functional Independence Measure and Glasgow Outcome Scale scores, at two and three months post-injury, but not necessarily at six months and beyond.
There is Level 2 evidence that multidisciplinary inpatient rehabilitation is more effective than a single discipline approach.
There is Level 4 evidence that increasing rehabilitation intensity reduces length of stay.
There is Level 2 evidence that therapy intensity predicts motor functioning at discharge, but not cognitive gain.
There is Level 4 evidence that patients with a long length of stay who receive high-intensity rehabilitation fair better on the Rancho Los Amigos Scale at discharge than those who receive low-intensity rehabilitation.
Increasing rehabilitation intensity may reduce length of stay.
High-intensity rehabilitation is associated with improved outcomes at discharge and at two and three months post-injury.
Multidisciplinary inpatient rehabilitation may be more effective than a single discipline approach.
Therapy intensity predicts motor functioning at discharge.
There is a reciprocal relationship between cognitive function and community integration.
Timing of Rehabilitation
It has long been identified that early onset of therapeutic interventions for those who have sustained a TBI is beneficial. Understanding the ideal time to initiate rehabilitation will help maximize the usefulness of resources that are available to patients for a limited amount of time. At one end of the spectrum a comatose patient may be unable to engage in therapy, while at the other end of the spectrum someone who has made a good recovery has no need for intervention. Several studies have shown that introducing a rehabilitation program during the acute phase does assist in the overall recovery of individuals with a TBI (Heinemann 1990). Cope’s (1995) review concluded that those who receive early intervention do in fact have better outcomes than those who do not. Further, León-Carrión et al. (2013) reported that patients who received neurorehabilitation earlier demonstrated better global functioning at discharge than patients who began treatment at a later point. We attempted to address the question of the ideal time to start the rigors of therapy in order to maximize patients’ function.
The studies available on the timing of rehabilitation demonstrate that earlier rehabilitation is associated with better outcomes than later rehabilitation (Hayden et al. 2013). After an ABI, individuals typically need much greater medical and nursing support in order to meet their basic care requirements. This evidence is consistent with theories of neuronal plasticity, which suggest that challenging the nervous system by means of therapy results in increased neuronal compensation and/or regeneration. However, delayed rehabilitation may reflect more severe or complicated brain injuries. Wagner et al. (2003) examined the proper timing for physical medicine and rehabilitation consultation. Using multivariate analysis, the authors found that when Physical Medicine and Rehabilitation consultations occurred earlier (<48 hours after hospital admission) patients experienced significantly better FIM scores for transfers and locomotion and had significantly shorter lengths of stay. Mackay et al. (1992) assessed the timing of inpatient rehabilitation during the earlier phase of recovery in their cohort study. They compared a formalized program (average of two days to initiation of therapy) with a non-formalized program (average of 23 days to initiation of therapy). The formalized program made greater functional and cognitive gains, had shorter LOS, and a greater likelihood of being discharged home. Modest findings were reported from High et al. (2006) in that all three time groups (less than 6 months, 6 to 12 months, greater than 12 months) demonstrated a significant decrease in required supervision from admission to discharge; however, the less than six month group continued to improve through to follow-up. Overall, starting rehabilitation early has been shown to be beneficial but there is an obvious need for an RCT to address this question.
Despite the evidence demonstrated in these studies, one study reported no significant differences in earlier or later admission to rehabilitation. Edwards et al. (2003) compared 26 patients admitted to inpatient rehabilitation more than 200 days after injury to 264 patients admitted to inpatient rehabilitation less than 200 days after injury. Although it was not significant, the discharge scores on the Barthel Index and FIM were lower in the former group than in the latter. Rehabilitation LOS was also similar for the two groups.
Moreover, LOS in rehabilitation has also been linked with timing of rehabilitation. Cope and Hall (1982) reported that those in the late intervention (>35 days) group spent significantly more time in acute care and inpatient rehabilitation. Kunik et al. (2006) also reported that those admitted sooner to rehabilitation were released on average 19 days post admission whereas those admitted later to rehabilitation were released on average 26 days post admission. Kunik et al. (2006) suggest that early admission is beneficial in terms of maximizing recovery and the overall cost of stay is less.
With LOS comes the cost of care. As previously alluded to, Kunik et al. (2006) reported lower costs with earlier admission with patients admitted more than four weeks post-injury costing two and a half times more than a patient admitted less than one week post-injury ($31,532 versus $12,416). Further, Aronow (1987) revealed that although there were no statistically significant differences on the individual outcomes, individuals admitted with less than one month of post-traumatic amnesia resulted in a cost saving of $11,949 a year. Furthermore, an estimated $335,842 (at time of writing) can be saved annually per year with effective and efficient rehabilitation (Aronow 1987).
Based on the findings from several studies, there is Level 2 evidence that early rehabilitation is associated with better outcomes such as shorter comas and lengths of stay, higher cognitive levels at discharge, better Functional Independence Measure scores, and a greater likelihood of discharge to home.
Early rehabilitation is associated with better outcomes.
Early rehabilitation has been shown to cost less.
Factors Affecting the Timing of Inpatient Care
Etiology and Inpatient Rehabilitation
In a retrospective, descriptive, case-matched study by O’Dell et al. (1998), 40 patients with brain tumors were compared with 40 patients with TBI. All participants underwent inpatient rehabilitation on a freestanding brain injury unit. Change in FIM scores, LOS, and discharge disposition were used as the main outcome measures. Overall, the patients with TBI made significantly greater gains in terms of total FIM change (34.6 versus 25.4), self-care (12.3 versus 8.5), and social cognition (5.2 versus 3.6). However, there were no statistically significant differences between the two groups regarding FIM efficiency (1.9 versus 1.5 FIM points per day) and LOS (22.1 versus 17.8 days). See the table below for details.
Age and Inpatient Rehabilitation
In Cifu et al. (1996) the Disability Rating Scale, Rancho Los Amigos Scale and FIM scores were compared at inpatient rehabilitation discharge for 50 patients ≥ 55 years of age and 50 patients aged 18 to 54. In this case-control study, subjects in the younger group showed a higher mean rate of change on functional measures than subjects in the older group.
Occupation and Inpatient Rehabilitation
In describing only one treatment arm of a RCT, Braverman et al. (1999) evaluated military service members’ return to work and return to duty after multidisciplinary inpatient rehabilitation. Multidisciplinary inpatient rehabilitation consisted of eight weeks of group and individual therapies geared towards returning the soldiers to duty. The rehabilitation team included a physiatrist, neurologist, neuropsychologist, and occupational therapist. The authors found that of the 67 subjects who participated in the study, 96% and 66% had returned to work and duty respectively at follow-up of one year. In a cohort of 5505 patients Dahdah et al. (2016) determined that participants who were employed at the time of injury had better functional outcomes at discharge from inpatient rehabilitation and at one year follow-up.
Transitional Living Setting and Inpatient Rehabilitation
In the study by McLaughlin and Peters (1993) the effects of a transitional living setting during the last weeks of inpatient LOS were evaluated using cognitive (Rancho Los Amigos Scale) and functional (Barthel Index) levels as main outcome measures. Results from a follow-up survey showed that patients who participated in both inpatient rehabilitation and a transitional living setting reported greater independence in activities of daily living than patients who received inpatient rehabilitation alone.
Previous reviews, in addition to literature presented here, have delineated the extent of knowledge of the efficacy of inpatient rehabilitation. There is reasonable evidence to support the use of interdisciplinary rehabilitation followed by a transitional living environment to assist in maximizing recovery (McLaughlin & Peters 1993). This suggests that a gradual return to the community is preferable to a sudden discharge from hospital to home. Certain factors have been found to influence discharge destination. Brown et al. (2012) found that older patients are less likely to be discharged home following inpatient care and females were more likely to be sent to care facilities than home. The authors speculate that because women tend to live longer than men, it may not be possible to discharge an older female patient home post-TBI, especially if they live alone (Brown et al. 2012). In terms of return to work after inpatient care, studies have yielded promising results. Braverman et al. (1999) reported 96% of the sample was employed at one year. Moreover, McLaughlin and Peters (1993) reported 53% were working and 21% were in volunteer work after a transitional living program. Although patients in the latter study did not differ significantly with a regular inpatient care group, the findings still offer optimism for patients with ABI. In a cohort of 5505 patients Dahdah et al. (2016) determined that participants who were employed at the time of injury had better functional outcomes at discharge from inpatient rehabilitation and at one year follow-up.
Functional gains continue to be a focus for studies investigating inpatient rehabilitation. Not surprisingly, younger patients tend to make greater functional gains in rehabilitation than their older counterparts; older patients also spend longer in rehabilitation than younger patients (Cifu et al. 1996). This is supported by Brown et al. (2012) who reported that older age and a longer LOS was significantly associated with being discharged to a care facility rather than home, thus older patients are less likely to be sent home post-rehabilitation. However, Cifu et al. (1996) point out that the majority of patients, regardless of age, are discharged into a community-based environment, this then appears to be dependent on physical limitations.
There is Level 2 evidence that a transitional living setting during the last weeks of inpatient rehabilitation results in greater functional independence in activities of daily living than inpatient rehabilitation alone.
There is Level 3 evidence that inpatient brain injury rehabilitation results in significantly greater gains in total Functional Independence Measure change, self-care, and social cognition for patients with TBI than patients with brain tumors. However, there are no statistically significant differences between the two groups regarding Functional Independence Measure efficiency and length of stay.
There is Level 3 evidence that inpatient rehabilitation results in a higher rate of change on functional measures in patients aged 18-54 than patients aged 55 years or older.
Based on the findings from one case series, there is Level 4 evidence that inpatient rehabilitation results in successful return to work and return to duty for many military service members.
There is Level 4 evidence suggesting that being older, female, and having a longer length of stay in inpatient care results in a lesser likelihood of being discharged home.
Rehabilitation results in a higher rate of change on functional measures in younger patients than in older patients.
Transitional living setting during the last weeks of inpatient rehabilitation is associated with greater independence than inpatient rehabilitation alone.
Females are more likely to be discharged to care facilities. As well, older patients are less likely to be discharged home than younger patients.