Keywords: TBI rehabilitation, access to rehabilitation, predicting access to rehabilitation, CENTER-TBI
Introduction – why do we need access to rehabilitation?
TBI is a significant cause of disability and death globally, impacting the quality of life of the affected individuals, those around them, and the society at large, leading to a wide array of disabilities, from physical, psychical, cognitive, to social and behavioral. The palette of injuries varies when considering TBI, from concussion to severe TBI. As a result, rehabilitation is one of the pillars of successful recovery after TBI [1,2].
Following the severity of the lesions and TBI, the rehabilitation process varies with strategies targeting the signs and symptoms that impact the patient’s functionality [3]. The rehabilitation mainly addresses the disability that hinders day-to-day activities, the patient’s independence, and the complete reintegration into society.
Furthermore, access to rehabilitation services is a significant aspect impacting the prognosis of the patients. On the one hand, a suitable type of rehabilitation has to be done in accordance with the patient’s health status and the gravity of the injury. On the other hand, of utter importance is the timing of rehabilitation. Nevertheless, the accessibility to TBI rehabilitation represents a significant step that needs to be taken by patients to ensure a better outcome.
The question is: can we predict access to rehabilitation for TBI patients?
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The importance of TBI rehabilitation
Per the definition of the World Health Organization, rehabilitation represents “a set of interventions designed to optimize functioning and reduce disability in individuals with a health condition who experience some form of limitation in functioning, across the continuum of care and throughout the lifespan.” [4].
Patients with a higher grade of severe brain injury (moderate or severe TBI) often require treatment in intensive care units (ICUs), followed by a transfer to subacute wards, rehabilitation wards, or other hospitals. From here on, the rehabilitation process can take different, individualized forms in accordance with the patient’s needs. TBI rehabilitation can be done as an inpatient or outpatient [1–3]. Furthermore, most of the recovery of TBI patients takes place during the first two years after the traumatic episode, extending up to 5 or even 10 years [5].
Access to rehabilitation: a necessity for every TBI patient
TBI rehabilitation has a significant positive effect on patients. Unfortunately, plenty of patients do not have access to a proper rehabilitation program following acute inpatient care. Andriessen TMJC et al. conducted a prospective multicenter study on 508 subjects. While concentrating on the epidemiology, severity, and outcome of TBI in the Netherlands, they showcased that almost half of the TBI patients with increased severity (moderate and severe) were sent home after acute care, with no rehabilitation after this phase [1].
Prediction of neurorehabilitation
Several studies have addressed the prediction of neurorehabilitation. A study by Jourdan C et al., from 2015, carried out in Paris on 354 individuals, managed to show the correlation of lack of referral to rehabilitation to those showcased in Figure 1.
Furthermore, another study by Schumacher R et al., undertaken in 2016 in Switzerland, on a national level, including 566 patients with increased severity of TBI, showed the correlation between rehabilitation during hospital admission (inpatient) and TBI severity, as well as older age. Nevertheless, these studies were not sufficient to enable proper prediction methods due to several limitations, including the lack of international, standardized settings for the need for rehabilitation. Moreover, other studies did not take into consideration several elements impacting rehabilitation (alcohol use, mental health disorders, living area: rural or urban, etc.) and, finally, the consideration of moderate and severe TBI [1].
In 2020, within the CENTER-TBI study, Jacob C et al. analyzed the factors predicting access to rehabilitation for patients who suffered an injury in the first year after the event. Their pursuit was supported by the fact that improving access to rehabilitation might lessen the post-TBI disability and burden. Patients of all ages were selected from European countries (except Israel), and were included in the study based on:
- The TBI diagnosis is decided from the results of clinical and paraclinical investigations, or anamnesis.
- Presentation in the first 24 hours after TBI.
- Clinically established need for a computer tomography of the brain.
- Lack of severe neurological comorbidities that would impact the assessment of outcomes after TBI.
Patients were assessed depending on the severity of the TBI in the emergency department, intensive care unit (ICU), and moment of admission on a ward, as well as follow-up assessment at 6 months (emergency room) and 12 months (emergency department). The data collection took place over 3 years, from 2014 to 2017. The data was collected using an electronic platform, respecting the Strengthening the Reporting of Observational Studies in Epidemiology guideline, with the organization and integration of data being done by a multidisciplinary team. In this study, the assessment of patients was done 3, 6, and 12 months post-TBI.
Consequently, two main categories were established, as showcased in Figure 2.
The predictors of access to rehabilitation
The predictors of access to rehabilitation included those presented in Figure 3.
The categorization of patients into strata (ICU, emergency room, and ward), mirroring the severity of the TBI, was done as part of the initial medical decision. Consequently, patients whose status could have worsened might have been readmitted to another stratum.
Results of the CENTER-TBI study
The statistical data analysis revealed that most TBI patients were:
- male with a median age of 50,
- one-third had received rehabilitation,
- admitted directly to ICU (receiving inpatient rehabilitation).
Additionally, access to rehabilitation was increased for employed patients living in the northern or southern part of Europe, with unintentional injury happening in a rural areas, as well as no use of medication. Moreover, the same applied to patients from the ICU stratum who needed surgery and suffered complications (intracranial or extracranial).
Finally, increased rehabilitation rates were also observed for patients experiencing a more severe TBI (mirrored in lower GCS scores before hospital admission and at the time of discharge or higher ISS), certain age groups, females, and those with a higher number of years of completed education. Over half of the received inpatient rehabilitation was carried out in specialized TBI rehabilitation units, followed by non-specialized rehabilitation units.
The outpatient rehabilitation was represented mainly by physical therapy, followed by occupational, psychological, cognitive, and speech therapies, but to a much lower degree than the first.
In contrast to those receiving rehabilitation, patients lacking rehabilitation were unemployed, living in central or eastern Europe, and either admitted to a hospital ward or discharged from the emergency room. Furthermore, comparable data was found overall in the 18-65 age group of patients and those admitted to the ICU. The general result of this study shows rather reduced access to rehabilitation one-year post-TBI regardless of the severity of the TBI, as revealed by other European countries.
The most frequently used type of rehabilitation was physical therapy, although, considering the TBI’s impact on cognition and behavior, more rehabilitation in this direction would have been expected to occur. This observation mirrors either the lack of resources for these patients’ needs or the lack of referral and consideration of the impact of the rehabilitation concerning these aspects.
Moreover, this study has emphasized that higher education and employment levels have led to more access to rehabilitation and consequently less burden after TBI. Adherence to rehabilitation was also increased in women and people with higher education.
Concurrently, this calls into question: how much does income and type of health insurance influence access to rehabilitation?
Besides, the lack of rehabilitation of unemployed people could also mirror the marginalization and limited support on a social level. The geographical differences might reflect differences in healthcare systems like the level of funding, available rehabilitation facilities, and available physiotherapists. An important mention regarding age in this study is that since its preclusion from the regression model, it was not considered a predicting factor for access to rehabilitation. However, other studies have shown contrasting results.
Furthermore, an important predictor of access to rehabilitation was the stratum of the patients (mirroring the severity of the TBI). Older patients were exposed to a higher risk of admission to other wards than to the ICU, with consequently lower access to rehabilitation. Similarly, patients transferred to non-specialized wards lacked referral to rehabilitation, as shown in another smaller study.
Other studies have also emphasized the importance of the patient’s pathway for access to rehabilitation, underlining the risk of limiting it for discharged TBI patients. Another predicting factor mirroring the positive correlation of the severity of TBI with access to rehabilitation was shown by the fact that the GCS score, ISS, need for surgery, and complications led to a longer period of rehabilitation done according to the patient’s state and needs.
Overall, the results were comparable to those found in other studies concentrating on the 18-65 age group and ICU stratum, so working age and severe TBI. Nevertheless, when considering these results, several aspects have to be taken into consideration:
- the smaller sample of patients between 18 years and over 65 years of age
- the lack of a standardized definition of access to rehabilitation
- the use of patient reports regarding attendance at rehabilitation
- the lack of information about the duration of rehabilitation and
- social factors influencing access to rehabilitation (income, level of insurance, type of disability, as well as ethnicity).
Lastly, data was only collected from patients that arrived at neurotrauma centers. Consequently, access to rehabilitation might be even lower in other types of hospitals. Additionally, the ED stratum had a smaller representation than the others, and the patients were assessed only at 6 months. Finally, according to the authors, the findings might be influenced by missing data at random. Nonetheless, the study used data from 17 countries, the sample size representing a major advantage [1].
Conclusions
As a global burden, TBI with a secondary disability impacts society on several levels; thus, rehabilitation after TBI represents an important step to be taken on national and international levels. Rehabilitation after TBI is associated with improved outcomes on several levels (physical, cognitive, social, and recovery of the patient’s functional independence).
In conclusion, the research of L. Jacob et al. has identified significant predicting factors for access to rehabilitation on a European level, underlining the identified differences between countries. Hence, rehabilitation after TBI leads to improved outcomes, the management of TBI should be harmonized on a European level, considering the results of this study as well as extending the collection of data and research on more countries.
It is essential to identify patients that would benefit from rehabilitation and to initiate it early, in a multidisciplinary manner uncovering the various array of disabilities.
Finally, rehabilitation types (telerehabilitation, day rehabilitation, at-home rehabilitation) have to be tailored in order to allow wider participation of TBI patients while considering the lower adherence to the rehabilitation of some patients – as observed in this study – male patients, unemployed and with a lower level of education [1,2,4].
References
- Jacob, L, Cogné, M, Tenovuo, O, Røe, et al., Predictors of Access to Rehabilitation in the Year Following Traumatic Brain Injury: A European Prospective and Multicenter Study. Neurorehabilitation and neural repair 2020, 34(9), 814–830. DOI: 10.1177/1545968320946038
- Schumacher, Rahel, et al. “Predictors of inpatient (neuro)rehabilitation after acute care of severe traumatic brain injury: An epidemiological study.” Brain injury vol. 30,10 (2016): 1186-93. DOI:10.1136/bmjopen-2017-016694
- Cicerone, KD, Langenbahn DM, Braden C, Malec et al. Evidence-based cognitive rehabilitation: an updated review of the literature from 2003 through 2008. Archives of physical medicine and rehabilitation 2011, 92(4), 519–530. DOI: 10.1016/j.apmr.2010.11.015
- Mills T, Marks E, Reynolds T, & Cieza A. Rehabilitation: Essential along the Continuum of Care. In D. T. Jamison (Eds.) et al., Disease Control Priorities: Improving Health and Reducing Poverty. (3rd ed.). The International Bank for Reconstruction and Development / The World Bank 2017. DOI: 10.1596/978-1-4648-0527-1_ch15
- Fleminger S, & Ponsford J. Long-term outcome after traumatic brain injury. BMJ (Clinical research ed.) 2005, 331(7530), 1419–1420. DOI: 10.1136/bmj.331.7530.1419
