To assess the prognostic utility of the Coma Recovery Scale-Revised (CRS-R) in rehabilitation of patients surviving from severe brain injury.
In this prospective cohort study, all patients ...consecutively admitted to an Italian Intensive Rehabilitation Unit, with a diagnosis of unresponsive wakefulness syndrome (UWS) or minimally conscious state (MCS) due to acquired brain injury, underwent clinical evaluations using the Italian version of the CRS-R. At discharge, patients transitioning from UWS to MCS or emergence from MCS (E-MCS) and from MCS to E-MCS were classified as improved responsiveness (IR). Score on the Glasgow Outcome Scale (GOS) at discharge was recorded.
In total, 137 (66 UWS, 71 MCS) subjects were enrolled. After a mean hospital stay of 5.3 ± 2.9 months, 81 (59.1%) patients achieved an IR. In the multivariable analysis, IR was associated with higher CRS-R score at admission (p = 0.002) and younger age at injury (p = 0.010). Moreover, higher GOS scores at discharge were related to younger age at injury (p = 0.018), shorter time post-onset (p = 0.003) and higher CRS-R score at admission (p < 0.001).
Higher CRS-R scores at admission in intensive rehabilitation unit can help differentiate patients with better outcome at discharge, providing information for rehabilitation planning and communication with patients and their caregivers.
Decompressive craniectomy (DC) is a life-saving procedure conducted to treat refractory intracranial hypertension. Although DC reduces mortality of severe Acquired Brain Injury (sABI) survivors, it ...has been associated with severe long-term disability. This observational study compares functional outcomes at discharge from an Intensive Rehabilitative Unit (IRU) between sABI patients with and without DC.
sABI patients undergoing DC before entering the Don Gnocchi Foundation IRU were compared with a group of sABI patients who did not undergo DC (No-DC group), after matching it by age, sex, aetiology, time post-onset, and clinical status. Inclusion criteria were: diagnosis of sABI, age 18+, time from the event <90 days.
A total of 87 (DC: 47) patients were included (median age: 60.5 IQR = 17.47). The two groups did not differ for admission clinical features except for the tracheostomy presence (more frequent in DC, p < 0.001). No significant differences were also found at discharge. DC group presented a significantly longer length-of-stay than No-DC group (p < 0.001) and a longer time to tracheostomy removal (p = 0.036). DC was not found to influence outcomes as consciousness improvement, tracheostomy removal, oral intake and functional independence.
sABI patients with DC improved after rehabilitation as much as No-DC patients did but they required a longer stay.
Implications for Rehabilitation
Decompressive craniectomy (DC) is practiced during the acute phase after hemorrhagic, ischemic, traumatic severe brain injury as a life-saving procedure to treat refractory intracranial hypertension
DC has been associated with follow-up severe long-term disability, but no study yet addressed whether DC may affect intensive rehabilitation outcomes.
Undergoing a DC is not a negative prognostic factor for achieving rehabilitation goals after a severe acquired brain injury
DC must be taken into account when customizing rehabilitation pathway especially because these patients required a longer time to reach the outcomes.
The aim of the study was to perform a third cognitive assessment in our pediatric-onset multiple sclerosis (MS) patient cohort and determine predictors of the individual cognitive outcome.
After 4.7 ...± 0.7 years from baseline evaluation, 48 of 63 patients in the original cohort were reassessed on an extensive neuropsychological battery and compared with 46 healthy controls. Two alternate versions of the tests were used at different assessment points. Cognitive impairment was defined as the failure of ≥3 tests; individual change in the cognitive impairment index was measured.
At year 5, 38% of the subjects with MS fulfilled our criterion for impairment. Between years 2 and 5, regarding individual cognitive impairment index change, 66.7% of the patients improved. However, comparing baseline and 5-year testing (when the same versions of the tests were used), cognitive impairment index deterioration was observed in 56% of the patients, improvement in 25%, and stability in 18.8%. A deteriorating performance was related to male sex, younger age and age at MS onset, and lower education. None of these variables, however, was retained in the multivariate analysis.
Cognitive outcome in pediatric-onset MS can be heterogeneous. Progression of cognitive problems in a few subjects and potential for compensation and improvement in others call for systematic cognitive screening in this population and development of effective treatment strategies.
Introduction
Previous studies showed that depression acts as an independent factor in functional recovery after stroke. In a prospective cohort of patients admitted to intensive inpatient ...rehabilitation after a stroke, we aimed to test depression as a moderator of the relationship between the functional level at admission and the effectiveness of rehabilitation at discharge.
Methods
All patients admitted to within 30 days from an ischemic or hemorrhagic stroke to 4 intensive rehabilitation units were prospectively screened for eligibility to a multicenter prospective observational study. Enrolled patients underwent an evidence-based rehabilitation pathway. We used clinical data collected at admission (T0) and discharge (T1). The outcome was the effectiveness of recovery at T1 on the modified Barthel Index (proportion of achieved over potential functional improvement). Moderation analysis was performed by using the PROCESS macro for SPSS using the bootstrapping procedure.
Results
Of 278 evaluated patients, 234 were eligible and consented to enrolment; 81 patients were able to answer to the Hospital Anxiety and Depression Scale (HADS) and were included in this analysis. The relationship between the functional status at admission and rehabilitation effectiveness was significant only in persons with fewer depressive symptoms; depression (HADS cut-off score: 5.9) moderated this relationship (P = .047), independent from age and neurological impairment.
Conclusions
Our results suggest that depression moderates between the functional status at admission and the functional recovery after post-stroke rehabilitation. This approach facilitates the identification of subgroups of individuals who may respond differently to stroke rehabilitation based on depression.
There is emerging confidence that quantitative EEG (qEEG) has the potential to inform clinical decision-making and guide individualized rehabilitation after stroke, but consensus on the best EEG ...biomarkers is needed for translation to clinical practice. This study investigates the spatial qEEG spectral and symmetry distribution in patients with a left/right hemispheric stroke, to evaluate their side-specific prognostic power in post-acute rehabilitation outcome.
Resting-state 19-channel EEG recordings were collected with clinical information on admission to intensive inpatient rehabilitation (within 30 days post stroke), and six months post stroke. After preprocessing, spectral (Delta-to-Alpha Ratio, DAR) and symmetry (pairwise and hemispheric Brain Symmetry Index) features were extracted. Patients were divided into Affected Right and Left (AR/AL) groups, according to the location of their lesion. Within each group, DAR was compared between homologous electrode pairs and the pairwise difference between pairs was compared across pairs in the scalp. Then, the prognostic power of qEEG admission metrics was evaluated by performing correlations between admission metrics and discharge mBI values.
Fifty-two patients with hemorrhagic or ischemic stroke (20 females, 38.5 %, median age 76 years IQR = 22) were included in the study. DAR was significantly higher in the affected hemisphere for both AR and AL groups, and, a higher frontal (to posterior) asymmetry was found independent of the side of the lesion. DAR was found to be a prognostic marker of 6-months modified Barthel Index (mBI) only for the AL group, while hemispheric asymmetry did not correlate with follow-up outcomes in either group.
While the presence of EEG abnormalities in the affected hemisphere of a stroke is well recognized, we have shown that the extent of DAR abnormalities seen correlates with disability at 6 months post stroke, but only for left hemispheric lesions. Routine prognostic evaluation, in addition to motor and functional scales, can add information concerning neuro-prognostication and reveal neurophysiological abnormalities to be assessed during rehabilitation.
Decannulation is a rehabilitation milestone in patients with Disorders of Consciousness (DoC). investigate the relationship between decannulation and improvement of responsiveness (IR) in DoC. 236 ...tracheostomized patients with severe Acquired Brain Injury and DoC admitted in the Intensive Rehabilitation Unit were retrospectively included. They received personalized interdisciplinary rehabilitation. At discharge, IR was evaluated. The association between IR and demographic/clinical data was investigated using a logistic regression analysis, both in the Unresponsive Wakefulness Syndrome (UWS) and Minimal Consciousness State (MCS) group, divided according to their Coma Recovery Scale-Revised score at admission. In the UWS group (N = 107), only decannulation was associated with IR at discharge (OR: 5.94, CI: 2.08-16.91, p = .001). In the MCS group (N = 129) time post-injury (OR: 0.983, CI: 0.97-0.99, p = .012) and decannulation were associated with IR at discharge (OR: 17.9, CI: 6.39-50.13, p < .001). Decannulation and IR were found to be strongly related, independently from the initial clinical state. While the retrospective nature of the study could not exclude that decannulation may be a consequence of a spontaneous recovery, the obtained results may disclose its potential influence on the clinical history of patients with DoC.
To verify whether trunk control test (TCT) upon admission to intensive inpatient post-stroke rehabilitation, combined with other confounding variables, is independently associated with discharge mBI.
...Multicentric retrospective observational cohort study.
Two Italian inpatient rehabilitation units.
A total of 220 post-stroke adult patients, within 30 days from the acute event, were consecutively enrolled.
Not applicable.
The outcome measure considered was the modified Barthel Index (mBI), one of the most widely recommended tools for assessing stroke rehabilitation functional outcomes.
All variables collected at admission and significantly associated with mBI at discharge in the univariate analysis (TCT, mBI at admission, pre-stroke modified Rankin Scale mRS, sex, age, communication ability, time from the event, Cumulative Illness Rating Scale, bladder catheter, and pressure ulcers) entered the multivariate analysis. TCT, mBI at admission, premorbid disability (mRS), communication ability and pressure ulcers (P<.001) independently predicted discharge mBI (adjusted R
=68.5%). Concerning the role of TCT, the model with all covariates and without TCT presented an R
of 65.1%. On the other side, the model with the TCT only presented an R
of 53.1%. Finally, with the inclusion of both TCT and all covariates, the model showed an R
increase up to 68.5%.
TCT, with other features suggesting functional/clinical complexity, collected upon admission to post-acute intensive inpatient stroke rehabilitation, independently predicted discharge mBI.
We hypothesized that appraisal of brain connectivity may shed light on the substrate of the radiologically isolated syndrome (RIS), a term applied to asymptomatic subjects with brain MRI ...abnormalities highly suggestive of multiple sclerosis. We thus used a multimodal MRI approach on the human brain by modeling measures of microstructural integrity of white matter (WM) tracts with those of functional connectivity (FC) at the level of resting state networks in RIS subjects, demographically matched normal controls (NC), and relapsing-remitting (RR) MS patients, also matched with RIS for brain macrostructural damage (i.e., lesions and atrophy). Compared with NC, in both RIS subjects and MS patients altered integrity of WM tracts was present. However, RIS subjects showed, at a less conservative threshold, lower diffusivities than RRMS patients in distinct cerebral associative, commissural, projection, and cerebellar WM tracts, suggesting a relatively better anatomical connectivity. FC was similar in NC and RIS subjects, even in the presence of important risk factors for MS (spinal cord lesions, oligoclonal bands, and dissemination in time on MRI) and increased in RRMS patients in two clinically relevant networks subserving "processing" (sensorimotor) and "control" (working memory) functions. In RIS, the lack of functional reorganization in key brain networks may represent a model of "functional reserve," which may become upregulated, with an adaptive or maladaptive role, only at a later stage in case of occurrence of clinical deficit.
The assessment of patients with severe Acquired Brain Injury (sABI) is mandatory in every phase and setting of care, and requires a multidimensional and interdisciplinary approach, to develop the ...individual rehabilitation project, and monitor long-term functional outcomes. In 2001 the Italian Society of Physical and Rehabilitation Medicine (SIMFER) published the minimal assessment protocol for traumatic sABI, providing a comprehensive, standardized functional assessment based on the International Classification of Functioning, Disability and Health (ICF), 2001. In 2007, a new protocol was published, extended to all sABI patients (PMGCA). In 2019, the SIMFER appointed a working group to provide a revised, updated version: the PMGCA2020.
The purpose of this study was to describe the minimal assessment protocol to be applied at every stage and setting of the care process of patients with sABI.
The working group, including one neurologist and 11 physiatrists experts in sABI rehabilitation, performed a review of the international recommendations for sABI assessment focusing on the following key words: "sABI assessment," "sABI rehabilitation," "sABI prognostic factors," "sABI rehabilitation assessment," "sABI outcome," in MEDLINE. Revision and integration proposals by each member were written and motivated, discussed and voted.
The PMGCA2020 is addressed to sABI adult patients. It investigates the main clinical problems of sABI at any time of the rehabilitation pathway. It includes a demographic/anamnestic section, a clinical/functional assessment section and an outcome measures section following the ICF model of functioning and the model of the construction of the rehabilitation project.
The PMGCA2020 provides an updated tool for the multidimensional rehabilitation assessment of sABI patients, at any stage of the rehabilitation pathway. Further studies will allow the validation of this minimum set of variables paving the way to an assessment standardization of patients with sABI in the rehabilitation settings.
This minimum set of variables, defining patient's functioning and clinical status and outcomes, at every stage and setting of the care process to provide a framework for the standardization of the clinical evaluation of patients with sABI in rehabilitation settings.
Stroke survivors report physical, cognitive, and psychological impairments, with a consequent limitation of participation. Participation is the most context-related dimension of functioning, but the ...literature on participation in Italian stroke patients is scant.
This study aimed to describe the recovery of participation six months after stroke with a validated Italian version of the Frenchay Activity Index (FAI) and to investigate potential correlates with higher participation scores.
The study is a prospective observational study.
The cohort of patients was enrolled in four intensive inpatient rehabilitation units of IRCCS Fondazione Don Carlo Gnocchi Onlus, Florence, Italy.
Adults addressing postacute intensive inpatient rehabilitation after an ischemic or hemorrhagic stroke occurred within 30 days from recruitment were prospectively enrolled.
Data were collected at admission to intensive inpatient rehabilitation, and a six-month follow-up. The primary outcome was participation, measured by a validated Italian version of the FAI; only patients whose data included both anamnestic FAI and FAI at six months follow-up were included in this analysis. The data were analyzed by univariate and multivariate linear regressions.
A cohort of 105 patients (median age 78 years interquartile range, IQR=21; 46.7% males) with completed FAI at follow-up were included in this study. The sample reported a FAI median score of 28 (IQR=8) at admission (referred to the participation in the 3-6 months before the stroke) and 13 (IQR=20) at follow-up. All items were significantly affected, with the exception of reading and making trips. The multivariate regression for all patients with good participation before the stroke (N.=101), showed that 6 months after the stroke a higher FAI Score was independently associated with better functioning in activities of daily living (modified Barthel Index) (B=0.133; P=0.015), and absence of cognitive impairment (B=4.755; P=0.027); a lower stroke severity in the postacute phase (NIHSS B=-0.832; P=0.001) and a higher prestroke FAI Score (B=0.410; P=0.028) were also independently related to follow-up FAI Score.
In our cohort of patients addressing postacute stroke rehabilitation, prestroke participation levels were on average good, while they were severely reduced six months after stroke for all the considered items except reading and making trips. Higher FAI at follow-up was independently associated with a higher functional level and no cognitive impairment at follow-up, with lower stroke severity in the postacute phase, as well as a higher anamnestic participation score.
Our results suggest that investigating prestroke participation may be highly relevant to predict, and possibly address, participation recovery after stroke.
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