Outcome of a comprehensive neurorehabilitation program for patients with traumatic brain injury.

OBJECTIVE: To evaluate the outcome of a comprehensive neurorehabilitation program compared with that of conventional clinical care and rehabilitation for patients with traumatic brain injury (TBI). DESIGN: Nonrandomized, controlled trial with a 2-year follow-up. SETTING: Nationwide rehabilitation center and level I trauma center, both in Finland. PARTICIPANTS: We studied 19 consecutive adults with a significant TBI who underwent a comprehensive neurorehabilitation program and 20 control patients who received conventional rehabilitation referred by physicians in the general health care system. The outcome of the control patients was not known before the selection. The groups were similar in age, sex, education, injury severity (assessed on the Glasgow Coma Scale, radiologic and neuropsychologic findings, neurosurgical interventions), time from the injury, and preinjury employment status. INTERVENTIONS: A postacute, intensive, interdisciplinary, 6-week rehabilitation program for TBI patients who are considered to have adequate potential to achieve productivity by this means; focus on neuropsychologic rehabilitation and psychotherapy with vocational interventions and follow-up support. MAIN OUTCOME MEASURE: Status of productivity, judged as productive (defined as working, studying, or participating in volunteer activities) or nonproductive, evaluated on questionnaires filled in by patients and their significant others at the time of follow-up evaluation. RESULTS: At follow-up, 89% of the treated patients were productive compared with 55% of the controls. The rehabilitation program was significantly predictive of the productive status at follow-up (odds ratio=6.96; 95% confidence interval, 1.26-38.44; P=.017). Other factors did not explain the better productivity of the treatment group. Two neuropsychologist-evaluators, who were blind to the rehabilitation history of patients and to each other's evaluations, were perfectly consistent in their classification of patients' productivity statuses. CONCLUSIONS: The findings support the proposition that comprehensive neuropsychologically oriented rehabilitation programs can improve psychosocial functioning in terms of productivity in postacute patients with moderate to severe TBI. Additional larger controlled studies are needed to establish the efficacy of TBI rehabilitation interventions.

Relationship of local infarctions to cognitive and psychosocial impairments after aneurysmal subarachnoid hemorrhage.

OBJECTIVE: Previous studies suggest that cognitive and psychosocial impairments after subarachnoid hemorrhage (SAH) result from diffuse brain damage caused by the initial bleeding rather than from focal lesions. We describe the relationship of local infarctions to these impairments and explore how well test and questionnaire results explain psychosocial outcome. METHODS: A total of 170 patients, selected from a consecutive series of patients with aneurysmal SAH, underwent neurological and neuroradiological examinations, and 138 of them were assessed with neuropsychological tests and questionnaires 1 year after SAH. RESULTS: Patients with left and bilateral infarctions performed worse on verbal memory tests than the other patients, and patients with left infarctions had more impaired working capacity than those with no infarction. The indices of the severity of SAH were related to reductions in both working capacity and social activity but less clearly to poor test performances. Whereas the modified Rankin scale was the most important correlate of working capacity, performance on cognitive tests was associated with return to work, and questionnaire ratings of mental impairments correlated with reduced working capacity and decreased social activity. CONCLUSION: Left-hemisphere infarctions cause deficits in verbal memory and working capacity. The severity of SAH is associated with impairments in working capacity and social activity rather than with specific cognitive deficits. Patients' and partners' opinions on patients' mental impairments could provide complementary information to clinical grades and cognitive tests in the evaluation of outcome after SAH.