Comprehensive-holistic neurorehabilitation, outcomes and their subjective appraisal in adults with traumatic brain injury

Traumatic brain injury (TBI) has a critical public health impact worldwide because of its high incidence, prevalence, and socioeconomic consequences. The common neuropathology following TBI contributes to a myriad of diverse interacting impairments in cognitive, behavioral, emotional, and motor functioning. Many people with TBI experience ongoing long-term, lifelong and also evolving symptoms that impact their general health, psychosocial outcomes, and overall well-being. Over the last three decades, standards of care, rehabilitation interventions, and research for TBI patients have developed, yet robust evidence for effective practices and evidence-based guidelines do not exist for most interventions. The effectiveness of postacute neuropsychologically oriented multidisciplinary comprehensive-holistic rehabilitation programs (CHRPs) in enhancing psychosocial adjustment and outcome has been supported by several studies, but controlled studies are scarce. Moreover, there is a shortage of research examining the associations between cognition and motor functions, particularly in patients with TBI, although such associations may have clinical implications for neurorehabilitation. Recently, awareness has increased of the need to supplement rehabilitation outcome assessment of TBI patients by subjective measures, which may have important implications for the allocation of different rehabilitation interventions and to enhance outcomes. The studies of this thesis investigated the psychosocial outcomes of an application of CHRP (Study I) and the relationship between the objective outcomes and their subjective self-appraisals in adults with postacute TBI (Study III) as well as the association between cognitive and motor functions for benefits in multidisciplinary neurorehabilitation after TBI (Study II). In Study I, the productivity of 19 consecutive adult patients with postacute moderate to severe TBI who underwent CHRP in a nationwide neurorehabilitation center setting was compared with that of 20 matched controls who received conventional clinical care and rehabilitation. After a six-week CHRP, the patients were followed up for two years and then evaluated for long-term outcome. The status of their productivity was judged as productive (defined as working, studying, or participating in volunteer activities) or nonproductive by two blinded and independent raters, and evaluated with structured questionnaires filled in by the patients and their significant others. In Study II, cognitive and motor functioning of 34 physically well-recovered men with postacute moderate to severe TBI was assessed. Cognitive functioning was measured in the domains of information processing, attention, and executive functions, particularly in regulation of voluntary movements. Motor performance was measured in postural balance, agility, and gross motor rhythm coordination. Study III comprised 54 adults with chronic moderate to severe TBI who had resumed working at various levels of competence following CHRPs running in two neurorehabilitation centers in two countries. The objective outcome measure was the level of work competence that participants had attained postrehabilitation. The subjective outcome measure was participants’ subjective self-appraisal of their rehabilitation outcomes by rating six measures: effort during rehabilitation, meaning in life, productivity, acceptance, social life, and intimate relationships. Study I showed that at the end of follow-up 89% of patients in the CHRP group were productive compared with 55% of controls. CHRP was found to be significantly predictive of a productive status at follow-up, and other factors did not explain the better productivity of the CHRP group. Moreover, the findings of Study III indicated that the levels of work obtained after a CHRP were not associated with the areas of subjective self-appraisals other than the ability to establish intimate relationships. Overall, the patients were found to be largely satisfied with the areas of wellness after CHRPs. The explorative Study II analyzing the relationship between cognitive and motor functions in postacute TBI found associations of measures of information processing, attention, and executive functioning with agility and dynamic balance. The fluency of information processing and executive functioning was reflected in the speed of walking/dynamic balance and running, and vice versa. The present results give evidence that the CHRP approach improves outcomes for individuals with moderate to severe postacute TBI even many years after injury (Studies I and III). The findings support the presumption that CHRPs facilitate achievement of a successful outcome through establishing a meaningful and satisfactory life after TBI in the face of persisting deficits. In line with the few previous studies, the findings of Study II support the interplay between cognition and motor performance supporting the possible multimodal effects of TBI rehabilitation and encouraging use of comprehensive multidisciplinary neurorehabilitation to enhance outcomes. Finally, the results of Study III are consistent with earlier studies that have noted a dissociation between functional outcomes and subjective well-being, especially in chronic TBI. Community functioning and the related satisfaction seem to be distinct aspects of participants’ experience that must be considered in the evaluation of rehabilitation outcomes following TBI. These findings may have implications for rehabilitation service provision and allocation, encouraging a move towards CHRP models in rehabilitation of individuals with TBI to improve their psychosocial outcomes and subjective well-being.