Her fear on changing position seemed to be absolutely justified therapeutically.
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At the same time, it emerged that the layout of the countertops in her kitchen was unfavorable, so she was not able to use the abilities she had effectively. Within a real therapeutic living environment e. This successfully laid the groundwork for stable posture, stable standing, and control in the supporting and nonsupporting legs while walking. To optimize environmental factors at home and ensure that changes were made, for example in washing and dressing, a TEAM therapist made 4 visits to the patient at home.
One week after the end of the TEAM treatment patient H had parked her wheelchair in the study and always walked around her apartment. She reported that she herself was amazed how much else had changed in her everyday life. She no longer needed the nursing bed that had been in the middle of the living room, as she could now get up and walk from her normal bed. In the mornings she had finished bathing after 60 minutes. A quite new discovery for her was that there was barely any increase in tension in her arm and leg, so this no longer caused her pain, and she no longer needed a rest in the mornings.
She was very happy that she could once again manage everyday housework without help: The modified Rankin Scale mRS was used for clinical characterization of the trial population on initial examination. Because this allows for only very rough outcome evaluation, mRS findings were not analyzed later in the trial details on the measuring tools used can be found in the eMethods section. Both the GAS for the primary outcome and the other measuring tools underwent per-protocol analysis after the 4-week intervention first treatment period.
The statistical methods used and further information on the trial design are detailed in the eMethods section. Fifty-three patients were randomized to the two treatment orders 26 patients to the trial intervention followed by standard treatment in the control phase, 27 to standard treatment followed by the trial intervention. Forty-seven patients 23 in the TEAM group, 24 in the control group completed the trial according to the schedule and were defined as the population to be analyzed in the per-protocol analysis. There were no differences between the 2 groups at the beginning of the trial in terms of either demographics or health- and illness-related factors table 1.
During the TEAM phases patients received This was split into 6. During the control phase patients received their standard treatment. In independence in daily activities, over the same period there was a significant increase in FIM score from Both the significantly higher extent of goal attainment and the improvement in FIM for the TEAM program were confirmed in sensitivity analyses performed for all 53 randomized patients, i.
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At 3 months at the end of the 2-month washout phase , there were no significant differences between the TEAM program and standard treatment in terms of either the tools used to evaluate quality of life and participation or those used to assess the situation of relatives providing care etable 1. Twelve months after the beginning of the trial Regardless of treatment order, there were significant improvements among the trial population in the domains independence in daily activities, QoL EQ-5D , participation, and care needs Figure 1 , Table 2.
Changes in various domains and outcomes during the one-year trial period. Significance data according to t-test for matched samples 2-tailed. FIM during trial, from initial value at beginning of trial, by treatment group. Significance data are from t-tests for independent samples 2-tailed at each point in time.
There were a total of 4 falls during TEAM treatment. The most common reason for medical consultations and treatments during TEAM treatment was adjustment of blood pressure medication, in most cases due to hypertensive values. In this randomized, controlled, investigator-blinded clinical trial, we were able to demonstrate that a participation-focused, intensive rehabilitation program lasting only 4 weeks enabled patient-specific goals highly relevant to everyday life to be attained more frequently than standard outpatient care, even among patients with serious acquired brain injury sustained a mean of 4 years previously.
This is important because during such a chronic phase it is normally assumed that there will be a plateau rather than further dynamic improvement However, other studies of rehabilitation interventions have already shown that significant functional or activity-related gains remain possible more than 6 months after brain injury 20 , Even the rather crude FIM tool to describe functional independence in daily activities showed small but significant improvements for the TEAM treatment.
After the crossover, patients in the group receiving TEAM first and standard treatment second were able to maintain their progress and even build on it over 12 months. In contrast, the patients who received standard treatment first and TEAM second did not improve until they were undergoing the TEAM treatment, including in independence in daily activities. This can be seen as further evidence of the efficacy of the trial intervention figure 2. The special feature of this trial is its focus on attainment of a predefined, participation-related goal relevant to everyday life and its verification of goal attainment in the real home environment.
There have already been multiple clinical studies of rehabilitation showing that specific measures can attain functional and activity-related improvements even in chronic patients, such as constraint-induced movement therapy for arm and hand function 22 , robotic arm and hand training 23 — 25 , task-specific arm and hand training 26 , and intensive speech therapy combined with transcranial magnetic stimulation Several of our trial participants had also achieved functional and activity-related gains during standard outpatient treatment, but they were unable to use these gains in their real home environments see eBox for case study.
Comprehensive rehabilitation programs should attach sufficient importance to all these factors in chronic-phase patients. Participation-focused treatment has also been performed in other studies of rehabilitation, for example in a smaller, uncontrolled case series of 12 chronically ill stroke patients In this study participation improved steadily over a 5-month observation period. There were similar findings in a nonrandomized trial involving 83 stroke patients, 27 of whom took part in a special outpatient treatment program The participation of patients in the intervention group improved significantly in comparison to untreated patients.
This is in line with the results we present here and illustrates that participation-focused intensive treatment programs can be successful even in chronic-phase patients. After 12 months our trial patients achieved increased participation, reduced care needs, greater independence, and better health-related quality of life than at baseline.
However, because this was a crossover trial, all patients received a one-month therapeutic intervention, so the trial could not examine whether the positive changes were due to the TEAM intervention. Nevertheless, the long-term positive improvements in quality of life are significant, as many earlier longitudinal studies had shown that after an improvement within the first 6 months quality of life did not improve further even after years 31 , Whether such long-term rehabilitation programs may also be worthwhile in terms of health economics should be clarified in future pilot projects.
Lesser care needs and greater independence in daily life may lead to a lessening of the burden on the social insurance system in multiple sectors in Germany. The finding that there is long-term potential for rehabilitation following acquired brain injury may sound ominous to those who provide funding, but it may have major implications for care in Germany, where this potential as yet remains almost untapped. Care after acquired brain injury is currently characterized by isolated function-focused, individual treatment components provided too infrequently.
There is often no coordination of these individual treatment components, which are undoubtedly performed very skillfully and with the best of intentions; primary care physicians and neurologists in private practice in particular are often unable to cope with the resulting workload through no fault of their own. Specific essentials such as determining which technical aids are required or advice on social services are usually completely absent.
In addition, experienced rehabilitation physicians are usually no longer involved at all in this phase of recovery, which often lasts for decades. However, the uncoordinated prescription of treatment and aids, performed with the best of intentions, leads to high costs even though they do not allow patients to achieve as many concrete goals as focused treatment programs Figure 3a. On the basis of the scientific evidence, it would be far more sensible to treat patients at regular intervals with further intensive rehabilitation programs in order to achieve their next goals which are relevant to their everyday lives Figure 3b.
We have previously been able to show that a similar approach with very seriously affected patients receiving inpatient rehabilitation at intervals can still result in significant improvements even after several years A comprehensive care structure should be put in place for this area as swiftly as possible. Attainment of independence and participation goals in daily life following acquired brain injury in relation to therapy and care structure.
After rehabilitation ends, typical therapeutic practice leads to only small improvements, or even to a plateau. TEAM can always allow new individual participation goals to be attained, and there is a sustained improvement in independence. One limitation we must acknowledge is that the design of this trial did not allow us to investigate whether or not the content of the TEAM rehabilitation program was more effective than other therapies; this would have required a control group receiving treatment at the same frequency but with different content.
An apparent contradiction in the findings of our trial is that although the number of individual patient goals achieved using the TEAM treatment was statistically significantly greater, this seems to have had no effect on generic measuring tools for health-related quality of life EQ-5D, SF or participation WHODAS at the end of the first treatment period, at one month. However, measuring quality of life and participation in neurological patients is difficult, particularly when generic and general measuring tools are used Attainment of specific everyday goals may lie below the sensitivity threshold of the measuring procedure.
Intention-to-treat analysis was performed only to confirm the extent of individual goal attainment. We are very grateful for this support. We would like to thank all the patients who took part in this trial, as well as Dr. Conflict of interest statement Prof. Bender, Luzia Fischer, Dr. Huber, and Kerstin Jawny are staff physicians in a neurological rehabilitation facility that provides a corresponding commercial outpatient rehabilitation program. Bender has received reimbursement of travel expenses and event fees from Bayer, and a lecture fee from Covidien.
He receives material resources for a research project from Hocoma and Hasomed. Straube declare that no conflict of interest exists. National Center for Biotechnology Information , U. Journal List Dtsch Arztebl Int v. Published online Sep Andreas Bender , Prof.
Find articles by Andreas Bender. Author information Article notes Copyright and License information Disclaimer. Received Feb 18; Accepted Jun Results of the randomized controlled crossover trial TEAM and control groups using data from the first treatment period T1 to T2 table 2. Results of the randomized controlled trial phase TEAM and control groups using data from the first one-month treatment period followed by a 2-month follow-up washout phase T1 versus T3, eTable 1.
Aspect tested Measuring tool 1. Extent of care needs New Appraisal Assessment: Nursing Care NAA 5. Open in a separate window. Abstract Background Patients with acquired brain injury who have been discharged from inpatient neurological rehabilitation often continue to suffer from limited independence, participation, and quality of life.
Conclusion The TEAM rehabilitation program can help patients in the chronic phase of acquired brain injury achieve participation goals that are relevant to everyday life. Methods This was a single-center, randomized, controlled, investigator-blinded trial with 6 trial visits. Patients Fifty-four chronic-phase patients who had suffered serious acquired brain injury ischemic cerebral infarction, intracerebral hemorrhage, subarachnoid hemorrhage, TBI were enrolled in the trial due to persistent disability and participation restriction; 53 were randomized to the 2 treatment orders, at a ratio of 1: The principal inclusion criteria were as follows: Cerebral infarction hemorrhage or ischemia or TBI 6 months or more ago.
Time from discharge from inpatient rehabilitation treatment to trial enrolment 3 months or more. Trial intervention The treatment phase lasted 4 weeks. Assessments and measuring tools The primary outcome was defined as the extent of individual goal attainment. The German New Appraisal Assessment: Statistical evaluation Both the GAS for the primary outcome and the other measuring tools underwent per-protocol analysis after the 4-week intervention first treatment period. Results Fifty-three patients were randomized to the two treatment orders 26 patients to the trial intervention followed by standard treatment in the control phase, 27 to standard treatment followed by the trial intervention.
Follow-up results Twelve months after the beginning of the trial Table 2 Changes in clinical evaluation scales in parallel-group analysis first one-month treatment period before crossover only and at one-year follow-up. Discussion In this randomized, controlled, investigator-blinded clinical trial, we were able to demonstrate that a participation-focused, intensive rehabilitation program lasting only 4 weeks enabled patient-specific goals highly relevant to everyday life to be attained more frequently than standard outpatient care, even among patients with serious acquired brain injury sustained a mean of 4 years previously.
Attainment of independence and participation goals in daily life following acquired brain injury in relation to therapy and care structure a Current care structure: Limitations One limitation we must acknowledge is that the design of this trial did not allow us to investigate whether or not the content of the TEAM rehabilitation program was more effective than other therapies; this would have required a control group receiving treatment at the same frequency but with different content.
There is potential for long-term rehabilitation in neurological patients with acquired brain injury. Intensive, participation-focused rehabilitation programs enable chronic patients to attain goals relevant to their daily lives and to achieve increased independence in daily activities. Participation, quality of life, and independence improve in the long term, with reduced care needs.
Supplementary Material eMETHODS This was a crossover trial with a total of 6 trial visits, a crossover after 3 months, and 6-month follow-up after the end of the two 1-month treatment phases efigure 1. Thus, the trial analysis is divided into the following three sections: Footnotes Conflict of interest statement Prof.
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Epidemiology of ischaemic stroke and traumatic brain injury. Best Pract Res Clin Anaesthesiol. Global and regional burden of stroke during Epidemiology of traumatic brain injury in Europe; pp. Rollnik JD, Janosch U. Current trends in the length of stay in neu-rological early rehabilitation. Long-term course of patients in neurological rehabilitation phase B. Results of the 6-year follow-up in a multicenter study. Value and application of the ICF in rehabilitation medicine. Wellek S, Blettner M. On the proper use of the crossover design in clinical trials: Perceptual processes as prerequisites for complex human behaviour.
Goal attainment scaling GAS in rehabilitation: The effect of combined somatosensory stimulation and task-specific training on upper limb function in chronic stroke: Relationships between impairment and physical disability as measured by the functional independence measure. Arch Phys Med Rehabil. Performance profiles of the functional independence measure.
Am J Phys Med Rehabil. EuroQolGroup EuroQol a new facility for the measurement of health-related quality of life. The reliability and validity of the SF health survey questionnaire for use with individuals with traumatic brain injury. Bull World Health Organ. Thornton M, Travis SS. Analysis of the reliability of the modified caregiver strain index. Long term effects of intensity of upper and lower limb training after stroke: J Neurol Neurosurg Psychiatry. Body-weight-supported treadmill rehabilitation after stroke.
N Engl J Med. Time course of functional and biomechanical improvements during a gait training intervention in persons with chronic stroke. J Neurol Phys Ther. Effects of modified constraint-induced movement therapy on reach-to-grasp movements and functional performance after chronic stroke: Robot-based hand motor therapy after stroke. A comparison of functional and impairment-based robotic training in severe to moderate chronic stroke: Comparing integrated training of the hand and arm with isolated training of the same effectors in persons with stroke using haptically rendered virtual environments, a randomized clinical trial.
Effects of task-oriented robot training on arm function, activity, and quality of life in chronic stroke patients: Our services are developed and guided by one-on-one time with in-house rehab professionals to support people build meaningful relationships, be connected to their community and be involved in functional and productive activities. CONNECT homes are residential in nature and self-supporting with residents and staff working in partnership to keep things running as you would in community.
Our homes blend naturally into the community allowing for easy interaction and integration with the neighbourhood. This flexibility is essential in meeting the enormous variety of unique needs presented by acquired brain injury and stroke and better emulates daily life after CONNECT in the community. First and foremost, however, our people are caring, compassionate and respectful which creates a workplace that is supportive and fun. This team is made up of therapists from a variety of disciplines including recreation therapy, physiotherapy, registered nursing, speech therapy, occupational therapy and neuropsychology, respectively.
I work with the residents and our CONNECT team to create a plan to progress their mobility and functional abilities, in order to allow them to become more independent with their lives. Seeing our residents become able to achieve their personal goals, and being a part of their journey on reclaiming their lives.
In my spare time I like to: Do yoga, mixed martial arts, and weightlifting.
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Coaching people with thinking problems! My job involves assisting Life Redesign Coaches with the Health and Wellness of residents, including care, medication delivery and any medical issues the residents may have. The residents do what they can for themselves with support from myself or the LRC, as needed.
The team dynamic and the community based approach to rehabilitation. I listen and try to be a support to my team and to my clients. Spend time with family, read, walk in the woods with my dog. I support residents to achieve their mobility and physical recreation goals. As a team, we assess residents and assist them to set and achieve their goals with regards to basic life skills as well as in regaining and redefining their life roles.
Anyone who overcomes adversity and holds on to humour and a sense of compassion Heroes are everywhere. Something that gives me energy: A good laugh or a dive in cold ocean water maybe not at the same time. Going on mini adventures in nature.
Long-term Rehabilitation in Patients With Acquired Brain Injury
Typically pedaling, paddling, skiing or walking. Our People Resources Coaches are the main points of contact for potential and current employees and our Business Resources Manager is our primary liaison with potential residents and community contacts. What I love about my job: The diversity in my role and the different people I get to connect with everyday both at work and in the community. My perfect day looks like: Coffee on the patio, walking with my dog Molly and spending time with my family and friends.
I love watching the residents improving while enjoying life. Best part of my job: The People Perfect day: A sunny day at the cottage Favorite Season: Spring in Vancouver, Fall in Ontario. Finding potential and challenging convention. We are always exploring better ways of doing things together. One word that describes me: People with the courage to try My perfect day: The culture and the shared commitment to making lives better.
Mountain bike, spend time with friends and family, travel as much as possible.
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As Site Leader, I manage the running of our Langley site in addition to services. While supporting the operation of the houses, I love helping the coaches own their Life Redesign roles so residents and their families fully experience the Life Redesign Model. In my spare time: I enjoy spending time with family and doing creative projects like cake decorating and refurbishing old furniture. We are available on short notice to provide detailed assessments and proposals for services and support.
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