Factors affecting functional outcomes of traumatic brain injury rehabilitation at a rehabilitation facility in Saudi Arabia

Methods

Results

This retrospective investigation identified 140 patients after excluding three patients who were transferred to acute care. The mean patient age was 27±11 years (range: 16–80 years), and the patients were predominantly male (92%) and single (72.1%) (Table 1). The TBI was caused by MVAs in 95% of patients. The mean initial GCS score after trauma in the ED was 6±2 (range: 0–15), and the mean coma duration was 47±38 days (range: 3-180 days). The mean time from injury to IPR admission was 264±357 days (range: 32–2220 days), and the mean IPR LOS was 75±52 days (range: 10–373 days). The mean FIM scores at admission and discharge were 54±31 (range: 18-126) and 87±33 (range: 18–126) respectively, with a mean FIM change of 33±21 (range: 0–86). Most (43.6%) of the patients were students, and nearly two-third of the patients were admitted with tetraplegia (71.4%). Additionally, nearly two-third (72.1%) of the patients had fractures other than skull fractures, and one-third (28.5%) were diagnosed with seizure disorder after TBI (Table 2).

The factors significantly correlated with FIM change were FIM at admission (p=0.003, r=-0.253), FIM at discharge (p<0.001, r=0.390), and time from injury to IPR admission (p=0.003, r=-0.250) (Table 3). Patients who were employed before the injury had high FIM scores upon admission (p=0.029, r=0.184) and discharge (p=0.003, r=0.252). Older patients had low FIM scores at admission (p=0.004, r=−0.244) and discharge (p<0.001, r=−0.330). Additionally, patients with a long coma duration after TBI and those with a long IPR LOS had lower FIM scores at admission (p<0.001) and discharge (p<0.001). Thus, coma duration and IPR LOS had moderate to large negative associations with FIM indicating worse outcomes and more disability with extension in time of coma duration and IPR LOS. Moreover, patients with a longer time from injury to IPR admission had a lower FIM score at discharge (p<0.003, r=−0.253).

Discussion

The TBI is becoming an important reason of preventable deaths in Saudi Arabia. We found MVA responsible for TBI in 95% patients. Other Saudi studies have also found MVA responsible for TBI in 89.3%, 69.4%, and 71.8% of patients.10⇓–12 These findings are consistent with regional reports from Qatar, Egypt, United Arab Emirates, Kuwait, and Sudan.13⇓⇓–16 Over-speeding remains a major concern in the Middle East, and it is associated with high velocity accidents in which brain injury is most likely to occur. Hence, appropriate measures for the prevention of MVA need to be considered in the region. This can be achieved by establishing advanced data record system, legislation and enforcement, awareness campaigns and education programs, induction of traffic and speed reduction measures, identification of susceptible crash sites, and engagement and coordination of key stake holders including ministry of health.17,18

The majority of the sampled patients were young males (average age: 27 years), similar to findings of regional studies in which TBI was found to be more frequent in younger males.7,11,13⇓⇓–16,19,20 The higher percentage of males than females was probably because the bulk majority of pedestrians and drivers on roads in Saudi Arabia are mostly males and therefore they are mostly involved in MVA.6,12,21 Saudi government has extended driving privileges to females in 2018 and availability of a female driver in the family may bar the younger males from driving in case of a commute requirement. Additionally, an analysis of human psychology suggests that young people consider driving a representation of autonomy, adulthood, and an opportunity to enjoy thrill associated with risky behaviors.21 There are gender and age differences in MVAs which can be addressed by strict implementation of age-bound restriction on driving.

The most important factor to affect functional outcome in our study was time to start rehabilitation after injury. Those patients who entered a rehabilitation program earlier had a better functional outcome at discharge. Likewise, Demir et al22 compared early and late rehabilitation and found that there was a significant improvement with early rehabilitation. Andelic et al23 also noted better functional outcomes in patients who received early rehabilitation. Additionally, Tepas et al24 discovered that rehabilitation delay reduced the effectiveness of rehabilitative care. Moreover, other studies have also reported that the time to IPR admission was related to the FIM score.6,25,26 The second factor worth mentioning is the FIM at admission. The patients with lower FIM at admission or in other words more disability at admission had better functional recovery or superior reduction in disability at the end of the IPR period. Qannam et al6 also, identified the FIM score at admission as the largest contributor to FIM score at discharge, which accounted for 45-65% of the variability in the models. Similar findings have been noted in other studies as well.25⇓–27

There were many comorbidities and complications observed by us in our study. Around 72% of patients had fractures other than skull fractures due to trauma. The most frequent complications after TBI were mental disorders (59.9%), contractures (50.7%), cranial nerve injuries (42.9%), and heterotopic ossification (HO) (34.3%). Ahmed et al28 had summarized the complications associated with TBI in Saudi population. They identified cognitive impairment, cranial nerve injuries, seizures, hydrocephalus, cerebrospinal fluid leakage, tinnitus, organ failure, and poly-trauma (including associated fractures) as short-term complications and Parkinson’s disease, Alzheimer’s disease, dementia, epilepsy, and several psychiatric disorders as long-term complications. In a Turkish cohort, Demir et al22 reported spasticity, seizures, dysphagia, contractures, and HO as common complications, with spasticity being the most frequent. Nearly half of the patients admitted to our center for rehabilitation had contractures at the time of admission, and nearly one-third had HO. This is alarming and reflects the lack of rehabilitation care during acute and subacute care after TBI. Thus, it is important to ensure early access to comprehensive rehabilitation in acute care facilities and to improve rehabilitation awareness among healthcare providers and other stakeholders involved in TBI care.

In this retrospective study, there were no associations with of age, gender, marital status, educational level, nature of occupation, etiology, or affected body side on functional outcomes. Age as a non-deciding factor was noted by Qannam et al6 and Gardner et al.29 On the other hand, most studies have suggested that age is a determining factor for better motor and cognitive recovery22,30,31 and survival rates later in life.32⇓–34 In one of the largest studies including 8719 patients investigating the association between age and functional outcome at 6 months, there was a strikingly linear relationship observed between age and outcome.35

The LOS has been analyzed in different perspectives. In one study, a reduced inpatient LOS did not adversely affect functional outcome one-year post brain injury; however, a multicenter study showed an evidence of significantly increasing daily cost of care with corresponding decreases in LOS.36,37 In our study, the initial GCS score in the ED and the LOS in the IPR facility were not associated with significant change in the FIM score at discharge. On the other hand, some studies have shown that the IPR LOS was associated with functional outcomes after TBI rehabilitation.22,26,38 Sandhaug et al25 reported that the predictors of the functional level at the time of discharge from rehabilitation were the GCS score at IPR admission and LOS in the rehabilitation unit.25 A review of the literature on TBI in older adults observed that shorter LOS and fewer hours of therapy per day in older people resulted in less functional ability both during and after IPR.29

In general, few Saudi studies have reported on LOS during acute care after TBI, but the time from injury to rehabilitation admission has been rarely reported.6 The average time from injury to IPR admission was 264 days in our study, which is similar to another recent report from Saudi Arabia by Qannam et al.6 It is interesting to observe that even though our average LOS was 11 days more as compared to this study, the FIM change was nearly similar. Additionally, our study included variables like comorbidities and complications post TBI. We analyzed different factors in relation to functional status, which have not been studied before in the region, and included employement status, educational level, occupation, and marital status. The LOS in acute care after TBI has been reported to be 50 and 94 days in local studies, but these reports do not mention if the patients underwent IPR after acute care.7,11 The duration from onset to admission to IPR is notably longer than that reported in studies from the United States and European countries.22,39⇓⇓⇓–43 The apparent reason probably is the approach to trauma practice in Saudi Arabia. After major injuries associated with polytrauma, such as a head injury, the focus remains mainly on life-saving and limb-saving approaches in acute care. Patients might have prolonged intensive care and their activities might be confined to a bed on a surgical floor with limited access to comprehensive rehabilitation. Cognitive and behavioral aspects of the injury are often overlooked during this critical phase of recovery. Consequently, patients tend to develop complications, and their stay in acute care is prolonged. The need of continued care among dependent patients remains a considerable barrier for discharge, and the locations and resources for comprehensive rehabilitation are limited. There are few rehabilitation facilities offering comprehensive rehabilitation in the country, with a prolonged waiting time for admission and a limited number of beds for TBI.20 The mean LOS during rehabilitation was higher in our study (75 days) than in previous local studies (57 days and 64 days respectively).6,20 It is also higher than what is reported in studies from European countries, Australia, and USA.27,30,44⇓–46 Presently, there is no general consensus on the optimal IPR LOS and the intensity of rehabilitation services for patients with TBI; however, there are guidelines,48⇓⇓⇓–52 which vary from one health system to another.