Article
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

To investigate the incidence, risk factors, and outcome in patients with fecal incontinence after acute brain injury. A retrospective study of the incidence of and risk factors contributing to fecal incontinence, and outcomes at admission to and discharge from inpatient rehabilitation and at 1-year follow-up. Medical centers in the federally sponsored Traumatic Brain Injury Model Systems (TBIMS). A total of 1,013 consecutively enrolled rehabilitation inpatients from 17 TBIMS centers who were admitted to acute care within 24 hours of traumatic brain injury and seen at 1-year postinjury between 1990 and 2000. Not applicable. Incidence of fecal incontinence, length of coma, length of posttraumatic amnesia (PTA), admission Glasgow Coma Scale (GCS) score, length of stay (LOS), FIM instrument scores, disposition at discharge and follow-up, and incidences of pelvic fracture, frontal contusion, and urinary tract infection (UTI). The incidence of fecal incontinence was 68% at admission to inpatient rehabilitation, 12.4% at rehabilitation discharge, and 5.2% at 1-year follow-up. Analysis of variance and chi-square analyses revealed statistically significant associations between the incidence of fecal incontinence at rehabilitation admission and admission GCS score, length of coma and PTA, LOS, and incidence of UTI and frontal contusion. Fecal incontinence at rehabilitation discharge was significantly associated with several variables, including age, discharge disposition, admission GCS score, length of coma, PTA, LOS, FIM scores, and incidence of pelvic fracture and frontal contusion. Significant associations were also found between fecal incontinence at 1-year follow-up and age, discharge and current 1-year disposition, admission GCS score, length of coma, LOS, FIM scores, and incidence of UTI (P<.05). Although logistic regression analyses were significant (P<.001), and predicted continence with 100% accuracy, demographics, injury characteristics, medical complications, and functional outcomes did not predict incontinence at discharge and at 1-year follow-up. Fecal incontinence is a significant problem after brain injury. Certain factors may increase its likelihood. Further studies evaluating mechanisms of fecal incontinence and treatment or control interventions would be useful.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... Traumatic brain injury was a shared factor associated with high odds of having FI and DI, which was consistent with other studies [36,37]. Two one-year follow-up studies found that traumatic brain injury was associated with an increased risk of urinary incontinence [36] and FI [37]. ...
... Traumatic brain injury was a shared factor associated with high odds of having FI and DI, which was consistent with other studies [36,37]. Two one-year follow-up studies found that traumatic brain injury was associated with an increased risk of urinary incontinence [36] and FI [37]. Traumatic brain injury is a nondegenerative, noncongenital insult to the brain from an external mechanical force, which might result in permanent or temporary impairment of cognitive, physical, or psychosocial function. ...
... Traumatic brain injury is a nondegenerative, noncongenital insult to the brain from an external mechanical force, which might result in permanent or temporary impairment of cognitive, physical, or psychosocial function. Incontinence is associated with a poor overall functional outcome following traumatic brain injury [36,37]. These correlations highlight the need for health professionals dealing with incontinence patients to assess whether there is a history of traumatic brain injury. ...
Article
Full-text available
Fecal and double incontinence are known to be more prevalent among the rural elderly. Yet, there have been few studies on their epidemic condition among Chinese rural elders. This study estimated the prevalence and correlates of fecal and double incontinence in rural elderly aged 65 years and over in North China. A multisite cross-sectional survey was conducted in 10 villages, yielding a sampling frame of 1250 residents. Fecal and urinary incontinence assessments were based on the self-reported bowel health questionnaire and the International Consultation on Incontinence Questionnaire-Short Form, respectively. The concomitant presence of fecal and urinary incontinence in the same subject was defined as double incontinence. The prevalence of fecal and double incontinence was 12.3% and 9.3%, respectively. Factors associated with fecal incontinence included urinary incontinence, lack of social interaction, traumatic brain injury, cerebrovascular disease, and poverty. Physical activities of daily living dependence, traumatic brain injury, lack of social interaction, and poor sleep quality were associated with higher odds of having double incontinence, whereas tea consumption was correlated with lower odds. Individualized intervention programs should be developed targeting associated factors and high-risk populations. These intervention programs should be integrated into existing public health services for the rural elderly to facilitate appropriate prevention and management of incontinence.
... Within the ABI population, incontinence is common. For example, as many as 85.9% of people with ABI from traumatic causes complain of urinary symptoms, and up to 68% report faecal incontinence [3,4]. Urinary incontinence is also reported to occur in 32%-79% of people with ABI from stroke in the first month after stroke [5][6][7][8][9][10][11] and remains prevalent compared to population controls up to 10 years later [12]. ...
... 3. Determine the change in quality of life for residents using assistive toileting technologies. 4. Provide a final report and recommendations to the Insurance Commission of Western Australia (Insurance Commission) and Brightwater. ...
... In addition to the impact on HRQOL, incontinence following brain injury has been associated with loss of independence, higher rates of admission to health services following acute care, and increased risk of mortality [4,7,32,33,[47][48][49][50][51][52][53]. In many cases, this relationship is independent of other prognostic factors. ...
... [22] Sphincter control problems represent a common functional deficit after brain injury, particularly in those with frontal TBI due to the involvement of the frontal lobe locus of continence. [23] It is worth noting that being discharged home may be delayed in patients with faecal incontinence, and a large multicentre study involving 1013 patients after acute brain injury showed that those with bowel incontinence stayed 53 more days in inpatient rehabilitation than continent patients. [23] There is also evidence that patients with TBI and multiple traumas may have worse functional outcomes as a result of impaired cognitive function and/or permanent disability. ...
... [23] It is worth noting that being discharged home may be delayed in patients with faecal incontinence, and a large multicentre study involving 1013 patients after acute brain injury showed that those with bowel incontinence stayed 53 more days in inpatient rehabilitation than continent patients. [23] There is also evidence that patients with TBI and multiple traumas may have worse functional outcomes as a result of impaired cognitive function and/or permanent disability. [24] GCS scores at admission were predictive of health outcomes at both admission and discharge. ...
Article
Purpose: To evaluate epidemiological and clinical data on patients with severe acquired brain injury (sABI) admitted to rehabilitation units in the first 6 years since the inception of a regional register (2005-2010) in the Emilia-Romagna region (Italy). Method: Retrospective multicentre study of a regional cohort using data from an online regional register (Gravi Cerebrolesioni Emilia-Romagna - GRACER). The study included 318 patients who suffered sABI (defined by Glasgow Coma Scale score ≤8 recorded in the initial 24 h following injury), who were admitted to and subsequently discharged from rehabilitation units. Physical and cognitive functions were evaluated at admission and discharge. Other data recorded included aetiology, presence of secondary conditions and need for specific medical support. Results: Three-quarters of patients displayed improvements in physical and/or cognitive function at discharge from rehabilitation units, with 71.4% of patients returning home. Better outcomes at discharge were associated in particular with younger age, traumatic brain injury (versus non-traumatic), or absence of tracheostomy at admission. Conclusion: The GRACER register is a useful tool for the assessment of epidemiological and clinical information on sABI patients. In light of the positive impact on patient outcomes, rehabilitation in specialised units is highly encouraged and should occur as soon as possible. Implications for Rehabilitation There is a need for more epidemiological and clinical data associated with severe acquired brain injury, particular regarding those of non-traumatic origin. In a retrospective multicentre study of a regional cohort using data from an online regional register in Italy (GRACER), more than three-quarters of patients displayed improvements in physical and/or cognitive function at discharge from the rehabilitation units. Better outcomes at discharge were associated in particular with younger age, traumatic brain injury (versus non-traumatic) or absence of tracheostomy at admission. Admission to a specialised rehabilitation unit is highly encouraged for patients with severe acquired brain injury, and should occur as soon as possible. Policy-makers and service planners should continue to develop strategies and allocate adequate resources for rehabilitation services due to their positive impact on patient outcomes. In particular, patients with conditions associated with increased likelihood of poor outcomes may require special attention during rehabilitation to improve outcomes at discharge.
... These complaints are common in individuals with sequelae due to CVA and TBI and lead to constraints and quality of life problems, often hampering patients' effective return to daily and social activities. 8,14 Getting to know the dimension of the problem in this population can contribute to further attention to these symptoms in this population, with a view to the early establishment of bowel retraining measures and, consequently, to a better quality of life for these people. Thus, the aim of this study was to investigate the prevalence of bowel dysfunction (intestinal constipation and anal incontinence) in patients admitted for rehabilitation at a neurologic rehabilitation ward. ...
... These factors are closely related with indi-viduals' intestinal function, as they change self-care for toilet use and also cause anal incontinence. 8,14 ...
Article
Full-text available
Bowel dysfunction is a common complaint among patients with brain damage due to stroke and traumatic brain injury. The aim of this study was to investigate the prevalence of bowel dysfunction (anal incontinence and intestinal constipation) in patients with brain damage due to stroke and traumatic brain injury admitted for rehabilitation. This is a retrospective case series study, based on the analysis of data from 138 charts of patients admitted in the first half of 2009. The prevalence of bowel dysfunction was 41%, with 33 (24%) cases of anal incontinence and 37 (27%) cases of intestinal constipation. Motor impairment, mobility aid, changes in memory and communication were associated with the presence of anal incontinence. The prevalence of bowel dysfunction is high in this population. Early identification of the symptoms and its related factors promoting bowel retraining, may help to improve the quality of life of patients with bowel dysfunction.
... Level of consciousness has an impact on a variety of abilities such as language [36], motor function [37], sphincter function [38] and feeding [39]. Most patients with DoC are fed by enteral feeding tube [40,41]. ...
Article
Full-text available
This literature review explores a wide range of themes addressing the links between swallowing and consciousness. Signs of consciousness are historically based on the principle of differentiating reflexive from volitional behaviors. We show that the sequencing of the components of swallowing falls on a continuum of voluntary to reflex behaviors and we describe several types of volitional and non-volitional swallowing tasks. The frequency, speed of initiation of the swallowing reflex, efficacy of the pharyngeal phase of swallowing and coordination between respiration and swallowing are influenced by the level of consciousness during non-pathological modifications of consciousness such as sleep and general anesthesia. In patients with severe brain injury, the level of consciousness is associated with several components related to swallowing, such as the possibility of extubation, risk of pneumonia, type of feeding or components directly related to swallowing such as oral or pharyngeal abnormalities. Based on our theoretical and empirical analysis, the efficacy of the oral phase and the ability to receive exclusive oral feeding seem to be the most robust signs of consciousness related to swallowing in patients with disorders of consciousness. Components of the pharyngeal phase (in terms of abilities of saliva management) and evoked cough may be influenced by consciousness, but further studies are necessary to determine if they constitute signs of consciousness as such or only cortically mediated behaviors. This review also highlights the critical lack of tools and techniques to assess and treat dysphagia in patients with disorders of consciousness.
... The prevalence of FI is high during the acute stage ( Emmanuel, 2010 ), with 23%-40% among patients with stroke and 68% among patients with TBI ( Leary et al., 2006 ). The condition is still apparent at admission to rehabilitation hospitals and remains after 1 year in 5%-12% of patients with TBI ( Foxx-Orenstein et al., 2003 ;Masel & DeWitt, 2010 ) and 11% of patients with stroke ( Emmanuel, 2010 ;Harari, Coshall, Rudd, & Wolfe, 2003 ). ...
Article
The aim of this prospective, descriptive cohort study is to describe the prevalence of lower bowel dysfunction, possible relationship to diagnosis and severity, use of laxatives, and defecation patterns in patients with acquired brain injury during inpatient rehabilitation. Enrollment consisted of all patients admitted to an inpatient rehabilitation hospital (n = 98) within a 3-month period and assessments of fecal incontinence and fecal constipation at admission were performed. Documentation of used laxatives, number of defecations, and the macroscopic form during 4 weeks was conducted. Analysis of variance and Kruskal-Wallis analyses were conducted using the statistical software package STATA v 12/IC. At admission 75% of the patients suffered from lower bowel dysfunction, which was related to the severity of injury and age but not major diagnosis or gender. Of these, 68% suffered from fecal incontinence and 32% from fecal constipation. Ninety percent of the patients received laxatives during the initial 28 days. After 28 days, 20% continued to receive laxative treatment. There was no difference between weekly defecations in patients who had functional constipation and patients who had no bowel dysfunction. There was a strong relationship between bowel dysfunction status and prescribed laxative treatment. These findings indicate that lower gastrointestinal dysfunction is a long-lasting, profound complication following an acquired brain injury.
... It is unclear whether the functional disability from having a stroke or that the disruption in neurological pathways (sensory mechanisms) that promote continence contributes more to FI among stroke survivors. Traumatic brain injury has also been linked with urinary incontinence and FI, but limited data exist on older adults from registry studies and single site studies [1028,1029]. Spinal cord injury (depending on the level of injury) may result in impaired muscular strength of the external anal sphincter, delayed transit time, abnormal defaecation reflexes, and impaired sensation [1030]. ...
Article
Background Evidence based guidelines for the management of frail older persons with urinary incontinence are rare. Those produced by the International Consultation on Incontinence represent an authoritative set of recommendations spanning all aspects of management.AimsTo update the recommendations of the 4th ICI.Materials and MethodsA series of systematic reviews and evidence updates were performed by members of the working group in order to update the 2009 recommendations. The resulting guidelines were presented at the 2012 meeting of the European Associatioon of Urology.ResultsAlong with the revision of the treatment algorithm and accompanying text. There have been significant advances in several areas including pharmacological treatment of overactive bladder.DiscussionThe committee continue to notes the relative paucity of data concerning frail older persons and draw attention to knowledge gaps in this area. Neurourol. Urodynam. © 2014 Wiley Periodicals, Inc.
... In posttraumatic brain injury rehabilitation, urinary incontinence prevalence at admission, discharge and at six months post-injury have been documented as 62%, 36.9% and 17.9% [3]. Faecal incontinence incidence after acute brain injury was 68% at the time of admission to rehabilitation in the Traumatic Brain Injury Model Systems group study [9]. The management of continence after ABI has an impact on rehabilitation nursing and may influence the discharge destination and care requirements. ...
Article
Full-text available
Purpose: Persistence of urinary incontinence post acquired brain injury (ABI) carries important prognostic significance. We undertook to document the incidence of urinary incontinence, its management and complications in rehabilitation inpatients following ABI and to assess adherence to post ABI bladder management guidelines. Method: A retrospective chart survey of a convenience sample of consecutive admissions to two adult neurorehabilitation units Forster Green Hospital, Belfast, and the Scottish Brain Injury Rehabilitation Service, Edinburgh (SBIRSE). Bladder continence and management on transfer to and discharge from rehabilitation, trial removal of catheter, use of bladder drill, ultrasound investigation, anticholinergic medication and complications were recorded. Results: One hundred and forty six patients were identified. Seventy-seven (52.7%) were independent and continent of urine at rehabilitation admission and 109 (74.7%) on discharge. In all, 13 patients had urinary tract infection, 7 had urethral stricture and 1 developed haematuria whilst catheterised. Ultrasound of renal tracts was underused. Trial removal of catheter after transfer to rehabilitation occurred at a median of 10 days. Conclusions: Urinary continence was achieved in almost half of incontinent ABI patients during rehabilitation. There is potential for increased use of investigation of the renal tracts. Rehabilitation physicians should consider urethral stricture in the management of continence post ABI.
... From comments made, it appeared that residential aged care staff generally expected their residents to be incontinent and did not usually provide the level of support required to ensure that a person with the potential to become continent could develop these skills. However, incontinence of bladder or bowel has a significant impact on access to group recreation activities and can be a significant factor in limiting community participation [35,36]. All participants in this study experienced incontinence while in the RAC setting. ...
Article
Nearly 3500 people under 60 years of age are living in residential aged care in Australia, a situation which is generally recognized as incompatible with optimum quality of life. The objective of the current study is to explore the transition experiences of young people with acquired brain injury who have lived in aged care facilities and moved into community-based settings. Grounded theory, qualitative design. Semi-structured interviews were conducted with seven individuals with very severe ABI, seven family caregivers and two disability support workers. Each interview was recorded and transcribed verbatim. Participants identified a range of positive outcomes that resulted from the transition from aged care settings to community living environments including increased independence in everyday activities, improved well-being and a greater degree of social inclusion. Participants also identified environmental factors that they deemed as crucial to facilitating positive outcomes. People with very severe ABI have the potential to increase their level of independence in community-based accommodation settings; a potential that is not fostered in most aged care environments. The findings inform the outcome variables and environmental factors that should be measured in studies of transition from aged care to the community.
Chapter
Traumatic brain injury (TBI), defined as a traumatic blow or jolt to the head, or penetrating trauma to the skull that injures the brain, is a worldwide epidemic that has a substantial impact on global health and function. In this chapter, we overview TBI epidemiology and health care costs as well as discuss the fundamental pathophysiology associated with primary and secondary injury. We discuss TBI across the injury severity spectrum and continuum of care and also in the context of other injury complex elements such as injury due to blast, hypoxic-ischemic brain injury, polytrauma, and shaken-baby syndrome. We discuss how TBI influences neurotransmission and the myriad of secondary symptoms, conditions, and complications that arise due to TBI. Key testing and medical management approaches are discussed, and the roles of rehabilitation team members across the continuum of care are outlined. Translational research perspectives, including biomarkers and imaging modalities, as well as community integration and TBI prevention strategies are discussed. This comprehensive overview of TBI provides up-to-date perspectives and the fundamental literature needed for rehabilitation clinicians to be knowledgeable and address TBI epidemiology, pathophysiology, secondary conditions, management, prognostication, outcome, community reintegration, and prevention. Pediatric perspectives on these areas as also provided.
Chapter
Fecal incontinence is a potentially debilitating condition that can have a grave impact on quality of life. Patients may be fearful to participate in their normal social activities and it is not uncommon for patients to report that they avoid leaving their house due to fear of embarrassment due to accidental bowel leakage. Unfortunately, the epidemiology of the disease is challenging to pinpoint given variations in definitions of incontinence and the reliance on self-reporting of the condition. Moreover, there is a wide range of etiologic factors that may result in fecal incontinence. Treatment of the disease starts with medical therapy and physical therapy but may also involve surgical management.
Article
Traumatic brain injury (TBI) is one of the leading causes of long-term disability in the United States. Persons with TBI can experience numerous alterations in functional status, self-care ability, and cognitive, emotional, and social functioning. Understanding TBI features, treatment, and rehabilitation is imperative for nurses in every setting. Trauma, intensive and acute care, and rehabilitation nurses are an essential part of the interprofessional team that promotes optimum outcomes through specific interventions to foster hope for TBI patients and families.
Chapter
Fecal incontinence (FI), defined as the involuntary loss of solid or liquid feces can impact daily life and lead to social withdrawal. The prevalence of FI in the community increases with age, and depending on survey methods and definition of FI, varies from 2.2- 15%. Only a minority of women with FI disclose the symptom to a physician. Hence women with diarrhea should be asked about FI. Scales assessing severity of FI should incorporate type, frequency, and amount of leakage, and fecal urgency. FI is associated with increasing age, obesity, diarrhea, multiple chronic illnesses, and obstetric trauma. Obstetric anal sphincter injury can cause FI. However, among unselected women in the community, FI typically begins 2-3 decades after vaginal delivery; in this population, diarrhea and rectal urgency are the strongest independent risk factors and obstetric trauma is not. FI is not an independent risk factor for institutionalization or mortality. This edition first published 2014 © 2014 John Wiley & Sons, Ltd.
Article
Elderly patients with acute neurological impairment are prone to severe disability, fecal incontinence (FI), and resultant complications. A suspension positioning system (SPS), based on the orthopedic suspension traction system commonly used for conservative treatment of pediatric femoral fracture and uncomplicated adult pelvic fracture, was developed to facilitate FI management in patients immobilized secondary to an acute neurological condition. To evaluate the effectiveness and safety of the system, a prospective, randomized, controlled study was conducted between October 2009 and July 2012. Two hundred (200) elderly, bedridden, hospitalized patients with acute, nonchronic neurological impairment were randomly assigned to receive routine FI nursing care (ie, individualized dietary modification, psychological support, health education, and social support for caregivers and family members [control group]) or routine incontinence care plus the SPS (experimental group) during the day. Rates of perianal fecal contamination, skin breakdown, incontinenceassociated dermatitis, pressure ulcer development, and lower urinary tract infection (LUTI) were significantly lower in the SPS than in the control group (P <0.05). Length of hospitalization and costs of care were also lower in the SPS group (P <0.05). Patient quality-of-life (QoL) and FI QoL scores were similar at baseline but significantly higher (better) at the 6-month follow-up interview in the SPS than in the control group (P <0.05). In this study, the rate of FI-associated morbidities was lower and 6-month patient QoL scores were higher in the SPS than in the control group. No adverse events were observed, and all patients completed the study. Further clinical studies are needed to examine the long-term effects of SPS use among neurologically impaired FI patients.
Article
Anal incontinence and gastrointestinal disorders are one of the major causes of impaired quality of life in patients with neurological disease. Patients are very often too embarrassed to spontaneously talk about these problems and problems of chronic constipation can lead to microbial maceration, a known risk factor for urinary tract infection. In this article, the authors review the physiology of defecation and describe the main disorders observed in the various neurological diseases and their management.
Article
Traumatic brain injury (TBI) is seen by the insurance industry and many health care providers as an "event." Once treated and provided with a brief period of rehabilitation, the perception exists that patients with a TBI require little further treatment and face no lasting effects on the central nervous system or other organ systems. In fact, TBI is a chronic disease process, one that fits the World Health Organization definition as having one or more of the following characteristics: it is permanent, caused by non-reversible pathological alterations, requires special training of the patient for rehabilitation, and/or may require a long period of observation, supervision, or care. TBI increases long-term mortality and reduces life expectancy. It is associated with increased incidences of seizures, sleep disorders, neurodegenerative diseases, neuroendocrine dysregulation, and psychiatric diseases, as well as non-neurological disorders such as sexual dysfunction, bladder and bowel incontinence, and systemic metabolic dysregulation that may arise and/or persist for months to years post-injury. The purpose of this article is to encourage the classification of TBI as the beginning of an ongoing, perhaps lifelong process, that impacts multiple organ systems and may be disease causative and accelerative. Our intent is not to discourage patients with TBI or their families and caregivers, but rather to emphasize that TBI should be managed as a chronic disease and defined as such by health care and insurance providers. Furthermore, if the chronic nature of TBI is recognized by government and private funding agencies, research can be directed at discovering therapies that may interrupt the disease processes months or even years after the initiating event.
Article
Full-text available
The natural history of fecal incontinence (FI) in community subjects is uncertain and the onset rate is unknown. The aim of the study is to estimate the prevalence, new-onset rate, and risk factors for FI in community subjects. A random sample of 2,400 community subjects aged > or =50 years was surveyed in 1993, using a validated questionnaire. Responders were recontacted in 2003. FI was defined as self-reported problems with leakage of stool. Onset rate was calculated as the proportion of subjects without FI who became new cases. Logistic regression models were constructed to identify predictive factors for developing FI and changes in bowel habit associated with the onset of FI. Overall, 1,540 (64%) subjects responded to the initial survey, and 674 (44%) of them responded to the second survey a median of 9 (8.8-9.5) years later. The prevalence of FI in the first survey was 15.3% (13.4-17.3%). In the second survey, 37 reported incident FI; thus, the onset rate of FI was 7.0% (5.0-9.6) per 10 years. Predictive factors at baseline for the onset of FI were self-reported diarrhea (odds ratio (OR)=3.8 (1.5, 9.4)), incomplete evacuation (OR=3.4 (1.2, 9.8)), and pelvic radiation (OR=5.1 (1.01, 25.9)). Development of urgency was the primary predictor among the set of predictors reflecting changes in bowel symptoms that were associated with the onset of FI (OR=24.9 (10.6, 58.4)). The onset rate of FI is approximately 7% per 10 years in community subjects aged > or =50 years. Prevention may be possible if bowel habit is appropriately managed in high-risk individuals.
Article
The aim of this retrospective study was to review the medical complications of patients with traumatic brain injury (TBI) who were followed in 2000-2006. The demographic data, functional and cognitive status of 116 persons with TBI were noted. The presence of communication problems, swallowing disturbances, urinary and faecal incontinence, pressure ulcer, deep venous thrombosis (DVT), post-traumatic seizure (PTS) and heterotopic ossification (HO) were recorded at first admission and follow-up. This study detected aphasia in 19.0%, dysarthria in 30.2%, dysphagia in 17.2%, pressure ulcers in 6.9% and DVT in 2.6% the our patients with TBI. Urinary and faecal incontinence on admission were 32.7% and 26.7%, respectively. Patients with incontinence had poorer cognitive function than those with normal continence. HO rate was 18.1% and the ambulation levels of patients with HO were worse than those without HO. PTS was seen in 13.8% of the patients on admission and this ratio increased to 21.6% during the follow-up. In these patients, the aetiological risk factors for PTS were gunshot and fall injuries. Considering the wide spectrum of complications, this study advocates that these persons with TBI should be followed promptly by a multidisciplinary team.
Article
Full-text available
The aim of the present manuscript is to review current methods for classifying initial severity and final outcome in traumatic brain injury (TBI) and to suggest a direction and form of further research. The literature on valid and reliable measurements used in TBI-research for classifying initial severity and final outcome was reviewed. Classifying initial severity in patients with head injury according to clinical condition or CT-parameters is valid. Classifying outcome according to measurement tools of disability showed adequate validity and reliability. Future research in TBI outcome, particularly in rehabilitation medicine, should focus on determinants of outcome, identifying those patients who will have the greatest chance of benefiting from intensive rehabilitation programmes. More research is needed to determine the long-term functional outcome in TBI, the long-term socio-economic costs, and the influence of behavioural problems on family cohesion. Finally, validation of outcome measures is required in the TBI-population; the relative value of various outcome measures needs to be determined, and the usefulness and applicability of measures for health related quality of life in TBI should be established.
Article
To identify outcome measures cited in published studies focusing on rehabilitation in the acute hospital and in early post-acute rehabilitation facilities, and to identify and quantify the concepts contained in these measures using the ICF as a reference. Electronic searches of Medline, Embase, CINAHL, Pedro and the Cochrane Library from 1997 to March 2002 were carried out. In a first step, abstracts of the retrieved studies were checked and data on the outcome measures and certain characteristics of the included studies were extracted. In a second step, the items of the questionnaires and their underlying concepts were specified. These concepts were then linked to ICF categories using standardized linkage rules. From the 1,657 abstracts retrieved, 259 studies met the inclusion criteria. In a second step, 277 formal assessment instruments and 351 single clinical measures were retrieved. A total of 1,353 concepts were extracted from the clinical and technical measures. Ninety-six percent of these concepts could be linked to ICF categories. Fifty-six second-level ICF categories representing the concepts contained in the measures. Twenty-six (46%) of the 56 categories belong to the component Body Functions, five (9%) to the component Body Structures, and 25 (45%) to the component Activities and Participation. The ICF provides a valuable reference to identify and quantify the concepts of outcome measures focusing on rehabilitation in the acute hospital and in early post-acute rehabilitation facilities. Our findings indicate a need to define and to agree on 'what should be measured' in rehabilitation care to allow for a comparison of patient populations.
Article
Full-text available
To compile a minimum data set for the follow-up of traumatic brain injury patients from discharge from hospital to one year post injury to assess functioning and participation in the physical, cognitive and psychosocial domains, and in quality of life. Repeated questionnaire interviews by two observers to establish inter-observer reliability of the measurement instruments at discharge and at one year post injury, as well as their sensitivity to change over time in traumatic brain injury patients. Department of neurosurgery of an academic hospital, department of a rehabilitation centre, and at the patients' homes in the Netherlands. The study at discharge included 25 patients aged 18-50 years with a moderate to severe traumatic brain injury (Glasgow Coma Scale score 3-14), whereas the one year post injury study included 14 patients aged 19-51 years. MAIN (OUTCOME) MEASURES: Physical domain: Barthel Index (BI), Functional Independence Measurement (FIM), Glasgow Outcome Scale (GOS), GOS Extended (GOSE). Cognitive domain: Disability Rating Scale (DRS), Functional Assessment Measurement (FAM), Levels of Cognitive Functioning Scale (LCFS), Neurobehavioural Rating Scale (NRS). Psychosocial domain: Community Integration Questionnaire (CIQ), Employability Rating Scale (ERS), Frenchay Activity Index (FAI), Multi Health Locus of Control (MHLC), Rehabilitation Activities Profile (RAP), Social Support List (SSL), Supervision Rating Scale (SRS), Wimbledon Self Reporting Rating Scale (WSRS). Quality of life: Coop/Wonca Charts (Coop), Rand SF-36 (Rand-36), Sickness Impact Profile-68 (SIP-68). At both discharge and at one year post injury, in the physical domain the FIM showed excellent squared weighted kappa (SWK ranging from 0.75 to 0.80), and intraclass correlation coefficient (ICC ranging from 0.75 to 0.92), and a relatively small standard error of measurement (SEM 3.22) and smallest detectable difference (SDD 8.92). In the cognitive domain the FAM and the NRS showed excellent SWK, and ICC, and a relatively small SEM and SDD. In the psychosocial domain the FAI showed excellent SWK (0.89), and ICC (0.87), and a relatively small SEM (2.64) and SDD (7.31). For quality of life, at both discharge and at one year post injury the SIP-68 and the Coop showed excellent SWK (0.87), and ICC (0.89), and a relatively small SEM (3.79) and SDD (10.51). At both time points SWK and ICC ranged from 0.80 to 0.89, SEM ranged from 1.47 to 1.98, and the SDD was 4.07. An example of a reliable minimum data set that is also able to detect changes over time is: the FIM, the FAM and the Coop for the early stages in recovery, extended with the NRS, the FAI, and the SIP-68 later in recovery, thereby covering all relevant domains after traumatic brain injury.
Article
To determine the profile of resolution of typical PTA behaviours and describe new learning and improvements in self-care during PTA. Prospective longitudinal study monitoring PTA status, functional learning and behaviours on a daily basis. Participants were 69 inpatients with traumatic brain injury who were in PTA. PTA was assessed using the Westmead or Oxford PTA assessments. Functional learning capability was assessed using a routine set of daily tasks and behaviour was assessed using an observational checklist. Data was analysed using descriptive statistics. Challenging behaviours that are typically associated with PTA, such as agitation, aggression and wandering resolved in the early stages of PTA and incidence rates of these behaviours were less than 20%. Independence in self-care and bowel and bladder continence emerged later during resolution of PTA. New learning in functional situations was demonstrated by patients in PTA. It is feasible to begin active rehabilitation focused on functional skills-based learning with patients in the later stages of PTA. Formal assessment of typically observed behaviours during PTA may complement memory-based PTA assessments in determining emergence from PTA.
Article
To investigate the prevalence, outcome and multidisciplinary management of incontinence in patients with acquired brain injury. Retrospective case notes review. Regional neurological rehabilitation unit. Two hundred and thirty-eight patients with acquired brain injury. Bladder and bowel subscores of the Barthel Index and Functional Independence Measure; number of multidisciplinary goals addressing bladder and bowel function. Fifty per cent of patients (n=112) had impaired bladder or bowel subscores on admission. Significant improvement was seen at discharge but 36% of patients (n=77) still had some degree of impairment. Over 90% of patients were set multidisciplinary goals addressing self-care (n=213) and mobility (n=205) but only 3.5% (n=8) were set multidisciplinary goals addressing bladder and bowel function. Incontinence was common in patients with brain injury on a neurological rehabilitation unit. Significant improvement was seen following rehabilitation. Bladder and bowel management was not well incorporated into the multidisciplinary management process.
Article
Anal incontinence and gastrointestinal disorders are one of the major causes of impaired quality of life in patients with neurological disease. Patients are very often too embarrassed to spontaneously talk about these problems and problems of chronic constipation can lead to microbial maceration, a known risk factor for urinary tract infection. In this article, the authors review the physiology of defecation and describe the main disorders observed in the various neurological diseases and their management.
Article
Full-text available
To examine whether the caregivers' coping style is associated with the functional outcome of the traumatic brain injury (TBI) patient 1 year post-injury. A cross-sectional study among patients with a TBI, including their primary caregivers. The study included 51 patients aged 17-64 years with a moderate-to-severe TBI and 51 caregivers (23 parents and 28 partners) aged 23-67 years. The coping preferences of the caregivers were assessed at minimum 6 and maximum 12 months post-injury, by filling out the Utrecht Coping List (UCL) and were related to limitations in activity, as measured with the Frenchay Activities Index and with restrictions in participation as measured with the Sickness Impact Profile-68 of TBI patients 1 year post-injury. The patients were interviewed at their homes; the caregivers received and returned the UCL by mail. The patients' age and the caregivers' coping style are independently associated with restrictions in participation 1 year post-injury. A passive coping style of the primary caregiver is negatively associated with the patient's functional outcome in terms of participation in society.
Article
Full-text available
To determine which basic and functional status characteristics of patients with a moderate or severe traumatic brain injury (TBI) are associated with discharge destination. Cross-sectional study among TBI patients. The study included 111 patients aged 16-67 years with a moderate-to-severe TBI (Glasgow Coma Scale (GCS) score 3-14). Functional outcome was assessed with Barthel Index (BI), Functional Independence Measurement (FIM), Level of Cognitive Functioning Scale (LCFS), Functional Assessment Measurement (FAM), Supervision Rating Scale (SRS) and Neurobehavioural Rating Scale (NRS). Patients were interviewed at the time of being discharged from hospital. Outcome variable was discharge destination; (1) home vs. institution and (2) rehabilitation centre vs. nursing home. Gender, age and length of stay were not associated with discharge destination. TBI severity, physical status, level of arousal and cognitive status were univariately associated. Multivariate analyses, however, showed that the risk of being admitted to an institution was significantly higher for those with severe TBI (adjusted OR = 14) and/or lowered cognitive status at the time of discharge from hospital (adjusted OR = 12). Discharge destination is associated with TBI-severity at admittance to the hospital and cognitive status at discharge from the hospital.
Article
Objectives: To describe the current status of the Traumatic Brain Injury Model Systems (TBIMS) National Data Base and present major descriptive findings based on the original research and demonstration issues for which the database was developed, and to describe patient outcomes at discharge from inpatient rehabilitation and at 1 year post injury. Design: Prospective, longitudinal multicenter study. Setting: TBIMS located at the Medical College of Virginia, Richmond, Va; Wayne State University/Rehabilitation Institute of Michigan, Detroit, Mich; The Institute for Rehabilitation and Research, Houston, Tex; and Santa Clara Valley Medical Center, San Jose, Calif. Data Set: Demographic, diagnostic, treatment, and outcome data on 660 individuals consecutively discharged from the four TBIMS between March 1989 and September 1995. Results: TBIMS individuals are typically in their mid-30s, male (77%), and white (51%); have a high school education or less (71%); and are as likely as not to be employed at the time of injury (50%). Vehicle-related injuries are the leading cause of injury (56%). Individuals tend to suffer moderate to severe brain injuries, with 77% experiencing loss of consciousness and 98% experiencing posttraumatic amnesia. The average combined length of stay for acute care and inpatient rehabilitation decreased approximately 25%, from 83 days in 1989 to 63 days in 1994. The Functional Independence Measure scores indicated overall functional improvement from an average level of requiring "Moderate Assistance" at the time of rehabilitation admission to an average level between "Moderate Independence" and "Complete Independence" at 1 year post injury. As indicated by the Community Integration Questionnaire, individuals tended to do best in the social aspects of community integration and worst in productivity. Conclusion: This article addresses the original research and demonstration issues posed by the creators of the TBIMS National Data Base. It describes the TBIMS population and presents outcomes at rehabilitation discharge and at 1 year post injury. This information provides a benchmark for future study. (C) Williams & Wilkins 1996. All Rights Reserved.
Article
Often one of the most difficult aspects of working with people with continence problems is the barrier caused by their embarrassment at what they consider a shameful subject. One way to break this barrier is to ensure they are properly informed.
Article
Part I of this series described the background of the study; the characteristics of the patient population; and their functional status before onset of stroke, at rehabilitation admission, at discharge, and at six months after discharge. Results at follow-up showed that patients with higher Barthel index scores living in the community were more likely to be satisfied with life in general, to have more person-to-person contacts, and to be more active in community affairs. Part II describes the utility of two sets of data derived from the admission Barthel index (combinations of independent performance of four basic items of the index vs the total score) in predicting the likely range of Barthel index scores at discharge and functional outcomes at six-month follow-up.
Article
An analysis of clinical and demographic data of 264 patients with severe head injury showed that a combination of the Glasgow Coma Scale (GCS) score, oculocephalic responses, and age can provide a simple but reliable prediction of outcome in severe head injury. Addition of other clinical data, excluding intracranial pressure and evoked potentials, improved the predictability only negligibly. A simple chart, which is constructed from the application of the logistic regression model, can be used to determine the odds of a good outcome from the combination of the three factors. A method is given by which the GCS score of a patient with a missing verbal response score can be accurately approximated in order to complete the chart. Among other values, the odds of a good outcome provide the clinician with a reliable measure of the relative severity of a patient's injury. The accuracy of the chart in prediction is expected to be 80% or above.
Article
In Part II we address tools for describing general functional levels of clients in acute care, in traumatic brain injury (TBI) rehabilitation programs, and in the community. Tools must be brief, have proven reliability, and measure characteristics common to moderately and severely brain-injured individuals. Possible components of a uniform dataset dedicated to TBI are described.
Article
This self-directed learning module highlights outcome after stroke rehabilitation. Part of the chapter on stroke rehabilitation in the Self-Directed Medical Knowledge Program for practitioners and trainees in physical medicine and rehabilitation, this article contains sections on predictors of stroke outcome; the ability of stroke rehabilitation to achieve functional improvement, maintain functional gains, and reduce costs; and the efficacy of varying levels of rehabilitation services.
Article
Urinary incontinence affects approximately 10 million Americans, mostly elderly persons in community and institutional settings. Despite the prevalence of UI and an estimated annual total cost of $ 10 billion in the United States alone, most affected persons do not seek help for incontinence. This is chiefly because of embarrassment or because they are not aware that help is available. In this article, we describe a community education and support program for persons with fecal and urinary incontinence. The program is based on the "I Will Manage" model from the Simon Foundation for Continence, founded to "increase public awareness of incontinence, remove social stigma attached to this disability, and provide education to those suffering from incontinence, their families, and the professionals responsible for their care." The program provides a comprehensive and practical framework to promote continence through community education. In this article, we outline the program and provide information we gathered from hosting it.
Article
To investigate improvement rates and medical services costs in older brain injured adults relative to younger patients. Descriptive statistics were computed in a prospective comparative study of 50 patients 55 years and older and 50 patients 18 to 54 years old matched for gender and injury severity (number of days in coma, admission Glasgow Coma Score, intracranial pressure). Independent t tests were performed to examine differences between the two samples on specific variables. Five medical centers in the federally sponsored Traumatic Brain Injury Model Systems Project that provide emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services. Patients were selected from a national database of 531 rehabilitation inpatients admitted to acute care within 8 hours of traumatic brain injury between 1989 and 1994. Disability Rating Scale, Functional Independence Measure, Rancho Los Amigos Levels of Cognitive Functioning Scale, length of stay, acute care and rehabilitation charges, and discharge disposition. Older persons averaged a significantly longer rehabilitation length of stay, higher total rehabilitation charges, and a lower rate of change on functional measures. No significant differences between groups were found for acute care length of stay, daily rehabilitation charges, acute care charges (daily or total), or discharge disposition. Although older persons demonstrated functional changes, the cost of change was substantially higher than for younger patients, coincident with longer lengths of stay. These higher overall charges and slower rates of change may effect changes in referral and management patterns.
Article
Anorectal disorders are the cause of significant discomfort and embarrassment in women. The onset typically follows childbirth and symptoms increase with age. Anal incontinence, rectovaginal fistula, rectal prolapse, anal fissure, and constipation are considered.
Article
Three cases of nerve root compromise in elderly women with insufficiency fractures of the sacrum are reported. Neurological compromise is generally felt to be exceedingly rare in this setting. A review of 493 cases of sacral insufficiency fractures reported in the literature suggested an incidence of about 2%. The true incidence is probably higher since many case-reports provided only scant information on symptoms; furthermore, sphincter dysfunction and lower limb paresthesia were the most common symptoms and can readily be overlooked or misinterpreted in elderly patients with multiple health problems. The neurological manifestations were delayed in some cases. A full recovery was the rule. The characteristics of the sacral fracture were not consistently related with the risk of neurological compromise. In most cases there was no displacement and in many the foramina were not involved. The pathophysiology of the neurological manifestations remains unclear. We suggest that patients with sacral insufficiency fractures should be carefully monitored for neurological manifestations.
Article
We studied the prevalence of anal incontinence and other anorectal symptoms in women and evaluated the proportion of those who had sought medical help. A structured questionnaire was distributed to 1228 women attending the obstetrics and gynecology outpatient clinics (general, antenatal, urogynecology) of our university hospital. We also screened an additional sample of 984 women, representative of the general population aged 35-74. The prevalence of anal incontinence was 5.6% in the general outpatient clinic, 6.7% in the antenatal clinic, 15.9% in the urogynecology clinic and 4.4% in the general population. Only 20% of women affected by anal incontinence from the general outpatient clinic had reported their symptoms to a medical practitioner. Anal incontinence affects many women, but only a minority seek help. Obstetriciangynecologists should systematically inquire about the presence of this symptom.
Article
Faecal incontinence is experienced by at least 2% of the population and 7% of those over 65 years of age. The true incidence is probably much higher because of the stigmata of the affliction leading to underreporting. The common causes of faecal incontinence are discussed.
Functional assessment instruments in medical rehabilita-tion
  • S Forer
Forer S. Functional assessment instruments in medical rehabilita-tion. J Organization Rehabil Evaluators 1982;2:29-41.
Medical and functional characteristics of older adults with traumatic brain injury: a multicenter analysis
  • Cifu Dx
  • Kreutzer Js
  • Jh M Marwitz
  • Englander
Cifu DX, Kreutzer JS, Marwitz JH, Rosenthal M, Englander J. Medical and functional characteristics of older adults with traumatic brain injury: a multicenter analysis. Arch Phys Med Rehabil 1996;77:883-8.