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The sooner patients begin neurorehabilitation, the better their functional

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DOI: 10.3109/02699052.2013.804204 · Source: PubMed

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ISSN: 0269-9052 (print), 1362-301X (electronic)

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! 2013 Informa UK Ltd. DOI: 10.3109/02699052.2013.804204

The sooner patients begin neurorehabilitation, the better their

functional outcome
José León-Carrión1, Fernando Machuca-Murga1, Ignacio Solı́s-Marcos1, Umberto León-Domı́nguez2, &
Marı́a del Rosario Domı́nguez-Morales2
1
Human Neuropsychology Laboratory, School of Psychology, Department of Experimental Psychology, University of Seville, Seville, Spain and
2
Center for Brain Injury Rehabilitation (CRECER), Seville, Spain

Abstract Keywords
Primary objective: To determine whether early neurorehabilitation improves a patient’s Early treatment, FAM, functional outcome,
functional recovery. FIM, neurorehabilitation programmes,
Brain Inj Downloaded from informahealthcare.com by 80.59.29.79 on 07/30/13

Research design: A retrospective study was carried out on patients with severe traumatic brain traumatic brain injury
injury (TBI) who underwent a minimum of 4 months of integral and multidisciplinary
neurorehabilitation. History
Methods and procedures: Fifty-eight patients with severe TBI were assessed at admission and at
discharge using the FIM þ FAM scale. Two groups were formed based on time elapsed from Received 12 November 2012
brain injury to onset of rehabilitation. The early treatment group (ET) included patients who Revised 29 April 2013
began rehabilitation within the first 9 months post-trauma; the late treatment group (LT) began Accepted 7 May 2013
after the 9-month cut-off date. Intra- and between-group analysis of FIM þ FAM scores were Published online 26 July 2013
carried out at admission and discharge. Multiple linear regression was used to determine the
For personal use only.

best predictors for functional rehabilitation.

Main outcomes and results: After neurorehabilitation, all subjects showed significant improve-
ment in cognitive, motor, communication and psychosocial functioning. Moreover, the ET
group showed better global functional outcome at discharge than patients who began later
treatment. The best predictors for functional neurorehabilitation were months since injury, age,
GCS score and months of treatment.
Conclusions: It is concluded that the sooner patients begin neurorehabilitation, the better their
functional outcome.

Introduction These efforts to lower mortality and morbidity also depend

on early identification of the patient’s clinical status,
Patients who survive traumatic brain injury (TBI)
especially within the ‘golden hour’ of acute care [7].
often require long-term care and support services [1, 2].
Studies indicate that early TBI management is also
TBI treatment constitutes a challenge for healthcare
crucial for the treatment of secondary brain injury, thereby
providers and a poor outcome will have a tremendous effect
reducing mortality rates and improving outcome [8, 9].
on patients, families and the insurance industry. Early
A study by Seelig et al. [10] argues for earlier action, if
TBI diagnosis and management in the acute setting helps
possible during the first 4 hours after injury. Any additional
prevent secondary injury, one of the most prominent causes of
delay, particularly in haematoma evaluation, severely
a patient’s deteriorating condition [3–5]. Children who suffer
increases mortality and worsens functional outcome in
a moderate or severe TBI may have substantial functional
patients who survive [11].
disabilities and reduced quality of life 2-years post-injury.
A number of TBI studies [12, 13] have also found that
Early intervention is vital to help prevent these sequelae as
spontaneous recovery may occur during the first few weeks
well as other long-lasting consequences of TBI. Timely
and even months after injury. An earlier study [14] on post-
emergency medical care is also essential in TBI treatment.
TBI cognitive deficits in patients who did not receive
Delayed emergency team activation is the strongest inde-
neuropsychological rehabilitation sought to identify the
pendent predictor of mortality in TBI patients, making
point at which cognitive deficits ceased to present signs of
quicker action a priority for hospitals operating rapid response
spontaneous recovery. Results showed no spontaneous recov-
systems [6].
ery beyond 8 months post-TBI.
The purpose of the present study is to examine the effect of
early rehabilitation designed to maximize individual recovery
in patients who survive TBI. It is hypothesized that the sooner
Correspondence: José León-Carrión, University of Seville - Experi-
mental Psychology, C/Camilo Jose Cela s/n Seville 41005, Spain. Tel: the patient begins neurorehabilitation, the better his/her
+34954574137. Fax: +34954374558. E-mail: leoncarrion@us.es functional outcome.
 2 J. León-Carrión et al.
Methods
Subjects
A retrospective study was carried out, selecting patients who
met the following inclusion criteria: severe TBI diagnosis,
Glasgow Coma Scale (GCS) score 8, a minimum of
4 months of integral multidisciplinary rehabilitation at the
Centre for Brain Injury Rehabilitation (CRECER, Seville,
Spain) and clinically confirmed neuropsychological disorders
at admission to rehabilitation. Exclusion criteria included
prior incidence of TBI or stroke, history of neurological or
psychiatric disorders and substance abuse.
A total of 58 patients met these criteria—44 male,
14 female, median age 20 and median GCS ¼ 5 (interquartile
range (IQR) ¼ 4–7). The median time interval between brain
injury and rehabilitation was 8 months. The median treatment
period was 10.5 months (see Table I).
Two groups were formed based on the time elapsed from
brain injury to onset of rehabilitation. The early treatment
group (ET) was comprised of patients who began rehabilita-
Brain Inj Downloaded from informahealthcare.com by 80.59.29.79 on 07/30/13
tion within the first 9 months post-trauma; the late treatment
group (LT) began after the 9-month cut-off date. The primary
reasons for this discrepancy are economic and geographic
limitations or a lack of knowledge on the ability of this
specialized treatment.
Materials
For personal use only.
Functional assessment: Functional Independence Measure
(FIM) þ Functional Assessment Measure (FAM)
The FIM þ FAM is a multidimensional functional assessment
scale widely used to measure the impact of rehabilitation on
patients with TBI. This scale combines items from the FIM
(Functional Independence Measure) and the FAM (Functional
Assessment Measure), providing a global functionality index.
The scale contains 30 items, 18 from FIM and 12 from FAM.
These items are divided into seven sub-scales designed to
evaluate the patient’s principal areas of functionality: self-care
(items 1–7), sphincter control (8–9), type of transfer (10–13),
locomotion (14–16), communication (17–21), psychosocial
adjustment (22–25) and cognitive functions (26–30).
All items are scored on a scale from 1–7, depending on the
patient’s degree of independence in carrying out the related
task. Lower scores indicate greater dependence and, thus,
lower functionality, while higher scores represent greater
independence and functionality. The overall score can range
between 30 points (total dependence in daily living activities)
and 210 points (total independence and fully functional in
daily living activities).
Table I. Patient demographics and clinical data.
Patient data (n ¼ 58) Median IQR
Gender (M/F) 44/14 –
Age 20 17–28.50
Education level 9 8–11
Months of treatment 10.5 6–18
Months since injury 8 3–19.5
GCS score 5 4–7
GCS, Glasgow Coma Scale; IQR, Interquartile Range.
Brain Inj, Early Online: 1–5
The FIM þ FAM scales have been widely studied and are
considered a valid assessment tool for patients with acquired
brain injury. Statistical studies found a reliability index of
0.86–0.97 [15, 16] and research by van Baalen et al. [17]
noted their reliability and sensitivity in assessing TBI
patients. The authors noted that both scales offered better
results during the first phases of post-TBI recovery, as their
effectiveness diminished during post-acute phases and
rehabilitation. However, other authors pointed out the
scale’s utility to monitor functionality during rehabilitation
given its precision in detecting significant changes in
functional level [18, 19]. Dodds et al. [20] reported evidence
of FIM þ FAM’s reasonable validity, internal consistency and
discriminative capacity between sub-populations with brain
damage. These characteristics render the FIM þ FAM scale
one of the most popular instruments for evaluating the
functional state of neurological patients.
Procedure
The FIM þ FAM scale is part of the ongoing patient
assessment protocol at CRECER. This study used data on
the patient’s functional state derived from FIM þ FAM scores
at admission and at discharge from rehabilitation. A com-
parison between these scores indicated the patient’s functional
gain in each FIM þ FAM sub-scale during the rehabilitation
process. Functionality indexes at admission (FA) and at
discharge (FD) were calculated by dividing the patient’s total
score in each sub-scale by the sub-scale’s maximum score and
multiplying by 100. Percentage functional gain (%FG) during
rehabilitation was determined using the following formula:
%FG ¼ ðFD  FAÞ=ð100  FAÞ
The %FG index allows one to quantify a patient’s
functional recovery from admission to discharge. These
indexes were compiled from clinical reports on patients that
met the inclusion criteria and had completed the rehabilitation
programme. They later underwent statistical analysis pertin-
ent to the study objectives.
Statistical analysis
Table II displays medians and IQRs for the two groups’
demographic and clinical data. Given that most of the
variables showed non-normal distributions, a non-parametric
statistical approach was used to analyse the data. Wilcoxon’s
test was utilized for intra-group comparison of FIM þ FAM
scores at admission and discharge to ascertain the efficacy of
rehabilitation on the two groups. To control confounding
factors (age, education level, months of treatment and GCS
score), ANCOVA non-parametric tests were used for
between-group comparison, following the procedure
described by Conover and Iman [21]. A chi-square test was
used to analyse categorical variables. All statistical analyses
were done using IBM SPSS Statistics 20 for Windows, with
alpha set at 0.05 for all tests.
A Stepwise multiple linear regression was applied to
explore predictors for functional gain in patients with brain
injury. Independent variables in this analysis included age,
education level, months since injury, months of treatment and
initial GCS score. This study selected total percentage
 DOI: 10.3109/02699052.2013.804204 Benefits of early rehabilitation 3

differences FD
Table III. Stepwise linear regression analysis. B coefficients and

B/t group

0.005*

0.012*

0.01**
0.002**

0.012**

0.002**
0.058

0.069
adjusted R2..

Standardized Adjusted
Model Variables Coefficient (B) Error Sig. R2

0.001**
p–value

0.073 1 Months since injury 1.053 0.192 0.000 0.35

0.283
0.376

0.332
0.07y
2 Months since injury 0.983 0.176 0.000 0.47
Age 1.017 0.298 0.001

GCS, Glasgow Coma Scale Score; %FG, total percentage functional gain; FA, Functionality at admission; FD, Functionality at discharge; y Chi2. All data expressed in median values.
3 Months since injury 0.962 0.169 0.000 0.51

differences FA
Age 1.149 0.292 0.000
B/t group

0.330
0.254
0.744
0.076
0.132
0.746
0.080
0.116
GCS score 4.251 1.860 0.027
4 Months since injury 0.976 0.163 0.000 0.54
Age 1.154 0.282 0.000
GCS score 4.052 1.800 0.029
Months of treatment 0.972 0.460 0.040

Excluded variable: Education level.

(31.25–81.25)

(49.44–92.78)
(40.48–100)

(52.08–100)

functional gain (%FG) as the dependent variable, given its

(87.5–100)

(56.67–95)

All between-group comparisons of functionality were controlled for the following variables: age, education level, months of treatment and GCS score.
(25–94.4)

role as a global indicator of patient functionality in each of the

(40–90)
FD

seven FIM þ FAM sub-scales (see Table III).

76.19b

79.17b
77.78b
83.33b
58.33b
70b
80.56b
100a
Brain Inj Downloaded from informahealthcare.com by 80.59.29.79 on 07/30/13

Table II. Differences between early and late treatment groups in demographics, clinical data and functionality at admission and discharge.

Results
LT group (n ¼ 29)

20.5 (19–30.25)

19 (14–28.5)
4.5 (4–6.25)

Patient demographics
8 (8–10)
8 (6–18)
25/4

Intra-group comparison between FA y FD: ap50.05; bp50.01. Between-group comparison for FA and FD, *p50.05; **p50.01.

Each group was comprised of 29 subjects. Table II shows that,

despite differences in demographic and clinical variables
(15.48–84.52)

(36.66–91.66)
(2.77–80.55)

(age, gender, level of education, months of treatment and GCS

(22.5–75.2)
(8.33–70)

score), only months since injury showed a significant effect.

(50–100)

(0–68.8)
(0–100)

However, given the potential effect of these variables on the

FA
For personal use only.

study’s dependent variables, the former were controlled for

50
54.76
100
41.67

76.67
20.83
36.67
53.33

posterior analysis.

Differences between early and late rehabilitation

Table II shows medians and IQR for each group’s
FIM þ FAM scores before and after rehabilitation. At admis-
(56.25–95.83)

(83.33–99.44)
(83.33–100)
(83.33–100)
(88.1–100)

sion, both groups showed similar levels of functionality in

(100–100)

(85–100)

(70–100)

most sub-scales, the highest being sphincter control (median

FD

ET ¼ 91.67; median LT ¼ 100) and the lowest, psychosocial

adjustment (median for both groups ¼ 20.83). Individually,
100.00b
100.00b
100.00b
94.44b
96.67b
75b
90b
93.33b

the ET group had the worst functionality in locomotion, with a

ET group (n ¼ 29)

median score of 5.55, much lower than the LT group

18 (16–24)
10 (8–11)
12 (6–18)
3 (3–4)
6 (4–7)

(median ¼ 50), although without significant effect

19/10

(p ¼ 0.076).
After intensive neurorehabilitation, both groups showed
(13.09–82.15)

(14.16–68.33)

significantly higher levels of functionality than at admission,

(6.24–93.75)

(2.08–43.75)
(3.33–58.33)
(33.33–100)

(15–88.33)
(0–69–44)

with p-values50.01 in most sub-scales. However, the ET

group’s overall functional outcome was notably higher than
FA

that of the LT group. Significant differences were found in all

areas except for sphincter control and communication, where
42.86
91.67

20.83

44.44
37.5
5.55
60

30

a tendency towards significance was observed.

Predictors for %FG

The percentage functional gain index (%FG) is a good
Patient demographic data

Psychosocial adjustment

indicator of a patient’s global functional recovery during

Months of treatment

Cognitive Functions
Months since injury

treatment, regardless of his/her functional state at admission

Sphincter Control
Type of transfer

and discharge. %FG was therefore selected as the dependent

Communication
Education level
Gender (M/F)

variable in the linear regression analysis to determine the best

FIM þ FAM

Locomotion

predictors for functional rehabilitation.

Self-care

Figure 1 displays %FG for both groups in each

Total
GCS
Age

FIM þ FAM sub-scale. The graph illustrates how the ET

 4 J. León-Carrión et al.
Figure 1. ?Percentages of functional gain
(%FG) in FIM þ FAM sub-scales.
Brain Inj Downloaded from informahealthcare.com by 80.59.29.79 on 07/30/13
group’s functional gain is greater than the LT group in every
area (all ps50.01). The ET group recovered over 80%
functionality in all areas except psychosocial adjustment
(68.42%) and recovered 100% of lost functionality in self-
care, sphincter control and type of transfer.
Table III shows the different models generated by the
For personal use only.
Stepwise linear regression analysis. The first analysis
included the variable months since injury (Adjusted
R2 ¼ 0.35). When age was added to the model, explained
variance rose to 47%. GCS score and months of treatment also
correlated linearly with the dependent variable, adding a 7%
increase to explained variance. The complete model explained
54% of total variance. The Stepwise analysis excluded
education level as a predictor for the dependent variable.
The residual analysis confirmed normalcy (Shapiro-
Wilks ¼ 0.97; p40.05), homoscedasticity and linearity.
Discussion
The results indicate that intensive integral multidisciplinary
rehabilitation programmes have a positive effect on the
neuropsychological outcome of patients with severe TBI.
After rehabilitation, all 58 subjects showed improvement in
deteriorated cognitive, motor, communication and psycho-
social functioning. Patients that entered the rehabilitation
programme earlier, before 9 months post-injury, showed
better global functionality than patients who began later
treatment. The LT group, while showing improvement, did
not obtain the same level of functionality as the early
treatment group. The data suggests that the earlier patients
begin rehabilitation, the better their functional outcome.
In FIM þ FAM assessment at admission, patients
from both groups scored below 60% in most sub-scales,
indicating the incapacity to live independently, particularly in
terms of locomotion, psychosocial adjustment and cognitive
functioning. After neurorehabilitation, these capacities
improved significantly, in many cases nearing functional
normalcy (470%). These results highlight the personal and
intimate independence that rehabilitation provides for
Brain Inj, Early Online: 1–5
these individuals. This improvement is highly valued by
patients and their families and from the authors’ standpoint,
should be sought out as soon as possible.
Early rehabilitation led to a 92.31% gain in locomotion
functionality. Communication also showed significant gain in
this group, reaching 91.67% in most cases (see Figure 1).
These improvements included enhanced expression, compre-
hension, reading, writing and speech intelligibility. These
results also revealed significant improvement in the ET
group’s cognitive capacity (85% functional gain), including
problem-solving, memory, orientation, concentration and
safety awareness. A significant effect was also observed in
these patients’ psychosocial adjustment (68.42%).
Different factors could partially explain these results,
although they are not part of the focus of this study. As
evidenced in the literature, a broad range of underlying
molecular and physiological mechanisms, along with com-
pensatory brain responses, may contribute to spontaneous
recovery, particularly during the first months after brain
injury. It is hypothesized that early neurorehabilitation may
potentiate these processes, taking advantage of a natural
tendency in the brain for self-repair.
Conclusion
It was found that intensive integral multidisciplinary rehabili-
tation has a positive effect on functional recovery after TBI.
This effect was stronger in the ET group, which showed
higher functional gain and better functional outcome.
Significant improvement was observed in motor, cognitive
and communication skills. The factors which best predicted
functional recovery were months since injury, age, GCS score
and months of treatment. It is concluded that the sooner
patients begin neurorehabilitation, the better their functional
outcome.
Declaration of interest
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of the paper.
 DOI: 10.3109/02699052.2013.804204
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