Impact of rehabilitation in the neurointensive care unit on long-term survival in patients with traumatic brain injury.

Abstract

Background: The study aimed to compare the difference in long-term mortality in patients with moderate to severe traumatic brain injury (TBI) receiving Early interdisciplinary rehabilitation (EIR) in our Neurointensive Care Unit (NICU) to patients being discharged from NICU without EIR.

Methods: Retrospective observational cohort study of adults aged 18-67 years with moderate to severe TBI (Glasgow Coma Scale 3-14), admitted to the NICU for >72 h from 2010 to 2022. We analyzed mortality differences from the start of follow-up (cessation of sedation in the Standard of care (SC) group and start of EIR in the EIR group) until 31.12.2023, using inverse probability of treatment weighted Cox proportional hazard models and Kaplan-Meier survival curves. Adjustments using weights were made for various variables, including age, days from injury to follow-up start, sociodemographic factors, comorbidities, and injury characteristics.

Results: A total of 698 patients were included, 461 received EIR and 237 SC. Sixty-three (27%) patients in the SC group and 59 (13%) patients in the EIR group died by the end of follow-up. In covariate-adjusted Kaplan-Meier curves, estimated survival at the end of follow-up was 56% (95% CI 0.36, 0.69) for the SC group and 74% (95% CI 0.58, 0.83) for the EIR group. Both groups had the highest mortality rate within 30 days. The mortality in the EIR group was significantly lower with an adjusted hazard ratio (HR) at 30 days of 0.57 (95% CI 0.37, 0.87) p-value = .010, and at the end of follow-up of 0.56 (95% CI 0.36, 0.89), p-value = .015.

Conclusions: Patients receiving EIR had better long-term survival, with both groups experiencing the highest mortality rate early on. Early rehabilitation in NICU may play an important role in preventing and identifying medical complications and should be explored as a potential mechanism in future prospective trials.

Editorial comment: Neurorehabilitation following intensive care for traumatic brain injury is important to help the patients regain function. However, it is uncertain whether survival is improved by the initiation of interdisciplinary rehabilitation already during neurointensive care, consisting of mobilization and training activities of daily living as well as swallowing. This study compared long-term survival in a retrospective cohort of patients with moderate to severe traumatic brain injury and found that those receiving early rehabilitation had a higher long-term survival, which persisted for up to 13 years but was mainly due to improved survival during the first 3 months. Whether this is due to physiological effects or an increased enthusiasm among healthcare providers to continue active treatment is unknown and should be further explored.