Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 236497

AbstractMaterial and MethodsResultsDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : August | Volume : 15 | Issue : 8 | Page : KC01 - KC04 Full Version

Assessment of Intensive Inpatient Rehabilitation Program in Acquired Brain Injury Patients using UK FIM+FAM Scale: A Retrospective Study


Published: August 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/49437.15280
Harleen Uppal, Shipra Chaudhary, Siddharth Rai

1. Research Associate, Department of Rehabilitation Medicine, Medanta the Medicity Hospital, Gurugram, Harayana, India. 2. Associate Professor, Department of Physical Medicine and Rehabilitation, ABVIMS and Dr RML Hospital, New Delhi, Delhi, India. 3. Assistant Professor, Department of Physical Medicine and Rehabilitation, Apex Trauma Centre, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

Correspondence Address :
Dr. Harleen Uppal,
Flat No. 222, Shriniketan Apartments, Plot No. 1, Sector 7, Dwarka, New Delhi-110075, India.
E-mail: harleenuppal@yahoo.com

Abstract

Introduction: Acquired Brain Injury (ABI) can lead to a combination of physical, cognitive, and behavioural impairments and requires comprehensive and structured inpatient rehabilitation program. A multidisciplinary rehabilitation program can deal comprehensively with all these issues together rather than focussing on a single aspect like motor function. Number of people suffering from Traumatic Brain Injury (TBI) in India has been documented to be between 1.5 million to two million per year whereas out of this approximately one million die due to TBI. The rationale of the present study was to document the outcome of multidisciplinary inpatient rehabilitation program objectively using a standard functional outcome measure.

Aim: To determine the change in functional outcomes of ABI patients being rehabilitated with a multidisciplinary inpatient neurorehabilitation program using UK version of Functional Independence Measure and Functional Assessment Measure (UK FIM+FAM).

Materials and Methods: The retrospective observational study was conducted in Medanta Hospital, Gurugram, Haryana, India, from September 2017 to June 2018. Retrospective analysis of previously maintained data was done from June 2018 to November 2018. Data was collected from the Department of Neurorehabilitation. Demographic data was collected including age, sex, type of injury, time from injury to admission and duration of stay in the neurorehabilitation unit. Functional outcome measure used in the study was the UK FIM+FAM. Data was collected in paper forms and collated in Microsoft Excel and transferred to IBM® Statistical Package for the Social Sciences (SPSS)® version 22.0 (IBM Corp., Armonk, NY) for analysis. The UK FIM+FAM data was analysed as aggregate total scores and motor and cognitive subscales. Non parametric tests were used as UK FIM+FAM is an ordinal scale. The test used to measure the change in score was Wilcoxon Test. The p-value <0.05 was considered statistically significant.

Results: Total number of patients who were analysed in the study were 45. Motor subset of scores showed significant improvement from admission (50) to discharge (72) (p-value=0.001). Similarly, the cognitive subset of scores also showed a significant improvement from admission (58) to discharge (68, p value=0.002). Apart from motor and cognitive subscales of UK FIM+FAM, change in score in sub divisions of self-care and transfers showed the maximum change with p-value=0.001. Other sub divisions of locomotion, sphincter, communication, psychological and cognition also showed a significant difference of p-value <0.05.

Conclusion: A physiatrist led intensive interdisciplinary inpatient rehabilitation program for patients with ABI may significantly reduce residual disability and improve functional independence. Such a program is not only effective in high income countries but also in Low Middle Income Countries (LMIC).

Keywords

Functional independence measure, Functional assessment measure, Head injury, Neurological rehabilitation, Physical and rehabilitation medicine

Acquired Brain Injury (ABI) can be defined as an injury to the brain which cannot be attributed to hereditary, congenital or degenerative causes (1). ABI can be categorised into Traumatic Brain Injury (TBI) and Non TBI (NTBI). TBI results from external mechanical forces, whereas NTBI is not caused by trauma, infact by a disease or illness (2). Various causes of NTBI are tumour, infections, stroke and vascular malformations (3). Stroke and TBI have been regarded as the two main causes of ABI (2). The ABI can lead to a combination of physical, cognitive, and behavioural impairments and requires comprehensive, intensive and structured inpatient rehabilitation program (4),(5). A multidisciplinary rehabilitation program can deal comprehensively with all these issues together rather than focussing on a single aspect like motor function. To support this, we have a Canadian study (6), which concluded that such a comprehensive multidisciplinary rehabilitation program with extended length of stay did show significant improvement in functional outcomes on discharge. Similar results were also quoted by a British study (7), which claimed that comprehensive multidisciplinary rehabilitation was indeed beneficial for TBI patients. They found that an average length of stay of seven months in the inpatient rehabilitation ward was more effective than community based rehabilitation.

Number of people suffering from TBI in India has been documented to be between 1.5 million to 2 million per year whereas out of this approximately 1 million die due to TBI (8). Functional Independence Measure (FIM) comprises of 18 functional activities on a seven-level scale (one implying total dependence and seven implying complete independence). This has been extensively used for medical rehabilitation, as an effective outcome measure. To this measure, were added a further 12 items pertaining to cognitive, behavioural and communicative measures, to formulate the Functional Assessment Measure (FAM) (9). This addition was a necessity as it was useful to assess psychological and cognitive issues in ABI patients. Further, the scale was modified in 1990s to develop the UK FIM+FAM which responded to many of the limitations of previous version of FIM+FAM (10). The UK FIM+FAM have 16 items pertaining to physical function and 14 items of cognitive and psychological function. Further six items of Extended Activities of Daily Living (EADL) were added which augmented its scoring accuracy and reliability (11). Since, there is no Indian version of FIM+FAM, it was decided to apply UK FIM+FAM in the study. UK FIM+FAM measures disability and functional independence in neurorehabilitation patients (12).

The current study was conducted to determine the change in UK FIM+FAM scores in ABI patients, after a structured rehabilitation program. The study was planned as there was not much published literature, describing the effectiveness of a comprehensive multidisciplinary rehabilitation program for ABI patients, in LMIC, especially in Indian setting. The objective was to determine the change in functional outcomes of ABI patients being intensively rehabilitated in a comprehensive and multidisciplinary inpatient neurorehabilitation program in a tertiary care hospital in Haryana, India.

Material and Methods

This was a retrospective observational study conducted in Medanta Hospital, Gurugram, Haryana, India, from September 2017 to June 2018. Retrospective analysis of previously maintained data was done from June 2018 to November 2018. Hence the study duration was six months. Demographic data as well as change in functional outcome measures were assessed and analysed from medical records maintained in the Department of Neurorehabilitation. The study was in accordance with the ethical standards of the Institutional Review Board (IRB) and The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans. The IRB approval was granted. There was a waiver of informed consent as analysis was conducted from medical records of the patients retrospectively.

Inclusion and Exclusion criteria: The ABI patients admitted for specialised neurorehabilitation program from September 2017 to June 2018 were incorporated in the study. Patients were identified from paper based medical records on the basis of inclusion and exclusion criteria. The age group included was 18-65 years of age. Patients suffering from moderate TBI, having Glasgow Coma Scale (GCS) of 9-12 were included in the study. Patients staying back for less than one week for neurorehabilitation were excluded as they would not meet even the lowest time threshold for repeat assessment. Patients who could not participate in the rehabilitation program due to co-morbidities, deterioration in clinical condition or poor comprehension were excluded from the study. As per the management protocol of the department, patients were discharged once patients, caregivers and family members realised maximal benefit with the rehabilitation program and were deemed appropriate to be discharged from the ward. The sample size calculated was 100, keeping 15% as relative error.

Sample size calculation: The total number of patients screened for the study was 120. Keeping in mind the inclusion and exclusion criteria, the number of patients who were recruited in the study were 50. Out of this 50, five patients had taken leave Against Medical Advice (AMA) in the middle of rehabilitation program and wanted to continue with home-based rehabilitation. Hence, the total number of patients was 45.

Study Procedure

Demographic data collected included age, sex, education, occupation, time from injury to admission and duration of stay in the neurorehabilitation unit. Functional outcome measure used in the study was the UK FIM+FAM (12). As per the protocol of the department, all ABI patients were evaluated clinically and demographic data were recorded. Clinical examination included general examination, cranial nerve examination, higher mental function assessment, motor system examination, sensory system examination, GCS Scoring. Patients were subjected to a comprehensive interdisciplinary inpatient neurorehabilitation program comprising of goal setting, weekly multidisciplinary rounds and meetings headed by Physical Medicine and Rehabilitation (PM&R) physician and attended by all the members of rehabilitation team, that is, occupational therapist, physiotherapist, speech and language pathologist, neuropsychologist, and rehabilitation nurse. These were conducted to chart the progress of the patients. Further, care plan meetings, to discuss the plan of discharge with the caregivers of patients were conducted. These care plan meetings were headed by PM&R physician and attended by all the above mentioned members of the team aimed at dealing with apprehensions of caregivers with respect to discharge of their patients and further ensuring that they were safe to be discharged to the community.

The patients were subjected to a tailor made, impairment specific, rehabilitation program comprising of PM&R physician consultations, supervised physiotherapy and occupational therapy sessions. Patients were also subjected to speech and language therapy sessions and sessions by neuropsychologist wherever appropriate. The hours of therapy were usually around three hours of combined physiotherapy, occupational therapy, speech and language therapy and psychological intervention. It was done every day for six days in a week. As per the Department’s protocol, UK FIM+FAM were scored within 48 hours of admission and then a day before the planned discharge. UK FIM+FAM scale was administered by the author of this paper, who has been trained to use it in United Kingdom. The reliability and validity of the rating scale, UK FIM+FAM has been well studied and published (12). Permission was also sought from the author of the scale (10), regarding its usage in the current study for academic purposes. In UK FIM+FAM, nine items are for self-care including bladder and bowel management; seven items deal with transfers and mobility; five items address communication and nine items address cognitive and psychosocial function (10).

The module of EADL was excluded while conducting the study as these activities was not very much India specific. Due to cultural and social reasons, in India, EADL like meal preparation, laundry, shopping etc., are conducted with the help of care givers, helpers or other family members except in a few cases.

Statistical Analysis

Data was collected in paper forms and collated in Microsoft Excel and transferred to IBM® SPSS version 22.0 (IBM Corp., Armonk, NY) for analysis. The UK FIM+FAM data was analysed as aggregate total scores and motor and cognitive subscales (9). Non parametric tests were used as UK FIM+FAM is an ordinal scale. The test used to measure the change in score was Wilcoxon Test. The p-value <0.05 was considered statistically significant.?

Results

The total number of patients screened were 45. Number of patients suffering from TBI was 10 whereas 35 patients had NTBI. There were almost three times as many men as women, recruited in the study. The total number of men recruited was 33 and women recruited were 12. In the TBI group, 80% were men and 20% women. In the NTBI group 71.4% were men and 28.5% women. The mean age at admission for TBI group was 31 with a range from 20-55. As expected, this was lesser than NTBI group having mean age of 50 with a range from 35-64. The mean duration from injury was 53 weeks in TBI group whereas it was 60 weeks in NTBI group. The mean of duration since injury for both the groups combined was 55 weeks, with a range from 35-110. The mean duration of stay in the neurorehabilitation unit for undergoing rehabilitation was 56 days i.e., eight weeks, while that for NTBI group was 49 days or seven weeks. The number of patients requiring ICU care was eight and 31 amongst TBI and NTBI group, respectively. The demographic data, grouped into TBI and NTBI, has been depicted in (Table/Fig 1).

The percentage of patients having stroke was around 55.5% (n=25), while of those suffering from TBI was 22.2% (n=10). Other causes of NTBI comprised of around 22.2% (n=10). Various causes of NTBI have been depicted in (Table/Fig 2). The UK FIM+FAM scores at admission and on discharge were analysed and compared. The UK FIM+FAM scores were available for 45 patients, i.e., 10 suffering from TBI while 35 having NTBI. It has been well defined that UK FIM+FAM change is the absolute difference between discharge and admission scores. Motor subset of scores showed significant improvement from admission to discharge (50 vs 72, p-value <0.001). Similarly, the cognitive subset of scores also showed a significant improvement from admission to discharge (58 vs 68, p-value <0.05). This change was more evident in the motor subscale. The significant difference in both the subsets has been given in (Table/Fig 3).

Apart from motor and cognitive subscales of UK FIM+FAM, change in score in further sub divisions of self-care (26 vs 34, p-value <0.001) and transfers (11 vs 18, p-value <0.001) showed the maximum change with p-value <0.001. Other sub divisions of locomotion (7 vs 11, p-value <0.05), sphincter (6 vs 10, p-value 0.05), communication (21 vs 25, p-value <0.05) psychological (15 vs 20, p-value <0.05) and cognition (20 vs 23, p-value <0.05) also showed a significant difference. The change in UK FIM+FAM score for patients in various sub-divisions has been shown in (Table/Fig 4).

Discussion

To the best of my knowledge, this is one of the few limited studies available to evaluate the effectiveness of multidisciplinary, comprehensive, specialised, inpatient rehabilitation program using UK FIM+FAM tool in an Indian setup. The study inferred that the program did produce a statistically significant change in both motor and cognitive sub scales in a diverse group of patients suffering from ABI, who attended the comprehensive inpatient rehabilitation program. All the patients at time of transfer to neurosciences ward had significant motor and cognitive disability. There is well established research demonstrating effectiveness of multidisciplinary rehabilitation program on ABI patients (12),(13),(14).

Similar to results of study published by Gray DS and Burnham RS, patient’s age at admission was higher in the NTBI group as older patients are more prone to causes like stroke and vascular malformations (15). The mean age of patients suffering from stroke has been documented as varying from around 60-75 years for men and between around 65-80 years for women, which is quite similar to study by Appelros P et al., (16). Since stroke comprises of a major cause amongst those suffering from NTBI, the findings in present study of relatively older population in NTBI group can be well justified.

Similar to findings in other studies, the ratio of men:women were much higher in both TBI and NTBI group (15),(17). This can be well justified as more men suffer from TBI due to being involved in outdoor activities as well as due to their job profile, which comprises of more risk taking activities. In a Swedish Systematic Review article, it has been clearly indicated that male stroke incidence rate was 33% higher and stroke prevalence was 41% higher than the females (16). However, as age progresses beyond 65 years, the ratio reverses (16). Since our study has been limited to 18-65 years, the findings of the study can be well justified.

Willer B et al., stated that the functional improvement in terms of motor, ADL, sensory and communication, behaviour, emotional and cognitive domains of functional abilities were significantly greater than the gains of matched sample of individuals who did not receive residential based rehabilitation (6). They conducted a case control study, on the contrary to this study, which is a reterospective analysis of previously maintained data. However, the results obtained are on similar lines. In their study, three Health and Activity Limitation Survey (HALS) Scales that is, Motor (8 items), ADL (8 items), Sensory and Communication (6 items) were used. Behaviour (8 items), Emotional (4 items) and Cognitive (8 items) scales were also added to HALS, to make it more appropriate for the TBI population.

In another study by Gray DS and Burnham RS, it was noted that motor subset scores as well as cognitive subset scores showed a significant change at the time of discharge as compared to admission values (15). This was again similar to the results of the current study.

British study conducted by Semelyn JK et al., has further reiterated the contention that multidisciplinary comprehensive in-patient rehabilitation services are more effective than community based rehabilitation and add to the process of natural recovery (7).

Limitation(s)

Limitations of the study are that since there was no Indian version, the components of UK FIM+FAM scale were not pretty much India specific. The components of EADL are not of much relevance in the Indian context and had to be excluded from our study as in India, activities like meal preparation, doing laundry and doing shopping are mostly done with the help of helpers or care givers due to social and cultural factors in the family.

The sample size on which the study was done was small. More such studies, preferably multicentric in origin should be undertaken in future. The lack of controls in the study further raises a question that whether the change in scores achieved is a result of spontaneous recovery or as a result of comprehensive rehabilitation. Similar issue of lack of control group has also plagued previous studies measuring the outcome of rehabilitation interventions (15).

The group of patients with ABI, who are discharged from other hospitals where a formal Department of PMR is not established and patients are not subjected to a comprehensive rehabilitation program, might be used as a control group in future studies of similar approach. The suggestion of multicentric studies being conducted in future can serve as a solution to this limitation. Further, since the time of admission of most patients was around one year after injury, the period of spontaneous recovery was over and this change can be considered as a result of the rehabilitation program.

Conclusion

A physiatrist led intensive interdisciplinary inpatient rehabilitation program for patients with acute brain injury may significantly reduce residual disability and improve functional independence. The study also highlights the fact that such kind of rehabilitation program was not only effective in high income countries, but also in LMIC. A tailor made rehabilitation program can prove to be of immense help to improve the functionality of ABI patients, even in sub-acute phase.

References

1.
Brain Injury Association of America (BIAUSA). What is the Difference Between Acquired Brain Injury and Traumatic Brain Injury? [Last accessed on 2020 Apr 30]. Available from: https://www.biausa.org/brain-injury/about-brain-injury/nbiic/what-is-the-difference-between-an-acquired-brain-injury-and-a-traumatic-brain-injury.
2.
Kamalakannan SK, Gudlavalleti AS, Murthy Gudlavalleti VS, Goenka S, Kuper H. Challenges in understanding the epidemiology of acquired brain injury in India. Ann Indian Acad Neurol. 2015;18(1):66-70.
3.
Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: A brief overview. J Head Trauma Rehabil. 2006;21:375. [crossref] [PubMed]
4.
Mair A. Medical Rehabilitation; the Pattern for the Future, Report of a Sub-Committee of the Standing Medical Advisory Committee, Edinburgh: Scottish Home and Health Department, HMSO; 1972.
5.
British Society of Rehabilitation Medicine. Rehabilitation after traumatic brain injury. London: British Society of Rehabilitation Medicine, 1998.
6.
Willer B, Button J, Rempel R. Residential home-based post-acute rehabilitation of individuals with traumatic brain injury: A case control study. Arch Phys Med Rehabil. 1999;80:399-406. [crossref]
7.
Semylen JK, Summers SJ, Barnes MP. Traumatic brain injury: Efficacy of multidisciplinary rehabilitation. Arch Phys Med Rehabil. 1998;79:679-83. [crossref]
8.
Gururaj G. Epidemiology of traumatic brain injuries: Indian scenario. Neurol Res. 2002;24:24-28. [crossref] [PubMed]
9.
Hall KM, Hamilton BB, Gordon WA, Zasler ND. Characteristics and comparisons of functional assessment indices: disability rating scale, functional independence measure, and functional assessment measure. J Head Trauma Rehabil. 1993;8:60-74. [crossref]
10.
Turner-Stokes L, Nyein K, Turner-Stokes T, Gatehouse C. The UK FIM+FAM: Development and evaluation. Clin Rehabil. 1999;13(4):277-87. [crossref] [PubMed]
11.
Law J, Fielding B, Jackson D, Turner-Stokes L. The UK FIM+FAM extended activities of daily living module: Evaluation of scoring accuracy and reliability. Disabil Rehabil. 2009;31(10):825-30. [crossref] [PubMed]
12.
Turner-Stokes L, Siegert RJ. A comprehensive psychometric evaluation of the UK FIM+FAM. Disabil Rehabil. 2013;35(22):1885-95. [crossref] [PubMed]
13.
Turner-Stokes L. Evidence for the effectiveness of multidisciplinary rehabilitation following acquired brain injury: A synthesis of two systematic approaches. J Rehabil Med. 2008;40(9):691-701. [crossref] [PubMed]
14.
Turner-Stokes L, Pick A, Nair A, Disler PB, Wade DT. Multi-disciplinary rehabilitation for acquired brain injury in adults of working age. Cochrane Database Syst Rev. 2015;(12):CD004170. [crossref] [PubMed]
15.
Gray DS, Burnham RS. Preliminary outcome analysis of a long-term rehabilitation program for severe acquired brain injury. Arch Phys Med Rehabil. 2000;81(11):1447-56. Doi: 10.1053/apmr.2000.16343. PMID: 11083347. [crossref] [PubMed]
16.
Appelros P, Stegmayr B, Terént A. Sex differences in stroke epidemiology: A systematic review. Stroke. 2009;40(4):1082-90. Doi: 10.1161/STROKEAHA.108.540781. Epub 2009 Feb 10. PMID: 19211488. [crossref] [PubMed]
17.
Jackson D, Seaman K, Sharp K, Singer R, Wagland J, Turner-Stokes L. Staged residential post-acute rehabilitation for adults following acquired brain injury: A comparison of functional gains rated on the UK Functional Assessment Measure (UK FIM+FAM) and the Mayo-Portland Adaptability Inventory (MPAI-4). Brain Inj. 2017;31(11):1405-13. [crossref] [PubMed]

DOI and Others

10.7860/JCDR/2021/49437.15280

Date of Submission: May 26, 2021
Date of Peer Review: Jun 11, 2021
Date of Acceptance: Jul 13, 2021
Date of Publishing: Aug 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. No

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: May 29, 2021
• Manual Googling: Jun 05, 2021
• iThenticate Software: Jun 24, 2021 (8%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com