Neurological and social long-term outcome after early rehabilitation following traumatic brain injury. 5-year report on 240 TBI patients.

The long term courses of patients after traumatic brain injury (TBI) are particularly influenced by the quality of neuropsychological rehabilitation and social reintegration. Though we do have data from different European countries about the success of surgery and intensive care, we don't know much about the long term courses, mirrored by the patients, their relatives and local physicians in their domestic environment. Supported by a pilot project of the government of Nordrhein--Westfalia we reviewed 252 patients with different grades of TBI, which were treated in our department from emergency to the end of early rehabilitation. At least 240 files could be completed, including observations up to 5 years after trauma (mean 26 months). 66% of the patients suffered from severe TBI according to the initial Glasgow Coma Scale (GCS), 23% showed moderate and 11% mild TBI. After discharge from early rehabilitation and during further treatment in rehabilitation hospitals patients with persistent vegetative state (PVS) did not show a significant benefit from therapy: Only 1 patient improved to GOS 3, fatal courses were observed in 3 patients, 11 patients remained unchanged. Patients with GOS 3 at the end of early rehabilitation on the other hand could improve in 51 cases to GOS 4 and 5. At the time of the actual investigation 32% of the patients reached GOS 5, 27% GOS 4. Unfavourable courses showed 21% (GOS 3), 5% (GOS 2) and 15% (GOS 1). Referred to the initial GCS only 16% of the severe, 27% of the moderate and 33% of the mild TBI could return to their former social activities and profession without any cuts. 145 of the total of surviving patients could return to their families, in the group of vegetative patients all except 1 patient were submitted for nursing homes. Only 58% of the patients practiced any kind of outpatient rehabilitation, a specialized neuropsychological training has been restricted to 7% of the patients. So we observe a significant gap between a high impact clinical medicine on one side and a deficient outpatient treatment on the other. At least many patients are standing alone after discharge from rehabilitation hospitals, resulting in prolonged stationary treatment with extensive costs to minimize damage from this situation. Our consequence for a more efficient treatment is, that we substantially need better programs by local administrations, insurance companies and employers for better and earlier reintegration to avoid isolation and unnecessary invalidation, especially of those patients with the best medical prognosis.