Brain Injury, June 2007; 21(7): 681–690

Does intensive rehabilitation improve the functional outcome

of patients with traumatic brain injury (TBI)? A randomized
controlled trial

X. L. ZHU1, W. S. POON1, CHETWYN C. H. CHAN2, & SUSANNA S. H. CHAN3

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1
Division of Neurosurgery, Departments of Surgery, Prince of Wales Hospital, the Chinese University of Hong Kong,
Hong Kong, PR, China, 2Department of Rehabilitation Science, Applied Cognitive Neuroscience Laboratory,
The Hong Kong Polytechnic University, Hong Kong, PR, China, and 3Shatin Cheshire Home, Hong Kong, PR, China

(Received 16 January 2007; revised 17 April 2007; accepted 6 May 2007)

Abstract
Objective: To evaluate the effects of an increase in the intensity of rehabilitation on the functional outcome of patients
For personal use only.

with traumatic brain injury (TBI).

Design and methods: Sixty-eight patients (age 12–65 years) with moderate-to-severe TBI were included. They were
randomized into high (4-hour/day) or control (2-hour/day) intensity rehabilitation programmes at an average of 20 days
after the injury. The programmes ended when the patients achieved independence in daily activities or when 6 months had
passed.
Outcome and results: No significant differences were found in the Functional Independence Measure (FIM) (primary
outcome) and Neurobehavioural Cognitive Status Examination (NCSE) total scores between the two groups. There were
significantly more patients in the high intensity group than in the control group who achieved a maximum FIM total score
at the third month (47% vs. 19%, p ¼ 0.015) and a maximum Glasgow Outcome Scale (GOS) score at the second
(28% vs. 8%, p ¼ 0.034) and third months (34% vs. 14%, p ¼ 0.044).
Conclusions: Early intensive rehabilitation may improve the functional outcome of patients with TBI in the early months
post-injury and hence increase the chance of their returning to work early. Intensive rehabilitation in this study speeded up
recovery rather than changed the final outcome.

Keywords: Traumatic brain injury, rehabilitation, intensity, Functional Independence Measure (FIM), Glasgow Outcome Scale
(GOS), Neurobehavioural Cognitive Status Examination (NCSE)

Introduction How should the intensity of rehabilitation be

It is generally accepted that rehabilitation is effective
for patients with brain injury [1–5], yet there is still
much to be done and specific questions to be
answered. One of these questions concerns the
relationship between the intensity of rehabilitation
and the outcome of traumatic brain injury (TBI) [6].
Will the outcome of patients who have suffered from
TBI improve if the level of intensity of rehabilitation
is increased? What is the optimal amount of
rehabilitation intensity that patients should receive?
measured?
There is no established standard for the level of
intensity of rehabilitation that should be provided to
patients following TBI. In most settings, the average
training received by patients is 1–2 hours per day.
However, this can vary from less than 1 hour to
8 hours per day [7–14]. To date, in the literature in
English, only a few observational and randomized
controlled trials have investigated the effect of the
level of intensity of rehabilitation on the global

Correspondence: W. S. Poon, Chief in Neurosurgery, Department of Surgery, Prince of Wales Hospital, Shatin, N.T., Hong Kong, PR China.
Tel: (852) 2632 2638. Fax: (852) 2637 7974. E-mail: wpoon@cuhk.edu.hk
ISSN 0269–9052 print/ISSN 1362–301X online ß 2007 Informa UK Ltd.
DOI: 10.1080/02699050701468941
 682 X. L. Zhu et al.
outcome of TBI patients [9, 10, 13–17]. The
findings, however, are largely inconsistent.
Blackerby [9] compared retrospectively the length
of stay of TBI patients before and after an increase in
the intensity of rehabilitation (from 5–8 hours per
day). The results showed that the length of stay
decreased by 31% for both coma and acute groups
in two hospitals. Spivack et al. [10] examined the
combined effect of intensity of treatment and length
of stay on 95 TBI patients. The results showed
that TBI patients who received a more intensive and
longer period of rehabilitation had greater
progress both cognitively and physically. In another
retrospective study [13], the intensity of rehabilita-
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tion in terms of hours of therapy per day was
analysed against functional status on discharge.
No benefit related to the intensity of therapy
was found. Two randomized controlled trials have
addressed the added benefits of enhanced rehabilita-
tion input [15, 16]. Shiel et al. [15] conducted
a prospective two-centre study of 60 moderate-
to-severe TBI patients with routine therapy of,
respectively, 580 and 402 minutes per week in the
two centres. Additional therapy was provided by
experienced healthcare professionals. The outcome
For personal use only.
was assessed at discharge and 1-year after discharge
by FIM þ FAM. A clear response to increased
therapy input was seen in one of the centres in the
form of more rapid functional improvement and
a shorter length of hospital stay. Another single blind
randomized controlled trial was carried out by Slade
et al. [16] with a group of 131 acquired brain injury
patients (n ¼ TBI 26, stroke 87 and other 28).
Although it was intended for the intensive group to
receive 67% more therapy than the control group,
they in fact only received 30% more. There was no
significant difference in functional outcome between
the two groups. The length of hospital stay of the
study group was 14 days less than that of the control
group. More recently, Cifu et al. [14] carried out
a multi-centre prospective non-randomized study of
491 TBI patients who presented to the emergency
department within 24 hours of injury and received
acute care and inpatient rehabilitation. A better
motor functional outcome as measured by the FIM
was found to significantly correlate with an increased
intensity of rehabilitation. In contrast to the diverse
results for TBI, intensive rehabilitation has been
found to be effective in stroke rehabilitation [18–20].
In a meta-analysis by Kwakkel et al. [18] in 1997
of nine controlled stroke rehabilitation studies in
which the study groups received an average of
twice the time allocation for rehabilitation than the
control group, a small but statistically significant
improvement was found in terms of activities of
daily living (ADL) and functional outcome in the
patients who had received intensive rehabilitation.
In a subsequent systemic review by the same group
in 2004, positive results in regard to functional
outcome were produced when the intensity of
rehabilitation was increased for post-stroke patients
[19, 20].
In an attempt to answer the question of whether
intensive rehabilitation changes the outcome of
patients who have suffered from TBI, this study
carried out a prospective randomized assessor-blind
trial to compare the functional outcome of two
groups of patients with TBI receiving different
intensity levels of rehabilitation at the early
post-traumatic stage. It quantified the intensity of
rehabilitation in terms of the number of hours of
professionally supervised training received by the
patients each day. The intensive rehabilitation
schedule was set at 4 hours of training, whereas the
control schedule was set at 2 hours, which was the
original programme received by existing patients.
The interim results of the study have been reported
elsewhere [21]. This paper reports the final results.
Patients and methods
Design
This was a prospective randomized controlled trial
in which the assessors of functional outcome were
blinded to the patients’ status of randomization.
Two groups of TBI patients received different
levels of intensity of rehabilitation at the early
post-traumatic stage (up to 6 months post-injury)
while the content and quality of the rehabilitation
programme and the personnel involved in delivering
the programme were controlled for. In the intensive
group, the patients received 4 hours of therapeutic
training each day for 5 days a week. In the control
group, the patients received 2 hours of therapeutic
training each day for 5 days a week. The assessment
schedule and outcome measures used to reveal the
treatment outcomes were the same for both groups.
Setting
The setting chosen was the academic neurosurgical
unit at the Prince of Wales Hospital, which has
a catchment population of two million in conjunc-
tion with Shatin Cheshire Home, a convalescence
and rehabilitation hospital. The neurosurgical
patients were under the care of a multi-disciplinary
rehabilitation team including neurosurgeons,
physicians, physiotherapists, occupational therapists,
speech therapists, nurses and medical social workers.
Psychological assessment and counselling were
also available. The duration of the rehabilitation
programme received by the existing patients was

2 hours each day and it was delivered by the
 Does intensive rehabilitation improve the functional outcome of patients with TBI?
multi-disciplinary team in designated treatment
areas. Leisure activities and/or extended training
were provided by the nurses in the patients’ wards.
Patients
All TBI patients admitted to the Prince of Wales
Hospital were screened for their eligibility to
participate in the study. The inclusion criteria
were: (1) suffering from moderate (Glasgow Coma
Score [GCS] 9–12/15) or severe (GCS  8/15) TBI
and (2) aged between 12–65 years old. The
exclusion criteria were: (1) suffering from severe
medical disease or other associated injury that may
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compromise the rehabilitation programme, (2) pre-
existing disabilities, (3) default treatment or follow-
up assessments, (4) rapid and good recovery that did
not require rehabilitation and (5) persistent vegeta-
tive state.
Randomization and intervention
When a patient had recovered from the acute stage
of head injury, had regained consciousness and
was able to participate in rehabilitation, his or her
informed consent was obtained and baseline assess-
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ments were conducted at the acute hospital (see
below for the outcome measures). The study was
also explained to the patient’s relatives or guardian
for their support and cooperation. The patients were
then randomly assigned to intensive or control
groups using stratified blocked randomization. The
patients were first stratified according to the severity
of the brain injury (moderate or severe) and then
pooled into groups of 10. Randomization was
conducted separately for each of the moderate-
to-severe sub-groups by drawing one of several
double-sealed envelopes. The number of envelopes
assigned to the intensive or conventional groups in
each randomization was kept as equal as possible.
The randomizations were conducted by a research
assistant who was not involved in the clinical
management. The patients, along with the sealed
envelopes, were then transferred to the rehabilitation
hospital where the rehabilitation programme was
carried out. All patients were assessed by the same
multi-disciplinary rehabilitation team before the
treatment protocol assignment, as indicated in the
sealed envelope, was revealed. Those patients who
were assigned to the intensive group received a total
of 4 hours of rehabilitation training, which simply
involved two sets of the 2-hour daily treatment
protocol that the patients in the control group
received.
The comprehensive rehabilitation programme was
designed with clear clinical outcome targets. All
training provided by the multi-disciplinary team was
intended to regain function, achieve independence in
683
ADL and facilitate reintegration into home and
community settings. The programme consisted
of physical and sensori-motor training from phy-
siotherapy, functional re-training such as self-care
and instrumental ADL, psycho-social re-training
including social skills from occupational therapy
and hearing and speech from speech therapy.
The content of the programme was tailored to fit
each individual patient’s needs and status. The case
therapists made adjustments to the programme
according to the patient’s progress. The criteria by
which the intervention was upgraded were based
on established standards that were the same for
both groups. This was deemed to be an essential
feature of the clinical protocol in that the quality
of the rehabilitation programme was largely con-
trolled whilst the quantity was manipulated in the
study group.
The quantity of training received by the patients
was counted in 1-hour units. The amount of training
received by the control group was two units: one unit
of physiotherapy (PT) and one unit of occupational
therapy (OT) delivered in the morning. The patients
in the intensive group received an additional
two units of training: one unit of PT and one unit
of OT delivered in the afternoon. In addition, one
unit of speech therapy was provided to the patients
in the control group and two units of speech therapy
were provided to the patients in the intensive group.
The attendance, unit of training received, progress
and upgrading status of each patient were recorded.
The duration of the training programme varied
with respect to the progress made by the patients.
However, the maximum duration of training
was limited to 6 months. To avoid bias, a neuro-
surgeon blinded to the study was responsible for
deciding whether to discharge the patients from
the programme. The criterion set was that a patient
could (1) perform self-care activities of eating,
grooming, dressing, toileting; (2) move from bed
to chair/wheelchair/shower chair independently;
(3) handle household appliances safely; and
(4) walk with or without aids within ward indepen-
dently. Upon discharge, all patients were referred to
the out-patient rehabilitation service of the hospital,
which offered a 2-hour follow-up rehabilitation
programme each week. Those patients who did not
meet the discharge criterion after 6 months were
discharged to a long-term care institution or a home
with good family support or continued to stay in the
rehabilitation hospital while receiving the existing
rehabilitation protocol 2 hours per day.
Outcome measures
The primary outcome measure was the Functional
Independence Measure (FIM), which measures the
 684 X. L. Zhu et al.
independence of patients in self-care and cognitive
functions (maximum total score ¼ 126) [22].
The secondary outcome measures included the
Glasgow Outcome Scale (GOS) [23] and the
Neurobehavioural Cognitive Status Examination
(NCSE) [24]. The GOS classifies the outcomes
after brain injury into death (1); vegetative state
(2); severe disability in which the patient cannot
independently perform ADL (3); moderate disability
in which the patient can independently perform
ADL but is not able to return to work or to resume
a normal social life (4); and a good recovery in which
the patient is able to return to gainful employment,
either their previous employment or a modified
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type of employment, or is able to resume a normal
social life (5). The NCSE assesses the cognitive
functions of language, construction, memory,
calculation and reasoning [24]. The Chinese version
of the NCSE was used in this study, its validity,
as well as its sensitivity in stroke patients, having
been previously evaluated [25–27].
All assessments were conducted in the acute
hospital by personnel who were not involved in the
randomization and who did not provide the rehabi-
litation training. The assessment occasions were: at
For personal use only.
the baseline, at monthly intervals after the baseline
up to the 6th month and at bi-monthly intervals from
the 8th to the 12th month. The patients either
travelled back to the acute hospital as day patients or
transferred from the rehabilitation hospital if
they had not been discharged. The GOS was
conducted by a neurosurgeon; the FIM by the
multi-disciplinary team composed of a nurse, a
physiotherapist, an occupational therapist and
a speech therapist; and the NCSE by an occupa-
tional therapist. All assessments were completed
in less than 1 day.
Statistics and data analysis
All data were collected prospectively and SPSSR
was used for statistical analysis. Chi-square
or Fisher’s Exact Test was used to test the
between-group differences in demographic and
medical characteristics and other clinical outcome
measures: sex, severity by GCS, proportion of
patients requiring intracranial pressure monitoring,
proportion of patients reaching a maximum GOS
score (5, good recovery) and proportion of
patients reaching a maximum FIM total score
(126). The age of patients was tested by a t-test.
The Mann-Whitney Test was used to test the
between-group differences in days of not obeying a
command (DNO)—indicated duration of the coma,
days of intracranial pressure (ICP) monitoring,
length of hospital stay (LOS) and FIM and NCSE
scores. Sequential FIM and NCSE mean scores
were analysed by repeated measures ANOVA.
The significance level for all tests was set at
p  0.05. The sample size of 68 cases—34 cases in
each group—was found to yield a power of 0.80
( ¼ 0.05, one-tail) for detecting a mean FIM score
difference of 18 or more (equivalent to one level
of independence).
Ethical approval
The study was approved by the Ethical Committee
of the hospital.
Results
One hundred and forty-nine patients with moderate-
to-severe TBI, aged 12–65 years, were admitted
to the Prince of Wales Hospital between January
1996 and August 1998. Of these, 81 patients
(moderate ¼ 17, severe ¼ 64) were excluded from
the study for various reasons (Figure 1). Among the
68 patients who were selected for the study, 32 were
randomly assigned to the intensive group and 36 to
the control group. One patient in each group was
discharged home upon their own request before
reaching discharge status. They had both completed
the whole assessment. Of the five patients who did
not complete one assessment occasion after their
discharge, four explained that it was because they
had returned to work. Subsequently, they were
asked to complete the GOS and FIM via the
phone. The fifth patient who missed the 4-month
assessment was due to be admitted to a psychiatric
hospital for his behavioural problems. The FIM
scores of this patient were treated as missing in the
4-month assessment.
The demographic and medical characteristics of
the 68 patients are listed in Table I. No statistically
significant differences were found between the two
groups of patients in terms of their demographic
characteristics, severity of TBI, DNO and number of
days requiring ICP monitoring. All patients were in
good health prior to the injury and were either
workers or students. The mean length of stay in the
acute hospital, calculated as the time interval
between the date of injury and randomization, was
22 days for both the intensive and control groups.
The mean FIM total scores of the patients in
the intensive group increased from 46 (SD ¼ 28)
at admission to 115 (SD ¼ 27) at the 6th month
to 116 (SD ¼ 27) at the 12th month. This was
similar to the scores of the patients in the control
group, which increased from 52 (SD ¼ 32) at
admission to 117 (SD ¼ 16) at the 6th month to
119 (SD ¼ 11) at the 12th month. Repeated
measures ANOVA indicated that the between-
group effect was statistically non-significant
 Does intensive rehabilitation improve the functional outcome of patients with TBI?
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For personal use only.
Figure 1. Flow chart for patients recruited into the trial.
( p ¼ 0.775). The FIM results were further analysed
by counting the proportion of patients who achieved
a full total score (126) at each assessment occasion.
Figure 2 shows the trend of increase in the number
of patients across the two groups (from 0–56% in the
intensive group; from 0–53% in the control group).
It appeared that, in the 3rd month, there were
significantly more patients in the intensive group
(n ¼ 15, 47%) who achieved a maximum FIM score
than in the control group (n ¼ 7, 19%) (2 ¼ 5.824,
df ¼ 1, p ¼ 0.016). The rest of the comparisons
were all statistically non-significant ( p ranged from
0.076 at the 2nd month to 0.483 at the 12th month).
Such a difference seemed to diminish from the
6-month assessment onward whereby the control
group caught up with the study group (Figure 2).
Similar to the FIM, the results of the GOS showed
that there was an increasing trend of patients
achieving a maximum GOS score across the
12-month period (Figure 3; 0–53% in the intensive
group and 0–42% in the control group). There were
significantly more patients in the intensive group
(n ¼ 9, 28%) than in the control group (n ¼ 3, 8%)
who achieved a maximum GOS score at the
685
2nd month (2 ¼ 4.566, df ¼ 1, p ¼ 0.034). The
same proportion of significant difference was
observed in the 3rd month between the intensive
group (n ¼ 11, 38%) and the control group (n ¼ 5,
14%) (2 ¼ 3.951, df ¼ 1, p ¼ 0.044). The rest of the
comparisons were statistically non-significant
( p ranged from 0.099 at the 1st month to 0.242 at
the 12th month). Such differences appeared to
diminish after the 6th month (Figure 3).
The mean NCSE total scores of the patients in the
intensive group increased from 24.9 (SD ¼ 24.7)
at the baseline to 70.3 (SD ¼ 17.8) at the 12th
month. Similarly, the mean NCSE total scores of the
patients in the control group increased from 25.4
(SD ¼ 24.2) to 71.4 (SD ¼ 17.6). Repeated
measures ANOVA did not reveal statistical signifi-
cance in the between-group differences in the scores
( p ¼ 0.775). When counting the number of patients
who achieved a total score of 78 or higher on the
NCSE, there was a slightly larger proportion
of patients that reached such scores in the
intensive group (0% at admission and 75% at the
12th month) than in the control group (0% at
admission and 63% at the 12th month). However,
 686 X. L. Zhu et al.

Table I. Summary of characteristics of the 68 patients included in the study.

Control group Intensive group

(n ¼ 36) (n ¼ 32) p-level

Sex
M 78% (28) 84% (27) 0.703 (x2)
F 22% (8) 16% (5)
Age
Mean (SD)1 36(13) 31(13) 0.149 (t-test)
Severity of head injury by Glasgow Coma Scale (GCS)
Severe TBI 58% (21) 69% (22) 0.992 (x2)
Moderate TBI 42% (15) 31%(10)
Days of not obeying command (DNO)
Range 1–90 1–90 0.825 (Mann–Whitney test)
Median 7 7
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CT pattens2
I 5% (2) 12% (4)
II 42% (15) 38% (12)
III 14% (5) 28% (9)
IV 3%(1) 6% (2)
V total 3(,%(13) 16%(5)
V with EDH3 17% (6) 6% (2)
Number of cases requiring intracranial (ICP) monitoring
75% (27) 69% (22) 0.762 (x2)
Days of ICF monitoring
Range 7–11 3–22 0.426 (Mann–Whitney test)
Median 7 7
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Mechanism of injury
Traffic accident 72% (26) 71.9% (23) 0.98 (x2, all mechanisms)
Industrial injury 5.6% (2) 6.3% (2)
Assault 5.6% (2) 9.4% (3)
Other 16.7% (6) 12.5% (4)
1
SD ¼ Standard deviation.
2
Classification of head injury (type I to V) according to CT findings45.
I: Diffuse injury 1 (no lesion), II: Diffuse injury II (small lesions), III: Diffuse injury III (swelling), IV (midline shift), V: Evacuated or
non-evacuated mass lesion.
3
Percentages of EDH for the whole conventional and intensive groups respectively; EDH ¼ Epidural haematoma.

Figure 2. Percentage of patients who achieved a maximum FIM Figure 3. Percentage of patients who achieved a score of 5 on
score vs. time (months post-randomization). Statistical signifi- GOS (good recovery) vs. time (months post-randomization).
cance was demonstrated at the 3rd month. Statistical significance was demonstrated at the 2nd and 3rd
months.

no statistically significant difference was found (Figure 4). Similar results were found for the
in the proportions of patients between the length of stay variable. The mean length of stay of
two groups (2 ¼ 0.868–0.980, df ¼ 1, p ¼ 0.290 at patients at the acute hospital was the same for both
the 1st month to 0.234 at the 12th month) the intensive and control groups, namely 22 days
 Does intensive rehabilitation improve the functional outcome of patients with TBI?
Table II. Length of hospital stay (LOS).
Conventional
LOS at Prince of Wales Hospital
Range
Mean(SD)1
Median
LOS at Shatin Cheshire Home
Range3
Mean (SD)1
Median
1
SD ¼ Standard deviation.
2
Mann–Whitney test.
3
The rehabilitation intervention of the trial was completed at six months. If a patient was still
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not able to be discharged after six months for any reason, the LOS was counted as 180 days.
There were three such patients in the conventional group and two in the intensive group.
For personal use only.
Figure 4. Percentage of patients who achieved a maximum NCSE
score vs. time (months post-randomization). There was a weak
trend of more patients achieving a full score in the intensive
group, but it is not statistically significant.
(SD ¼ 15). The mean length of stay at the rehabilita-
tion hospital of patients in the intensive group was
43 days (SD ¼ 45), which was slightly less than the
43 days (SD ¼ 52) for the control group. However,
this difference was statistically insignificant
(Table II, p ¼ 0.754).
Discussion
The results of the study indicate that a change in
the intensity of rehabilitation training from a 2-hour
to a 4-hour protocol each day can significantly
improve the functional outcome of patients with
TBI. These positive effects of an increase in
treatment intensity were found to be prominent
during the first few months of intervention. More
687
Intensive
group group p2
4–61 5–51 0.9952
22(15) 22(15)
15 17
6–180 7–180 0.7542
43 (52) 43 (45)
28.5 25
patients were achieving independent daily function-
ing, as indicated by a maximum FIM score in the
3rd month, as well as good functional regain by
returning to work and resuming a normal social life,
as indicated by a maximum GOS score in the 2nd
and 3rd months, after the patients had engaged in
the intensive programme. Nevertheless, an increase
in the intensity of the rehabilitation programme did
not seem to have positive effects on other outcomes
such as regain of cognitive functioning and length of
stay in the rehabilitation hospital. Its positive effects
also did not appear to extend beyond the 3rd month,
particularly when patients were discharged from the
intensive rehabilitation programme, which was a
hospital-based programme, and then participated in
other maintenance rehabilitation programmes such
as a weekly day-hospital-based programme.
These findings concur with those of other
studies that showed that functional recovery
after TBI occurred during the first 6 months after
injury [8, 28]. Patients in both the intensive and
control groups of this study showed significant
increases in most of the clinical outcome measures
(self-care, social functions and return to work)
after engaging in the rehabilitation training. More
importantly, an intensive rehabilitation protocol was
found to promote the rate of regain of these
functions up to the level of independent self-care
in home and community settings within the first
3 months. This was supported by the significantly
higher proportion of patients who obtained the
maximum score on the FIM (independent ADL)
and the GOS (independent social functions and
return to work) during this period. Two interesting
observations can be made. First, not all patients in
the intensive rehabilitation group benefitted from the
increase in treatment intensity: 47% and 59% of
patients achieved full independence in self-care
at the 4- and 6-month assessments, respectively.
This suggests an association between patients’
 688 X. L. Zhu et al.
readiness and the intensity of rehabilitation. It is
intuitive that patients who had reached a satisfactory
level of recovery of neurological and cognitive
functions could have been involved in a more
intensive rehabilitation protocol. The small sample
size of this study did not enable one to further break
down patients based on whether they got maximum
or less than maximum scores and compare their
demographic and medical characteristics. Future
studies could address this interesting research
question.
Secondly, the intensive rehabilitation protocol did
not seem to increase the potential of functional
regain, which is reflected in the treatment outcomes
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of these patients at the end of this clinical trial.
No significant differences were found in all the
clinical outcome measures beyond the 3rd month
between the two groups. There are several explana-
tions for this phenomenon. First, the patients’
rehabilitation potential could have been limited by
the extent to which their brain was damaged.
Available clinical studies only revealed that early
rehabilitation increases the rate of recovery. There is
a general lack of evidence establishing the causal
For personal use only.
effect of early rehabilitation on promoting recovery
of a damaged brain. Secondly, the facilitating
effect seemed to coincide with the duration of the
intensive rehabilitation programme. The majority of
the patients were discharged from the intensive
rehabilitation programme within 90 days (mean ¼
43 days, SD ¼ 45 days). This suggests that the
increase in the rate of functional regain did not
continue after the termination of the programme.
The design of this study, however, meant that it was
impossible to determine whether the same increase
in the rate of improvement would be sustained if the
intensive rehabilitation was to be continued after
the patients were discharged from the existing
programme. Again, future studies could attempt to
address this research question.
In 1980, Garraway et al. [29, 30] reported the
results of a stroke rehabilitation study in which
intensive rehabilitation was found to improve the
patients’ outcome but its effectiveness was not
sustained. In a randomized controlled trial, a group
of patients who received more rehabilitation and
started therapy earlier achieved a better functional
independence outcome than others after 6 months.
However, after 1 year, this benefit had disappeared.
In this study, the difference in the proportion
of patients who achieved maximum GOS and
maximum FIM scores between the two groups
diminished 6 months post-injury. In contrast to the
stroke studies [29, 30], these results show that it is
the catching up of the control group that leads to the
approximation of the two curves rather than
the diminishment of the effect in the study group.
The different nature of brain damage and the
different ages of patients might have contributed to
the differences.
As in other studies, the FIM results
obtained in this study suffered from the ceiling
effect [26, 31, 32]. As a result, those patients who
had a greater ability to perform more complicated
daily tasks than self-care tasks (as measured by the
FIM) were not identified by the FIM scores. The
strategy of using the proportion of patients who had
attained a maximum FIM score was found to better
reflect the abilities of the patients and, hence, the
differences between the patients in the two groups.
It has also been suggested that the spectrum of FIM
is inadequate for TBI patients who have
prominent communicative, cognitive and beha-
vioural disturbances [2, 33]. Adding the Functional
Assessment Measure (FAM), with its assessment of
cognitive, behavioural, communicative and commu-
nity functions, to the FIM (FIM þ FAM) may
improve its spectrum in assessing the psycho-social
disability of TBI patients [34, 35], especially when
predicting the community re-integration and
employment status of TBI patients [36].
Similar to the FIM results, there were no
significant differences in the NCSE mean scores
between the two groups. Cognitive function is
a known important factor affecting the tendency to
re-enter employment. However, this was not
reflected in this study, in spite of the fact that more
patients in the intensive group returned to work than
in the conventional group. There are several
possible explanations for this phenomenon. First,
the instruments used in this study to reflect the
clinical outcomes may not be sensitive enough
[37–39]. Secondly, there could be other factors
that contributed to the different outcomes of the two
groups [40–44]. Previous findings suggest that the
NCSE cannot differentiate between those who are
ADL independent only from those who are ADL
independent and at the same time manage to return
to work [37]. This could be due to the fact that the
NCSE does not assess language functions such as
reading, writing and spelling or other frontal
lobe functions such as sustained attention, self-
monitoring and shifting set in response to environ-
mental cues [24]. Impairments in these areas may
prevent patients from returning to work. There are
also many factors that could confound return to
work as a treatment outcome of TBI patients,
notably behavioural and emotional problems
[40–42]. Social isolation and lack of cooperation
related to personality changes are important factors
 Does intensive rehabilitation improve the functional outcome of patients with TBI?
that might prevent them from returning to work
[43, 44]. Unfortunately, these behavioural and
emotional outcomes were not measured in this
study. The issue of compensation can also be an
important confounding factor for returning to work,
especially after work-related injury. As industrial
injuries, mostly arising from traffic accidents,
accounted for only a small proportion of the injuries
suffered by the patients in this study, and as the
proportions of industrial injuries in each group were
similar, this study did not examine in detail the issue
of compensation.
The above discussion of the FIM and the NCSE
also underline the main limitation of this study; that
Brain Inj Downloaded from informahealthcare.com by Nanyang Technological University on 06/02/14
is that TBI actually covers a heterogeneous group of
patients. The change from being independent in
ADL to returning to work or resuming a normal
social life is affected by a lot of factors such as the
behavioural, emotional and compensatory problems
mentioned above. This study does not put a tight
control on all of these variables which could have
confounded the effects of the intensive
rehabilitation.
For personal use only.
Conclusion
The results of this study suggest that early intensive
rehabilitation can improve the functional outcome of
patients with TBI in the early months post-injury
and, hence, increase the chance of their returning
to work early. Intensive rehabilitation in this study
speeded up recovery rather than changed the final
outcome. The results may stimulate more research
on intensive rehabilitation for brain injury and on
brain plasticity.
Acknowledgements
We gratefully acknowledge the advice on statistics
given by Miss A. L. M. Yu, BSc, Centre for Clinical
Trials and Epidemiological Research, the Chinese
University of Hong Kong and Miss Stephanie C. P.
Ng, Division of Neurosurgery, the Chinese
University of Hong Kong. We would like to thank
all the nurses of the Surgical Wards in the Shatin
Cheshire Home and of the Neurosurgical Wards (3C
and 3D) in the Prince of Wales Hospital, as well as
all the occupational therapists, physiotherapists and
speech therapists in both the Cheshire Home and the
Prince of Wales Hospital. Without their hard work,
it would have been impossible to have carried out
this study. The study was supported by a grant
from the Hong Kong Health Service Research Fund.
689
This study was presented at the International
Conference on Neurotraumatology (ICRAN),
20–23 November 1999, Taipei, Taiwan, China.
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