British Journal of Neurosurgery, February 2013; 27(1): 24–29
© 2013 The Neurosurgical Foundation
ISSN: 0268-8697 print / ISSN 1360-046X online
DOI: 10.3109/02688697.2012.714818
ORIGINAL ARTICLE
Acute neurorehabilitation versus treatment as usual
James N. Thompson1, Jaydip Majumdar1, Russell Sheldrick1 & Fayez Morcos2
1Salford Royal Hospital NHS Foundation Trust, Manchester, UK, and 2Pennine Acute Hospital NHS Trust, Manchester, UK
Br J Neurosurg Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/27/14
Abstract
Several clinical and government reviews have recommended
specialised rehabilitation services for those recovering from
neurological insult or neurosurgical intervention. Despite
this, provision of ‘rapid access’/acute neurorehabilitation
units is extremely limited in the UK. In some areas, millions
of people have no access to such facilities. Numerous articles
have indicated that delayed access to neurorehabilitation in
the acute recovery stage may worsen clinical outcomes and
increase length of stay for patients. However, there has been a
lack of studies directly comparing clinical outcomes between
matched samples of patients in acute neurorehabilitation
units versus patients receiving treatment-as-usual. In a study
For personal use only.
believed to be the first of its kind, this paper: (A) Describes the
rationale and evidence base for acute neurorehabilitation.
(B) Provides a comparison of clinical outcome scores Functional
Independence Measure/Functional Assessment Measure
(FIM-FAM) and also length of stay times for both of the
aforementioned groups. The results show that all outcome
areas except the ‘communication’ domain saw clinically
and statistically significant improvements in the acute
neurorehabilitation group. Length of stay was significantly
reduced in the acute neurorehabilitation group. The case for
reviewing the provision of acute neurorehabilitation units is
now even more urgent and difficult to ignore.
Keywords: acute; comparison; head injury; neurorehabilitation;
outcomes
Introduction
In the last 13 years, several reports from both government
and clinical working groups have repeatedly stressed that
patients recovering from neurological insults should be
treated in specialist neurorehabilitation units and that the
placement of such patients in facilities such as acute surgical,
orthopaedic or general wards was not acceptable.1–4
Whilst provision of active participation, slow stream and
community neurorehabilitation is now fairly widespread,
several articles have recently addressed the lack of acute
neurorehabilitation units in the UK,5–9 some citing examples
Correspondence: James N. Thompson, Salford Royal Hospital NHS Foundation Trust, Stott Lane, Salford, M6 8HD. Tel: 0161 206 5588. E-mail: jamest33@hotmail.
co.uk
Received for publication 20 July 2011; accepted 17 July 2012
24
of regions where several million people have no access to
such services.8,9 Many patients in need of neurorehabilita-
tion during the acute recovery phase still have to depend on
the general rehabilitation services of district general hospi-
tals. Most often, patients will spend the early weeks of their
recovery being treated on a neurology or neurosurgical wards
where rehabilitation will not begin apace until discharge to a
dedicated unit, thus failing to optimise input in the crucial
early period.
The overriding concern in these articles is that the tradi-
tional notion of providing acute treatment and rehabilitation
in series is inadequate and that acute treatment and rehabili-
tation should be conducted in parallel.8
The articles collectively present the case that such a model,
achieved by the existence of an acute neurorehabilitation
unit, would allow neurorehabilition to start at the earliest
opportunity which would result in (A) cost-of-treatment sav-
ings in time and money. (B) improved clinical outcomes.
As regards the former notion of time and cost efficiencies,
it has been demonstrated that lengths of stay for acute neu-
rorehabilitation patients are usually equal to or shorter than
patients receiving treatment as usual;7,10 that acute neurore-
habilitation units could significantly reduce ‘bedblocking’ on
acute neurosurgical wards5 and that early access to neurore-
habilitation reduces overall treatment costs.10,11
The evidence for the notion of improved clinical outcomes
also appears promising.10–16 However, given the paucity of
acute neurorehabilitation units in the UK, there has been
very little research comparing clinical outcome measures
between patients who receive acute neurorehabilitation and
those who do not.
This paper seeks to address this gap in research, in the
hope that it will inform the ongoing discussion regarding
acute neurorehabilitation service provision. The study exam-
ines the clinical efficacy of treatment and length of stay on an
acute neurorehabilitation ward, compared with treatment as
usual. Two matched samples of patients provide the basis for
this comparison, with outcomes measured across a broad
range of neurological, psychological and social domains.
To our knowledge a study of this kind has never before been
published.

Rationale for neurorehabilitation
Recovery of functional ability in the physical, cognitive and
social domains following a central nervous system insult
occurs via four main mechanisms: (i) reduction of phys-
iological factors impeding the function of intact neurones
such as inflammation;17,18 (ii) neuroplastic reorganisation
of other intact synaptic networks to provide new neural
substrates for functions previously localised in the lesioned
areas;19–21 (iii) restitution of lesioned networks via regenera-
tion of damaged neurones– a process which occurs on a very
small and arguably unnoticeable scale when compared with
peripheral nerve regeneration;22,23 (iv) compensation for
Br J Neurosurg Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/27/14
impairments using other intact functional systems, external
aids and alternative methods of task completion.18,21,24,25
Neurorehabilitation seeks to complement and enhance
the natural recovery process in the following ways: (i) pro-
viding stimulation to damaged neural networks to encour-
age reorganisation of function; (ii) reducing maladaptive
neurological responses (e.g. spasticity, epilepsy) which may
inhibit optimal function and compete for reorganised sub-
strates; (iii) promoting safe and appropriate compensation
strategies; (iv) managing factors indirectly impeding recov-
ery e.g. behavioural problems or co-morbid medical condi-
tions which may delay rehabilitation and increase length of
stay.14,18,21,26,27
The key principle of acute neurorehabilitation is that
For personal use only.
recovery is expected to be significantly greater if started
earlier.7–9,13–16 In recent years, work from animal paradigms
has indicated that early interventions providing an enriched
environment (multisensory, motor and cognitive stimula-
tion) and physical training result in clear motor function
increases and reduced neuronal loss when compared within
controls,28 although iatrogenic damage can occur due to
excessive input.29 An enriched environment leads to signifi-
cant changes in neuronal physiology, including increased
dendritic branching and neuronal density throughout the
CNS; non-neuronal changes such as increased glial cell count
and enhanced contact between astrocytes and synaptic ele-
ments and finally metabolic changes such as the increased
expression of neurotrophic and nerve growth factors.18
In the clinical setting, patients who receive rehabilitation
in the early stages of recovery have demonstrated improved
outcomes following ischemic injury compared to those
whose rehabilitation began later.13,15,16 This finding has
been replicated in patients with traumatic brain injury.7–9
Patients recovering from acquired brain injury are recom-
mended to begin rehabilitation as soon as possible for best
results.14,26,30
Provision of acute neurorehabilitation
Acute interventions are often difficult to achieve on neurol-
ogy and neurosurgical wards where staff roles and equipment
are optimised to treat medically unstable patients rather than
provide rehabilitation. A dedicated acute neurorehabilitation
ward within a neurosciences service (accessing neurology,
neurosurgery and neuroradiology) can manage acute neu-
rological issues and provide specialist staff and equipment
(such as a gym and occupational therapy kitchen). Such a ser-
vice will be better placed to provide intensive rehabilitation
Acute Neurorehabilitation versus Standard Treatment 25
to patients and create the enriched environment required
during the crucial early stages of recovery whilst working to
prevent seriously disabling complications.
In order to properly assess, manage and rehabilitate
patients with complex physical, cognitive and social issues,
the neurorehabilitation team must be skilled, co-ordinated
and multidisciplinary. Ideally, it is comprised of occupational
therapists, physiotherapists, nurses, trained support work-
ers, neuropsychologists, speech therapists and a specialist
rehabilitation medical team. The team should also be able
to liaise closely and involve social, prosthetic and orthotic
services, arrange special equipments and property modifica-
tions and sometimes facilitate radical lifestyle changes for
patients.5,6,26,27
Neurorehabilitation in the greater manchester area
The Greater Manchester Neurosciences Centre incorpo-
rates neurology, neurosurgery and neuroradiology services
and is based at Salford Royal NHS Hospital Foundation
Trust (SRFT). In keeping with the above principles and the
evidence base for the provision of early rehabilitation, the
Neuroscience Centre also incorporates an Acute Neuroreha-
bilitation unit on site which receives patients from neurosur-
gery and neurology wards. Neurorehabilitation commences
on this unit at the acute stage until the patient’s medical
condition has stabilised to such an extent that they no lon-
ger require acute neuroscience medical services. A patient
who still requires inpatient rehabilitation is transferred to
one of four local Intermediate Neurorehabilitation Units.
Patients who no longer require acute neuroscience medical
services and are assessed to have no further need of inpatient
services are discharged home with referrals made to local
community neurorehabilitation teams.
The Acute Neurorehabilitation unit at SRFT
The Acute Neurorehabilitation service was opened on ward
C2 at SRFT in 2001. The service aims to start rehabilitation
at an early stage and simultaneously address any acute
neurological or medical events arising during the process
of rehabilitation. Over the years this purpose-built unit has
gradually developed into a unique service, managing and
rehabilitating patients who are at risk of developing early
complications whilst recovering from neurosurgery or acute
neurological illness. A multidisciplinary team composed of
occupational therapists, physiotherapists, nurses, neuropsy-
chologists, speech therapists and a specialist rehabilitation
medics treat patients with the benefit of access to support
from the on site Neuroscience Centre and a dedicated phys-
iotherapy gym, occupational health kitchen and patients
lounge on the ward. The ward admits patients with signifi-
cant neurological and cognitive impairments, sometimes
presenting with challenging behaviour or minimally con-
scious states. Some patients are very acute, often requiring a
tracheostomy tube for airway management.
Study aims
This study aims to examine the clinical efficacy of treatment
and length of stay on an acute neurorehabilitation ward,
compared with treatment as usual. Two matched samples of
 26 J. N. Thompson et al.
patients provide the basis for this comparison, with outcomes
measured across a broad range of neurological, psychologi-
cal and social domains.
Method
Two samples of patients were used in the study. Data
were derived from ratings on the Functional Independence
Measure/Functional Assessment Measure (FIM-FAM) shortly
before and after discharge. The results of the two samples
were then compared statistically. The information was then
stored on an audit database, in keeping with Trust guidelines
Br J Neurosurg Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/27/14
on confidentiality and data protection.
Sample 1: Treatment as usual
The first sample consisted of 49 patients (23 female,
26 male) who had been admitted to hospital for treatment
of intracerebral haemorrhage, subarachnoid haemorrhage
or traumatic brain injury prior to the availability of an acute
neurorehabilitation service. These patients were admitted
for acute treatment of initial neurological insult before trans-
fer to a general medical ward for recovery prior to discharge.
Thus, they did not receive specialist Acute Neurorehabilita-
tion and accessed post-acute neurorehabilitation services
(both inpatient and community) after their general hospital
inpatient episode.
For personal use only.
Specifically, of the 49; 8 were discharged home directly, 18
spent time on a general ward before discharge home, 6 were
sent to a general ward and then a general rehab ward before
discharge home, 18 were sent to a general ward and then a
standard neurorehabilitation ward before discharge home
and 2 were sent to a general ward and then a nursing home.
Average length of stay (from admission to SRFT to dis-
charge elsewhere) was 112.7 days (SD ⫽ 105.3). Average
patient age was 44.9 years (SD ⫽ 41.3). The initial FIM-FAM
was completed by a treating MDT within a few days of admis-
sion and the follow-up assessment was completed after
discharge from the inpatient ward.
Sample 2: Acute neurorehabilitation
The second data set was taken from patients treated on the
acute neurorehabilitation (ANR) ward at SRFT (Ward C2)
between the years 2006 and 2009. The data included over 400
cases which were blindly matched to the first data set. This
resulted in a final sample of 49 matched patients who had
been admitted with an acute neurological insult and trans-
ferred to the acute neurorehabilitation ward.
Average length of stay was 77.9 days (SD ⫽ 53.1) Average
patient age was 42.7 years (SD ⫽ 14.4). The initial FIM-FAM
was completed by the team within a few days of admission
and the follow-up completed within one week of discharge.
Sample matching process
Patients were matched blindly using a database without
identifying information visible. Researchers matched suit-
able patients on the basis of age, sex, diagnosis and Glasgow
Coma Scale (GCS) on admission. For GCS on admission,
patients were matched by three score ranges, these being:
‘Severe’ ⱕ 8, ‘Moderate’ ⫽ 9–12 and ‘Minor’ ⱖ 13. For age,
patients were matched as closely as possible, with the major-
ity being matched to within three years, the mean difference
being 6.3 years (SD ⫽ 7.2).
The FIM-FAM assessment tool
The FIM FAM is an outcome measure for medical rehabilita-
tion that is both a popular and well validated tool with high
internal reliability in the assessment of patient progress
following head injury or other neurological insult.31–33
It combines both the FIM and the FAM. The former com-
prises 18 functional activities rated on a seven point scale,
whilst the latter rates a further 12 items which pertain to com-
munication, cognition and behaviour. The FIM-FAM gener-
ates scores for six domains of neurorehabilitation: selfcare,
bladder and bowel, mobility, communication, psychosocial
functioning and cognition. If scores are taken at the begin-
ning of an episode of rehabilitation and upon closure of that
episode, the FIM-FAM may be used as an outcome measure.
Results
Descriptive statistics
Scores for admission and discharge FIM-FAM were com-
pared to determine the change which had occurred across
the six domains during inpatient treatment. A ‘Change’ score
result was determined for individual patients in the following
domains: selfcare, bladder and bowel, mobility, communi-
cation, psychosocial and cognition.
Mean ‘Change’ scores in each domain were determined
for the two groups: Sample 1 ‘TAU’ and Sample 2 ‘ANR’ (see
Table I). Comparison of mean scores between groups showed
that improvements in all domains were greater in the ‘Acute
Neurorehabilitation’ group than the ‘TAU’ group.
Mann Whitney test to compare means
A Mann-Whitney test was used to compare means between
groups in each domain. The test was used due to the lack of
a normal distribution in the majority of sample scores. The
results showed a statistically significant difference between
‘Change’ scores of both groups in the domains: Change in
Selfcare Scores (P ⫽ 0.03), Change in Bladder and Bowel
Scores (P ⫽ 0.05), Change in Mobility Scores (P ⫽ 0.01),
Change in Psychosocial Scores (P ⫽ 0.02) and Change in
Cognition Scores (P ⫽ 0.01). The exception was the Change
in Communication Score domain, where the difference was
not statistically significant.
Correlation analysis
In order to explore the relationship between domain scores
and patient variables, correlation analyses between domain
Table I. Mean ‘Change in domain’ scores by patient groups.
‘TAU’ ‘ANR’
mean (SD) mean (SD)
Change in Selfcare Scores 2.41 (3.63) 6.33 (8.01)
Change in Bladder and Bowel Scores 0.80 (2.19) 3.90 (7.53)
Change in Mobility Scores 2.98 (3.45) 13.02 (12.65)
Change in Communication Scores 4.18 (5.13) 5.67 (6.04)
Change in Psychosocial Scores 2.57 (4.02) 5.37 (7.27)
Change in Cognition Scores 2.65 (3.74) 7.82 (7.76)

scores and the variables Age and GCS on admission were
conducted for the two patient groups.
A small and significant positive correlation was noted
between Age and Change in Bladder and Bowel scores for
patients in the ‘Acute Neurorehabilitation’ group (r ⫽ 0.31,
P ⫽ 0.03). No other significant correlations were found.
Further correlation analyses between domain scores and
the variables Age and GCS on admission were conducted for
all the patient data as one group.
There was a small and significant positive correlation
between Age and Change in Bladder and Bowel scores when
both groups were analysed together (r ⫽ 0.2, P ⫽ 0.04). No
Br J Neurosurg Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/27/14
other significant correlations were found.
Correlation analyses were conducted between the vari-
ables themselves: Age and GCS on admission. No significant
correlations were found.
Length of stay scores
A one tailed t-test was used to compare mean length of stay
scores between groups (see Table II). The results showed a
statistically significant difference between groups (P ⫽ 0.02).
Discussion
The results show that functional improvements occurring
between admission and discharge were greater for those who
For personal use only.
received acute neurorehabilitation compared with those who
had treatment as usual. The difference was both statistically
and clinically significant in all functional domains with the
exception of the Communication domain. The researchers
ascribe these results to the ‘enriched environment’ created
by intensive acute rehabilitation from a multidisciplinary
team with dedicated facilities, and the beneficial physiologi-
cal changes induced within the central nervous system that
engender recovery of function through a combination of the
recovery mechanisms described earlier.
Mobility scores
This domain witnessed the largest proportional difference
between the groups’ ‘change scores’. The presence of a
physiotherapy gym is the most notable difference in mate-
rial resources between standard neurology and purpose-
built acute rehabilitation wards. Such a facility is capable of
accommodating mobile patients as well as those currently
confined their beds, allowing for work to begin immediately
even for those with severe impairments by using equipment
such as tilt tables.
The results indicate that early motor stimulation is essen-
tial for regaining function. Furthermore, the gains noted
across different domains may be partially attributable to such
physical input, since animal studies have noted improve-
ments in other domains following motor exercise shortly
after lesioning.28 It may be that improvements in areas such
Table II. Mean ‘Length of Stay’ scores by patient groups.
‘TAU’ ‘ANR’
mean (SD) mean (SD)
Length of stay (days) 112.7 (105.3). 77.9 (53.1)
Acute Neurorehabilitation versus Standard Treatment 27
as cognition may be, in part, due to enhanced plasticity and
neuroprotective factors engendered by motor stimulation.
Selfcare scores
In this domain the ‘Acute Neurorehabilitation’ group demon-
strated significantly superior outcomes over the ‘TAU’ group.
Again, the researchers posit that the presence of facilities
such as a dedicated therapy kitchen, fully equipped Occupa-
tional therapy room and a high level of both Occupational
therapy and physiotherapy staff providing daily sessions
around all aspects of individual’s health care is responsible
for this difference. The regular, focussed stimulation and
guided retraining in tasks of everyday living that range from
toileting and food preparation tasks to completing tasks off
the ward using the Multiple Errands assessment, was not
present for the control group from an early stage and appears
to have had a considerable impact on the ‘Acute Neuroreha-
bilitation’ Group.
Psychosocial scores
As before, the ‘Acute Neurorehabilitation’ group demon-
strated significantly superior outcomes over the ‘TAU’ group.
The presence on the acute ward of a patient’s lounge, well
stocked with games and used for regular group sessions
provides an excellent milieu to monitor and model social
behaviour and identify difficulties such as disinhibition. The
presence of a dedicated Neuropsychology team on the ward
allows for rapid assessment, formulation and intervention
for concerns ranging from challenging behaviour (which
can often disrupt the rehabilitation of the patient concerned
and those recovering nearby) to emotional consequences of
trauma like panic disorder, low mood and adjustment diffi-
culties. Management of these symptoms can prevent them
undermining compliance in therapy and prevent a serious
source of distress to the patient and their family.
Cognition scores
Here also, the ‘Acute Neurorehabilitation’ group demon-
strated significantly superior outcomes over the ‘TAU’ group
and again the result is attributed to the presence of a special-
ist Neuropsychology team working in tandem with occupa-
tional therapy and other disciplines to identify, manage and
intervene where necessary to begin cognitive rehabilitation
and implement approaches reliant on early intervention
to prevent the formation of unhelpful learned responses,
behaviours and coping strategies.
Bladder and bowel scores
As well as demonstrating improved outcomes for the ‘Acute
Neurorehabilitation’ group, the data also showed a signifi-
cant positive correlation between age and functional scores
in this domain. Whilst correlation cannot imply causation,
the researchers speculate that this result may be attribut-
able to the mechanism of injury. Those patients presenting
with traumatic brain injury were, on average younger than
those with subarachnoid or intracerebral bleeding. The like-
lihood of diffuse axonal rather than focal injury occurring is
greater in traumatic rather than haemorrhagic injury, and
the researchers suggest that the diffuse injuries seen in the
 28 J. N. Thompson et al.
younger patients may have an increased chance of damage
occurring in related structures such as the pontine micturi-
tion centre and periaqueductal grey, although it is not pos-
sible to draw any hard conclusions from the available data.
The superior performance of the ‘Acute Neurorehabilitation’
group may be attributable to the presence of a highly skilled
medical and nursing team who address bladder and bowel
functioning problems as soon as a patient is admitted to the
Acute Neurorehabilitation ward.
Communication scores
It is possible that the lack of a significant difference between
Br J Neurosurg Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/27/14
groups in the Communication domain was due to the fact
that there is not a full time speech therapist available on the
Acute Neurorehabilitation ward. As such the results did not
accurately reflect the impact of full time acute rehabilitation
as they did in other domains where specialist staff were avail-
able for full time input.
Length of stay scores
The ‘Acute Neurorehabilitation’ group demonstrated signifi-
cantly shorter mean length of stay than the ‘TAU’ group. This
finding appears to indicate that functional gains occurred
faster in the ‘Acute Neurorehabilitation’ group, necessitating
discharge sooner. This is congruent with earlier findings7,10
and highlights potential fiscal savings for care providers
For personal use only.
due to reduced inpatient duration. However, it should be
noted that this result may be due to a combination of factors.
Patients often remain as inpatients for periods greater than
their treatment requires them to, due to unavoidable delays
such as waiting for bed space in destination units, social care
packages or home modifications. Since such delays were not
accounted for in either sample, this result should be treated
with caution.
Conclusions
The results of this study validate the notion that early and
intense neurorehabilitation provided by a specialist multi-
disciplinary team within an appropriate environment can
lead to clinical improvements, across almost all functional
areas. This study indicates that the improvements gained
by Acute Neurorehabilitation are significantly greater than
those achieved with treatment as usual and potentially lead
to shorter admission periods.
Whilst there is currently no way to accurately determine
the extent to which functional improvements are due to
natural synaptic recovery rather than rehabilitation, the
researchers feel that the matched control trial design is suffi-
cient to conclude that the significantly greater improvements
in the acute rehabilitation group were attributable to clinical
intervention as opposed to natural recovery alone.
Future research would be greatly aided by long-term fol-
low up to determine if the difference in functional capability
is sustained years after discharge and the paradigm would
benefit from being extended to other patient groups such as
those suffering from demyelinating diseases. More data on
individual treatment programmes and comparative hours
of input between groups could provide a fuller picture and
increase variable controls. A design that could provide a valid
measure of the extent to which stimulation in one domain
(e.g. motor) impacts on gains in another (e.g. cognitive)
would provide hard data regarding the ‘cross-domain stimu-
lation’ hypothesis suggested previously. Accounting for non-
medical delays to discharge, would permit a more controlled
investigation into whether the shorter inpatient stays seen in
acute neurorehabilitation patients are actually due to faster
functional improvement.
Given the lack of research into the efficacy of acute neu-
rorehabilitation, there is a strong case for continued study
based upon these results and should further data prove
fruitful, a cost benefit analysis should also be undertaken
to inform implementation of a nationwide acute neurore-
habilitation guidelines. It is hoped that this information can
provide a model for further study and add to the existing
data which demonstrate clear clinical and fiscal imperatives
for acute multidisciplinary neurorehabilitation to be made
available for patients suffering from an acquired brain injury/
neurological insults.
Acknowledgements
The authors kindly acknowledge Dr Krystyna Walton, Con-
sultant in rehabilitation Medicine on ward C2 for bringing
the study data to our attention.
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content
and writing of this article.
References
1. Royal College of Surgeons of England. Report of the working party
on the management of patients with head injury. London: RCS,
1999.
2. Royal College of Physicians and British Society of Rehabilitation
Medicine. Rehabilitation following acquired brain injury. National
Clinical Guidelines. Turner-Stokes L, ed. London: BSRM, RCP, 2003.
3. Royal College of Physicians. Medical Rehabilitation for people
with physical and complex disabilities. London: RCP, 2000.
4. House of Commons. Health Committee third report. Head injury:
rehabilitation. London: The Stationary Office, 2001.
5. Bradley LJ, Kirker SGB, Corteen E, Seeley HM, Pickard JD,
Hutchinson PJ. Inappropriate acute neurosurgical bed occupancy
and short falls in rehabilitation: implications for the National
Service Framework. Br J Neurosurg 2006;20:36–9.
6. Pickard JD, Seeley HM, Kirker S, et al. Mapping rehabilitation
resources for head injury. J R Soc Med 2004;97:384–9.
7. Greenwood RJ, Strens LHA , Watkin J, Losseff N, Brown MM.
A study of acute rehabilitation after head injury. Br J Neurosurg
2004;18:462–6.
8. Greenwood R. Acute rehabilitation after severe head injury. Br J
Neurosurg 2004;18:573–5.
9. Seeley HM, Kirker S, Harkin C, et al. Head injury rehabilitation:
the role of the neurotrauma clinic. Br J Neurosurg 2009;23:530–7.
10. Sirois MJ, Lavoie A , Dionne CE. Impact of transfer delays to
rehabilitation of patients with severe trauma. Arch Phys Med
Rehabil 2004;85:184–91.
11. Cowen TD, Meythaler JM, DeVivo MJ, Ivie CS, Lebow J, Novack TA .
Influence of early variables in traumatic brain injury on functional
independence measure scores and rehabilitation length of stay
and charges. Arch Phys Med Rehabil 1995;76:797–803.
12. Mackay LE, Berstein BA , Chapman PE, Morgan AS, Milazzo LS.
Early intervention in severe head injury: long term benefits of a
formalized programme. Arch Phys Med Rehabil 1992;73:635–41.

13. Hu MH, Hsu SS, Yip PK , Jeng JS, Wang YH. Early and intensive
rehabilitation predicts good functional outcomes in patients
admitted to the stroke intensive care unit. Disabil Rehabil
2010;32:1251–9.
14. Irdesel J, Aydiner SB, Akgoz S. Rehabilitation outcome after
traumatic brain injury. Neurocirugia 2007;18:5–15.
15. Salter K, Jutai J, Hartley M, et al. Impact of early vs delayed
admission to rehabilitation on functional outcomes in persons
with stroke. J Rehabil Med 2006;38:113–17.
16. Paolucci S, Antonucci G, Grasso MG, et al. Early versus delayed
inpatient stroke rehabilitation: a matched comparison conducted
in Italy. Arch Phys Med Rehabil 2000;81:695–700.
17. Schwab ME. Repair of injured fibre tracts in the mammalian
central nervous system. Int Congr Ser 2007;1302:131–40.
18. Komitova M, Johansson BB, Eriksson PS. On neural plasticity,
new neurons and the postischemic milieu: an integrated view on
Br J Neurosurg Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/27/14
experimental rehabilitation. Exp Neurol 2006;199:42–55.
19. Butefisch CM, Kleiser R, Seitz RJ. Post lesional cerebral
reorganisation: evidence from functional neuroimaging and
transcranial magnetic stimulation. J Physiol Paris 2006;99:437–54.
20. Wittenberg GF. Experience, cortical remapping and recovery in
brain disease. Neurobiol Dis 2010;37:252–8.
21. Robertson IH, Murre JMJ. Rehabilitation of brain damage:
brain plasticity and principles of guided recovery. Psychol Bull
1999;125:544–75.
22. Brandtlow CE. Regeneration in the central nervous system. Exp
Gerontol 2003;38:79–86.
23. Case LC, Tessier-Lavigne M. Regeneration of the adult central
nervous system. Curr Biol 2005;15:749–53.
24. Sarajuuri JM, Kaipio M, Koskinen SK , Niemela MR, Servo AR,
Vilkki JS. Outcome of a comprehensive neurorehabilitation
For personal use only.
Acute Neurorehabilitation versus Standard Treatment 29
program for patients with traumatic brain injury. Arch Phys Med
Rehabil 2005;86:2296–302.
25. Moon L , Bunge MB. From animal models to humans: strategies for
promoting CNS axon regeneration and recovery of limb function
after spinal cord injury. J Neurol Phys Ther 2005;29:55–69.
26. Turner-Stokes L, Nair A , Sedki I, Disler PB, Wade DT. Multi-
disciplinary rehabilitation for acquired brain injury in adults
of working age. Coch Database Syst Rev 2005; Issue 3 Article
No: CD004170.
27. Rollnik JD, Janosch U. Current trends in the length of stay in
neurological early rehabilitation. Dtsch Arztebl Int 2010;107:286–92.
28. Lippert-Grüner M, Maegele M, Pokorny J. Early rehabilitation
model shows positive effects on neural degeneration and reco-
very from neuromotor deficits following traumatic brain injury.
Physiol Res 2007;56:359–68.
29. Bland ST, Pillai RN, Aronowski J, Grotta JC, Schallert T. Early
overuse and disuse of the affected forelimb after moderately
severe intraluminal suture occlusion of the middle cerebral artery
in rats. Behav Brain Res 2001;126:33–41.
30. Taricco M, Liberati A . Rehabilitation of traumatic brain injury.
Eura Medicophys 2006;42:69–71.
31. Donaghy S, Wass PJ. Interrater reliability of the functional
assessment measure in a brain injury rehabilitation program.
Arch Phys Med Rehabil 1998;79:1231–6.
32. Hawley CA , Taylor R, Hellawell DJ, Pentland B. Use of the
functional assessment measure (FIM ⫹ FAM) in head injury
rehabilitation: a psychometric analysis. J Neurol Neurosurg
Psychiat 1999;67:749–54.
33. Wilson FC, Wheatley-Smith L, Downes C. Analysis of intensive
outpatient neuro-rehabilitation outcomes using FIM ⫹ FAM(UK).
Neurorehabilitation 2009;24:377–82.