not permitted.

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© 2016 EDIZIONI MINERVA MEDICA European Journal of Physical and Rehabilitation Medicine 2017 February;53(1):91-7
Online version at http://www.minervamedica.it DOI: 10.23736/S1973-9087.16.04163-0

ORIGINAL ARTICLE

Postoperative rehabilitation for chronic subdural

hematoma in the elderly. An observational study focusing
on balance, ambulation and discharge destination
Ettore CARLISI 1 *, Lucia FELTRONI 1, Carmine TINELLI 2,
Mariarosaria VERLOTTA 3, Paolo GAETANI 3, Elena DALLA TOFFOLA 1

1Rehabilitation Unit, I.R.C.C.S. Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy; 2Department of Clinical Biometrics

and Epidemiology, I.R.C.C.S. Policlinico San Matteo Foundation, Pavia, Italy; 3Neurosurgery Unit, I.R.C.C.S. Policlinico San Matteo
Foundation, Pavia, Italy
*Corresponding author: Ettore Carlisi, MD, I.R.C.C.S. Policlinico San Matteo Foundation, Piazzale Golgi 19, 27100 Pavia, Italy. E-mail: e.carlisi@smatteo.pv.it

ABSTRACT
Background: Chronic subdural hematoma (CSDH) can have a negative impact on autonomy of the elderly. Ambulatory and functional
status may remain limited despite successful surgical evacuation.
Aim: To evaluate the outcome of a postoperative assisted rehabilitation program.
Design: Single-institution short-term observational study.
Setting: Inpatient (Neurosurgery Unit of a University Hospital).
Population: Thirty-five patients, aged 65 or older, who underwent burr-hole drainage for chronic subdural hematoma.
Methods: Postoperatively all participants underwent a rehabilitation program, described in details, aimed at recovering standing position and
gait as soon as possible. The program involved daily 30-minute individual sessions assisted by a physiotherapist, until discharge from hospital.
The Markwalder’s Grading Scale was used to assess the neurological status preoperatively and at discharge. The Trunk Control Test, the Stand-
ing Balance by Bohannon Scale and the Modified Rankin Scale were used to evaluate balance and general function (primary outcome) in the
immediate postoperative and at discharge. We also recorded the rate of pre-CSDH walking patients who maintained ambulation at discharge and
the discharge destination (secondary outcome).
Results: Total scores of Markwalder’s Grading Scale, Trunk Control Test, Standing Balance by Bohannon Scale and Modified Rankin Scale
improved (P<0.05), indicating a global favorable outcome, especially for balance. Excluding the patients who were dependent pre-CSDH, the
others maintained gait function in 74.2% of cases. Only 45.7% of the patients were discharged home, the others being divided between inpatient
medical settings and rehabilitation.
ConclusionS: The rehabilitation program was well tolerated by the patients. Our study showed a clear improvement in trunk control and
standing balance and an overall favorable outcome for neurological and ambulatory status at discharge. Despite an assisted postoperative re-
habilitation program, the residual impairment in general function was the main factor that prevents us to discharge more elderly patients home
rather than to assisted settings.
Clinical Rehabilitation impact: The results of this descriptive study suggest that an assisted rehabilitation program may be helpful in
improving short-term postoperative balance and ambulatory status (more than functional status), but further studies, with a randomized control-
led design, are certainly justified to understand the efficacy of rehabilitation in this context.
(Cite this article as: Carlisi E, Feltroni L, Tinelli C, Verlotta M, Gaetani P, Dalla Toffola E. Postoperative rehabilitation for chronic subdural hema-
toma in the elderly. An observational study focusing on balance, ambulation and discharge destination. Eur J Phys Rehabil Med 2017;53:91-7. DOI:
10.23736/S1973-9087.16.04163-0)
Key words: Hematoma, subdural, chronic - Neurological rehabilitation - Aged.
or other proprietary information of the Publisher.

C hronic subdural hematoma is a disease occurring

mainly in the elderly. Data from literature show that
both incidence (7.4/100.000 per year in people over 70
years old) 1 and mortality increase with age at presen-
tation.2, 3 Head injury is considered the most common
cause, while anticoagulation therapies and propensity

Vol. 53 - No. 1 European Journal of Physical and Rehabilitation Medicine 91

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CARLISI POSTOPERATIVE REHABILITATION FOR CSDH
to falls may increase the risk of onset.4 Chronic sub-
dural hematoma may present clinically as an alteration
of the level of consciousness, headache, seizure or it
can mimic neurological conditions such as dementia or
stroke.5 When surgical evacuation is needed, the post-
operative mortality rates range from 0% to 10%.6 An
improvement in survival and neurological outcomes has
been observed in recent decades as a result of improved
knowledge in diagnostic and surgical techniques.7 Be-
cause of the progressive increase of the aged popula-
tion, it seems that postoperative care specific to elderly
patients will play a more important role also in chronic
subdural hematoma surgery. Nevertheless, only a small
number of studies have investigated postoperative func-
tional outcomes 8-12 and even fewer have investigated
the role of rehabilitation, with those there are mainly
focusing on prevention of postoperative complications
and hematoma recurrence.13-16 Patients who underwent
surgical evacuation were traditionally nursed in supine
position in order to favor brain re-expansion. Effective-
ly, early mobilization after surgery seems to reduce the
number of postoperative complication, without increas-
ing the risk of recurrence, particularly among elderly
patients, whose low physical compensatory reserve is at
greatest risk of being affected by postoperative physical
stress.13 A recent study has indicated that postoperative
improvement in neurological status frequently did not
translate into functional improvement, especially in the
elderly.11
The aim of this observational study was to evaluate
the outcome (balance, ambulation and functional status)
of an assisted rehabilitation program in a population of
elderly patients surgically treated for chronic subdural
hematoma (CSDH). As secondary outcome, we estimat-
ed the rate of pre-CSDH walking patients who main-
tained ambulation at discharge.
Materials and methods
Population and study design
In a single-institution short-term observational study,
conducted from February 2011 to November 2013, data
were collected on 35 consecutive elderly patients with
or other proprietary information of the Publisher.
CSDH undergoing hematoma evacuation surgery. Pa-
tients signed their consent in accordance with the in-
dications of the bioethics committee of the I.R.C.C.S.
Policlinico San Matteo Foundation of Pavia. All the
92 European Journal of Physical and Rehabilitation Medicine February 2017
procedures complied with the standards established by
the Declaration of Helsinki.
Inclusion criteria were age 65 or older and a diagno-
sis, confirmed by computed tomography scan, of CSDH
(with hematoma maximum size major than 1.5 cm asso-
ciated to midline shift) in presence of focal neurological
symptoms, as defined by the Markwalder’s Neurological
Grading Scale.17 We recorded outcome measures (see be-
low) in three consecutive stages: at the time of hospital-
ization (T0), postoperatively at the beginning of the Reha-
bilitation Program (T1) and at the discharge from hospital
(T2). At T0, general information was collected on basic
demographics, anticoagulant drug usage and pre-opera-
tive comorbidities (the age-adjusted Charlson Comorbid-
ity Index-CCI 18, 19 was calculated for each patient).
Procedures
Burr-hole subdural drainage was performed under
local anesthesia. The drainage system was removed af-
ter 24-48 hours upon verification of brain re-expansion
by computed tomography scan. After drain removal, as
soon as they were considered clinically stable by the sur-
geon, patients were evaluated by a physiatrist and start
a Rehabilitation Program (RP), carried out in the same
inpatient setting as the neurosurgical treatment. The RP
had two objectives: maintenance of muscle strength
in all four limbs and recovery as soon as possible of
standing position and gait. The program involved daily
30-minute individual sessions assisted by a physiothera-
pist, until discharge from hospital. The program usually
started with active isotonic exercises for the four limbs
with the patient lying supine and with exercises aimed at
improving trunk control in a bedside sitting position. As
soon as general and neurological conditions allowed, the
program turned to recovery of the standing position and
gait, by means of balance and pre-gait exercises (includ-
ing sit-to-stand, bilateral hip abduction, tiptoe stance
and marching on the spot). Initially, gait training was
usually aided with canes or a walker, but only transition-
ally. Progressively, the patients were asked to perform
longer distances and to correct gait pattern if necessary.
Outcome
In Figure 1, we reported a visual summary of the
study, including procedures and outcome measures in
relation with the stages of evaluation.
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means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use i
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POSTOPERATIVE REHABILITATION FOR CSDH CARLISI
Figure 1.—Procedures, outcome measures and stages of evaluation.
We assessed the neurological performance of the pa-
tients, pre-operatively (T0) and at discharge (T2), with
the Markwalder’s Neurological Grading Scale (MGS).19
The MGS is the most commonly used clinical grading
system for CSDH and evaluates the neurological status
on a scale of 0-4, the higher score indicating a worse
performance. We recorded the start date of the RP (ex-
pressed as number of days after surgery), the length of
treatment (expressed as number of sessions of physio-
therapy until discharge).
As primary outcome, we recorded the total scores
of three evaluation scales, measured at the first phys-
iotherapy session (T1) and at discharge (T2): the Trunk
Control Test (TCT),20-22 the Bohannon’s Standing Bal-
ance Scale (SBBS) 23, 24 and the Modified Rankin Scale
(MRS).25, 26 These scales are commonly used in post-
stroke care.22 The TCT evaluates sitting position on a
scale of 0-100, higher scores indicating efficient trunk
control and autonomy in supine-to-sitting position. The
SBBS evaluates the standing position on a scale of 0-4,
the highest score indicating the ability to maintain the
standing position, feet together, for more than 30 sec-
onds and the MRS estimates general function on a scale
of 0-5, the highest score indicating a completely depen-
dent, bed-bound patient.
or other proprietary information of the Publisher.
As secondary outcome, we calculated the rate of pre-
CSDH walking patients who maintained ambulation at
discharge. At T0, we gathered information about pre-
CSDH walking performance in order to compare it to
Vol. 53 - No. 1 European Journal of Physical and Rehabilitation Medicine 93
ambulatory status at discharge (T2). For the aims of the
present study, ambulatory status was classified accord-
ing to three categories: independent (patient walking
without aids or assistance); aided (patients who were
ambulant with walking aids and/or assistance), and de-
pendent (bed-bound or wheelchair-bound patients). We
were particularly interested in determining the rate of
pre-CSDH walking patients who maintained ambula-
tion at discharge. Destination at discharge from the hos-
pital was categorized into one of three groups: home;
inpatient medical setting (including neurology setting)
and inpatient rehabilitation setting.
Statistical analysis
Power considerations: with a total sample of 35 pa-
tients the study achieves 82% of power to detect an effect
size of 0.5 (e.g.: mean of performance score of paired
differences of 10.0 with an estimated standard deviation
of differences of 20.0). The power was calculated using
a two-sided paired t-test with a significance level (al-
pha) of 0.05. The Shapiro-Wilk Test was used to test the
normality of distribution of the quantitative variables;
the results were expressed as mean values and SD as
they were all normally distributed; qualitative variables
were summarized as counts and percentages. The paired
t-test was used to analyze pre-post therapy differences.
A P<0.05 was considered statistically significant and all
tests were two-sided. Data analysis was performed with
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CARLISI POSTOPERATIVE REHABILITATION FOR CSDH
Table I.—General characteristics of the population.
Sample (N.)
Age, years (SD)
Sex, male (%)
Charlson Comorbity Index (SD)
Anticoagulant drugs, N. (%)
History of trauma, N. (%)
Distance from trauma, days (SD)
N.: number of patients; %: percentage; SD: standard deviation.
the STATA statistical package (release 11,1,2010, Stata
Corporation, College Station, Texas, USA).
Results
Descriptive data
General characteristics of the population are de-
scribed in Table I.
A high preoperative comorbidity burden and a high
rate of anticoagulant drug usage were recorded for this
geriatric population. Forty-one CSDH surgical evacua-
tion procedures (19 left, 10 right, 6 bilateral) were per-
formed on 35 patients (62.9% men), within 24 hours
from hospitalization (0.8 days, SD: 1.3). The length of
stay in hospital was 10.3 (SD: 6) days. Patients were
able to start the rehabilitation program 4.7 (SD: 2) days
after surgery. The number of physiotherapy sessions be-
fore discharge was 3.7 (SD: 3).
or other proprietary information of the Publisher.
Figure 2.—MRS, TCT, SBBS total scores post-surgery (T1) and at dis-
charge (T2).
94 European Journal of Physical and Rehabilitation Medicine February 2017
©
The rehabilitative program was generally well toler-
35 ated by the patients. Nine patients were not able to per-
81.3 (6.3) form the balance-gait training because they were unable
22 (62.9) to stand up (3 cases) or because they were prematurely
5.7 (1.6)
22 (62.9)
discharged (6 cases). Recurrence, with second surgi-
22 (62.9) cal intervention being required, occurred in 3 patients
37.1 (27.4) (8.6%): one died postoperatively; another was trans-
ferred to an intensive care unit, and the third had a re-
currence after discharge (23 days after surgery).
Outcome
The MGS showed a statistically significant improve-
ment (P<0.05) in neurological status, passing from an
average value of 2.4 (SD: 0.7) preoperatively (T0) to a
value of 1.7 (SD: 0.7) at discharge (T2).
In Figure 2, we report the TCT, SBBS and MRS
scores in T1 and T2: all the total scores improved sig-
nificantly (P<0.05), showing a global favorable out-
come, especially for balance. With respect to scores at
T1, trunk control (TCT) and standing balance (SBBS)
had improved by 30% and 71% respectively, whereas
general function (MRS) had improved by only 9% at
the time of discharge from the neurosurgery unit.
Data on ambulatory status are reported in Figure 3.
Despite a mean age of 81 years, 31 patients (88.6%)
were able to walk before CSDH, 14 (40%) with aids or
assistance. At discharge, 24 patients (67.7%) were able
Figure 3.—Ambulatory status pre-csdh and at discharge (T2).
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POSTOPERATIVE REHABILITATION FOR CSDH CARLISI
to walk, 15 (61.8%) aided or assisted and 11 patients
(32.3%) were wheelchair or bed-bound. These data,
indicating persistent need for assistance during gait at
discharge, are in line with the MRS score.
If we exclude the patients who were dependent pre-
CSDH (4-11.4%), the remaining maintained gait func-
tion in 74.2% of cases (23 patients), but only 15 pa-
tients (44.1%) of our sample recovered their pre-CSDH
ambulatory status, with the other 55.9% (20 patients)
presenting a worse ambulatory status.
Despite moderately good gait recovery, only 16 pa-
tients (45.7%) returned home at discharge from hos-
pital, the remaining 17 patients (48.6%) being divided
between inpatient medical settings (7 patients-20%) and
rehabilitation (10 patients-28.6%).
Discussion
The published studies on postoperative outcome in
CSDH have focused mainly on mortality, morbidity and
recurrence rates.7, 13-16, 27 Some data are now available
about functional outcome in the elderly.8-12 Data on re-
habilitation are extremely scarce and restricted to the
role of early mobilization in reducing the rate of post-
operative complications.13, 14 Given the vulnerability of
the elderly to even short term bed-rest, we agree that
early postoperative exercise is crucial to prevent com-
plications, but more evidence about its effectiveness in
improving specific measures of autonomy like balance,
gait and functional status is also needed. We therefore
carried out a preliminary study to evaluate the outcome
of a rehabilitative intervention aimed at recovering
balance, gait and function after surgical treatment for
CSDH.
In line with previous medical literature,13, 28, 29 in our
geriatric population we found preoperatively high rates
of comorbidity, of anticoagulant drug usage and of un-
steady gait and low rates of hematoma recurrence (and
mortality) post-surgery. In our experience, at the time
of drainage removal, patients are usually able to reach
bedside sitting position alone or with some help, but fre-
quently they are not yet able to maintain the standing po-
sition without support (or with feet together), as shown
or other proprietary information of the Publisher.
by the TCT and SBBS values in T1. Consequently, they
are usually afraid of walking and are more vulnerable
to falls: this postoperatively “acquired” disability rep-
resents the rationale of our rehabilitative intervention.
Vol. 53 - No. 1 European Journal of Physical and Rehabilitation Medicine 95
In a recent report on a geriatric population, Mulli-
gan observed a significant improvement in neurologi-
cal but not in functional status one month after acute/
chronic subdural hematoma surgical evacuation.11 Our
study on a sample of elderly patients evaluated after
CSDH burr-hole drainage came to similar conclusions.
At discharge from hospital, we observed an average
MRS score of 4 in 70.6% of our patients, reflecting
a persistent need for physical assistance, despite a
marked improvement in neurological status (the MGS
average score indicating an absent or mild neurological
deficit), in trunk control (TCT) and in standing balance
(SBBS). Taking into account that the MRS expresses
only marked variations in functional and ambulatory
performance, to better assess the improvement in gait
function we calculated the rate of pre-CSDH walk-
ing patients who maintained ambulation at discharge
(74.2%). This result better shows a favorable function-
al outcome, at least for gait. Nevertheless, only 44% of
our sample recovered their pre-CSDH ambulatory sta-
tus at discharge, with the other 56% presenting a worse
ambulatory status. In a retrospective study,8 Borger
reported a similar overall favorable outcome (72% in
a sample of 322 elderly patients undergoing surgical
CSDH evacuation), a result comparable to those re-
ported in previous studies.27 However he reported bet-
ter results for the MRS (MRS 3-6 in 49% of 53 cases
aged 75-84 years).8 The reason for this difference is
not clear, and perhaps it is due to different lengths of
postoperative hospital stay.
Multiple factors usually affect the choice of discharge
destination after surgical CSDH evacuation, the most
important being neurological and general clinical con-
ditions, general function and the caregivers’ readiness
to receive their relatives back home. A recent retrospec-
tive study by Dumont on 301 elderly patients affected
by CSDH (only 55% of whom were undergoing surgical
drainage) yielded interesting data on discharge, show-
ing that only 55% of surviving patients were discharged
home or to self-care, the others being sent to nursing
home or rehabilitation.2 Our overall results are in line
with these, with 45.7% of our entire sample of patients
being discharged home and the remaining 48.6% being
divided between inpatient medical settings and rehabili-
tation. Despite an assisted postoperative rehabilitation
program, the residual impairment in general function
(more than in ambulatory status) was the main factor
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, log
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use i
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
©
COPYRIGHT 2017 EDIZIONI MINERVA MEDICA
CARLISI POSTOPERATIVE REHABILITATION FOR CSDH
that prevents us to discharge more elderly patients home
rather than to assisted settings.
Limitations of the study
The present study has several limitations, in particu-
lar the lack of a control group (not performing rehabili-
tation), which prevents us to demonstrate the efficacy
of the intervention. Moreover, additional limitations are
the lack of a longer follow-up, which prevents evalua-
tion of the medium and long-term impact of our rehabil-
itation program, and a small sample from a single cen-
ter. We also have to specify that the Trunk Control Test
and the Standing Balance by Bohannon Scale, among
measurement tools of balance for neurological condi-
tions, showed a poor profile for what regard psychomet-
ric properties.30 On the other hand, none of the previ-
ously cited studies has taken into account the potential
of rehabilitation to improve the functional outcome of
burr-hole drainage. We believe that our rehabilitative
program, performed mainly in the first postoperative
week, could play a precious role in functional recovery,
especially in the elderly. It also has the important advan-
tage of being easy to perform during the hospital stay,
without any additional time burden for the patients. We
think it would be worthwhile to evaluate in the mid-term
(3-6 months) the outcome of our rehabilitative program
in the patients discharged home and in those discharged
to assisted settings. Further studies, with a randomized
controlled design, are certainly justified to understand
the efficacy of rehabilitation in this context.
Conclusions
Ambulatory and functional status may remain limited
despite successful CSDH surgical evacuation, especial-
ly in elderly patients. The results of the current study
suggest that an assisted rehabilitation program may be
helpful in improving short-term postoperative balance
and ambulatory status (more than functional status).
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Conflicts of interest.—The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.
Acknowledgements.—The Authors thank Claire Archibald for linguistic revision.
Article first published online: May 4, 2016. - Manuscript accepted: May 3, 2016. - Manuscript revised: April 15, 2016. - Manuscript received: December 4,
2015.
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Vol. 53 - No. 1 European Journal of Physical and Rehabilitation Medicine 97