Rehabilitation after trauma research group

Leader: Nada Andelic

The Rehabilitation after Trauma Research Group stems from the Department of Physical Medicine and Rehabilitation at Oslo University Hospital (OUH). The goal of this research group is to generate knowledge of the mechanisms and consequences of trauma, trends and challenges in treatment and rehabilitation including the patient's healthcare needs focused on traumatic brain injury (TBI), multiple trauma and atraumatic subarachnoid hemorrhage (aSAH). The research conducted by this group is multidisciplinary, where collaboration between genetic and intensive care medicine, neurosurgery, neuroradiology, neuropsychology and rehabilitation has been established over the last 18 years.

The main aims of the research group for 2020-2025 are to:

Better understand the mechanisms, course and consequences of TBI, aSAH and multiple trauma by using translational research
Develop (and implement) cost-effective rehabilitation interventions to target TBI-related challenges in the short- and long-term
Improve collaboration and knowledge transfer between primary and secondary health care services to ensure seamless rehabilitation for trauma patients
Strengthen existing and initiate new national and international multicenter research collaborations

The specific aims of the research group are to generate research-based knowledge of:

The organization of patient care and rehabilitation trajectories, including patients’ needs and use of health care services after trauma
Effective rehabilitation interventions to target trauma-related challenges in the short- and long-term; both holistic and specific interventions
Cost-effectiveness of rehabilitation interventions
Build evidence-based efficient protocols for the implementation of new cost-effective rehabilitation interventions into existing guidelines and services
Collaboration between primary and secondary health care services
Long-term outcomes and recovery process after aSAH
The biomarkers of TBI and the severity of injuries including morphological changes in the brain

Selected main ongoing projects:

Managing symptoms and disability in the sub-acute phase after traumatic injury - A pragmatic randomised controlled trial of a self-management support program

Principal investigators: Nada Andelic, Mari S. Rasmussen and Solveig L. Hauger. PhD fellows: Joanna Nordhagen Selj and Vilde Marie Danielsen. Funded by the South-Eastern Norway Regional Health Authority.

This project includes a newly developed and innovative self-management support (SMS) program that aims to enhance patients` self-efficacy by building skills and self-management strategies to cope with injury-related consequences. The program will be delivered to patients in the sub-acute phase (within the first three to four months after injury), in the transitioning phase between structured hospital care and reestablishment of daily life. In the main study, we will compare the effectiveness of a SMS program (intervention group) to treatment as usual (control group) following moderate to severe traumatic injury in a randomised controlled trial. Main collaborators are from Oslo University Hospital (OUH), Sunnaas Rehabilitation Hospital (SRH), Oslo Municipality and the National Association for the Traumatically Injured (Personskadeforbundet LTN).

Sub-threshold training in patients with persistent post-concussion symptoms after mild TBI – a randomized controlled study

Principal investigator: Ingerid Kleffelgård. PhD fellow: Lars-Johan Valaas. Funded by the The Norwegian Fund for Post-graduate Training in Physiotherapy (Fond til etter- og videreutdanning av fysioterapeuter).

The main objective is to examine whether sub-threshold training, in addition to usual multi-professional rehabilitation at the hospital outpatient clinic, will lead to a normalization of exercise intolerance and reduced symptom burden in patients with persistent post-concussion symptoms after mild traumatic brain injury (TBI) when compared with a control group.

The study aims to determine the effectiveness of an individually tailored training program based on the Buffalo Concussion Treadmill Test (BCTT) for patients with mild TBI. The goal is to improve exercise intolerance and reduce post-concussion symptoms, as well as improve health- related quality of life.

Traumatic Brain Injury – Rehabilitation and user satisfaction

Principal investigator: Marit V. Forslund. PhD fellow Camilla Guren Hovset. Funded by Foundation Dam.

The main objective of this study is to increase the knowledge about rehabilitation services for patients with TBI and evaluate the quality of services in the southeast region of Norway. The project consists of three work packages (WPs) with a mixed methods design, and the primary outcome is user satisfaction with received services. WP1 (quantitative) will examine predictors of patient satisfaction with rehabilitation services in the primary and secondary healthcare system based on data from the quality registry “Oslo TBI Registry – Rehabilitation”. WP2 (qualitative) will obtain in-depth knowledge of organization and resources in the rehabilitation services, and the patients’ experience, participation in and satisfaction with services through focus group interviews. WP3 (qualitative) will similarly explore the physicians’ experiences with services and coordination collaboration, and their satisfaction with rehabilitation outcome for patients.

Exploring the role of personality traits in symptom-burden, return to work and health related quality of life one year after mild-to-moderate traumatic brain injury

Principal investigator: Emilie Isager Howe. PhD fellow: Benedikte Årebrot Madsen. Funded by Oslo University Hospital.

This project aims to assess the relationship between personality traits and persistent post-concussion symptoms, return to work and health-related quality of life in patients with mild-to-moderate TBI one year post-injury. This project draws on the randomised controlled trial (RCT) “The effect evaluation of combined cognitive and vocational interventions after mild-to-moderate traumatic brain injury” conducted between 2017 and 2021. Personality traits were measured with The NEO Five Factor Inventory-3, a questionnaire measuring the five-factor model of personality. Main collaborators are from Oslo University Hospital, Sunnaas Rehabilitation Hospital, the National Association for the Traumatically Injured (Personskadeforbundet LTN).

Traumatic brain injury in the chronic phase: Needs and treatment options - a randomized controlled community-based intervention

Principal investigator: Cecilie Røe. PhD fellow: Ida M. Borgen Henriksen. Postdoc fellows: Solveig Hauger, Marit V. Forslund and Ingerid Kleffelgaard.

This project is a randomized controlled trial that will explore a goal-oriented and patient-centered rehabilitation program for patients with chronic TBI. The project is based on current knowledge of common symptom profiles, as well as individually identified symptoms and functional limitations. The project was conducted in the patient’s home environment, and included the patient’s family and local health care providers if feasible. The study indicated that the patient-centered, goal-oriented intervention was feasible with goal attainment. Both the intervention and control group showed improvement in TBI-related quality of life whereas the decline in symptoms and improvement in general quality of life was highest in the intervention group. Project findings will have innovation potential in establishing new modes of collaboration and knowledge transition between specialized acute and post-acute neurosurgical and rehabilitation facilities, and rehabilitation services in the municipalities. Collaborators include OUH, SRH, the National Association for the Traumatically Injured (Personskadeforbundet LTN), Norwegian Research School for Research and development of municipal health and Care (MUNI-Health-Care), Norwegian University of Science and Technology Gjøvik and the University of North Norway. International collaborations are from Philadelphia Research and Education Foundation and Virginia Commonwealth University, Richmond, USA.

Rehabilitation needs, service provision and costs in the first year following traumatic injuries

Principal investigator: Nada Andelic. PhDs fellows: Håkon Moksnes (OUH) and Christoph Schafer (UNN). Postdoc fellow: Mari S. Rasmussen. Funded by the South-Eastern Norway Regional Health Authority.

This is an innovative, longitudinal, population-based research study in a representative national paediatric and adult trauma patient cohort, which describes the burden of injury at the individual and family level, in addition to societal impact including direct and indirect costs. The study focuses on the first year following trauma when patients might be expected to gain functional independence as a result of specialized and community-based rehabilitation efforts.

This study will use data from National Trauma Registry to estimate the prevalence of rehabilitation needs on the national level. Costs of rehabilitation interventions, healthcare, and social services and informal care will be estimated.

Main collaborators are from Oslo University Hospital (OUH), University Hospital of North Norway, National Trauma Registry and National Association for the Traumatically Injured (Personskadeforbundet LTN),

Trauma Rehabilitation: User Experiences and Unmet Needs

Postdoc fellow: Emilie I. Howe. Main supervisor: Nada Andelic. Funded by Foundation Dam.

This qualitative study will explore experiences with available rehabilitation services from the perspectives of the users who receive the services, their family members, and health-care professionals who provide rehabilitation services. The aim of adopting a multiple perspective approach is to generate a more comprehensive understanding of how rehabilitation needs and current practices are experienced. Moreover, to generate broad knowledge of unmet rehabilitation needs, different perspectives on why needs are not met, and how the gap between met and unmet rehabilitation needs can be narrowed.

Changes in physical, cognitive and emotional function 5 and 10 years after aneurysmal subarachnoid haemorrhage.

Principal investigators: Tonje Haug Nordenmark and Tanja Karic. Funded by the Department of Physical Medicine and Rehabilitation, OUH.

This study is a continuation of the study “Effect of early rehabilitation in patients with acute subarachnoid haemorrhage”. Patients treated for an aSAH at Oslo University Hospital in 2011-2012 were assessed in the acute phase, at 3 and 12 months post ictus as part of the original study, and were subsequently asked to participate in a 5- and 10-year follow-up. The main aim of the present study is to assess physical, cognitive and emotional function at 5 and 10 years after aSAH. The second aim is to describe quality of life and work-status from the acute stage after aSAH to the chronic phase. The project will try to develop a new questionnaire that specifically covers the problems involved in the post-aSAH syndrome. Selection of items will be based on the participants’ responses to the Rivermead Post-concussion Symptoms Questionnaire and the Mental Fatigue Scale.

Previous projects

Several large prospective cohort studies on adult populations with moderate-to-severe TBI residing in South-East Norway have been conducted in the last decade in collaboration with Sunnaas Rehabilitation Hospital (SRH) and Sørlandet Hospital, Kristiansand. Five PhD degrees have been completed. The studies have addressed the incidence and risk factors of TBI, and factors modulating the medical, emotional, neurocognitive and rehabilitation outcomes in a longitudinal perspective. As reestablishing optimal quality of life for persons with TBI is the ultimate goal of rehabilitation, the research has also focused on trajectories and predictors of health related quality of life. Because the TBI population is young and sustain disability that may have an impact across the entire life span, the studies have included long-term follow-up. Such designs have previously been lacking in international research.

A national multicenter study on rehabilitation after severe TBI, involving all four regional university hospitals in Norway has also been completed. The results have increased our understanding of the epidemiology, course of recovery and functional recovery, in addition to olfactory dysfunction in adults and elderly with severe TBI. Genetic susceptibility and relevant biomarkers were also investigated.

In order to assess the underlying structural brain damage of patients with mild TBI, a PhD project utilizing advanced radiological methods (functional and volumetric MRI) combined with genetic markers and clinical and neuropsychological evaluation has also been completed.

In collaboration, the Institute of Health and Society, Research Centre for Habilitation and Rehabilitation Models and Services (CHARM) and the Department of Health Management and Health Economics, University of Oslo, Oslo, Norway, and Virginia Commonwealth University, Richmond, USA, have developed a methodology for evaluating health economic TBI consequences and rehabilitation trajectories. The organization of services, their effectiveness and costs are also of major importance. Hence, the research group is a main consortium participant in CHARM, building a competency platform in rehabilitation services research.

Severe injuries have the greatest consequences for the individual, and their perspective on rehabilitation services and social factors that affect life after injury is important. The Norwegian Research Council (NRC) funded project "Transitions in rehabilitation: Biographical reconstruction, experiential knowledge and professional expertise", originating from Oslo Metropolitan University in collaboration with the Rehabilitation after trauma research group.

Several interventional PhD projects have also been conducted. These include early rehabilitation in a continuous chain of treatment after severe TBI; two PhD projects on vestibular rehabilitation after TBI; two PhD projects on the effect of early rehabilitation in patients with aSAH and a family-centered intervention, as well as two PhD projects on combined cognitive and vocational interventions after mild-to-moderate traumatic brain injury.

The research group has also participated in the large-scale EU study (2014-2021): CENTER-TBI (Collaborative European NeuroTrauma Effectiveness Research in TBI), https://www.center-tbi.eu/. The main aims of the project were to improve the characterization and classification of TBI and health care delivery and treatment of TBI through the identification of the most effective clinical interventions and the provision of high quality evidence in support of treatment recommendations and guidelines. Our research network was particularly involved in Work Package 14 “Transition of care”, exploring structural variations in timing of transitions and clinical interventions approaches across Europe, and the effect of this on patient outcomes.

In addition, the TBI research groups from OUH and SRH form a research network, the Oslo Traumatic Brain Injury Outcome and Rehabilitation Research Group (OBIOR).