Follow-up intensive neurorehabilitation in patients with acquired severe brain injury – treatment results and experiences from the first phase of the pilot project (PP NINR)

Summary

The aim of the projeck is to integrate early neurorehabilitation into the healthcare system for patients with acquired severe brain injury in the Czech Republic.Objectives. Methods: The intensive neurorehabilitation (NINR) pilot project implements phase B1 of the neurorehabilitation phase model, which is defined as the early rehabilitation phase. During this phase, intensive care must be provided if necessary, including the possibility of artificial pulmonary ventilation. Patients indicated for admission to the NINR facility are conditiontransferred from intensive or acute neurosurgical care units, such as traumatic brain injury, inflammatory brain dis ease, brain tumor, cerebral stroke or impaired cerebrospinal fluid production, flow and resorption. Admission is possible within one month of the onset of the condition, according to admission criteria. The maximum duration of care provided to one patient at NINR facility is 12 weeks. If necessary, the length of stay at an NINR facility can be prolonged due to a deferred prognosis; in such cases, an ‚indication seminar` is held with representatives of the health insurance company in attendance, where justification for such a proposal is assessed and further actions are recommended. A stay at the NINR facility will end if there has been no improvement for an uninterrupted period of up to six weeks, or if a Barthel Index value of 30 has been achieved at any time during the stay. Under the NINR program, patients receive up to 12 weeks of 3 to 4 h of intensive therapy per day. Results: The project is currently operating at three locations in the Czech Republic. As of the end of June 2025, early neurorehabilitation as part of the project had been completed in 122 patients, who were admitted on average 18 days after the onset of acute illness. The average hospitalization time at NINR facility was 45.8 days. Upon admission, 53.6% of patients were on mechanical ventilation, compared to 9.7% at discharge. Of those admitted with tracheostomy (79.5%), 29.5% remained upon discharge. A Barthel Index score of 30 or more was achieved by 75 (61.5%) patients at discharge. 38% were able to progress to the next phase of rehabilitation, 30% were transferred to fol lowor longintensive care units, and 11% were released to home care. Conclusion: The project results demonstrate the feasibility of successfully implementing this approach into the healthcare system in the Czech Republic. Following the completion of the project, we hope to extend this care to other facilities.

Keywords:

neurosurgery – early neurorehabilitation – CNS damage – functional therapy

This is an unauthorised machine translation into English made using the DeepL Translate Pro translator. The editors do not guarantee that the content of the article corresponds fully to the original language version.

Introduction

The number of patients with severe CNS damage is rising [1], due both to demographic factors and to significant advances in emergency and acute medical care. Patients with severe and previously fatal brain damage often survive, frequently with severe functional sequelae. For ethical and health policy reasons, it is essential that these patients achieve the best possible quality of life and self-sufficiency, enabling them to find their place in society again. Early neurorehabilitation should accompany the patient from the acute phase of the disease [2]. The goal is to promote spontaneous recovery, prevent complications, and make intensive use of the brain’s capacity for regeneration, reorganization, and plasticity. Pharmacological interventions aimed at promoting neuroplasticity have not yet demonstrated any demonstrable benefits compared to standard care and require further investigation. In contrast, we are increasingly encountering evidence of the effectiveness (good evidence) of innovative rehabilitation therapies and technologies (such as the use of virtual reality, robotics, or neuromodulation), which are gaining a foothold in individualized rehabilitation programs with the aim of positively influencing the outcome of neurorehabilitation by supporting neuroplasticity [3,4].

Caring for patients with acquired brain injury is both time-consuming and costly. Although the number of patients with severe acquired brain injury is increasing every year in the Czech Republic, there is still no continuity of specialized rehabilitation care that meets the needs of patients at each stage of the rehabilitation process. There is also a lack of a concept for early neurorehabilitation. To date, patients in the acute phase of their illness receive highly qualified and very costly care; however, they subsequently do not receive the necessary follow-up intensive neurorehabilitation, which significantly limits their chances of successful reintegration into society. Patients are often transferred from one department to another (“rehabilitation tourism”), or are placed in long-term care facilities or home care, even though they retain rehabilitation potential for improving functional abilities, which has a significant impact not only on their quality of life but also an economic impact on society as a whole.

A good example for organizing the rehabilitation process is the so-called “Phase Model of Rehabilitation,” which has been practiced in the Federal Republic of Germany for many years. The Phased Model has helped optimize the structure of rehabilitation facilities and ensured transparency in the rehabilitation process. The criteria for determining which phase a patient should be admitted to are clearly defined, and placement in each phase is based on the Barthel Index (BI). The duration and intensity of therapy are also specified, which in turn determines the daily cost. The main benefit of this model is that it allows for the early initiation of rehabilitation, in many cases already during the acute phase of the illness, and ensures the continuity and quality of the rehabilitation process within the rehabilitation continuum.

The phased model of neurorehabilitation (Fig. 1) distinguishes between:

A) The acute phase of the disease.

B) Early rehabilitation phase, during which intensive care must be provided if necessary, including the option of mechanical ventilation. (Provided by specialized facilities; see below for the division into Phases B1 and B2. Phase B1: these facilities do not exist in the Czech Republic; Phase B2: Cranial Program, Spinal Program.)

C) The rehabilitation phase in which the patient is already capable of active cooperation during therapy. (These are specialized rehabilitation facilities, e.g., the Cranial Program, the Spinal Program.)

D) The phase of rehabilitation following the achievement of partial mobility and self-sufficiency. (Provided by existing rehabilitation facilities; care is organized. This also includes outpatient rehabilitation and neurorehabilitation facilities, as well as telerehabilitation and home care.)

E) Rehabilitation phase following the completion of intensive medical rehabilitation and vocational rehabilitation. (This is no longer addressed by the Czech Neurosurgical Society, as it involves competencies other than medical ones; it pertains to social and vocational rehabilitation.)

F) The phase of rehabilitation in which long-term supportive care and procedures to maintain the patient’s condition are necessary. (It takes place in long-term intensive nursing care facilities [DIOP]; after the patient’s condition has stabilized, it may also take place in the home environment with the support of a home care program.)

 

Rehabilitation therapy should be initiated early and tailored to individual needs. An interdisciplinary, patient-centered team and well-informed family members should be involved in every phase. The therapeutic program focuses primarily on existing deficits, taking into account the patient’s current physical capacity. To date, the so-called cranioprograms (e.g., at the Hrabyně Rehabilitation Institute and the Kladruby Rehabilitation Institute) are best suited to meet the needs of comprehensive specialized neurorehabilitation in the Czech Republic, where these patients receive rehabilitation care of adequate intensity. Here, patients can be admitted in phases B2, C, and D. However, specialized beds for the preceding phase B1 are currently lacking. Patients are therefore initially managed in neurological or neurosurgical departments, followed by departments of post-acute intensive care [NIP], DIOP, or in long-term care facilities, where they are entitled only to the standard time allocation for rehabilitation care.

The goal of the Acute Neurorehabilitation Section of the Czech Neurosurgical Society was therefore to initiate the establishment of follow-up intensive neurorehabilitation units, which subsequently, in collaboration with the Czech Neurorehabilitation Society [5] and the General Health Insurance Company (VZP), led to the launch of the pilot project “Follow-up Intensive Neurorehabilitation for Patients with Acquired Severe Brain Injury” (PP NINR). In January 2024, beds for follow-up intensive neurorehabilitation (NINR) were opened at the Královské Vinohrady University Hospital in Prague, at the Surgal Clinic in Brno, and at the Central Military Hospital in Prague. The aim of the project is to validate the proposed concept of early follow-up intensive neurorehabilitation for patients with acquired brain injury. Within the NINR program, Phase B1 of the phased model (Fig. 1) is being implemented, defined as the early neurorehabilitation phase, during which intensive care must be provided if necessary, including the option of mechanical ventilation. The NINR unit could be established either at an acute inpatient care provider specializing in neurosurgery that also has an NIP unit, or at an NIP provider where a neurosurgical unit is available within a 30-minute travel distance.

 

Methodology

VZP insured individuals with acquired brain injury may be admitted to the NINR pilot project provided they meet the admission criteria. Generally, patients are eligible if they have (taking into account their biological age and other comorbidities) a reasonable chance of improvement and survival with a quality of life that would be acceptable to them. Admission is indicated for patients with severe neurological deficits who also meet the criteria for the need for intensive care, the necessity of suctioning during invasive airway management, or the need for mechanical ventilation. Furthermore, the candidate must demonstrate stability of vital signs while lying down, show no signs of sepsis, and have stabilized intracranial pressure.

 

Indications for admission

1) Conditions following transfer from beds in the intensive or acute neurosurgical care unit (neurosurgical intensive care unit or the Department of Anesthesiology, Resuscitation, and Intensive Care Medicine):

following traumatic brain injury (no later than 1 month after the injury or surgery);

    following inflammatory brain disease (no later than 1 month from the start of hospitalization in an acute care bed);

    for brain tumors (no later than 1 month after neurosurgical surgery);

    following a stroke (primarily hemorrhagic, but also ischemic, within 1 month);

    disorders of cerebrospinal fluid production, flow, and resorption.

 

2) Indications based on current medical condition (at least one of the following):

neurological deficit or quantitative or qualitative impairment of consciousness requiring intensive care;

the need for suctioning during invasive airway management (usually tracheostomy);

mechanical ventilation.

3) Additional criteria for admission to the NINR unit, in particular:

the patient has completed primary acute therapy in an acute or intensive neurosurgery bed;

the patient currently  does not require any surgical interventions;  

the patient shows no signs of sepsis;  

the patient shows no signs of active osteomyelitis;  

the patient has stable intracranial pressure;  

the patient’s cardiopulmonary functions  are at least stabilized while lying down;  

The patient lacks the ability to actively cooperate;  

The patient is fully dependent on comprehensive and intensive nursing care;  

In most cases, the patient is dependent on nutrition via at least a nasogastric tube;  

In most cases, the patient is incontinent.

 

In the neurosurgery inpatient unit, the patient’s “early index” (VI, see Table 1) is assessed prior to potential inclusion in the NINR program; an adult patient may be indicated for NINR if their VI value ranges from –325 to –100 and they are simultaneously categorized as Category 3 (requiring increased supervision), category 4 (immobile), or category 5 (unconscious) according to the definitions provided for each category of in-hospital care (3 to 5) in Chapter 6 of the current List of Medical Procedures with Point Values (SZV).

A candidate meeting the admission criteria may be enrolled in the NINR project for a maximum of 12 weeks. During their stay, patients are assessed on a weekly basis using the Timely Index (VI) and BI [6].

 

Termination of the NINR stay:

if, during an uninterrupted NINR stay of up to 6 weeks, there is no improvement in the patient’s category of institutional care according to Chapter 6 of the SZV;

upon reaching a BI value of 30 at any time during the stay;

upon the expiration of 12 weeks, unless an extension was decided upon based on an “indication seminar”;

the occurrence of any of the above-mentioned contraindications, unless the patient is expected to return to the NINR.

 

The project is based on the collaboration of an interdisciplinary team consisting of a neurosurgeon, an intensivist, a rehabilitation physician, a physical therapist, an occupational therapist, a clinical speech-language pathologist, a neuropsychologist, and nursing staff, who set common functional and measurable goals at weekly meetings (team conferences) based on selected priorities and ongoing evaluation of relevant tests. The required daily volume of early intensive neurorehabilitation therapy is a minimum of 3 hours and consists of physical therapy, occupational therapy, speech therapy, and rehabilitative nursing. Medical rounds are also conducted several times a day. Therapies focused on functional recovery utilize evidence-based rehabilitation procedures, robotics, and neuromodulation. When possible and appropriate, we strive to involve the family in the patient’s care.

Main therapeutic areas at NINR:

weaning;

passive, assisted, or active movement in functional movement patterns;

verticalization, mobilization;

stimulation—vibration, movement simulation, multisensory stimulation;

dysphagia therapy;

basic training in activities of daily living and cognitive functions.

 

The project began on January 1, 2024, and will run until June 30, 2026, with providers submitting a final evaluation by April 30, 2026 (the evaluation will cover the period from January 1, 2024, to December 31, 2025). The last patient will be admitted to the PP NINR on March 31, 2026 (i.e., 12 weeks before the end of the pilot project).

 

Results

Since the project’s inception, that is, through June 30, 2025, a total of 122 patients (75 men and 47 women) with an average age of 50.1 years (median 52 years) have been treated through the NINR project at all three sites. Of these, 62 had traumatic brain injury, 34 had hemorrhagic stroke, 8 had ischemic stroke, 10 had subarachnoid hemorrhage, 2 had a neurological infection, and 6 patients belonged to other diagnostic groups. Patients were admitted with an average VI score of –246 points (median –275 points) and an average BI score of 3 points (median 0 points), on average 18 days (median 17 days) after the onset of the acute illness (Fig. 2). They spent an average of 45.7 days (median 42 days) in the NINR project and were discharged with an average VI score of –92 points (median –50 points) and a BI score of 35.1 points (median 40 points). At discharge, 75 (61.5%) patients achieved a BI score of 30 or higher.

Upon admission to the project, 59 (53.6%) patients were on mechanical ventilation; upon discharge, 11 (9.7%) were. The improvement rate observed here was 81.4%. Upon admission, 76.5% of patients had a tracheostomy tube; upon discharge, 29.5% did. Dysphagia is also a very common and serious functional disorder; we observed it in 84.6% of patients upon admission and in 40.8% upon discharge. Oral feeding was possible in 67.4% of patients upon discharge.

Discussion and Conclusion

The results of the NINR project have been very positive so far, even when compared to the international literature, such as the multicenter study by Pohl et al. [7], which was published in 2016 and included 754 patients from 16 early neurorehabilitation centers (Phase B). 50.8% of patients, with an average age of 68 years, were transferred from the intensive care unit, including 297 women (39.4%) and 457 men (60.6%). Unlike the NINR project, patients with a BI score of up to 30 points were included, so this cohort had a lower degree of functional impairment than our patients. The average length of treatment was 56 days, which is about 10 days longer than our results; patients were admitted on average 31 days after the onset of acute injury, which is later compared to the NINR cohort, in which patients were admitted on average after 18 days. The spectrum of diagnoses also differed significantly from the NINR project; more than half of the patients (52.1%) were treated following a stroke. The second most common diagnosis, at 17.1%, was polyneuropathy (CIP) or myopathy (CIM) in critical illness—a diagnosis not yet accounted for in the NINR project—which may also explain why this study achieved an average BI improvement of 17 points, compared to the NINR cohort, where an average BI improvement of 32.2 points was achieved. Similarly, the lower average age of patients in the NINR project must be taken into account. Better outcomes in the NINR cohort can also be observed in the area of mechanical ventilation. In Pohl’s multicenter study, only 26% of patients were on mechanical ventilation at admission (compared to 53% of NINR patients). The success rate of weaning from ventilation was 65% here; in the NINR cohort, we recorded an 81.4% success rate for weaning from mechanical ventilation.

The pilot project runs until June 30, 2026, and we firmly believe that it will then be expanded to other facilities, thereby filling one of the gaps in care for patients with acquired brain injury. This will lead to more frequent and earlier returns of patients to normal life with a better quality of life and the possibility of further active economic participation in society. Despite the higher costs of providing intensive neurorehabilitation care, we anticipate that healthcare expenditures for this patient group will be optimized [8].

Another positive outcome is that 38% of NINR patients could be transferred to subsequent phases of rehabilitation, which is comparable to the data published by Pohl et al. [9], where the figure was 37.8%. Although this comparability appears satisfactory at first glance, the continuity of rehabilitation in the Czech Republic remains a serious problem, as it has not been systematically resolved (Fig. 3). A patient who has reached the 30-point BI threshold within NINR remains dependent on another person’s care for some activities of daily living and still requires intensive rehabilitation. Both the level of nursing care and the need for intensive and comprehensive rehabilitation therapy are incomparably higher than, for example, in patients with chronic back pain or those who have undergone total joint replacement. Here we see the need to further adjust the structure of the rehabilitation process according to a phased model, which would help ensure the continuity of neurorehabilitation.

In summary, it can be stated that advances in acute and intensive care, in particular, along with the increasingly early transfer of patients from acute care beds, are changing the patient profile and prognosis in neurorehabilitation and increasing the severity of functional limitations [7,10–12]. The fact that early neurorehabilitation works is demonstrated in an international context by studies from neurorehabilitation centers, where nearly 40% of patients treated there could be discharged to the next rehabilitation phase C [7,13]. Current developments in the field of early neurological and neurosurgical rehabilitation are likely to continue in the coming years. The rehabilitation team must be able to continually improve care for patients with complex disease courses [13]. The growing number of patients on mechanical ventilation and with tracheostomy tubes already represents a significant patient group for neurorehabilitation today. However, only a limited number of established therapeutic approaches can be used for this group of patients [13], and thus rehabilitation therapy will remain at the forefront, particularly weaning from mechanical ventilation and tracheostomy tubes. Although the number of professional guidelines for early neurorehabilitation following acquired brain injury remains limited, we find an increasing number of evidence-based studies in the literature [14–16]. Prognostic findings are also important for the future development of early neurorehabilitation; these findings point to a link between longer intervals between discharge from the intensive care unit and admission to rehabilitation and adverse outcomes that cannot be attributed solely to the severity of the initial injury [17]. Patients also have more favorable outcomes when rehabilitation is seamlessly integrated into a continuous process that begins as early as the intensive care unit [18].

The NINR pilot project was designed precisely on the basis of these findings. In our view, the positive results achieved are based on the integration of rehabilitation procedures into intensive care, the possibility of timely transfer to rehabilitation phase B1, and continuity of care in the sense of a phased rehabilitation model.

 

Ethical Aspects

This is a VZP pilot project commencing on January 1, 2024. The last patient may be admitted on March 31, 2026.

 

Conflict of interest

The authors declare that they have no conflict of interest regarding the subject of the study.

 

Table 1. Early Index.

 

Early Index (VI)

___________

• Condition requiring intensive medical supervision/care (e.g., vegetative crisis): patients require intensive care.  

Yes                  –50 points

No                   0 points

• Tracheostomy requiring suctioning

Yes                  –50 points

No                   0 points

• Need for mechanical ventilation    

Yes                  –50 points

No                   0 points

• Supervision required due to dysphagia

Yes                  –50 points

No                   0 points

•    Supervision required due to behavioral disorder (risk of self-harm or harm to others)

Yes                  –50 points

No                   0 points

• Supervision required due to disorientation   

Yes                  –50 points

No                   0 points

• Severe communication impairment    

Yes                  –25 points

No                   0 points

 ___________

(min. –325, max. 0 points)