Medical complications in patients with severe traumatic brain injury during inpatient rehabilitation: a retrospective study

Abstract

Background

Traumatic brain injury (TBI) necessitates comprehensive inpatient rehabilitation for optimal outcomes, addressing challenges across physical, cognitive, and psychosocial domains. This study fills gaps in Indian literature by exploring medical complications during rehabilitation and correlating them with functional outcomes. Emphasizing the preventable nature of complications, our research underscores the importance of early diagnosis and interventions, contributing valuable insights to enhance TBI patient care in inpatient rehabilitation settings.

Aim

To analyze medical complications during inpatient rehabilitation of patients with severe TBI during 2017-2019, exploring associations with patient demographics and injury characteristics.

Materials and methods

This study included 100 individuals over 18 years, admitted following severe TBI (Glasgow coma scale (GCS) 3-8) for rehabilitation to the Department of Physical Medicine and Rehabilitation from 1 August 2017 to 31 August 2019. A retrospective analysis of their medical records, employing a structured questionnaire, was conducted.

Results

Among 100 TBI patients, 81% were male, primarily aged 40-60 years (35%). The mean (SD) age was 35 (15.81) years, and the mean (SD) time since injury was 15.84 (26.13) months. Road traffic accidents accounted for 81% of injuries, with 39% admitted within 6 months. 87% of them had complications, predominantly neurobehavioral issues (35%) and heterotopic ossification (20%).

Conclusion

Medical complications were prevalent in 87% of patients admitted for rehabilitation, showing associations with age, duration since injury, and level of consciousness. This study emphasizes the importance of regular medical input for individuals with TBI admitted for inpatient rehabilitation and the need for regular follow-up.

Level of evidence

Level III, retrospective.

WHAT IS ALREADY KNOWN ON THIS TOPIC.

WHAT THIS STUDY ADDS

• This study demonstrates that 87% of patients with severe TBI undergoing inpatient rehabilitation in a South Indian tertiary care hospital experienced one or more medical complications.

• The most common complications were neurobehavioral issues (35%), heterotopic ossification (20%), and pneumonia (17%), with a higher burden seen in patients admitted within 3 months of injury and those with lower cognitive responsiveness (Ranchos Los Amigos stages 3–4).

• The findings highlight specific time windows and patient subgroups at higher risk, underscoring the need for early identification and targeted management of complications during the rehabilitation phase.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE, OR POLICY

• Encourages further studies in LMICs to explore preventable causes of post-TBI complications and develop context-specific rehabilitation protocols.

• Highlights the importance of proactive, multidisciplinary care during early rehabilitation to reduce complication rates and improve functional outcomes.

• Supports the integration of standardized screening and monitoring protocols for common complications in neurorehabilitation programs, particularly in resource-constrained settings.

Introduction

Traumatic brain injury (TBI) is a major global health concern that can result in long-term disability, including persistent physical, cognitive, and behavioral impairments that often require structured rehabilitation to optimize recovery.

Patients with severe TBI are particularly vulnerable to a wide range of medical complications during the recovery period. These complications may arise from the primary brain injury itself or from secondary systemic effects such as prolonged immobilization, neurological impairment, and invasive medical interventions.¹ However, the implementation of specialized rehabilitation programs has significantly improved outcomes and likely reduced the occurrence of these complications.²

Although several studies have examined complications in patients with TBI, most research has focused on the acute care phase. Data describing the spectrum of complications encountered during inpatient rehabilitation remains limited, particularly in developing countries.³,⁶

Even after transitioning from acute neurosurgical care, these patients continue to face ongoing medical and neurological issues that require timely intervention and effective management.⁷ Understanding the pattern of complications during rehabilitation may help clinicians identify high-risk patients and implement timely interventions. Therefore, this study aimed to analyze the medical complications observed among patients with severe TBI admitted for inpatient rehabilitation and to describe their clinical characteristics.

Methodology

This retrospective observational study was conducted in the Department of Physical Medicine and Rehabilitation in a tertiary care teaching hospital in South India.

Inclusion criteria included all patients with severe TBI (GCS 3–8) in the age group 18–80 years admitted for rehabilitation between 1 August 2017 and 31 August 2019. Patients with mild-moderate TBI, age less than 18 and more than 80 years at the time of assessment, brain injuries resulting from non-traumatic causes, such as stroke, brain tumors, infections, or neurodegenerative diseases, as well as those with the presence of a premorbid history of psychiatric disease or severe disability, were excluded. The electronic medical records of patients diagnosed with “traumatic brain injury” who were admitted to the Rehabilitation Institute at Christian Medical College, Vellore during this period were reviewed by the principal investigator.

Details on demographic data, clinical symptoms, hematological parameters, imaging findings, and outcomes were obtained from the hospital records. The occurrence of any new complication during the inpatient stay of rehabilitation was noted. Patient confidentiality was maintained using unique identifiers and password-protected data entry software with restricted users.

Data analysis and statistics

Descriptive statistics were employed for all the variables in the study. All categorical variables were expressed as frequencies and percentages. Continuous data were expressed as mean with SD. SPSS Statistics 21.0 software was used for all data analysis. A two-tailed p value <0.05 was considered significant for all comparisons.

Results

This study comprised a cohort of 100 patients with severe TBI, consisting of 81 males and 19 females. At the time of assessment, the mean (SD) age was 35 (15.81) years, and the mean (SD) time since injury was 15.84 (26.13) months. Table 1 provides an overview of patient characteristics.

Table 1. Characteristics of study population (n=100).

Characteristics	Frequency (%)
Age distribution (years)
Mean age±SD (years)	35.53±15.81
< 25 years	28 (28%)
25–40 years	30 (30%)
40–60 years	35 (35%)
> 60 years	7 (7%)
Gender
Male	81 (81%)
Female	19 (19%)
Education
Primary school	11 (11%)
High school	38 (38%)
Graduate	44 (44%)
Postgraduate	7 (7%)
Comorbidities
Absent	83 (83%)
Present	17 (17%)
Diabetes mellitus	10 (58.8%)
Hypertension	13 (76.4%)
Hypothyroidism	4 (23.5%)
Etiology of injury
RTA	81 (81%)
Pedestrians	8 (8%)
Fall	4 (4%)
Others (assault, bull gore injury, gunshot)	7 (7%)
GCS
Severe (3-8)	100 (100%)
Type of injury
Focal	73 (73%)
Diffuse	13 (13%)
Combined	14 (14%)
Initial management
Surgical	61 (61%)
Conservative	39 (39%)
Time since injury (months)
Mean±SD	15.84±26.13
1–3 months	33 (33%)
3–6 months	18 (18%)
6–12 months	15 (15%)
12–24 months	13 (13%)
> 24 months	21 (21%)
Duration of inpatient rehabilitation (weeks)
Mean±SD	8.39±5.01
4 weeks	28 (28%)
5–10 weeks	47 (47%)
11–15 weeks	19 (19%)
16–24 weeks	6 (6%)
RLA stages
Stage 2	17 (17%)
Stage 3–4	34 (34%)
Stage 5 or above	49 (49%)

RLA, Ranchos Los Amigos; RTA, Road traffic accident.

The patients were assessed using the Ranchos Los Amigos (RLA) scale, which evaluates cognitive and functional status after brain injury. At the time of admission for rehabilitation, 17% of participants were classified as being at RLA stage 2, 34% were at RLA stages 3 to 4, and 49% were at RLA stage 5 or higher.

During their inpatient stay, 87% of the patients experienced complications. Figure 1 presents the distribution of complications among patients. Most patients (87%) experienced at least one complication, while 13% had no documented complications.

Figure 1. Distribution of patients by number of complications.

The prevalence of medical complications among study participants is shown in table 2. The most common complications included neurobehavioral issues (35%), manifested as depression, anxiety, apathy, anger/aggression, irritability, impulsivity, adjustment disorders, sleep disturbances, emotional lability, mood swings, psychosis, and personality changes.

Table 2. Common complications.

Medical complications (n=87)	%
Neurobehavioral issues	35
HO	20
Pneumonia and other respiratory tract infections	17
Contractures	16
Electrolyte imbalances	14
Tracheostomy-related complications	12
Peristomal, infra- and suprastomal granulations	5
Tracheal obstruction due to mucous plug	2
Tracheo-cutaneous fistula	2
Tracheal stenosis	2
Hemorrhage	1
UTIs	11
Seizures	8
Focal	3
Generalized	5
Pressure ulcers	7
Hydrocephalus	5
PSH	4
Fractures	2
DVT	2
PTE	1
Others (pulmonary edema, cellulitis, sunken flap syndrome, phenytoin toxicity, shoulder subluxation, anal fissures)	25

.PTE, Pulmonary thromboembolismDVT, deep vein thrombosis; HO, heterotopic ossification; PSH, paroxysmal sympathetic hyperactivity; UTIs, urinary tract infection.

Other common complications included heterotopic ossification (HO) (20%), respiratory infections such as pneumonia (17%), contractures (16%), electrolyte imbalances (14%), tracheostomy-related complications (12%), and urinary tract infections (UTIs) (11%).

Seizures occurred in 8% of patients, Electroencephalogram (EEG) epileptiform activity in the frontal and temporal regions in three, and pressure ulcers in 7% of patients. Less common complications included hydrocephalus, paroxysmal sympathetic overactivity, fractures (femoral neck fracture and acetabular fracture), deep vein thrombosis (DVT), and pulmonary thromboembolism (PTE).

Pneumonia (p=0.01) was significantly associated with time since injury, being most common in the first 3 months (52.9%) and declining to 0% after 24 months, likely due to factors such as immobility, ventilator dependence, and impaired lung function.

Similarly, tracheostomy-related complications (p=0.01) were highly prevalent in the early recovery phase (75% within the first 3 months), reflecting the challenges associated with airway management, mechanical ventilation, and weaning processes in patients with severe TBI. Contractures (p=0.02), on the other hand, showed a significantly increasing trend over time, peaking at 6–12 months post-injury (37.5%), likely due to prolonged immobility and insufficient early rehabilitation efforts. These findings are summarized in table 3.

Table 3. Comparison between duration since injury and the occurrence of complications in patients with severe TBI.

Complications	Duration since injury (months)					p Value
	<3	3-6	6-12	12-24	>24
Neurobehavioral issues	15 (42.9%)	5 (14.3%)	6 (17.1%)	2 (5.7%)	7 (20%)	0.35
HO	4 (20%)	2 (10%)	5 (25%)	4 (20%)	5 (25%)	0.29
Pneumonia	9 (52.9%)	6 (35.3%)	1 (5.9%)	1 (5.9%)	0	0.01
Contractures	1 (6.3%)	4 (25%)	6 (37.5%)	2 (12.5%)	3 (18.8%)	0.02
Electrolyte imbalances	8 (57.1%)	3 (21.4%)	1 (7.1%)	1 (7.1%)	1 (7.1%)	0.23
Tracheostomy-related complications	9 (75%)	2 (16.7%)	0	1 (8.3%)	0	0.01
UTIs	7 (63.6%)	1 (9.1%)	1 (9.1%)	1 (9.1%)	1 (9.1%)	0.25
Seizures	4 (50%)	0	2 (25%)	0	2 (25%)	0.39
Pressure ulcers	3 (42.9%)	2 (28.6%)	1 (14.3%)	1 (14.3%)	0	0.68
Hydrocephalus	3 (60%)	1 (20%)	1 (20%)	0	0	0.54
PSH	3 (75%)	1 (25%)	0	0	0	0.35
Fractures	1 (50%)	0	0	0	1 (50%)	0.74
DVT	1 (50%)	0	1 (50%)	0	0	0.57
PTE	1 (100%)	0	0	0	0	0.72
Others	8 (32%)	5 (20%)	6 (24%)	2 (8%)	4 (16%)	0.90

.PTE, Pulmonary thromboembolismDVT, deep vein thrombosis; HO, heterotopic ossification; PSH, paroxysmal sympathetic hyperactivity; UTIs, urinary tract infection.

Discussion

This study highlights a high incidence of medical complications in patients with TBI during the early post-injury months, emphasizing the importance of comprehensive inpatient rehabilitation. Neurobehavioral issues such as agitation, mood disturbances, and cognitive dysfunction were indeed common during the recovery phase following severe TBI. In this study, they were categorized as complications because they required clinical attention and management during inpatient rehabilitation and had the potential to interfere with rehabilitation progress.

In our cohort, pneumonia (17%) and tracheostomy-related complications (12%) were also common, consistent with previous reports indicating higher complication rates during the early recovery phase after TBI.^{8 9}

Additionally, individuals admitted within 3 months of injury had a higher complication rate, suggesting a critical early period in which close monitoring and proactive management were essential to support recovery.

In contrast to earlier studies reporting aphasia, dysarthria, dysphagia, and sunken flap syndrome among common complications, these were not observed in our cohort. This difference may be related to the differences in patient characteristics, referral patterns, and the retrospective nature of the study.^{7 10} Emerging evidence also indicates that endocrine dysfunction after TBI may be under-recognized despite its potential impact on recovery and long-term outcomes.¹¹,¹³ Kimata et al showed that pneumonia, UTIs, and DVT significantly burden outcomes for individuals with isolated TBI and were associated with the highest impact on short-term outcomes in terms of population-attributable risk.¹⁴ Moreover, the presence of multiple complications during inpatient rehabilitation has been linked to worse clinical outcomes.^{15 16}

Our study highlights the critical role of early medical intervention in improving functional outcomes for patients with TBI. Timely, targeted care is essential in mitigating secondary injury and facilitating the initiation of effective rehabilitation strategies. By addressing acute medical needs promptly, clinicians can better support neurological recovery and lay a strong foundation for subsequent therapeutic interventions.

Conclusion

Severe TBI is frequently associated with a high risk of complication burden, affecting most patients (87%), particularly those in the early recovery phase. Neurobehavioral issues (35%), heterotopic ossification (20%), and pneumonia (17%) are among the most common challenges, emphasizing the need for proactive management. Early intervention within the first 6 months post-injury, combined with a coordinated multidisciplinary approach involving rehabilitation, medical management, and continuous monitoring, is essential for reducing complications, enhancing functional recovery, and improving long-term quality of life.

Data availability statement

Data are available upon reasonable request.