Brain Injury Rehabilitation Service Research Articles

Developing an understanding of the Frontal Lobe Paradox through clinical group discussions

This discussion paper presents reflections from a group of clinical, forensic and neuropsychologists on their clinical caseloads in brain injury rehabilitation services at Cygnet Healthcare. These services specialise in working with people with coexisting mental health or behavioural difficulties where the work involves frequent staff discussions on interpreting an individual’s behaviour, considering its functions and whether it is part of an involuntary neuro-psychological disorder related to their brain injury, specifically the Frontal Lobe Paradox. Through consideration of six patients, the cognitive mechanisms that may relate to, or underlie apparent Frontal Lobe Paradox were highlighted. Several additional reasons were found to explain why people might show this paradox, including testing conditions, slowed processing, reduced attention, disinhibition, self-monitoring problems, and premorbid difficulties. The authors also discuss interventions, which could be used to support these individuals, with the aim of broadening clinical understanding and discussion surrounding the causes of, and treatment approaches for individuals presenting with potential Frontal Lobe Paradox.

The Measure of an Outcome: Comparing Norming and Stacking to Benchmark the Effectiveness of Brain Injury Rehabilitation Services.

Practitioners have a clinical, ethical, academic, and economic responsibility to dispassionately consider how effective their services are. Approaches to measure how "good" or "bad" healthcare is include clinical audit, satisfaction surveys, and routine outcome measurement. However, the process of comparing the clinical outcomes of a specific service against the 'best' services in the same specialism, also known as benchmarking, remains challenging, and it is unclear how it affects quality improvement. This paper piloted and compared two different approaches to benchmarking to assess clinical outcomes in neurorehabilitation. Norming involved comparing routine measures of clinical outcome with external validators. Stacking involved pooling and comparing internal data across several years. The analyses of routine clinical outcome data from 167 patients revealed significant differences in the patient characteristics of those admitted to the same service provider over time, but no differences in outcomes achieved when comparing with historical data or with external reference data. These findings illustrate the potential advantages and limitations of using stacking and norming to benchmark clinical outcomes, and how the results from each approach might be used to evaluate service effectiveness and inform quality improvement within the field of brain injury rehabilitation.

A service evaluation measuring the effectiveness of ABC training on staff confidence in reporting ABCs and their understanding of the framework rationale

The Antecedent-Behaviour-Consequence (ABC) model is commonly used to document and analyse challenging behaviours within brain injury rehabilitation services. Data from these recordings can be utilised to implement Positive Behavioural Support (PBS) plans and inform effective support strategies to manage challenging behaviour. Therefore, it is pivotal that staff within these settings are adequately trained in recognising and reporting challenging behaviours and feel confident in their ability to do so. Currently, there is no existing literature that evidences the effect of ABC framework training on staff confidence in recognising and reporting challenging behaviours. In this service improvement project, nineteen staff members from a neurorehabilitation service completed one training session focusing on challenging behaviours and the ABC framework. Participants completed an eight item Likert scale questionnaire pre-training (immediately before training), post-training (immediately after training) and at a four-week follow-up to assess their self-perceived confidence in their knowledge around the ABC model, the rationale behind this framework and their ability to effectively complete an ABC report. Descriptive statistics and a repeated measures ANOVA were conducted to examine whether training had an effect on self-reported confidence scores. Findings revealed a significant effect of training on staff confidence, Wilks Lambda = 0.35, F (1,18) = 1252.42, p = .000, with an effect size of np2 = .98, with an increase in confidence post-training. This effect was also maintained at follow-up indicating that staff confidence was retained after a 4-week period.

Psychosocial functioning mediates change in motor and cognitive function throughout neurorehabilitation for adults with acquired brain injury (ABI-RESTaRT)

ObjectivesThis study aimed to evaluate the mediational role of change in psychosocial abilities, adjustment and participation on change in motor and cognitive function from admission to discharge from a staged community-based brain injury rehabilitation (SCBIR) service in Western Australia, 2011–2020.MethodsA retrospective cohort study of n = 324 adults with ABI enrolled in SCBIR using routinely collected rehabilitation outcome measures data. Motor and cognitive function were assessed with the UK Functional Independence and Assessment Measure and psychosocial function with the Mayo-Portland Adaptability Inventory-4. Six multilevel mediation regression analyses were conducted to determine whether change in psychosocial function (abilities, adjustment and participation) mediated change in motor and cognitive function from admission to discharge.ResultsParticipants demonstrated clinically significant improvements in both motor (+ 11.8, p < 0.001) and cognitive (+ 9.5, p < 0.001) functioning from admission to discharge. Statistically significant improvements in psychosocial abilities (− 4.8, p < 0.001), adjustment (− 2.9, p = 0.001) and participation (− 2.5, p < 0.001) were also seen but were not clinically significant. Mediation analyses showed that participation accounted for 81% of improvements in motor function at discharge and 71% of cognitive function improvements. Adjustment accounted for 26% and 32% of change in motor and cognitive function, respectively. Abilities accounted for 60% of change in cognitive function but did not significantly influence change in motor function. Changes in psychosocial participation fully mediated change in motor function during neurorehabilitation.ConclusionsPsychosocial function, particularly participation, is an important driver of motor and cognitive recovery throughout neurorehabilitation. Functional rehabilitation programs should target psychosocial improvement as an important mechanism of change.

Inpatient trial of a tablet app for communicating brain injury rehabilitation goals

Purpose We examine the use of a custom iPad application, the Rehab Portal, to provide clients in an inpatient brain injury rehabilitation service with access to short videos where clinicians—or the clients themselves—discuss their current rehabilitation goals. Materials and Methods We developed an initial version of the Rehab Portal app based on our previous co-design with service users, their families, and clinicians. This was examined in a field trial with a series of six clients over the course of their stays in inpatient rehabilitation, collecting quantitative data on clinician and client engagement with the Rehab Portal, alongside a thematic analysis of qualitative interviews with clients and clinicians at the point of discharge. Results Engagement with the platform was high for two clients while it was limited with four more. In our thematic analysis we discuss how introduction of the Rehab Portal disrupted practice, changing how things are done, causing deviation from usual routines, adding burden, and threatening professional integrity. At the same time, where it worked well it led to a repositioning of goal planning away from being clinician directed and towards an ongoing, dynamic collaboration between clinicians, clients and their families. Finally, in some cases we identified a reverting to the status quo, with client demotivation having an unexpected impact on clinician behaviour leading to the process being abandoned. Conclusions The current findings do not provide wholesale support for this approach, yet we continue to feel that approaches that support clinician-client communication using asynchronous video may offer considerable future value and are worthy of further investigation. IMPLICATIONS FOR REHABILITATION The use of a novel technique to communicate rehabilitation goals via video disrupted practice, changed how things are done, caused deviation from usual routines, added burden, and threatened professional integrity for clinicians. Where it worked well it led to a repositioning of goal planning away from being clinician-directed and towards an ongoing, dynamic collaboration between clinicians, clients and their families. Approaches that support clinician-client communication using asynchronous video may offer considerable future value and are worthy of further investigation.

Neurobehavioral Symptom Inventory Item-Level Change Complements the Reliable Change Method.

To determine correspondence between the statistically derived 8-point reliable change index for the Neurobehavioral Symptom Inventory (NSI) against clinically significant item-level change in symptom severity from intake to discharge for mild traumatic brain injury (mTBI). Brain Injury Rehabilitation Service at Brooke Army Medical Center, Fort Sam Houston, San Antonio, Texas. In total, 655 active-duty service members with a diagnosis of mTBI who received treatment and completed self-report measures between 2007 and 2020. Observational retrospective analysis of outpatient clinical outcomes data. NSI total score change was used to divide patients into responder and nonresponders based on whether they met an 8-point decrease between intake and discharge. In addition, patients who had at least one NSI item that changed from a rating of 3 (severe) or 4 (very severe) at intake to a rating of 0 (none) or 1 (mild) at discharge were coded as an individual with significant item-level change. Forty-five percent of the sample had significant item-level change and were classified as responders according to the reliable change method. Eight percent of the sample had significant item-level change but did not meet the 8-point reliable change threshold. Fifteen percent of the sample did not experience significant item-level change but were classified as responders according to reliable change. Thirty-one percent did not meet either method's criterion for change. Classification agreement between the reliable change and item-level change methods was 76%, which was statistically significant ( = 181.32, P < .001). There is good correspondence between reliable change and item-level change on the NSI in this population. Reliable change is easily calculated and thus much more accessible than the item-level change method. There may be some situations where calculating item-level change may be helpful.

Use of a Driving Simulator in Medical Fitness to Drive Evaluations: Lessons Learned

<h3>Research Objectives</h3> Current gold standard for medical fitness to drive is on-road driving test conducted by a certified driving rehabilitation specialist (CDRS). Due to scarcity of CDRS, we evaluated whether driving simulator yields objective data that can inform decisions on medical fitness to drive. <h3>Design</h3> Prospective observational design. A single CDRS evaluated on-road driving and videos of simulated driving. The CDRS was "blinded" to participant status on videos of simulated driving. <h3>Setting</h3> Brain Injury Rehabilitation Service at Brooke Army Medical Center, Fort Sam Houston, San Antonio, TX. <h3>Participants</h3> 12 brain injury patients (5 with on-road driving test), 30 controls. <h3>Interventions</h3> None. <h3>Main Outcome Measures</h3> On-road driving safety. Safety based on simulated driving. Team decision based on sensory, cognitive, motor, and medical evaluations. <h3>Results</h3> The correspondence between safety from on-road driving and simulated driving was only 60%. It was more difficult to pass simulated driving than on-road driving. The correspondence between safety from on-road driving and team decision (based on sensory, cognitive, motor, medical evaluations) was only 60%. The correspondence between simulated driving and team decision (controls were presumed to be safe) was a dismal 40%. <h3>Conclusions</h3> Logistic and technical barriers precluded usefulness of objective simulator data. Nevertheless, important clinical lessons learned include: Simulated driving that includes opportunities to demonstrate handling of hazards appeared to be more difficult to pass than on-road driving tests. Controls enjoy a privilege of presumed driving safety while brain injury patients under medical scrutiny do not have this privilege. Each of three components considered (on-road driving; simulated driving; and team input of sensory, cognitive, motor and medical findings) contribute unique data that are valuable to determination of medical fitness to drive. <h3>Author(s) Disclosures</h3> Disclaimer: The views expressed in this abstract are those of the authors and do not necessarily represent the official policy or position of the Defense Health Agency, Department of Defense, or any other U.S. government agency. For more information, please contact dha.TBICOEinfo@mail.mil. UNCLASSIFIED.

Perceptions of People Living With Moderate to Severe Traumatic Brain Injury About Grocery Shopping Performance

<h3>Research Objectives</h3> To investigate the impact of brain injury (TBI) on grocery shopping performance from the viewpoint of those who have suffered a moderate or severe TBI. <h3>Design</h3> Exploratory and descriptive qualitative approach. <h3>Setting</h3> Specialised acquired brain injury rehabilitation service (inpatient and community rehabilitation services). <h3>Participants</h3> Maximum variation purposive sampling was used to recruit 14 adults with moderate to severe TBI. A total of 8 people were recruited from the inpatient rehabilitation ward, while 6 were community dwelling. All participants had participated in rehabilitation which addressed grocery shopping. <h3>Interventions</h3> Not applicable. <h3>Main Outcome Measures</h3> Semi-structured interviews ranging from 20-60 minutes were conducted. Data were analysed using a thematic approach, with deductive coding to the American Occupational Therapy Practice Framework. Demographic data (age, time post injury, living situation, severity of injury) were gathered from the medical record and the Functional Independence Measure (FIM™) was completed on all participants. Double coding of >10% of interviews was completed to increase rigor. <h3>Results</h3> Five key themes emerged from the data; getting to the shops, generation and use of a list, searching and locating items, selecting items, budgeting and paying for items. Brain injury related impairments (cognitive and visual) and external factors (social environment, physical environment, and restrictions on driving and financial management) were identified as being the most common factors which impacted on grocery shopping from the perspectives of those living with TBI. The physical layout and familiarity with the grocery store environment was seen to directly impact on the associated cognitive demands and grocery shopping performance. <h3>Conclusions</h3> People with TBI perceive grocery shopping as a highly contextualised multi-step activity which is impacted by cognitive and visual impairments. Clinical rehabilitation should include consideration of the multiple demands and environmental context of grocery shopping to inform targeted rehabilitation interventions for this population. <h3>Author(s) Disclosures</h3> None

Rehabilitation outcomes at discharge from staged community-based brain injury rehabilitation: A retrospective cohort study (ABI-RESTaRT), Western Australia, 2011-2020.

ObjectiveTo evaluate change in functional independence, psychosocial functioning, and goal attainment at discharge from a slow-stream Staged Community-Based Brain Injury Rehabilitation (SCBIR) service in Western Australia, 2011–2020.MethodsRetrospective cohort study of n = 323 adults with acquired brain injury (ABI) enrolled in a post-acute SCBIR service compared against a control cohort of n = 312 with ABI admitted to three non-rehabilitation programs. Outcome measures were the UK Functional Independence Measure and Functional Assessment Measure (FIM+FAM), Mayo Portland Adaptability Inventory-4 (MPAI-4), and Goal Attainment Scale. Change in FIM+FAM and MPAI-4 scores and predictors of goal attainment at discharge were evaluated using multilevel mixed-effects regression.ResultsMedian SCBIR length of stay was 20.5 months. Rehabilitation clients demonstrated clinically significant functional gains at discharge, adjusted mean change = +20.3, p < 0.001 (FIM+FAM). Peak gains of +32.3 were observed after 24–30 months and clinically significant gains were observed 5 years post-admission. Individuals discharged ≤6 months had the smallest functional gains (+12.7). Small psychosocial improvements were evidenced at discharge, mean reduction = −2.9T, p < 0.001 (MPAI-4) but not clinically significant. 47% of rehabilitation clients achieved their goals at the expected level or higher at discharge. Compared to the control, rehabilitation clients evidenced significantly greater functional gains and psychosocial improvement but lower goal attainment. Significant predictors of goal attainment at discharge were >2 years since injury, higher cognitive function and higher emotional adjustment at admission.ConclusionsFunctional recovery after ABI is a gradual and ongoing process. SCBIR is effective for functional rehabilitation post-injury but can be improved to achieve clinically meaningful psychosocial improvement.

Pathways through rehabilitation for traumatic brain injury: preliminary results from an Irish study

Abstract Background Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. In Ireland, little data exists on the number of TBI survivors or the availability of brain injury rehabilitation services. To address this, we examined nationally representative data to estimate the number of moderate to severe TBI survivors and to learn of their rehabilitation experiences. Methods A two-year mixed-methods, observational, cohort study was used to investigate the rehabilitation pathways of moderate to severe TBI survivors (N = 120). Participants were surveyed on two occasions six months apart using a range of standardised instruments (EQ-5D-3L, WHOQOL BREF and EBIQ). Preliminary findings from first surveys are reported. Results Fifty percent of participants reported having received some rehabilitation during their initial hospitalization. Following discharge, inpatient rehabilitation was recommended in 55.8% of cases (N = 67); 62.5% (N = 75) in an outpatient setting and 52.1% (N = 62) in a specialised brain injury community-based setting. Rehabilitation was not recommended in 9.2% (N = 11) of cases. Univariant analyses showed statistically significant differences between the experiences of males (N = 87) and females (N = 33) in three main elements; Isolation: males (M), mean 1.88, SD .488, females (F) mean 1.64, SD .476, (p = .015); Communication: M mean 1.85, SD .565, F mean 1.57, SD .469 (p = .012); Cognitive difficulties: M mean 1.81, SD .456, F mean 1.59, SD .426 (p = .020). Discussion Referrals to rehabilitation services varied substantially in this cohort of TBI survivors with evidence to suggest that, overall, males experience greater impacts on quality of life than do females. These findings support the need to, a) increase political priority and resource allocation for rehabilitation services for TBI survivors in Ireland and b) further study gender differences in TBI survivor outcome. Key messages Survivors of moderate to severe brain injury in Ireland have very divergent, and often inadequate experiences of rehabilitation. There is some evidence that male survivors of moderate to severe traumatic brain injury face more challenges than do female survivors.

Characteristics of Responders and Non-Responders in a Military Post-Concussion Rehabilitation Program

<h3>Research Objectives</h3> To characterize treatment responders and non-responders as measured by the Neurobehavioral Symptom Inventory (NSI). <h3>Design</h3> Observational retrospective analysis of extant clinical outcomes data. <h3>Setting</h3> Brain Injury Rehabilitation Service at Brooke Army Medical Center, Fort Sam Houston, San Antonio, TX. <h3>Participants</h3> Active duty military patients with a diagnosis of mild traumatic brain injury (mTBI) who received treatment between the years 2007 - 2020 and completed self-report measures as part of routine care. The final dataset included patients who completed NSI and World Health Organization Quality of Life Instrument-Abbreviated Version (WHOQOL-BREF) at both intake and discharge (n=717). The majority of patients were male (82.01%). Mean age was 34.41 years (SD=9.63). The most prevalent military rank was Senior Enlisted (53.56%). <h3>Interventions</h3> None. <h3>Main Outcome Measures</h3> NSI, WHOQOL-BREF, Post-Traumatic Stress Disorder Checklist for DSM-5 (PCL-5), Post-Traumatic Stress Disorder Checklist Military Version (PCL-M). <h3>Results</h3> Responders reported significantly more distress on the NSI at intake (M=41.81, SD=14.84) than non-responders, (M=33.75, SD=16.08), t(715)=6.92, p < .001, and this was found for all NSI subscales. Females (n=129) responded proportionally more (70.54%) than males (n=588, 55.61%) in comparison to their total gender group. Responders reported a greater functional impact from pain at intake, t(665.733)=-2.16, p < .05) as well as greater satisfaction with social support, t(715)=2.16, p < .05). <h3>Conclusions</h3> Self-reported symptom burden, pain, and social support at intake as well as gender impact response to rehabilitation interventions in this setting. Different programming may be more effective for targeting some populations. <h3>Author(s) Disclosures</h3> None.

Life altering effects on children when a family member has an acquired brain injury; a qualitative exploration of child and family perceptions

Objective To investigate the impact of familial acquired brain injury on children and adult family members, including their views of the support provided, gaps and recommendations for future interventions. Research design Qualitative exploratory study using a phenomenological approach. Method Twenty-six participants were recruited from 12 families across the South Australian Brain Injury Rehabilitation Service (SABIRS) and external community brain injury agencies in Adelaide, South Australia. Sixteen children aged 5–18 participated through ten semi-structured interviews. Ten adults attended six interviews. Following transcription and member checking, thematic analyses occurred with pooled data from all interviews undergoing open, axial and selective coding. Main results Analyses revealed four main themes: (1) help parents help their children, (2) improve family functioning by giving children meaningful roles, (3) staff: don’t leave children “in the dark,” and (4) support for children is not one size fits all. Conclusions Children and adults reported significant gaps in support offered by acute and brain injury services after familial acquired brain injury. Children and adults need to receive intervention in addition to the patient. To fill identified gaps, participants recommended more input by clinical staff including the use of technology; specifically, the development of age-appropriate applications, educational videos and interactive games. IMPLICATIONS FOR REHABILITATION Providing intervention directly to children and non-injured adults by clinical staff as early as the Intensive Care Unit and sub-acute rehabilitation after parental acquired brain injury is recommended to support their adjustment and improve family functioning. The development of age-appropriate and engaging tools via the use of technology is proposed to fill consumers identified gaps in brain injury support and education which could widen access and provide a flexible approach for support to be available anywhere, any time.

Long-term follow-up of use of therapy services for patients with moderate-to-severe traumatic brain injury.

To examine the probabilities and baseline predictors of the use of physical therapy, occupational therapy and speech therapy over a period of 10 years after traumatic brain injury. Longitudinal prospective follow-up at 1, 2, 5 and 10 years after traumatic brain injury. A total of 97 patients with moderate-to-severe traumatic brain injury recruited from Oslo University Hospital, Norway, during acute hospital admission in 2005-2007. Socio-demographics and injury characteristics were recorded at baseline. Use of physical therapy, occupational therapy and speech therapy were recorded at follow-ups. Hierarchical linear modelling was applied to examine service use probabilities across the 4 time-points. Service use decreased substantially over time, with physical therapy being the main service utilized at the 10-year follow-up (physical therapy 16%, occupational therapy 1%, speech therapy 3%). Use of services was related to severity of injury (CT head severity scores and post-traumatic amnesia), female sex, and pre-injury employment. In addition, in this sample, time since injury was associated with use of occupational therapy and speech therapy. This study presents a novel model for the long-term probability of use of physical therapy, occupational therapy and speech therapy following traumatic brain injury. The use of services was much lower than the expected problem profile of severe traumatic brain injuries, suggesting an insufficient long-term provision of traditional traumatic brain injury rehabilitation services.

Somatic symptoms are associated with Insomnia disorder but not Obstructive Sleep Apnoea or Hypersomnolence in traumatic brain injury.

Previous studies examining insomnia in populations with traumatic brain injury (TBI) have not distinguished between transient insomnia symptoms and insomnia disorder and associations have been confounded by other highly prevalent sleep disorders post-TBI. To investigate the associations between affective symptoms and somatoform symptoms in patients with TBI and insomnia, sleep apnoea and hypersomnolence. Twenty-four participants from a multidisciplinary brain injury rehabilitation service with TBI were assessed for insomnia disorder, using Diagnostic and Statistical Manual Fifth Edition (DSM-5) criteria. Associations with affective and somatic symptoms were assessed, using the DASS-21 and PHQ-15 respectively. The same cohort was divided for Obstructive Sleep Apnoea (OSA) and hypersomnolence and analysed for the same outcomes. Associations were assessed using Pearson's correlation and a logistic binary regression model was developed to predict insomnia in patients with brain injury. The insomnia disorder group (n = 11) had significantly higher rates somatoform symptoms (p < 0.05), compared to those without insomnia disorder (n = 13). These factors were not significantly associated with OSA or hypersomnolence. Pain was significantly associated with insomnia disorder. Insomnia disorder, not OSA or hypersomnolence, may be related to the presence of somatoform symptoms in people with TBI. Addressing insomnia disorder may potentially improve recovery.

“You felt like a prisoner in your own self, trapped”: the experiences of Aboriginal people with acquired communication disorders

Purpose Aboriginal Australians are under-represented in brain injury rehabilitation services despite a high incidence of both stroke and traumatic brain injury in this population. This study aimed to explore the experiences of Aboriginal Australian adults with acquired communication disorders (ACDs) after brain injury for the first time to inform the development of accessible and culturally secure service delivery models. Methods and materials Semi-structured interviews were undertaken with 32 Aboriginal people who had experienced a brain injury resulting in ACDs (aged 35–79 years) and 18 family members/carers across Western Australia. Thematic analysis identified common themes across participants. Results Overall themes related to communication (both related to the communication disorder and general healthcare interactions), health and social contexts, recovery, and support, being away from family and country, knowledge and beliefs about brain injury, and follow-up. Conclusions An increase in healthcare staff’s appreciation of the health and social contexts of Aboriginal people after brain injury is needed in order to improve communication with Aboriginal patients and the ability to offer accessible rehabilitation services. Ongoing support is required, with cultural identity noted as key to ensuring cultural security and ultimately recovery. Involvement of family and other Aboriginal people in recovery processes, as well as access to relevant Aboriginal languages and proximity to ancestral lands is central. Implications for rehabilitation Acknowledgment of cultural identity and strengths through involvement of extended family and Aboriginal Hospital Liaison Officers, access to language and proximity to country all central to rehabilitation planning for Aboriginal people after brain injury. Cultural security training for rehabilitation staff is recommended focusing on clear two-way communication skills to make medical information accessible for Aboriginal patients and to listen to patients’ concerns in a way that respects cultural context. Information regarding practical support and implications for ongoing management of life after brain injury (for the person and their family) is essential, and should supplement the medical-related information provided. Follow-up post discharge from hospital best facilitated through establishing contact with local Aboriginal community through Aboriginal community controlled health services, community elders, and Aboriginal health workers across organisations.

Single-Item Versus Multiple-Item Headache Ratings in Service Members Seeking Treatment for Brain Injury.

Headaches are the most common complaint after traumatic brain injury (TBI) and a significant cause of morbidity and disability among military personnel. Currently, there are a several measures which can assess headache disability, but there is a significant burden to assess each individual symptom given this heterogeneous polymorbid population. The objective of this proposed study was to validate the single headache item from the Neurobehavioral Symptom Inventory (NSI) compared to the 6-item Headache Impact Test (HIT-6). Participants included consecutive treatment-seeking outpatients at the Brain Injury Rehabilitation Service at the Brooke Army Medical Center from August 2007 to January 2010 who were administered a battery of assessment measures at initial intake, as part of usual care. Archival record review was conducted using procedures approved by the local Institutional Review Board. Inclusionary criteria included completion of both the HIT-6 and NSI. Participants with a cut-off score of >22 on the NSI Validity-10 were excluded in a post hoc analysis to validate findings among those who passed validity screen. The Pearson correlation between the single-item NSI headache measure and the HIT-6 revealed at least 64% shared variance in this military sample (r = 0.8, p < 0.001), indication a high association between the two measures. The NSI single-item headache measure adequately captured headache severity in this military cohort. Use of the single-item NSI headache measure may minimize survey burden on participants whose primary complaint is not headaches, or who present with multiple symptoms. Future studies are needed to validate the single-item headache measure in other samples.

Applying bifactor modelling to improve the clinical interpretive values of Functional Independence Measure in adults with acquired brain injury

Purpose: To apply a modern robust approach, bifactor modeling, to critically examine psychometric properties of Functional Independence Measure (FIM) in adults with acquired brain injury and to propose a solution to improve the clinical interpretive values of the FIM to inform policy and clinical practice.Methods: The data came from a state-wide specialist in-patient brain injury rehabilitation service in Queensland, Australia for adults with acquired brain injury and discharged between 2012 and 2017. The sample included 457 people. Three measurement models (unidimensional, correlated first-order and bifactor) for FIM were tested using confirmatory factor analysis with structural equation modeling. Then, model-based reliability and incremental validity were assessed.Results: The bifactor model best fit the data. When operationalized as latent factors under structural equation modeling framework, general care burden had a large predictive effect, while Motor and Cognitive showed medium and small predictive effects respectively on rehabilitation length of stay.Conclusions: The total score of FIM was a reliable measure of general care burden, while the subscale scores were not. A solution is to apply a bifactor modeling approach based on structural equation modeling to disentangle the unique variance attributable to Motor and Cognitive factors. In the structural equation modeling framework, the FIM demonstrated good incremental validity to inform policy and clinical practice.Implications for rehabilitationClinicians and researchers can confidently use FIM total score in adults with acquired brain injury.The current study proposed an alternative solution to the poor reliability of Motor and Cognitive scores, that is, by applying a bifactor modeling approach, the unique contributions of the Motor and Cognitive factors can be examined.The current study has demonstrated the strengths of bifactor modeling in the robust validation and interpretation of FIM to better inform clinical practice and policy decision-making.The current study has the potential to make an important contribution to enhance more equitable decision-making in the areas of national benchmarking of rehabilitation outcomes and other program eligibility criteria and funding allocation.

The relationship between agitation and impairments of orientation and memory during the PTA period after traumatic brain injury

ABSTRACTAgitation is common during the post-traumatic amnesia (PTA) period after traumatic brain injury (TBI), although our knowledge of what causes or predicts agitation is limited. The current study aimed to examine the association of agitation in PTA with the concurrent impairments in orientation and memory while controlling for covariates of agitation. Participants were 125 patients in PTA following moderate to extremely severe TBI recruited from an inpatient brain injury rehabilitation service who were assessed throughout PTA on the Agitated Behavior Scale (ABS) and the Westmead PTA Scale (WPTAS). Agitation was observed in 42.4% of participants (ABS score > 21), with disinhibited behaviours (e.g., distractibility and impulsivity) most common. Multilevel modelling found daily ABS scores to be associated with daily scores on the WPTAS but in a non-linear pattern. Analysis of covariates found that shorter time post-admission, younger age, presence of infection and higher antipsychotic doses were associated with higher ABS scores. These results support a relationship between agitation and the concurrent cognitive impairment during PTA. While a causal link cannot yet be inferred, management strategies that can potentially interfere with cognition (e.g., sedating medications, environmental changes) should be used cautiously in case they exacerbate agitation.

Association between cognitive impairments and obsessive-compulsive spectrum presentations following traumatic brain injury

ABSTRACTThis study examined the association between self-reported obsessive-compulsive spectrum symptomatology and cognitive performance in a sample of patients with traumatic brain injury (TBI). Twenty-four adults with a moderate-severe TBI accessing a community brain injury rehabilitation service were recruited. Age ranged between 19 and 69 years. Participants completed a battery of neuropsychological tasks assessing memory, executive functioning, and speed of information processing. Self-report questionnaires assessing obsessive-compulsive (OC) symptoms and obsessive-compulsive personality disorder (OCPD) traits were also completed. Correlational analyses revealed that deficits in cognitive flexibility were associated with greater self-reported OC symptomatology and severity. Greater OC symptom severity was significantly related to poorer performance on a visual memory task. Verbal memory and speed of information processing impairments were unrelated to OC symptoms. Performance on tasks of memory, executive functioning, and speed of information processing were not associated with OCPD traits. Overall, results indicate that greater OC symptomatology and severity were associated with specific neuropsychological functions (i.e., cognitive flexibility, visual memory). OCPD personality traits were unrelated to cognitive performance. Further research is needed to examine the potential causal relationship and longer-term interactions between cognitive sequelae and obsessive-compulsive spectrum presentations post-TBI.

Post-acute care referral and inpatient rehabilitation admission criteria for persons with brain injury across two Canadian provinces

Purpose: Investigate health care providers’ perceptions of referral and admission criteria to brain injury inpatient rehabilitation in two Canadian provinces.Methods: Health care providers (n = 345) from brain injury programs (13 acute care and 16 rehabilitation facilities) participated in a cross-sectional web-based survey. The participants rated the likelihood of patients (traumatic brain injury and cerebral hypoxia) to be referred/admitted to rehabilitation and the influence of 19 additional factors (e.g., tracheostomy). The participants reported the perceived usefulness of referral/admission policies and assessment tools used.Results: Ninety-one percent acute care and 98% rehabilitation participants reported the person with traumatic brain injury would likely or very likely be referred/admitted to rehabilitation compared to respectively 43% and 53% for the patient with hypoxia. Two additional factors significantly decreased the likelihood of referral/admission: older age and the combined presence of minimal learning ability, memory impairment and physical aggression. Some significant inter-provincial variations in the perceived referral/admission procedure were observed. Most participants reported policies were helpful. Similar assessment tools were used in acute care and rehabilitation.Conclusions: Health care providers appear to consider various factors when making decisions regarding referral and admission to rehabilitation. Variations in the perceived likelihood of referral/admission suggest a need for standardized referral/admission practices.Implications for RehabilitationVarious patient characteristics influence clinicians’ decisions when selecting appropriate candidates for inpatient rehabilitation.In this study, acute care clinicians were less likely to refer patients that their rehabilitation counter parts would likely have admitted and a patient with hypoxic brain injury was less likely to be referred or admitted in rehabilitation than a patient with a traumatic brain injury.Such discrepancies suggest that policy-makers, managers and clinicians should work together to develop and implement more standardized referral practices and more specific admission criteria in order to ensure equitable access to brain injury rehabilitation services.