Inpatient Brain Injury Rehabilitation Research Articles

Caring for Our Caregivers: a feasibility study of caregiver preparedness training within inpatient brain injury rehabilitation

Background/aims Evidence-based inpatient caregiver training may ensure that caregiver needs are met and hospital readmission costs reduced. The aim of this study was to evaluate the feasibility of implementing a caregiver education model, Caring for Our Caregivers, within an inpatient brain injury programme. Methods A total of 32 adults were admitted to inpatient neurorehabilitation during the 7-week feasibility trial. The three-step Caring for Our Caregivers programme included evidence-based recommendations following a caregiver needs assessment, goal setting and hands-on training. Satisfaction levels and caregiver preparedness were assessed via a survey. Results The caregiver needs assessment and goal collaboration was completed within 5 days 66% of the time. Results indicated an even distribution of hands-on (47%) and discussion-based (53%) education. Caregivers and staff identified high levels of satisfaction with the programme. Conclusions Early engagement, collaborative goals and hands-on training of the family caregiver of a client with acquired brain injury during inpatient rehabilitation demonstrated initial feasibility with positive implications for caregiver satisfaction and community discharge.

COVID-19 issues related to pediatric neuropsychology and inpatient rehabilitation – challenges to usual care and solutions during the pandemic

Objective: To describe the challenges related to COVID-19 affecting pediatric neuropsychologists practicing in inpatient brain injury rehabilitation settings, and offer solutions focused on face-to-face care and telehealth.Methods: A group of pediatric neuropsychologists from 12 pediatric rehabilitation units in North America and 2 in South America have met regularly since COVID-19 stay-at-home orders were initiated in many parts of the world. This group discussed challenges to clinical care and collaboratively problem-solvedsolutions.Results: Three primary challenges to usual care were identified, these include difficulty providing 1) neurobehavioral and cognitive assessments; 2) psychoeducation for caregivers and rapport building; and 3) return to academic instruction and home. Solutions during the pandemic for the first two areas focus on the varying service provision models that include 1) face-to-face care with personal protective equipment (PPE) and social distancing and 2) provision of care via remote methods, with a focus on telehealth. During the pandemic,neuropsychologists generally combine components of both the face-to-face and remote care models. Solutions to the final challenge focus on issues specific to returning to academic instruction and home after an inpatient stay.Conclusions: By considering components of in-person and telehealth models of patient care during the pandemic, neuropsychologists successfully serve patients within the rehabilitation setting, as well as the patient’s family who may be limited in their ability to be physically present due to childcare, illness, work-related demands, or hospital restrictions.

An examination of the nature and characteristics of patients readmitted to acute care from inpatient brain injury rehabilitation.

To describe the nature of readmission to acute care and identify patient characteristics associated with avoidable readmission to acute care from inpatient brain injury rehabilitation. A retrospective cohort design. Data prospectively documented between 1 January 2012 -31 December 2018 in local clinical and administrative database were used. Patient medical records were accessed when missing data were identified. Descriptive statistics were used to describe the nature of readmission episodes and univariate and multivariable logistic regression were used to identify patient characteristics associated with readmission to acute care. Of the 383 patients admitted for rehabilitation, 83 (22%) experienced readmission to acute care for a total of 171 episodes. Thirty-seven percent of readmission episodes were due to hospital acquired complications and therefore potentially avoidable. Infection accounted for 63% of hospital acquired complications. Patients with an avoidable readmission episode (N=38) were more likely to have a significantly lower Functional Independence Measure score, be incontinent, have a tracheostomy, require a mobility aid, and be prescribed a dysphagia diet on rehabilitation admission. Patients with a tracheostomy on rehabilitation admission had a 56% probability for an avoidable readmission to acute care. Brain injury rehabilitation patients with an avoidable readmission to acute care were more likely to have a higher burden of care on rehabilitation admission and infection was the leading cause of avoidable readmission episodes. Research into readmission to acute care in the mixed brain injury inpatient rehabilitation population is limited. In this patient population, readmission to acute care is a contemporary issue that can occur at any time during a patient's rehabilitation admission. This study provides valuable information informing practice change for preventing avoidable readmission episodes. Locally developed policy aimed at preventing readmission episodes should include proactive prevention, early recognition of complications and discrete escalation care pathways.

1124 Central Sleep Apnea and Traumatic Brain Injury: A NIDILRR and VA TBI Model System Study

Abstract Introduction Sleep-related breathing disorders are common after TBI. To date, two single site studies have reported divergent findings in post-TBI patients with one reporting predominantly obstructive sleep apnea (OSA, Holcomb et al., 2016) and the other central sleep apnea (CSA, Webster and Bell, 1998). The purpose of this analysis is to explore prevalence, demographics, and injury characteristics of patients with a clinical diagnosis of CSA in a recently-completed multicenter comparative-effectiveness trial during inpatient rehabilitation following moderate to severe TBI. Methods Participants in a six-center diagnostic comparative effectiveness trial underwent Level-1 polysomnography (PSG) during inpatient rehabilitation for TBI. Studies were scored at a centralized scoring center by one of two certified PSG technicians with final interpretation by a board-certified sleep medicine physician. Results 21 of 248 (8.5%) participants evidenced elevated CSA indices >5. Predominant CSA was rare (n=3 [1.2%], age range: 36-59; 100% male; 33-52 days post-TBI). One participant was on opioid, anti-depressant and antiepileptic drugs, one was on an antiepileptic, and another was on an opioid. PAP therapy was not initiated during PSG thus there was no treatment-emergent CSA. All had a central apnea-hypopnea index (AHI) in the moderate to severe range (29-49). Two out of the three had a GCS <8 and one participant had a GCS of 14. Conclusion In this multi-center clinical trial, predominant CSA was rare. The common practice of reducing polypharmacy in order to minimize sedation and optimize mental status in specialized inpatient brain-injury rehabilitation programs may contribute to the low CSA incidence in this cohort. Attention to medication side-effects and their influence on sleep-related breathing should be routinely considered. Support PCORI (CER-1511-33005), GDHS (W91YTZ-13-C-0015) for DVBIC, NIDILRR (90DPTB0008-03-00; 90DPTB0013-01-00).

The Lived Experience and Patient-reported Benefits of Yoga Participation in an Inpatient Brain Injury Rehabilitation Setting.

Context:The multifactorial benefits of yoga have been well documented in the literature, with the integration of yoga therapy into healthcare being an emerging field. In general, yoga therapy programs are utilized in the community as an adjunct to other therapy. At present, limited rehabilitation units routinely incorporate integrative therapy options within a hospital environment.Aims:The aim of this study is to explore the lived experience and patient-reported benefits of yoga in an inpatient brain injury rehabilitation setting.Settings and Design:Thirty-one participants were recruited to the study after voluntarily participating in a yoga class within an inpatient brain injury rehabilitation unit of a major metropolitan hospital. Yoga sessions were held weekly for 60 min and consisted of a modified Hatha yoga style. This was a mixed-methods, quasi-experimental one-group pretest–posttest study.Methodology:Quantitative data were collected to measure perceptions of relaxation and well-being before and after yoga classes, along with the satisfaction of the class. Semi-structured interviews were utilized to collect qualitative data of experiences and perceptions associated with yoga participation.Statistical Analysis Used:Thematic analysis was completed for qualitative data. Quantitative data were analyzed using nonparametric statistical methods, and descriptive statistics were also provided.Results:The benefits described by participants are reported in this paper. These include improved relaxation, physical well-being, emotional well-being, being present, and self-awareness.Conclusions:This study describes the personal benefits experienced from regular yoga participation within an inpatient rehabilitation setting.

Predictors of unplanned readmission to acute care from inpatient brain injury rehabilitation.

To identify the predictors of unplanned readmission to acute care (RTAC) from inpatient brain injury rehabilitation and to develop a risk prediction model. RTAC from inpatient rehabilitation is not uncommon. Individual rehabilitation patient populations require their own body of evidence regarding predictors of RTAC. Retrospective cohort study. Adult patients with new onset acquired brain injury admitted to a stand-alone rehabilitation facility between 1 January 2012-31 December 2018 were included in the study. The main measures were RTAC, sensitivity, specificity, the C-statistic and Youden's index. This paper is reported using the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. Of 383 patients admitted for rehabilitation, 83 (22%) experienced a RTAC; 69 (18%) patients had at least one unplanned RTAC episode. Patients requiring unplanned RTAC were more likely to have lower Glasgow Coma Scale (GCS) and Functional Independence Measure (FIM) scores on rehabilitation admission, a higher burden of care on rehabilitation discharge and be discharged to a nonhome residence. Rehabilitation admission GCS and motor FIM were identified as the independent RTAC predictors in multivariate regression modelling. The combined C-statistic was 0.86. A GCS cut-off score of≤14 and motor FIM cut-off score of≤40 were identified as optimal, yielding a combined Youden's index of 0.56 (sensitivity=0.72; specificity=0.83). Patients requiring an unplanned RTAC had a lower functional status on rehabilitation admission. A prediction model for unplanned RTAC has been developed using validated and readily available clinical measures. The developed RTAC risk prediction model is the first step in preventing unplanned RTAC from inpatient brain injury rehabilitation. Future research should focus on discrete interventions for preventing unplanned RTAC from inpatient brain injury rehabilitation.

Reducing Patient Falls on an Acute Inpatient Brain Injury Rehabilitation Unit Through Improved Patient Monitoring

Reducing Patient Falls on an Acute Inpatient Brain Injury Rehabilitation Unit Through Improved Patient Monitoring

Family Involvement in Traumatic Brain Injury Inpatient Rehabilitation: A Propensity Score Analysis of Effects on Outcomes During the First Year After Discharge

ObjectiveTo evaluate the effect of family attendance at inpatient rehabilitation therapy sessions on traumatic brain injury (TBI) patient outcomes at discharge and up to 9 months postdischarge. DesignPropensity score methods are applied to the TBI Practice-Based Evidence database, a database consisting of multisite, prospective, longitudinal, and observational data. SettingNine inpatient rehabilitation centers in the United States. ParticipantsPatients (N=1835) admitted for first inpatient rehabilitation after an index TBI. InterventionFamily attendance during therapy sessions. Main Outcome MeasuresParticipation Assessment for Recombined Tools-Objective-17 (Total scores and subdomain scores of Productivity, Out and About, and Social Relations), Functional Independence Measure, Satisfaction with Life Scale, and Patient Health Questionnaire-9. ResultsParticipants whose families were in attendance for at least 10% of the treatment time were more out and about in their communities at 3 and 9 months postdischarge than participants whose families attended treatment less than 10% of the time. Although findings varied by propensity score method, improved functional independence in the cognitive area at 9 months was also associated with increased family attendance. ConclusionsFamily involvement during inpatient rehabilitation may improve community participation and cognitive functioning up to 9 months after discharge. Rehabilitation teams should engage patients’ families in the rehabilitation process to maximize outcomes.

Using audit and feedback to increase clinician adherence to clinical practice guidelines in brain injury rehabilitation: A before and after study.

ObjectiveThis study evaluated whether frequent (fortnightly) audit and feedback cycles over a sustained period of time (>12 months) increased clinician adherence to recommended guidelines in acquired brain injury rehabilitation.DesignA before and after study design.SettingA metropolitan inpatient brain injury rehabilitation unit.ParticipantsClinicians; medical, nursing and allied health staff.InterventionsFortnightly cycles of audit and feedback for 14 months. Each fortnight, medical file and observational audits were completed against 114 clinical indicators.Main outcome measureAdherence to guideline indicators before and after intervention, calculated by proportions, Mann-Whitney U and Chi square analysis.ResultsClinical and statistical significant improvements in median clinical indicator adherence were found immediately following the audit and feedback program from 38.8% (95% CI 34.3 to 44.4) to 83.6% (95% CI 81.8 to 88.5). Three months after cessation of the intervention, median adherence had decreased from 82.3% to 76.6% (95% CI 72.7 to 83.3, p<0.01). Findings suggest that there are individual indicators which are more amenable to change using an audit and feedback program.ConclusionA fortnightly audit and feedback program increased clinicians’ adherence to guideline recommendations in an inpatient acquired brain injury rehabilitation setting. We propose future studies build on the evidence-based method used in the present study to determine effectiveness and develop an implementation toolkit for scale-up.

Contextualized Treatment in Traumatic Brain Injury Inpatient Rehabilitation: Effects on Outcomes During the First Year After Discharge

ObjectiveTo evaluate the effect of providing a greater percentage of therapy as contextualized treatment on acute traumatic brain injury (TBI) rehabilitation outcomes. DesignPropensity score methods are applied to the TBI Practice-Based Evidence (TBI-PBE) database, a database consisting of multi-site, prospective, longitudinal observational data. SettingAcute inpatient rehabilitation. ParticipantsPatients enrolled in the TBI-PBE study (N=1843), aged 14 years or older, who sustained a severe, moderate, or complicated mild TBI, received their first inpatient rehabilitation facility admission in the US, and consented to follow-up 3 and 9 months post discharge from inpatient rehabilitation. InterventionsNot applicable. Main Outcome MeasuresParticipation Assessment with Recombined Tools-Objective (PART-O)-17, FIM Motor and Cognitive scores, Satisfaction with Life Scale, and Patient Health Questionnaire-9. ResultsIncreasing the percentage of contextualized treatment during inpatient TBI rehabilitation leads to better outcomes, specifically in regard to community participation. ConclusionsIncreasing the proportion of treatment provided in the context of real-life activities appears to have a beneficial effect on outcome. Although the effect sizes are small, the results are consistent with other studies supporting functional-based interventions effecting better outcomes. Furthermore, any positive findings, regardless of size or strength, are endorsed as important by consumers (survivors of TBI). While the findings do not imply that decontextualized treatment should not be used, when the therapy goal can be addressed with either approach, the findings suggest that better outcomes may result if the contextualized approach is used.

Advanced Therapy in Traumatic Brain Injury Inpatient Rehabilitation: Effects on Outcomes During the First Year After Discharge

ObjectiveTo use causal inference methods to determine if receipt of a greater proportion of inpatient rehabilitation treatment focused on higher level functions, for example, executive functions, ambulating over uneven surfaces (advanced therapy [AdvTx]), results in better rehabilitation outcomes. DesignA cohort study using propensity score methods applied to the traumatic brain injury practice-based evidence (TBI-PBE) database, a database consisting of multisite, prospective, longitudinal observational data. SettingAcute inpatient rehabilitation facilities. ParticipantsPatients enrolled in the TBI-PBE study (N=1843), aged 14 years or older, who sustained a severe, moderate, or complicated mild TBI, receiving their first inpatient rehabilitation facility admission to 1 of 9 sites in the United States, and consented to follow-up 3 and 9 months postdischarge from inpatient rehabilitation. InterventionsNot applicable. Main Outcome MeasuresParticipation Assessment with Recombined Tools-Objective-17, FIM motor and cognitive scores, Satisfaction with Life Scale, and Patient Health Questionnaire-9. ResultsControlling for measured potential confounders, increasing the percentage of AdvTx during inpatient TBI rehabilitation was found to be associated with better community participation, functional independence, life satisfaction, and decreased likelihood of depression during the year after discharge from inpatient rehabilitation. Participants who began rehabilitation with greater disability experienced larger gains on some outcomes than those who began rehabilitation with more intact abilities. ConclusionsIncreasing the proportion of treatment targeting higher level functions appears to have no detrimental and a small, beneficial effect on outcome. Caution should be exercised when inferring causality given that a large number of potential confounders could not be completely controlled with propensity score methods. Further, the extent to which unmeasured confounders influenced the findings is not known and could be of particular concern due to the potential for the patient’s recovery trajectory to influence therapists’ decisions to provide a greater amount of AdvTx.

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.

Making sense of recovery after traumatic brain injury through a peer mentoring intervention: a qualitative exploration

ObjectiveTo explore the acceptability of peer mentoring for people with a traumatic brain injury (TBI) in New Zealand.DesignThis is a qualitative descriptive study exploring the experiences reported by mentees and...

Caregiver Preparedness Training Within Inpatient Brain Injury Rehabilitation: A Scoping Review

To examine caregiver training used within brain injury inpatient facilities, report descriptions of caregiver trainings and mastery outcomes, and report hospital-driven cost outcomes to determine hospital benefit. The review informs recent policy that advocates for providing inpatient caregiver training for families of clients with acquired brain injuries. Providing this evidence will also inform practice to ensure that caregiver needs are met, best practice is established, and hospital readmission costs are reduced.

Translating Brain Injury Clinical Guidelines Into Practice: an Interrupted Time Series Study

To evaluate whether a fortnightly audit and feedback program leads to increases in rates of clinician adherence to brain injury rehabilitation clinical practice guideline recommendations. Design: A controlled interrupted time series design was used to evaluate the audit-feedback program which was embedded within an inpatient brain injury rehabilitation unit. Staff participated in fortnightly cycles of audit and feedback for 14 months. Following the audit-feedback program, there was a 3-month follow-up period. There were 8 assessments at baseline, 8 assessments at end of intervention and 20 assessments at follow-up.

Patient perceptions of participation in group-based rehabilitation in an inpatient brain injury rehabilitation setting

ObjectivesThe use of groups is common in healthcare. There is a paucity of research which captures patient experiences of group participation. The aims of this study were to explore the perceptions and experiences of people with traumatic brain injury (TBI) about their participation in inpatient occupational therapy rehabilitation groups. MethodA phenomenological approach guided the study. Patients with a TBI who were participating in an inpatient occupational therapy group program were recruited. Data were collected through semi-structured interviews and analysed using content analysis. ResultsFifteen participants consented to the study. Three themes emerged from the data; 1) feeling normal, comfortable and connected; 2) learning by doing, seeing and sharing and; 3) practicalities of groups. Participants highlighted that groups facilitated opportunities to practice skills and prepared them for the real world. Opportunities for interaction and support were also emphasised as positive by participants. ConclusionPerceptions of patients about participation in groups were generally positive, and as such a consumer-focused approach to healthcare would support the use of occupational therapy groups in TBI rehabilitation. Practice implicationsRecommendations from the perspectives of patients include consideration of the selection of group participants, and meeting individual needs and goals within a group setting.

Family Needs on an Inpatient Brain Injury Rehabilitation Unit: A Quantitative Assessment.

To examine the needs of family members in an inpatient setting and factors predicting extent to which needs are perceived as met. University health system inpatient rehabilitation unit. Adult survivors of traumatic brain injury and family members (n = 85). Prospective, cross-sectional. Family Needs Questionnaire-Revised (FNQ-R). Needs related to the Health Information subscale were most frequently rated as met, whereas needs related to the Instrumental Support and Emotional Support subscales were most frequently rated as unmet. Predictors related to the FNQ-R included family income, gender, and ethnicity. For 4 of 6 subscales, white family members were more likely to rate needs as unmet than minority members. For 3 subscales, females were more likely to rate needs as unmet than males. Greater household income was associated with fewer met needs for 2 subscales. The ranking of met and unmet needs in the present study was remarkably similar to previous studies within and outside the United States. Clinicians should not assume that families with relatively higher incomes will experience fewer unmet needs. Through structured assessment, clinicians can reveal perceived needs that might have otherwise been unrecognized and facilitate appropriate supports. Findings provide direction for inpatient program development.

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.

A Factor Analysis of Functional Independence and Functional Assessment Measure Scores Among Focal and Diffuse Brain Injury Patients: The Importance of Bifactor Models

ObjectiveTo explore the factor structure of the UK Functional Independence Measure and Functional Assessment Measure (FIM+FAM) among focal and diffuse acquired brain injury patients. DesignCriterion standard. SettingA National Health Service acute acquired brain injury inpatient rehabilitation hospital. ParticipantsReferred sample of adults (N=447) admitted for inpatient treatment following an acquired brain injury significant enough to justify intensive inpatient neurorehabilitation InterventionNot applicable. Outcome MeasureFunctional Independence Measure and Functional Assessment Measure. ResultsExploratory factor analysis suggested a 2-factor structure to FIM+FAM scores, among both focal-proximate and diffuse-proximate acquired brain injury aetiologies. Confirmatory factor analysis suggested a 3-factor bifactor structure presented the best fit of the FIM+FAM score data across both aetiologies. However, across both analyses, a convergence was found towards a general factor, demonstrated by high correlations between factors in the exploratory factor analysis, and by a general factor explaining the majority of the variance in scores on confirmatory factor analysis. ConclusionsOur findings suggested that although factors describing specific functional domains can be derived from FIM+FAM item scores, there is a convergence towards a single factor describing overall functioning. This single factor informs the specific group factors (eg, motor, psychosocial, and communication function) after brain injury. Further research into the comparative value of the general and group factors as evaluative/prognostic measures is indicated.

Participant evaluation of an inpatient occupational therapy groups programme in brain injury rehabilitation.

Therapy groups are commonly used in brain injury rehabilitation yet patient perceptions of participation in groups are largely uninvestigated. This paper describes the occupational therapy groups programme at an inpatient brain injury rehabilitation unit and presents an evaluation from the patient's perspective. Participants were in patients with traumatic brain injury who participated in the groups programme and completed a customised self-report questionnaire measuring perceptions about and satisfaction with four occupational therapy groups. Data were analysed descriptively and comparisons made between groups with a functional focus (meal preparation and community access) and an impairment focus (cognitive and upper limb) using Z scores. Thirty-five participants (30 males, five females) completed a total of 83 questionnaires. Over 90% of responses agreed or strongly agreed that working with others was enjoyable, that the groups provided feedback and individualised treatment, and were useful for them. There were no significant differences in perceptions about the functional and impairment-focussed groups. An illustrative case example of participation in the groups programme is presented. Overall, consumer feedback on different aspects of the occupational therapy groups programme in brain injury rehabilitation was positive. Further in-depth investigation of patient perceptions of groups including processes that facilitate or challenge participation is warranted.