Mayo-Portland Adaptability Inventory Research Articles

Pre-injury psychiatric history, subacute symptoms and personality traits predict social reintegration at 3-month post-mild traumatic brain injury

ABSTRACT Background The purpose of the study was to identify whether the presence of a pre-injury psychiatric history, subacute post-concussive symptoms (PCS) and personality traits were predictive of less favorable social reintegration for 3 months following a mild traumatic brain injury (mTBI). Method A total of 76 patients with mTBI were included, and the presence of a pre-injury psychiatric history was identified from the medical chart. One-month post-accident, these patients completed the Millon Multiaxial Clinical Inventory, 3rd Edition assessing personality traits and the Rivermead Post-Concussion Symptoms Questionnaire to measure subacute PCS. Social reintegration was measured using the Mayo-Portland Adaptability Inventory, 4th Edition at 3-month post-accident. Results The presence of pre-injury psychiatric history, high levels of subacute PCS and Cluster B personality traits such as histrionic and borderline features were significant predictors of social reintegration quality at 3-month post injury. Conclusion This study provides new insights on cluster B personality traits and its influence on recovery and social reintegration at 3-month post mTBI.

The Australian Traumatic Brain Injury Initiative: Review and Recommendations for Outcome Measures for Use With Adults and Children After Moderate-to-Severe Traumatic Brain Injury.

The Australian Traumatic Brain Injury Initiative (AUS-TBI) aims to select a set of measures to comprehensively predict and assess outcomes following moderate-to-severe traumatic brain injury (TBI) across Australia. The aim of this article was to report on the implementation and findings of an evidence-based consensus approach to develop AUS-TBI recommendations for outcome measures following adult and pediatric moderate-to-severe TBI. Following consultation with a panel of expert clinicians, Aboriginal and Torres Strait Islander representatives and a Living Experience group, and preliminary literature searches with a broader focus, a decision was made to focus on measures of mortality, everyday functional outcomes, and quality of life. Standardized searches of bibliographic databases were conducted through March 2022. Characteristics of 75 outcome measures were extracted from 1485 primary studies. Consensus meetings among the AUS-TBI Steering Committee, an expert panel of clinicians and researchers and a group of individuals with lived experience of TBI resulted in the production of a final list of 11 core outcome measures: the Functional Independence Measure (FIM); Glasgow Outcome Scale-Extended (GOS-E); Satisfaction With Life Scale (SWLS) (adult); mortality; EuroQol-5 Dimensions (EQ5D); Mayo-Portland Adaptability Inventory (MPAI); Return to Work /Study (adult and pediatric); Functional Independence Measure for Children (WEEFIM); Glasgow Outcome Scale Modified for Children (GOS-E PEDS); Paediatric Quality of Life Scale (PEDS-QL); and Strengths and Difficulties Questionnaire (pediatric). These 11 outcome measures will be included as common data elements in the AUS-TBI data dictionary. Review Registration PROSPERO (CRD42022290954).

Distinguishing Characteristics of Admissions to Various Types of Posthospital Brain Injury Rehabilitation Programs.

Describe and compare the demographic characteristics and disability profiles of individuals admitted to 6 types of posthospital brain injury rehabilitation (PHBIR) programs. Data from Residential Neurobehavioral, Residential Neurorehabilitation, Home and Community Neurorehabilitation, Day Treatment, Outpatient Neurorehabilitation, and Supported Living programs serving individuals with acquired brain injury (ABI). Two thousand twenty-eight individuals with traumatic brain injury (TBI), stroke, or other ABI. Sex, age, time since injury, and Mayo-Portland Adaptability Inventory, 4th edition (MPAI-4). Retrospective analyses of demographic variables and MPAI-4 Total, Index, and subscale Rasch-derived T-scores on admission comparing diagnostic categories and program types within diagnostic categories. Participants with TBI were predominantly male, and those with stroke were generally older. Admissions to more intensive and supervised programs (residential neurobehavioral and residential neurorehabilitation) generally showed greater disability than admissions to home and community programs who were more disabled than participants in day treatment and outpatient programs. Residential neurobehavioral and supported living program participants generally were male and had TBI. Home and community admissions tended to be more delayed than residential neurorehabilitation admissions. The majority of those with other ABI were admitted to outpatient rather than more intensive programs. Additional analyses demonstrated significant differences in MPAI-4 profiles among the various program types. Admissions with TBI, stroke, and other ABI to PHBIR differ in demographic factors and disability profiles. When examined within each diagnostic category, demographic features and disability profiles also distinguish among admissions to the various program types. Results provide insights about decision-making in referral patterns to various types of PHBIR programs, although other factors not available for analysis (eg, participant/family preference, program, and funding availability) likely also contribute to admission patterns.

Rasch Analysis of the Mayo-Portland Adaptability Inventory for Posthospital Brain Injury Rehabilitation.

(1) Reexamine the item structure and reliability of the Mayo-Portland Adaptability Inventory (4th ed; MPAI-4) through Rasch analysis of admission and discharge scores for a large sample of adults with acquired brain injury (ABI) who participated in various types of posthospital brain injury rehabilitation (PHBIR) programs; (2) compare differential item functioning (DIF) for traumatic brain injury (TBI), stroke and other ABI; and (3) explore the viability of more specific subscales in addition to the established indices. Data from Residential Neurobehavioral, Residential Neurorehabilitation, Home and Community, Day Treatment, and Outpatient rehabilitation programs serving individuals with ABI. A total of 2154 individuals with TBI, stroke, or other ABI. Retrospective analysis of de-identified admission and discharge data from the Foundation to Advance Brain Rehabilitation (FABR) consortium database. MPAI-4. After adjusting 4 misfitting items and eliminating 20 misfitting persons, the MPAI-4 demonstrated real person reliability/separation = 0.93/3.52 and real item reliability/separation = 1.00/24.02. Independent Rasch analyses by diagnostic category found similar reliabilities and separations. Residual item correlations and principal component analysis of residuals (PCAR) indicated areas of local dependence arranged hierarchically reflecting the full-scale item hierarchy and providing the basis for 3 new subscales of Physical Abilities, Cognitive Abilities, and Autonomy. DIF across diagnostic categories revealed differences in item elevations characteristic of typical patients in each category. Measure means and SDs were very similar across categories. MPAI-4 items demonstrate very good person and item reliabilities for individuals with TBI, stroke, and other ABI at a level that supports individual evaluation. Variations in item calibrations across diagnostic categories reflect the differential characteristics of typical patients within categories. The entire measure provides an overall assessment of common sequalae of ABI, and standard indices used in combination with newly derived subscales provide more specific assessments of rehabilitation needs for treatment planning.

Sustainability of an outcome measure in outpatient stroke rehabilitation: A realist evaluation.

Only half of newly implemented evidence-based practices are sustained. Though poor sustainment can lead to negative consequences for clinical teams, organizationsand patients, the causal explanations of sustainment are largely unknown. We aimed to ascertain how (mechanisms) and in what circumstances (context) a newly implemented outcome measure in rehabilitation was sustained or not (outcome). Informed by an integrated knowledge translation approach, we conducted a realist evaluation using a mixed method, embedded single case study design with data collection up to 18 months following the implementation of the Mayo-Portland Adaptability Inventory - version 4 (MPAI-4), a rehabilitation outcome measure. Quantitative data (survey and patient charts) was analysed using descriptive statistics, then integrated with qualitative data (interviews with 10 key informants) and analysed using inductive and deductive retroduction. We integrated the data to develop a case description and ultimately, to refine the programme theory to better understand the sustainability of the MPAI-4. We linked context, mechanismsand outcomes, and also emphasized sustainability strategies in 18 explanations of how sustainability works. These explanations provide evidence for four overarching patterns: (1) implementation and sustainability phases are interconnected, (2) outcomes build on each other recursively, with patient benefits as the keystone outcome, (3) sustainment is achieved to varying levels across different sustainability outcomes [e.g., high level (e.g., rate of MPAI-4 scoring: 77.7%) to low level (e.g., rate of MPAI-4 application to clinical decision-making: 3.7%)] and (4) the work of sustaining the MPAI-4 is shared amongst different stakeholders. Implementation teams can draw from this programme theory to improve the sustainment of outcomes measures while researchers could continue to refine the theory. Continued investigation of sustainability, including diverse and continuous sustainability outcomes, is needed to understand how to maintain improvements in quality of care and patient outcomes.

Components of self-awareness affecting caregiver burden: a long-term follow-up study

ABSTRACT Objective Studies utilizing the discrepancy model of the Mayo-Portland Adaptability Inventory-4 (MPAI-4) have commonly used the cognitive and physical domains to estimate self-awareness. This study included other aspects of self-awareness such as awareness of one’s social and emotional status and daily functioning to explore their effects on caregiver burden for ABI survivors. Methods We studied 64 patient-caregiver pairs up to 29 years post-discharge from a holistic, milieu-oriented outpatient neurorehabilitation program. Discrepancy scores between ABI survivors’ and caregivers’ reports on the MPAI-4 subscales (i.e. Abilities, Adjustment, and Participation) and Total Score were used to determine self-awareness. Caregiver burden was measured using the Zarit Burden Interview (ZBI). Results Exploratory linear regression analyses revealed that caregiver burden derived from the ZBI was predicted by the discrepancy scores generated from the Abilities (p < 0.0001), Adjustment (p < 0.01), Participation subscales (p = 0.01), and Total Score (p < 0.001), respectively. Among the exploratory models generated, the Total Score model had the highest predictive value (R2 = .33) for caregiver burden. Conclusions Measures of self-awareness should be comprehensive by considering diverse components of self-awareness. Increasing ABI survivors’ self-awareness in different domains has the potential to effectively alleviate caregiver burden.

A - 168 Self-Awareness in Survivors of Acquired Brain Injury and the Impact on Family Burden.

Caregiver burden is commonly experienced by family members of survivors of acquired brain injury (ABI). Research has demonstrated that self-awareness of survivors of ABI impacts family member burden (Rubin et al. 2020). This study utilized the discrepancy model of the Mayo-Portland Adaptability Inventory-4 (MPAI-4) to measure self-awareness by calculating a discrepancy score from self and family member-rated MPAI-4 total score. We examined the relationship between family member burden, time since injury, and level of self-awareness of survivors of ABI at discharge following holistic neurorehabilitation. This retrospective study analyzed data on 28 individuals with heterogeneous ABI's who participated in a holistic milieu-oriented outpatient neurorehabilitation program from 2020-2023. Demographic information (age, education, race/ethnicity), injury history (injury type, age at injury, chronicity), program variables (length of program participation), functionality (MPAI-4), and family burden (Zarit Burden Interview) at discharge were collected. A multiple linear regression analysis was run to predict family burden from self-awareness of survivors of ABI and time since injury. The multiple regression model statistically significantly predicted family burden, F(2, 24) = 6.698, p < 0.005, adj. R2 = 0.305. Only self-awareness added statistically significantly to the prediction, p < 0.002. Self-awareness accounted for 33.4% of the variance in family burden. Among family members of survivors of ABI, self-awareness of the survivor is an important predictor of burden experienced by family. Self-awareness, as measured by utilizing the MPAI-4 discrepancy model, explained a significant proportion of the variance in family burden regardless of time since injury.

Rehabilitation needs of people with brain tumours in Ireland: Protocol for a prospective, mixed methods action research study ("Brain-RESTORE").

Background: Approximately 480 people annually in Ireland are diagnosed with a primary brain tumour. Brain tumours are a heterogeneous group of conditions, varying in histopathology, location, and progression. A consistent feature is neurological impairment, which can lead to profound effects on physical and cognitive function. There is evidence that people with brain tumours can benefit from rehabilitation, but pathways are poorly described, and no best practice is defined. This leads to significant unmet need. The aim of this study is to understand the rehabilitation needs of people diagnosed with a brain tumour in Ireland, and gain insight to inform policy and practice. Methods: A prospective, mixed methods study with embedded action research will be conducted. Patients (n=122) with a new diagnosis of primary brain tumour, and optionally, a nominated carer or family member, will be recruited through a national neuro-oncology service. Rehabilitation need (Mayo-Portland Adaptability Inventory), quality of life (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Brain Cancer Module, EuroQol-5D-5L), healthcare utilisation and, optionally, carer needs (Carer Support Needs Assessment Tool) will be assessed at four, eight and 12 months post diagnosis. An embedded qualitative study will invite 30 patients and carers to a semi-structured interview to explore their lived experience of rehabilitation needs and services following brain tumour diagnosis. Finally, using an Action Research approach, healthcare professionals involved in caring for people with brain tumours will be invited to participate in co-operative inquiry groups, to reflect on emerging aggregate findings and identify actions that could be undertaken while the study is underway. Conclusions: By understanding rehabilitation need, the findings will help healthcare professionals and health service providers understand how to prioritise the supports required and encourage policy makers to adequately resource neurorehabilitation to meet the needs of people with a brain tumour diagnosis.

Sex/gender differences in service use patterns, clinical outcomes and mortality risk for adults with acquired brain injury: a retrospective cohort study (ABI-RESTART).

To identify sex/gender differences in functional, psychosocial and service use patterns in community-based post-acute care for acquired brain injury. Design: Retrospective cohort study. Adults with acquired brain injury enrolled in post-acute neurorehabilitation and disability support in Western Australia (n = 1,011). UK Functional Independence Measure and Functional Assessment Measure (FIM + FAM), Mayo-Portland Adaptability Inventory-4, goal attainment, length of stay (LOS), number of episodes of care and deaths were evaluated using routinely collected clinical and linked administrative data. At admission, women were older (p < 0.001) and displayed poorer functional independence (FIM + FAM; p < 0.05) compared with men. At discharge, there were no differences in goal attainment, psychosocial function or functional independence between men and women. Both groups demonstrated functional gains; however, women demonstrated clinically significant gains (+ 15.1, p < 0.001) and men did not (+ 13.7, p < 0.001). Women and men had equivalent LOS (p = 0.205). Aboriginal and/or Torres Strait Islander status predicted longer LOS for women but not for men. Being partnered predicted reduced LOS for women but not men. Women had a higher risk of multiple episodes of care (p < 0.001), but not death (p = 0.409), compared with that of men. At admission to rehabilitation and disability support services for acquired brain injury, women have poorer functional independence and higher risk of multiple episodes of care, compared with men, suggesting greater disability in the community. By the time of discharge from these services, women and men make equivalent functional and psychosocial gains. The higher risk of multiple episodes of care for women relative to men suggestwomen may need additional post-discharge support, to avoid readmission.

The potential of using virtual reality-based self-paced treadmill to assess road-crossing safety and self-evaluation with traumatic brain injuries: a series case study

AbstractImpaired self-awareness (ISA) is common following traumatic brain injury (TBI) and can significantly impact safe road-crossing. Road-crossing interventions are variable and involve high-risk real-world situations. Virtual reality (VR)-based road-crossing can elicit changes in real-world functioning but has not been trialled in the TBI population. The primary objective of this research was to explore whether VR-based self-paced treadmill technology offers a safe road-crossing assessment mechanism for people with TBI. Three participants with TBI completed two road-crossing pilot-trials using a VR-based self-paced treadmill. Avatar feedback and verbal feedback were provided between trials. Participants were provided with a safe road-crossing strategy for the second pilot-trial. The Researcher and Participant evaluated road-crossing following each trial using the Mayo-Portland Adaptability Inventory and the number of safe road-crossings to assess changes in self-evaluation and performance between trials. One of the participants perceived improvements in self-evaluation and performance in the second pilot-trial. All participants attempted to apply the safe road-crossing strategy advised. No safety issues were identified using the VR-based self-paced treadmill within this study’s protocol thereby supporting the primary objective of the work. Future research is warranted to strengthen the evidence-base for using VR to elicit improvements in ISA in road-crossing and in generalising findings to the wider TBI population.

Evaluating the implementation of the Mayo-Portland Adaptability Inventory-4 (MPAI-4) in three rehabilitation settings in Quebec: a mixed-methods study protocol

IntroductionStroke is a leading cause of morbidity and mortality worldwide, placing an immense burden on patients and the health system. Timely access to rehabilitation services can improve stroke survivors’ quality...

Unmet Need for Outpatient Occupational Therapy Services Among Veterans With Mild Traumatic Brain Injury in the Veterans Health Administration: The Role of Facility Characteristics

ObjectiveTo investigate whether participation restrictions, an indicator of need for occupational therapy (OT), was associated with outpatient OT utilization in the Veterans Health Administration (VHA) among Veterans with mild traumatic brain injury (mTBI), and whether this relation differs by facility characteristics. DesignIn a secondary analysis of national VHA data, we used modified Poisson regression to model OT utilization (yes/no) as a function of participation restrictions (Mayo-Portland Adaptability Inventory Participation Index [M2PI]), facility characteristics, and covariates. Facility characteristics included complexity, geographic region, and self-reported access to specialty care. Covariates included prior OT utilization, sociodemographic factors, injury characteristics, and spatial access (eg, drive time). Interactions estimated whether the relation between participation restrictions and OT utilization differed across facility characteristics. SettingOutpatient setting in the VHA. Participants8684 Veterans with a clinician-confirmed mTBI who received outpatient VHA care between 2012 and 2020 (N=8684). InterventionsNone. Main Outcome Measure(s)OT utilization was measured within a year of M2PI administration using VHA administrative data. ResultsMany Veterans who did not receive OT reported participation limitations, indicating unmet need for OT (eg, 67% with leisure restrictions). Participation restrictions were associated with increased likelihood of receiving OT (risk ratio [RR]=1.01; 95% confidence interval [CI]=1.006-1.019), suggesting a tendency for Veterans’ OT-related needs to be satisfied. However, interactions indicated that this was not the case among Veterans receiving care in lower complexity facilities, and those in the South. Veterans with longer drive times were less likely to receive OT (RR=0.82; 95% CI=0.744-0.904). ConclusionsParticipation restrictions were associated with OT utilization, yet many Veterans with mTBI who may have benefited did not receive such care. Specific barriers to accessing OT (eg, OT practitioner supply) should be investigated. Novel care models can ensure access to OT services among Veterans seeking care at less-resourced and/or geographically distant VHA facilities.

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.

Long-term neurorehabilitation outcomes of pediatric vs. adult onset acquired brain injury.

Functional outcomes of intensive neurorehabilitation for pediatric onset acquired brain injury (ABI) are understudied. The extent and pervasiveness of impairments are often uncovered years after an ABI and can worsen over time, leading to a cascade of academic, functional, and psychosocial difficulties. To examine the long-term outcomes of survivors with pediatric onset vs. adult onset ABI who completed holistic milieu-oriented neurorehabilitation up to 30 years ago. One hundred twenty-three survivors of ABI including a pediatric onset group (n = 22) and an adult onset group (n = 101) with heterogeneous neurological etiologies who attended holistic, milieu-oriented neurorehabilitation. Productivity, driving, and functional outcomes were evaluated using the Mayo-Portland Adaptability Inventory-4 (MPAI-4) and a psychosocial outcome questionnaire. Treatment for the pediatric onset group started much later than onset. A one-way analysis of covariance revealed no significant differences between the two groups on the MPAI-4. At the follow-up survey, there was no significant difference between age at onset of injury and productivity status. The average follow-up time was ~8 years (SD = 6.28) from time of discharge to the time of the survey. Although there was no significant difference between the two groups for driving at the time of admission, the adult onset group was significantly more likely to return to driving after treatment. This study demonstrates the positive and enduring benefits of holistic, milieu-oriented neurorehabilitation for survivors of pediatric onset ABI regardless of the time between initial injury and engagement in rehabilitative therapies.

Characterising Posttraumatic Growth in Individuals With TBI Based on Social Participation, Self-Awareness, and Self-Identity

<h3>Research Objectives</h3> To characterise individuals with higher and lower posttraumatic growth based on their social participation, self-awareness, and self-identity. <h3>Design</h3> A sequential explanatory/exploratory mixed-methods design. <h3>Setting</h3> General community in British Columbia. <h3>Participants</h3> 15 participants with moderate to severe TBI (average age=49.7, male=10, average years post-injury= 15.2). <h3>Interventions</h3> Not applicable. <h3>Main Outcome Measures</h3> Qualitative data were collected through semi-structured interviews (approximately 40 minutes). Quantitative data were obtained from self-report questionnaires that assessed social participation (Impact of Participation and Autonomy), self-awareness (Awareness Questionnaire), self-identity (Head Injury Semantic Differential Scale-III), and global functioning (Mayo-Portland Adaptability Inventory-4). For the analysis, qualitative data were used to categorise participants into two groups of higher (n=8) and lower (n=7) posttraumatic growth. The quantitative data were then used to characterise the participants. <h3>Results</h3> Participants with higher posttraumatic growth had more social participation, higher self-awareness, and fewer negative discrepancies in their pre- and post-injury identities. Participants with lower posttraumatic growth had less social participation, lower self-awareness, and more negative discrepancies in pre- and post-injury identities. <h3>Conclusions</h3> This study contributes to the growing literature of posttraumatic growth after TBI by describing the characteristics of participants with higher and lower levels of posttraumatic growth. By integrating qualitative and quantitative data, this study provides a more comprehensive understanding about the subsequent growth that may take place after a TBI. Findings can facilitate future experimental studies to explore the relationships between posttraumatic growth and social participation, self-awareness, and self-identity in individuals with TBI. <h3>Author(s) Disclosures</h3> There are no author disclosures.

Functional Improvements 6+ Months After GOALS Training Predicted Decreased PTSD Symptoms Among Veterans with PTSD/mTBI

<h3>Research Objectives</h3> To examine whether long-term improvements in functional outcomes following Goal-Oriented Attentional Self-Regulation (GOALS) training predicts changes in PTSD symptoms among veterans with comorbid PTSD and mild TBI (mTBI). <h3>Design</h3> Archival data from a randomized-controlled, evaluator-blinded, trial for GOALS executive function training. Assessments of daily and emotional functioning were completed at baseline and 6 months post-treatment. <h3>Setting</h3> VA Medical Center. <h3>Participants</h3> 24 veterans with a history of chronic mTBI and a confirmed diagnosis of PTSD that completed GOALS training. <h3>Interventions</h3> GOALS is a cognitive rehabilitation intervention that incorporates mindfulness-based attention regulation training, and goal management strategies applied to participant-defined goals. It consists of ten 2-hour sessions administered in small group format, and three individual 1-hour sessions. <h3>Main Outcome Measures</h3> The Mayo-Portland Adaptability Inventory (MPAI) and PTSD Checklist, Military Version (PCLM) were chosen from archival data collected from the original study. <h3>Results</h3> Paired-samples T-Tests indicate significant improvements 6 months post GOALS training in total PTSD symptoms on PCLM-Total (p=.007), Re-experiencing (p=.009) and Hyperarousal (p=.002). There were also significant improvements in overall functioning on MPAI-Total (p=.007), including Participation (e.g. initiation, socialization, employment; p=0.01) and Ability (e.g. problem solving, memory, attention; p=0.014) 6 months post GOALS training. Results from simple linear regressions indicate that improved MPAI-Participation 6 months post GOALS training predicted decreases in PCLM-Hyperarousal (R²=.29), PCLM-Avoidance (R²=.20), and PCLM-Reexperiencing (R²=.17). Further, improved MPAI-Ability also predicted decreases in PCLM-Hyperarousal (R²=.19), PCLM-Avoidance (R²=.27), and PCLM-Reexperiencing (R²=.18). <h3>Conclusions</h3> Persistence of improvements in functional abilities 6+ months after GOALS training predicted decreased PTSD symptoms in Veterans with mTBI and PTSD. The results highlight the impact functional status has on emotional functioning, and suggest that improvements in functional abilities following cognitive rehabilitation training may strengthen emotional regulation skills, resulting in decreases in emotional distress. <h3>Author(s) Disclosures</h3> None.

An Observational Cohort Study of the Role of Level of Effort in Residential Brain Rehabilitation

<h3>Research Objectives</h3> To investigate the role of participant level of effort (LoE) on outcome in residential brain rehabilitation with the hypothesis that greater effort is associated with more positive outcomes. <h3>Design</h3> Observational cohort study. <h3>Setting</h3> Comprehensive integrated brain rehabilitation program within a skilled nursing facility. <h3>Participants</h3> 101 consecutive admissions with acquired brain injury. <h3>Interventions</h3> Individualized interdisciplinary brain rehabilitation; therapist rating of participant LoE during physical therapy, occupational therapy, and speech and language pathology sessions. <h3>Main Outcome Measures</h3> Mayo-Portland Adaptability Inventory (MPAI-4); Supervision Rating Scale (SRS) <h3>Results</h3> Linear regression showed that discharge MPAI-4 Total scores were significantly associated with mean LoE rating, admission MPAI-4 scores, age at admission, and days from injury (Adj R2 = 0.72; F=65.28; p< 0.0001) but not with LoE variability, sex, type of injury, length of stay, or treatment before or during the COVID pandemic. Discharge SRS scores were significantly associated with mean LoE rating, admission SRS scores, and age. After controlling for other variables, a one-unit increase in mean LoE rating was associated with an improvement of 5.1 in discharge Total MPAI-4 score and 1.5 in discharge SRS score. Logistic regression showed the odds of achieving a Minimal Clinically Important Difference on the MPAI-4 were 8.34 times higher with each one-unit LoE increase. Admission MPAI-4 was negatively associated with mean LoE (β= -0.07, t=-8.85, p< 0.0001). Exploratory propensity score analysis suggests a potential causal effect of mean LoE on outcome. <h3>Conclusions</h3> Average LoE is positively associated with and, pending further study, may be causally related to outcome. Age, time since injury, and initial level of disability are also associated with outcome; initial level of disability is negatively associated with LoE. <h3>Author(s) Disclosures</h3> The authors have no conflicts of interest to disclose.

Measurement Properties of the Mayo-Portland Adaptability Inventory (MPAI-4) and Related Measures: A Systematic Review

<h3>Objective(s)</h3> (1) To assess the MPAI-4 and related measure's (e.g., Participation Index (M2PI)) measurement properties and evidence quality; and (2) identify the interpretability and feasibility of these measures. <h3>Data Sources</h3> Two independent reviewers searched nine electronic databases and trials registries from inception to 2021 using the 2018 COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines for systematic reviews. <h3>Study Selection</h3> Forty-eight of the 605 retrieved peer-reviewed primary articles concerning the MPAI-4 or related measures were retained. <h3>Data Extraction</h3> We extracted study and patient characteristics, critically appraised risk-of-bias (COSMIN checklist) and rated the extracted results. <h3>Data Synthesis</h3> We used COSMIN's approach to synthesize measurement properties (insufficient, sufficient), and modified GRADE approach to assess evidence quality (very low, low, moderate, high) by diagnosis (traumatic brain injury (TBI), stroke) and setting (inpatient, outpatient). The MPAI-4 is sufficiently comprehensible (GRADE: very low), with no evidence reported for its relevance or comprehensiveness. The MPAI-4 and M2PI have sufficient interrater reliability for stroke and TBI outpatients (GRADE: moderate), whereas interrater reliability between TBI inpatients and clinicians is insufficient (GRADE: moderate). There is no evidence for measurement error. The MPAI-4 and M2PI have sufficient construct validity and responsiveness across TBI inpatients (GRADE: high) and outpatients (GRADE: high), and stroke outpatients (GRADE: moderate-high). There is one study with mixed insufficient/sufficient evidence for each adapted version (21- and 22-item MPAI, 9-item M2PI) (GRADE: low-high). <h3>Conclusions</h3> In response to recent outcome standardization initiatives using the MPAI-4 and M2PI, this systematic review provides diagnosis and setting-specific supporting evidence for each measure. The MPAI-4 and M2PI have sufficient evidence to support their use in TBI inpatient and outpatient, and stroke outpatient populations. Adapted versions of the MPAI-4 warrant further study to generate clear recommendations for use. Since the MPAI-4 and related measures are formative as opposed to reflective models, structural validity, internal consistency and cross-cultural validity results are uninterpretable. Future studies should focus on measurement properties congruent with a formative model, especially reliability, measurement error, content validity and predictive validity. <h3>Author(s) Disclosures</h3> The authors have no conflicts of interest.

Characteristics of a Post-Coronavirus-19 Sample Undergoing Rehabilitation: An Exploratory Study

<h3>Research Objectives</h3> Describe sample presenting to a brain rehabilitation clinic with cognitive impairment after COVID-19 infection. <h3>Design</h3> Pre- and post-intervention measures from a clinical sample. <h3>Setting</h3> Outpatient Brain Rehabilitation Clinic. <h3>Participants</h3> Eight patients undergoing outpatient rehabilitation after COVID-19 infection (Mean age = 47.1, Range: 38-55 years; females = 6, males = 2; 4 hospitalized at time of acute infection, Mean time to treatment 243 days, Range: 84-415 days). <h3>Interventions</h3> Treatment by an experienced team of interdisciplinary providers with composition and treatment frequency tailored to individual needs. <h3>Main Outcome Measures</h3> Patient Health Questionnaire (PHQ-9); Participation Index of the Mayo-Portland Adaptability Inventory (M2PI); Satisfaction with Life Scale (SWLS); Neurobehavioral Symptom Inventory – 22 (NSI-22). <h3>Results</h3> Average number visits = 6.5 (Range: 0-25). Treatment attendance was close to 100%. Mean PHQ-9 on admission 10.625 (Range: 3-18) and at discharge 10.25 (Range: 1-17). Mean M2PI on admission was 13 (Range:8-24, and on discharge was 10.875 (Range: 0-20). Mean SWLS was the same at admission and discharge, 20.625 (Range: Admit: 15-29, Discharge 10-29). NSI-22 mean on admission 37.375 (Range 16-49) and on discharge 31.5 (Range:6-54). <h3>Conclusions</h3> Most of our sample reported moderate to moderate-severe depression. Most endorsed moderate-severe disability on the M2PI. This changed only slightly over treatment. This sample reported highly variable symptom complaint and life satisfaction. Of 5 patients with worsening scores over treatment, 4 were patients who started treatment well over 200 days after their initial diagnosis (Range: 229-415 days). Our treatment sample reports variable symptomatology and outcomes that may be tied to time to initiating rehabilitation. <h3>Author(s) Disclosures</h3> None.

Alexithymia as a risk factor for poor emotional outcomes in adults with acquired brain injury

ABSTRACT Emotional disorders are pervasive in the acquired brain injury (ABI) population, adversely affecting quality of life and rehabilitation. This study aimed to explore the unique associative effects of alexithymia as measured by the Perth Alexithymia Questionnaire (PAQ; i.e., difficulty identifying positive/negative feelings, difficulty describing positive/negative feelings, and externally orientated thinking), on emotional outcomes as measured by the Depression Anxiety Stress Scale-21 (DASS-21) and Mayo-Portland Adaptability Inventory (MPAI-4) Adjustment index, in 83 adults with ABI. The addition of alexithymia to hierarchical multiple regression models (controlling for demographic, injury-related, and functional outcome variables) yielded statistically significant changes in R2 for all emotional outcome measures (i.e., Depression, Anxiety, Stress, and Adjustment). Difficulty identifying negative feelings was found to be a significant unique predictor of Depression (β = .43 p = <.001), Anxiety (β = .40, p <.001), Stress (β = .49, p <.001), and Adjustment (β = .26, p = .001). Externally oriented thinking was found to be a significant unique predictor of Adjustment (β = -.15, p = .033). These findings strengthen the argument that alexithymia, especially difficulties identifying negative feelings, may be an important risk factor for psychological distress in ABI and should be considered during early rehabilitation.