Post-Hospital Brain Injury Rehabilitation Research Articles

Role and Outcomes of Supported Community Living Programs in Post-Hospital Brain Injury Rehabilitation Programs.

(1) To determine the proportion of participants admitted to supported community living (SCL) programs over the course of 5 years who improve, decline, or maintain functioning and community integration and (2) to examine the associations of time since injury, time in program, and age to their functional trajectory. Data from SCL programs serving individuals with acquired brain injury (ABI). 104 individuals with traumatic brain injury (TBI), stroke, or other ABI. Sex, age, time since injury, Mayo-Portland Adaptability Inventory (4th edition; MPAI-4). Retrospective analyses of MPAI-4 total and MPAI-4 indices using Linear Mixed Models (LMM) of Rasch-derived T-scores from admission to 5 years into service delivery. MPAI-4total, index, and subscale scores for yearly intervals of SCL services from admission to 5years showed a high degree of stability in function (defined using the standard error of measurement (SEM) for the MPAI-4, defined as change≥3T-score points) with all intervals showing at least 89% of patients with improved scores or no change. The rate of change over time did not significantly vary by time since injury, time in the program, or age. The expectations for services in the SCL portion of the care continuum for ABI are unique. Unlike intensive rehabilitation programs which focus on improvement often earlier in the course of recovery, the goal of SCL services is sustained functioning over the long term. Analyses reported here indicate this can be achieved for at least 5years, potentially mitigating the increased risk for rehospitalization and increased care needs in the ABI population. This study highlights a key finding of MPAI-4 stability within these understudied brain injury service lines. Additional exploration of comorbidities and more nuanced delineation of diagnostic information could further clarify factors influencing outcome stability over time.

The Foundation to Advance Brain Rehabilitation: Organization, History, and Collaborative Database.

To describe the history, organization, goals, and data management procedures of the Foundation to Advance Brain Rehabilitation (FABR). Postacute brain injury rehabilitation following acute inpatient care. FABR was incorporated in 2019 with a primary mission to advance brain rehabilitation through scientific and strategic analysis of industry-wide data. Contributing FABR member organizations include Bancroft NeuroRehab, Collage Rehabilitation Partners, On With Life, Pate NeuroRehabilitation, and Shepherd Center. These organizations contribute demographic, admission, discharge, and follow-up data on persons served in 5 types of intensive posthospital brain injury rehabilitation programs (neurobehavioral residential, neurorehabilitation residential, home and community neurorehabilitation, day treatment, and outpatient) and 3 types of supported living programs (neurobehavioral residential, residential, and community-based) to a collaborative database managed by Inventive Software Solutions. Inventive Software Solutions provides FABR researchers with a dataset that is de-identified both for participant and organizational identifying information.

Evaluation of Posthospital Brain Injury Rehabilitation Outcomes With Quasi-Experimental Controls.

To further evaluate, using quasi-experimental methodologies, posthospital brain injury rehabilitation outcomes described in an accompanying report of a large observational study (n =2120). Data from Intensive Rehabilitation (IR: Residential Neurobehavioral, Residential Neurorehabilitation, Home and Community Neurorehabilitation, Day Treatment, Outpatient Neurorehabilitation) and Supported Living (SL) programs serving individuals with acquired brain injury (ABI). Two hundred twenty-eight individuals with traumatic brain injury, stroke, or other ABI in propensity score analysis; 1344 in analysis by extent of recommended treatment completed (TC) rating. Sex, age, time since injury, Mayo-Portland Adaptability Inventory-4th edition (MPAI-4) Rasch-derived T-scores, and TC rating. Analyses of covariance (1) of discharge MPAI-4 Total, index, and subscale T-scores on propensity score-matched samples of IR and SL participants controlling for admission scores and (2) of MPAI-4 T-scores by TC rating and diagnostic category. Propensity score-matched groups showed superior outcomes for IR participants compared to SL participants on MPAI-4 Total T-score (F =77.21, P <.001; partial η2=0.257) and all MPAI-4 index and subscale T-scores controlling for sex, age, and baseline scores. Participants with traumatic brain injury and stroke who completed the recommended course of rehabilitation had superior outcomes on all MPAI-4 T-scores compared to those who completed less than or much less than the recommended treatment. No additional benefit was apparent for those who completed more than the recommended course. The association between TC rating and outcome was not significant for the other ABI group. These analyses using quasi-experimental controls provide more scientifically rigorous evidence of the benefit of IR provided through posthospital brain injury rehabilitation programs after acute inpatient care, consistent with the results of numerous observational studies. However, improved internal validity limits external validity and generalization. The absence of a significant association between TC rating and outcomes for the other ABI group most likely reflects the difficulty prescribing rehabilitation for this highly heterogeneous group.

Outcomes of Six Specific Types of Post-Hospital Brain Injury Rehabilitation Programs.

Evaluate outcomes of intensive posthospital brain injury rehabilitation programs compared to supported living (SL) programs; explore variations in outcome by diagnostic category (traumatic brain injury, stroke, and other acquired brain injury [ABI]) and specific program type. Data were obtained from Residential Neurobehavioral, Residential Neurorehabilitation, Home and Community Neurorehabilitation, Day Treatment, Outpatient Neurorehabilitation, and SL programs serving individuals with ABI. A total of 2120 individuals with traumatic brain injury, stroke, or other ABI participated in this study. The main measures are 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 and discharge. Gains on MPAI-4 Total T-scores were significantly greater for the intensive rehabilitation (IR) group in comparison to stable functioning in the SL group (F =236.69, P <.001, partial η2=.101) while controlling for admission/time 1 scores; similar results were found for MPAI-4 indices and subscales. For the IR cohort, discharge scores differed by diagnostic category after controlling for admission scores for the Total MPAI-4 T-score (F =22.65, P <.001, partial η2=.025), as well as all indices and subscales. A statistically significant interaction between program type and diagnostic group on discharge MPAI-4 Total T-scores (F =2.55, P =.018, partial η2=.01) after controlling for admission scores indicated that differing outcomes across diagnoses also varied by program type. Varying significant main effects and interactions were apparent for MPAI-4 indices and subscales with generally small effect sizes. Significant gains on MPAI-4 variables across IR program types compared to no change over a comparable period of time for SL programs supports the effectiveness of posthospital brain injury rehabilitation. This finding in the presence of small effect sizes on outcome variables for program type and for significant interactions between program type and diagnostic category suggests that participants generally were appropriately matched to program type and benefited from interventions provided through specific program types.

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.

The experiences of support staff in a traumatic brain injury rehabilitation center.

Employee turnover is a major issue for health care organizations. Burnout is a leading contributor to such turnover. Extensive research on burnout has been conducted in health care settings; however, it has primarily been focused on health care professionals ignoring other critical staff. In particular, traumatic brain injury rehabilitation is an area of health care that includes unique challenges and stressors that may contribute to burnout. Brain injury professionals report experiencing high levels of burnout that further increase as they spend more time with patients; however, little is known about the experiences of brain injury paraprofessionals. This study explores the unique experiences of support staff in traumatic brain injury rehabilitation centers. The present study used a grounded theory method to explore the phenomena of burnout, turnover, and job satisfaction from the perspective of paraprofessional support staff in 1 posthospital brain injury rehabilitation center. Support staff participated in the research via small group interviews (N = 4) and survey (N = 11). The analysis resulted in a grounded theory model, entitled "The Balance model of Rehabilitation Support Work." This model is a framework of risk and protective factors that appeared to influence whether these frontline rehabilitation staff experienced negative outcomes from this often challenging/stressful work environment. The model includes 4 axial-level themes: doing the work, protective factors, risk factors, and imbalance of factors. Within the 4 axial categories are twenty open-coding level categories. Implications for traumatic brain injury rehabilitation organizations and areas for future research are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Response to the COVID-19 Pandemic Among Posthospital Brain Injury Rehabilitation Providers

Rehabilitation after significant acquired brain injury (ABI) to address complex independent activities of daily living and return to family and community life is offered primarily after initial hospitalization in outpatient day treatment, group home, skilled nursing, and residential settings and in the home and community of the person served. The coronavirus 2019 pandemic threatened access to care and the health and safety of staff, persons served, and families in these settings. This article describes steps taken to contain this threat by 7 leading posthospital ABI rehabilitation organizations. Outpatient and day treatment facilities were temporarily suspended. In other settings, procedures for isolation, transportation, cleaning, exposure control, infection control, and use of personal protective equipment (PPE) were reinforced with staff. Visitation and community activities were restricted. Staff and others required to enter facilities were screened with symptom checklists and temperature checks. Individuals showing symptoms of infection were quarantined and tested, as possible. New admissions were carefully screened for infection and often initially quarantined. Telehealth played a major role in reducing direct interpersonal contact while continuing to provide services both to outpatients and within facilities. Salary, benefits, training, and managerial support were enhanced for staff. Despite early outbreaks, these procedures were generally effective, with preliminary initial infections rates of only 1.1% for persons served and 2.1% for staff. Reductions in admissions, services, and unanticipated expenses (eg, PPE, more frequent and thorough cleaning) had a major negative financial effect. Providers continue to be challenged to adapt rehabilitative approaches and to reopen services.

Prediction of Functional Outcome in Post-Hospital Brain Injury Rehabilitation

Post-hospital brain injury rehabilitation programs are afforded limited time to reduce chronic disability resulting from acquired brain injury. Therefore, the purpose of this study was to identify deficit areas resulting from acquired brain injury that have the greatest impact on functional outcomes to enable greater efficiency in rehabilitation programming. Study participants were 1717 persons with acquired brain injury treated in residential post-hospital rehabilitation programs. Participants were assessed at admission and discharge on the MPAI-4. Functional status at discharge was evaluated based on T-scores derived from MPAI-4 discharge participation index items: Initiation, self-care and residence. The data base of 1717 was randomly divided into two subsets. Items from admission Abilities Index and select person variables were entered into stepwise multiple regression on subset one and then in a hierarchical multiple regression on subset two. Rash analysis demonstrated satisfactory construct validity and internal consistency of admission and discharge MPAI-4 evaluations (Person reliability > 0.90, Item reliability = 0.99). Both regression analyses revealed that Mobility and Novel Problem Solving accounted for 40% of the variance in functional outcome, p < 0.001. Acquired brain injury results in a myriad of cognitive and physical impairments. Of the many possible deficits, the greatest gains in overall functional outcomes may be achieved by allocating additional treatments aimed at reducing disability in mobility and novel problem solving.

Rasch Analysis and Functional Measurement in Post-Hospital Brain Injury Rehabilitation

Rasch analysis is a statistical technique used in determining statistical properties of functional measures for use in research and treatment. The technique was used in the current study to determine the reliability and validity of the Mayo Portland Adaptability Inventory-Version 4 (MPAI-4) for use with three different acquired brain injury samples. Subjects were 777 adults (each group comprised of 259 individuals) with acquired brain injury treated in one of three rehabilitation program types: Neurorehabilitation (NR), Neurobehavioral (NB), or Supported Living (SL). The MPAI-4 was administered to each participant upon admission to program. Rasch analysis was conducted to assess item fit, reliability, and separation statistics for MPAI-4 assessments conducted within each program. Item difficulty values were examined to determine if the MPAI-4 differentiated among groups based on deficit profiles. The results revealed that for each group, fit statistics fell with appropriate levels (0.5 – 1.5) for at least 24 of 29 items. Rasch person reliability statistics were 0.89 for NR and NB, and 0.90 for SL. Item reliability was 0.99 for each of the groups. Item difficulty values accurately differentiated the three groups based on their specific deficit profiles expected. Specifically, NR participants’ greatest deficits demonstrated by the MPAI-4 were within cognitive and physical functions. For the NB participants, the greater deficits demonstrated were within the behavioral and adjustment items. Supported Living participants had the most limitation within the instrumental activities of daily living items. As in prior research findings, the current Rasch analysis supported the use of the MPAI-4 within this heterogeneous, acquired brain injury population. This unique statistical approach translates to treatment priorities that may assist clinicians with identifying treatment goals specific to unique treatment group characteristics (e.g., NR, NB, and SL).

Outcome prediction in home- and community-based brain injury rehabilitation using the Mayo-Portland Adaptability Inventory

The objective of the study was to develop statistical formulas to predict levels of community participation on discharge from post-hospital brain injury rehabilitation using retrospective data analysis. Data were collected from seven geographically distinct programmes in a home- and community-based brain injury rehabilitation provider network. Participants were 642 individuals with post-traumatic brain injury. Interventions consisted of home- and community-based brain injury rehabilitation. The main outcome measure was the Mayo-Portland Adaptability Inventory (MPAI-4) Participation Index. Linear discriminant models using admission MPAI-4 Participation Index score and log chronicity correctly predicted excellent (no to minimal participation limitations), very good (very mild participation limitations), good (mild participation limitations), and limited (significant participation limitations) outcome levels at discharge. Predicting broad outcome categories for post-hospital rehabilitation programmes based on admission assessment data appears feasible and valid. Equations to provide patients and families with probability statements on admission about expected levels of outcome are provided. It is unknown to what degree these prediction equations can be reliably applied and valid in other settings.

Post-Hospital Brain Injury Rehabilitation: Comparison of Neurobehavioral Intensity and Neurorehabilitation Outcomes

To: 1) determine outcome differences between Neurorehabilitation (NR) and Neurobehavioral (NB) clients following post-hospital brain injury rehabilitation; 2) determine effectiveness of programming to reduce symptoms of behavioral dyscontrol among NB individuals; 3) identify predictors of independent functioning for each group.