Post-acute Brain Injury Rehabilitation Research Articles

An Observational Cohort Study of the Role of Level of Effort in Post-Acute Brain Injury Rehabilitation

ObjectiveTo investigate the role of participant level of effort (LoE) on outcome in post-acute brain injury rehabilitation with the hypothesis that greater effort is associated with more positive outcomes. DesignObservational cohort study. SettingComprehensive integrated rehabilitation program for brain injury within a skilled nursing facility. ParticipantsConsecutive admissions with acquired brain injury (N=101). InterventionsIndividualized interdisciplinary brain injury rehabilitation; therapist rating of participant LoE with Acquired Brain Injury LoE Scale (ABI-LoES) during physical therapy, occupational therapy, and speech and language pathology sessions. Main Outcome MeasuresMayo-Portland Adaptability Inventory, fourth edition (MPAI-4); Supervision Rating Scale (SRS). ResultsLinear regression showed that discharge MPAI-4 Total T scores were significantly associated with mean ABI-LoES rating, admission MPAI-4 Total T scores, age at admission, and days from injury but not with standard deviation of ABI-LoES rating, sex, injury type, length of stay, or treatment before or during the COVID-19 pandemic. Discharge SRS scores were significantly associated with mean ABI-LoES rating, admission SRS scores, and age. A 1-unit increase in mean ABI-LoES rating was associated with 5.1-unit lower discharge MPAI-4 Total T scores and 1.5 lower discharge SRS scores, after controlling for other variables. Logistic regression showed that the odds of achieving a minimal clinically important difference on the MPAI-4 were 8.34 times higher with each 1-unit increase in mean ABI-LoES rating after controlling for other variables. Admission MPAI-4 was negatively associated with mean ABI-LoES rating (β=−0.07, t=−8.85, P<.0001). ConclusionsAfter controlling for nonmodifiable variables, average ABI-LoES rating is positively associated with outcome. Initial level of disability is negatively associated with mean ABI-LoES rating.

The Behavioural Assessment of Self-Structuring (BASS): A Factor Analysis in a Post-Acute Brain Injury Rehabilitation Programme

Research has indicated structure and a client’s ability to self-structure is integral to post-acute brain injury rehabilitation. Self-structuring has previously been theorised to include components referred to as Anchors, Scaffolding, and Strategies. A reliable and validated measure of self-structuring – The Behavioural Assessment of SelfStructuring (BASS) – was used in the current study aimed to identify possible sub-groups of the scale and further explore construct validity. 197 consecutive admissions to the Transitional Rehabilitation Units (TRU) were assessed using the BASS and the results were subjected to a varimax rotation factor analysis. Four factors were revealed, all of which could be related to the theoretical model of self-structuring including Systems (Scaffolding), Routines (Anchors), Awareness and Self-Regulation (both emerging as two sub-divisions of Strategies). Despite orthogonality, all four factors were highly correlated. Only age at brain injury and cause of brain injury showed a significant relationship with Awareness (Strategies), Routines (Anchors), and Systems (Scaffolding). No significant relationship was found for gender, age at admission or length of admission. In conclusion, the findings are consistent with previous research and confirm theoretical models of self-structuring. Further insight has been gained into the complexities of self-structuring as the results propose compelling evidence that the 26-items of the BASS can now be sub-divided into four distinct sub-categories: Awareness, Systems, Routines, and Self-Regulation. Sub-categories can now be utilised to identify individual strengths and areas of weakness within self-structuring. This can inform the adaptation of neurorehabilitation programmes or approaches dependent on client need, and change in scores could be evaluated over time.

Role of Self-Awareness in Initiation and Social Engagement During Post-Acute Outpatient Brain Injury Rehabilitation

Role of Self-Awareness in Initiation and Social Engagement During Post-Acute Outpatient Brain Injury Rehabilitation

Injury Severity and Depressive Symptoms in a Post-acute Brain Injury Rehabilitation Sample.

This study explored the relationship between injury severity and depressive symptoms for treatment-seeking individuals with traumatic brain injury (TBI). The Mayo Classification System was used to classify TBI severity in 72 participants who completed the Patient Health Questionnaire at admission and at dismissal from rehabilitation. Patients with mild TBI reported more depressive symptoms than those with moderate or severe TBI at admission and at dismissal. Although injury severity groups differed by gender composition, gender had no effect on severity of depressive symptoms. All participants reported fewer depressive symptoms at dismissal from rehabilitation, including lower endorsement of dysphoria by discharge. Participants with mild TBI, however, continued to report depressive symptoms of a mild severity at dismissal, with residual problems with anhedonia. These findings underscore the benefit of interdisciplinary post-acute rehabilitation services for persons with TBI of any severity, including those with mild injury.

Reduction in Post-concussive Symptom Severity Following Sub-Acute Interdisciplinary Cognitive Rehabilitation

To determine the utility of a structured, interdisciplinary, post-acute brain injury rehabilitation program in addressing persisting symptoms of brain injury.

Areas of Functional Recovery and Return to Work Following Milieu-Oriented Post-Acute Brain Injury Rehabilitation

Areas of Functional Recovery and Return to Work Following Milieu-Oriented Post-Acute Brain Injury Rehabilitation

Family needs at a post-acute rehabilitation setting and suggestions for supports

Objective: To explore the perceived needs, obstacles to services, psychological distress and social problem-solving abilities of family members of persons with ABI at a post-acute community-based brain injury rehabilitation facility and offer suggestions for methods of assessment and providing support.Participants: Twenty-nine family members who did not provide daily care, but were involved in the care process.Design: Participants completed self-report questionnaires including the FNQ:R, SOS, DASS-21, WHO-QOL BREF and SPSI:R-S.Results: Participants reported informational and professional needs as most met and involvement in care, instrumental support and emotional support as most unmet. Most were satisfied with the amount of professional help and services and had confidence in the quality of care. Nearly half of the family members felt there were few ABI-related resources in the community and one third were unaware of good ABI treatment resources in their community. Psychosocial functioning was generally average.Conclusion: Family members who do not provide daily care are still impacted by the neurobehavioural changes that progress throughout the long-term, post-acute community phase. This study offers suggestions regarding an effective methodology for assessing family needs and recommends accessible and practical supports.

Effect of Focused Behavior Intervention on Durability of Outcomes in Post-Acute Brain Injury Rehabilitation

Effect of Focused Behavior Intervention on Durability of Outcomes in Post-Acute Brain Injury Rehabilitation

Reliability and Validity of the PERPOS for Post-Acute Brain Injury Rehabilitation

Reliability and Validity of the PERPOS for Post-Acute Brain Injury Rehabilitation

Prescribing practice and off-label use of psychotropic medications in post-acute brain injury rehabilitation centres: A cross-sectional survey

Objective: Guidance on pharmacotherapy of neurobehavioural sequelae post-acquired brain injury (ABI) is limited. Clinicians face the choice of prescribing off-label. This survey assesses prescribing practice and off-label use of psychotropic medications in Italian brain injury rehabilitation centres and factors associated with atypical antipsychotics use.Materials and methods: Centres were identified through the roster of the Italian Society for Rehabilitation Medicine. Information was collected through a structured questionnaire. This study calculated the prevalence of centres reporting to use off-label individual medications and unconditional logistic regression Odds Ratio (OR), with 95% confidence interval (95% CI) of atypical antipsychotics use.Results: Psychotropic medications were commonly used. More than 50% of the 35 centres (participation ratio 87.5%) reported to use off-label selected antipsychotics, mostly for agitation (90.5%) and behavioural disturbances (19.0%), and antidepressants, mostly for insomnia (37.5%) and pain (25.0%). Atypical antipsychotic use was directly associated with age <40 years (OR = 2.68; 95% CI = 1.25–5.76), recent ABI (1.74; 0.74–4.09), not with reported off-label use (0.98; 0.44–2.18).Conclusion: In clinical practice, the effectiveness and safety of medications, in particular off-label, should be systematically monitored. Studies are needed to improve the quality of evidence guiding pharmacotherapy and to evaluate effectiveness and safety of off-label prescribing.

C-70 * Brain Injury Rehabilitation and Cognitive Therapy: A Program Evaluation of Outcomes

Objective: This study sought to examine the effects of the implementation of cognitive therapy program changes on patient outcomes in a post-acute care inpatient facility for brain injury rehabilitation. These changes include the implementation of a new cognitive therapy program, facilitated by licensed clinicians, that assesses and treats neurocognitive deficits in patients with brain injuries by using empirically supported techniques and individualized approaches in rehabilitation. Method: Data were collected on 548 residents at an inpatient post-acute care brain injury rehabilitation facility. The outcomes were evaluated using the Mayo-Portland Adaptability Inventory (MPAI) and the Level of Observation Tool (LOOT). The data were collected for two years prior to the implementation of the new program and for 2 years afterwards, between 2010–2013. The information was collected from persons with both traumatic and acquired brain injuries. Results: Measures of ability on the MPAI were significant (p < 0.05) and level of supervision required according to the LOOT approached significance (p = 0.053). These results were for the entire sample and TBI's, right and left CVA's, hypoxia/encephalopathy will be looked at separately. Conclusion(s): These findings show support for cognitive therapy in post-acute brain injury rehabilitation when treatment is facilitated by trained professionals who use empirically supported interventions and address deficits through individualized treatment planning approaches. The implementation of these changes has resulted in significant reduction in the level of care a patient requires post-treatment, as reflected by the improved patient outcomes in terms of their ability as reflected in the MPAI. NEUROPSYCHOLOGICAL DOMAINS: ATTENTION

Structure to self-structuring: infrastructures and processes in neurobehavioural rehabilitation.

The importance of structure in post-acute brain injury rehabilitation is repeatedly mentioned in clinical practice. However, there has been little exploration of the key elements of structure that promote greater levels of functioning and emotional/behavioural stability and how these elements are optimally integrated within the infrastructure of a rehabilitation service. The nature of structure and why it is helpful is explored initially. Thereafter, the processes involved in transition from externally supported structure to the client 'self-structuring' are described. The infrastructure for facilitating these transitional processes are considered in terms of the design of services for systemic neurorehabilitation encompassing environmental factors (e.g. living environments, vocational and recreational options, step-up services and social milieus), therapeutic alliances (rehabilitation professionals, family, friends), organisational structures (service delivery, rehabilitation coaching, transdisciplinary teams) and rehabilitation philosophies and practice. It is concluded that the process of supporting individuals to transition from the 'structure' of the environment and other people towards self-structuring skills is a critical process in rehabilitation. This is reliant upon a comprehensive and robust organisational infrastructure that can successfully and flexibly integrate the core elements of structure across a transitional pathway towards increased independence and self-structuring.

Post-traumatic growth, illness perceptions and coping in people with acquired brain injury

Post-traumatic growth is a process by which an individual who has faced a significantly adverse and life-altering event, can show evidence of an ability meaningfully to construe benefits from such adversity. The purpose of this study was to investigate, in a sample of people with acquired brain injury (ABI), the contribution of illness perceptions, distress, disability, and coping strategies and health to post-traumatic growth. Seventy people with an ABI took part in this cross-sectional investigation, comprising 70% males and 30% females. Traumatic brain injury accounted for the majority of brain injuries (56%), with 31% arising from a cerebrovascular accident and the remaining 13% arising from hypoxia, brain tumours, brain abcesses and encephalitis. The average time since injury was 70.43 months (SD = 55.30, range = 7–350). Participants completed assessments comprising post-traumatic growth (Post-traumatic Growth Inventory), beliefs about their condition (Illness Perception Questionnaire Revised), coping strategies (Brief COPE), anxiety and depression (Hospital Anxiety and Depression Scale) and functional disability (Functional Independence Measure and Functional Assessment Measure). All participants were accessing post-acute brain injury rehabilitation and support services. Results showed that greater levels of post-traumatic growth were associated with greater use of adaptive coping strategies (r=.597), lower levels of distress (r = –.241) and stronger beliefs about treatment-induced controllability of the effects arising from brain injury (r=.263). Greater use of adaptive coping strategies accounted for the greater proportion of the variance in post-traumatic growth (sr 2 = 0.287) and was the only variable found to make a unique and statistically significant contribution to the prediction of growth. Illness perceptions more generally were not significantly associated with growth experiences. This study provides additional evidence of the factors associated with the process of post-traumatic growth, in particular adaptive coping strategies that may help to facilitate growth, although the direction of this relationship requires further empirical investigation. The findings of this study may have implications for professionals providing neurorehabilitation services.

Balint's syndrome and post-acute brain injury rehabilitation: A case report

Background: Balint's syndrome includes the clinical symptom triad of simultagnosia, ocular apraxia and optic ataxia. These symptoms, in combination, are rare and can be quite debilitating as they impact visuospatial skills, visual scanning and attentional mechanisms.Case Study: The literature addressing rehabilitation of individuals with Balint's syndrome is sparse. The current case report describes the outcome of a 58-year old male who presented with Balint's syndrome secondary to severe traumatic brain injury and following completion of a comprehensive post-acute brain injury rehabilitation programme. The patient was 4-months post-injury onset upon admission and received 6 months of rehabilitation services as an inpatient. The patient's comprehensive rehabilitation programme involved a 3-pronged approach including the implementation of (a) compensatory strategies, (b) remediation exercises and (c) transfer of learned skills in multiple environments and situations with implementation of psychoeducation and psychotherapy. Comprehensive neuropsychological and occupational therapy evaluations were performed at admission and at discharge in order to monitor cognitive, affective, neurological and functional change over time.Conclusions: Neuropsychological test improvements were noted on tasks that assess visuospatial functioning, although most gains were noted for functional and physical abilities.

Ecological validity of the screening module and the Daily Living tests of the Neuropsychological Assessment Battery using the Mayo-Portland Adaptability Inventory-4 in postacute brain injury rehabilitation.

The assessment of ecological validity of neuropsychological measures is an area of growing interest, particularly in the postacute brain injury rehabilitation (PABIR) setting, as there is an increasing demand for clinicians to address functional and real-world outcomes. In the current study, we assessed the predictive value of the Screening module and the Daily Living tests of the Neuropsychological Assessment Battery (NAB) using clinician ratings from the Mayo-Portland Adaptability Inventory-4 (MPAI-4) in patients with moderate to severe traumatic brain injury. Forty-seven individuals were each administered the NAB Screening module (NAB-SM) and the NAB Daily Living (NAB-DL) tests following admission to a residential PABIR program. MPAI-4 ratings were also obtained at admission. Linear regression analysis was used to examine the association between these functional and neuropsychological assessment measures. We replicated prior work (Temple at al., 2009) and expanded evidence for the ecological validity of the NAB-SM. Furthermore, our findings support the ecological validity of the NAB-DL Bill Payment, Judgment, and Map Reading tests with regards to functional skills and real-world activities. The current study supports prior work from our lab assessing the predictive value of the NAB-SM, as well as provides evidence for the ecological validity for select NAB-DL tests in patients with moderate to severe traumatic brain injury admitted to a residential PABIR program.

Effectiveness of Community-Based Rehabilitation After Traumatic Brain Injury for 489 Program Completers Compared With Those Precipitously Discharged

Altman IM, Swick S, Parrot D, Malec JF. Effectiveness of community-based rehabilitation after traumatic brain injury for 489 program completers compared with those precipitously discharged. Objective To evaluate outcomes of home- and community-based postacute brain injury rehabilitation (PABIR). Design Retrospective analysis of program evaluation data for treatment completers and noncompleters. Setting Home- and community-based PABIR conducted in 7 geographically distinct U.S. cities. Participants Patients (N=489) with traumatic brain injury who completed the prescribed course of rehabilitation (completed-course-of-treatment [CCT] group) compared with 114 who were discharged precipitously before program completion (precipitous-discharge [PD] group). Intervention PABIR delivered in home and community settings by certified professional staff on an individualized basis. Main Outcome Measures Mayo-Portland Adaptability Inventory (MPAI-4) completed by means of professional consensus on admission and at discharge; MPAI-4 Participation Index at 3- and 12-month follow-up through telephone contact. Results Analysis of covariance (CCT vs PD group as between-subjects variable, admission MPAI-4 score as covariate) showed significant differences between groups at discharge on the full MPAI-4 (F=82.25; P<.001), Ability Index (F=50.24; P<.001), Adjustment Index (F=81.20; P<.001), and Participation Index (F=59.48; P<.001). A large portion of the sample was lost to follow-up; however, available data showed that group differences remained statistically significant at follow-up. Conclusions Results provided evidence of the effectiveness of home- and community-based PABIR and that treatment effects were maintained at follow-up.

Poster 3: Effectiveness of Community-Based Rehabilitation After Traumatic Brain Injury for 489 Program Completers Compared to Those Precipitously Discharged

Objective: To evaluate outcomes of home- and community-based postacute brain injury rehabilitation. Design: Retrospective analysis of program evaluation data for treatment completers and noncompleters. Setting: Home- and community-based postacute brain injury rehabilitation conducted in 7 geographically distinct U.S. cities. Participants: 489 individuals with traumatic brain injury who completed the prescribed course of rehabilitation (CR) compared to 114 who were precipitously discharged prior to program completion (PD). Interventions: Postacute brain injury rehabilitation delivered in home- and community-settings by certified professional staff on an individualized basis. Main Outcome Measures: Mayo-Portland Adaptability Inventory (MPAI-4) completed by professional consensus on admission and at discharge; MPAI-4 Participation Index at 3- and 12-month follow-up through telephone contact. Results: Analysis of covariance (CR vs PD = between-subjects variable; admission MPAI-4 score = covariate) showed significant differences between groups at discharge on the full MPAI-4 (F=82.25, P<.0001), Abilities Index (F=50.24, P<.0001), Adjustment Index (F=81.20, P<.0001), and Participation Index (F=59.48, P<.0001). A large portion of the sample was lost to follow-up; however, available data showed group differences remained statistically significant at follow-up. Conclusions: Results provide evidence of the effectiveness of home- and community-based postacute brain injury rehabilitation and that treatment effects are maintained at follow-up.

Poster 7: Use of Functional Near Infrared Spectroscopy to Assess Changes in Prefrontal Activation Associated With Recovery of Response Inhibition Following Traumatic Brain Injury

Objective: To determine the relationship of prefrontal cerebral activation to inhibitory control following traumatic brain injury and to assess the relationship of improvements in inhibitory control to increased prefrontal activation as a function of recovery. Design: Mixed design with repeated measures taken weekly. Setting: Functional near infrared spectroscopy (fNIRS) lab in a postacute brain injury rehabilitation clinic. Participants: Patients (n=16) with subacute severe traumatic brain injury (TBI) and age-matched controls (n=16). Interventions: All subjects performed a modified computerized Stroop task while measures of cerebral activation were obtained via a 3 × 11 optode configuration covering anterior temporal and frontal cerebral regions. Main Outcome Measures: Errors during performance of the Stroop task and measures of cerebral activation assessed by relative oxyhemoglobin concentrations obtained in one tenth second intervals. Results: Controls demonstrated significantly fewer Stroop errors (P<.01) and greater prefrontal activation (P<.01) compared with patients during the first week. By the third week, there were no significant differences between groups for either the number of Stroop errors or for prefrontal cerebral activation. Further analyses revealed that patients demonstrated significantly fewer Stroop errors (P<.01) and greater prefrontal activation (P<.01) by the third week. Conclusions: Improved inhibitory control was observed over a 3-week period for patients with severe TBI. This improved control appeared to be related to increased prefrontal activation. Although recovery is thought to have been the major reason for this improvement, practice effects due to repeated trials cannot be ruled out. This latter point is of note, since use of fNIRS may provide a useful procedure for assessing brain activation related change as a function of rehabilitation. Future research should assess changes in cerebral activation with fNIRS as related to specific rehabilitation approaches.

Measuring perceived difficulty in post-acute brain injury rehabilitation: The Sister Kenny Symptom Management Scale

Primary objective: Patients’ perceptions of difficulty managing symptoms contribute to disability after brain injury. This study introduces the Sister Kenny Symptom Management Scale (KSMS) and reports on its factor structure, reliability, validity and clinical value.Method: Archived data from (overlapping) samples of patients with brain injuries of mixed aetiologies, seen at an outpatient clinic over 16 years were used in development and validation studies of the KSMS. Comparison measures included the Profile of Mood States (POMS), neuropsychological test scores and employment.Results: Factor analysis of 34 items (n = 328) identified five sub-scales with satisfactory internal consistency and test–re-test stability representing difficulty with executive functions, language, recent memory, aggressive behaviour and physical symptoms. A pattern of correlations (n = 336) with Profile of Mood States (POMS) sub-scales of similar and different content supported the concurrent validity of KSMS sub-scales. Only the Memory sub-scale correlated with its test index. The Language score and test index approached significance. The Executive sub-scale did not. Hierarchical regression analysis (n = 102) that included ratings of mood and symptom management showed that employment after discharge was only predicted by post-treatment ratings of difficulty with cognitive functions.Conclusion: Self-assessments of difficulty managing symptoms can be reliably assessed and may contribute to understanding patients’ disability, treatment response and future prospects.

Changes in supervision needs following participation in a residential post-acute brain injury rehabilitation programme

Objective: Supervision needs typically increase following moderate-to-severe traumatic brain injury (TBI). Research assessing the impact of TBI residential rehabilitation programmes on supervision needs is limited.Research design: Prospective cross-sectional study.Methods and procedures: Ninety-four participants with moderate-to-severe TBI admitted to a post-acute brain injury rehabilitation programme (PABIR) were administered the supervision rating scale (SRS) at admission and at 1 month post-discharge. To account for spontaneous neurological recovery, patients were separated into those who were less than 1 year (L1Y, n = 55) or greater than 1 year (G1Y, n = 39) post-injury.Experimental intervention: None.Main outcomes and results: A mixed factorial design yielded a significant interaction (F(1, 92) = 18.2; p < 0.0001) with post-hoc results revealing that the L1Y group improved more dramatically in terms of supervision needs than the G1Y group. Using reliable change methodologies, 52.7% of the L1Y demonstrated decreasing scores on the SRS vs 20.5% of the G1Y group.Conclusions: Decreases in supervision needs following PABIR can be found, even after accounting for the impact of spontaneous neurological recovery both at the group and individual level.