Traumatic Brain Injury Rehabilitation Services Research Articles

Neuropsychological functioning predicts psychosocial adjustment after postacute rehabilitation for traumatic brain injury.

To examine neuropsychological functioning as a predictor of psychosocial adjustment difficulties at discharge from a postacute residential rehabilitation facility for traumatic brain injury (TBI) and depression as a potential mediator. A retrospective record review was conducted of 172 adults who received rehabilitation services for TBI. Individuals completed a full battery of neuropsychological tests, depression assessment, and functional assessments at admission. Functional assessments were also obtained at discharge. A two-phase structural equation model analysis was performed. The first phase specified a good fitting model of a cognitive functioning (CF) latent construct with four indicators of cognitive domains measuring verbal fluency, cognitive flexibility, verbal learning, and working memory. Worse CF was associated with greater psychosocial adjustment impairment at discharge, but not related to depression. Psychosocial adjustment impairment at admission was positively associated with depression when controlling for CF, however depression did not predict psychosocial adjustment at discharge. Thus, depression was not found to be a significant mediator of psychosocial adjustment impairment at discharge. Results provide support for neuropsychological functioning at the start of postacute rehabilitation for TBI as an important predictor of psychosocial functioning difficulties that remain upon discharge and highlights the need to examine mechanisms beyond depression.

Acute Imaging Findings Predict Recovery of Cognitive and Motor Function after Inpatient Rehabilitation for Pediatric Traumatic Brain Injury: A Pediatric Brain Injury Consortium Study.

Traumatic brain injury (TBI) is a major cause of morbidity and mortality in children; survivors experience long-term cognitive and motor deficits. To date, studies predicting outcome following pediatric TBI have primarily focused on acute behavioral responses and proxy measures of injury severity; unsurprisingly, these measures explain very little of the variance following heterogenous injury. In adults, certain acute imaging biomarkers help predict cognitive and motor recovery following moderate to severe TBI. This multi-center, retrospective study, characterizes the day-of-injury computed tomographic (CT) reports of pediatric, adolescent, and young adult patients (2 months to 21 years old) who received inpatient rehabilitation services for TBI (n = 247). The study also determines the prognostic utility of CT findings for cognitive and motor outcomes assessed by the Pediatric Functional Independence Measure, converted to age-appropriate developmental functional quotient (DFQ), at discharge from rehabilitation. Subdural hematomas (66%), contusions (63%), and subarachnoid hemorrhages (59%) were the most common lesions; the majority of subjects had less severe Rotterdam CT scores (88%, ≤ 3). After controlling for age, gender, mechanism of injury, length of acute hospital stay, and admission DFQ in multivariate regression analyses, the highest Rotterdam score (β = -25.2, p < 0.01) and complete cisternal effacement (β = -19.4, p < 0.05) were associated with lower motor DFQ, and intraventricular hemorrhage was associated with lower motor (β = -3.7, p < 0.05) and cognitive DFQ (β = -4.9, p < 0.05). These results suggest that direct detection of intracranial injury provides valuable information to aid in prediction of recovery after pediatric TBI, and needs to be accounted for in future studies of prognosis and intervention.

The utility of the Modified Mini-Mental State Examination in inpatient rehabilitation for traumatic brain injury: preliminary findings

ABSTRACT Objective The Modified Mini-Mental State Examination (3MS) could provide useful information about cognitive status in traumatic brain injury (TBI), yet has not been validated in this population. We studied the reliability, construct validity, clinical responsiveness, and cognitive impairment classification-ability of the 3MS compared to the Mini-Mental State Examination (MMSE). Methods Adult participants receiving inpatient rehabilitation services for TBI were administered the 3MS and MMSE at admission and discharge (n = 72). Construct validity and classification agreement were assessed through relationships of each measure with cognitive items of the Functional Independence MeasureTM (FIM) and rehabilitation length of stay (LOS). Results 3MS reliability at admission and discharge (Cronbach’s alphas = .871 and .839, respectively) exceeded that for the MMSE (Cronbach’s alpha = .748 and .653, respectively). 3MS construct validity was marginally better than for the MMSE as assessed through correlations with FIM cognitive scores and LOS. Standard error of measurement as a percentage of the total scale was lower for the 3MS; responsiveness of the 3MS was superior as assessed by the 95% confidence interval for minimal detectable change. Cognitive impairment classification-ability was superior for the 3MS. Conclusions While both instruments had reasonable psychometric properties, the 3MS had a superior psychometric profile in the acute phase of TBI.

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

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

Trajectories of Functional Change After Inpatient Rehabilitation for Traumatic Brain Injury

ObjectiveTo examine trajectories of functional recovery after rehabilitation for traumatic brain injury (TBI). DesignProspective study. SettingInpatient rehabilitation hospitals in the Uniform Data System for Medical Rehabilitation. ParticipantsA subset of individuals receiving inpatient rehabilitation services for TBI from 2002 to 2010 who also had postdischarge measurement of functional independence (N=16,583). InterventionsInpatient rehabilitation. Main Outcomes MeasuresAdmission, discharge, and follow-up data were obtained from the Uniform Data System for Medical Rehabilitation. We used latent class mixture models to examine recovery trajectories for both cognitive and motor functioning as measured by the FIM instrument. ResultsLatent class models identified 3 trajectories (low, medium, high) for both cognitive and motor FIM subscales. Factors associated with membership in the low cognition trajectory group included younger age, male sex, racial/ethnic minority, Medicare or Medicaid (vs commercial or other insurance), comorbid conditions, and greater duration from injury date to rehabilitation admission date. Factors associated with membership in the low motor trajectory group included older age, racial/ethnic minority, Medicare or Medicaid coverage, comorbid conditions, open head injury, and greater duration to admission. ConclusionsStandard approaches to assessing recovery patterns after TBI obscure differences between subgroups with trajectories that differ from the overall mean. Select demographic and clinical characteristics can help classify patients with TBI into distinct functional recovery trajectories, which can enhance both patient-centered care and quality improvement efforts.

The PQRS-Montreal: a measure of patients’ perceptions of the quality of rehabilitation services for persons with a traumatic brain injury

Purpose To determine the factorial validity, internal consistency, criterion-related and concurrent validity of the Perception of Quality of Rehabilitation Services – Montreal (PQRS-Montreal) questionnaire for persons receiving traumatic brain injury (TBI) rehabilitation services. Design Cross-sectional study. Setting Seventeen facilities providing acute care and intensive inpatient and outpatient TBI adult rehabilitation. Participants Five-hundred thirty adults (GCS = 3–15; mean age = 41.5 ± 16.9 years) who received rehabilitation were administered the questionnaire during an interview near time of discharge. Subjects responded to the 61 PQRS-Montreal items (five-point scale of agreement) and to the Client Satisfaction Question (CSQ8). Results Exploratory and confirmatory factor analyses identified three potential subscales (one- and two-factor solutions) explaining 26.1–41% of the variance (ecological approach, quality of team, service organization). The subscales’ internal structures were interpretable and their internal consistency varied from 0.51 to 0.90 (Cronbach’s α). Rehabilitation phase significantly and positively impacted factor scores and all factor scores were significantly and moderately correlated with CSQ8 scores. Conclusions The PQRS-Montreal possesses adequate psychometric properties supporting its use as a valid tool to measure patients’ perception of the quality of TBI rehabilitation services. This tool could help guide the development and monitoring of TBI rehabilitation service delivery. Implications for RehabilitationThe importance of measuring and monitoring quality of care is increasingly important in rehabilitation.Using the experiences and perceptions of care of service users is a valid way of assessing the quality of rehabilitation services.The PQRS-Montreal has adequate psychometric properties supporting its use as a valid tool to measure patients’ perception of the quality of TBI rehabilitation services.This tool could help guide the development and monitoring of TBI rehabilitation service delivery.

Mental health disorders after traumatic brain injury in a New Zealand caseload

Primary objective: This study investigated psychological disorders for patients receiving traumatic brain injury (TBI) rehabilitation within a community-based TBI service in New Zealand.Research design: Cross-sectional study involving retrospective review of clinical notes for all referrals received in a 6-month period. This methodology was selected to gain a sample of individuals reflective of the range of patients seen in TBI rehabilitation services in New Zealand.Methods and procedures: The clinical records for 279 patients were reviewed for formal psychiatric diagnoses and references to moderate or severe psychological symptoms.Main outcomes and results: Of the clinical records, 57.7% noted significant psychological problems post-injury (n = 161) and 8.6% had a psychiatric diagnosis recorded, with 10.8% reporting psychological disorders pre-injury. In comparison, 15.1% had input from a clinical psychologist and 2.2% had involvement from a mental health team.Conclusions: The rate of psychological symptoms was significantly higher post-TBI than pre-TBI and few of the patients reporting significant psychological symptoms were receiving intervention from mental health professionals. Further research is needed regarding the ability of TBI rehabilitation professionals in New Zealand to identify and respond to the psychological implications of TBI and on the ability of TBI and mental health teams to liaise effectively.

Facial affect recognition difficulties in traumatic brain injury rehabilitation services

Primary objective: The occurrence of facial affect recognition difficulties in a sample of people accessing traumatic brain injury (TBI) rehabilitation services was examined. It was hypothesized that between 13–39% of participants would demonstrate clinically significant impairment in facial affect recognition.Research design: Cross-sectional sample of eligible participants who were current clients of eight brain injury services were invited to participate.Methods and procedures: Forty-five participants with mild-to-severe TBI were assessed for facial affect recognition difficulties using the facial affect discrimination, naming, selection and matching sub-tests of the Florida Affect Battery.Main outcomes and results: Fifty-one per cent of participants had at least moderate difficulties with facial affect recognition.Conclusions: The current sample was not a random selection from the population of people with TBI, so the results do not establish a formal estimate of prevalence. Nonetheless, the data indicate that when assessing typical clients with severe brain injuries presenting to neurorehabilitation services, there is likely to be a high frequency of occurrence of facial affect recognition difficulties. Rehabilitation outcomes may be improved by screening for and treating facial affect recognition difficulties following TBI. Further examination and development of treatment options is warranted.

Poster 44 The Utility of the Modified Mini-Mental State Examination in Inpatient Rehabilitation for Traumatic Brain Injury

The Modified Mini-Mental State Examination (3MS) could provide useful information about cognitive status in traumatic brain injury (TBI), yet has not been validated in this population. We studied the association of the 3MS with inpatient rehabilitation functional status compared to the Mini-Mental State Examination (MMSE), and the ability of the 3MS to assist with predicting length of stay (LOS). Patients receiving inpatient rehabilitation for TBI were consecutively approached to participate. Participants were administered the 3MS, MMSE, and Functional Independence Measure (FIM) at admission and discharge. Inpatient rehabilitation facility. Male and female patients receiving inpatient rehabilitation services for TBI. Not applicable. 3MS, MMSE, FIM, LOS. The admission 3MS had stronger correlations with admission FIM total, cognitive, and motor scores (r = .72, .76, .56, respectively; all p < .005) than the MMSE. The discharge 3MS had stronger correlations with discharge FIM total, cognitive, and motor scores (r = .86, .73, .68, respectively; all p < .001) than the MMSE. Prediction of LOS was significantly improved with admission 3MS included as a predictor with admission FIM (R^2 change from .53 to .64). Construct validity of the 3MS in a TBI sample was illustrated through significant correlations with the FIM. The 3MS can provide clinicians with more specific information about patterns of cognitive deficits than the cognitive FIM items, which could inform treatment. The improved accuracy in predicting LOS by combining admission 3MS scores with admission FIM scores can be useful for resource planning.

Effectiveness of Rehabilitation in Enhancing Community Integration After Acute Traumatic Brain Injury: A Systematic Review

We assessed evidence for post-acute traumatic brain injury (TBI) rehabilitation interventions used to enhance community integration (CI) relevant to occupational therapy. We conducted a systematic review of intervention studies on TBI rehabilitation from 1990 to 2007. We analyzed and summarized 10 studies that met the inclusion criteria. Of 10 studies, 7 found that post-acute TBI rehabilitation benefits CI; all effective studies involved occupational therapy or involved interventions occupational therapists can do. Many CI programs show positive results and should be studied more rigorously. Such promising programs should also be considered when decisions about post-acute TBI rehabilitation services for clients are being made. To further establish that post-acute TBI rehabilitation interventions improve CI, future studies should include intervention strategies based on injury severity, a control group, and longer term follow-up. The role of occupational therapy in these effective programs should be further explored.

Poster 9: Does Depression Influence Persons' Perception of the Quality of Traumatic Brain Injury Rehabilitation Services?

Objective: To explore the relation between the level of depression and the perception of the quality of rehabilitation services for persons with traumatic brain injury (TBI). Design: Cross-sectional. Setting: Rehabilitation facilities in Quebec, Canada. Participants: 30 adults (21 men; mean age, 41.8y) with TBI (all severities) receiving rehabilitation. Interventions: Subjects responded to questionnaires during a 40-minute interview at rehabilitation discharge: 61-item Perception of Quality of Rehabilitation Services−Montreal Questionnaire (PQRS-Montreal) and the Beck Depressive Inventory−II (BDI-II).

Ethnic Differences in Discharge Destination Among Older Patients With Traumatic Brain Injury

Chang P-F, Ostir GV, Kuo Y-F, Granger CV, Ottenbacher KJ. Ethnic differences in discharge destination among older patients with traumatic brain injury. Objective To estimate the association between ethnicity and discharge destination in older patients with traumatic brain injury (TBI). Design A retrospective analysis. Setting Nationally representative sample of older patients from the Uniform Data System for Medical Rehabilitation in 2002 and 2003. Participants Patients (N=9240) aged 65 years or older who received inpatient rehabilitation services for TBI. Interventions Not applicable. Main Outcome Measures Discharge destination (home, assisted living facility, institution) and ethnicity (white, black, Hispanic). Results Multinomial logit models showed that older Hispanics (odds ratio [OR]=2.24; 95% confidence interval [CI], 1.66–3.02) and older blacks (OR=2; 95% CI, 1.55–2.59) with TBI were significantly more likely to be discharged home than older whites with TBI, after adjusting for relevant risk factors. Older blacks were also 78% less likely (OR=.22; 95% CI, .08–.60) to be discharged to an assisted living facility than whites after adjusting for relevant risk factors. Conclusions Our findings indicate that older minority patients with TBI were significantly more likely to be discharged home than white patients with TBI. Studies are needed to investigate underlying factors associated with this ethnic difference.

Mood disorders following traumatic brain injury: identifying the extent of the problem and the people at risk

The extent of mood disorders following traumatic brain injury (TBI), and the possible risk factors, are investigated. New data are presented from a prospective study of consecutive hospital admissions. Six months post-TBI, 99 adults completed a standardized assessment of emotional state, the Wimbledon Self-Report Scale. Cognitive performance and the impact of the injury on everyday functioning were also assessed. The rate of clinically significant mood disorders (caseness) was 38%. Of the demographic or injury characteristics, only pre-injury occupational status predicted post-injury caseness. Those unoccupied pre-injury were more likely to report mood disturbances post-injury. In contrast, post injury occupational status was not related to caseness either for the whole group or the subgroup of those previously occupied, despite the adverse effects on occupational functioning for a significant proportion of subjects. Associations were found between emotional state and cognitive and everyday functioning 6 months post-injury. Psychosocial disabilities appeared more strongly associated to mood disorders than did physical disabilities. A significant level of unmet need has been highlighted, and possible risk factors identified, which may inform the purchase and provision of TBI rehabilitation services. Follow-up data on these subjects are available and will be reported separately.