Patient Effort in Traumatic Brain Injury Inpatient Rehabilitation: Course and Associations With Age, Brain Injury Severity, and Time Postinjury

doi:10.1016/j.apmr.2014.10.027

Archives of Physical Medicine and Rehabilitation

Volume 96, Issue 8, Supplement, August 2015, Pages S235-S244

https://doi.org/10.1016/j.apmr.2014.10.027 Get rights and content

Abstract

Objective

To describe patients' level of effort in occupational, physical, and speech therapy sessions during traumatic brain injury (TBI) inpatient rehabilitation and to evaluate how age, injury severity, cognitive impairment, and time are associated with effort.

Design

Prospective, multicenter, longitudinal cohort study.

Setting

Acute TBI rehabilitation programs.

Participants

Patients (N=1946) receiving 138,555 therapy sessions.

Interventions

Not applicable.

Main Outcome Measures

Effort in rehabilitation sessions rated on the Rehabilitation Intensity of Therapy Scale, FIM, Comprehensive Severity Index brain injury severity score, posttraumatic amnesia (PTA), and Agitated Behavior Scale (ABS).

Results

The Rehabilitation Intensity of Therapy Scale effort ratings in individual therapy sessions closely conformed to a normative distribution for all 3 disciplines. Mean Rehabilitation Intensity of Therapy Scale ratings for patients' therapy sessions were higher in the discharge week than in the admission week (P<.001). For patients who completed 2, 3, or 4 weeks of rehabilitation, differences in effort ratings (P<.001) were observed between 5 subgroups stratified by admission FIM cognitive scores and over time. In linear mixed-effects modeling, age and Comprehensive Severity Index brain injury severity score at admission, days from injury to rehabilitation admission, days from admission, and daily ratings of PTA and ABS score were predictors of level of effort (P<.0001).

Conclusions

Patients' level of effort can be observed and reliably rated in the TBI inpatient rehabilitation setting using the Rehabilitation Intensity of Therapy Scale. Patients who sustain TBI show varying levels of effort in rehabilitation therapy sessions, with effort tending to increase over the stay. PTA and agitated behavior are primary risk factors that substantially reduce patient effort in therapies.

Section snippets

Study population

As part of a prospective observational investigation, we studied a cohort aged ≥14 years with complicated mild, moderate, and severe TBI from 9 IR centers located throughout the United States.² Participants were enrolled from October 2008 to August 2011 and received interdisciplinary rehabilitation services that typically included physiatry, nursing, psychology/neuropsychology, case management, PT, OT, ST, and therapeutic recreation. Details of inclusion criteria, procedures, and enrollment

Participants

A total of 1981 patients were enrolled in 9 U.S. centers participating in the practice-based evidence study. After excluding from analysis patients who had a disorder of consciousness for most or all of their stay (n=35), the final sample had 1946 participants. Patient demographics and injury, time from injury, and severity characteristics at admission are summarized in table 1. The sample was diverse with regard to age, sex, and race/ethnicity. Most patients were injured as a result of motor

Discussion

In the United States there is a growing emphasis on providing patient-centered care, optimizing service utilization, and improving treatment effectiveness and efficiency.34, 35 In rehabilitation, understanding how patient factors impact treatment delivery and ultimately outcomes is a key to providing patient-centered care.³⁶ Level of effort in therapies is considered an important mediator of therapeutic effectiveness; however, few studies have described patients' effort in TBI IR or identified

Conclusions

Our study provides evidence that patients' level of effort can be observed and reliably rated in the TBI IR setting using the single-item Rehabilitation Intensity of Therapy Scale effort rating criteria. Patients who sustain TBI show a wide range of effort levels in their IR therapies. The level typically improves over the course of their stay. Presence of PTA and agitated behavior are primary factors that substantially reduce patient effort.

Suppliers

a.
SAS version 9.2; SAS Institute.
b.
R statistics version 2.12.1; R: A Language and Environment for Statistical Computing. Available at: http://www.R-project.org.

Acknowledgments

We thank the contributions of the clinical and research staff at each of the 9 inpatient rehabilitation facilities represented in the Improving Outcomes in Acute Rehabilitation for TBI Study and Individualized Planning for the First Year Following Acute Rehabilitation, collectively known as the TBI Practice Based Evidence (TBI-PBE) study. We also thank the staff of the Institute for Clinical Outcomes Research, International Severity Information Systems, Inc, Salt Lake City, UT, who also

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Cited by (22)

Acute Management of Moderate to Severe Traumatic Brain Injury
2024, Physical Medicine and Rehabilitation Clinics of North America
An Observational Cohort Study of the Role of Level of Effort in Post-Acute Brain Injury Rehabilitation
2023, Archives of Physical Medicine and Rehabilitation
To 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.
Observational cohort study.
Comprehensive integrated rehabilitation program for brain injury within a skilled nursing facility.
Consecutive admissions with acquired brain injury (N=101).
Individualized 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.
Mayo-Portland Adaptability Inventory, fourth edition (MPAI-4); Supervision Rating Scale (SRS).
Linear 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).
After 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.
Rehabilitation of social cognition impairment after traumatic brain injury: A systematic review
2022, Neurologia
Múltiples estudios han descrito la presencia de dificultades para procesar y generar conductas de tipo social en pacientes que han sufrido un traumatismo craneoencefálico (TCE). Tales dificultades, englobadas bajo el término genérico de cognición social (CS), provocan un deterioro en las relaciones personales, tanto a nivel familiar como laboral o comunitario. No obstante, los programas terapéuticos dirigidos a la mejora de la CS continúan siendo una asignatura pendiente en la práctica clínica. El objetivo de este trabajo es realizar una revisión sistemática de la literatura existente sobre rehabilitación de la CS en pacientes con TCE, valorar su calidad metodológica y la efectividad terapéutica de las estrategias rehabilitadoras empleadas.
Se realizó una búsqueda bibliográfica hasta junio de 2018 en las bases de datos Medline/PubMed, Google Scholar, PsycInfo y ClinicalTrials.gov. De los 198 artículos potencialmente interesantes, 10 cumplieron los criterios de elegibilidad. Dos de los autores evaluaron, de forma independiente y ciega, la calidad metodológica de los estudios incluidos en la revisión mediante la escala PEDro.
Los artículos incluidos en esta revisión sistemática han estudiado esencialmente el efecto de diferentes intervenciones dirigidas a la rehabilitación de la CS en pacientes con TCEs en fase crónica. El análisis muestra que su calidad metodológica es adecuada y que el nivel de evidencia es aceptable. Se constata la necesidad de analizar el efecto de estas intervenciones en pacientes con TCE en fases subaguda y postaguda.
Many studies have described the presence of difficulty processing and generating social behaviour in patients who have suffered a traumatic brain injury (TBI). These difficulties in social cognition (SC) deteriorate personal relationships in the family, at work, or in the community. However, therapeutic programmes aiming to improve SC continue to be an outstanding issue in clinical practice. We performed a systematic review of the existing literature on the recovery of SC in patients with TBI, assessing the methodological quality of the included studies and the therapeutic effectiveness of the rehabilitation strategies used.
We performed a bibliographic search of papers published before June 2018 in the Medline/PubMed, Google Scholar, PsycINFO, and ClinicalTrials.gov databases. Of the 198 potentially relevant articles, 10 met our eligibility criteria. Two of the authors independently and blindly assessed the methodological quality of these studies using the PEDro scale.
The articles included in this systematic review essentially studied the effect of different interventions aimed at the rehabilitation of SC in patients with chronic TBIs. The analysis showed adequate methodological quality and an acceptable level of evidence. Future research should analyse the effect of these interventions in patients with TBIs in the sub- and post-acute phases.
Factors Affecting Participation in Physical Therapy During Posttraumatic Amnesia
2021, Archives of Physical Medicine and Rehabilitation
Citation Excerpt :
Findings demonstrated that increased levels of agitation interfered with patients’ ability to engage in physical therapy and were associated with lower FIM-motor change after PTA. This provides support for the contention that agitation represents a significant barrier to rehabilitation and is associated with poorer patient outcome.20-22 Agitation was not related to the amount of therapy received, a pattern also previously observed for time in occupational therapy sessions during PTA.23
To examine the effect of agitation, cognitive impairment, fatigue, and pain on physical therapy participation and outcomes during posttraumatic amnesia (PTA) after traumatic brain injury (TBI).
Prospective longitudinal study.
Inpatient rehabilitation hospital.
Participants (N=77) with moderate-to-severe TBI who were deemed to be experiencing PTA using the Westmead Post-Traumatic Amnesia Scale.
Not applicable.
The Pittsburgh Rehabilitation Participation Scale and time in therapy (min) were recorded twice daily after routine physical therapy sessions during PTA. The FIM-motor (select items related to physical therapy) score rated on admission and after emergence from PTA was used to calculate FIM-motor change.
Agitation was associated with lower participation in therapy. The presence of agitation and pain both predicted lower FIM-motor change at emergence from PTA. Higher levels of cognitive impairment and fatigue were also associated with lower participation and less time in therapy.
The presence of agitation, fatigue, pain, and cognitive impairment impede rehabilitation success during PTA. This study strengthens the case for implementing environmental and behavioral recommendations, such as conducting therapy earlier in the day within a familiar space (ie, on the ward) and tailoring session duration to patient needs. This is with the aim of minimizing fatigue, agitation, and pain, while promoting cognitive recovery and arousal during PTA to maximize physical gains. Further research is warranted to examine the factors associated with rehabilitation success across other therapeutic disciplines.
Multiple intubation attempts in the emergency department and in-hospital mortality: A retrospective observational study
2020, American Journal of Emergency Medicine
Citation Excerpt :
It is also possible that to save time during resuscitation with very ill patients, intubation was done promptly without spending time to draw medications. Similar to previous reports [22,23], older patients (adjusted OR 0.95, 95%CI 0.93–0.98, p < 0.01) and those with a brain injury (adjusted OR 0.15, 95%CI 0.04–0.56, p < 0.01) were less likely to be discharged home from the hospital. There are several limitations to our study.
Multiple intubation attempts in the Emergency Department (ED) have been associated with adverse events, but no study examined the influence of multiple intubation attempts on survival during hospitalization. Our aim was to compare one or more intubation attempts in the ED with risk of morbidity and mortality during hospitalization.
We conducted a single center retrospective analysis of all patients undergoing emergency intubation in the ED and then admission to the hospital, during September 2010 to April 2016. The primary exposure was multiple intubation attempts. The primary outcome was mortality during hospitalization after intubation in the ED.
Of 181 patients, 63 (35%) required two or more attempts. We found no significant difference in mortality (p = 0.11), discharge from the hospital (p = 0.45), length of stay in hospital (p = 0.34), intensive care unit (ICU) (p = 0.32), ED (p = 0.81) or intubation period (p = 0.64), between one or more intubation attempts. After adjustment for the number of intubation trials, age, sex, intubation methods, first intubator training level and diagnostic category, use of medications during intubation was the only independent prognostic variable for hospital death (adjusted OR 0.21, 95%CI 0.1–0.45, p < 0.01). Number of trials to achieve successful intubation was not associated with discharge disposition (OR 0.77 95%CI 0.24–2.46, p = 0.66). Age (OR 0.95, 95%CI 0.93–0.98, p < 0.01) and brain injury as a diagnostic category (OR 0.15 95%CI 0.04–0.56, p < 0.01) were independent prognostic variables.
We found multiple intubation attempts were not associated with increased mortality and morbidity during hospitalization.
Comparative Effectiveness of Inpatient Rehabilitation Interventions for Traumatic Brain Injury: Introduction
2019, Archives of Physical Medicine and Rehabilitation
The Comparative Effectiveness of Inpatient Rehabilitation Interventions for Traumatic Brain Injury (TBI-CER) project used causal inference methods as an alternative to randomized controlled trials to evaluate rehabilitation practices. The TBI practice-based evidence dataset afforded the opportunity to compare the outcomes of different rehabilitation approaches while controlling for a large set of potential confounders using propensity score methods (PSMs). PSMs rely on 4 assumptions: positivity, exchangeability, consistency, and correct specification of the propensity score model. When these assumptions are met, PSMs provide a transparent means for evaluating potential causal relations between interventions and outcomes using observational data. In combination, the series of studies resulting from the TBI-CER project suggested that the content and approach used in treatment have a stronger effect on outcomes than the amount of time spent in treatment. Further, engagement of the patient and family in treatment is key to optimizing outcomes up to 9 months postdischarge from rehabilitation.

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: Supported by the National Institutes of Health, National Center for Medical Rehabilitation Research (grant no. 1R01HD050439-01), and the National Institute on Disability and Rehabilitation Research (grant no. H133A080023).

: However, the contents do not necessarily represent the policy of the Department of Education, and you should not assume endorsement by the Federal Government.

: Publication of this article was supported by the American Congress of Rehabilitation Medicine.

: Disclosures: none.

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Original researchPatient Effort in Traumatic Brain Injury Inpatient Rehabilitation: Course and Associations With Age, Brain Injury Severity, and Time Postinjury

Abstract

Objective

Design

Setting

Participants

Interventions

Main Outcome Measures

Results

Conclusions

Section snippets

Study population

Participants

Discussion

Conclusions

Suppliers

Acknowledgments

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

J Clin Epidemiol

It's more than a black box; it's a Russian doll: defining rehabilitation treatments

Am J Phys Med Rehabil

Traumatic Brain Injury–Practice Based Evidence study: design and patients, centers, treatments, and outcomes

Arch Phys Med Rehabil

Sociological and cultural aspects in postacute neuropsychological rehabilitation

J Head Trauma Rehabil

A critical review of the concept of patient motivation in the literature on physical rehabilitation

Soc Sci Med

Cluster analysis of self-awareness levels in adults with traumatic brain injury and relationshipto outcome

J Head Trauma Rehabil

Psychometric properties of the Rehabilitation Therapy Engagement Scale when used among individuals with acquired brain injury

Rehabil Psychol

Agitation in acquired brain injury: impact on acute rehabilitaion therapies

J Head Trauma Rehabil

The impact of patient-center information on patients' treatment satisfaction and outcomes in traumatic brain injury rehabilitation

Rehabil Psychol

Team size in spinal cord injury inpatient rehabilitation and patient participation in therapy sessions: the SCIRehab project

J Spinal Cord Med

The Rehabilitation Intensity of Therapy Scale

Reliability and validity of the Disability Rating Scale and the Levels of Cognitive Functioning Scale in monitoring recovery from severe head injury

Arch Phys Med Rehabil

Original research
Patient Effort in Traumatic Brain Injury Inpatient Rehabilitation: Course and Associations With Age, Brain Injury Severity, and Time Postinjury