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Measuring Outcomes in Brain Injury Rehabilitation

Measuring Outcomes in Brain Injury Rehabilitation. By: Kyle Haggerty, Ph.D. Learning Objectives. What is Traumatic Brain Injury (TBI) Goals of Rehabilitation Measuring Outcomes in Brain Injury Rehabilitation The Outcome Measures We Use and Why Our Results Challenges/Ideas for Future.

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Measuring Outcomes in Brain Injury Rehabilitation

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  1. Measuring Outcomes in Brain Injury Rehabilitation By: Kyle Haggerty, Ph.D.

  2. Learning Objectives • What is Traumatic Brain Injury (TBI) • Goals of Rehabilitation • Measuring Outcomes in Brain Injury Rehabilitation • The Outcome Measures We Use and Why • Our Results • Challenges/Ideas for Future

  3. Traumatic Brain Injury

  4. Traumatic Brain Injury • Traumatic Brain Injury (TBI): cerebral damage that occurs after birth, and is not directly related to a developmental disorder or a progressive damaging of the brain. Traumatic brain injury refers to a specific form of acquired brain injury that is the result of a sudden trauma. • Acquired Brain Injury (ABI): includes all types of traumatic brain injuries and also brain injuries caused after birth by cerebral vascular accidents (commonly known as stroke), and loss of oxygen to the brain (hypoxic brain injury). 

  5. Classification of TBIs Traumatic brain injuries are classified by severity into one of three categories: mild, moderate, or severe. Classification into one of the three categories is usually based upon the following four criteria. Glasgow Coma score Duration of loss of consciousness Duration of alteration of consciousness Severity of post-traumatic amnesia

  6. Glasgow Coma Scale Not part of original scale

  7. Classification Guidelines

  8. Some Stats In 2003, approximately 1.5 million Americans experienced a traumatic brain injury. Of those 1.5 million, 290,000 were hospitalized and 50,000 died. 62.3 per 100,000 adults age 15 and over are living in the community with impairments due to brain injury.

  9. Continued • Twice as many males are affected by TBI as females. • Ages 15-24 and >60 are at the highest risk. • Individuals in rural areas are more at risk.

  10. Causes

  11. Physical Causes Bruising/Bleeding, Tearing, Swelling, Open/Closed injuries

  12. Costs Costs of traumatic brain injury in the U. S. have been estimated to be $48.3 billion annually. Survivors cost $31.7 billion. Fatalities cost $16.6 billion. Lifetime cost per person is about $4 million. About 75% of patients with severe TBI do not return to work. About 66% require assistance with daily living. 90% report dissatisfaction with social integration.

  13. TBI and Mental Illness • Prevalence rates for psychiatric disorders are high after TBI. • Depression rates have been reported in 14 to 77% of patients • Substance abuse 5 to 28% • PTSD 3 to 27% • Other anxiety disorders 3 to 28%

  14. TBI and Quality of Life • Life satisfaction appears to steadily decline after an individual experiences a brain injury. • Injury severity has not been found to be significantly correlated with measures of life satisfaction.

  15. Continued • Many variables have been shown to correlate with life satisfaction in individuals who have suffered TBIs. • Marital Status • Employment • Problem Solving • Executive Functioning

  16. Goals of Rehabilitation

  17. Purpose of Rehab • The overall goal of Rehabilitation following a TBI is to improve the person’s served functioning at home. • This can be done by helping to restore a client’s physical, sensory, psychological, or cognitive abilities, or by helping them develop compensatory strategies.

  18. Rehabilitation Focus • Cognitive: Cognitive Rehabilitation/Neuropsychology/Speech • Physical: Physical Therapy/Occupational Therapy • Emotional/Adjustment: Neuropsychology • Participation: Entire team

  19. Memory (Cog and Neuropsych) • Immediate Memory • Digit Span • Not a Common Complaint • Short Term Memory • Most Common Deficit in TBI • Long Term Memory • Missing details due to STM loss

  20. Language/Word Finding (Speech and Neuropsych • Aphasia • Circumlocution • Hand Gestures • Tip of the tongue • Common due to anatomy of skull

  21. Ambulation/Motor (PT/OT) • Difficulties with balance/walking • Impairments in fine motor skills • Decreased strength and stamina

  22. Chronic Pain (PT/OT) • Headaches • Spinal Cord Injuries • Ineffectiveness of Pain Medication

  23. Overload (Neuropsych/OT) • Brought on by large crowds, lots of noise, or information presented too quickly. • Inability to process external environment • Fatigue • Rise in emotions

  24. Emotions (Neuropsych) • Emotions can become flat or amplified. • Lack of inhibition • Trouble analyzing social situations • Difficulty with facial expression or tone of voice

  25. Measuring Outcomes

  26. Outcome Measures Used • What measures are used depends on the setting (acute or long-term rehabilitation) • Acute settings frequently use: • Functional Independence Measure (FIM): An 18-item scale used to assess the patient's level of independence in mobility, self-care, and cognition • Glasgow Outcome Scale (GOS) • Disability Rating Scale (DRS): Measures general functional changes over the course of recovery after TBI

  27. What about long-term? • No measures are universally agreed upon • Some measures frequently used include: • Mayo Portland Adaptability Inventory (MPAI) • Supervision Rating Scale (SRS) • Community Integration Questionnaire (CIQ) • Disability Rating Scale (DRS) • Independent Living Scale (ILS) And many more

  28. Difficulties • What outcomes are the most significant/important? • The goals of rehabilitation are individualized making it difficult to identify a universal outcome • The complexity of the cases makes it difficult to make causal references • Substance abuse, multiple treatment modalities, social support, etc.

  29. Continued Questions about the accuracy of self-report • Some researchers have found that in people who have suffered TBIs, self-report is not a reliable measure. • Language deficits • Awareness • Abstract Reasoning • Memory

  30. Who We Serve

  31. Total Number of Persons Served

  32. Who We Serve Age:

  33. Continued

  34. Who We Serve Gender and Ethnicity

  35. Who We ServeTypes of Injuries

  36. Our Measures

  37. Standardized Measures Bancroft is a member of the Pennsylvania Association of Rehabilitation Facilities (PARF), a collaborative data collection and outcomes measurement project designed to: • Enhance clinical evaluation • Verify the treatment provided produces the desired outcomes • Allow providers to make better decisions regarding program/service components • Provide aggregate data to funders to assist with evaluation of needs and services In conjunction with our PARF colleagues, we utilize three standardized outcome measures: Mayo-Portland Adaptability Inventory (MPAI-4, Malec, J., 2005); Supervision Rating Scale (SRS, Boake, C., 2001); and most recently the World Health Organization Quality of Life Index (WHOQOL-BREF, WHO, 2004). A project to develop standardized satisfaction surveys is in progress.

  38. Outcomes Process • Data is collected annually • Data collection included an annual neuropsychological assessment • Entire rehabilitation team is invloved

  39. Supervision Rating Scale • Measures the level and type of supervision that a patient/subject receives from caregivers • The SRS rates level of supervision on a single 13-point ordinal scale • SRS ratings have shown consistent relationships with type of living arrangement and with independence in self-care and instrumental ADL

  40. WHOQOL-BREF • The WHOQOL-BREF instrument comprises 26 self-reported items, which measure the following broad domains: physical health, psychological health, social relationships, and environment • Research has found that the WHOQOL-BREF has strong psychometric properties • Raw scores on the measure can range from 24 to 120, with higher scores being indicative of a higher quality of life.

  41. MPAI-4 MPAI-4: Ability Index • Mobility • Use of hands • Audition • Vision • Motor speech • Dizziness • Verbal Communication • Nonverbal Communication • Memory • Attention/ concentration • Fund of information • Novel Problem-solving • Visuospatial abilities

  42. Continued MPAI-4: Adjustment Index • Anxiety • Depression • Irritability, anger, aggression • Pain/headache • Fatigue • Sensitivity to mild symptoms • Inappropriate social interaction • Impaired self-awareness • Family/significant relationships • Initiation • Social contact • Leisure activities

  43. Continued MPAI-4: Participation Index • Initiation • Social contact • Leisure activities • Self care • Residence • Transportation • Employment • Managing Money

  44. MPAI-4 Database Project • Initiative to develop an electronic national database for MPAI-4 scores • Would allow different rehab centers to combine data to study changes in outcomes over the course of post-acute rehabilitation

  45. Results From Our Population

  46. EffectivenessSupervision Rating Scale (SRS) Overnight Supervision Full-Time Indirect Supervision Part-Time Supervision Independent Full-Time Direct Supervision

  47. EffectivenessQuality of Life (WHOQOL-BREF) Range of Norms In General Population

  48. Effectiveness (MPAI-4)

  49. Satisfaction Key Measure Persons Served

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