The Influence of Substance Use on Traumatic Brain Injury Recovery and Rehabilitation Outcomes: The Outcome-ABI Study.

OBJECTIVE: This study characterized substance use (alcohol, illicit drugs, amphetamines) in patients with traumatic brain injury (TBI) receiving rehabilitation to determine potential benefit of rehabilitation and whether substance use influenced outcomes in moderate-severe TBI. DESIGN: Prospective, longitudinal study of adults with moderate or severe TBI receiving inpatient rehabilitation. SETTING: Specialist-staffed acquired brain injury rehabilitation center in Melbourne, Australia. PARTICIPANTS: A total of 153 consecutive inpatients with TBI admitted between January 2016 and December 2017 (24 months). INTERVENTIONS: All inpatients with TBI (n=153) received specialist-provided brain injury rehabilitation in accordance with evidence-based guideline care at one 42-bed rehabilitation center. MAIN OUTCOME MEASURES: Data were collected at time of TBI, upon rehabilitation admission, and discharge and 12 months' post-TBI. Recovery was measured by posttraumatic amnesia posttraumatic amnesia length-days and change in Glasgow Coma Scale (admission-discharge). Functional independence was measured on the FIM, Functional Assessment Measure, and Mayo Portland Adaptability Index. Quality of life (QOL) was measured on the EuroQOL-5D-5L and Quality of Life After Brain Injury (QOLIBRI) instruments. RESULTS: Inpatients with history of illicit drug use (n=54) reported lower QOL and adjustment at 12 months' post-TBI compared with those with no history (QOLIBRI social relationships: ratio of means=0.808, P=.028; Mayo Portland Adaptability Index adjustment: incidence rate ratio, 1.273; P=.032). Amphetamine use at time of injury (n=10) was associated with quicker recovery (posttraumatic amnesia length-days: incidence rate ratio, 0.173; P<.01); however, lower QOL at 12 months post-TBI was noted in those with a history of amphetamine use (n=34) compared with those without (QOLIBRI bothered feelings: ratio of means, 0.489, P=.036). CONCLUSIONS: All participants made improvements with rehabilitation post-TBI; however, a history of substance use was associated with lower reported 12-month QOL. These findings add insight to the associations between substance use and acute recovery, potentially suggestive of a short-term recovery-promoting effect of amphetamines but highlighting the importance of rehabilitation to address long-term sequalae.

Mixed methods study to understand the experiences of adults with acquired brain injury and their family members who receive specialised rehabilitation.

BACKGROUND AND AIM: Rehabilitation therapy is a key part of the recovery pathway for people with severe acquired brain injury (ABI). The aim of this study was to explore inpatients' and their family members' experiences of a specialist ABI rehabilitation service. METHODS: A cross sectional, prospective mixed method study was undertaken at a metropolitan specialist ABI rehabilitation unit in Victoria, Australia. All inpatients and their family members of the service were invited to complete a satisfaction survey. Employing purposive sampling, semi-structured interviews were conducted with inpatients and/or their family members. RESULTS: In total, 111 people completed the satisfaction survey and 13 were interviewed. High levels of satisfaction with the specialist service were reported; the majority of inpatients (74%) and family members (81%) rated the overall quality of care received in the service as 'high' or 'very high'. Interviews revealed four main themes: (i) satisfaction with rehabilitation services, (ii) inconsistent communication, (iii) variable nursing care, and (iv) strengths and weakness of the rehabilitation environment. Overall, important components of a positive experience were being involved in decision making and discharge planning, effective communication and information processes, and being able to form therapeutic relationships with staff. Key sources of dissatisfaction for inpatients and family members related to inconsistency in care, accessing information about treatments in a format easily understood, and communication. CONCLUSION: Specialised rehabilitation is valued by inpatients and their family members alike. The findings highlight the importance of exploring inpatient experiences to optimise service delivery in a tailored, specialised rehabilitation programme.

Activity, Participation, and Goal Awareness After Acquired Brain Injury: A Prospective Observational Study of Inpatient Rehabilitation.

OBJECTIVE: To examine the frequency and timing of inpatient engagement in meaningful activities within rehabilitation (within and outside of structured therapy times) and determine the associations between activity type, goal awareness, and patient affect. METHODS: This prospective observational study performed behavioral mapping in a 42-bed inpatient brain injury rehabilitation unit by recording patient activity every 15 minutes (total 42 hours). The participants were randomly selected rehabilitation inpatients with acquired brain injury; all completed the study. The main outcome measures included patient demographics, observation of activity, participation, goal awareness, and affect. RESULTS: The inpatients spent 61% of the therapeutic day (8:30 to 16:30) in their single room and were alone 49% of the time. They were physically socially inactive for 76% and 74% of their awake time, respectively, with neutral affect observed for about half of this time. Goal-related activities were recorded for only 25% of the inpatients' awake time. The odds of physical activity were 10.3-fold higher among in patients receiving support to address their goals within their rehabilitation program (odds ratio=10.3; 95% confidence interval, 5.02-21.16). CONCLUSION: Inpatients in a mixed brain injury rehabilitation unit spent a large amount of their awake hours inactive and only participated in goal-related activities for a quarter of their awake time. Rehabilitation models that increase opportunities for physical, cognitive, and social activities outside of allied health sessions are recommended to increase overall activity levels during inpatient rehabilitation.

Designing an intervention process that embeds work-focussed interventions within inpatient rehabilitation: An intervention mapping approach.

INTRODUCTION: Returning to work is a goal for many people after brain injury. The failure to return to work after injury brings both economic and personal (quality of life) costs to those living with stroke or brain injury, their families, and society. This study explored the barriers to providing work-focused interventions during hospital-based rehabilitation and co-created solutions with rehabilitation providers to increase the provision of work-focused intervention during inpatient rehabilitation. METHODS: This study used an Intervention Mapping approach (a six-step protocol that guides the design of complex interventions) based on an action research methodology. Focus group data, in addition to best evidence from systematic reviews, practice guidelines and key articles were combined with theoretical models for changing behaviour and clinician experience. This was then systematically operationalised into an intervention process using consensus among clinicians. The process was further refined through piloting and feedback from key stakeholders, and group consensus on the final process. RESULTS: A detailed five phase return to work intervention process for inpatient rehabilitation was developed. The key features of the process include; having one key allied health clinician to coordinate the process, choosing assessments based on pre-injury work demands, emphasising the importance of core work skills and considering the most appropriate service for referral at the conclusion of rehabilitation. CONCLUSION: We used a systematic approach, guided by the intervention mapping approach and behaviour change theory to tailor existing workfocused interventions to the inpatient setting.

Using audit and feedback to increase clinician adherence to clinical practice guidelines in brain injury rehabilitation: A before and after study.

OBJECTIVE: This study evaluated whether frequent (fortnightly) audit and feedback cycles over a sustained period of time (>12 months) increased clinician adherence to recommended guidelines in acquired brain injury rehabilitation. DESIGN: A before and after study design. SETTING: A metropolitan inpatient brain injury rehabilitation unit. PARTICIPANTS: Clinicians; medical, nursing and allied health staff. INTERVENTIONS: Fortnightly cycles of audit and feedback for 14 months. Each fortnight, medical file and observational audits were completed against 114 clinical indicators. MAIN OUTCOME MEASURE: Adherence to guideline indicators before and after intervention, calculated by proportions, Mann-Whitney U and Chi square analysis. RESULTS: Clinical and statistical significant improvements in median clinical indicator adherence were found immediately following the audit and feedback program from 38.8% (95% CI 34.3 to 44.4) to 83.6% (95% CI 81.8 to 88.5). Three months after cessation of the intervention, median adherence had decreased from 82.3% to 76.6% (95% CI 72.7 to 83.3, p<0.01). Findings suggest that there are individual indicators which are more amenable to change using an audit and feedback program. CONCLUSION: A fortnightly audit and feedback program increased clinicians' adherence to guideline recommendations in an inpatient acquired brain injury rehabilitation setting. We propose future studies build on the evidence-based method used in the present study to determine effectiveness and develop an implementation toolkit for scale-up.

Determining client cognitive status following mild traumatic brain injury.

BACKGROUND: People with mild traumatic brain injury (mTBI) commonly experience cognitive impairments. Occupational therapists working in acute general hospitals in Australia routinely access client Glasgow Coma Scale (GCS) scores, and assess cognitive status using standardized tools and by observing basic activity of daily living (ADL) performance. However, limited evidence exists to identify the best assessment(s) to determine client cognitive status. AIM/OBJECTIVES: To determine whether cognitive status assessed by GCS score and the Cognistat are predictive of basic ADL performance among clients with mTBI in an acute general hospital and make inferences concerning the clinical utility of these assessment tools. MATERIAL AND METHODS: Retrospective analysis of medical record data on demographics, Cognistat, GCS, and modified Barthel Index (MBI) using descriptive statistics, chi-square tests and linear regression. RESULTS: Data analysis of 166 participants demonstrated that no associations exist between GCS and Cognistat scores, or Cognistat scores and MBI dependency level. The presence of co-morbid multi-trauma injuries and length of stay were the only variables that significantly predicted MBI dependency level. CONCLUSION AND SIGNIFICANCE: While the MBI scores are of value in identifying clients with difficulty in basic ADLs, Cognistat and GCS scores are of limited use in differentiating client levels of cognitive impairment and the authors caution against the routine administration of the Cognistat following mTBI. Further research is required to identify more suitable assessments for use with a mTBI population.

Improving older trauma patients' outcomes through targeted occupational therapy and functional conditioning.

OBJECTIVE: Hospitalized older people are at risk of functional decline, and risk increases with length of stay (LOS). We measured the impact on LOS and discharge destination of targeted occupational therapy and a functional conditioning program (FCP) for older adults admitted to a metropolitan trauma unit. METHOD: The intervention group consisted of 50 participants > 65 yr old living independently in the community before admission. Outcomes were compared with historical control group data (N = 105). RESULTS: The intervention group's mean LOS was 2 days less than that of the control group (p = .04). A higher proportion in the intervention group was also discharged to home, but the difference was not statistically significant. Referrals to occupational therapy increased significantly (p = .05), and participants were seen 1.5 days sooner (p = .003) than the control group. Referral to FCP was 7 times higher in the intervention group (p = .001). CONCLUSION: Targeted occupational therapy and FCP can improve LOS in older trauma patients.