Contextualized Treatment in Traumatic Brain Injury Inpatient Rehabilitation: Effects on Outcomes During the First Year After Discharge.

OBJECTIVE: To evaluate the effect of providing a greater percentage of therapy as contextualized treatment on acute traumatic brain injury (TBI) rehabilitation outcomes. DESIGN: Propensity score methods are applied to the TBI Practice-Based Evidence (TBI-PBE) database, a database consisting of multi-site, prospective, longitudinal observational data. SETTING: Acute inpatient rehabilitation. PARTICIPANTS: Patients enrolled in the TBI-PBE study (N=1843), aged 14 years or older, who sustained a severe, moderate, or complicated mild TBI, received their first inpatient rehabilitation facility admission in the US, and consented to follow-up 3 and 9 months post discharge from inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participation Assessment with Recombined Tools-Objective (PART-O)-17, FIM Motor and Cognitive scores, Satisfaction with Life Scale, and Patient Health Questionnaire-9. RESULTS: Increasing the percentage of contextualized treatment during inpatient TBI rehabilitation leads to better outcomes, specifically in regard to community participation. CONCLUSIONS: Increasing the proportion of treatment provided in the context of real-life activities appears to have a beneficial effect on outcome. Although the effect sizes are small, the results are consistent with other studies supporting functional-based interventions effecting better outcomes. Furthermore, any positive findings, regardless of size or strength, are endorsed as important by consumers (survivors of TBI). While the findings do not imply that decontextualized treatment should not be used, when the therapy goal can be addressed with either approach, the findings suggest that better outcomes may result if the contextualized approach is used.

Advanced Therapy in Traumatic Brain Injury Inpatient Rehabilitation: Effects on Outcomes During the First Year After Discharge.

OBJECTIVE: To use causal inference methods to determine if receipt of a greater proportion of inpatient rehabilitation treatment focused on higher level functions, for example, executive functions, ambulating over uneven surfaces (advanced therapy [AdvTx]), results in better rehabilitation outcomes. DESIGN: A cohort study using propensity score methods applied to the traumatic brain injury practice-based evidence (TBI-PBE) database, a database consisting of multisite, prospective, longitudinal observational data. SETTING: Acute inpatient rehabilitation facilities. PARTICIPANTS: Patients enrolled in the TBI-PBE study (N=1843), aged 14 years or older, who sustained a severe, moderate, or complicated mild TBI, receiving their first inpatient rehabilitation facility admission to 1 of 9 sites in the United States, and consented to follow-up 3 and 9 months postdischarge from inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participation Assessment with Recombined Tools-Objective-17, FIM motor and cognitive scores, Satisfaction with Life Scale, and Patient Health Questionnaire-9. RESULTS: Controlling for measured potential confounders, increasing the percentage of AdvTx during inpatient TBI rehabilitation was found to be associated with better community participation, functional independence, life satisfaction, and decreased likelihood of depression during the year after discharge from inpatient rehabilitation. Participants who began rehabilitation with greater disability experienced larger gains on some outcomes than those who began rehabilitation with more intact abilities. CONCLUSIONS: Increasing the proportion of treatment targeting higher level functions appears to have no detrimental and a small, beneficial effect on outcome. Caution should be exercised when inferring causality given that a large number of potential confounders could not be completely controlled with propensity score methods. Further, the extent to which unmeasured confounders influenced the findings is not known and could be of particular concern due to the potential for the patient's recovery trajectory to influence therapists' decisions to provide a greater amount of AdvTx.

Family Involvement in Traumatic Brain Injury Inpatient Rehabilitation: A Propensity Score Analysis of Effects on Outcomes During the First Year After Discharge.

OBJECTIVE: To evaluate the effect of family attendance at inpatient rehabilitation therapy sessions on traumatic brain injury (TBI) patient outcomes at discharge and up to 9 months postdischarge. DESIGN: Propensity score methods are applied to the TBI Practice-Based Evidence database, a database consisting of multisite, prospective, longitudinal, and observational data. SETTING: Nine inpatient rehabilitation centers in the United States. PARTICIPANTS: Patients (N=1835) admitted for first inpatient rehabilitation after an index TBI. INTERVENTION: Family attendance during therapy sessions. MAIN OUTCOME MEASURES: Participation Assessment for Recombined Tools-Objective-17 (Total scores and subdomain scores of Productivity, Out and About, and Social Relations), Functional Independence Measure, Satisfaction with Life Scale, and Patient Health Questionnaire-9. RESULTS: Participants whose families were in attendance for at least 10% of the treatment time were more out and about in their communities at 3 and 9 months postdischarge than participants whose families attended treatment less than 10% of the time. Although findings varied by propensity score method, improved functional independence in the cognitive area at 9 months was also associated with increased family attendance. CONCLUSIONS: Family involvement during inpatient rehabilitation may improve community participation and cognitive functioning up to 9 months after discharge. Rehabilitation teams should engage patients' families in the rehabilitation process to maximize outcomes.

Occupational, Physical, and Speech Therapy Treatment Activities During Inpatient Rehabilitation for Traumatic Brain Injury.

OBJECTIVE: To describe the use of occupational therapy (OT), physical therapy (PT), and speech therapy (ST) treatment activities throughout the acute rehabilitation stay of patients with traumatic brain injury. DESIGN: Multisite prospective observational cohort study. SETTING: Inpatient rehabilitation settings. PARTICIPANTS: Patients (N=2130) admitted for initial acute rehabilitation after traumatic brain injury. Patients were categorized on the basis of admission FIM cognitive scores, resulting in 5 fairly homogeneous cognitive groups. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Percentage of patients engaged in specific activities and mean time patients engaged in these activities for each 10-hour block of time for OT, PT, and ST combined. RESULTS: Therapy activities in OT, PT, and ST across all 5 cognitive groups had a primary focus on basic activities. Although advanced activities occurred in each discipline and within each cognitive group, these advanced activities occurred with fewer patients and usually only toward the end of the rehabilitation stay. CONCLUSIONS: The pattern of activities engaged in was both similar to and different from patterns seen in previous practice-based evidence studies with different rehabilitation diagnostic groups.

Predictors of Agitated Behavior During Inpatient Rehabilitation for Traumatic Brain Injury.

OBJECTIVE: To identify predictors of the severity of agitated behavior during inpatient traumatic brain injury (TBI) rehabilitation. DESIGN: Prospective, longitudinal observational study. SETTING: Inpatient rehabilitation centers. PARTICIPANTS: Consecutive patients enrolled between 2008 and 2011, admitted for inpatient rehabilitation after index TBI, who exhibited agitation during their stay (n=555, N=2130). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Daytime Agitated Behavior Scale scores. RESULTS: Infection and lower FIM cognitive scores predicted more severe agitation. The medication classes associated with more severe agitation included sodium channel antagonist anticonvulsants, second-generation antipsychotics, and gamma-aminobutyric acid-A anxiolytics/hypnotics. Medication classes associated with less severe agitation included antiasthmatics, statins, and norepinephrine-dopamine-5 hydroxytryptamine (serotonin) agonist stimulants. CONCLUSIONS: Further support is provided for the importance of careful serial monitoring of both agitation and cognition to provide early indicators of possible beneficial or adverse effects of pharmacologic interventions used for any purpose and for giving careful consideration to the effects of any intervention on underlying cognition when attempting to control agitation. Cognitive functioning was found to predict agitation, medications that have been found in previous studies to enhance cognition were associated with less agitation, and medications that can potentially suppress cognition were associated with more agitation. There could be factors other than the interventions that account for these relations. In addition, the study provides support for treatment of underlying disorders as a possible first step in management of agitation. Although the results of this study cannot be used to draw causal inferences, the associations that were found can be used to generate hypotheses about the most viable interventions that should be tested in future controlled trials.

Traumatic Brain Injury Patient, Injury, Therapy, and Ancillary Treatments Associated With Outcomes at Discharge and 9 Months Postdischarge.

OBJECTIVE: To examine associations of patient and injury characteristics, inpatient rehabilitation therapy activities, and neurotropic medications with outcomes at discharge and 9 months postdischarge for patients with traumatic brain injury (TBI). DESIGN: Prospective, longitudinal observational study. SETTING: Inpatient rehabilitation centers. PARTICIPANTS: Consecutive patients (N=2130) enrolled between 2008 and 2011, admitted for inpatient rehabilitation after an index TBI injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Rehabilitation length of stay, discharge to home, and FIM at discharge and 9 months postdischarge. RESULTS: The admission FIM cognitive score was used to create 5 relatively homogeneous subgroups for subsequent analysis of treatment outcomes. Within each subgroup, significant associations were found between outcomes and patient and injury characteristics, time spent in therapy activities, and medications used. Patient and injury characteristics explained on average 35.7% of the variation in discharge outcomes and 22.3% in 9-month outcomes. Adding time spent and level of effort in therapy activities and percentage of stay using specific medications explained approximately 20% more variation for discharge outcomes and 12.9% for 9-month outcomes. After patient, injury, and treatment characteristics were used to predict outcomes, center differences added only approximately 1.9% additional variance explained. CONCLUSIONS: At discharge, greater effort during therapy sessions, time spent in more complex therapy activities, and use of specific medications were associated with better outcomes for patients in all admission FIM cognitive subgroups. At 9 months postdischarge, similar but less pervasive associations were observed for therapy activities, but not classes of medications. Further research is warranted to examine more specific combinations of therapy activities and medications that are associated with better outcomes.

Cognitive-motor interference during functional mobility after stroke: state of the science and implications for future research.

Cognitive-motor interference (CMI) is evident when simultaneous performance of a cognitive task and a motor task results in deterioration in performance in one or both of the tasks, relative to performance of each task separately. The purpose of this review is to present a framework for categorizing patterns of CMI and to examine the specific patterns of CMI evident in published studies comparing single-task and dual-task performance of cognitive and motor tasks during gait and balance activities after stroke. We also examine the literature for associations between patterns of CMI and a history of falls, as well as evidence for the effects of rehabilitation on CMI after stroke. Overall, this review suggests that during gait activities with an added cognitive task, people with stroke are likely to demonstrate significant decrements in motor performance only (cognitive-related motor interference), or decrements in both motor and cognitive performance (mutual interference). In contrast, patterns of CMI were variable among studies examining balance activities. Comparing people poststroke with and without a history of falls, patterns and magnitude of CMI were similar for fallers and nonfallers. Longitudinal studies suggest that conventional rehabilitation has minimal effects on CMI during gait or balance activities. However, early-phase pilot studies suggest that dual-task interventions may reduce CMI during gait performance in community-dwelling stroke survivors. It is our hope that this innovative and critical examination of the existing literature will highlight the limitations in current experimental designs and inform improvements in the design and reporting of dual-task studies in stroke.

Functional skill learning in men with traumatic brain injury.

The number of people with traumatic brain injury (TBI) having persistent deficits that compromise their ability to perform everyday skills is increasing. Previous occupation-based studies indicate that computer-based skills using repetitive practice may be a viable option for retraining. We investigated the effects of different practice schedules on skill learning in 6 men with TBI. Participants with significant impairments in processing and fine motor control practiced 3 tasks using a random (n = 3) or a blocked (n = 3) ordered practice schedule. Practice occurred for 55 min/day for 13 days with retention and transfer trials taking place 2 weeks after training. Both groups showed a significant increase in performance during skill acquisition and maintained this performance. Only the random-practice group, however, was able to transfer this learning to another task. The findings provide evidence that people with TBI can improve their everyday skills with randomly structured practice.

Botulinum toxin a, evidence-based exercise therapy, and constraint-induced movement therapy for upper-limb hemiparesis attributable to stroke: a preliminary study.

OBJECTIVE: To determine whether the combination of botulinum toxin A (BTX-A) treatment for the upper limb and a 4-wk course of exercise therapy could improve motor function sufficiently to allow those with poststroke hemiparesis and spasticity to achieve the minimal motor criteria (MMC) to be enrolled in constraint-induced movement therapy (CIMT), and to determine the feasibility of enrolling participants into CIMT if they meet MMC after treatment with a combination of BTX-A plus exercise therapy. DESIGN: Twelve individuals received BTX-A and exercise therapy for 1 hr/day, three times per week, for 4 wks. Those who met MMC were enrolled in 2 wks of CIMT, and the rest received a home exercise program. Outcome measures included the Ashworth Scale, Wolf Motor Function Test (WMFT), the Motor Activity Log (MAL), the Box and Blocks Test (BBT), and the upper-extremity subtest of the Fugl-Meyer Assessment of Motor Function (FM-UE). RESULTS: Ashworth Scale scores declined from a mean score of 2.0-1.2 (P = 0.01). Four of 12 subjects were able to achieve MMC (P = 0.026). CIMT participants improved in the BBT, the MAL, and the WMFT compared with their own baseline. Gains achieved during CIMT receded by week 24 as spasticity returned. CONCLUSION: BTX-A plus exercise therapy shows potential to improve function for those with severe hand paresis and spasticity after stroke. Those who meet MMC may initially realize further modest gains through CIMT. However, gains are likely to recede as spasticity returns. Adding medications or modifying the therapy protocol to include activities such as functional neuromuscular stimulation or robotic training may yield a more potent effect.