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
2
Traumatic Brain Injury
3
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).
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
Glasgow Coma Scale
1
2
3
4
Eyes
Does not
open eyes
Opens eyes
in response
to painful
stimuli
Opens eyes
in response
to voice
Opens eyes
spontaneous N/A
ly
Verbal
Makes no
sounds
Incomprehe Utters
Confused,
nsible
inappropriat
disoriented
sounds
e words
Oriented,
converses
normally
N/A
Makes no
movements
Abnormal
Extension to
flexion to
painful
painful
stimuli
stimuli
Localizes
painful
stimuli
Obeys
commands
Motor
Not part of
original scale
Flexion /
Withdrawal
to painful
stimuli
5
6
N/A
Classification Guidelines
Mild
Moderate
Severe
Glasgow Coma
score
13-15
9-12
3-8
Duration of loss of
consciousness
<30 Minutes
>30Minutes<24Ho
urs
>24 Hours
Duration of
alteration of
consciousness
<24 Hours
>24 Hours
>24 Hours
Severity of posttraumatic amnesia
<24 Hours
>24 Hours<7 Days
>7 Days
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.
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.
Causes
10
Physical Causes
Bruising/Bleeding, Tearing, Swelling, Open/Closed injuries
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.
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%
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.
Continued
Many variables have been shown to correlate with
life satisfaction in individuals who have suffered
TBIs.
Marital Status
Employment
Problem Solving
Executive Functioning
Goals of Rehabilitation
16
Purpose of Rehab
• The overall goal of Rehabilitation following a
TBI is to improve the person’s served
functioning at home.
•
17
This can be done by helping to restore a client’s physical,
sensory, psychological, or cognitive abilities, or by helping
them develop compensatory strategies.
Rehabilitation Focus
Cognitive: Cognitive
Rehabilitation/Neuropsychology/Speech
Physical: Physical Therapy/Occupational Therapy
Emotional/Adjustment: Neuropsychology
Participation: Entire team
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
Language/Word Finding
(Speech and Neuropsych
Aphasia
Circumlocution
Hand Gestures
Tip of the tongue
Common due to anatomy of skull
Ambulation/Motor (PT/OT)
• Difficulties with balance/walking
• Impairments in fine motor skills
• Decreased strength and stamina
21
Chronic Pain (PT/OT)
Headaches
Spinal Cord Injuries
Ineffectiveness of Pain Medication
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
Emotions (Neuropsych)
Emotions can become flat or amplified.
Lack of inhibition
Trouble analyzing social situations
Difficulty with facial expression or tone of voice
Measuring Outcomes
25
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
26
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
27
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
•
28
Substance abuse, multiple treatment modalities, social
support, etc.
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.
•
•
•
•
29
Language deficits
Awareness
Abstract Reasoning
Memory
Who We Serve
30
Total Number of Persons
Served
Who We Serve
Age:
Current Age
20s
30s
40s
50s
60s
Age at Admission
70s
0-18
19-29
30-44
45-60
61+
1%
14%
3%
9%
9%
25%
21%
30%
28%
27%
33%
Continued
33
Who We Serve
Gender and Ethnicity
Ethnicity
Caucasian
Gender
Black/Afr. Amr.
Other
Men
Women
2%
16%
31%
69%
82%
Who We Serve
Types of Injuries
Causes of Injury
7%
4%
7%
Motor Vehicle
Disease/stroke
Fall
12%
51%
Pedestrian
Assault
Other
19%
Our Measures
36
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.
37
Outcomes Process
• Data is collected annually
• Data collection included an annual
neuropsychological assessment
• Entire rehabilitation team is invloved
38
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
39
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
42
• Nonverbal
Communication
• Memory
• Attention/
concentration
• Fund of information
• Novel Problem-solving
• Visuospatial abilities
Continued
MPAI-4: Adjustment Index
• Anxiety
• Depression
• Irritability, anger,
aggression
• Pain/headache
• Fatigue
• Sensitivity to mild
symptoms
43
• Inappropriate social
interaction
• Impaired self-awareness
• Family/significant
relationships
• Initiation
• Social contact
• Leisure activities
Continued
MPAI-4: Participation
Index
• Initiation
• Social contact
• Leisure activities
• Self care
• Residence
44
• Transportation
• Employment
• Managing Money
MPAI-4 Database Project
• Initiative to develop an electronic national
database for MPAI-4 scores
•
45
Would allow different rehab centers to combine data to
study changes in outcomes over the course of post-acute
rehabilitation
Results From Our Population
46
Effectiveness
Supervision Rating Scale (SRS)
47
Effectiveness
Quality of Life (WHOQOL-BREF)
48
Effectiveness
(MPAI-4)
23
22
21
20
2011
2012
19
18
17
16
Abilities
55.5
55
54.5
54
Total
53.5
53
52.5
52
2011
2012
Adjustment
Participation
Satisfaction Key Measure
Persons Served
Would they Recommend this Program to
Others (DTS)
Recommend
Not Recommend
Would they Recommend this Program
to Others (Residential)
Recommend
Not Recommend
16%
24%
76%
84%
Satisfaction – Persons Served
Outpatient Satisfaction
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Comfort of
Treatment
Space
Do you Feel
Safe
How
Treated with Responded to Accuracy of
Supported is
Respect
in a Timely
Information
Your Physical
Manner
Provided
Health
Your
How Satisfied
Participation You are with
in Your Own Your Goals
Goals
Overall
Satisfaction
with DTS
Satisfaction – Persons Served
Residential Satisfaction
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Comfort of
Residential
Space
Do you Feel How Supported Treated with
Safe
is Your Physical
Respect
Health
Responded to
in a Timely
Manner
Accuracy of
Your
How Satisfied
Information Participation in You are with
Provided
Your Own
Your Goals
Goals
Overall
Satisfaction
with DTS
Satisfaction – Persons Served
53
Satisfaction - Families
Family Survey Results
All BI Programs
4.80
5.00
4.57
4.22
4.15
4.65
4.08
4.00
3.00
2.00
1.00
Achieving Goals
54
Community
Involvement
Person-Centered
Safety
Empathy
Family
Involvement
Satisfaction – Funders, Case
Managers
55
Recent Research
Accepted Publications:
DeLuca, N., Eichenbaum, E., Hartwig, A., Brownsberger, M., & Lindgren, K.
(2012). MPAI-4 Depression item predicts quality of life following TBI
[abstract]. Journal of Head Trauma Rehabilitation, 27(5), E20
56
Recent Research
Accepted Presentations:
DeLuca, N., Eichenbaum, E., Hartwig, A., Brownsberger, M., & Lindgren, K.
(2012, September). MPAI-4 Depression item predicts quality of life following
TBI. Poster presented at the 10th Annual Conference on Brain Injury of the
North American Brain Injury Society (NABIS), Miami, FL
Eichenbaum, E., DeLuca, N., Brownsberger, M., & Lindgren, K. (2012,
February).Examining the relationship between Quality of Life and MPAI score
following TBI: Preliminary results. Poster presented at Division 22’s 14th Annual
Rehabilitation Psychology Conference, Fort Worth, TX
Haggerty, K. (2013), Social Problem Solving among Individuals with Traumatic Brain
Injury: Relationships with Quality of Life, Executive Functioning, and Community
Integration. Poster presented at the annual meeting of Division 22
Rehabilitation Psychology Conference, Jacksonville, FL.
57
Difficulties and New Ideas
58
Challenges
• Goals related to the abilities scale in the MPAI-4 are
difficult to obtain in a sub acute rehab population
• In general the MPAI-4 is useful for detecting
significant long-term changes in functioning. Not as
useful as an immediate measure of progress
• WHOQOL-BREF has robust findings, but still suffers
from concerns over self-report.
59
Future Ideas
• Continue to explore how to measure
satisfaction
• A specific measure of financial capacity
• Better measures of risk assessment
60
Thank You!
Questions?
61
Contact Me
Email: kyle.haggerty@bancroft.org
Twitter: @DrKyleHaggerty
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