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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Traumatic Brain Injury

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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). 

Traumatic Brain Injury

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 scoreDuration of loss of consciousnessDuration of alteration of consciousnessSeverity of post-traumatic amnesia

Classification of TBIs

1 2 3 4 5 6

Eyes Does not open eyes

Opens eyes in response to painful stimuli

Opens eyes in response to voice

Opens eyes spontaneously

N/A N/A

Verbal Makes no sounds

Incomprehensible sounds

Utters inappropriate words

Confused, disoriented

Oriented, converses normally

N/A

Motor Makes no movements

Extension to painful stimuli

Abnormal flexion to painful stimuli

Flexion / Withdrawal to painful stimuli

Localizes painful stimuli

Obeys commands

Glasgow Coma Scale

Not part of original scale

Mild Moderate Severe

Glasgow Coma score

13-15 9-12 3-8

Duration of loss of consciousness

<30 Minutes >30Minutes<24Hours

>24 Hours

Duration of alteration of consciousness

<24 Hours >24 Hours >24 Hours

Severity of post-traumatic amnesia

<24 Hours >24 Hours<7 Days >7 Days

Classification Guidelines

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.

Some Stats

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.

Continued

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Causes

Physical Causes

Bruising/Bleeding, Tearing, Swelling, Open/Closed injuries

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.

Costs

Prevalence rates for psychiatric disorders are high after TBI.Depression rates have been reported in 14 to 77% of patientsSubstance abuse 5 to 28%PTSD 3 to 27%Other anxiety disorders 3 to 28%

TBI and Mental Illness

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.

TBI and Quality of Life

Many variables have been shown to correlate with life satisfaction in individuals who have suffered TBIs.Marital StatusEmploymentProblem Solving Executive Functioning

Continued

Goals of Rehabilitation

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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.

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Cognitive: Cognitive Rehabilitation/Neuropsychology/Speech

Physical: Physical Therapy/Occupational Therapy

Emotional/Adjustment: NeuropsychologyParticipation: Entire team

Rehabilitation Focus

Immediate MemoryDigit SpanNot a Common Complaint

Short Term MemoryMost Common Deficit in TBI

Long Term MemoryMissing details due to STM loss

Memory (Cog and Neuropsych)

Aphasia CircumlocutionHand GesturesTip of the tongue

Common due to anatomy of skull

Language/Word Finding (Speech and Neuropsych

Ambulation/Motor (PT/OT)• Difficulties with balance/walking

• Impairments in fine motor skills

• Decreased strength and stamina

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Headaches

Spinal Cord Injuries

Ineffectiveness of Pain Medication

Chronic Pain (PT/OT)

Brought on by large crowds, lots of noise, or information presented too quickly.Inability to process external environmentFatigue Rise in emotions

Overload (Neuropsych/OT)

Emotions can become flat or amplified. Lack of inhibitionTrouble analyzing social situations

Difficulty with facial expression or tone of voice

Emotions (Neuropsych)

Measuring Outcomes

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Outcome Measures UsedWhat 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

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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

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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.

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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

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Who We Serve

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Total Number of Persons Served

Who We Serve Age:

Continued

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Who We Serve Gender and Ethnicity

Who We ServeTypes of Injuries

Our Measures

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Standardized MeasuresBancroft 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.

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Outcomes Process

• Data is collected annually

• Data collection included an annual neuropsychological assessment

• Entire rehabilitation team is invloved

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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

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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.

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MPAI-4

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Continued

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Continued

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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

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Results From Our Population

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EffectivenessSupervision Rating Scale (SRS)

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EffectivenessQuality of Life (WHOQOL-BREF)

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Effectiveness (MPAI-4)

Satisfaction Key Measure

Persons Served

Satisfaction – Persons Served

Satisfaction – Persons Served

Satisfaction – Persons Served

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Satisfaction - Families

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Satisfaction – Funders, Case Managers

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Recent ResearchAccepted 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 

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Recent ResearchAccepted 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.

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Difficulties and New Ideas

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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.

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Future Ideas

• Continue to explore how to measure satisfaction

• A specific measure of financial capacity

• Better measures of risk assessment

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Thank You!

Questions?

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Contact Me

Email: kyle.haggerty@bancroft.orgTwitter: @DrKyleHaggerty

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