Standardized outcome assessment in brain injury rehabilitation for younger adults

Purpose: To explore possible candidates for a common outcome measure for brain injury rehabilitation in younger adults. Method: Patients recovering from brain injury pass through several different stages of rehabilitation, illustrated by the 'Slinky model'. Outcome measures used to assess progress must not only meet scientific criteria for validity and reliability - they must be practical to use in a clinical setting and relevant to the rehabilitation goals at each stage. Within most major rehabilitation settings, the commonest goals focus on reducing disability or dependency. Among the most widely used measures in the UK are the Barthel Index, the Functional Independence Measure (FIM) and the extended Functional Assessment Measure (FIM+FAM). The relationship between these instruments is discussed. Conclusion: No single outcome measure is suitable for all brain injury rehabilitation, but by taking these most widely used measures and understanding the relationship between them, we already have a potential common language in disability measurement between the majority of rehabilitation centres in the UK and beyond. These instruments, however, have clear floor and ceiling effects and further work is needed to agree common measures for rehabilitation intervention that falls outside the sensitivity range of these three scales.     

Goal attainment scaling and outcome measurement in postacute brain injury rehabilitation

Relationships among two-month and final goal attainment scaling (GAS) scores, preadmission and final Portland Adaptability Inventory (PAI) scores, and work outcome for 16 graduates of a comprehensive, postacute brain injury rehabilitation program were examined. Final GAS scores were higher for program graduates who obtained the most desirable work outcomes, and preadmission and final PAI scores were lower for the successful program graduates. Final GAS scores were significantly correlated with other outcome measures. Preadmission PAI scores predicted work outcome, and two-month GAS scores predicted final GAS scores. Initial PAI scores distinguished between program successes and failures, but not between program successes and dropouts. A brief look at one case illustrates the modified application of GAS in postacute brain injury rehabilitation. Results of this study and case analyses support GAS as a quantifiable, individualized measure that is useful for (1) monitoring patient progress, (2) structuring team conferences, (3) ongoing rehabilitation planning and decision-making, (4) concise, relevant communication to family, referral sources, and funding sources, and (5) overall program evaluation when used in the context of other objective outcome measures. Although our results support the clinical utility of GAS, further study is recommended to assess the psychometric characteristics of GAS in this application.     

Process and outcome during early inpatient rehabilitation after brain injury

Purpose: To describe aspects of process and outcome during early inpatient rehabilitation of younger adults after single incident brain injury.

Method: Analysis of a database of 290 patients discharged from an inner-city hospital based inpatient unit for younger adults after single incident neurological events, over a 5-year period.

Results: Analysis showed a stable case-mix of patients over the 5 years surveyed with a preponderance of young male patients after traumatic brain injury. Improvements in patients' disability and dependency, measured by the Barthel Index and Functional Independence Measure, were recorded in the majority of patients. The ethnic diversity of the patients, reflecting the multi-cultural nature of the catchment population, did not appear to affect rehabilitation outcome. Failure to record improvement in 15% of patients was related to the floor and ceiling effects of the instruments. A useful regression equation was produced relating length of stay to Barthel score on admission.

Conclusions: These data demonstrate the changes that occur during early inpatient rehabilitation after single incident brain injury. They explore clinical indicators of dependency and outcome, and aspects of resource utilization that characterize our service. Publication of data of this sort, from this and other units, should encourage the development and improvement of current rehabilitation service delivery after brain injury.     

Reliability of the relative's questionnaire for assessment of outcome after brain injury

PURPOSE: The relative's questionnaire (RQ) was developed to assess outcome after brain injury. The present study investigated its test-retest reliability when used in a postal survey. METHOD: Hospital records were used to identify and contact 288 surviving patients treated for brain injury five to seven years earlier. Patients were sent a copy of the RQ (RQ1) and one month later a second copy (RQ2) was sent to those who returned RQ1. RESULT: Two hundred and eleven patients were successfully contacted, of whom 128 (61%) returned RQ1, and 94 of these (73%) returned RQ2. The reliability of items was variable, with most having a kappa value of > 0.6 suggesting 'substantial agreement' or better. CONCLUSION: The data presented suggest that the RQ is a reliable instrument in collecting outcome information in brain-injured patients by postal survey. Further research is recommended to test the suitability of the RQ for the use as a telephone interview.     

Training in brain injury rehabilitation

Purpose: To evaluate our current training programme for professionals involved in brain injury rehabilitation, which involves disability simulation, and to consider the ethics and consequences of such programmes. Method: Seventy-two professionals took part in a brain injury disability simulation exercise and completed questionnaires pre and post the workshop. Results: Results suggest that participants have increased insight into the challenges faced by people with brain injuries. Conclusions: We believe that brain injury simulation exercises help professionals increase their understanding of the impairments and disabilities that may follow brain injury and can therefore form an important part of a training programme for rehabilitation staff.     

Reliability of the relative's questionnaire for assessment of outcome after brain injury

Purpose : The relative's questionnaire (RQ) was developed to assess outcome after brain injury. The present study investigated its test-retest reliability when used in a postal survey. Method : Hospital records were used to identify and contact 288 surviving patients treated for brain injury five to seven years earlier. Patients were sent a copy of the RQ (RQ1) and one month later a second copy (RQ2) was sent to those who returned RQ1. Result : Two hundred and eleven patients were successfully contacted, of whom 128 (61%) returned RQ1, and 94 of these (73%) returned RQ2. The reliability of items was variable, with most having a kappa value of < 0.6 suggesting 'substantial agreement' or better. Conclusion : The data presented suggest that the RQ is a reliable instrument in collecting outcome information in brain-injured patients by postal survey. Further research is recommended to test the suitability of the RQ for the use as a telephone interview.     

Comparison of rehabilitation outcome in patients with aphasic and non-aphasic traumatic brain injury.

OBJECTIVE: To compare the functional, cognitive and disability status of aphasic and non-aphasic traumatic brain injury patients. DESIGN: A prospective comparative study in which 103 patients with traumatic brain injury participated. SUBJECTS: Fifty-one aphasic and 52 non-aphasic patients with traumatic brain injury. METHODS: Functional Independence Measure and Disability Rating Scale were used to determine functional status and disability. Cognitive status was evaluated by the Mini-Mental Status Examination. Aphasic patients were evaluated using the Gülhane Aphasia Test for language disorders. RESULTS: The most frequent type of aphasia was Broca aphasia at 26.49% followed by anomic at 19.6% and trans-cortical motor at 15.6%. Functional Independence Measure, Disability Rating Scale and Mini-Mental Status Examination scores at admission and at discharge showed significant differences in aphasic patients (p<0.001). There were no significant differences in the Functional Independence Measure, Disability Rating Scale and Mini-Mental Status Examination gains between the aphasic and non-aphasic patients (p>0.01). CONCLUSION: Although aphasia could be accepted as a negative prognostic indicator in patients with traumatic brain injury, we could not detect any difference in functional and cognitive gains between the aphasic and non-aphasic patients.     

Effectiveness of brain injury rehabilitation

Despite the problems posed by diversity of condition and the lack of agreement among researchers over what outcome to measure, there is now increasingly robust evidence for the effectiveness of rehabilitation in brain-injured populations. Meta-analysis has demonstrated clearly that stroke units provide a better outcome than management on a general medical ward, at the level of survival, discharge destination and dependency. The extent of this advantage may be summarized in the following terms. For every 100 patients treated in a stroke unit, four deaths and two institutional admissions are avoided, and five patients are discharged home. This benefit appears to arise from a combination of good-quality acute management and the coordinated input of a multidisciplinary team. Therapy programmes are shown to be of benefit and intensive therapy programmes of somewhat greater benefit. Smaller numbers and heterogeneity among the head-injured population tend to confound randomized controlled trial designs, but there is no good reason to suppose that brain injury resulting from trauma should be less responsive to similar good management principles than that arising from stroke. In any event, we have progressed to a stage where the weight of evidence supports the notion that rehabilitation is effective, and nontreatment controls are ethically no longer acceptable. It is time now to unravel the threads of rehabilitation and consider which are the critical components. There are still many opportunities for comparison of different models for delivery of care, and the existing evidence for these is discussed.     

A new instrument for outcome assessment in rehabilitation medicine: Spinal cord injury ability realization measurement index

OBJECTIVES: To introduce a new measure of disability weighted for the neurologic deficit in patients with spinal cord lesions and to examine the effect on the instrument of being in rehabilitation. DESIGN: Development of instrument and preliminary comparative before-after study. SETTING: Spinal department in a rehabilitation hospital in Israel. PARTICIPANTS: Seventy-nine patients with spinal cord lesions. INTERVENTIONS: Patients were repeatedly assessed during rehabilitation with the American Spinal Injury Association Impairment Scale (AIS) to measure neurologic motor impairment and with the Spinal Cord Independence Measure (SCIM-II) to measure disability. Scores of the 2 assessments were combined to create the Spinal Cord Injury Ability Realization Measurement Index (SCI-ARMI). MAIN OUTCOME MEASURES: A preliminary formula for the calculation of SCI-ARMI using the individual patients' SCIM-II and AIS motor scores and changes in SCI-ARMI values through rehabilitation. RESULTS: The highest observed SCIM-II scores at patients' AIS level correlated highly with the AIS motor scores (r=.96, P<.01). A regression performed for this linear relationship resulted in a preliminary SCI-ARMI formula. The calculated SCI-ARMI values improved during rehabilitation irrespective of patient age, gender, lesion level, or lesion severity (P<.001). CONCLUSIONS: The preliminary version of the SCI-ARMI can be used to assess quantitatively changes in functional ability, isolating them from the effect of neurologic changes.     

Tackling evaluation: applying a programme logic model to community rehabilitation for adults with brain injury

Programme evaluation has become an important component of many rehabilitation initiatives in both institutional and community environments. Of key importance is a need for information on developing an evaluation framework to determine and address programme processes and outcomes. This paper presents a programme logic model used to guide the evaluation of a community rehabilitation programme for adults with brain injury. Programme logic models are visual models that provide a framework to organize and integrate information about programme inputs, processes and outcomes. The model is also used in this programme to incorporate the client-centred values of the programme. It was developed through the consensus of the entire team, and was used to plan implementation and outcome evaluations. A similar programme logic model will be useful to occupational therapists and other health care professionals planning programme evaluations of their services.     

Time of rehabilitation admission and severity of trauma: effect on brain injury outcome

Outcome after traumatic brain injury, defined by the Glasgow Outcome Scale (GOS) and length of stay in acute rehabilitation, was measured in 59 patients admitted to an intensive rehabilitation program to examine the effects of severity of the initial brain injury, severity of multiple trauma, and length of stay in the acute care hospital. Severity of initial brain injury, best measured by length of coma, was the most significant predictor of GOS outcome. Length of acute hospitalization was a small, but significant, predictor of GOS. Severity of initial brain injury, length of acute hospitalization, and gender emerged as predictors of length of rehabilitation hospital stay. Although length of acute hospitalization is apparently affected by severity of brain injury, it adds significantly--more than severity of brain injury--to the prediction of length of rehabilitation.     

FIM量表在外伤性颅脑损伤患者康复疗效评价中的应用

目的 :运用功能独立性评价量表 (FIM )评价外伤性颅脑损伤 (TBI)患者的康复治疗疗效 ,比较闭合性颅脑损伤 (CBI)和开放性颅脑损伤 (OBI)患者的临床特点和康复治疗的效果。方法 :79例TBI患者中 ,5 7例为CBI、2 2例为OBI。运用FIM量表评价两组患者康复治疗前后的功能情况 ,统计患者的入院天数 ,计算FIM效率。结果 :CBI和OBI患者入院时的FIM总评分分别为 81.5 1和 73.0 9;出院时FIM总评分分别为 115 .0 4和 117.77,两组平均增加 4 1%和 5 3%。两组患者康复治疗前后FIM各项评分自身相比有非常显著差异 (P <0 .0 0 1) ,但两组之间相比无显著差异。两组患者的FIM效率分别为 1.99分 /天和 1.71分 /天。结论 :康复治疗可有效改善TBI(无论是CBI还是OBI)患者的功能情况。康复治疗应强调早期和综合性治疗     

Cardiac rehabilitation exercise program: outcome assessment

Medically supervised exercise programs have increasingly gained acceptance in management of the coronary patient. Beneficial postexercise results published include: Improved exercise and work tolerance, a decrease in frequency and severity of angina, and earlier return to work. The present retrospective study evaluates the outcome of a three-month cardiac rehabilitation exercise program with changes in exercise performance, compliance with postdischarge exercise routine, and return to work pattern. The study group included 38 patients with documented coronary artery disease and two participants free of ischemic heart disease. Thirty patients were treated with beta blocker medications, ten were not. Time of follow-up ranged from six months to two years. Pre- and postexercise performance expressed in VO2 ml/kg/min was assessed at target heart rate using a modified exercise protocol. Training resulted in statistically significant increases in median exercise performance in both patient groups: 2.38 ml O2/kg/min (range 1.33, 7.18; p 0.0068, one-tail) in the untreated group, and 3.45 ml O2/kg/min (range 2.63, 11.48; p 0.001, one-tail) in the beta blocker treated group. Fifty-seven percent of the participants complied with a postdischarge exercise routine while 7/12 (58%) patients unemployed at time of referral resumed work during or following completion of the exercise program. Such programs appear to be a valuable component in the management of the coronary patient. Further studies involving larger numbers of patients are indicated to document cost effectiveness of such programs.     

创伤性脑损伤的临床康复

创伤性脑损伤(traumaticbraininjury,TBI)在欧美发病率较高,初步统计是创伤性脊髓损伤的30～40倍,在某些方面,接近于脑卒中的发病率。病因多为交通事故、体育活动、工伤和暴力袭击。患者主要为青年男性,美国统计,15～24岁青年男性的发病率≥550人/100000人口。严重TBI的良好结局依赖于长期的综合性康复治疗,大多数患者的社会生活能力较差,家庭和社会为此负担较大。     

Simple assessment of outcome after acute brain injury using the Glasgow Outcome Scale

To evaluate alternative methods of determining Glasgow Outcome Scale scores, a postal survey was made of 288 general practitioners and 128 relatives of patients who had sustained acute brain injuries 5-7 years previously. The Glasgow Outcome Scale score from the general practitioner and relative were compared with that calculated from questionnaire information by an experienced rater. There was poor agreement between general practitioner and rater (K = 0.17) and relative and rater (K = 0.35) scores. Both general practitioners and relatives indicated more favourable outcomes than the rater, with a higher level of agreement (K = 0.61) between them. When Glasgow Outcome Scale scores are used, the methods employed should be valid and reliable; failure to ensure this may be responsible for a considerable proportion of variability in reported studies of brain injury outcome.