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

Setting the foundation for a national collaborative learning health system in acute TBI rehabilitation: CARE4TBI Year 1 experience

Introduction

A learning health system (LHS) approach is a collaborative model that continuously examines, evaluates, and re-evaluates data eventually transforming it into knowledge. High quantity of high-quality data are needed to establish this model. The purpose of this article is to describe the collaborative discovery process used to identify and standardize clinical data documented during daily multidisciplinary inpatient rehabilitation that would then allow access to these data to conduct comparative effectiveness research.

Methods

CARE4TBI is a prospective observational research study designed to capture clinical data within the standard inpatient rehabilitation documentation workflow at 15 TBI Model Systems Centers in the US. Three groups of stakeholders guided project development: therapy representative work group (TRWG) consisting of frontline therapists from occupational, physical, speech-language, and recreational therapies; rehabilitation leader representative group (RLRG); and informatics and information technology team (IIT). Over a 12-month period, the three work groups and research leadership team identified the therapeutic components captured within daily documentation throughout the duration of inpatient TBI rehabilitation.

Results

Data brainstorming among the groups created 98 distinct categories of data with each containing a range of data elements comprising a total of 850 discrete data elements. The free-form data were sorted into three large categories and through review and discussion, reduced to two categories of prospective data collection-session-level and therapy activity-level data. Twelve session data elements were identified, and 54 therapy activities were identified, with each activity containing discrete sub-categories for activity components, method of delivery, and equipment or supplies. A total of 561 distinct meaningful data elements were identified across the 54 activities.

Discussion

The CARE4TBI data discovery process demonstrated feasibility in identifying and capturing meaningful high quantity and high-quality treatment data across multiple disciplines and rehabilitation sites, setting the foundation for a LHS coalition for acute traumatic brain injury rehabilitation.

Lifespace and occupational participation following acquired brain injury during driving disruption: a mixed methods study

PURPOSE

To examine the lifespace of participants referred for occupational therapy driving assessment following acquired brain injury, to understand how, why, where and with whom access and participation in community-based occupations is occurring during the period of driving disruption.

MATERIALS AND METHODS

The mixed methods, convergent research design utilised a travel diary and Lifespace Mobility Assessment-Composite quantitative elements and semi-structured interviews analysed qualitatively with an interpretive description lens.

RESULTS

Forty-eight participants (56.25% male) aged between 26 and 65 years, left home on average once/day, primarily to conduct instrumental activities of daily living, health management, and social participation community-based occupations. Most reported restricted lifespace (54.2%) requiring assistance to conduct community occupations (68.1%). Support was primarily provided by family members (80.3%). Analysis of semi-structured interviews (n = 15) created three themes that shaped participant occupational experience during driving disruption: (i) changes to occupational participation; (ii) reliance on others for community access and participation; and (iii) trying to move forward.

CONCLUSION

The period of driving disruption following the onset of acquired brain injury is a time of occupational disruption which restricts lifespace, changing how, why, where and with whom participation in community-based occupations occurs. Rehabilitation facilitating occupational adaptation process to enhance community access capacity is indicated.

Using Electronic Health Record Data for Occupational Therapy Health Services Research: Invited Commentary

Health services research (HSR) is a field of study that examines how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and health and well-being. HSR approaches can help build the occupational therapy evidence base, particularly in relation to population health. Data from electronic health record (EHR) systems provide a rich resource for applying HSR approaches to examine the value of occupational therapy services. Transparency about data preparation procedures is important for interpreting results. Based on our findings, we describe a six-step cleaning protocol for preparing EHR and billing data from an inpatient rehabilitation facility for research and provide recommendations for the field based on our experience. Using and reporting similar strategies across studies will improve efficiency and transparency, and facilitate comparability of results.

Physical Therapy Dose After Orthopedic Multilevel Surgery Varies by Ambulatory Status in Children With Cerebral Palsy: A Pilot Study

PURPOSE

To characterize physical therapy (PT) dose for children with cerebral palsy (CP) after multi-level surgery (MLS) and examine variation by ambulatory status and surgical burden.

METHODS

PT dose (Frequency, Intensity, Time, Type) data were extracted from electronic records of children with CP who received outpatient PT the year after MLS.

RESULTS

Seventeen children, mean 9 years, female (n=10), ambulatory (n=10), and high surgical burden (n=12) were included. In the year after surgery, 345 visits occurred. Intensity across visits was above average. Time was greatest for pre-functional activities, gait, and transitions/transfers. Types most often delivered were neuromuscular, musculoskeletal, and education/training. Ambulatory children received significantly more visits, higher intensity, and time in pre-functional activities and gait than non-ambulatory children. No differences in type by ambulatory status and PT dose by surgical burden were found.

CONCLUSION

PT dose varied the first year after MLS indicating the need for guidelines by ambulatory status.

VIDEO ABSTRACT

Supplemental Digital Content available at: http://links.lww.com/PPT/A516.

Spreading Standardized Documentation of Pediatric Occupational and Physical Therapy Dose: A Quality Improvement Initiative

IMPORTANCE

Clinicians and researchers can leverage clinical documentation of therapy services for quality improvement and research purposes. However, documentation is often institution specific and may not adequately capture the dose of therapy delivered, thus limiting collaboration.

OBJECTIVE

To implement documentation of pediatric occupational and physical therapy dose from one institution to another institution. Dose documentation includes the frequency, intensity, time, and type of interventions delivered (FITT Epic® Flowsheet) at each session.

DESIGN

Prospective time-series quality improvement study.

SETTING

Two large urban pediatric hospitals.

PARTICIPANTS

Occupational and physical therapy staff members.

INTERVENTION

Staff training and feedback loops utilizing existing groups.

OUTCOMES AND MEASURES

The process measure (number of available staff trained and using the FITT Epic Flowsheet over time) and the outcome measure (percentage of FITT Epic Flowsheets used for treatment visits each month) were analyzed using a statistical process control chart. The balancing measure (percentage of notes closed before 7 p.m. on the same day as the encounter) was analyzed using mean per month across three time periods.

RESULTS

Fifty-seven staff members (68%) attended formal training. On average, clinicians documented 90% of sessions using the FITT Epic Flowsheet after implementation. There was no change observed in the balancing measure.

CONCLUSIONS AND RELEVANCE

Documentation of dose was spread from one institution to another. Shared documentation will facilitate future collaboration for quality improvement and research purposes. Occupational therapy practitioners and leaders should consider implementing documentation with common dose elements. Plain-Language Summary: Occupational therapy documentation is often institution specific and may not adequately capture the dose of therapy (frequency, intensity, time) or types of interventions that were delivered, thus limiting opportunities for collaboration between institutions. This article adds to the literature on administrative supports for clinical and quality improvement research by illustrating a specific example of how documentation of dose can be shared from one institution to another. The data show that clinicians at one institution started using a new style of documentation using the FITT Epic® Flowsheet and shared discrete dose elements with another institution, creating new opportunities for collaboration. Shared documentation can facilitate future collaboration for quality improvement and research purposes.

Inpatient rehabilitation patients are more active during rehabilitation times and days than non-rehabilitation times and days: An observational study

Introduction

The effectiveness of inpatient rehabilitation services has been well supported. However, patients receiving inpatient rehabilitation may be physically inactive outside of therapy. The primary objectives were to determine differences in activity levels between rehabilitation time and non-rehabilitation time and rehabilitation day and non-rehabilitation day during inpatient rehabilitation stay. The secondary objective was to determine differences among rehabilitation services.

Methods

In all, 50 participants wore an ActiGraph GT9X Link on their non-dominant wrist during their inpatient rehabilitation stay.

Results

We found significant differences in total activity counts between rehabilitation time and non-rehabilitation time (z = 6.15, p < 0.001) and between rehabilitation day and non-rehabilitation day (z = 5.82, p < 0.001). We found significant differences in total activity counts between occupational therapy and physical therapy (z = 5.71, p < 0.001), occupational therapy and speech-language pathology (z = 3.41, p < 0.001), and physical therapy and speech-language pathology (z = 3.07, p = 0.002). The degrees of all differences were large.

Conclusion

To increase the activity levels during non-rehabilitation times and days, patients receiving inpatient rehabilitation may benefit from strategies which increase activity levels such as an individualized program that can be safely and independently performed outside of rehabilitation sessions.

Music Therapy in Global Aphasia: A Case Report

Patients affected by global aphasia are no longer able to understand, produce, name objects, write and read. It occurs as a result of functional damage of ischemic or hemorrhagic origin affecting the entire peri-silvan region and frontal operculum. Rehabilitation training aims to promote an early intervention in the acute phase. We described a case of a 57-year-old female patient with left intraparenchymal fronto-temporo-parietal cerebral hemorrhage and right hemiplegia. After admission to clinical rehabilitative center, the patient was not able to perform simple orders and she presented a severe impairment of auditory and written comprehension. Eloquence was characterized by stereotypical emission of monosyllabic sounds and showed compromised praxis-constructive abilities. Rehabilitation included a program of Neurologic Music Therapy (NMT), specifically Symbolic Communication Training Through Music (SYCOM) and Musical Speech Stimulation (MUSTIM). Rehabilitative treatment was measured by improved cognitive and language performance of the patient from T0 to T1. Music rehabilitative interventions and continuous speech therapy improve visual attention and communicative intentionality. In order to confirm the effectiveness of data presented, further extensive studies of the sample would be necessary, to assess the real role of music therapy in post-stroke global aphasia.

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

OBJECTIVE

To evaluate the effect of providing quasi-contextualized speech therapy, defined as metacognitive, compensatory, or strategy training applied to cognitive and language impairments to facilitate the performance of future real-life activities, on functional outcomes up to 1 year following traumatic brain injury (TBI).

SETTING

Acute inpatient rehabilitation.

PARTICIPANTS

Patients enrolled during the TBI-Practice-Based Evidence (TBI-PBE) study (n = 1760), aged 14 years or older, who sustained a severe, moderate, or complicated mild TBI, received speech therapy in acute inpatient rehabilitation at one of 9 US sites, and consented to follow-up 3 and 9 months postdischarge from inpatient rehabilitation.

DESIGN

Propensity score methods applied to a database consisting of multisite, prospective, longitudinal observational data.

MAIN MEASURES

Participation Assessment with Recombined Tools-Objective-17, FIM Motor and Cognitive scores, Satisfaction With Life Scale, and Patient Health Questionnaire-9.

RESULTS

When at least 5% of therapy time employed quasi-contextualized treatment, participants reported better community participation during the year following discharge. Quasi-contextualized treatment was also associated with better motor and cognitive function at discharge and during the year after discharge. The benefit, however, may be dependent upon a balance of rehabilitation time that relied on contextualized treatment.

CONCLUSIONS

The use of quasi-contextualized treatment may improve outcomes. Care should be taken, however, to not provide quasi-contextualized treatment at the expense of contextualized treatment.

Retrospective study demonstrating therapy time impact on inpatient rehabilitation functional gains

PURPOSE

The purpose of this retrospective study is to evaluate the association of total therapy time during inpatient rehabilitation and gain in functional independence for patients admitted to an inpatient rehabilitation facility (IRF).

MATERIALS AND METHODS

The study utilized a retrospective design that included all IRF patients from three IRFs in California from January 1, 2012 to December 31, 2013. Patient data collected as part of usual, routine medical, and rehabilitation care were used and includes demographics, medical variables, and functional outcomes data.

RESULTS

There were 3212 patients discharged from the three IRFs, with 2,777 patients having received speech language pathology (SLP) therapy along with occupational therapy and physical therapy. Speech language pathology services were not provided for 435 patients in the database. Our results support that among all types of patients, increased therapy hours were associated with increased functional gains. For total functional independence measure (FIM) gain, an additional hour of PT therapy per day was associated with an increase of 7.55 FIM gain points (p < 0.001) and an additional hour of OT therapy per day was associated with an increase of 1.16 FIM gain points (p = 0.045), when adjusted for other variables in the model. SLP hours per day did not remain in the FIM gain model.

CONCLUSIONS

The findings of this study add to the understanding of therapy time and functional gain in an inpatient rehabilitation program. There is a positive relationship between total therapy time and functional gain. In the future determining the intensity and the related therapy activities provided will be needed to impact functional change. This has implications for shaping rehabilitation practice in the future.Implications for rehabilitationIncreased number of therapy hours were associated with functional gains in an inpatient rehabilitation program for all types of patients.An additional hour of physical therapy per day was associated with an increase of 7.55 functional independence measure (FIM) point gain.An additional hour of occupational therapy per day was associated with an increase of 1.16 FIM point gain.Determining the intensity and related activities are needed to impact functional change which has implications for shaping rehabilitation practice.

Profile of patients undergoing speech-language therapy in a physical and rehabilitation medicine hospital service

ABSTRACT Purpose: to analyze the profile and risk factors of patients attended by speech therapists in a hospital service of physical and rehabilitation medicine (P&RM) of the public health system. Methods: a retrospective cohort study was carried out. The variables were summarized using frequencies, proportions, and measures of central tendency. Relative risks (RR) were estimated, using the incidence ratio (IC:95%) and the bilateral Fisher's exact test. A level of significance was considered p <0.05. Results: 23,365 speech therapy activities distributed in 8,416 sessions were carried out between September 2016 to September 2018, with patients admitted to a P&RM service. The activities focused people over 60 years in the areas of swallowing (28.6%) and cognition (11.7%). Age equal to or greater than 60 years was identified as a risk factor for admission, due to cerebrovascular disease of 1.36 (95% CI: 1.24-1.49; p = 0.001), and belonging to section B of the National Health Fund (FONASA), 1.37 (95% CI: 1.29-1.46, p = 0.001). The RR for respiratory pathology was greater in the winter period: 1.63 (95% CI: 1.50-1.76; p = 0.001). Conclusion: elderly and low-income people are more likely to need speech therapy rehabilitation in the context of P&RM service.

Evaluating the effectiveness of on-road driving remediation following acquired brain injury: A wait-list feasibility study with follow-up

INTRODUCTION

Return to driving is an important goal for people recovering from acquired brain injury. Occupational therapy driving assessments aim to determine the impact of acquired brain injury on a person's capacity to drive and may include on-road driving rehabilitation. The primary objective of this project was to conduct a feasibility randomised controlled trial (RCT) of an on-road driving remediation program for adults with acquired brain injury. Secondary objectives were to measure the effectiveness of the on-road driving program and determine sample size required for a randomised controlled trial.

METHODS

A wait-list randomised controlled trial with blinded assessment and 6-month follow-up aimed to recruit 10 participants with acquired brain injury. Concealed methods randomly allocated participants to receive the on-road driving rehabilitation program immediately (intervention group) or after 6 weeks (wait-list group). The primary outcome measure of functional fitness to drive, was assessed pre- and post-intervention, and at 6-month follow-up. Driving performance was measured by percentage of correct manoeuvres and driving instructor intervention.

RESULTS

Eight participants (seven male; average age 46 years; six traumatic brain injury and two stroke) were recruited. The protocol was feasible. Results of the RCT suggest intervention effectiveness initially with two of the three interventions, and no wait-list, participants achieving fitness to drive. This increased to five out of eight participants after the wait-list group completed the intervention. While three participants retained this outcome at 6-month follow-up, universal deterioration in on-road driving performance was evident for all participants at 6-month follow-up.

CONCLUSION

The trial was feasible and findings suggest that on-road driving remediation assists people with acquired brain injury to achieve functional fitness to drive but the skills may not be maintained 6 months later. A full RCT is warranted to further determine the effectiveness of on-road driving remediation and capacity of participants to maintain the skills developed.

Developing an evidence-based reading intervention for early brain injury rehabilitation

Introduction:

Providing evidence-based services in areas with emerging or low-level evidence is a challenge for many clinicians. The aim of the current study was to apply a newly designed novel methodology to develop and describe a new intervention for cognitive-communication reading comprehension deficits in early acquired brain injury rehabilitation.

Methods:

An emergent multi-phase mixed methods design allowed phases of different research activity to build an evidence base of quantitative and qualitative data. A pragmatic clinical framework was developed to combine these traditional research findings with principles from knowledge translation and implementation science, evidence-based practice and intervention development models, clinical contextual practice guidelines and the Medical Research Council’s guidelines for developing and evaluating complex interventions, to create an evidence-based contextually driven clinical intervention.

Results:

The resulting reading comprehension intervention and service delivery model is presented and involves a multiple-strategy intervention across increasing level of reading comprehension complexity. In areas where traditional methodologies provide low-level evidence, this method provides an alternate way to conduct evidence-based clinical research.

Strategy-based reading comprehension therapy during early acquired brain injury rehabilitation: preliminary results

Introduction: An evidence-based intervention and service delivery model for early acquired brain injury reading comprehension rehabilitation (involving multiple-strategy, hierarchical reading) was investigated with 3 clients <3 m post onset as part of their brain injury rehabilitation program.Materials and methods: A multiple-baseline single case experimental design was used for each participant, with data analysed using Tau-U. Assessments of reading comprehension (impairment and activity level) were performed pre/post intervention, and at follow-up (3-6 months post-treatment). Participants' perceptions of the intervention and service delivery model were captured via semi-structured interviews.Results: All participants demonstrated improved reading comprehension post-intervention on all formal measures. At follow-up, reading comprehension was grossly maintained by 2 participants. The single case experimental design results (Tau-U) showed moderate-large intervention effect sizes for factual and inferential reading comprehension, two participants had significant (p = 0.01) changes. Participants reported overall positive experiences with the intervention.Conclusion: The intervention and service delivery model were successfully implemented in clinical practice, and preliminary results show the intervention has clinical promise with an early acquired brain injury population.IMPLICATIONS FOR REHABILITATIONCognitive communication reading comprehension deficits occur following acquired brain injury and impact participation during rehabilitation and in the community.An evidence-based intervention for the early rehabilitation of cognitive communication reading comprehension deficits following acquired brain injury has been developed and trialled in clinical practice with adults <3 months post-acquired brain injury, via a series of single-case experimental designs.Improvements in reading comprehension skill and activity/participation occurred for all participants post-intervention; statistically significant changes occurred for 2 of 3 clients.Early rehabilitation of cognitive communication reading comprehension deficits can be successfully implemented as a component of a multidisciplinary rehabilitation program.

Physiotherapy in children hospitalized with traumatic brain injury in a South African tertiary paediatric hospital

INTRODUCTION

Physical impairments following traumatic brain injury (TBI) may limit participation in daily living. Physiotherapy could assist in managing these limitations, however, there is a paucity of literature on the physiotherapy management of children in the acute phase of TBI.

OBJECTIVES

To describe the characteristics, course and outcome of children hospitalized with TBI, with specific reference to the role of physiotherapy.

METHODS

A retrospective folder review of all children (n = 130, median 5.37 years [IQR 1.88-7.88]) admitted in 2016 with a primary diagnosis of TBI was conducted at a tertiary paediatric hospital.

RESULTS

Most cases presented with mild TBI (66.2%). The most common cranial manifestation of the TBI was brain bleeds (80%) and most occurred as a result of road traffic accidents (50%, including both pedestrian and motor vehicle accidents). Physiotherapy was administered in 35 cases (26.9%), with functional interventions, such as mobilizations out of bed, the most common form of therapy (71.4%). Children involved in road traffic accidents, presenting with severe diffuse TBI, resulting in altered tone and coordination problems, admitted to intensive care, monitored with an intracranial pressure or Licox monitor, and receiving occupational therapy and/or been followed up by dieticians, were more likely to receive physiotherapy. The duration of hospitalization (median 4 days [IQR 2-9]) was associated with infections, severity of TBI, presence of an intracranial monitoring, and parietal lobe injury.

CONCLUSION

This is the first study in South Africa investigating standard physiotherapy care in children admitted with TBI. Physiotherapy was provided in a small portion of children and appeared to be well tolerated. However, due to the limited information recorded in the physiotherapy notes, results of this study need to be confirmed in larger, more well-documented studies before generalizations can be made.

A Novel Intervention Platform for Service Members With Subjective Cognitive Complaints: Implementation, Patient Participation, and Satisfaction

Introduction

Program overview of a novel cognitive training platform at Walter Reed National Military Medical Center (WRNMMC) for service members with subjective cognitive complaints: analysis of patient participation, satisfaction with the program, and perceived areas of improvement.

Materials and Method

Retrospective review of 1,030 participants from November 2008 through May 2017. Data were obtained within an approved protocol (WRNMMC-EDO-2017-0004/# 876230).

Results

The program has shown growth in numbers of referrals, types of patient populations served, and patient visits. Patients report satisfaction with the program and endorse improvements in cognitive functions.

Conclusions

This program model may benefit other military facilities looking to provide and assess novel therapeutic approaches.

Occupational and Physical Therapy Activities and Level of Effort in Patients With Traumatic Brain Injury: Association With Functional Outcomes

BACKGROUND

Although some attention has been given to the association of functional outcomes with rehabilitation intensity, the evidence is still sparse in this field.

OBJECTIVE

To investigate the effect of inpatient rehabilitation (IR) on discharge cognitive and motor function and the association of time spent in occupational and physical therapy and level of effort with cognitive and motor function in patients with traumatic brain injury (TBI).

DESIGN

Secondary analysis of TBI-Practice Based Evidence dataset.

SETTINGS

Inpatient rehabilitation.

PARTICIPANTS

One hundred forty-nine patients with TBI who were consecutively admitted for IR between 2008 and 2011 in Ontario, Canada.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASUREMENTS

Admission and discharge Functional Independence Measure-Rasch Cognitive and Motor Scores.

RESULTS

Patients showed significant improvement in cognitive and motor function from admission to discharge (P < .0001). After controlling for confounding factors, discharge FIM-Rasch cognitive and motor scores were not associated with either level of effort or time spent in physical therapy activities. Discharge motor, but not cognitive function, was associated with more time spent in the complex (β = 0.20, confidence interval [CI] 0.005, 0.05) and less time spent in simple OT activities (β = -0.13, CI -0.13, -0.01).

CONCLUSION

This study provides valuable information for clinicians about the effectiveness of IR on the improvement of motor and cognitive outcomes and the importance of considering the amount of time spent in activities based on their level of complexity rather than the total time of therapy to improve motor outcomes in this population.

LEVEL OF EVIDENCE

III.

Content of inpatient rehabilitation for patients with traumatic brain injury: A comparison of Canadian and American facilities

Objective: To compare components of inpatient rehabilitation (IR) for patients with traumatic brain injury (TBI) between Canada and the US facilities. Design: Secondary analysis of the TBI-practice-based evidence dataset. Participants: Patients with TBI who had a higher Functional Independence Measure (FIM^TM) cognitive function score (≥21) that were admitted to 1 IR facility in Canada (n = 103) and 9 IR facilities in the US (n = 401). Main measures: demographic and clinical characteristics, type and intensity of activities by discipline, discharge location, FIM-Rasch score, social participation and quality of life. Results: Time from injury to rehabilitation admission was significantly longer in the Canadian cohort and they experienced a longer rehabilitation length of stay (p < .001, Cohen's d > .8). Patients in Canada received a greater total time of individual therapy and lower intensity of interventions per week from all disciplines. They also showed a higher score at discharge in FIM components, while US patients had better cognitive recovery and community participation long-term post-discharge. Conclusions: This study informs stakeholders of the large variation in service provision for patients who were treated in these two countries. These findings suggest the need for robust analyzes to investigate predictors of short and long-term outcomes considering the variation in health-care delivery. List of abbreviations: TBI: traumatic brain injury, CSI: comprehensive severity index, LoS: length of stay, OT: occupational therapy, PT: physical therapy, SLP: speech language pathology, IR: inpatient rehabilitation.

Knowledge, Confidence, and Practice Patterns of Speech-Language Pathologists Working With Adults With Traumatic Brain Injury

PURPOSE

Although speech-language pathologists (SLPs) are important members of the health care team serving adults with traumatic brain injury (TBI) with cognitive-communication disorders, little is known about services SLPs deliver and how they rate their own knowledge and skills. The aims of this study were to identify practice patterns, knowledge, and confidence levels of SLPs working with adults with TBI with cognitive-communication disorders.

METHOD

We surveyed 100 SLPs from rural and urban hospitals, skilled nursing facilities, and outpatient clinics in Wisconsin and analyzed data descriptively.

RESULTS

SLPs in this sample had a combination of accurate and inaccurate knowledge related to TBI. Although all participants reported working with individuals with TBI, many participants rated themselves as lacking confidence or knowledge in this practice area. SLPs reported variable use of evidence-based procedures and training related to TBI.

CONCLUSION

Results confirmed the high prevalence of TBI-related practice among SLPs in medical settings, but there was variable knowledge, confidence, and use of current evidence in practice. SLP graduate training programs, individual providers, health care administrators, and the American Speech-Language-Hearing Association can use results from this study to advance and improve SLP clinical services for adults with TBI.

Predictors of discharge destination from acute care in patients with traumatic brain injury

INTRODUCTION

Many studies have assessed the predictors of morbidity/mortality of patients with traumatic brain injury (TBI) in acute care. However, with the increasing rate of survival after TBI, more attention has been given to discharge destinations from acute care as an important measure of clinical priorities. This study describes the design of a systematic review compiling and synthesising studies on the prognostic factors of discharge settings from acute care in patients with TBI.

METHODS AND ANALYSIS

This systematic review will be conducted on peer-reviewed studies using seven databases including Medline/Medline in-Process, Embase, Cochrane Database of Systematic Reviews, Cochrane CENTRAL, PsycINFO, CINAHL and Supplemental PubMed. The reference list of selected articles and Google Scholar will also be reviewed to determine other relevant articles. This study will include all English language observational studies that focus on adult patients with TBI in acute care settings. The quality of articles will be assessed by the Quality in Prognostic Studies tool.

ETHICS AND DISSEMINATION

The results of this review will provide evidence that may guide healthcare providers in making more informed and timely discharge decisions to the next level of care for patient with TBI. Also, this study will provide valuable information to address the gaps in knowledge for future research.

TRIAL REGISTRATION NUMBER

Trial registration number (PROSPERO) is CRD42016033046.

Process for developing rehabilitation practice recommendations for individuals with traumatic brain injury

Background

Attempts at measuring quality of rehabilitation care are hampered by a gap in knowledge translation of evidence-based approaches and lack of consensus on best practices. However, adoption of evidence-based best practices is needed to minimize variations and improve quality of care. Therefore, the objective of this project was to describe a process for assessing the quality of evidence of clinical practices in traumatic brain injury (TBI) rehabilitative care.

Methods

A multidisciplinary team of clinicians developed discipline-specific clinical questions using the Population, Intervention, Control, Outcome process. A systematic review of the literature was conducted for each question using Pubmed, CINAHL, PsychInfo, and Allied Health Evidence databases. Team members assessed the quality, level, and applicability of evidence utilizing a modified Oxford scale, the Agency for Healthcare Research and Quality Methods Guide, and a modified version of the Grading of Recommendations, Assessment, Development, and Evaluation scale.

Results

Draft recommendations for best-practice were formulated and shared with a Delphi panel of clinical representatives and stakeholders to obtain consensus.

Conclusion

Evidence-based practice guidelines are essential to improve the quality of TBI rehabilitation care. By using a modified quality of evidence assessment tool, we established a process to gain consensus on practice recommendations for individuals with TBI undergoing rehabilitation.

Knowing What We're Doing: Why Specification of Treatment Methods Is Critical for Evidence-Based Practice in Speech-Language Pathology

PURPOSE

The purpose of this clinical focus article is to describe the conceptual framework of the multidisciplinary rehabilitation treatment taxonomy (RTT) and illustrate its potential use in speech-language pathology (SLP) clinical practice and research.

METHOD

The method used was a critical discussion.

RESULTS

Current methods of defining and classifying SLP and other rehabilitation interventions maintain the "black box" of rehabilitation by referring to hours or days of therapy or using problem-oriented labels (e.g., naming treatment) to describe treatments, none of which reveal what is actually done to effect desired changes in patient functioning. The RTT framework uses treatment targets, ingredients, and mechanisms of action defined by treatment theory to specify SLP and other rehabilitation interventions with greater precision than current methods of treatment labeling and classification. It also makes a distinction between the target of treatment at which ingredients are directed and broader aims of treatment, which may be downstream effects explained instead by enablement/disablement theory.

CONCLUSION

Future application of the RTT conceptual scheme to SLP intervention may enhance clinical practice, research, and knowledge translation as well as training and program evaluation efforts.

A Scoping Review of Clinical Practice Improvement Methodology Use in Rehabilitation

Context

The Clinical Practice Improvement (CPI) approach is a methodological and quality improvement approach that has emerged and is gaining in popularity. However, there is no systematic description of its use or the determinants of its practice in rehabilitation settings.

Method

We performed a scoping review of the use of CPI methodology in rehabilitation settings.

Results

A total of 103 articles were reviewed. We found evidence of 13 initiatives involving CPI with six different populations. A total of 335 citations of determinants were found, with 68.7% related to CPI itself. Little information was found about what type of external and internal environment, individual characteristics and implementation process might facilitate or hinder the use of CPI.

Conclusion

Given the growing popularity of this methodological approach, CPI initiatives would gain from increasing knowledge of the determinants of its success and incorporating them in future implementation.

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.

Traumatic Brain Injury-Practice Based Evidence Study: Design and Patients, Centers, Treatments, and Outcomes

OBJECTIVES

To describe study design, patients, centers, treatments, and outcomes of a traumatic brain injury (TBI) practice-based evidence (PBE) study and to evaluate the generalizability of the findings to the U.S. TBI inpatient rehabilitation population.

DESIGN

Prospective, longitudinal, observational study.

SETTING

Ten inpatient rehabilitation centers.

PARTICIPANTS

Patients (N=2130) enrolled between October 2008 and September 2011 and admitted for inpatient rehabilitation after an index TBI injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Return to acute care during rehabilitation, rehabilitation length of stay, FIM at discharge, residence at discharge, and 9 months postdischarge rehospitalization, FIM, participation, and subjective well-being.

RESULTS

The level of admission FIM cognitive score was found to create relatively homogeneous subgroups for the subsequent analysis of best treatment combinations. There were significant differences in patient and injury characteristics, treatments, rehabilitation course, and outcomes by admission FIM cognitive subgroups. TBI-PBE study patients were overall similar to U.S. national TBI inpatient rehabilitation populations.

CONCLUSIONS

This TBI-PBE study succeeded in capturing naturally occurring variation in patients and treatments, offering opportunities to study best treatments for specific patient impairments. Subsequent articles in this issue report differences between patients and treatments and associations with outcomes in greater detail.