Patient Effort in Traumatic Brain Injury Inpatient Rehabilitation: Course and Associations With Age, Brain Injury Severity, and Time Postinjury

Abstract

Objective-To describe patients' level of effort in occupational, physical, and speech therapy sessions during traumatic brain injury (TBI) inpatient rehabilitation and to evaluate how age, injury severity, cognitive impairment, and time are associated with effort.Design-Prospective, multicenter, longitudinal cohort study. Setting-Acute TBI rehabilitation programs.Participants-Patients (N=1946) receiving 138,555 therapy sessions. Interventions-Not applicable.Main Outcome Measures-Effort in rehabilitation sessions rated on the Rehabilitation Intensity of Therapy Scale, FIM, Comprehensive Severity Index brain injury severity score, posttraumatic amnesia (PTA), and Agitated Behavior Scale (ABS).Results-The Rehabilitation Intensity of Therapy Scale effort ratings in individual therapy sessions closely conformed to a normative distribution for all 3 disciplines. Mean Rehabilitation Intensity of Therapy Scale ratings for patients' therapy sessions were higher in the discharge week than in the admission week (P<.001). For patients who completed 2, 3, or 4 weeks of rehabilitation, differences in effort ratings (P<.001) were observed between 5 subgroups stratified by admission FIM cognitive scores and over time. In linear mixed-effects modeling, age and HHS Public AccessAuthor manuscript Arch Phys Med Rehabil. Author manuscript; available in PMC 2017 July 11. Author Manuscript Author ManuscriptAuthor Manuscript Author ManuscriptComprehensive Severity Index brain injury severity score at admission, days from injury to rehabilitation admission, days from admission, and daily ratings of PTA and ABS score were predictors of level of effort (P<.0001).Conclusions-Patients' level of effort can be observed and reliably rated in the TBI inpatient rehabilitation setting using the Rehabilitation Intensity of Therapy Scale. Patients who sustain TBI show varying levels of effort in rehabilitation therapy sessions, with effort tending to increase over the stay. PTA and agitated behavior are primary risk factors that substantially reduce patient effort in therapies. KeywordsAmnesia; anterograde; Craniocerebral trauma; Psychomotor agitation; RehabilitationInterdisciplinary traumatic brain injury (TBI) inpatient rehabilitation (IR) is a complex and multifaceted process. The individual and interactive contributions that patient, environment, and treatment factors make to outcomes remains understudied and not well understood. 1,2 Rehabilitation, as all health care fields, faces increasing pressure to deliver high-quality services that maximize outcomes and minimize length of stay (LOS). A key element in the quality service equation is providing patient-centered care that takes into account injury severity and patient strengths; the match of treatments to patients' deficits and desired outcomes; and, importantly, the level of patients' involvement in care. Rehabilitation clinicians often consider the level of patients' behavioral involvement in their therapies when evaluating treatment effectiveness and outcomes. 3 Motivation for t...

Level of Effort and 3 Hour Rule Compliance

“…therapist feedback, and persevering when therapies become challenging. 10 A number of steps were taken to minimize rater variability, bias and missing data. Therapists were trained in making RITS LOE ratings and tested twice during the study for accuracy.…”

“…8 9 For individuals with TBI, the severity of the presenting disability is an important factor influencing the ability to participate effortfully in treatment, as well as responsiveness to different therapeutic approaches. 10 The present study is one of a series utilizing propensity score methodology to control measured confounders while evaluating rehabilitation approaches and methods of delivery. We hypothesized that patients' level of effort (LOE) during therapy sessions modifies the impact of…”

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

“…Therefore, the lack of correlation between level of effort and motor outcome in the current study might be explained by relatively high admission FIM cognitive scores (≥21). Further investigations are needed to examine the mediating effect of other factors such as mental health issues, environmental factors, cultural values of patients and caregivers, severity of injury, and complexity of activities on patients' tolerance and level of participation in rehabilitation treatments …”

“…In addition, because of a significant amount of missing data in SLP, data from this discipline were removed from the analysis. Level of effort was measured using the Rehabilitation Intensity of Therapy Scale, which includes 60 goal‐directed activities and is scored weekly with a single‐item, 7‐point scale . Effort is described as physical and mental energy of patients within a therapy context including initiating activity, incorporating therapist feedback, and persevering when therapies become challenging …”

Diffuse Axonal Injury: A Devastating Pathology

“…Often hard to accomplish even for the first time, therapists work on these skills as well as social skills for life outside of the medical center. While the title of speech therapy seems limited to the physical act of producing speech, it is actually a major component of not only speech-forming techniques but also techniques that must be remastered in areas such as cognition and basic physical skills such as balance [57][58][59][60]. The process of relearning task one learned earlier in life, involves the reconstruction of neuronal networks, is an example of the many neuronal networks and pathways within a human mind [61].…”