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

Abstract

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

Individual and contextual factors influencing children's effort in pediatric rehabilitation interventions

“…heart rate, blood lactate concentration, or electromyography), 7 task‐related measures of force or acceleration, or self‐report measures (e.g. Perceived Exertion Scale, Rehabilitation Intensity of Therapy Scale) 2 …”

“…Zarshenas et al define effort in an adult rehabilitation context as the ‘physical and mental energy of patients within a therapy context including initiating activity, incorporating therapist feedback, and persevering when therapies become challenging.’ 2 ‘Physical energy’ alludes to physical effort, often conceptualized as exertion or intensity and evaluated using physiological measures (e.g. heart rate, blood lactate concentration, or electromyography), 7 task‐related measures of force or acceleration, or self‐report measures (e.g.…”

“…Perceived Exertion Scale, Rehabilitation Intensity of Therapy Scale). 2 'Mental energy' alludes to cognitive effort, defined by Westbrook and Braver as 'decision-making about whether to initiate or maintain engagement with demanding tasks'. 8 Factors such as arousal, attention, and initiation have been measured as cognitive effort 'proxies' in adults with traumatic brain injuries.…”

“…As such, effort may be a key determinant of therapy outcomes, as waning effort may limit active participation, potentially decreasing either the quantity or the quality of therapy. [1][2][3] In particular, interventions that target neuroplastic change and motor learning necessitate effort on the part of the child to achieve the practice dosage and intensity required for neuroplastic change. 4 Yet effort is rarely defined, described, or measured in the pediatric rehabilitation literature.…”

“…While factors such as intervention duration, setting, and content are determined by rehabilitation professionals, children are largely in control of the effort they expend in the rehabilitation process. As such, effort may be a key determinant of therapy outcomes, as waning effort may limit active participation, potentially decreasing either the quantity or the quality of therapy 1–3 . In particular, interventions that target neuroplastic change and motor learning necessitate effort on the part of the child to achieve the practice dosage and intensity required for neuroplastic change 4 .…”