Anne M. Moessner

Differing problem perceptions of staff, survivors, and significant others after brain injury

Objective:To examine the relationships of the perceptions of staff, survivors of brain injury (DI), and significant others (SOs) as represented on their respective versions of the Mayo-Portland Adaptability Inventory (MPAI) to each other, to psychometric markers of memory and executive cognitive function, and to depression. Design:Nonparametric analyses of data obtained from consecutive clinical cases; exploratory individual item comparisons of MPAI forms. Setting:Outpatient clinic in a hospital-based comprehensive rehabilitation center. Participants:45 to 51 pairs of staff, survivors, and SOs who had rated the survivor on the appropriate form of the MPAI. Main Outcome Measures:Ratings on staff, survivor, and SO forms of the MPAI; MPAI indicator of depression; Trailmaking Test; Rivermead Behavioral Memory Test. Results:Staff and survivor MPAIs correlated moderately well with each other only for subjects identified as depressed by staff. SO MPAI summary scores correlated moderately well with Staff MPAI scores for both depressed and nondepressed survivors. SO MPAI summary scores were more strongly related to those of staff than to those of survivors for nondepressed survivors. Survivors with impaired self-awareness (ISA) (ie, those who tended to greatly underestimate their problems relative to staff) were infrequently depressed and had more difficulty on a measure of executive cognitive function than did other survivors. Depressed survivors did not consistently over- or underestimate their level of disability relative to staff. Conclusions:A degree of dysphoria may represent an appropriate reaction to DI and set an appropriate emotional tone for accurate self-assessment after BI. Conversely, more extensive disability, impaired executive cognitive function, and ISA subsequent to BI are likely to interfere with normal emotional adaptation. Primary and exploratory analyses suggest six major sources of bias affecting problem assessment by survivors, SO, and staff: depression, ISA, lay versus professional terminology, values, observational opportunities, and impact/burden.

Predicting family functioning after TBI: Impact of neurobehavioral factors

ObjectiveTo identify risk factors for poor family functioning and neurobehavioral problems after traumatic brain injury (TBI) or orthopedic injuries (OI). DesignLongitudinal analyses of data from an inception cohort. ParticipantsSeventy-five patients with moderate/severe TBI, 47 patients with mild TBI, and 44 patients with OI at discharge; and 49 patients with moderate/severe TBI, 24 patients with mild TBI, and 33 patients with OI at 1-year follow-up. Outcome measures: Measures of family functioning (Family Assessment Device) and Neurobehavioral Functioning Index at hospital discharge and 1-year follow-up. ResultsAt discharge, patients with moderate/severe TBI had more symptoms of depression, memory/attention problems, and motor impairments than patients with OI and greater communication difficulties than patients with OI or mild TBI. At follow-up, patients with moderate/severe TBI continued to have more problems in memory/attention, depression, and communication. Approximately one third of each group had unhealthy family functioning at each assessment period. Few patients reported both impaired family functioning and clinical depression. Distressed family functioning correlated strongly with increased rates of neurobehavioral symptoms. Family dysfunction at follow-up was best predicted by family dysfunction at discharge and depression or memory/attention deficits at follow-up. ConclusionsAfter TBI, patients at the greatest risk for distress at follow-up were those with family dysfunction at discharge and continued neurobehavioral problems. High-risk families need to be identified so that necessary referrals and/or treatment can be offered.

A Survey of Very-Long-Term Outcomes after Traumatic Brain Injury among Members of a Population-Based Incident Cohort

To assess quality of life and barriers to participation in vocational and community life for persons with traumatic brain injury (TBI) over the very-long term, a population-based cohort was identified in Olmsted County, Minnesota; 1623 individuals were identified as having experienced a confirmed TBI while a resident of Olmsted County, Minnesota, during the period from 1935-2000. A survey was sent to eligible individuals that included elements of standardized instruments addressing health status and disability, and questions that assessed issues important to successful social reintegration after TBI. Of 1623 eligible participants sent surveys, 605 responded (37% response rate). Thirty-nine percent of respondents were female and 79% had mild injuries. Mean age at injury was 30.8 years, and mean years since injury was 28.8. Overall, respondents reported living in the community; the majority were married and had achieved education beyond high school. Problems with memory, thinking, and physical and emotional health were most often reported. Respondents reported low levels of depression and anxiety, and high levels of satisfaction with life. Seventy-three percent of respondents reported no problems that they attributed to their TBI. Increasing injury severity was associated with a significant risk of reporting injury-related problems at survey completion. Respondents with a longer time since injury were less likely to report any TBI-related problems. These results indicate that self-reported outcomes and adaptation to impairment-related limitations improve as the time since injury increases. These findings highlight the importance of providing coordinated medical rehabilitation and community-based support services to promote positive outcomes over the life span after TBI.

A Preliminary Model for Posttraumatic Brain Injury Depression

OBJECTIVE To develop, based on previous research, and evaluate a model for depression after traumatic brain injury (TBI). DESIGN Cross-sectional structural equation modeling (SEM) of data from consecutively recruited patients. SETTING Acute hospital and inpatient rehabilitation units. PARTICIPANTS Adult patients (N=158) after hospital admission for moderate to severe TBI. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES External appraisal of ability in participants was measured by the Mayo-Portland Adaptability Inventory (MPAI-4) Ability Index completed by a TBI clinical nurse specialist. Patient self-appraisal of post-TBI ability and depression were measured by the Awareness Questionnaire and Beck Depression Inventory-II. Functional outcome 1 year after injury was assessed with the MPAI-4 Participation Index. RESULTS Successive SEM resulted in a parsimonious model with excellent fit. Consistent with prior research, a moderately strong association between self-appraisal of post-TBI ability and depression was found. Injury severity, as measured by the duration of posttraumatic amnesia (PTA), was not significantly associated with post-TBI depression. The 1-year functional outcome was associated with depression and TBI severity. CONCLUSIONS The strong association between self-appraisal of post-TBI ability and depression is consistent with the cognitive-behavioral model of depression and recommends consideration and further study of cognitive-behavioral therapy for post-TBI depression. The lack of association between TBI severity and depression may represent the indirect and proxy nature of current measures of TBI severity such as PTA. Emerging neuroimaging techniques (eg, diffusion tensor imaging, magnetic resonance imaging spectroscopy) may provide the more direct measures of disruption of brain function after TBI that are needed to advance this line of research.

Replicated positive results for the VCC model of vocational intervention after ABI within the social model of disability

Primary objective: Replicated evaluation of the Vocational Case Co-ordinator (VCC) Model for vocational rehabilitation after acquired brain injury (ABI). Research design: Referral cohort studied within the social modelof disability. Methods and procedures: One hundred and thirty-eight participants with ABI were assisted by a VCC to develop self-directed vocational plans and networks of medical centre and community services. Early intervention, work trials, temporary or long-term supported employment and employer education are fundamental features of the VCC Model. Main outcomes and results: One year after initial placement 80% of participants remained in community-based employment, 56% of the total sample with no support. Better outcomes were associated with earlier intervention but not with initial injury severity. Conclusions: Results replicate original findings of the effectiveness of the VCC Model of vocational rehabilitation after ABI with a different VCC. Implications for social change within the social modelof disability are discussed.

Maximizing Vocational Outcome after Brain Injury: Integration of Medical and Vocational Hospital-Based Services

OBJECTIVE To describe a medical and vocational case-management system that has been implemented at the Mayo Medical Center in Rochester, Minnesota, to decrease the time between onset of brain injury and successful community reintegration. DESIGN Barriers to employment are identified and targeted as part of a system that integrates medical center- and community-based services. MATERIAL AND METHODS The success of the project will be determined by several sources, including the Mayo-Portland Adaptability Inventory, a vocational rating scale, and traditional measures of vocational success (for example, level of independent living, job type and setting, rate of pay, and the type and cost of vocational supports being used). Overall study outcomes will be compared against benchmarks derived from the literature on vocational outcome after brain injury. RESULTS Preliminary data are encouraging that project goals are attainable. The medical case-management system has decreased the amount of time between injury and initiation of vocational and other rehabilitation services. During the first year, 67 persons with brain injury began receiving vocational services through the project, and 34% are in community-based nonsheltered work or training programs. Second-year data will reveal whether the goal of 70% placement within 9 months after admission to the project can be maintained.

Injury severity and disability in the selection of next level of care following acute medical treatment for traumatic brain injury

Primary objective: To evaluate the association of demographic factors, post-traumatic amnesia (PTA) and a standardized measure of ability limitations with clinical decisions for Next Level of Care following acute hospital treatment for moderate–severe traumatic brain injury (TBI). Research design: A TBI Clinical Nurse specialist recorded PTA for 212 individuals and rated 159 on the Ability and Adjustment Indices of the Mayo-Portland Adaptability Inventory (MPAI-4) for comparison with clinical decisions. Main outcomes and results: Multivariate logistic regression analyses revealed that independent ratings on the MPAI-4 Ability Index and PTA were associated with the clinical decision to admit to Inpatient Rehabilitation vs discharge to Home in 92.7% of the sample; ratings on the Ability Index alone were associated with this decision in 92.2% of cases. Age over 65 was the only variable associated with discharge to a Skilled Nursing Facility, correctly predicting this decision in 64% of cases. Conclusions: Use of a standardized measure of ability limitations appears feasible to provide supportive documentation and potentially improve the consistency of decision-making in recommending Inpatient Rehabilitation vs discharge to Home. Although age is a significant factor in the decision to discharge to a Skilled Nursing Facility, this decision appears complex and merits further study.

A randomized practical behavioural trial of curriculum-based advocacy training for individuals with traumatic brain injury and their families.

Abstract Primary objective: To test whether a curriculum-based advocacy training programme improves advocacy behaviour when compared to a matched group engaged in self-directed advocacy activities. Research design: Community-based randomized practical behavioural trial. Methods and procedures: Adults with moderate–severe TBI 1 or more years post-injury and their family members were recruited in Minnesota (4 years), Iowa and Wisconsin (each 3 years) and randomized into a curriculum-based or self-directed advocacy training group. Both groups met on the same day, at separate locations in the same city, once per month for 4 consecutive months. Main outcomes and results: Pre–post written and video testimony were rated using the Advocacy Behaviour Rating Scale (ABRS). Mean ABRS scores increased after intervention in both groups (curriculum n = 129, self-directed n = 128), but there was no significant difference in this increase between groups. When groups were combined, a significant pre–post improvement in mean ABRS scores was observed. Conclusions: Curriculum-based advocacy training was not superior to a self-directed approach in improving ABRS scores. A significant improvement in expression of an advocacy message was observed when intervention groups were combined. These findings suggest that bringing together like-minded motivated individuals is more important than programme structure or content in changing advocacy behaviour.

Two new measures for assessing advocacy activities and perceived control after acquired brain injury.

Purpose. To develop and evaluate the psychometric properties of measures of advocacy activity and perceived control specific to those affected by acquired brain injury (ABI). Method. Questionnaires, including initial forms of the Advocacy Activities Scale (AAS) and Perceived Control Scale for brain injury (PCS-BI), Craig Hospital Inventory of Environmental Factors, Satisfaction with Life Scale and SF-12, were mailed through the State Brain Injury Associations in three states in the Upper Midwestern U.S. Through multiple mailings, 322 (21.4%) complete response sets of 1550 possible were obtained; 196 from individuals with ABI, 99 from significant others (SOs), and 27 with no indication of whether the respondent was a person with BI or SO. The AAS and PCS-BI were analyzed and refined using a two parameter item response theory model. Concurrent validity was examined through simple correlations and principal components analyses of all measures. Results. After modification based on IRT analyses, the AAS showed satisfactory internal consistency (Person reliability = 0.77; item reliability = 0.97) as did the PCS-BI (Person reliability = 0.78; item reliability = 0.99). Although more complex than the predicted, relationships with other measures supported the concurrent validity of the AAS and PCS-BI. Conclusions. The AAS and PCS-BI are reliable and valid measures of advocacy activity and an associated sense of perceived control among those affected by ABI for use in survey research and assessing the effectiveness of interventions to increase advocacy activity.

Ice hockey summit II: Zero tolerance for head hits and fighting

This study aimed to present currently known basic science and on-ice influences of sport-related concussion (SRC) in hockey, building upon the Ice Hockey Summit I action plan (2011) to reduce SRC. The prior summit proceedings included an action plan intended to reduce SRC. As such, the proceedings from Summit I served as a point of departure for the science and discussion held during Summit II (Mayo Clinic, Rochester, MN, October 2013). Summit II focused on (1) Basic Science of Concussions in Ice Hockey: Taking Science Forward, (2) Acute and Chronic Concussion Care: Making a Difference, (3) Preventing Concussions via Behavior, Rules, Education, and Measuring Effectiveness, (4) Updates in Equipment: Their Relationship to Industry Standards, and (5) Policies and Plans at State, National, and Federal Levels To Reduce SRC. Action strategies derived from the presentations and discussion described in these sectors were voted on subsequently for purposes of prioritization. The following proceedings include the knowledge and research shared by invited faculty, many of whom are health care providers and clinical investigators. The Summit II evidence-based action plan emphasizes the rapidly evolving scientific content of hockey SRC. It includes the most highly prioritized strategies voted on for implementation to decrease concussion. The highest-priority action items identified from the Summit include the following: (1) eliminate head hits from all levels of ice hockey, (2) change body checking policies, and (3) eliminate fighting in all amateur and professional hockey.