Jeffrey S. Smigielski

Outcome evaluation and prediction in a comprehensive-integrated post-acute outpatient brain injury rehabilitation programme

Outcomes for 29 individuals with brain injuries (BI) were examined following a comprehensive-integrated rehabilitation programme. From programme admission to completion, proportion living with no supervision increased from 59% to 93%; proportion in transitional or competitive work placements increased from 7% to 59%; unemployment decreased from 76% to 31%. Significant changes in behaviour and functional abilities and achievement of individual goals were also documented with the Portland Adaptability Inventory (PAI) and Goal Attainment Scaling. One year follow-up of 21 graduates indicated general maintenance of gains in independent living and work. At follow-up 86% were living without supervision; 48% were in competitive work; one in transitional work; and 29% unemployed. Although individuals entering treatment less than 1 year after injury showed greater gains than those injured more than 1 year prior to admission, both early and late intervention groups showed significant changes on outcome measures. More extensive disabilities as measured by the PAI had a negative impact on programme outcome. Except for reading ability, neuropsychological measures obtained prior to admission did not significantly predict outcome. Programme costs are reported. Results indicate that the group-oriented comprehensive-integrated approach to post-acute brain injury rehabilitation is effective and cost-effective, and recommend early intervention for optimal outcomes.

Cluster analysis of neuropsychological test results among patients with traumatic brain injury (TBI): implications for a model of TBI-related disability

Abstract Neuropsychological test data and educational attainment for 47 patients with traumatic brain injury (TBI) were submitted to cluster analysis. Relationships of cluster membership to injury severity (coma days) and disabilities (Portland Adaptability Inventory; PAI) were examined. Cluster 1 was composed of highly educated individuals with relatively mild initial injuries, neuropsychological impairment, and disabilities. Impairments for Cluster 1 appeared more significant in contrast to probably high preinjury functioning. Cluster 2, whose members had lowest test performances on measures of remote memory and reading, may have been marginally functioning prior to injury. Those in Cluster 2 had only mild initial injuries, but showed moderately extensive disabilities on the PAI. Patients in Cluster 3 had mild initial injuries, very mild neuropsychological impairments, and mild disabilities, characterized by difficulties with planning and irritability. Individuals in Clusters 4 and 5 had more severe ini...

Mayo Medical Center Brain Injury Outpatient Program: Treatment Procedures and Early Outcome Data

The rehabilitation of persons with brain injuries has proved challenging; community reintegration is often unsuccessful. Herein we describe our intensive group-oriented outpatient treatment program for persons with brain injury and report outcome data for the graduates of the program thus far. This interdisciplinary program emphasizes the development of cognitive skills, compensation techniques, social skills, emotional adjustment, leisure skills, physical fitness, and health maintenance. Although goals are individually determined, independent living and employment are goals for most participants in the program. Before initial participation, all candidates undergo an extensive 2-day assessment. Typically, a patient remains in the program for approximately 6 months. The specific group treatment approaches used in the program are discussed. Outcome data are assessed with use of the Portland Adaptability Inventory and goal attainment scaling, as well as comparisons of preprogram and postprogram employment status and level of independent living. Our initial results support the conclusion that this comprehensive and integrated treatment program is efficacious in rehabilitating persons with mild to moderate sequelae of brain injury.

Estimating the Diagnostic Value of the Trail Making Test for Suboptimal Effort in Acquired Brain Injury Rehabilitation Patients

This investigation explored the classification accuracy of Trail Making Test (TMT; Reitan & Wolfson, 1992) indices for suboptimal effort in a sample of non-litigious acquired brain injury patients seeking outpatient rehabilitation. Patients who exhibited optimal effort completed TMT A and B faster than suboptimal effort patients. Although TMT A time to completion demonstrated adequate sensitivity to suboptimal effort, positive predictive value was fair to poor unless the base rate of suboptimal effort was inflated to 40%. TMT B time to completion yielded poor sensitivity and positive predictive value for suboptimal effort. While TMT A time to completion appears to have some value as a validity indicator, no TMT validity indicator should replace more precise symptom validity tests during neuropsychological assessment.

Achievement of client-centred goals by persons with acquired brain injury in comprehensive day treatment is associated with improved functional outcomes

Objectives: To study the relationship between goal achievement and vocational and independent living at discharge and 1-year follow-up in persons with acquired brain injury (ABI) participating in a Comprehensive Day Treatment (CDT) programme. Design: A retrospective review of longitudinal data. Methods: One hundred and fifty-four participants with ABI were included in the analyses. Personal, short-term and graduation goals were generated for each participant. A graduation goal was generated in each of four primary domains of the intervention (Orientation, Cognitive, Social Awareness and Communication). Participants who achieved all graduation goals at discharge were classified as ‘goals met’, while those who did not meet all goals were classified as ‘goals unmet’. Results: Forty-eight percent of participants were classified into the goals met group and 52% were classified into the goals unmet group. There were no group differences at programme admission. A significantly greater percentage of individuals in the goals met group were both living independently and engaging in community-based employment at programme discharge than individuals in the goals unmet group. These group differences were maintained or exceeded at 1-year follow-up. Conclusions: The results demonstrate that achievement of individualized CDT graduation goals is associated with greater levels of vocational and residential independence following acquired brain injury.

Point of Entry and Functional Outcomes After Comprehensive Day Treatment Participation

OBJECTIVES To explore the relationship between point of entry into a comprehensive day treatment (CDT) program and outcomes after acquired brain injury (ABI). We hypothesized that participants entering our program 0 to 6 months postinjury would demonstrate greater declines in neurobehavioral sequelae and improvements in residential/vocational independence than those entering >6 to 12 and >12 to 24 months postinjury. DESIGN Retrospective examination of admission, discharge, and 1-year follow-up data from a CDT program. SETTING A large Midwestern academic medical center. PARTICIPANTS Adult CDT participants with traumatic brain injuries (TBI) (n=54) or cerebrovascular accidents (CVAs) (n=29). INTERVENTIONS A CDT rehabilitation program. MAIN OUTCOME MEASURES Portland Adaptability Inventory/Mayo-Portland Adaptability Inventory (percent change scores between admission and discharge) and the Independent Living and Vocational Independence Scales. RESULTS Time since injury was categorically coded into the 3 aforementioned point of entry groups. A 2 (injury type) × 3 (point of entry) between subjects analysis of covariance revealed a significant main effect for the point of entry (P<.001). Post hoc tests indicated that individuals entering the program 0 to 6 months postinjury demonstrated significantly greater treatment gains than those entering 6 to 12 or 12 to 24 months postinjury. Within group chi-square analyses revealed that a significantly higher percentage of the early entry participants were living and working independently at discharge and 1-year follow-up. CONCLUSIONS Entry into a CDT program (0-6mo postinjury) is associated with significantly greater declines in neurobehavioral sequelae and improvements in residential and vocational independence in participants with TBI or CVA. Sustainable modest treatment gains were also observed in the late entry groups, suggesting that these individuals also benefit significantly from CDT program participation.

Pre-treatment compensation use is a stronger correlate of measures of activity limitations than cognitive impairment

Objectives: This study examined the relationship between baseline compensation use, activity limitations and cognitive impairment in persons who sustained moderate-to-severe acquired brain injury. Design: Randomized controlled clinical trial. Methods: A total of 22 individuals with medically documented brain injury and their family members completed a baseline assessment including measures of cognitive functioning (Repeatable Battery of Neuropsychological Assessment; RBANS), activity limitations (Neurobehavioural Functioning Inventory; NFI) and compensatory strategies use (Compensation Techniques Questionnaire; CTQ). There were no gender differences on measures of cognitive impairment, activity limitations or compensation use. Results: As predicted, cognitive impairment was not significantly associated with frequency of baseline compensation strategy use. Weaker word-list learning on RBANS was associated with greater family-reported memory problems on the NFI. Lower frequency of compensatory strategy use was correlated with greater patient-reported activity limitations on NFI, while it was not related to family ratings of activity limitations. After adjusting for history of depression and anxiety, baseline compensation use uniquely accounted for 16% of variance in predicting greater patient ratings of mood difficulties. Conclusions: Results indicate that, after acquired brain injury, baseline compensation use is more strongly associated with measures of activity limitations than is cognitive impairment.