Transcript Brain Injury Rehabilitation: Does It Work?

Brain Injury Rehabilitation
Science, Efficacy, and Service
Delivery Models
David X. Cifu, M.D.
Co-Director, NIDRR TBI Model Systems
Co-Director, Brain Injury Rehab Services
VCU/MCV
Treatment Controversy
 Rehabilitation services for TBI are
extremely expensive (up to $1500/day).
 Providing the least amount of therapy
services that are effective will maximize the
efficiency of rehabilitation resources.
 Optimizing treatment settings to the least
restrictive environment respects the rights
of the disabled individual.
Treatment Controversy
 Treatment teams typically find
interdisciplinary settings and services the
easiest to work in.
 Greater intensities of services are often
advocated to decrease lengths of stay.
Treatment Controversy
 Increasingly, data exist on the efficacy of
specialized treatment settings, types of
therapy, and intensity of services.
 Providing the optimal dosing, type, and
setting of rehabilitation services should
improve outcomes and efficiencies.
Components of Rehabilitation
 Specificity (Generalized Therapy, Focused
Therapy, Dedicated Team, Team
Composition)
 Setting (InPatient, Day, Transitional,
Outpatient, Home Health)
 Intensity (Therapy, InPatient vs.. Subacute)
Measures of Efficacy





Functional Improvement
Return to Home
Cost Benefit
Return to Work
Quality of Life
Standardizing Treatments
 NICHD/NIH TBI Network Sites project
 8 clinical sites with 100+ moderate and
severe TBI’s/yr
 Manage all patients within “strict” set of
pre-hospital, ER, ICU, Acute Care and
Rehab (inpatient and outpatient) guidelines
 Standardized, multidimensional outcome
measures
Standardizing Treatments
 Timing, intensity and specificity of all rehab
interventions must be standardized.


PT, OT, SLP, Psychology
Medications
 Goal will be to assess efficacy of specific
interventions by systematically altering
them and monitoring outcomes.
Treatment Efficacy: Stroke
 22 randomized controlled trials have
demonstrated that after stroke,
interdisciplinary vs multidisciplinary team
care results in decreased mortality,
dependency, and nursing home placement.
Langhorne Lancet 342:1993
Ottenbacher Arch Neurol 5:1993
 Interdisciplinary acute rehabilitation shown
superior to SNF or custodial NH.
Kramer JAMA 277;1997
Treatment Specificity: Coma
 Directed Multisensory Stimulation (DMS)
demonstrated superior (increased
responsiveness, improved RLAS, improved
GCS) versus Non-Directed Stimulation
(NDS) in RLAS II patients
Hall:Brain Injury 1992:6:435-45
Treatment Specificity: Team
 Formal TBI Rehabilitation results in an
increased rate of return to the community,
decreased utilization of medical services,
and decreased disability.
Cope:Brain Injury 1995;9:649-70
Bell:Arch Phys Med Rehabil 1998;79S:21-5
Treatment Specificity: Team
 Acute rehabilitation utilizing a dedicated
TBI program resulted in decreased LOS,
improved cognitive skills, and improved
return to home rates.
Mackay:Arch Phys Med Rehab 1992;73:635-41
Treatment Specificity: Team
 Interdisciplinary Team versus Multidisciplinary Team demonstrated improved
functional outcome, maintenance of gains,
and reduced caregiver stresses.
Semlyen:Arch Phys Med Rehabil 1998;79:678-83
Treatment Setting: Post-Acute
 TBI patients >3 months post-injury
demonstrated improvement in behavior,
physical ability, functional skills, and
independent living. Maintained improvements 18months post-completion.
Malec:Brain Injury 1993;7:15-29
Mills:Brain Injury 1992;6:219-28
Treatment Setting: HMO
 Comparison of TBI Rehabilitation provided
through an HMO network compared to
historical efficacy of non-HMO rehabilitation demonstrated similar costs and
outcomes.
Bryant:J Head Trauma Rehabil 1993;8:15-29
Intensity of Therapy: Coma
 Comatose patients receiving structured
sensory stimulation in addition to physical
therapies and nursing care demonstrated
decreased coma duration and improved
cognitive skills at 3 months versus those
receiving only physical therapies and
nursing care.
Kater:W J Nursing Res 1989;11:20-33
Mitchell:Brain Injury 1990;4:273-9
Intensity of Therapy: InPatient
 Comatose and acute TBI patients receiving
greater therapy intensity (by 60%)
demonstrated a 31% decrease in length of
stay.
Blackerby:Brain Injury 1989;4:167-73
Intensity of Therapy: InPatient
 Acute TBI patients stratified into high
versus low intensity therapy groups
demonstrated improved RLAS levels and
cognitive skills at discharge.
Spivack:Brain Injury 1992;6:419-34
Intensity of Therapy: InPatient
 Multiple regression analysis revealed that
intensity of PT, OT, and SLP services did
not affect outcome, but greater Psychology
services intensity resulted in improved
cognitive skills at discharge.
Heinemann:Am J Phys Med Rehabil 1995;74:315-26
Intensity of Therapy: InPatient
 Multiple regression analysis revealed that
intensity of PT and OT services did not
affect outcome, but greater Psychology
services intensity resulted in improved
cognition and greater SLP services intensity
resulted in improved cognitive and physical
skills at discharge.
Cifu:Arch Phys Med Rehabil 1997;78:1029 (abstract)
Cifu DX, Kreutzer JS, Kolakowsky-Hayner
SA, Marwitz JH, Englander J:
The relationship between therapy intensity
and rehabilitative outcomes after traumatic
brain injury: A Multi-Center Analysis.
Arch Phys Med Rehabil 2003 (in press)
Methodology
 Consecutive TBI patients >16 years old
 All demographic, clinical, and outcome data
available.
 Assessed the variability of therapy services
delivered due to patient and non-patient
factors.
 Assessed the association between therapy
intensity and rehabilitation functional
outcomes.
Results
 491 patients enrolled followed for 12
months.
 Mean therapy received = 2 hr 55 mins




65 minutes occupational therapy per day
54 minutes physical therapy per day
35 minutes speech therapy per day
19 minutes psychological services per day
 Limited variability in therapy received.
Results: Factors Affecting Intensity
 Multiple regression analysis was used to
determine if age, functional status at admission,
interruption in rehabilitation, length of stay, or
onset-admission interval predicted therapy
intensity.




PT/OT not affected.
Younger age and lower onset-admission predicted
increased psychology service intensity.
Higher admission FIM motor score predicted higher
SLP service intensity.
Older age predicted decreased total therapy intensity.
Results: Effect of Intensity
 Cognitive outcomes were not affected by therapy
intensity.
 Increased FIM motor discharge score, FIM motor
potential achieved and FIM motor efficiency were
predicted by increased speech and physical
therapy intensity.
 Rehabilitation LOS was not affected by therapy
intensity.
 Increased rehabilitation charges were predicted by
increased physical therapy intensity.
Conclusions
 Younger age, shorter acute LOS and higher
admission motor scores predicted greater
intensity of cognitive services.
 Increased speech and physical therapy
affect improved motor outcomes.
Rehabilitation Efficacy: Summary
 Specificity- Cognitive (Coma) services and
structured TBI Team have been shown to
improve outcome.
 Setting - Post-acute services have been
shown to improve outcomes. HMO settings
do not decrease outcomes.
 Intensity - Greater therapy intensity (e.g.
SLP, PT, Psychology) improve outcomes.