Stay current with research or you might miss the boat!!

1. Analysis of Post-hospital NeurologicalRehabilitation Outcomes2014Gordon J. Horn, Ph.D. (Presenter)Frank D. Lewis, Ph.D. & Robert Russell, B.A.National Clinical Outcomes

2. Stay current with research or you might miss the boat!!

3. 2013 Research Findings using MPAI-4 Hayden, et al. 2013 Green, et al. 2013 Lewis and Horn, 2013 There are many studies ranging from 2004 to 2012 that established the validity, reliability, and accuracy of the MPAI measuring post-hospital functional outcomes. This is the 4th revision of the measure (Malec & Lezak). Uses 0-4 scale. The following analyses demonstrate continuous data collection and research with data mining capacities.

4. 2013 Research Findings using MPAI-4 • Mayo Sample (N = 134) • Males/females = 61%/39% • Average age = 38 years • Time since Injury = 5.3 years • Type of injury = TBI (65%), CVA (15%), Other (20%) • Severity: Mild (29%), Moderate (12%), Severe (44%) • National Sample (N = 386) • Males/females = 73%/27% • Average age = 38 years • Time since Injury = 6.9 years • Type of injury = TBI (88%), CVA (6%), Other (6%) • Severity: Mild (5%), Moderate (29%), Severe (39%) • NeuroRestorative Sample (N = 604) • Males/females = 74%/26% • Average age = 40 years • Time since Injury = 3.48 years • Type of injury = TBI (70.1%), CVA (10.2%), Anoxic (4.5%), Tumor (1.5%), Other (11%) • Severity: Severe (72%)

5. MPAI-4: Abilities Index • Mobility (01):walking, moving, balance • Use of Hands (02):strength or coordination in one or both hands • Vision (03): problems seeing; double vision; visual field deficits • Audition (04):problems hearing, ringing in the ears • Dizziness (05):feeling unsteady, lightheaded, or dizzy • Motor Speech (06): articulation, phonation, rate of speech • Verbal Communication (07-A): problems expressing/comprehending • Non-Verbal Communication (07-B): problems expressing thoughts through gestures, facial expression, or other non-language behaviors or understanding such expressions from others • Attention/Concentration (08):problems ignoring distractions; difficulty shifting attention • Memory (09):problems learning and recalling new information • Fund of Information (10):information learned in school or on the job or general knowledge • Novel Problem Solving (11): problems generating solutions or picking the best solutions • Visual-Spatial Abilities (12): problems drawing, assembling things together, being visually aware of both the left and right sides

6. MPAI-4: Adjustment Index • Anxiety (13):tense, nervous, fearful, phobic, symptoms of post-traumatic stress disorder such as nightmares, flashbacks of stressful events. • Depression (14): Sad, blue, hopeless, poor appetite, poor sleep, worry, self-criticism. • Irritability, Anger, Aggression (15):verbal or physical expressions of anger. • Pain and Headache(s) (16): pain complaints and behaviors; if pain originates from multiple body areas (head, back), then rate overall impact. • Fatigue (17):feeling tired, low in energy; fatigability, that is, feeling low in mental or physical energy after a relatively low level of mental or physical activity; fatigue may be a symptom of depression and should not be rated here. • Sensitivity to Mild Symptoms (18): focusing on post-traumatic cognitive, physical, or emotional problems; this rating is based on how distressed or concerned the individual is about their functioning. • Inappropriate Social Interaction (19): acting childish, silly, rude; behavior not consistently fitting to the time and place or age-appropriate. • Impaired Self-Awareness (20):lack of recognition of personal limitations and disabilities and how they interfere with everyday activities, work or school. • Family/Significant Relationships (21): interactions with close others; describes stress within the family or those closest to the person with brain injury.

7. MPAI-4: Participation Index • Initiation (22): problems getting started on activities without prompting • Social contact with friends, work associates, and other people who are not family, significant others or professionals (23):the frequency of contacts and consistency of relationships with people who are not related to or have a professional relationship with the person with brain injury • Leisure and Recreational Activities (24): involvement in hobbies, sports, and other active and passive activities primarily for enjoyment either alone or with others • Self-Care (25): involves eating, dressing, bathing, and hygiene; this considers the amount of independence with which basic self-care activities are performed • Residence (26): responsibilities of independent living and homemaking (such as meal prep, home repairs and maintenance), medication management, and personal health maintenance beyond basic hygiene • Transportation (27): independence in moving oneself outside of the home in the community; in rating this item, consider ability to perform these activities without assistance as well as environmental limitations • Paid Employment (28-A):work for pay; you can only rate on 28-A or 28-B; an unemployed person that is looking for employment is rated on 28-A, but if that person were returning to school or homemaking, then they are rated on 28-B. • Other Employment (28-B): unpaid work, such as, formal schooling, volunteer work, homemaking, and retirement for those over age 60. • Managing Money/Finance (29): shopping, keeping a checkbook or other bank account, managing personal income and investments

8. 2013 MPAI study – comparison of groups Rehabilitation is provided in many levels of care. Comprehensive post-hospital neurological rehabilitation programs have been less available with limited outcome data to analyze the effects of continued rehabilitation after the hospital. This study addressed: 1) whether post-hospital rehabilitation could reduce disability as measured by the Mayo Portland Adaptability Inventory-4, 2) whether the level of intensity of post-hospital care leads to differences in disability reduction, and 3) whether differences in the MPAI Indices could be found within various levels of post-hospital care.

9. Demographics

10. Demographics

11. Demographics

12. Samples The total sample used was 575 participants in the study from a larger sample of 676 participants all within the NeuroRestorative System of care throughout the United States. The average length of time from onset of injury to participation in the NeuroRestorative program was 3.3 years.

13. Samples and Interventions 1) Neurorehabilitation: received active therapy including PT, OT, SP, Counseling, CM, Medical Management, and community integration, 5-7 days p/week. 2) Neurobehavioral: received active OT, counseling and/or behavioral services, CM, medical management, and intermittent PT and SP, and community integration. 3) Supported Living Rehabilitation: received medical management, CM, intermittent therapy services (1 of 3 therapy types as needed), community integration. 4) Day Treatment: services included PT, OT, SP, Community skills, and social skills. This group had successfully completed the inpatient residential program and was living at home when services were provided.

14. Methods • Each participant was evaluated with an initial Mayo Portland Adaptability Inventory – 4. • The protocol guidelines included having this initial evaluation completed within 30 days following admission. This 30 day period was provided as part of the initial clinical review. • Each participant was then rated a second time with the MPAI within 1 day after discharge. • The MPAI scores were obtained by consensus within the rehabilitation teams.

15. Analysis of Findings Multivariate Analyses of Variance evaluated differences between the groups on the MPAI admission to discharge T-scores, and with each Index of this measure (Abilities, Adjustment, Participation). Main effects were found for time of assessment (admission to discharge). Each group demonstrated improved scores on the Mayo Portland demonstrating reduced disability from admission to discharge(p < .01). Main effect between groups on the Mayo Portland Indices (Abilities, Adjustment, and Participation) was also found (p < .01).

16. Specific Findings Significance was achieved at p < .05 (a) Significance was achieved at p < .01 (b) Significance was achieved at p < .001 (all other scores charted)

17. Multiple Comparisons for Admission Data Abilities Index The inpatient residential programs (NR, NB, SL) did not differ from one another on admission, but differed from the day treatment program on admission scores. Adjustment Index The Neurorehabilitation program did not differ from the Supported Living program on admission; the Neurobehavioral program had higher adjustment scores (worst) upon admission compared to all other programs. Day Treatment had the lowest adjustment scores (best) on admission. Participation Index The Day Treatment program had the lowest participation scores (best) upon admission. Participation was not significantly different upon admission for Neurorehabilitation, Neurobehavioral, and Supported Living.

18. Multiple Comparisons for Discharge Data Abilities Index The inpatient residential programs (NR, NB, SL) did not differ from one another at discharge on Abilities, but the day treatment program had lower scores at discharge on Abilities. Adjustment Index The Neurorehabilitation program did not differ from the Supported Living program at discharge; the Neurobehavioral program had higher adjustment scores (worst) at discharge compared to Neurorehabilitation, and Day Treatment, but not Supported Living. Day Treatment had the lowest adjustment scores (best) at discharge. Participation Index The Day Treatment program had the lowest participation scores (best) at discharge, followed by the Neurorehabilitation program, then Supported Living and the Neurobehavioral programs. Neurobehavioral program did not differ from Supported Living on the discharge scores. Despite the complexity of the behavioral intensity, Neurobehavioral programming showed improvement from a T-score of 55.76 at admission to 50.53 at discharge (p < .001).

19. Discussion • Reduced disability was demonstrated by all of the programs despite their average length of time since injury of 3.3 years, and program affiliation. • The greatest gains were seen in the neurorehabilitation program at the facility level. • Day Treatment demonstrated the greatest gains overall. Those who progressed to the structured Day Treatment program continued making functional gains in all areas of the MPAI. • Even participants in the Neurobehavioral and structured Supported Living Rehabilitation programs showed significantly reduced disability as measured by the MPAI at the time of discharge.

20. Discussion • As the prior literature indicated (Hayden, 2013), greater outcomes may be achieved when participants are able to access rehabilitation within 3 months of the time since injury. • Our sample was able to show reduced disability despite admission to the program exceeding the initial 3 months of recovery. • The current findings also suggest that intensity and structure of programming may be a factor in achieving significant functional gains from admission to discharge, irrespective of program type or possibly length of time since injury. This is consistent with a study in press showing that participants improve even after a year of recovery before starting post-hospital care (Lewis & Horn, 2013).

21. Discussion • The current results appeared contrary to popular belief that neurological recovery and rehabilitation gains can only be appreciated within the first year of recovery. • This notion has been within the literature for many years, but the current outcomes would suggest that post-hospital recovery may continue for years beyond the injury onset (e.g., neuroplasticity). • Structured programming reduces disability and reduces intensity and need for supervision by the time of discharge. • Therefore, rehabilitation emphasis may need to be reconsidered for a longer length of time before indicating that disability or function has plateaued.

22. Neurorehabilitation vs. Neurobehavioral Programs

23. Neurorehabilitation vs. Neurobehavioral Objectives This study investigated outcome differences in two post-hospital rehabilitation program types (Neurorehabilitation [NR] and Neurobehavioral [NB]). Criteria were established for group affiliation using the Mayo Portland Adaptability Inventory (MPAI-4) which assesses the level of functional disability reduction in post-hospital rehabilitation. The study objectives were: 1) determining differences between groups using the MPAI-4; 2) determine effectiveness of programming to reduce symptoms of behavioral dyscontrol among NB individuals; and 3) identify outcome predictors of independent functioning for each group.

24. Neurorehabilitation vs. Neurobehavioral Methods Subjects: A total sample of 289 brain injured adults met inclusion criteria. NB participants (N=70) were identified by 1) obtaining moderate or severe ratings on MPAI-4 variables (Irritability-Anger-Aggression, Novel Problem-Solving, Inappropriate Social Interaction, and Impaired Self-Awareness); and 2) onset to admission greater than eight months duration. Most (N=219) met criteria for the NR group including 1) MPAI-4 Irritability score no greater than mild, and 2) onset-to-admission <8 months duration. The average onset of injury to admission length was 99.6 months (8.3 years) for NB, and 3.1 months for NR. Diagnoses for both groups were predominately TBI (NB=83% and NR=60%). Measure: The MPAI-4 was completed within 30 days of admission and at discharge for comparison. Scores were converted to T- scores for direct comparisons.

25. Neurorehabilitation vs. Neurobehavioral Results Repeated Measures Multivariate Analysis of Variance revealed a significant group main effect [F(1,286)=97.29,p=.0001]. The NR group demonstrated lower scores than the NB group on the Ability, Adjustment, and Participation Indices. This analysis also revealed significant within subjects effects [F(2,286)=98.66,p=.0001]. A follow-up Wilcoxon Z-test for the NB group demonstrated statistical differences from admission to discharge for each of the four variables defining behavioral dyscontrol (p<.0001). Lastly, a stepwise multiple regression analysis using the MPAI-4 variables for each group revealed that Initiation and Novel Problem Solving significantly predicted Participation T-scores for the NB group [F(1,69)=20.42, p< .0001; Adjusted R2 = .33)]. Initiation, Length of Onset to Admission, Fund of Information and Memory significantly predicted Participation T-scores for the NR group [F (4,213) = 22.86, p< .0001; Adjusted R2=.29)].

26. Neurorehabilitation vs. Neurobehavioral Conclusion Participation in the comprehensive post-hospital rehabilitation programs lead to significant reduction in disability for both groups. Significant disability reduction was demonstrated within the NB group which is remarkable since this group is chronically impaired, averaging 8.3 years post injury at the time of study inclusion, with behavioral dyscontrol. The improvements noted in the NB group were not attributed to time or natural healing. Prior research demonstrated that time significantly impacts recovery during the initial 3-6 months of care only. Finally, the MPAI-4 provided different predictor variables for each group. The Initiation variable demonstrated the strongest predictor of independent functioning for both groups.

27. Depression Outcomes Depression rates through meta-analysis has been shown to be as high as 34% in studies. Depression in the general population ranges from 5-20%.

28. Depression Findings Background The annual incidence of traumatic brain injury (TBI) in the United States is 1.5 million or 3% (Borlongan et al., 2013). In 2005-2006, the incidence of depression in the United States was 5.4% for ages 12 and older (Center for Disease Control, 2012). Chaudhury et al. (2013) meta-analysis revealed a 30% prevalence rate of depression in TBI across multiple time points with 33% prevalence >12 months since injury across samples. Given this prevalence, the current study focused on the functional impact of differing levels of depression on TBI post-hospital rehabilitation outcome.

29. Depression Findings Methods Subjects: The total sample was 903 participants with admission to discharge measures completed; 435 participants met inclusion criteria for TBI receiving active post-hospital neurorehabilitation care. Most of the participants were male (82%) vs. female (18%). Average age was 40 years. Average length of stay was 5.8 months with an average of 34.06 months duration from onset of injury to admission for post-hospital care. Measure: The Mayo Portland Adaptability Inventory-4 (MPAI-4) was completed within 30 days of admission and at discharge. Scores were converted to T-scores for comparisons.

30. Depression Findings

31. Depression Findings Results A Multivariate Analysis of Variance (MANOVA) revealed a main effect for depression, Wilkes’ Lambda=.88, F(12,1124)=4.6, p<.001, partial eta=.042. Power to detect the effect was 1.000. Post-hoc analysis determined the depression groups differed on the MPAI measures at admission and discharge (p<.01). The mean differences for Abilities were significant when comparing the severely depressed group to mildly depressed and non-depression groups (p<.01). The moderately depressed group differed significantly from the non-depressed group (p<.01), but not from the severe or mildly depressed groups. Those in the non-depressed group differed from each of the depressed groups (p<.01) for Abilities. The mean differences for Participation were significant when comparing the severely depressed group to other depressed and non-depressed groups (p<.01). The moderately depressed group differed significantly from the severe and non-depressed groups (p<.01), but did not approach significance with the mildly depressed group. Those in the non-depressed group differed from each of the depressed groups (p<.01) for Participation.

32. Depression Findings Discussion Consistent with Chaudhury et al. (2013), this study found a high prevalence of depression (34%) among a group of 435 TBI adults. Those that exhibited the greatest depressive symptomatology demonstrated the poorest outcomes on measures of cognitive functioning and overall independence in the home and community. Therefore, comprehensive assessment and treatment of depression should be an integral component of post hospital rehabilitation programming.

33. Anxiety Outcomes Anxiety estimates range from 20-70% across studies based on meta-analysis of findings. Anxiety has been shown to occur between 5-20% in the general population.

34. Anxiety Findings Objectives: To examine the impact of anxiety on functional outcomes for Traumatic Brain Injury adults in post-hospital rehabilitation programs. To measure the effectiveness of anxiety reduction by post-hospital neurorehabilitation programming. Design: Prospective cohort pretest – posttest. Setting: Twenty-three residential post-hospital brain injury rehabilitation programs in 13 states.

35. Anxiety Findings Participants: 378 traumatically brain injured adults divided into 4 groups based on MPAI-4 anxiety ratings. Interventions: Multidisciplinary treatment by physicians, nursing, PTs, OTs, SLPs, counseling/psychology. Main Outcome Measure: Mayo Portland Adaptability Inventory-4 (MPAI-4) T-scores and MPAI-4 anxiety ratings.

36. Anxiety Findings Results. Repeated Measures MANOVA revealed a significant main effect for treatment F(1,374)=419.62, p< .001. Each of the anxiety groups improved significantly from admission to discharge on the MPAI-4 T-scores. The main effect for anxiety was significant across groups F(3,374)=35.45, p<.001. Follow-up Bonferroni pair-wise comparisons demonstrated MPAI-4 T-scores at discharge at a higher level of impairment in the severe anxiety group than each of the other groups, p< .001. Wilcoxon-Z post-hoc tests demonstrated the severe and moderate anxiety groups showed significantly reduced anxiety scores at discharge (p<.001). Conclusions: Of 378 TBI participants, those that received the highestanxiety ratingsat admissionhad the poorest overall functional outcomes at discharge. The severe group showed significant reduction in anxiety ratings admission to discharge (mean of 4 vs. 2.58). Even mild to moderate levels of anxiety was shown to mitigate functional gains achieved in post-hospital rehabilitation programs. All groups significantly improved from admission to discharge.

37. Aging and post-hospital care

38. Aging and post-hospital care It has long been assumed that the brain’s ability to recover from serious injury lessens as we age. However, recent research on brain plasticity shows that the brain has remarkable ability to change in response to stimulating environments even in persons beyond the age of fifty. This finding poses an interesting question for post-hospital rehabilitation programs: Can older adults make functional progress following a TBI as a result of participating in challenging rehabilitation programs, and if so is that progress comparable to that of younger adults. The current study focused on evaluating 413 adults with TBI who were treated within the NeuroRestorative neurorehabilitation programs throughout the country. The 413 participants were divided into six age groups: 18 – 24 (n=73), 25 – 34 (n=86), 35 – 44(n=70), 45 -54 (n=97), 55-64 (n=68), and 65+ (n=19). Each of these participants were evaluated using the Mayo Portland Adaptability Inventory-Version 4 (MPAI-4) at admission and then again at discharge.

39. Aging and post-hospital care The results of the study were somewhat surprising. First, and perhaps the most notable, they found that no matter the age group, participants showed statistically significant improvement from admission to discharge on the MPAI-4 Abilities, Adjustment and Participation Indices. This means that irrespective of age, participants showed important reduction in disability and greater independence after completing their program. The second analysis examined differences between groups in overall functioning. The expectation would be that the youngest age group would show the greatest functional improvement. Surprisingly this was true in only one comparison. The youngest group (18-24) showed significantly greater improvement than the 45-54 year old group in adjustment to disability score. Each of the other age groups showed improvement that was not significantly different from the youngest group. The second effect for age was also found in the comparison between the 45-54 group and the 55-64 group on the adjustment score. The 45-54 year-old group showed greater adjustment to disability than the 55-64 year-old age group. Each of the other comparisons across age groups revealed they did not differ significantly in the magnitude of functional gains made at discharge.

40. Aging and post-hospital care The take home message is that all age groups improved as a result of neurological rehabilitation efforts. This exciting finding illustrates that older TBI survivors (50 and older) can make improvements in function that are comparable to survivors in their twenties.

41. Pediatric Outcomes

42. Pediatric Outcomes Injury types and outcomes varies from adults. Outcomes are age-dependent meaning that success of outcome may be based on when the neurodevelopmental process is disrupted a) injury before age 6 b) injury from 7-10 c) injury from 11-13 d) injury from 14-17 e) injury from 18-24

43. Pediatric Post-hospital Rehabilitation Objectives: This study addressed post-hospital neurorehabilitation outcomes in a pediatric sample. The study objectives were to: 1) determine if differences exist from admission to discharge for the pediatric sample using the Mayo Portland Adaptability Inventory -4 (MPAI-4); 2) determine if differences exist between pediatric participants in active rehabilitation vs. behaviorally intense rehabilitation, and 3) provide indication of discharge disposition based on sub-group affiliation (e.g., active rehabilitation vs. behaviorally intense).

44. Pediatric Post-hospital Rehabilitation Methods: Subjects: The sample consisted of 74 brain injured pediatrics referred to post-hospital comprehensive rehabilitation. Forty-one of those participants met criteria for inclusion in the neurobehavioral intensity (NBI) group: 1) MPAI-4 scores of moderate to severe on Irritability, Novel Problem Solving, Inappropriate Social Interaction, and Impaired self-awareness, and 2) onset to admission of greater than eight months. The remaining subjects (33) met criteria for the active neurorehabilitation (NR) group. The average age of injury onset was 6.9 years but the average time from injury onset to admission to the post-hospital program was 8.3 years. The average age in the program was 13.60 years (ranging from 2-18 years of age). The average length of stay for the entire sample was 5.25 months. The total sample was comprised mostly of traumatic brain injury (65%).

45. Pediatric Post-hospital Rehabilitation Measure. The MPAI-4 was completed within 30 days of admission and again at discharge. Scores were converted to T- scores for comparison. Results: A Repeated Measures Multivariate Analysis of Variance revealed a significant main effect for Abilities F (1,73) = 5.609, p = .0001; Adjustment F (1,73) = 5.654, p = .0001; and Participation F (1,73) = 7.775, p = .0001. More specifically, follow up analysis revealed no group differences (NR vs. NBI) on the Mayo Portland Abilities and Participation admission scores. No significant group differences were found among the Mayo Portland Abilities and Adjustment scores at discharge. Significant differences were found between the groups on Mayo Portland Participation scores at discharge F (1,73) = 4.112, p < .05. At the time of discharge, the Adjustment scores were not statistically different though the two groups differed upon admission within this index (F = 11.22, p < .001).

46. Pediatric Post-hospital Rehabilitation Conclusion: Participation in the comprehensive post-hospital rehabilitation programs lead to significant reduction in disability for both the Pediatric NBI and the NR groups across the three indices of the Mayo Portland outcome measure. While both groups did not differ upon admission with Abilities or Participation, both groups differed statistically with Adjustment. However, based on the intervention effect, even those with significant behavioral impairments were able to show the same Adjustment outcome at discharge as those without behavioral intensity. 81% of the total sample was able to successfully return home following intervention within this milieu.

47. Evidenced-Based Pathways to Rehabilitation

48. Current Database – Total Sample (N = 1,105) 3 Month Follow up = 131 participants 12 Month Follow up = 47 participants

49. Current Database – Neurorehabilitation Sample (N = 653) 3 Month Follow up = 79 participants 12 Month Follow up = 28 participants

50. Current Database – Neurobehavioral Sample (N = 114) 3 Month Follow up = 12 participants 12 Month Follow up = 5 participants