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 ImprovementReturn to HomeCost BenefitReturn to WorkQuality of Life

Standardizing Treatments

NICHD/NIH TBI Network Sites project8 clinical sites with 100+ moderate and

severe TBI’s/yrManage 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 Multi-disciplinary 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 improve-ments 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 rehab-ilitation 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 oldAll 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 IntensityMultiple 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.