Beyond Standard Care and Treatment in Brain Injury rehabilitation D - - PowerPoint PPT Presentation

Beyond Standard Care and Treatment in Brain Injury rehabilitation

DR SUE COPSTICK CATH MURRAY-HOWARD The Disabilities Trust

European Neuroconvention, ExCel, London, 6-7 June 2018

How to rehab ABI?

The effects of ABI are complex and multi modal. Capturing complexity of clinical presentation an

• ngoing challenge.

Establishing meaningful and effective outcome measures ongoing challenge. Various bodies have produced guidelines re how to rehabilitate ABI to ensure the right people get the right services.

Clinical standards

• NICE, SIGN, BSRM, RCP

– All stress MDT medic-led services for post-acute care (less so community rehabilitation) – medical leadership for delivery of restorative therapy and psycho social adjustment – emphasise what services are rather than clinical

• utcomes per se (although outcome measures such as

Fim Fam and MPAI are requested by e,g, UKRoC).

Clinical audit and governance

• Necessary to ensure standards of care, for

service users, family and our commissioners.

• Clinical standards should ensure good
• utcomes.
• But what outcomes were we looking for;
• This depended on who was in our services,

and this seemed to be changing.

Changes in people served at The Disabilities Trust (I)

• Older

Changes in people served at The Disabilities Trust (II)

• Older
• Admitted directly

from hospital…

Changes in people served at The Disabilities Trust (III)

• Older
• Admitted directly

from hospital…

• … and sooner

since injury

Changes in people served at The Disabilities Trust (IV)

• Older
• Admitted directly

from hospital

• … and sooner

since injury

• Shorter stays

Analysing our clinical data in terms of impairment rather than dx

• We found there were three clusters of

impairment of those commissioned (putting dx to the side for a moment)

• One cluster had global impairment
• Another had severe cognitive and

behavioural impairment but more physically able.

• Another had very specific impairment of

mobility or language with good cognition.

“Complex” consequences of ABI

1 2 3 4

Individual differences on the Mayo-Portland Adaptability Inventory (MPAI)

• Larger splats mean greater impairment -

Moreover, the clusters differed in clinical outcomes; care needs

• The globally impaired group tended to require

long term specialist care and enablement.

• The socially impaired or dysexecutive group

were discharged home or to supported living

• The group with specific deficits were

discharged home or to supported living.

• Assessed by Accommodation scale and SRS

Our challenge

• Making sense of this complexity

– Understanding individual rehabilitation needs – Matching care and treatment to those needs… – … In a cost-effective way. – Using outcomes that would reflect our BIRT service and what they targeted. Producing clinical outcome measures which were appropriate and effective, taken we had to show cost effectiveness/reducing the care costs.

BIRT; expertise in anterior BF.

• All three clusters had problems with at least 3 of the six NB domains of

anterior brain function.

• Self awareness or insight, with learning and memory deficits were the

most common problems reducing social participation in all groups.

• Our treatments targeted these issues, along with improving or restoring

function, and use of compensatory strategies.

• How important is such cognition in predicting outcome of rehab following

stroke, taken that use of restorative strategies depended on people recognised (had insight into) the effects of their ABI?

Holistic neurobehavioral rehab

• Psychotherapeutic approaches incorporating

neuropsychological formulation based on expert understanding of the ABI on functioning.

• constant, sensitive social support and effective 24

hr staff communication.

• Family involvement key and predictive.
• Constant positive support for rehearsal of

restorative methods, with positive feedback and errorless learning techniques.

Holistic neurobehavioral rehab following severe stroke

• 20% increase in such referrals.
• Lack of self awareness common in this

population, neglect and inattention well documented.

• What is it about our HNB approach that might

enhance clinical outcomes?

• What is it about our HNB physical

environments that might enhance outcomes?

Pilot study; how important is self awareness in predicting social participation?

• N = 96 service users
• Aged 18 to 82
• Up to one year post-stroke
• All first stroke occurrence
• Exclusions: premature discharge, active

psychosis, cognitive impairment due co- morbid condition.

What determined social participation and reduced supervision needs on discharge?

• Multi-variate correlational analyses
• Independent variables: gender; age; type of stroke;

side of stroke; lowest Glasgow Coma Scale score (GCS); time since injury on admission (TSI); length of stay in rehabilitation (LOS).

• Outcome measures pre-, during and post-

rehabilitation: MPAI Participation sub-scale and self- awareness score, Hospital Anxiety and Depression Scale (HADS), Supervision Rating Scale (SRS), BIRT Independent Living Scales (BILS).

N=97, 62 males, 35 females

M SD Mdn Whole sample (n = 97) Age on Admission 55.05 11.36 54 Length of Rehabilitation Stay 18 8.09 15 Time Since Injury 3.82 2.83 3.0 Lowest GCS (n = 16) 7.56 3.79 7.5

Note: BSC = Brainstem/Cerebellum. PACS = Partial Anterior Circulation Syndrome. POCS = Posterior Circulation

• Syndrome. TACS = Total Anterior Circulation Syndrome. BGT = Basal Ganglia/Thalamus. PIHCA = Anterior primary

intracerebral haemorrhage. PIHCMP = Middle or posterior cortical primary intracerebral haemorrhage. SAHMP = Middle or posterior subarachnoid circulation haemorrhage. SAHA = Anterior subarachnoid circulation haemorrhage.

Frequency Percent of sample Full sample (n = 97) Stroke type (n = 35) BSC 1 1 PACS 2 2.1 POCS 2 2.1 TACS 3 3.1 BGT 4 4.1 PIHCMP 4 4.1 PIHA 5 5.2 SAHA 7 7.2 SAHMP 7 7.2 Side of stroke (n = 41) Left 18 23.7 Right 23 18.6 Gender Female 35 36.1 Male 62 63.9

Results: what correlated with social participation following rehab?

0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Age on admission Length of stay Time since injury Anxiety Depression Self-awareness

• n admission

Self-awareness

• n discharge

Correlations with Social Participation (MPAI-C) on Discharge

** *

(*)

Results: distribution of self-awareness scores from admission to discharge

Self-awareness Admission Discharge None or very mild problems Mild problems (interferes with activities 24% of the time) Moderate to severe problems TOTAL % improved 8 38 67 51 % unchanged 59 37 25 25 % deteriorated 33 25 8 14

Conclusions

• Self-awareness in stroke patients improves

using our HNB approach to rehabilitation.

• Those with less insight into difficulties on

admission are more likely to benefit from rehabilitation.

• The more insight, and less anxiety a person
• n discharge, the more likely they are to

participate in life.

So what?...

• Regardless of type of severe stroke a person’s your

awareness of what has happened ‘predicts’ their ability to participate in life.

• Holistic neurobehavioural rehabilitation improves
• insight. Should this be a key outcome in future?
• Our enriched social and physical environments, with

errorless learning and ongoing daily rehearsal of strategies, helps the person increase his acceptance and self awareness of how s/he has to cope.

• Service – outcome relationship. More research is

underway.

To learn more about the evidence base for this approach

Clinical effectiveness

• Cattelani et al. (2010). Rehabilitation

treatments for adults with behavioral and psychosocial disorders following acquired brain injury: A systematic review. Neuropsychology Review, 20(1), 52–85.

• Cicerone et al. (2011). Evidence-Based

Cognitive Rehabilitation: Updated Review

• f the Literature From 2003 Through 2008.

Archives of Physical Medicine and Rehabilitation, 92(4), 519–530.

• Geurtsen et al. (2010). Comprehensive

rehabilitation programmes in the chronic phase after severe brain injury: A systematic review. Journal of Rehabilitation Medicine, 42(2), 97–110

Cost effectiveness

• Andelic, N., Ye, J., Tornas, S., Roe, C., Lu, J.,

Bautz-Holter, E., ... & Aas, E. (2014). Cost- effectiveness analysis of an early-initiated, continuous chain of rehabilitation after severe traumatic brain injury. Journal of neurotrauma, 31(14), 1313-1320.

• Oddy, M., & Ramos, S. (2013). The clinical

and cost-benefits of investing in neurobehavioural rehabilitation: A multi-centre

• study. Brain Injury, 9052, 1–8. *Open Access*
• VanHeugten CM, Geurtsen GJ, Derksen RE,

Martina JD, Geurts ACH, Evers SMAA. Interve ntion and societal costs of residential community integration for patients with acquired brain injury: A cost-analysis of the brain integration programme. Journal of Rehabilitation Medicine 2011;43:647–652