Patient Effort in Traumatic Brain Injury Inpatient Rehabilitation: Course and Associations With Age, Brain Injury Severity, and Time Postinjury

Abstract

Objective: To describe patients' level of effort in occupational, physical, and speech therapy sessions during traumatic brain injury (TBI) inpatient rehabilitation and to evaluate how age, injury severity, cognitive impairment, and time are associated with effort.

Design: Prospective, multicenter, longitudinal cohort study.

Setting: Acute TBI rehabilitation programs.

Participants: Patients (N=1946) receiving 138,555 therapy sessions.

Interventions: Not applicable.

Main outcome measures: Effort in rehabilitation sessions rated on the Rehabilitation Intensity of Therapy Scale, FIM, Comprehensive Severity Index brain injury severity score, posttraumatic amnesia (PTA), and Agitated Behavior Scale (ABS).

Results: The Rehabilitation Intensity of Therapy Scale effort ratings in individual therapy sessions closely conformed to a normative distribution for all 3 disciplines. Mean Rehabilitation Intensity of Therapy Scale ratings for patients' therapy sessions were higher in the discharge week than in the admission week (P<.001). For patients who completed 2, 3, or 4 weeks of rehabilitation, differences in effort ratings (P<.001) were observed between 5 subgroups stratified by admission FIM cognitive scores and over time. In linear mixed-effects modeling, age and Comprehensive Severity Index brain injury severity score at admission, days from injury to rehabilitation admission, days from admission, and daily ratings of PTA and ABS score were predictors of level of effort (P<.0001).

Conclusions: Patients' level of effort can be observed and reliably rated in the TBI inpatient rehabilitation setting using the Rehabilitation Intensity of Therapy Scale. Patients who sustain TBI show varying levels of effort in rehabilitation therapy sessions, with effort tending to increase over the stay. PTA and agitated behavior are primary risk factors that substantially reduce patient effort in therapies.

Keywords: Amnesia, anterograde; Craniocerebral trauma; Psychomotor agitation; Rehabilitation.

Fig 1

Box-and-whisker plot of admission and discharge week mean level of effort rating for ST, OT, and PT sessions combined, stratified by admission FIM cognitive subscale score (N=1946). The distributions plotted represent the sample mean of patients' mean level of effort scores for all their sessions during the admission and discharge week, respectively. Patients (n=118) with ≤8 days of IR LOS were included in the admission week only. The lower and upper edges of the box represent the 25th and 75th percentiles, whereas the horizontal line in the middle of the box represents the 50th percentile (median). The dashed, vertical lines (whiskers) extending from the box indicate the range of data up to the 1.5 quartile range. Circles indicate values that extend further than 1.5 quartiles from the box. Abbreviations: Adm, admission; Cog, cognitive.

Fig 2

Mean level of effort rating for ST, OT, and PT sessions combined for successive weeks of the stay by admission FIM cognitive subscale score category. Patients who completed at least 2, 3, or 4 weeks of IR within each of the 5 admission FIM cognitive subscale score (Adm FIM cog) groups were included in this graph. The values (different shaped dots) plotted on each line represent patients' mean level of effort scores for all their sessions during a given week. The vertical lines and error bars represent the upper and lower 95% CIs. Week is the week of IR in which patients' level of effort was rated. Abbreviation: CI, confidence interval.