- Email: [email protected]
Shopping Around:How are Mild TBI Patients Straining Canadian Health Services?
Brain Injury to hospitalized patients with orthopedic trauma (OT); To qualitatively examine preliminary associations between sleep, neurorecoveryand cognitive statusfor those with TBI. Design: Cross sectional evaluation of polysomnographic recordings. Setting: Level 1 Regional Trauma Centre Participants: Hospitalized patients with acute moderate-severe traumatic brain injury or orthopedic trauma. Interventions: NA Main Outcome Measure(s): Polysomnographic (PSG) measures of: Total Sleep Time (TST), Sleep Efficiency, Number, Duration of awakenings, Percentage of each Sleep Stage and Rapid Eye Movement (REM) sleep characteristics. Rancho Los Amigos(RLA) Level of Cognitive Functioning and Galveston Orientation and Amnesia Test (GOAT). Results: No significant between group differences were noted for total sleep duration. However, during the sleep period the TBI participants (NZ8, 4Males mean age 24.3 + 10.5yrs)spent>50% time awake; 156.6 109.5 minutes as compared to 76.1 42.7 for the OT participants (NZ5, 3 males).Total number of awakenings within the sleep period was greater for the TBI group; 47.7 33.11 compared to 33.2 15.6 (OT). Within the TBI group, shorter total sleep time and increased number and duration of awakenings were associated with delayed resolution of post traumatic amnesia, poorer RLA and GOAT scores at hospital discharge. Conclusions: These preliminary results indicate that hospitalized patients with acute moderate-severe TBI have increased TST compared to those with orthopedic trauma, but poor sleep efficiency(fragmented sleep with multiple awakenings).Multiple fragmentations are associated with slower cognitive recovery for those with TBI.Improving sleep in the early stages post TBI mayfacilitate recovery. Key Words: sleep, traumatic brain injury, cognition, neurorecovery Disclosure(s): None disclosed. Poster 151 Using the Electronic Health Record to Improve Measurement of Unemployment in Veterans With TBI Dezon Finch, Christina Dillahunt-Aspillaga (USF- Department of Rehabilitation and Mental Health Counseling), Stephen Luther, James A. McCart Objective: 1) To determine if information about employment status, goals, and work-related barriers reported by service members and Veterans with mild traumatic brain injury (mTBI) and post-deployment stress is can be identified in the Electronic Health Record (EHR). 2)Develop annotation schema and a training set of annotated documents to support the future development of a natural language processing (NLP) system to extract employment information. Design: Retrospective cohort study data from selected progress notes stored in the EHR. Setting: Post-deployment Rehabilitation and Evaluation Program (PREP) at the James A. Haley Hospital in Tampa, Florida. Participants: Electronic records (NZ60) service members and Veterans with TBI who completed the PREP program. Interventions: Not applicable. Main Outcome Measure(s): Documentation of employment status, goals, and work-related barriers reported by service members and recorded in the EHR. Results: Two-hundred notes were examined and unique vocational information was found indicatinga variety of self- reported employment barriers and challenges. Current employment status and future vocational goals along with information about cognitive, physical, and behavioral symptoms that affect return- to work were extracted from the EHR. The annotation schema developed for this study provides an excellent tool upon which NLP studies can be developed. Conclusions: Information related to employment status and vocational history is stored as a text documents in the EHR system, but does not support easy summarization for research and rehabilitation planning
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e53 purposes. Using NLP systems, larger-scale retrospective and prospective studies necessary to improve the understanding and measurement of employment in this important cohort are possible. Key Words: Veterans, Traumatic Brain injury, Rehabilitation, Vocational, Employment Status, Unemployment Acknowledgement “Funding for this work was provided by VHA QUERI RRP 12-450. The views expressed in this work are those of the authors and do not necessarily reflect the position or policy of the Dept. of Veterans Affairs or the US Government.” Disclosure(s): Nothing further to disclose. Poster 152 Sensitivity of the Montreal Cognitive Assessment for Out-Patients With Mild Traumatic Brain Injury Cindy Hunt (St. Michael’s Hospital), Donna Ouchterlony Objective: We aimed to assess the sensitivity of the Montreal Cognitive Assessment (MoCA) to screen for cognitive impairments amongst patients with mild traumatic brain injury (mTBI) seen in an outpatient head injury clinic. Our research questions: 1) What proportion of assessed patients demonstrated cognitive impairments as per the MoCA? 2) What patient factors were associated with cognitive impairment as per the MoCA? Design: Cross sectional survey. Setting: Level 1 tertiary care urban outpatient head injury clinic. Participants: mTBI patients (nZ117) assessed between July 2013 and January 2014. Interventions: Not applicable. Main Outcome Measure(s): MoCA overall and sub-component scores. Results: Patients were assessed on average 37 weeks (range 0-329 weeks) post-injury. Overall, 41.8% (nZ49) were cognitively impaired as per the MoCA (score <26/30). The naming and delayed recall sub-components were the most challenging for patients, with 99% (nZ116) and 79% (nZ92) demonstrating impairments in these components, respectively. Multiple linear regression was used to identify patient specific factors associated with MoCA scores. Controlling for gender, increasing patient age (pZ.03), and higher Rivermead Post-Concussion Symptom Questionnaire score (pZ.004) were significantly associated with decreasing MoCA scores, collectively explaining 31% of the variance. Duration of loss of consciousness, history of mental illness, history of drug use, and use of alcohol a month prior to injury were not significant in the model. Our findings were similar using Logistic Regression (outcome measured by MoCA score <26/30 versus 26/30). Conclusions: The MoCA is sensitive in detecting cognitive impairments amongst patients with persisting post-concussive symptoms assessed in an outpatient setting months following injury. Key Words: mild Traumatic brain injury, MoCA, cognitive assessment Disclosure(s): None Disclosed. Poster 153 Shopping Around:How are Mild TBI Patients Straining Canadian Health Services? Cindy Hunt (St. Michael’s Hospital), Donna Ouchterlony Objective: To describe the frequency and estimate the cost of health services encounters by patients with a mTBI prior to their first appointment in a specialized clinic. Design: Cross sectional survey Setting: Level 1 tertiary care outpatient head injury clinic in a Canadian city. Participants: mTBI patients (nZ145) assessed between July 2013 and January 2014. Interventions: Not applicable. Main Outcome Measure(s): Health services utilization. Results: In our study sample (nZ145) the mean age was 42.4 years (SD 18, range16-87) with 58.8% males. The activity during injury: transportation (pedestrian, MVA, bike) 47%, falls 29%, sports 8%, violence 6%
e54 and unknown 10%. The average time since current head injury was 8.15 months (SD 11.9, range 0-75 months). Among patients who visited the Emergency Department 40 % did so two times or more (maximum of 10 visits), likewise of those who visited Family Practice 59% did so twice or more (maximum of 72 visits), while among patients who visited a neurologist 34% did so twice or more (maximum of 5 visits). In the group of patients visiting a psychiatrist, 37% visited two times or more (maximum of 20 visits) and 80 % who visited a chiropractor once, revisited a second time or more (max of 120 visits). Conclusions: A total of 3304 health service encounters (mean of 23, SDZ45.8, range 0-307) occurred prior to the first visit to the head injury clinic which resulted in an estimated cost of $826,000, (estimate based on 2013 OHIP billing fees cost of services rendered by personnel). Key Words: health services costs, health service utilization, mild traumatic brain injury Disclosure(s): None Disclosed. Poster 154 An Item Level Analysis and Validation Study of the Problem-Solving Questionnaire’s Emotional Self-Regulation Scale Coralynn Long (NYU Rusk Institute), Jay Verkuilen, Joseph F. Rath, Lucia Smith-Wexler, Hilary Bertisch, Venessa Singhroy, Donna Langenbahn, Rose Lynn Sherr, Leonard Diller Objective: Increase efficiency in measuring emotional self-regulation (ESR) in adults with traumatic brain injury (TBI) by assessing ordinality, validity, and items in need of revision on the Problem Solving Questionnaire’s (PSQ) ESR scale. Design: Item response theory (IRT) and classical test theory (CTT) analyses of an archival database of 6-point Likert-type scale responses on the PSQ-ESR. Setting: Large, urban hospital Participants: 189 healthy controls completed the PSQ as part of a neurorehabilitation assessment (75% female; age M Z 25.13, SD Z 9.83). Interventions: Not applicable. Main Outcome Measure(s): PSQ-ESR scale Results: IRT analyses produced item trace lines, to be provided. Examination of curves showed reversal effects, indicating disordinality in the 6point scale, suggesting that some choices on the Likert were redundant. Redundant categories were combined, simplifying the scale into a 4-point scale. Final models showed the revised scale had fewer ordinality violations and comparable marginal reliability (.89) to the 6-point scale (.88). After establishing ordinality, several items were identified that may benefit from revision. Supplementary analyses revealed similar findings for the PSQ-ESR in a smaller cohort of individuals with TBI. Sufficient CTT validity for the PSQ-ESR was attained for both cohorts (p < .05). Conclusions: Simplified scaling and revision of potentially problematic items offers an optimal balance of ordinality and reliability on the PSQ-ESR. These revisions improve the PSQ-ESR scale’s ability to measure ESR deficits, while also increasing efficiency and manageability. These considerations are essential when assessing individuals with cognitive difficulties.Further analyses should be conducted with larger TBI samples, and similar IRT methods should be implemented during future clinical scale development. Key Words: TBI (Traumatic Brain Injury), Reliability and validity, Self regulation Disclosure(s): None Disclosed.
Brain Injury Data Sources: Three major health and medical research databases (Medline, CINAHL, Scopus) were used to search the literature. Key words included three categories: 1) mild traumatic brain injury, concussion 2) return to school, school re-integration, return to learn 3) children, adolescents. Study Selection: The initial process of study selection involved a review of article titles and abstracts from 1996-2013 that addressed all three categories by two reviewers. Data Extraction: Information pertaining to current practices and guidelines was extracted.In particular, the evidence or lack of evidence for practices and guidelines in improving school performance was noted. Data Synthesis: Current practices and guidelines commonly suggest; Gradual re-entry in school, Multi-disciplinary collaborative assessment of needs, Implementing an individualized intervention plan, Monitoring symptoms, and Adjusting the plan with recovery. However, there is limited evidence to support these recommendations, and the impact on occupational performance is not considered. Conclusions: While current recommendations appear to consider multiple dimensions of return to school, there is a paucity of evidence to support and inform the goal of occupational performance.A holistic approach should be taken by targeting individual, environmental and activity based factors such that it enables and enhances participation, and thus, performance, in school based occupation. This will guide the generation of evidence necessary for effective return to school guidelines. Key Words: Return-to-school, Concussion, Youth, Child and Adolescent, Mild Traumatic Brain Injury Disclosure(s): None Disclosed. Poster 156 Aggressive Mobilization in Disorders of Consciousness During Acute Rehabilitation: An Untapped Intervention Cynthia L. Beaulieu (Brooks Rehabilitation Hospital), Sarah Lahey, Jennifer Schinke, Jennifer O’Neal Walworth, Kenneth T. Ngo
Return to School Post-Concussion: Informing Improved Occupational Performance Amongst Youth
Objective: To present preliminary evidence for the potential benefit of implementing aggressive mobilization protocols (AMP) for patients with disorders of consciousness (DOC) in the acute inpatient rehabilitation setting. Design: Retrospective abstraction of 25 records. Setting: Inpatient rehabilitation hospital. Participants: 25 patients (2-48 years of age) admitted into a low-level brain injury program between September 2011 and August 2013. Interventions: Patients received one or more of four facilitated mobilization interventions–body-weight supported treadmill training, Arjo walker, LiteGait, and/or manual facilitation. Main Outcome Measure(s): Emergence from DOC as defined by standardized clinical protocols and scales. Results: Of the 25 patients admitted, 11 received one of four types of facilitated mobilization.Of the 11 patients who received facilitated mobilization, 7 patients emerged either prior to discharge (NZ4) or shortly after discharge to home (NZ3) and were subsequently readmitted for acute rehabilitation. Of the 14 patients who did not receive any form of facilitated mobilization only 3 emerged prior to discharge. Conclusions: AMP should be formally investigated as a potential valuable addition to care plans for patients with DOC.AMP may assist patients with suspected DOC to overcome severe weakness, debility, or learned disuse that may be negatively impacting their ability to respond to external stimuli. AMP may also facilitate recovery of arousal and awareness in low-level clinical profiles. Key Words: Physical Therapy Modalities, Brain Injury, Consciousness Disorders Disclosure(s): None Disclosed.
Courtney S. Ostrega (University of Toronto), Dhruti Bhandari
Poster 157
Poster 155
Objective: To review current literature regarding return to school postconcussion and how it promotes occupational performance. Within this context, occupational performance is defined as ‘the ability to choose and satisfactorily perform in school based activities’.
Categorizing Cognitive Performance in Traumatic Brain Injury Using Multiple Correspondence Analysis David Martinez (Center for BrainHealth at the University of Texas at Dallas), Daniel Krawczyk, Barry N. Rodgers, Sandi Chapman
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e53 purposes. Using NLP systems, larger-scale retrospective and prospective studies necessary to improve the understanding and measurement of employment in this important cohort are possible. Key Words: Veterans, Traumatic Brain injury, Rehabilitation, Vocational, Employment Status, Unemployment Acknowledgement “Funding for this work was provided by VHA QUERI RRP 12-450. The views expressed in this work are those of the authors and do not necessarily reflect the position or policy of the Dept. of Veterans Affairs or the US Government.” Disclosure(s): Nothing further to disclose. Poster 152 Sensitivity of the Montreal Cognitive Assessment for Out-Patients With Mild Traumatic Brain Injury Cindy Hunt (St. Michael’s Hospital), Donna Ouchterlony Objective: We aimed to assess the sensitivity of the Montreal Cognitive Assessment (MoCA) to screen for cognitive impairments amongst patients with mild traumatic brain injury (mTBI) seen in an outpatient head injury clinic. Our research questions: 1) What proportion of assessed patients demonstrated cognitive impairments as per the MoCA? 2) What patient factors were associated with cognitive impairment as per the MoCA? Design: Cross sectional survey. Setting: Level 1 tertiary care urban outpatient head injury clinic. Participants: mTBI patients (nZ117) assessed between July 2013 and January 2014. Interventions: Not applicable. Main Outcome Measure(s): MoCA overall and sub-component scores. Results: Patients were assessed on average 37 weeks (range 0-329 weeks) post-injury. Overall, 41.8% (nZ49) were cognitively impaired as per the MoCA (score <26/30). The naming and delayed recall sub-components were the most challenging for patients, with 99% (nZ116) and 79% (nZ92) demonstrating impairments in these components, respectively. Multiple linear regression was used to identify patient specific factors associated with MoCA scores. Controlling for gender, increasing patient age (pZ.03), and higher Rivermead Post-Concussion Symptom Questionnaire score (pZ.004) were significantly associated with decreasing MoCA scores, collectively explaining 31% of the variance. Duration of loss of consciousness, history of mental illness, history of drug use, and use of alcohol a month prior to injury were not significant in the model. Our findings were similar using Logistic Regression (outcome measured by MoCA score <26/30 versus 26/30). Conclusions: The MoCA is sensitive in detecting cognitive impairments amongst patients with persisting post-concussive symptoms assessed in an outpatient setting months following injury. Key Words: mild Traumatic brain injury, MoCA, cognitive assessment Disclosure(s): None Disclosed. Poster 153 Shopping Around:How are Mild TBI Patients Straining Canadian Health Services? Cindy Hunt (St. Michael’s Hospital), Donna Ouchterlony Objective: To describe the frequency and estimate the cost of health services encounters by patients with a mTBI prior to their first appointment in a specialized clinic. Design: Cross sectional survey Setting: Level 1 tertiary care outpatient head injury clinic in a Canadian city. Participants: mTBI patients (nZ145) assessed between July 2013 and January 2014. Interventions: Not applicable. Main Outcome Measure(s): Health services utilization. Results: In our study sample (nZ145) the mean age was 42.4 years (SD 18, range16-87) with 58.8% males. The activity during injury: transportation (pedestrian, MVA, bike) 47%, falls 29%, sports 8%, violence 6%
e54 and unknown 10%. The average time since current head injury was 8.15 months (SD 11.9, range 0-75 months). Among patients who visited the Emergency Department 40 % did so two times or more (maximum of 10 visits), likewise of those who visited Family Practice 59% did so twice or more (maximum of 72 visits), while among patients who visited a neurologist 34% did so twice or more (maximum of 5 visits). In the group of patients visiting a psychiatrist, 37% visited two times or more (maximum of 20 visits) and 80 % who visited a chiropractor once, revisited a second time or more (max of 120 visits). Conclusions: A total of 3304 health service encounters (mean of 23, SDZ45.8, range 0-307) occurred prior to the first visit to the head injury clinic which resulted in an estimated cost of $826,000, (estimate based on 2013 OHIP billing fees cost of services rendered by personnel). Key Words: health services costs, health service utilization, mild traumatic brain injury Disclosure(s): None Disclosed. Poster 154 An Item Level Analysis and Validation Study of the Problem-Solving Questionnaire’s Emotional Self-Regulation Scale Coralynn Long (NYU Rusk Institute), Jay Verkuilen, Joseph F. Rath, Lucia Smith-Wexler, Hilary Bertisch, Venessa Singhroy, Donna Langenbahn, Rose Lynn Sherr, Leonard Diller Objective: Increase efficiency in measuring emotional self-regulation (ESR) in adults with traumatic brain injury (TBI) by assessing ordinality, validity, and items in need of revision on the Problem Solving Questionnaire’s (PSQ) ESR scale. Design: Item response theory (IRT) and classical test theory (CTT) analyses of an archival database of 6-point Likert-type scale responses on the PSQ-ESR. Setting: Large, urban hospital Participants: 189 healthy controls completed the PSQ as part of a neurorehabilitation assessment (75% female; age M Z 25.13, SD Z 9.83). Interventions: Not applicable. Main Outcome Measure(s): PSQ-ESR scale Results: IRT analyses produced item trace lines, to be provided. Examination of curves showed reversal effects, indicating disordinality in the 6point scale, suggesting that some choices on the Likert were redundant. Redundant categories were combined, simplifying the scale into a 4-point scale. Final models showed the revised scale had fewer ordinality violations and comparable marginal reliability (.89) to the 6-point scale (.88). After establishing ordinality, several items were identified that may benefit from revision. Supplementary analyses revealed similar findings for the PSQ-ESR in a smaller cohort of individuals with TBI. Sufficient CTT validity for the PSQ-ESR was attained for both cohorts (p < .05). Conclusions: Simplified scaling and revision of potentially problematic items offers an optimal balance of ordinality and reliability on the PSQ-ESR. These revisions improve the PSQ-ESR scale’s ability to measure ESR deficits, while also increasing efficiency and manageability. These considerations are essential when assessing individuals with cognitive difficulties.Further analyses should be conducted with larger TBI samples, and similar IRT methods should be implemented during future clinical scale development. Key Words: TBI (Traumatic Brain Injury), Reliability and validity, Self regulation Disclosure(s): None Disclosed.
Brain Injury Data Sources: Three major health and medical research databases (Medline, CINAHL, Scopus) were used to search the literature. Key words included three categories: 1) mild traumatic brain injury, concussion 2) return to school, school re-integration, return to learn 3) children, adolescents. Study Selection: The initial process of study selection involved a review of article titles and abstracts from 1996-2013 that addressed all three categories by two reviewers. Data Extraction: Information pertaining to current practices and guidelines was extracted.In particular, the evidence or lack of evidence for practices and guidelines in improving school performance was noted. Data Synthesis: Current practices and guidelines commonly suggest; Gradual re-entry in school, Multi-disciplinary collaborative assessment of needs, Implementing an individualized intervention plan, Monitoring symptoms, and Adjusting the plan with recovery. However, there is limited evidence to support these recommendations, and the impact on occupational performance is not considered. Conclusions: While current recommendations appear to consider multiple dimensions of return to school, there is a paucity of evidence to support and inform the goal of occupational performance.A holistic approach should be taken by targeting individual, environmental and activity based factors such that it enables and enhances participation, and thus, performance, in school based occupation. This will guide the generation of evidence necessary for effective return to school guidelines. Key Words: Return-to-school, Concussion, Youth, Child and Adolescent, Mild Traumatic Brain Injury Disclosure(s): None Disclosed. Poster 156 Aggressive Mobilization in Disorders of Consciousness During Acute Rehabilitation: An Untapped Intervention Cynthia L. Beaulieu (Brooks Rehabilitation Hospital), Sarah Lahey, Jennifer Schinke, Jennifer O’Neal Walworth, Kenneth T. Ngo
Return to School Post-Concussion: Informing Improved Occupational Performance Amongst Youth
Objective: To present preliminary evidence for the potential benefit of implementing aggressive mobilization protocols (AMP) for patients with disorders of consciousness (DOC) in the acute inpatient rehabilitation setting. Design: Retrospective abstraction of 25 records. Setting: Inpatient rehabilitation hospital. Participants: 25 patients (2-48 years of age) admitted into a low-level brain injury program between September 2011 and August 2013. Interventions: Patients received one or more of four facilitated mobilization interventions–body-weight supported treadmill training, Arjo walker, LiteGait, and/or manual facilitation. Main Outcome Measure(s): Emergence from DOC as defined by standardized clinical protocols and scales. Results: Of the 25 patients admitted, 11 received one of four types of facilitated mobilization.Of the 11 patients who received facilitated mobilization, 7 patients emerged either prior to discharge (NZ4) or shortly after discharge to home (NZ3) and were subsequently readmitted for acute rehabilitation. Of the 14 patients who did not receive any form of facilitated mobilization only 3 emerged prior to discharge. Conclusions: AMP should be formally investigated as a potential valuable addition to care plans for patients with DOC.AMP may assist patients with suspected DOC to overcome severe weakness, debility, or learned disuse that may be negatively impacting their ability to respond to external stimuli. AMP may also facilitate recovery of arousal and awareness in low-level clinical profiles. Key Words: Physical Therapy Modalities, Brain Injury, Consciousness Disorders Disclosure(s): None Disclosed.
Courtney S. Ostrega (University of Toronto), Dhruti Bhandari
Poster 157
Poster 155
Objective: To review current literature regarding return to school postconcussion and how it promotes occupational performance. Within this context, occupational performance is defined as ‘the ability to choose and satisfactorily perform in school based activities’.
Categorizing Cognitive Performance in Traumatic Brain Injury Using Multiple Correspondence Analysis David Martinez (Center for BrainHealth at the University of Texas at Dallas), Daniel Krawczyk, Barry N. Rodgers, Sandi Chapman
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