Traumatic Brain Injury–Practice Based Evidence Study

Article Reviews
, , , , ,
1

Read Full Text: Traumatic Brain Injury–Practice Based Evidence Study: Design and Patients, Centers, Treatments, and Outcomes (Free)
Journal: Archives of Physical Medicine and Rehabilitation
Year Published: 2015
Ranked 71st on our 2015-2020 list of the 100 most influential OT-related articles

Anecdotally, we know there’s significant variation in how traumatic brain injury (TBI) presents. Yet, when it comes to research and best practice discussions, we tend to lump all TBI cases together as if they’re the same…

Luckily, this paper represents a major trend we are seeing in research: subdividing broad diagnoses into more meaningful subcategories.

You’ll see how statistical modeling might usher in a new era of more precision-based OT interventions.

And, as we eagerly await what the future holds, this paper ensures we’re prepared to do our best. Not only does it serve as a helpful intro to the subtypes of TBI, it also provides insight to the current care provided in inpatient settings.

Let’s dive in.

The good news and the bad news about acute TBI treatment

The GOOD news is that past research indicates that people with TBI do tend to make functional gains during inpatient rehab. Specifically, these improvements are noted in ambulation, independence, and cognition.

The BAD news is that we really don’t know what accounts for these gains.

  • How much of it is just natural recovery?
  • How much should just be attributed to patient characteristics.
  • What can we do, as therapy providers, to make the most impact?

We simply don’t have these answers (yet).

Past research seems to imply that there is a level of complexity to recovery that we haven’t been able to fully explain. In one interesting study, the time spent in OT and PT did not account for variance in outcomes, but the time spent on specific OT and PT activities did.

Which leads us to this paper:

What did the researchers hope to achieve?

This paper is the first published work in a massive 5-year research study, called the TBI-PBE (Traumatic Brain Injury-Practice Based Evidence) project.

While this project has multiple aims, this week’s paper aligns best with the first aim, which is to:

Identify patient characteristics that might be associated with specific treatment outcomes.

(Hint: They are going to accomplish this!)

Important aside on “Practice-Based Evidence”

Before we dive into the specific methods of this research, I wanted to highlight the concept of Practice-Based Evidence (PBE), because the phrase was new to me.

Practice-Based Evidence denotes the practice of data being collected and analyzed from real-world patients—in other words, not from a structured study.

One of the major problems with traditional research is that results from a highly controlled environment don’t necessarily translate to the messy real world. Luckily, the major databases that are emerging (like the TBI-PBE database) are offering new ways to analyze both what is and what isn’t working.

PBE is a major shift for healthcare! Here’s a great article about it.

Ok, back to this week’s article:

The methods behind this massive study

10 rehab centers participated in this study. 950+ therapists were trained on a standardized point of care documentation that captured what kind of care they were delivering and time spent on it.

Also, intense chart reviews were done to collect all kinds of data points on specific patient characteristics and their healthcare journey post-TBI.

What were the main outcomes and assessments they were looking at?

What results did they find related to patient characteristics?

2130 patients ended up being included in this study, and there was significant variation in terms of demographics, injury, and functional level.

After multiple attempts to find patterns and distinct groupings in their pool of patients data, the researchers made a discovery:

When they grouped the patients into 5 groups based on their FIM cognitive scores at admission, they suddenly started seeing groupings that looked much more homogenous in terms of demographics, injury, treatment, rehab course, and outcomes.

For example, the LESS impaired group members (according to their FIM scores) were:

  • Generally older
  • Had a greater percentage of women
  • Had a higher percentage of injury due to falling
  • Showed less midline shift
  • Had less time from injury to rehab admission

Treatment for a group like this would naturally look different than for a young male with a severe injury and severe cognitive impairment, and in the initial data they looked at they were seeing unique treatment patterns for these different groups.

Conclusions/Discussion

The authors believe they have found a meaningful way to subdivide TBI patients, by stratifying them by their FIM cognitive score at admission.

This is important because it is the first step to determining whether certain treatments are more effective for different groupings of TBI.

Bonus content:

Here are some more articles from the TBI-PBE project. I’m hoping we get to review more articles from this database in the future!

Takeaways for OT practitioners

(These were our personal takeaways, and were not mentioned in the article.)

1. What a great assessment mix!

I tend to immediately check which assessments are being used in research papers, looking for ones that might be helpful in clinical practice.

And, honestly, there are sometimes assessments that just do not seem realistic to use in the real world. They are either too complex or not accessible to buy. But, the mix of assessments this group used really stood out to me as being super helpful and accessible.

And, it occurred to me that this is because we are looking at an example of Practice-Based Evidence (PBE)—and that means these are assessments already being used by clinicians in the real world. Which leads me to my next takeaway:

2. Is PBE the link we are missing to truly improve our care?

Over the past few decades, we’ve made evidence-based practice a pillar of healthcare. But, I’m sure I’m not the only one wondering whether our care is even improving?

The past few decades have also seen a massive transition to the use of electronic medical records (EMRs). And, we’re still left wondering: did that transition really improve our care of our patients?

Is PBE (where we take real-life data from our EMR databases and analyze what is and isn’t working) the next iteration we need in healthcare? I look forward to following this trend with you all!!

Here’s the full APA citation for this article:

Horn, S. D., Corrigan, J. D., Bogner, J., Hammond, F. M., Seel, R. T., Smout, R. J., . . . Whiteneck, G. G. (2015). Traumatic Brain Injury–Practice Based Evidence Study: Design and Patients, Centers, Treatments, and Outcomes. Archives of Physical Medicine and Rehabilitation, 96(8). doi:10.1016/j.apmr.2014.09.042

What questions/thoughts does this article raise for you?

1 Like
3

Thank you Sarah for another thought-provoking article. I am currently a capstone student teaching a course on evidence-based practice (EBP) for post-professional OTD students. The model we use to describe EBP importantly includes both patient perspective and client preference - often times I’ve found that many definitions of EBP only include what the literature says about [insert diagnosis, intervention approach, assessment, etc.] and doesn’t take into account the client’s perspective/needs/goals. I am so excited about this concept of practice-based evidence (PBE) - another new term to me - and how it could improve healthcare, specifically by improving the time it takes new evidence to be disseminated and integrated. I think that by focusing on PBE over EBP (or maybe in addition to?), the time from research to dissemination to practice will hopefully be shortened because the research/evidence directly supports how it will be utilized in practice to improve patient care.

8 Likes
4

I love the model of EBP you are using! I definitely think of EBP in that way!

And, I love your point about the current lag in integration of new evidence. My all time favorite article on EBP is “When Evidence Says No, But Doctors Say Yes.” It outlines the problem you are describing in a really compelling way! Have you read it?

3 Likes
5

@SarahLyon No, I haven’t read this yet! I’ll add it to the list with the PBE highlight article from above. Thanks!

1 Like
6

Another great, thought provoking article!! I work several PRN jobs with one of them being on an inpatient rehab unit. This article and the emphasis on the importance of the patient reminded me of
last week when I was working with a gentleman who suffered a major stroke involving some severe hemiparesis and neglect. I checked with a therapist who had been seeing him, she said said that we really haven’t gotten him to do much yet. I started to try to work with him in the the therapy gym, but quickly decided that wasn’t the best option for this day. I took him into his room and rolled him up to his sink. I handed him a tooth brush, and he put it in his mouth but required hand over hand assistance. He required hand over hand assistance initially to comb his hair, but after several times, he started to comb BOTH sides of his hair on his own. Next I gave him a wet wash cloth and his face lit up. He picked it up and washed both sides of his face for about 3 minutes with absolutely no cues. He just kept washing. He looked at me and squeezed my arm after he had finished. He wasn’t able to speak, but I felt like the look in his eye showed so much joy. I’ve been thinking about that look for the last week now…it reminded me of how important it is to do functional tasks that are important to the patient. Even thinking about my previous work on a LTAC unit with severe TBI patients…it was amazing to see how well they did when they were working or doing things that they use to do and that were important to them!

I love seeing this research, especially for TBI treatment that is headed in this direction! I believe Client-centered treatment is invaluable and when we do the things they want to do, we will see great outcomes!!

6 Likes
7

@Rsaltzgaber, I LOVE it when stories from our practices match what we are finding in research. Here is the results from a 2019 study examining the TBI-PBE data base:

Increasing the proportion of treatment provided in the context of real-life activities appears to have a beneficial effect on outcome. Although the effect sizes are small, the results are consistent with other studies supporting functional-based interventions effecting better outcomes. Furthermore, any positive findings, regardless of size or strength, are endorsed as important by consumers (survivors of TBI). While the findings do not imply that decontextualized treatment should not be used, when the therapy goal can be addressed with either approach, the findings suggest that better outcomes may result if the contextualized approach is used.

https://www.archives-pmr.org/article/S0003-9993(19)30082-6/fulltext

Keep up the good work!!!

2 Likes
8

I agree, thank you Sarah for bringing this to our attention! I have seen in my transition from school to working over the past 4 years how the emphasis we have on EBP doesn’t seem to live up to what I was taught when practicing day to day. PBE seems to give a real chance for us to improve while continuing to be client-centered and meeting the immediate needs we see.

Very interesting as well looking at sub-dividing TBIs which, as you state, are so varied. I’m currently working with a few children/young adults with TBIs in my outpatient setting and have been at a loss at times with best practice as they do not fit the research I have found. I’m excited to look into the other resources you shared.

3 Likes
9

Sarah,
Evidence-based practice always seemed like something hard to do, and like Allison mentioned, including the research but not the link to my specific client. When I returned to school for graduate work, I was introduced to Mary Law’s framework of evidence-based practice that introduced the practitioner’s critical thinking regarding the application of the research that included considering the fit of the research to the client as well as the client’s context including (a person, occupation, and environment). Additionally, the OT practitioner should consider the client’s preferences and values to create a client-centered approach and application of research. I can include an article I found and a picture similar to the one in Mary Law’s Rehabilitation book.
The link to practice-based evidence and the ‘Evidence says No, But Doctors Say yes’ was thought-provoking. Two years ago, my husband began experiencing A-fib, and there was a concern that it was related to sleep apnea. He was sent for a sleep apnea test, which showed minimal sleep apnea on his back with a Hypopnea Index (AHI) of < 10 but AHI on his side was 0. The None; Minimal range is AHI <5 per hour, Mild range AHI >5, <15 per hour, and Moderate was AHI >15, but <than 30. The doctor immediately wanted to prescribe a CPAP at night. I asked about the O score on the side and suggested training my husband to sleep on his side. The doctor disagreed, so we asked for a second opinion, and this doctor indicated that it was a viable option. My husband did another test at home, not in a sleep study clinic, to double-check he was not having any episodes in side-lying. The second test confirmed no episodes, and he is now a side sleeper. He also lost 10 pounds, which has helped too. The doctor immediately jumped to prescribing a machine without considering other options based on evidence and did not hear the client. The second practitioner listened, considered, and assessed to allow for a more client-centered approach.
The client-centered approach makes occupational therapy practice unique. As OT practitioners, we need to speak to our clients regarding the use of their values, desires, and goals within the evidence we present during treatment. It is well known the saying, “When you have seen an individual with an X diagnosis ( TBI, Stroke, etc.), you have seen that client. Each is different based on values, context, and injury, etc. “ Good reminders to highlight occupational therapies’ uniqueness!

ebp OT.PNG
ebp OT.PNG552×525 48.5 KB


Full article.
4 Likes
10

  1. I used to work in inpatient rehab and the only time I’d say the FIM scores weren’t as predictable was when they still had amnesia but were kept long enough to come out of it (not related to the event itself but to the point of not recognizing family members or remembering they are in a hospital). I like the idea of using FIM scores to categorize treatments versus mild vs mod vs severe TBI.

  2. Yes! I feel practice based evidence is great, thanks for sharing. It’s so hard to use research to inform practice with the more “normal” research model. I especially felt the weight of this when trying to prep for outpatient TBI return to work, coming from inpatient. There’s no industrial rehab textbook so I was trying to sift through research articles and got pretty discouraged. Also, a side effect of using PBE is hopefully it will help therapists reduce the risk of burnout by helping ameliorate imposter syndrome!

Speaking of lack of usable evidence… I’m looking into treating sensory difficulties with outpatient adult TBI . While sensory reintegration definitely needs to be treated and I’m very open to adapting treatments for kids to adults (though I’ve never worked in pediatrics) but I looked into the research and it’s not very compelling to show what works for sure so I don’t know where to start.
If anyone is familiar with the Guide for Implementing Ayres Sensory Integration manual? If so, could this potentially be translatable to adults with TBI or if I should just read the Ayres book to get a background and try to develop my own treatments?
Does anyone know of someone working with adults trying to focus on all the senses? Any of the senses? (besides compensation for hearing / vision sensitivity and mirror therapy or adults in a coma).
I’m using COPM (among other assessments) for tracking changes overall but haven’t done any sensory specific testing. Thoughts?

2 Likes
11

Hey @kyrstin, I was just thinking of your previous question on this and I am so glad you chimed in here! Without giving any patient identifiers, I’m really curious what specific sensory changes you are seeing?

We recently talked about post concussion syndrome and in my reading I was surprised how much the condition overlapped with POTS, which is something that I’m pretty sure I had. I had horrible vision changes and light sensitivity…(I actually still do), but my neuropthamologist suggested that I switch from contacts to glasses, and for some reason that made it much more bearable.

Anyways, I guess I’m just curious if there is some adaptation like that that we could help you brainstorm.

Im also curious whether @bryden or @DevonCochrane have any insight, since they might be more familiar with adult sensory changes?

Oh, and one more thought: Do you have access to the Adult Sensory Profile? They only research we’ve looked at in the Club about adult onset of sensory changes was actually related to psychosis… apparently lots of people experience sensory changes as a precursor to psychosis, and the Sensory Profile was the assessment they used in research to track the changes. (I’m not implying psychosis in your patient! Just saying that that is the preferred assessment we’ve seen in adult onset sensory changes :slight_smile: )

12

What a great article you shared! I’m going to print it off to read it again more carefully! I’ve thought a lot about the phrase “evidence-based practice” because like you alluded to, I don’t think it emphasizes the critical thinking of the practitioner enough.

Right now, use the phrase “evidence based practice” when promoting the Club, but I would love to transition to calling it something like a “clinical reasoning support.” Because, I do think it is very important to be exposed to new evidence, but it is just as important to think critically about how it applies to patients in front of us.

Your story with your husband was such a great example of what a client centered approach looks like.

As always, thanks for chiming in, @sherry! I always learn so much from you!!!

13

Ringing in the ears, Tone sensitivity, light sensitivity, vision changes, dizziness with movement (dorsal vision stream issues), proprioception and motor planning (which I realize motor planning might be in balance / motor vs sensory but it’s all functional movement) especially with having to look at their feet while walking or when playing guitar knows what chord to play and “tells” their fingers what to play but they won’t move (or move fast enough). Less commonly reported (though maybe I’m not asking the right questions) I numbness and tingling that aren’t explained by nerve issues. Same with sense of taste / smell. I don’t hear it too often but I also don’t think to ask.

I’ve heard of that assessment but haven’t seen it before. This year I haven’t wanted to ask for anything in addition on the budget but will if it’s the right assessment. My current OTD student was looking into it but said it wasn’t used to track changes. Sounds like that was a misunderstanding.

1 Like
14

How long post-TBI? How severe was the TBI? Has the patient tried vestibular repositioning for the dizziness? (That had the most success in the post-concussion article we looked at.)

I’ve had horrible dizziness with movement before and tingling in my right extremities (lasted 2 years)…and this sounds crazy but the only thing that helped me was a graded exercise program. I started with 3 minutes seated exercise and was able to work up to full exercise sessions…over about 9 months…

Here’s a great article about exercise post concussion… https://www.cognitivefxusa.com/blog/exercise-after-a-concussion

(Sorry to bring in personal anecdotes! But I just sympathize so personally with these symptoms.)

16

They are usually 4 months - 10 years out from injury with the most frequent being about 1 year out (in the 9-18 month range).
PT always assesses vestibular but usually they get PT for any vestibular issues prior to this program so we don’t see a lot of that.
I just looked up POTS, I totally forgot about it! Thanks for telling me about your experience (and reminding me about the diagnosis!). And graded exercise doesn’t sound crazy because it would get your blood flow going but you also wouldn’t want to go too quickly and pass out! Speaking of personal experiences, I remember while pregnant with my daughter I would feel faint every time I stood up and had to keep moving or lying down (not sitting or standing) to not feel miserable. A little rough working on rehab where there’s so much standing in the room :stuck_out_tongue:
I’m going to check out that article right now (I love having a nearly independent OTD student so I can work on improving the TBI program while she writes the notes, haha:D), thanks!

2 Likes
17

Autonomic dysfunction is a fairly well recognized set of issues in TBI, even in concussion these days. POTS as far as I understand it isn’t a super well defined condition either, but the linkage here is basically trouble regulating blood pressure. It’s thought that the main problem with exertion intolerance in concussion is a result of issues with regulating cerebral blood pressure. The postural intolerance that you see in POTS is probably similar when we see these things in TBI too, just under a different name…

As for the sensory questions: there is definitely a lot of interest and research into sensory issues (eg. sensitivities, balance and vestibular problems, etc…) which would related to “sensory integration”. I am biased in that I don’t think Ayre’s work is sufficiently evidence based or based on solid neurobiology but the idea of stimulating and working with all the systems makes good practical sense. If you take concussion for example, most of the approaches to treatment are based around exercising sensory systems (vision therapy, vestibular therapy, etc…) but I don’t know of a treatment protocol that kind of brings it all together. Lucky for us, we just get to pick the activities that people want to do and hopefully that’s enough stimulation of the required senses…

So I guess I would say: stick to the basics! Choose some meaningful activities and occupations for our patients that challenge them in all the right ways, and don’t worry too much about getting specific protocols to hit components of the sensory systems. Keep it occupation-based! :slight_smile:

2 Likes
18

Is there a podcast that goes along with this article? Having a little trouble navigating this site.

19

Hey @jaime! There is not a podcast with this article :frowning_face: I’m really glad you brought this up. We have only recently introduced our podcast based courses, and I can definitely see the benefit of making it easier to see which articles have podcasts with them. I will be thinking on that! (@mitchell-lyon and @yvonne, let’s brainstorm this!) In the meantime, here are the podcast based courses we currently offer: https://club.otpotential.com/c/ce-courses

20

Thank you so much for the link!!

1 Like