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Long-Term Outcome > TBI: Three Models. Mary Pepping, Ph.D., ABPP-CN Professor, Dept. of Rehabilitation Medicine University of Washington Medical Center. Severe TBI: What Is It?. Caused by blow to head or severe acceleration-deceleration injury Length of coma > 24 hours

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long term outcome tbi three models

Long-Term Outcome > TBI: Three Models

Mary Pepping, Ph.D., ABPP-CN

Professor, Dept. of Rehabilitation Medicine

University of Washington Medical Center

severe tbi what is it
Severe TBI: What Is It?
  • Caused by blow to head or severe acceleration-deceleration injury
  • Length of coma > 24 hours
  • Glasgow Coma Scale < 9
  • Length of Post-Traumatic Amnesia (PTA) > 1 week
  • Time to follow commands > 24 hours
other indicators of severity
Other indicators of severity
  • Brain contusion
  • Brain hemorrhage
  • Skull fracture
  • Brain swelling
  • Shear injury
  • Infection
what is long term psychosocial outcome
What is long-term psychosocial outcome?
  • Level of function achieved & maintained in a range of real-life roles and settings > 5-10 yrs
    • Activities of daily living (ADLs)
    • School
    • Work
    • Productive activity
    • Family, friends, relationships
    • Leisure
the challenges of objective measurement
The challenges of objective measurement
  • What outcomes should we measure?
  • How do we best define/measure them?
  • How can we be sure the groups of patients are comparable?
  • Why has return to work been used so often as “the gold standard?”
what about indirect measures
What about indirect measures?
  • Level of caregiver burden
  • Degree of social isolation for patients and families
  • Incidence of stress, decreased mental health, and alcohol problems among families of survivors
  • Drug and alcohol abuse in survivors
  • Chronic depression, anxiety, loneliness
  • Economic impact
long term outcome stats
Long-term outcome stats
  • Thomsen - Scandinavian study
    • 10 years post injury
    • Severe TBI
    • 1/3 obtained and maintained paid employment after inpatient rehabilitation
    • 2/3 not working at 10 years post-injury
    • (Note: what are non-TBI work rates?)
comprehensive interdisciplinary neuro rehab
Comprehensive Interdisciplinary Neuro-Rehab
  • Early 1980s (Ben-Yishay; Prigatano)
    • 34% back to work after intensive rehab
  • Late 1980s (e.g., Prigatano)
    • Introduction of work trials = 50% RTW
  • Mid 1990s (Klonoff, Pepping & Grant)
    • 60% RTW
  • 2000-2007 (Klonoff, et al)
    • > 80% RTW or productive activity
disincentives for rtw
Disincentives for RTW
  • Disability income
  • Lack of acceptance of change in skills
  • Current earning power
  • Litigation, depending on patient
  • Worries about maintaining employment
  • Concerns about health insurance
  • Family needs and pressures
three models
Three Models
  • Rehab Without Walls
    • Home and Community Model
  • Intensive Outpatient Neuro-Rehab
    • Barrow Model; UWMC Model
  • Supported Employment
    • Projects with Industry; Co-worker coaches
rehab without walls
Rehab Without Walls
  • Strengths
    • Therapies delivered in home: no travel logistics
    • Rapid access to treatment
    • Clinical coordinator for each patient
    • Interdisciplinary team
    • Highly functional therapy focus
    • Strategies developed and taught where they will be used
    • Regular involvement of family
rehab without walls1
Rehab Without Walls
  • Weaknesses
    • No group treatment opportunities for patients or their families
    • Vocational counselors and other specialty services tend not to be part of the core team and program
    • Cost of program
    • Does not accept Medicare or Medicaid
intensive outpatient nrp
Intensive Outpatient NRP
  • Strengths
    • Full range of clinic based rehab services, e.g., OT, PT, SP, Neuropsychology, Psychology, Vocational Counselors, Therapeutic Rec, Social Work, Rehab Medicine physicians (physiatrists)
    • Specialties: Job Stations, Assistive Technologies, Certified Driving Evaluators, specialty MD care
    • Treatment groups for patients and families
    • Research opportunities, e.g., exercise study
    • Access to continuing education presentations
    • Most or all insurances accepted
intensive outpatient nrp1
Intensive Outpatient NRP
  • Weaknesses
    • How well will treatments generalize to home and community?
    • Transportation can be a challenge for patients and families
    • How long does it take to get admitted and seen for treatment or specialty care?
supported employment model
Supported employment model
  • Strengths
    • Direct treatment and support for work-related goals and needs
    • Use of peer job coaches
    • Capitalizes upon patient’s desire to be back to work = a major motivator for use of strategies and improved behavior
    • Patient is earning money and feels more normal and less isolated
supported employment model1
Supported employment model
  • Weaknesses
    • Has a more limited treatment focus so that other important personal/family problems > TBI may not get addressed
    • Patient needs to be ready for return to work process, e.g., aware and accepting of new status
    • It is not clear to what extent compensations learned for one job will generalize to other jobs
how are these models doing
How are these models doing?
  • With good “matching” of patient to experienced programs, outcomes are strong in all models, e.g., 60-90%
  • We have learned from our failures, e.g., why don’t people with potential RTW > TBI?
  • The importance of volunteer work
  • Formal and informal follow-up
  • Added help at major transitions
long term needs we don t yet address well
Long term needs we don’t yet address well
  • Post-program support for families
    • Respite
    • Quality of their work and personal lives
    • Economic advisors
    • Psychotherapeutic support
  • Friendships and intimate relationships for people who survive severe TBI
  • Telephone and internet based supports