Improving Assessment of the Invisible Brain Injury
Suzanne Simpson, Occupational Therapist, Dr Carol Kelly, Senior Lecturer Edge Hill University; Dr Jayne Martlew, Consultant Clinical Neuropsychologist;
Jacqui Isaac, Trauma Therapy Co-ordinator; Cathy Stoneley, Vascular Specialist Nurse; Amanda Chesterton, Occupational Therapist & Anne Jammes, Occupational Therapist
The Walton Centre NHS Foundation Trust & Edge Hill University
Acquired Brain Injury (ABI)
• Patients considered asymptomatic after ABI and
discharged home without follow up may in fact be
exhibiting cognitive deficits (Morrison et al, 2013;
Planton et al, 2012).
• Fride et al (2015) - cognitive and emotional deficits
have a negative impact on return to work following
stroke. Stroke patients are getting younger and this is
having a significant impact on national economies.
• Radford et al (2013) - there is a huge societal cost
linked to traumatic brain injury (TBI) reinforcing the
need for timely rehabilitation following TBI.
Occupational Therapy
• Unique assessment approach combining functional
and cognitive assessments to make inferences about
wider functional ability, and rehabilitation needs (Koh
et al 2009; Korner-Bitensky et al, 2011; Sansonetti
and Hoffman, 2013; Pilegaard et al 2014).
• Majority of hospitals rely on frontline staff (nurses,
doctors) who are not trained in cognitive assessment
to identify subtle deficits purely through observation.
• It is not feasible to refer all patients with ABI to
occupational therapy as this would have significant
cost implications.
Current screening assessments
• Focus on the key components of cognition and
developers claim they can predict functional outcome
(Chaytor and Schmitter-Edgecombe, 2003).
• Williams et al (2013) report that neuropsychological
assessments can predict return to work outcomes
post TBI.
• Others suggest these tools have poor ecological
validity failing to identify problems that are also
present in other places or settings (Sansonetti and
Hoffmann, 2013).
Cognitive Functional Performance Measure (CFPM)
Studies are yet to consider the potential to combine the assessment of cognition with the assessment of OP to form one quickly administered screening tool.
Cognitive Functional Performance Measure (CFPM)
The CFPM is a paper based screening assessment tool containing 5 subtests (orientation, memory, verbal fluency, clock drawing test and an occupational
performance based task) with a maximum total score of 30.
Scores less than 30 indicate the need to trigger an occupational therapy referral.
CFPM design
Clinical experience and research findings guided the choice of subtests chosen to form the CFPM.
The occupational performance based subtest was influenced by the Executive Functional Performance Task (EFPT). Baum et al (2008) looked at the validity and
reliability of the EFPT with mild and moderate stroke compared to matched controls. They found significant differences between groups and the test correlated with
some neuropsychological test battery subtests and functional measures.
Aims
The aim of this pilot study is to establish the validity of the CFPM to identify cognitive deficits
and the need for referral to OT within a single neurological hospital. In order to test the
potential validity of the tool the objectives of the study will be:
1. To compare the CFPM with that of two existing measures on a sample of mild ABI patients.
2. To test whether the CFPM can accurately identify those patients requiring OT intervention by
comparing those patients deemed as needing and not needing OT.
Design - Pilot cross-sectional correlational study.
Convenience sample
Recruitment of patients meeting the inclusion criteria until a sample of 100 is reached.
Sample size
• The Kettle Test (Hartman Meir, Harel and Katz, 2009) was used to determine sample size
(36 participants/36 controls).
• It is anticipated more patients will have ‘impairment’ therefore recruitment of 100
patients will provide sufficient numbers for the ‘no impairment/not needing OT’ group.
Inclusion Criteria
Diagnosis of ABI to include traumatic
brain injury and haemorrhagic stroke
Exclusion Criteria
A diagnosis of brain tumour
A reported GCS of 15
A diagnosis of brain infection to include
brain abscess, hydrocephalus or
encephalitis
Independently mobile on the ward
A pre-existing diagnosis of dementia or
already known to a memory clinic
Reported to be able to attend to their
own personal care to include
washing/dressing/toileting without
assistance from nursing staff
English not first language
Data collection
• All participants will be tested with the CFPM by members of the MDT (nurse, physiotherapist).
• The comparison measures are the MoCA (Nasreddine et al, 2005) and Kettle Test (Hartman Meir,
Harel and Katz, 2009). These will be administered by the OT service.
• Patient’s will be recorded as needing or not needing OT based on their CFPM score.
• Data relating to age, gender, diagnosis and age of leaving full time education will also be collected.
Minimising bias
Blinding of OT assessors to the CFPM score will be implemented.
Analysis
• Data will be analysed using Spearman’s Rho to identify any correlations between scores.
• Considering the scoring systems for the tools a desired result would be a positive correlation
between the tool and MoCA and a negative correlation with the kettle test.
Acknowledgements
Participants
References
Baum, C., M., Connor, L., T., Morrison, T., Hahn, M., Dromerick, A., W. and Edwards, D., F. (2008) 'Reliability, Validity, and Clinical Utility of the Executive Function Performance Test: A Measure of Executive Function in a Sample of People With Stroke' American Journal of
Occupational Therapy [online] 62 (4) pp. 446–455.
Chaytor, N. and Schmitter-Edgecombe, M. (2003) 'The Ecological Validity of Neuropsychological Tests: A Review of the Literature on Everyday Cognitive Skills' Neuropsychology Review [online]. 13 (4) pp. 181–197.
Fride, Y., Adamit, T., Maeir, A., Ben Assayag, E., Bornstein, N.M., Korczyn, A.D. and Katz, N., 2015. What are the correlates of cognition and participation to return to work after first ever mild stroke? Topics in Stroke Rehabilitation. 22 (5), pp. 317–325.
Hartman Meir, A., Harel, H. and Katz, N. (2009) 'Kettle Test--A Brief Measure of Cognitive Functional Performance: Reliability and Validity in Stroke Rehabilitation' American Journal of Occupational Therapy [online]. 63 (5), pp. 592–599.
Koh, C.-L., Hoffmann, T., Bennett, S. and Mckenna, K., 2009. Management of patients with cognitive impairment after stroke: A survey of Australian occupational therapists. Australian Occupational Therapy Journal. 56 (5), pp. 324–331.
Korner-Bitensky, N., Barrett-Bernstein, S., Bibas, G. and Poulin, V., 2011. National survey of Canadian occupational therapists’ assessment and treatment of cognitive impairment post-stroke. Australian Occupational Therapy Journal. 58 (4), pp. 241–250.
Morrison, M.,T., Giles, G., M., Ryan, J., D., Baum, C., M., Dromerick, A., W., Polatajko, H., J. and Edwards, D., F. (2013) 'Multiple Errands Test-Revised (MET-R): A Performance-Based Measure of Executive Function in People With Mild Cerebrovascular Accident' American Journal
of Occupational Therapy [online]. 67 (4) pp. 460–468.
Nasreddine, Z.S., Phillips, N.A., Bedirian, V., Charbonneau, S., Whitehead, V., Collin, I., Cummings, J.L. and Chertkow, H. (2005) 'The Montreal Cognitive Assessment, MoCA: A Brief Screening Tool For Mild Cognitive Impairment' Journal of the American Geriatrics Society [online].
53 (4) pp. 695–699.
Pilegaard, M.S., Pilegaard, B.S., Birn, I., Kristensen, H.K. and Morgan, M.F.G., 2014. Assessment of occupational performance problems due to cognitive deficits in stroke rehabilitation: A survey. International Journal of Therapy and Rehabilitation. 21 (6), pp. 280–288.
Planton, M., Peiffer, S., Albucher, J.F., Barbeau, E.J., Tardy, J., Pastor, J., Januel, A., C., Bezy, C., Lemesle, B., Puel, M., Demonet, J., F., Chollet, F. and Pariente, J. (2012) 'Neuropsychological outcome after a first symptomatic ischaemic stroke with ‘good recovery’ European Journal
of Neurology [online]. 19 (2) pp. 212–219.
Radford, K., Phillips, J., Drummond, A., Sach, T., Walker, M., Tyerman, A., Haboubi, N. and Jones, T., 2013. Return to work after traumatic brain injury: Cohort comparison and economic evaluation. Brain Injury. 27 (5), pp. 507–520.
Sansonetti, D. and Hoffmann, T. (2013) 'Cognitive assessment across the continuum of care: The importance of occupational performance-based assessment for individuals post-stroke and traumatic brain injury' Australian Occupational Therapy Journal [online]. 60 (5) pp. 334–
342.
Williams, M.W., Rapport, L.J., Hanks, R.A., Millis, S.R. and Greene, H.A., 2013. Incremental validity of Neuropsychological evaluations to computed tomography in predicting long-term outcomes after traumatic brain injury. The Clinical Neuropsychologist [online]. 27 (3), pp. 356–
375.
Dr Carol Kelly – Academic Supervisor & Senior Lecturer; Edge Hill University
Dr Jayne Martlew – Clinical Supervisor & Consultant Clinical Neuropsychologist, WCFT
Trauma Therapy Team, WCFT
Vascular Specialist Nurses, WCFT
Occupational Therapy Team, WCFT
Denise Lee – Therapy Manager, WCFT
Therapies R&DI Group, WCFT
The R&D Department, WCFT
Contact – Suzanne Simpson
E-mail: [email protected]