Assessment for Neuropsychological Rehabilitation Planning (Chapter 4)

Key goal in rehabilitation (1→1)

• Satisfying return to family and community engagement

  • Not just reduction impairment, but specifically reduction of physical impairment and environmental barriers, and building on strengths, such that the above can occur

Model for rehabilitation planning (1)

• Synthesises the medical model and the social model

Medical model (2)

• Focuses on diagnosis and clinical intervention

• Targets internal personal deficits/disabilities with behavioural and pharmacological treatment

Social model (1→2, 1→2)

• Views disability as primarily environmental

  • Physical

  • Social

• Focuses on removing environmental modifications by making physical and social accomodations

  • Physical → e.g. ramps for wheelchairs

  • Social → e.g. community/family education → social acceptance and support

Why integrate both models? (2)

• Because simply reducing impairment is insufficient achieve end goal if environmental barriers remain (e.g. unaccommodating employers, dysfunctional family dynamics)

• Conversely, individuals frequently achieve high quality of life and community reintegration despite persistent, un-remediated cognitive or physical impairments.

Areas of assessment (9)

• Pre-injury history

• Injury parameters

• Associated injuries and comorbidities

• Physical limitations

• Cognitive functioning

• Emotional status and psychotherapy

• Behavioural self-management and self-awareness

• Interpersonal and social skills

• Social and family adjustment

• Community engagement

Pre-injury history: what to consider (2 physical factors, 2 social/personality) and why (4)

• Chronic conditions

  • Inextricably linked to ABI management

  • E.g. remembering to take medication (insulin) for diabetes e.g.

• Personality and educational background

  • If was high achieving → may have more difficulty accepting limitations

• Prior brain injury, psychiatric disorders, substance abuse

  • Increased risk of aggravating

• Family history

  • Family dynamics can affect rehabilitation success

Injury parameters (2→2) + note

• Initial ABI severity often measured based on:

  • LOC

  • Length of amnesia

• Extent + location of damage

  • CT MRI

• Doesn’t always predict recovery outcomes

Associated injuries + comorbidities: common comorbidities

• Depression

• Chronic pain

• Sleep disturbance

• Systemic fatigue

Physical limitations: important key word

• Ambulation: walking and moving about

Cognitive functioning: 2 areas assessed, how + examples

• Baseline impairment assessed through neuropsychometric testing

  • Visuospatial memory

  • WM

  • Language skills

• Assess how daily living is impaired through functional testing

  • Functional memory

  • Executive functioning

Behavioural self-management + self-awareness: examples

• Behavioural disturbance example: disinhibition (aggression, impulsivity)

• Impaired self-awareness → inability to recognise physical and cognitive deficits

Social interaction (1)

• ABI frequently affects turn-taking skills, non-verbal communication, facial affect recognition + empathy → major hurdles to social reintegration

Family adjustment

• Family dynamics significantly influence patient outcomes

• So assessments like the family assessment device (FAD) are used to triage families into three clinical categories

FAD categories (3)

1. Severely Disturbed Families: Require intensive family therapy or, in rare cases of severe pathology, helping the participant establish independent living arrangements away from the family environment.

2. Significantly Stressed Families: Require structured interventions focused on stress management and adaptive coping skills.

3. Normally Stressed Families: Require standard psychoeducation regarding ABI, clear communication, and reinforcement of basic coping mechanisms.

Community participation functional domains (5)

1. Independent living

2. Social and recreational activities

3. Productive activities: e.g. employment (paid or unpaid), managing household

4. Financial management

5. Transportation

Goal setting acronym (1→5)

SMART

• Specific

• Meaningful

• Action-oriented

• Realistic

• Timely

Step 1 (1)

Assessment

What three criteria should assessment satisfy?

• Systematic

• Standardised

• Comprehensive

What’s an example of such an assessment? (1)

The Mayo-Portland Adaptability Inventory (MPAI-4)

What does the MPAI-4 evaluate? (2)

• 30 functional items

• 5 comorbidity factors

Examples of functional items (7)

• Mobility

• Use of hands

• Vision

• Hearing

• Self care

• Social interaction

• Money management

The 5 comorbidity factors

• Alcohol abuse

• Drug abuse

• Legal problems

• Comorbid physical disabling conditions

• Comorbid cognitive disabling conditions

How is data collected for the MPAI-4? (1)

• Corroborate and compare ratings from patient, rehab team and participant/patient

Step 2

Use data from assessment to create plan

Crucial note on translating assessment data into rehab plan (1 → 2)

• Not every deficit needs to be addressed

• E.g. if:

  • Unlikely to improve

  • its remediation will not meaningfully advance the client towards their goals

Step 3 (1)

Continue assessment throughout rehabilitation to track progress towards goals and adjust interventions where needed

What is a method of goal-setting and tracking progress?

• Goal attainment scaling (GAS)

GAS 5-point continuum

+2: Much better than expected outcome

+1: Better than expected outcome

0: Expected outcome following intervention (represents the minimal clinically important change)

-1: Less than expected outcome (typically represents baseline performance at admission)

-2: Much less than expected outcome (represents clinical decline or deterioration)

Note on use of standardised assessment instruments (1)

• They enhance reliability and efficiency, but should be applied flexibly and combined with interviews and qualitative scales