Becky Moran, OT

Shannon McGuire, PT

Parkwood Institute

BrainEx 90: Using a Circuit Training, Group Model of Treatment

to Promote Recovery after mTBI

Our Team

• Interdisciplinary team:

– Physiotherapy, Occupational Therapy, Speech-

Language Pathology, Social Work

• Ministry of Health funded

• See patients with mild, moderate and

severe brain injuries

• Have developed expertise treating

persistent symptoms post concussion

(mTBI)

• Regional program so patients often travel

to see us

Outpatient Acquired Brain

Injury Team

Referral Pattern

0

50

100

150

200

250

300

350

400

450

2009 2010 2011 2012 2013 2014 2015

# of referrals

# of referrals

Staffing Levels

0

1

2

3

4

5

6

2008 2009 2010 2011 2012 2013 2014 2015 2016

FTE

FTE

4.5 FTE

Triage

Return to School

Office Hours

BrainEx 90

Ex Graduates

Mind Matters

WARM uP 1 to 1

services

ABI 101

Parkwood Outpatient ABI Services

ABI Outreach

Ministry of Health ABI Team

Neurotrauma Rehab

Outpatient Physiatry

Jaybirds Walking Group

Our Website

https://www.sjhc.london.on.ca/concussion-mtbi

• ABI 101: Steps to Success Videos • Survivor & Family Education Series • Video of how to do Binasal Occlusion • Information about Pacing and Planning • Referral form • Helpful links

BrainEx 90

• Developed on a plane ride home from a conference – April 2013

• Goals of group:

– Decrease wait times

– Minimize impact of cancellation/no show

– Decrease length of stay

BrainEx 90

• 7 patients maximum per group • 3 different groups (8 or 16 weeks long):

– Group A: Tues/Thurs 8:45-10:45 – Group B: Tues/Thurs 11:00-1:00 – Group C: Wed 10:00-12:00

• 90 minutes of circuit training with prep time before and paperwork time after (120 min total)

• Max of 2 new people at a time • Staffed by 1 OT, 1 PT and 1-2 students or patient

volunteers

BrainEx 90 Stations

5 Minute Stations

• Vision x 2

• Vestibular

• Balance & Core x 2

• Cognition x 2*

• Cardio/Dynamic Balance x 1-2

• Wild Card x 2

• Rest x 1-2

20 Minute Station

• Self Management 10 Minute Station

• Education

Cognitive Station goals:

• Memory training and strategies

• Attention training and strategies

• Problem solving

– Deductive reasoning

– Divergent thinking

– Convergent thinking

• Visual puzzles/visual attention tasks

Cognitive Station Examples

Cognitive/Vision Station (iPad)

Count Battle Blockwick

Omicron

Non-tech ideas (cheapest version)

Wild Card Example – Q-Bitz

Wild Card – Rebus Riddles

Wild Card – Spot It

X

Vestibular Station: VOR Exercise

Balance Station: PQBD Ex

Balance Activities Example:

Everybody on your feet!!

Education: Ted Talks

Jonathan Froer

Kelly McGonigal

Phil Hansen

• Mindfulness

• Yoga & Exercise

• Leisure Ideas

• Dealing with special events

• Forever seeking normal

• Dealing with noise

• Coping with mood changes

Education: Discussion

BrainEx 90 Attendance

0

10

20

30

40

50

60

70

11-20 sessions < 10 sessions > 20 sessions Total

Group A

Group B

Group C

Total n = 166

0

10

20

30

40

50

60

70

In HighSchool

In PostSecondary

< HighSchool

HighSchool

PostSecondary

Unknown

Level of Education

Sex

Male

Female

0

10

20

30

40

50

60

70

Work/School Status

Effectiveness of Group

• Patient Satisfaction Surveys – easy to develop, collect and analyze data with Survey Monkey

• School of Physiotherapy Research Project

– REB approval for collection of demographic and pre/post assessment measures for 300 participants to determine change after participating in BrainEx 90

– Preliminary data only – data collection is ongoing

Patient Outcomes

• Patient Report – Rivermead Post Concussion Symptom Survey (RPQ), Headache Impact Test (HIT-6), Generalized Anxiety Disorder (GAD-7), Brain Injury Visual Symptom Scale (BIVSS), Canadian Occupational Performance Measure (COPM)

• Walking Speed – 10 metre walk, normal & max speed

• Static & Dynamic Balance – mCTSIB, Functional Gait Assessment

• Vision/Vestibular – Vestibular Ocular Motor Screen (VOMS)

Patient Satisfaction Surveys: Survey Monkey (100 respondents)

• 94% found the 90 minute time frame appropriate

• 96% found the rest time adequate

• 91% felt that their questions were answered at the end of each session

• 99%! found the OT Self Management Station helpful

• 96% found the Education sessions helpful and relevant

What is your favourite station?

00.5

11.5

22.5

33.5

44.5

5

Patient Satisfaction Surveys: (100 respondents)

• 98% found the skills they learned in group transferable to their daily life

• 78% felt the program helped them reach their goals

• 95% thought that being in a group setting was helpful and enhanced the rehab process

• 98% would recommend this program to other brain injury patients

Canadian Occupational Performance Measure

0

1

2

3

4

5

6

Pre Post

COPM Satisfaction (n=89)

0

1

2

3

4

5

6

7

Pre Post

Sco

re

COPM Performance (n=89)

p <0.001 p <0.001

Rivermead Post Concussion Questionnaire

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

Pre Post

Sco

res

RPQ-3 & RPQ-13 (n=98)

RPQ-3 RPQ-13

RPQ-13 p < 0.001

RPQ-3 p=0.002

56.00

57.00

58.00

59.00

60.00

61.00

62.00

63.00

Pre Post

Headache Impact Survey (n=88)

p = 0.26

0.00

2.00

4.00

6.00

8.00

10.00

12.00

Pre Post

Generalized Anxiety Disorder 7 (n=88)

p = 0.04

0.00

10.00

20.00

30.00

40.00

50.00

60.00

Pre Post

Brain Injury Visual Symptom Survey (n-88)

p = 0.21

0.00

2.00

4.00

6.00

8.00

10.00

12.00

Pre Post

10 Metre Walk (n=96)

Self Selected Speed

Max Speed

self p <0.001 max p=0.003

0.00

5.00

10.00

15.00

20.00

25.00

30.00

Pre Post

Sco

re

Functional Gait Assessment (n=99)

P <0.001

0.00

20.00

40.00

60.00

80.00

100.00

Pre Post

Tandem Stance (n=97)

P <0.001

0.00

20.00

40.00

60.00

80.00

Pre Post

Single Leg Stance (n=97)

Right SLS

Left SLS

Right p=0.002 Left p=0.001

100.00

105.00

110.00

115.00

120.00

Pre Post

mCTSIB (n=97)

p=0.004

In their own words…

“I recommend that anyone should take this. It was the

only help I got when I needed it. I would not be where

I am today (returning to work) without this program. No

one else understands this injury.”

“The amount of knowledge I have acquired is very

helpful and has made a big difference in living with

brain injury.”

“Appreciated the knowledge, support and care. To learn

that there is a way to improve daily life... life

changing program.”

“I found that that this group was a huge self discovery

process of identifying the "new me" and learning hope

to cope and improve my systems.”

“Everyone did an amazing job even helped me achieve a

goal that I didn’t think possible.”

Unanticipated Benefits

• Power of group treatment & social connections made

• How much patients learn from and inspire each other

• How well patients tolerated the challenge over time

• The mutual benefit for our patient volunteers

• Both our inpatient ABI team and 3rd Party team have used this format for their patients

Jaybirds Walking Group

They even started their own Facebook page…

Lasting Friendships

4 Peas in a Pod: Positively Peaceful Parkwood Pacers

We now think group treatment is preferred over individualized,

and our patients agree

Our Next Challenge

• To make this model of treatment available to others

• Our goal is to package BrainEx 90 so that other facilities can implement

Ex Graduates Group

• Self-Management Maintenance Group

– developed to meet demand for ongoing OT support in Self Management

– Saw need for patients to continue to have social support in a group format

– Need to graduate from BrainEx 90 first

– Asked patients for ideas to determine format

Ex Graduates Group

• 2-OT’s managing 1-4 groups each

• Meet for a total of 5-7 sessions

• Held in BrainEx 90 room

• Unstructured, no curriculum

• Focus on discussion of managing this ongoing issue and possible return to work strategies

• Patients can use BrainEx 90 equipment, select a topic from cards to discuss, play board games, etc

Thank you to our team

• Laura Graham • Dalton Wolfe • Nicole Visek • Stephanie Marrocco • Nicole McLean • Sandra VanNest • Grace Kary • Melissa Richardson • Roja Rohani • Justin Shyr • Megan Smith • Ellen Xu

Questions?