Abstract
Objective
To describe the amount and content of group therapies provided during inpatient rehabilitation for traumatic brain injury (TBI), and assess the relationships of group therapy with patient, injury, and treatment factors as well as outcomes.
Design
Prospective observational cohort.
Setting
Inpatient rehabilitation.
Participants
2,130 consecutive admissions for initial TBI rehabilitation at 10 inpatient rehabilitation facilities (9 in US and 1 Canada) from October 2008 to September 2011.
Interventions
n/a
Main Outcome Measure(s)
proportion of sessions that were group therapy (two or more patients were treated simultaneously by one or more clinicians); proportion of patients receiving group therapy; type of activity performed and amount of time spent in group therapy, by discipline; rehabilitation length of stay (RLOS); discharge location; FIM Cognitive and Motor scores at discharge.
Results
79% of patients received at least 1 session of group therapy, with group therapy accounting for 13.7% of all therapy sessions and 15.8% of therapy hours. On average, patients spent 2.9 hours per week in group therapy. The greatest proportion of treatment time in group format was in Therapeutic Recreation (25.6%), followed by Speech Therapy (16.2%), Occupational Therapy (10.4%), Psychology (8.1%), and Physical Therapy (7.9%). Group therapy time and type of treatment activities varied among admission FIM cognitive subgroups and treatment sites. Several factors appear to be predictive of receiving group therapy, with treatment site being a major influence. However, group therapy as a whole offered little explanation of differences in the outcomes studied.
Conclusion(s)
Group therapy is commonly used in TBI rehabilitation, to varying degrees among disciplines, sites, and cognitive impairment subgroups. Various therapeutic activities take place in group therapy, indicating its perceived value in addressing many domains of functioning. Variation in outcomes is not explained well by overall percent of therapy time delivered in groups.
Keywords: Brain injuries, Rehabilitation, Therapeutics, Health services, Health services research, Occupational therapy, Physical therapy specialty, Psychology, Recreation therapy, Speech therapy
Group therapy may have unique advantages beyond those achievable through individual rehabilitation therapies. Frequently cited advantages stem from the benefit of peer interactions.1 Interacting with others experiencing similar circumstances may enhance the learning experience, allow for vicarious learning, provide a sense of support, enhance motivation, as well as decrease social isolation and depression.2-6 Gauthier et al also noted that group therapy may enhance coping and mood.7 Additionally, group therapy allows more patients to be seen by fewer staff, which may reduce treatment costs and decrease staff needs that in turn may help address staff shortages.3,5,8 For some treatments, delivery in a group format may be as effective 3 or even more effective 2 than individual therapies.
A disadvantage of group therapy is a lack of flexibility in both scheduling and individualizing interventions.4 In scheduling group therapy during inpatient brain injury rehabilitation, a major challenge is that of managing the varied functional levels across group members and moment-to-moment fluctuations within individual patients. It is important to match client appropriateness (e.g., cognitive and psychological function) for group therapy with the group therapy treatment goals.9
Group therapy has been used for a variety of treatment purposes. Surveys of occupational therapists (OTs) working in various settings (including medical facilities, schools, community facilities) across the United States in 1983 and 1993 found group therapy was utilized for exercise, cooking, activities of daily living, arts and crafts, self-expression, feeling-oriented discussions, reality-oriented discussions, sensory integration, and education.10 Several studies have characterized the utilization of group therapies during inpatient spinal cord injury.5,11,12 Group therapy usage has been reported to vary by treatment center, therapy discipline, therapist, goals, and tasks.5,10-12 Zanca et al12 found that in 6 facilities providing inpatient spinal cord injury rehabilitation, 98% of patients received at least one group therapy session with 83%, 81%, 80%, and 54% receiving at least one session of physical therapy (PT), OT, therapeutic recreation (TR), and psychology (PSY), respectively. Group therapy accounted for 24% of the total therapy sessions and 27% of the therapy time delivered. The most common interventions delivered in a group format were strength and endurance training and therapeutic recreation outings. More hours/week spent in OT groups was associated with fewer hours/week in individual OT, with the opposite being true for TR (patients who received more group TR also received more individual TR). For the other disciplines studied (PT and PSY) the relationship between individual and group therapy time varied among subgroups of patients, depending on the classification of their spinal cord injury.
Group therapy is used commonly in the treatment of brain injury, although studies of group therapies in this population generally have been in the outpatient environment and have not compared group therapy to an otherwise equivalent individual therapy.13-15 The most recent study of this nature compared Italian patients (outpatients, or inpatients transitioning to outpatient status) who received individual multidisciplinary therapy only, with those receiving a mixture of individual and group therapy.16 The authors concluded that those receiving both individual and group therapy on average made larger FIM gains. However, not all patients were considered suitable for group therapy, raising doubt about the conclusion that a mixture of group and individual therapy is more effective (which was based on their not finding statistically significant differences in Disability Rating Scale and Ranchos Los Amigos Cognitive Functioning after treatment). The findings for a sample that was on average 15 months post TBI may not provide useful information for inpatient rehabilitation in the United States, where most patients are weeks rather than months post onset.
Although data are not available to inform the selection of therapy mode in TBI inpatient rehabilitation, it is logical to assume that some treatment activities may be amenable to a group format while others may not. A significant challenge in delivering TBI rehabilitation is determining the most beneficial treatment approach given the diverse nature of the injury and its effects. For example, various factors may be important considerations in determining if group or individual therapy is the best delivery mode including: patient functional level (e.g., arousal, orientation, awareness, memory, problem solving, attention, agitation, communication deficits, physical ability), treatment target (e.g., strength, endurance, range of motion, memory, swallowing, social and cognitive skills), therapist availability, cost containment needs, payer reimbursement formulas, treatment effectiveness, and the benefits of peers being present (e.g., work on social interaction skills).
Currently there are limited data on group therapy in TBI rehabilitation, with no studies found that focus specifically on group therapy during inpatient TBI rehabilitation. Characterization of current usage patterns and outcomes of group therapy during TBI inpatient rehabilitation will provide preliminary data needed for the development and refinement of group treatment protocols, and eventual study of specific group therapies in brain injury. The aims of this paper are: 1) to describe variation in the amount and content of group therapies provided during inpatient TBI rehabilitation, by patient cognitive functioning level (as measured by Functional Independence Measure (FIM) Cognitive score at rehabilitation admission)and by treatment site; 2) to assess the relationship between receipt of group therapy and individual treatment services, by discipline; 3) to investigate characteristics of individuals in relation to amount of time spent in group therapy within each discipline; and 4) to evaluate the relationship between the proportion of therapy received in groups and outcomes at rehabilitation discharge (as measured by rehabilitation disposition location, rehabilitation length of stay (RLOS), and FIM Motor and Cognitive scores at the time of discharge).
Methods
Study design, study sites, and participants
The present analysis is part of the TBI-Practice Based-Evidence (TBI-PBE) Project, a multi-center investigation of the TBI inpatient rehabilitation process for 2,130 patients treated at nine inpatient rehabilitation facilities in the United States and one in Canada from October 2008 to September 2011. 17 The study design for the TBI-PBE project has been described elsewhere, including the PBE research methodology, quality control methods, data collection, and analysis plan.17 The study was a prospective observational cohort of individuals admitted for inpatient TBI rehabilitation. Consecutive admissions that were eligible were approached for enrollment. Eligibility criteria required participants to be 14 years of age or older, give (or their parent/guardian give) informed consent, and admission to the facility's adult Brain Injury unit for initial rehabilitation following TBI. Each site received Institutional Review Board approval.
Variables and data collection
Patient characteristics
Research coordinators were trained to collect through chart review the demographic characteristics, injury severity, medical diagnoses, and other data needed to describe the participants. Key information included age, gender, race, education level, employment status at the time of injury, marital status, body mass index, previous number of brain injuries, driving status prior to injury, substance use prior to and at time of injury, and injury etiology. Glasgow Coma Scale (GCS) score after resuscitation in the Emergency Department, amount of agitation and presence of posttraumatic amnesia upon admission to rehabilitation, presence of contusions/hemorrhages/crush injuries, facial and skull fractures, bilateral injuries, amount of midline shift, brainstem involvement, presence of subdural hematoma, epidural hematoma, subarachnoid hemorrhage and/or intraventricular hemorrhage, whether a weight-bearing precaution was ordered, and time from injury to rehabilitation admission were used to describe injury severity. FIM Motor and Cognitive sum scores at admission and discharge were separately transformed to a 0 to 100 range using Rasch-analysis based tables published previously.18 The admission Comprehensive Severity Index (CSI)17 was used to transform information about all medical diagnoses present at the time of admission into a measure of medical comorbidity severity. Two CSI subscores were created: those signs and symptoms directly attributable to the brain (CSI-brain), and all other remaining comorbidities (CSI-nonbrain). Greater illness burden is indicated by higher CSI scores. Additionally, medical diagnoses were included as indicators: attention deficit hyperactivity disorder, anxiety, asthma, coronary artery disease, congestive heart failure, depression, diabetes, high cholesterol, hypertension, learning disorder, paralysis, renal failure, dysphagia, aphasia, and ataxia. We also included binary indications of whether patients received acute-care craniotomies or craniectomies.
Rehabilitation interventions
Therapists providers documented details about each therapy session including the following: treatment setting (individual vs. group), type(s) of treatment activities, and number of minutes spent on each activity. A group therapy session was defined as any session where two or more patients were treated simultaneously by one or more clinicians. Providers received documentation training and completed periodic reliability checks, with retraining provided when needed.
Outcomes
Outcomes were collected using chart review, which included RLOS, type of discharge location, and Rasch-transformed FIM Motor and FIM Cognitive scores at rehabilitation discharge. RLOS was defined as the number of days between rehabilitation admission and final discharge, minus any days spent readmitted to acute care or other treatment interruptions.
Data processing and analysis
Calculation of therapy time
The total hours of group and individual therapy received during the rehabilitation stay were calculated for each discipline. Percent of time spent in group and individual therapies for PT, OT, ST, TR, and PSY was calculated for each patient, by therapeutic activity (e.g.: strengthening/endurance, range of motion/stretching, etc.), by discipline, and for all disciplines combined. Total hours per week of group and individual therapy sessions were also calculated to serve as a RLOS-adjusted indicator of therapy amount.
Comparison by functioning levels at admission
Patients were divided into 5 subgroups defined by the patient's ‘raw’ FIM Cognitive score so as to create subgroups of patients with comparable functional status, at least at the time of rehabilitation admission. Analysis of variance with a 2-tailed alpha level of .05 was performed to assess differences in the amount of group therapy received across FIM Cognitive subgroups. SAS 9.2 software was utilized for all analyses.a
Comparison by site
The amount of group therapy was compared between inpatient rehabilitation facilities using analysis of variance.
Factors Associated with the hours of group therapy received
Ordinary least-squares stepwise linear regression models were used to determine patient characteristics associated with hours per week of group therapy received. Independent variables allowed to enter the model included: age; gender; race; body mass index; education; marital status; employment status at the time of injury; alcohol and other drug use prior to and at the time of injury; patient ability to drive; previous number of brain injuries; comorbidities present at time of rehabilitation admission including: attention deficit disorder, anxiety, asthma coronary artery disease, congestive heart failure, depression, diabetes, high cholesterol, hypertension, learning disorder, paralysis, and renal failure; GCS score; presence of posttraumatic amnesia at time of rehabilitation admission; time from injury to admission; Rasch-transformed admission FIM Motor and Cognitive scores; and admission CSI,; indications of dysphagia, aphasia, and ataxia upon admission to rehab; use of acute surgery craniotomy or craniectomy; weight-bearing precaution administered upon entrance to rehab; injury etiology; closed vs. open injury with or without contusions and hemorrhages; presence of facial and/or skull fractures; side of brain injury (i.e. left, right, or bilateral); amount of midline shift in the brain; presence of any of the following: subdural hematoma, epidural hematoma, subarachnoid hemorrhage, and intraventricular hemorrhage; injury to the brainstem; and admission agitation. Finally, dummy variables for site were entered to assess any additional variance that could not be explained by the patient and injury characteristics alone.
Relationship of hours of group therapy received with outcome
Ordinary least squares regression models were used to determine the association of the amount group therapy received during acute inpatient rehabilitation with rehabilitation disposition, RLOS, and Rasch-adjusted FIM Motor and Cognitive scores at discharge. The cases from the Canadian site were removed from the RLOS analysis due to differences in the system of care with different practices related to average RLOS.
Results
Participant characteristics
Details of the demographic and injury characteristics of the sample are described in a related article.17 Briefly, the sample was 73% male, 74% white, 37% married, and 51% employed at the time of injury, with an average age of 45 years. Vehicular accidents were the most common cause of injury (56%), followed by falls or being hit by a falling object (32%), violence (7%), and sports (2%). GCS score distributions for the sample were: 15% mild (GCS 13-15); 8% moderate (GCS 9-12); 32% severe (GCS 3-8); 12% intubated/sedated; 33% unknown. Mean time from injury to rehabilitation admission was 29 days (SD 34), and mean RLOS 27 days (SD 20). The mean raw FIM at admission was 35 (SD 20) for the Motor score and 15 (SD 8) for the Cognitive score.
General overview of the use of group therapy
The extent of group therapy received by study participants is summarized in table 1. Of the patients, 79.9% received at least 1 group therapy session, and group therapy accounted for an average of 13.7% of a patient's therapy sessions and 15.8% of all therapy hours, because the average group session was somewhat longer (44.8 minutes) than the average individual session (36.7 minutes). Patients spent on average 2.9 hours in group therapy each week (compared to 13.4 hours per week of individual therapies), with an average of 10.8 hours in group therapy during the course of their rehabilitation stay (compared to 49.9 hours of individual therapies during rehabilitation stay).
Table 1. Group therapy recipients, sessions, and time by Admission FIM Cognitive subgroup, overall and by discipline.
| Admission FIM Cognitive Score* | |||||||
|---|---|---|---|---|---|---|---|
| Variable | Total (n=2130) | <=6 (n=339) | 7-10 (n=374) | 11-15 (n=495) | 16-20 (n=408) | >=21 (n=504) | P-Value |
| All Disciplines Combined | |||||||
| % of patients receiving group therapy | 79.9% | 77.6% | 89.0% | 87.9% | 80.9% | 65.9% | <.001 † |
| Mean (SD) % of sessions delivered in group | 13.7 (12.3) | 12.1 (12.4) | 14.2 (11.5) | 16.3 (12.4) | 14.3 (12.6) | 11.3 (12.1) | <.001 § |
| Mean (SD) total hours group therapy received‡ | 10.8 (14.4) | 15.1 (20.6) | 14.0 (14.4) | 12.8 (14.0) | 8.7 (11.6) | 5.1 (8.4) | <.001 § |
| Mean (SD) hours per week group therapy received‡ | 2.9 (3.1) | 2.5 (2.7) | 3.1 (2.7) | 3.7 (3.2) | 3.0 (3.2) | 2.3 (3.1) | <.001 § |
| Mean (SD) % total therapy time spent in groups‡ | 15.8 (14.3) | 13.7 (13.4) | 16.5 (12.7) | 19.2 (14.6) | 16.3 (14.7) | 13.1 (14.6) | <.001 § |
| Mean (SD) minutes of group sessions | 44.8 (17.3) | 44.7 (16.3) | 44.6 (18.3) | 45.3 (16.3) | 43.4 (18.1) | 46.0 (17.8) | 0.416 § |
| Mean (SD) minutes of individual sessions | 36.7 (6.5) | 35.9 (5.0) | 35.4 (5.4) | 35.9 (5.6) | 36.5 (6.6) | 39.2 (8.0) | <.001 § |
| Mean (SD) minutes of all sessions | 37.8 (6.8) | 36.6 (5.2) | 36.5 (5.8) | 37.4 (6.2) | 37.5 (7.0) | 40.3 (8.3) | <.001 § |
| Occupational Therapy | |||||||
| % of patients receiving group therapy | 55.1% | 53.1% | 62.6% | 65.5% | 53.9% | 41.7% | <.001 † |
| Mean (SD) % of sessions delivered in group | 10.4 (14) | 10.4 (14.5) | 9.8 (12.5) | 12.2 (14.6) | 10.6 (13.6) | 9.0 (14.3) | 0.008 § |
| Mean (SD) total hours group therapy received‡ | 2.3 (3.9) | 3.4 (5.5) | 2.6 (3.6) | 2.7 (3.8) | 1.9 (3.7) | 1.2 (2.5) | <.001 § |
| Mean (SD) hours per week group therapy received‡ | 0.6 (0.9) | 0.6 (0.8) | 0.6 (0.8) | 0.8 (1.0) | 0.6 (0.9) | 0.5 (1.0) | <.001 § |
| Mean (SD) % total therapy time spent in groups‡ | 11.6 (15.2) | 10.6 (14.3) | 10.8 (12.8) | 14.7 (16.7) | 11.7 (14.9) | 9.8 (15.8) | <.001 § |
| Mean (SD) minutes of group sessions | 46.8 (29.9) | 44.1 (28.3) | 47.3 (34.5) | 50.1 (30.4) | 44.9 (25.5) | 45.6 (29.4) | 0.154 § |
| Mean (SD) minutes of individual sessions | 37.9 (8.3) | 38.0 (7.5) | 36.6 (7.4) | 36.5 (7.6) | 37.7 (8.6) | 40.5 (9.4) | <.001 § |
| Mean (SD) minutes of all sessions | 38.5 (8.2) | 37.9 (6.8) | 37.0 (7.6) | 37.9 (7.9) | 38.2 (8.4) | 41.0 (9.3) | <.001 § |
| Physical Therapy | |||||||
| % of patients receiving group therapy | 45.3% | 40.1% | 51.3% | 52.5% | 47.1% | 35.5% | <.001 † |
| Mean (SD) % of sessions delivered in group | 7.9 (13.1) | 6.6 (12.7) | 6.8 (11.1) | 8.2 (11.6) | 9.3 (14.5) | 8.4 (14.9) | 0.018 § |
| Mean (SD) total hours group therapy received‡ | 2.1 (4.7) | 3.2 (7.7) | 2.5 (4.9) | 2.1 (3.6) | 1.8 (3.5) | 1.5 (3.3) | <.001 § |
| Mean (SD) hours per week group therapy received‡ | 0.6 (1.1) | 0.5 (1.1) | 0.6 (1.0) | 0.6 (1.0) | 0.7 (1.2) | 0.6 (1.3) | 0.407 § |
| Mean (SD) % total therapy time spent in groups‡ | 10.0 (15.7) | 8.0 (14.7) | 9.0 (13.7) | 10.8 (14.6) | 11.4 (17.1) | 10.1 (17.5) | 0.025 § |
| Mean (SD) minutes of group sessions | 54.5 (27.1) | 59.0 (30.3) | 56.7 (29.0) | 54.4 (27.1) | 50.4 (23.0) | 53.6 (26.3) | 0.047 § |
| Mean (SD) minutes of individual sessions | 37.9 (8.7) | 39.1 (7.9) | 37.0 (8.1) | 36.7 (7.9) | 37.6 (9.0) | 39.3 (9.9) | <.001 § |
| Mean (SD) minutes of all sessions | 39.1 (9.0) | 39.9 (8.3) | 38.2 (8.5) | 38.1 (8.3) | 38.8 (9.2) | 40.4 (10.1) | <.001 § |
| Speech Therapy | |||||||
| % of patients receiving group therapy | 59.6% | 69.9% | 76.2% | 71.9% | 55.6% | 30.8% | <.001 † |
| Mean (SD) % of sessions delivered in group | 16.2 (17.7) | 16.6 (17.1) | 20.3 (17.3) | 21.1 (18.1) | 15.7 (17.8) | 8.6 (15.1) | <.001 § |
| Mean (SD) total hours group therapy received‡ | 3.6 (5.2) | 5.2 (6.3) | 5.3 (5.8) | 4.4 (5.3) | 2.5 (4.0) | 1.1 (2.8) | <.001 § |
| Mean (SD) hours per week group therapy received‡ | 0.9 (1.1) | 0.9 (1.0) | 1.1 (1.1) | 1.2 (1.2) | 0.8 (1.1) | 0.5 (1.0) | <.001 § |
| Mean (SD) % total therapy time spent in groups‡ | 17.4 (18.9) | 18.6 (18.5) | 21.5 (18.0) | 22.4 (19.3) | 16.7 (18.9) | 9.3 (16.6) | <.001 § |
| Mean (SD) minutes of group sessions | 36.1 (15.1) | 37.3 (12.7) | 35.5 (16.6) | 35.6 (15.1) | 34.5 (13.0) | 38.6 (17.8) | 0.064 § |
| Mean (SD) minutes of individual sessions | 32.9 (7.4) | 30.6 (4.7) | 31.9 (5.4) | 32.2 (5.8) | 32.6 (7.1) | 36.3 (10.5) | <.001 § |
| Mean (SD) minutes of all sessions | 33.5 (7.6) | 31.5 (4.9) | 32.5 (5.7) | 33.0 (6.2) | 33.1 (7.2) | 36.8 (10.7) | <.001 § |
| Psychology | |||||||
| % of patients receiving group therapy | 28.6% | 22.7% | 34.8% | 38.8% | 30.9% | 16.3% | <.001 † |
| Mean (SD) % of sessions delivered in group | 8.1 (15.9) | 6.8 (16.5) | 9.6 (17.0) | 9.9 (15.4) | 9.4 (17.5) | 5.1 (13.2) | <.001 § |
| Mean (SD) total hours group therapy received‡ | 0.7 (2.7) | 1.3 (5.5) | 0.9 (2.3) | 0.8 (1.3) | 0.6 (1.6) | 0.4 (1.3) | <.001 § |
| Mean (SD) hours per week group therapy received‡ | 0.2 (0.5) | 0.2 (0.5) | 0.2 (0.4) | 0.2 (0.4) | 0.2 (0.6) | 0.2 (0.5) | 0.045 § |
| Mean (SD) % total therapy time spent in groups‡ | 9.1 (17.7) | 8.3 (19.1) | 11.2 (19.2) | 10.9 (16.9) | 10.0 (18.8) | 5.5 (14.8) | <.001 § |
| Mean (SD) minutes of group sessions | 56.1 (31.1) | 58.2 (31.2) | 56.8 (32.6) | 59.6 (32.2) | 48.8 (25.2) | 55.7 (33.0) | 0.042 § |
| Mean (SD) minutes of individual sessions | 41.4 (21.3) | 33.8 (13.9) | 39.2 (20.0) | 44.9 (20.4) | 43.5 (24.0) | 42.8 (23.8) | <.001 § |
| Mean (SD) minutes of all sessions | 41.1 (21.0) | 34.5 (14.1) | 39.5 (19.6) | 44.9 (20.6) | 42.2 (24.2) | 41.6 (22.7) | <.001 § |
| Therapeutic Recreation | |||||||
| % of patients receiving group therapy | 48.3% | 43.4% | 58.3% | 59.8% | 47.1% | 33.5% | <.001 † |
| Mean (SD) % of sessions delivered in group | 25.6 (32.9) | 21.1 (31.6) | 28.5 (31.6) | 31.8 (33.2) | 25.4 (32.7) | 20.5 (33.5) | <.001 § |
| Mean (SD) total hours group therapy received‡ | 2.1 (3.8) | 2.0 (3.8) | 2.8 (4.0) | 2.9 (4.6) | 1.9 (3.5) | 1.0 (2.2) | <.001 § |
| Mean (SD) hours per week group therapy received‡ | 0.6 (1.0) | 0.3 (0.6) | 0.6 (0.9) | 0.9 (1.2) | 0.7 (1.1) | 0.5 (1.0) | <.001 § |
| Mean (SD) % total therapy time spent in groups‡ | 30.1 (36.6) | 25.2 (34.9) | 35.1 (36.4) | 37.7 (36.9) | 29.1 (36.2) | 23.2 (36.1) | <.001 § |
| Mean (SD) minutes of group sessions | 60.0 (33.2) | 63.1 (33.9) | 64.7 (36.2) | 61.1 (32.2) | 53.1 (28.0) | 56.6 (34.2) | 0.003 § |
| Mean (SD) minutes of individual sessions | 30.1 (11.5) | 29.7 (8.5) | 30.4 (11.6) | 31.9 (12.3) | 29.6 (12.0) | 27.4 (10.9) | <.001 § |
| Mean (SD) minutes of all sessions | 40.3 (21.8) | 38.9 (20.6) | 43.0 (23.4) | 42.9 (22.5) | 38.3 (19.4) | 37.2 (22.2) | <.001 § |
Note: Abbreviations: SD, standard deviation; FIM, Functional Independence Measure.
n=10 patients missing admission FIM cognitive score.
Chi-Square analysis.
Calculated based on all patients, including those who did not receive specified discipline.
Analysis of variance test.
Group therapy by discipline
TR provided the greatest proportion of treatment time in group therapy, followed by ST. Patients on average received 10.4% of OT, 7.9% of PT, 16.2% of ST, 8.1% of PSY, and 25.6% of TR treatment time in a group. A different perspective is provided by the percent of patients who receive one or more sessions in a group format, with lowest percent in PSY (28.6%) and highest in ST (59.6%). While table 1 information is based on patients, information at the session level is provided in table 2, which summarizes the group's participant size and duration by discipline. The majority of sessions, especially in OT and PT, are individual ones; group sessions have a small number of participants. Withith ST and TR groups of 5 or more made up 10% of all sessions received by patients. There is a trend for group sessions to be longer, especially in PT and TR; in OT and ST the mean session duration is similar for multiple participant sessions and for individual therapy.
Table 2. Percent of sessions and their average duration by number of participants, by discipline*.
| Number of patients | Discipline | |||||
|---|---|---|---|---|---|---|
| Percent of sessions | OT | PT | SLP | PSY | TR | Total |
| 1 (individual therapy) | 88.4% | 92.0% | 77.1% | 83.5% | 61.8% | 84.5% |
| 2 | 3.1% | 2.1% | 4.6% | 7.2% | 11.5% | 3.9% |
| 3 | 2.4% | 1.0% | 4.2% | 4.0% | 8.7% | 2.9% |
| 4 | 2.3% | 0.8% | 4.3% | 2.5% | 7.7% | 2.7% |
| 5 or more patients | 3.9% | 4.0% | 9.9% | 2.9% | 10.3% | 6.0% |
| Total | 100.0% | 100.0% | 100.0% | 100.0% | 100.0% | 100.0% |
| Sessions | 60,685 | 61,704 | 58,066 | 10,671 | 11,855 | 202,981 |
| Duration (in minutes) | ||||||
| 1 (individual therapy) | 37.9 | 38.1 | 31.7 | 41.9 | 30.2 | 33.9 |
| 2 | 35.4 | 39.4 | 32.0 | 46.4 | 39.9 | 36.2 |
| 3 | 42.6 | 58.4 | 35.8 | 54.7 | 55.5 | 36.7 |
| 4 | 47.7 | 69.3 | 35.6 | 60.8 | 66.0 | 44.6 |
| 5 or more patients | 40.9 | 61.0 | 34.0 | 51.6 | 77.0 | 47.8 |
| Total | 38.3 | 39.5 | 32.3 | 43.5 | 41.1 | 37.4 |
Note: Abbreviations: OT, occupational therapy; PSY, psychology; PT, physical therapy; ST, speech therapy; TR, therapeutic recreation.
The count of sessions and calculation of minutes is from the perspective of patients – i.e., an OT session with 3 participants is represented 3 times in the top and bottom panel of the table.
Group therapy by functional status and discipline
Table 1 data indicate that, for all disciplines combined, those with admission cognitive levels in the middle range were more likely to receive group therapy, and had a larger percent of their therapy time and sessions consisting of group sessions, than is true for the subgroups with the lowest and highest admission FIM Cognitive scores (i.e., 6 or lower, or 21 or higher). Even if the various disciplines have significant differences in the use of group therapy, the trend that group therapy is used least often with those with the highest and the lowest cognitive functioning holds true throughout. However, the actual time underlying Figure 1 indicates that the patients with the most serious cognitive deficits get the most group therapy time, and those admitted with a FIM score of 21 or more the least; this is a direct consequence of the large difference in LOS between the groups.
Figure 1. Hours spent in individual versus group therapy over the rehabilitation stay, by discipline and FIM Cognitive score at admission.
Group therapy versus Individual therapy time
For all patient groups and all disciplines combined the correlation between hours per week of individual treatment time and group treatment time is 0.03 – suggesting the absence of a relationship (Table 3). However, for the five cognitive subgroups the correlations range from -0.24 for the patients admitted with the most significant deficits, to 0.09 for those with the least. The difference may be the result of the various mixes of disciplines that patients in these five cognitive subgroups receive. For PT and OT the correlation is negative in all admission cognitive subgroups: those who receive more group therapy tend to receive less individual therapy. In contrast, for ST, PSY, and TR, across most of the FIM cognitive subgroups, those who receive more group therapy also tend to receive more individual therapy, with the trend strongest in TR, where the variance in one explains 8% to 14% of the variance in the other - still a modest number.
Table 3. Correlations between individual and group therapy time, both calculated as mean hours per week, by discipline and by admission FIM cognitive subgroup.
| Discipline | |||||
|---|---|---|---|---|---|
| All disciplines combined | |||||
| OT PT ST PSY | |||||
| TREC | |||||
| Admission FIM Cognitive Score* | |||||
| Total (n=2130) | <=6 (n=339) | 7-10 (n=374) | 11-15 (n=495) | 16-20 (n=408) | >=21 (n=504) |
| -0.03 | -.24§ | -.16‡ | -0.05 | -0.03 | .09† |
| -.19§ | -.33§ | -.20§ | -.27§ | -.15‡ | -0.08 |
| -.19§ | -.29§ | -.25§ | -.23§ | -.20§ | -0.07 |
| . 18§ | -0.03 | -0.07 | 0.04 | .15‡ | .32§ |
| .36§ | .43§ | .43§ | .52§ | .47§ | .46§ |
| .49§ | .29§ | .35§ | .34§ | .30§ | .37§ |
Note: All correlations are Spearman's Rho. Abbreviations: FIM, Functional Independence Measure OT, occupational therapy; PSY, psychology; PT, physical therapy; ST, speech therapy; TR, therapeutic recreation.
n=10 patients missing admission FIM cognitive score.
p<.05.
p<.01.
p<.001
Group therapy activities performed
The nature of therapy content by admission FIM Cognitive group is summarized in Supplemental Digital Content (SDC) for all therapy activities administered to at least 5% of one or more of the Cognitive subgroups. Group activities that were administered to at least 10% of the sample are used in subsequent analyses to determine associations with outcomes. These group format activities are diverse and are in line with the types of activities typically performed by these disciplines, with PT working on mobility and therapeutic exercise, OT addressing cognitive and functional activities with a focus on upper extremity, ST focusing on cognitive-linguistic skills, PSY on behavior, and TR on leisure and community issues.
Group therapy use across treatment sites
Figure 2 depicts the delivery of group therapy by treatment site, indicating that the use of group therapy varied tremendously from one site to the next. For all disciplines combined, the average time patients spent in group therapy ranged from 0.3 (site 3) to 28.3 (site 5) total hours. Separate calculations (not shown) indicate that only a very small (albeit significant) part of this variation is explained by site differences in admission cognitive level. Sites that use group therapy for one discipline tend to use it for all disciplines, with minor exceptions (e.g., ST in site 2).
Figure 2. Total group therapy hours by discipline and site.
Factors Associated with Group Therapy
Multivariate regression showed that the mean number of hours of group therapy per week is predicted by a number of factors, as summarized in table 4. Together these factors explain 18% of the variance in group therapy hours per week. However, when site is allowed to enter as a predictor, the percentage explained goes up to 54%, strongly suggesting that practice variations are a major factor. When we used percent of all therapy hours delivered in a group format, the results were similar. The same also held true for prediction of hours of group therapy per week within specific disciplines: of OT hours 9% was explained without site as a predictor, 25% with site; PT 21% and 64%, respectively; ST 16% and 37%; PSY 9% and 26%; TR 17% and 37%.
Table 4. Factors associated with hours per week of group therapy for all disciplines combined, and all patients.
| Step R2 | ||||||
|---|---|---|---|---|---|---|
| Patient characteristics only: 0.181 | ||||||
| Site only: 0.524 | ||||||
| Patient characteristics and Site: 0.545* | Patient characteristics only | Patient characteristics and Site | ||||
| Covariate | OLS Estimate | OLS Standardized Estimate | P-Value | OLS Estimate | OLS Standardized Estimate | P-Value |
| Intercept | 4.24 | 0.00 | <.001 | 0.90 | 0.00 | <.001 |
| Employment- not employed | -0.50 | -0.06 | 0.006 | . | . | . |
| Marital status- single | 0.46 | 0.08 | <.001 | . | . | . |
| Marital status- married | . | . | . | -0.19 | -0.03 | 0.048 |
| Drive prior to injury- no | -1.07 | -0.11 | <.001 | . | . | . |
| Drive prior to injury- yes | -0.75 | -0.11 | <.001 | . | . | . |
| Admission Paralysis | 0.31 | 0.05 | 0.026 | . | . | . |
| Days from injury to rehab admission | -0.02 | -0.17 | <.001 | -0.01 | -0.07 | <.001 |
| Admission non-brain injury CSI | . | . | . | -0.01 | -0.04 | 0.029 |
| Admission FIM Cog Rasch-transformed | 0.02 | 0.14 | <.001 | . | . | . |
| Admission FIM Motor Rasch-transformed | -0.02 | -0.10 | <.001 | 0.02 | 0.09 | <.001 |
| PTA cleared prior to rehab admission | -0.53 | -0.09 | 0.001 | . | . | . |
| Average of first 3-days ABS scores | 0.04 | 0.06 | 0.01 | . | . | . |
| Acute surgery- craniectomy | 1.20 | 0.10 | <.001 | . | . | . |
| Admission aphasia moderate to severe | -0.32 | -0.05 | 0.02 | . | . | . |
| Admission ataxia mild to severe | -0.38 | -0.05 | 0.029 | . | . | . |
| Injury etiology- violence | -0.55 | -0.05 | 0.024 | . | . | . |
| Brain injury details- midline shift NOS | -1.35 | -0.14 | <.001 | . | . | . |
| Brain injury details- midline shift none | -1.78 | -0.27 | <.001 | . | . | . |
| Brain injury details- midline shift 0-5mm | -1.09 | -0.12 | <.001 | . | . | . |
| Brain injury details- midline shift >5mm | -1.09 | -0.12 | <.001 | . | . | . |
| Brain injury details- brainstem involvement | -0.87 | -0.07 | 0.002 | . | . | . |
| GCS- mild | -0.51 | -0.06 | 0.005 | . | . | . |
| GCS- severe | 0.36 | 0.06 | 0.014 | 0.29 | 0.05 | 0.005 |
| Alcohol misuse at time of injury | -0.93 | -0.08 | <.001 | . | . | . |
Note: Abbreviations: OLS, Ordinary Least Squares; FIM, Functional Independence Measure; CSI, Comprehensive Severity Index; BMI, Body Mass Index; PTA, Post-Traumatic Amnesia; ABS, Agitated Behavior Scale.
When patient characteristics and site enter together, site OLS estimates range from -1.35 to 5.24; OLS standardized estimates range from -0.11 to 0.63.
Group Therapy Association with Outcomes
Table 5 displays the results of the regression analyses to determine the contribution of time spent in group therapy to the prediction of RLOS, discharge to home, and discharge FIM Motor and Cognitive scores. Group therapy amounted to at least 10% of the therapy activity hours per week. By itself, group therapy explains only 2-3% of the variation in the outcomes. When patient and site variables are allowed to enter the models, group therapy offers little to the explanation of these outcomes.
Table 5. Association of Group Therapy Hours Per Week with Outcomes.
| Step | RLOS R2 | DC FIM motor R 2 | DC FIM cognitive R2 | DC Home c-statistic | |
|---|---|---|---|---|---|
| patient characteristics only | 0.336 | 0.579 | 0.495 | 0.790 | |
| site only | 0.140 | 0.200 | 0.091 | 0.617 | |
| Independent | group total therapy hours per week only | 0.020 | 0.042 | 0.029 | 0.583 |
| individual total therapy hours per week only | 0.035 | 0.051 | 0.028 | 0.599 | |
| activity-specific group therapy hours per week only* | 0.075 | 0.089 | 0.118 | 0.633 | |
| activity-specific individual therapy hours per week only† | 0.216 | 0.506 | 0.311 | 0.765 | |
| Step | RLOS R2 | DC FIM motor R 2 | DC FIM cognitive R2 | DC Home c-statistic | |
| patient characteristics only | 0.336 | 0.579 | 0.495 | 0.790 | |
| patient + activity-specific group therapy hours per week* | 0.346 | 0.584 | 0.509 | 0.797 | |
| Cumulative | patient + activity-specific group therapy hours per week* + activity-specific individual therapy hours per week† | 0.394 | 0.657 | 0.558 | 0.829 |
| patient + activity-specific group therapy hours per week* + activity-specific individual therapy hours per week† + site | 0.495 | 0.682 | 0.590 | 0.831 |
Note: Abbreviations: FIM, Functional Independence Measure; RLOS, rehabilitation length of stay.
Only activities administered in group-form to at least 10% of patients are included in this step.
These are the individual-form complements of those group-form activities administered to at least 10% of patients.
Discussion
Extent of Group Therapy Use Among Patients and Sites
While the majority of therapy is delivered in individual sessions, group therapy contributes substantially to the TBI inpatient rehabilitation package. Most patients (>75%) receive at least one group therapy session during rehabilitation, with 15.8% of total treatment hours spent in group therapy, on average combining all disciplines. In general, patients in the mid-range of the continuum of admission FIM Cognitive functioning (scores of 7-20) received slightly more group therapy than those with mild or very severe cognitive impairments, whether group therapy is measured by percent of patients receiving group therapy (range: 80.9-89.0% versus 65.9-77.6%), percent of sessions delivered in groups (14.2-16.3% versus 11.3-12.1%), or percent of therapy hours/week delivered in groups (16.3-19.2% versus 13.1-13.7%). One possible explanation for this is that those on the extremes of the cognitive FIM continuum require one-to-one therapist attention to participate productively in rehabilitation, either because they need considerable support to participateor because they are involved in highly advanced activities that require an individualized format.
A striking finding is the wide variation in group therapy time provided across the sites. Significant differences in case mix do exist among the sites,19 and patient characteristics account for approximately 18% of variance when site is not included in a prediction model for hours/week of group therapy. However, once site enters the prediction model, 54% of the variance in group therapy hours/week is explained, suggesting that site-associated factors other than case-mix are driving use of group therapy. Such factors could include staffing patterns (staff to patient ratio and types of staff present), state or local policies on the use of group therapy and total required hours of therapy, treatment philosophies, availability of space for group activities, or other site-related characteristics. The sites involved in the study varied by facility type with eight IRFs and one Long Term Acute Care Hospital in the United States and one Canadian rehabilitation facility. State regulations for one of the US IRF sites required 4.5 hours of therapy daily, while the other US IRFs were under the less intense Centers for Medicare & Medicaid Services requirement of at least 15 hours of intensive rehabilitative therapy in PT, OT and/or ST within a 7-consecutive day period or 3 hours per day for 5 days weekly.20 According to the Centers for Medicare & Medicaid Services regulations for IRFs, group therapy is acceptable although it should not constitute the majority of therapy provided to the patient. Long term acute care hospitals that provide comprehensive physical medicine and rehabilitation services may admit patients who cannot undergo the intensive rehabilitation therapy required for IRF admission and do not require a specified number of therapy hours or quantity of individual versus group therapy. 21 The wide variation in practice suggests value in developing greater guidance about the use of group therapy in TBI rehabilitation.
Group Therapy Time and Activities Among Disciplines
Use of group therapy varied among disciplines, with TR providing the greatest proportion of its treatment in group format, followed by ST, OT, PSY, and PT (range 7.9-25.6% of total treatment hours). TR's considerable use of group therapy is not surprising, given that therapeutic recreation incorporates multiple participants in social and recreation activities to address therapeutic goals. ST showed the greatest diversity in the types of activities using a group format performed, reflecting the many areas that ST addresses (communication, cognition, swallowing, among others). Common themes in group therapy across two or more disciplines included community-oriented activities (community re-integration or mobility) that address underlying impairments (therapeutic exercise, pre-functional activity), and functional activities important in everyday life (transfers, gait, standing, conversation, feeding, etc.). Group therapy may provide a useful venue for patients to practice functional skills they were taught in individual therapy and may provide a efficient way to deliver lower-complexity activities (such as strengthening exercises) that may not require one-on-one work with a therapist. The variety of cognitive and motor activities performed in group therapy implies that this format is considered a valuable means to achieve many inpatient rehabilitation treatment goals.
A question at the outset of this investigation concerned the extent to which a trade-off might occur between group and individual therapy time. Do patients who receive more group therapy receive less individual therapy? We found the answer to vary by discipline. In general, more group therapy hours per week was associated with fewer individual therapy hours for PT and OT, though the magnitudes of these correlations were generally small (Rho ranged from -0.15 to -0.33 across those with admission FIM ≤6-20 and <-0.07 for those with admission cognitive FIM ≥21). In contrast, patients who received more group PSY or TR treatment also received more individual treatment (Rho range 0.29-0.52), as did ST patients in the higher admission cognitive FIM groups (FIM ≥16; (Rho range 0.15-0.32). Many domains of functioning addressed by OT and PT (mobility, impairments in range of motion and strength, use of assistive devices, for example) do not have a social component, while domains addressed by TR, PSY, and ST (such as communication or appropriate social interaction) often require interpersonal interaction. Therefore, TR, ST, and PSY may have a greater need to conduct therapy using groups to address the full spectrum of therapeutic goals they have for patients with TBI. In contrast, OT and PT may use group therapy as an alternative means of accomplishing the same set of goals, giving those disciplines the option of using either group or individual therapy depending on patients' status and needs.
Relationship of Group Therapy to Outcomes
The question of how group therapy affects outcomes is complex. “Group therapy” is not a single phenomenon but includes a wide variety of treatment activities to address many different functional deficits. Prior analyses have shown that total hours/week of individual therapy is not predictive of outcomes,22 but that variation in outcome can be explained when times spent in specific therapy activities are examined. Our analysis of group therapy time showed a similar pattern of findings, but with even less variation explained by group therapy activity time. Group therapy hours/week explained only a small proportion of the variation in outcomes (between 2.0-4.2%) and was similar to that explained by individual therapy hours/week (2.8-5.1%). However, specific group therapy activities (delivered to at least 10% of patients) explained 7.5-11.8% of the variation for the four outcomes examined. This proportion was considerably less than that explained by hours/week spent on those activities in individual therapy (21.6-50.6%; see table 5). While one could interpret these findings to mean that group therapy has little influence (positive or negative) on outcomes beyond that of individual therapy, it is more likely the case that the analyses performed here are insufficient to reveal relationships between group therapy and outcomes. The outcomes examined here are broad (motor function in general rather than walking ability, for example) and the models include activities that would not be used clinically to address these broad outcomes. For example, therapy to enhance community mobility may specifically improve step length, balance, gait speed, gait safety or endurance with a possible positive influence on RLOS, disposition, and FIM-Motor scores and no expected impact on FIM Cognitive scores. More specific analyses, beyond the scope of this paper, are needed to understand the relationship between a particular outcome and specific group therapy activities used clinically to address that outcome.
Study Limitations
Generalizability of the study findings to all inpatient rehabilitation facilities may be limited by the fact that the study sites were highly specialized brain injury rehabilitation centers. Such specialized centers may have greater levels of provider experience, enhanced programming infrastructure, and higher patient volumes that may facilitate the use of group therapies. The influence of such site-specific factors is highlighted by the findings of site differences even among the ten study sites. Two of the facilities (one in Canada and one Long Term Acute Care Hospital) did not have regulatory requirements for hours of therapy that must be delivered daily/weekly, which may have impacted the total number of therapy hours provided, disciplines used, and use of group therapy. Treatment data for this project were collected from 2008 to 2011. The present study did not investigate variation across the years of the study, and would not reflect any changes in practice after 2011. Group therapy is defined broadly as any therapy with two or more patients were treated simultaneously. Accordingly, a wide range of treatments and patient interactions were included in this study. Study participants were categorized based upon FIM Cognitive score at admission; this study did not take into account admission motor functional level in the analysis of group therapies.
Future Clinical and Research Directions
The analyses reported here provide the most comprehensive survey of the use of group therapy in TBI rehabilitation to date; however, many questions remain to be answered. Factors driving site differences in group therapy use are not clearly understood. Future studies, perhaps including qualitative interviews with administrators and clinicians, may shed light on decision-making processes involved in group therapy use. These data, combined with findings from a more extensive analysis of specific outcomes and group therapy activities thought to be related to those outcomes, would inform the development of guidelines for optimal use of group therapy in TBI rehabilitation.
Conclusion
The authors believe this is the first published study detailing data on group therapy for TBI during inpatient rehabilitation. Group therapy is commonly used in TBI rehabilitation, to varying degrees among disciplines, sites, and cognitive impairment subgroups. Site appears to be the strongest predictor of group therapy use, for reasons as yet unknown. A variety of therapeutic activities are delivered in group format, indicating its perceived value in addressing many domains of functioning. Variation in outcomes is not explained well by percent of therapy time delivered in groups, particularly when group time is examined as a whole (rather than by discipline). More detailed analyses of specific outcomes and the group therapy activities used to address those outcomes are needed to better understand the role that group therapy may play in addressing TBI rehabilitation goals.
Supplemental Digital Content: Percentage of patients receiving specific therapeutic activities in group format (at least once), and mean minutes per week of group therapy for patients who received that activity type*
Acknowledgments
We gratefully acknowledge the contributions of clinical and research staff at each of the 10 inpatient rehabilitation facilities represented in the Improving Outcomes in Acute Rehabilitation for TBI Study and Individualized Planning for the First Year Following Acute Rehabilitation, collectively known as the TBI Practice Based Evidence (TBI-PBE) study. The study site directors included: John D. Corrigan, PhD and Jennifer Bogner, PhD (Ohio Regional TBIMS at Ohio State University, Columbus, OH); Nora Cullen, MD (Toronto Rehabilitation Institute, Toronto, ON Canada); Cynthia L. Beaulieu, PhD (Brooks Rehabilitation Hospital, Jacksonville, FL); Flora M. Hammond, MD (Carolinas Rehabilitation, Charlotte, NC [now at Indiana University]); David K. Ryser, MD (Neuro Specialty Rehabilitation Unit, Intermountain Medical Center, Salt Lake City, UT); Murray E. Brandstater, MD (Loma Linda University Medical Center, Loma Linda, CA); Marcel P. Dijkers, PhD (Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, NY); William Garmoe, PhD (Medstar National Rehabilitation Hospital, Washington, DC); James A. Young, MD (Physical Medicine and Rehabilitation, Rush University Medical Center, Chicago, IL); Ronald T. Seel, PhD (Brain Injury Research, Shepherd Center, Atlanta, GA).
We want to acknowledge members of the staff of the Institute for Clinical Outcomes Research, International Severity Information Systems, Inc, Salt Lake City, UT, who also contributed significantly to the success of this study: Susan D. Horn, PhD (Senior Scientist); Randall J. Smout, MS (Vice President, Analytic Systems); Ryan S. Barrett (Project Manager and Analyst); Michael Watkiss (Study Coordinator); and Patrick B. Brown (Project Manager and Systems Administrator). In addition, we acknowledge the help of Gale G. Whiteneck, PhD (Craig Hospital, Englewood, CO).
Funding for this study came from the National Institutes of Health, National Center for Medical Rehabilitation Research (grant 1R01HD050439-01), the National Institute on Disability and Rehabilitation Research (grant H133A080023), and the Ontario Neurotrauma Foundation (grant 2007-ABI-ISIS-525).
Abbreviations
- ACA
Affordable Care Act
- CSI
Comprehensive Severity Index
- FIM
Functional Independence Measure
- GCS
Glasgow Coma Scale
- IRF
Inpatient rehabilitation facility
- LOS
Length of stay
- OT
Occupational therapy
- PPS
Prospective Payment System
- PSY
Psychology
- PT
Physical therapy
- RLOS
Rehabilitation length of stay
- ST
Speech therapy
- TBI
Traumatic Brain Injury
- TBI-PBE
Traumatic Brain Injury-Practice-Based Evidence
- TR
Therapeutic recreation
Footnotes
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