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?