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QTB QUALITY TOOL BOX Overview QTBs are a resource for Academy members that include existing tools which may be useful in physiatric practice. Tools included in the mild Traumatic Brain Injury QTB were identified by subject matter experts who treat patients with this condition, and the Academy’s Performance Metrics Committee has evaluated the tools for their methodological quality. Central Nervous System Rehabilitation Council mild Traumatic Brain Injury Table of Contents Review Articles, References and Other Resources Evidence-Based Clinical Practice Guidelines ACKNOWLEDGMENTS The Academy gratefully acknowledges the Central Nervous System Rehabilitation Council and Performance Metrics Committee for identifying and compiling clinical tools to help Physiatrists treating Assessment Instruments Measurement Resources Educational Resources patients with mild Traumatic Brain Injury. AAPM&R Resources Central Nervous System Rehabilitation Council Subject Matter Experts External Resources Amy L. Murphy, MD Christian Shenouda, MD Michael R. Yochelson, MD (Council Lead for QTB Project) Performance Metrics Committee David Berbrayer, MD Michael Hatzakis, MD Kurtis M. Hoppe, MD Amy Houtrow, MD Elizabeth Sandel, MD (PMC Chair and Lead for QTB Project) Deepthi Saxena, MD Michael Schaefer, MD Felicia Skelton, MD (PMC Lead for QTB project) QTB Review Articles, References and Other Resources 1. Barkhoudarian G, Hovda DA, Giza CC. The molecular pathophysiology of concussive brain injury. Clinics in sports medicine. 2011 Jan;30(1):33-48, vii-iii. 2. Lee YK, Hou SW, Lee CC, Hsu CY, Huang YS, Su YC. Increased risk of dementia in patients with mild traumatic brain injury: a nationwide cohort study. PloS one. 2013;8(5):e62422. 3. Nygren-de Boussard C, Holm LW, Cancelliere C, Godbolt AK, Boyle E, Stalnacke BM, et al. Nonsurgical interventions after mild traumatic brain injury: a systematic review. Results of the International Collaboration on Mild Traumatic Brain Injury Prognosis. Archives of physical medicine and rehabilitation. 2014 Mar;95(3 Suppl):S257-64. 4. Waljas M, Iverson GL, Lange RT, Liimatainen S, Hartikainen KM, Dastidar P, et al. Return to work following mild traumatic brain injury. The Journal of head trauma rehabilitation. 2014 Sep-Oct;29(5):443-50. 5. Marras C, Hincapie CA, Kristman VL, Cancelliere C, Soklaridis S, Li A, et al. Systematic review of the risk of Parkinson’s disease after mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis. Archives of physical medicine and rehabilitation. 2014 Mar;95(3 Suppl):S238-44. 6. Boyle E, Cancelliere C, Hartvigsen J, Carroll LJ, Holm LW, Cassidy JD. Systematic review of prognosis after mild traumatic brain injury in the military: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis. Archives of physical medicine and rehabilitation. 2014 Mar;95(3 Suppl):S230-7. 7. Karr JE, Areshenkoff CN, Garcia-Barrera MA. The neuropsychological outcomes of concussion: a systematic review of meta-analyses on the cognitive sequelae of mild traumatic brain injury. Neuropsychology. 2014 May;28(3):321-36. 8. Ciuffreda KJ, Ludlam DP, Kapoor N. Clinical oculomotor training in traumatic brain injury. Optom Vis Dev 2009;40(1):16-23. 9. Omalu B. Chronic traumatic encephalopathy. Progress in neurological surgery. 2014; 28:38-49. 10. Yi J, Padalino DJ, Chin LS, Montenegro P, Cantu RC. Chronic traumatic encephalopathy. Current sports medicine reports. 2013 Jan-Feb;12(1):28-32. 11. Lucas S. Headache Management in Concussion and Mild Traumatic Brain Injury. October 2011 Volume 3, Issue 10, Supplement 2, Pages S406–S412. 12. DVBIC Sleep Factsheet Evidence-Based Clinical Practice Guidelines • Guidelines for Mild Traumatic Brain Injury and Persistent Symptoms developed by the Ontario Neurotrauma Foundation 2 QTB Assessment Instruments Symptoms • Neurobehavioral Symptom Inventory (NSI) — A questionnaire that can be administered to someone who sustains a concussion or other form of traumatic brain injury to measure the presence and severity of symptoms. The NBSI takes approximately 10 minutes to administer. Core Constructs • The Rivermead Post Concussion Symptoms Questionnaire — Questionnaire to measure severity of symptoms. Core Constructs were identified to help guide the selection of Assessment Instruments. Core Constructs are based on the International Classification of Functioning, Disability and Health (ICF) framework. More information on the ICF Framework can be found here. HISTORY The Core Constructs for this QTB related to mTBI are: • Dizziness Handicap Inventory (DHI) — A 25-item self-assessment inventory •Symptoms •Cognitive status •Behavioral health •Life Satisfaction •Participation/Social roles • Screening for TBI Exposure— Ohio State University TBI Screening Form— Assesses the patient’s prior history of TBI. It takes approximately 5–35 minutes to administer depending on the patient’s medical history. HEADACHE • The Migraine Disability Assessment Test (MIDAS) — Measure of migraine disability (only if needed from NSI/Rivermead). PHYSICAL designed to evaluate the self-perceived handicapping effects imposed by dizziness. • Balance Error Scoring System (BESS) — A measure of assessing static postural stability (only if needed from NSI/Rivermead). SLEEP • Insomnia Severity Index — 7-item questionnaire that asks respondents to rate the nature and symptoms of their sleep problems using Likert-type scales. • Morningness-Eveningness Questionnaire — A 19-item scale developed to assess differences in the degree to which respondents are active and alert at certain times of the day. • Fatigue Visual Analog Scale — An 18-item scale that assesses subject experience of fatigue. • Epworth Sleepiness Scale — Evaluates overall daytime sleepiness based on how likely they are to fall asleep in eight different situations (only if needed from NSI/Rivermead) Cognitive Status • Montreal Cognitive Assessment (MOCA) — Rapid screen of cognitive abilities designed to detect mild cognitive dysfunction. • Moss attention rating scale — The MARS is an observational tool used to measure attention-related behaviors after TBI. continued on next page 3 QTB Assessment Instruments Behavioral Health • Patient Health Questionnaire (PHQ-9) — Assesses the presence and intensity of depressive symptoms • CAGE Questionnaire — A 4-item questionnaire for screening for alcohol abuse • Primary Care – Post Traumatic Stress Disorder Screen (PC-PTSD) — A 4-item screen used to screen for PTSD • Generalized Anxiety Disorder (GAD-7) — A self-reported questionnaire for screening and severity measuring of generalized anxiety disorder (GAD) Participation/Social Roles • Community Integration Questionnaire (CIQ) — Used to assess the social role limitations and community interaction of people with acquired brain injury • Glasgow Outcome Scale Extended (GOS-E) — Used to classify global outcome in TBI survivors. Life Satisfaction • Quality of Life After Brain Injury (QOLIBRI) — 37 items questionnaire covering six dimensions of health related quality of life. Measurement Resources • The Center for Outcome Measurement in Brain Injury • National Institute of Neurological Disorders and Stroke (NINDS) Common Data Elements for TBI Educational Resources • Brain Injury Association • Centers for Disease Control • U.S. Department of Veterans Affairs 4 QTB Other Resources AAPM&R Resources • Evidence-Based Resources • Vetted PQRS Measures • Performance Measure Resources • Endorsed Clinical Practice Guidelines • Quality Glossary External Resources Evidence/Literature: • Cochrane Library An online collection of databases that brings together in one place rigorous and up-to-date research on the effectiveness of healthcare treatments and interventions, as well as methodology and diagnostic tests • Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence Defines a process of finding appropriate evidence feasible and its results explicit Clinical Practice Guidelines: • National Guidelines Clearinghouse A public resource for evidence-based clinical practice guidelines Assessment Instruments/Performance Measures: • National Quality Measure Clearinghouse A public resource for evidence-based quality measures and measure sets. • National Quality Forum (NQF) Quality Positioning System NQF’s measure search tool that helps you find the endorsed measures you need quickly and easily. • Rehabilitation Measures Database The Rehabilitation Clinician’s Place to Find the Best Instruments to Screen Patients and Monitor Their Progress. 5