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Time to rebalance the scales in rehab?



The ability to produce an accurate assessment of the level of someone’s neurobehavioural disability (NBD) is critical in determining the appropriate treatment pathway.

It sets expectations and goals for the individual in question and allows care providers (along with their funders) to put the appropriate resources in place for treatment and support.

It means families can be informed and better understand the nature of NBD and the challenges this creates and it allows us as professionals to validate the benefits of neurobehavioral rehabilitation (NbR) methods.

However, whilst all tools rely on evaluating symptoms of NBD using rating scales, all of these are compromised to an extent by the context in which assessments are made. 

This important issue is explored in a recent journal paper, which describes research conducted by myself and long- standing colleagues from Swansea University, Professor Rodger Wood and Dr Claire Williams.

In it we argue that the time has come for a rethink and explain why current indices may be giving us a misleading picture of someone’s true independence levels.

That is why we suggest the time is right to recalibrate ratings of neurobehavioural disability from the SASNOS scale.What is the principle reason for this?

Crucially we may have overlooked the impact that the context in which current ratings are decided upon has on those scores.

By that I mean the care environment that a person is living in and experiencing, when they are assessed.Imagine for a momentthat a person with an acquired brain injury ismaking excellent progress in theirrehab journey.

Repeat assessmenton outcome measures suggests greater independence and autonomy, including a reduction in symptoms of NBD on the SASNOS. Good news.

There then comes a moment when a decision is taken, partially based on these assessments, that the personis now ready to move on from rehabilitation in an NbR hospital and would be better suited to living in a supported living environment in the community. A fine ambition. However, within weeks of moving into the community the individual starts to regress.

Ratings of NBD symptoms on the SASNOS noted to have reduced in the hospital setting are on the increase, including verbal and physical aggression.

As their behaviour in the community deteriorates there is contact with the police and the criminal justice system and eventually short term custodial sentences are imposed.

A huge cost to the individual, society and the tax payer. What has gone wrong here? Well, I would argue that the NBD rating made in the hospital rehab setting was perfectly valid, but only meaningful for that context.

In hospital, the highly structured and therapeutic environment provides a prosthetic that undermines the factors driving NBD, whatever these are, such as cognitive impairment.

When these drivers are dynamic they are amenable to change which is independent of the environment the individual is in.

But when they are static and fixed, reduction in NBD is achieved through the environment and the support given within it.

Bluntly, take away the support and we see the true extent of that person’s disability.What is ideally required is a method that assists interpretation of results from an instrument that provides measures of the rich variety of symptoms of NBD, rather than a single aspect, that can be applied at any stage in rehabilitation.

We argue that we need to weight the SASNOS scores to take into account the impact that the environment has on the individual.

To achieve this we recommend that the SASNOS scoresare recalibrated to reflect the degree of help or support rehabilitation participants receive for the management of each of the 49 NBD symptoms using a supplementary scoring system.

This means adding an additional dependency rating to each item: 1 – ‘no help or support’, 2 – ‘receives help or support’, 3 – ‘receives a structured programme / intervention’.

All our findings show us that adjusting standard scores to reflect dependence on the environment is beneficial.

It reduces risk of underestimating the extent of NBD in other settings; facilitates understanding of whether reduction in NBD symptoms is attributable to modification of dynamic vs. static factors; provides further evidence of the benefits of NbR; and makes a valuable contribution to rehabilitation, especially goal planning, evaluation and assessment of future needs.

I would urge NbR practitioners to adopt these new ratingsso we can all deliver the highest quality and most effective support for the people in our care – especially as a means of determining rehabilitation outcomes.

Knowledge is power and we would argue that by using this supplementary scoring system, SASNOS assessments further increase the information needed to do the very best we can for people with acquired brain injury.

Prof Alderman is clinical director of neurobehavioural rehabilitation services with Elysium Healthcare. He is also an honorary professor at Swansea University and visiting professor at the University of the West of England. He chairs INPA’s research & outcomes group, and the East Midlands Acquired Brain Injury Forum. 

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