Original research| Volume 100, ISSUE 10, P1827-1836, October 2019

Level of Effort and 3 Hour Rule Compliance

Published:February 20, 2019DOI:



      To determine if patients’ level of effort (LOE) in therapy sessions during traumatic brain injury (TBI) rehabilitation modifies the effect of compliance with the 3-Hour Rule of the Centers for Medicare & Medicaid Services.


      Propensity score methodology applied to the TBI Practice-Based Evidence database, consisting of multisite, prospective, longitudinal observational data.


      Acute inpatient rehabilitation facilities (IRF).


      Patients (N=1820) who received their first IRF admission for TBI in the United States and were enrolled for 3- and 9-month follow-up.

      Main Outcome Measures

      Participation Assessment with Recombined Tools-Objective-17, FIM Motor and Cognitive scores, Satisfaction with Life Scale, and Patient Health Questionnaire-9.


      When the full cohort was examined, no strong main effect of compliance with the 3-Hour Rule was identified and LOE did not modify the effect of compliance with the 3-Hour Rule. In contrast, LOE had a strong positive main effect on all outcomes, except depression. When the sample was stratified by level of disability, LOE modified the effect of compliance, particularly on the outcomes of participants with less severe disability. For these patients, providing 3 hours of therapy for 50% or more of therapy days in the context of low effort resulted in poorer performance on select outcome measures at discharge and up to 9 months postdischarge compared to patients with <50% of 3-hour therapy days.


      LOE is an active ingredient in inpatient TBI rehabilitation, while compliance with the 3-Hour Rule was not found to have a substantive effect on the outcomes. The results support matching time in therapy during acute TBI rehabilitation to patients’ LOE in order to optimize long-term benefits on outcomes.


      List of abbreviations:

      ASD (absolute standardized difference), CI (confidence interval), CMS (Centers for Medicare & Medicaid Services), IPW (inverse probability weighting), IRF (inpatient rehabilitation facility), LOE (level of effort), LOS (length of stay), OT (occupational therapy), PART-O (Participation Assessment with Recombined Tools-Objective), POC (point of care), PT (physical therapy), ST (speech therapy), SWLS (Satisfaction with Life Scale), TBI (traumatic brain injury), TBI-PBE (Traumatic Brain Injury Practice-Based Evidence)
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