An Observational Cohort Study of the Role of Level of Effort in Post-acute Brain Injury Rehabilitation

Published:August 04, 2022DOI:



      To investigate the role of participant level of effort (LoE) on outcome in post-acute brain injury rehabilitation with the hypothesis that greater effort is associated with more positive outcomes.


      Observational cohort study.


      Comprehensive integrated rehabilitation program for brain injury within a skilled nursing facility.


      101 consecutive admissions with acquired brain injury.


      Individualized interdisciplinary brain injury rehabilitation; therapist rating of participant LoE with Acquired Brain Injury Level of Effort Scale (ABI-LoES) during physical therapy, occupational therapy, and speech and language pathology sessions.

      Main Outcome Measures

      Mayo-Portland Adaptability Inventory (MPAI-4); Supervision Rating Scale (SRS)


      Linear regression showed that discharge MPAI-4 Total T-scores were significantly associated with mean ABI-LoES rating, admission MPAI-4 Total T-scores, age at admission, and days from injury but not with standard deviation of ABI-LoES rating, sex, injury type, length of stay, or treatment before or during the COVID pandemic. Discharge SRS scores were significantly associated with mean ABI-LoES rating, admission SRS scores, and age. A one-unit increase in mean ABI-LoES rating was associated with 5.1 unit lower discharge MPAI-4 Total T-scores and 1.5 lower discharge SRS scores, after controlling for other variables. Logistic regression showed the odds of achieving a Minimal Clinically Important Difference on the MPAI-4 were 8.34 times higher with each one-unit increase in mean ABI-LoES rating after controlling for other variables. Admission MPAI-4 was negatively associated with mean ABI-LoES rating (β= -0.07, t=-8.85, p<0.0001).


      After controlling for nonmodifiable variables, average ABI-LoES rating is positively associated with outcome. Initial level of disability is negatively associated with mean ABI-LoES rating.

      Key Words

      List of abbreviations:

      ABI (Acquired brain injury), ABI-LoES (Acquired Brain Injury Level of Effort Scale), CI (Confidence interval), CIRP/BI-SNF (Comprehensive Integrated Rehabilitation Program for Brain Injury within a Skilled Nursing Facility), IQR (Interquartile range), LoE (Level of effort), LOS (Length of stay), MCID (Minimal clinically important difference), MPAI-4 (Mayo-Portland Adaptability Inventory, 4th edition), MT (Music Therapy), OT (Occupational Therapy), PSM (Propensity score matching), PT (Physical Therapy), RT (Recreation Therapy), SLP (Speech and Language Pathology), SNF (Skilled nursing facility), SRS (Supervision Rating Scale)
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