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Brain Injury
ISSN: 0269-9052 (Print) 1362-301X (Online) Journal homepage: http://www.tandfonline.com/loi/ibij20
The interrelationship of functional skills in
individuals living in the community, following
moderate to severe traumatic brain injury
Gordon Muir Giles, Jo Clark-Wilson, Doreen M. Tasker, Ross Baxter, Mark
Holloway & Stephanie Seymour
To cite this article: Gordon Muir Giles, Jo Clark-Wilson, Doreen M. Tasker, Ross Baxter, Mark
Holloway & Stephanie Seymour (2018): The interrelationship of functional skills in individuals
living in the community, following moderate to severe traumatic brain injury, Brain Injury, DOI:
10.1080/02699052.2018.1539762
To link to this article: https://doi.org/10.1080/02699052.2018.1539762
© 2018 The Author(s). Published by Taylor &
Francis.
Published online: 14 Nov 2018.
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The interrelationship of functional skills in individuals living in the community,
following moderate to severe traumatic brain injury
Gordon Muir Giles
a,b
, Jo Clark-Wilson
c
, Doreen M. Tasker
c
, Ross Baxter
c
, Mark Holloway
c,d
, and Stephanie Seymour
c
a
Department of Occupational Therapy, Samuel Merritt University, Oakland, CA, California, USA;
b
Crestwood Treatment Center 2171 Mowry Avenue,
Fremont, CA, California, USA;
c
Head First, Grove Mills, Hawkhurst, UK;
d
School of Sociology & Social Policy, University of Nottingham, UK
ABSTRACT
Objective: The Adaptive Behaviour and Community Competency Scale was used to investigate the
interrelationship of 22 basic and instrumental activities of daily living (ADL/IADL) in individuals with
moderate to severe traumatic brain injury (TBI). The relationship of self-awareness to task performance
was also investigated.
Research design: Prospective descriptive study.
Method: The profiles of 100 community dwelling individuals were used to compare the degree to which
independence in each ADL/IADL was associated with independence in every other ADL/IADL. The
interrelationship of these skills was further explored in a factor analysis, and comparisons made between
the degree of self-awareness of those who could and could not complete IADL independently.
Results: We found evidence of a hierarchy of skills: individuals who were independent in IADL were more
able to perform ADL, than vice versa.
Factor analysis supported a two-factor solution distinguishing ADL and IADL. Self-awareness was
more strongly associated with IADL than with ADL independence.
Conclusions: A subset of individuals with moderate to severe TBI are able to perform a range of IADL.
This group appears to have higher levels of self-awareness than those who are limited to performing
only ADL skills. Implications for the applications of functional retraining interventions are discussed.
ARTICLE HISTORY
Received 13 August 2017
Revised 24 May 2018
Accepted 19 October 2018
KEYWORDS
Traumatic brain injury; brain
injury; activities of daily
living; self-awareness;
executive function
In the USA, functional skills are typically divided into activ-
ities of daily living (ADL) and instrumental activities of daily
living (IADL). ADL include, but are not limited to, the rou-
tine self-care activities of eating, bathing, dressing, toileting,
and transferring (1–3). IADL include a range of activities
related to independent functioning, such as meal preparation,
shopping, community mobility skills (4,5), and other activities
that involve managing social interaction or environmental
variability. IADL are more varied, and typically performed
in a greater range of settings than are ADL (6,7).
Moderate to severe traumatic brain injury (TBI) is a major
cause of long-term ADL and IADL disability (8,9). Indeed, direct
assessment of ADL and IADL appear to be the best predictor of an
individual’s need for support or ability to function independently
in the community (6,7). The frequency with which individuals can
perform ADL versus IADL would suggest the latter are more
difficult to accomplish. For instance, in a 3–5 year follow-up
study, Dikmen and colleagues (10) estimated that approximately
10% of persons in their severe TBI sample required long-term
assistance or were dependent on others for help with ADL tasks.
By contrast, 60% had difficulty or required support with IADL
tasks. Powell et al. (11) identified similar rates of ADL and IADL
dependence. However, observing the frequency with which defi-
cits occur is insufficient for a full understanding of what makes
some tasks more difficult than others. There is evidence that ADL/
IADL skills are hierarchically organized in older individuals across
diagnostic categories (12), but to our knowledge this finding has
not been replicated amongst people following moderate to severe
TBI. There is evidence that executive functioning is the best pre-
dictor of functional performance in older adults living in the
community (13) and predicts progress during acute TBI rehabili-
tation (14). Lack of insight is generally associated with poorer
functional recovery and worse rehabilitation and employment
outcomes (15–17). It has been proposed that adequate IADL
performance post TBI depends on both the individual’scognitive
status and their self-awareness (18,19). In a prior publication we
reported that lack of insight was associated with increased need for
case management and care-support for individuals living in the
community following TBI (20). To our knowledge, there have
been no studies that have examined how insight relates directly
to ADL versus IADL performance after TBI (18). An enhanced
understanding of the way in which ADL/IADL skills interrelate
could provide a rationale for choosing the order in which func-
tional independence skills are addressed in rehabilitation.
The current study was designed to test the following
hypotheses:
(1) A hierarchical relationship exists between IADL and
ADL skills in individuals following moderate to
severe TBI. Independent performance of IADL skills
is more strongly associated with independent perfor-
mance of ADL skills, than the other way around
(2) An exploratory factor analysis of ADL and IADL
independence would support a two-factor solution:
CONTACT Gordon Muir Giles, PhD ggiles@samuelmerritt.edu OTR/L, FAOTA, Crestwood Treatment Center, 2171 Mowry Avenue, Fremont, CA, USA.
BRAIN INJURY
https://doi.org/10.1080/02699052.2018.1539762
© 2018 The Author(s). Published by Taylor & Francis.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.
a procedural/motoric factor, and a planning, pro-
blem-solving and decision-making factor
(3) Individuals who are unable to perform IADL would
be more impaired in self-awareness than those who
are able to perform IADL.
Methods
Procedure
Data were collected as part of a larger study and the current report
is a secondary analysis. A detailed description of the data-collec-
tion procedures is reported elsewhere (20). There were 141 client
recordsderivedfromtwoindependentsamplesofprofilespro-
vided by UK brain injury case managers from different case
management companies. Case managers were knowledgeable
about the clients whose profiles they contributed. In the prior
paper, we found that the two samples were comparable in the
frequency with which clients could accomplish ADL/IADL tasks,
suggesting that the relative frequencies of independence in these
skills did not occur by chance. There were no differences in the
distribution of the ADL and IADL items between data sets, so the
sampleswerecombinedtoproduceasingledataset(20). The
Mayo system was used to classify injury severity and only those
clientprofileswithadefinitemoderatetosevereTBIclassification
were included (21), yielding a total of 100 profiles. Samuel Merritt
University Institutional Review Board approved the study.
Study population
Client profiles were included if clients were living in the com-
munity (i.e., not in residential or other institutional care), over
the age of 12 years at the time of injury, and had sustained a TBI
(e.g., vehicular, falls, assaults, sporting injuries), hypoxia, anoxia,
or anesthetic accident, or a limited range of vascular events (e.g.,
subarachnoid hemorrhage). Clients were excluded if they had
sustained a stroke, or brain injury associated with a cardiac
event, as these diagnostic groups were considered to have differ-
ent patterns of cognitive and functional outcomes from those
seen in TBI (22). Individuals were not excluded on the grounds
of substance abuse or psychiatric impairment.
Measure
Adaptive Behaviour and Community Competency Scale
The Adaptive Behaviour and Community Competency Scale
(ABCCS) was designed specifically to be sensitive to the types
of problems experienced by clients with TBI living in the com-
munity in the post-acute period (20,23). The ABCCS uses ordi-
nal scales linked to concrete behavioral descriptions or a
specification of the need for prompting or physical assistance,
in line with the World Health Organization level of impairment
and ability. The ABCCS has excellent interrater and test–retest
reliability when used with a UK TBI community population
(23,24). Each item relating to ADL/IADL was dichotomized
into independent or not independent. Independence in an activ-
ity was defined as safe, habitual task performance without the
need for physical or verbal prompting, assistance or supervision.
A definition of each of the 22 ADL/IADL items used in the
ABCCS is given in Appendix A. The ABCCS also includes a 4-
point Insight scale measuring the client’s global self-awareness,
based on the descriptive theory of Crosson et al. (25)(Table 1
provides the ABCCS Insight scale).
Data analysis
SPSS version 19 (26) was used to examine client demographics.
The frequency with which independence was achieved in
each of the 22 ABCCS ADL/IADL items was calculated, and
the items ordered in terms of most (item 1) to least (item 22)
frequently completed independently.
The rates of independence versus dependence and Fisher
Exact Probability Test with Bonferroni correction were calcu-
lated using a 2 × 2 contingency table as a guide for each bi-
directional ADL/IADL skill pair (27)(for further explanation
of how data for Table 3 were calculated see Appendix B).
An exploratory factor analysis was conducted to determine
whether the 22 ADL and IADL items truly represent two differ-
ent types of activity. Since the data are binary, the exploratory
factor analysis was conducted on a tetrachoric correlation matrix
for the 22 functional skills using minimum residual observed
least squares and varimax rotation. Fox’s (2014) polycor package
in R was used to calculate the tetrachoric correlation matrix (28).
Having ordered the 22 ADL and IADL in terms of the
frequency with which clients were independent in these skills,
the midpoint activity was identified (i.e. Health Maintenance).
Items above Health Maintenance in Table 3 were considered
mostly ADL and those below it were considered mostly IADL.
Mann–Whitney Utest SPSS version 19 (26) was used to analyze
whether severity of injury was associated with independence in
items above or below this midpoint Health Maintenance (i.e., the
ADL versus IADL items). A similar procedure was used to
determine if there were differences between the lack of aware-
ness of clients who could perform activities above or below the
Health Maintenance item. The z distribution was used to calcu-
late the effect size from the Mann–Whitney Uresults (29).
Results
Client characteristics
Client demographics, severity of injury and indicators of severity
of outcome are provided in Table 2. Data were available for 84
individuals regarding their employment status pre- and post-
injury (see Table 2). Post-injury only 3 clients were in competitive
Table 1. ABCCS “Insight”scale.
Insight
(Please select the statement that best applies. If the client is unable to
respond or communicate, please do not record anything)
3 Recognizes the effects of impairments on daily functioning, foresees
potential problems and implements compensatory strategies
appropriately
2 Describes physical, cognitive, and emotional impairments, if asked,
but does not understand the implications of impairments
1 Acknowledges physical impairments, if asked, but not other
impairments
0 Does not acknowledge any impairment
2G. M. GILES ET AL.
employment and only 10 clients were in education, with a further
12 clients in voluntary or sheltered work settings. Most clients (74)
were living at home alone or with family post-injury with the
remainder(26)intheirownhomewithsupport(seeTable 2): all
clients were receiving case management.
Independence rates
Table 3 provides the 462 independent, pairwise comparisons for
each ADL or IADL skill with every other ADL or IADL skill,
ordered from most-to-least commonly achieved. In examining
the table, the reader should first read acrossthe top of the table to
locate the predictor ADL or IADL skill of interest (labeled 1–22),
below which is given the number of people in the sample who
are independent in that predictor skill. Looking at each cell by
row, the first number indicates the absolute number of people
who are independent in the predictor skill who are also inde-
pendent in the associated skill (identified by the name at the side
of the table row). The second number in each cell is the percen-
tage of people who are independent in the predictor skill (who
are also independent in the associated skill). Visual inspection of
Table 3 reveals that the number of people achieving indepen-
dence in the list of reordered items gradually reduces in each
column, with only some minor exceptions (i.e. the hierarchy is
not perfect). Those individuals who achieve independence in the
lower items in the table (e.g. items 19, 20, 21, 22; items that are
typically considered IADL) are far more likely to be independent
in items higher in the table (e.g. 1, 2, 3, 4; items that are typically
considered ADL) than vice versa. If, for example, the reader
examines column 19 Laundry/Housework, 13/100 people are
independent in the IADL Laundry/Housework and almost all
are also independent in most of the items above the midpoint
Health Maintenance in the table (≥84–100%, i.e. in the ADLs
items Telephone Use, Continence, Outdoor and Indoor Mobility,
Oral Care, Showering, Dressing and Nail Care).If,however,the
reader examines column 8, 49/100 people are rated as indepen-
dent in Dressing, but only 13/100 (26%) are independent in the
IADL of Laundry/Housework.Appendix B (Tables 5 and 6)
illustrate the creation of the 2 × 2 table.
Exploratory factor analysis
An exploratory factor analysis was conducted to determine
whether the 22 ADL and IADL represent two underlying types
of skills. First, a tetrachoric correlation matrix was computed
(available on request from the first author). Almost all of the
tetrachoric correlations for each pair of ADL and IADL skills
were significant at the 95 percent confidence level. Using 0.40 as
the cut-off value for factor loadings, it was determined that
eleven ADL and IADL skills loaded on both factors, seven
ADL and IADL skills loaded only on factor 1, and four ADL
and IADL skills loaded only on factor 2. In the cases where a
functional skill loaded on both factors, the factor with the higher
factor loading for each ADL or IADL skill was chosen as the final
factor. In Table 4, boxes have been drawn around the final ADL
and IADL skills included in each factor which we labeled: (1)
procedural/motoric, and (2) planning, problem-solving, and deci-
sion-making.
A comparison was made between clients who were inde-
pendent in Health Management and/or independent in one
or more of the items below Health Management in Table 3
(IADL-independent group) and clients who were dependent
for Health Management and all tasks below it in Table 3
(IADL-dependent group). This grouping resulted in an
IADL-independent group of 58 clients and an IADL-depen-
dent group of 42 clients. Mann–Whitney analysis of
Glasgow Coma Scale (GCS), coma duration or post trau-
matic amnesia (PTA) indicated that the IADL-independent
and IADL-dependent groups did not differ significantly in
any of the TBI severity measures. Thus for PTA, the IADL-
dependent group (n= 31) had a mean rank of 38.0 while
the IADL-independent group (n=40)hadameanrankof
34.5 with the resultant Mann–Whitney U= 558.0, p= 0.36.
For the GCS, the IADL-dependent group (n=36)hada
mean rank of 41.0 and the IADL-independent group (n=
51) had a mean rank of 46.2 with the resultant Mann–
Whitney U= 808.5, p= 0.13. For duration of coma, the
IADL-dependent group (n= 28) had a mean rank of 38.5,
and the IADL-independent group (n= 39) had a mean rank
of 30.8 with a resultant Mann–Whitney Uthat approached,
but did not reach, significance = 420.5, p=0.06.
The Mann–Whitney Utest was used to compare the same
IADL-dependent and IADL-independent grouping on the 4-
point ABCCS Insight scale (see Table 1). The IADL-dependent
group had an average score of 1.94 on Insight and the IADL-
independent group an average score of 2.21. The IADL-depen-
dent group (n= 42) had a mean rank of 31.0 while the IADL-
independent group (n= 58) had a mean rank of 40.0, with the
Table 2. Sample demographic and clinical characteristics.
N= 100
Variable Mean SD
Age 34.99 ± 12.2
Age when injured 25.92 ± 11.21
Years post-injury 9.09 ± 5.26
Gender N(%)
Male 66 (66)
Female 34 (34)
GCS Score N=87
3–8 74 (85%)
9–12 9 (10%)
13–15 4 (5%)
Coma duration N=67
≤1 hour 2 (3%)
1–24 hours 3 (4%)
2–7 days 18 (27%)
>7 days 44 (66%)
Duration of PTA N=71
1–7 days 3 (4%)
1–4 weeks 17 (24%)
>4 weeks 51 (72%)
Post-injury living situation N= 100
Living alone 23 (23%)
With family 51 (51%)
With care-support 26 (26%)
Work and educational status N(%)
Pre-injury
Competitive employment 56 (61)
In educational setting 28 (30)
Missing 8 (9)
Post-injury
Competitive employment 3 (3)
Volunteer work 17 (17)
Sheltered work 2 (2)
In educational setting
Not working or in education
10 (10)
68 (68)
BRAIN INJURY 3
resultant Mann–Whitney U=772,p= 0.001. Effect size calcula-
tion indicates an eta squared of 0.10 indicating that 10% of the
variability in self-awareness as measured by the ABCCS variable
Insight can be attributed to the IADL-independent and IADL-
dependent groups.
Discussion
Hypothesis 1, that a hierarchical relationship exists between IADL
and ADL skills in individuals following moderate to severe TBI
was supported. Hypothesis 2, that an exploratory factor analysis of
the 22 ADL and IADL skills would support a two-factor solution
which we labeled procedural/motoric vs planning, problem-solving,
and decision-making was partially supported. The two-factor solu-
tion found that 7 of the 22 skill items (mostly ADL) loaded
predominantly on factor one (procedural/motoric), and four
items (predominantly complex IADL) loaded mostly on factor 2
(planning, problem-solving, and decision-making). The other
skills loaded on both factors. Hypothesis 3, that clients rated as
dependent on IADL items are more impaired in self-awareness
Table 3. The co-occurrence of functional skill independence in 100 community dwelling individuals with moderate to severe TBI.
Functional skills
12
N=34
13
N=26
14
N=22
15
N=20
16
N=17
17
N=17
18
N=14
19
N=13
20
N=13
21
N=12
22
N=8
1. Telephone use 34/100 25/96 22/100 19/95 17/100 17/100 14/100 13/100 13/100 12/100 08/100
2. Continence 34/100 24/92 22/100 20/100 17/100 17/100 14/100 13/100 13/100 11/91 08/100
3. Eating 33/97 22/48 20/90 18/90 17/100 17/100 14/100 12/92 12/92 11/91 07/88
4. Outdoor mobility 30/88 21/80 21/95 18/90 16/94 16/94 13/92 13/100 13/100 10/83 08/100
5. Indoor mobility 28/82 18/69 20/90 18/90 15/88 13/76 10/76 13/100 12/92 08/100 08/100
6. Oral care 30/88* 22/84 22/100* 16/80* 16/94 16/94 13/92 13/100 13/100 10/83 07/88
7. Showering 29/85* 19/73 19/86 16/80 16/94* 14/82 12/85 13/100 12/92 09/75 07/88
8. Dressing 26/76 18/69 18/82 16/80 17/100* 15/88 12/85 13/100* 10/76 09/75 07/88
9. Nail care 25/73* 16/61 18/82* 15/75* 15/88* 14/82 11/78 13/100* 12/92 07/58 07/88
10. Street crossing 23/67* 17/65 21/95* 17/85* 13/76 13/76 12/85 11/84 10/76 09/75 06/75
11. Med management 19/56 14/53 14/64 13/65 13/76 10/58 10/71 12/92* 08/61 08/66 07/88
12. Health Maintenance –18/69* 14/64 12/60 13/76 11/64 12/85* 12/92* 10/76 09/75 07/88
13. Shopping 18/53* –10/45 09/45 09/53 11/64 10/71 09/69 08/61 10/83* 04/50
14. Route finding 14/41 10/38 –13/65* 07/41 08/47 09/64 06/46 10/76* 06/50 03/37
15. Driving 12/35 09/34 13/59* –07/41 06/35 06/42 05/38 05/38 05/41 02/25
16. Room tidy 13/38 09/34 07/31 07/35 –06/35 05/36* 11/84 04/30 05/41 06/75
17. Meal preparation 11/32 11/42 08/36 06/30 06/35 –10/71* 06/46 06/46 05/41 03/37
18. Community skills 12/35* 10/36 09/41 06/30 05/29 10/58* –05/38 07/53 05/41 01/13
19. Laundry/Housework 12/35* 09/34 06/27 05/25 11/64* 06/35 05/36 –06/46 05/41 07/88*
20. Public transport 10/29 08/30 10/45* 05/25* 04/23 06/35 07/50 06/46 –04/33 03/37
21. Finances 09/26 10/38* 06/27 05/25 05/29 05/29 05/36 05/38 04/30 –03/37
22. House maintenance 07/20 04/15 03/14 02/10 06/35 03/17 01/07 07/53* 03/23 03/33 –
Bonferroni Corrected * p≤0.00022 = 0.05/231.
Note: The Fisher exact test of statistical significance is affected by both the rate of independence and the rate of dependence in a particular pair of ADL and IADL
skills though only the rate of independence is included in Table 2. At the top and the bottom of the hierarchy the number of persons who may or may not be able
to perform a particular ADL and IADL skill is small (e.g., only 16 clients are incontinent in the sample). This combined with the number of tests conducted and the
resulting magnitude of the Bonferroni Corrected *p≤0.00022 = 0.05/231 resulted in many of the Fisher exact tests being non-significant where visual inspects
suggests the presence of a relationship between the skills.
Table 3. The co-occurrence of functional skill independence in 100 community dwelling individuals with moderate to severe TBI with Bonferroni corrected
significance.
Functional skills
1
N=84
2
N=83
3
N=80
4
N=69
5
N=65
6
N=59
7
N=52
8
N=49
9
N=44
10
N=39
11
N=35
N(%)
1. Telephone use –77/93* 73/91 69/100* 63/97 58/98* 50/96 47/95 44/100* 38/97 34/97
2. Continence 77/92* –74/92* 66/96 64/98* 59/100* 52/100* 49/100* 44/100* 39/100* 35/100
3. Eating 73/87 74/89* –64/93 63/97* 52/88 48/92 44/89 40/91 36/92 34/97
4. Outdoor mobility 69/82* 66/79 64/80 –61/94* 50/84 45/86 45/91* 42/95* 37/95* 32/91
5. Indoor mobility 63/75 64/77* 63/79* 61/88* –49/83* 45/86* 41/84* 40/91 35/90* 30/86
6. Oral care 58/69* 59/71* 52/65 50/72 49/75* –49/94* 46/93* 43/98* 36/92* 29/83
7. Showering 50/59 52/62* 48/60 45/65 45/69* 49/83* –43/88* 38/86* 31/79* 27/77
8. Dressing 47/56 49/59* 44/55 45/65* 41/63 46/78* 43/82* –40/91* 33/85* 27/77*
9. Nail care 44/52* 44/53* 40/50 42/60* 40/61* 43/73* 38/73* 40/81* –32/82* 24/68
10. Street crossing 38/45 39/46* 36/45 37/53* 35/54* 36/61* 31/60* 33/67* 32/73* –25/71*
11. Med management 34/36 35/42 34/42 32/46 30/46 29/49 27/52 27/55* 24/54 25/64* –
12. Health maintenance 34/36 34/40 33/41 30/43 28/43 30/51* 29/56* 26/53 25/57* 23/59* 19/54
13. Shopping 25/30 24/28 22/27 21/30 18/28 22/37 19/36 18/36 16/36 17/43 14/40
14. Route finding 22/26 22/26 20/25 21/30 20/31 22/37* 19/36 18/36 18/41* 21/54* 14/40
15. Driving 19/22 20/24 18/22 18/28 18/27 16/31 16/32 16/32 15/34 17/33* 13/37
16. Room tidy 17/20 17/20 17/21 16/23 15/23 16/27 16/31* 17/34* 15/34* 13/33 13/37
17. Meal preparation 17/20 17/20 17/21 16/23 13/20 16/27 14/27 15/30 14/32 13/33 10/28
18. Community skills 14/16 14/17 14/17 13/19 10/15 13/22 12/23 12/24 11/25 12/31 10/28
19. Laundry/Housework 13/15 13/16 12/15 13/19 13/20 13/22 13/25 13/26* 13/29* 11/28 12/34*
20. Public transport 13/15 13/16 12/15 13/19 12/18 13/22 12/23 10/20 12/27 10/26 08/23
21. Finances 12/14 11/13 11/14 10/14 08/12 10/17 09/17 09/18 07/16 09/23 08/23
22. House maintenance 08/09 08/09 07/08 08/12 08/12 07/11 07/14 07/16 07/15 06/20 07/20
Bonferroni corrected *p≤0.00022 = 0.05/231. (continued).
4G. M. GILES ET AL.
than those clients who are able to perform IADL was supported.
Severity of injury did not differentiate between those who were or
were not independent in IADL.
We interpret the data as suggesting that the key distinction
between the ADL and IADL functions is not “complexity”per se,
but rather the necessity for planning, in-the-moment problem-
solving, and decision-making. Many ADL can be accomplished
in a highly routine manner where one step follows another in an
invariant sequence. During IADL tasks the client needs to use
executive functions to adapt responses to novelty and changing
environmental demands. Although IADL tasks can become
easier with practice, because of the need for novel problem-
solving, they do not become fully automatic (30,31).
Individuals, who lack insight and are poor at recognizing that
they might experience difficulty with task performance, are
unlikely to use compensatory strategies. The data presented in
Table 3 allow the clinician a method to identify inconsistencies
in a client’s pattern of skills, which need to be explained with
reference to the client’s particular circumstances or addressed in
a more systematic way. Clients with impaired executive func-
tioning may be unable to generate ways to work around their
cognitive or physical impairments and may need others to do
this for them. For example, one of our early reports (32)
described a 23-year-old male with a very severe injury who
received 12 months of intensive in-patient rehabilitation. At
25-month post-injury, he could manage his personal finances,
but could not bathe or dress due to a combination of physical
skills (lower extremity hypertonicity, and contractures) and
executive function deficits. The application of a structured bath-
ing and dressing retraining program resulted in independence
after only 11 days of treatment (32). Conversely, based on our
findings, we hypothesize that, if after sufficient training, a client
is unable to manage the problem-solving required for indepen-
dence in an IADL task, it is unlikely that the client will be able to
learn to perform tasks that have greater problem-solving
demands (20). What seems to be required is to reduce the on-
the-spot decision-making requirements so the task becomes
invariant. At the core of decisions about rehabilitation is the
recognition that some activities require novel problem-solving
and some do not. For ADL, the therapist’s role is to perform a
task analysis and construct a procedure the client can carry out
successfully (32,33). Learning can then take place via the repeti-
tive enactment of behavior chains using errorless learning pro-
cedures (30,32–35). This is not possible for IADL that require a
response to novelty and changing task and environmental
demands. Independence in such tasks may be more achievable
usingaproblem-solvingstrategy-basedtraining,butonlyifthe
client has the ability to make use of this type of intervention (20).
Clearly these ideas are conjectural and based on a combi-
nation of our data and clinical experience. Further work is
required to establish their general validity. At present we can
simply say that, within this sample of 100 community dwell-
ing individuals with moderate to severe TBI, independence in
ADL and IADL skills was hierarchically organized, albeit
imperfectly. The conceptual distinction between ADL and
IADL skills is supported by the data and corresponds to
observations of the everyday performance of individuals
with moderate to severe TBI. Level of awareness was asso-
ciated with IADL independence.
Limitations
The study sample consisted of clients who had sustained a
moderate to severe TBI who were receiving case management,
and may not be representative of the wider population of indi-
viduals with moderate to severe TBI. We were not able to explore
the effects of age, gender, or ethnicity of participants, although
there is little evidence that these variables are significant pre-
dictors of outcome in the post-acute period (36). Despite an
overall sample size of 100, for some 2 × 2 comparisons, sample
sizes were small. Results are entirely dependent on the specific
definition of independence used in the ABCCS definitions of the
22 ADL/IADL items. For example, shopping independence on
the ABCCS requires that a client is able to shop for items that
typically require planning and problem-solving (e.g., major
appliances, furniture: see Appendix A). Additionally, there are
many factors that may affect an individual’sengagementin
ADL/IADL that are not addressed here. Mood and motivational
factors, as well as personal choice, may all affect activity engage-
ment. Our data did not include details of the client’sprevious
rehabilitation services, and whether, for instance, the current
results might have been achieved because of a selective focus
on teaching ADL, rather than IADL skills. The current results
will need to be validated in a prospective study with a larger
sample size.
Acknowledgments
We would like to thank the following organizations and individuals for
their contributions to data collection: Anglia Case Management, Ben
Holden, Brain Injury Case Management, Bush and Co, Care For Life,
Case Management Services, Coochi, Debbie Eaton Case Management
Limited, Family Focused Case Management Limited, Head First,
Medico Rehab Limited, Independent Case Management, Independent
Case Management Services, Jacky Parker and Associates, Maggie
Sargent and Associates, N-Able, The Rehabilitation Partnership, RT
Disability and West Country Case Management.
Table 4. Exploratory factor analysis loadings for functional skills.
Functional skill Factor 1 Factor 2
Indoor mobility 0.94 −0.06
Laundry/housework 0.87 0.39
Nail care 0.85 0.39
Outdoor mobility 0.84 0.21
House maintenance 0.84 0.08
Continence 0.82 0.56
Dress 0.77 0.43
Shower 0.76 0.43
Room tidy 0.73 0.39
Oral care 0.70 0.58
Phone use 0.68 0.65
Med management 0.65 0.39
Street crossing 0.64 0.59
Eating 0.48 0.46
Public transport 0.55 0.58
Health maintenance 0.53 0.66
Route finding 0.51 0.62
Driving 0.42 0.45
Meal preparation 0.34 0.76
Community skills 0.23 0.90
Finances 0.11 0.76
Shopping 0.03 0.79
Note. In this table, a loading threshold of 0.40 is used. Grey cells signify that the
loading is above the 0.40 threshold
BRAIN INJURY 5
Disclosure statement
Jo Clark-Wilson, Stephanie Seymour, Ross Tasker, and Mark Holloway
are managing partner, employees, or contractors with Head First, a case
management company in Kent, UK. There are no other declarations of
interest.
References
1. Velikonja D, Oakes J, Brum C, Sachdeva M. Assessing the validity
of task analysis as a quantitative tool to measure the efficacy of
rehabilitation in brain injury. Brain Inj. 2017;31:68–74.
doi:10.1080/02699052.2016.1212090.
2. State University of New York. Guide for the uniform data set for
medical rehabilitation (including the FIM™instrument 5.1 ed.).
Buffalo, NY: Uniform Data System for Medical Rehabilitation;
1997.
3. Mahoney FL, Barthel DW. Functional evaluation: the Barthel
Index. Marryland State Med J. 1965;14:61–65.
4. Lawton MP, Brody EM. Assessment of older people: self-main-
taining and instrumental activities of daily living. Gerontologist.
1969;9:176–86. doi:10.1093/geront/9.3_Part_1.179.
5. American Occupational Therapy Association. Occupational ther-
apy practice framework: domain and process. Am J Occup Ther.
2014;68(suppl.1):S1–S48. doi:10.5014/ajot.2014.682006.
6. Morrison MT, Edwards DF, Giles GM. Performance-based testing
in mild stroke: identification of unmet opportunity for occupa-
tional therapy. Am J Occup Ther. 2015;69:1–5.
7. Schmitter-Edgecombe M, Parsey C, Cook DJ. Cognitive correlates
of functional performance in older adults: comparison of self-
report, direct observation, and performance-based measures. J
Int Neurosychological Soc. 2011;17:853–64. doi:10.1017/
S1355617711000865.
8. Livingston DH, Tripp T, Biggs C, Lavery RF. A fate worse than
death? Long-term outcome of trauma patients admitted to the
surgical intensive care unit. J Trauma. 2009;67:341–48. discussion
348–349. doi:10.1097/TA.0b013e3181a5cc34.
9. Bender A. Bauch, S. and Grill, E.: Efficacy of a post-acute interval
inpatient neurorehabilitation programme for severe brain injury.
Brain Inj. 2014;28:44–50. doi:10.3109/02699052.2013.850177.
10. Dikmen SS, Machamer JE, Powell JM, Temkin NR. Outcome 3 to
5 years after moderate to severe traumatic brain injury. Arch Phys
Med Rehabil. 2003;84:1449–57.
11. Powell JM, Temkin NR, Machamer JE, Dikmen SS. Gaining
insight into patients’perspectives on participation in home man-
agement activities after traumatic brain injury. Am J Occup Ther.
2007;61:269–79.
12. Spector WD, Katz S, Murphy JB, Fulton JP. The hierarchical
relationship between activities of daily living and instrumental
activities of daily living. J Chronic Dis. 1987;40:481–89.
doi:10.1016/0021-9681(87)90004-X.
13. Cahn-Weiner DA, Boyle PA, Malloy PF. Tests of executive func-
tion predict instrumental activities of daily living in community-
dwelling older individuals. Appl Neuropsychol. 2002;9:187–91.
doi:10.1207/S15324826AN0903_8.
14. Hanks RA, Rapport LJ, Millis SR, Deshpande SA. Measures of
executive functioning as predictors of functional ability and social
integration in a rehabilitation sample. Arch Phys Med Rehabil.
1999;80:1030–37.
15. Prigatano GP, Altman IM. Impaired awareness of behavioural
limitations after traumatic brain injury. Arch Phys Med Rehabil.
1990;71:1058–64.
16. O’Callaghan A, McCallister L, Wilson L. Insight vs readiness:
factors affecting engagement in therapy from the perspectives of
adults with TBI and their significant others. Brain Injury.
2012;26:1599–610. doi:10.3109/02699052.2012.698788.
17. Shereer M, Bergloff P, Levin E, High WM, Oden KE, Nick TG.
Impaired awareness and employment outcome after traumatic
brain injury. J Head Trauma Rehabil. 1998;13:52–61.
18. Goverover Y. Categorization, deductive reasoning, and self-aware-
ness: association with everyday competence in persons with acute
brain injury. J Clin Exp Neuropsychol. 2004;26:737–49. doi:10.1080/
13803390490509321.
19. Abreu BC, Seale G, Scheibel RS, Huddleston N, Zhang L, Ottenbacher
KJ. Levels of self-awareness after acute brain injury: how patients’and
rehabilitation specialists’perceptions compare. Arch Phys Med
Rehabil. 2001;82:49–56. doi:10.1053/apmr.2001.9167.
20. Clark-Wilson J, Giles GM, Seymour S, Tasker R, Baxter DM, Holloway
M. Factors influencing community case management and care hours
for clients with traumatic brain injury living in the UK. Brain Inj.
2016;30:872–82. doi:10.3109/02699052.2016.1146799.
21. Malec JF, Brown AW, Leibson CL, Flaada JT, Mandrekar JN,
Diehl NN, Perkins PK. The Mayo classification system for trau-
matic brain injury severity. J Neurotruama. 2007;24:1417–24.
doi:10.1089/neu.2006.0245.
22. Malec JF, Kean J, Altman IM, Swick S. Mayo-Portland adaptabil-
ity inventory: comparing psychometrics in cerebrovascular acci-
dent to traumatic brain injury. Arch Phys Med Rehabil.
2012;93:2271–75. doi:10.1016/j.apmr.2012.06.013.
23. Giles GM. Assessing adaptive behaviour in the post-acute setting
following traumatic brain injury: initial reliability and validity of the
Adaptive Behavior and Community Competency Scale (ABCCS).
Brain Inj. 2007;21:521–29. doi:10.1080/02699050701311067.
24. World Health Organization. International classification of function-
ing, disability, and health (ICF). Geneva, Switzerland: Author; 2001.
25. Crosson B, Barco P, Velozo C, Bolesta MM, Cooper PV, Werts D,
Brobeck TC. Awareness and compensation in post acute head
injury rehabilitation. J Head Trauma Rehabil. 1989;4:46–54.
doi:10.1097/00001199-198909000-00008.
26. IBM Corp. IBM SPSS statistics for windows (Version 19.0).
Armonk, NY: Author;2010.
27. McDonald JH. Fisher’s exact test of independence. In: Handbook of
biological statistics. Baltimore, MD: Sparky House Publishing;2014;
77–85.
28. R Core Team. R. A language and environment for statistical
computing. [Accessed 2015]. https://www.r-project.org/.
29. Fritz CO, Morris PE, Richler JJ. Effect size estimates: current use,
calculations, and interpretation. J Exp Psychol. 2012;141:2–18.
doi:10.1037/a0024338.
30. Trevena-Peters J, McKay A, Spitz G, Suda R, Renison B, Ponsford
J. Efficacy of activities of daily living retraining during post-trau-
matic amnesia: a randomised controlled trial. Arch Phys Med
Rehabil. 2018;99:329–37. doi:10.1016/j.apmr.2017.08.486.
31. Clark-Wilson J, Baxter D, Giles GM. Revisiting the neurofunc-
tional approach: conceptualising the essential components for the
rehabilitation of everyday living skills. Brain Inj. 2014;28:646–
1656. doi:10.3109/02699052.2014.946449.
32. Giles GM, Ridley J, Dill A, Frye S. A consecutive series of brain
injured adults treated with a washing and dressing retraining
program. Am J Occup Ther. 1997;51:256–66.
33. Holmqvist K, Ivarsson A-B, Holmefur M. Occupational therapists
practice patterns in relation to clients with cognitive impairment
following acquired brain injury. Brain Inj. 2014;28:1365–73.
doi:10.3109/02699052.2014.919529.
34. Reber PJ. The neural basis of implicit learning and memory: a review
of neuropsychological and neuroimaging research. Neuropsychologia.
2013;51:2026–42. doi:10.1016/j.neuropsychologia.2013.06.019.
35. Trevena-Peters J, Ponsford J, McKay A. Agitated behavior and activ-
ities of daily living retraining during posttraumatic amnesia. J Head
Trauma Rehabil. 2017;33:317–325. doi: 10.1097/HTR.000000000
0000363.
36. Ponsford J. Factors contributing to outcome following traumatic
brain injury. NeuroRehabilitation. 2013;32:803–15. doi:10.3233/
NRE-130904.
6G. M. GILES ET AL.
Appendix A. ABCCS definitions of independence
ABCCs Scale
Number
independent Definition of independence
Phone use 84 Makes and receives calls with land-line telephone independently
Continence 83 Is fully continent of bowel and bladder or manages own incontinence independently
Eating and drinking safely 80 Eats and drinks safely and independently
Outdoor mobility 72 Walks or uses wheel chair sufficiently well to travel in the local community independently
Indoor mobility 67 Walks indoors safely and independently (with or without an assistive device)
Oral care 59 Initiates and completes oral hygiene independently
Bathing/Shower 52 Initiates and completes bathing/showering independently
Dressing 49 Completely dresses self independently and changes clothes regularly
Nail care 44 Initiates and performs nail care independently
Street crossing 39 Is believed to be at no more than normal risk when street crossing
Medication management 35 Receives no routinely prescribed medication or manages own medication and can obtain prescriptions and have
prescriptions filled without help or reminders
Health management 34 Manages own minor ailments (e.g., colds) independently and knows when to seek medical assistance
Shopping 27 Makes major purchases requiring planning (e.g., buys own shoes, furniture etc.)
Route finding 22 Travels to novel destinations in the local community independently
Driving 20 Drives a car and is believed to be at no more than normal risk
Room tidying 17 Keeps household clean and tidy without reminders
Meal preparation 17 Plans and prepares complex meals (multistep multi-item) can use the stove top (hob) and oven safely and
independently
Community tasks 14 Completes multiple novel community tasks each day (e.g., tasks are not purely routine, but involve different
places, people, shops, etc.)
Laundry/housework 13 Completes own laundry/ housework independently (includes washing dishes, household cleaning, and taking out
the trash/rubbish)
Public transport 13 Usesa public transport (e.g., railway, bus, taxis) on unfamiliar journeys independently
Finances 12 Handles own finances (uses banking facilities, pays own bills, etc.) independently
Household maintenance 8 Able to perform household maintenance activities independently (e.g., gardening, simple household repairs,
decorating, etc.)
BRAIN INJURY 7
Appendix B.
Appendix B (Tables 5 and 6)provideexamplesofhowTable 3 was
developed using 2 × 2 tables. The independence rate is the number
of clients who are independent in skill A and independent in skill B
divided by the total number of clients who are independent in skill
A.Thisprovidesthenumberandthepercentageofpeoplewhoare
independent in skill B who are also independent in skill A. In
Table 5,thefirst2×2tableLaundry/Housework is the predictor
skill and Street Crossing is the associated skill and the Fisher’sexact
probability test pvalue with the Bonferroni correction is non-sig-
nificant. In Table 6,the2×2tableRoom Tidying is the predictor
skill and Dressing is the associated skill and the Fisher’sexactprob-
ability test pvalue with the Bonferroni correction is significant.
Visual inspection of the frequency with which clients are indepen-
dent however suggests that individuals who are independent in doing
Laundry/Housework arelikelytobeindependentinStreet crossing
and individuals who are independent in Room tidying are likely to be
independent in Dressing.
Fisher’s exact probability test (two-tailed) was calculated with
Bonferroni correction for each 2 × 2 contingency table. In understanding
the Fisher’s exact probability test, it should be recognized that the test is
influenced by differential rates of both independence and dependence
between the predictor and the associated variable. The pvalues of the
tests are also provided in Table 3.
Table 5. Two-by-two contingency table for the functional skills of laundry/housework and street crossing.
Associated skill: street crossing
Condition present: independence
(Can cross the street)
Condition absent: dependence
(Cannot cross the street) TOTAL
Predictor skill:
Laundry/
housework
Independence
(Can do laundry/housework)
11 2 13
Dependence
(Cannot do laundry/housework)
28 59 87
Total 39 61 100
Table 6. Two-by-two contingency table for room tidying and dressing.
Associated skill:
dressing
Condition present:
Independence
(Can Dress)
Condition absent: Dependence
(Cannot dress) TOTAL
Predictor skill:
Room tidying
Independence
(Can tidy room)
17* 0 17
Dependence
(Cannot tidy room)
32 51 83
Total 49 51 100
Bonferroni Corrected * p≤0.00022 = 0.05/231
8G. M. GILES ET AL.
