Community integration and satisfaction with functioning after intensive cognitive rehabilitation for traumatic brain injury11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the author(s) or on any organization with which the author(s) is/are associated

‘Participate to learn’: A promising practice for community ABI rehabilitation

OBJECTIVE

To identify best practices and promising practices to enhance participation in meaningful and productive activities.

METHOD

An electronic search of the ABI rehabilitation research literature since 1990 yielded 974 articles of which 30 focused on interventions that targeted participation and evaluated effectiveness using direct measures of participation. Three reviewers rated these articles according to the standards set out by the Centre for Reviews and Dissemination. Following the systematic review, an interpretive review of the same articles was completed.

RESULTS

Only three studies were rated as strong. No best practices were identified. Three promising practices found some support. The interpretive review suggested 'Participate to learn' as a useful rehabilitation model. The model rests on roles as goals, learning by experience in real-life contexts and the use of personal and environmental support to enable participation.

CONCLUSIONS

'Participate to learn' is both a credible rehabilitation model and deserving of more study.

Community reintegration following acquired brain injury

OBJECTIVE

To evaluate the interventions and strategies used to enable transition from acute care or post-acute rehabilitation to the community following brain injury.

METHODS AND MAIN OUTCOMES

A systematic review of the literature from 1980-2005 was conducted focusing on ABI rehabilitation. Five major aspects of community reintegration, including: independence and social integration, caregiver burden, satisfaction with quality of life, productivity and return to driving were considered.

RESULTS

With the exception of one, the majority of interventions are supported by only limited evidence, denoting an absence of randomized controlled trials (RCTs) in the literature. Of 38 studies evaluated for this review, only one RCT was found. That RCT provided moderate evidence that behavioural management, coupled with caregiver education, did not help to improve caregiver burden.

CONCLUSIONS

Further research, using an interventional approach, is required to advance the evidence base of reintegration into the community following brain injury.

The influence of neuropsychological rehabilitation on symptomatology and quality of life following brain injury: A controlled long-term follow-up

PRIMARY OBJECTIVE

To establish whether, following acquired brain injury, intensive post-acute neuropsychological rehabilitation could have long-term beneficial effects.

METHODS AND PROCEDURES

A group of 37 adults who had suffered cerebrovascular accidents or traumatic brain injuries and who had undergone a rehabilitation programme were followed up 12-22 years post-injury, together with a non-rehabilitated control group of 13 adults, matched for brain-injury and demographics characteristics. Both groups completed a set of questionnaires concerning broad aspects of psychological well-being. Significant others completed similar questionnaires.

MAIN OUTCOMES AND RESULTS

The rehabilitation group showed significantly lower levels of brain injury symptoms and higher levels of competency at follow-up. They also rated internal locus of control and general self-efficacy as significantly higher than the control group. Anxiety and depression levels were significantly lower and quality of life significantly higher in the rehabilitation group for both the subjects themselves and for their significant others.

CONCLUSIONS

Within methodological limitations this study suggests that post-acute neuropsychological rehabilitation can have long-term beneficial effects.

Cognitive interventions post acquired brain injury

OBJECTIVE

Cognitive rehabilitation represents a substantial portion of rehabilitative efforts put forth in increasing independence following an acquired brain injury.

MAIN OUTCOMES AND RESULTS

This review examined four major areas of cognitive therapy including: attention/concentration, learning and memory, executive functioning, and general cognitive rehabilitation approaches. In total, 64 studies were evaluated throughout the four major areas, which provided the evidence-base for 18 conclusions. The majority of the conclusions were based on moderate and limited evidence, however three strong and one conflicting conclusions were made.

CONCLUSIONS

Future research should explore functional outcome measures and long-term effects of treatment interventions through follow-up.

Cognitive rehabilitation following traumatic brain injury: assessment to treatment

Cognitive rehabilitation refers to a set of interventions that aim to improve a person's ability to perform cognitive tasks by retraining previously learned skills and teaching compensatory strategies. Cognitive rehabilitation begins with a thorough neuropsychological assessment to identify cognitive strengths and weaknesses and the degree of change in cognitive ability following a brain injury. The conclusions of the assessment are used to formulate appropriate treatment plans. Common interventions for improvements in attention, memory, and executive function, as well as the nature of comprehensive programs, which combine treatment modalities, are reviewed. Cognitive rehabilitation is effective for mild-to-severe injuries and beneficial at any time post-injury. Sufficient evidence exists supporting the efficacy and effectiveness of cognitive rehabilitation, which has become the treatment of choice for cognitive impairments and leads to improvements in cognitive and psychosocial functioning.

Relationship between processing speed and executive functioning performance among OEF/OIF veterans: implications for postdeployment rehabilitation

BACKGROUND

Comorbid mild traumatic brain injury (mTBI) with posttraumatic stress disorder (PTSD) is a common clinical presentation among troops returning from Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). This study examined processing speed and executive functioning in a sample of OEF/OIF veterans who had sustained mTBI, a subset of whom also had comorbid PTSD.

METHODS

Fifty-three OEF/OIF veterans with a history of mTBI completed Wechsler Adult Intelligence Scale-III Symbol Search and Digit Symbol-Coding subscales, Stroop Word, color and color-word trials, and Trail Making Test, Parts A and B as part of a comprehensive neuropsychological test battery.

RESULTS

Excluding from analysis those who scored poorly on effort testing, multiple regression showed that measures of processing speed accounted for 43% of the variance in performance on the Trail Making Test, Part B and 50% of the variance in performance on the Stroop task. Significant differences in processing speed and executive functioning were found on the basis of presence of comorbid PTSD. Stroop Color (F = 9.27, df = 52, P < .004) and Stroop Color Word (F = 7.19, df = 52, P < .01) scores differed significantly between the groups. Those having comorbid PTSD (+TBI/+PTSD) scored significantly poorer than the mTBI-only group (+TBI/-PTSD). Implications for treatment of the comorbid conditions are discussed.

Holistic neuro-rehabilitation in the community: is identity a key issue?

Many people experience identity change after brain injury. Impaired self-awareness after acquired brain injury is also common and can, along with other factors, affect the identity change a person may experience. Holistic rehabilitation programmes attempt to address both cognitive and emotional difficulties and specifically problems of self-awareness after brain injury. Does identity change require longer-term rehabilitation interventions? This paper describes a community-based neuro-rehabilitation service that has incorporated some principles from more traditional holistic programmes with a view to providing long-term, low-intensity brain injury rehabilitation. Specific reference is made to problems of identity and how these may be addressed during long-term psychotherapeutic follow-up. The potential relevance of the total duration of rehabilitation input rather than simply the number of sessions when working with adjustment and identity change after brain injury in community settings is discussed. The service model is compared to more traditional holistic rehabilitation programmes. A case study and early outcome data are presented to illustrate some of these points and to provide more information about the nature of the programme.

Traumatic brain injury research priorities: the Conemaugh International Brain Injury Symposium

In 2005, an international symposium was convened with over 100 neuroscientists from 13 countries and major research centers to review current research in traumatic brain injury (TBI) and develop a consensus document on research issues and priorities. Four levels of TBI research were the focus of the discussion: basic science, acute care, post-acute neurorehabilitation, and improving quality of life (QOL). Each working group or committee was charged with reviewing current research, discussion and prioritizing future research directions, identifying critical issues that impede research in brain injury, and establishing a research agenda that will drive research over the next five years, leading to significantly improved outcomes and QOL for individuals suffering brain injuries. This symposium was organized at the request of the Congressional Brain Injury Task Force, to follow up on the National Institutes of Health Consensus Conference on TBI as mandated by the TBI ACT of 1996. The goal was to review what progress had been made since the National Institutes of Health (NIH) Consensus Conference, and also to follow up on the 1990's Decade of the Brain Project. The major purpose of the symposium was to provide recommendations to the U.S. Congress on a priority basis for research, treatment, and training in TBI over the next five years.

Traumatic brain injury: future assessment tools and treatment prospects

Traumatic brain injury (TBI) is widespread and leads to death and disability in millions of individuals around the world each year. Overall incidence and prevalence of TBI are likely to increase in absolute terms in the future. Tackling the problem of treating TBI successfully will require improvements in the understanding of normal cerebral anatomy, physiology, and function throughout the lifespan, as well as the pathological and recuperative responses that result from trauma. New treatment approaches and combinations will need to be targeted to the heterogeneous needs of TBI populations. This article explores and evaluates the research evidence in areas that will likely lead to a reduction in TBI-related morbidity and improved outcomes. These include emerging assessment instruments and techniques in areas of structural/chemical and functional neuroimaging and neuropsychology, advances in the realms of cell-based therapies and genetics, promising cognitive rehabilitation techniques including cognitive remediation and the use of electronic technologies including assistive devices and virtual reality, and the emerging field of complementary and alternative medicine.

Neuropsychological rehabilitation

Neuropsychological rehabilitation (NR) is concerned with the amelioration of cognitive, emotional, psychosocial, and behavioral deficits caused by an insult to the brain. Major changes in NR have occurred over the past decade or so. NR is now mostly centered on a goal-planning approach in a partnership of survivors of brain injury, their families, and professional staff who negotiate and select goals to be achieved. There is widespread recognition that cognition, emotion, and psychosocial functioning are interlinked, and all should be targeted in rehabilitation. This is the basis of the holistic approach. Technology is increasingly used to compensate for cognitive deficits, and some technological aids are discussed. Evidence for effective treatment of cognitive, emotional, and psychosocial difficulties is presented, models that have been most influential in NR are described, and the review concludes with guidelines for good practice.

Measuring participation in people living with multiple sclerosis: a comparison of self-reported frequency, importance and self-efficacy

PURPOSE

To compare three dimensions related to participation in everyday situations in community-dwelling adults with multiple sclerosis (MS).

METHODS

Mail survey was obtained from 112 respondents. Data were analyzed using Kendall's tau-b correlation coefficients between responses to participation items relative to three question dimensions (importance, frequency, and self-efficacy) and criterion variables (mobility, depression, general health, fatigue and pain).

RESULTS

No significant associations were found between item responses in the importance dimension and the criterion variables. Weak associations were found for items in the frequency dimension, and stronger associations were found for items in the self-efficacy dimension.

CONCLUSIONS

Different dimensions of participation in specific life situations yielded different responses and associations of those responses with key criterion measures. Subjective importance of participating in everyday situations is relatively independent of measures of mobility, general health, depression, fatigue and pain. Subjective judgments of self-efficacy for participation are more closely linked to these criterion measures. Caution is warranted when interpreting scales of participation because participation is a complex construct, potentially composed of several dimensions.

Techniques and devices to restore cognition

Executive planning, the ability to direct and sustain attention, language and several types of memory may be compromised by conditions such as stroke, traumatic brain injury, cancer, autism, cerebral palsy and Alzheimer's disease. No medical devices are currently available to help restore these cognitive functions. Recent findings about the neurophysiology of these conditions in humans coupled with progress in engineering devices to treat refractory neurological conditions imply that the time has arrived to consider the design and evaluation of a new class of devices. Like their neuromotor counterparts, neurocognitive prostheses might sense or modulate neural function in a non-invasive manner or by means of implanted electrodes. In order to paint a vision for future device development, it is essential to first review what can be achieved using behavioral and external modulatory techniques. While non-invasive approaches might strengthen a patient's remaining intact cognitive abilities, neurocognitive prosthetics comprised of direct brain-computer interfaces could in theory physically reconstitute and augment the substrate of cognition itself.

Evaluation of cognitive rehabilitation as a treatment paradigm

PURPOSE

The construct of 'cognitive rehabilitation' has not been defined in a consensual manner and the variations in usage have produced misunderstanding and controversy. At one extreme, it refers to a paradigm of complex, sophisticated, integrated interventions and at the other to a poorly conceptualized and largely ineffectual service modality. A number of articles criticizing cognitive rehabilitation make little effort to differentiate between these usages, thus subjecting very different clinical procedures to the same complaints.

METHODS

This article abstracts five major criticisms from this literature to examine the best-developed, 'holistic' versions.

CONCLUSION

A treatment selection standard is proposed, specifying the conditions under which a holistic model or the 'contextualized' training alternative is likely to be more viable.

Satisfaction with communicative participation as defined by adults with multiple sclerosis: a qualitative study

PURPOSE

This study examined satisfaction with communicative participation as reported by adults with multiple sclerosis (MS).

METHOD

Eight community-dwelling adults with MS participated in semi-structured interviews. They were asked to discuss their satisfaction with their communication in a variety of situations. Interviews were analyzed using a constant comparative method of qualitative description.

RESULTS

Themes derived included: Comfort, consisting of Ease and Confidence; Success of the Outcome, including Function is Achieved and A Connection is Made; and Personal Meaning of Participation, including Personal Preferences, Comparison with the Past, and Thinking about One's Own Communication.

CONCLUSIONS

Participants described multiple facets of satisfaction with communicative participation. Some of the dimensions were similar to those in existing assessment instruments such as levels of ease or difficulty with performance. Participants did not talk about frequency of activities as a key part of their satisfaction. Implications for identifying intervention targets and treatment outcome measurements are provided.

LEARNING OUTCOMES

The reader should be able to: 1) define communicative participation and identify key elements of this construct; 2) identify the issues that were most relevant to satisfaction with communicative participation with participants with MS; and 3) identify reasons for greater emphasis on the subjective viewpoint of people with communication disorders in measurement of treatment outcomes.

Perceptions of self-efficacy and rehabilitation among neurologically disabled adults

OBJECTIVE

To explore constructs relevant to self-efficacy in neurological rehabilitation.

DESIGN

Qualitative methods using semi-structured interviews.

SETTING

Specialist neurological rehabilitation unit, Liverpool, UK.

SUBJECTS

Twenty-four patients (12 male) with experience of inpatient rehabilitation, aged 17-59 (mean 38.1) years at onset, with diagnoses of stroke (n = 8), traumatic brain injury (n = 6) or other monophasic neurological impairment (n = 10).

RESULTS

Eleven themes emerged from the data that reflect self-efficacy beliefs: self-reliance and independence were deemed important and many patients recognized the importance of determination, making time to take an active role and working in partnership with the multidisciplinary team. Patients had complex information needs but were able to use goal setting and the vicarious experiences of other inpatients to map out the stages of their own recovery. It was important for patients to be able to recognize for themselves that they were making progress and they valued external reassurance on this from other patients, staff and visitors. A number of difficulties were identified that interfered with their developing self-efficacy in rehabilitation, such as structuring their time. Two different models for rehabilitation emerged from the data, 'recovery' and 'adaptation'.

CONCLUSIONS

Patients consistently identified 11 factors falling in the supraordinate themes of self, others and process, and these influenced their self-efficacy to participate in neurological rehabilitation. Patients consider rehabilitation in terms of either an 'adaptation' or 'recovery' model.

Long-Term Multidimensional Functional Consequences of Severe Multiple Injuries Two Years After Trauma: A Prospective Longitudinal Cohort Study

BACKGROUND

The assessment of outcome after multiple injuries in a rehabilitation perspective is increasingly important in trauma research. The purpose of this study was to assess functioning and quality of life after severe injuries using a prospective cohort design.

METHODS

One hundred and five patients with a New Injury Severity Score >15, aged 18 to 67 years, and admitted to a Level I trauma center were included consecutively starting January 2002 through June 2003. Outcomes were assessed 6 weeks after discharge and 1 and 2 years after injury. Self-reported functioning and quality of life was measured by Short Form (SF)-36, World Health Organization Disability Assessment Schedule II (WHODAS II) and a cognitive function scale (COG).

RESULTS

Mean age was 35.3 years (standard deviation [SD], 14.0), 83% were male. Mean New Injury Severity Score was 34.6 (SD, 12.6). Disease burden measured by SF-36 showed scores below the general population. Effect sizes showed that the largest difference was for physical functioning, social functioning, and physical and emotional role functioning. The WHODAS II disability score showed substantially worse functioning compared with general population data. Profession, injury severity, pain, and physical, cognitive, and social functioning made independent contributions to WHODAS II 2 years after injury and explained 69% of the variance of the model.

CONCLUSIONS

Long-lasting functional problems after multiple injuries affect most life domains. Knowledge about the reduced physical, mental, cognitive, social, and role functioning should impact the rehabilitation services provided for severely injured patients, from primary care to community rehabilitation.

Community neurorehabilitation: a synthesis of current evidence and future research directions

Over the past decade, community neurorehabilitation has emerged as a promising extension of neurological rehabilitation. The goal of community neurorehabilitation is to maximize functional ability and quality of life through multidimensional rehabilitation that occurs while the individual is living in a home versus acute or transitory care setting. Because of its multidisciplinary focus, many variations of community neurorehabilitation teams have been implemented. Critical gaps exist, however, in understanding of the influence of structural and procedural differences among programs, as well as patient level variables such as social support, on recovery. This paper examines the current evidence of the effectiveness of community neurorehabilitation through a review of the findings of systematic reviews and meta-analyses of four neurological conditions: stroke, multiple sclerosis, traumatic brain injury, and Parkinson's disease. It focuses in particular on the data regarding physical therapy and occupational therapy, which are two of the primary components of community neurorehabilitation programs.

Rehabilitation for cognitive impairments after cerebral malaria in African children: strategies and limitations

Cerebral malaria results in short- to long-term cognitive impairments in many of its child survivors. Although some of the risk factors for impairments have been identified, no attempts have been made to address the plight of those who develop cognitive impairments. This paper discusses the burden of cognitive impairment caused by cerebral malaria and suggests some rehabilitation strategies based on brain injury and cognitive rehabilitation studies. Potential cognitive rehabilitation solutions such as cognitive exercises, environmental enrichment, nutritional supplementation, physical therapy and speech therapy are highlighted. The limitations of implementing these interventions and solutions are discussed in light of the limited human resources and infrastructure of the developing countries that are malaria endemic.

Treatment of post-TBI executive dysfunction: application of theory to clinical practice

The authors propose a theory-based model for the treatment of post-traumatic brain injury executive dysfunction that integrates (1) theories of cerebral function and organization, (2) cognitive-behavioral theory of problem solving, and (3) learning theory. The model delineates appropriate targets of and methods for the treatment of executive dysfunction. A practical application of the theoretical model is described in the form of a comprehensive day treatment program, Executive Plus. A test of the model is also discussed, focused on the comparison of Executive Plus and a standard day treatment program along parameters dictated by the model.

Assessment of subjective health and health-related quality of life in persons with acquired or degenerative brain injury

PURPOSE OF REVIEW

Health-related quality of life is a new outcome variable in neurology. Several generic measures aim at assessing this variable in adults with neurological diseases. Disease-specific measures are still rare; however, individuals with neurological diseases frequently suffer from cognitive impairment, yet are often excluded from health-related quality of life investigations. When included in such studies, cognitive functioning is not monitored via neuropsychological evaluation, possibly leading to methodological problems. Papers from May 2004 until July 2005 are reviewed with respect to psychometric quality and information about persons after traumatic brain injury, stroke, Parkinson's disease or dementia.

RECENT FINDINGS

Several new cross-sectional and longitudinal outcome studies are reviewed. The Medical Outcome Study Short Form with 36 items, the Sickness Impact Profile and the Nottingham Health Profile were identified as the most frequently used measures in neurology. For traumatic brain injury, two new generic instrument validations (Life Satisfaction Index-A, Subjective Quality of Life Profile) and one internationally validated disease-specific development (Quality of Life after Brain Injury) were found; for stroke, one disease-specific tool (Burden of Stroke Scale) was identified. In Parkinson's disease, the disease-specific health-related quality of life measure Parkinson's Disease Questionnaire-39 is well validated. In dementia, three dementia-specific instruments (Quality of Life for Dementia, Quality of Life in Late-Stage Dementia Scale and Quality of Life in Alzheimer's Disease Scale) seem to be valid.

SUMMARY

In neurology, only a few measures have been developed and validated for respondents with cognitive impairment, often showing poorer validity results than studies involving healthy persons. Health-related quality of life assessment should therefore be validated in the specific diseases and, if necessary, combined with a neuropsychological evaluation and a disease-specific health-related quality of life measure.

Early Versus Later Admission to Postacute Rehabilitation: Impact on Functional Outcome After Traumatic Brain Injury

OBJECTIVE

To examine the impact of participation in a postacute community reentry program on functional outcome after traumatic brain injury (TBI).

DESIGN

Cohort, nonrandomized, intervention study. Pretest-posttest, follow-up design.

SETTING

Nonprofit outpatient community reentry program affiliated with an inpatient rehabilitation hospital.

PARTICIPANTS

Three groups of persons with moderate to severe TBI differing in length of time between injury and admission. The first group entered postacute rehabilitation within 6 months of injury (n=115); the second group, between 6 and 12 months (n=23); and the third group, greater than 12 months (n=29).

INTERVENTIONS

Persons with TBI participated in a postacute community reentry program (average, 4.3mo) that emphasized (1) teaching compensatory strategies to address residual cognitive deficits; (2) arranging environmental supports to maximize functioning; (3) counseling and education to address personal and family adjustment and to improve accurate self-awareness; and (4) transition from simulated activities in the clinic to productive activities in the community.

MAIN OUTCOME MEASURES

Disability Rating Scale, Supervision Rating Scale, and the Community Integration Questionnaire.

RESULTS

All groups showed improvements between admission and discharge on measures of overall disability, independence, home competency, and productivity, and these gains were maintained at follow-up. For the group beginning postacute rehabilitation the earliest (<6mo postinjury) independence continued to improve after discharge. Community integration total score and home competency also continued to improve even after discharge.

CONCLUSIONS

The results point toward the effectiveness of postacute rehabilitation in improving functional outcome after TBI even for persons who have reached stable neurologic recovery at 12 or more months postinjury.

Appraising evidence on community integration following brain injury: a systematic review

A systematic review of the community integration (CI) literature for persons with traumatic brain injury was undertaken to evaluate: (1) How do we best measure CI? (2) Can we predict CI following rehabilitation? (3) Does social and activity participation have an effect on CI? (4) Does CI have an effect on quality of life/life satisfaction? Seventy-two articles were analysed. The results demonstrated: (1) strong evidence supporting the use of the Community Integration Questionnaire (CIQ), (2) mixed evidence supporting the ability to predict CI, with the prominent predictive variables being severity of injury, age, gender, education, prior work, living environment, cognition, emotional status, functional performance and disability. The literature search was restricted to articles published in English and the heterogeneity in the outcomes, methods, participants and other characteristics not reported. Further research is needed to examine the complex relationship of person, environment and CI.

Post-acute rehabilitation following traumatic brain injury: are both early and later improved outcomes possible?

This outcome study investigated the effectiveness of community based multi-disciplinary neuro-rehabilitation for persons with a traumatic brain injury (TBI) at varying times since injury. From case records all persons with a (TBI) who had two-point outcome data (European Brain Injury Questionnaire) available (n=55) were identified and included in this study. Significantly improved outcome on self-rating were observed for the group, not only for those less than 2 years post-injury, but also for those more than 2 years after (TBI). Family/care ratings also confirmed improved outcome, except for the group of patients who were more than 2 years post-(TBI).

Pushing the frames of reference in traumatic brain injury rehabilitation

Cognitive rehabilitation is an empirically based field driven by multiple sources of activities and knowledge bases. Drawing on frames of reference provided by rehabilitation, neuropsychology, and rehabilitation psychology, cognitive rehabilitation has evolved to a point where studies have been generated to qualify for consideration in tables of evidence. At the center of cognitive rehabilitation is the effort to teach people to overcome or adapt to limitations. While rehabilitation has traditionally been focused on activity, a recent trend in the literature is to incorporate the individuals experience into a frame of reference for rehabilitation. Emphasizing the experience of the person in the situation fits into cognitive rehabilitation and raises the bar for rehabilitation not only in viewing rehabilitation as an activity to relieve burdens but also in terms of how rehabilitants come to grips with limitations. Dealing with limitations is an important indicator of mental health.

Cognitive outcome in traumatic brain injury survivors

PURPOSE OF REVIEW

This review discusses recent studies investigating the cognitive and psychiatric outcome of posttraumatic brain injury. In addition, it aims to highlight key areas for future research.

RECENT FINDINGS

Detailed cognitive assessments have revealed particular deficits in processing speed in the visual domain and the detrimental impact of interference on attentional performance. A pilot functional imaging study revealed neural changes in survivors performing a response inhibition task, even when matched to controls on behavioural indices. Recent psychiatric studies highlight the incidence of these disorders in the survivors and attempt to characterize distinct psychiatric profiles. Adult and child survivors appear to show differential difficulties. Successful rehabilitation strategies addressing these psychiatric and cognitive deficits include holistic intensive neuropsychological interventions and the introduction of electronic devices. Systematic randomized trials are needed to provide an adequate evidence base for clinical practice. The potential for cognitive enhancement using psychopharmacological agents has yet to be exploited. These treatments may lead to improved quality of life for traumatic brain injury survivors and their families.

SUMMARY

Survivors of head injury show a diverse pattern of cognitive and psychiatric profiles. Recent research highlights the nature of some of these deficits and possible ways to enhance functioning. However, the area is well poised for rapid progress in the understanding of cognitive and emotional dysfunction following traumatic brain injury (TBI) and its rehabilitation through neuropsychological and psychopharmacological means.

Participation objective, participation subjective: a measure of participation combining outsider and insider perspectives

BACKGROUND

Participation now replaces community integration or handicap as concepts reflecting the social and interpersonal aspects of disability. If rehabilitation is to adequately measure participation, new measures of participation are needed. To represent the voice of the consumer, such measures should reflect not just "objective," normative aspects, but also subjective ones, tapping the consumer's view of participation.

OBJECTIVES

To describe the development of and preliminary metrological information on a new measure of participation, Participation Objective, Participation Subjective (POPS).

METHODS

A total of 454 community-living individuals with traumatic brain injury (TBI) completed the POPS, as well as measures of quality of life (Life 3), depressive mood (BDI), and TBI symptoms (BISQ). The POPS requires reporting of the share of household activities performed, or the frequency or hours of nonhousehold activities. For each, the subject indicates whether he or she wants to perform more, the same, or less of the activity, and the importance of the activity to well-being. Five subscales and a total scale are calculated, for an objective component (PO), and a subjective component (PS) that reflects importance-weighted satisfaction with activity level.

RESULTS

Individuals with mild TBI scored minimally higher than those with moderate-severe TBI on PO subscores, but desired more change on the PS. Test-retest reliability for the PO and the PS and the subscales was from weak (intraclass correlation coefficient 0.28) to adequate (0.89), with PS components having better reliability. The PS component scores had the expected correlations with TBI symptoms, depressed mood, and life satisfaction, among both those with mild injury and those with moderate-severe injury. Injury severity and time since onset were not related to PO or PS scores.

CONCLUSIONS

The POPS shows promise as a measure of participation. It fills a void in that it reflects both insider and outsider perspectives on participation after TBI.

Participation as an Outcome of Traumatic Brain Injury Rehabilitation

OBJECTIVES

Participation in meaningful life situations is an important aspect of functioning after traumatic brain injury (TBI). However, to date, few studies have included measures of social participation or community integration as outcome measures after TBI rehabilitation. This paper is a selective review of the literature that examines the effects of TBI rehabilitation on measures of participation or community integration. It also addresses the related questions of clinically significant improvements in community integration, variability in patterns of community functioning, and the relationship of participation and quality of life after TBI.

DESIGN

Literature review.

CONCLUSIONS

A small number of studies suggest that postacute TBI rehabilitation can produce improvements in participation and community integration. However, a considerable amount of variability in rehabilitation outcomes may be apparent. Analysis of clinically significant changes in individual's functioning suggests that rehabilitation may exert its benefits not only by facilitating improvements, but also by preventing declines in community functioning. Subjective well-being and quality of life have generally been ignored as TBI rehabilitation outcomes. There is considerable evidence that participation and subjective well-being represent distinct and dissociable outcomes after TBI, which may reflect the importance of patients' preferences and values in evaluating the effectiveness of rehabilitation.