Development of the Participation Assessment With Recombined Tools–Objective for Use After Traumatic Brain Injury

Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Outcomes and Endpoints

BACKGROUND

Clinical management of persons with disorders of consciousness (DoC) is dedicated largely to optimizing recovery. However, selecting a measure to evaluate the extent of recovery is challenging because few measures are designed to precisely assess the full range of potential outcomes, from prolonged DoC to return of preinjury functioning. Measures that are designed specifically to assess persons with DoC are often performance-based and only validated for in-person use. Moreover, there are no published recommendations addressing which outcome measures should be used to evaluate DoC recovery. The resulting inconsistency in the measures selected by individual investigators to assess outcome prevents comparison of results across DoC studies. The National Institute of Neurological Disorders and Stroke (NINDS) common data elements (CDEs) is an amalgamation of standardized variables and tools that are recommended for use in studies of neurologic diseases and injuries. The Neurocritical Care Society Curing Coma Campaign launched an initiative to develop CDEs specifically for DoC and invited our group to recommend CDE outcomes and endpoints for persons with DoCs.

METHODS

The Curing Coma Campaign Outcomes and Endpoints CDE Workgroup, consisting of experts in adult and pediatric neurocritical care, neurology, and neuroscience, used a previously established five-step process to identify and select candidate CDEs: (1) review of existing NINDS CDEs, (2) nomination and systematic vetting of new CDEs, (3) CDE classification, (4) iterative review and approval of panel recommendations, and (5) development of case report forms.

RESULTS

Among hundreds of existing NINDS outcome and endpoint CDE measures, we identified 20 for adults and 18 for children that can be used to assess the full range of recovery from coma. We also proposed 14 new outcome and endpoint CDE measures for adults and 5 for children.

CONCLUSIONS

The DoC outcome and endpoint CDEs are a starting point in the broader effort to standardize outcome evaluation of persons with DoC. The ultimate goal is to harmonize DoC studies and allow for more precise assessment of outcomes after severe brain injury or illness. An iterative approach is required to modify and adjust these outcome and endpoint CDEs as new evidence emerges.

Cognitive Performance is Associated With 1-Year Participation and Life Satisfaction Outcomes: A Traumatic Brain Injury Model Systems Study

OBJECTIVE

To determine, in persons with traumatic brain injury (TBI), the association between cognitive change after inpatient rehabilitation discharge and 1-year participation and life satisfaction outcomes.

DESIGN

Secondary analysis of prospectively collected TBI Model Systems (TBIMS) data.

SETTING

Inpatient rehabilitation and community.

PARTICIPANTS

499 individuals with TBI requiring inpatient rehabilitation who completed the Brief Test of Adult Cognition by Telephone (BTACT) at inpatient rehabilitation discharge (ie, baseline) and 1-year postinjury.

MAIN OUTCOME MEASURES

Participation Assessment with Recombined Tools-Objective (PART-O) and Satisfaction with Life Scale (SWLS).

RESULTS

Of 2,840 TBIMS participants with baseline BTACT, 499 met inclusion criteria (mean [standard deviation] age = 45 [19] years; 72% male). Change in BTACT executive function (EF) was not associated with 1-year participation (PART-O; β = 0.087, 95% CI [-0.004, 0.178], P = .061) when it was the sole model predictor. Change in BTACT episodic memory (EM) was associated with 1-year participation (β = 0.096, [0.007, 0.184], P = .035), but not after adjusting for demographic, clinical, and functional status covariates (β = 0.067, 95% CI [-0.010, 0.145], P = .089). Change in BTACT EF was not associated with life satisfaction total scores (SWLS) when it was the sole model predictor (β = 0.091, 95% CI [-0.001, 0.182], P = .0503). Change in BTACT EM was associated with 1-year life satisfaction before (β = 0.114, 95% CI [0.025, 0.202], P = .012) and after adjusting for covariates (β = 0.103, [0.014, 0.191], P = .023). In secondary analyses, change in BTACT EF was associated with PART-O Social Relations and Out and About subdomains before (Social Relations: β = 0.127, 95% CI [0.036, 0.217], P = .006; Out and About: β = 0.141, 95% CI [0.051, 0.232], P = .002) and after (Social Relations: β = 0.168, 95% CI [0.072, 0.265], P < .002; Out and About: β = 0.156, 95% CI [0.061, 0.252], P < .002) adjusting for functional status and further adjusting for covariates (Social Relations: β = 0.127, 95% CI [0.040, 0.214], P = .004; Out and About: β = 0.136, 95% CI [0.043, 0.229], P = .004). However, only the models adjusting for functional status remained significant after multiple comparison correction (ie, Bonferroni-adjusted alpha level = 0.002).

CONCLUSION

EF gains during the first year after TBI were related to 1-year social and community participation. Gains in EM were associated with 1-year life satisfaction. These results highlight the potential benefit of cognitive rehabilitation after inpatient rehabilitation discharge and the need for interventions targeting specific cognitive functions that may contribute to participation and life satisfaction after TBI.

Association Between Participation and Satisfaction With Life Over Time in Older Adults With Traumatic Brain Injury: A TBI Model Systems Study

OBJECTIVE

To examine the association between participation and satisfaction with life at 1, 2, 5, and 10 years after traumatic brain injury (TBI) in older adults.

SETTING

Community.

PARTICIPANTS

Participants ( N = 2362) who sustained complicated mild to severe TBI, requiring inpatient rehabilitation, at age 60 years or older and had follow-up data on participation and satisfaction with life for at least 1 follow-up time point across 1, 2, 5, and 10 years. Age at each time period was categorized as 60 to 64 years, 65 to 75 years, and 75 years or older.

DESIGN

Secondary data analysis of a large multicenter database.

MAIN MEASURES

Three domains (Productivity, Social Relations, Out and About) of the Participation Assessment With Recombined Tools-Objective (PART-O); Satisfaction With Life Scale (SWLS).

RESULTS

SWLS increased over the 10 years after TBI and was significantly associated with greater frequency of participation across all domains. There was a significant interaction between age and PART-O Social Relations such that there was a weaker relationship between Social Relations and SWLS in the oldest group (75 years or older). There was no interaction between Productivity or Out and About and age, but greater participation in both of these domains was associated with greater life satisfaction across age groups.

CONCLUSIONS

These findings indicate that greater participation is associated with increased satisfaction with life in older adults, across all participation domains over the first 10 years postinjury, suggesting that rehabilitation should target improving participation even in older adults. The decreased association of social relations with satisfaction with life in the oldest age group suggests that frequency of social relations may not be as important for life satisfaction in the oldest adults, but quality may still be important.

Factors related to social inferencing performance in moderate-severe, chronic TBI

OBJECTIVE

Following traumatic brain injury (TBI), deficits in social cognition are common. Social inferencing is a crucial component of social cognition that enables an individual to understand the thoughts, feelings, and intentions of a communication partner when this information is not explicitly stated. Existing literature suggests a variety of factors contribute to social inferencing success (e.g. biological sex, executive functioning), yet findings are not conclusive, largely because these factors have been examined in isolation.

METHOD

In this cross-sectional study, stepwise regression with cross validation was used to examine the extent that several theoretically motivated factors were associated with social inferencing (measured by performance on The Awareness of Social Inference Test [TASIT]) in adult participants with TBI (n = 105). Demographic information, executive functioning, aggression, emotional functioning measures, and participation in society were all examined in relation to social inferencing performance.

RESULTS

The findings confirm the importance of higher-level cognitive skills (i.e. executive functioning) in social inferencing, and advance the literature by underlining the potential importance of productive participation in social inferencing performance.

CONCLUSION

This study innovatively highlights factors linked with social inferencing skills and, in doing so, how deficits in social inferencing might manifest in the lives of individuals with TBI.

Developing multidimensional participation profiles after traumatic brain injury: a TBI model systems study

Purpose. To characterize societal participation profiles after moderate-severe traumatic brain injury (TBI) along objective (Frequency) and subjective (Satisfaction, Importance, Enfranchisement) dimensions.Materials and Methods. We conducted secondary analyses of a TBI Model Systems sub-study (N = 408). Multiaxial assessment of participation included the Participation Assessment with Recombined Tools-Objective and -Subjective questionnaires (Participation Frequency and Importance/Satisfaction, respectively) and the Enfranchisement Scale. Participants provided responses via telephone interview 1-15 years post-injury. Multidimensional participation profiles (classes) were extracted using latent profile analysis.Results. A 4-class solution was identified as providing maximal statistical separation between profiles and being clinically meaningful based on profile demographic features. One profile group (48.5% of the sample) exhibited the "best" participation profile (High Frequency, Satisfaction, Importance, and Enfranchisement) and was also the most advantaged according to socioeconomic indicators. Other profile groups showed appreciable heterogeneity across participation dimensions. Age, race/ethnicity, education level, ability to drive, and urbanicity were features that varied between profiles.Conclusions. Societal participation is a critical, but inherently complex, TBI outcome that may not be adequately captured by a single index. Our data underscore the importance of a multidimensional approach to participation assessment and interpretation using profiles. The use of participation profiles may promote precision health interventions for community integration.Implications for RehabilitationOur study found unidimensional measures of societal participation in traumatic brain injury (TBI) populations that focus exclusively on frequency indicators may be overly simplistic and miss key subjective components of participationTaking a multidimensional perspective, we documented four meaningfully distinct participation subgroups (including both objective and subjective dimensions of societal participation) within the TBI rehabilitation populationMultidimensional profiles of participation may be used to group individuals with TBI into target groups for intervention (e.g., deeper goal assessment for individuals who do not rate standard participation activities as important, but also do not participate and do not feel enfranchised).

Mood Tracker: A Randomized Controlled Trial of a Self-Monitoring Intervention for Emotional Distress After Traumatic Brain Injury

OBJECTIVE

Persons with traumatic brain injury (TBI) frequently experience emotional distress (ED) manifested in anxiety and depression. However, they may not access mental health services due to external (eg, access, transportation, and cost) or internal (eg, stigma and discomfort with traditional counseling) barriers. Based on substantial literature indicating that self-monitoring can ameliorate several health conditions, we conducted a randomized, parallel group, wait-list control (WLC) trial of a self-monitoring intervention to decrease ED after TBI.

SETTING

Community in the southwestern United States.

PARTICIPANTS

Persons with medically documented complicated mild, moderate, and severe TBI.

DESIGN

About 127 participants were randomized in blocks of 6 to an active treatment (AT) group, wherein they completed multiple assessments of ED each week over a 6-week period via a smartphone app, or a WLC group in a parallel group, controlled trial. Participants received weekly support calls to promote self-monitoring of ED using ecological momentary assessment.

MAIN MEASURES

ED (Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7), Satisfaction with Life Scale, and Participation Assessment with Recombined Tools-Objective.

RESULTS

Analysis of the primary study outcome at 6 weeks after initiation of treatment for the AT group did not demonstrate that self-monitoring was effective in decreasing ED as compared to the WLC group. Brief support calls made weekly to promote compliance with self-monitoring were effective in achieving the target number of self-assessments. About 80% of support calls lasted less than 5 minutes. Greater ED was associated with lower life satisfaction and lower participation indicating the importance of addressing ED in persons with TBI.

CONCLUSION

Additional work is needed to develop nontraditional interventions to circumvent barriers that prevent persons with TBI from accessing care for ED. Brief support calls may be an effective, low-cost intervention to improve compliance with self-monitoring or self-management interventions.

Predictors of Multidimensional Profiles of Participation After Traumatic Brain Injury: A TBI Model Systems Study

OBJECTIVES

To identify personal, clinical, and environmental factors associated with 4 previously identified distinct multidimensional participation profiles of individuals following traumatic brain injury (TBI).

SETTING

Community.

PARTICIPANTS

Participants (n = 408) enrolled in the TBI Model Systems (TBIMS) Participation Module, all 1 year or more postinjury.

DESIGN

Secondary data analysis of cross-sectional data from participants in a multicenter TBIMS module study on participation conducted between May 2006 and September 2007. Participants provided responses to questionnaires via a telephone interview at their study follow-up (1, 2, 5, 10, or 15 years postinjury).

MAIN MEASURES

Participants provided responses to personal (eg, demographic), clinical (eg, function), environmental (eg, neighborhood type), and participation measures to create multidimensional participation profiles. Data from measures collected at the time of injury (preinjury questionnaire, injury characteristics) were also included. The primary outcome was assignment to one of 4 multidimensional participation profile groups based on participation frequency, importance, satisfaction, and enfranchisement. The measures used to develop the profiles were: Participation Assessment with Recombined Tools-Objective, Importance, and Satisfaction scores, each across 3 domains (Productivity, Social Relationships, Out and About in the Community) and the Enfranchisement Scale (contributing to one's community, feeling valued by the community, choice and control).

RESULTS

Results of the multinomial regression analysis, with 4 distinct participation profile groups as the outcome, indicated that education, current employment, current illicit drug use, current driving status, community type, and Functional Independence Measure Cognitive at follow-up significantly distinguished participation profile groups. Findings suggest a trend toward differences in participation profile groups by race/Hispanic ethnicity.

CONCLUSIONS

Understanding personal, clinical, and environmental factors associated with distinct participation outcome profiles following TBI may provide more personalized and nuanced guidance to inform rehabilitation intervention planning and/or ongoing clinical monitoring.

A Network Analysis of the PART-O at 1 and 2 Years After TBI: A Veterans Affairs Model Systems Study

OBJECTIVE

The construct of participation after traumatic brain injury (TBI) can be difficult to operationalize. Psychometric network analysis offers an empirical approach to visualizing and quantifying the associations between activities that comprise participation, elucidating the relations among the construct's components without assuming the presence of a latent common cause and generating a model to inform future measurement methods. The current research applied psychometric network analysis to the Participation Assessment with Recombined Tools-Objective (PART-O) within a sample of service members and veterans (SM/Vs) with a history of TBI at 1 and 2 years ( T1 and T2 ) postinjury.

PARTICIPANTS

Participants ( N = 663) were SM/Vs with a history of TBI who completed comprehensive inpatient rehabilitation services at a Department of Veterans Affairs (VA) Polytrauma Rehabilitation Center (PRC).

SETTING

Five VA PRCs.

DESIGN

Cross-sectional, retrospective analysis of data from the VA TBI Model Systems study.

MAIN MEASURES

PART-O.

RESULTS

Network analysis demonstrated that the PART-O structure was generally consistent over time, but some differences emerged. The greatest difference observed was the association between "spending time with friends" and "giving emotional support" to others. This association was more than twice as strong at T2 as at T1 . The "out of the house" item was most central, as demonstrated by dense connections within its own subscale (Out and About) and items in other subscales (ie, Social Relations and Productivity). When examining items connecting the 3 subscales, the items related to giving emotional support, internet use, and getting out of the house emerged as the strongest connectors at T1 , and the internet was the strongest connector at T2 .

CONCLUSION

Providing emotional support to others is associated with greater participation across multiple domains and is an important indicator of recovery. Being out and about, internet use, and engagement in productive activities such as school and work shared strong associations with Social Relations. Network analysis permits visual conceptualization of the dynamic constructs that comprise participation and has the potential to inform approaches to measurement and treatment.

Participation in the Chronic Phase after Traumatic Brain Injury: Variations and Key Predictors

Participation is of major importance for individuals with traumatic brain injury (TBI). This study evaluates participation over a period of one year among persons with TBI in the chronic phase and explores sociodemographic, psychological, and environmental predictors of levels and trajectories of participation. One hundred and twenty home-living survivors of TBI with persistent injury-related consequences at least two years post-injury who participated in a goal-oriented randomized trial were assessed at baseline and after four and twelve months. Linear mixed-effects model analysis was applied to evaluate height, trajectory slope, and predictors of the Participation Assessment with the Recombined Tools-Objective (PART-O) total score and the subscales Productivity, Social Relations, and Being Out and About. Being married, having a higher education, and having good global functioning predicted more frequent participation. Education, executive- and global functions predicted Productivity, while age and being married predicted Social Relations. Participating in the study during the COVID-19 pandemic had a negative impact on Productivity. Participation was relatively stable over 12 months, with a slight decline, but may be influenced by demographic factors and functional consequences. Rehabilitation services should particularly focus on people with TBI living alone with lower levels of global and executive function.

Neighborhood safety, fall indices, physical activity level and social participation restrictions from a population of community-dwelling older adults in Nsukka, Enugu State, Nigeria

BACKGROUND

Restriction in physical activity (PA) and social participation restriction (PR) can be heightened in the presence of fear of fall (FOF), fall experience, and perceived unsafe neighborhood, particularly among older adults. Despite the enormous benefits of social participation and physical activity, many older adults remain vulnerable to participation restriction and this probably accounts for a significant proportion of health challenges for older adults.

OBJECTIVE

This study investigated the relationship between neighborhood safety (NS), fall indices, physical activity, and social participation restriction among older adults from selected communities in Nsukka, Enugu state, Nigeria.

METHODS

This was a cross-sectional survey of 170 recruited via consecutive non-probability sampling techniques. Socio-demographic variables, co-morbidities, and fall prevalence were obtained using a self-administered questionnaire. The study instruments include the PA neighborhood environment scale - Nigeria (PANES-N), PA scale for elderly (PASE), Participation scale (PS), Modified fall efficacy scale (MFES), and Fall risk assessment tool (FRAT) and fall indices.

STATISTICAL ANALYSIS

Descriptive statistics of mean and standard deviations, frequency counts, and percentages were used to analyze the socio-demographic variables, and Inferential statistics of Spearman rank order correlation were used to determine the relationship among the neighborhood safety, fall indices, physical activity level, and participation restrictions.

RESULTS

PR has a negative relationship with NS (r = -0.19, p- 0.01), and fall efficacy (r = -0.52, p- 0.001). However, PR has a positive relationship with fall risk (r = 0.36, p = 0.001).

CONCLUSION

Participation restriction is negatively correlated with neighborhood safety, fall efficacy, and PA. The PR has a positive relationship with fall risk (FR).

Effect of an Individually Tailored and Home-Based Intervention in the Chronic Phase of Traumatic Brain Injury: A Randomized Clinical Trial

Importance

Traumatic brain injury (TBI) can cause long-lasting and heterogeneous difficulties that require an individually tailored approach to rehabilitation. However, high-quality studies of treatment options in the chronic phase of TBI are lacking.

Objective

To evaluate the effect of a home-based, individualized, and goal-oriented rehabilitation intervention in the chronic phase of TBI.

Design, Setting, and Participants

This study was an intention-to-treat parallel-group assessor-blinded randomized clinical trial with 1:1 randomization to an intervention or control group. Participants included adults in southeastern Norway who had sustained a TBI more than 2 years earlier, lived at home, and had ongoing TBI-related difficulties. A population-based sample of 555 individuals were invited, and 120 were included. Participants were assessed at baseline, 4 months, and 12 months after inclusion. Specialized rehabilitation therapists provided the intervention in patients' homes or via video conference and telephone. Data collection was conducted between June 5, 2018, and December 14, 2021.

Interventions

The intervention group received an 8-session individually tailored and goal-oriented rehabilitation program over 4 months. The control group received usual care in their municipality.

Main Outcomes and Measures

Preestablished primary outcomes were disease-specific health-related quality of life (HRQOL; measured by the Quality of Life After Brain Injury [QOLIBRI] overall scale) and social participation (measured by the Participation Assessment With Recombined Tools-Objective [PART-O] social subscale). Preestablished secondary outcomes included generic HRQOL (measured by the EuroQol 5-dimension 5-level [EQ-5D-5L] questionnaire), difficulty with TBI-related problem management (target outcomes; mean severity calculated across 3 main self-identified problem areas that were individually measured using a 4-point Likert scale), TBI symptoms (measured by the Rivermead Post Concussion Symptoms Questionnaire [RPQ]), psychological distress (depression and anxiety; measured by the Patient Health Questionnaire 9-item scale and the Generalized Anxiety Disorder 7-item scale [GAD-7], respectively), and functional competency (measured by the Patient Competency Rating Scale).

Results

Among 120 participants in the chronic phase of TBI, the median (IQR) age was 47.5 (31.0-55.8) years, and the median (IQR) time since injury was 4 (3-6) years; 85 (70.8%) were male. A total of 60 participants were randomized to the intervention group, and 60 were randomized to the control group. Between baseline and 12 months, no significant between-group effects were found for the primary outcomes of disease-specific HRQOL (QOLIBRI overall scale score: 2.82; 97.5% CI, -3.23 to 8.88; P = .30) or social participation (PART-O social subscale score: 0.12; 97.5% CI, -0.14 to 0.38; P = .29). At 12 months, the intervention group (n = 57) had significantly higher generic HRQOL (EQ-5D-5L score: 0.05; 95% CI, 0.002-0.10; P = .04) and fewer symptoms of TBI (RPQ total score: -3.54; 95% CI, -6.94 to -0.14; P = .04) and anxiety (GAD-7 score: -1.39; 95% CI, -2.60 to -0.19; P = .02) compared with the control group (n = 55). At 4 months only, the intervention group (n = 59) had significantly less difficulty managing TBI-related problems (target outcomes mean severity score: -0.46, 95% CI, -0.76 to -0.15; P = .003) compared with the control group (n = 59). No adverse events were reported.

Conclusions and Relevance

In this study, no significant results were observed for the primary outcomes of disease-specific HRQOL or social participation. However, the intervention group reported improvements in secondary outcomes (generic HRQOL and symptoms of TBI and anxiety) that were maintained at 12-month follow-up. These findings suggest that rehabilitation interventions could help patients even in the chronic phase of TBI.

Trial Registration

ClinicalTrials.gov Identifier: NCT03545594.

Comparison of Informational and Educational Resource Provision for Individuals Living With Traumatic Brain Injury Based on Language, Nativity, and Neighborhood

OBJECTIVE

To examine a resource provision program for individuals living with moderate-to-severe traumatic brain injury (TBI), using a comparison of the resources provided across social differences of language, nativity, and neighborhood.

SETTING

The Rusk Rehabilitation TBI Model System (RRTBIMS) collects data longitudinally on individuals from their associated private and public hospitals, located in New York City.

PARTICIPANTS

A total of 143 individuals with TBI or their family members.

DESIGN

An observational study of relative frequency of resource provision across variables of language, nativity, and neighborhood, using related-samples nonparametric analyses via Cochran's Q test.

MAIN MEASURES

Variables examined were language, place of birth, residence classification as medically underserved area/population (MUA), and resource categories.

RESULTS

Results indicate that US-born persons with TBI and those living in medically underserved communities are provided more resources than those who are born outside the United States or reside in communities identified as adequately medically served. Language was not found to be a factor.

CONCLUSION

Lessons learned from this research support the development of this resource provision program, as well as guide future programs addressing the gaps in health information resources for groups negatively impacted by social determinants of health (SDoH). An approach with immigrant participants should take steps to elicit questions and requests, or offer resources explicitly. We recommend research looking at what interpreter strategies are most effective and research on SDoH in relation to the dynamic interaction of variables in the neighborhood setting.

Predictors of Social Participation Outcome after Traumatic Brain Injury Differ According to Rehabilitation Pathways

Social participation (SP) is one of many objectives in the rehabilitation of patients with traumatic brain injury (TBI). Studies on predictors of SP specific to post-acute universally accessible specialized rehabilitation pathways following TBI are scarce. Our objectives were to: 1) characterize SP, as well as a set of pre-injury, injury-related, and post-injury variables in individuals participating in inpatient-outpatient or outpatient rehabilitation pathways within a universally accessible and organized trauma continuum of care; and 2) examine the ability of pre-injury, injury-related, and post-injury variables in predicting SP outcome after TBI according to rehabilitation path. Participants (N = 372) were adults admitted to an inpatient-outpatient rehabilitation pathway or an outpatient rehabilitation pathway after sustaining a TBI between 2016 and 2020, and for whom Mayo-Portland Adaptability Intentory-4 (MPAI-4) outcomes were prospectively obtained at the start and end of rehabilitation. Additional data was collected from medical files. For both rehabilitation pathways, predicted SP outcome was MPAI-4 Participation score at discharge from outpatient rehabilitation. Multiple regression models investigated the predictive value of each variable for SP outcome, separately for each care pathway. Main findings show that for the inpatient-outpatient sample, three variables (education years, MPAI-4 Ability and Adjustment scores at rehabilitation intake) significantly predicted SP outcome, with the regression model accounting for 49% of the variance. For the outpatient sample, five variables (pre-morbid hypertension and mental health diagnosis, total indirect rehabilitation hours received, MPAI-4 Abilities and Adjustment scores at rehabilitation intake) significantly predicted SP outcome, with the regression model accounting for 47% of the variance. In conclusion, different pre-morbid and post-injury variables are involved in predicting SP, depending on the rehabilitation path followed. The predictive value of those variables could help clinicians identify patients more likely of showing poorer SP at discharge and who may require additional or different interventions.

A scoping review to identify process and outcome measures used in acceptance and commitment therapy research, with adults with acquired neurological conditions

Background

Acceptance and Commitment Therapy interventions are increasing in use in neurological populations. There is a lack of information on the measures available.

Purpose

To identify and classify the measures used in Acceptance and Commitment Therapy research studies with adults with acquired neurological conditions.

Methods

PRISMA-ScR guided scoping review. MEDLINE, PsycInfo and CINAHL databases searched (up to date 29/06/2022) with forward and backward searching. All study types included. Extraction of Acceptance and Commitment Therapy process-of-change and health-related outcome measures. Outcomes coded using the Core Outcome Measures in Effectiveness Trials (COMET) taxonomy.

Results

Three hundred and thirty three papers found on searching. Fifty four studies included and 136 measurement tools extracted. Conditions included multiple sclerosis, traumatic brain injury and stroke. Thirty-eight studies measured processes of change, with 32 measures extracted. The process measure most often used was the Acceptance and Action Questionnaire ( n = 21 studies). One hundred and four health-related outcome measures extracted. Measures exploring quality of life, health status, anxiety and depression occurred most frequently, and were used in all included neurological conditions. COMET domains most frequently coded were emotional functioning/well-being ( n = 50), physical functioning ( n = 32), role functioning ( n = 22) and psychiatric ( n = 22).

Conclusions

This study provides a resource to support future identification of candidate measures. This could aid development of a Core Outcome Set to support both research and clinical practice. Further research to identify the most appropriate and relevant targets and tools for use in these populations should include expert consensus, patient, carer and public involvement and psychometric examination of measures.

A Study Protocol for a Multisite Randomized Controlled Trial of an Intervention to Improve Outcomes After Spinal Cord Injury

Background

The consequences of spinal cord injury (SCI) can place significant demands on an individual's coping mechanisms. Interventions to promote psychological adjustment and coping are often included in inpatient rehabilitation programs; however, following discharge, many individuals with SCI do not receive ongoing counseling or education about psychological adjustment to disability. Effective postacute treatment models are needed to help individuals with SCI build skills that help them adapt to the stresses associated with a chronic physical disability, alleviate the consequences of anxiety and depression, and enhance subjective well-being.

Objectives

To describe the protocol for a randomized clinical trial (RCT) of a 6-week intervention designed to improve psychosocial outcomes after SCI.

Methods

To test efficacy and replicability of the intervention, we designed a three-arm, multisite RCT with assessments conducted at six time points. Our primary hypothesis is that participants in the Group arm will report greater improvements in psychosocial outcomes than participants who complete the intervention individually via video (Individual arm) or those who do not receive the intervention (Control arm). We also hypothesize that participants in the Group arm will maintain greater improvements in psychosocial outcomes longer than those in the individual or control arms.

Conclusion

Results of the RCT will be presented and published to professionals and consumers, and intervention training and materials will be made available upon request.

Social integration: A concept analysis

BACKGROUND

In recent decades, social isolation has been increasingly linked to serious health conditions. However, social integration (SI) is a complex concept that has not been systematically explored or defined in nursing. It is essential for nurses and healthcare providers to have a clearer concept of SI to better provide holistic care to support optimal health.

PURPOSE

This concept analysis aimed to clarify the concept of SI in health research and to identify attributes, antecedents, and consequences of the concept of SI to enhance understanding of the concept and its implications for human health.

METHODS

Walker and Avant's framework was used as the methodology for the concept analysis of SI. A literature search using PubMed, CINAHL, and Embase databases on SI was conducted with keywords: "integration," "social integration," "social relationships," "social participation," "community integration," "socialization." Studies included in the search were published from 2001 to 2021.

RESULTS

SI is affected by multidimensional individual, societal, and environmental factors. Defining attributes are productive activities, social relationships, community engagement, and leisure activities. SI is effective in promoting multiple aspects of health as well as healthy aging and overall well-being.

CONCLUSION

The analysis contributes to a comprehensive and fundamental understanding of SI and contributes to helping nurses better understand patients' circumstances that promote or inhibit SI. This knowledge will support the development of interventions that support optimal health and well-being, in assisting patients to remain integrated or reintegrate into society during and following an illness or injury.

Patient-Reported Problem Areas in Chronic Traumatic Brain Injury

OBJECTIVE

The aims of this study were to (1) assess self-reported main problem areas reported by patients with traumatic brain injury (TBI) and their family members in the chronic phase, and (2) compare the self-prioritized problems with difficulties captured by questionnaires and neuropsychological screening through linking to the International Classification of Functioning, Disability and Health (ICF).

SETTING

Outpatient clinic at the Oslo University Hospital, Norway.

PARTICIPANTS

In total, 120 patients with TBI were recruited, of whom, 78 had a participating family member. Eligibility criteria were a clinical TBI diagnosis with verified intracranial injury, living at home, aged 18 to 72 years, 2 years or more postinjury, and experiencing perceived TBI-related difficulties, reduced physical and mental health, or difficulties with participation in everyday life. Patients with severe psychiatric or neurological disorders or inability to participate in goal-setting processes were excluded.

DESIGN

Cross-sectional.

MAIN MEASURES

Target Outcomes, that is, 3 main TBI-related problem areas reported by patients and family members, collected in a semistructured interview; standardized questionnaires of TBI-related symptoms, anxiety, depression, functioning, and health-related quality of life; neuropsychological screening battery.

RESULTS

Target Outcomes were related to cognitive, physical, emotional, and social difficulties. Target Outcomes were linked to 12 chapters and 112 distinct categories in the ICF, while standardized measures only covered 10 chapters and 28 categories. Some aspects of post-TBI adjustment were found to be insufficiently covered by the ICF classification, such as identity issues, lack of meaningful activities, and feeling lonely.

CONCLUSION

The Target Outcomes approach is a useful assessment method in a population with chronic TBI. The standardized questionnaires capture the spectrum of problems, whereas the Target Outcomes approach captures the prioritized individual problems hindering everyday life after TBI. While the standardized measures are an irreplaceable part of the assessment, Target Outcomes ensures patient involvement and may help clinicians better tailor relevant rehabilitation efforts.

Cognitive functioning following traumatic brain injury in older adults: associations with social participation and health-related quality of life

OBJECTIVES

To describe objective and subjective cognitive functioning older adults who sustained TBI at age 65 or over, and to determine whether cognitive functioning is associated with health-related quality of life (HRQoL) and social participation.

METHOD

The sample consisted of 40 individuals with TBI (mean age = 73 years; 65% mild, 35% moderate/severe TBI). On average 15 months post-injury, they completed measures of objective and subjective cognitive functioning (Telephone Interview for Cognitive Status-Modified, Alphaflex, Medical Outcomes Study Cognitive Functioning Scale), HRQoL (SF-12), and social participation (Participation Assessment with Recombined Tools - Objective).

RESULTS

Mean score for objective cognitive functioning was lower than normative values, while mean scores for executive functioning and subjective cognitive functioning were comparable to normative values. There was no relationship between objective and subjective measures. Subjective cognitive functioning and (to a lesser extent) global objective cognitive functioning were significantly associated with mental HRQoL but not with physical HRQoL or social participation.

CONCLUSION

These results underscore the importance of considering both subjective perception and objective performance when assessing and intervening on cognition to promote better mental HRQoL in older adults with TBI.

Changes in social participation between 1 and 2 years following moderate-severe traumatic brain injury

Objective

To examine patterns of change in social participation in persons with moderate-severe traumatic brain injury (msTBI) between 1 and 2 years postinjury, and predictors of observed change.

Participants

375 participants with msTBI enrolled in a single TBI Model System site.

Measures and Methods

The dependent variable in a linear regression was a reliable change score for the Social Relations subscale of the Participation Assessment with Recombined Tools-Objective, administered at 1- and 2-year follow-ups. Predictors of change included demographics, injury severity, social and functional status at Year 1, and changes in function and life circumstances between years 1 and 2.

Results

Social participation status did not change substantially for 34 of the sample, while approximately equal proportions of the remainder improved or declined. The regression model was significant (p < 0.001). Improvement was predicted by private vs. public insurance and decline was predicted by a reduction in the FIM functional outcome measure from year 1 to year 2. Marginal predictors included education (higher levels predicting improvement) and year 1 marital status (single status predicting decline).

Conclusions

Longitudinal change in social participation in the chronic phase of msTBI deserves further study, with attention to resource limitations and the impact of changes in functional status.

Participation Predicts Cognitive Functioning in Older Adults Using the PART-O Transformed Scores Systems

Participation has been shown to be a protective factor for cognition in older adults, but instruments to assess it are limited. The main objective was to determine the validity of two scoring systems (direct vs transformed) for the Participation Assessment with Recombined Tools-Objective (PART-O) by applying structural equation modeling to the relationship between the subscales and the cognitive functions, in a sample of 245 people over 60 years of age. The transformed scores model showed stronger relationships and larger explained variance in overall participation (55.4% vs 37.4%), especially in the Social Relations subscale (31.4% vs 14.6%). Participation was a direct predictor of cognitive functions in both models. Age and depression inversely influenced participation in the transformed scores model. The proposed score transformation for the PART-O provides a more appropriate measurement of the older adults' participation. Participation has a mediating role in the relationship between cognition and both age and depression.

Psychosocial and Functional Predictors of Depression and Anxiety Symptoms in Veterans and Service Members With TBI: A VA TBI Model Systems Study

OBJECTIVE

To identify psychosocial and functional predictors of self-reported depression and anxiety symptoms at year 2 following traumatic brain injury (TBI).

SETTING

Five Department of Veterans Affairs (VA) Polytrauma Rehabilitation Centers (PRCs) within the TBI Model Systems (TBIMS).

PARTICIPANTS

A total of 319 service members/veterans enrolled in VA TBIMS who were eligible for and completed both 1- and 2-year follow-up evaluations.

DESIGN

Secondary analysis from multicenter prospective longitudinal study.

MAIN MEASURES

Demographic, injury-related, military, mental health, and substance use variables. Questionnaires included the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and Neurobehavioral Symptom Inventory. Rating scales included the Participation Assessment with Recombined Tools-Objective and Disability Rating Scale.

RESULTS

The final sample was largely male (96%) and predominantly White (65%), with a median age of 27 years. In unadjusted analyses, pre-TBI mental health treatment history and year 1 employment status, community activity, sleep difficulties, and self-reported depression and anxiety symptoms were associated with year 2 PHQ-9 scores; pre-TBI mental health treatment history and year 1 community activity, social contact, problematic substance use, sleep difficulties, and self-reported depression and anxiety symptoms were associated with year 2 GAD-7 scores. In multivariable analyses, only year 1 community activity and depression symptoms uniquely predicted year 2 PHQ-9 scores, and only year 1 employment status, community activity, problematic substance use, and anxiety symptoms uniquely predicted year 2 GAD-7 scores.

CONCLUSION

Anxiety and depression commonly occur after TBI and are important treatment targets. Some predictors (eg, participation and substance use) are modifiable and amenable to treatment as well. Early identification of anxiety and depression symptoms is key.

Race/Ethnicity and Community Participation Among Veterans and Service Members With Traumatic Brain Injury: A VA Traumatic Brain Injury Model Systems Study

OBJECTIVE

To examine racial/ethnic disparities in community participation among veterans and active duty service members with traumatic brain injury (TBI).

SETTING

Five Department of Veterans Affairs (VA) TBI Model Systems (TBIMS) Polytrauma Rehabilitation Centers (PRCs). Participants: Three hundred forty-two community-dwelling adults (251 White, 34 Black, and 57 Hispanic) with TBI enrolled in the VA TBIMS National Database who completed a 1-year follow-up interview. Mean age was 38.6 years (range, 19-84 years).

DESIGN

Cross-sectional analysis of a prospective observational cohort study. Main Measures: Community participation at 1 year postinjury assessed by 3 domains of the Participation Assessment with Recombined Tools-Objective (PART-O): Out & About, Productivity, and Social Relations.

RESULTS

Significant differences were observed among race/ethnicity groups in PART-O Productivity and Out & About domains without controlling for relevant participant characteristics; Productivity scores were significantly higher for non-Hispanic Black than for non-Hispanic White participants (t = 2.40, P = .0169). Out & About scores were significantly higher for Hispanic than for non-Hispanic White participants (t = 2.79, P = .0056). However, after controlling for demographic, injury severity, and 1-year follow-up characteristics, only differences in the Out & About domain remained statistically significant (t = 2.62, P = .0094), with scores being significantly higher for Hispanics than for non-Hispanic Whites.

CONCLUSIONS

The results, which differ from findings from studies conducted in non-VA healthcare settings where there are greater racial/ethnic disparities in participation outcomes, could reflect differences between military and civilian samples that may reduce disparities.

Detecting change in community participation with the Enfranchisement scale of the community participation indicators

OBJECTIVE

This study determined the sensitivity to change of the Enfranchisement scale of the Community Participation Indicators in people with stroke.

DATA SOURCES

We analyzed data from two studies of participants with stroke: an intervention study and an observational study.

MAIN MEASURES

The Enfranchisement Scale contains two subscales: the Importance subscale (feeling valued by and contributing to the community; range: 14-70) and the Control subscale (choice and control: range: 13-64).

DATA ANALYSIS

Assessments were administered 6 months apart. We calculated minimum detectable change and minimal clinically important difference.

RESULTS

The Control subscale analysis included 121 participants with a mean age of 61.2 and mild-moderate disability (Functional Independence Measure, mean = 97.9, SD = 24.7). On the Control subscale, participants had a mean baseline score of 51.4 (SD = 10.4), and little mean change (1.3) but with large variation in change scores (SD = 11.5). We found a minimum detectable change of 9 and a minimum clinically important difference of 6. The Importance subscale analysis included 116 participants with a mean age of 60.7 and mild-moderate disability (Functional Independence Measure, mean = 98.9, SD = 24.5). On the Importance subscale, participants had a mean baseline score of 44.1 (SD = 12.7), and again demonstrated little mean change (1.08) but with large variation in change scores (SD = 12.6). We found a minimum detectable change of 11 and a minimum clinically important difference 7.

CONCLUSIONS

The Control subscale required 9 points of change, and the Importance subscale required 11 points of change, to achieve statistically and clinically meaningful changes, suggesting adequate sensitivity to change.

Do state supports for persons with brain injury affect outcomes in the 5 Years following acute rehabilitation?

While a substantial literature has examined the effects of individual and family-level factors on outcomes following traumatic brain injury (TBI), minimal attention has been directed to the potential influence of the larger environmental context on outcomes. The purpose of the current study was to investigate the effects of state-level resources and supports as an environmental factor influencing long-term outcomes from TBI using data from the TBI Model Systems. We examined the effects of U.S. state supports that specifically target people with TBI (federal funding for state brain injury programs, per capita revenue generated by brain injury trust funds, and expenditures for brain injury specific Medicaid waivers) and one measure of the relative quality of a state's Long-Term Services and Supports (LTSS) for all people with disabilities. The primary hypothesis was that community participation, global functioning, and life satisfaction will be higher on average among people with TBI living in states with more brain injury specific programs and resources and better LTSS. The results of multilevel and fixed-effects modeling indicated that state supports have a small but significant impact on participation and life satisfaction. The most consistent finding indicated that states with better LTSS had higher levels of community participation and life satisfaction on average for people with TBI over and above individual-level differences and fluctuations in these outcomes over time. There was some indication that more brain injury specific supports also result in better participation in the community. These findings deserve replication and extension to include other environmental factors, particularly community level characteristics, that might affect outcomes from TBI.

Assessment of Participation within the International Classification of Functioning, Disability, and Health (ICF): The Turkish Validity and Reliability of the Participation Scale

Objective

The aim of the study was to investigate the reliability and validity of the Turkish version of the Participation Scale (P-Scale).

Methods

A total of 152 students, with a mean age of 20.27 ± 2.19, participated in the study. Sociodemographic information (age, gender, and family income) was recorded; all participants completed the P-Scale twice with a 15-day interval. Translation and cross-cultural adaptation were performed to analyze the validity and reliability of the P-Scale. Cronbach's alpha and McDonald's alpha were used for scale reliability statistics and explanatory (EFA) and confirmatory (CFA) factor analysis; Mardia's multivariate normality and assumption tests were used for the validity of the scale. The factor extraction methods were minimum rank factor analysis in EFA and weighted least squares mean and variance adjusted estimator polychoric correlation matrix in CFA.

Results

Internal consistency of the scale was found good with Cronbach's alpha (0.852) and excellent with McDonald's alpha (0.924). The EFA and CFA resulted in two-factored structure, with the explained variance found to be higher than 30%.

Conclusions

Analysis demonstrated that the P-Scale had a satisfactory level of reliability and validity in Turkish university students.

Aging with Traumatic Brain Injury: Deleterious Effects of Injury Chronicity Are Most Pronounced in Later Life

Understanding the effects of age on longitudinal traumatic brain injury (TBI) outcomes requires attention to both chronic and evolving TBI effects and age-related changes in health and function. The present study examines the independent and interactive effects of aging and chronicity on functional outcomes after TBI. We leveraged a well-defined cohort of individuals who sustained a moderate/severe TBI and received acute inpatient rehabilitation at specialized centers with high follow up rate as part of their involvement in the TBI Model Systems longitudinal study. We selected individuals at one of two levels of TBI chronicity (either 2 or 10 years post-injury) and used an exact matching procedure to obtain balanced chronicity groups based on age and other characteristics (N = 1993). We found that both older age and greater injury chronicity were related to greater disability, reduced functional independence, and less community participation. There was a significant age by chronicity interaction, indicating that the adverse effects of greater time post-injury were most pronounced among survivors who were age 75 or older. The inflection point at roughly 75 years of age was corroborated by post hoc analyses, dividing the sample by age at 75 years and examining the interaction between age group and chronicity. These findings point to a need for provision of rehabilitation services in the chronic injury period, particularly for those who are over 75 years old. Future work should investigate the underlying mechanisms of this interaction towards the goal of developing interventions and models of care to promote healthy aging with TBI.

Quasi-Contextualized Speech Treatment in Traumatic Brain Injury Inpatient Rehabilitation: Effects on Outcomes During the First Year After Discharge

OBJECTIVE

To evaluate the effect of providing quasi-contextualized speech therapy, defined as metacognitive, compensatory, or strategy training applied to cognitive and language impairments to facilitate the performance of future real-life activities, on functional outcomes up to 1 year following traumatic brain injury (TBI).

SETTING

Acute inpatient rehabilitation.

PARTICIPANTS

Patients enrolled during the TBI-Practice-Based Evidence (TBI-PBE) study (n = 1760), aged 14 years or older, who sustained a severe, moderate, or complicated mild TBI, received speech therapy in acute inpatient rehabilitation at one of 9 US sites, and consented to follow-up 3 and 9 months postdischarge from inpatient rehabilitation.

DESIGN

Propensity score methods applied to a database consisting of multisite, prospective, longitudinal observational data.

MAIN MEASURES

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

RESULTS

When at least 5% of therapy time employed quasi-contextualized treatment, participants reported better community participation during the year following discharge. Quasi-contextualized treatment was also associated with better motor and cognitive function at discharge and during the year after discharge. The benefit, however, may be dependent upon a balance of rehabilitation time that relied on contextualized treatment.

CONCLUSIONS

The use of quasi-contextualized treatment may improve outcomes. Care should be taken, however, to not provide quasi-contextualized treatment at the expense of contextualized treatment.

Refining understanding of life satisfaction in elderly persons with traumatic brain injury using age-defined cohorts: a TBI model systems study

OBJECTIVE

Examine effects of age cohort on post-injury life satisfaction in elderly persons with TBIDesign: Retrospective cohortSetting: TBI Model Systems centers.

PARTICIPANTS

5,109 elderly participants with TBI in the TBI Model Systems National DatabaseInterventions: Not applicableMain Outcome Measures: Demographics, injury characteristics and cause, outcomes, age at time of analysis, time to follow commands, maximum follow-up period, and scores on the Satisfaction With Life Scale (SWLS) and Participation Assessment with Recombined Tools-Objective (PART-O) scores at 1, 2, 5, or 10 years post-injury.

RESULTS

Life satisfaction post-TBI across groups increased with age. The young-old sub-group demonstrated the poorest life satisfaction outcomes, while the oldest sub-group experienced greatest life satisfaction. In contrast, participation decreased with age.

CONCLUSIONS

Findings show diversity in satisfaction with life following moderate to severe TBI for three elderly age-cohorts. Differences may be due to variations in generation-based lived experience, in perceived meaningfulness of participation, could echo prior evidence of greater resilience in the oldest group, or could reflect bias within the study sample. Further research into between- and within- differences for elderly TBI age cohorts is needed to more precisely meet their needs for physical and functional rehabilitation as well as psychological supports.

Primary Language and Participation Outcomes in Hispanics With Traumatic Brain Injury: A Traumatic Brain Injury Model Systems Study

OBJECTIVE

To examine the relationship between primary language and participation outcomes in English- and Spanish-speaking persons with complicated mild to severe traumatic brain injury (TBI) at 1 year post-injury.

SETTING

Community following discharge from inpatient rehabilitation.

PARTICIPANTS

A total of 998 Hispanic participants with outcomes available at year 1 follow-up; 492 (49%) indicated English as their primary language and 506 (51%) indicated Spanish as their primary language.

DESIGN

Prospective, multicenter, cross-sectional, observational cohort study.

MAIN MEASURES

Community participation at 1 year post-injury was assessed by 3 domains of the Participation Assessment with Recombined Tools-Objective (PART-O): Out and About, Productivity, and Social Relations.

RESULTS

Unadjusted group comparisons showed better participation outcomes for English versus Spanish speakers for all PART-O domains and for the Balanced Total score. After controlling for relevant covariates, English-speaking participants had significantly better PART-O Balanced Total scores and better scores on the Social Relations domain, although effect sizes were small.

CONCLUSIONS

Hispanic persons with TBI whose primary language is Spanish may require greater assistance integrating socially back into their communities after TBI. However, potential cultural differences in value placed on various social activities must be considered. Potential cultural bias inherent in existing measures of participation should be investigated in future studies.

Subjective factors of depressive symptoms, ambulation, pain, and fatigue are associated with physical activity participation in cardiac arrest survivors with fatigue

AIM

This study aimed to examine the associations between participation in physical activities and objective and subjective factors modifiable by rehabilitation in cardiac arrest survivors with fatigue.

METHODS

Participants in a clinical feasibility study (N = 19) completed several subjective (patient-reported) and objective outcome measures on one occasion only. The associations between an individual's level of participation in physical activities (Participation Objective Participation Subjective) and their levels of cognition (Computer Assessment of Mild Cognitive Impairment), body movement (Keitel Functional Test), depressive symptoms (Center for Epidemiologic Studies Depression Scale), ambulation and pain (Health Utilities Index Mark 3), and fatigue impact (Modified Fatigue Impact Scale) were explored. Pearson's correlation coefficientr was calculated for all associations, except for body movement (Spearman's correlation coefficient rs ).

RESULTS

As hypothesized, we found weak-to-moderate, positive associations between participation in physical activities and objective factors of cognition (r = 0.370) and body movement (rs  = 0.414) and a subjective factor of ambulation ability (r = 0.501). We found moderate, negative associations between participation in physical activities and subjective factors of depressive symptoms (r=-0.590), pain (r=-0.495), physical fatigue impact (r=-0.629), cognitive fatigue impact (r=-0.591), and psychosocial fatigue impact (r=-0.557).

CONCLUSION

The moderate, negative and positive associations between participation in physical activities and subjective factors suggest that subjective complaints of depressive symptoms, ambulation ability, pain, and fatigue impact may be important factors when seeking to improve participation in physical activities. In particular, addressing physical and cognitive endurance as well as perceptions of fatigue may hold the key to increasing physical activity in cardiac arrest survivors with fatigue.

Improving transition from inpatient rehabilitation following traumatic brain injury: Protocol for the BRITE pragmatic comparative effectiveness trial

Moderate to severe traumatic brain injury (TBI) is a common cause of long-term disability. Due to challenges that include inconsistent access to follow-up care, persons with TBI being discharged from inpatient rehabilitation facilities (IRFs) are at risk for rehospitalization, poor reintegration into the community, family stress, and other unfavorable outcomes resulting from unmet needs. In a six-center randomized pragmatic comparative effectiveness study, the BRITE trial (Brain Injury Rehabilitation: Improving the Transition Experience, ClinicalTrials.govNCT03422276), we compare the effectiveness of two existing methods for transition from IRF to community living or long-term nursing care. The Rehabilitation Discharge Plan (RDP) includes patient/family education and referrals for continued care. The Rehabilitation Transition Plan (RTP) provides RDP plus individualized, manualized care management via phone or videoconference, for 6 months. Nine hundred patients will be randomized (1:1) to RDP or RTP, with caregivers also invited to participate and contribute caregiver-reported outcomes. Extensive stakeholder input, including active participation of persons with TBI and their families, has informed all aspects of trial design and implementation planning. We hypothesize that RTP will result in better patient- and caregiver-reported outcomes (societal participation, quality of life, caregiver well-being) and more efficient use of healthcare resources at 6-months (primary outcome) and 12-months post-discharge, compared to RDP alone. Planned analyses will explore which participants benefit most from each transition model. With few exclusion criteria and other pragmatic features, the findings of this trial are expected to have a broad impact on improving transitions from inpatient TBI rehabilitation. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT03422276.

Social Media and People With Traumatic Brain Injury: A Metasynthesis of Research Informing a Framework for Rehabilitation Clinical Practice, Policy, and Training

Purpose The aim of the study was to investigate the experiences of people with traumatic brain injury (TBI) and rehabilitation professionals in use of social media after TBI. Design Metasynthesis of a multilevel mixed-methods research design was used in the study. Method A qualitative metasynthesis of (a) evidence in the literature regarding the use of communication technologies and social media after TBI, (b) Twitter data and network analysis, (c) interviews with people with TBI (n = 13), (d) focus groups with TBI rehabilitation professionals (n = 11), and (e) a review of current guidance on safe use of social media was conducted. Results People with TBI adopt a trial-and-error approach to using social media. Their meaningful use and a sense of connection enable them to develop social media mastery. TBI rehabilitation professionals' concerns regarding potential risks associated with using social media might lead them to restrict social media use during rehabilitation. Conclusions Access to proactive training in social media use and a supportive network of rehabilitation professionals, family, and friends can enable people with TBI to develop social media mastery through working collaboratively on social media goals. This metasynthesis of research culminates in an evidence-based protocol for assessing and supporting a person with TBI's social media goals to guide clinical practice and future research in the field.

Negative Attribution Bias and Related Risk Factors After Brain Injury

OBJECTIVE

In participants with traumatic brain injury (TBI) and peer controls, examine (1) differences in negative attributions (interpret ambiguous behaviors negatively); (2) cognitive and emotional factors associated with negative attributions; and (3) negative attribution associations with anger responses, life satisfaction, and participation.

SETTING

Two TBI outpatient rehabilitation centers.

PARTICIPANTS

Participants with complicated mild to severe TBI (n = 105) and peer controls (n = 105).

DESIGN

Cross-sectional survey study.

MAIN MEASURES

Hypothetical scenarios describing ambiguous behaviors were used to assess situational anger and attributions of intent, hostility, and blame. Executive functioning, perspective taking, emotion perception and social inference, alexithymia, aggression, anxiety, depression, participation, and life satisfaction were also assessed.

RESULTS

Compared with peer controls, participants with TBI rated behaviors significantly more intentional, hostile, and blameworthy. Regression models explained a significant amount of attribution variance (25%-43%). Aggression was a significant predictor in all models; social inference was also a significant predictor of intent and hostility attributions. Negative attributions were associated with anger responses and lower life satisfaction.

CONCLUSION

People with TBI who have higher trait aggression and poor social inferencing skills may be prone to negative interpretations of people's ambiguous actions. Negative attributions and social inferencing skills should be considered when treating anger problems after TBI.

Brain Injury Functional Outcome Measure (BI-FOM): A Single Instrument Capturing the Range of Recovery in Moderate-Severe Traumatic Brain Injury

OBJECTIVE

To develop a measure of global functioning after moderate-severe TBI with similar measurement precision but a longer measurement range than the FIM.

DESIGN

Phase 1: retrospective analysis of 5 data sets containing FIM, Disability Rating Scale, and other assessment items to identify candidate items for extending the measurement range of the FIM; Phase 2: prospective administration of 49 candidate items from phase 1, with Rasch analysis to identify a unidimensional scale with an extended range.

SETTING

Six TBI Model System rehabilitation hospitals.

PARTICIPANTS

Individuals (N=184) with moderate-severe injury recruited during inpatient rehabilitation or at 1-year telephone follow-up.

INTERVENTIONS

Participants were administered the 49 assessment items in person or via telephone.

MAIN OUTCOME MEASURES

Item response theory parameters: item monotonicity, infit/outfit statistics, and Factor 1 variance.

RESULTS

After collapsing misordered rating categories and removing misfitting items, we derived the Brain Injury Functional Outcome Measure (BI-FOM), a 31-item assessment instrument with high reliability, greatly extended measurement range, and improved unidimensionality compared with the FIM.

CONCLUSIONS

The BI-FOM improves global measurement of function after moderate-severe brain injury. Its high precision, relative lack of floor and ceiling effects, and feasibility for telephone follow-up, if replicated in an independent sample, are substantial advantages.

Unmet Rehabilitation Needs Indirectly Influence Life Satisfaction 5 Years After Traumatic Brain Injury: A Veterans Affairs TBI Model Systems Study

OBJECTIVE

To describe the association between unmet rehabilitation needs and life satisfaction 5 years after traumatic brain injury (TBI).

DESIGN

Prospective observational cohort.

SETTING

Five Veterans Affairs (VA) Polytrauma Rehabilitation Centers.

PARTICIPANTS

VA TBI Model Systems participants (N=301); 95% male; 77% white; average age, 39±14y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Satisfaction With Life Scale (SWLS).

RESULTS

Average SWLS score was 22±8. Univariable analyses demonstrated several statistically significant predictors of life satisfaction, including employment status, participation, psychiatric symptom severity, past year mental health treatment, and total number of unmet rehabilitation needs (all P<.05). Multivariable analyses revealed that depression and participation were each associated with life satisfaction. An ad hoc mediation model suggested that unmet rehabilitation needs total was indirectly related to life satisfaction. Total unmet rehabilitation needs ranged from 0-21 (mean, 2.0±3.4). Correlational analyses showed that 14 of the 21 unmet rehabilitation needs were associated with life satisfaction.

CONCLUSIONS

Findings support the need for rehabilitation engagement in later stages of TBI recovery. Ongoing assessment of and intervention for unmet rehabilitation needs in the chronic phase of recovery have the potential to mitigate decline in life satisfaction.

Heterogeneity in Temporal Ordering of Depression and Participation After Traumatic Brain Injury

OBJECTIVE

To examine heterogeneity in the temporal patterns of depression and participation over the first 2 years post traumatic brain injury (TBI).

DESIGN

Observational prospective longitudinal study.

SETTING

Inpatient rehabilitation centers, with 1- and 2-year follow-up conducted primarily by telephone.

PARTICIPANTS

Persons with TBI (N=2307) enrolled in the Traumatic Brain Injury Model Systems database, followed at 1 and 2 years post injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Patient Health Questionnaire-9 (PHQ-9) and Participation Assessment With Recombined Tools-Objective (PART-O).

RESULTS

Using latent class modeling we examined heterogeneity in the longitudinal relationship between PHQ-9 and PART-O. The identified 6 classes were most distinct in terms of (1) level of PHQ-9 score and (2) association between the year 1 PART-O score and year 2 PHQ-9 score. For most participants, PART-O at year 1 predicted PHQ-9 at year 2 more than the reverse. However, there was a subgroup of participants that demonstrated the reverse pattern, PHQ-9 predicting later PART-O, who were on average, older and in the "other" employment category.

CONCLUSIONS

Results suggest that links between participation and depression are stronger for some people living with TBI than for others and that variation in the temporal sequencing of these 2 constructs is associated with demographic characteristics. These findings illustrate the value in accounting for population heterogeneity when evaluating temporal among outcome domains.

Race/Ethnicity and Informal Caregiver Burden After Traumatic Brain Injury: A Scoping Study

Background: Informal caregivers for persons with traumatic brain injury (TBI) face a range of unique issues, and racial/ethnic group differences in caregiver challenges are poorly understood. We undertook a scoping study of peer-reviewed literature to assess the quantity and quality of available research describing differences by race/ethnicity in informal caregiving roles and burden.

Methods: Using Arksey and O'Malley's framework and guided by the Preferred Reporting Items of Systematic Reviews and Meta-analyses Extension for Scoping Reviews, we conducted electronic searches of PubMed, CINAHL, PsycARTICLES, PsycINFO, Social Work Abstracts, Embase, and Scopus to identify peer-reviewed studies that examined TBI informal caregiver burden and reported on the influences of race or ethnicity.

Results: Among 4523 unique publications identified and screened, 11 studies included sufficient race/ethnicity data and were included in the analysis. Of these, six studies described civilian populations and five described military Veterans Affairs (VA). Included studies revealed that nonwhite caregivers and white caregivers use different approaches and coping strategies in their caregiving role. Some studies found differences in caregiver burden by race or ethnicity, others did not. Most were limited by a small sample size and overdependence on assessment tools not validated for the purposes or populations for which they were used. This was particularly true for race/ethnicity as a factor in TBI caregiver burden in VA groups, where essential characteristics moderate the association of race/ethnicity with socioeconomic factors.

Conclusions: This scoping study highlights the paucity of information on race/ethnicity as a factor in TBI caregiver burden and roles, and suggests that innovative and alternative approaches to research are needed to explore needed changes in practice.

Mortality Secondary to Unintentional Poisoning after Inpatient Rehabilitation among Individuals with Moderate to Severe Traumatic Brain Injury

Studies have shown reduced life expectancy following moderate-severe traumatic brain injury (TBI) with death from unintentional poisoning (UP) being 11 times higher following TBI than in the general population. The characteristics of those who die of unintentional poisoning are compared with the characteristics of those who die of other causes (OC) in a retrospective cohort who received inpatient rehabilitation following TBI and enrolled in the TBI Model Systems National Database between 1989 and 2017 (n = 15,835 cases with 2,238 deaths recorded). Seventy-eight cases (3.5%) of deaths were the result of UP, 76% were the result of OC, and 20.5% were from an unknown cause. Among the UP deaths, 90% involved drugs (of these, 67% involved narcotic drugs and 14% involved psychostimulants), and 8% involved alcohol. Age-adjusted risk for UP death was associated with: white/non-Hispanic race/ethnicity, living alone, non-institutionalization, pre- and post-injury illicit drug use and alcohol/drug problem use, any alcohol use at last follow-up, better Functional Independence Measure^TM (FIM) scores, history of arrest, moderate disability (vs. severe disability or good recovery), less supervision needed, and greater anxiety. Adults who receive inpatient rehabilitation for TBI who die from UP are distinguishable from those who die of OC. Factors such as pre-injury substance use in the context of functional independence may be regarded as targets for prevention and/or intervention to reduce substance use and substance-related mortality among survivors of moderate-severe TBI. The current findings may have implications for medical care, surveillance, prevention, and health promotion.

A randomized controlled trial of acceptance and commitment therapy for psychological distress among persons with traumatic brain injury

Psychological distress is common in persons with traumatic brain injury (TBI) but treatments remain underdeveloped. This randomized controlled trial of Acceptance and Commitment Therapy (ACT) was designed to address this gap. Ninety-three persons with medically-documented complicated mild to severe TBI, normal-to-mildly impaired memory, and clinically significant psychological distress in the chronic phase of recovery were randomized to receive eight weeks of ACT (manualized with adaptations to address TBI-related cognitive impairments) or a single session of needs assessment, brief counseling/education, and referral. The ACT group showed significantly greater reduction of psychological distress (Brief Symptom Inventory 18) and demonstrated improvements in psychological flexibility and commitment to action (Acceptance and Action Questionnaire-II (AAQ-II) scores). The number of treatment responders (post-treatment BSI 18 GSI T scores <63) was larger in the ACT group than in the control group. Entry of AAQ-II scores into the model of between-group differences in BSI 18 GSI T scores indicated that core ACT processes explained the variance in treatment group outcomes. Provision of ACT reduces psychological distress in persons with TBI in the chronic phase of recovery when adaptations are made to accommodate TBI-related cognitive impairments. Additional clinical trials with a structurally equivalent control group are needed.

Traumatic brain injury-needs and treatment options in the chronic phase: Study protocol for a randomized controlled community-based intervention

BACKGROUND

Traumatic brain injury (TBI) is often associated with life-long medical, cognitive, emotional, and behavioral changes. Although long-lasting disabilities are expected, research on effective treatment options in the chronic phase of TBI is scarce.

METHODS/DESIGN

This study protocol describes a randomized controlled trial (RCT) aimed at evaluating the effectiveness of a goal-oriented and community-based intervention for increasing community integration, quality of life, and functional independence in the chronic phase of complicated mild to severe TBI. Participants will be recruited from Oslo University Hospital, Norway. Patients aged 18-72 years living at home with MRI/CT-verified intracranial abnormalities, a TBI diagnosis, a time since injury of ≥ 2 years, and who experience either current TBI-related problems or restrictions in community integration will be included. The 120 participants will be randomized 1:1 to either (a) an intervention group, which will receive an in-home intervention program over 4 months, or (b) a control group receiving standard care in the municipalities. The intervention will consist of six home visits and two telephone contacts with a rehabilitation professional. A SMART-goal approach will be adopted to target the individual's self-reported TBI difficulties in everyday life. Primary outcomes will be self-reported quality of life and participation. Secondary outcomes include symptom burden, emotional functioning, and clinician-assessed global outcome and need for rehabilitation services. Outcomes will be evaluated at baseline and 4-5 and 12 months after baseline. Caregiver burden and general health will be assessed in participating family members. Goal attainment and acceptability will be evaluated in the intervention group. A process evaluation will be carried out to evaluate protocol adherence, and a cost-effectiveness analysis will be applied if the intervention is found to be effective.

DISCUSSION

The current study provides an innovative approach to rehabilitation in the chronic phase of TBI evaluated using an RCT design that may inform treatment planning, health policies, and coordination of patient care. Further, the study may demonstrate new modes of establishing collaboration and knowledge transition between specialized rehabilitation facilities and local rehabilitation services that may improve patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03545594. Registered on June 4th, 2018.

Participation differences by age and depression 5 years after moderate-to-severe traumatic brain injury

Participation restrictions, including restrictions in employment, recreational activities, and social interactions, and depression are common after traumatic brain injury (TBI) and can profoundly affect individuals. Participation and depression demonstrate complex relationships with each other and over time as individuals age. This study (1) identified differences in participation between different age groups; (2) determined if participation differed between those with and without clinically significant depressive symptoms within each age group; and (3) determined the effect of the interaction between age groups and the presence or absence of clinically significant depressive symptoms on participation in community-dwelling adults with a moderate-to-severe TBI. Results indicate that, among community-dwelling adults 5 years post-TBI, there are significant differences in participation between age groups across the lifespan, with younger adults generally having higher levels of participation. Individuals with clinically significant depressive symptoms participate less than individuals without it within the same age group, except for adults over 65 years-old. For the productivity domain, age interacted with depressive symptoms, such that the presence of clinically significant depressive symptoms was associated with a larger difference in productivity in early-to-middle adulthood. Based on these findings, depression should be considered when providing interventions for participation and vice versa.

Participation Following Inpatient Rehabilitation for Traumatic Disorders of Consciousness: A TBI Model Systems Study

Severe traumatic brain injury (TBI) may result in a disorder of consciousness (DoC) and lead to substantial long-term disability. While level of independence with activities of daily living, especially for persons who recover consciousness during inpatient rehabilitation, generally improves over time, the degree of change in participation remains unknown. We determined level of participation among persons with TBI between 2005 and 2017 who were admitted to inpatient rehabilitation unable to follow commands and subsequently enrolled in the TBI Model Systems National Database. Participation on the Participation Assessment with Recombined Tools-Objective (PART-O) Productivity, Social Relations, and Out and About subscales was evaluated at 1-5 years post-injury. We used a mixed-effects model to longitudinally compare participation between persons who did and did not regain command-following during inpatient rehabilitation. We further explored the level of participation associated with increasing levels of functional independence (FIM). The analysis included 333 persons (229 recovered command-following during rehabilitation, mean age = 35.46 years, 74.9% male). Participation across groups, at all follow-up time points, on all PART-O subscales, was remarkably low (mean range = 0.021-1.91, maximum possible score = 5). Performance was highest on the Social Relations subscale and lowest on the Productivity subscale. Longitudinal analyses revealed no difference in level of participation or change in participation across time for persons who regained command-following during rehabilitation compared to those who did not. While productivity increased over time, social participation did not and participation outside the home increased more for younger than for older persons. Across all three PART-O subscales, FIM Motor scores positively predicted participation. FIM Cognitive scores positively predicted level of participation on the Productivity and Social Relations subscales. Exploratory analyses revealed that even persons who achieved independence on the FIM Motor and Cognitive subscales had low levels of participation across domains and follow-up years. In summary, persons with severe TBI who were admitted to inpatient rehabilitation unable to follow commands were found to be unlikely to participate in productive tasks, social endeavors, or activities outside of the home up to 5 years post-injury, even if functional independence was recovered.

Factors associated with the remission of insomnia after traumatic brain injury: a traumatic brain injury model systems study

Objective: To examine the factors associated with the remission of insomnia by examining a sample of individuals who had insomnia within the first two years after traumatic brain injury (TBI) and assessing their status at a secondary time point.Design and Methods: Secondary data analysis from a multicenter longitudinal cohort study. A sample of 40 individuals meeting inclusion criteria completed a number of self-report scales measuring sleep/wake characteristics (Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Insomnia Severity Index, Sleep Hygiene Index), fatigue and depression (Multidimensional Assessment of Fatigue, Patient Health Questionnaire-9), and community participation (Participation Assessment with Recombined Tools-Objective). One cohort was followed at 1 and 2 years post-injury (n = 19) while a second cohort was followed at 2 and 5 years post-injury (n = 21).Results: Remission of insomnia was noted in 60% of the sample. Those with persistent insomnia had significantly higher levels of fatigue and depression at their final follow-up and poorer sleep hygiene across both follow-up time-points. A trend toward reduced community participation among those with persistent insomnia was also found.Conclusion: Individuals with persistent post-TBI insomnia had poorer psychosocial outcomes. The chronicity of post-TBI insomnia may be associated with sleep-related behaviors that serve as perpetuating factors.

The Association of Rehospitalization With Participation 5 Years After Traumatic Brain Injury

OBJECTIVE

To determine whether rehospitalization during the first 2 years after moderate to severe traumatic brain injury (TBI) is associated with poor participation at 5 years post-TBI, after controlling for demographic and severity factors.

SETTING

TBI Model Systems Program.

PARTICIPANTS

Community-dwelling individuals with TBI, 16 years or older (n = 1940).

DESIGN

Retrospective data analysis of a multicenter prospective study.

MAIN MEASURES

Participation Assessment with Recombined Tools-Objective (PART-O).

RESULTS

After controlling for demographic and severity factors, a general linear model indicated that rehospitalization status (ie, never rehospitalized during years 1 and 2, rehospitalized either during year 1 or 2, or rehospitalized during both years 1 and 2) predicted less participation at 5 years post-TBI (P = .0353). The PART-O scores were in the hypothesized direction, with the lowest covariate-adjusted mean participation score found for the group with rehospitalizations during both years and the highest covariate-adjusted mean participation score found in the group with no rehospitalizations. Examining total number of rehospitalizations during years 1 and 2, rather than rehospitalization status, yielded analogous results (P = .0148).

CONCLUSIONS

This study suggests that rehospitalization in the first 2 years after TBI is negatively associated with participation at 5 years after injury. Since participation is considered a key indicator of successful TBI rehabilitation, minimizing the need for rehospitalizations and promoting health in the community setting should be a priority of postacute care for individuals with TBI.

Volunteering and its association with participation and life satisfaction following traumatic brain injury

Background: Volunteering has been found to improve life satisfaction and participation in the general population, but its impact has not been thoroughly studied among those with traumatic brain injury (TBI). It is important to investigate whether volunteering is helpful in addressing participation and life satisfaction to inform future treatment.Objective: To characterize those who volunteer after moderate-severe TBI and to investigate the association of volunteering with participation and life satisfaction after TBI.Methods: Using data from a single site contributing to the TBI Model Systems National Database, a retrospective analysis of 725 individuals with TBI was conducted. General Linear Models were used to compare outcomes of those who volunteer and those who do not after controlling for important covariates.Results: Volunteers were more likely to be employed/students, have better current functioning, be further post-injury, non-Hispanic white, and have more education. Significant relationships, after controlling for covariates, were found between volunteering and higher life satisfaction, more frequent community engagement, and greater social relations. No significant relationship between volunteering and productivity emerged.Conclusions: Given the positive relationship between volunteer status with life satisfaction and aspects of participation, future research should investigate the barriers/facilitators of volunteering to improve well-being and participation after TBI.