Systematic Review of Caregiver and Dyad Interventions After Adult Traumatic Brain Injury

Supporting Individuals With an Acquired Brain Injury: An Interpretative Phenomenological Study Exploring the Everyday Lives of Caregivers

Acquired brain injury (ABI) is one of the most common causes of disability and death globally. Support from informal caregivers is critical to the well-being and quality of life of people with ABI and supports the sustainability of global health and social care systems. This study presents an in-depth qualitative analysis of the experiences of eight British informal caregivers supporting someone with ABI. Semi-structured interviews were conducted with narratives transcribed verbatim and analysed using interpretative phenomenological analysis (IPA). Three superordinate themes were generated: making sense of brain injury; being consumed by caregiving; and, the changing self. These data highlight the impact of caregiving on the caregiver's illness perceptions and sense of self. By identifying negative and positive changes in the caregiver's sense of self, and dilemmas regarding the care recipient's behaviour, we address less understood aspects of caregiver experiences. Caregiving can pose both challenges to the caregiver's sense of identity and an opportunity for self-growth. Some caregivers exhibit resilience throughout their journey, with post-traumatic growth more apparent in the later stages of caregiving. Illness perceptions shape caregiver well-being and family dynamics and indicate the need to address stigmatisation and discrimination faced by ABI survivors and caregivers. Although some caregivers acquired positive meaning and enrichment from their caregiving, previously described challenges of ABI caregiving are supported. Overall, our findings support the need for timely psychological/mental health support for caregivers, caregiver education, and the provision of short breaks from caregiving.

Psychometric properties of the Danish version of the Caregiver Burden Scale: Investigating predictors and severity of burden after stroke, spinal cord injury, or traumatic brain injury

OBJECTIVE

To investigate (i) psychometric properties of the Danish version of the Caregiver Burden Scale, (ii) predictors of burden in caregivers of persons with stroke, spinal cord injury, or traumatic brain injury, and (iii) severity of caregiver burden, and compare level of severity of burden in caregivers of persons with stroke, spinal cord injury, or traumatic brain injury.

DESIGN

Cross-sectional study.

PARTICIPANTS

Pooled sample of 122 caregivers.

METHODS

Psychometric properties including internal consistency, floor and ceiling effects, inter-item and item-total correlation were investigated using the Caregiver Burden Scale. Severity of burden was compared using Fisher's exact test and ANOVA, and predictors of burden were investigated using multiple linear regression models.

RESULTS

The total burden score exhibited good internal consistency (α = 0.93), with no floor or ceiling effects. Longer time as a caregiver was a significant predictor of higher total score. The majority (52.2%) reported a low level of caregiver burden (below cut-off of 2.00). Mean scores on the Caregiver Burden Scale were not significantly different among caregivers across diagnostic groups. Differences were found when comparing spinal cord injury caregivers with brain injury caregivers (traumatic brain injury and stroke, collectively), χ2(2) = 6.38, p = 0.04, as spinal cord injury caregivers were more likely to report low levels of burden.

CONCLUSION

Good psychometric properties were reported, and most caregivers reported a low level of burden, and longer time as a caregiver was associated with higher burden. Consequently, the Caregiver Burden Scale is a valid measure to use when measuring burden in caregivers of stroke, spinal cord injury, and traumatic brain injury patients.

Caregiver Burden and Readiness in Patients with Moderate and Severe Traumatic Brain Injury: The Chain Mediation Effect of Disease Uncertainty and Mental Resilience

OBJECTIVE

To analyze the mediating effects of caregiver illness uncertainty and psychological resilience in caregiver burden and readiness in patients with moderate-to-severe traumatic brain injuries (TBIs). This can help improve caregiver readiness in patients with moderate-to-severe TBIs.

METHODS

A purposive sampling method was used to recruit patients with moderate-to-severe TBIs, and their caregivers, who were hospitalized in the Department of Neurosurgery of the Affiliated Hospital of Yangzhou University between October 2022 and August 2023. The Zarit Caregiver Burden Interview, Mishel Uncertainty In Scale for Family Member, Connor-Davidson Resilience Scale, and Caregivers Preparedness Scale, as well as general information questionnaire, were used to conduct the survey.

RESULTS

Caregiver readiness correlated with caregiver burden, illness uncertainty, and psychological resilience in patients with moderate-to-severe TBI (P < 0.01). Caregiver readiness was not only directly affected by caregiver burden (95% confidence interval: -0.510, -0.196) but was also affected through the chain mediation of illness uncertainty and psychological resilience (95% confidence interval: -0.146, -0.011).

CONCLUSIONS

Caregiver burden in patients with moderate-to-severe TBI influences caregiver readiness levels and is mediated by illness uncertainty and psychological resilience. By improving caregivers' illness uncertainty and increasing their psychological resilience, the impact of low caregiver readiness caused by high caregiver burden could be reduced.

Co-constructed communication therapy for individuals with acquired brain injury: A systematic review

BACKGROUND

Meaningful, varied, joyful conversation is an important therapy target for adults with language or cognitive-communication disorders following acquired brain injury (ABI). However, the complexity of daily communication is often reduced to component parts within intervention programmes, with mixed evidence of generalization to everyday conversation. Interventions targeting co-construction of communication within a dyad offer a structured way in which to retain and treat elements of everyday conversation for individuals and their communication partner (CP). Such interventions exist but they are variably labelled, target different ABI populations and have not been synthesized.

AIMS

To identify the nature, scope and effects of intervention studies targeting co-constructed communication in adults with ABI.

METHOD

This systematic review was completed using PRISMA Guidelines. Six databases (MEDLINE, Embase, CINAHL, Scopus, LLBA, PsychInfo) were searched and 1210 studies were screened. Data were extracted and studies were rated for methodological quality and completeness of reporting. Outcome measures and effects of treatment were collated through descriptive synthesis.

MAIN CONTRIBUTION

This review highlights an emerging evidence base in relation to an intervention approach that targets everyday communication. Co-constructed communication interventions have been reported by 13 studies, from a total of 206 participants with post-stroke aphasia, traumatic brain injury and progressive language impairments. These interventions take a range of formats, including referential communication tasks, retell/recount therapies and communication training programmes. Methodological quality evaluation indicated mostly low-level study designs. Heterogeneity was identified in primary outcome measures, with 28 unique primary outcome measures reported across studies. Most studies demonstrated change in task-specific or broad communication outcome measures.

CONCLUSIONS

Co-constructed communication interventions may offer clinicians a systematic, protocolized, replicable way to target everyday communication for adults with ABI. More high-quality, experimental designs with complete reporting and psychometrically sound outcome measures are needed to strengthen the evidence base.

WHAT THIS PAPER ADDS

What is already known on this subject Everyday conversation is an important therapy target for adults with ABI, but there is mixed evidence of therapy gains generalizing to everyday life. Many interventions reduce conversation to component parts such as naming or sentence construction. A different approach is needed to capture the social, dyadic, interactive and multifaceted nature of conversation. We propose the term 'co-constructed communication interventions' as a therapy genre targeting semi-structured dialogue. These interventions retain elements of everyday conversation (such as multimodal communication and situating tasks within dyads), combined with experimental elements (where stimuli prompt interactions and responses can be scored against normative data). What this paper adds to existing knowledge This review proposes and describes a distinct genre of discourse intervention within the current evidence base with a novel operational definition of 'co-constructed communication'. What are the potential or actual clinical implications of this work? Co-constructed communication interventions directly target elements of everyday communication by situating the therapy goals within a dyadic, interactive, multimodal task. A range of intervention tasks have been identified, including collaborative storytelling and problem-solving. This review will be of interest to clinicians working with adults with ABI; co-constructed communication interventions may offer a useful, replicable way to target aspects of everyday communication. This synthesis of the current evidence base encourages clinicians' informed, evidence-based decisions around these interventions.

The Effects of a Blended Care Intervention in Partners of Patients With Acquired Brain Injury - Results of the CARE4Carer Randomized Controlled Trial

OBJECTIVE

To assess effects of the CARE4Carer blended care intervention on caregiver mastery and psychosocial functioning compared with usual care in partners of patients with acquired brain injury (ABI).

DESIGN

Multicenter randomized controlled trial.

SETTING

Nine sites for rehabilitation medicine.

PARTICIPANTS

120 partners of outpatients with ABI were randomly allocated to blended care (N=59) or usual care (N=61).

INTERVENTION

The blended care intervention (20 weeks) was aimed at improving caregiving skills and consisted of 9 online sessions, combined with 2 face-to-face consultations with a social worker.

MAIN OUTCOME MEASURES

Mastery was assessed with the Caregiver Mastery Scale, secondary outcome measures were caregiver strain (Caregiver Strain Index), family functioning (Family Assessment Device), anxiety and depression (Hospital Anxiety and Depression Scale), burden (self-rated), and quality of life (CarerQol). Assessments were performed at baseline, 24, and 40 weeks.

RESULTS

The adjusted mean difference in caregiver mastery between intervention and control group at week 24 was 1.31 (SD3.48, 95% confidence interval (CI) -0.12 to 2.74, P=.072) and at week 40 was 1.31 (SD3.69, 95% CI -0.26 to 2.88, P=.100). In the per protocol analysis, the adjusted mean difference in caregiver mastery at week 24 was 1.53 (SD3.38, 95% CI 0.10 to 2.96, P=.036) and at week 40 was 1.57 (SD3.63, 95% CI 0.01 to 3.14, P=.049). Regarding secondary outcomes, caregiver strain was lower in the intervention group in the per protocol analysis at week 40. Family functioning was higher in the intervention group in week 24, whereas anxiety was lower at both timepoints.

CONCLUSIONS

In the subset of participants who were able to complete the intervention, caregiver mastery and psychosocial functioning improved. Future work should focus on improving adherence as this will optimize beneficial effects of blended care.

Predictors of Quality of Life Among Omani Family Caregivers of Patients With Traumatic Brain Injury

Objectives

This study aimed to explore the quality of life (QoL) of Omani family caregivers (FCs) of patients with traumatic brain injury (TBI). After acute care, the burden of caring for patients with TBI is mainly shouldered by FCs.

Methods

This cross-sectional study was conducted at Khoula Hospital, Muscat, Oman. Patient data were collected at the time of discharge and 8 weeks post-discharge between April 2019 and December 2021. The SF-12 General Health Survey and Preparedness for Caregiving scale were used to measure the caregivers' QoL and preparedness, respectively. The Disability Rating and TBI Symptom scales were used to measure the patients' disability and symptoms, respectively.

Results

A total of 36 FCs and patients with TBI were recruited. Most caregivers were the parent (41.7%) or child (27.8%) of the patient with TBI. Overall, the caregivers had good physical QoL (PQoL) and mental health QoL (MHQoL) but low caregiving preparedness at the time of discharge. At 8 weeks post-discharge, there were significant improvements in caregiving preparedness (P <0.01) and patient disability (P <0.05) but a depreciation in caregivers' MHQoL (P <0.05), with no change in their PQoL. The caregiver's employment status and the severity of the patient's sleep and mood problems were modifiable predictors of the caregivers' PQoL. Caregiver's preparedness, the patient's inability to live independently, and the severity of the patient's mood and behavioural problems were predictors of caregivers' MHQoL.

Conclusion

Caring for patients with TBI negatively impacts the QoL of Omani FCs; this correlates with the physical, emotional, and mental health symptoms of the patient.

Iterative Development of the Caregiver Wellness After Traumatic Brain Injury Program (CG-Well)

OBJECTIVES

(1) To iteratively design a web/phone-based intervention to support caregivers of adults acutely following traumatic brain injury (TBI), Caregiver Wellness (CG-Well), and (2) to obtain qualitative and quantitative feedback on CG-Well from experts and caregivers to refine the intervention.

SETTING

A level I trauma and tertiary medical center.

PARTICIPANTS

Convenience sample of a total of 19 caregivers and 25 experts.

DESIGN

Multistep prospective study with iterative changes to CG-Well: (1) developed intervention content based on qualitative feedback from a prior study and literature review; (2) obtained qualitative feedback from 10 experts; (3) refined content using a modified Delphi approach involving 4 caregivers and 6 experts followed by qualitative interviews with 9 caregivers; (4) designed CG-Well website and videos; and (5) obtained feedback on program acceptability, appropriateness, and feasibility from 6 caregivers and 9 experts.

INTERVENTIONS

CG-Well included content on TBI, self-care and support, and skill-building strategies delivered through a website and telephone calls.

MAIN OUTCOME MEASURES

Qualitative data were analyzed using content analysis. Caregivers and experts completed Likert-type scales to rate module relevance, clarity, accuracy, utility and website acceptability, appropriateness, and feasibility (1 = strongly disagree to 5 = strongly agree). Means and standard deviations (SD) characterized ratings.

RESULTS

Qualitative findings were instrumental in designing and refining CG-Well. Ratings were positive for modules (means and SD for relevant [4.9, 0.33], clear [4.6, 0.53], accurate [4.9, 0.33], and useful [5, 0]) and the website (means and SD for acceptable [4.8, 0.36], appropriate [4.8, 0.35], and feasible [4.8, 0.36]).

CONCLUSIONS

The iterative design process for CG-Well resulted in a highly acceptable program. An early-stage randomized controlled trial is underway to estimate treatment effects for a future well-powered clinical trial.

Investigating the Effectiveness of a Family Intervention after Acquired Brain or Spinal Cord Injury: A Randomized Controlled Trial

(1) Background: Acquired brain injury (ABI) or spinal cord injury (SCI) constitutes a severe life change for the entire family, often resulting in decreased quality of life (QoL) and increased caregiver burden. The objective of this study was to investigate the effectiveness of a family intervention in individuals with ABI or SCI and in their family members. (2) Methods: An RCT of a family intervention group (FIG) vs. a psychoeducational group (PEG) (ratio 1:1) was performed. The FIG received an eight-week manual-based family intervention, and the PEG received one psychoeducational session. Self-reported questionnaires on QoL with the Mental Component Summary (MCS) and on caregiver burden with the Caregiver Burden Scale (CBS) were the primary outcomes. The data analysis involved linear mixed-effects regression models. (3) Results: In total, 74 participants were allocated randomly to the FIG and 84 were allocated randomly to the PEG. The FIG had significantly larger improvements on the MCS and significantly larger reductions on the CBS at the two-month follow-up than participants in the PEG (mean differences of 5.64 points on the MCS and -0.26 points on the CBS). At the eight-month follow-up, the between-group difference remained significant (mean difference of 4.59 points) on the MCS, whereas that on the CBS was borderline significant (mean change of -0.14 points). (4) Conclusions: Family intervention was superior to psychoeducation, with larger improvements in QoL and larger reductions in caregiver burden.

An educational intervention to promote a culture of gender equity among persons with traumatic brain injury and caregivers: A pilot study

Background

Traumatic brain injury (TBI) outcomes are dependent on patients' biological sex (e.g., hormone levels) and sociocultural gender (e.g., norms, responsibilities). Informal caregivers additionally experience disruptions to identity and roles post-TBI. However, information on this topic remains largely unavailable to patients and caregivers.

Purpose

This study aimed to determine the effectiveness of a one-time educational intervention on sex and gender influences in TBI for patients and informal caregivers.

Materials and methods

We conducted a pilot pre-test/post-test randomized control-group design study. Groups (i.e., passive, active and control) consisted a total of 16 persons with TBI and caregivers (75% persons with TBI, 63% women). Individual and group learning gains, and group-average normalized gain, were computed for three learning domains: knowledge, attitude, and skill. An intervention with an average normalized gain of ≥30% was considered effective. Educational intervention evaluation and qualitative comments post-participation were summarized.

Results

The passive group demonstrated the highest average normalized gain across the three learning domains, including 100% for knowledge, 40% and 61% for attitude, and 37% for skill. The remaining groups did not reach an average normalized gain of ≥30%, except for the attitude domain of the control group (33% and 32%). Two key categories were identified qualitatively: (1) gendered self-expectations post-injury and (2) implications of gender stereotypes in rehabilitation, including the need for rehabilitation treatment to look beyond sex and gender. The post-participation educational session evaluation conveyed high appraisal of content, organization, and usability of the intervention.

Conclusion

A one-time passive educational intervention on sex and gender in TBI may improve knowledge, attitude, and skill on the topic of sex and gender among adults with TBI and caregivers. Obtaining knowledge and skill on sex and gender effects in TBI can potentially help persons with TBI and caregivers adapt to changes in roles and behaviours post-injury.

Efficacy of resilience interventions for dyads of individuals with brain injury and their caregivers: A systematic review of prospective studies

BACKGROUND

Acquired brain injury (BI) is associated with negative mental health outcomes for both people with BI, their caregivers (CG), and patient-CG dyads, which may be mitigated through increased resilience. However, little is known regarding the efficacy of resilience interventions focused on CGs of individuals with BI, as well as dyads, which may be instrumental for positive outcomes.

OBJECTIVE

To systematically review the evidence of the efficacy of resilience interventions focused on CGs and/or dyads of individuals with BI.

METHODS

A search of MEDLINE, Embase, APA PsycINFO, CINAHL with Full Text, Scopus, SCIE, and ESCI was conducted. Each title and abstract were screened by two authors independently. Each full text review, study data extraction, and study quality assessment was performed independently by two authors. Study quality was assessed using the Joanna Briggs Institute (JBI) critical appraisal tool.

RESULTS

Out of 11,959 articles retrieved, 347 full text articles were assessed for review and 18 met inclusion criteria for data extraction and quality assessment. Resilience interventions were stratified into 5 different categories based on the type of intervention.

CONCLUSION

This systematic review suggests that dyadic/CG resilience interventions may improve mental health related outcomes, but conclusions were limited secondary to heterogenous outcomes and lack of a standardized resiliency construct. Future efforts are compulsory to create a standardized resiliency construct and associated outcomes focused on persons with BI, their CGs, and dyads.

Predictors of caregiver burden in caregivers of individuals with traumatic or non-traumatic brain injury: A scoping review

BACKGROUND

Caregivers of individuals with traumatic (TBI) or non-traumatic (nTBI) brain injuries are at risk of significant caregiver burden. Consequently, it is crucial to examine predictors of caregiver burden to enable early identification and intervention.

OBJECTIVE

To examine predictors of caregiver burden in caregivers of individuals with TBI/nTBI.

METHODS

A scoping review was conducted in the bibliographic databases PubMed, EMBASE (Ovid) and APA PsycInfo (EBSCO). Search terms included: 'acquired brain injur*', 'traumatic brain injur*', 'brain injur*', 'non-traumatic brain injur*', or 'stroke*' combined with 'burden', 'caregiver burden', 'perceived burden', or 'caregiver strain'. The search was limited to articles written in English and published in academic journals between 2000 and March 2022. EndNote was used to manage the references and identify duplicates.

RESULTS

Twenty-four studies were included. Care recipient-related predictors of caregiver burden included more severe injuries, functional disabilities (including decreased physical and neuropsychological functioning), and worse mental health. Caregiver-related predictors included more time spent caregiving, worse mental health, and unmet needs. For several predictor variables, evidence was mixed or vague.

CONCLUSION

The results highlight which caregivers are at risk of caregiver burden and point to several areas of potential intervention to prevent caregiver burden. Future research should explore the relationship between characteristics of the caregiver and caregiver burden, including coping style, problem-solving techniques, and personality, as these have been sparsely investigated and are potentially modifiable through intervention. Further research is needed to elucidate if burden can be prevented by interventions targeting caregivers at risk. Addressing these gaps may clarify the link between caregiver burden and predictor variables and assist in development of interventions that may prevent burden.

Mediating role of dyadic satisfaction on social support and health outcomes in a sample of military family care-givers

LAY SUMMARY

Military family caregivers (MFCs) can experience many health-related challenges associated with caregiving responsibilities. Perceived support from a spouse or partner can influence dyadic satisfaction and health outcomes among those who care for a spouse or partner. This study examined the relations among social support, dyadic satisfaction, and mental (i.e., depressive and anxiety symptoms) and physical (i.e., somatic symptoms) health outcomes in a sample of MFCs. This sample consisted of 104 MFCs who were the spouse or partner of their care recipient. The findings indicate that more support predicted greater dyadic satisfaction and greater dyadic satisfaction predicted fewer anxiety symptoms. This study highlights the importance of considering relationship-focused contributors to mental health outcomes.

The Experience of Caregivers Following a Moderate to Severe Traumatic Brain Injury Requiring ICU Admission

OBJECTIVES

Survivors of moderate and severe traumatic brain injury (TBI) require substantial care, much of which is ultimately provided by friends and family. We sought to describe the unmet needs of informal caregivers.

DESIGN

Qualitative, semistructured interviews with informal caregivers of moderate and severe TBI survivors were conducted 72 hours, 1 month, 3 months, and 6 months after injury.

SETTING

Intensive care unit of a level 1 trauma center.

PARTICIPANTS

Informal caregivers were friends or family who planned to provide care for the patient. Patients were 18 years or older with a moderate to severe TBI, and not expected to imminently die of their injuries.

MEASUREMENTS AND MAIN RESULTS

Eighteen patient-caregiver dyads were enrolled. Fifty-three interviews with caregivers were completed and analyzed over the course of 6 months. Three themes were identified in the qualitative analysis: caregiver burden, caregiver health-related quality of life, and caregiver needs for information and support.

CONCLUSIONS

This study provides new information about the experience of informal caregivers during the 6 months after their friend or family member survived a moderate to severe TBI. Interventions to promote caregiving may be a substantial opportunity to improve patient-centered outcomes following TBI.

Caregivers' perspectives of the challenges faced with survivors of traumatic brain injury: A scoping review

INTRODUCTION

Traumatic Brain Injury (TBI) has wide-ranging neuropsychological, physical, social and financial implications. The impact on caregivers of moderate to severe TBI survivors, particularly in low- and middle-income countries, is under-investigated.

AIM

Identify and describe the experiences of caregivers' of moderate to severe TBI survivors postdischarge from healthcare facilities.

METHODS

A scoping review was conducted utilising seven electronic databases. Two reviewers screened articles using eligibly criteria related to setting (postdischarge), caregiving (informal), age of TBI survivors (>  18 years) and injury severity (moderate-severe). Studies published in English between 1999 -2018 were included.

RESULTS

Fourteen articles met the inclusion criteria. Articles reporting on the same sample were merged during data charting. The final analyses included 11 articles comprised of qualitative, quantitative and mixed-methods studies. Ten themes were identified: psychological distress, social functioning, financial burden, family experiences, coping strategies, access to services, time burdens and physical, cognitive and behavioural difficulties. Characteristics of caregivers and TBI survivors were also reported.

CONCLUSION

Caregivers of moderate to severe TBI survivors experience challenges in various life domains, and there is limited research concerning caregivers in low- and middle-income countries. Future research should focus on understanding more nuanced experiences across various environments, which may increase comprehensive, flexible and long-term support.

A systematic review of psychosocial interventions for Latinx and American Indian patient-family caregiver dyads coping with chronic health conditions

Latinx and American Indians experience high rates of chronic health conditions. Family members play a significant role as informal caregivers for loved ones with chronic conditions and both patients and family caregivers report poor psychosocial outcomes. This systematic review synthesizes published studies about psychosocial interventions for Latinx and American Indian care dyads to determine: (i) the benefits of these interventions; (ii) their distinguishing features or adaptations, and; (iii) recommendations for future intervention development. Out of 366 records identified, seven studies met inclusion criteria. Interventions demonstrated benefits to outcomes such as disease knowledge, caregiver self-efficacy and burden, patient and caregiver well-being, symptom distress, anxiety and depression, and dyadic communication. Distinguishing features included tailoring to cultural values, beliefs, and delivery preferences, participants' level of acculturation, and population-specific issues such as migratory stressors and support networks. Based upon this review, six recommendations for future intervention development are put forth.

The effectiveness of a family-centred intervention after traumatic brain injury: A pragmatic randomised controlled trial

Objectives:

To determine the effectiveness of a family-centred intervention for patients with traumatic brain injury and family members.

Design:

Open-labelled, two-armed randomised controlled trial.

Settings:

Outpatient clinic and family residences.

Participants:

Sixty-one patients (33 women) with traumatic brain injury, with mean (SD) age 43.8 (12.2), and 63 family members (33 women), with mean (SD) age 42.6 (11.3), were assign to intervention (n = 30 families) and control group (n = 31 families).

Intervention:

An eight-session single-family intervention to improve individual and family functioning.

Outcome measures:

Self-reported questionnaires at start-of-treatment, median (IQR) 11.4 (8.4, 15.9) months post-injury, and at two follow-ups, 2.7 (2.3, 3.8) and 9.2 (8.2, 9.9) months after start-of-treatment. Primary outcome measures were the SF-36 Mental Component Summary (MCS) and Caregiver Burden Scale (CGB). Secondary outcome measures were the Family Adaptability and Cohesion Evaluation Scale (FACES) and Quality of Life after Brain Injury Questionnaire (QOLIBRI). Group differences were analysed with linear mixed-model analysis for repeated measurements.

Results:

No significant between-group differences were found. The intervention group significantly improved on the MCS, the CGB and FACES in the treatment period, whereas the controls did not. The mean (SD) MCS change in the treatment period was 2.4 (1.1) points P = 0.028 in the intervention group. Mean (SE) MCS scores were 47.9 (1.26) and 47.3 (1.27) in the intervention and control group at last follow-up.

Conclusions:

Receiving an eight-session family intervention, in addition to specialised rehabilitation for the patients, was not superior to rehabilitation at a specialised traumatic brain injury outpatient clinic.

The impact of cognitive-communication difficulties following traumatic brain injury on the family; a qualitative, focus group study

Primary Objective: To identify how families experience cognitive-communication difficulties following Traumatic Brain Injury (TBI). Experiences of information, training and support for managing communication changes were also explored. Research Design: Qualitative focus group methodology using thematic analysis. Method: 15 family members of individuals with cognitive-communication difficulties following severe TBI participated in the study; four parents, six spouses, three siblings and two offspring. The majority of participants were female (80%, n = 12), with a mean age of 51 (range 19-71). Four focus groups were held with family members at 0-12 months, 12-36 months and 36+ months post-injury. The data were transcribed verbatim and analyzed using NVIVO 12.Results: Cognitive-communication difficulties were found to impact upon family functioning and psychological wellbeing for several years post-injury. Changes to social cognition, insight and the "filter switch" of the person following TBI were key areas of distress. Participants highlighted the need for information about communication changes to be provided at several time points post-injury. The need for peer support from other families with experience of cognitive-communication difficulties was also identified.Conclusion: Cognitive-communication difficulties impact upon family functioning for many years following injury with families continuing to have support needs for communication well beyond the acute rehabilitation stage.

Development of the life change adaptation scale for family caregivers of individuals with acquired brain injury

AIM

Life changes due to the sudden onset of acquired brain injury (ABI) are drastic personal and social changes that require adaptation and are also an important indicator of the quality of life of family caregivers. However, there are no instruments for evaluating life change adaptation among family caregivers of individuals with acquired brain injury. This study aimed to develop the Life Change Adaptation Scale (LCAS) for family caregivers of individuals with ABI and examine its reliability and validity.

METHODS

A cross-sectional study was conducted using a self-reported questionnaire. A total of 1622 family caregivers of individuals with ABI who belonged to 82 associations for families of individuals with ABI were selected as eligible participants. The construct validity was evaluated using a confirmatory factor analysis. Internal consistency was calculated using Cronbach's alpha. The K6 was also administered to assess the criterion-related validity of the LCAS.

RESULTS

In total, 339 valid responses were received. The confirmatory factor analysis identified eight items from two domains, "Changes in the appraisal of caregiving resources" and "Changes in the health belief as a caregiver" (goodness of fit index = 0.963, adjusted goodness of fit index = 0.926, comparative fit index = 0.986, root mean square error of approximation  = 0.043.) Cronbach's alpha was 0.84. The LCAS was negatively correlated with the K6 (r = -0.504; P<0.001).

CONCLUSIONS

The LCAS is a brief, easy-to-administer instrument that is reliable and valid for family caregivers of individuals with ABI. This study contributes to the assessment and identification by family caregivers of individuals with ABI who require aid in adapting to life changes. Further research should be undertaken to verify the predictive value in a longitudinal study and to attempt to apply the LCAS to assess a broader range of subjects in a wider range of settings.

Mental Health and Family Functioning in Patients and Their Family Members after Traumatic Brain Injury: A Cross-Sectional Study

Traumatic brain injury (TBI) affects the family as a whole. This study aimed to describe and compare mental health and family functioning in TBI patients and their family members, and to identify individual and family-related factors that were associated with mental health. It was conducted at an urban, specialized, TBI outpatient clinic and included 61 patients with mild to severe TBI and 63 family members. Baseline demographics and injury-related data were collected, and the participants answered standardized, self-reported questionnaires 6-18 months post-injury that assessed mental health; general health; family functioning, communication, and satisfaction; depression and anxiety; self-efficacy; resilience; and condition-specific quality of life. The patients reported significantly worse mental health, depression, resilience, self-efficacy, and general health compared with the family members. Patients and family members had similar perceptions, showing balanced family functioning, high family communication levels, and moderate family satisfaction. Factors significantly associated with mental health in patients and family members were depression, anxiety, and resilience, explaining 56% of the variance (p < 0.001). Family-related factors were not associated with mental health. The disease burden was mainly on the patients; however, the family members also reported emotional distress. Family-targeted interventions across the TBI continuum should be considered.

Burden and Preparedness amongst Informal Caregivers of Adults with Moderate to Severe Traumatic Brain Injury

This study examined the patterns of informal (unpaid) caregiving provided to people after moderate to severe traumatic brain injury (TBI), explore the self-reported burden and preparedness for the caregiving role, and identify factors predictive of caregiver burden and preparedness. A cross-sectional cohort design was used. Informal caregivers completed the Demand and Difficulty subscales of the Caregiving Burden Scale; and the Mutuality, Preparedness, and Global Strain subscales of the Family Care Inventory. Chi-square tests and logistic regression were used to examine the relationships between caregiver and care recipient variables and preparedness for caregiving. Twenty-nine informal caregivers who reported data on themselves and people with a moderate to severe TBI were recruited (referred to as a dyad). Most caregivers were female (n = 21, 72%), lived with the care recipient (n = 20, 69%), and reported high levels of burden on both scales. While most caregivers (n = 21, 72%) felt “pretty well” or “very well” prepared for caregiving, they were least prepared to get help or information from the health system, and to deal with the stress of caregiving. No significant relationships or predictors for caregiver burden or preparedness were identified. While caregivers reported the provision of care as both highly difficult and demanding, further research is required to better understand the reasons for the variability in caregiver experience, and ultimately how to best prepare caregivers for this long-term role.

Establishing the Factor Structure of a Health-Related Quality of Life Measurement System for Caregivers of Persons Living With Traumatic Brain Injury

OBJECTIVES

To understand the factor structure of health-related quality of life specific to caregivers of people living with traumatic brain injury (TBI).

DESIGN

Prospective, cross-sectional data collection.

SETTING

Three TBI Model Systems rehabilitation hospitals, an academic medical center, and a military medical treatment facility.

PARTICIPANTS

Caregivers (N=558) of people who have sustained a TBI (344 caregivers of civilians and 214 caregivers of service members or veterans; 85% women; 58% spouses; mean age, 46.12±14.07y) who have provided care for an average of 5.82±5.40 years.

INTERVENTIONS

Not applicable.

MAIN OUTCOMES MEASURES

The Traumatic Brain Injury Caregiver Quality of Life (TBI-CareQOL) measurement system including 10 Patient-Reported Outcomes Measurement Information System item banks (anger, anxiety, depression, social isolation, sleep disturbance, fatigue, ability to participate in social roles and activities, satisfaction with social roles and activities, emotional support, informational support) and 5 TBI-CareQOL banks (feelings of loss-self, feelings of loss-person with TBI, feeling trapped, caregiver-specific anxiety, caregiver strain).

RESULTS

Confirmatory factor analysis model fit indices were compared for 14 empirically derived and 5 theoretically derived models. Confirmatory factor analysis results indicated that the best model fit was for a 6-factor model with dimensions that included mental health, social support, social participation, social isolation, physical health, and caregiver emotion.

CONCLUSIONS

Results indicated that a 6-factor model provided the best model fit for health-related quality of life in caregivers of individuals with TBI. These results have utility for both research and clinical applications. Establishing the TBI-CareQOL's factor structure provides preliminary evidence of the measurement system's construct validity, helps inform the selection of measures for specific research or clinical interventions, and informs the development of composite scores.

Healthy together: A systematic review of theory and techniques used in health interventions for persons with chronic neurological conditions and their caregivers

OBJECTIVE

To evaluate the level of theory application and use of behaviour change techniques (BCTs) in dyadic health interventions for persons with chronic neurological conditions (CNCs) and their caregivers.

METHODS

A systematic review of five databases was conducted to locate articles published before January 2019. Methodological quality was assessed, study characteristics, theory application and BCTs were narratively summarized.

RESULTS

More than half of the studies identified (59% [16/27]) did not mention theory, and only 22% (6/27) were explicitly theory-based. Across the 27 studies, two to 17 BCTs (mean = 6.8 ± 4.02) were used. Common BCTs were related to intervention implementation (e.g., credible source), knowledge (e.g., instruction on how to perform behaviour) and skill development (e.g., behavioural practice/rehearsal).

CONCLUSIONS

Researchers need to incorporate theory-based dyadic techniques that target both people with CNCs and their caregivers into the design and implementation of future health interventions.

PRACTICE IMPLICATIONS

Health professionals require explicitly theory-based interventions to provide dyads with CNCs techniques that they can apply in their daily life to the benefit of each individual and the partnership.

Systematic Review of Technology-Based Interventions Targeting Chronically Ill Adults and Their Caregivers

The purpose of this systematic review is to synthesize the study design features as well as the attributes and outcomes of technology-based health interventions targeting chronically ill adults and their family caregivers. Twenty papers representing 19 studies met the inclusion criteria. Various theoretical foundations or approaches guided the interventions in 11 studies. Interventions either aimed to support patient self-management and improve patient outcomes or enhance shared illness management and improve patient and caregiver outcomes. The interventions included educational, behavioral, and support components and were delivered using various technologies ranging from text messaging to using the Internet. Overall, patients and caregivers expressed improvements in self-management outcomes (or support) and quality of life. Interventions with a dyadic focus reported on interpersonal outcomes, with improvements noted mostly in patients. This review captures an emerging area of science, and findings should be interpreted in light of the methodological limitations of the included studies.

A manual-based family intervention for families living with the consequences of traumatic injury to the brain or spinal cord: a study protocol of a randomized controlled trial

Background

Acquiring a traumatic injury constitutes a severe life change for the survivor, but also for the surrounding family. The paradigm of helping the family has primarily been on psychosocial interventions targeting caregivers. However, interventions including both survivor and caregivers should be an essential part of treatment, as the whole family’s functional level and mental health can be affected. The current study protocol presents a manualized family intervention for families living with traumatic injury to the brain (TBI) or spinal cord (tSCI). The objectives are to investigate if the intervention improves quality of life (QoL) and decreases burden. It is hypothesized that the family intervention improves problem-solving strategies and family dynamics, which will reduce the burden. This may improve the caregivers’ mental health, which will improve the support to the survivor and QoL.

Methods

The study is an interventional, two-arm, randomized controlled trial. During a 2-year period, a total of 132 families will be included. Participants will be recruited from East-Denmark. Inclusion criteria are (1) TBI or tSCI, (2) ≥ 18 years of age, (3) ≥ 6 months to ≤ 2 years since discharge from hospital, (4) ability to understand and read Danish, (5) cognitive abilities that enable participation, and (6) a minimum of one family member actively involved in the survivor’s life. Exclusion criteria are (1) active substance abuse, (2) aphasia, (3) prior neurologic or psychiatric diagnose, and (4) history of violence. Within each disease group, families will be allocated randomly to participate in an intervention or a control group with a ratio 1:1. The intervention groups receive the family intervention consisting of eight sessions of 90 min duration. Families in the control groups receive 2 h of psychoeducation. All participants complete questionnaires on QoL, self-perceived burden, family dynamics, problem-solving strategies, mental health, and resilience at pre-intervention, post-intervention, and 6-month follow up.

Conclusion

If the intervention is found to have effect, the study will contribute with novel knowledge on the use of a manual-based intervention including the entire family. This would be of clinical interest and would help families living with the consequences of TBI or tSCI.

Trials registration

ClinicalTrials.gov, NCT03814876. Retrospectively registered on 24 January 2019.

Protocol for a clinical trial of telehealth-based social communication skills training for people with traumatic brain injury and their communication partners

Background: A previous clinical trial of training communication partners of people with traumatic brain injury (TBI) demonstrated positive outcomes [Togher, Power, McDonald, Tate, & Rietdijk (2009). Brain Impairment, 10(2), 188-204]. Adapting communication partner training for delivery via telehealth could improve access to this intervention.

Objectives: To compare outcomes across in-person communication partner training, telehealth communication partner training and a control group

Method: Protocol for a partially randomised controlled trial. People with moderate-severe TBI will be allocated to either an in-person or telehealth-based training program. Comparison data will be drawn from the original trial control group, which was recruited using the same eligibility criteria as this protocol. Outcomes after training will be compared between the in-person training group, the telehealth training group and the historical control group.

Discussion: This protocol uses specific design features with the aim of maximising the study’s power, including a partially randomised allocation process and a historical control group. The results will inform about the feasibility and effectiveness of delivering TBI rehabilitation via telehealth.

Trial registration: Australian and New Zealand Clinical Trials Registry: ACTRN12615001024538.

Increasing Caregiver Access to Programming: A Qualitative Exploration of Caregivers' Experience of a Telehealth Powerful Tools for Caregivers Program

Family caregivers can benefit from education-based wellness programs, but many face barriers to attending such programs. The purpose of this research was to explore telehealth as a delivery format for an education-based caregiver wellness program. This qualitative research examined the caregiver experience of a specific program called Powerful Tools for Caregivers (PTC). The traditionally in-person program was delivered via telehealth in four states. Twelve caregivers participated in focus groups the week after completing the telehealth PTC program. Three major themes emerged from the focus groups: Knowledge Gained, Interrelatedness, and Technology Pros and Cons. All affirmed a positive experience of the telehealth delivered PTC program. Participants expressed gratitude for the opportunity to participate in the program and knowledge gained including relaxation techniques, communication skills, resources to support caregiving, and goal setting for self-care. Furthermore, participants were appreciative of the opportunity to connect with other caregivers from the comfort of their home.