A Systematic Review of the Efficacy of Community-based, Leisure/Social Activity Programmes for People with Traumatic Brain Injury

Interventions that aim to increase social participation through recreation or leisure activity for adults with moderate to severe traumatic brain injury: a scoping review

PURPOSE

Social isolation and reduced social participation are common after traumatic brain injury (TBI). Developing interventions that aim to increase social participation through recreation or leisure activities continues to be challenging. This scoping review was conducted to provide an overview of interventions used to increase social participation through in-person recreation or leisure activity for adults with moderate to severe TBI living in the community.

METHODS

Using the Arksey and O'Malley framework, a scoping review of the literature published from 2005 to 2023 was conducted across four databases: Medline, CINAHL, PsycINFO and Scopus. Quality appraisals were conducted for included studies.

RESULTS

Following the removal of duplicates, 10,056 studies were screened and 52 were retained for full-text screening. Seven papers were included in the final review. Studies varied with respect to the type of intervention and program outcomes. The interpretation was impeded by study quality, with only two studies providing higher levels of evidence. Barriers and facilitators to successful program outcomes were identified.

CONCLUSIONS

Few studies with interventions focused on increasing social participation in leisure or recreation activity were identified. Further research incorporating mixed methods and longitudinal design to evaluate effectiveness over time is needed to build the evidence base for increasing social participation through leisure activity.

Factors Influencing Self-Esteem After a Traumatic Brain Injury

OBJECTIVE

Traumatic brain injury (TBI) and its consequences can significantly impact an individual's identity and self-esteem. However, there is limited research with respect to the trajectory of change over time and factors that may influence self-esteem levels. This study aimed to investigate: (1) changes in self-esteem over 3 years post-TBI; and (2) factors associated with self-esteem post-TBI.

SETTING

Outpatient.

PARTICIPANTS, DESIGN, AND MEASURES

Self-esteem was measured in 1267 individuals with predominantly moderate to severe TBI (mean age = 36.38 years, mean days in posttraumatic amnesia = 26.16 days) using the Rosenberg Self-Esteem Scale at 1-, 2, and 3 years post-injury. Participants also completed the Structured Outcome Questionnaire and the Glasgow Outcome Scale-Extended (GOS-E).

RESULTS

Linear mixed modeling indicated that self-esteem significantly declined between 1 and 2 years but remained stable between 2 and 3 years post-injury. Higher self-esteem was significantly associated with better functional outcomes (as measured by the GOS-E), more years of education, more participation in leisure activities, and lower reported anxiety and depression levels.

CONCLUSIONS

Findings suggest that functional impacts of injury and emotional functioning influence self-esteem increasingly between 1 and 2 years post-injury. This highlights the importance of timely psychological interventions to maximize self-esteem in individuals with TBI post-injury.

Implementation of a leisure reintegration programme for people with acquired brain injury in a community rehabilitation programme: a feasibility study

BACKGROUND

Participation in leisure activities is significantly impacted following acquired brain injury (ABI). Despite this being a common community rehabilitation goal, re-engagement with leisure activities following ABI is poorly addressed within Australian community rehabilitation services, which often cater to a mixed-diagnostic group of both ABI and non-ABI clients.

OBJECTIVES

To evaluate the feasibility and effect of a leisure reintegration group programme within a community rehabilitation service.

METHOD

A single-site, pre- and post-test feasibility study was conducted. Three cohorts of a semi-structured leisure group programme were offered, each conducted over eight sessions within 4 weeks. The Nottingham Leisure Questionnaire (NLQ) and Leisure Satisfaction Measure (LSM) were used as primary outcome measures. Measures of acceptability, including adherence, and a post-intervention participant survey were also completed.

RESULTS

Of the 14 consenting participants, 9 completed all outcome measures. Mean change score for the NLQ was -3.63 (p = 0.11) and the LSM 4.25 (p = 0.46). The programme was well attended (79%), acceptable for ABI and non-ABI participants and able to be implemented within an existing community rehabilitation service.

CONCLUSION

Providing a leisure reintegration group programme met an identified need, developed client and carer capacity and could be delivered within a community rehabilitation service for clients with mixed diagnoses including ABI. A larger trial is warranted to examine the effectiveness and cost-effectiveness of this intervention for people with ABI.

Do single-case experimental designs lead to randomised controlled trials of cognitive behavioural therapy interventions for adolescent anxiety and related disorders recommended in the National Institute of Clinical Excellence guidelines? A systematic review

Background

Although Cognitive Behavioural Therapy (CBT) is effective for 60% of adolescents with anxiety disorders, only 36% are in remission post-intervention. This indicates that more effective treatments are needed which should be reflected in the NICE guidelines. We hypothesised that Single-case experimental designs (SCEDs) may provide a framework for accelerating the development of novel interventions. The primary purpose of this review was to investigate whether SCEDs are currently followed by randomised controlled trials (RCTs) of CBT intervention for adolescent anxiety disorders named in the NICE guidelines. The secondary objective was to investigate whether using SCEDs prior to RCTs could be a helpful approach.

Method

For the primary search of SCEDs five databases were used (PsycINFO, PubMed, PsycArticles, Web of Science and ProQuest). Nineteen articles met eligibility criteria including a total of 107 participants. For the secondary search of RCTs named in the NICE guidelines for adolescent anxiety disorders 53 articles met inclusion criteria and were included in the systematic review.

Results

The 19 SCED studies included in the review were conducted with participants with a diverse range of anxiety disorders and across a range of CBT formats. Two of the SCEDs were followed by RCTs, but neither of these were named in the NICE guidelines for anxiety disorders. All of the SCEDs identified were rated as low quality with none meeting the criteria for the highest or second highest quality rating. From the secondary searches, none of the RCTs named in the NICE guide were preceded by SCEDs.

Conclusions

It was concluded that currently SCEDs were not followed by RCTs of CBT interventions named in the NICE guidelines for adolescent anxiety disorders. However, it was suggested that SCEDs may provide an important framework for the development of more effective interventions for adolescents with anxiety.

Psychosocial functioning mediates change in motor and cognitive function throughout neurorehabilitation for adults with acquired brain injury (ABI-RESTaRT)

OBJECTIVES

This study aimed to evaluate the mediational role of change in psychosocial abilities, adjustment and participation on change in motor and cognitive function from admission to discharge from a staged community-based brain injury rehabilitation (SCBIR) service in Western Australia, 2011-2020.

METHODS

A retrospective cohort study of n = 324 adults with ABI enrolled in SCBIR using routinely collected rehabilitation outcome measures data. Motor and cognitive function were assessed with the UK Functional Independence and Assessment Measure and psychosocial function with the Mayo-Portland Adaptability Inventory-4. Six multilevel mediation regression analyses were conducted to determine whether change in psychosocial function (abilities, adjustment and participation) mediated change in motor and cognitive function from admission to discharge.

RESULTS

Participants demonstrated clinically significant improvements in both motor (+ 11.8, p < 0.001) and cognitive (+ 9.5, p < 0.001) functioning from admission to discharge. Statistically significant improvements in psychosocial abilities (- 4.8, p < 0.001), adjustment (- 2.9, p = 0.001) and participation (- 2.5, p < 0.001) were also seen but were not clinically significant. Mediation analyses showed that participation accounted for 81% of improvements in motor function at discharge and 71% of cognitive function improvements. Adjustment accounted for 26% and 32% of change in motor and cognitive function, respectively. Abilities accounted for 60% of change in cognitive function but did not significantly influence change in motor function. Changes in psychosocial participation fully mediated change in motor function during neurorehabilitation.

CONCLUSIONS

Psychosocial function, particularly participation, is an important driver of motor and cognitive recovery throughout neurorehabilitation. Functional rehabilitation programs should target psychosocial improvement as an important mechanism of change.

Pilot of a dog-walking program to foster and support community inclusion for people with cognitive disabilities

PURPOSE

To evaluate a dog-walking program (called "Dog Buddies") designed to address the need for evidence-based programs that create opportunities for people with cognitive disabilities to be more socially included in mainstream society. The research question was: Does community dog walking foster social interaction for people with cognitive disabilities?

MATERIALS AND METHODS

Single-case experimental design was used with four individuals (three with intellectual disability; one with Acquired Brain Injury (ABI)) recruited via two disability service providers in Victoria. Target behaviours included frequency and nature of encounters between the person with disability and community members. Change was measured from baseline (five community meetings with a handler but no dog) to intervention period (five meetings minimum, with a handler and a dog). Semi-structured interviews, audio-recorded and transcribed verbatim, provided three participants' subjective experiences of the program.

RESULTS

Dog Buddies increased the frequency of encounters for all participants. The presence of the dog helped to foster convivial encounters, community members were found to be more welcoming, and some participants were recognised or acknowledged by name over time in the intervention phase.

CONCLUSIONS

The dog-walking program offered a simple means of influencing the frequency and depth of community-based social interactions for people with cognitive disabilities.IMPLICATIONS FOR REHABILITATIONThe co-presence of people with disabilities in the community with the general population does not ensure social interaction occurs.Both disability policy, and the programs or support that is provided to people with disabilities, needs to have a strong commitment to the inclusion of people with disabilities in mainstream communities.Dog Buddies is a promising example of a program where the presence of a pet dog has been demonstrated to support convivial, bi-directional encounters of people with cognitive disabilities and other community members.Dog-walking offers a simple means of influencing the frequency and depth of community-based social interactions for people with cognitive disabilities.

The Effectiveness of Community Occupational Therapy Interventions: A Scoping Review

Background: This review aims to evaluate the level of scientific evidence for the effectiveness of Community Occupational Therapy interventions. Methods: A systematic review was used to analyze and synthesize the studies collected. The databases of Cochrane, OTseeker, OTCATS, Web of Science, Scielo and Scopus were used in order to collect articles published between 2007 and 2020. PRISMA recommendations were followed. Results: A total of 12 articles comprised part of the study (7 randomized controlled studies, 4 systematic reviews and 1 meta-analysis). The main areas of practice were geriatric gerontology (22.1%) and mental health (19.7%), which were statistically significant (χ²; p < 0.005) compared to the rest. Regarding the studies analyzed, all of them had scores of >7 on the PEDro and AMSTAR scales. Conclusions: Research on Community Occupational Therapy constitutes a consolidated line of research but the objectives and areas of research were limited. Descriptive qualitative methodology predominated and studies on the effectiveness of Community Occupational Therapy interventions showed a medium–low level of evidence.

Mood, Activity Participation, and Leisure Engagement Satisfaction (MAPLES): a randomised controlled pilot feasibility trial for low mood in acquired brain injury

Background

Acquired brain injury (ABI) affects approximately 79.3 million individuals annually and is linked with elevated rates of depression and low mood. Existing methods for treating depression in ABI have shown mixed efficacy. Behavioural activation (BA) is a potentially promising intervention. Its premise is that individuals with low mood avoid planning and engaging in activities due to low expectations of a positive outcome. Consequently, their exposure to positive reinforcement is reduced, exacerbating low mood. BA aims to break this cycle by encouraging activity planning and engagement. It is unknown whether cognitive demands of traditional BA may undermine efficacy in ABI. Here, we assess the feasibility and acceptability of two groups designed to increase activity engagement. In the activity planning group (traditional BA), the importance of meaningful and positive activity will be discussed and participants encouraged to plan/engage in activities in everyday life. The activity engagement group (experiential BA) instead focuses on engagement in positive experiences (crafts, games, discussion) within the group. The primary aims are to evaluate the feasibility and acceptability of the two groups in ABI. A secondary aim is to explore relative efficacy of the groups compared to an equivalent period of waitlist controls.

Method

This study outlines a parallel-arm pilot feasibility trial for individuals with low mood and ABI that compares a traditional vs experiential BA group vs waitlist controls. Adults (≥ 18 years) will be recruited from local ABI services and randomised to condition. Feasibility and acceptability will be assessed via recruitment, retention, attendance and participant feedback. Groups will be compared (pre- and post-intervention and 1 month follow-up) by assessing self-reported activity engagement. Secondary outcomes include self-report measures of depression, anxiety, post-traumatic distress related to the ABI, motivation, participation and sense of control over one’s life.

Ethics and dissemination

The trial has been approved by the Health Research Authority of the NHS in the UK (East of England—Cambridge Central, REF 18/EE/0305). Results will inform future research on interventions for mood in ABI and be disseminated broadly via peer-reviewed journals, conference presentations and social media.

Trial registration

ClinicalTrials.gov, NCT03874650 pre-results. Protocol version 2.1, March 5, 2019

Developing a model of long-term social rehabilitation after traumatic brain injury: the case of the head forward centre

Background: Social isolation and inactivity are highly problematic long-term consequences of Traumatic Brain Injury. They are rarely addressed by rehabilitation programmes, which focus on early phases of recovery. Day centres, or "drop-in" peer support groups, have emerged as an informal solution to social rehabilitation needs. However, there is a lack of knowledge regarding the therapeutic ingredients of these services.Methods: Twelve survivors of Traumatic Brain Injury that attended a social rehabilitation service (Head Forward Centre, UK; HFC), were interviewed to explore the meanings attached to the service and its activities. Thematic analysis was used to describe emerging themes and build a model of social rehabilitation.Results: Four therapeutic functions were attached to HFC: (a) HFC as a safe and predictable milieu; (b) HFC as a space where identity can be reconstructed; (c) HFC as a place where survivors can remain cognitive and socially active; (d) HFC as a network of continuous support.Conclusion: A model of long-term social rehabilitation should consider both psychological and practical/functional ingredients. Such a model can help informal rehabilitation services reflect upon their goals and activities, as well as articulate therapeutic actions along the rehabilitation path. The conceptualization of these four therapeutic ingredients in holistic rehabilitation models is described, and contrasted with its use in long-term social rehabilitation.IMPLICATIONS FOR REHABILITATIONSocial isolation and inactivity are important problems in the long-term rehabilitation of people with TBI. Both problems can be addressed by social rehabilitation services (day centres and peer support groups).Participation in social rehabilitation can promote a sense of normality and belongingness, which contribute to the long-term process of identity reconstruction.Social rehabilitation can help maintaining people with TBI cognitive and socially active, as well as developing a network of continuous support.

Loss of friendship following traumatic brain injury: A model grounded in the experience of adults with severe injury

Relationships make important contributions to wellbeing and maintenance of self-worth. For those who sustain traumatic brain injury (TBI), life is frequently characterized by declining interpersonal relationships. The aim of this study was to understand the post-injury experience of friendship from the perspective of adults with severe TBI. Participants were 23 adults who had sustained severe TBI on average 10 years earlier; the majority was between 25 and 45 years old. The experience of friendship was explored using a convergent mixed methods design (quantitative self-report measures and in-depth interviews). Qualitative analysis of interview transcripts employed open and focussed coding to reveal themes and categories. Participants nominated on average 3.35 (SD 2.19) friends. When paid carers and family members were excluded, the mean dropped to 1.52 (SD 1.38). Exploratory correlations between number of friends and quality of life, depression and strong-tie support revealed significant associations of moderate to large effects. The post-injury experience of friendship was broadly conceptualized as "going downhill" with four overlapping phases: losing contact, being misunderstood, wanting to share and hanging on. Participants' stories illustrated how rehabilitation can focus on friendship by supporting established relationships and facilitating access to activities that afford interpersonal encounters and opportunities to share experiences.

The factor structure of the Quality of Life Inventory (QOLI) following traumatic brain injury

Quality of life is a key indicator of outcome following traumatic brain injury (TBI). Research has reported several different factor structures for the Quality of Life Inventory (QOLI, Frisch, 1994). We compared the fit of existing factor models and examined the clinical utility of the QOLI's factors in a sample of Australian adults with TBI. Archival data from 901 participants were provided by the Neurotrauma Register of Tasmania. Participants were aged 16-80 years and 63% were male. Approximately 69% had mild TBI (PTA < 24 h), approximately 24% had moderate TBI (PTA >1 day, <7 days) and 7% had severe TBI. Both cross sectional and longitudinal analyses were utilized, as participants provided data at one or more of seven time-points, up to 3 years following injury. The results showed the data best fitted a three-factor model, comprising Self-functioning and activity, Self-actualization and Family and environment factors, and a second order Overall QOL factor. Differences in the trajectory of recovery were noted between the QOLI factor scores over time and in relation to demographic and injury variables. In conclusion, the three-factor structure of the QOLI provided useful clinical information about the recovery of patients' subjective quality of life following TBI.

What is Known About Transitional Living Services for Adults With an Acquired Brain Injury? A Scoping Review

Transitional living service (TLS) programmes for adults with an acquired brain injury are considered an important part of rehabilitation. However, considerable variability exists in the design and structure of these services, with limited research to guide the development of a programme based on best evidence. A scoping literature review was completed to answer the question ‘What is known about TLS programmes for adults with an acquired brain injury?’ Four electronic databases were systematically searched, followed by a grey literature search (from 1996 to 2015). 3183 articles were screened and 13 articles were included in the final review. Themes that emerged from the literature include the types of residents using TLS programmes, the subjective experience of residents and staff, intervention approaches, programme staffing, and programme outcomes. The research reviewed supports the use of TLS programmes to maximise functional independence and community integration of individuals with an acquired brain injury. Clinical practise recommendations were developed to help support implementation of TLS programmes based on best evidence, these included: to use multiple outcome measures, implement collaborative goal setting, support generalisation of skills learnt in the TLS to the home environment and for eligibility criteria for these programmes to include individuals across all phases of recovery.

Community integration and health-related quality-of-life following acquired brain injury for persons living at home

PRIMARY OBJECTIVE

To study predictors of community integration (CI) and health-related quality-of-life (HRQoL) in a sample of Canadian adult, urban, multi-ethnic persons with acquired brain injury (ABI) receiving publicly-funded community services. Hypothesis 1 examined the predictive utility of age, ratings of disability, functioning and cognition for CI and HRQoL. Hypothesis 2 examined the correlation between CI and HRQoL.

RESEARCH DESIGN

Cohort study.

METHODS AND PROCEDURES

A convenience sample of community-residing clients completed measures with their care co-ordinators: Resident Assessment Instrument-Home Care (RAI-HC), Disability Rating Scale (DRS), Community Integration Questionnaire (CIQ) and the Quality-of-Life after Brain Injury Instrument (QOLIBRI).

RESULTS

Regression analysis showed DRS scores explained significant variance in CIQ and QOLIBRI. Correlations also showed that cognitive skill and ADL/IADL functioning are strongly related to CI and the Daily life and autonomy QOLIBRI sub-scale. The CIQ Total was not correlated with QOLIBRI Total, although there were some significant correlations between the CIQ social sub-scale and QOLIBRI.

CONCLUSIONS

Lesser degree of disability is a key predictor of greater CI and QoL. The present findings suggest that rehabilitation efforts should focus on minimizing disability and promoting social integration and involvement to avoid adverse long-term effects of ABI for community-resident persons.