Impact of comprehensive day treatment on societal participation for persons with acquired brain injury

"We can all relate": patient experience of an emotion-oriented group intervention after Acquired Brain Injury

Introduction

Group interventions are carried out routinely across neuropsychological rehabilitation services, to improve understanding of brain injury and aspects of impairment. Treatment provided in a group modality can bring additional perceived benefits, such as co-operative learning. However, there are very few studies which explore patient perceptions and experiences of such interventions. In the present study we investigated the experience of attending a group-based educational intervention for the consequences of acquired brain injury (ABI), which had a strong focus on emotion and emotion regulation.

Methods

Using qualitative semi-structured interviews (approximately 20 minutes), the study explores the lived experience of participating in the seven-session programme, the better to identify the perceived efficacy, salience and value of individual elements. Twenty participants with ABI took part in individual interviews, after completion of the group programme (the Brain Injury Solutions and Emotions Programme, BISEP). The study adopted a descriptive phenomenological philosophy, which focuses on lived experience to explore a phenomenon (i.e. the experience of BISEP). As regards methods, the study employed thematic analysis to cluster experiences into themes of meaning.

Results

Five themes were identified: (1) 'Long term consequences and psychological needs', which related to the persistent nature of direct consequences of injury and adjustment, and how these result in a need for interventions such as BISEP. (2) 'Positive experiences of participating in the programme', referred to participants' overall experience of the programme and valued elements within it. The remaining themes referred to the programme as (3) a social milieu; (4) a place to learn; and (5) a place to promote positive emotional experiences.

Discussion

Similar to previous studies, many people reported high acceptability and perceived value of the group programme, and its role in facilitating adjustment and understanding of injury. Of particular importance was the opportunity to socialise with people who "can all relate", in line with a growing emphasis on social rehabilitation. The findings especially highlight the relevance of emotion-focused group programmes for ABI, promoting emotion regulation, and practical tools that are delivered optimistically. Further implications for practice and future research include to focus on long term rehabilitation, a social milieu, and strategies to support adjustment.

Level of Evidence of Telehealth Rehabilitation and Behavioral Health Services for Traumatic Brain Injury: A Scoping Review

Traumatic brain injury (TBI) can result in significant impairments in functioning associated with partial or permanent disabilities. Examining the evidence for domain-specific telehealth interventions is necessary to guide the development of effective clinical and research programs for this population. The present scoping review characterizes the level of evidence across a range of TBI-related disabilities and impairments. A literature search was performed across comprehensive databases using search terms related to TBI, rehabilitation, telehealth, and outcome. A total of 19 publications from 17 studies met inclusion criteria. Articles focused on telehealth interventions to improve global, cognitive, emotional, and physical functioning post-TBI. Levels of evidence ranged from 1 to 4 across domains, with predominantly experimental designs (level 1). Outcomes demonstrating improvement or benefit from telehealth treatments were reported across all functional domains (50-80% of studies). Results highlight the potential of telehealth interventions across the span of comprehensive interdisciplinary rehabilitation care. Expanded research is needed on remote treatment options for physical symptoms, for subgroups within TBI populations (i.e., mild TBI, military populations), as well as on remote and hybrid comprehensive rehabilitation programs.

The Australian Traumatic Brain Injury Initiative: Review and Recommendations for Outcome Measures for Use With Adults and Children After Moderate-to-Severe Traumatic Brain Injury

The Australian Traumatic Brain Injury Initiative (AUS-TBI) aims to select a set of measures to comprehensively predict and assess outcomes following moderate-to-severe traumatic brain injury (TBI) across Australia. The aim of this article was to report on the implementation and findings of an evidence-based consensus approach to develop AUS-TBI recommendations for outcome measures following adult and pediatric moderate-to-severe TBI. Following consultation with a panel of expert clinicians, Aboriginal and Torres Strait Islander representatives and a Living Experience group, and preliminary literature searches with a broader focus, a decision was made to focus on measures of mortality, everyday functional outcomes, and quality of life. Standardized searches of bibliographic databases were conducted through March 2022. Characteristics of 75 outcome measures were extracted from 1485 primary studies. Consensus meetings among the AUS-TBI Steering Committee, an expert panel of clinicians and researchers and a group of individuals with lived experience of TBI resulted in the production of a final list of 11 core outcome measures: the Functional Independence Measure (FIM); Glasgow Outcome Scale-Extended (GOS-E); Satisfaction With Life Scale (SWLS) (adult); mortality; EuroQol-5 Dimensions (EQ5D); Mayo-Portland Adaptability Inventory (MPAI); Return to Work /Study (adult and pediatric); Functional Independence Measure for Children (WEEFIM); Glasgow Outcome Scale Modified for Children (GOS-E PEDS); Paediatric Quality of Life Scale (PEDS-QL); and Strengths and Difficulties Questionnaire (pediatric). These 11 outcome measures will be included as common data elements in the AUS-TBI data dictionary. Review Registration PROSPERO (CRD42022290954).

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.

Comparison of TBI and CVA outcomes: Durability of gains following post-hospital neurological rehabilitation

BACKGROUND

With the effectiveness of post-hospital brain injury rehabilitation clearly demonstrated, research focus has shifted to durability of treatment gains over time.

OBJECTIVE

Study objectives were threefold: (1) examined the stability of outcomes following post-hospital rehabilitation for persons with acquired brain injury, (2) compare differences in short and long-term outcome for TBI and CVA groups, and (3) identify predictors of long-term outcomes.

METHODS

Subjects (n = 108) were selected from 2,177 neurologically impaired adults with consecutive discharges from 18 post-hospital programs in 12 states from 2011 through 2019. The study sample included TBI, CVA, and Mixed neurological groups. All persons were evaluated using the Mayo Portland Adaptability Inventory -4 Participation Index at four assessment intervals: admission, discharge, and 3 and 12 month follow-up. Additional analyses included repeated measures 2x4 design addressing TBI and CVA by the four measurement periods, and hierarchical multiple regression to identify outcome predictors.

RESULTS

The total sample demonstrated a reduction in Participation T-scores (indicating less disability) from admission to discharge. Reductions in disability were maintained at the 3 and 12 month follow-up assessments (Greenhouse-Geisser F (2.37) = 76.87, p < 0.001, partial eta2 = 0.418, power to detect = 0.99). The CVA group demonstrated greater disability at each assessment interval, however, those differences were not statistically significant. Significant predictors of outcome at 12 months post-discharge were length of stay in program and type of injury. TBIs with longer length of stay experienced better outcome at 12 months than non-TBIs with shorter length of stays (hierarchical multiple regression adjusted R2 = 0.085, p < 0.05).

CONCLUSION

Post-hospital residential neurorehabilitation programs provide a return on investment. Gains are realized from admission to discharge, and maintained one year following discharge from rehabilitation.

Use of person-centered goals to direct interdisciplinary care for military service members and Veterans with chronic mTBI and co-occurring psychological conditions

OBJECTIVE

To explore the use of person-centered goals (PCGs) to direct interdisciplinary care to support PCG attainment in military service members and Veterans (SM/Vs) with chronic mild traumatic brain injury (mTBI) and co-occurring psychological conditions.

METHODS

A retrospective chart review was completed for 146 United States military SM/Vs reporting chronic symptoms following mTBI and co-occurring psychological conditions who received care in the SHARE Military Initiative intensive outpatient program, a donor-funded program administered by a not-for-profit hospital, between April 1, 2015 and March 31, 2019. PCGs were used to direct care consisting of individual and group-based interventions and therapies delivered by an interdisciplinary, co-located team including behavioral health, case management, neurology or physiatry, nursing, occupational therapy, physical therapy, recreation therapy, speech-language pathology, and transition support. The primary outcome measure was PCG attainment measured via goal attainment scaling.

RESULTS

Increased PCG attainment was demonstrated at program discharge and throughout the first year following program discharge. Predictors of goal attainment at discharge included longer participation in treatment, greater reduction in depressive symptoms and greater improvement in adjustment at discharge, male gender, and higher cognitive and physical abilities on admission.

CONCLUSIONS

This sample of military SM/Vs with mTBI and co-occurring psychological conditions who received intensive, interdisciplinary, PCG directed care demonstrated increased PCG attainment at program discharge which further increased with transition support over the year post-discharge. Results suggest PGC goal directed care is a feasible, promising methodology of individualizing treatment in this population. This exploratory study lays a foundation for future prospective, controlled, comparative effectiveness research that will further understanding of the effectiveness of intensive, interdisciplinary, PCG directed care.

American Speech-Language-Hearing Association Clinical Practice Guideline: Cognitive Rehabilitation for the Management of Cognitive Dysfunction Associated With Acquired Brain Injury

BACKGROUND

Cognitive-communication impairments following acquired brain injury (ABI) can have devastating effects on a person's ability to participate in community, social, vocational, and academic preinjury roles and responsibilities. Guidelines for evidence-based practices are needed to assist speech-language pathologists (SLPs) and other rehabilitation specialists in the delivery of cognitive rehabilitation for the adult population.

PURPOSE

The American Speech-Language-Hearing Association, in conjunction with a multidisciplinary panel of subject matter experts, developed this guideline to identify best practice recommendations for the delivery of cognitive rehabilitation to adults with cognitive dysfunction associated with ABI.

METHOD

A multidisciplinary panel identified 19 critical questions to be addressed in the guideline. Literature published between 1980 and 2020 was identified based on a set of a priori inclusion/exclusion criteria, and main findings were pooled and organized into summary of findings tables. Following the principles of the Grading of Recommendations Assessment, Development and Evaluation Evidence to Decision Framework, the panel drafted recommendations, when appropriate, based on the findings, overall quality of the evidence, balance of benefits and harms, patient preferences, resource implications, and the feasibility and acceptability of cognitive rehabilitation.

RECOMMENDATIONS

This guideline includes one overarching evidence-based recommendation that addresses the management of cognitive dysfunction following ABI and 11 subsequent recommendations focusing on cognitive rehabilitation treatment approaches, methods, and manner of delivery. In addition, this guideline includes an overarching consensus-based recommendation and seven additional consensus recommendations highlighting the role of the SLP in the screening, assessment, and treatment of adults with cognitive dysfunction associated with ABI. Future research considerations are also discussed.

What is the effect of personalized cognitive strategy instruction on facilitating return-to-learn for individuals experiencing prolonged concussion symptoms?

The purpose of this study was to evaluate the degree to which personalized cognitive strategy instruction (PCSI) assisted students with prolonged concussion symptoms (PCS) to achieve functional and academic-related goals. It was hypothesized that goal attainment on collaboratively developed functional goals and selected scores on the pre/post outcome measurements would improve following the delivery of PCSI. A non-concurrent multiple baseline design was utilized across three female participants ages 13-16. The weekly status tracking measurement of participant performance served as the primary measurement analysed to determine the existence of a functional relation between the addition of PCSI to psychoeducation and the achievement of participant outcome. Although visual analysis of the plotted status tracking data did not support the existence of a functional relation, all three participants met or exceeded functional goals on their goal attainment scales. A Tau-U analysis supported a small treatment effect. The positive response to the intervention from two of the three participants in addition to goal attainment for all three participants suggests PCSI has potential to mitigate cognitive challenges in adolescents with PCS. Implications for future research and methods to promote ecological measurement of intervention effects are discussed.

Implementation of a Mobile Technology-Supported Diaphragmatic Breathing Intervention in Military mTBI With PTSD

BACKGROUND

Diaphragmatic breathing is an evidence-based intervention for managing stress and anxiety; however, some military veterans with mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) report challenges to learning and practicing the technique. BreatheWell Wear assists performance of breathing exercises through reminders, biofeedback, and visual, tactile, and auditory guidance.

OBJECTIVE

To evaluate feasibility of implementing BreatheWell Wear, a mobile smartwatch application with companion smartphone app, as an intervention for stress management in military veterans with mTBI and PTSD.

METHODS

Thirty veterans with chronic symptoms of mTBI and PTSD recruited from an interdisciplinary, intensive outpatient program participated in this pilot pragmatic clinical trial. Participants were randomly assigned to the experimental (BreatheWell Wear and conventional care) and control (conventional care) groups for 4 weeks. Conventional care included instruction on relaxation breathing and participation in behavioral health therapy. Effects on goal attainment, treatment adherence, diaphragmatic breathing technique knowledge, and stress were measured through surveys and diaries. Changes in symptoms, mood, and well-being were measured pre/postintervention via the Posttraumatic Checklist for DSM-5, Beck Anxiety Inventory, Beck Depression Inventory, and Flourishing Scale.

RESULTS

Person-centered goal attainment (t = 4.009, P < .001), treatment adherence (t = 2.742, P = .001), diaphragmatic breathing technique knowledge (t = 1.637, P < .001), and reported ease of remembering to practice (t = -3.075, P = .005) were significantly greater in the experimental group. As expected, measures of PTSD, anxiety, depression, and psychological well-being showed clinically meaningful change in both groups, and both groups demonstrated reduced stress following diaphragmatic breathing.

CONCLUSION

These preliminary findings indicate that BreatheWell Wear may be a clinically feasible tool for supporting diaphragmatic breathing as an intervention in veterans with mTBI and PTSD, and a future effectiveness trial is warranted.

Value and Cost Savings From Access to Multi-disciplinary Rehabilitation Services After Severe Acquired Brain Injury

Acquired brain injury (ABI) is a major global public health problem and source of disability. A major contributor to disability after severe ABI is limited access to multidisciplinary rehabilitation, despite evidence of sustained functional gains, improved quality of life, increased return-to-work, and reduced need for long-term care. A societal model of value in rehabilitation matches patient and family expectations of outcomes and system expectations of value for money. A policy analysis of seven studies (2009-2019) exploring outcomes and cost-savings from access to multi-disciplinary rehabilitation identified average lifetime savings of $1.50M per person, with costs recouped within 18 months. Recommendations: Increase access to multi-disciplinary rehabilitation following severe ABI; strengthen prevention focus; increase access to case management; support return-to-work; and systematically collect outcome and cost data.

Client experiences with holistic neuropsychological rehabilitation: "It is an ongoing process"

The effectiveness of holistic neuropsychological rehabilitation for people with acquired brain injury has previously been demonstrated by means of standardized and routinely administered outcome measures. However, the most important outcomes from the perspective of former clients are largely unknown. This study explored the experience of participating in a holistic neuropsychological rehabilitation programme by conducting three focus groups with twelve former clients who had sustained a brain injury. Data were transcribed verbatim and analysed using thematic analysis. "It is an ongoing process" emerged as the overarching theme for the experience of recovery from brain injury. Four subthemes, or phases, were identified. Participants went through (1) a phase of confrontation, after which they (2) trained their skills and strategies, and (3) experimented with these in daily life. In the end, clients reached a phase of (4) coming to terms with their injury. Participants described increased levels of self-esteem, sense of competence, and adaptation as the most important outcomes of the programme, as these factors helped them regain a sense of identity. The results indicate that including these factors in outcome evaluations of complex interventions after brain injury may be important as they appear essential for capturing the client's perspective on change.

Validation of the Mayo-Portland Adaptability Inventory-4 (MPAI-4) and reference norms in a French-Canadian population with traumatic brain injury receiving rehabilitation

PURPOSE

Validate the factor structure and establish internal consistency reliability of the French-Canadian version of the Mayo-Portland Adaptability Inventory (MPAI-4), using a Canadian sample of adults with traumatic brain injury (TBI) receiving post-acute rehabilitation services.

MATERIALS AND METHODS

Psychometric analysis of French-Canadian MPAI-4 data from TBI adults (N = 1012) who received rehabilitation interventions and for whom a first French-Canadian MPAI-4 measure was completed between 2016 and 2020.

RESULTS

Exploratory factor analysis was used to evaluate the factor structure of the French-Canadian MPAI-4. The final and best solution revealed three factors, which accounted for 48.68% of the variance. Using Cronbach's alpha, all subscales showed good internal consistency (all 0.70 ≤ α ≤ 0.89). Reference norms for the TBI sample are provided, as well as descriptive raw data according to sex, age, TBI severity and rehabilitation setting.

CONCLUSIONS

The French-Canadian MPAI-4 factor structure is validated. The three factors extracted are similar to the three subscales of the original MPAI-4. The questionnaire shows good psychometric properties and represents a suitable tool for TBI adults receiving rehabilitation services in a French-Canadian context. The provided reference norms will also help guide the clinical use of the MPAI-4 in French-Canadian TBI populations.Implications for rehabilitationThe MPAI-4 questionnaire measures functional abilities, global outcome and community integration following traumatic brain injury (TBI).The questionnaire can be used in inpatient, outpatient and vocational rehabilitation settings to assess TBI patients' progress and outcomes, plan interventions and evaluate the effect of rehabilitation.The French-Canadian version of the MPAI-4 is validated and suitable to be used in French-Canadian post-acute TBI rehabilitation settings.

Community reintegration following holistic milieu-oriented neurorehabilitation up to 30 years post-discharge

BACKGROUND

The primary goal of neurorehabilitation for individuals with acquired brain injury (ABI) is successful community reintegration, which commonly focuses on home independence, productivity, and social engagement. Previous research has demonstrated that holistic treatment approaches have better long-term outcomes than other treatment approaches. Holistic approaches go beyond the fundamental components of neurorehabilitation and address metacognition and self-awareness, as well as interpersonal and functional skills.

OBJECTIVES

The present study aimed to examine community reintegration of individuals with ABI who completed holistic milieu-oriented neurorehabilitation at the Center for Transitional Neuro-Rehabilitation (CTN), Barrow Neurological Institute (BNI) at up to 30-years post-discharge. We evaluated (a) functional independence, (b) productivity and driving status, and (c) psychosocial profiles of the brain injury survivors.

METHOD

Participants included 107 individuals with ABI with heterogeneous etiologies who attended holistic milieu-oriented neurorehabilitation between 1986 and 2016. These participants completed the Mayo-Portland Adaptability Inventory-4 (MPAI-4) and a long-term outcome questionnaire (LOQ) specifically developed for this study.

RESULTS

The results demonstrate that 89% of participants were productive at up to 30 years post-discharge (73% engaged in competitive work and/or school) after excluding the retired participants. Almost all of the participants who were engaged in work and/or school reported using compensatory strategies on a long-term basis. Furthermore, only 14% out of 102 study participants were driving at the time of program admission; whereas 58% out of 96 were driving at the time of discharge; and impressively, 70% out of 107 participants were driving at the time of follow-up. Regression analyses revealed that older age at the time of injury, shorter duration between injury and treatment, and better functionality indicated by lower MPAI-4 Ability Index scores significantly predicted a return to driving status at the time of study participation. Psychosocial data from the LOQ revealed positive findings with respect to patients' marital status, living situation, income, and quality of social life.

CONCLUSION

The findings from this study suggest that functional gains made during holistic neurorehabilitation have enduring effects and that patients can benefit highly from holistic milieu therapy beyond the early post-acute phases of their recovery. Additionally, they provide evidence that there is potential to return to driving, years after treatment completion.Our holistic milieu treatment approach addressing metacognition, self-awareness, social and coping skills training, and actively transitioning to community settings, is thought to have contributed to the exceptional and long-lasting outcomes in this study.

Predictors of Access to Rehabilitation in the Year Following Traumatic Brain Injury: A European Prospective and Multicenter Study

BACKGROUND

Although rehabilitation is beneficial for individuals with traumatic brain injury (TBI), a significant proportion of them do not receive adequate rehabilitation after acute care.

OBJECTIVE

Therefore, the goal of this prospective and multicenter study was to investigate predictors of access to rehabilitation in the year following injury in patients with TBI.

METHODS

Data from a large European study (CENTER-TBI), including TBIs of all severities between December 2014 and December 2017 were used (N = 4498 patients). Participants were dichotomized into those who had and those who did not have access to rehabilitation in the year following TBI. Potential predictors included sociodemographic factors, psychoactive substance use, preinjury medical history, injury-related factors, and factors related to medical care, complications, and discharge.

RESULTS

In the year following traumatic injury, 31.4% of patients received rehabilitation services. Access to rehabilitation was positively and significantly predicted by female sex (odds ratio [OR] = 1.50), increased number of years of education completed (OR = 1.05), living in Northern (OR = 1.62; reference: Western Europe) or Southern Europe (OR = 1.74), lower prehospital Glasgow Coma Scale score (OR = 1.03), higher Injury Severity Score (OR = 1.01), intracranial (OR = 1.33) and extracranial (OR = 1.99) surgery, and extracranial complication (OR = 1.75). On contrast, significant negative predictors were lack of preinjury employment (OR = 0.80), living in Central and Eastern Europe (OR = 0.42), and admission to hospital ward (OR = 0.47; reference: admission to intensive care unit) or direct discharge from emergency room (OR = 0.24).

CONCLUSIONS

Based on these findings, there is an urgent need to implement national and international guidelines and strategies for access to rehabilitation after TBI.

Time between acquired brain injury and admission to community-based rehabilitation: differences in cognitive and functional gains

OBJECTIVE

To determine differences in rehabilitation gains made by people with an acquired brain injury undergoing staged community-based brain injury rehabilitation (SCBIR) at different times between injury and admission.

METHOD

Retrospective cohort analysis of routinely collected demographic and rehabilitation data from clients admitted to SCBIR service 2011-2017 (n=92). Outcome measures: Mayo-Portland Adaptability Inventory-4 (MPAI-4) and UK Functional Assessment Measure (UK FIM+FAM) collected on admission and annually thereafter until discharge. Analysis was stratified by time since injury on admission: 'Early' (<1 year (n=36)), 'Middle' (1-2 years (n=34)) and 'Late' (>2 years (n=22)). Between-group differences were tested using bootstrapped one-way ANOVA. Within-group differences were tested using paired T tests.

RESULTS

Total cohort made significant gains in MPAI-4 and UK FIM+FAM total and all subscales (p = .001). Early group made greatest change in all subscales of both outcome measures (p < .01). Middle cohort improved significantly in all subscales (p < .02) excluding MPAI-4 Adjustment. Late cohort still made statistically significant gains in all UK FIM+FAM subscales (p < .05) and MPAI-4 Participation (p < .01). Item level changes are presented.

CONCLUSION

More than 2 years after injury, people are able to make improvements in participation and functional independence following SCBIR.

Traumatic Brain Injury Caused by Work Accidents: How can Occupational and Vocational Recovery be Achieved?

Issues connected with the reintegration of individuals affected by severe brain injury are numerous and complex. Extensive data indicate the effectiveness of treatments based on an holistic approach, which integrates medical interventions with social programmes and offers continuity, leading to the rapid achievement of independent living outcomes and return to work. In Italy, extensive resources are available for the clinical and rehabilitation management of individuals affected by traumatic brain injury in the acute and post-acute phase, but there are only a few organized services to support the reintegration phase. This paper describes a model created via a 2-year collaboration between the National Institute for Insurance against Accidents at Work (INAIL) in Rome and the National Federation of Traumatic Brain Injury Associations (FNATC). The combined effort of these organizations led to the development of an Italian Model of Vocational Rehabilitation (IMoVR), which was exportable to all 20 Italian Regions. Due to the experience gained by a few avant-garde teams, IMoVR was used to pioneer an approach characterized by structured phases and actions aimed at designing high-quality interventions, and at monitoring their long-term effectiveness. These teams comprised experts in different areas, including: forensic doctors, social workers, administrative managers of INAIL, neuropsychologists, psychotherapists, educators working in associations registered with FNATC, all of whom are members of a service network that had already activated small individual vocational projects. In total, the collaboration comprised 42 pro-fessionals working in 7 Italian cities: Ancona, Arezzo, Ferrara, Milano, Pordenone, Rimini and Vicenza.

Effectiveness of Post-Hospital Intensive Residential Rehabilitation after Acquired Brain Injury: Outcomes of 256 Program Completers Compared to Participants in a Residential Supported Living Program

Post-hospital residential brain injury rehabilitation outcomes research is a complicated undertaking because of the custom-tailoring of interventions needed to meet the complex and unique need of each individual. As such, there tends to be great variability across program settings, which generally limits large-scale intervention studies. Growing literature demonstrates that post-hospital residential programs are beneficial. The main criticisms of this work include the absence of randomized-controlled studies, lack of clear definition of treatment types/settings, and small sample sizes. This study is a retrospective analysis of program evaluation data for a large, multi-site, national provider of post-hospital residential brain injury rehabilitation services. Specifically, outcome of participants completing Intensive Residential Rehabilitation (IRR) were compared to participants in the Residential Supported Living (RSL) program. Results demonstrate that participants in the IRR program improve and that participants in the RSL group preserve functional ability over time, suggesting that each program is effective in achieving its intended outcome. The IRR treatment group achieved significantly better outcomes than those in the same setting not receiving the intervention. To isolate treatment effects of IRR, a subsample of participants across program types were matched on time post-injury, age, and sex. The treatment effect of IRR was strengthened in this analysis, suggesting that chronicity alone does not account for the variance between the two groups.

Efficacy of Postacute Neuropsychological Rehabilitation for Patients with Acquired Brain Injuries is Maintained in the Long-Term

OBJECTIVES

We examined the long-term maintenance of treatment outcomes in patients with acquired brain injuries who participated in community-based neuropsychological rehabilitation (NR) programs, in a prospective, within-subject, longitudinal, partial double-blind cohort study.

METHODS

One hundred forty-three patients (39 females, mean age 33.5 years) who had experienced a brain injury (BI) (mean time since injury 3.95 years) were referred to a postacute community-based NR institute. Patients participated in one of the three programs aimed at improving their functional outcome: comprehensive-holistic neuropsychological rehabilitation, vocational-focused neuropsychological rehabilitation, and individual neuropsychological rehabilitation. Self-reported data regarding employment, community integration, perceived quality of life (PQoL), and mood were collected at program start and end, and annually for 3 years post program completion. Group placement was based on clinical considerations, such that the study did not aim to compare the programs, but rather to assess their long-term benefits.

RESULTS

Employment status and stability, community integration, and PQoL improved significantly after program completion and continued to improve for the following 3 years. The proportion of individuals with mood disturbances did not change during or after the programs.

CONCLUSIONS

A clear consensus regarding BI rehabilitation is that long-term maintenance of treatment outcomes is imperative to its efficacy. Our findings suggest that postacute NR programs provide participants with various tools, skills, and psychological perspectives that they continue to gain from and generalize to real life after program completion, reflecting transformational processes with stable long-term benefits.

Activity Performance, Participation, and Quality of Life Among Adults in the Chronic Stage After Acquired Brain Injury-The Feasibility of an Occupation-Based Telerehabilitation Intervention

Objective: Acquired brain injury (ABI) is a leading cause of long-term disability. This calls for effective and accessible interventions to support participation in the community over time. One promising avenue to answer this need is telerehabilitation. Prior to conducting a larger trial, the main objective of this pilot study is to explore the feasibility, acceptability, and preliminary efficacy of a metacognitive occupation-based intervention in a telerehabilitation format with adults and older adults in the chronic phase after ABI.

Methods: Five community dwelling participants (ages 65–72), 6–10 months post-ABI, with scores 2–4 on the modified Rankin scale and without dementia, completed the teleintervention. The intervention included ~10 weekly videoconferencing sessions administered by an occupational therapist using the Cognitive Orientation to Daily Occupational Performance approach. Each participant defined five functional goals and three were trained and two were not trained during the intervention. Evaluations were conducted at pre, post, and 3-month follow-up. The primary outcome measures included activity performance (The Canadian Occupational Performance Measure; COPM), participation (the Mayo-Portland Adaptability Inventory-4 Participation Index; MPAI-4-P), and quality of life (QoL) (stroke impact scale; SIS). Other measures included a feedback interview, satisfaction questionnaire, field notes, and a treatment fidelity checklist.

Results: The teleintervention was found to be feasible and the participants expressed a high degree of satisfaction with the intervention and the technology use. A Wilcoxon Signed-Ranks test indicated statistically significant improvements post intervention in COPM performance (z = −2.023, p = 0.043) and satisfaction (z = −2.023, p = 0.043) ratings. Additionally, clinically significant improvements (≥2 points) in both performance and satisfaction with performance were found for each participant in at least three of their five defined functional goals. Trends toward significant improvement were found in MPAI-4-P ratings post intervention (z = −1.826, p = 0.068). Furthermore, clinically significant improvements (≥15 points) post intervention were found for each participant in some subscales of the SIS. Results were partially maintained at 3-month follow-up.

Conclusions: This pilot study demonstrated the feasibility of a metacognitive occupation-based telerehabilitation intervention and its potential benefits in activity performance, participation, and QoL for older adults coping with long-term disability following ABI.

Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03048708.

Improving Self-awareness After Acquired Brain Injury Leads to Enhancements in Patients’ Daily Living Functionality

Objective:

To explore whether the improvement in self-awareness induced by a structured intervention programme in patients suffering a brain injury is associated with an enhancement in their functional outcomes.

Method:

This study uses a pre- and post-test control group design with a sample of 56 patients with acquired brain injury randomly assigned to an experimental and a control group. Pre- and post-intervention measurements were self-awareness (using a previously developed scale) and functional outcome (using the Lawton Instrumental Activities of Daily Living Scale).

Results:

Patients who received the intervention programme showed a greater improvement in their self-awareness level and functional outcome than patients in the control group. Additionally, the correlation analyses between improvements at both measures showed a relation between improvement in self-awareness and improvement in functional outcome, especially when the pre-treatment self-awareness level was considered.

Conclusions:

Implementing an intervention programme in self-awareness, in the context of a global rehabilitation process of patients with acquired brain injury, is useful for improving their self-awareness level and the functionality in their daily activities.

Clinical utility of neuropsychological tests for employment outcomes in persons with cognitive impairment after moderate to severe traumatic brain injury

OBJECTIVE

To retrospectively examine the clinical utility of neuropsychological tests (NPTs) for predicting employment outcomes in persons with cognitive impairment after moderate to severe traumatic brain injury (TBI).

METHODS

132 individuals of working age with cognitive impairment after moderate to severe TBI were classified into three groups by employment status: competitive employment (CE); supported employment (SE); and unemployed (UE). NPT scores were compared among groups. Using multinomial logistic regression with group allocation as the dependent variable, significant variables were identified, and receiver operating characteristic (ROC) curves were calculated.

RESULTS

Comparison of NPT results among the three groups showed significant differences for all NPTs (all items, p < 0.01). Using multinomial logistic regression analysis, Rivermead Behavioral Memory Test (RBMT) and Behavioral Assessment of the Dysexecutive Syndrome from CE versus SE and Trail Making Test-B and RBMT from SE versus UE were identified. ROC curve analysis indicated small to moderate accuracy (area under the curve, 0.63-0.84).

CONCLUSION

NPT scores can predict future employment status in patients with cognitive impairment after TBI. These findings may lead to improved clinical assessments when providing work support. Future research should consider occupational categories, managerial categories, and types of re-employment.

Group-Based Trajectory Analysis of Emotional Symptoms Among Survivors After Severe Traumatic Brain Injury

OBJECTIVES

Depressive symptoms and anxiety are fairly common emotional outcomes after severe traumatic brain injury (TBI). Life satisfaction is a main factor in the general construct of subjective well-being. However, there is limited literature available on the interrelationship between emotional outcomes and life satisfaction post-severe TBI over time. The purpose of this study was to characterize distinct patterns of change in depressive symptoms, anxiety, and life satisfaction over 24 months after severe TBI and evaluate the interrelationship of different trajectory groups among them as well as associated subject characteristics.

METHODS

This prospective study used longitudinal data collected from the University of Pittsburgh Brain Trauma Research Center from survivors of severe TBI (N = 129). In addition to demographic and injury-related data, depressive symptoms, anxiety, and life satisfaction were collected at 3, 6, 12, and 24 months postinjury. A group-based trajectory model was performed to identify distinct longitudinal patterns of depressive symptoms, anxiety, and life satisfaction. The interrelationships of distinct trajectory groups were examined using χ tests. A multivariate logistic regression model was used to examine the predictors of different emotional symptom trajectories.

RESULTS

The group-based trajectory model identified 2 distinct patterns of each of 3 outcomes: constantly low and constantly high depressive symptoms group (70.4% vs 29.6%), constantly low and constantly high anxiety group (69.1% vs 30.9%), and low-decreasing and high-stable life satisfaction groups (56.3% vs 43.7%). A strong pairwise association was observed between trajectory group membership for depressive symptoms and anxiety (P < .0001), depressive symptoms and life satisfaction (P < .0001), and anxiety and life satisfaction (P < .001). Subjects with increased severe injury were more likely to belong to the high-stable depressive symptoms group, while there were no significant associations between age, gender, race, education, marriage status and distinct depressive symptoms, anxiety, and life satisfaction trajectory groups.

CONCLUSIONS

A group-based trajectory model revealed patterns of emotional symptoms that have not been fully explored among survivors of severe TBI. There appear to be distinct trajectory patterns for depressive symptoms, anxiety, and life satisfaction, respectively. There was strong interrelationship among emotional symptoms. The findings add to our understanding of psychosocial outcomes experienced over time after severe TBI.

The Minimal Clinically Important Difference for the Mayo-Portland Adaptability Inventory

OBJECTIVES

To determine the Minimal Clinically Important Difference (MCID) and Robust Clinically Important Difference (RCID) of the Mayo-Portland Adaptability Inventory-4 (MPAI-4) as measures of response to intervention.

METHODS

Retrospective analysis of existing data. Both distribution- and anchor-based methods were used to triangulate on the MCID and to identify a moderate, that is, more robust, level of change (RCID) for the MPAI-4. These were further evaluated with respect to clinical provider ratings.

PARTICIPANTS

Data for individuals with acquired brain injury in rehabilitation programs throughout the United States in the OutcomeInfo Database (n = 3087) with 2 MPAI-4 ratings.

MAIN MEASURES

MPAI-4, Supervision Rating Scale, Clinician Rating of Global Clinical Improvement.

RESULTS

Initial analyses suggested 5 T-score points (5T) as the MCID and 9T as the RCID. Eighty-one percent to 87% of clinical raters considered a 5T change and 99% considered a 9T change to indicate meaningful improvement.

CONCLUSIONS

5T represents the MCID for the MPAI-4 and 9T, the RCID. Both values are notably less than the Reliable Change Index (RCI). While the RCI indicates change with a high level of statistical confidence, it may be insensitive to change that is considered meaningful by providers and participants as indicated by the MCID.

Impact of neuropsychological rehabilitation on activities of daily living and community reintegration of patients with traumatic brain injury

OBJECTIVES

The present study was targeted to observe the impact of neuropsychological rehabilitation on activities of daily living (ADL) and community reintegration of patients with traumatic brain injury (TBI).

SETTINGS AND PARTICIPANTS

Based on purposive sampling technique, ten patients with TBI falling in the age range of 20-40 years and fulfilling the inclusion and exclusion criteria were chosen from All India Institute of Speech and Hearing, Mysuru, India.

DESIGN

A quasi-experimental design, i.e., nonequivalent control group design was chosen for the study.

MATERIALS AND METHODS

Patients were assessed on Luria-Nebraska Neuropsychological Battery for Adults, Cognitive Symptoms Checklist, and Community Integration Questionnaire. Patients in experimental group were given neuropsychological rehabilitation for 6 months. Brainwave-R and Talking Pen were used as rehabilitative tools.

RESULTS

Patients with TBI have significant neuropsychological deficits observed in memory, visuo-spatial organization, arithmetic, spelling, writing, fine motor coordination, and executive functioning. Neuropsychological deficits have a major impact on ADL and community reintegration. Neuropsychological rehabilitation is effective in rehabilitating neuropsychological deficits, which in turn leads to improvement in ADL and community reintegration.

CONCLUSION

Neuropsychological rehabilitation should be one of the major goals in rehabilitation procedures for patients with TBI in order to bring overall improvement in them.

Outcomes of a community-based treatment programme for people with acquired brain injury in the chronic phase: a pilot study

The objective of the study was to evaluate the outcomes of Brainz, a low intensity community-based treatment programme for people with acquired brain injury (ABI). Participants were 62 people with sustained ABI (5.2 years post-injury, SD = 4.5) and 35 family caregivers. Participants attended two to five cognitive and physical group modules and received two hours of individual home treatment every two weeks. Primary outcomes for people with ABI were participation, perceived difficulties in daily life and need of care, level of goal attainment, and self-esteem. Primary family caregiver outcome was perceived burden of care. Attrition rate of people with ABI was 24% (n = 15), and of family caregivers was 31% (n = 11). People with ABI were more satisfied with the level of their participation after completing Brainz (p < .01), but showed no change in participation frequency or in restrictions (both ps > .01). They perceived fewer difficulties in daily life and less need of care (both ps < .01). Also, in two cognitive modules people improved on their goal achievement (p < .01). However, their self-esteem was reduced (p < .01). Caregiver burden was reduced (p < .01). This study has provided preliminary evidence of the effectiveness of a combined group-based clinical and individual home-based treatment programme, but more research is needed, preferably in larger controlled studies.

Traumatic Brain Injury Incidence, Clinical Overview, and Policies in the US Military Health System Since 2000

Exposure to explosive armaments during Operation Iraqi Freedom and Operation Enduring Freedom contributed to approximately 14% of the 352 612 traumatic brain injury (TBI) diagnoses in the US military between 2000 and 2016. The US Department of Defense issued guidelines in 2009 to (1) standardize TBI diagnostic criteria; (2) classify TBI according to mechanism and severity; (3) categorize TBI symptoms as somatic, psychological, or cognitive; and (4) systematize types of care given during the acute and rehabilitation stages of TBI treatment. Polytrauma and associated psychological and neurologic conditions may create barriers to optimal rehabilitation from TBI. Given the completion of recent combat operations and the transition of TBI patients into long-term care within the US Department of Veterans Affairs system, a review of the literature concerning TBI is timely. Long-term follow-up care for patients who have sustained TBI will remain a critical issue for the US military.

Effects of intensive neuropsychological rehabilitation for acquired brain injury

The objective of the study was to examine the effects of a comprehensive neuropsychological rehabilitation programme (Intensive NeuroRehabilitation, INR) on the emotional and behavioural consequences of acquired brain injury (ABI). The participants were 75 adult patients suffering from ABI (33 traumatic brain injury, 14 stroke, 10 tumour, 6 hypoxia, 12 other), all of whom were admitted to the INR treatment programme. The main outcome measures were: general psychological well-being (Symptom-Checklist-90), depression and anxiety (Beck Depression Inventory-II, Hospital Anxiety and Depression Scale, State Trait Anxiety Inventory), and quality of life (Quality of Life in Brain Injury). The study was a non-blinded, waiting-list controlled trial. During the waiting-list period no or minimal care was provided. Multivariate analysis of the main outcome measures showed large effect sizes for psychological well-being (partial η² = .191, p < .001), depression (partial η² = .168, p < .001), and anxiety (partial η² = .182, p < .001), and a moderate effect size for quality of life (partial η² = .130, p = .001). Changes on neuropsychological tests did not differ between the groups. It was concluded that the INR programme improved general psychological well-being, depressive symptoms, anxiety, and quality of life. The programme does not affect cognitive functioning.

Dysexecutive symptoms and carer strain following acquired brain injury: Changes measured before and after holistic neuropsychological rehabilitation

BACKGROUND

Following acquired brain injury (ABI), deficits in executive functioning (EF) are common. As a result many brain-injured patients encounter problems in every-day functioning, and their families experience significant strain. Previous research has documented the benefits of cognitive rehabilitation for executive dysfunction, and rehabilitation programmes designed to ameliorate functional problems associated with ABI.

OBJECTIVES

This study primarily aims to evaluate whether a neuropsychological rehabilitation programme reduces reported symptoms of everyday dysexecutive behaviour and carer strain.

METHODS

In this study 66 ABI outpatients attended comprehensive holistic neuropsychological rehabilitation programme. A repeated-measures design was employed to determine the effect of rehabilitation on EF and carer strain, as part of a service evaluation. Outcome measures comprised the dysexecutive questionnaire (DEX/DEX-I) and carer strain index (CSI), applied pre- and post-rehabilitation.

RESULTS

Results indicate rehabilitation benefited clients and carers in 5 of 6 DEX/DEX-I subscales, and 2 of 3 CSI subscales, (p < 0.05). An effect of aetiology on rehabilitation was found on the metacognitive scale of the DEX-I.

CONCLUSIONS

Therefore, this study supports a comprehensive holistic neuropsychological rehabilitation programme as effective in reducing reported symptoms of dysexecutive behaviour and carer strain following ABI.

Successful outcomes following neurorehabilitation in military traumatic brain injury patients in the United Kingdom

BACKGROUND

The Defence Medical Rehabilitation Centre Headley Court is the UK military rehabilitation unit. A pilot study identified the Mayo-Portland Adaptability Inventory-4 (MPAI-4) as the most appropriate rehabilitation outcome measure in young military patients with acquired brain injury.

METHODS

MPAI-4 scores were prospectively recorded for patients on admission and discharge. At 4 months, independent living and employment status were recorded. Inclusion criteria were all new admissions with traumatic brain injury (TBI). Before injury, all patients were fully employed and lived independently.

RESULTS

In a 3-year period from April 2011, there were 91 TBI patients with complete admission-discharge episodes: by US Department of Defense criteria, 21 were mild, 35 were moderate, and 35 were severe. There was a significant positive relationship between TBI severity and MPAI-4 score on admission (χ = 12.77, df = 2, p = 0.0017).Median age was 27 years, and median duration of admission was 63 days. Employment and independent living status were available for 79 patients at 4 months. Seventy-three patients (92%) were in community-based employment, with 64 (81%) employed in a competitive or transitional work; 6 (8%) were unemployed or in sheltered work. Sixty-nine (87%) were living independently, and 10 (13%) were living with support in their own home, with no one requiring institutional care.Complete MPAI-4 scores were available for 79 patients. There were statistically and clinically significant improvements in MPAI-4 scores between admission and discharge for the overall group: median admission T score was 40.0 (95% confidence interval, 36.0-42.0) and on discharge was 31.0 (95% confidence interval, 27.0-36.0), a nine-point change (Z = 6.53, p < 0.0001). These improvements with rehabilitation were sustained when patients were subdivided by TBI severity or MPAI-4 limitations.

CONCLUSION

This study demonstrates significant functional improvements in military TBI patients following intensive inpatient multidisciplinary rehabilitation, which includes substantial vocational rehabilitation. At 4 months, 92% were employed, and 87% were living independently.

LEVEL OF EVIDENCE

Therapeutic study, level V; prognostic/epidemiologic study, level IV.

Post-Inpatient Brain Injury Rehabilitation Outcomes: Report from the National OutcomeInfo Database

This study examined outcomes for intensive residential and outpatient/community-based post-inpatient brain injury rehabilitation (PBIR) programs compared with supported living programs. The goal of supported living programs was stable functioning (no change). Data were obtained for a large cohort of adults with acquired brain injury (ABI) from the OutcomeInfo national database, a web-based database system developed through National Institutes of Health (NIH) Small Business Technology Transfer (STTR) funding for monitoring progress and outcomes in PBIR programs primarily with the Mayo-Portland Adaptability Inventory (MPAI-4). Rasch-derived MPAI-4 measures for cases from 2008 to 2014 from 9 provider organizations offering programs in 23 facilities throughout the United States were examined. Controlling for age at injury, time in program, and time since injury on admission (chronicity), both intensive residential (n = 205) and outpatient/community-based (n = 2781) programs resulted in significant (approximately 1 standard deviation [SD]) functional improvement on the MPAI-4 Total Score compared with supported living (n = 101) programs (F = 18.184, p < 0.001). Intensive outpatient/community-based programs showed greater improvements on MPAI-4 Ability (F = 14.135, p < 0.001), Adjustment (F = 12.939, p < 0.001), and Participation (F = 16.679, p < 0.001) indices than supported living programs; whereas, intensive residential programs showed improvement primarily in Adjustment and Participation. Age at injury and time in program had small effects on outcome; the effect of chronicity was small to moderate. Examination of more chronic cases (>1 year post-injury) showed significant, but smaller (approximately 0.5 SD) change on the MPAI-4 relative to supported living programs (F = 17.562, p < 0.001). Results indicate that intensive residential and outpatient/community-based PIBR programs result in substantial positive functional changes moderated by chronicity.

Outcome prediction in home- and community-based brain injury rehabilitation using the Mayo-Portland Adaptability Inventory

The objective of the study was to develop statistical formulas to predict levels of community participation on discharge from post-hospital brain injury rehabilitation using retrospective data analysis. Data were collected from seven geographically distinct programmes in a home- and community-based brain injury rehabilitation provider network. Participants were 642 individuals with post-traumatic brain injury. Interventions consisted of home- and community-based brain injury rehabilitation. The main outcome measure was the Mayo-Portland Adaptability Inventory (MPAI-4) Participation Index. Linear discriminant models using admission MPAI-4 Participation Index score and log chronicity correctly predicted excellent (no to minimal participation limitations), very good (very mild participation limitations), good (mild participation limitations), and limited (significant participation limitations) outcome levels at discharge. Predicting broad outcome categories for post-hospital rehabilitation programmes based on admission assessment data appears feasible and valid. Equations to provide patients and families with probability statements on admission about expected levels of outcome are provided. It is unknown to what degree these prediction equations can be reliably applied and valid in other settings.

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

Background: Many people who have a severe traumatic brain injury (TBI) are not able to resume employment and consequently experience profound changes in their lifestyle. They have increased amounts of ’spare time’ yet often find it difficult to engage in meaningful activity. Leisure activities are one way in which meaningful activity can be increased.

Aims: This systematic review has two purposes: first, to identify and evaluate the efficacy of community-based interventions for leisure/social activity after TBI, and second to provide details on the types of intervention.

Method: Systematic searches were conducted of Medline, PsycINFO and PsycBITE to October 2014, as well as hand searches of two occupational therapy journals. Inclusion criteria were as follows: peer reviewed journal articles on adults with TBI who had participated in a trial evaluating a community-based intervention specifically targeting leisure/social activity. All research methodologies using primary studies that provided empirical, quantitative data were considered. Scientific quality of the studies was evaluated using the PEDro Scale for controlled trials and the Risk of Bias in N-of-1 Trials Scale for single-case designs.

Results: Two independent raters screened 196 abstracts, resulting in nine articles that met selection criteria. Data were then independently extracted by the raters. Four of the nine studies used a control condition in their research design (two randomised controlled trials, one controlled but non-randomised study, and one single-case experiment using a changing criterion design). Two of the studies conducted between-group analyses with significant treatment effects for mood and quality of life using active leisure programmes (Tai Chi Qigong and a combined programme of outdoor adventure experiences and goal setting respectively). Intervention programmes identified in the review were then grouped and described according to the approach or model used, including active leisure programmes, social peer mentoring, individual brokered leisure services and a therapeutic recreation model. Additional intervention models and approaches that did not result directly from the systematic review were also described because they provide information on the current approaches used in practice (Clubhouse model and leisure education programmes in the stroke population).

Conclusions: There is some evidence for the effectiveness of community-based interventions for leisure/social activity for people who have had a TBI to improve mood and quality of life. The conclusions of this review are that the interventions for this area need to be planned and specific, structured and goal-driven, intensive and conducted over a period of months.

Development of Self-Awareness After Severe Traumatic Brain Injury Through Participation in Occupation-Based Rehabilitation: Mixed-Methods Analysis of a Case Series

OBJECTIVE. We examined participation in goal planning and development of self-awareness for people with impaired self-awareness after traumatic brain injury.

METHOD. We performed a mixed-methods study of 8 participants recently discharged from inpatient rehabilitation. Self-awareness was measured using discrepancy between self and significant other ratings on the Mayo–Portland Adaptability Index (MPAI–4) at four time points. We calculated effect size to evaluate the change in MPAI–4 discrepancy over time.

RESULTS. Seven participants identified their own goals. We found a large reduction in mean MPAI–4 discrepancy (M = 8.57, SD = 6.59, N = 7, d = 1.08) in the first 6 wk and a further small reduction (M = 5.33, SD = 9.09, N = 6, d = 0.45) in the second 6 wk of intervention. Case data indicated that 7 participants demonstrated some growth in self-awareness.

CONCLUSION. Engagement in occupation-based, goal-directed rehabilitation appeared to foster awareness of injury-related changes to varying extents.

Integrating Interventions after Traumatic Brain Injury: A Synergistic Approach to Neurorehabilitation

Deficits in attention, processing speed and executive functioning are among the most commonly reported and functionally limiting cognitive impairments among individuals with TBI. Changes in mood can exacerbate cognitive deficits and reduce life quality. Contemporary hierarchical models of cognitive functioning suggest that attention/arousal processes underlie and support higher-order functions. Building on decades of clinical research, a synergistic, integrative approach to neurorehabilitation is described, which combines bottom-up and top-town cognitive interventions in addition to psychotherapeutic interventions for mood. This approach is intended to address directly impairments in both foundational (i.e., attention) and higher-order (i.e., executive functions) processes. Executive dysfunction is addressed in a top-down fashion through the application of a series of problem-solving and emotional regulation modules that teach and integrate strategies that can be generalised across situations with practice. Attention, arousal and information processing are necessary prerequisites of successful higher-order thinking, attention skills, and are addressed in a bottom-up fashion through intensive individualised attention and processing training tasks. Combining top-down and bottom-up approaches within a comprehensive day-treatment programme can effect a synergistic improvement of overall functioning.

Healthcare Consumers' Need for Brain-injury Services: The Critical Importance of Timing in Planning Future Services

Developing an awareness of the preferences of healthcare consumers is essential in determining the ‘reality’ of service provision, in planning the provision of brain-injury services and in service evaluation. Consumers should be given the opportunity to express satisfaction or dissatisfaction with the services they receive, offering their perceptions of barriers to service access, which could be removed once known. This article presents narratives of the healthcare journeys of three adults with a moderate to severe brain injury. The experiences of these participants were elicited through in-depth interviews. The aim of this article is to convey how the needs and experiences of adults with brain injury change throughout time, affecting their ability to access care over time. Previous research by the authors of this paper identified five factors that affect consumers’ experiences of care: acceptance and readiness, support, advocacy, the right service at the right time and mismatched expectations. The fluidity and interaction of these factors through time is demonstrated in this article as facilitating and impeding access to services. The implications for clinicians in considering these factors when planning services for adults with moderate to severe brain injuries are explored.

Insight vs readiness: factors affecting engagement in therapy from the perspectives of adults with TBI and their significant others

INTRODUCTION

Adults sustain significant, often irreversible impairments following brain injury. The process they go through coming to terms with these impairments can seriously interfere with their readiness to engage in rehabilitation.

AIM

This study aimed to look beyond the development of self-awareness and insight in order to explore the concept of readiness as it relates to clients' experiences of engaging with therapy.

METHOD

Sixteen in-depth interviews were conducted with 14 adults with a moderate-severe traumatic brain injury (TBI) and nine of their significant others. These participants were asked to speak about the continuum of care they experienced and the factors that effected their engagement with care.

RESULTS

The results of this study indicated that participants believed their ability to engage in therapy was related to the degree to which they were aware of and accepted their impairments and motivated to engage in rehabilitation. Participants reported that the rate and degree to which they developed awareness varied according to the type of impairments they experienced (i.e. physical vs cognitive). Participants also stated that one way to augment their awareness was to compare their new vs old selves and to compare their recovery to those of others with a similar impairment. Finally, participants reported that it was important to be able to access services when they had accepted their impairment and were ready to engage in therapy.

CONCLUSION

The clinical implications for considering the degree of awareness of impairments and readiness for engagement in care of an adult with a moderate-severe TBI are discussed in relation to future services planning.

Mayo-Portland adaptability inventory: comparing psychometrics in cerebrovascular accident to traumatic brain injury

OBJECTIVES

(1) To evaluate the measurement reliability and construct validity of the Mayo-Portland Adaptability Inventory, 4th revision (MPAI-4) in a sample consisting exclusively of patients with cerebrovascular accident (CVA) using single parameter (Rasch) item-response methods; (2) to examine the differential item functioning (DIF) by sex within the CVA population; and (3) to examine DIF and differential test functioning (DTF) across traumatic brain injury (TBI) and CVA samples.

DESIGN

Retrospective psychometric analysis of rating scale data.

SETTING

Home- and community-based brain injury rehabilitation program.

PARTICIPANTS

Individuals post-CVA (n=861) and individuals with TBI (n=603).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

MPAI-4.

RESULTS

Item data on admission to community-based rehabilitation were submitted to Rasch, DIF, and DTF analyses. The final calibration in the CVA sample revealed satisfactory reliability/separation for persons (.91/3.16) and items (1.00/23.64). DIF showed that items for pain, anger, audition, and memory were associated with higher levels of disability for CVA than TBI patients; whereas, self-care, mobility, and use of hands indicated greater overall disability for TBI patients. DTF analyses showed a high degree of association between the 2 sets of items (R=.92; R(2)=.85) and, at most, a 3.7 point difference in raw scores.

CONCLUSIONS

The MPAI-4 demonstrates satisfactory psychometric properties for use with individuals with CVA applying for interdisciplinary posthospital rehabilitation. DIF reveals clinically meaningful differences between CVA and TBI groups that should be considered in results at the item and subscale level.

Referral to Rehabilitation After Severe Traumatic Brain Injury

Background. After a severe traumatic brain injury (TBI), some patients are discharged home without rehabilitation, although rehabilitation is assumed to improve outcome. Objective. To assess factors that predict referral to rehabilitation following acute care. This study is part of a larger inception cohort study assessing the care network in the Parisian area (France). Methods. Between July 2005 and April 2007, 504 adults with severe TBI (Glasgow Coma Scale score ≤8) were prospectively recruited by mobile emergency services. This study included 254 acute care survivors (80% male, median age 32 years). Data regarding demographics, injury severity, and acute care pathway were collected. The first analysis compared patients referred to a rehabilitation facility with patients discharged to a living place. The second analysis compared patients referred to a specialized neurorehabilitation (NR) facility with patients referred to nonspecialized rehabilitation. Univariate and multivariate statistics were computed. Results. In all, 162 patients (64%) were referred to rehabilitation, 115 (45%) of which were referred to NR and 47 (19%) to nonspecialized rehabilitation. The following factors were significantly predictive of nonreferral to rehabilitation: living alone, a lower income professional category, pretraumatic alcohol abuse, lower TBI severity, and transfer through a nonspecialized medical ward before discharge. Patients referred to specialized NR were significantly younger and from a higher income professional category. Conclusions. These results raise concern regarding care pathways because many patients were discharged to living places, probably without adequate assessment and management of rehabilitation needs. Injury severity and social characteristics influenced discharge destination.

A Systematic Review of Early Prognostic Factors for Return to Work After Traumatic Brain Injury

This article presents a systematic review identifying variables and their prognostic value for return to work (RTW) after traumatic brain injury (TBI). RTW has been identified as being a key goal following TBI, with estimates ranging from 10% to 70%. Prediction of postinjury employment is important for planning rehabilitation and structuring individualised vocational services. Studies examining prognostic factors were identified by searching four electronic databases, until June 2006. Searches yielded 1948 studies of which 55 met inclusion criteria and were subsequently rated for methodological quality. Mean methodological score for included studies was 3.9/6 (SD0.9, range 1–6). Analysis focused on a subset of 27 studies which provided sampling from all three domains of preinjury, injury and early postinjury variables. Few studies considered preinjury variables, apart from simple demographics. Only five studies considered preinjury employment, which was a significant predictor in each case. Severity of injury variables were invariably examined, but were significant predictors in only 8/27 studies (30%). For early postinjury variables, 14/27 studies entered cognitive variables with 12/14 (86%) identifying them as significant predictors; 3/27 studies examined neurophysical variables, with 2/3 (67%) studies finding them significant; and 12/27 studies examined multidimensional/participation variables which were statistically significant individual predictors in 8/12 (67%) cases. The results are discussed in the context of methodological issues encountered during the course of the review that require addressing in future studies.

Postacute Programming for Community Integration: A Scoping Review

There has been a dramatic increase in recent years in the literature available on community integration among people with acquired brain injuries. At the same time, however, clinicians are calling for information that has utility in the complex environment of community practice. The study was a scoping review to address the question:What is known from the existing literature regarding the best ways to promote community integration in the postacute phase of brain injury recovery?From a preliminary pool of 925 studies identified by electronic searching of 5 databases in a 15-year time window, a final set of 30 was selected for further review, referring to 25 distinct programs. This scoping review has shown that there are 5 types of programs typically offered to survivors of brain injuries to assist with community integration: supported employment, traditional rehabilitation, environmental adaptation, support development and transitional living. These 5 approaches were primarily used to address 2 aspects of community integration: traditional rehabilitation was most commonly used to promote independent living, and supported employment was the most common approach used to promote productive occupation. Themes that emerged from the review were the need for highly individualised programming, in vivo approaches, tailored supports, early intervention and a focus on participation. Methodologically, the study represents an important acknowledgment of the valuable information that is available in the literature in descriptive and small sample research.