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

'I had nothing. It's just life experience that helped me through that situation': Australian audiologists' perspectives on audiological clinical practice for traumatic brain injury and rehabilitation

OBJECTIVE

Australian Audiologists' perspectives on standard non-specialized clinical practice in the context of Traumatic Brain Injury (TBI) were examined, including the perceived barriers to optimal service provision.

DESIGN

A qualitative research design utilizing semi-structured interviews was conducted using purposive sampling. Nine participants were interviewed about their understanding of the impact of TBI on hearing and balance; identification, diagnosis and management of auditory and vestibular dysfunction following TBI; barriers to service delivery; training relating to complex clients (i.e., TBI); and awareness of referral pathways.

RESULTS

Three major themes, each with subthemes, were evident in the data. The major themes reflected general considerations of audiological professional culture and specific issues related to knowledge of TBI and clinical practice with patients. Analysis revealed that professional culture seemed to act as a contextual barrier and interacted with the perceived lack of TBI related knowledge to hinder optimal clinical practice in this patient population.

CONCLUSION

Application of the biopsychosocial model, including interdisciplinary care in the management of patients with TBI, is needed. An improvement in theoretical and practical knowledge encompassing the wide-ranging effects of TBI is critical for the optimal audiological service delivery.

Age- and sex-specific predictors of inpatient rehabilitation facility discharge destination for adult patients with traumatic brain injury

OBJECTIVE

: To determine age- and sex-specific predictors of discharge destination among patients with traumatic brain injury (TBI) receiving inpatient rehabilitation facility (IRF) care.

DESIGN

: Secondary analysis of Uniform Data System for Medical Rehabilitation data.

METHODS

: Logistic regression of patients (N = 221,961) age ≥18, TBI diagnosis, admitted to IRF between 2002 and 2018.

OUTCOME

: Discharge destination (subacute vs. home/community settings).

RESULTS

: Approximately 16% were discharged to subacute vs. 84% home. Younger versus older adults had lower odds of subacute discharge [OR = 0.72; 95% CI: 0.69, 0.76]. Younger females had lower odds of subacute discharge (vs. home) than older females [OR = 0.68; 95% CI: 0.63, 0.74]; younger males had lower odds of subacute discharge (vs. home) than older males [OR = 0.74; 95% CI: 0.70, 0.78]. Younger females versus younger males had lower odds of subacute discharge (vs. home) [OR = 0.83; 95% CI: 0.79, 0.87]. Older females versus older males had lower odds of subacute discharge (vs. home) [OR = 0.93; 95% CI: 0.90, 0.97]. Predictors of discharge destination for age- and sex-stratified groups varied.

CONCLUSIONS

: Younger (vs. older) and female (vs. male) patients had lower odds of subacute discharge vs. home.

Current practices and beliefs regarding supporting dating skills in rehabilitation for traumatic brain injury: a survey study

BACKGROUND

Relationships are important to quality of life after traumatic brain injury (TBI). However, there has been limited research into how to support dating skills or how professionals view this area.

METHOD

An online 52-item survey was developed and sent to professionals in the UK involved in rehabilitation after TBI. Recruitment was through professional networks, special interest groups and social media.

RESULTS

125 participants from a range of professions completed the survey. Many agreed that dating skills are important in rehabilitation (81.6%), but fewer (51.2%) reported engaging in this work. Psychologists, SLTs and OTs were identified as well placed to address dating skills. Case managers also appeared aware of this work. Participants reported using a range of activities to address dating skills, including managing disinhibited behavior and teaching interaction skills. Perceived barriers were both personal and professional, including lack of resources and feeling embarrassed.

CONCLUSION

This study has highlighted an awareness of the importance of dating in brain injury, but professionals face multiple barriers to supporting dating skills. It is possible to draw on recommendations from related areas, including rehabilitation for cognitive communication difficulties and sexual dysfunction with further research to specifically link these areas to dating skills.

Recommendations for the Design and Implementation of Virtual Reality for Acquired Brain Injury Rehabilitation: Systematic Review

BACKGROUND

Virtual reality (VR) is increasingly being used for the assessment and treatment of impairments arising from acquired brain injuries (ABIs) due to perceived benefits over traditional methods. However, no tailored options exist for the design and implementation of VR for ABI rehabilitation and, more specifically, traumatic brain injury (TBI) rehabilitation. In addition, the evidence base lacks systematic reviews of immersive VR use for TBI rehabilitation. Recommendations for this population are important because of the many complex and diverse impairments that individuals can experience.

OBJECTIVE

This study aims to conduct a two-part systematic review to identify and synthesize existing recommendations for designing and implementing therapeutic VR for ABI rehabilitation, including TBI, and to identify current evidence for using immersive VR for TBI assessment and treatment and to map the degree to which this literature includes recommendations for VR design and implementation.

METHODS

This review was guided by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). A comprehensive search of 11 databases and gray literature was conducted in August 2019 and repeated in June 2020. Studies were included if they met relevant search terms, were peer-reviewed, were written in English, and were published between 2009 and 2020. Studies were reviewed to determine the level of evidence and methodological quality. For the first part, qualitative data were synthesized and categorized via meta-synthesis. For the second part, findings were analyzed and synthesized descriptively owing to the heterogeneity of data extracted from the included studies.

RESULTS

In the first part, a total of 14 papers met the inclusion criteria. Recommendations for VR design and implementation were not specific to TBI but rather to stroke or ABI rehabilitation more broadly. The synthesis and analysis of data resulted in three key phases and nine categories of recommendations for designing and implementing VR for ABI rehabilitation. In the second part, 5 studies met the inclusion criteria. A total of 2 studies reported on VR for assessment and three for treatment. Studies were varied in terms of therapeutic targets, VR tasks, and outcome measures. VR was used to assess or treat impairments in cognition, balance, and anxiety, with positive outcomes. However, the levels of evidence, methodological quality, and inclusion of recommendations for VR design and implementation were poor.

CONCLUSIONS

There is limited research on the use of immersive VR for TBI rehabilitation. Few studies have been conducted, and there is limited inclusion of recommendations for therapeutic VR design and implementation. Future research in ABI rehabilitation should consider a stepwise approach to VR development, from early co-design studies with end users to larger controlled trials. A list of recommendations is offered to provide guidance and a more consistent model to advance clinical research in this area.

Influence of concomitant injuries on post-concussion symptoms after a mild traumatic brain injury - a prospective multicentre cohort study

Objectives: To compare post-concussion symptoms (PCS) and return to normal activities between mild Traumatic Brain Injury (mTBI) patients with or without concomitant injuries at 7-and 90 days post-mTBI.Methods: Design: Sub-analysis of a multicentre prospective cohort study.

PARTICIPANTS AND SETTING

patients with mTBI from 7 Canadian Emergency Departments.

PROCEDURE

Research assistants conducted telephone follow-ups using the Rivermead Postconcussion Symptoms Questionnaire (RPQ) at 7-, 30- and 90 days post-mTBI.

MAIN OUTCOME

Presence of PCS (RPQ: ≥3 symptoms) at 90 days.

SECONDARY OUTCOMES

RPQ score ≥21, prevalence of individual RPQ symptoms and patients' return to normal activities, at 7- and 90-days. Adjusted risk ratios (RR) were calculated.Results: 1725 mTBI patients were included and 1055 (61.1%) had concomitant injuries. Patients with concomitant injuries were at higher risk of having ≥3 symptoms on the RPQ (RR:1.26 [95% CI 1.01-1.58]) at 90 days. They were also at higher risk of experiencing specific symptoms (dizziness, fatigue, headaches and taking longer to think) and of non-return to their normal activities (RR:2.11 [95% CI 1.30-3.45]).Conclusion: Patients with concomitant injuries have slightly more PCS and seemed to be at higher risk of non-return to their normal activities 90 days, compared to patients without concomitant injuries.

Engagement in rehabilitation therapy and functional outcomes among individuals with acquired brain injuries

Purpose : The purpose was to examine the role of therapy engagement as a potential mediator for the relationship between neuropsychological performance and functional outcomes. Materials and method : Participants were 94 adults with medically documented ABI recruited from three outpatient rehabilitation clinics at the start of occupational therapy. Participants (57% men) ranged from 18 to 82 in age, with the majority (81%) having completed 12 or more years of education. They completed a comprehensive neuropsychological assessment at baseline. Separately, occupational therapists (OTs) assessed functional independence and disability at baseline and follow up. The OTs also rated the participants' therapy engagement. Results : Therapy engagement predicted functional outcomes and mediated the relationship between neuropsychological performance and outcomes. Moreover, therapy engagement accounted for unique variance in functional outcome, even after accounting for education, comorbid health conditions, emotional distress, apathy, and baseline functional ability. Conclusions : Engagement in therapy is a crucial patient characteristic in successful rehabilitation outcome. Cognitive deficits associated with ABI undermine full engagement in rehabilitation therapy, which in turn diminishes potential gains made in therapy and functional recovery. Neuropsychological assessment can enhance rehabilitation outcomes by identifying characteristics that underlie therapy engagement, which can ultimately be used to maximize the effectiveness of individualized treatment plans. Implications for rehabilitation Neuropsychological assessment can identify cognitive abilities that are strongly related to functional outcomes during occupational therapy for acquired brain injury. Therapy engagement is an important pathway by which neuropsychological impairment predicts functional outcomes after acquired brain injuries.

Making sense of recovery after traumatic brain injury through a peer mentoring intervention: a qualitative exploration

OBJECTIVE

To explore the acceptability of peer mentoring for people with a traumatic brain injury (TBI) in New Zealand.

DESIGN

This is a qualitative descriptive study exploring the experiences reported by mentees and mentors taking part in a feasibility study of peer mentoring. Interviews with five mentees and six mentors were carried out. Data were analysed using conventional content analysis.

SETTING

The first mentoring session took place predischarge from the rehabilitation unit. The remaining five sessions took place in mentees' homes or community as preferred.

PARTICIPANTS

Twelve people with TBI took part: six mentees (with moderate to severe TBI; aged 18-46) paired with six mentors (moderate to severe TBI >12 months previously; aged 21-59). Pairing occurred before mentee discharge from postacute inpatient brain injury rehabilitation. Mentors had been discharged from rehabilitation following a TBI between 1 and 5 years previously.

INTERVENTION

The peer mentoring programme consisted of up to six face-to-face sessions between a mentee and a mentor over a 6-month period. The sessions focused on building rapport, exploring hopes for and supporting participation after discharge through further meetings and supported community activities.

RESULTS

Data were synthesised into one overarching theme: making sense of recovery. This occurred through the sharing of experiences and stories; was pivotal to the mentoring relationship; and appeared to benefit both mentees and mentors. Mentors were perceived as valued experts because of their personal experience of injury and recovery, and could provide support in ways that were different from that provided by clinicians or family members. Mentors required support to manage the uncertainties inherent in the role.

CONCLUSIONS

The insight mentors developed through their own lived experience established them as a trusted and credible source of hope and support for people re-engaging in the community post-TBI. These findings indicate the potential for mentoring to result in positive outcomes.

Cognitive behavioural therapy for aggression among individuals with moderate to severe acquired brain injury: a systematic review and meta-analysis

BACKGROUND

Aggression is common after an acquired brain injury (ABI). Cognitive behavioural therapy (CBT) is a form of psychotherapy, in which therapists help patients to identify their maladaptive behaviours.

OBJECTIVE

The objective of this systematic review and meta-analysis was to evaluate the effectiveness of CBT interventions in treating aggression in an ABI population.

METHODS

A systematic literature search was conducted using: PubMed/MEDLINE, CINAHL, EMBASE and PsycINFO from database inception to August 2016. English articles were included if: at least 50% of the study sample had a moderate to severe ABI, there were at least three adult human participants, and use of a CBT intervention for the treatment of aggression.

RESULTS

Seven articles met inclusion criteria: one RCT, an RCT crossover and five pre-post trials. Of these, four articles were included in a pre-post meta-analysis for treatment efficacy on subscales of the State Trait Anger Expression Inventory (STAXI) and STAXI-2 outcome measures. The meta-analysis found CBT was effective in moderating the external behaviours of aggression, but not internal anger.

CONCLUSION

The differences in outcomes may be related to the differential management of anger expression and anger suppression. CBT shows promise, but further studies with comparator groups are needed before conclusions about its efficacy can be made.

Interdisciplinary eHealth for the care of people living with traumatic brain injury: A systematic review

OBJECTIVE

To identify literature which discusses the barriers and enablers of eHealth technology and which evaluates its role in facilitating interdisciplinary team work for the care of people with a traumatic brain injury (TBI).

DESIGN

Systematic review.

DATA SOURCES

Studies were identified by searching CINAHL, Embase, Medline, PsycINFO, Scopus, and Web of Science.

STUDY SELECTION

Studies included in the review were required to feature an eHealth intervention which assisted interdisciplinary care for people with TBI.

DATA EXTRACTION

Descriptive data for each study described the eHealth intervention, interdisciplinary team, outcomes, and barriers and facilitators in implementing eHealth interventions.

RESULTS

The search resulted in 1389 publications, of which 35 were retrieved and scanned in full. Six studies met all the inclusion criteria for the review. Four different eHealth interventions were identified: (i) an electronic goals systems, (ii) telerehabilitation, (iii) videoconferencing, and (iv) a point-of-care team-based information system. Various barriers and facilitators were identified in the use of eHealth.

CONCLUSION

eHealth interventions have been reported to support interdisciplinary teams for the care of TBI. However, there is a substantial gap in existing literature regarding the barriers and enablers which characterize a successful interdisciplinary eHealth model for people with TBI.

Home and family in cognitive rehabilitation after brain injury: Implementation of social reserves

The focus of the present article is the home and family environment of patients suffering acquired brain injury. In order to obtain the optimal outcome of posttraumatic cognitive rehabilitation it is important (a) to obtain a sufficient intensity of rehabilitative training, (b) to achieve the maximum degree of generalization from formalized training to the daily environment of the patient, and (c) to obtain the best possible utilization of "cognitive reserves" in the form of cognitive abilities and "strategies" acquired pretraumatically. Supplementing the institution-based cognitive training with (potentially computer-based) home-based training these three goals may more easily be met. Home-based training supports a higher intensity of training. Training in the home environment also allows better utilization of cognitive strategies acquired pretraumatically and more direct transfer of training results from formalized training to activities of daily living of the patient.

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.

Accompanying citizen of persons with traumatic brain injury in a community integration project: An exploration of the role

BACKGROUND

The APIC (Citizen Accompaniment Project for Community Integration) is an innovative program that seeks to increase the community integration of people with a traumatic brain injury (TBI) by offering the support of an accompanying citizen (AC) in the accomplishment of significant life activities.

OBJECTIVE

This article aims to better define the AC's role in this process, by underlining the mental health risks they face, the strategies they use, and the impacts the role has on their own lives.

METHODS

This qualitative study is based on the analysis of interviews conducted with the AC following the first year of implementation. The data is part of a larger project aimed at the implementation and evaluation of APIC program. The data were analysed according to the rules of thematic content analysis, which encourages grouping main ideas into categories. This is an iterative process allowing for the constant emergence of new categories during the analysis.

RESULTS

Accompaniment is full of joys and positive moments for the AC and participants. However, some difficult situations are encountered and the AC are constantly faced with challenges and constraints. The emerging study themes are as follows: the environment, the characteristics of the person accompanied, the AC's personal limits, and the ambiguities in the accompanier-accompanied relationship.

CONCLUSIONS

Five principles drawn from the results will help oversee this practice more efficiently and limit the mental health risks of accompaniers. These findings may permit further development of this type of program for people living with disabilities.

Testing and development of an instrument for self-report of participation and related environmental factors - Your Ideas about Participation and Environment (YIPE) among adults with brain injury

PURPOSE

To examine the usability of the self-report instrument, Your Ideas about Participation and Environment (YIPE), among adults with a brain injury by exploring the value and acceptability of the instrument.

METHODS

A qualitative descriptive research design was used for the purpose of testing and developing the YIPE for use among adults with a brain injury. The study involved administering the YIPE followed by in-depth interviewing about the experience of taking the instrument with seven adults with a brain injury, recruited through a community-based support service organization. A descriptive thematic approach was used to analyse the content of the interview data, categorize common ideas and identify areas for improvement within the instrument.

RESULTS

Participants were generally positive about the importance of the participation and environment topics and willing to engage in self report. The YIPE (2012), resulting from changes made to the language and structure, was found to be more useable, valued and accepted by these participants than the previous version, YIPE (2011).

CONCLUSIONS

The YIPE was found to be a useful tool among study participants. The YIPE topics were found to have importance and relevance when considering participants' satisfaction with areas of life and aspects of environment requiring change. More development of the tool is required in terms of the wording, format and method of administration to improve the overall usability of the instrument. Implications for Rehabilitation The preliminary results from this small sample study illustrated that people with brain injury were able to use an International Classification of Functioning, Disability and Health-based tool, and confirmed the importance of considering both participation and the environment together. People with cognitive impairments associated with brain injury reported on areas of everyday life where they were satisfied or dissatisfied. They related their satisfaction to environmental factors that were facilitators or barriers to valued everyday activities. The opportunity to choose important life areas promotes individuals' motivation to engage and enables service providers to tailor rehabilitation. In the course of the two stages of research, it was necessary to make minor modifications to the language, structure and scoring system of the tool, to simplify the task and shorten the time to interview participants.

Inpatient physical therapy rehabilitation provided for a patient with complete vision loss following a traumatic brain injury

BACKGROUND

Data from the World Health Organization estimates the global incidence of traumatic brain injury resulting in hospitalization or mortality to be close to 10 million people each year. People who sustain a blast-related TBI are more likely to sustain visual impairment than people injured by other means. There is a lack of published literature regarding the most effective means to assist a patient's recovery from TBI with new vision loss. The aim of this report is to describe the physical therapy management of a person regaining functional mobility when newly blind following a blast-related TBI.

METHOD

This case report describes the inpatient rehabilitation physical therapy (PT) services provided for a single subject who experienced a blast-related TBI with complete vision loss.

OUTCOMES

The subject spent 3.5 weeks in IPR and participated in 21 PT sessions before being discharged home. Improvements in cognition, transfers and functional mobility with adaptations for vision loss were achieved, as well as caregiver training, to provide 24-hour supervision in the home.

DISCUSSION

Collaborating with a blind specialist teacher assisted the rehabilitation of this subject. Further research is needed regarding the effective interventions for those with TBI and vision loss.

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.

[Citizen accompaniment for community integration : a challenge for mental health ?]

APIC (Citizen Accompaniment Project for Community Integration) offers support for the social integration of people living with traumatic brain injury. The accompanying citizen meets the person three hours a week for a period of a year in order to offer assistance in the accomplishment of his/her projects and activities. This role confronts the accompanying citizen with many challenges that may put their mental health at risk. This article offers a reflection on this practice from the accompanying citizen's perspective. Five principles that can help better delimit and define citizen accompaniment are drawn from the results: 1) finding a "good distance" in the relationship to the accompanied person, 2) considering all of the actors in the process, 3) putting the accompanied person and their desires at the heart of the practice, 4) accepting not knowing everything, 5) being committed to the project and accepting it may transform you.

Life habits performance of individuals with brain injury in different living environments

BACKGROUND

Little is known about variations in social participation among individuals with traumatic brain injury (TBI) living in different environments.

OBJECTIVE

To examine the social participation of individuals with moderate-to-severe TBI across various living arrangements.

METHODS

One hundred and thirty-six individuals with moderate-to-severe TBI, living either in natural settings (e.g. home), intermediate settings (e.g. group homes or foster families) or structured settings (e.g. nursing home or long-term care facilities) and requiring daily assistance, were interviewed using the LIFE-H tool, which measures the level of difficulty and the assistance required to carry out life habits and resulting social participation. Participation in six categories of life habits pertaining to Activities of Daily Living and five categories pertaining to Social Roles were examined.

RESULTS

The level of difficulty and the assistance required to carry out the life habits and the overall level of social participation were associated with living arrangements. Participation scores in Activities of Daily Living varied across living arrangements while Social Roles scores did not.

CONCLUSION

Living arrangements (such as intermediate settings) may better support social participation in individuals with TBI. There is a need to further study the issue of living arrangements as they seem to facilitate the performance of life habits, which impacts the social participation of individuals with TBI.

Reflections on life: experiences of individuals with brain injury during the transition from hospital to home

BACKGROUND

The transition from hospital to home has been described as a distinct rehabilitation phase for individuals with brain injury. As most research to date has quantitatively measured outcomes or used a sample with mixed brain injury diagnoses, less is known about the experience of transition following traumatic brain injury (TBI).

AIMS

This study aimed to examine the lived experiences of individuals with TBI during the first 6 months following discharge from hospital.

DESIGN

A qualitative investigation was conducted with 16 individuals with TBI using semi-structured interviews.

DATA ANALYSIS

Data were analysed thematically using a Framework approach.

RESULTS

Transition experiences were characterized by a desire to return to normality and a changed perspective on life, by accepting change or altering priorities. The process of transition was dynamic as individuals experienced the dominant themes in cyclical patterns.

CONCLUSIONS

Research has highlighted the significant adjustment for individuals with TBI, particularly in relation to identity change, appraisal and coping. The themes of wanting normality and changing life perspective which were dominant in the current study highlight the significance of the transition phase in the process of adjustment and that transition is characterized by adapting to a new normality.

Encouraging family engagement in the rehabilitation process: a rehabilitation provider's development of support strategies for family members of people with traumatic brain injury

PURPOSE

After a moderate to severe traumatic brain injury, it is widely recommended that family members be actively engaged in the client's rehabilitation journey because evidence suggests that this is associated with better outcomes. The ability of family members to fully engage in rehabilitation may be hindered by the barriers (logistical and psychological) they encounter. However, rehabilitation services can facilitate family engagement through a person-centred approach that provides support to remove barriers. Limited published guidance exists regarding practical and effective methods for delivering such support. This paper describes how one rehabilitation service has developed an eight-tiered approach.

KEY MESSAGES AND IMPLICATIONS

Family support is provided by explicit structuring of services to include (i) early engagement, (ii) meeting cultural needs, (iii) keeping families together, (iv) actively listening, (v) active involvement, (vi) education, (vii) skills training, and (viii) support for community re-integration. Implementation of these support strategies are individualised based on the expressed needs of each family. Families report a high level of satisfaction with the service.

CONCLUSION

A practice-based quality improvement model identified challenges, implemented changes, and observed/evaluated the results to successfully develop a multifaceted strategy for supporting families, thereby encouraging their engagement in rehabilitation. Ongoing refinements and evaluation are planned.

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.

Integrating situated learning theory and neuropsychological research to facilitate patient participation and learning in traumatic brain injury rehabilitation patients

PURPOSE

Traumatic brain injury (TBI) constitutes a major health problem throughout the world. Despite interdisciplinary efforts, patients reach varying outcomes in terms of every-day life functioning and quality-of-life. This paper suggests that a situated learning perspective supplemented with evidence from neurophysiologic and neuropsychological research provides a perspective to get a grasp of problems typically encountered in rehabilitation. Applying such a perspective may help to facilitate patient participation and learning during the rehabilitation process by taking their altered abilities into consideration.

METHOD

Qualitative study. Theoretical analysis and synthesis of 'situated learning theory', neuropsychological theory and empirical studies of cognitive and emotional functioning following a TBI collected through interviews with 11 interdisciplinary rehabilitation experts and a field study of two patients at a rehabilitation hospital. The data were analysed from a hermeneutic perspective using N-VIVO 8.

RESULTS/CONCLUSION

Patients with severe TBI pose challenges in terms of being participants in the 'rehabilitation practice community'. Two levels of pedagogical challenges seem to exist: Helping the patient regain or compensate for changed learning abilities and supporting the patient in learning or compensating for lost abilities. This study highlighted six main categories of changed abilities that need to be considered in developing a practice which fosters re-learning: perception, attention, memory, language, physical competencies and emotion/model of behaviour.

A model for neurorehabilitation after severe traumatic brain injury: facilitating patient participation and learning

BACKGROUND

During intensive neurorehabilitation, it is a professional challenge that patients with severe traumatic brain injury may have changed abilities to learn.

PURPOSE

To develop, initially test, and evaluate a model for neurorehabilitation aimed at systematizing and facilitating professionals' efforts of promoting patients' participation and learning.

METHODS

Qualitative study inspired by action research. Empirical data were analyzed by a theoretical framework of "didactic relation model," "situated learning theory," and neurophysiologic/neuropsychological categories of learning premises.

FINDINGS

Our findings indicate that the model for neurorehabilitation expands and systematizes the professional's reflections and interventions aimed at facilitating learning among patients with traumatic brain injury.

Community integration interventions for youth with acquired brain injuries: a review

OBJECTIVE

To identify and summarize published literature that examined the effectiveness of social and community integration interventions for children and adolescents with ABI in order to provide recommendations regarding future research on this topic.

METHODS

A literature review was conducted to identify studies that focused on social and community integration interventions for youth with ABI. Further manual searching of relevant journals with a paediatric rehabilitation focus was also carried out.

RESULTS

Currently, limited research has been published evaluating such interventions. The lack of research may stem largely from issues relating to how to measure community integration. Recommendations regarding intervention settings and structure are discussed.

CONCLUSION

Additional studies investigating social and community integration interventions are necessary, including those with measures tailored specifically to community integration, larger samples, as are better controls and recruitment of youth with varying severities of brain injuries.

Effectiveness of Rehabilitation in Enhancing Community Integration After Acute Traumatic Brain Injury: A Systematic Review

OBJECTIVE. We assessed evidence for post–acute traumatic brain injury (TBI) rehabilitation interventions used to enhance community integration (CI) relevant to occupational therapy.

METHOD. We conducted a systematic review of intervention studies on TBI rehabilitation from 1990 to 2007.

RESULTS. We analyzed and summarized 10 studies that met the inclusion criteria. Of 10 studies, 7 found that post–acute TBI rehabilitation benefits CI; all effective studies involved occupational therapy or involved interventions occupational therapists can do.

CONCLUSION. Many CI programs show positive results and should be studied more rigorously. Such promising programs should also be considered when decisions about post–acute TBI rehabilitation services for clients are being made. To further establish that post–acute TBI rehabilitation interventions improve CI, future studies should include intervention strategies based on injury severity, a control group, and longer term follow-up. The role of occupational therapy in these effective programs should be further explored.

Executive skills and their functional implications: Approaches to rehabilitation after childhood TBI

BACKGROUND

It is widely acknowledged that children recover differently from adults following traumatic brain injury. The impact of neurological injury in the context of developing skills and changing expectations of behaviour requires a developmental approach to rehabilitation that considers children's abilities across home, school and community environments.

METHODS

This article aims to provide an overview of the impact of executive deficits on everyday functioning and to review information about intervention strategies that support long term development of skills.

RESULTS AND CONCLUSIONS

While individual disciplines are not directly referred to in this paper, input from a comprehensive and co-ordinated interdisciplinary team is crucial to understanding and reducing the impact of executive deficits on functional performance.

The description of severe traumatic brain injury in light of the ICF classification

PURPOSE

To review on the application of the ICF Classification to assess the person with traumatic brain injury (TBI) and his/her interaction with the environment.

METHOD

Studies and reviews about the use of ICF in TBI have been included, by searching in Pubmed and in the proceedings of international meetings.

RESULTS

Eleven studies have been identified and classified into three types: (a) application of the classification; (b) single case study; (c) the use of other scales. Some studies are related to the application of ICF checklist. Finally, we analyse the most used ICF codes.

CONCLUSIONS

The ICF is a useful tool describes conditions and needs of patients with TBI. A diffuse utilisation could become the key resource for both health professionals and administrators that are in charge of allocating resources to pursue quality of life improvement. The ICF could be applied as a shared language to define health programmes' goals and as system for carrying out epidemiological studies. For this reason, it is desirable to define and validate the ICF Core Sets for TBI to provide a mean to be easily used, comprehensive and universal.