Profiling early outcomes during the transition from hospital to home after brain injury

Biopsychosocial factors of quality of life in individuals with moderate to severe traumatic brain injury: a scoping review

PURPOSE

Individuals with moderate to severe traumatic brain injury (TBI) experience changes in their quality-of-life (QOL) post-injury. Given the vast literature that exists about QOL after TBI, a scoping review was performed to identify the different biopsychosocial factors that affect a person's QOL after a moderate to severe TBI.

METHODS

A scoping review was conducted using the following electronic databases: MEDLINE, CINAHL, Embase, and PsycINFO. Terms relating to TBI and QOL were used.

RESULTS

There were 7576 articles obtained from the databases, resulting in 535 full-text articles. Ultimately, 52 articles were extracted, which consisted of biopsychosocial QOL factors after TBI. The biopsychosocial factors of QOL after TBI included 19 biological factors (i.e., sex, TBI severity, cognition), 16 psychological factors (i.e., depression, self-efficacy, coping styles), and 19 social factors (i.e., employment, social participation, social support). Factors such as fatigue, self-awareness, transition, and discharge from hospitals are known issues in TBI literature but were minimally reported in studies in this review, identifying them as potential gaps in research.

CONCLUSION

Identifying biopsychosocial factors relating to QOL after TBI can enable health services to develop targeted rehabilitation programs for individuals with TBI.

Perceived service adequacy and unmet need after discharge from brain injury rehabilitation

PURPOSE

The present study aimed to quantify the perceived needs and adequacy of realised access to post-acute services in a sample of people with acquired brain injury in the first 6-months after discharge from inpatient rehabilitation. A secondary focus was the influence of access to funding and specialist transitional rehabilitation on unmet needs.

MATERIALS AND METHODS

Participants were 51 adults with a median age of 50 (IQR 35-57) recruited from an inpatient rehabilitation unit in an Australian tertiary hospital. The sample was those who had an acquired brain injury, including 23 who sustained a traumatic injury and 28 who sustained a non-traumatic injury. Measures were collected via telephone at 3- and 6-months, in a prospective observational cohort design using the Needs and Provisions Complexity Scale. A series of logistic regression models were used to determine the effects of participation in a transitional rehabilitation program and funding pathway on adequacy and unmet needs.

RESULTS

Unmet needs for rehabilitation were most commonly reported (60%), followed by unmet needs in relation to health care (40%), social care (35%), personal care (32%) and environment-related (14%). Participants who attended transitional rehabilitation were more likely to indicate unmet health care needs (OR = 6.40, 95% CI = 1.40-29.24, p = 0.02).

CONCLUSIONS

The study highlights the need to look beyond functional impairment when conceptualising appropriate access. Additionally, the present research highlighted the need for greater work into an expectation of services.IMPLICATIONS FOR REHABILITATIONThe majority of people with an acquired brain injury report unmet needs at 6 months post discharge.Present findings support the utility of patient reported measures when considering treatment evaluation with people with ABI, where assessing the personal appraisal of individuals needs may prove to be a key indicator to facilitate optimal service access.There are specific services that needed and not provided including psychological, speech pathology, family carer needs and vocational rehabilitation, and therefore are a key target for ensuring appropriate support is provided.

"It gave her that soft landing": Consumer perspectives on a transitional rehabilitation service for adults with acquired brain injury

Transitional rehabilitation service models for people with acquired brain injury (ABI) may address sub-optimal support for individuals returning home after hospitalization for ABI. This study investigated perspectives of people with ABI and close others who received transitional rehabilitation. A qualitative study involving semi-structured interviews with 10 individuals with ABI and 12 associated close others was conducted as part of a mixed-method evaluation of an Australian transitional rehabilitation service (TRS) pilot project. Thematic analysis based on the Framework method was conducted independently by two researchers. Three broad themes illustrated participants' experience of the TRS: (1) structure after hospital discharge; (2) a "soft landing"; and (3) equipped for community living. Findings suggest that home-based, interdisciplinary transitional rehabilitation after hospital discharge was perceived as an important stage of rehabilitation by participants. Valued features relate to post-hospital rehabilitation structure: a single point of contact to facilitate organization and information exchange, a known discharge destination, and consistent communication; support and therapy within a familiar home environment; and being equipped with relevant knowledge and strategies to manage ongoing challenges. Further research exploring the experiences of individuals with ABI without close family or social support, and research capturing longitudinal outcomes from transitional rehabilitation is recommended.

Personal experiences of appropriate access to post-acute care services in acquired brain injury: a scoping review

People with an acquired brain injury (ABI) experience substantial access inequalities and unmet health needs, with many experiencing insufficient access to appropriate rehabilitation in the community. To deepen our understanding of what appropriate access to post-acute care services is for this population, and to facilitate optimal recovery, there is a need to synthesise research from the service user perspective. A scoping review study was conducted to identify key characteristics of 'appropriate' access to post-acute care services, as defined by the personal experiences of adults with ABI. Electronic scientific databases Medline, PsycINFO, Proquest Central and CINAHL were searched for studies published between 2000 and 2020. The initial search identified 361 articles which, along with articles retrieved from reference list searches, resulted in 52 articles included in the final analysis. Results indicated that a majority of the studies sampled participants with an average of over 1 year post-injury, with some studies sampling participants ranging over 10 years in difference in time post-injury. A thematic synthesis was conducted and results indicated a number of dominant elements which relate to (1) the characteristics of services: provider expertise, interpersonal qualities, partnership and adaptability; (2) characteristics of the health system: navigable system, integrated care, adequacy, and opportunity. These findings provide some insight into what might be considered appropriate. However, rigorous research, focused on personalised access to post-acute care services, is recommended to verify and elaborate on these findings.

Barriers and facilitators linked to discharge destination following inpatient rehabilitation after traumatic brain injury in older adults: a qualitative study

PURPOSE

To identify facilitators and barriers associated with returning home for older adults having received inpatient rehabilitation after traumatic brain injury (TBI).

METHODS

A qualitative design was used. Five older patients with TBI and four family caregivers were interviewed and six healthcare professionals participated in a focus group.

RESULTS

Main facilitators to returning home highlighted by all participants were: (1) Patient's adequate health condition and functional status, (2) Access to health and other services at home, (3) Availability of help from a family caregiver. Conversely, if one of these factors was not met, it represented a barrier. Other facilitators identified were (4) Attachment to one's home, (5) Feeling of commitment toward a loved one, (6) Having the possibility of going through a transitional phase, (7) United front between the patient and the family caregiver towards a return home. Additional barriers to returning home included: (8) Incongruent perspectives, and (9) Unclear knowledge about available health and other services at home.

CONCLUSION

The results of this study could be translated into a practical tool to guide patients, families and professionals in the decision about returning home or exploring an alternative option after inpatient rehabilitation for TBI in older adults.IMPLICATIONS FOR REHABILITATIONWhen orienting an older patient home or to an alternative living environment after a traumatic brain injury (TBI), the perspective of rehabilitation professionals can differ from that of patients and caregivers.Professionals tend to emphasize security, whereas patients and caregivers' focus on the well-being associated with home and on the importance of being with their loved one.Integrating the views, values and wishes of older patients with TBI and their caregivers will support a shared decision-making approach for orientation after rehabilitation.

Relationship and Social Network Change in People With Impaired Social Cognition Post Right Hemisphere Stroke

Purpose This article investigated relationship and social network change in the presence of a social cognition impairment post right hemisphere (RH) stroke. Impaired emotion perception and inferential reasoning are sources of interpersonal difficulty in people with social cognition impairment after traumatic brain injury. People with an RH stroke have also been identified as vulnerable to interpersonal relationship change. However, the influence of impairments in particular domains of communication or cognition on relationship and social network maintenance is yet to be explored. Method A multiple-case study methodology allowed for testing of theoretically developed propositions by exploring social networks and relationships within and between seven participant-proxy dyads. Purposeful recruitment was based on first-onset RH stroke and impaired social cognition, as determined by The Awareness of Social Inference Test. Results Social network size reduction (71.4%, n = 5) and interpersonal relationship change (85.7%, n = 6) were attributed to altered communication style, impairments in social cognition, and reduced insight and/or motivation. The spouse emerged as a facilitator of social engagement. Conclusion This study contributes to our understanding of the challenges experienced by people with impaired social cognition post RH stroke in maintaining relationships and their social networks.

Beyond Broken Bodies and Brains: A Mixed Methods Study of Mental Health and Life Transitions After Brain Injury

Purpose: Clients with an acquired brain injury (ABI) are at risk of mental health problems and it has been argued that transitions throughout the rehabilitation process are a challenge for rehabilitation practice; however, the link between transitions and psychosocial outcome has been under-researched. Therefore, this study aims to (1) investigate the status of clients with moderate or severe ABI two-year post-discharge on the following outcomes variables: Physical and cognitive function, depression, quality of life, civil and work status, (2) examine correlations between these outcomes and (3) explore through qualitative interviews the subjective experiences of individuals with ABI in order to increase our understanding of clients’ perspectives on this outcome and its relation to life transitions in a two-year period.

Method: 37 individuals aged 18–66 with moderate or severe ABI were interviewed two years after discharge. At this time, they also completed standard measures of depression (MDI), quality of life (WHOQOL-bref) and functional independence (FIM™). Historical data of their FIM™ status at discharge were obtained for comparison.

Results: We found psychological problems two years post-hospitalization, especially depression (35.1%) and decreased psychological QOL (61%). Analysis of interviews found six main factors perceived as important for psychosocial outcome: family relations, return to work, waiting lists, psychological support, fatigue and personal competences.

Conclusions: Clients’ status two years post-hospitalization is often characterized by psychological problems. Based on clients’ accounts, we found a connection between psychosocial outcome and life transition experiences and developed a model of factors that are perceived as helping and hindering positive outcome.

The Transition from Hospital to Home: Protocol for a Longitudinal Study of Australian Aboriginal and Torres Strait Islander Traumatic Brain Injury (TBI)

Background: Traumatic brain injury (TBI) is a leading cause of disability in Australia. Evidence shows that multidisciplinary rehabilitation and support in the six months following TBI is important for successful independent living and social re-integration. Despite this, access to services and supports during this period is often limited by environmental, socio-economic, geographic and cultural factors. Australian studies on outcomes after brain injury have reported primarily on non-Indigenous people. This study will investigate key sentinel events during the transition from hospital to home after a TBI in the first longitudinal study with Indigenous Australians.

Method: Indigenous Australians admitted to one of three major trauma hospitals in northern Australia with a TBI, and their care givers, will be recruited. Clinical and brain injury risk factor information, along with measures of cognitive function, transition events, mental health and community re-integration will be collected at three time points prior to hospital discharge, and at three and six months post-discharge. Qualitative interviews will also be conducted. Data will be analysed using regression methods for the quantitative component, and situational analysis for the qualitative component. Annual rates of brain injury will be calculated for patients admitted to tertiary hospital facilities in the study region with a diagnosis of TBI.

Discussion: Understanding the experience and events which shape the transition period is critical to determining the services and supports that may enhance transition outcomes, and ensure that such services are culturally appropriate and endorsed by Indigenous families and communities.

Exploring self-concept, wellbeing and distress in therapeutic songwriting participants following acquired brain injury: A case series analysis

Acquired brain injury (ABI) presents a significant threat to sense of self and necessitates a complex process of psychosocial adjustment. Self-concept changes remain understudied in the early stages of inpatient rehabilitation. The aim of the current study was to examine changes in self-concept, distress, wellbeing and functional skills for five inpatients undertaking a music therapy intervention within a subacute rehabilitation centre in Victoria, Australia. Participants completed a six-week, 12-session therapeutic songwriting programme to produce past-, current- and future-self-focused songs. A range of self-concept, subjective wellbeing and distress measures were completed pre-, mid- and post-intervention. A descriptive case series approach was applied to determine trends in pre-post scores for five individual cases. Participants showing the greatest gains across self-concept and subjective wellbeing indices also showed the greatest functional gains on the Functional Independence Measure (FIM) from admission to discharge. The current study highlights the importance of examining early changes in self-concept, wellbeing and distress in subacute rehabilitation, and suggests that individualised songwriting programmes warrant further research attention in neurological populations.

The feasibility and impact of a yoga pilot programme on the quality-of-life of adults with acquired brain injury

OBJECTIVE

This pilot study measured the feasibility and impact of an 8-week yoga programme on the quality-of-life of adults with acquired brain injury (ABI).

METHODS

Thirty-one adults with ABI were allocated to yoga (n = 16) or control (n = 15) groups. Participants completed the Quality of Life After Brain Injury (QOLIBRI) measure pre- and post-intervention; individuals in the yoga group also rated programme satisfaction. Mann-Whitney/Wilcoxon and the Wilcoxon Signed Rank tests were used to evaluate between- and within-group differences for the total and sub-scale QOLIBRI scores, respectively.

RESULTS

No significant differences emerged between groups on the QOLIBRI pre- or post-intervention. However, there were significant improvements on overall quality-of-life and on Emotions and Feeling sub-scales for the intervention group only. The overall QOLIBRI score improved from 1.93 (SD = 0.27) to 2.15 (SD = 0.34, p = 0.01). The mean Emotions sub-scale increased from 1.69 (SD = 0.40) to 2.01 (SD = 0.52, p = 0.01), and the mean Feeling sub-scale from 2.1 (SD = 0.34) to 2.42 (SD = 0.39, p = 0.01).

CONCLUSION

Adults with ABI experienced improvements in overall quality-of-life following an 8-week yoga programme. Specific improvements in self-perception and negative emotions also emerged. High attendance and satisfaction ratings support the feasibility of this type of intervention for people with brain injury.

Holistic Practice in Traumatic Brain Injury Rehabilitation: Perspectives of Health Practitioners

Given that the literature suggests there are various (and often contradictory) interpretations of holistic practice in brain injury rehabilitation and multiple complexities in its implementation (including complex setting, discipline, and client-base factors), this study aimed to examine the experiences of practitioners in their conceptualization and delivery of holistic practice in their respective settings. Nineteen health practitioners purposively sampled from an extensive Brain Injury Network in Queensland, Australia participated in individual interviews. A systematic text analysis process using Leximancer qualitative analysis program was undertaken, followed by manual thematic analysis to develop overarching themes. The findings from this study have identified several items for future inter-professional development that will not only benefit the practitioners working in brain injury rehabilitation settings, but the patients and their families as well.

[What happens after the accident? Psychosocial needs of people with traumatic brain injury and their families]

OBJECTIVE

To identify factors that people with a traumatic brain injury and their families perceived as helping to improve their quality of life.

METHODS

Three focus groups and five interviews were conducted with a total of 37 participants: 14 persons with traumatic brain injury and 23 caregivers. A content analysis was conducted. The constant comparative method was applied.

RESULTS

We detected five factors that improved the quality of life of persons with a traumatic brain and their families: 1) Informal support (family and friends); 2) formal support (counseling, employment, built and bureaucratic environment); 3) type of clinical characteristics; 4) social participation, and 5) social visibility.

CONCLUSIONS

The needs expressed by our participants primarily focused on social and emotional factors. For persons with severe traumatic brain injury attempting to achieve the best possible community integration, a new semiology is required, not limited to medical care, but also involving social and psychological care tailored to the needs of each individual and family and their environment.

Anxiety related to discharge from inpatient neurorehabilitation: Exploring the role of self-efficacy and internal health control beliefs

The study aimed to determine the prevalence of anxiety related to discharge, among a group of 42 participants who were likely to have sustained an at least moderate to severe ABI and who were due to be discharged home following a period of inpatient neurorehabilitation. Differential relationships between psychological factors (self-efficacy and internal health control beliefs) were examined, alongside the relative influence of demographic and clinical characteristics on discharge anxiety. Data were obtained via self-report measures and retrospective reviews of participant's inpatient medical records. While relatively few participants (n = 6; 14%) reported markedly elevated trait-anxiety, almost half the sample (n = 19; 45%) reported clinically significant levels of transient state-anxiety. Notably, state-anxiety was strongly associated with discharge anxiety. Multivariate analyses revealed that age, self-efficacy and internal health control beliefs made independent contributions to self-reported discharge anxiety, with perceived self-efficacy alone explaining 69% of the variance and mediating the effects of age and internal health control beliefs. None of the other demographic or clinical characteristics examined was significantly associated with discharge anxiety. While causality cannot be inferred, findings suggest that anxiety related to discharge from rehabilitation might be best predicted by poor perceptions of self-efficacy. Implications for clinical practice and future research are discussed.

Coping and Health Problems of Caregivers of Survivors with Traumatic Brain Injury

Objetivos: Evaluar el afrontamiento y los problemas de salud de los cuidadores en el momento en que el sobreviviente fue dado de alta y un mes después de que el sobreviviente fue dado de alta y determinar las correlaciones entre los datos de carácter personal, afrontamiento y los problemas de salud de los cuidadores y la incapacidad de los sobrevivientes. Método: Ochenta y cinco díadas de supervivientes con lesiones cerebrales traumáticas y sus cuidadores fueron incluidos en la investigación. Los instrumentos utilizados para la recolección de datos fueron la versión tailandesa de la Escala de Medición del Proceso de Afrontamiento y Adaptación – Formato Corto, con 27 ítems, el Cuestionario de Problemas de Salud para los cuidadores y la Clasificación de Escala de Discapacidad para los sobrevivientes. El Modelo de Adaptación de Roy se utilizó como marco conceptual para este estudio. La correlación producto-momento de Pearson se utilizó para el análisis. Resultados: No se encontraron diferencias estadísticas entre los problemas de afrontamiento y de salud en los cuidadores. Los problemas de salud reportados más frecuentemente por los cuidadores fueron dolor de cabeza en el día de alta y ningún problema de salud después de un mes de participación en el cuidado del sobreviviente. El nivel de la discapacidad de los sobrevivientes y el estado civil de los cuidadores se correlacionaron negativamente con el afrontamiento (r = - 0,245 , p = 0,024 , r = - 0,220 , p = 0,043 , respectivamente). Conclusiones: Los resultados demuestran que los cuidadores permanecieron capaces de manejar las dificultades que implica el cuidado de los sobrevivientes en casa con menos problemas de salud. Los cuidadores casados eran propensos a manejar esta carga mejor que otros cuidadores.

Traumatic brain injury and post-acute decline: what role does environmental enrichment play? A scoping review

Objectives: While a growing number of studies provide evidence of neural and cognitive decline in traumatic brain injury (TBI) survivors during the post-acute stages of injury, there is limited research as of yet on environmental factors that may influence this decline. The purposes of this paper, therefore, are to (1) examine evidence that environmental enrichment (EE) can influence long-term outcome following TBI, and (2) examine the nature of post-acute environments, whether they vary in degree of EE, and what impact these variations have on outcomes.

Methods: We conducted a scoping review to identify studies on EE in animals and humans, and post-discharge experiences that relate to barriers to recovery.

Results: One hundred and twenty-three articles that met inclusion criteria demonstrated the benefits of EE on brain and behavior in healthy and brain-injured animals and humans. Nineteen papers on post-discharge experiences revealed that variables such as insurance coverage, financial, and social support, home therapy, and transition from hospital to home, can have an impact on clinical outcomes.

Conclusion: There is evidence to suggest that lack of EE, whether from lack of resources or limited ability to engage in such environments, may play a role in post-acute cognitive and neural decline. Maximizing EE in the post-acute stages of TBI may improve long-term outcomes for the individual, their family and society.

Clinicians’ Expectations and Early Experiences of a New Comprehensive Rehabilitation Case Management Model in a Specialist Brain Injury Rehabilitation Unit

This article presents early findings from the implementation and ongoing evaluation of a new model of care that employs a comprehensive approach to rehabilitation case management for clients with traumatic brain injury, with the aim of improving transition from inpatient rehabilitation to community settings. The evaluation explores the design, implementation, utility and acceptability of the new model using clinicians’ perceptions and experiences. Method: The evaluation framework employs a participatory evaluation approach, drawing on semistructured interview data. Interviews were conducted with brain injury unit clinicians, rehabilitation case managers and external stakeholders at the model's implementation and four months later, as part of a 12-month evaluation period. The data were descriptively organised, then coded and subjected to interpretative analysis to identify key issues. Results: Early findings suggest that the new model provides increased consistency for staff, clients and carers; promotes efficiency in discharge planning and facilitates a more streamlined and seamless transition between inpatient rehabilitation and community services. Data gathered across the remainder of the implementation trial will extend understanding of this comprehensive rehabilitation case management model and its potential utility in other services and settings.

Transitions and Brain Injury: A Qualitative Study Exploring the Journey of People with Traumatic Brain Injury

This qualitative study aimed to explore transitions from hospital to the home over a period of one year.

Methods and procedures: A longitudinal, phenomenological approach was employed and 18 individuals with severe traumatic brain injury, their family members and rehabilitation professionals were interviewed using semistructured interviews, when the person with brain injury was discharged from the ward, after 6 months and again after one year.

Results: Themes identified within the data included returning home, getting back to normal, moving forward and the role of rehabilitation in the transitional period. Further subthemes were also identified including issues of life-course disruption, self-identity, status and reconstruction.

Conclusions: Data suggested that access to rehabilitation programs employing individualised, contextual interventions following discharge to the home were integral in enabling the transition through to autonomy and independence. Consideration of issues of identity and status can enable a different and potentially important perspective on the experience of transitions for those with brain injury. Reclaiming personal autonomy and control appeared to be central to the reconstruction of a coherent sense of self, enabling a meaningful life after brain injury.