Characteristics and outcomes of a home and community-based neurorehabilitation programme

Family involvement in rehabilitation programmes for children and adolescents with acquired brain injury: A scoping literature review

Paediatric acquired brain injury (ABI) can adversely impact families, and it is widely accepted that families should be involved in the rehabilitation of children/adolescents with ABI. However, there is limited guidance about how to best involve families in paediatric ABI rehabilitation. Several programmes involving the families of children/adolescents with ABI have been developed, but there are no published reviews outlining their characteristics. This scoping literature review aimed to synthesize information about these programmes and develop an understanding of how families are involved in them. Four databases were systematically searched to identify sources of evidence that described programmes in paediatric ABI rehabilitation that involve family members. One hundred and eight sources of evidence describing 42 programmes were included. Programmes were categorized as: service coordination (n = 11), psychosocial (n = 17), support groups (n = 4), training/instruction (n = 9), and education (n = 1). Families' involvement in these programmes varied across programme development, delivery, and evaluation stages. The findings of this scoping literature review outline how families can be involved in paediatric ABI rehabilitation. While this review outlines many approaches to supporting families, it also highlights the need for models of family-centred care to better articulate how clinicians and services can involve families in paediatric ABI rehabilitation.

In search of the 'self': Holistic rehabilitation in restoring cognition and recovering the 'self' following traumatic brain injury: A case report

BACKGROUND

Following mild-moderate traumatic brain injury (TBI), an individual experiences a range of emotional changes. It is often difficult for the patient to reconcile with their post-injury persona, and the memory of pre-injury personhood is particularly painful. Insight into one's cognitive deficits subsequent to injury can lead to an existential crisis and a sense of loss, including loss of self.

OBJECTIVE

Restoration of cognitive functions and reconciliation with loss of pre-traumatic personhood employing a holistic method of neuropsychological rehabilitation in a patient suffering from TBI.

METHODS

Ms. K.S, a 25-year-old female, presented with emotional disturbances following TBI. She reported both retrograde and anterograde amnesia. A multidimensional holistic rehabilitation was planned. Treatment addressed cognitive deficits through the basic functions approach. Cognitive behavioural methods for emotional regulation like diary writing helped reduce irritability and anger outbursts. Use of social media created new modes of memory activation and interactions. Compensatory strategies were used to recover lost skills, music-based attention training helped foster an individualised approach to the sense of one's body and self.

RESULTS

As a result of these differing strategies, changes were reflected in neuro-psychological tests, depression score and the patient's self-evaluation. This helped generate a coherent self-narrative.

CONCLUSION

Treatment challenges in such cases are increased due to patient's actual deficits caused by neuronal/biochemical changes. Innovative and multi-pronged rehabilitation strategies which involve everyday activities provided an answer to some of these problems. This method of rehabilitation may provide an optimistic context for future research.

Cognitive strategy use in adults with acquired brain injury

Objective: Difficulty applying cognitive strategies during task performance is a hallmark feature of brain injury. This study aimed to develop a cognitive strategy profile of people living in a transitional living unit for people with brain injury.Research design: Prospective, longitudinal study (n = 16)Method: Cognitive strategy application was assessed using the Perceive, Recall, Plan, and Perform (PRPP) System of Task Analysis. Functional measures were also administered. Data were examined using Rasch analysis (FACETS 3.71.4) and relationships between variables were analyzed.Results: Rasch analysis of PRPP data generated a hierarchy of cognitive strategies: from the most complex executive processing strategies to the simplest perceptual and recall strategies. The functional profile revealed a more impaired group of clients than has been previously reported in similar residential programs. Cognitive strategy use (PRPP Total score) was correlated with functional independence (r = .61), the performance of instrumental activities of daily living (r = .45), and community participation (r = -.63).Conclusions: The PRPP System enabled assessment of cognitive strategy difficulties and generation of individual profiles that allowed for individualized intervention planning. More efficient and effective application of cognitive strategies was related to the improved functional performance of everyday tasks and activities, greater independence and community participation.

Efficacy and acceptability of a home-based, family-inclusive intervention for veterans with TBI: A randomized controlled trial

OBJECTIVE

Traumatic brain injury (TBI) often undermines community re-integration, impairs functioning and produces other symptoms. This study tested an innovative programme for veterans with TBI, the Veterans' In-home Programme (VIP), delivered in veterans' homes, involving a family member and targeting the environment (social and physical) to promote community re-integration, mitigate difficulty with the most troubling TBI symptoms and facilitate daily functioning.

SETTING

Interviews and intervention sessions were conducted in homes or by telephone.

PARTICIPANTS

Eighty-one veterans with TBI at a VA polytrauma programme and a key family member.

DESIGN

This was a 2-group randomized controlled trial. Control-group participants received usual-care enhanced by two attention-control telephone calls. Follow-up interviews occurred up to 4 months after baseline interview.

MAIN MEASURES

VIP's efficacy was evaluated using measures of community re-integration, target outcomes reflecting veterans' self-identified problems and self-rated functional competence.

RESULTS

At follow-up, VIP participants had significantly higher community re-integration scores and less difficulty managing targeted outcomes, compared to controls. Self-rated functional competence did not differ between groups. In addition, VIP's acceptability was high.

CONCLUSION

A home-based, family-inclusive service for veterans with TBI shows promise for improving meaningful outcomes and warrants further research and clinical application.

Rehabilitation of children with traumatic brain injury: a critical review

The purpose of this critical review of the English literature published between 1975 and 2009 was to assess the quality of the evidence for the efficacy of rehabilitation intervention after traumatic brain injury in children. "Evidence for intervention studies" was used to classify the research strength of design and report. Only a minority (16/439) of the published studies has been related to traumatic brain injury in children and has used a scientific or quasiscientific design. Only one study met the criteria of class I "evidence for intervention" studies. However, this study included adults, as well as children. The other 15 studies, although reporting positive results, had many methodologic deficiencies, and consequently their validity is questionable. Although the methodologic and ethical difficulties involved are acknowleged, a multicenter approach is required to achieve valid conclusions. Use of designs such as comparative effectiveness research might prove to be a practical solution. High-quality intervention research would facilitate stronger evidence-based counseling for children and families requiring posttraumatic brain injury intervention and to policy makers.

The Neurorehabilitation Pathways Team (NRPT): a model of good practice?

Background:

It is suggested that community based neurorehabilitation can provide benefits to both patients and health care providers in the shape of improved clinical outcomes and lower costs relative to inpatient care in tertiary centres. National guidelines within the UK have also called for care to be delivered ‘closer to home’. However, there is very little research on community based models of care for complex neurological patients and little evidence of how these models can deliver improved outcomes.

Content:

This article describes the model of care employed by Central Surrey Health and presents data from an audit of clinical records to support its effectiveness.

Conclusions:

This article has shown that the Neurorehabilitation Pathways Team (NRPT) achieve important clinical improvements for our patients whether treated as inpatients or in the community. As a group of experienced senior clinicians the NRPT accurately predict the likely clinical outcomes for each patient (90–97%) and give health care purchasers accurate predictions of the care pathway each patient will follow (84%). This provides a model of care which meets national guidelines and is potentially delivering both good clinical outcomes and cost savings for the health service compared to the former and more common model of care used in the UK.

Community-Based Rehabilitation Following Brain Injury: Comparison of a Transitional Living Program and a Home-Based Program

Background and aims: Community-based rehabilitation programs for people with a brain injury are diverse. Comparative program evaluation is required to identify optimal type, intensity and duration of programs. The aim of this study was to compare the effectiveness of two community-based rehabilitation programs using a set of standardised outcome measures.

Methods: The study used a quantitative, multicentre, longitudinal design. Persons with severe traumatic brain injury (TBI,n= 39) and acquired brain impairment (n= 2) were recruited from two residential, transitional living programs (TLU;n= 21) and two home-based community rehabilitation programs (CR;n= 20). Participants were assessed via interview at program entry, 2 months and 6 months later using a broad range of standardised measures. The quantity and types of intervention provided to study participants were recorded. Results: No significant differences were identified between the TLU and CR groups at baseline or 6-month follow-up. Two significant group-by-time interactions were identified on the Community Integration Questionnaire (CIQ). First, the CR group had significantly greater changes in productivity (p= .003;d= 1.0) compared to the TLU group over time; by contrast, the TLU group showed significantly greater improvements in social integration (p= .007;d= .86). The TLU participants received up to five times more intervention than the CR participants. This finding is significant considering the similar levels of improvement in function made by both TLU and CR participants.

Conclusions: Both TLU and CR groups improved on a range of measures. The TLU group however, received significantly more face-to-face interventions. Further examination of the relationship between participant contextual factors, such as coping style and self-esteem, and impairments such as challenging behaviour and decreased self-awareness, of people attending TLU and CR programs is required.

Changes in Functional Behaviour of Adults With Brain Injury and Spouse-Caregiver Burden With In-Home Neurobehavioural Intervention

A within-participant multiple baseline experiment evaluated effects of in-home neurobehavioural interventions on functional behaviour of 3 persons with brain injury, and their spouses' burden of care. The 6-week individualised interventions included in-home and telephone consultations. Measures consisted of functional behaviour of the injured persons, spouses' burden of care using the QRS-SF at preand postintervention and at 1 month follow-up, and social validity. Results show interventions were efficacious in improving functional behaviour, but effects on burden of care and social validity were mixed. One caregiver who presented with high levels of burden at preintervention reported reduced burden, while the other 2 who presented with low to moderate burden reported no changes.

Single Participant Studies in Positive Behaviour Support for Parents of Individuals With Brain Injuries

Three single participant studies examined effects of in-home parent-implemented Positive Behaviour Support (PBS) interventions on behaviour of individuals with brain injuries. Parental and independent observations of morning routine behaviour or problem behaviour (viz., noncompliance during meals or morning routines, yelling, kicking, swearing, and so on) were taken during baselines and PBS interventions, which consisted of person-centred functional assessments of behaviour, emphasis on changing behavioural antecedents, parent participation in assessing, treating, and evaluating behaviour change, and in-home parent coaching and support. Results show decreased problem behaviour or improved morning routine behaviour, which corroborate and add to the few studies that applied similar parent-implemented interventions. Future comparative studies between PBS and out-patient interventions are indicated.

Progress assessed with the Mayo-Portland Adaptability Inventory in 604 participants in 4 types of post-inpatient rehabilitation brain injury programs

OBJECTIVE

To compare progress in 4 types of post-inpatient rehabilitation brain injury programs.

DESIGN

Quasiexperimental observational cohort study.

SETTING

Community and residential.

PARTICIPANTS

Individuals (N=604) with acquired brain injury.

INTERVENTIONS

Four program types within the Pennsylvania Association of Rehabilitation Facilities were compared: intensive outpatient and community-based rehabilitation (IRC; n=235), intensive residential rehabilitation (IRR; n=78), long-term residential supported living (SLR; n=246), and long-term community-based supported living (SLC; n=45). With the use of a commercial web-based data management system developed with federal grant support, progress was examined on 2 consecutive assessments.

MAIN OUTCOME MEASURE

Mayo-Portland Adaptability Inventory (MPAI-4).

RESULTS

Program types differed in participant age (F=10.69, P<.001), sex (χ(2)=22.38, P<.001), time from first to second assessment (F=20.71, P<.001), initial MPAI-4 score (F=6.89, P<.001), and chronicity (F=13.43, P<.001). However, only initial MPAI-4 score and chronicity were significantly associated with the second MPAI-4 rating. On average, SLR participants were 9.1 years postinjury compared with 5.1 years for IRR, 6.0 years for IRC, and 6.8 years for SLC programs. IRR participants were more severely disabled per MPAI-4 total score on admission than the other groups. Controlling for these variables, program types varied significantly on second MPAI-4 total score (F=5.14, P=.002). Both the IRR and IRC programs resulted in significant functional improvement across assessments. In contrast, both the SLR and SLC programs demonstrated relatively stable MPAI-4 scores.

CONCLUSIONS

Results are consistent with stated goals of the programs; that is, intensive programs resulted in functional improvements, whereas supported living programs produced stable functioning. Further studies using data from this large, multiprovider measurement collaboration will potentially provide the foundation for developing outcome expectations for various types of postacute brain injury programs.

Effectiveness of community-based rehabilitation after traumatic brain injury for 489 program completers compared with those precipitously discharged

OBJECTIVE

To evaluate outcomes of home- and community-based postacute brain injury rehabilitation (PABIR).

DESIGN

Retrospective analysis of program evaluation data for treatment completers and noncompleters.

SETTING

Home- and community-based PABIR conducted in 7 geographically distinct U.S. cities.

PARTICIPANTS

Patients (N=489) with traumatic brain injury who completed the prescribed course of rehabilitation (completed-course-of-treatment [CCT] group) compared with 114 who were discharged precipitously before program completion (precipitous-discharge [PD] group).

INTERVENTION

PABIR delivered in home and community settings by certified professional staff on an individualized basis.

MAIN OUTCOME MEASURES

Mayo-Portland Adaptability Inventory (MPAI-4) completed by means of professional consensus on admission and at discharge; MPAI-4 Participation Index at 3- and 12-month follow-up through telephone contact.

RESULTS

Analysis of covariance (CCT vs PD group as between-subjects variable, admission MPAI-4 score as covariate) showed significant differences between groups at discharge on the full MPAI-4 (F=82.25; P<.001), Ability Index (F=50.24; P<.001), Adjustment Index (F=81.20; P<.001), and Participation Index (F=59.48; P<.001). A large portion of the sample was lost to follow-up; however, available data showed that group differences remained statistically significant at follow-up.

CONCLUSIONS

Results provided evidence of the effectiveness of home- and community-based PABIR and that treatment effects were maintained at follow-up.

A home programme for patients with cognitive dysfunction: a pilot study

OBJECTIVE

To evaluate the effectiveness of a 12-week individualized home programme of rehabilitation for patients with cognitive impairment.

METHODS

Six patients with cognitive dysfunction, after haemorrhagic stroke, participated in this study. A programme was carried out in the home environment that consisted of four mixed training programmes: cognitive remediation therapy, story retelling, cognitive enhancing games and aerobic exercise. The patients performed the home programme for 2 hours a day, 7 days a week, for 12 weeks. The main outcomes were measured using the MMSE, Neurobehavioural Cognitive Status Examination (NCSE), domain-specific computerized neuropsychological test for attention, memory and executive function, the Lowenstein Occupational Therapist Cognitive Assessment (LOTCA), the Modified Barthel Index (MBI) and the Seoul-Instrumental Activity of Daily Living (S-IADL).

RESULTS

After completion of a 12-week home programme, the patients' S-IADL scores improved significantly (p < 0.05). The patients' MMSE and NCSE scores improved marginally, with mean score changes of 4.2 (p = 0.058), 4.7 (p = 0.078) and 6.8 (p = 0.068) points, respectively. However, the patients' domain-specific cognitive test and LOTCA scores did not significantly change.

CONCLUSION

The results of this study showed that an individualized home programme improved IADL performance in patients with cognitive dysfunction and may have a beneficial effect on cognition, as assessed by general cognitive measures.

Characteristics of home-based community integration programmes for adults with brain injury

OBJECTIVES

To conduct a nationwide telephone survey in order to gather data on some of the quantifiable characteristics of home-based community integration programmes available in the US to adults with brain injury.

DESIGN

Survey.

METHODS

The Community Integration Programme Questionnaire (CIPQ) was used to interview 13 home-based community integration programmes. This study then used descriptive statistics to analyse the characteristics of the programmes.

OUTCOME

There was a good deal of variability in client and programmatic characteristics.

CONCLUSIONS

There is considerable variability in characteristics among home-based community integration programmes.

Achieving Optimal Functional Outcomes in Community-Based Rehabilitation following Acquired Brain Injury: A Qualitative Investigation of Therapists' Perspectives

The aim of this study was to explore therapists' opinions about the rehabilitation approaches that they perceived contributed to positive outcomes for people with acquired brain injury in community-based rehabilitation settings in order to develop a set of practice principles for clinicians working in this area. Semi-structured interviews were conducted with eight Australian and three British therapists, with a mean of 5.2 years' experience of working with people with acquired brain injury in community-based rehabilitation settings. The interviews were analysed thematically. A summary of the themes was presented to a larger group of acquired brain injury service providers (n = 35) for validation.

The participants emphasised the importance of environmental factors, such as collaboration with and inclusion of others in rehabilitation, especially those in the person's support network. Strategy use, client-centred goal setting, the provision of education and the development of a therapeutic relationship were identified as facilitators in community-based rehabilitation. Problems with self-awareness and motivation, drug and alcohol use, and behavioural difficulties were commonly identified barriers to optimal outcomes. The key practice principles derived from the findings were the need for community-based rehabilitation for people with acquired brain injury to be (1) environment focused and contextually appropriate, (2) collaborative and (3) goal directed and client centred.

Risk assessment and management for providers of community-based rehabilitation to people with acquired brain injury: health professionals' perspectives

PURPOSE

This study aimed to explore health professionals' perspectives regarding the presence, assessment and management of risks when providing community-based rehabilitation (CBR) to clients with acquired brain injury (ABI).

METHOD

A qualitative approach using semi-structured interviews of health professionals working in CBR.

RESULTS

The main themes were: (1) risk assessment in CBR settings is an informal, unstructured, complex, multi-phase and cyclical process extending over a period of time; (2) structured and standardised risk assessments were not considered ideal for use in CBR services catering for people with ABI; (3) CBR services face numerous challenges in providing effective risk assessment and management; (4) the risks encountered by health professionals in CBR settings are not always predictable or preventable; and (5) CBR risk management focuses on implementing a range of practical strategies.

CONCLUSIONS

A flexible risk assessment process supported by a range of practical risk management strategies to minimise and manage potential risks is advocated by health professionals working in CBR services for people with ABI. There is a need for more research into the effectiveness of current risk assessment and management strategies for CBR services.

"The left hand does not know what the right hand is doing": rural and urban cultures of care for persons with traumatic brain injuries

This qualitative study examined systems of care for individuals with brain injury, from the providers' perspective, in two Colorado communities, one rural and one small urban, from 1998 to 2001. Using a guided interview format the researchers interviewed 53 medical, rehabilitation, community, and school service providers in the two sites. Of the 53 providers, ethnicity was reported as 100% Caucasian. Client ethnicity in the rural area was 87.9% Caucasian and 6.2% Hispanic, and the urban reported 67.3% Caucasian and 29% Hispanic. Both communities noted problems with care coordination, information about other available services, housing and transportation, and large underserved groups (persons with mild brain injury, non-English speakers, and persons without or with insufficient health insurance). The two communities noted strengths in having peer support networks and options for supported recreation. The rural community demonstrated strengths in dealing with trauma care but had few resources available for long-term rehabilitation and community-integrated services for its residents with brain injuries. The urban community uniquely had an array of alternative treatment approaches available.

Understanding the lingering consequences of what we treat and what we do

Granja and colleagues have helped us by showing that long-term follow-up is feasible and by trying to tease out whether select intensive care unit patient populations are at particular risk of adverse outcomes. This work gives us clues for future investigations which will hopefully interrogate further the potential mechanisms of action that underlie poor long-term outcomes. In the meantime, we can hope that this quality of follow-up will move from the research arena to become a part of routine clinical care.

A home program of rehabilitation for moderately severe traumatic brain injury patients. The DVHIP Study Group

We have recently reported the results of a prospective controlled randomized trial comparing home versus inpatient cognitive rehabilitation for patients with moderate to severe head injury. That study showed no overall difference in outcomes between the two groups.(1) In this article, we provide further details of the home program arm of the study. All patients in the home program received medical treatment as needed, a multidisciplinary in-hospital evaluation, and TBI counseling before entering the eight-week home program, which then included guidance on home activities, as well as weekly telephone calls from a psychiatric nurse.