A Scoping Review of Predictors of Community Integration Following Traumatic Brain Injury: A Search for Meaningful Associations

Lower extremity muscle activity during reactive balance differs between adults with chronic traumatic brain injury and controls

Background

Control of reactive balance is key to achieving safe independent walking and engagement in life activities. After traumatic brain injury (TBI), motor impairments and mobility challenges are persistent sequelae. To date, no studies have explored muscle activity of individuals with chronic TBI during a task that requires reactive control of balance.

Objective

To investigate lower extremity muscle activity during a reactive balance test performed by adults with chronic severe TBI and matched controls. We hypothesized that abnormal activity of lower extremity muscles would be related with poorer reactive balance performance. Also, we performed an exploratory analysis for those with TBI investigating the impact of unilateral versus bilateral lower extremity involvement in the control of reactive balance.

Methods

Ten adults with chronic severe TBI who were independent community ambulators and ten matched controls performed the computerized reactive balance test (Propriotest®) while lower extremity muscle activity was recorded. Electromyographic (EMG) activity was contrasted (Mann-Whitney U Test) between groups across each 10 s epoch of the 120 s test. Additionally, test scores were correlated (Spearman) with lower extremity composite EMG activity to distinguish muscle activity patterns related with reactive balance performance. Lastly, reactive balance test scores were correlated with reactive balance test scores and clinical functional measures only for the TBI group.

Results

Although the TBI group exhibited greater EMG activity across the entire test compared with the control group, significant differences were not observed. Greater composite EMG activity correlated significantly with poorer reactive balance performance across most of the 10 s windows of the test.

Conclusion

Greater muscle activity exhibited during the reactive balance test by individuals with chronic severe TBI compared to those without disabilities, particularly at small unexpected perturbations, highlights the greater physiologic effort required to control reactive balance even after independent ambulation is achieved.

Ongoing Challenges Related to the COVID-19 Pandemic Among People With Brain Injury

The COVID-19 pandemic exacerbated social isolation among people with traumatic brain injury (TBI). Yet, little is known about how changes in personal factors, environmental factors, or the characteristics of activities affected social participation. We examined experiences with social isolation and barriers to social participation using the person-environment-occupation-performance model as a framework. Twelve adults with TBI participated in a series of three focus groups. Data were analyzed using thematic analysis. We identified two primary themes with sub-themes: (1) social isolation experiences: (1a) emotional impact and (1b) managing personal risk; and (2) greater barriers but a lack of strategies to address them: (2a) access and opportunities and (2b) social and societal factors. New environmental barriers and task demands affected occupational performance, and participants identified few successful strategies to overcome these barriers. Occupational therapy can develop new strategies to re-balance the person-environment fit and enhance social participation.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Introduction

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

Methods

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

Results

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

Discussion

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

The effect of self-reported balance confidence on community integration after brain injury: an observational study

OBJECTIVE

To evaluate the correlation between self-reported balance confidence and community integration related to home management for community-dwelling adults with acquired brain injury (ABI).

METHODS

This is a study of 141 participants over the age of 18 with a history of ABI, living in the community, who completed an online survey. The survey included a series of demographic questions followed by the Activities-Specific Balance Confidence Scale (ABC) and the Home Integration subscale of the Community Integration Questionnaire (CIQ-H).

RESULTS

Data from 119 completed surveys were included in the analysis. Significant positive correlations were found between the ABC and the CIQ-H total scores (rs = 0.241, p = 0.008). There was no significant difference between CIQ-H total scores in individuals by injury type (traumatic vs non-traumatic) or by level of severity (mild, moderate, severe) (p > 0.05). There was no significant difference between ABC total scores by injury type (p > 0.05).

CONCLUSIONS

Higher levels of balance confidence may be associated with improved community integration related to home management for individuals with traumatic and non-traumatic BI. This study's results support future research to evaluate the integration of strategies to improve balance confidence as a component of interdisciplinary assessment and rehabilitation to maximize community integration in community-dwelling adults with ABI.

Predictors of cognitive gains during inpatient rehabilitation for older adults with traumatic brain injury

INTRODUCTION

Traumatic brain injury (TBI) among older adults is increasing and can affect cognition. To effectively meet the rehabilitation needs of older adults, a clearer picture is needed of patient-, clinical-, and facility-level characteristics that affect cognitive recovery during inpatient rehabilitation facility (IRF) stays.

OBJECTIVE

To identify patient, clinical, and facility factors associated with cognitive recovery among older adults with TBI who received IRF care.

DESIGN

Secondary data analysis.

SETTING

Uniform Data System for Medical Rehabilitation-participating IRFs in the United States.

PATIENTS

Patients were 65 to 99 years of age at IRF admission for TBI. Participants received IRF care between 2002 and 2018 (N = 137,583); 56.3% were male; 84.2% were white; mean age was 78.7 years.

MAIN OUTCOME MEASURE

Change in Functional Independence Measure Cognitive Score (FIM-Cognitive) from IRF admission to discharge, categorized as favorable (FIM-cognitive score gains ≥3 points) or poor (FIM-cognitive score gains <3 points) cognitive outcomes.

INTERVENTIONS

Not applicable.

RESULTS

Patients had greater odds of favorable cognitive recovery if they were female (adjusted odds ratio [aOR] 1.05, 95% confidence interval [CI] 1.05-1.08), had higher motor functioning at IRF admission (aOR 1.03, 95% CI 1.03-1.04), longer length of stay (aOR 1.07, 95% CI 1.06-1.07), or received care at a freestanding IRF (vs. hospital rehab unit) (aOR 1.57, 95% CI 1.52-1.61). Patients who were older (aOR 0.99, 95% CI 0.98-0.99), Black (aOR 0.79, 95% CI 0.75-0.83), Hispanic or Latino (aOR 0.97, 95% CI 0.91-1.02), or were part of another racial or ethnic group (aOR 0.85, 95% CI 0.81-0.90) (vs. White), had high-cost comorbid conditions (aOR 0.71, 95% CI 0.65-0.76), or who had higher cognitive functioning at IRF admission (aOR 0.90, 95% CI 0.90-0.91) had lower odds of favorable cognitive recovery.

CONCLUSIONS

Patient (age, sex, race, ethnicity), clinical (level of functioning at IRF admission, length of stay) and facility (e.g., freestanding IRF) factors contributed to the cognitive recoveries of older adults during IRF stays.

Community Integration and Associated Factors 10 Years after Moderate-to-Severe Traumatic Brain Injury

This study evaluated the impact of baseline injury characteristics and one-year functional level on the 10-year community integration outcomes for working-age patients with moderate-to-severe traumatic brain injury (TBI). Patients aged 16-55 and diagnosed with moderate-to-severe TBI within 24 h of injury were eligible for the study. Multivariable hierarchical linear regression was utilized to assess the impact of baseline characteristics and one-year functional measures on the mean Community Integration Questionnaire (CIQ) scores 10 years after injury. Of 133 original study participants, 97 survived 10 years, and 75 were available for this study. The mean total CIQ score changed positively from one to 10 years post-injury, from 18.7 (±5.5) to 19.8 (±4.8) (p = 0.04). The results suggested that age (β = -0.260, p = 0.013), FIM-Cognitive subscale (β = 0.608, p = 0.002), and the bodily pain subscale (BP) (β = 0.277, p = 0.017) of the SF-36 were significantly associated with the mean CIQ scores. In conclusion, this study demonstrated improved community integration from one to 10 years in a sample of working-age patients with moderate-to-severe TBI. The findings also showed that age, cognitive function, and bodily pain were significant predictors of long-term community integration, suggesting post-acute rehabilitation should focus on factors related to long-term risk and protective factors to improve long-term outcomes.

Living in a reshaped reality: Exploring social participation and self-identity after TBI

Individuals with a moderate to severe traumatic brain injury (TBI) experience substantial changes in their life. This constructivist grounded theory study aimed to develop an explanatory model that explores the impact of changes in social participation and self-identity after sustaining a TBI. Sixteen participants with moderate to severe TBI (mean age = 49.8, 69% male) were recruited, and were on average 16.4 years post-injury (SD = 10.4). Data from semi-structured interviews were analysed thematically. An overarching theme of "living in a reshaped reality" was identified, which depicted how changes in social participation and self-identity influenced ongoing experiences with TBI. Three main themes were generated: (1) "there's nothing that's the same" highlighted the daily challenges individuals faced post-injury, (2) "rebuilding and restarting" described how individuals with TBI navigated through their unfamiliar reality, and (3) "embrace it and run with it" explored participants' reactions towards life with a TBI. An explanatory model was developed, consisting of the overarching theme ("living in a reshaped reality") with the three integrated themes. Future research and clinical practices can build on this understanding to develop programmes to help individuals address their needs in post-injury life.

Social Determinants of Health in Physiatry: Challenges and Opportunities for Clinical Decision Making and Improving Treatment Precision

Physiatry is a medical specialty focused on improving functional outcomes in patients with a variety of medical conditions that affect the brain, spinal cord, peripheral nerves, muscles, bones, joints, ligaments, and tendons. Social determinants of health (SDH) play a key role in determining therapeutic process and patient functional outcomes. Big data and precision medicine have been used in other fields and to some extent in physiatry to predict patient outcomes, however many challenges remain. The interplay between SDH and physiatry outcomes is highly variable depending on different phases of care, and more favorable patient profiles in acute care may be less favorable in the outpatient setting. Furthermore, SDH influence which treatments or interventional procedures are accessible to the patient and thus determine outcomes. This opinion paper describes utility of existing datasets in combination with novel data such as movement, gait patterning and patient perceived outcomes could be analyzed with artificial intelligence methods to determine the best treatment plan for individual patients in order to achieve maximal functional capacity.

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.

Inpatient rehabilitation facility discharge destination among younger adults with traumatic brain injury: differences by race and ethnicity

OBJECTIVE

: To determine the association of race and ethnicity with discharge destination among patients with traumatic brain injury (TBI) receiving inpatient rehabilitation facility (IRF) care.

DESIGN

Secondary analysis using Uniform Data System for Medical Rehabilitation data.

METHODS

: Patients (N = 99,614) diagnosed with TBI, age 18-64, admitted for IRF care between 2002 and 2018. Logistic regression was used to analyze data.

OUTCOME

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

RESULTS

: Most younger adults (age 18-64) with TBI were discharged home (89.24%) after IRF care vs. subacute (10.76%). Of those discharged home, 63.16% were white, 10.42% Black, 8.94% Hispanic/Latino, and 6.72% other races/ethnicities. After adjusting for covariates, patients who were Hispanic/Latino [OR = 1.26; 95% CI: 1.15, 1.37] and other race/ethnicities [OR = 1.10; 95% CI: 1.00, 1.21] (vs. White) had higher odds of discharge home vs. subacute. There was no difference in discharge destination for Black patients (vs. white). Predictors of discharge destination for groups stratified by race/ethnicity varied.

CONCLUSIONS

: Younger patients with TBI who were Hispanic/Latino or other races/ethnicities (vs. white) were more likely to go home vs. subacute. Findings can be used to inform IRF planning, resource allocation, and transitional care planning.

Motivational and cognitive correlates of community integration in homeless veterans entering a permanent supported housing program

Homelessness is a major public health problem, and serious mental illness (SMI) is highly prevalent in the homeless population. Although supported housing services-which provide permanent housing in the community along with case management-improve housing outcomes, community integration typically remains poor, and little is known about the underlying determinants of poor community integration postresidential placement. The general SMI literature has indicated that motivational and cognitive ability factors are key determinants of successful community integration, which provides a foundation for examining this issue. This study evaluated whether interview- and performance-based assessments of motivation, nonsocial and social-cognitive ability, and psychiatric symptoms were associated with community integration indices in 2 samples of homeless veterans either with (N = 96) or without (N = 80) a psychotic disorder who had recently been admitted to a supported housing program but who had not yet attained housing. Motivation indices, including experiential negative symptoms and defeatist performance attitudes, stood out as the most robust correlates (rs = -.30 to -.69) of community integration across both samples, particularly for social role participation. Demographics, general psychiatric symptoms, and nonsocial cognition showed generally weak relations with community integration, though social cognition showed a few relations. The consistent findings across samples point to the importance of motivational factors for understanding the determinants of poor community integration in this complex population. Further, interventions that target motivational challenges may have widespread usefulness for enhancing community integration outcomes beyond obtaining housing. (PsycINFO Database Record (c) 2020 APA, all rights reserved).