A supported relationships intervention to increase the social integration of persons with traumatic brain injuries

Examining the Evidence From Single-Case Experimental Designs to Treat Challenging Behaviors Following Moderate to Severe Traumatic Brain Injury

OBJECTIVE

To evaluate evidence on the effectiveness of behavioral interventions using single-case experimental design (SCED) methodology and to identify behavioral interventions with sufficient evidence for possible inclusion in the development of guidelines for the management of challenging behaviors in adults following moderate to severe traumatic brain injury (TBI).

METHODS

As a subinvestigation of a larger systematic review process designed to identify evidence for guidelines development, the current review focused on studies using SCED methodology applied to persons with challenging behaviors following moderate to severe TBI. Articles were identified from a search of the published literature through January 2021, identifying studies in CINAHL, Cochrane Database of Systematic Reviews, EMBASE, MEDLINE/Ovid, and PsycINFO. Articles meeting inclusion criteria were assessed for design rigor to allow for effect size determination. The identified cases were then critically appraised using the RoBiNT (Risk-of-Bias in N-of-1 Trails) Scale to determine strength of evidence for causal inference.

RESULTS

Thirty-four studies met inclusion criteria, with a total of 44 cases evaluated for effect of the treatment intervention on defined target behaviors. Seventeen cases had effect sizes rated as large, 22 cases as medium, 3 cases as small, and 3 as no effect. An observed trend was for large and medium effect sizes to be associated with lower RoBiNT Scale internal validity scores. Randomization, blinded provider and assessor, and assessment of treatment adherence were the internal validity items unlikely to meet criteria.

CONCLUSIONS

SCED methodology was found to produce large and medium effect sizes for behavioral interventions targeting challenging behaviors following moderate to severe TBI. However, the strength of the evidence is limited because of weaknesses in study designs. Most of the studies failed to meet established internal validity criteria designed to reduce risk of bias in SCED studies as such rigor is difficult to establish or often not practical in clinical settings. Suggestions and recommendations are outlined for improving the quality of published cases using SCED methodology, which, in turn, will improve credibility of evidence and better inform the development of treatment guidelines for behavior regulation.

Navigation ability in patients with acquired brain injury: A population-wide online study

The ability to travel independently is a vital part of an autonomous life. It is important to investigate to what degree people with acquired brain injuries (ABI) suffer from navigation impairments. The aim of this study was to investigate the prevalence and characteristics of objective and subjective navigation impairments in the population of ABI patients. A large-scale online navigation study was conducted with 435 ABI patients and 7474 healthy controls. Participants studied a route through a virtual environment and completed 5 navigation tasks that assessed distinct functional components of navigation ability. Subjective navigation abilities were assessed using the Wayfinding questionnaire. Patients were matched to controls using propensity score matching. Overall, performance on objective navigation tasks was significantly lower in the ABI population compared to the healthy controls. The landmark recognition, route continuation and allocentric location knowledge tasks were most vulnerable to brain injury. The prevalence of subjective navigation impairments was higher in the ABI population compared to the healthy controls. In conclusion, a substantial proportion (39.1%) of the ABI population reports navigation impairments. We advocate the evaluation of objective and subjective navigation ability in neuropsychological assessments of ABI patients.

Loss of friendship following traumatic brain injury: A model grounded in the experience of adults with severe injury

Relationships make important contributions to wellbeing and maintenance of self-worth. For those who sustain traumatic brain injury (TBI), life is frequently characterized by declining interpersonal relationships. The aim of this study was to understand the post-injury experience of friendship from the perspective of adults with severe TBI. Participants were 23 adults who had sustained severe TBI on average 10 years earlier; the majority was between 25 and 45 years old. The experience of friendship was explored using a convergent mixed methods design (quantitative self-report measures and in-depth interviews). Qualitative analysis of interview transcripts employed open and focussed coding to reveal themes and categories. Participants nominated on average 3.35 (SD 2.19) friends. When paid carers and family members were excluded, the mean dropped to 1.52 (SD 1.38). Exploratory correlations between number of friends and quality of life, depression and strong-tie support revealed significant associations of moderate to large effects. The post-injury experience of friendship was broadly conceptualized as "going downhill" with four overlapping phases: losing contact, being misunderstood, wanting to share and hanging on. Participants' stories illustrated how rehabilitation can focus on friendship by supporting established relationships and facilitating access to activities that afford interpersonal encounters and opportunities to share experiences.

The Things that Help, the Things that Get in the Way: Working Together to Improve Outcome Following Acquired Brain Injury

Working in neurological rehabilitation brings with it numerous opportunities to gain an understanding of the factors that contribute to shaping meaningful living and wellbeing for those tackling the major life changes encountered following acquired brain injury (ABI). These opportunities come in many forms: challenging and brave clients, wise and worrying families, questioning and inspiring colleagues, empowering and limiting work environments and rigid and advancing policy and legislative contexts.

Our personal and collective understanding ofthe things that helpandthe things that get in the wayof effective rehabilitation continuously emerges from the convergence of the experience and knowledge afforded by these opportunities. The aim of this paper is to considerthe things that helpandthe things that get in the wayas they have been identified by people with ABI, their families and those who work with them and have been further evidenced through research targeted towards improving short, medium and long-term outcomes for those living with the consequences of ABI. Thesethingsas discussed in this paper capture the essential role of the self, the importance of rights and access to rehabilitation, the impact of the family and the contribution of social connection.

Community-based interventions for adolescents following traumatic brain injury: A systematic review

BACKGROUND

Chronic impairment following childhood traumatic brain injury has the potential to increase risk of negative outcomes. This highlights potential value in community-based rehabilitation programs.

OBJECTIVES

To identify research studies examining existing intervention programmes available in community-based rehabilitation to adolescents following TBI to assist with the transition back into the community.

METHODS

A systematic review of community-based interventions was conducted across different national contexts. All included studies involved a clinical population with TBI, aged 11 to 25 years inclusive. Risk of bias was rated for each included study.

RESULTS

Seventeen studies were identified for inclusion in the review, of these eleven distinct interventions were found. The quality of evidence was largely weak and highly variable.

CONCLUSION

The results suggest some improvement in adolescent outcomes following community-based interventions, however higher quality evidence is needed to support specific interventions.

Informing design of an app-based coaching intervention to promote social participation of teenagers with traumatic brain injury

OBJECTIVE

To examine perspectives of multiple stakeholders to inform the design of an app-based coaching intervention to promote social participation in teenagers with traumatic brain injury (TBI).

METHODS

Teenagers and college students with and without TBI and parents of teenagers with TBI were recruited from two children's hospitals and two universities in the USA (n = 39). Data were collected via interviews, focus groups, and surveys and examined using descriptive statistics and content analyses.

RESULTS

Teenagers with TBI reported more social participation barriers and fewer strategies for addressing these barriers than teenagers without TBI. There was consensus across groups about the value of college student coaches and use of smartphones and apps. Participants expressed mixed views on the use of chat rooms and degree of parent involvement.

CONCLUSION

Results provided insights about the possible benefits of the intervention, and informed its initial design (e.g., desired coach qualities, and type of coach training and supervision).

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.

Post-traumatic growth following acquired brain injury: a systematic review and meta-analysis

The idea that acquired brain injury (ABI) caused by stroke, hemorrhage, infection or traumatic insult to the brain can result in post-traumatic growth (PTG) for individuals is increasingly attracting psychological attention. However, PTG also attracts controversy as a result of ambiguous empirical findings. The extent that demographic variables, injury factors, subjective beliefs, and psychological health are associated with PTG following ABI is not clear. Consequently, this systematic review and meta-analysis explores the correlates of variables within these four broad areas and PTG. From a total of 744 published studies addressing PTG in people with ABI, eight studies met inclusion criteria for detailed examination. Meta-analysis of these studies indicated that growth was related to employment, longer education, subjective beliefs about change post-injury, relationship status, older age, longer time since injury, and lower levels of depression. Results from homogeneity analyses indicated significant inter-study heterogeneity across variables. There is general support for the idea that people with ABI can experience growth, and that various demographics, injury-related variables, subjective beliefs and psychological health are related to growth. The contribution of social integration and the forming of new identities post-ABI to the experience of PTG is explored. These meta-analytic findings are however constrained by methodological limitations prevalent in the literature. Clinical and research implications are discussed with specific reference to community and collective factors that enable PTG.

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.

Long-term social integration and community support

TBI often results in reduced social participation. This decrease in social participation is independent of injury severity and time since injury. Thus, it is one of the many stable hallmarks of TBI. Changes in social participation have been related to many factors, including emotional dysregulation and disturbance and executive dysfunction. While there are evidenced-based treatments available to improve mood and executive functioning, none of the research has examined the impact of the various treatments on social participation or social integration. Therefore, while it is reasonable to expect that individuals who are feeling better about themselves and who improve their approach to day-to-day function will also experience increased social contact, there is no evidence to support this claim. This chapter reviews the literature on post-TBI social integration and its relationship to depression and executive dysfunction. In addition the intervention research in this area is briefly examined.

[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.

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.

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

OBJECTIVE

To identify best practices and promising practices to enhance participation in meaningful and productive activities.

METHOD

An electronic search of the ABI rehabilitation research literature since 1990 yielded 974 articles of which 30 focused on interventions that targeted participation and evaluated effectiveness using direct measures of participation. Three reviewers rated these articles according to the standards set out by the Centre for Reviews and Dissemination. Following the systematic review, an interpretive review of the same articles was completed.

RESULTS

Only three studies were rated as strong. No best practices were identified. Three promising practices found some support. The interpretive review suggested 'Participate to learn' as a useful rehabilitation model. The model rests on roles as goals, learning by experience in real-life contexts and the use of personal and environmental support to enable participation.

CONCLUSIONS

'Participate to learn' is both a credible rehabilitation model and deserving of more study.

Community reintegration following acquired brain injury

OBJECTIVE

To evaluate the interventions and strategies used to enable transition from acute care or post-acute rehabilitation to the community following brain injury.

METHODS AND MAIN OUTCOMES

A systematic review of the literature from 1980-2005 was conducted focusing on ABI rehabilitation. Five major aspects of community reintegration, including: independence and social integration, caregiver burden, satisfaction with quality of life, productivity and return to driving were considered.

RESULTS

With the exception of one, the majority of interventions are supported by only limited evidence, denoting an absence of randomized controlled trials (RCTs) in the literature. Of 38 studies evaluated for this review, only one RCT was found. That RCT provided moderate evidence that behavioural management, coupled with caregiver education, did not help to improve caregiver burden.

CONCLUSIONS

Further research, using an interventional approach, is required to advance the evidence base of reintegration into the community following brain injury.

Neuropsychological rehabilitation

Neuropsychological rehabilitation (NR) is concerned with the amelioration of cognitive, emotional, psychosocial, and behavioral deficits caused by an insult to the brain. Major changes in NR have occurred over the past decade or so. NR is now mostly centered on a goal-planning approach in a partnership of survivors of brain injury, their families, and professional staff who negotiate and select goals to be achieved. There is widespread recognition that cognition, emotion, and psychosocial functioning are interlinked, and all should be targeted in rehabilitation. This is the basis of the holistic approach. Technology is increasingly used to compensate for cognitive deficits, and some technological aids are discussed. Evidence for effective treatment of cognitive, emotional, and psychosocial difficulties is presented, models that have been most influential in NR are described, and the review concludes with guidelines for good practice.

A comparison of challenges faced by parents of children with ABI with and without access to third party funding

BACKGROUND

In Canada, allocation of rehabilitation services is often based on the assumption that families who have third party insurance funding are well served by the private sector system and are not in need of publicly funded rehabilitation services. However, there has been little research comparing the experiences of caregivers with and without access to third party insurance funding; data that could inform service planning and provision.

METHOD

The current study compared the stresses, resources and psychological health of caregivers of children with Acquired Brain Injury (ABI) with and without third party funding.

RESULTS

Caregivers with third party funding (MVA) reported a similar level of stress in comparison to caregivers without funding (non-MVA); however there were differences in what these families perceived as stressful.

CONCLUSIONS

Although results indicated significant psychological distress and depressive symptoms for both groups, parents in both groups reported high availability of and satisfaction with services, although they used very few services. Implications for clinical services are discussed.

Rural versus urban social support seeking as a moderating variable in traumatic brain injury outcome

OBJECTIVE

To investigate personal beliefs about seeking social support following traumatic brain injury (TBI) and the relationship of these appraisals to demographic and injury variables, social integration, and quality of life ratings.

SETTING

The central region of a Midwest state.

PARTICIPANTS

Fifty-six adults with TBI who were more than 6 months postinjury and living in the community.

MAIN OUTCOME MEASURES

The Hesitation Scale, a 20-item survey that assesses reasons that people might hesitate to reach out to others in the community, and portions of the Living Life After Traumatic Brain Injury Scale.

RESULTS

Negative attitudes and beliefs about seeking social support were significantly related to lower perceptions of social support, lower ratings of quality of life, longer time since injury, being divorced or separated, and living in an urban area. Predictors of higher quality of life ratings included more positive appraisals about seeking social support, living in a rural area, and the ability to engage in productive activity.

CONCLUSIONS

Positive outcomes after TBI appear to be moderated by living in a rural area, which is associated with more openness to seeking social supports and contributes to better quality of life.