Psychosocial sequelae of closed head injury: effects on the marital relationship

Factors related to the quality and stability of partner relationships after traumatic brain injury: A systematic literature review

OBJECTIVE

The latest literature review on partner relationships following traumatic brain injury (TBI), conducted a decade ago, discussed solely quantitative work and noted significant knowledge gaps. The current review updates and expands on this work by providing an overview of the current state of knowledge on factors related to relationship quality and stability following TBI.

DATA SOURCES

CINAHL, Embase, MEDLINE, Psychology and Behavioral Sciences Collection, APA PsycINFO, and PubMed were searched on April 23, 2020, for literature on factors associated with 1)relationship quality and 2)relationship stability following TBI.

STUDY SELECTION

English quantitative and qualitative studies investigating factors associated with relationship quality and/or stability following TBI were included. Two reviewers independently assessed eligibility. If consensus was not reached, a third reviewer's conclusion was decisive. Forty-three studies were included.

DATA EXTRACTION

Information regarding study objectives and characteristics, participant demographics, (in)dependent variables, and main findings was extracted. Study quality was rated using the JBI Checklist for Analytical Cross Sectional Studies and/or the CASP Checklist for Qualitative Research. Both were performed by the lead reviewer and checked by the second reviewer.

DATA SYNTHESIS

Thirty-eight factors related to relationship quality and/or stability were identified, covering injury characteristics (e.g., severity), body functions (e.g., personality changes), activities (e.g., communication), participation (e.g., social dependence), environment (e.g., children), and personal factors (e.g., coping strategies).

CONCLUSIONS

Relationship quality and stability following TBI are found to be related to a multitude of factors, including newly identified factors such as personality changes and dependence. Future research may wish to quantitatively investigate factors thus far only identified in qualitative research, explore possible positive effects of TBI on relationships, study the experiences of same-sex couples, and include the perspectives of both partners with and without the injury.

An App-Based Just-in-Time Adaptive Self-management Intervention for Care Partners (CareQOL): Protocol for a Pilot Trial

BACKGROUND

Care partners (ie, informal family caregivers) of individuals with health problems face considerable physical and emotional stress, often with a substantial negative impact on the health-related quality of life (HRQOL) of both care partners and care recipients. Given that these individuals are often overwhelmed by their caregiving responsibilities, low-burden self-management interventions are needed to support care partners to ensure better patient outcomes.

OBJECTIVE

The primary objective of this study is to describe an intensive data collection protocol that involves the delivery of a personalized just-in-time adaptive intervention that incorporates passive mobile sensor data feedback (sleep and activity data from a Fitbit [Fitbit LLC]) and real time self-reporting of HRQOL via a study-specific app called CareQOL (University of Michigan) to provide personalized feedback via app alerts.

METHODS

Participants from 3 diverse care partner groups will be enrolled (care partners of persons with spinal cord injury, care partners of persons with Huntington disease, and care partners of persons with hematopoietic cell transplantation). Participants will be randomized to either a control group, where they will wear the Fitbit and provide daily reports of HRQOL over a 3-month (ie, 90 days) period (without personalized feedback), or the just-in-time adaptive intervention group, where they will wear the Fitbit, provide daily reports of HRQOL, and receive personalized push notifications for 3 months. At the end of the study, participants will complete a feasibility and acceptability questionnaire, and metrics regarding adherence and attrition will be calculated.

RESULTS

This trial opened for recruitment in November 2020. Data collection was completed in June 2021, and the primary results are expected to be published in 2022.

CONCLUSIONS

This trial will determine the feasibility and acceptability of an intensive app-based intervention in 3 distinct care partner groups: care partners for persons with a chronic condition that was caused by a traumatic event (ie, spinal cord injury); care partners for persons with a progressive, fatal neurodegenerative disease (ie, Huntington disease); and care partners for persons with episodic cancer conditions that require intense, prolonged inpatient and outpatient treatment (persons with hematopoietic cell transplantation).

TRIAL REGISTRATION

ClinicalTrials.gov NCT04556591; https://clinicaltrials.gov/ct2/show/NCT04556591.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/32842.

Sleep impairment is related to health-related quality of life among caregivers of lower-functioning traumatic brain injury survivors

Objective: The purpose of this study was to examine perceived sleep-related impairment in caregivers of individuals with traumatic brain injury (TBI). Specifically, we examined the relationship between caregiver-perceived sleep-related impairment and different aspects of health-related quality of life (HRQOL) and explored whether these relationships were moderated by the perceived level of everyday function in the person with TBI. Method: Three hundred forty-one caregivers of individuals with TBI completed surveys to determine whether the association between sleep-related impairment and HRQOL was moderated by caregiver-perceived functional impairment of the person with injury. Participants completed measures from the Patient-Reported Outcomes Measurement Information System and the TBI-CareQOL. These measures were used to examine different aspects of HRQOL: caregiver-specific HRQOL, mental HRQOL, social HRQOL, and fatigue. The Mayo-Portland Adaptability Inventory-4 was used to measure caregiver perceptions of the level of everyday function in the person with injury. Results: Results indicated that caregiver-perceived sleep-related impairment was associated with each of the four HRQOL scores. This relationship was moderated by the caregiver-reported level of everyday function in the person with TBI for both caregiver-specific HRQOL and fatigue but not mental or social HRQOL. For caregiver-specific HRQOL and fatigue, caregiver-perceived sleep-related impairment was associated with worse HRQOL for those caring for individuals with lower perceived levels of everyday function, but not for those caring for individuals with higher levels of everyday function. Conclusions: Interventions to improve caregiver sleep and HRQOL should consider both psychosocial and environmental factors (i.e., factors related to the person with the TBI). (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Families' Experiences Living with Acquired Brain Injury: "Thinking Family"-A Nursing Pathway for Family-Centered Care

The objective of this study was to examine families' experiences living with acquired brain injury (ABI) using a research approach that included both the affected individual family member and the family together as a family group. A narrative inquiry study, informed by the life-stage approach of Lieblich, Tuval-Mashiach, and Zilber, was used to obtain family stories. Families experiencing an ABI event were purposefully selected from different regions in a western Canadian province. Centered on the life stages of before the ABI event, now living with the ABI, and the future, thematic findings included: Families, a grounding force; Losses, individual and family; Family adaptive capacities; Experiences with the healthcare system-hospital to home; and A patchwork future-entering the unknown. Themes affirmed the significant impacts of ABI on individual and family members and acknowledged ABI as an ambiguous loss event. The findings also illuminated families' strengths and resiliencies in coping with living with ABI. The study results suggest by “thinking family” nurses can contribute towards a healthcare model that focuses on “family” as the central unit of care.

Relationship Satisfaction and Depression After Traumatic Brain Injury: An Actor-Partner Interdependence Model of Patients and Caregivers in Mexico and Colombia

OBJECTIVE

Traumatic brain injury represents a major public health concern, particularly in low- and middle-income countries like in Latin America. Family members are often caregivers for individuals with traumatic brain injury, which can result in significant stress. Research is needed to examine depression and quality of the caregiving relationship in these dyads. This study examined relationship quality and depression longitudinally after traumatic brain injury within the caregiving relationship.

DESIGN

Dyads (N = 109) composed of individuals with traumatic brain injury and their caregivers were recruited from three hospitals in Mexico and Colombia. They self-reported depression and relationship satisfaction during hospitalization and at 2 and 4 mos after hospitalization.

RESULTS

A 2-lag Actor Partner Interdependence Model demonstrated that patients and caregivers reporting high relationship satisfaction at baseline experienced lower depression 2 mos later, which then predicted higher caregiver relationship satisfaction at 4 mos. Moreover, patients with high relationship satisfaction at baseline had caregivers with lower depression at 2 mos, which was then associated with patients' higher satisfaction at 4 mos.

CONCLUSIONS

Within individuals with traumatic brain injury and caregivers, depression and relationship satisfaction seem to be inversely related. Furthermore, patients' and caregivers' depression and relationship satisfaction impact each other over time, demonstrating interdependence within the caregiving relationship.

The computerized cognitive training alliance - A proposal for a therapeutic alliance model for home-based computerized cognitive training

Background

To increase the number of hours available for cognitive rehabilitation, it may be an option to use the spouse or paid assistants to assist with computerized home training. However, the delegation of training responsibilities may affect the normal roles of the therapist, the spouse and the training assistants.

Objective

This article suggests a new model for understanding the impact of computerized home training on the therapeutic alliance between the therapist, the patient and training assistants. Aspects of this knowledge are relevant also for the development and use of computerized training systems in clinical settings.

Method

Qualitative Interpretative Phenomenological Analysis (IPA) of semi-structured interviews was used to analyse the experience gained during home-based computerized cognitive training.

Results

Home-based computerized training enforces the delegation of aspects of the therapeutic alliance established between the therapist and the patient. The perceived authority of assistants and computer training systems may differ from the authority established through the patient/therapist alliance. Information may be lost in transition impacting skills and expertise long-term.

Conclusion

Roles and responsibilities between the therapist, the assistants and the computerized training system need to be clearly defined. A Cognitive Training Alliance model is being proposed which takes into consideration the challenges of delegating training responsibility to computer systems and non-professional assistants.

A predictive model of resilience among family caregivers supporting relatives with traumatic brain injury (TBI): A structural equation modelling approach

Constructs from positive psychology were employed to create an explicit model of caregiver resilience. Predictive and mediating relationships among resilience and related variables (personality, coping, self-efficacy, hope, social support) were then tested for their association with burden and psychological adjustment among family members caring for relatives with severe TBI. Family participants (n = 131) from six rehabilitation units from New South Wales and Queensland completed assessments which elicited explanatory (Eysenck Personality Questionnaire, Ways of Coping Questionnaire), mediating (Connor-Davidson Resilience Scale, General Self-Efficacy Scale, Herth Hope Scale, Medical Outcome Study Social Support Survey), and caregiver outcome (Caregiver Burden Scale, Mental Health sub-Scale-SF36, General Health Questionnaire, and Positive and Negative Affect Scale) variables. Structural Equation Modeling (SEM) showed that resilience had a direct effect on positive affect in caregivers. Resilience also played a protective role in relation to two variables associated with caregiver vulnerability: an indirect association with caregiver burden mediated through social support; a direct effect on hope, which, in turn, was associated with positive mental health. Positive mental health then played a buffering role in relation to psychological distress and negative affect. Resilience, in combination with other psychological attributes, was associated with reduced morbidity among family caregivers after severe TBI.

Understanding Health-Related Quality of Life in Caregivers of Civilians and Service Members/Veterans With Traumatic Brain Injury: Reliability and Validity Data for the TBI-CareQOL Measurement System

OBJECTIVES

To establish the reliability and validity of the newly developed TBI-CareQOL patient-reported outcome (PRO) measures in caregivers of civilians and service members/veterans (SMVs) with traumatic brain injury (TBI) so that they can be used with confidence in clinical research and practice.

DESIGN

Computer-based surveys delivered through an on-line data capture platform.

SETTING

Three TBI Model Systems rehabilitation hospitals, an academic medical center, and a military medical treatment facility.

PARTICIPANTS

Caregivers (N=560) of individuals with TBI; this included 2 different study samples: 344 caregivers of civilians with TBI and 216 caregivers of SMVs with TBI.

INTERVENTION

Not Applicable.

MAIN OUTCOME MEASURES

Five Traumatic Brain Injury Caregiver Quality of Life (TBI-CareQOL) item banks.

RESULTS

Reliabilities for the TBI-CareQOL measures were excellent (all Cronbach's α >.88); 3-week test-retest reliability ranged from .75 to .90 across the 2 samples. Convergent validity was supported by moderate to high associations among the TBI-CareQOL measures and moderate correlations between the TBI-CareQOL measures and other measures of health-related quality of life (HRQOL) and caregiver burden. Discriminant validity was supported by low correlations between the TBI-CareQOL measures and less-related constructs (eg, caregiver satisfaction). Known-groups validity was supported: caregivers of individuals that were low functioning had worse HRQOL than caregivers of high-functioning individuals.

CONCLUSIONS

Results provide psychometric support for the new TBI-CareQOL item banks. As such, these measures fill a significant gap in the caregiver literature where sensitive PRO measures that capture changes in HRQOL are needed to detect improvements for interventions designed to assist family caregivers.

The TBI-CareQOL Measurement System: Development and Preliminary Validation of Health-Related Quality of Life Measures for Caregivers of Civilians and Service Members/Veterans With Traumatic Brain Injury

OBJECTIVE

To develop a new measurement system, the Traumatic Brain Injury Caregiver Quality of Life (TBI-CareQOL), that can evaluate both general and caregiving-specific aspects of health-related quality of life (HRQOL) in caregivers of persons with traumatic brain injury (TBI).

DESIGN

New item pools were developed and refined using literature reviews, qualitative data from focus groups, and cognitive debriefing with caregivers of civilians and service members/veterans with TBI, as well as expert review, reading level assessment, and translatability review; existing item banks and new item pools were assessed using an online data capture system. Exploratory and confirmatory factor analysis, item response theory, and differential item functioning analyses were utilized to develop new caregiver-specific item banks. Known-groups validity was examined using a series of independent samples t tests comparing caregivers of low-functioning vs high-functioning persons with TBI for each of the new measures, as well as for 10 existing Patient-Reported Outcomes Measurement Information System (PROMIS) measures.

SETTING

Three TBI Model Systems rehabilitation hospitals, an academic medical center, and a military medical treatment facility.

PARTICIPANTS

Caregivers (N=560) of civilians (n=344) or service members/veterans with TBI (n=216).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The TBI-CareQOL measurement system (including 5 new measures and 10 existing PROMIS measures).

RESULTS

Exploratory and confirmatory factor analysis, item response theory, and differential item functioning analyses supported the development of 5 new item banks for Feelings of Loss-Self, Feelings of Loss-Person with TBI, Caregiver-Specific Anxiety, Feeling Trapped, and Caregiver Strain. In support of validity, individuals who were caring for low-functioning persons with TBI had significantly worse HRQOL than caregivers that were caring for high-functioning persons with TBI for both the new caregiver-specific HRQOL measures, and for the 10 existing PROMIS measures.

CONCLUSIONS

The TBI-CareQOL includes both validated PROMIS measures and newly developed caregiver-specific measures. Together, these generic and specific measures provide a comprehensive assessment of HRQOL for caregivers of civilians and service members/veterans with TBI.

How Do Iranian People with Spinal Cord Injury Understand Marriage?

Background: Spinal cord injury (SCI) is a life-altering experience. There is little information about the perspectives of people with SCI toward marriage. Purpose: To explore the understandings of Iranian adults with SCI about marriage. Methods: In this qualitative inquiry, using a semi-structured interview guide, we collected data from 53 single adults with SCI (41 men and 12 women) who were referred to the Brain and Spinal Cord Injury Research Center, Tehran University of Medical Sciences in Tehran. Barun and Clarke's thematic analysis approach was applied for data analysis. Results: "Marriage" was thematized in outer and inner scenarios. The outer scenario was explored in terms of physical disability identified as a seminal determinant in successful marriage. "Attractiveness," "able body for breadwinning," "sexually active," and "reproduction" were dominant concepts extracted from the participants' narratives. The participants' inner scenarios revealed that marriage would be welcomed if a potential partner accepted them as a "whole person" regardless of their SCI condition. Conclusion: The findings suggest that adults with SCI do not ignore or reject marriage, however it was not their life priority due to major concerns that they had internalized. Considering the quality of care, people with SCI must be reassured about their potential to get married. SCI-based sexuality education and premarital counseling support the patients in their postmarital lives. Our findings will provide decision makers and health providers with significant insight for utilizing culturally appropriate services for people with SCI.

Investigation of a New Couples Intervention for Individuals With Brain Injury: A Randomized Controlled Trial

OBJECTIVES

This study aimed to (1) examine the efficacy of a treatment to enhance a couple's relationship after brain injury particularly in relationship satisfaction and communication; and (2) determine couples' satisfaction with this type of intervention.

DESIGN

Randomized waitlist-controlled trial.

SETTING

Midwestern outpatient brain injury rehabilitation center.

PARTICIPANTS

Participants (N=44; 22 persons with brain injury and their intimate partners) were randomized by couples to the intervention or waitlist-controlled group, with 11 couples in each group.

INTERVENTIONS

The Couples Caring and Relating with Empathy intervention is a 16-week, 2-hour, manualized small group treatment utilizing psychoeducation, affect recognition, empathy training, cognitive-behavioral and dialectical-behavioral strategies, communication skills training, and Gottman's theoretical framework for couples adjusted for individuals with brain injury.

MAIN OUTCOME MEASURES

The Dyadic Adjustment Scale, Quality of Marriage Index (QMI), and the Four Horsemen of the Apocalypse communication questionnaire were implemented. Measures were completed by the person with brain injury and that person's partner at 3 time points: baseline, immediate postintervention, 3-month follow-up.

RESULTS

The experimental group showed significant improvement at posttest and follow-up on the Dyadic Adjustment Scale and the Horsemen questionnaire compared to baseline and to the waitlist-controlled group which showed no significant changes on these measures. No significant effects were observed on the QMI for either group. Satisfaction scores were largely favorable.

CONCLUSIONS

Results suggest this intervention can improve couples' dyadic adjustment and communication after brain injury. High satisfaction ratings suggest this small group intervention is feasible with couples following brain injury. Future directions for this intervention are discussed.

Understanding Health-Related Quality of Life in Caregivers of Civilians and Service Members/Veterans With Traumatic Brain Injury: Establishing the Reliability and Validity of PROMIS Fatigue and Sleep Disturbance Item Banks

OBJECTIVE

To examine the reliability and validity of Patient-Reported Outcomes Measurement Information System (PROMIS) measures of sleep disturbance and fatigue in traumatic brain injury (TBI) caregivers and to determine the severity of fatigue and sleep disturbance in these caregivers.

DESIGN

Cross-sectional survey data collected through an online data capture platform.

SETTING

A total of 4 rehabilitation hospitals and Walter Reed National Military Medical Center.

PARTICIPANTS

Caregivers (N=560) of civilians (n=344) and service member/veterans (SMVs) (n=216) with TBI.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

PROMIS sleep and fatigue measures administered as both computerized adaptive tests (CATs) and 4-item short forms (SFs).

RESULTS

For both samples, floor and ceiling effects for the PROMIS measures were low (<11%), internal consistency was very good (all α≥0.80), and test-retest reliability was acceptable (all r≥0.70 except for the fatigue CAT in the SMV sample r=0.63). Convergent validity was supported by moderate correlations between the PROMIS and related measures. Discriminant validity was supported by low correlations between PROMIS measures and measures of dissimilar constructs. PROMIS scores indicated significantly worse sleep and fatigue for those caring for someone with high levels versus low levels of impairment.

CONCLUSIONS

Findings support the reliability and validity of the PROMIS CAT and SF measures of sleep disturbance and fatigue in caregivers of civilians and SMVs with TBI.

Targeted areas for improving health literacy after traumatic brain injury

OBJECTIVE

To develop a framework to identify targeted areas for improving health literacy for caregivers after traumatic brain injury (TBI).

METHOD

Qualitative study using inductive and deductive qualitative content analysis was conducted in a large, urban, level I trauma centre. Interviews were conducted with 23 caregivers of persons with TBI. Participants' perspectives on communication and preparation for discharge were explored and understanding of commonly used words and discharge instructions were assessed.

RESULTS

Four types of communication patterns were identified: formal, informal, indirect and caregiver-initiated. Informal and caregiver-initiated communication were the most common. All caregivers reported confusion about their family member's condition, care plan or discharge plan. Caregivers were not able to define commonly used terms in discharge instructions, and were confused by formatting and medical language. Caregivers were not aware of expected caregiving roles upon discharge. Conceptualizing findings within a family-centred care model, we offer specific strategies to improve health communication and caregiver capacity building to enhance health literacy.

CONCLUSIONS

Health literacy and caregiver capacity to care for loved ones with TBI after hospital discharge is low. We offer specific target areas for improvement in verbal and written communication and capacity building that take into account provider, patient and family characteristics.

Quality of relationship between veterans with traumatic brain injury and their family members

OBJECTIVES

The quality of the relationship between patients with many illnesses and their family members has been shown to affect the well-being of both. Yet, relationship quality has not been studied in traumatic brain injury (TBI), and giving and receiving aspects have not been distinguished. The present study of veterans with TBI examined associations between relationship quality and caregiver burden, satisfaction with caregiving, and veterans' competence in interpersonal functioning, rated by veterans and family members.

METHOD

In this cross-sectional study, 83 veterans and their family members were interviewed at home. Measures of quality of relationship, veterans' interpersonal competence and sociodemographics were collected for both, caregiver burden and satisfaction for family members only.

RESULTS

As predicted, veteran-rated Q_rel/Giving was associated with family-rated Q_rel/Receiving, and veteran-rated Q_rel/Receiving with family-rated Q_rel/Giving. Lower caregiver burden and higher caregiving satisfaction were associated with higher Q_rel/Receiving scores but not with Q_rel/Giving scores. Veterans' interpersonal competence was associated with total Q_rel as rated by either veterans or family members.

CONCLUSIONS

Relationship quality should be included in family research in TBI, and giving and receiving aspects should be differentiated. Findings suggest that lower caregiver burden and greater satisfaction should be more achievable by increasing caregivers' sense of benefits received from the relationship.

The Relationship between Training and Mental Health among Caregivers of Individuals with Polytrauma

This was a hypothesis-generating exploration of relationships between caregiver training during TBI/polytrauma rehabilitation and caregiver mental health. In this cross-sectional study, 507 informal caregivers to US service members with TBI who received inpatient rehabilitation care in a Veterans Affairs' Polytrauma Rehabilitation Center from 2001 to 2009 completed a retrospective, self-report survey. Embedded in the survey were measures of caregiver mental health, including the National Institutes of Health's Patient Reported Outcome Measurement Information System (PROMIS) Anxiety and Depression Short Forms, the Rosenberg Self-Esteem scale, and the Zarit Burden Short Form. Though no groups endorsed clinical levels, mental health symptoms varied by caregiver training category (Trained, Not Trained, and Did Not Need Training). Caregivers who did not receive training on how to navigate healthcare systems endorsed higher depression and burden and lower self-esteem than those who did. Caregivers who did not receive training in supporting their care recipients' emotions endorsed higher anxiety, depression, and burden and lower self-esteem than those who did. Analyses also suggested a different association between training and mental health based on caregivers' relationship to the care recipient and the intensity of care recipient needs. Potential hypotheses for testing in future studies raised by these findings are discussed.

How Partners Experience Personality Change After Traumatic Brain Injury – Its Impact on Their Emotions and their Relationship

Objective: The aim of this qualitative study was to explore how spouses/partners experience social, emotional and behavioural changes in persons following traumatic brain injury (TBI), with a particular focus on their emotional impact and the effect on the couple relationship.

Method: Interpretative phenomenological analysis (IPA) of interview data explored five women's experiences of these changes in their partners following TBI.

Results: Themes describe the direct emotional impact of living with the changes as well as the emotional impact of attempts to manage and make sense of the changes (identity change, managing the changes and making sense of the changes). The impact on the couple relationship is described under the themes of feeling love and receiving love. Changes led three of the participants to experience their partner as having been replaced by a new person; they actively disliked this new person; they felt unable to love the new person in the same way as the old person; and their love was defined in terms of a caring relationship, rather than a spousal relationship.

Conclusions: The study provides insight into why social, emotional and behavioural changes might be so consistently associated with reduced emotional wellbeing and lower levels of relationship quality and satisfaction.

A Randomized Controlled Trial to Evaluate the Veterans' In-home Program for Military Veterans With Traumatic Brain Injury and Their Families: Report on Impact for Family Members

BACKGROUND

Traumatic brain injury (TBI) creates many challenges for families as well as for patients. Few intervention studies have considered both the needs of the person with TBI and his or her family and included both in the intervention process. To address this gap, we designed an innovative intervention for veterans with TBI and families-the Veterans' In-home Program (VIP)-targeting veterans' environment, delivered in veterans' homes, and involving their families.

OBJECTIVES

To determine whether the VIP is more effective than standard outpatient clinic care in improving family members' well-being in 3 domains (depressive symptoms, burden, and satisfaction) and to assess its acceptability to family members.

DESIGN

In this randomized controlled trial, 81 dyads (veteran/family member) were randomly assigned to VIP or an enhanced usual care control condition. Randomization occurred after the baseline interview. Follow-up interviews occurred 3-4 months after baseline, and the interviewer was blinded to group assignment.

SETTING

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

PARTICIPANTS

A total of 81 veterans with TBI recruited from a Veterans Affairs (VA) polytrauma program and a key family member for each participated. Of the 81 family members, 63 completed the follow-up interview.

INTERVENTION

The VIP, guided by the person-environment fit model, consisted of 6 home visits and 2 telephone calls delivered by occupational therapists over a 3- to 4-month period. Family members were invited to participate in the 6 home sessions.

MAIN OUTCOME MEASURES

Family member well-being was operationally defined as depressive symptomatology, caregiver burden, and caregiver satisfaction 3-4 months after baseline. Acceptability was operationally defined through 3 indicators.

RESULTS

Family members in the VIP showed significantly lower depressive symptom scores and lower burden scores when compared to controls at follow-up. Satisfaction with caregiving did not differ between groups. Family members' acceptance of the intervention was high.

CONCLUSIONS

VIP represents the first evidence-based intervention that considers both the veteran with TBI and the family. VIP had a significant impact on family member well-being and thus addresses a large gap in previous research and services for families of veterans with TBI.

Positive Person–Environment Factors as Mediators of the Relationship Between Perceived Burden and Quality of Life of Caregivers for Individuals With Traumatic Brain Injuries

The purpose of this study was to determine whether personal (caregiving mastery and problem-solving coping) and environmental (social support and professional and community support) caregiver resources mediate the relationship between caregiver perceived burden and quality of life (QOL). The sample consisted of 108 caregivers recruited from support groups who were predominantly White women. The majority of care-recipients had a severe head injury. Measures administered were the Interpersonal Support Evaluation List, the COPE, Family Needs Questionnaire, Modified Caregiving Appraisal Scale, and the World Health Organization Quality of Life–Brief Version. Results showed that social, professional, and community supports mediate the link between perceived burden and QOL. Caregivers of persons with traumatic brain injury frequently face elevated levels of burden, stress, and depression. Positive personal and environmental support, particularly social support, professional/community supports, and mastery, could lessen the negative impact of caregiving burden on QOL of the caregiver.

Long Term Changes in Family Needs After Brain Injury: A Preliminary Review

When a family member acquires a brain injury the family as a whole is likely to experience severe emotional stress and strain in coping with and adjusting to the injured family member. Longitudinal studies of family adjustment have shown that families find it increasingly difficult to cope with the brain injured family member as the time (years) since injury increases. The increasing difficulty family members experience in coping with their brain injured relative led several researchers to investigate the needs of family members. Research investigating family needs after brain injury is limited to the first couple of years post trauma despite the finding that stress and burden continue to increase as the years progress. This paper reviews family needs research over the last three decades and provides a discussion of family needs and surrounding issues relevant to rehabilitation professionals.

Assessment of sexuality following traumatic brain injury: validation of the Brain Injury Questionnaire of Sexuality

BACKGROUND

The importance of effectively identifying and managing sexuality issues following acquired brain injury is being increasingly recognized within clinical and research domains. However, a tool specifically developed to measure sexuality following brain injury is yet to be validated.

OBJECTIVES

In this study, the reliability and validity of the Brain Injury Questionnaire of Sexuality (BIQS) was evaluated.

METHOD

Eight hundred and sixty-five people who had sustained traumatic brain injury participated in this study. All participants completed the BIQS, and a subsample also completed the Derogatis Interview for Sexual Functioning-Self-Report version (DISF-SR).

RESULTS

Exploratory factor analysis supported a 3-subscale structure of the BIQS, which aligns with contemporary conceptual models of sexuality in chronic disease. All subscales of the BIQS demonstrated very good internal consistency. Convergent and divergent validity of all BIQS subscales was also demonstrated.

CONCLUSIONS

Results from the study support the reliability and validity of the BIQS, which shows promise as a measurement tool for future traumatic brain injury sexuality research. Further validation work including evaluation for potential clinical applications is encouraged.

Sexual functioning 1 year after traumatic brain injury: findings from a prospective traumatic brain injury model systems collaborative study

OBJECTIVE

To investigate the incidence and types of sexual difficulties in men and women with traumatic brain injury (TBI) 1 year after injury, as well as their comfort level in discussing problems with health care professionals.

DESIGN

Prospective cohort study.

SETTING

Community.

PARTICIPANTS

Persons with TBI (N=223; 165 men and 58 women) who had been treated at 1 of 6 participating TBI Model Systems inpatient rehabilitation units and were living in the community.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Derogatis Interview for Sexual Functioning-self-report (DISF-SR); Global Sexual Satisfaction Index (GSSI); structured interview regarding changes in sexual functioning; and comfort level discussing sexuality with health care professionals.

RESULTS

Women with TBI scored significantly below the normative sample for all subscales of the DISF-SR, including sexual cognition/fantasy, arousal, sexual behavior/experience, and orgasm. Men scored significantly below the normative sample on all scales except arousal. Women reported greater dysfunction than men for sexual cognition/fantasy and arousal. Twenty-nine percent of participants reported dissatisfaction with sexual functioning on the GSSI, with a greater percentage of men reporting dissatisfaction. Sixty-eight percent of participants indicated that they would spontaneously raise issues of sexual difficulties with health care professionals, while the remainder would either bring it up only if directly asked or would not discuss it at all.

CONCLUSIONS

Sexual difficulties were present in a substantial portion of community-dwelling people with TBI at 1 year after injury. Educational interventions to increase awareness among people with TBI and rehabilitation professionals are warranted, as well as interventions to improve sexual functioning.

The needs of aging parents caring for an adult with acquired brain injury

This study focused on issues of concern to and service needs of older parents caring for an adult son or daughter with an acquired brain injury (ABI) in Ontario. Three issues were identified as particularly challenging: diagnosis of the brain injury, parents' feelings about the cause of the brain injury, and planning for long-term accommodation for their family member with a brain injury. The most frequently cited services needed for the person with ABI were social and/or recreational activities, day programs, and residential placement. The most frequently cited services needed by parents were parent education and support groups. The information gathered provides a base for further research in other sectors. Implications of these initial findings for clinical practice and policy and program development are discussed.

Psychological and marital adjustment in couples following a traumatic brain injury (TBI): A critical review

The first part of this paper examines current data describing the psychological and marital adjustment of couples following a traumatic brain injury (TBI). Although these findings reveal some discrepancies, they highlight that adjustment following a TBI represents a genuine challenge for those involved in the process. The second part moves toward the examination of factors associated with psychological and marital adjustment in both couple partners. Here again, there exists a large diversity in empirical data and theoretical models informing this emerging area of interest. Nevertheless, cognitive variables such as coping skills are commonly seen as critical variables to explain the adjustment level in people with TBI and their spouse/caregivers. Concurrently with the discussion of the methodological issues and pitfalls encountered in this area of research, the conclusion provides suggestions of further steps to undertake in this endeavour toward a better understanding of the adjustment process following TBI.

Exploring the impact of traumatic brain injury on the older couple: ‘Yes, but how much of it is age, I can’t tell you …’

PRIMARY OBJECTIVE

To qualitatively explore the partner relationships of older couples faced with traumatic brain injury (TBI).

RESEARCH DESIGN

Qualitative analysis comparing individuals with TBI and a comparison group.

METHODS AND PROCEDURES

Twenty-one individuals were interviewed using a semi-structured format focusing on various aspects of their partner relationship. A qualitative analysis of transcripts identified general themes.

MAIN OUTCOMES AND RESULTS

Variability of relationship experiences (relationship relatedness and persistence of the partnership) was shown across groups. Aspects of relationship commitment to the partnership were revealed. Many individuals with TBI and their partners attributed various relationship changes to ageing and age-related issues and not to the TBI.

CONCLUSIONS

These findings suggest that the effects of TBI are not clearly distinguished from age-related causes for change in the partners and their relationship. Older couples' experiences may be different from those of younger couples impacted by TBI, in the areas of sexuality, inter-personal support and role functions.

Prevalence, characteristics and causes of aggressive behaviour observed within a neurobehavioural rehabilitation service: Predictors and implications for management

PRIMARY OBJECTIVE

To describe the characteristics and determinants of aggressive behaviour observed within a neurobehavioural unit.

RESEARCH DESIGN

Statistical analysis of a database of routinely administered clinical measures, including the Overt Aggression Scale-Modified for Neurorehabilitation.

METHODS AND PROCEDURES

Records of aggressive behaviour shown by 108 patients over 14 days were studied. Patient characteristics were also captured using 23 items from the Rehabilitation Institute of Chicago-Functional Assessment Scale. Four factors were identified: 'communication', 'cognition/function', 'neurobehavioural disability' and 'mood & self-esteem'. Relationships between patient characteristics, external factors and their interactions with aggression were examined.

MAIN OUTCOMES AND RESULTS

Many (5548) episodes of aggression were recorded. Whilst most comprised verbal aggression, 729 physical assaults were made on others. Aggressive behaviour typically followed staff prompting or no obvious antecedent. Medical intervention was rare, most aggression was managed by staff not reinforcing this behaviour. Over 80% of physical assaults were made by people rated as having severe symptoms of neurobehavioural disability and poor communication.

CONCLUSIONS

Neurobehavioural units require sufficient staff resources to engage patients in purposeful activities as these were associated with the least severe aggression. Despite increased OAS-MNR usage, a standardized methodology for investigating aggression is required to ensure compatibility between datasets.

Acute predictors of real-world outcomes following traumatic brain injury: a prospective study

PRIMARY OBJECTIVE

To determine whether the recovery of acute attention and memory improves the prediction of real-world outcomes over that provided by standard demographic and injury-severity measures.

RESEARCH DESIGN

Participants were recruited consecutively at the time of injury and followed prospectively at 1 (time 1, or T1) and 4 years (time 2, or T2).

METHODS AND PROCEDURES

Measures of attention and memory and the Galveston Orientation and Amnesia Test (GOAT) were administered to 94 participants daily from the time of injury until the criterion was met. Sixty-three per cent returned at T1 and 53% returned at T2. Outcomes were psychosocial distress, return to work and/or school, and quality of life.

MAIN OUTCOMES AND RESULTS

Recovery of attention, memory and orientation did not significantly improve prediction of outcomes at T1, but did so at T2. At T2, recovery of free recall of three words over 24 h was a more sensitive predictor of psychosocial distress and return to productivity than the GOAT.

CONCLUSIONS

Free recall of three words may be a useful acute clinical test to enhance prediction of long-term outcomes.

Psychosocial outcomes 1–7 years after comprehensive milieu-oriented neurorehabilitation: The role of pre-injury status

PRIMARY OBJECTIVE

To explore pre-injury variables related to post-discharge psychosocial status and identify factors related to work and driving outcomes.

METHODS AND PROCEDURES

Ninety-three brain-injured patients attended a holistic milieu-oriented neurorehabilitation program and were contacted 1-7 years post-discharge.

EXPERIMENTAL INTERVENTIONS

Questionnaire data addressing pre-injury and post-injury work, driving, income, marital status and living situation.

MAIN OUTCOMES AND RESULTS

74.3% were involved in competitive work and/or school with 86.0% productive at follow-up. Post-injury income decreased significantly compared with pre-injury levels. Pre-injury relationship status did not differ significantly from post-injury; 81.1% remaining in a stable relationship or married at follow-up. Pre-injury and post-injury accident rates were related; 73.1% drove at follow-up. Higher education, non-right hemispheric injury, shorter treatment length and return to work related to driving. Younger age, higher education, non-right hemispheric injury and driving post-injury related to positive work status.

CONCLUSIONS

Pre-injury psychosocial data provide an important context for understanding post-discharge outcome after brain injury. Holistic milieu-oriented rehabilitation facilitates long-term successful work, driving and relationship stability.

Emotion perception deficits following traumatic brain injury: a review of the evidence and rationale for intervention

While the cognitive disturbances that frequently follow severe traumatic brain injury (TBI) are relatively well understood, the ways in which these affect the psychosocial functioning of people with TBI are yet to be determined and have thus received little attention in treatment research. Growing evidence indicates that a significant proportion of individuals with TBI demonstrate an inability to recognize affective information from the face, voice, bodily movement, and posture. Because accurate interpretation of emotion in others is critical for the successful negotiation of social interactions, effective treatments are necessary. Until recently, however, there have been no rehabilitation efforts in this area. The present review examines the literature on emotion perception deficits in TBI and presents a theoretical rationale for targeted intervention. Several lines of research relevant to the remediation of emotion perception in people with TBI are considered. These include work on emotion perception remediation with other cognitively impaired populations, current neuropsychological models of emotion perception and underlying neural systems, and recent conceptualizations of remediation processes. The article concludes with a discussion of the importance of carrying out efforts to improve emotion perception within a contextualized framework in which the day-to-day relevance of training is clear to all recipients.

Spousal relationship satisfaction following acquired brain injury: The role of insight and socio-emotional skill

Spousal relationships following brain injury are particularly vulnerable to strain and breakdown. Changes in personality and socio-emotional processing and behaviour have been implicated as causal factors. We examined spousal relationship satisfaction following an acquired brain injury to one partner. Couples affected by chronic pain and a group of healthy couples were used for comparison and control. Compared to healthy controls current satisfaction was poorer in the brain injury couples, and satisfaction with the relationship had reduced from pre to post-injury. We found an especially important role for empathy, which differentiated between the groups in terms of functioning and insight.

Stress and coping among families of patients with traumatic brain injury: a review of the literature

AIMS AND OBJECTIVES

This literature review aims to structure the available information on the psychological reactions of family members confronted with traumatic brain injury. The stress-coping theory and the systems theory provide the theoretical framework for this review.

METHOD

Literature review.

RESULTS

The level of stress experienced by the family members of patients who have traumatic brain injury is such that professional intervention is appropriate, even after 10-15 years. Not the severity of the injury but the nature of the injuries determines the level of stress. Partners experience more stress than parents. Children have specific difficulties. Young families with little social support, financial, psychiatric and/or medical problems are the most vulnerable. Coping with traumatic brain injury can be described in phases. The better family members can cope with the situation, the better the patient's recovery. There are functional and non-functional coping mechanisms and coping is influenced by such factors as gender, social and professional support and the possibility to have reciprocal communication or an affective relation with the patient.

RELEVANCE TO CLINICAL PRACTICE

Support from professionals reduces the stress being experienced and encourages people to cope effectively. Conflicts with professional carers should be avoided. Every attempt should be made to develop models of long-term support and care that alleviate sources of burden on relatives. Further research is necessary to develop such models.

Exploring self-concepts of persons with brain injury

BACKGROUND

This study explored the self-concepts of Hong Kong Chinese adults with brain injury.

OBJECTIVES

The Adult Source of Self-concept Inventory (ASSEI) Chinese Version was adopted to identify the sources and basis of the self-conceptions of 120 persons with brain injury.

METHOD

The Adult Source of Self-Esteem Inventory (ASSEI), a self evaluation tool using open-ended questions and interviewing, was used to identify the sources and basis of the self-concept of persons with and without brain injury. The subjects' important life aspects were identified through interpreting their responses to open-ended questions and interviews. Moreover, a structured questionnaire on their subjective perceptions of importance and satisfaction in different life areas was used to identify the relationships between discrete self-concept variables. The subjects' responses to the 20 items of the ASSEI were also subjected to an exploratory factor analysis.

MAIN OUTCOME AND RESULTS

Five self-concept related factors, which accounted for 65.55% of the total variance, were successfully identified. They were family self, physical self, moral self, personal achievement and social self. The self-concept factors match the results of content analysis of the subjects' responses to the open-ended questions. The results showed that family, physical health, work and friends were the most important domains in lives of individuals with brain injury. Brain injury survivors felt good towards their family, work and friends in their daily life. However, the majority expressed the view that they felt bad due to deteriorating physical health, poor family relationships, emotional difficulties and poor working relationship with others.

CONCLUSION

Findings from this study identified the self-concept basis of persons with brain injury that can indicate self-concept enhancement strategies to improve their rehabilitation outcomes. Hopefully, they can develop more positive self-images and, thus, achieve better community integration.

Long-term adjustment of families following traumatic brain injury where comprehensive rehabilitation has been provided

OBJECTIVES

The present study aimed to examine long-term family and emotional adjustment in close relatives of individuals with TBI, who had access to comprehensive rehabilitation services. It also examined the relative influence thereon of factors including injury severity, handicap and cognitive and behavioural changes in the injured person, relationship with the injured person and caregiver status.

METHODS

Participants were 143 TBI individuals and their close relatives. They completed the Family Assessment Device (FAD), Leeds Scales of Anxiety and Depression, Structured Outcome Questionnaire, CHART, SIP Psychosocial Dimension and Novaco Anger Control Questionnaire 2-5 years post-injury.

RESULTS

Results showed that families were, on average, functioning in the normal range on the FAD. Anxiety and depression were more likely to be present in those responsible for care of their injured relative. There were no differences between spouses and parents. Presence of cognitive, behavioural and emotional changes was the strongest predictor of anxiety and depression in relatives and of unhealthy family functioning.

CONCLUSIONS

Every attempt should be made to develop models of long-term support and care that alleviate these sources of burden on relatives.

Crisis and its assessment after brain injury

PRIMARY OBJECTIVE

To develop a measure to assess crisis after acquired brain injury (ABI).

RESEARCH DESIGN

A triangulated research strategy, using both qualitative and quantitative methods, was employed to develop the crisis measure.

METHODS AND PROCEDURES

The measure was developed in two phases. In the first phase, by using focus group methodology, the experience of crisis following brain injury was described. The second phase involved developing the questionnaire items, pilot testing the measure and conducting initial reliability testing.

MAIN OUTCOMES AND RESULTS

The six themes derived from the content analysis led to the creation of the measure, with versions for individuals who have an ABI, family members and professionals. Test-re-test reliability results (n = 40) were adequate.

CONCLUSIONS

The results suggest that crisis is experienced as precarious homeostasis with individuals with brain injury, varying in intensity over time, subjectively viewed as never really absent.