Reengagement in Meaningful Occupations During the Transition From Hospital to Home for People With Acquired Brain Injury and Their Family Caregivers

Methodologies to measure access to care post-discharge in adults with serious injury-related disability: a scoping review

PURPOSE

This scoping review examined the methodologies used to measure access to care in serious injury-related disability populations, for whom access to care post-discharge has significant implications for patient outcomes and rehabilitation trajectories.

METHODS

Four electronic databases were searched for literature published between 1 January 2000 and 15 February 2022. Relevant articles needed to relate to access to care in adult community-dwelling trauma and rehabilitation populations.

RESULTS

The initial search identified 679 articles. Following de-duplication, the title/abstract screening was completed on 533 articles, and 56 full-text articles were reviewed. Thirty-eight articles met the eligibility criteria and were included in this review. Of the 38 studies included, there was large heterogeneity in the methodologies used to measure access to care. Two articles used multidimensional measures of access to care.

CONCLUSIONS

There is an urgent need to establish the use of multidimensional measures as standard practice in access-to-care research. Failure to account for the multidimensional nature of access to care limits the full realisation of access for people with serious injury-related disability and prevents the implementation of processes that could improve access to health, rehabilitation, and support services and enhance the quality of care for individuals with a serious injury-related disability.

Interventions for Driving Disruption in Community Rehabilitation: A Chart Audit

PURPOSE

After injury or illness, a person's ability to drive may be impacted and they may experience a period of "driving disruption," a period during which they cannot drive although they have not permanently ceased driving. They may require additional information and supports from treating rehabilitation services; however, this process is less understood than others related to driving.

MATERIALS AND METHODS

This study aimed to document the prevalence of driving-related issues and the current practices of a community rehabilitation service, regarding driving interventions. An audit of 80 medical records was conducted in a multidisciplinary community rehabilitation service in Brisbane, Australia.

RESULTS

In total, 61% of clients were "driving-disrupted" on admission and 35% remained driving-disrupted on discharge. Majority of driving-disrupted clients had an acquired brain injury (ABI). Driving-related interventions were not routinely provided, with 29% receiving no information or supports. Clients with ABI more frequently received information; provision of psychosocial support and community access training was infrequent.

CONCLUSIONS

This study highlights that return to driving is a common issue and goal for people undergoing community rehabilitation, with the period of driving disruption extending beyond rehabilitation discharge. It also highlights gaps in community rehabilitation practice, and opportunities to better support these clients.IMPLICATIONS FOR REHABILITATIONMany clients of community rehabilitation services experience driving disruption, often beyond discharge.Driving disruption should be recognised and documented by community rehabilitation services.Current practices may not adequately address the practical and psychological needs of clients experiencing driving disruption.

Therapeutic groups run for community-dwelling people with acquired brain injury: a scoping review

PURPOSE

Therapeutic group interventions are commonly provided in acquired brain injury (ABI) inpatient rehabilitation settings, but little is known about the extent of therapeutic groups run for community-dwellers with ABI. This paper seeks to review current literature concerning the nature of therapeutic groups run for community-dwellers with ABI and the involvement of occupational therapists.

MATERIALS & METHODS

A scoping review was conducted with systematic searching of relevant databases guided by Arksey and O'Malley's framework. Studies were included if they reported on therapeutic groups for community-dwellers with ABI. Articles were collated and summarised with key findings presented in narrative form with accompanying tables.

RESULTS

Seventy articles met inclusion. Groups are used as therapeutic change agents for community-dwellers with ABI and target a diverse range of participation barriers. Participants valued group programs that established safe environments, a sense of belonging, growth opportunities and social connections. Group accessibility needs to be improved, with better funding avenues available for service providers, as well as greater consumer involvement in group design and facilitation.

CONCLUSIONS

Groups are a valuable therapeutic modality supporting community-dwellers with ABI. Further research is warranted into the use of groups by occupational therapists working with community-dwellers with ABI.IMPLICATIONS FOR REHABILITATIONTherapeutic groups can support the development of social connections, community participation and help community-dwellers with ABI re-establish a positive self-identity.Conducting groups in community settings and involving consumers in group design and facilitation may enhance the group experience for participants.Occupational Therapists should be involved in the design and delivery of occupation-based and participation focused group-based programs.

'What's next?' The journey from hospital to community engagement from the perspectives of adults following severe acquired brain injury: a scoping review protocol

INTRODUCTION

Community integration and social participation remain a challenge for many individuals following acquired brain injury (ABI) and the transition from hospital to home is a complex journey. It is important to conceptualise this transition from the perspective of people with ABI, to inform future research with the overall aim of improving the experience of community re-engagement and maintaining important relationships within social networks.

METHODS AND ANALYSIS

The methodology outlined by Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis: extension for Scoping Reviews will be used to guide the review. A comprehensive electronic database search will be conducted in MEDLINE, CINAHL, Scopus, Embase and PsychINFO. The search will aim to locate only published, qualitative or mixed methods studies and will be limited to citations published in English, from January 2014 to the date of final search completion. Quality assessment using the Critical Appraisal Skills Programme will be completed and reported.Data extraction will include participant and study characteristics.Finally, qualitative data from each citation, including participant quotes, will be extracted and thematic analysis will be completed to support conceptualisation of community participation from those who have experienced the transition to the community following discharge from hospital. Three individuals with lived experiences of ABI will be engaged as paid consultants to review and comment on the findings of the review.

ETHICS AND DISSEMINATION

It is intended that the findings from this review will be made available to relevant stakeholders through peer-reviewed publications and conference presentations. This scoping review does not require an ethics application.

Participation experience for persons with oculomotor impairments after acquired brain injury

Introduction

While individuals with acquired brain injury (ABI) often receive occupational therapy, relatively little is known about how those with related oculomotor problems characterize their ability to participate in everyday activities and life roles. This study describes the difficulties experienced by this population.

Method

This study is a thematic analysis of qualitative responses to open-ended questions based on answers to a standardized assessment. Thirty rehabilitation outpatients with ABI-related oculomotor impairments participated in semi-structured interviews to describe their experiences of difficulties in everyday activities.

Results

Difficulties were associated with three themes: challenges of the activities and environments (activity requirements, physical and socioeconomic environments, and time), self-identified personal difficulties (physical, cognitive, and socioemotional), and changes in habits/roles/priorities (modifications to activities and environments, loss and negative consequences, and life management changes).

Conclusion

How people with ABI-related oculomotor impairments experience difficulties while participating in activities is dynamic and complex. Challenging activity requirements and environments often led to personal difficulties, which limited participation. Activity modifications, changes in priorities, and managing energy budget enhanced participation. A model of the experience is proposed. Findings suggest using activity analysis and teaching compensatory methods and life management strategies with individuals may assist in ability to participate.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The role of occupational participation for people with traumatic brain injury: a systematic review of the literature

PURPOSE

Improving participation and quality of life is a desirable goal following traumatic brain injury (TBI). The purpose of this systematic review was to summarize existing findings concerning the role of occupational participation for persons with TBI.

METHODS

A systematic literature search using four electronic databases was followed by a review of all titles and abstracts. Articles were included if the studies were conducted with adults with TBI, used a qualitative methodology and explored the role or meaning of occupations and occupational participation from the perspectives of individuals with TBI. Following data extraction, a thematic synthesis was conducted.

RESULTS

A total of 642 articles were identified, of which 14 met all inclusion criteria. Three themes related to the role of occupations for people with TBI emerged: reflecting on change in occupational performance and occupational participation, occupational adaptation, and individual meaning of occupational participation.

CONCLUSION

The findings demonstrate the significance of occupational participation for people following TBI. Occupational participation enabled better understanding of one's abilities and limitations, assisted in occupational adaptation, and held unique meaning for participants. The findings also highlight the importance of providing long-term services focused on enabling participation in occupations in order to ensure successful adaptation following TBI.Implications for rehabilitationFor persons with TBI, occupational participation enables recognition of changes in their performance, contributes to the process of adaptation and identity (re)construction, fulfils various intrinsic needs and provides a sense of personal meaning.Rehabilitation professionals should recognize persons with TBI as occupational beings and work with individuals to identify the meaning of important occupations in the process of understanding and adapting to changes in capability, performance and participation.The rehabilitation process should focus on enabling persons to perform and participate in the occupations they want, need or are expected to do in their daily lives.National and regional health care systems should ensure that persons with TBI are provided with appropriate physical, social and institutional support and services in order to achieve meaningful occupational engagement.

Right people, right time? a qualitative study of service access experiences of adults with acquired brain injury following discharge from inpatient rehabilitation

Purpose:

The intention of this paper is to develop the personal concept of appropriate access. We report on the service access experiences and opportunities of adults with an acquired brain injury after leaving inpatient rehabilitation. The benefits of appropriate access underpin standards in early and long-term recovery, though users’ access needs are highly personal.

Methods:

The study used a qualitative design involving 16 semi-structured interviews with Australian adults with an acquired brain injury after discharge from inpatient brain rehabilitation. Data were thematically analysed.

Results:

Three main themes were derived from the analysis. Theme 1 shows that participants valued being steered to services that providers thought appropriate for them early after discharge from inpatient rehabilitation. Theme 2 highlights the tensions between timing and personal recovery and perceived needs. Theme 3 captures participants’ insights into the challenges of gaining access vis-a-vis what the system offers and the enablers of actualising appropriate access.

Conclusion:

The positive experiences of being directed to specialist services early after discharge suggest that continuity of care constitutes appropriateness of access for participants in this study. However, it is also clear that continuity should not displace flexibility in the timing of services, to accord with individuals’ perceived needs. This, in addition to enablement of access opportunities, through funding and transport, are important in maintaining a personalised approach.

Individual and family experiences of loss after acquired brain injury: A multi-method investigation

After a person experiences an acquired brain injury (ABI), there can be grieving for what has been lost. Little is known about the loss felt by relatives of people with ABI. This study investigates concepts of loss among individuals with ABI and their families. Forty participants, recruited from a brain injury charity client pool, took part in a semi-structured interview. Of the participants, 17 were in dyadic relationships (53% spouses, 41% parent/child and 6% sibling relationships). They also completed the Brain Injury Grief Inventory (BIGI; Coetzer, B. R., Vaughan, F. L., & Ruddle, J. A. (2003). The Brain Injury Grief Inventory. Unpublished Manuscript. North Wales Brain Injury Service, Conwy & Denbighshire NHS Trust) as a quantitative measure of loss after ABI. Five main themes emerged from the interviews: loss of person; loss of relationships; loss of activity/ability; loss of future; unclear loss. There were distinct differences qualitatively between individuals and relatives and only two dyads experienced similar loss, but there were no significant differences in loss as measured quantitatively by the BIGI. The differences between relatives' loss and individuals with ABIs' loss are discussed. This research suggests that it is important when supporting families to consider individual experiences, because even though the loss originates from the same injury, the loss as experienced may substantially differ among those affected by it.

A Service User Perspective Informing the Role of Occupational Therapy in School Transition Practice for High School Learners with TBI: An African Perspective

Background

In the South African context, there are no specific guidelines regarding how to prepare and support adolescents for the transition from a health care to a high school setting post TBI. This raises questions about the relevance and responsiveness of the current transition practices in occupational therapy in terms of adequately preparing and supporting these adolescents to participate in school and hence exercise their right to a quality education.

Method

This study explored adolescents and other key role players' perspectives on and experiences of the high school transition (i.e., school reentry and continued school participation) post TBI. It was anticipated that this would provide an increased understanding of the enablers and barriers to high school reentry and participation post TBI. This served as a basis to explore the main aim of this study which was to help occupational therapists identify where efforts in terms of service delivery are needed. This study was situated in the interpretivist qualitative paradigm and used a multicase study design, which included semistructured interviews with eight adolescent learners with TBI, their primary caregivers, teachers, and principals as well as observations and documentation review.

Results

This paper will focus on a central theme in the research, namely, the nature and extent of support needed to facilitate the high school transition of adolescents with TBI within a developing context. Similar to the findings of studies conducted in developed contexts, participants highlighted that they felt that adolescents need support at various stages of the school transition. Participants further alluded to support that should be collaborative, coordinated, flexible, and monitored to ensure it is relevant and responsive to these adolescents' changing needs.

Conclusion

The study findings conclude that occupational therapists have a crucial role in fostering an enabling environment (directly and indirectly) through fulfilling various roles including that of a facilitator, intermediary, coach, collaborator, supporter, and advocator.

Health, wellness, and safety concerns of persons with moderate-to-severe traumatic brain injury and their family caregivers: a qualitative content analysis

BACKGROUND

Persons with moderate-to-severe traumatic brain injury (TBI) face issues with health, wellness, and safety that affect their ability to independently manage their care, even for individuals who are ≥75% independent in activities of daily living. These issues often lead to increased family involvement in managing the person's condition after discharge home.

PURPOSE

We explored health, wellness, and safety concerns after discharge home from inpatient rehabilitation from the perspectives of persons with TBI who are ≥75% independent in activities of daily living and their family caregivers.

MATERIALS AND METHODS

We interviewed 27 persons with TBI and family caregivers and used conventional content analysis to analyse the data.

RESULTS

Seven themes related to health, wellness, and safety encompassed participants' experience. Health themes included: (1) attempting to manage medications and (2) navigating mental health difficulties. Wellness themes included: (1) working to stay physically active, (2) dealing with sleep and sleeplessness, and (3) adjusting to changing social relationships. Safety themes were: (1) addressing mobility challenges and (2) compensating for complications with cognitive functioning.

CONCLUSIONS

Findings can guide the development of tools, supports, and resources to promote health, wellness, and safety of persons with TBI as they recover after discharge home.Implications for rehabilitationFindings on numerous concerns related to health, wellness, and safety suggest the need for implementation or development and testing of tools, supports, and resources to promote health, wellness, and safety of persons with traumatic brain injury as they recover after discharge home.Our findings can be used to educate healthcare providers and increase awareness of the nuanced challenges patients and families face after discharge home.Findings can also be used by providers to educate patients and families on realistic expectations for life after discharge.

The nature of occupational gaps and relationship with mood, psychosocial functioning and self-discrepancy after severe traumatic brain injury

Purpose: To examine the nature of occupational gaps and desired re-engagement following severe traumatic brain injury (TBI), and the relationship to mood, self-discrepancy, and psychosocial functioning.Materials and methods: Fifty-nine adults with severe TBI (73% male, M age = 36.50, SD = 12.54) were administered measures of past, current, and desired occupations (Occupational Gaps Questionnaire), mood (Depression Stress and Anxiety Scale - 21), and self-discrepancy (Head Injury Semantic Differential Scale - version 3). Psychosocial functioning was rated by relatives on the Sydney Psychosocial Reintegration Questionnaire.Results: Participants reported that they engaged in significantly fewer occupations than prior to their injury (p < 0.001). Further, they participated in fewer occupations than they desired (p < 0.001). Desired re-engagement was identified for 18 of the 30 occupations (e.g., working, sports, managing personal finances, and supporting others). A higher number of these re-engagement gaps was significantly related to greater anxiety (r = 0.30, p < 0.05) and lower psychosocial functioning (r = -0.29, p < 0.05). A mediation analysis revealed that re-engagement gaps were indirectly related to self-discrepancy through an association with anxiety.Conclusions: Occupational gaps are commonly experienced after severe traumatic brain injury. Lack of engagement in desired occupations is associated with greater anxiety and poorer psychosocial functioning. Anxiety regarding these gaps may contribute to negative comparisons between one's pre-injury and post-injury self. Identification of occupational gaps and their psychological impact may guide the focus of client-centred rehabilitation approaches.Implications for RehabilitationGaps between current activity engagement (i.e., post injury) and desired activity engagement are commonly experienced after severe traumatic brain injury.Greater desired re-engagement gaps (i.e., when individuals report they are not completing activities that they would like to do) are associated with greater anxiety and poorer psychosocial functioning.Individuals who are unable to re-engage in desired activities are more likely to experience anxiety, which in turn may contribute to negative self-discrepancy.It may be beneficial to explore the personal meaning of changes in occupation after traumatic brain injury.

The Occupation-Based Intervention of Bathing: Cases in Home Health Care

Although bathing skills can be an indicator of long term placement, documentation of occupational therapists doing bathing as an occupation-based intervention is limited. Five clients were referred to a hospital-based home health agency with various diagnoses and at different levels of functioning. Each client was assessed at admission and discharge using the Outcomes and Assessment Information Set and the occupational therapists used the Activities of daily living (ADL) of bathing as the intervention based on client centered expressed needs. Findings reveal a statistically significant change in individuals pre- and post-assessment of bathing (Z = -2.032, p = .042) supporting occupation-based interventions, specifically bathing, should be further researched as a means of significantly improving the functional status of clients.

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

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

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

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

Role of Occupational Therapy in Case Management and Care Coordination for Clients With Complex Conditions

Specific aspects of the profession of occupational therapy support a distinct value for its practitioners participating fully in the development of case management and care coordination systems. The expectation in the 21st century is that the U.S. health care system must be transformed from one that promotes volume of service to one that promotes value of care. Case management and care coordination will be critical components of that transformation. Occupational therapy's principles, education, practice, approach, and perspective offer much to benefit this increased attention to case management and care coordination. Occupational therapy practitioners should promote themselves and their profession as these system changes develop.

Testing and development of an instrument for self-report of participation and related environmental factors - Your Ideas about Participation and Environment (YIPE) among adults with brain injury

PURPOSE

To examine the usability of the self-report instrument, Your Ideas about Participation and Environment (YIPE), among adults with a brain injury by exploring the value and acceptability of the instrument.

METHODS

A qualitative descriptive research design was used for the purpose of testing and developing the YIPE for use among adults with a brain injury. The study involved administering the YIPE followed by in-depth interviewing about the experience of taking the instrument with seven adults with a brain injury, recruited through a community-based support service organization. A descriptive thematic approach was used to analyse the content of the interview data, categorize common ideas and identify areas for improvement within the instrument.

RESULTS

Participants were generally positive about the importance of the participation and environment topics and willing to engage in self report. The YIPE (2012), resulting from changes made to the language and structure, was found to be more useable, valued and accepted by these participants than the previous version, YIPE (2011).

CONCLUSIONS

The YIPE was found to be a useful tool among study participants. The YIPE topics were found to have importance and relevance when considering participants' satisfaction with areas of life and aspects of environment requiring change. More development of the tool is required in terms of the wording, format and method of administration to improve the overall usability of the instrument. Implications for Rehabilitation The preliminary results from this small sample study illustrated that people with brain injury were able to use an International Classification of Functioning, Disability and Health-based tool, and confirmed the importance of considering both participation and the environment together. People with cognitive impairments associated with brain injury reported on areas of everyday life where they were satisfied or dissatisfied. They related their satisfaction to environmental factors that were facilitators or barriers to valued everyday activities. The opportunity to choose important life areas promotes individuals' motivation to engage and enables service providers to tailor rehabilitation. In the course of the two stages of research, it was necessary to make minor modifications to the language, structure and scoring system of the tool, to simplify the task and shorten the time to interview participants.

Factors Affecting Readiness for Low Vision Interventions in Older Adults

OBJECTIVE

We sought to identify factors that facilitate and inhibit readiness for low vision interventions in people with vision loss, conceptualized as readiness for change in the way they perform daily activities.

METHOD

We conducted 10 semistructured interviews with older adults with low vision and analyzed the results using grounded theory concepts.

RESULTS

Themes involving factors that facilitated change included desire to maintain or regain independence, positive attitude, and presence of formal social support. Themes related to barriers to change included limited knowledge of options and activity not a priority. Themes that acted as both barriers and facilitators were informal social support and community resources.

CONCLUSION

This study provides insight into readiness to make changes in behavior and environment in older adults with vision loss. Study findings can help occupational therapy practitioners practice client-centered care more effectively and promote safe and satisfying daily living activity performance in this population.

Maintenance of treatment effects of an occupation-based intervention with video feedback for adults with TBI

BACKGROUND

Video feedback interventions have been found to improve self-awareness and occupational performance to a greater extent than other feedback interventions after traumatic brain injury (TBI). However, it is unclear whether the effects of video feedback are maintained over time.

OBJECTIVE

To evaluate the maintenance of gains in self-awareness achieved with a video feedback intervention in people with TBI.

METHODS

There were 32 participants with TBI and impaired self-awareness who had completed a randomized controlled trial with three feedback conditions (video plus verbal, verbal and experiential). Eight to ten weeks after the final feedback intervention session, a follow-up assessment was conducted. The primary outcome was maintenance of gains in online awareness measured by the number of errors made during a meal preparation task. Group outcomes were compared using an unstructured linear mixed regression model.

RESULTS

The video plus verbal feedback group continued to demonstrate significantly greater gains in online awareness compared to the verbal feedback group (mean difference 20.6, 95% CI 8.8 to 32.3) and the experiential feedback group (mean difference 14.4, 95% CI 3.1 to 25.6). There was no significant impact of the interventions on participants' emotional status at the 8 to 10 week follow-up.

CONCLUSIONS

A combination of video plus verbal feedback is an effective technique for achieving maintained gains in self-awareness in people with TBI.

Negative neuroplasticity in chronic traumatic brain injury and implications for neurorehabilitation

Based on growing findings of brain volume loss and deleterious white matter alterations during the chronic stages of injury, researchers posit that moderate-severe traumatic brain injury (TBI) may act to “age” the brain by reducing reserve capacity and inducing neurodegeneration. Evidence that these changes correlate with poorer cognitive and functional outcomes corroborates this progressive characterization of chronic TBI. Borrowing from a framework developed to explain cognitive aging (Mahncke et al., Progress in Brain Research, 157, 81–109, 2006a; Mahncke et al., Proceedings of the National Academy of Sciences of the United States of America, 103(33), 12523–12528, 2006b), we suggest here that environmental factors (specifically environmental impoverishment and cognitive disuse) contribute to a downward spiral of negative neuroplastic change that may modulate the brain changes described above. In this context, we review new literature supporting the original aging framework, and its extrapolation to chronic TBI. We conclude that negative neuroplasticity may be one of the mechanisms underlying cognitive and neural decline in chronic TBI, but that there are a number of points of intervention that would permit mitigation of this decline and better long-term clinical outcomes.

Managing driving issues after an acquired brain injury: strategies used by health professionals

BACKGROUND/AIM

The ability to drive safely can be affected by an acquired brain injury. Following acquired brain injury, clients may experience driving disruptions, formal assessment, return to driving or permanent cessation. Health professionals may be involved in formal driving or component skills' assessment and rehabilitation, or interventions for continued community participation. Meeting the needs of clients related to driving remains a challenging area of clinical practice. The aim of this study was to investigate how driving issues are currently managed by acquired brain injury rehabilitation teams.

METHOD

This study utilised a qualitative phenomenological approach to gain insight into the approaches undertaken by four rehabilitation teams working with clients post-acquired brain injury. Semi-structured, audiotaped interviews were conducted with 25 participants who had identified driving as part of their role.

RESULTS

Health professional participants described three major areas of clinical focus, describing strategies and challenges associated with each. These were as follows: 'Integrating driving goals into rehabilitation' which involved optimising timing and acknowledging the clients' focus on driving while enhancing driving and rehabilitation outcomes; 'Managing emotional responses' which required protecting therapeutic relationships and providing information, as well as responding to more extreme responses; and finally 'Managing unlicensed driving and meeting long-term needs', which participants identified as the most challenging aspect. Strategies involved using set procedures, building on knowledge of the client, supporting the family and exploring alternatives.

CONCLUSION

The teams described a range of strategies used to address the challenges related to driving and driving cessation which can be applied to successfully manage this issue in acquired brain injury rehabilitation.

Development and Preliminary Psychometric Evaluation of the Self-Perceptions in Rehabilitation Questionnaire (SPIRQ) for Brain Injury Rehabilitation

OBJECTIVE. The Self-Perceptions in Rehabilitation Questionnaire (SPIRQ) is a brief measure developed to monitor client self-perceptions, motivation, and emotional reactions throughout rehabilitation. We describe the SPIRQ’s development and preliminary psychometric evaluation.

METHOD. One hundred five adults with traumatic brain injury attending two brain injury rehabilitation units completed the SPIRQ during occupational therapy sessions. A subset (n = 33) completed the SPIRQ twice over a 5- to 7-day interval to examine test–retest reliability.

RESULTS. Exploratory factor analysis yielded three factors: Changes in Self and Life Plans, Self in Rehabilitation, and Emotional Reactions. Their internal consistency was sound (αs = .72–.83). Test–retest reliability was generally acceptable (rs = .67–.81), and scores did not significantly change between testing occasions (p &gt; .05).

CONCLUSION. We found preliminary support for the SPIRQ scales’ reliability and construct validity. Future empirical evaluation and potential clinical applications of the SPIRQ in occupational therapy are discussed.

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

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

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

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

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

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

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

Patient experiences of transitioning from hospital to home: an ethnographic quality improvement project

BACKGROUND

Little is known about patient perspectives of the transition from hospital to home.

OBJECTIVE

To develop a richly detailed, patient-centered view of patient and caregiver needs in the hospital-to-home transition.

DESIGN

An ethnographic approach including participant observation and in-depth, semi-structured video recorded interviews.

SETTING

Kaiser Permanente's Southern California, Colorado, and Hawaii regions.

PATIENTS

Twenty-four adult inpatients hospitalized for a range of acute and chronic conditions and characterized by variety in diagnoses, illness severity, planned or unplanned hospitalization, age, and ability to self manage.

RESULTS

During the hospital-to-home transition, patients and caregivers expressed or demonstrated experiences in 6 domains: 1) translating knowledge into safe, health-promoting actions at home; 2) inclusion of caregivers at every step of the transition process; 3) having readily available problem-solving resources; 4) feeling connected to and trusting providers; 5) transitioning from illness-defined experience to "normal" life; and 6) anticipating needs after discharge and making arrangements to meet them. The work of transitioning occurs for patients and caregivers in the hours and days after they return home and is fraught with challenges.

CONCLUSIONS

Reducing readmissions will remain challenging without a broadened understanding of the types of support and coaching patients need after discharge. We are piloting strategies such as risk stratification and tailoring of care, a specialized phone number for recently discharged patients, standardized same-day discharge summaries to primary care providers, medication reconciliation, follow-up phone calls, and scheduling appointments before discharge.

Has Occupational Science Taken Away the Occupational Therapy Evidence Base? A Debate

Health policy requires occupational therapy to demonstrate evidence-based clinical outcomes and efficiency in order to survive. This has significant implications for occupational therapy researchers and managers and suggests a re-evaluation of the profession's priorities for research. This opinion piece aims to stimulate debate regarding the impact of occupational science on occupational therapy and the need for research that evaluates the effectiveness of occupational therapy interventions. This is achieved by reflecting on a personal experience of evaluating research evidence for clinical guidelines and by exploring current and future challenges.

Development of depressive symptoms during early community reintegration after traumatic brain injury

The early onset of depression following traumatic brain injury (TBI) is associated with poorer psychosocial outcomes; however, the direction of this relationship is unclear. This study investigated the relationship between progress in resuming preinjury lifestyle (transition events), change in perceived functioning and level of depressive symptoms at discharge and 3-months postdischarge. As part of a prospective longitudinal study of brain injury outcomes, 96 consecutively discharged patients with TBI completed measures of transition events (Sentinel Events Questionnaire) and perceived functioning (Mayo-Portland Adaptability Inventory-4 Ability and Adjustment indices) at discharge and 3-months follow-up. Level of depressive symptoms was assessed at discharge and 3-months follow-up using the Depression Anxiety Stress Scale 21. After controlling for age and discharge depressive symptoms, change in perceived functioning was found to mediate the relationship between total transition events and depressive symptoms at 3-months postdischarge (β reduced from .21 to .14), with a significant indirect effect observed. The present findings indicate that lack of progress in resuming preinjury lifestyle contributes to postdischarge depressive symptoms through an influence on perceived functioning, thus providing an improved conceptualization of reactive depression in the context of brain injury.