Adapting a Dutch Web-Based Intervention to Support Family Caregivers of People With Dementia in the UK Context: Accelerated Experience-Based Co-Design

BACKGROUND

Around 700,000 family caregivers provide unpaid care for 900,000 people living with dementia in the United Kingdom. Few family caregivers receive support for their own psychological needs and funding for community respite services has declined. These trends are seen across Europe as demographic and budgetary pressures have intensified due to public spending cuts arising from the 2008 financial crisis and the COVID-19 pandemic. The World Health Organization has prioritized the need to expand the provision of support for caregivers and families of people with dementia by 2025. Web-based interventions have the potential for development as they require modest investment and can be accessed by family caregivers at home. Further cost benefits can be realized by adapting existing interventions with demonstrated effectiveness for new contexts. This paper reports initial findings from the CareCoach study, which is adapting Partner in Balance (PiB), a web-based coaching intervention developed in the Netherlands, for family caregivers in the United Kingdom.

OBJECTIVE

This study aims to work with unpaid family caregivers and staff in adapting the Dutch web-based support tool PiB to improve its acceptability and usability for use in the United Kingdom.

METHODS

Accelerated Experience-Based Co-Design (AEBCD) was used with caregivers, staff, and core stakeholders. Interviews, workshops, and stakeholder consultations were conducted. Data were analyzed iteratively. Recommendations for the redesign of PiB for use across the United Kingdom were adjudicated by the study Adaptation Working Party.

RESULTS

Sixteen caregivers and 17 staff took part in interviews. Thirteen caregivers and 17 staff took part in workshops. Most (n=26) participants were White, female, and retired. All except 4 caregivers (2 male and 2 female) found the PiB's offer of web-based self-help learning acceptable. Caregivers identified complexity and lack of inclusivity in some wording and video resources as problematic. The staff took a stronger perspective on the lack of inclusivity in PiB video resources. Staff and caregivers coproduced new inclusive wording and recommended creating new videos to adapt PiB for the UK context.

CONCLUSIONS

AEBCD methods facilitated the engagement of caregivers and staff and advanced the adaptation of the PiB complex intervention. An important addition to the AEBCD method in this process was the work of an Adaptation Working Party, which adjudicated and agreed to new wording where this could not be established in consultation with caregivers and staff.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN12540555; https://doi.org/10.1186/ISRCTN12540555.

Post-stroke emotionalism: Diagnosis, pathophysiology, and treatment

BACKGROUND

Post-stroke emotionalism affects one in five stroke sufferers 6 months after their stroke, but despite its frequency remains a poorly understood stroke symptom. The literature is limited, especially compared to other frequently observed neurological conditions such as aphasia and visual neglect.

AIM AND METHODS

This narrative review presents a summary of the post-stroke emotionalism literature, to inform clinical practice and future research. We cover discussion of definitions, prevalence, neurobiology, predisposing and precipitating factors, and treatment.

RESULTS

Increasing evidence suggests that damage to specific areas functionally linked to emotion expression or regulation processes, disruption to structural pathways and those related to serotonin production and modulation individually or in concert give rise to emotionalism-type presentations. A range of emotionalism measurement tools have been used in research contexts making between study comparisons difficult. Testing for Emotionalism after Recent Stroke-Questionnaire (TEARS-Q) has recently been developed to allow standardized assessment. Treatment options are limited, and there have been few adequately powered treatment trials. Antidepressants may reduce severity, but more trial data are required. There have been no randomized-controlled trials of non-pharmacological interventions.

CONCLUSIONS

More research is needed to improve recognition and treatment of this common and disabling symptom. We conclude with research priorities and recommendations for the field.

Group-based positive psychotherapy for people living with acquired brain injury: a protocol for a feasibility study

BACKGROUND

Acquired brain injury (ABI) and other chronic conditions are placing unprecedented pressure on healthcare systems. In the UK, 1.3 million people live with the effects of brain injury, costing the UK economy approximately £15 billion per year. As a result, there is an urgent need to adapt existing healthcare delivery to meet increasing current and future demands. A focus on wellbeing may provide an innovative opportunity to reduce the pressure on healthcare services while also supporting patients to live more meaningful lives. The overarching aims of the study are as follows: (1) evaluate the feasibility of conducting a positive psychotherapy intervention for individuals with ABI and (2) ascertain under what conditions such an intervention would merit a fully powered randomised controlled trial (RCT) compared to a standard control group (TAU).

METHODS AND ANALYSIS

A randomised, two-arm feasibility trial involving allocation of patients to either a treatment group (positive psychotherapy) or control group (treatment as usual) group, according to a 1:1 ratio. A total of 60 participants at three sites will be recruited including 20 participants at each site. Assessments will be conducted at baseline, on completion of the 8-week intervention and 3 months following completion. These will include a range of questionnaire-based measures, psychophysiology and qualitative outcomes focusing on feasibility outcomes and participant experience. This study has been approved by the Wales Research Ethics Committee (IRAS project ID: 271,251, REC reference: 19/WA/0336).

DISCUSSION

This study will be the first to examine the feasibility of an innovative, holistic positive psychotherapy intervention for people living with ABI, focused on individual, collective and planetary wellbeing, and will enable us to determine whether to proceed to a full randomised controlled trial.

TRIAL REGISTRATION

ISRCTN12690685 , registered 11th November 2020.

An Evaluation of the Use of the Child and Adolescent Scale of Participation (CASP) to Measure Social Participation After Pediatric ABI in a Specialist Service in East Anglia

Pediatric acquired brain injury (ABI) can lead to lifelong challenges restricting social participation, which is an important goal for rehabilitation due to associations with improved wellbeing. This evaluation considered the utility of the Child Adolescent Scale of Participation (CASP) in ABI rehabilitation services. The 20-item measure is rated on a Likert scale with reference to what the rater would expect of their child at that age, including "not applicable" (N/A). It showed high internal consistency (α = 0.954-0.968). Two-step cluster analysis indicated greater difficulties in children with lower participation, including more impairments of executive function and higher staff involvement. Between-group analysis indicated higher rates of N/A answers for younger children and those of ethnic minorities. Overall, the CASP is reliable and clinically useful on an individual level, helping identify people who may need prioritizing for neurorehabilitation; however, group-level analyses were more challenging due to high frequency of N/A responses.

Comparing the Symptomatology of Post-stroke Depression with Depression in the General Population: A Systematic Review

Previous research into the phenomenological differences of post-stroke depression (PSD) has typically focused on comparisons of symptom profiles between stroke and non-stroke population controls. This systematic review aimed to synthesize these findings with results from other methodological approaches that contribute to an understanding of phenomenological differences. Articles were identified via a systematic search of seven databases and additional manual searching. A narrative synthesis approach was adopted because of the high methodological heterogeneity. Twelve articles comparing the symptomatology of depression between stroke and non-stroke controls were included. Three distinct methodological approaches, relevant to the aim, were identified: comparisons of profiles among groups with similar overall depression severity, comparisons of the strengths of correlations between a symptom and depression, and comparisons of latent symptom severity. The symptomatology of depression was generally similar between the groups, including somatic symptoms, despite the hypothesized interference of comorbid physical stroke effects. Despite high heterogeneity, there was a tentative indication that post-stroke depression manifests with comparatively less severe/prevalent anhedonia. Possible mechanisms for the observed similarities and differences are explored, including suggestions for future research.

Post-stroke emotionalism (PSE): a qualitative longitudinal study exploring individuals' experience with PSE

PURPOSE

Post-stroke emotionalism (PSE) is a common consequence of stroke characterised by episodes of crying or laughing. There is only one published qualitative study exploring the experience of emotionalism to date. This study aimed to explore individual's experience of PSE and develop a theoretical client-derived framework to shape future psychological interventions.

MATERIALS AND METHODS

A primary analysis of the qualitative pseudonymised pre-collected semi-structured interview data of the TEARS study was completed. Participants were recruited from nine acute stroke units in Scotland with participants commencing the study at baseline (two-weeks) and they either continued or dropped out. Interviews were completed at two-weeks, six-months and 12-months post-stroke.

RESULTS

Data was analysed from 52 participants at two-weeks, 25 participants at six-months and 23 participants at 12-months. Three major themes were identified: "In the moment," describing characteristics and triggers, "Ways of coping," highlighted a variation of coping strategies including avoidance or acceptance and "Impact," outlining the longer-term effects of PSE such as individuals' beliefs.

CONCLUSION

The results indicate specific psychological aspects of PSE which could be viable targets in psychological interventions such as increasing adaptive coping strategies and challenging negatively held beliefs.IMPLICATIONS FOR REHABILITATIONEmotionalism can cause emotional consequences such as distress, embarrassment and fear.Helping individuals to develop insight into triggers for emotionalism could be beneficial to help gain understanding and awareness whereby post-stroke emotionalism (PSE) has the potential to be anticipated and adapted to psychologically.Potential adaptive responses such as acceptance or control and better anticipation of episodes of emotionalism could help to reduce the emotional consequences of PSE.

A qualitative exploration of fatherhood after acquired brain injury (ABI)

Acquired Brain Injury (ABI) significantly affects individuals across multiple areas of intimate, familial, and parental domains. Gender and identity are pivotal research areas in navigating life after ABI. To date, scant research has explored gendered experiences, particularly those related to the masculine lifeworld. This study aimed to explore how men who were fathers before their injuries experience fatherhood after ABI. An Interpretative phenomenological analysis (IPA) methodology was used, and seven fathers participated in the semi-structured interviews (time since injury 1-18 years, age range 27-66 years) which explored their meaning-making. Four superordinate themes were drawn from all interviews through engaging with the qualitative research process: (1) what being a father means, (2) altered relationships with others, (3) becoming lost and finding their way through, and (4) renewed fatherhood. The findings show intersectionality between pre-and post-injury comparisons of self and social identities, alongside the contextual and societal identities in the subjective fathering experiences. Through increased understanding, we may enable fathers to find new ways to resolve, reformulate, and connect to move into their future possible fatherhood. The importance of this research is in giving voice to these less represented men so that we may shape our understanding to aid future fathers post-ABI.

A new model to guide identity-focused multidisciplinary rehabilitation for children and young people following acquired brain injury: I-FoRM

A complexity of biological, psychological, environmental and systemic factors influences a child's adaption after acquired brain injury (ABI), all of which transform as the child matures. Multidisciplinary rehabilitation teams are challenged by balancing family system needs and the child's needs, whilst promoting the child's functional skills in difficult or unappealing tasks. This paper presents the conceptual basis for a model for use in childhood ABI neurorehabilitation to address these challenges. A non-systematic narrative review of literature pertinent to integrated neurorehabilitation of pediatric ABI was conducted. Contemporary models of adult and pediatric psychosocial adaptation involving identity following ABI were reviewed. Key findings were then synthesized with models of pediatric resilience and self-concept development. The resulting model describes a cyclical adaptation process whereby the child learns experientially about their self and their world after ABI. Processes of identity development play a central role - particularly emotive processes of self-evaluation - by influencing the child's motivation for participation, tolerance for challenge, self-regulation and emerging self-awareness. The model directs clinicians to use the psychosocial processes of identity development to enhance the child's willingness and capacity to engage in the daily challenges of rehabilitation. Further systematic development and evaluation of the model is needed.

The process of identity change following ABI from the perspectives of adolescents and their mothers: A relational grounded theory approach

This study explored the process of identity adjustment following adolescent brain injury, within the systemic context of the parent-adolescent dyad. Six young people with an ABI (mean age 16.5 years, range 15-18 years; TBI: n = 3) were individually interviewed, and six respective mothers (mean age 45 years, range 37-50 years). A novel relational qualitative grounded theory approach was used, with analyses of dyads linked in an attempt to capture the shared process of adaptation post-injury for young people and their parents. Shared themes emerged for adolescents and mothers regarding "continuity and change" and "acknowledging or rejecting" experiences of change post injury. Adolescents experienced change as an, at times, distressing sense of being "not normal". While mothers turned towards their child, working hard to try to "fix everything", adolescents sought continuity of identity in the context of peer relationships, withdrawing socially to avoid feeling abnormal, reframing or finding new relationships. Some mothers sought to fill social losses through family or disability-specific activity. This study provides a relational understanding of the process of identity adjustment post adolescent BI. Future research and clinical practice should recognize the significant work of mothers, and significance of social relationships to adolescents' emerging post-injury identity.

Predictors and correlates of emotionalism across acquired and progressive neurological conditions: A systematic review

Emotionalism can develop following a range of neurological disorders; however the aetiology of emotionalism is still unclear. To identify anatomical, neuropsychological and psychological predictors and correlates of emotionalism across neurological disorders: stroke, Parkinson's disease, multiple sclerosis, traumatic brain injury, Alzheimer's disease, vascular dementia and amyotrophic lateral sclerosis. To explore if these predictors and correlates of emotionalism differ across neurological disorders. A comprehensive systematic search was completed of four databases: MEDLINE, CINAHL Complete, PsycINFO and EMBASE. Methodological quality was assessed using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and each study was graded according to the level of evidence using the Scottish Intercollegiate Guidelines Network. Fifty papers (participants N = 1922) were included. 25 studies were rated as "Fair," 21 "Good" and 4 "Poor." The review identified predictors and correlates found in several neurological disorder such as bulbar networks, serotonergic pathways, genetics and female gender. Multiple studies across diseases (stroke, MS, ALS) indicate emotionalism is associated with cognitive impairment, especially frontal deficits. Due to the disproportionate number of studies identified across neurological disorders, it is difficult to draw definitive answers. Further research is required across neurological disorders to explore similarities and differences in anatomical, neuropsychological and psychological predictors and correlates.

Psychometric Properties of the Revised Dysexecutive Questionnaire in a Non-clinical Population

Aims

The aim of this study was to assess the psychometric properties of the revised self-rated version of the Dysexecutive Questionnaire (DEX-R) within a non-clinical sample.

Methods

The study was hosted online, with 140 participants completing the DEX-R, GAD-2 and PHQ-2. Sixty participants also completed the FrSBe, with 99 additionally completing the DEX-R again 3 weeks later. Correlations with demographic factors and symptoms of anxiety and depression were conducted. Rasch and factor analysis were also used to explore underlying subconstructs.

Results

The DEX-R correlated highly with the FrSBe, indicating sound concurrent validity. Internal consistency, split-half reliability and test-retest reliability were excellent. Age and symptoms of depression and anxiety correlated with DEX-R scores, with older age associated with less dysexecutive problems. The Rasch analysis confirmed the multidimensionality of the rating scale, and a three-factor structure was found relating to activation-self-regulatory, cognitive and social-emotional processes. Frequencies of responses on DEX-R items varied, many were not fully endorsed indicating specific relevance of most but not all items to patients.

Conclusion

Interpretations of DEX-R ratings of dysexecutive problems should consider mood and individual variation. Systematic comparison of DEX-R responses between healthy and clinical groups could help identify a suitable cut off for dysexecutive symptoms.

What Factors are Associated with Posttraumatic Growth in Older Adults? A Systematic Review

OBJECTIVES

Posttraumatic growth (PTG) is of increased theoretical and clinical interest. However, less is known about PTG in older adults specifically. This systematic review aimed to identify domains where PTG is studied for older adults; investigate factors associated with PTG in older adults; consider how these might differ between historical and later life traumas.

METHODS

Online databases were searched for quantitative studies examining PTG outcomes in adults aged ≥ 60 years.

RESULTS

15 studies were subject to a narrative synthesis.

CONCLUSIONS

Older adults can experience substantial levels of PTG, from traumas during later life or across the lifespan, and historical wartime traumas. Traumas can be diverse, some studies found equivalent levels of PTG from different traumas across the lifespan. Social processes may be a key variable for older adults. Additional psychosocial factors are found; however, diverse findings reflect no overall model, and this may be consistent with variations found in other PTG literature.

CLINICAL IMPLICATIONS

Clinical considerations are discussed. As diverse studies, findings may not be widely generalizable and directions for further research are highlighted. PROSPERO: CRD42020169318.

The experiences of wives following acquired brain injury (ABI). A qualitative analysis exploring realisations of change following the ABI of a "loved one."

The experiences of family members following Acquired Brain Injury (ABI) are well established, with spouses in particular facing multiple relational and personal changes. Qualitative studies have analysed accounts pertaining to a range of sequelae, however, "change" itself has yet to be addressed. This study explored the experiences of realisation of change for married women living with their husbands following ABI. Nine participants took part in semi-structured interviews focussing on becoming aware of changes in both their spouse and themselves post-injury. An Interpretative Phenomenological Analysis (IPA) was completed, arriving at two overarching themes; "bravery to face changes" and "lost and trapped in an unsolvable maze," with accompanying subthemes. Participants generally experienced realisation of change gradually, in some cases finding strategies to control their exposure to distress. They often referred to "acceptance," which held varied meanings, and metaphors appeared to aid personal meaning making. Relationship changes generated both dilemmas and the feeling of being trapped. Overall, this study contributes greater insights into the experiential mechanisms underpinning realisation of change in spouses after brain injury.

The experience of families following traumatic brain injury in adult populations: A meta-synthesis of narrative structures

BACKGROUND

Traumatic brain injury has a significant effect on uninjured family members. Typically, this has been examined with a focus on psychopathological outcomes including stress, depression and anxiety. However, in recent years there has been increasing interest in the subjective experiences of families post-injury leading to a plethora of qualitative studies. Therefore, an in-depth examination and synthesis of this literature is now relevant and timely.

OBJECTIVE

To examine the subjective experiences of families following traumatic brain injury in adult populations in the sub/post-acute period through the synthesis of original qualitative research.

DESIGN

This paper presents a meta-synthesis using Thomas and Harden's framework of 'thematic synthesis' rooted in a critical realist philosophy.

DATA SOURCES

In July 2019 five electronic databases, were searched for the terms 'traumatic brain injury', 'family' and 'qualitative'. Studies were included if the primary research reported qualitative data about the subjective experiences of family members of adults with traumatic brain injury and had been published in a peer reviewed journal. Studies with mixed brain injury samples, child or adolescent traumatic brain injury or disorders of consciousness were excluded. Hand searching and citation searches were also completed.

REVIEW METHODS

Two reviewers screened titles, abstracts and full text and reached consensus through critical discussion. Thirty papers were finally agreed for inclusion in this review. Each study was then assessed for relevance, resonance and rigour using the Critical Appraisal Skills Programme (CASP) tool. Line by line coding of the findings in each paper was conducted as the basis for a thematic analysis and synthesis.

RESULTS

Descriptive themes were identified followed later by analytical themes. This final stage was informed by a narrative lens and from these, eight narrative functions belonging to four dimensions were identified from the subjective experiences of families post-traumatic brain injury. Specifically, these were: (1) Displacing and Anchoring; (2) Rupturing and Stabilising; (3) Isolating and Connecting; (4) Harming and Healing.

CONCLUSIONS

The interpretation of the narrative functions revealed the substantial existential work involved in negotiating lives, maintaining family system equilibrium and moving forward. As such, family members have their own unique narrative needs. Despite contemporary service models built around the injured person, service providers are well placed to support families in this everyday narrative work through actively attending to narrative structures and understanding the implications of these for family experience. The study protocol was registered with PROSPERO (International prospective register of systematic reviews) in July 2018 (Registration number: CRD42018085824). Tweetable abstract: This synthesis showed the immense and invisible work required for family members to maintain family system equilibrium and negotiate their lives post-TBI.

Psychometric evaluation of a newly developed measure of emotionalism after stroke (TEARS-Q)

Objective:

To evaluate, psychometrically, a new measure of tearful emotionalism following stroke: Testing Emotionalism After Recent Stroke – Questionnaire (TEARS-Q).

Setting:

Acute stroke units based in nine Scottish hospitals, in the context of a longitudinal cohort study of post-stroke emotionalism.

Subjects:

A total of 224 clinically diagnosed stroke survivors recruited between October 1st 2015 and September 30th 2018, within 2 weeks of their stroke.

Measures:

The measure was the self-report questionnaire TEARS-Q, constructed based on post-stroke tearful emotionalism diagnostic criteria: (i) increased tearfulness, (ii) crying comes on suddenly, with no warning (iii) crying not under usual social control and (iv) crying episodes occur at least once weekly. The reference standard was presence/absence of emotionalism on a diagnostic, semi-structured post-stroke emotionalism interview, administered at the same assessment point. Stroke, mood, cognition and functional outcome measures were also completed by the subjects.

Results:

A total of 97 subjects were female, with a mean age 65.1 years. 205 subjects had sustained ischaemic stroke. 61 subjects were classified as mild stroke. TEARS-Q was internally consistent (Cronbach’s alpha 0.87). TEARS-Q scores readily discriminated the two groups, with a mean difference of −7.18, 95% CI (−8.07 to −6.29). A cut off score of 2 on TEARS-Q correctly identified 53 of the 61 stroke survivors with tearful emotionalism and 140 of the 156 stroke survivors without tearful emotionalism. One factor accounted for 57% of the item response variance, and all eight TEARS-Q items acceptably discriminated underlying emotionalism.

Conclusion:

TEARS-Q accurately diagnoses tearful emotionalism after stroke.

Detecting mental health problems after paediatric acquired brain injury: A pilot Rasch analysis of the strengths and difficulties questionnaire

The parent-reported Strengths and Difficulties Questionnaire (SDQ-P) is commonly used to assess for mental health problems, but its psychometric properties have not been studied in the paediatric Acquired Brain Injury (ABI) population. This study investigated the properties of the SDQ-P and its subscales in this population using Rasch analysis. One hundred and forty-three SDQ-Ps and 123 Impact Supplements were analyzed. Sixty-nine percent of SDQ-Ps were completed by female carers, 59% of young people were male, and 58% had Traumatic Brain Injury (TBI). In this population the SDQ-P Total Difficulties Scale and the Conduct Problems subscale showed questionable construct validity. The individual subscales and Impact Supplement did not meet the criteria for reliability. Two items had disordered thresholds. The individual subscales showed mistargeting and 13-24% person misfit. Two items were significantly underdiscriminating. There was differential item functioning with age and time post-injury, and local dependence between subscale items. The Total Difficulties scale was multidimensional. The most easily endorsed items were in keeping with common symptoms of brain injury. These findings suggest the SDQ-P in its current form may not be a reliable and valid assessment measure for mental health difficulties in the paediatric ABI population and requires further investigation.

"Putting a new perspective on life": a qualitative grounded theory of posttraumatic growth following acquired brain injury

Purpose: An acquired brain injury (ABI) is often described as a devastating experience and yet positive changes as a result of this event have been described. This study sought to understand the process of developing posttraumatic growth (PTG) following ABI.Method: Semi-structured interviews were conducted with 10 adults with ABI, recruited from three sites of a community day service for people with ABI. Grounded theory was used to explore the development of positive changes experienced as a result of the injury.Results: PTG appeared to occur in a non-linear way as participants negotiated processes captured in the following themes: "living with a life changing injury," "trying to beat it and acceptance," "identifying with a new you and others," and "meaningful positive change." Intra- and inter-personal comparisons emerged as important in accepting changes and reconnecting with pre-injury identity. This seemed to underpin accessing social and practical opportunities giving rise to connection with strengths and growth.Conclusions: This study extends prior research into the process of adjustment and positive outcomes such as growth, although conclusions are limited to this specific sample and context. Further research and clinical practice development addressing acceptance and community engagement to develop positive change following ABI is required.IMPLICATIONS FOR REHABILITATIONExperience of PTG develops over time and influenced by intra-and-inter-personal processes.Acceptance and shared experiences with others may contribute to positive psychological change.Interventions supporting pre-and-post injury comparisons with others could help acceptance.The focus on the management and expression of emotions associated with loss may be beneficial.

Building Wellbeing in People With Chronic Conditions: A Qualitative Evaluation of an 8-Week Positive Psychotherapy Intervention for People Living With an Acquired Brain Injury

Research indicates that Acquired Brain Injury (ABI) is associated with significant and chronic impairment across multiple areas of functioning including physical, cognitive, emotional and behavioral domains. Whilst impairments associated with ABI can be ameliorated, cure is seldom possible. The emergence of positive psychology reflects a paradigm shift in health and wellbeing research, highlighting the role of character strengths, positive emotions, meaning, and resilience. Positive psychology interventions have been demonstrated to improve wellbeing in a variety of populations, although research investigating the impact of positive psychotherapy for people living with ABI are sparse. Here we characterize the experience of an 8-week positive psychotherapy intervention for 13 people living with ABI including four mentors and nine participants using thematic analysis of transcripts collected during mini-groups and one-to-one interviews. Six main themes were identified including empowerment, social opportunity, coping, cultivation of positive emotion, consolidation of skills and barriers. Results indicated that wellbeing can be promoted and improved in individuals with ABI. Recent theoretical developments in wellbeing science highlight scope to improve the intervention by connecting individuals to their communities and spending time in nature.

Emotional adjustment post-stroke: A qualitative study of an online stroke community

Understanding of emotional adjustment after stroke is limited. Under one-third of stroke survivors reporting emotional problems receive support. The aim of this study was to explore the process of emotional adjustment post-stroke and investigate the role played by participation in an online stroke community. We applied thematic analysis to 124 relevant posts within 114 discussion threads, written by 39 survivors and 29 carers. The contribution of online community engagement to emotional adjustment was explored using the Social Support Behaviour Code. Stroke survivors share common experiences of emotional adjustment and may not necessarily reach complete acceptance. Positive and negative trajectories of emotional adjustment were identified. Survivors progressed along, or moved between, positive and negative pathways not in a time-dependent manner but in response to "trigger events," such as physical setbacks or anti-depressant treatment, which may occur at any chronological time. An adapted version of Suhr's 1990 Social Support Behaviour Code showed that support provided through the online community took many forms, including advice, teaching, empathy and normalization of concerns. Participation in the stroke community was itself deemed to be a positive "trigger event." There is need to improve awareness of emotional adjustment and their "triggers" amongst stroke survivors, carers and clinicians.

HeART of Stroke: randomised controlled, parallel-arm, feasibility study of a community-based arts and health intervention plus usual care compared with usual care to increase psychological well-being in people following a stroke

INTRODUCTION

People often experience distress following stroke due to fundamental challenges to their identity.

OBJECTIVES

To evaluate (1) the acceptability of 'HeART of Stroke' (HoS), a community-based arts and health group intervention, to increase psychological well-being; and (2) the feasibility of a definitive randomised controlled trial (RCT).

DESIGN

Two-centre, 24-month, parallel-arm RCT with qualitative and economic components. Randomisation was stratified by centre and stroke severity. Participant blinding was not possible. Outcome assessment blinding was attempted.

SETTING

Community.

PARTICIPANTS

Community-dwelling adults ≤2 years poststroke recruited via hospital clinical teams/databases or community stroke/rehabilitation teams.

INTERVENTIONS

Artist-facilitated arts and health group intervention (HoS) (ten 2-hour sessions over 14 weeks) plus usual care (UC) versus UC.

OUTCOMES

The outcomes were self-reported measures of well-being, mood, capability, health-related quality of life, self-esteem and self-concept (baseline and 5 months postrandomisation). Key feasibility parameters were gathered, data collection methods were piloted, and participant interviews (n=24) explored the acceptability of the intervention and study processes.

RESULTS

Despite a low recruitment rate (14%; 95% CI 11% to 18%), 88% of the recruitment target was met, with 29 participants randomised to HoS and 27 to UC (57% male; mean (SD) age=70 (12.1) years; time since stroke=9 (6.1) months). Follow-up data were available for 47 of 56 (84%; 95% CI 72% to 91%). Completion rates for a study-specific resource use questionnaire were 79% and 68% (National Health Service and societal perspectives). Five people declined HoS postrandomisation; of the remaining 24 who attended, 83% attended ≥6 sessions. Preliminary effect sizes for candidate primary outcomes were in the direction of benefit for the HoS arm. Participants found study processes acceptable. The intervention cost an estimated £456 per person and was well-received (no intervention-related serious adverse events were reported).

CONCLUSIONS

Findings from this first community-based study of an arts and health intervention for people poststroke suggest a definitive RCT is feasible. Recruitment methods will be revised.

TRIAL REGISTRATION NUMBER

ISRCTN99728983.

Computerized Cognitive Behavioral Therapy to Treat Emotional Distress After Stroke: A Feasibility Randomized Controlled Trial

BACKGROUND

Depression and anxiety are common complications following stroke. Symptoms could be treatable with psychological therapy, but there is little research on its efficacy.

OBJECTIVES

The aim of this study was to investigate (1) the acceptability and feasibility of computerized cognitive behavioral therapy (cCBT) to treat symptoms of depression and anxiety and (2) a trial design for comparing the efficacy of cCBT compared with an active comparator.

METHODS

Of the total 134 people screened for symptoms of depression and anxiety following stroke, 28 were cluster randomized in blocks with an allocation ratio 2:1 to cCBT (n=19) or an active comparator of computerized cognitive remediation therapy (cCRT, n=9). Qualitative and quantitative feedback was sought on the acceptability and feasibility of both interventions, alongside measuring levels of depression, anxiety, and activities of daily living before, immediately after, and 3 months post treatment.

RESULTS

Both cCBT and cCRT groups were rated as near equally useful (mean = 6.4 vs 6.5, d=0.05), while cCBT was somewhat less relevant (mean = 5.5 vs 6.5, d=0.45) but somewhat easier to use (mean = 7.0 vs 6.3, d=0.31). Participants tolerated randomization and dropout rates were comparable with similar trials, with only 3 participants discontinuing due to potential adverse effects; however, dropout was higher from the cCBT arm (7/19, 37% vs 1/9, 11% for cCRT). The trial design required small alterations and highlighted that future-related studies should control for participants receiving antidepressant medication, which significantly differed between groups (P=.05). Descriptive statistics of the proposed outcome measures and qualitative feedback about the cCBT intervention are reported.

CONCLUSIONS

A pragmatic approach is required to deliver computerized interventions to accommodate individual needs. We report a preliminary investigation to inform the development of a full randomized controlled trial for testing the efficacy of computerized interventions for people with long-term neurological conditions such as stroke and conclude that this is a potentially promising way of improving accessibility of psychological support.

A Randomized Controlled Trial of Assisted Intention Monitoring for the Rehabilitation of Executive Impairments Following Acquired Brain Injury

BACKGROUND

Acquired brain injury (ABI) can impair executive function, impeding planning and attainment of intentions. Research shows promise for some goal-management rehabilitation interventions. However, evidence that alerts assist monitoring and completion of day-to-day intentions is limited.

OBJECTIVE

To examine the efficacy of brief goal-directed rehabilitation paired with periodic SMS text messages designed to enhance executive monitoring of intentions (assisted intention monitoring [AIM]).

METHODS

A randomized, double-blind, controlled trial was conducted. Following a baseline phase, 74 people with ABI and executive problems were randomized to receive AIM or control (information and games) for 3 weeks (phase 1) before crossing over to either AIM or no intervention (phase 2). The primary outcome was change in composite score of proportion of daily intentions achieved. A total of 59 people (71% male; 46% traumatic brain injury) completed all study phases.

RESULTS

Per protocol crossover analysis found a significant benefit of AIM for all intentions [ F(1, 56) = 4.28; P = .04; f = 0.28; 3.7% mean difference; 95% CI = 0.1%-7.4%] and all intentions excluding a proxy prospective memory task [ F(1, 55) = 4.79; P = .033; f = 0.28, medium effect size; 3% mean difference; 95% CI = 0.3%-5.6%] in the absence of significant changes on tests of executive functioning. Intention-to-treat analyses, comparing AIM against control at the end of phase 1 revealed no statistically significant differences in the attainment of intentions.

CONCLUSION

Combining brief executive rehabilitation with alerts may be effective for some in improving achievement of daily intentions, but further evaluation of clinical effectiveness and mechanisms is required.

The nature of self-esteem and its relationship to anxiety and depression in adult acquired brain injury

Acquired brain injury (ABI) has a negative impact on self-esteem, which is in turn associated with mood disorders, maladaptive coping and reduced community participation. The aim of the current research was to explore self-esteem as a multi-dimensional construct and identify which factors are associated with symptoms of anxiety or depression. Eighty adults with ABI aged 17-56 years completed the Robson Self-Esteem Scale (RSES), of whom 65 also completed the Hospital Anxiety and Depression Scale; 57.5% of the sample had clinically low self-esteem. The RSES had good internal consistency (α =   .89), and factor analysis identified four factors, which differed from those found previously in other populations. Multiple regression analysis revealed anxiety was differentially predicted by "Self-Worth" and "Self-Efficacy", R² =   .44, F(4, 58) =   9, p <   .001, and depression by "Self-Regard", R² =   .38, F(4, 58) =   9, p <   .001. A fourth factor, "Confidence", did not predict depression or anxiety. In conclusion, the RSES is a reliable measure of self-esteem after ABI. Self-esteem after ABI is multidimensional and differs in structure from self-esteem in the general population. A multidimensional model of self-esteem may be helpful in development of transdiagnostic cognitive behavioural accounts of adjustment.

Selection and visualisation of outcome measures for complex post-acute acquired brain injury rehabilitation interventions

BACKGROUND

Outcome measurement challenges rehabilitation services to select tools that promote stakeholder engagement in measuring complex interventions.

OBJECTIVES

To examine the suitability of outcome measures for complex post-acute acquired brain injury (ABI) rehabilitation interventions, report outcomes of a holistic, neuropsychological ABI rehabilitation program and propose a simple way of visualizing complex outcomes.

METHODS

Patient/carer reported outcome measures (PROMS), experience measures (PREMS) and staff-rated measures were collected for consecutive admissions over 1 year to an 18-week holistic, neuropsychological rehabilitation programme at baseline, 18 weeks and 3- and 6-month follow-up.

RESULTS

Engagement with outcome measurement was poorest for carers and at follow-up for all stakeholders. Dependence, abilities, adjustment, unmet needs, symptomatology including executive dysfunction, and self-reassurance showed improvements at 18 weeks. Adjustment, social participation, perceived health, symptomatology including dysexecutive difficulties, and anxiety were worse at baseline for those who did not complete rehabilitation, than those who did. A radar plot facilitated outcome visualization.

CONCLUSIONS

Engagement with outcome measurement was best when time and support were provided. Supplementing patient- with staff-rated and attendance measures may explain missing data and help quantify healthcare needs. The MPAI4, EBIQ and DEX-R appeared suitable measures to evaluate outcomes and distinguish those completing and not completing neuropsychological rehabilitation.

'HeART of Stroke (HoS)', a community-based Arts for Health group intervention to support self-confidence and psychological well-being following a stroke: protocol for a randomised controlled feasibility study

INTRODUCTION

Over 152,000 people in the UK have strokes annually and a third experience residual disability. Low mood also affects a third of stroke survivors; yet psychological support is poor. While Arts for Health interventions have been shown to improve well-being in people with mild-to-moderate depression post-stroke, their role in helping people regain sense of self, well-being and confidence has yet to be evaluated. The main aim of this study is to explore the feasibility of conducting a pragmatic multicentre randomised controlled trial to assess the effectiveness and cost-effectiveness of an Arts for Health group intervention ('HeART of Stroke' (HoS)) for stroke survivors. HoS is a 10-session artist-facilitated group intervention held in the community over 14 weeks. It offers a non-judgemental, supportive environment for people to explore sense of self, potentially enhancing well-being and confidence.

METHODS AND ANALYSIS

Sixty-four people, up to 2 years post-stroke, recruited via secondary care research staff or community stroke/rehabilitation teams in two UK centres will be randomised to either HoS plus usual care or usual care only. Self-reported outcomes, measured at baseline and approximately 5 months postrandomisation, will include stroke-related, well-being, mood, self-esteem, quality of life and process measures. Analyses will focus on estimating key feasibility parameters (eg, rates of recruitment, retention, intervention attendance). We will develop outcome and resource use data collection methods to inform an effectiveness and cost-effectiveness analysis in the future trial. Interviews, with a sample of participants, will explore the acceptability of the intervention and study processes, as well as experiences of the HoS group.

ETHICS AND DISSEMINATION

National Health Service (NHS), Research and Development and University ethical approvals have been obtained. Two peer-reviewed journal publications are planned plus one service user led publication. Findings will be disseminated at key national conferences, local stakeholder events and via institutional websites.

TRIAL REGISTRATION NUMBER

ISRCTN99728983.

Compassion Focused Therapy After Traumatic Brain Injury: Theoretical Foundations and a Case Illustration

Acquired brain injury (ABI) commonly results in a range of interacting difficulties including regulating emotion, managing social interactions and cognitive changes. Emotional adjustment to ABI can be difficult and requires adaptation of standard psychological therapies. This article outlines a case where cognitive– behavioural therapy (CBT) was of limited effectiveness but was significantly enhanced with compassion focused therapy (CFT). This article describes Jenny, a 23-year-old woman who suffered a traumatic brain injury 3 years prior to attending rehabilitation. Jenny presented with low self-esteem and mental health difficulties. Neuropsychological assessment revealed executive functioning difficulties. Jenny entered a holistic neuropsychological rehabilitation program aimed at improving complex interacting difficulties, receiving CBT as part of this. As CBT was of limited effectiveness, reformulation of Jenny's difficulties was presented to her based on CFT. The CFT intervention employed aimed to help Jenny develop self-validation and acceptance through producing feelings of kindness and warmth. Shifting the affective textures to the self is a key process for CFT. Self-report measures of mental health and self-esteem showed positive changes and the usefulness of CFT for Jenny. Adaptations in the context of Jenny's ABI are discussed. In conclusion, CFT may be useful in conceptualising emotional responses and developing intervention in rehabilitation after ABI, especially because CFT is based on a neurophysiological model of affect regulation that pays particular attention to the importance of affiliative emotions in the regulation of threat-focused emotion and self-construction.

The factor structure of the Hospital Anxiety and Depression Scale in acquired brain injury

PRIMARY OBJECTIVE

To evaluate the factor structure of the Hospital Anxiety and Depression Scale (HADS) as a mood assessment in a sample of individuals with acquired brain injury (ABI).

RESEARCH DESIGN

Cohort study.

METHODS AND PROCEDURES

HADS data from 140 people with ABI was subjected to principle components analysis (PCA).

EXPERIMENTAL INTERVENTIONS

None.

MAIN OUTCOMES AND RESULTS

A three-factor solution emerged. Items loading on the first two factors map on to the anxiety and depression scales. However, two items from the depression sub-scale did not load significantly on either of these two main factors. Possible reasons are discussed.

CONCLUSIONS

This study suggests that the HADS is a useful tool for examining depression and anxiety in a brain injured population, but interpretation of responses to some items should be cautious.

"Am not was": cognitive-behavioural therapy for adjustment and identity change following herpes simplex encephalitis

The cognitive sequelae of encephalitis are well documented, and it is increasingly recognised that disorders of mood and anxiety can accompany these sequelae. Loss of identity is emerging as a key theme in psychotherapeutic interventions in adjustment following acquired brain injury (ABI). Cognitive-behavioural therapy can be applied to construct a new model of the self in the context of behavioural, cognitive and social sequelae of the ABI, with consideration of pre-illness identity. Behavioural experiments, in particular, may be an effective means of redefining the meaning of current situations to create a positive sense of self. In the current paper we describe the therapeutic intervention to address anxiety and changes in identity in a woman recovering from herpes simplex viral encephalitis. The intervention highlights the need to take into account the interplay between cognitive changes, such as memory and executive function, with emotion in adjustment following herpes simplex viral encephalitis.

Awareness of disability after acquired brain injury and the family context

The dimension of family context for awareness of disability following acquired brain injury (ABI) is examined through a qualitative discourse analysis. Three participants with ABI, who were identified by clinicians and relatives as demonstrating difficulties with awareness of disability, and three relatives were interviewed. The findings highlight important contextual parameters influencing the emergence of families' accounts for disability after ABI: (1) availability of sense-making resources and use of pre-injury meanings, and (2) incongruity within family sense-making and resultant orientating, disputing and contesting of accounts within families. These findings are discussed in relation to pre-existing literature, and applications are suggested for family intervention following ABI.

Finding out if “The ‘me’ will shut down”: Successful cognitive-behavioural therapy of seizure-related panic symptoms following subarachnoid haemorrhage: A single case report

Successful cognitive and behavioural therapies for anxiety disorders in separate cases of acquired brain injury and seizure disorder have been reported although evidence of efficacy is limited. This paper describes the presentation and cognitive-behavioural therapy (CBT) of seizure-related panic symptoms in the context of subarachnoid haemorrhage and cavernoma. Multidisciplinary clinical assessment was conducted and 12 sessions of CBT according to the model of Clark (1986) were delivered. Outcome was measured in terms of goal attainment, belief ratings of target cognitions and completion of standardised questionnaire measures pre and post-treatment. Process was measured through client's ratings of anxiety-related beliefs through treatment. The client attained all goals, eliminated avoidance and other unhelpful coping behaviour, and rated reduced levels of anxiety on a standardised measure. Changes in identified target cognitions were also evident. It is concluded that a cognitive-behavioural approach may be helpful in understanding and treating anxiety disorders where symptom presentation is complicated by neurological problems. Further investigation of the relationship between development of anxiety disorders, occurrence of neurological events, and processes of CBT following acquired brain injury is suggested.

Egocentric Disorientation following Bilateral Parietal Lobe Damage

Aguirre and D'Esposito (1999) suggested a taxonomy and theoretical framework for understanding topographical disorders. One of the problems they described involved egocentric disorientation, in which deficits are not strictly confined to the topographical sphere but are seen on a wide variety of visuo-spatial paradigms. Here, we report a neuropsychological investigation of MU, a person with egocentric disorientation. To test the usefulness of Aguirre and D'Esposito's framework, we administered tests which were predicted to be easy or difficult for people with egocentric disorientation to show that MU was impaired on tasks sensitive to egocentric disorientation and that he showed adequate performance on tests sensitive to other types of topographical representation. Thus MU showed normal performance on a test of recognition of famous landmarks and he could identify photographs of personally familiar places in his home town, yet he could not say how to get from a recognised building to another place in his environment. His performance fulfils the criteria for egocentric disorientation and fits the predictions derived from Aguirre and D'Esposito's views.

Emotional adjustment following cognitive recovery from 'persistent vegetative state': psychological and personal perspectives

Previously, the cognitive recovery of a 26 year old woman, Kate, who developed a severe encephalomyelopathy and was in a 'minimally conscious/persistent vegetative state' for 6 months was reported. After 6 months, Kate began to respond to her environment and, at 2 years post-illness, neuropsychological assessment indicated that Kate was functioning within the normal range on tests of general intellectual functioning, executive functioning and most memory functions (with the exception of visual recognition memory). Although Kate has a severe dysarthria necessitating the use of a communication board and severe physical disabilities that require her to use a wheelchair, she has demonstrated an almost complete cognitive recovery and is among a tiny percentage of minimally conscious patients to do so. This single case report describes the emotional factors central to Kate's rehabilitation. Using a newly developed model of cognitive rehabilitation as a framework, the pivotal role that emotional and psychological factors played in Kate's adjustment to the consequences of her illness and the role of psychotherapeutic intervention in facilitating this adjustment are discussed.

Cognitive recovery from "persistent vegetative state": psychological and personal perspectives

This study reports on the case of a young woman who, at the age of 26, developed a severe encephalomyelopathy and was in a vegetative state or minimally conscious state for 6 months. She showed a sleep-wake cycle, but no evidence of cognitive functioning. Six months after her illness, she began to respond to her environment and eventually returned home to the care of her parents, with regular periods of respite care in a home for people with severe physical disabilities. She remains in a wheelchair with a severe dysarthria and communicates via a letter board. Two years after her illness, staff at the home requested an assessment of her cognitive functioning. On the WAIS-R verbal scale and the Raven's Progressive Matrices, the woman's scores were in the normal range. So too were her recognition of real versus nonsense words and her memory functioning (apart from a visual recognition memory test which was in the impaired range). Although she enjoyed the tests, she became distressed when asked about her illness and previous hospitalization. She was reassessed 1 year later, when there were few significant changes in her test scores but she could talk about her illness and hospitalization without becoming distressed. She was angry, however, about her experiences in the first hospital. Further tests suggested good executive functioning. In short, this woman's cognitive functioning is in the normal range for most tasks assessed, despite a severe physical disability and dysarthria, and despite the fact that she was vegetative for 6 months. Although some recovery following 6 months of being vegetative/minimally conscious is not unknown, it is rare, particularly for those with non-traumatic injuries, and the majority of people similarly affected remain with significant cognitive deficits. This client has, by and large, made an almost complete cognitive recovery. She feels positive about her life now and says the formal assessment showed people she was not stupid and this made her happy. The paper concludes with the young woman's own comments and views about what happened to her and her present feelings.