Life satisfaction and disability after severe traumatic brain injury

Quality of Life after Brain Injury (QOLIBRI): scale validity and correlates of quality of life

The QOLIBRI (Quality of Life after Brain Injury) is a novel health-related quality-of-life (HRQoL) instrument specifically developed for traumatic brain injury (TBI). It provides a profile of HRQoL in six domains together with an overall score. Scale validity and factors associated with HRQoL were investigated in a multi-center international study. A total of 795 adults with brain injury were studied from 3 months to 15 years post-injury. The majority of participants (58%) had severe injuries as assessed by 24-h worst Glasgow Coma Scale (GCS) score. Systematic relationships were observed between the QOLIBRI and the Glasgow Outcome Scale-Extended (GOSE), Hospital Anxiety and Depression Scale (HADS), and SF-36. Within each scale patients with disability reported having low HRQoL in two to three times as many areas as those who had made a good recovery. The main correlates of the total QOLIBRI score were emotional state (HADS depression and anxiety), functional status (amount of help needed and outcome on the GOSE), and comorbid health conditions. Together these five variables accounted for 58% of the variance in total QOLIBRI scores. The QOLIBRI is the first tool developed to assess disease-specific HRQoL in brain injury, and it contains novel information not given by other currently available assessments.

Quality of life after traumatic brain injury: the clinical use of the QOLIBRI, a novel disease-specific instrument

OBJECTIVE

To report the clinical use of the QOLIBRI, a disease-specific measure of health-related quality-of-life (HRQoL) after traumatic brain injury (TBI).

METHODS

The QOLIBRI, with 37 items in six scales (cognition, self, daily life and autonomy, social relationships, emotions and physical problems) was completed by 795 patients in six languages (Finnish, German, Italian, French, English and Dutch). QOLIBRI scores were examined by variables likely to be influenced by rehabilitation interventions and included socio-demographic, functional outcome, health status and mental health variables.

RESULTS

The QOLIBRI was self-completed by 73% of participants and 27% completed it in interview. It was sensitive to areas of life amenable to intervention, such as accommodation, work participation, health status (including mental health) and functional outcome.

CONCLUSION

The QOLIBRI provides information about patient's subjective perception of his/her HRQoL which supplements clinical measures and measures of functional outcome. It can be applied across different populations and cultures. It allows the identification of personal needs, the prioritization of therapeutic goals and the evaluation of individual progress. It may also be useful in clinical trials and in longitudinal studies of TBI recovery.

Children's conceptualization of the term 'satisfaction': relevance for measuring health outcomes

BACKGROUND

Health outcomes measurement is integral to planning and evaluating paediatric health care. Recent outcome measures have been developed to capture children's participation in everyday activities, a core component of which is the child's perceived satisfaction. Satisfaction, however, is a complex concept and it is not known how children conceptualize satisfaction and hence how it should best be measured. The purpose of this study was to explore children's conceptualization of the term 'satisfaction' and compare this with the description of satisfaction given in the literature to inform how satisfaction can be assessed in children.

METHODS

Forty children aged between 10 and 15 years participated in eight focus groups, guided by a descriptive qualitative approach, to describe how they conceptualize 'satisfaction'. Children with disabilities were excluded as it was considered important to first ascertain how children without disabilities conceptualize satisfaction. Recruitment occurred through seven urban and rural public schools. Data were analysed using qualitative content analysis.

RESULTS

Participants identified three methods by which a person may determine their level of satisfaction (i) making comparisons with previous experiences, and other's and self-expectations; (ii) evaluating one's emotions; and (iii) receiving positive external feedback. Participants described drawing upon one of these methods in isolation, rather than integrating outcomes from each method into one judgement of satisfaction. Participants also demonstrated confusion between the terms 'satisfaction' and 'satisfactory'.

CONCLUSIONS

Partial congruence between children's conceptualization of satisfaction and that reported in the literature was observed in this study. Not all children between the ages of 10 and 15, however, have a full understanding of satisfaction. Caution must therefore be taken when using the term satisfaction in children's assessments to minimize the potential for varying interpretations of the question. Further studies are required to explore how children with disabilities view the term satisfaction and if their understanding differs to that of typically developing children.

Individualized vs. global assessments of quality of life after head injury and their susceptibility to response shift

PRIMARY OBJECTIVE

The aim was to compare individualized and global assessments of quality of life (QoL) after traumatic brain injury (TBI) and to investigate perceived changes in QoL.

METHODS AND PROCEDURES

The Schedule for the Evaluation of Individual Quality of Life (SEIQoL-DW) and Hadorn's overall 1-10 QoL Scale were administered to 28 participants 1-10 years post-injury together with the GOS-E, HADS and SF-36. Perceived change in quality of life after TBI was investigated by comparing current and retrospective judgements.

MAIN OUTCOME AND RESULTS

Correlations between the QoL measures confirm validity of the SEIQoL-DW; however, correlations were generally stronger for the simpler 1-10 Scale. Paradoxically, there was little overall change in the mean QoL when current and retrospective judgements were compared; with some participants reporting worse quality of life before injury. A positive change in perceived QoL was associated with better overall functioning.

CONCLUSIONS

Where an overall rating of QoL is required it seems that Hadorn's 1-10 Scale is a simpler and more direct measure than the SEIQoL-DW. The greater detail provided by the SEIQoL-DW may mean it is of benefit when looking at individual differences. The results suggest that both the SEIQoL-DW and Hadorn's scale are susceptible to response shift (where a person changes the basis on which they evaluate QoL); and this has implications for the interpretation of QoL assessments.

Changes in coping strategies, social support, optimism and health-related quality of life following traumatic brain injury: A longitudinal study

PRIMARY OBJECTIVE

To study longitudinal changes in psychological coping strategies, social support, life orientation and health-related quality of life in the late period after traumatic brain injury (TBI).

SUBJECTS

Thirty-one patients with TBI who were first investigated on average 2.3 years after injury and were prospectively followed on average 5.7 years later.

METHODS

Estonian versions of the COPE-D Test, the Brief Social Support Questionnaire, the Life Orientation Test and the RAND-36 questionnaire.

RESULTS

During the late follow-up period health-related quality of life and resuming work did not improve significantly. Persons with TBI reported an increase in seeking social/emotional support (p<0.05), frequent use of avoidance-oriented styles and reduced use of task-oriented styles. This was accompanied by low social support and low satisfaction with support, both of which were associated with health-related quality of life and resuming work after TBI. Although the patients had become more optimistic (p<0.05), this did not correlate with their health status and social well-being.

CONCLUSIONS

This prospective study revealed maladaptive changes in the profile of coping strategies and an increase in optimism. As social support, satisfaction with support and health-related quality of life did not improve, then rehabilitation, social and psychological support are continuously needed.

Community reintegration following acquired brain injury

OBJECTIVE

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

METHODS AND MAIN OUTCOMES

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

RESULTS

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

CONCLUSIONS

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

Post-traumatic growth in acquired brain injury: A preliminary small scale study

PRIMARY OBJECTIVE

To examine the nature, degree and time course of positive psychological change in people with severe acquired brain injury.

RESEARCH DESIGN

This preliminary exploratory study employed a cross-sectional design, comparing two matched samples, one early post-brain injury (M = 7 months) and one late post-brain injury (M = 10 years).

METHODS AND PROCEDURES

The Posttraumatic Growth Inventory (PTGI), Sense of Coherence Scale-13 (SOC-13) and Hospital Anxiety and Depression Scale (HADS) were administered.

MAIN OUTCOMES AND RESULTS

The samples differed significantly with respect to reported post-traumatic growth, with the late sample reporting higher levels. HADS anxiety was significantly associated with post-traumatic growth. Both samples achieved high scores on the SOC-13.

CONCLUSIONS

The participants showed evidence of substantial positive psychological change, demonstrating that it is not precluded by severe brain injury. The results suggest that this develops slowly over time and requires a degree of emotional engagement.

Health policy and future planning for survivors of critical illness

PURPOSE OF REVIEW

Few health policy decisions directly address the needs of intensive care unit survivors. This review will assess some of the health system-level barriers to effective post-intensive care unit care and provide a framework for policy decisions directed at improving outcomes for survivors of critical illness.

RECENT FINDINGS

Intensive care unit survivors incur significant morbidity, and account for enormous financial and opportunity costs. Despite our understanding of these burdens, relatively little is known about how to structure the healthcare system to improve outcomes after intensive care unit discharge. Several ongoing clinical trials will aid in system design and inform policy decisions. While we await more evidence, lessons learned in other disease states such as coronary care, acute stroke and traumatic brain injury can help us understand the attributes of a comprehensive longitudinal care model for critical illness. Future planning for the care of intensive care unit survivors should include defining the post-intensive care unit syndrome, expanding the use of information technology, educating providers, and developing a robust public health infrastructure that integrates acute and chronic care.

SUMMARY

Advances in our understanding of the long-term outcomes of critical illness must be accompanied by healthcare system changes designed to meet the specific needs of intensive care unit survivors.

Perceived self-efficacy and life satisfaction after traumatic brain injury

OBJECTIVE

To investigate the contribution of activity-related satisfaction and perceived self-efficacy to global life satisfaction after traumatic brain injury (TBI).

PARTICIPANTS

Convenience sample of 97 adults who were living in their community at least 6 months after sustaining a TBI.

MEASURES

Community Integration Questionnaire, Quality of Community Integration Questionnaire, Self-Efficacy Questionnaire for TBI, Perceived Quality of Life Scale, Satisfaction with Life Scale.

RESULTS

Among demographic and injury-related variables, gender and time since injury made significant contributions to the prediction of global life satisfaction. Productivity made a modest, significant contribution to life satisfaction. Satisfaction with productivity and with leisure/social activities both contributed to global life satisfaction. The greatest contribution to the prediction of global life satisfaction was made by the person's perceived self-efficacy, particularly perceived self-efficacy for the management of cognitive symptoms. Perceived cognitive self-efficacy also appeared to mediate the relation between community integration and global life satisfaction.

CONCLUSION

Community integration, activity-related satisfaction, and global life satisfaction represent distinct constructs, and dissociable aspects of psychosocial outcome after TBI. Perceived self-efficacy for the management of cognitive symptoms may mediate the relation between the individual's expectations and achievements and thereby contribute to overall subjective well-being.

The QOLIBRI--towards a quality of life tool after traumatic brain injury: current developments in Asia

INTRODUCTION

There is no disease-specific health-related quality of life (HRQoL) tool devoted to traumatic brain injury (TBI).

MATERIAL AND METHODS

Over 1500 TBI patients from 10 countries filled out a preliminary version of the QOLIBRI taking TBI specificities into account. 3 successive versions and consecutive statistical analyses were necessary to get a psychometrically-reliable tool.

RESULTS

The QOLIBRI final version, filled out in 15 min, consists of 2 parts. The first part assesses satisfaction with HRQoL and is composed of 6 overall items and 29 items allocated to 4 subscales: thinking, feelings, autonomy and social aspects. The second part, devoted to "bothered" questions, is composed of 12 items in 2 subscales: negative feelings and restrictions. The 6 subscales meet standard psychometric criteria. In addition, 2 items evaluate medical-oriented aspects. The questionnaire is validated in German, Finnish, Italian, French, English, Dutch.

CONCLUSION

TBI patients may now be assessed, beyond more "objective" measures including handicap and recovery, with a new measure of assessing the TBI patient's own opinion on his/her HRQoL, applicable across different populations and cultures. Validations in China Mainland, Hong-Kong, Taiwan, Japan, Egypt, Poland, Norway, Indonesia, and Malaya are on the way.

Children and young adults in a prolonged unconscious state after severe brain injury: long-term functional outcome as measured by the DRS and the GOSE after early intensive neurorehabilitation

OBJECTIVE

To investigate the long-term (2-15 years) functional outcome of children and young adults who received an early intensive neurorehabilitation programme (EINP) after a prolonged period of unconsciousness due to severe brain injury; to differentiate between traumatic brain injury (TBI) and non-traumatic brain injury (nTBI); and to compare the results on two different outcome scales: the Disability Rating Scale (DRS) and the Glasgow Outcome Scale Extended (GOSE).

SUBJECTS

One hundred and forty-five patients, who were admitted to EINP between December 1987 and January 2001.

OUTCOME MEASURES

The Post-Acute Level of Consciousness scale (PALOC-s), the DRS, including categorized scores (DRScat), and the GOSE.

RESULTS

The long-term functional level of 90 patients could be determined, of whom 25 were deceased. The mean DRS-score of the surviving patients was 6.8 (SD = 6.6); the mean score on the GOSE was 4.5 (SD = 1.7). There was a significant difference in the outcome amongst traumatic and non-traumatic patients (t88 = 4.21; p < 0.01). The correlation between the DRS and the GOSE was high (Spearman rho = 0.85; p < 0.01), as well as the correlation between the categorized scores of the DRS and the GOSE (Spearman rho = 0.81; p < 0.01). The distribution of outcome scores on the DRScat is more diverse than on the GOSE. Especially item 7 of the DRS, measuring functional independence, showed considerable variance in discriminating between different outcome levels.

CONCLUSIONS

More patients with TBI than expected reached a (semi-) independent level of functioning, indicating a possible effect of EINP. Patients suffering from nTBI did not demonstrate these outcome levels. Only a few patients stayed in a vegetative state for more than a couple of years. In this cohort of severe brain-injured young people, the DRS offered the best investigative possibilities for long-term level of functioning.

A Longitudinal Study of Health-Related Quality of Life After Traumatic Brain Injury

OBJECTIVE

To examine the longitudinal course of health-related quality of life from 1 month to 3 to 5 years after traumatic brain injury (TBI).

DESIGN

Longitudinal cohort study with 4 evaluation points.

SETTING

Level I trauma center.

PARTICIPANTS

Consecutive hospital admissions of 133 adolescents and adults with complicated mild to severe TBI who completed the outcome measure at all 4 time points, 111 general trauma patients, and 87 healthy friend controls.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Sickness Impact Profile.

RESULTS

TBI patients reported significant limitations at 1 month postinjury, with substantial improvement occurring by 6 months, especially in the physical domain. Psychosocial improvement was smaller, and perceived cognitive, emotional, and communication difficulties did not change over the time period assessed. Persons with TBI had clear difficulties relative to healthy peers, but their reported level of difficulties was very similar to that of the persons who had sustained a general trauma by 1 year postinjury.

CONCLUSIONS

In this sample, TBI was associated with significant early limitations in most aspects of everyday life. Considerable improvement was noted over the first 6 months postinjury, especially in physical domains. Some aspects of psychosocial functioning also improved, although reported limitations in communication, cognitive, and emotional domains remained constant over time. These findings highlight the persistence of injury-related difficulties that compromise quality of life.

Assessment of subjective health and health-related quality of life in persons with acquired or degenerative brain injury

PURPOSE OF REVIEW

Health-related quality of life is a new outcome variable in neurology. Several generic measures aim at assessing this variable in adults with neurological diseases. Disease-specific measures are still rare; however, individuals with neurological diseases frequently suffer from cognitive impairment, yet are often excluded from health-related quality of life investigations. When included in such studies, cognitive functioning is not monitored via neuropsychological evaluation, possibly leading to methodological problems. Papers from May 2004 until July 2005 are reviewed with respect to psychometric quality and information about persons after traumatic brain injury, stroke, Parkinson's disease or dementia.

RECENT FINDINGS

Several new cross-sectional and longitudinal outcome studies are reviewed. The Medical Outcome Study Short Form with 36 items, the Sickness Impact Profile and the Nottingham Health Profile were identified as the most frequently used measures in neurology. For traumatic brain injury, two new generic instrument validations (Life Satisfaction Index-A, Subjective Quality of Life Profile) and one internationally validated disease-specific development (Quality of Life after Brain Injury) were found; for stroke, one disease-specific tool (Burden of Stroke Scale) was identified. In Parkinson's disease, the disease-specific health-related quality of life measure Parkinson's Disease Questionnaire-39 is well validated. In dementia, three dementia-specific instruments (Quality of Life for Dementia, Quality of Life in Late-Stage Dementia Scale and Quality of Life in Alzheimer's Disease Scale) seem to be valid.

SUMMARY

In neurology, only a few measures have been developed and validated for respondents with cognitive impairment, often showing poorer validity results than studies involving healthy persons. Health-related quality of life assessment should therefore be validated in the specific diseases and, if necessary, combined with a neuropsychological evaluation and a disease-specific health-related quality of life measure.

Évaluation des incapacités et de la qualité de vie des patients présentant des troubles cognitifs

OBJECTIVE

To identify disability, handicap and quality of life questionnaires available for patients with cognitive impairment.

MATERIALS AND METHODS

We systematically reviewed the literature in Medline using the keywords assessment, evaluation, deficiency, disability, disadvantage, handicap, quality of life, scale, index, questionnaire, ICIDH-1, and ICIDH-2, combined with the cognitive deficits dysexecutive syndrome, memory deficits, attention deficits, neglect, apraxia, aphasia, agnosia and mood disorders. We focused on validated scales and distinguished scales dedicated to assess disability, handicap and quality of life.

RESULTS

At the level of disability, global and specific scales are available. Specific scales exist for dysexecutive syndrome, memory deficits, attention deficits, unilateral neglect, aphasia and mood disorders. French adaptations of foreign language tests and original tests developed in French have been validated in these areas. No specific tool is available for isolated apraxia or agnosia. Generic scales and pathology-specific scales (for stroke, traumatic brain injury, and multiple sclerosis) are available for quality of life. For aphasia, specific tools are available for incapacity handicap and quality of life.

CONCLUSION

Previous results show the impact of the ICIDH-1 framework on functional outcome assessment of cognitive impairments. This approach is often limited by the lack of theoretical background and by the difficulty to assess the involvement of environment and anosognosia.