Subjective experience in patients with brain injury and their close relatives before and after a rehabilitation programme

Exploration of patient- and relative-reported outcomes of cognitive, emotional, and social function after encephalitis

Objective: We evaluated cognitive, emotional, and social function after encephalitis, as perceived and reported by individuals post-encephalitis and their relatives.Hypothesis: There will be differential effects on various domains as self-reported by individuals post-encephalitis. Outcomes will be worse than in prior studies of other forms of acute brain injury. Post-encephalitis relative-report will demonstrate worse outcomes than self-report.Methods and Procedures: Members of The Encephalitis Society residing in the United Kingdom and Ireland were recruited to complete a demographic questionnaire and the European Brain Injury Questionnaire (EBIQ).Results: 266 individuals affected by encephalitis and 140 relatives participated in this study. The three domains with the highest (worst) mean scores were somatic, cognitive, and communication (p < .001). Individuals post-encephalitis self-reported worse outcomes than individuals post-stroke in seven of nine domains (p < .005), but there were no differences compared to individuals post-traumatic brain injury (TBI). Relatives reported worse encephalitis outcomes in seven of nine domains than did individuals directly affected by encephalitis (p < .005).Conclusions: Individuals affected by encephalitis experience the most significant symptoms in the somatic, cognitive, and communication domains. Outcomes as assessed by relatives were notably worse than those assessed by individuals themselves in nearly all domains.

Comparison of cognitive behavioral therapy and supportive psychotherapy for the treatment of depression following traumatic brain injury: a randomized controlled trial

OBJECTIVE

To determine the efficacy of 2 different interventions (cognitive behavioral therapy [CBT] and supportive psychotherapy [SPT]) to treat post-traumatic brain injury (TBI) depression.

PARTICIPANTS

A sample of 77 community-dwelling individuals with a TBI, and a diagnosis of depression. Participants were randomized into treatment conditions either CBT or SPT and received up to 16 sessions of individual psychotherapy.

MEASURES

Participants completed the Structured Clinical Interview for DSM-IV and self-report measures of depression (Beck Depression Inventory-Second Edition), anxiety (State-Trait Anxiety Inventory), perceived social support (Interpersonal Support Evaluation List), stressful life events (Life Experiences Survey), and quality of life (QOL) before beginning and immediately following treatment.

RESULTS

No significant differences were found at baseline between CBT and SPT groups on demographic factors (sex, age, education, race, and time since injury) or baseline measures of depression, anxiety, participation, perceived social support, stressful life events, or QOL. Analyses of variance revealed significant time effects for the Beck Depression Inventory-Second Edition, State-Trait Anxiety Inventory, and QOL outcome measures but no group effects. Intention-to-treat mixed effects analyses did not find any significant difference in patterns of scores of the outcome measures between the CBT and SPT intervention groups.

CONCLUSIONS

Both forms of psychotherapy were efficacious in improving diagnoses of depression and anxiety and reducing depressive symptoms. These findings suggest that in this sample of individuals with TBI, CBT was not more effective in treating depression than SPT, though further research is needed with larger sample sizes to identify different components of these interventions that may be effective with different TBI populations. ClinicalTrials.gov Identifier: NCT00211835.

Reporting of neuropsychological dysfunction remains discrepant between individuals with traumatic brain injury and their close others up to five years post-injury

PURPOSE

The degree to which individuals with traumatic brain injury (TBI) and their close others share a common understanding and experience of post-injury neuropsychological changes is currently unclear. The aim of this preliminary study was to longitudinally examine levels of agreement between self and close other reports of neuropsychological dysfunction following TBI and explore factors associated with these agreement levels.

METHOD

Sixty-three people with TBI and their nominated close others independently completed the Structured Outcome Questionnaire at 1- and 5-years post-injury, reporting whether the person with TBI was experiencing any negative cognitive, behavioural or emotional changes compared to pre-injury.

RESULTS

Agreement levels between pair members ranged from chance to approximately 75% across neuropsychological domains and did not significantly change over 1- and 5-year time points. In the case of pair disagreement, close others were generally more likely to report difficulties. Pair disagreement was significantly associated with close other anxiety.

CONCLUSIONS

Agreement between self and close others remains limited up to 5-years post-injury which questions the practice of using these reports interchangeably in research and clinical practice. Preliminary findings suggest some association between pair disagreement and close other psychological function; however, further research is warranted. Implications for Rehabilitation Reporting of neuropsychological dysfunction between individuals with TBI and their close others is not sufficiently reliable to warrant interchangeable use within research or clinical practice. Including both individuals with TBI and their close others in clinical assessments will facilitate a more holistic understanding of the client's difficulties and their relationships with those close to them. Preliminary findings indicate that disagreement between individuals with TBI and their close others may be associated with close other anxiety. Clinicians should be aware of the potential for disagreement to impact on the psychological health of close others.

Diagnosis and Treatment of Depression Following Traumatic Brain Injury

Depression is one of the most common psychiatric diagnoses among individuals with traumatic brain injury (TBI). Prevalence of post-TBI depression (PTBID) ranges from 12 to 60% and is generally higher than rates reported in the general population. The wide range in reported rates is attributed to methodological variability across studies, including measurement and sampling differences. Several systematic reviews have been published in the past 5 years, reporting on outcomes for depression across different classes of interventions, including pharmacological, biomedical and behavioural. The consensus across reviews is that more research is necessary to develop evidence-based practice guidelines. The present narrative review synthesises the findings of previous studies, focusing on the nature of the interventions, the eligibility criteria for inclusion and the assessment of outcome. Pharmacological studies are generally more rigorous methodologically, but provide mixed findings. Other biomedical interventions are only at the initial stages of research development, including case and pilot studies. The results of behavioural studies are positive regarding improvements in mood. However, the number of efficacy studies of behavioural interventions for depression is extremely limited. Recommendations for designing interventions are provided.

Spanish, French, and British cross-cultural validation of the European Brain Injury Questionnaire

OBJECTIVE

To explore the factor structure of the European Brain Injury Questionnaire and to assess the cross-cultural and construct validity of this questionnaire by using Rasch analysis.

PARTICIPANTS

A total of 366 individuals with traumatic brain injury or stroke were recruited from 3 different countries: Spain (116 participants), the United Kingdom (110 participants), and France (140 participants).

ANALYSES

We first performed a factor analysis and then applied Rasch analysis to the resulting factors to examine construct and cross-cultural validity.

RESULTS

Three subscales labeled Depressive Mood, Cognitive Dysfunction, and Poor Social and Emotional Self-regulation were extracted using the factor analysis. In the Rasch analyses, 8 items were removed because of misfit and 7 items showed differential item functioning by country.

CONCLUSION

Rasch analyses showed good fit to the model, unidimensionality, construct validity, and good reliability of the 3 European Brain Injury Questionnaire subscales. However, only the Depressive and Cognitive subscales showed cross-cultural validity.

Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008

OBJECTIVE

To update our clinical recommendations for cognitive rehabilitation of people with traumatic brain injury (TBI) and stroke, based on a systematic review of the literature from 2003 through 2008.

DATA SOURCES

PubMed and Infotrieve literature searches were conducted using the terms attention, awareness, cognitive, communication, executive, language, memory, perception, problem solving, and/or reasoning combined with each of the following terms: rehabilitation, remediation, and training for articles published between 2003 and 2008. The task force initially identified citations for 198 published articles.

STUDY SELECTION

One hundred forty-one articles were selected for inclusion after our initial screening. Twenty-nine studies were excluded after further detailed review. Excluded articles included 4 descriptive studies without data, 6 nontreatment studies, 7 experimental manipulations, 6 reviews, 1 single case study not related to TBI or stroke, 2 articles where the intervention was provided to caretakers, 1 article redacted by the journal, and 2 reanalyses of prior publications. We fully reviewed and evaluated 112 studies.

DATA EXTRACTION

Articles were assigned to 1 of 6 categories reflecting the primary area of intervention: attention; vision and visuospatial functioning; language and communication skills; memory; executive functioning, problem solving and awareness; and comprehensive-holistic cognitive rehabilitation. Articles were abstracted and levels of evidence determined using specific criteria.

DATA SYNTHESIS

Of the 112 studies, 14 were rated as class I, 5 as class Ia, 11 as class II, and 82 as class III. Evidence within each area of intervention was synthesized and recommendations for Practice Standards, Practice Guidelines, and Practice Options were made.

CONCLUSIONS

There is substantial evidence to support interventions for attention, memory, social communication skills, executive function, and for comprehensive-holistic neuropsychologic rehabilitation after TBI. Evidence supports visuospatial rehabilitation after right hemisphere stroke, and interventions for aphasia and apraxia after left hemisphere stroke. Together with our prior reviews, we have evaluated a total of 370 interventions, including 65 class I or Ia studies. There is now sufficient information to support evidence-based protocols and implement empirically-supported treatments for cognitive disability after TBI and stroke.

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.

Patient compliance in brain injury rehabilitation in relation to awareness and cognitive and physical improvement

The purpose of the present study was to investigate the relationship between patients' compliance and awareness and outcome of brain injury rehabilitation. Subjects were 98 patients who underwent a holistic neuropsychological outpatient rehabilitation programme. Patients had suffered a traumatic brain injury (n = 26), a cerebrovascular accident (n = 58), or another neurological insult (n = 14).

MEASURES

Two staff members, a neuropsychologist and a physiotherapist, retrospectively and separately rated patients' awareness and their compliance. Outcome was measured with the d2 test of concentration, measures of oxygen uptake, strength endurance, running speed, and patients' and relatives' ratings of patients' cognitive, physical, and overall problems on the European Brain Injury Questionnaire (EBIQ). The discrepancy between patients' and relatives' ratings on the EBIQ was incorporated as a second measure of patients' awareness.

RESULTS

The neuropsychologist's compliance ratings were significantly related to measures of insight, improvement of d2 performance accuracy and stability, improvement of oxygen uptake, and reduction of cognitive and overall problems as reported by the patients, while the physiotherapist's compliance ratings were related to measures of insight, improvement of d2 performance speed, improvement of oxygen uptake and strength endurance, and all three EBIQ patient scales.

DISCUSSION

The results suggest a differential relationship between situation-specific compliance and outcome.

Subjective well-being and quality of life following traumatic brain injury in adults: A long-term population-based follow-up

PRIMARY OBJECTIVE

To assess subjective well-being and quality-of-life in nationally representative samples of patients at long intervals following traumatic brain injuries.

METHODS AND PROCEDURES

Patients with either cranial fractures or cerebral lesions were identified in a national computer-based register of hospital admissions and random samples were selected among those who had suffered the injury at 5, 10 or 15 years prior to the follow-up. Postal questionnaires were sent to them covering quality of life, e.g. return to employment, family relations and current subjective well-being in terms of symptomatology, e.g. somatic complaints, cognitive dysfunction. A response rate of 76% was obtained, comprising 114 patients with cranial fracture and 126 with cerebral lesions.

MAIN OUTCOMES AND RESULTS

The group with cerebral lesions had markedly poorer quality of life and subjective well-being than the group with cranial fractures and this did not vary across time. In both groups, the most common symptoms concerned cognition. Among the cerebral lesion group, quality of life outcome was fairly well predicted by severity of injury, but subjective well-being was less well predicted.

CONCLUSIONS

The negative consequences of traumatic cerebral lesions are marked and do not vary at long periods following injury.

Treatment for depression after traumatic brain injury: a systematic review

The aim of this systematic review was to critically evaluate the evidence on interventions for depression following traumatic brain injury (TBI) and provide recommendations for clinical practice and future research. We reviewed pharmacological, other biological, psychotherapeutic, and rehabilitation interventions for depression following TBI from the following data sources: PubMed, CINAHL, PsycINFO, ProQuest, Web of Science, and Google Scholar. We included studies written in English published since 1980 investigating depression and depressive symptomatology in adults with TBI; 658 articles were identified. After reviewing the abstracts, 57 articles met the inclusion criteria. In addition to studies describing interventions designed to treat depression, we included intervention studies in which depressive symptoms were reported as a secondary outcome. At the end of a full review in which two independent reviewers extracted data, 26 articles met the final criteria that included reporting data on participants with TBI, and using validated depression diagnostic or severity measures pre- and post-treatment. Three external reviewers also examined the study methods and evidence tables, adding 1 article, for a total of 27 studies. Evidence was classified based on American Academy of Neurology criteria. The largest pharmacological study enrolled 54 patients, and none of the psychotherapeutic/rehabilitation interventions prospectively targeted depression. This systematic review documents that there is a paucity of randomized controlled trials for depression following TBI. Serotonergic antidepressants and cognitive behavioral interventions appear to have the best preliminary evidence for treating depression following TBI. More research is needed to provide evidence-based treatment recommendations for depression following TBI.

Traumatic brain injury and long-term quality of life: findings from an Australian study

Recent calls have been made for the inclusion of health-related quality of life (HRQoL) in traumatic brain injury studies. This study reports the impact of TBI on traditional measures (general health, depression, social isolation, labor force participation), self-assessed health function status using the SF-36 version 2 (SF-36V2), and self-assessed health preference using two generic utility instruments, the assessment of quality of life (AQoL) and the SF6D. A random sample of TBI cases (n = 66) was drawn from a trauma registry and matched (gender, age, education, and relationship status) with non-trauma-exposed cases from a population health survey. All participants were interviewed and the two cohorts compared. When compared with matched comparators, TBI cases experienced worse general health, elevated probabilities of depression, social isolation, and worse labor force participation rates. The TBI-cohort reported worse health status on the SF-36V2. The most affected areas were social function, role emotion, and mental health (effect sizes -0.70 to -0.86). The reported utility values indicative of a HRQoL between 13 and 24% worse than their non-TBI contemporaries (effect sizes -0.80 to -0.81). The findings suggest that TBI has long-term consequences across all aspects of peoples' lives, and that these consequences can be self-assessed using generic instruments. The challenge is to provide and evaluate long-term services targeted at the life areas that those with TBI find particularly difficult.

Subjective outcome of brain injury rehabilitation in relation to the therapeutic working alliance, client compliance and awareness

OBJECTIVE

To investigate the relationship between working alliance, compliance, awareness and subjective outcome of brain injury rehabilitation. Subjects were 86 patients who were clients in an holistic neuropsychological outpatient rehabilitation programme. They had suffered a traumatic brain injury (n = 27), a cerebrovascular accident (n = 49) or some other neurological insult (n = 10).

MEASURES

The therapeutic alliance, clients' awareness and their compliance were rated four times during the 14-week rehabilitation programme. The therapeutic alliance was rated by both clients and therapist using the Working Alliance Inventory (WAI), awareness and compliance were rated by the therapists. Clients completed the European Brain Injury Questionnaire (EBIQ) at programme start and end. Clients and therapists rated the overall success of their collaboration at programme end.

RESULTS

Clients' experience of a good emotional bond between themselves and therapists in mid-therapy was predictive for the reduction of clients' report of depressive symptoms on the EBIQ depression sub-scale (R = 0.68, n = 43, p < 0.001). Good compliance early in the programme was predictive of changes on the EBIQ. Improvement of awareness was related to the amplification of depressive symptoms (r = -0.27, n = 56, p < 0.05).

CONCLUSIONS

Brain injury rehabilitation should be seen as a dynamic process that develops between clients and therapists. Future research should further investigate the relationship between process and outcome and how the therapeutic process can be optimized.

The influence of neuropsychological rehabilitation on symptomatology and quality of life following brain injury: A controlled long-term follow-up

PRIMARY OBJECTIVE

To establish whether, following acquired brain injury, intensive post-acute neuropsychological rehabilitation could have long-term beneficial effects.

METHODS AND PROCEDURES

A group of 37 adults who had suffered cerebrovascular accidents or traumatic brain injuries and who had undergone a rehabilitation programme were followed up 12-22 years post-injury, together with a non-rehabilitated control group of 13 adults, matched for brain-injury and demographics characteristics. Both groups completed a set of questionnaires concerning broad aspects of psychological well-being. Significant others completed similar questionnaires.

MAIN OUTCOMES AND RESULTS

The rehabilitation group showed significantly lower levels of brain injury symptoms and higher levels of competency at follow-up. They also rated internal locus of control and general self-efficacy as significantly higher than the control group. Anxiety and depression levels were significantly lower and quality of life significantly higher in the rehabilitation group for both the subjects themselves and for their significant others.

CONCLUSIONS

Within methodological limitations this study suggests that post-acute neuropsychological rehabilitation can have long-term beneficial effects.

Holistic neuro-rehabilitation in the community: is identity a key issue?

Many people experience identity change after brain injury. Impaired self-awareness after acquired brain injury is also common and can, along with other factors, affect the identity change a person may experience. Holistic rehabilitation programmes attempt to address both cognitive and emotional difficulties and specifically problems of self-awareness after brain injury. Does identity change require longer-term rehabilitation interventions? This paper describes a community-based neuro-rehabilitation service that has incorporated some principles from more traditional holistic programmes with a view to providing long-term, low-intensity brain injury rehabilitation. Specific reference is made to problems of identity and how these may be addressed during long-term psychotherapeutic follow-up. The potential relevance of the total duration of rehabilitation input rather than simply the number of sessions when working with adjustment and identity change after brain injury in community settings is discussed. The service model is compared to more traditional holistic rehabilitation programmes. A case study and early outcome data are presented to illustrate some of these points and to provide more information about the nature of the programme.

The European Brain Injury Questionnaire (EBIQ) as a reliable outcome measure for use with people with brain injury

PRIMARY PURPOSE

There is a need to develop reliable outcome measures to determine well-being after brain injury. In 1997, Teasdale et al. published the European Brain Injury Questionnaire (EBIQ), a self-report and relative-report measure of the subjective experience of cognitive, emotional and social difficulties experienced by people with brain injury. It is now used in several rehabilitation centres as an outcome measure, but its test-re-test reliability has yet not been determined. The primary purpose of the present study is to establish this degree of reliability.

RESEARCH DESIGN

The EBIQ was administered twice within an approximately 1-month period to 50 people with brain injury, to 20 relatives of people with brain injury and to 51 normal controls.

RESULTS

The results showed significant and satisfactory test-re-test reliabilities for all three groups across all nine EBIQ scales (r = 0.55-0.90).

CONCLUSION

It is concluded that the EBIQ is a clinically reliable measure to determine the subjective well-being of people with brain injury and to assess change of subjective concerns over time.

Post-acute rehabilitation following traumatic brain injury: are both early and later improved outcomes possible?

This outcome study investigated the effectiveness of community based multi-disciplinary neuro-rehabilitation for persons with a traumatic brain injury (TBI) at varying times since injury. From case records all persons with a (TBI) who had two-point outcome data (European Brain Injury Questionnaire) available (n=55) were identified and included in this study. Significantly improved outcome on self-rating were observed for the group, not only for those less than 2 years post-injury, but also for those more than 2 years after (TBI). Family/care ratings also confirmed improved outcome, except for the group of patients who were more than 2 years post-(TBI).