Unmet Service Needs of Persons With Traumatic Brain Injury

Use of Social Media Data Mining to Examine Needs, Concerns, and Experiences of People With Traumatic Brain Injury

PURPOSE

Given the limited availability of topic-specific resources, many people turn to anonymous social media platforms such as Reddit to seek information and connect to others with similar experiences and needs. Mining of such data can therefore identify unmet needs within the community and allow speech-language pathologists to incorporate clients' real-life insights into clinical practices.

METHOD

A mixed-method analysis was performed on 3,648 traumatic brain injury (TBI) subreddit posts created between 2013 and 2021. Sentiment analysis was used to determine the sentiment expressed in each post; topic modeling and qualitative content analysis were used to uncover the main topics discussed across posts. Subgroup analyses were conducted based on injury severity, chronicity, and whether the post was authored by a person with TBI or a close other.

RESULTS

There was no significant difference between the number of posts with positive sentiment and the number of posts with negative sentiment. Comparisons between subgroups showed significantly higher positive sentiment in posts by or about people with moderate-to-severe TBI (compared to mild TBI) and who were more than 1 month postinjury (compared to less than 1 month). Posts by close others had significantly higher positive sentiment than posts by people with TBI. Topic modeling identified three meta-themes: Recovery, Symptoms, and Medical Care. Qualitative content analysis further revealed that returning to productivity and life as well as sharing recovery tips were the primary focus under the Recovery theme. Symptom-related posts often discussed symptom management and validation of experiences. The Medical Care theme encompassed concerns regarding diagnosis, medication, and treatment.

CONCLUSIONS

Concerns and needs shift over time following TBI, and they extend beyond health and functioning to participation in meaningful daily activities. The findings can inform the development of tailored educational resources and rehabilitative approaches, facilitating recovery and community building for individuals with TBI.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24881340.

Building resilience among families supporting relatives with ABI in rural NSW: testing the feasibility of telephone delivery of Strength2Strength program

BACKGROUND

Strength2Strength (S2S) is a group psychoeducational program aiming to build resilience among families supporting relatives after traumatic injury.

OBJECTIVE

To test the feasibility, acceptability and outcomes of teleconference delivery of a 5 hour S2S program in rural New South Wales.

METHODS

A mixed methods design investigated the (i) convenience of telephone-based delivery; and (ii) acceptability of the program material (purpose-designed survey and the Narrative Evaluation of Intervention Interview). Program efficacy was measured with the Resilience Scale (RS) and Connor-Davidson Resilience Scale (CD-RISC); the Positive and Negative Affect Scale (PANAS); Depression, Anxiety and Stress Scale - 21 (DASS-21); Carer Assessment of Managing Index (CAMI); and Caregiver Burden Scale (CBS). Participant outcome data were collected at baseline, post program and 3 months follow-up.

RESULTS

11 participants supporting adult relatives with severe brain injury completed the program. All participants and facilitators commented positively about the cost, ease of use and quality of the teleconference facility. Statistically significant gains were found between pre-program and follow-up scores on the RS, CD-RISC, PANAS-Positive, and CAMI, with statistically significant reductions found on the DASS-21 Depression Scale and CBS scores.

CONCLUSION

The study provides preliminary evidence for the efficacy of telephone-based delivery of S2S to family participants.

Perceived service adequacy and unmet need after discharge from brain injury rehabilitation

PURPOSE

The present study aimed to quantify the perceived needs and adequacy of realised access to post-acute services in a sample of people with acquired brain injury in the first 6-months after discharge from inpatient rehabilitation. A secondary focus was the influence of access to funding and specialist transitional rehabilitation on unmet needs.

MATERIALS AND METHODS

Participants were 51 adults with a median age of 50 (IQR 35-57) recruited from an inpatient rehabilitation unit in an Australian tertiary hospital. The sample was those who had an acquired brain injury, including 23 who sustained a traumatic injury and 28 who sustained a non-traumatic injury. Measures were collected via telephone at 3- and 6-months, in a prospective observational cohort design using the Needs and Provisions Complexity Scale. A series of logistic regression models were used to determine the effects of participation in a transitional rehabilitation program and funding pathway on adequacy and unmet needs.

RESULTS

Unmet needs for rehabilitation were most commonly reported (60%), followed by unmet needs in relation to health care (40%), social care (35%), personal care (32%) and environment-related (14%). Participants who attended transitional rehabilitation were more likely to indicate unmet health care needs (OR = 6.40, 95% CI = 1.40-29.24, p = 0.02).

CONCLUSIONS

The study highlights the need to look beyond functional impairment when conceptualising appropriate access. Additionally, the present research highlighted the need for greater work into an expectation of services.IMPLICATIONS FOR REHABILITATIONThe majority of people with an acquired brain injury report unmet needs at 6 months post discharge.Present findings support the utility of patient reported measures when considering treatment evaluation with people with ABI, where assessing the personal appraisal of individuals needs may prove to be a key indicator to facilitate optimal service access.There are specific services that needed and not provided including psychological, speech pathology, family carer needs and vocational rehabilitation, and therefore are a key target for ensuring appropriate support is provided.

Personal experiences of appropriate access to post-acute care services in acquired brain injury: a scoping review

People with an acquired brain injury (ABI) experience substantial access inequalities and unmet health needs, with many experiencing insufficient access to appropriate rehabilitation in the community. To deepen our understanding of what appropriate access to post-acute care services is for this population, and to facilitate optimal recovery, there is a need to synthesise research from the service user perspective. A scoping review study was conducted to identify key characteristics of 'appropriate' access to post-acute care services, as defined by the personal experiences of adults with ABI. Electronic scientific databases Medline, PsycINFO, Proquest Central and CINAHL were searched for studies published between 2000 and 2020. The initial search identified 361 articles which, along with articles retrieved from reference list searches, resulted in 52 articles included in the final analysis. Results indicated that a majority of the studies sampled participants with an average of over 1 year post-injury, with some studies sampling participants ranging over 10 years in difference in time post-injury. A thematic synthesis was conducted and results indicated a number of dominant elements which relate to (1) the characteristics of services: provider expertise, interpersonal qualities, partnership and adaptability; (2) characteristics of the health system: navigable system, integrated care, adequacy, and opportunity. These findings provide some insight into what might be considered appropriate. However, rigorous research, focused on personalised access to post-acute care services, is recommended to verify and elaborate on these findings.

Alternative Structure Models of the Traumatic Brain Injury Rehabilitation Needs Survey: A Veterans Affairs TBI Model Systems Study

OBJECTIVE

To explore the factor structure of the Rehabilitation Needs Survey (RNS).

DESIGN

Secondary analysis of observational cohort study who were 5-years post-traumatic brain injury (TBI).

SETTING

Five Inpatient Rehabilitation Facilities.

PARTICIPANTS

Veterans enrolled in the TBI Model Systems longitudinal study who completed the RNS at 5-year follow-up (N=378).

MAIN OUTCOME MEASURE(S)

RNS.

RESULTS

RNS factor structure was examined with exploratory factor analysis (EFA) with oblique rotation. Analyses returned 2- and 3-factor solutions with Cronbach alphas ranging from 0.715 to 0.905 and corrected item-total correlations that ranged from 0.279 to 0.732. The 2-factor solution accounted for 61.7% of the variance with ≥3 exclusively loading items on each factor with acceptable internal consistency metrics and was selected as the most parsimonious and clinically applicable model. Ad hoc analysis found the RNS structure per the EFA corresponded with elements of the International Classification of Functioning, Disability and Health (ICF) conceptual framework. All factors had adequate internal consistency (α≥0.70) and 20 of the 21 demonstrated good discrimination (corrected item-total correlations≥0.40).

CONCLUSIONS

The 2-factor solution of the RNS appears to be a useful model for enhancing its clinical interpretability. Although there were cross-loading items, they refer to complex rehabilitation needs that are likely influenced by multiple factors. Alternatively, there are items that may require alteration and redundant items that should be considered for elimination.

Experiences of individuals with acquired brain injury and their families interacting with community services: a systematic scoping review

PURPOSE

This scoping review aims to (1) synthesise the research findings on the experiences of individuals with acquired brain injuries, and their families, when interacting with, or accessing, community-based services and (2) identify where gaps in service provision may exist and their cause.

METHODS

A systematic search strategy was employed across multiple databases to identify all studies relating to the experiences of individuals with acquired brain injuries and their families when interacting with, or accessing, community-based services. Inclusion was assessed by at least two reviewers at each stage and data extraction was completed by one researcher and validity checked by another. A narrative synthesis was employed.

RESULTS

A total of 101 papers met the inclusion criteria with the narrative synthesis identifying three main themes of (1) unmet needs, (2) types of access, and (3) barriers to access.

CONCLUSIONS

The results identify that those with acquired brain injuries, and their families, experience significant difficulties interacting with community-based services and often do not receive appropriate access. Many barriers to access were identified including a lack of knowledge of the long-term effects of acquired brain injury amongst professionals working in health and social care services.Implications for rehabilitationBrain injury is a leading cause of disability worldwide with a range of physical, cognitive, emotional, and behavioural difficulties.It is important that service users and families are given appropriate information about the long-term difficulties associated with ABI so they are better informed about the types of support they may need upon discharge from hospital.Rehabilitation professionals need to ensure they have good level of knowledge of the difficulties associated with ABI to ensure appropriate access to services for individuals and their families.Understanding more about unmet needs allows community rehabilitation services to be tailored and person-centred.

Design, methods, and baseline characteristics of the Brain Injury Education, Training, and Therapy to Enhance Recovery (BETTER) feasibility study: a transitional care intervention for younger adult patients with traumatic brain injury and caregivers

OBJECTIVES

We developed a patient- and family-centered traumatic brain injury (TBI) transitional care intervention, called BETTER (Brain Injury Education, Training, and Therapy to Enhance Recovery), to improve quality of life (via SF-36) of younger TBI patients of different racial groups discharged home from acute hospital care and caregivers. We describe our design, methods, and baseline characteristics for our feasibility study.

METHODS

We co-developed BETTER with input from key stakeholders (TBI patients and caregivers, healthcare providers, and interdisciplinary research team members). BETTER is guided by the Individual and Family Self-Management Theory, our team's prior research, as well as literature used to support, educate, and train patients and families recovering from TBI and other conditions. The intervention is delivered by trained clinical interventionists (transitional care managers), beginning 24-72 h pre-discharge to 16 weeks post-discharge. BETTER offers tailored transitional care support to patient/family dyads, including assessing needs; establishing goals; coordinating post-hospital care, services, and resources; and providing patient/family education and training on brain injury coping skills. The majority of the intervention is delivered remotely via phone and remote video conferencing platform (Clinicaltrials.gov: NCT04584554).

RESULTS

We enrolled 15 dyads (N = 31, 15 patients, 16 caregivers) in this single arm, single center feasibility study. Most patients were men (n = 11, 73.33%), had a mean age of 39.07 (SD: 15.15), and were Black (n = 9, 60%), White (n = 5, 33.3%), or American Indian (n = 1, 0.66%). Injury severities were mild (n = 6, 40%), moderate (n = 4, 26.6%) or severe (n = 5, 33.33%). Most patients were insured (n = 10; 66.7%), had a high school education (n = 6; 40%); and earned $30,000 or less per year (n = 11; 73.3%). Most caregivers were married (n = 9, 56.25%) women (n = 14, 87.5%) with a mean age of 43.38 (SD: 10.45) and were Black (n = 8, 50%), White (n = 7, 43.75%), or American Indian (n = 1, 0.62%). Most caregivers identified as the spouse (n = 7; 43.75%) or parent (n = 6; 37.5%) of the patient.

CONCLUSIONS

BETTER is among the first TBI transitional care intervention to address needs/preferences for younger TBI patients of different racial groups after discharge home from acute hospital care and families. Findings can be used to inform future work.

The influence of personal factors, unmet need and service obstacles on the relationship between health service use and outcome after brain injury

Background

This exploratory study aimed to: (i) examine the relationship between health service use and quality of life, psychological wellbeing, global function and participation after discharge from brain injury inpatient rehabilitation, and (ii) determine the influence of personal factors, unmet need for services and service obstacles on the relationship between service use and these outcomes.

Methods

Using a prospective cohort design, 41 adults with acquired brain injury (median age = 46 years; 71% male; 61% severe traumatic injury) were followed for 6-months after discharge from specialist brain injury inpatient rehabilitation. Service use was continuously recorded and obtained through data linkage methods, focusing on the use of: outpatient medical services, outpatient nursing, outpatient allied health; medical acute services; incidents of re-hospitalization; and transitional rehabilitation service use. Outcome questionnaire measures were completed via telephone, at 6-months after discharge, and included: the EuroQol-5D; Depression Anxiety and Stress Scale, Mayo-Portland Adaptability Inventory and Sydney Psychosocial Reintegration Scale. Data were analyzed in a heterogeneous treatment effects framework, using Bayesian Additive Regression Trees.

Results

There was weak evidence that transitional rehabilitation service use was associated with better psychological wellbeing scores. The posterior probability of lower depression, anxiety and stress scores was .87, .81 and .86, respectively (average treatment effect). There was also weak evidence that re-hospitalization was associated with worse independent living skills scores. The posterior probability of worse scores was .87. However, most re-hospitalizations were due to unavoidable medical complications. We did not find that place of residence at discharge, marital status, unmet need, or service obstacles affected the relationship between service use and the studied outcomes.

Conclusions

This study may highlight the importance of participation in transitional rehabilitation, in the 6-months after discharge from brain injury rehabilitation. Replication in a larger sample size is required to confirm these findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07811-y.

Development of RehaBot-A Conversational Agent for Promoting Rewarding Activities in Users With Traumatic Brain Injury

OBJECTIVE

In this article, we describe the development and preliminary testing of RehaBot-a chatbot that users communicate with via text messaging designed to augment behavioral activation (BA) treatment of reducing depression and increasing participation in individuals with moderate to severe traumatic brain injury (TBI).

SETTING

Outpatient brain injury rehabilitation facility.

PARTICIPANTS

Outpatient brain injury clinicians and individuals with moderate to severe TBI.

DESIGN

Focus groups, software demonstration trials, and single-case experiments with an A-B-A design.

MAIN MEASURES

System Usability Scale (SUS) and self-reported completed target activities.

RESULTS

Focus group feedback guided the development of a flexible system to be used in conjunction with face-to-face therapy, designed to provide reminders, encouragement, and supportive feedback. Two of 3 participants completed all 6 RehaBot tasks independently. One completed 4 tasks independently and a fifth with assistance. Average SUS score in demonstration trials was 76.77 (SD = 21.19). In 4 single-case experiments, participants completed their highest proportion of planned activities in the RehaBot phase and the lowest proportion of planned activities in the reversal phase. They all interacted with RehaBot daily, exchanging an average of 225 messages over the 1-week period, and average SUS score was 95 (SD = 4.74). Their open-ended feedback revealed that participants found RehaBot enjoyable and easy to use. They felt it was a helpful memory aid and promoted better adherence to planned activities by providing accountability and positive reinforcement.

CONCLUSIONS

This article presents a chatbot development process heavily involving consumer input, which may serve as a model for future development efforts. Our findings provide preliminary evidence suggesting that RehaBot is usable and may promote better adherence to planned target activities. However, future research is needed to establish usability and efficacy of RehaBot and to explore applications of chatbots to other domains of TBI rehabilitation.

Enhancing Self-Advocacy After Traumatic Brain Injury: A Randomized Controlled Trial

OBJECTIVE

To evaluate the efficacy of a novel intervention aimed at enhancing self-advocacy in individuals living with traumatic brain injury (TBI).

SETTING

Community.

PARTICIPANTS

Sixty-seven (35 allocated to treatment, 32 to control) community-dwelling adults 9 months or more post-TBI (mean of 8.9 years postinjury); previously discharged from inpatient or outpatient TBI rehabilitation; able to travel independently in the community, indicating a level of independence needed to engage in self-advocacy.

DESIGN

Longitudinal randomized 2-arm controlled trial (NCT no. 03385824). Computer-generated block randomization allocated participants to treatment/intervention or control/no-intervention. All outcome assessments completed by blinded study staff.

INTERVENTION

A manualized group intervention, Self-Advocacy for Independent Life (SAIL), addressing the self-efficacy beliefs, knowledge, and skills for self-advocacy following TBI.

MAIN OUTCOME MEASURES

The Self-Advocacy Scale (SAS) (primary); General Self-Efficacy Scale (GSE); Personal Advocacy Activity Scale (PAAS); Satisfaction With Life Scale (SWLS).

RESULTS

The treatment group showed significantly greater improvement than controls from baseline to posttreatment on the primary measure (SAS) of self-efficacy specific to self-advocacy after TBI (effect size = 0.22). Similar improvements were found on secondary measures of general self-efficacy and satisfaction with life from baseline to posttreatment. However, significant between-groups gains for primary and secondary measures were not maintained over 6- and 12-week follow-up.

CONCLUSIONS

Individuals living with chronic TBI sequelae can increase self-efficacy specific to self-advocacy, general self-efficacy, and satisfaction with life, through a TBI-specific intervention aimed at empowering individuals to advocate for their own needs and wishes. Sustaining gains over time may require ongoing community collaboration and support. This could involve community-based systems of self-advocacy education, resources, and peer support.

CONNECT: A pragmatic clinical trial testing a remotely provided linkage to service coordination after hospitalization for TBI

OBJECTIVE

To test whether a complex behavioral intervention delivered remotely to connect individuals to clinical resources after hospitalization for TBI improved their quality of life.

DESIGN/METHODS

Community-based randomized pragmatic clinical trial. Main measures TBI-QOL, Activity Measure for Post-Acute Care (AM-PAC), Clinical Satisfaction and Competency Rating Scale.

RESULTS

332 individuals ≥18 years-old hospitalized for TBI in four upper Midwest states were randomized to Remote (n = 166) and Usual Care (n = 166) groups. The groups were equivalent and representative of their state population's racial and ethnic composition, age, and proportion living in rural communities. There were no significant differences within or between experimental groups over the study period in TBI-QOL t-scores. There was a significant improvement in AM-PAC Daily Activities within the Remote group and a significant between-group improvement in clinical satisfaction for the Remote group.

CONCLUSION

Enrolling a representative, regional community-based sample of individuals with TBI can be successful, and delivering a customized complex behavioral intervention remotely is feasible. The overall lack of intervention effectiveness was likely due to enrolling individuals without pre-identified clinical needs, initiating intervention after the immediate post-acute phase when needs are often highest, inability to provide direct clinical care remotely, and potential lack of outcome measure responsiveness in our sample.

Organizational characteristics of Brain Injury Clubhouse Model programs

OBJECTIVE

We provide an overview of the Clubhouse Model and the history and development of Brain Injury Clubhouses. We describe organizational-level characteristics associated with eight Brain Injury Clubhouses to address gaps in the literature and inform future studies or program development.

METHODS

A electronic survey, the Clubhouse Profile Questionnaire (CPQ) was tailored for Brain Injury Clubhouses. The CPQ gathers program-level data that can be used to identify active ingredients of Clubhouses, understand best practices, examine, and evaluate program characteristics. The brain injury version of the CPQ was administered to a sample of eight Clubhouses affiliated with the International Brain Injury Clubhouse Association as part of a project designed to gather data on Clubhouse program characteristics and describe sociodemographic characteristics of people served by Brain Injury Clubhouses.

RESULTS

CPQ data from eight Brain Injury Clubhouses was analyzed. Brain Injury Clubhouse programs in this sample served approximately 17 members per day. There was wide variability in the size, funding and funding mechanisms, and length of operation of Brain Injury Clubhouses in this study.

CONCLUSIONS

Findings suggest that Brain Injury Clubhouses offer a wide range of services and supports. Additional research on the impact of Brain Injury Clubhouses is needed.

Does Integrating Cognitive and Psychological Interventions Enhance Wellbeing After Acquired Brain Injury? Study Protocol for a Phase II Randomized Controlled Trial of the VaLiANT (Valued Living After Neurological Trauma) Group Program

Background and Objectives

Cognitive and emotional changes affect the majority of individuals with acquired brain injury (ABI) and are associated with poorer outcomes. The evidence for “siloed” rehabilitation approaches targeting cognition and mood separately remains mixed. Valued living (i.e., acting consistently with personal values) is associated with better psychological functioning and participation in work and other productive activities. Rehabilitation interventions that concurrently address cognitive and emotional barriers to valued living may therefore result in improved outcomes. VaLiANT (Valued Living After Neurological Trauma) is an 8-week group intervention developed by our team, which uniquely combines cognitive rehabilitation and psychological therapy to improve wellbeing and meaningful participation (i.e., valued living) following ABI.

Method

This protocol describes the design and implementation of a Phase II parallel-group randomized controlled trial with blinded outcome assessors, to evaluate the potential efficacy of VaLiANT and the feasibility of a Phase III trial. Participants are adults with a history of ABI at least 3 months prior to study entry, who experience cognitive and/or emotional difficulties and associated reduced participation in valued activities. Random allocation to the treatment condition (8-week VaLiANT group program) or a usual care waitlist control condition occurs at a 2:1 treatment: control ratio. The primary outcome is wellbeing, measured by the Warwick-Edinburgh Mental Wellbeing Scale. Secondary outcomes include measures of valued living, mood, cognitive complaints, quality of life, community participation, post-traumatic growth, and self-efficacy. All measures are collected across three time points by blinded assessors (baseline, 8-week follow-up, 16-week follow-up). Trial feasibility will be evaluated against recruitment rates, drop-out rates, intervention acceptability, and treatment fidelity (manual adherence and therapist competence).

Discussion

This trial will extend current knowledge on how to improve long-term outcomes following ABI by evaluating an innovative integrated, multi-domain approach to rehabilitation concurrently addressing cognitive and emotional barriers to participation in meaningful life roles.

Quality of life, community integration, service needs and clinical outcomes of people with traumatic brain injury in urban, regional and remote areas of Queensland, Australia

OBJECTIVE

To understand and explore the traumatic brain injury (TBI) outcomes for people returning to urban versus rural communities post-injury, and if geographical location plays a role in those outcomes.

DESIGN

Cross-sectional mail-out survey of TBI patients, using standardised, quantitative measures.

SETTING

Data were drawn from three Accessibility Remoteness Index of Australia (ARIA) areas in Queensland to model the contribution of these areas and other factors to TBI outcomes.

PARTICIPANTS

Using hospital records, 662 people with mild to severe TBI were identified. These people were sent a survey, postdischarge. Usable surveys were returned by 91 individuals, 6- to 18-months post-injury. Location was coded using the ARIA (urban n = 22, rural n = 43, remote n = 26).

MAIN OUTCOME MEASURES

TBI-related symptoms, quality of life, service obstacles, unmet needs, mental health and community integration.

RESULTS

No group differences in TBI outcomes due to location were found. While the participant's gender, age, and injury severity were significant independent predictors of five of the six outcomes, location did not play a role.

CONCLUSION

Consistent with previous findings, geographical remoteness did not affect self-reported TBI outcomes. Older people, women and those with severe TBI had worse outcomes and required additional supports, and men require community integration assistance. An Australia-wide study with regular follow-ups is strongly recommended to support direct regional comparisons and improve service planning.

Traumatic Brain Injury Screening and the Unmet Health Needs of Shelter-Seeking Women with Head Injuries Related to Intimate Partner Violence

Background: Unmet health needs of women with head injuries sustained by intimate partner violence (IPV) include risk of traumatic brain injury (TBI). The purpose of this evaluation was to explore the potential effectiveness of TBI screening as a health promotion strategy for shelter-seeking women with IPV head injuries. We wanted to learn if shelter-seeking women, willing to disclose IPV, would accept TBI screening if offered.

Methods: An extended version of the HELPS TBI screening tool and survey of daily symptoms and health needs were used to screen new residents of an urban shelter for women.

Results: The participants (N = 18) primarily were educated black women with one or more self-reported IPV-related head injury. Most participants (77.8%) had positive TBI screens for probable brain injury. The majority (88.8%) lived with one or more daily symptoms they did not have before sustaining a IPV head injury. The symptoms reported most frequently were depression (88.9%), anxiety (77.8%), and headache (66.7%). All participants had one or more unmet health need. Although most (77.8%) needed to see a primary care provider, mental health care was the most important health need identified.

Conclusions: TBI screening could be considered an effective health promotion strategy for IPV survivors if screening facilitates treatment for positive screens and other unmet health needs. Further research is needed to properly assess this.

Psychotropic medication use among patients with a traumatic brain injury treated in the intensive care unit: a multi-centre observational study

BACKGROUND

Psychiatric sequelae after traumatic brain injury (TBI) are common and may impede recovery. We aimed to assess the occurrence and risk factors of post-injury psychotropic medication use in intensive care unit (ICU)-treated patients with TBI and its association with late mortality.

METHODS

We conducted a retrospective multi-centre observational study using the Finnish Intensive Care Consortium database. We included adult TBI patients admitted in four university hospital ICUs during 2003-2013 that were alive at 1 year after injury. Patients were followed-up until end of 2016. We obtained data regarding psychotropic medication use through the national drug reimbursement database. We used multivariable logistic regression models to assess the association between TBI severity, treatment-related variables and the odds of psychotropic medication use and its association with late all-cause mortality (more than 1 year after TBI).

RESULTS

Of 3061 patients, 2305 (75%) were alive at 1 year. Of these, 400 (17%) became new psychotropic medication users. The most common medication types were antidepressants (61%), antipsychotics (35%) and anxiolytics (26%). A higher Glasgow Coma Scale (GCS) score was associated with lower odds (OR 0.93, 95% CI 0.90-0.96) and a diffuse injury with midline shift was associated with higher odds (OR 3.4, 95% CI 1.3-9.0) of new psychotropic medication use. After adjusting for injury severity, new psychotropic medication use was associated with increased odds of late mortality (OR 1.19, 95% CI 1.19-2.17, median follow-up time 6.4 years).

CONCLUSIONS

Psychotropic medication use is common in TBI survivors. Higher TBI severity is associated with increased odds of psychotropic medication use. New use of psychotropic medications after TBI was associated with increased odds of late mortality. Our results highlight the need for early identification of potential psychiatric sequelae and psychiatric evaluation in TBI survivors.

The Experience of Caregivers Following a Moderate to Severe Traumatic Brain Injury Requiring ICU Admission

OBJECTIVES

Survivors of moderate and severe traumatic brain injury (TBI) require substantial care, much of which is ultimately provided by friends and family. We sought to describe the unmet needs of informal caregivers.

DESIGN

Qualitative, semistructured interviews with informal caregivers of moderate and severe TBI survivors were conducted 72 hours, 1 month, 3 months, and 6 months after injury.

SETTING

Intensive care unit of a level 1 trauma center.

PARTICIPANTS

Informal caregivers were friends or family who planned to provide care for the patient. Patients were 18 years or older with a moderate to severe TBI, and not expected to imminently die of their injuries.

MEASUREMENTS AND MAIN RESULTS

Eighteen patient-caregiver dyads were enrolled. Fifty-three interviews with caregivers were completed and analyzed over the course of 6 months. Three themes were identified in the qualitative analysis: caregiver burden, caregiver health-related quality of life, and caregiver needs for information and support.

CONCLUSIONS

This study provides new information about the experience of informal caregivers during the 6 months after their friend or family member survived a moderate to severe TBI. Interventions to promote caregiving may be a substantial opportunity to improve patient-centered outcomes following TBI.

A single-case experimental evaluation of a new group-based intervention to enhance adjustment to life with acquired brain injury: VaLiANT (valued living after neurological trauma)

Adjustment to life with acquired brain injury (ABI) requires self-identity and behaviour to be updated, incorporating injury-related changes. Identifying and enabling new values-consistent behaviours could facilitate this process. We evaluated the feasibility, acceptability, and preliminary efficacy of VaLiANT, a new group intervention that aims to enhance "valued living" following ABI. We used a non-concurrent multiple baseline single-case experimental design (SCED) with an 8-week follow-up phase and randomization to multiple baseline lengths (5-7 weeks). Eight participants (50% women, aged 26-65; 4 Stroke, 3 Traumatic Brain Injury, 1 Epilepsy) attended eight group sessions with assessments before, during, and after the group. Target behaviour was valued living, assessed weekly by the Valued Living Questionnaire. Secondary outcomes included measures of wellbeing, mood, psychological acceptance, self-efficacy regarding ABI consequences, cognitive complaints, and intervention acceptability. Target behaviour was analysed through visual and statistical analysis while secondary outcome data were analysed via reliable change indices and descriptive statistics. Target behaviour data displayed no convincing patterns of improvement. Reliable improvements were found for most participants on secondary outcomes, particularly subjective wellbeing and anxiety. Intervention delivery was feasible with high acceptability ratings. Further investigation of VaLiANT is warranted, based on the feasibility and acceptability of intervention delivery and signals of efficacy identified across adjustment-related secondary outcomes.

The impact of obstacles to health and rehabilitation services on functioning and disability: a prospective survey on the 12-months after discharge from specialist rehabilitation for acquired brain injury

PURPOSE

Little is known about obstacles to health and rehabilitation services experienced by people with acquired brain injury (ABI) over time and what impact these have on recovery. This study utilised the International Classification of Functioning, Disability, and Health model to better understand the impact of service obstacles. The aims were: (1) describe and compare service obstacles reported in the 12-months post-discharge from inpatient rehabilitation; (2) examine service obstacles as a moderator of the relationship between functional impairment and activities and participation.

MATERIALS AND METHODS

Prospective survey of 41 people who received ABI inpatient rehabilitation in Queensland, Australia. Validated self-report measures of service obstacles, functional impairment, and activities and participation were administered at 6- and 12-months post-discharge.

RESULTS

Transportation was the highest-rated obstacle at 6-months post-discharge, and this decreased at 12-months. Dissatisfaction with treatment resources and financial obstacles were, on average, low-to-moderate and remained constant. Specifically, the moderation analyses showed that financial obstacles may exacerbate the negative impact of functional impairment on independent living skills.

CONCLUSIONS

Our findings suggest that people living in Queensland, Australia, who experience financial obstacles to services after brain injury may be at risk of poorer recovery outcomes. Rehabilitation policy should consider prioritising individuals who experience financial obstacles to accessing services.IMPLICATIONS FOR REHABILITATIONIn Queensland, Australia, financial obstacles to accessing health services after brain injury may exacerbate the negative impact of functional impairment on independent living skills, in the first 12-months after hospital discharge.There may be a need to prioritize rehabilitation policy that targets individuals who experience financial obstacles to accessing health and rehabilitation services, after brain injury, irrespective of a health system's potential to enable access.

Rehabilitation Needs at 5 Years Post-Traumatic Brain Injury: A VA TBI Model Systems Study

OBJECTIVE

Describe rehabilitation needs and factors associated with unmet needs at 5 years post-traumatic brain injury (TBI).

SETTING

Five Veterans Affairs (VA) polytrauma rehabilitation centers (PRCs).

PARTICIPANTS

VA TBI Model Systems participants (N = 283; 96% male, 75%, 57% severe TBI).

DESIGN

Prospective observational cohort.

MAIN MEASURES

Rehabilitation Needs Survey (21-item survey that assesses cognitive, emotional, social, and functional needs); Craig Hospital Inventory of Environmental Factors (25-item survey of potential environmental barriers).

RESULTS

Participants endorsed a mean of 8 (SD: 6.2) ongoing and 3 (SD: 4.7) unmet rehabilitation needs at 5 years post-TBI. Approximately 65% of participants reported at least 1 rehabilitation need that remained unmet. The number and nature of needs differed across TBI severity groups. In unadjusted and adjusted linear regression models, Black race and environmental barriers (Craig Hospital Inventory of Environmental Factors total score) were predictive of unmet needs (P < .001). Those with greater unmet needs reported the physical environment (54%-63%), informational sources (54%), social attitudes (55%), healthcare access (40%), public policy (32%-37%), transportation availability (33%), and in-home assistance (32%) as the most frequent environmental barriers at 5 years post-TBI.

CONCLUSION

Veterans and Service Members continue to have rehabilitation needs at 5 years post-TBI. Veterans Affairs programs to address ongoing needs and policy to support them are needed.

Predictors of traumatic brain injury morbidity and mortality: Examination of data from the national trauma data bank: Predictors of TBI morbidity & mortality

BACKGROUND

There is evidence to suggest that traumatic brain injuries (TBI) are increasing in the United States. It is important to examine predictors of TBI outcomes to formulate better prevention and care strategies.

RESEARCH DESIGN

National Trauma Data Bank (NTDB) data from 2016 were used to report the percentage of TBI by age, sex, race/ethnicity, health insurance status, intent/mechanism of injury, Glasgow Coma Scale (GCS), disposition at emergency department, and trauma center level. Logistic regression models were run to estimate the adjusted odds ratios of patient and facility characteristics on length of hospital stay and in-hospital mortality (analyzed in 2020).

RESULTS

There were 236,873 patients with TBI in the NTDB in 2016. Most patients with a TBI were male, non-Hispanic white, and had sustained a TBI due to an unintentional injury. After adjusting for other factors, individuals age 0-17, those who self-pay, and those with intentional injuries had increased odds of a shorter hospital stay. Older individuals, non-Hispanic black or Hispanic patients, those who had sustained an intentional injury, and those who were not seen in a Level I trauma center had higher odds of mortality following their TBI.

CONCLUSIONS

Public health professionals' promotion of fall and other TBI prevention efforts and the development of strategies to improve access to Level I trauma centers, may decrease adverse TBI health outcomes. This may be especially important for older adults and other vulnerable populations.

Development of the traumatic brain injury Rehabilitation Needs Survey: a Veterans Affairs TBI Model Systems study

PURPOSE

To describe the development of the Rehabilitation Needs Survey (RNS) for persons in the chronic phase of traumatic brain injury (TBI) recovery.

MATERIALS AND METHODS

RNS items were generated following a literature review (January - March 2015) on the topic of rehabilitation needs and revised via consensus from an expert panel of TBI clinicians and researchers. The RNS was added to the VA TBI Model Systems longitudinal study; data collection occurred between 2015-2019. Needs were classified as current (if endorsed) or absent; if current, needs were classified as unmet if no help was received. Need frequency and association with rehabilitation outcomes were presented.

RESULTS

Eight studies examined rehabilitation needs and formed the initial item pool of 42 needs. This was reduced to form the 21-item RNS which was administered at year 1 (n = 260) and year 2 (n = 297) post-TBI. Number of needs endorsed was 8-9, and number of unmet needs was 1-2, on average. Number of needs was correlated with functional status, neurobehavioral symptoms, and mental health symptoms (p < 0.05) suggesting support for convergent validity of the RNS.

CONCLUSION

The RNS is a new measure of rehabilitation needs following TBI. Further investigation into its psychometrics and clinical utility is recommended.Implications for rehabilitationVeterans and Service Members with traumatic brain injury across the severity spectrum have ongoing rehabilitation needs during the chronic phase of recovery.The Rehabilitation Needs Survey is a standardized measure of rehabilitation needs following traumatic brain injury.Identification of unmet rehabilitation needs is important for raising awareness of service gaps and providing justification for resource allocation.

"Just tell me in a simple way": A qualitative study on opportunities to improve the transition from acute hospital care to home from the perspectives of patients with traumatic brain injury, families, and providers

OBJECTIVE

The purpose of this study was to identify areas to improve the transition from acute hospital care to home for patients with traumatic brain injury and their families.

DESIGN

Qualitative, descriptive.

SETTING

Level I trauma centered located in the Southeastern United States.

SUBJECTS

A total of 36 participants (12 patients with traumatic brain injury, 8 family caregivers, 16 providers).

MAIN MEASURES

We conducted 55 semi-structured interviews with participants and used conventional content analysis to analyze the data.

RESULTS

Findings showed patients, families, and providers recommend three areas for improvement in the transition home from acute hospital care, described in three themes. Theme 1 was "improving patient and family education," with the following sub-themes: (a) TBI-related information and (b) discharge preparation. Theme 2 was "additional provider guidance," with the following sub-themes: (a) communication about patient's recovery timeline and (b) recovery roadmap development. Theme 3 was "increasing systems-level support," with the following sub-themes: (a) scheduling follow-up appointments, (b) using a patient navigator, (c) creating a provider follow-up structure, (d) linking pre-discharge care with post-discharge resources, and (e) addressing social issues.

CONCLUSIONS

These findings delineate multiple areas where patients and families need additional support and education during the transition from acute hospital care to home in ways that are currently not being addressed. Findings may be used to improve education and support from providers and health systems given to patients with traumatic brain injury and families and to inform development and testing of transitional care interventions from acute hospital care to home.

Estimates of Long-Term Disability Among US Service Members With Traumatic Brain Injuries

BACKGROUND

Traumatic brain injury (TBI) is a significant health issue in the US military. The purpose of this study was to estimate the probability of long-term disability among hospitalized service members (SMs) with TBIs, using the South Carolina Traumatic Brain Injury and Follow-up Registry (SCTBIFR) model developed on civilian hospitalized patients.

METHODS

We identified military patients in military or civilian hospitals or theater level 3 to 5 military treatment facilities (MTFs) whose first TBI occurred between October 1, 2013, and September 30, 2015. TBI-related disability at 1-year post-hospital discharge was estimated using regression coefficients from the SCTBIFR.

RESULTS

Among the identified 4877 SMs, an estimated 65.6% of SMs with severe TBI, 56.2% with penetrating TBI, 31.4% with moderate TBI, and 12.0% with mild TBI are predicted to develop long-term disability. TBI patients identified at theater level 4 and 5 MTFs had an average long-term disability rate of 56.9% and 61.1%, respectively. In total, we estimate that 25.2% of all SMs hospitalized with TBI will develop long-term disability.

CONCLUSION

Applying SCTBIFR long-term probability estimates to US SMs with TBIs provides useful disability estimates to inform providers and health systems on the likelihood that particular subgroups of TBI patients will require continued support and long-term care.

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

Purpose:

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

Methods:

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

Results:

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

Conclusion:

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

Unmet Rehabilitation Needs Indirectly Influence Life Satisfaction 5 Years After Traumatic Brain Injury: A Veterans Affairs TBI Model Systems Study

OBJECTIVE

To describe the association between unmet rehabilitation needs and life satisfaction 5 years after traumatic brain injury (TBI).

DESIGN

Prospective observational cohort.

SETTING

Five Veterans Affairs (VA) Polytrauma Rehabilitation Centers.

PARTICIPANTS

VA TBI Model Systems participants (N=301); 95% male; 77% white; average age, 39±14y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Satisfaction With Life Scale (SWLS).

RESULTS

Average SWLS score was 22±8. Univariable analyses demonstrated several statistically significant predictors of life satisfaction, including employment status, participation, psychiatric symptom severity, past year mental health treatment, and total number of unmet rehabilitation needs (all P<.05). Multivariable analyses revealed that depression and participation were each associated with life satisfaction. An ad hoc mediation model suggested that unmet rehabilitation needs total was indirectly related to life satisfaction. Total unmet rehabilitation needs ranged from 0-21 (mean, 2.0±3.4). Correlational analyses showed that 14 of the 21 unmet rehabilitation needs were associated with life satisfaction.

CONCLUSIONS

Findings support the need for rehabilitation engagement in later stages of TBI recovery. Ongoing assessment of and intervention for unmet rehabilitation needs in the chronic phase of recovery have the potential to mitigate decline in life satisfaction.

Regional Variations in Rehabilitation Outcomes of Adult Patients With Traumatic Brain Injury: A Uniform Data System for Medical Rehabilitation Investigation

OBJECTIVES

To examine regional differences in rehabilitation outcomes among adult patients with moderate-to-severe traumatic brain injury (TBI) who received care at an inpatient rehabilitation facility (IRF).

DESIGN

We conducted a secondary analysis of a large, multi-center dataset from the Uniform Data System for Medical Rehabilitation.

SETTING

More than 70% of all IRFs in the United States.

PARTICIPANTS

Adult TBI patients (N=175,358) aged 18 years or older who were admitted and discharged from an IRF in the United States between 2004 and 2014. Qualifying etiology included traumatic brain dysfunction Impairment Group codes 02.21 (traumatic, open injury) and 02.22 (traumatic, closed injury).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Discharge functional status (total, cognitive, motor), length of stay, and discharge to home.

RESULTS

Patient and clinical characteristics varied significantly by geographic location, as did median functional status, length of stay, and percentage of patients discharged home. The region where IRF care was received, race and ethnicity, age, occurrence of 1 or more falls during the IRF stay, case mix group, and insurance status were associated with discharge functional status, length of stay, and discharge to home.

CONCLUSIONS

Our findings provide evidence of geographic differences in outcomes and potential disparities in care of TBI patients who received IRF care. More research is needed to identify TBI patients at risk for poor discharge outcomes to inform development and testing of interventions to reduce disparities in outcomes for these patients.

Exploring Participant Perceptions of a Community-Based Program for People With Brain Injury

An acquired brain injury presents complex challenges to survivors returning to the community, and as more individuals survive, the need for programs that support optimal quality of life increases. To explore participant perceptions of a community-based program. To accomplish objectives, 10 individuals living with chronic brain injury who were attendees of the community program were interviewed. Applying qualitative study procedures, all narrative data were transcribed and analyzed. All participants expressed that the program positively impacted several personal life satisfaction factors as well as their participation within their respective communities. Themes included (1) Acceptance, (2) Sense of Community, (3) Sense of Purpose, (4) Autonomy, and (5) Personal Development. Discussion includes analysis of program elements that help explain participant responses. Description of the occupational therapy grounded program offers a guide to others wishing to develop similar programs for individuals living with brain injury.

Finding a new balance in life: a qualitative study on perceived long-term needs of people with acquired brain injury and partners

Objective: Although the long-term consequences of acquired brain injury are frequent and diverse, care and support over the longer term is an under-addressed issue. This study aims to identify the perceived needs of people with acquired brain injury and their partners.Methods: Interviews with four focus groups of people with brain injury (n = 17) and three partner groups (n = 19) were audio- and videotaped, transcribed verbatim and analyzed using inductive content analysis.Results: Needs were perceived on the intrapersonal, social, healthcare and societal levels, focusing on three themes: 1) Adaptation to changes, including awareness of consequences, acceptance, role changes and dealing with these; 2) Understanding from relatives/friends, professionals, institutions and society; 3) Timely, individualized care, involving information, transition to home, searching for support, peer support and support for partner/family.Discussion: The variety and complexity of needs show that people with brain injury and their partners need to find a new balance in order to live a fulfilling life despite the consequences of brain injury. The overarching need for continuity of care from the transition to home onwards provides important implications for supporting the process of learning how to live well with brain injury.

Postconcussion Academic Support in Children Who Attend a Primary Care Provider Follow-up Visit after Presenting to the Emergency Department

OBJECTIVE

To examine whether a primary care provider (PCP) follow-up visit after emergency department evaluation of concussion improved the children's likelihood of receiving academic support.

STUDY DESIGN

This was a prospective cohort study. Concussed children, aged 8-18 years, presenting to a regional pediatric trauma center emergency department (n = 160) were contacted 7 and 30 days after injury to gather data on PCP follow-up, symptoms, quality of life, and receipt of academic support instituted after and because of the concussion. Bivariate comparisons of demographics, concussion characteristics, quality of life, and symptoms were made between children who did and did not receive support using independent samples t tests, Wilcoxon rank sum tests, or χ² tests. ORs and 95% CIs were calculated using multivariable logistic regression with backwards elimination to test the association between attending an outpatient follow-up visit and the receipt of academic support for variables where P < .2 in bivariate comparisons.

RESULTS

Overall, 51.3% (n = 82) received academic support; of these, 84.2% attended a follow-up visit compared with 71.8% of 78 children who attended a follow-up visit but did not receive support (P = .06). Children who received support were more likely to have commercial insurance; experience a sports-related injury mechanism; have parents whose primary language was English; suffer from learning disabilities and migraines; and be non-Hispanic (P < .05). There was no association between attending a follow-up visit and receipt of academic support (adjusted OR 1.83; 95% CI 0.75-4.45).

CONCLUSIONS

Although the majority of children received academic support postconcussion, accommodations were associated with several demographic, medical history, and injury characteristics, but not attending a PCP follow-up visit.

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

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

Care coordination experiences of people with traumatic brain injury and their family members in the 4-years after injury: a qualitative analysis

TITLE

Care coordination experiences of people with traumatic brain injury and their family members 4-years after injury: A qualitative analysis.

AIM

To explore experiences of care coordination in the first 4-years after severe traumatic brain injury (TBI).

METHODS

A qualitative study nested within a population-based longitudinal cohort study. Eighteen semi-structured telephone interviews were conducted 48-months post-injury with six adults living with severe TBI and the family members of 12 other adults living with severe TBI. Participants were identified through purposive sampling from the Victorian State Trauma Registry. A thematic analysis was undertaken.

RESULTS

No person with TBI or their family member reported a case manager or care coordinator were involved in assisting with all aspects of their care. Many people with severe TBI experienced ineffective care coordination resulting in difficulty accessing services, variable quality in the timing, efficiency and appropriateness of services, an absence of regular progress evaluations and collaboratively formulated long-term plans. Some family members attempted to fill gaps in care, often without success. In contrast, effective care coordination was reported by one family member who advocated for services, closely monitored their relative, and effectively facilitated communication between services providers.

CONCLUSION

Given the high cost, complexity and long-term nature of TBI recovery, more effective care coordination is required to consistently meet the needs of people with severe TBI.

Craniectomy and Craniotomy in Traumatic Brain Injury: A Propensity-Matched Analysis of Long-Term Functional and Quality of Life Outcomes

OBJECTIVE

To report the comprehensive long-term functional and quality of life outcomes after craniectomy (CE) and craniotomy (CO) in individuals with traumatic brain injury (TBI).

METHODS

Information on all individuals with TBI who had undergone CE or CO were extracted from the TBI Model Systems database from 2002 to 2012. A 1:1 propensity matching with replacement technique was used to balance the baseline characteristics across groups. The matched sample was analyzed for outcomes during hospitalization, acute rehabilitation, and ≤2 years of follow-up.

RESULTS

We identified 1470 individuals who had undergone CE or CO. Individuals undergoing CE compared with CO demonstrated a longer length of stay in the hospital (median, 22 vs. 18 days; P < 0.0001) and acute rehabilitation (median 26 vs. 21 days; P < 0.0001). Individuals with CE had required rehospitalization more often by the 1-year follow-up point (39% vs. 25%; P < 0.0001) for reasons other than cranioplasty, including seizures (12% vs. 8%; P < 0.0001), neurologic events (i.e., hydrocephalus; 9% vs. 4%; P < 0.0001), and infections (10% vs 6%; P < 0.0001). Individuals with CE had significantly greater impairment using the Glasgow Outcome Scale-Extended, required more supervision, and were less likely to be employed at 1 and 2 years after TBI. No difference was observed in the satisfaction with life scale scores at 2 years. The Kaplan-Meier mortality estimates at 1 and 2 years showed no differences between the 2 groups (hazard ratio, 0.57; P = 0.4).

CONCLUSION

In a matched cohort, individuals undergoing CE compared with CO after TBI had a longer length of stay, decreased functional status, and more rehospitalizations. The survival at 2 years and the satisfaction with life scale scores were similar.

Traumatic Brain Injury Occludes Training-Dependent Cortical Reorganization in the Contralesional Hemisphere

Rehabilitative training drives plasticity in the ipsilesional (injured) motor cortex that is believed to support recovery of motor function after either stroke or traumatic brain injury (TBI). In addition, adaptive plasticity in the contralesional (uninjured) motor cortex has been well-characterized in the context of stroke. While similar rehabilitation-dependent plasticity in the intact hemisphere may occur after TBI, this has yet to be thoroughly explored. In this study, we investigated the effects of TBI and forelimb training on reorganization of movement representations in the intact motor cortex. Rats were trained to proficiency on the isometric pull task and then received a controlled cortical impact (CCI) in the left motor cortex to impair function of the trained right forelimb. After TBI, animals underwent forelimb training on the pull task for 2 months. At the end of training, intracortical microstimulation was used to document the organization of the intact motor cortex (the contralesional hemisphere). TBI significantly decreased the cortical area eliciting movements of the impaired forelimb in untrained animals. In the absence of TBI, training significantly increased forelimb map area, compared with in untrained controls. However, training of the impaired forelimb after TBI was insufficient to increase forelimb map area. These findings are consistent with other studies showing impaired rehabilitation-dependent plasticity after TBI and provide a novel characterization of TBI on rehabilitation-dependent plasticity in contralesional motor circuits.

Does history of substance use disorder predict acute traumatic brain injury rehabilitation outcomes?

BACKGROUND/OBJECTIVE

The study explored whether premorbid substance use disorder (SUD) predicts acute traumatic brain injury (TBI) outcomes.

METHODS

143 participants with moderate (34.2%) and severe (65.8%) TBI were enrolled at two Level 1 trauma center inpatient brain injury rehabilitation units. Acute outcomes were measured with the Disability Rating Scale (DRS), the FIMTM; self and informant ratings of the Patient Competency Rating Scale (PCRS); self and family rating of the Frontal Systems Behavioral Scale (FrSBe), and the Neurobehavioral Rating Scale-Revised (NRS-R).

RESULTS

Hierarchical linear modeling revealed that SUD history significantly predicted trajectories of PCRS clinician ratings, PCRS self-family and PCRS self-clinician discrepancy scores, and more negative FrSBE family ratings. These findings indicate comparatively greater post-injury executive functions (EF) impairments, particularly self-awareness (SA) of injury-related deficits, for those with SUD history. No significant SUD*time interaction effect was found for FIM or NRS-R scores.

CONCLUSIONS

SUD history and TBI are associated with impaired SA and EF but their co-occurrence is not a consistent predictor of acute post-injury functional outcomes. Pre-morbid patient characteristics and rater expectations and biases may moderate associations between SA and recovery after TBI.

Improving personal self-advocacy skills for individuals with brain injury: A randomized pilot feasibility study

OBJECTIVE

To investigate the feasibility of a self-advocacy intervention for individuals with acquired brain injury (ABI).

DESIGN

Two-arm, parallel-design, randomized feasibility study.

METHODS

Twelve participants, 1-year or more post-ABI (TBI and cerebral vascular accident (CVA)), were randomized into treatment/control groups. The treatment group received a group intervention and workbook; the control group received the workbook only. Outcome measures, taken at baseline, post-treatment and 6-weeks follow-up, included the General Self-Efficacy Scale (GSES), Satisfaction with Life Scale (SWLS) and Goal Attainment Scale (GAS) and two exploratory measures developed for the study: the Self Advocacy Scale (SAS) and the Personal Advocacy Activity Scale (PAAS).

RESULTS

Participants were successfully recruited and treated per protocol. The treatment group exhibited improvements from baseline to post-treatment on all measures; the control group improved on the GSES and declined on all others. Both groups exhibited improvement on all measures at follow-up, except the PAAS, which declined. There were no significant group differences on non-parametric analysis at any assessment points; however, the magnitude of change at post-treatment approached significance for the SAS and PAAS.

CONCLUSIONS

Initial feasibility for the methodology was demonstrated. Positive trends were noted. Further research could result in an evidence-based intervention to enhance self-advocacy post-ABI.

The experience of patients with ABI and their families during the hospital stay: A systematic review of qualitative literature

BACKGROUND

Patients with acquired brain injury (ABI) and their families have unique experiences and needs during the hospital stay; yet, limited literature exists on this topic. The purpose of this systematic review was to compile and synthesize literature on the experience of patients with ABI and their families during the hospital stay.

METHODS

A systematic review of qualitative studies was conducted by searching for studies from seven databases. Content analysis was used to analyse and synthesize studies' findings separately for the patient and family experience.

RESULTS

The initial search provided 2871 records. Ultimately, 11 studies relevant to the research question were included in this review. No studies were excluded based on critical quality appraisal. Findings on the patient experience showed patients had negative perceptions of the rehabilitation environment and a perceived need for information. Findings on the family experience included difficulty adjusting after the patient's injury, a desire to be involved in the patient's care, mixed feelings about staff support and a high perceived need for information.

CONCLUSIONS

Findings provide awareness for healthcare providers on the multifaceted experiences of patients with ABI and their families during the hospital stay, strategies to make care more patient- and family-centred and directions for future research.

Effectiveness of an Educational Intervention on Reducing Misconceptions Among Ethnic Minorities With Complicated Mild to Severe Traumatic Brain Injury

OBJECTIVE

To evaluate the effectiveness of an educational intervention designed to reduce traumatic brain injury (TBI)-related misconceptions among blacks and Latinos with complicated mild to severe TBI.

DESIGN

Randomized controlled trial with masked 1-month follow-up.

SETTING

Community.

PARTICIPANTS

Persons (N=52) with complicated mild to severe TBI (mean best day 1 Glasgow Coma Scale score, 11.27±3.89) were randomly recruited from 141 eligible participants (mean age, 37.71±13.88y; age range, 19-66y; mean months postinjury, 24.69±11.50); 25 participants (48.1%) of participants were black and 27 (51.9%) were Hispanic/Latino. Of the Hispanic/Latino participants, 18 (66.7%) were non-U.S. born and 12 (44.4%) spoke Spanish as their primary language. Twenty-seven individuals were randomized to the educational intervention group and 25 were randomized to the wait-list control group.

INTERVENTIONS

Single-session educational intervention with written materials provided in English or Spanish.

MAIN OUTCOME MEASURES

Forty-item Common Misconceptions about Traumatic Brain Injury Questionnaire administered at baseline and 1-month follow-up.

RESULTS

After controlling for ethnic and language differences, a significant between-group main effect (P=.010) and a significant time-group interaction for the Common Misconceptions about Traumatic Brain Injury Questionnaire were noted (Wilks Λ=.89; F_1,46=6.00; P=.02). The intervention group showed a decrease in TBI misconception percentages, whereas the wait-list control group maintained similar percentages. At 1-month follow-up, the wait-list control group reported more misconceptions than did the intervention group (P=.019).

CONCLUSIONS

An educational intervention developed to address the recovery process, common symptoms, and ways to handle the symptoms provides promise as a tool to decrease TBI misconceptions among persons from ethnically and educationally diverse backgrounds. The effects of therapist characteristics and the client-therapist relation on outcomes should be further explored.

Sense of Community and Its Impact on the Life Satisfaction of Adults With Brain Injury

Sense of community (SOC) refers to feelings of belonging and attachment one has for a community. Despite a growing focus on adjustment and community outcomes following disability, this construct has received little attention in the rehabilitation literature. The primary aim of this study was to examine the extent to which SOC and social identification with one’s town contribute to life satisfaction outcomes among adults with brain injury, controlling for demographic, disability, and other related social constructs (e.g., social support and social integration). Members from brain injury associations across the United States ( N = 177) participated in a survey-based study. Results from hierarchical regression analysis indicated that the final model accounted for 45% of the variance in life satisfaction, with SOC variables contributing 11%. Symptom severity, perceived emotional support, and the SOC dimension reinforcement of needs were significant independent predictors of life satisfaction. Findings from this study highlight the importance of examining SOC variables among clients with brain injury to enhance subjective well-being.

Functional outcomes of community-based brain injury rehabilitation clients

BACKGROUND

Community-based rehabilitation can help to maximize function following acquired brain injury (ABI); however, data on treatment outcome is limited in quantity.

OBJECTIVE

To describe and evaluate client outcomes of an outpatient programme for adults with moderate-to-severe traumatic and non-traumatic ABI.

METHODS

Two phase design involving retrospective and longitudinal study of programme completers with ABI (n = 47). Changes in functioning were measured with the Mayo-Portland Inventory (MPAI-4), administered pre- and immediately post-rehabilitation and at 3 years follow-up. Self-ratings were supplemented with MPAI-4 data from significant others (n = 32) and staff (n = 32).

RESULTS

Injured individuals and informants reported improved physical and psychosocial functioning immediately following the completion of community rehabilitation, with medium-to-large and significant treatment gains noted on the MPAI-4 ability, adjustment and participation sub-scales (Cohen's d range = 0.31-1.10). A deterioration in individuals' adjustment was further reported at follow-up, although this was based on limited data. Issues with longer-term rehabilitation service provision were additionally noted.

CONCLUSIONS

The data support the need for continuity of care, including ongoing emotional support, to cater to the complex and dynamic needs of the ABI population. However, these results need to be considered in the context of a small sample size and quasi-experimental design.

Global Outcome Trajectories After TBI Among Survivors and Nonsurvivors: A National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems Study

OBJECTIVE

To compare long-term functional outcome trajectories of individuals with traumatic brain injury (TBI) who survive with those who expire more than 5 years postinjury, using individual growth curve analysis.

DESIGN

Secondary analysis of data from a multicenter longitudinal cohort study.

SETTING

Acute inpatient rehabilitation facilities that are current or former TBI Model Systems.

PARTICIPANTS

Individuals 16 years and older with a primary diagnosis of TBI.

MAIN OUTCOME MEASURES

Glasgow Outcome Scale-Extended; Disability Rating Scale.

RESULTS

Individuals in the TBI Model Systems who expire several years after injury demonstrate worse functional status at baseline and a steeper rate of decline over time as measured by both the Glasgow Outcome Scale-Extended and the Disability Rating Scale. There was significant variability in each growth parameter (P < .05) for both instruments. A reduced model was built for each outcome, including all covariates that related significantly to the growth parameters. An interactive tool was created for each outcome to generate individual-level trajectories based on various combinations of covariate values.

CONCLUSION

Individuals with TBI who die several years after injury demonstrate functional trajectories that differ markedly from those of survivors. Opportunities should be sought for health management interventions to improve health and longevity after TBI.

Long-term outcomes after moderate-to-severe traumatic brain injury among military veterans: Successes and challenges

OBJECTIVE

To assess long-term outcomes after traumatic brain injury (TBI) among veterans and service members.

SETTING

Regional Veterans Affairs medical centre.

PARTICIPANTS

One hundred and eighteen veterans and military personnel, aged 23-70 years (median = 35 years), 90% male, had moderate-to-severe TBI (82% in coma > 1 day, 85% amnesic > 7 days), followed by acute interdisciplinary rehabilitation 5-16 years ago (median = 8 years).

DESIGN

Cross-sectional analysis of live interviews conducted via telephone.

MAIN MEASURES

TBI follow-up interview (occupational, social, cognitive, neurologic and psychiatric ratings), Community Integration Questionnaire, Disability Rating Scale (four indices of independent function) and Satisfaction with Life Scale.

RESULTS

At follow-up, 52% of participants were working or attending school; 34% ended or began marriages after TBI, but the overall proportion married changed little. Finally, 22% were still moderately-to-severely disabled. However, 62% of participants judged themselves to be as satisfied or more satisfied with life than before injury. Injury severity, especially post-traumatic amnesia, was correlated with poorer outcomes in all functional domains.

CONCLUSIONS

After moderate-severe TBI, most veterans assume productive roles and are satisfied with life. However, widespread difficulties and functional limitations persist. These findings suggest that veteran and military healthcare systems should continue periodic, comprehensive follow-up evaluations long after moderate-to-severe TBI.