Patient-Reported Problem Areas in Chronic Traumatic Brain Injury

Exploring the goals and outcomes of adults with severe acquired brain injury participating in an extended inpatient brain injury rehabilitation unit in Australia

PURPOSE

To explore the rehabilitation goals and evaluate goal attainment outcomes of people with severe acquired brain injury (ABI), and investigate the relationship between goal engagement and goal attainment.

MATERIALS AND METHODS

Mixed-methods cohort study with twenty-nine adults with severe ABI in Australia. Demographic data, goal statements and pre-post program Goal Attainment Scale scores as well as Goal Engagement Scale scores were collected. Goals were coded using inductive content analysis and categorised by ICF component and domain. Goal attainment within ICF categories was described and compared using descriptive statistics. Pre-post program change in goal attainment was evaluated using Wilcoxon signed rank tests and correlations between goal engagement and attainment was explored using Spearman's (rho).

RESULTS

94% of 320 goals were categorised as ICF Activity and Participation. There was significant improvement in goal attainment between admission and discharge (z=-0.47, p < 0.01). There was no significant relationship between goal engagement and goal attainment however there was a positive association between engagement in goal setting at admission and discharge.Conclusions: This interdisciplinary, inpatient rehabilitation program underpinned by key-worker facilitated person-centred, role-based goal setting resulted in goal attainment in chosen goals, which were primarily activity and participation-focused.

Children and families with chronic pediatric acquired brain injury in need of rehabilitation: characteristics and main challenges in daily life

PURPOSE

To increase our understanding of child and parent characteristics, family functioning and main challenges in daily life in children and families in need of rehabilitation in the chronic phase of pediatric acquired brain injury (pABI).

METHODS

Fifty-eight children (aged 6-16, 48% girls) were included at least one year post ABI. Demographics and questionnaire data regarding children's symptom burden, parents' emotional symptoms and family functioning were collected. Children and parents named their main pABI-related challenges in daily life, and these were categorized in accordance with the International Classification of Functioning, Disability and Health (ICF). Descriptive statistical analyses were performed.

RESULTS

Parents' emotional symptom loads were high; 22.3% had moderate, moderate-severe or severe depression symptoms while the equivalent number for anxiety symptoms was 17.9%. Problematic family functioning was reported by 32.1% of parents. When asked about their main pABI-related challenges in daily life, 69% of children named school. The most frequent ICF chapters for children and parents were school education, energy and drive functions (mainly fatigue), and emotional functions. Codes spanned across all ICF-domains.

CONCLUSIONS

Rehabilitation for pABI should have a broad, interdisciplinary, and family-centered approach, with school, fatigue, and emotional functioning of parents and children as potential core elements.

Process evaluation of a complex intervention evaluating the effectiveness of home-based rehabilitation in the chronic phase of traumatic brain injury

PURPOSE

To perform a process evaluation of a randomized controlled trial (RCT) evaluating a manualized intervention aiming to ameliorate long-term symptoms of traumatic brain injury (TBI) by assessing implementation fidelity, delivery context and acceptability of the intervention.

METHODS

Data from 60 participants were collected during recruitment, intervention delivery and outcome data collection in the RCT. Enrollment records, logs and checklists documented the delivery of the intervention (implementation fidelity) and the collaboration with family members and outside collaborators (delivery context). Attendance-rate, self-reported acceptability and willingness to participate in future studies were used to assess the acceptability of the intervention.

RESULTS

The main elements and dose of the intervention were delivered as intended with an excellent adherence to the manual items. Family members co-participated in the intervention for 39 (65%) of the participants. Outside collaborators were contacted for 32 (53%) of the participants. Acceptability scores were high for participants, family members and therapists.

CONCLUSIONS

The intervention was successfully delivered with high acceptability. This process evaluation informs researchers, clinicians and stakeholders about important factors influencing the outcomes of the intervention that should be considered in clinical implementation of rehabilitation interventions.

TRIAL REGISTRATION

Pre-registered 4th of June 2018 at clinicaltrials.gov (NCT03545594).

Self-management support program delivered in the sub-acute phase after traumatic injury-study protocol for a pragmatic randomized controlled trial

BACKGROUND

Traumatic injuries, defined as physical injuries with sudden onset, are a major cause of distress and disability, with far-reaching societal consequences. A significant proportion of trauma survivors report persistent symptoms and difficulties after the injury, and studies show unmet health care needs. Self-management programs delivered in the sub-acute phase after traumatic injuries are scarcely evaluated. The aim of the present study is to evaluate the effectiveness of a self-management program (SEMPO), delivered 3-4 months after moderate-to-severe traumatic injury.

METHODS

This study protocol describes a pragmatic randomized controlled trial (RCT) with two classical RCT arms (intervention and control) and an explorative self-selection arm. 220 patients will be recruited from Oslo University Hospital, the largest Trauma Referral Centre in Norway. Patients aged 18-72 years residing in the south-east region of Norway, admitted to the Trauma Centre directly or within 72 h after having sustained a moderate to severe traumatic injury, defined as a New Injury Severity Score > 9, having at least 2 days hospital stay, and reporting injury-related symptoms and impairment at discharge from the acute hospital will be included. Patients will be randomly assigned to either a classical RCT randomization arm (intervention or control arm) or to a self-selection arm. In the randomization arm, participants are further randomized into intervention or control group. Participants allocated to the self-selection arm will choose to partake either in the intervention or control arm. The primary outcome is the level of self-efficacy in trauma coping assessed 6 months after completion of the intervention, with a similar time point for the control group. Secondary outcomes include symptom burden, physical functioning and disability, return to work and health care utilization, health-related quality of life, and communication competency. In addition, patients will be asked to nominate one domain-related measurement as their preferred outcome measure.

DISCUSSION

This RCT will determine the effect of a self-management program tailored to patients with moderate to severe physical trauma, and the self-selection arm incorporates the potential influence of patient treatment preferences on intervention results. If the intervention proves effective, cost-effectiveness and cost-utility analyses will be performed and thereby provide important information for clinicians and policy makers.

TRIAL REGISTRATION

The study is registered in Clinical Trials with the identifier: NCT06305819. Registered on March 05, 2004.

Family member reported symptom burden, predictors of caregiver burden and treatment effects in a goal-oriented community-based randomized controlled trial in the chronic phase of traumatic brain injury

BACKGROUND

Family members are often affected by the long-term consequences of traumatic brain injury, but are rarely involved in rehabilitation programs in the chronic phase. We thus do not know what family members´ main concerns are in the chronic phase, what factors are associated with perceived caregiver burden, and whether family members´ health and functioning improves due to rehabilitation efforts received by the patients. This study explored family-members` functioning, predictors of caregiver burden and effect for family members of a goal-oriented intervention in the chronic phase of traumatic brain injury.

METHODS

Family members self-reported data measuring their caregiver burden, depression, general health, loneliness, and their evaluation of patient competency in everyday life, patient awareness levels, main problem areas (target outcomes) for the patient related to the brain injury, and demographic data were collected. Regression models were used to explore predictors of caregiver burden, and mixed models analysis was used to explore treatment effects.

RESULTS

In total, 73 family members were included, 39 in the intervention group and 34 in the control group. Moderate to high caregiver burden was reported by 40% of family members, and 16% experienced clinical levels of depression. Family member loneliness and their evaluation of the patient`s level of functional competency explained 57% of the variability in caregiver burden. There were no treatment-related changes in caregiver burden, family member depression or general health. At T2 there was however a significant reduction in how family members rated severity of target outcomes that the family members had nominated at baseline (-0.38, 95% CI, -0.75 to -0.02, p = 0.04), but not for the target outcomes the patients had nominated.

CONCLUSIONS

A significant proportion of family members to patients in the chronic phase of TBI continue to experience challenging caregiver burden and emotional symptoms. Both family member-related and patient factors contribute to caregiver burden. Interventions targeting patient complaints do not automatically alleviate family members´ burden. It is important to address social support for family members early after injury, and there is a need for more interventions specifically targeting family members´ needs.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov, NCT03545594 on the 4th of June 2018.

Updated Canadian Clinical Practice Guideline for the Rehabilitation of Adults With Moderate to Severe Traumatic Brain Injury: Mental Health Recommendations

OBJECTIVE

Objective: After sustaining a moderate to severe traumatic brain injury (MSTBI), individuals often experience comorbid mental health conditions that can impair the rehabilitation and recovery process. The objective of this initiative was to update recommendations on the assessment and management of mental health conditions for the Canadian Clinical Practice Guideline for the Rehabilitation of Adults with MSTBI (CAN-TBI 2023).

OBJECTIVE

Design: A systematic search was conducted by the Evidence-Based Review of Moderate to Severe Acquired Brain Injury to identify new and relevant articles. Expert Panel reviewed and discussed the new and existing evidence, evaluated its quality, and added, removed, or modified recommendations and tools as needed. A consensus process was followed to achieve agreement on recommendations.

OBJECTIVE

Results: CAN-TBI 2023 includes 20 recommendations regarding best practices for the assessment and management of mental health conditions post-MSTBI. About 17 recommendations were updated, 1 new recommendation was formed, and 2 recommendations remained unchanged. The Guideline emphasizes the importance of screening and assessment of mental health conditions throughout the rehabilitation continuum. The Expert Panel recommended incorporating multimodal treatments that include pharmacological and nonpharmacological approaches to manage mental health concerns.

OBJECTIVE

Conclusion: The CAN-TBI 2023 recommendations for the assessment and management of mental health conditions should be used to inform clinical practice. Additional high-quality research in this area is needed, as 13 recommendations are based on level C evidence, 4 on level B evidence, and 3 on level A evidence.

The Participation Assessment with Recombined Tools-Objective (PART-O): measurement properties of the Norwegian version after traumatic brain injury

OBJECTIVE

To translate and evaluate the validity of the Participation Assessment with Recombined Tools-Objective (PART-O) in a Norwegian context.

METHODS

One hundred and twenty persons with TBI with verified intracranial lesions and persistent symptoms lasting more than 2 years, included in a randomized controlled trial, rated their participation using the PART-O at baseline. The PART-O with its three subscales (Productivity, Out and About, and Social Relations) was translated to Norwegian. Descriptive statistics, Cronbach's alpha, Rasch analysis, and correlation analysis were applied.

RESULTS

The Rasch analysis indicated a unidimensional construct of PART-O and its subscales (χ2 < 12.69, p > 0.28). The internal consistency was moderate (Cronbach's alpha 0.48-0.52) and there was a need to reduce scaling options for most of the items. The Out and About and Productivity subscales had considerable floor effects. PART-O showed moderate positive correlation to TBI-related quality of life and global functioning.

CONCLUSIONS

PART-O and its subscales reflect unidimensional aspects of participation. In the present Norwegian TBI population the original scaling of PART-O was too detailed for all subscales. The floor effects and suboptimal targeting between items and subjects participation level of the Out and About subscale is a matter of concern.

International classification of functioning, disability and health with long-term consequences of cranio-brain injury

OBJECTIVE

Aim: To describe health status and related functioning of patients with different severity of traumatic brain injury (TBI) in past medical history in Ukraine and determining the feasibility of using the International Classification of Functioning, Disability and Health (ICF) Brief Core Set for TBI.

PATIENTS AND METHODS

Materials and Methods: A total of 102 patients, who were treated in the neurological department of Dnipropetrovsk regional clinical hospital and State Institution ≪Ukrainian State Scientific Research Institute of Medical and Social Problems of Disability of Health Ministry of Ukraine≫, had been examined. Patients were divided into three groups: mild, moderate and severe TBI in past history and evaluated using ICF Brief Core Set for TBI.

RESULTS

Results: Тhe most common problems in the functioning and health of patients in remote period of TBI, along with the influencing factors have been identified in the study. The most frequent categories from ≪Body Functions≫ and ≪Activity and Participation≫ sections in which patients had alterations were: memory functions, emotional functions, sensation of pain, functions of attention, brain structure, complex interpersonal interactions, family relationships. The increase in the amount and severity of disturbances with increasing severity of TBI had been established in all categories, except complex interpersonal interactions and family relationships.

CONCLUSION

Conclusions: Patients of all groups identified the family and close relatives, healthcare service and social welfare services, as the most frequent relieving factors of life activity. The use of the ICF Brief Core Set for assessing the subjects with TBI in past history provides a convenient procedure to standardize and structure functioning description. Information collected by the ICF Brief Core Set may be used for different purposes: clinical assessment, administration of medical services, planning and implementation of rehabilitation and evaluation of results, in scientific research, reports and health care statistics.

Prognostication in Prolonged and Chronic Disorders of Consciousness

Patients with prolonged disorders of consciousness (DOCs) longer than 28 days may continue to make significant gains and achieve functional recovery. Occasionally, this recovery trajectory may extend past 3 (for nontraumatic etiologies) and 12 months (for traumatic etiologies) into the chronic period. Prognosis is influenced by several factors including state of DOC, etiology, and demographics. There are several testing modalities that may aid prognostication under active investigation including electroencephalography, functional and anatomic magnetic resonance imaging, and event-related potentials. At this time, only one treatment (amantadine) has been routinely recommended to improve functional recovery in prolonged DOC. Given that some patients with prolonged or chronic DOC have the potential to recover both consciousness and functional status, it is important for neurologists experienced in prognostication to remain involved in their care.

Effect of an Individually Tailored and Home-Based Intervention in the Chronic Phase of Traumatic Brain Injury: A Randomized Clinical Trial

Importance

Traumatic brain injury (TBI) can cause long-lasting and heterogeneous difficulties that require an individually tailored approach to rehabilitation. However, high-quality studies of treatment options in the chronic phase of TBI are lacking.

Objective

To evaluate the effect of a home-based, individualized, and goal-oriented rehabilitation intervention in the chronic phase of TBI.

Design, Setting, and Participants

This study was an intention-to-treat parallel-group assessor-blinded randomized clinical trial with 1:1 randomization to an intervention or control group. Participants included adults in southeastern Norway who had sustained a TBI more than 2 years earlier, lived at home, and had ongoing TBI-related difficulties. A population-based sample of 555 individuals were invited, and 120 were included. Participants were assessed at baseline, 4 months, and 12 months after inclusion. Specialized rehabilitation therapists provided the intervention in patients' homes or via video conference and telephone. Data collection was conducted between June 5, 2018, and December 14, 2021.

Interventions

The intervention group received an 8-session individually tailored and goal-oriented rehabilitation program over 4 months. The control group received usual care in their municipality.

Main Outcomes and Measures

Preestablished primary outcomes were disease-specific health-related quality of life (HRQOL; measured by the Quality of Life After Brain Injury [QOLIBRI] overall scale) and social participation (measured by the Participation Assessment With Recombined Tools-Objective [PART-O] social subscale). Preestablished secondary outcomes included generic HRQOL (measured by the EuroQol 5-dimension 5-level [EQ-5D-5L] questionnaire), difficulty with TBI-related problem management (target outcomes; mean severity calculated across 3 main self-identified problem areas that were individually measured using a 4-point Likert scale), TBI symptoms (measured by the Rivermead Post Concussion Symptoms Questionnaire [RPQ]), psychological distress (depression and anxiety; measured by the Patient Health Questionnaire 9-item scale and the Generalized Anxiety Disorder 7-item scale [GAD-7], respectively), and functional competency (measured by the Patient Competency Rating Scale).

Results

Among 120 participants in the chronic phase of TBI, the median (IQR) age was 47.5 (31.0-55.8) years, and the median (IQR) time since injury was 4 (3-6) years; 85 (70.8%) were male. A total of 60 participants were randomized to the intervention group, and 60 were randomized to the control group. Between baseline and 12 months, no significant between-group effects were found for the primary outcomes of disease-specific HRQOL (QOLIBRI overall scale score: 2.82; 97.5% CI, -3.23 to 8.88; P = .30) or social participation (PART-O social subscale score: 0.12; 97.5% CI, -0.14 to 0.38; P = .29). At 12 months, the intervention group (n = 57) had significantly higher generic HRQOL (EQ-5D-5L score: 0.05; 95% CI, 0.002-0.10; P = .04) and fewer symptoms of TBI (RPQ total score: -3.54; 95% CI, -6.94 to -0.14; P = .04) and anxiety (GAD-7 score: -1.39; 95% CI, -2.60 to -0.19; P = .02) compared with the control group (n = 55). At 4 months only, the intervention group (n = 59) had significantly less difficulty managing TBI-related problems (target outcomes mean severity score: -0.46, 95% CI, -0.76 to -0.15; P = .003) compared with the control group (n = 59). No adverse events were reported.

Conclusions and Relevance

In this study, no significant results were observed for the primary outcomes of disease-specific HRQOL or social participation. However, the intervention group reported improvements in secondary outcomes (generic HRQOL and symptoms of TBI and anxiety) that were maintained at 12-month follow-up. These findings suggest that rehabilitation interventions could help patients even in the chronic phase of TBI.

Trial Registration

ClinicalTrials.gov Identifier: NCT03545594.

Participatory co-creation of an adapted physical activity program for adults with moderate-to-severe traumatic brain injury

Background

Research about using physical activity (PA) to improve health, quality of life, and participation after moderate-to-severe traumatic brain injury (TBI) is receiving growing attention. However, best-practices for maintaining PA participation after TBI have yet to be defined. In this context, a team of researchers and stakeholders with a moderate-to-severe TBI (including program participants and peer mentors) participated in a co-creation process to optimize a 9-month, 3-phased, community-based, adapted PA program named TBI-Health.

Purpose

The study aimed to provide a detailed account of the participation in and co-creation of a new TBI-Health Program to enhance sport and exercise participation for adults with moderate-to-severe TBI. Specifically, we carried out an in-depth exploration of the perceived experiences and outcomes of users over one cycle of the program to assist the co-creation process.

Methods

An interpretive case study approach was used to explore the experiences and outcomes of the participatory co-creation within and across phases of the TBI-Health program. A purposeful sample of fourteen adults with moderate-to-severe TBI (program participants n = 10; peer mentors n = 4) were involved in audio-recorded focus groups after each program phase. Reflexive thematic analyses within and across the phases identified three higher-order themes.

Results

Program Participation included barriers, facilitators, sources of motivation and suggested modifications to optimize the program; Biopsychosocial Changes highlighted perceived physical, psychological, and social outcomes, by self and others, that resulted from program participation; PA Autonomy emphasized transitions in knowledge, sex- and gender-related beliefs, and abilities related to exercise and sport participation.

Conclusions

Study findings suggest the TBI-Health program can increase autonomy for and reduce barriers to PA for adults with moderate-to-severe TBI, which results in increased PA participation and important physical, psychological, and social benefits. More research is needed about the TBI-Health program with larger samples.

Goal Attainment in an Individually Tailored and Home-Based Intervention in the Chronic Phase after Traumatic Brain Injury

Traumatic brain injury (TBI) is a heterogeneous condition with long-term consequences for individuals and families. Goal-oriented rehabilitation is often applied, but there is scarce knowledge regarding types of goals and goal attainment. This study describes goal attainment in persons in the chronic phase of TBI who have received an individualized, SMART goal-oriented and home-based intervention, compares goal attainment in different functional domains, and examines indicators of goal attainment. Goal attainment scaling (GAS) was recorded in the intervention group (n = 59) at the final session. The goal attainment was high, with 93.3% increased goal attainment across all goals at the final session. The level of goal attainment was comparable across domains (cognitive, physical/somatic, emotional, social). Gender, anxiety symptoms, self-reported executive dysfunction, and therapy expectations were indicators of goal attainment. These results indicate a potential for the high level of goal attainment in the chronic phase of TBI. Tailoring of rehabilitation to address individual needs for home-dwelling persons with TBI in the chronic phase represents an important area of future research.