Functional outcomes of community-based brain injury rehabilitation clients

Understanding the barriers and facilitators of healthcare services for brain injury and concurrent mental health and substance use issues: a qualitative study

BACKGROUND

People with acquired brain injury (ABI) may experience concurrent conditions such as, mental health and substance use concerns, that require specialized care. There are services that aim to support people with ABI and these conditions separately; however, little is known about the facilitators and barriers of these services. Therefore, the purpose of this study was to engage stakeholders to investigate the facilitators and barriers of healthcare services for ABI and concurrent issues.

METHODS

Semi-structured focus groups were conducted in-person and virtually with people with ABI, caregivers, healthcare professionals, and policy makers during a one-day event in British Columbia, Canada. Manifest content analysis was used with a constructivist perspective to analyze data.

RESULTS

90 participants (including 34 people with ABI) provided insights during 15 simultaneous focus groups. Three categories were identified: (1) complexity of ABI, (2) supports, (3) structure of care. Complexity of ABI outlined the ongoing basic needs after ABI and highlighted the need for public awareness of ABI. Supports outlined healthcare professional and community-based supports. Structure of care described people with ABI needing to meet criteria for support, experiences of navigating through the system and necessity of integrated services.

CONCLUSIONS

These findings highlight the facilitators and barriers of healthcare services for ABI and concurrent conditions and provide insights into the changes that may be needed. Doing so can improve the accessibility and quality of ABI healthcare services.

The pervasive and unyielding impacts of cognitive-communication changes following traumatic brain injury

BACKGROUND

Cognitive-communication disorders (CCDs) are common in the traumatic brain injury (TBI) population. Despite this, there has been limited research that explores the long-term impacts of reduced cognitive-communication functioning on daily life for this population.

AIMS

To identify the long-term impacts of cognitive-communication impairment as reported by adults with TBI and their significant others.

METHODS & PROCEDURES

A qualitative descriptive approach grounded in phenomenology was used. Semi-structured, one-on-one interviews were conducted with adults with CCDs following TBI (n = 16) and their significant others (n = 12) to explore their lived experiences.

OUTCOMES & RESULTS

Reflexive thematic analysis revealed an overarching theme of 'The pervasive and unyielding impacts of cognitive-communication changes on daily life following TBI'. Within this overarching theme, three subthemes were identified: (1) self-awareness of communication changes; (2) fatigue; and (3) self-identity and life roles.

CONCLUSION & IMPLICATIONS

The findings from this study highlight the long-term negative impacts of reduced cognitive-communication functioning on daily life. Health professionals supporting this population should consider ways to reduce the significant impact CCDs have on the lives of adults following TBI and their significant others. In addition, the findings highlight the importance of long-term rehabilitation services following TBI, with further research needed that explores how these services can be optimised.

WHAT THIS PAPER ADDS

What is already known on this subject Cognitive-communication disorders (CCDs) affect the majority of adults who experience moderate to severe traumatic brain injury (TBI) and encompass any component of communication that is affected by cognition. The hallmark characteristic of CCDs are breakdowns that affect social communication skills as well as cognitive-linguistic deficits. Combined, these can have dramatic implications for a person's quality of life, their level of independence, employment opportunities and social participation. There has been limited research to date that explores the long-term impacts of CCDs on the lives of adults following TBI. Further research that explores these impacts is needed to improve the support services and rehabilitation models of care available for this population. What this study adds The overarching theme was 'The pervasive and unyielding impacts of communication changes on daily life following TBI' with subthemes including changed communication, self-awareness of communication changes, fatigue and self-identity and life roles. The findings from this study highlight the long-term negative impacts of reduced cognitive-communication functioning on everyday functioning and quality of life as well as the importance of long-term rehabilitation services following TBI. What are the clinical implications of this work? Speech-language therapists and other health professionals working with this clinical population should consider how to address the significant and long-lasting impacts of CCDs. Due to the complex nature of the barriers experienced by this clinical population, an interdisciplinary targeted approach is advised wherever possible when providing rehabilitation services.

Sex/gender differences in service use patterns, clinical outcomes and mortality risk for adults with acquired brain injury: a retrospective cohort study (ABI-RESTART)

OBJECTIVE

To identify sex/gender differences in functional, psychosocial and service use patterns in community-based post-acute care for acquired brain injury.  Design: Retrospective cohort study.

SUBJECTS/PATIENTS

Adults with acquired brain injury enrolled in post-acute neurorehabilitation and disability support in Western Australia (n = 1,011).

METHODS

UK Functional Independence Measure and Functional Assessment Measure (FIM + FAM), Mayo-Portland Adaptability Inventory-4, goal attainment, length of stay (LOS), number of episodes of care and deaths were evaluated using routinely collected clinical and linked administrative data.

RESULTS

At admission, women were older (p < 0.001) and displayed poorer functional independence (FIM + FAM; p < 0.05) compared with men. At discharge, there were no differences in goal attainment, psychosocial function or functional independence between men and women. Both groups demonstrated functional gains; however, women demonstrated clinically significant gains (+ 15.1, p < 0.001) and men did not (+ 13.7, p < 0.001). Women and men had equivalent LOS (p = 0.205). Aboriginal and/or Torres Strait Islander status predicted longer LOS for women but not for men. Being partnered predicted reduced LOS for women but not men. Women had a higher risk of multiple episodes of care (p < 0.001), but not death (p = 0.409), compared with that of men.

CONCLUSION

At admission to rehabilitation and disability support services for acquired brain injury, women have poorer functional independence and higher risk of multiple episodes of care, compared with men, suggesting greater disability in the community. By the time of discharge from these services, women and men make equivalent functional and psychosocial gains. The higher risk of multiple episodes of care for women relative to men suggest women may need additional post-discharge support, to avoid readmission.

Predictors of Social Participation Outcome after Traumatic Brain Injury Differ According to Rehabilitation Pathways

Social participation (SP) is one of many objectives in the rehabilitation of patients with traumatic brain injury (TBI). Studies on predictors of SP specific to post-acute universally accessible specialized rehabilitation pathways following TBI are scarce. Our objectives were to: 1) characterize SP, as well as a set of pre-injury, injury-related, and post-injury variables in individuals participating in inpatient-outpatient or outpatient rehabilitation pathways within a universally accessible and organized trauma continuum of care; and 2) examine the ability of pre-injury, injury-related, and post-injury variables in predicting SP outcome after TBI according to rehabilitation path. Participants (N = 372) were adults admitted to an inpatient-outpatient rehabilitation pathway or an outpatient rehabilitation pathway after sustaining a TBI between 2016 and 2020, and for whom Mayo-Portland Adaptability Intentory-4 (MPAI-4) outcomes were prospectively obtained at the start and end of rehabilitation. Additional data was collected from medical files. For both rehabilitation pathways, predicted SP outcome was MPAI-4 Participation score at discharge from outpatient rehabilitation. Multiple regression models investigated the predictive value of each variable for SP outcome, separately for each care pathway. Main findings show that for the inpatient-outpatient sample, three variables (education years, MPAI-4 Ability and Adjustment scores at rehabilitation intake) significantly predicted SP outcome, with the regression model accounting for 49% of the variance. For the outpatient sample, five variables (pre-morbid hypertension and mental health diagnosis, total indirect rehabilitation hours received, MPAI-4 Abilities and Adjustment scores at rehabilitation intake) significantly predicted SP outcome, with the regression model accounting for 47% of the variance. In conclusion, different pre-morbid and post-injury variables are involved in predicting SP, depending on the rehabilitation path followed. The predictive value of those variables could help clinicians identify patients more likely of showing poorer SP at discharge and who may require additional or different interventions.

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.

Cohort profile: the Acquired Brain Injury Community REhabilitation and Support Services OuTcomes CohoRT (ABI-RESTaRT), Western Australia, 1991-2020

PURPOSE

Transition back into the community following acute management of acquired brain injury (ABI) is a critical part of recovery. Post-acute rehabilitation and transitional care can significantly improve outcomes. The Acquired Brain Injury Community REhabilitation and Support Services OuTcomes CohoRT (ABI-RESTaRT) is a novel whole-population cohort formed to better understand the needs of individuals with ABI receiving post-acute rehabilitation and disability services in Western Australia (WA), and to improve their outcomes. To do this a unique combination of (1) internal clinical/rehabilitation data, and (2) externally linked health data from the WA Data Linkage System was used, including hospitalisations, emergency department presentations, mental health service use and death records, to measure longitudinal needs and outcomes of individuals with ABI over 29 years, making this the largest, most diverse post-acute ABI cohort in Australia to date.

PARTICIPANTS

Whole-population cohort of individuals (n=1011) with an ABI who received post-acute community-based neurorehabilitation or disability support services through Brightwater Care Group from 1991 to 2020.

FINDINGS TO DATE

Comprehensive baseline demographic, clinical and rehabilitation data, outcome measures and linked health data have been collected and analysed. Non-traumatic brain injury (eg, stroke, hypoxia) was the main diagnostic group (54.9%, n=555), followed by traumatic brain injury (34.9%, n=353) and eligible neurological conditions (10.2%, n=103). Mean age at admission was 45.4 years, and 67.5% were men (n=682). The cohort demonstrated significant heterogeneity, socially and clinically, with differences between ABI groups across a number of domains.

FUTURE PLANS

ABI-RESTaRT is a dynamic whole-population cohort that will be updated over time as individuals enrol in the service. Future analyses will assess longitudinal brain injury outcomes, the changing health and social needs of individuals with ABI and evaluate and inform post-acute services to best support these individuals.

REGISTRATION

This cohort is not linked to a clinical trial, and is not registered.

Validation of the Mayo-Portland Adaptability Inventory-4 (MPAI-4) and reference norms in a French-Canadian population with traumatic brain injury receiving rehabilitation

PURPOSE

Validate the factor structure and establish internal consistency reliability of the French-Canadian version of the Mayo-Portland Adaptability Inventory (MPAI-4), using a Canadian sample of adults with traumatic brain injury (TBI) receiving post-acute rehabilitation services.

MATERIALS AND METHODS

Psychometric analysis of French-Canadian MPAI-4 data from TBI adults (N = 1012) who received rehabilitation interventions and for whom a first French-Canadian MPAI-4 measure was completed between 2016 and 2020.

RESULTS

Exploratory factor analysis was used to evaluate the factor structure of the French-Canadian MPAI-4. The final and best solution revealed three factors, which accounted for 48.68% of the variance. Using Cronbach's alpha, all subscales showed good internal consistency (all 0.70 ≤ α ≤ 0.89). Reference norms for the TBI sample are provided, as well as descriptive raw data according to sex, age, TBI severity and rehabilitation setting.

CONCLUSIONS

The French-Canadian MPAI-4 factor structure is validated. The three factors extracted are similar to the three subscales of the original MPAI-4. The questionnaire shows good psychometric properties and represents a suitable tool for TBI adults receiving rehabilitation services in a French-Canadian context. The provided reference norms will also help guide the clinical use of the MPAI-4 in French-Canadian TBI populations.Implications for rehabilitationThe MPAI-4 questionnaire measures functional abilities, global outcome and community integration following traumatic brain injury (TBI).The questionnaire can be used in inpatient, outpatient and vocational rehabilitation settings to assess TBI patients' progress and outcomes, plan interventions and evaluate the effect of rehabilitation.The French-Canadian version of the MPAI-4 is validated and suitable to be used in French-Canadian post-acute TBI rehabilitation settings.

Time between acquired brain injury and admission to community-based rehabilitation: differences in cognitive and functional gains

OBJECTIVE

To determine differences in rehabilitation gains made by people with an acquired brain injury undergoing staged community-based brain injury rehabilitation (SCBIR) at different times between injury and admission.

METHOD

Retrospective cohort analysis of routinely collected demographic and rehabilitation data from clients admitted to SCBIR service 2011-2017 (n=92). Outcome measures: Mayo-Portland Adaptability Inventory-4 (MPAI-4) and UK Functional Assessment Measure (UK FIM+FAM) collected on admission and annually thereafter until discharge. Analysis was stratified by time since injury on admission: 'Early' (<1 year (n=36)), 'Middle' (1-2 years (n=34)) and 'Late' (>2 years (n=22)). Between-group differences were tested using bootstrapped one-way ANOVA. Within-group differences were tested using paired T tests.

RESULTS

Total cohort made significant gains in MPAI-4 and UK FIM+FAM total and all subscales (p = .001). Early group made greatest change in all subscales of both outcome measures (p < .01). Middle cohort improved significantly in all subscales (p < .02) excluding MPAI-4 Adjustment. Late cohort still made statistically significant gains in all UK FIM+FAM subscales (p < .05) and MPAI-4 Participation (p < .01). Item level changes are presented.

CONCLUSION

More than 2 years after injury, people are able to make improvements in participation and functional independence following SCBIR.

Referral decision support in patients with subacute brain injury: evaluation of the Rehabilitation Complexity Scale - Extended

PURPOSE

To test if the Rehabilitation Complexity Scale Extended (RCS-E) can be used as decision support for patient referral to primary rehabilitation as either complex specialized services (CSS) or district specialist services (DSS).

METHOD

Two independent expert teams analyzed medical records on 299 consecutive patients admitted for CSS or DSS rehabilitation. One team provided a golden standard for the patient referrals, and the other team provided RCS-E scores. Models for predicting referrals from RCS-E scores were developed on data for 149 patients and tested on the remaining 150 patients.

RESULTS

The optimal RCS-E sum score threshold for referral prediction was 11, predicting the golden standard for patient referral with sensitivity 88%, specificity 78% and correct classification rate 81%. Improved referral prediction performance was achieved by using RCS-E item-wise score thresholds (sensitivity 81%, specificity 89%, correct classification rate 87%). The RCS-E sum score range for patients referred CSS and DSS by the item-wise model was, respectively, 0-12 and 2-22 suggesting strong non-linear interaction of the RCS-E items.

CONCLUSIONS

We found excellent referral decision support in the RCS-E and the item specific threshold model, when patients with acquired brain injury are to be referred to CSS or DSS as their primary rehabilitation. Implications for Rehabilitation Efficient rehabilitation after acquired brain injury requires rehabilitation settings that meet patient needs. Validated tools for referral decision support make the process more transparent. Patient rehabilitation complexity can be stratified by the RCS-E with high sensitivity, specificity and predictive value of positive test. RCS-E is an excellent tool for referral decision support.

Changes in aspects of social functioning depend upon prior changes in neurodisability in people with acquired brain injury undergoing post-acute neurorehabilitation

Post-acute community-based rehabilitation is effective in reducing disability. However, while social participation and quality of life are valued as distal outcomes of neurorehabilitation, it is often not possible to observe improvements on these outcomes within the limited time-frames used in most investigations of rehabilitation. The aim of the current study was to examine differences in the sequence of attainments for people with acquired brain injury (ABI) undergoing longer term post-acute neurorehabilitation. Participants with ABI who were referred to comprehensive home and community-based neurorehabilitation were assessed at induction to service, at 6 months and again at 1.5 years while still in service on the Mayo-Portland Adaptability Index (MPAI-4), Community Integration Questionnaire, Hospital Anxiety and Depression Scale, and World Health Organisation Quality of Life measure. At 6 months post-induction to service, significant differences were evident in MPAI abilities, adjustment, and total neurodisability; and in anxiety and depression. By contrast, there was no significant effect at 6 months on more socially oriented features of experience namely quality of life (QoL), Community Integration and Participation. Eighteen month follow-up showed continuation of the significant positive effects with the addition of QoL-related to physical health, Psychological health, Social aspects of QoL and Participation at this later time point. Regression analyses demonstrated that change in QoL and Participation were dependent upon prior changes in aspects of neurodisability. Age, severity or type of brain injury did not significantly affect outcome. Results suggest that different constructs may respond to neurorehabilitation at different time points in a dose effect manner, and that change in social aspects of experience may be dependent upon the specific nature of prior neurorehabilitation attainments.