Provider Perspectives of Facilitators and Barriers to Reaching and Utilizing Chronic Pain Healthcare for Persons With Traumatic Brain Injury: A Qualitative NIDILRR and VA TBI Model Systems Collaborative Project

OBJECTIVE

To identify facilitators and barriers to reaching and utilizing chronic pain treatments for persons with traumatic brain injury (TBI) organized around an Access to Care framework, which includes dimensions of access to healthcare as a function of supply (ie, provider/system) and demand (ie, patient) factors for a specified patient population.

SETTING

Community.

PARTICIPANTS

Clinicians (n = 63) with experience treating persons with TBI were interviewed between October 2020 and November 2021.

DESIGN

Descriptive, qualitative study.

MAIN MEASURES

Semistructured open-ended interview of chronic pain management for persons with TBI. Informed by the Access to Care framework, responses were coded by and categorized within the core domains (reaching care, utilizing care) and relevant subdimensions from the supply (affordability of providing care, quality, coordination/continuity, adequacy) and demand (ability to pay, adherence, empowerment, caregiver support) perspective.

RESULTS

Themes from provider interviews focused on healthcare reaching and healthcare utilization resulted in 19 facilitators and 9 barriers reaching saturation. The most themes fell under the utilization core domain, with themes identified that impact the technical and interpersonal quality of care and care coordination/continuity. Accessibility and availability of specialty care and use of interdisciplinary team that permitted matching patients to treatments were leading thematic facilitators. The leading thematic barrier identified primarily by medical providers was cognitive disability, which is likely directly linked with other leading barriers including high rates of noncompliance and poor follow-up in health care. Medical and behavioral health complexity was also a leading barrier to care and potentially interrelated to other themes identified.

CONCLUSION

This is the first evidence-based study to inform policy and planning for this complex population to improve access to high-quality chronic pain treatment. Further research is needed to gain a better understanding of the perspectives of individuals with TBI/caregivers to inform interventions to improve access to chronic pain treatment for persons with TBI.

Provider Perceived Facilitators and Barriers to Identifying, Perceiving, and Seeking Healthcare for Chronic Pain After TBI: A Qualitative NIDILRR and VA TBI Model Systems Collaborative Project

OBJECTIVE

Identify determinants to chronic pain healthcare for persons with traumatic brain injury (TBI) informed by an Access to Care Framework. Findings related to the Access Framework's core domains of identifying a need, perceptions of the need, and seeking healthcare are reported.

SETTING

Community.

PARTICIPANTS

Healthcare providers (n = 63) with 2 or more years of experience treating persons with TBI interviewed between October 2020 and November 2021.

DESIGN

Descriptive, qualitative study.

MAIN MEASURES

Semi-structured interviews with open-ended questions of chronic pain management for persons with TBI. Informed by the Access Framework, responses were coded by and categorized within the domains of identifying healthcare needs, perceptions of needs, and factors related to healthcare seeking from the supply and demand perspective.

RESULTS

For the overall sample, 14 facilitators and 6 barriers were endorsed by more than 20% of the provider cohort. Top facilitators included on-site availability of needed resources and treatments (94%), adequate time and provider capability to ensure patient comprehension of diagnosis and treatment plans (83%), and establishing patient motivation and buy-in with the treatment plan (75%). Barriers most endorsed included policies impacting access (46%), wait times for services (41%), and patient uncertainty regarding telehealth commonly due to cognitive and physical challenges (37%). Unique determinants are reported across civilian versus Department of Veterans Affairs (VA) healthcare systems and different provider types.

CONCLUSION

This is the first evidence-based study to inform policy and planning to improve access to high-quality chronic pain treatments for persons with TBI. Results will inform future interventions at the systems, patient, and policy levels of healthcare that can be tailored to healthcare settings (VA, Civilian) and types of providers (rehabilitation therapists, psychologists, and medical). Evidence-informed interventions may help minimize healthcare disparities experienced by persons with TBI and facilitate access to high-quality, evidence-informed chronic pain care.

Stakeholder Engagement to Identify Implementation Strategies to Overcome Barriers to Delivering Chronic Pain Treatments: A NIDILRR and VA TBI Model Systems Collaborative Project

OBJECTIVE

The purpose of this article is to illustrate the process of stakeholder-engaged intervention mapping approach to identify implementation strategies to overcome data-driven prioritized barriers to receiving chronic pain services for persons with traumatic brain injury (TBI).

SETTING

Community.

PARTICIPANTS

Healthcare providers (n = 63) with 2 or more years' experience treating persons with TBI, interviewed between October 2020 and November 2021 provided data for identification of barriers. TBI, chronic pain, and qualitative research subject matter experts (SMEs) participated in the mapping approach.

DESIGN

Participatory-based research design, using descriptive and intervention mapping approaches.

RESULTS

Four barriers to accessing chronic pain treatment by persons with TBI which emerged from provider interviews were prioritized for intervention mapping: cognitive deficits of patients (67%); patient comorbidities (63%); mental health and/or substance abuse issues (59%); and patient participation (62%). SMEs used prioritized barriers to develop 4 primary objectives and implementation strategies designed to: (1) engage consumers to validate and identify strategies; (2) tailor pain treatment and delivery to overcome barriers; (3) develop and disseminate guidelines and best practices when delivering care to persons with TBI to support spread; and (4) increase awareness, skills, and readiness of workforce to deliver pain treatment to persons with TBI. SMEs used an evidence-based approach to develop a mapping matrix of the prioritized barriers, implementation objectives, and aligned implementation strategies to impact change.

CONCLUSION

Implementation science is needed to facilitate knowledge translation into practice for this complex population to overcome barriers to care. Implementation strategies to address barriers to accessing chronic pain care for individuals with TBI were chosen through a participatory approach to engaging SMEs to support these rehabilitation implementation efforts. Future work includes gathering input from individuals with TBI and chronic pain and to move the intervention (implementation) mapping matrix forward to inform future implementation research, policy, and practice.

Caregiver resilience following traumatic brain injury: Findings at six months postinjury

PURPOSE/OBJECTIVE

Examine contributors to resilience among caregivers of individuals who have sustained a moderate-to-severe traumatic brain injury (TBI), with the goal of identifying important targets for an intervention to improve caregiver resilience as well as outcomes for people with TBI.

RESEARCH METHOD/DESIGN

Participants were adult caregivers (n = 176) and individuals with TBI who required inpatient rehabilitation at six TBI Model System sites. Measures included the Connor-Davidson Resilience Scale-10, Family Needs Questionnaire, Zarit Burden Interview, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7. Data were collected between September 2018 and June 2021.

RESULTS

Caregivers endorsed levels of personal resilience that were comparable to norms for community samples and slightly higher than groups under stress or with medical illness. Reports of the burden associated with the caregiving role were relatively low, as was reported psychological distress. In a multivariable model, higher proportions of met emotional support needs were associated with increased resilience.

CONCLUSIONS/IMPLICATIONS

Resilience may be strengthened by emotional support networks, including friends or family who may not already be directly involved in the provision of care. Supporting engagement with community agencies, peer mentors, or other informal resources within the family system that provide emotional support may bolster resilience outcomes for caregivers. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Evolution of rehabilitation services in response to a global pandemic: reflection on opportunities and challenges ahead

The rapidly evolving COVID-19 public health emergency has disrupted and challenged traditional healthcare, rehabilitation services, and treatment delivery worldwide. This perspective paper aimed to unite experiences and perspectives from an international group of rehabilitation providers while reflecting on the lessons learned from the challenges and opportunities raised during the COVID-19 pandemic. We discuss the global appreciation for rehabilitation services and changes in access to healthcare, including virtual, home-based rehabilitation, and long-term care rehabilitation. We illustrate lessons learned by highlighting successful rehabilitation approaches from the US, Belgium, and Japan.

Rehabilitation of Neuropsychiatric Symptoms in Patients With Long COVID: Position Statement

Long COVID, a term used to describe ongoing symptoms after COVID-19 infection, parallels the course of other postviral syndromes. Neuropsychiatric symptoms of long COVID can be persistent and interfere with quality of life and functioning. Within the biopsychosocial framework of chronic illness, rehabilitation professionals can address the neuropsychiatric sequelae of long COVID. However, current practice models are not designed to address concurrent psychiatric and cognitive symptoms in adults living with long COVID. Thus, we present a biopsychosocial framework for long COVID and provide treatment strategies based on evidence from current literature of postviral chronic illness. These recommendations will guide rehabilitation professionals in identifying common neuropsychiatric symptoms in long COVID that can be targeted for intervention and addressing these symptoms via integrative interventions taking into account the biopsychosocial presentation of long COVID symptoms.

Using Machine Learning to Examine Suicidal Ideation After Traumatic Brain Injury: A Traumatic Brain Injury Model Systems National Database Study

OBJECTIVE

The aim of the study was to predict suicidal ideation 1 yr after moderate to severe traumatic brain injury.

DESIGN

This study used a cross-sectional design with data collected through the prospective, longitudinal Traumatic Brain Injury Model Systems network at hospitalization and 1 yr after injury. Participants who completed the Patient Health Questionnaire-9 suicide item at year 1 follow-up ( N = 4328) were included.

RESULTS

A gradient boosting machine algorithm demonstrated the best performance in predicting suicidal ideation 1 yr after traumatic brain injury. Predictors were Patient Health Questionnaire-9 items (except suicidality), Generalized Anxiety Disorder-7 items, and a measure of heavy drinking. Results of the 10-fold cross-validation gradient boosting machine analysis indicated excellent classification performance with an area under the curve of 0.882. Sensitivity was 0.85 and specificity was 0.77. Accuracy was 0.78 (95% confidence interval, 0.77-0.79). Feature importance analyses revealed that depressed mood and guilt were the most important predictors of suicidal ideation, followed by anhedonia, concentration difficulties, and psychomotor disturbance.

CONCLUSIONS

Overall, depression symptoms were most predictive of suicidal ideation. Despite the limited clinical impact of the present findings, machine learning has potential to improve prediction of suicidal behavior, leveraging electronic health record data, to identify individuals at greatest risk, thereby facilitating intervention and optimization of long-term outcomes after traumatic brain injury.

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.

Identifying group-based patterns of suicidal ideation over the first 10 years after moderate-to-severe TBI

OBJECTIVE

To identify group-based patterns in suicidal ideation (SI) over the first 10 years after traumatic brain injury (TBI).

METHODS

Participants included 9539 individuals in the TBI Model Systems National Database who responded to Patient Health Questionnaire-9 Item 9 assessing SI at 1, 2, 5, and/or 10 years post-injury. A k-means cluster analysis was conducted to determine group-based patterns of SI, and pre-injury variables were compared with ANOVAs and chi-square tests.

RESULTS

SI and attempts decreased over time. Four group-based patterns emerged: Low, increasing, moderate, and decreasing SI. The low SI group comprised 89% of the sample, had the highest pre-injury employment, fewer mental health vulnerabilities, least severe injuries, and were oldest. The increasing SI group had the most severe TBIs, were youngest, and disproportionately Black or Asian/Pacific Islander.

CONCLUSION

These findings reinforce the importance of mental health and suicide risk assessment during chronic recovery from TBI.

Relations among Suicidal Ideation, Depressive Symptoms, and Functional Independence during the Ten Years after Traumatic Brain Injury: A Model Systems Study

OBJECTIVE

To investigate relative causality in relations among suicidal ideation (SI), depressive symptoms, and functional independence over the first 10 years after traumatic brain injury (TBI).

DESIGN

Prospective longitudinal design with data collected through the TBI Model Systems (TBIMS) network at acute rehabilitation hospitalization, as well as 1, 2, 5, and 10 years after injury.

SETTING

United States Level I/II trauma centers and inpatient rehabilitation centers with telephone follow-up.

PARTICIPANTS

Individuals enrolled into the TBIMS National Database (N=9539) with at least one SI score at any follow-up data collection (72.1% male, mean age = 39.39 years).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Patient Health Questionnaire-9 and Functional Independence Measure at years 1, 2, 5, and 10 post-injury.

RESULTS

A cross-lagged panel structural equation model (SEM), which is meant to indirectly infer causality through longitudinal correlational data, suggested that SI, depressive symptoms, and functional independence each significantly predicted themselves over time. Within the model, bivariate correlations among variables were all significant within each time point. Between years 1 and 2 and between years 2 and 5, depressive symptoms had a larger effect on SI than SI had on depressive symptoms. Between years 5 and 10, there was reciprocal causality between the two variables. Functional independence more strongly predicted depressive symptoms than the reverse between years 1 and 2 as well as years 2 and 5, but its unique effects on SI over time were extremely marginal or absent after controlling for depressive symptoms.

CONCLUSIONS

A primary goal for rehabilitation and mental health providers should be to monitor and address elevated symptoms of depression as quickly as possible before they translate into SI, particularly for individuals with TBI who have reduced functional independence. Doing so may be a key to breaking the connection between low functional independence and SI.

Outcome prediction from post-injury resilience in patients with TBI

PURPOSE/OBJECTIVE

The objective of the study was to evaluate the extent to which 1- and 2-year outcomes after traumatic brain injury (TBI) are predicted by resilience. Research Method/Design: This was an observational, longitudinal study of persons (n = 158) with moderate or severe TBI who completed both 1- and 2-year outcome assessments. Outcomes included anxiety (Generalized Anxiety Disorder-7), depression (Patient Health Questionnaire-9), life satisfaction (Satisfaction with Life Scale), substance misuse, and return-to-work measures. The Connor-Davidson Resilience Scale was used to assess resilience at 3 or 6 months after injury.

RESULTS

Greater resilience predicted less anxiety, depression, and substance use and better satisfaction with life and return to work at 1 year after injury for both adjusted and unadjusted models. Standardized regression coefficients were all greater than 0.38 for continuous outcomes, whereas odds ratios were 1.34 and 0.81 for the return to work and substance misuse outcomes, respectively (p < .05). Similar but weaker trends were found at 2 years after injury, with statistical significance no longer met for all outcomes.

CONCLUSIONS/IMPLICATIONS

Resilience was shown to have predictive ability for outcomes at 1 and 2 years after TBI. Resilience appears to be a salient and important variable for long-term outcomes in person with TBI after adjusting for injury and demographic characteristics. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Injury Severity and Depressive Symptoms in a Post-acute Brain Injury Rehabilitation Sample

This study explored the relationship between injury severity and depressive symptoms for treatment-seeking individuals with traumatic brain injury (TBI). The Mayo Classification System was used to classify TBI severity in 72 participants who completed the Patient Health Questionnaire at admission and at dismissal from rehabilitation. Patients with mild TBI reported more depressive symptoms than those with moderate or severe TBI at admission and at dismissal. Although injury severity groups differed by gender composition, gender had no effect on severity of depressive symptoms. All participants reported fewer depressive symptoms at dismissal from rehabilitation, including lower endorsement of dysphoria by discharge. Participants with mild TBI, however, continued to report depressive symptoms of a mild severity at dismissal, with residual problems with anhedonia. These findings underscore the benefit of interdisciplinary post-acute rehabilitation services for persons with TBI of any severity, including those with mild injury.

Longitudinal Examination of Resilience After Traumatic Brain Injury: A Traumatic Brain Injury Model Systems Study

OBJECTIVES

To evaluate (1) the trajectory of resilience during the first year after a moderate-severe traumatic brain injury (TBI); (2) factors associated with resilience at 3, 6, and 12 months postinjury; and (3) changing relationships over time between resilience and other factors.

DESIGN

Longitudinal analysis of an observational cohort.

SETTING

Five inpatient rehabilitation centers.

PARTICIPANTS

Patients with TBI (N=195) enrolled in the resilience module of the TBI Model Systems study with data collected at 3-, 6-, and 12-month follow-up.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Connor-Davidson Resilience Scale.

RESULTS

Initially, resilience levels appeared to be stable during the first year postinjury. Individual growth curve models were used to examine resilience over time in relation to demographic, psychosocial, and injury characteristics. After adjusting for these characteristics, resilience actually declined over time. Higher levels of resilience were related to nonminority status, absence of preinjury substance abuse, lower anxiety and disability level, and greater life satisfaction.

CONCLUSIONS

Resilience is a construct that is relevant to understanding brain injury outcomes and has potential value in planning clinical interventions.

Characteristics of Firearm Brain Injury Survivors in the Traumatic Brain Injury Model Systems (TBIMS) National Database: A Comparison of Assault and Self-Inflicted Injury Survivors

OBJECTIVE

To characterize and compare subgroups of survivors with assault-related versus self-inflicted traumatic brain injuries (TBIs) via firearms at the time of inpatient rehabilitation and at 1-, 2-, and 5-year follow-up.

DESIGN

Secondary analysis of data from the Traumatic Brain Injury Model Systems National Database (TBIMS NDB), a multicenter, longitudinal cohort study.

SETTING

Retrospective analyses of a subset of individuals enrolled in the TBIMS NDB.

PARTICIPANTS

Individuals 16 years and older (N=399; 310 via assault, 89 via self-inflicted injury) with a primary diagnosis of TBI caused by firearm injury enrolled in the TBIMS NDB.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Disability Rating Scale, Glasgow Outcome Scale-Extended, sociodemographic variables (sex, age, race, marital status), injury-related/acute care information (posttraumatic amnesia, loss of consciousness, time from injury to acute hospital discharge), and mental health variables (substance use history, psychiatric hospitalizations, suicide history, incarcerations).

RESULTS

Individuals who survived TBI secondary to a firearm injury differed by injury mechanism (assault vs self-inflicted) on critical demographic, injury-related/acute care, and mental health variables at inpatient rehabilitation and across long-term recovery. Groups differed in terms of geographic area, age, ethnicity, education, marital status, admission Glasgow Coma Scale score, and alcohol abuse, suicide attempts, and psychiatric hospitalizations at various time points.

CONCLUSIONS

These findings have implications for prevention (eg, mental health programming and access to firearms in targeted areas) and for rehabilitation planning (eg, by incorporating training with coping strategies and implementation of addictions-related services) for firearm-related TBI, based on subtype of injury.

Prevalence of suicidal behaviour following traumatic brain injury: Longitudinal follow-up data from the NIDRR Traumatic Brain Injury Model Systems

OBJECTIVE

This study utilized the Traumatic Brain Injury Model Systems (TBIMS) National Database to examine the prevalence of depression and suicidal behaviour in a large cohort of patients who sustained moderate-to-severe TBI.

METHOD

Participants presented to a TBIMS acute care hospital within 72 hours of injury and received acute care and comprehensive rehabilitation in a TBIMS designated brain injury inpatient rehabilitation programme. Depression and suicidal ideation were measured with the Patient Health Questionnaire (PHQ-9). Self-reported suicide attempts during the past year were recorded at each follow-up examination, at 1, 2, 3, 10, 15 and 20 years post-injury.

RESULTS

Throughout the 20 years of follow-up, rates of depression ranged from 24.8-28.1%, suicidal ideation ranged from 7.0-10.1% and suicide attempts (past year) ranged from 0.8-1.7%. Participants who endorsed depression and/or suicidal behaviour at year 1 demonstrated consistently elevated rates of depression and suicidal behaviour 5 years after TBI.

CONCLUSION

Compared to the general population, individuals with TBI are at greater risk for depression and suicidal behaviour many years after TBI. The significant psychiatric symptoms evidenced by individuals with TBI highlight the need for routine screening and mental health treatment in this population.

Trajectories of life satisfaction after traumatic brain injury: Influence of life roles, age, cognitive disability, and depressive symptoms

OBJECTIVES

(a) Identify life satisfaction trajectories after moderate to severe traumatic brain injury (TBI); (b) establish a predictive model for these trajectories across the first 5 years postinjury; and (c) describe differences in these life satisfaction trajectory groups, focusing on age, depressive symptoms, disability, and participation in specific life roles.

RESEARCH METHOD

Analysis of the longitudinal TBI Model Systems National Database was performed on data collected prospectively at 1-, 2-, and 5-years post-TBI. Participants (n = 3,012) had a moderate to severe TBI and were 16 years old and older.

RESULTS

Four life satisfaction trajectories were identified across the first 5 years postinjury, including: stable satisfaction, initial satisfaction declining, initial dissatisfaction improving, and stable dissatisfaction. Age, depressive symptoms, cognitive disability, and life role participation as a worker, leisure participant, and/ or religious participant at 1-year postinjury significantly predicted trajectory group membership. Life role participation and depressive symptoms were strong predictors of life satisfaction trajectories across the first 5 years post-TBI.

CONCLUSIONS

The previously documented loss of life roles and prevalence of depression after a moderate to severe TBI make this a vulnerable population for whom low or declining life satisfaction is a particularly high risk. Examining individual life role participation may help to identify relevant foci for community-based rehabilitation interventions or supports.

Satisfaction with Cognitive Rehabilitation Delivered via the Internet in Persons with Acquired Brain Injury

We examined the level of satisfaction with cognitive rehabilitation delivered via the Internet in persons with moderate to severe acquired brain injury (ABI). Fifteen adults with moderate to severe ABI were randomized to 30 days of Internet-based active treatment (AT) or to a wait list (WL) group, and crossed over to the opposite condition after 30 sessions. Both caregivers and participants were assessed at three time points during the study. This study focused on participant satisfaction with receiving treatment in this manner. Though the results of this study showed no significant treatment effect, the vast majority of participants (>87%) were satisfied with treatment. Treatment satisfaction accounted for 25% of additional variance in predicting lower family ratings of mood difficulties after final assessment (p<.03). Greater satisfaction with treatment was positively correlated with greater employment rate after treatment (r=.63, p=.02), as well as lower family ratings of memory and mood difficulties after final assessment (r=−.59, p=.03; r=−.58, p=.03,). Results suggest that treatment satisfaction in persons with ABI is related to less activity limitations, and maintaining employment after cognitive rehabilitation delivered via the Internet.

Psychology: Current practice and training issues in treatment of cognitive dysfunction

Psychology has a primary role in cognitive rehabilitation along with other disciplines, but may be best qualified for evaluating specific cognitive abilities directing, cognitive-behavioral intervention programs, and measuring outcomes. Several specialties within psychology provide cognitive rehabilitation services; however, current training guidelines are not specific enough to ensure adequate training. These specialties all have areas of strength and limitations, but none of them has published guidelines specific to training in cognitive rehabilitation. In this paper we critique current guidelines, and make suggestions for training to be followed for those psychologists conducting CR.

Telehealth for persons with severe functional disabilities and their caregivers: facilitating self-care management in the home setting

Persons with severe functional disabilities are the highest users of health care services. Caring for the needs of this population represents a significant percentage of our national health care costs. A growing body of research has demonstrated the efficacy of self-management strategies and caregiver engagement for effective long-term care for individuals with chronic medical conditions. Economic forces over the past decade have led to new challenges and resulted in major changes in health care delivery resulting in shortened length of inpatient stays and greater limits on the length of outpatient treatment. Telehealth is an innovative method for health care delivery and a means of meeting this new challenge. This article highlights the findings of 3 pilot studies on the use of telecommunications technologies in promoting self-care management and enhancing health care outcomes in persons with severe disabilities and their family caregivers. The importance of matching technology to the needs of this population, lessons learned from these investigations, and future directions for research are addressed.

Satisfaction ratings after receiving internet-based cognitive rehabilitation in persons with memory impairments after severe acquired brain injury

OBJECTIVE

This study looked at patient satisfaction with an Internet-based cognitive rehabilitation program, which has been previously shown to be associated with functional improvements.

MATERIALS AND METHODS

Fourteen individuals with documented traumatic brain injury and memory impairments completed this study. Participants completed 60 sessions of Internet-based cognitive rehabilitation: 30 sessions of an active calendar intervention and 30 sessions of a control diary intervention. A four-question satisfaction questionnaire (responses were generated using a seven-point Likert scale) was completed after 30 sessions and again after 60 sessions.

RESULTS

No significant differences in satisfaction were found between time of assessment and treatment condition. In addition, a higher level of calendar use prior to beginning the study was associated with greater satisfaction at study completion.

CONCLUSION

These results suggest that persons with traumatic brain injury are not only willing to use the Internet to receive cognitive rehabilitation treatment, but are generally highly satisfied with the treatment. Further, individuals with some baseline compensatory strategies may be particularly well suited to this method of treatment.

Evidence-based cognitive rehabilitation: recommendations for clinical practice

OBJECTIVE

To establish evidence-based recommendations for the clinical practice of cognitive rehabilitation, derived from a methodical review of the scientific literature concerning the effectiveness of cognitive rehabilitation for persons with traumatic brain injury (TBI) or stroke.

DATA SOURCES

A MEDLINE literature search using combinations of these key words as search terms: attention, awareness, cognition, communication, executive, language, memory, perception, problem solving, reasoning, rehabilitation, remediation, and training. Reference lists from identified articles also were reviewed; a total bibliography of 655 published articles was compiled.

STUDY SELECTION

Studies were initially reviewed according to the following exclusion criteria: nonintervention studies; theoretical, descriptive, or review papers; papers without adequate specification of interventions; subjects other than persons with TBI or stroke; pediatric subjects; pharmacologic interventions; and non-English language papers. After screening, 232 articles were eligible for inclusion. After detailed review, 61 of these were excluded as single case reports without data, subjects other than TBI and stroke, and nontreatment studies. This screening yielded 171 articles to be evaluated.

DATA EXTRACTION

Articles were assigned to 1 of 7 categories according to their primary area of intervention: attention, visual perception and constructional abilities, language and communication, memory, problem solving and executive functioning, multi-modal interventions, and comprehensive-holistic cognitive rehabilitation. All articles were independently reviewed by at least 2 committee members and abstracted according to specified criteria. The 171 studies that passed initial review were classified according to the strength of their methods. Class I studies were defined as prospective, randomized controlled trials. Class II studies were defined as prospective cohort studies, retrospective case-control studies, or clinical series with well-designed controls. Class III studies were defined as clinical series without concurrent controls, or studies with appropriate single-subject methodology.

DATA SYNTHESIS

Of the 171 studies evaluated, 29 were rated as Class I, 35 as Class II, and 107 as Class III. The overall evidence within each predefined area of intervention was then synthesized and recommendations were derived based on consideration of the relative strengths of the evidence. The resulting practice parameters were organized into 3 types of recommendations: Practice Standards, Practice Guidelines, and Practice Options.

CONCLUSIONS

Overall, support exists for the effectiveness of several forms of cognitive rehabilitation for persons with stroke and TBI. Specific recommendations can be made for remediation of language and perception after left and right hemisphere stroke, respectively, and for the remediation of attention, memory, functional communication, and executive functioning after TBI. These recommendations may help to establish parameters of effective treatment, which should be of assistance to practicing clinicians.

Relationship between stress, coping, and postconcussion symptoms in a healthy adult population

Study 1 examined the association between intensity of postconcussive symptoms (PCS), impact of daily stress, and level of perceived stress over the past month in a group of healthy young adults. There was a significant relationship between intensity of PCS and impact of daily stress, as well as level of perceived stress over the past month, independent of the frequency of stressful events experienced. Study 2 assessed the stability of the relationship between PCS and stress. Subjects rated intensity of PCS, impact of daily stress, and level of perceived stress on two separate occasions approximately 1 month apart. The Perceived Stress Scale demonstrated high test-retest reliability. Significant relationships were again found between intensity of PCS and level of perceived stress at both time points, independent of the frequency of stressful events. These results suggest that persistent symptoms in some individuals with postconcussive syndrome may be due, at least in part, to individual differences in the perceived stress of incurring a mild traumatic brain injury.

Awareness and goal setting with the traumatically brain injured

One of the most disabling effects of traumatic brain injury is limited awareness of cognitive, emotional and interpersonal functioning. For this reason it is often difficult for a traumatically brain-injured person to form realistic goals and appreciate the need for rehabilitation. A goal-setting process is outlined in which therapists play a supportive but nondirective role and goals are developed which incorporate information in self-awareness. The aim of this approach is to create goals which are realistic and increase the likelihood of maintenance following treatment. Specific strategies to incorporate patient awareness during goal setting are discussed.