Community-based Brain Injury Rehabilitation Research Articles

Psychosocial functioning mediates change in motor and cognitive function throughout neurorehabilitation for adults with acquired brain injury (ABI-RESTaRT)

ObjectivesThis study aimed to evaluate the mediational role of change in psychosocial abilities, adjustment and participation on change in motor and cognitive function from admission to discharge from a staged community-based brain injury rehabilitation (SCBIR) service in Western Australia, 2011–2020.MethodsA retrospective cohort study of n = 324 adults with ABI enrolled in SCBIR using routinely collected rehabilitation outcome measures data. Motor and cognitive function were assessed with the UK Functional Independence and Assessment Measure and psychosocial function with the Mayo-Portland Adaptability Inventory-4. Six multilevel mediation regression analyses were conducted to determine whether change in psychosocial function (abilities, adjustment and participation) mediated change in motor and cognitive function from admission to discharge.ResultsParticipants demonstrated clinically significant improvements in both motor (+ 11.8, p < 0.001) and cognitive (+ 9.5, p < 0.001) functioning from admission to discharge. Statistically significant improvements in psychosocial abilities (− 4.8, p < 0.001), adjustment (− 2.9, p = 0.001) and participation (− 2.5, p < 0.001) were also seen but were not clinically significant. Mediation analyses showed that participation accounted for 81% of improvements in motor function at discharge and 71% of cognitive function improvements. Adjustment accounted for 26% and 32% of change in motor and cognitive function, respectively. Abilities accounted for 60% of change in cognitive function but did not significantly influence change in motor function. Changes in psychosocial participation fully mediated change in motor function during neurorehabilitation.ConclusionsPsychosocial function, particularly participation, is an important driver of motor and cognitive recovery throughout neurorehabilitation. Functional rehabilitation programs should target psychosocial improvement as an important mechanism of change.

Rehabilitation outcomes at discharge from staged community-based brain injury rehabilitation: A retrospective cohort study (ABI-RESTaRT), Western Australia, 2011-2020.

ObjectiveTo evaluate change in functional independence, psychosocial functioning, and goal attainment at discharge from a slow-stream Staged Community-Based Brain Injury Rehabilitation (SCBIR) service in Western Australia, 2011–2020.MethodsRetrospective cohort study of n = 323 adults with acquired brain injury (ABI) enrolled in a post-acute SCBIR service compared against a control cohort of n = 312 with ABI admitted to three non-rehabilitation programs. Outcome measures were the UK Functional Independence Measure and Functional Assessment Measure (FIM+FAM), Mayo Portland Adaptability Inventory-4 (MPAI-4), and Goal Attainment Scale. Change in FIM+FAM and MPAI-4 scores and predictors of goal attainment at discharge were evaluated using multilevel mixed-effects regression.ResultsMedian SCBIR length of stay was 20.5 months. Rehabilitation clients demonstrated clinically significant functional gains at discharge, adjusted mean change = +20.3, p < 0.001 (FIM+FAM). Peak gains of +32.3 were observed after 24–30 months and clinically significant gains were observed 5 years post-admission. Individuals discharged ≤6 months had the smallest functional gains (+12.7). Small psychosocial improvements were evidenced at discharge, mean reduction = −2.9T, p < 0.001 (MPAI-4) but not clinically significant. 47% of rehabilitation clients achieved their goals at the expected level or higher at discharge. Compared to the control, rehabilitation clients evidenced significantly greater functional gains and psychosocial improvement but lower goal attainment. Significant predictors of goal attainment at discharge were >2 years since injury, higher cognitive function and higher emotional adjustment at admission.ConclusionsFunctional recovery after ABI is a gradual and ongoing process. SCBIR is effective for functional rehabilitation post-injury but can be improved to achieve clinically meaningful psychosocial improvement.

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

ABSTRACT 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.

Community Rehabilitation Outcomes for Different Stroke Diagnoses: An Observational Cohort Study

ObjectiveTo determine the differences in functional and cognitive rehabilitation gains made in community-based rehabilitation following a stroke based on stroke diagnosis (left or right hemisphere, hemorrhagic, or ischemic). DesignA 12-month follow-up observational retrospective cohort study. SettingStaged community-based brain injury rehabilitation. ParticipantsClients (N=61) with hemorrhagic left brain stroke (n=10), hemorrhagic right brain stroke (n=8), ischemic left brain stroke (n=27), or ischemic right brain stroke (n=16) participating in rehabilitation for at least 12 months. InterventionNot applicable. Main Outcome MeasuresThe Mayo-Portland Adaptability Inventory-4 (MPAI-4) was completed at admission and 12 months post admission to staged community-based brain injury rehabilitation by consensus of a multidisciplinary team. ResultsAfter 12 months in staged community-based brain injury rehabilitation, the study population made significant gains in Total (P<.001) and across Ability (P<.001) and Participation (P<.001) subscales of the MPAI-4. All diagnostic groups made significant gains in Participation T-scores, and no groups made significant gains in Adjustment. The ischemic left and right hemisphere stroke groups also made significant gains in Ability and Total T-scores from admission to 12 months. Clients with ischemic left hemisphere stroke had more severe limitations in motor speech (P<.05) than clients with right hemisphere stroke at admission and/or review and were also more impaired in verbal communication (P<.01) than the hemorrhagic right hemisphere group at admission. ConclusionsThere are some differences in outcomes on presentation to rehabilitation based on type of stroke; there are also differences in rehabilitation gains. Improvement in physical ability does not always translate to improvement in social participation and independence; those with right brain stroke need further assistance to translate physical gains into participatory outcomes.

Family needs at a post-acute rehabilitation setting and suggestions for supports

Objective: To explore the perceived needs, obstacles to services, psychological distress and social problem-solving abilities of family members of persons with ABI at a post-acute community-based brain injury rehabilitation facility and offer suggestions for methods of assessment and providing support.Participants: Twenty-nine family members who did not provide daily care, but were involved in the care process.Design: Participants completed self-report questionnaires including the FNQ:R, SOS, DASS-21, WHO-QOL BREF and SPSI:R-S.Results: Participants reported informational and professional needs as most met and involvement in care, instrumental support and emotional support as most unmet. Most were satisfied with the amount of professional help and services and had confidence in the quality of care. Nearly half of the family members felt there were few ABI-related resources in the community and one third were unaware of good ABI treatment resources in their community. Psychosocial functioning was generally average.Conclusion: Family members who do not provide daily care are still impacted by the neurobehavioural changes that progress throughout the long-term, post-acute community phase. This study offers suggestions regarding an effective methodology for assessing family needs and recommends accessible and practical supports.

Current Practices and Perceived Needs of Community-Based Brain Injury Rehabilitation Programs

Current Practices and Perceived Needs of Community-Based Brain Injury Rehabilitation Programs

Outcome prediction in home- and community-based brain injury rehabilitation using the Mayo-Portland Adaptability Inventory

The objective of the study was to develop statistical formulas to predict levels of community participation on discharge from post-hospital brain injury rehabilitation using retrospective data analysis. Data were collected from seven geographically distinct programmes in a home- and community-based brain injury rehabilitation provider network. Participants were 642 individuals with post-traumatic brain injury. Interventions consisted of home- and community-based brain injury rehabilitation. The main outcome measure was the Mayo-Portland Adaptability Inventory (MPAI-4) Participation Index. Linear discriminant models using admission MPAI-4 Participation Index score and log chronicity correctly predicted excellent (no to minimal participation limitations), very good (very mild participation limitations), good (mild participation limitations), and limited (significant participation limitations) outcome levels at discharge. Predicting broad outcome categories for post-hospital rehabilitation programmes based on admission assessment data appears feasible and valid. Equations to provide patients and families with probability statements on admission about expected levels of outcome are provided. It is unknown to what degree these prediction equations can be reliably applied and valid in other settings.

Outcome Prediction in Home- and Community-Based Brain Injury Rehabilitation using the Mayo-Portland Adaptability Inventory

Outcome Prediction in Home- and Community-Based Brain Injury Rehabilitation using the Mayo-Portland Adaptability Inventory

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.

A prospective interrupted time series study of interventions to improve the quality, rating, framing and structure of goal-setting in community-based brain injury rehabilitation

Objective: To investigate whether the introduction of an electronic goals system followed by staff training improved the quality, rating, framing and structure of goals written by a community-based brain injury rehabilitation team. Design: Interrupted time series design. Intervention: Two interventions were introduced six months apart. The first intervention comprised the introduction of an electronic goals system. The second intervention comprised a staff goal training workshop. Methods: An audit protocol was devised to evaluate the goals. A random selection of goal statements from the 12 months prior to the interventions (Time 1 baseline) were compared with all goal statements written after the introduction of the electronic goals system (Time 2) and staff training (Time 3). All goals were de-identified for client and time-period, and randomly ordered. Results: A total of 745 goals (Time 1 n = 242; Time 2 n = 283; Time 3 n = 220) were evaluated. Compared with baseline, the introduction of the electronic goals system alone significantly increased goal rating, framing and structure (χ2 tests 144.7, 18.9, 48.1, respectively, p < 0.001). The addition of staff training meant that the improvement in goal quality, which was only a trend at Time 2, was statistically significant at Time 3 (χ2 15.0, p ≤ 001). The training also led to a further significant increase in the framing and structuring of goals over the electronic goals system (χ2 11.5, 12.5, respectively, p ≤ 0.001). Conclusion: An electronic goals system combined with staff training improved the quality, rating, framing and structure of goal statements.

Development and predictors of psychological adjustment during the course of community-based rehabilitation of traumatic brain injury: A preliminary study

The aim of the study was to describe the development and predictors of psychological adjustment during community-based traumatic brain injury (TBI) rehabilitation. Forty-two adolescent and adult individuals with TBI (mean age 32 years, 88% male, median post-traumatic amnesia 11 days) participated in a single-group, longitudinal design study. The main measures used were the Reactions to Impairment and Disability Inventory, Adjustment subscale; Sydney Psychosocial Reintegration Scale; Hospital Anxiety and Depression Scale; and Self-awareness of Deficits Interview. At rehabilitation start, individuals differed significantly from each other with respect to their level of psychological adjustment. Individual trajectories of psychological adjustment were highly variable. However, for the sample as a whole, psychological adjustment did not change during the course of rehabilitation (multilevel regression models; p > .05). Good psychological adjustment was related to low levels of emotional distress and a small discrepancy between current and aspired functional status. Poor functional status had a more minor impact on psychological adjustment in individuals with poor self-awareness than in individuals with high levels of self-awareness. The results confirm parts of theoretical models of psychological adjustment to acquired brain injury, especially the importance of goal refinement. However, the results need to be treated cautiously, given the limited sample size.

Mayo-Portland Adaptability Inventory: Comparing Psychometrics in Cerebrovascular Accident to Traumatic Brain Injury

Malec JF, Kean J, Altman IM, Swick S. Mayo-Portland Adaptability Inventory: comparing psychometrics in cerebrovascular accident to traumatic brain injury. Objectives(1) To evaluate the measurement reliability and construct validity of the Mayo-Portland Adaptability Inventory, 4th revision (MPAI-4) in a sample consisting exclusively of patients with cerebrovascular accident (CVA) using single parameter (Rasch) item-response methods; (2) to examine the differential item functioning (DIF) by sex within the CVA population; and (3) to examine DIF and differential test functioning (DTF) across traumatic brain injury (TBI) and CVA samples. DesignRetrospective psychometric analysis of rating scale data. SettingHome- and community-based brain injury rehabilitation program. ParticipantsIndividuals post-CVA (n=861) and individuals with TBI (n=603). InterventionsNot applicable. Main Outcome MeasureMPAI-4. ResultsItem data on admission to community-based rehabilitation were submitted to Rasch, DIF, and DTF analyses. The final calibration in the CVA sample revealed satisfactory reliability/separation for persons (.91/3.16) and items (1.00/23.64). DIF showed that items for pain, anger, audition, and memory were associated with higher levels of disability for CVA than TBI patients; whereas, self-care, mobility, and use of hands indicated greater overall disability for TBI patients. DTF analyses showed a high degree of association between the 2 sets of items (R=.92; R2=.85) and, at most, a 3.7 point difference in raw scores. ConclusionsThe MPAI-4 demonstrates satisfactory psychometric properties for use with individuals with CVA applying for interdisciplinary posthospital rehabilitation. DIF reveals clinically meaningful differences between CVA and TBI groups that should be considered in results at the item and subscale level.

Utility of the Canadian Occupational Performance Measure in community-based brain injury rehabilitation

Primary objective: To investigate the clinical utility of the Canadian Occupational Performance Measure (COPM) for community-based individuals with acquired brain injury (ABI).Methods and procedures: Thirty-four individuals with ABI (M = 5.32 years post-injury, SD = 3.92) were administered the COPM with self- and relative ratings of performance and satisfaction obtained. Relatives completed the Brain Injury Community Rehabilitation Outcome 39 (BICRO-39) scales. Measures of awareness of deficits, emotional status and cognitive function were obtained. A sub-group of participants was randomly allocated into a no-intervention group (n = 15) or an 8-week treatment group (n = 10). Initial assessments and 8-week follow-up assessments were conducted.Main outcomes and results: A pre- and post-assessment comparison for the treatment group identified a significant improvement on most COPM ratings (p < 0.05), but not the BICRO-39 (p > 0.05). However, self-ratings of satisfaction improved for the no-intervention group (p < 0.05). Self-ratings of satisfaction were significantly correlated with anxiety (r = −0.42, p < 0.05), although there were no other significant associations between COPM ratings and awareness, mood state and cognitive function.Conclusions: The findings generally support the utility of the COPM in community-based rehabilitation; however, the need for self-ratings to be interpreted in the context of other outcome indicators is recommended.

An organizational perspective on goal setting in community-based brain injury rehabilitation

Purpose. To use a taxonomy of goal content, developed in community-based brain injury rehabilitation to examine and compare the content of goals set within two different service settings; and to further examine the potential of the taxonomy to be a reliable and comprehensive framework for classifying goals.Method. Qualitative analysis and categorization of 1492 goal statements extracted from a community-based brain injury rehabilitation service over two time periods (1996 – 97, 1998 – 99), and cross-organizational comparison of ratings of goal classifications using a random sample of 100 goal statements drawn from this data set and the original 1765 goal statements used in developing the taxonomy.Results. Application of the taxonomy beyond the original service setting in which it was developed indicated a strong inter-rater reliability, with a high test-retest agreement reported over time. For both services, a small number of categories accounted for a substantial proportion of goals set within the two time periods, while considerable change was evident in goals between the two periods for one service. Further, both placed emphasis on individually focused goals rather than relationship or family-related goals.Conclusion. The taxonomy provides a reliable means for classifying goals and is a useful tool for exploration of the multiple influences on goal setting. Further application of the taxonomy to examine the relative influence on goal setting of client factors versus a range of organizational factors would be beneficial.

Developing a Suicide Prevention Strategy Based on the Perspectives of People with Brain Injuries

To develop a service-relevant, suicide prevention strategy based on the perspectives of people with brain injuries and their family members. Structured interview-based, qualitative case design. Interviews were conducted in the context of community-based brain injury rehabilitation service delivery. Ten persons with moderate to severe brain injuries who exhibited suicidal orientations and four family member/carers of these participants. Qualitative analysis of interview transcripts revealed a number of relevant themes. The primary theme was that informal relationships play a key role in preventing suicide. Secondary themes included the potential role of specialist brain injury rehabilitation services in suicide prevention and the need for provision of more information about brain injury to family and friends to promote understanding. Some discrepancy was noted between the perspectives of people with brain injuries and family members. The need for multiple strategies to respond to suicide risk was reinforced. Service-relevant resources (suicide risk screen, contract, and brochure) have been developed and included in service delivery.

Outcome in Community Rehabilitation: Measuring the Social Impact of Disability

This paper explores the range of outcome measures that can be employed in a post-acute community-based brain injury rehabilitation programme for people with complex patterns of neurobehavioural disability. In addition to standardised scales and structured interviews, the paper considers the use of behavioural measures of social and functional behaviour that can be used to give structure to observational methods when recording socially adaptive behaviour.