Injury Rehabilitation Setting Research Articles

Exploring racial performance disparities with the Modified Mini-Mental State Exam (3MS) in an acute brain injury rehabilitation setting.

The Modified Mini-Mental State Exam (3MS) is a brief, widely used cognitive screening tool. This study examined differences in 3MS performance between Black and White individuals undergoing acute brain injury rehabilitation. Participants were Black (44.1%; n = 78) and White (55.9%; n = 99) individuals admitted over a 2-year period to inpatient rehabilitation for an acute neurological injury or illness at a major, urban mid-Atlantic medical center. An attending psychologist administered the 3MS during assessment at admission, and demographic and injury-related information was extracted from electronic medical records. While there were no significant racial differences in the subsamples' gender, employment status, marital status, years of education, or days on the rehabilitation unit, Black participants were older and had a higher proportion of focal injuries or stroke. There were no significant racial differences in 3MS total scores. At the item level, Black participants scored lower on abstract reasoning, repetition, visuospatial construction, and comprehension. When adjusting for age and type of injury, significant differences remained in repetition and comprehension. The 3MS's internal consistency was adequate and comparable across races, as were item-total correlations, with the exception of White participants having a larger item-total correlation for the basic attention item. These findings underscore a point of caution about interpreting the results of a cognitive screening measure like the 3MS without the context of an individual's neurological history and race. Black individuals might be at risk for being inappropriately screened to be cognitively impaired, and some level of racial sensitivity should be taken at the item level for repetition and comprehension constructs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Supporting Sexual Functioning and Satisfaction During Rehabilitation after Spinal Cord Injury: Barriers and Facilitators Identified by Healthcare Professionals.

To explore healthcare professionals' perspectives on the barriers and facilitators impacting provision of support for sexual functioning/satisfaction during spinal cord injury rehabilitation. Qualitative, semi-structured interview design. Sixteen healthcare professionals working in spinal cord injury rehabilitation settings were recruited (14 females, 2 males). Semi-structured interviews were conducted using a 9-item interview guide. Interviews were transcribed verbatim and inductively analysed following Braun and Clarke's (2006) 6 phases of thematic analysis. Five inductive themes were generated describing healthcare professional-perceived barriers and facilitators impacting upon care delivery postspinal cord injury: (1) Integrating sexual wellbeing in rehabilitation; (2) Sex-informed multi-disciplinary teams; (3) Acknowledging awkwardness; (4) Enhancing approachability; and (5) Recognizing the partner. Sexual functioning and satisfaction are priority areas for rehabilitation, yet they are persistently side-lined in multi-disciplinary team (MDT) rehabilitation agendas. Healthcare professionals do not feel supported to engage with their patients to improve and manage sexual functioning/satisfaction. Ensuring that healthcare professionals are equipped and made aware of sexuality-specific guidelines and operational frameworks, which can be easily interpreted, structured and implemented as a standard part of spinal cord injury rehabilitation is key. This would be instrumental in enabling healthcare professionals to be more informed and comfortable in creating an atmosphere in which sexual topics can be openly discussed to support individuals with spinal cord injury.

Promoting Strength-Based Rehabilitation Programs for Optimal Pain and Injury Management and Recovery: A Professional Perspective

A frequent and prevalent issue in pain and injury rehabilitation settings is the under-dosing and underutilization of exercise- and strength-based intervention methods designed for long-term improvements. Currently, rehabilitation settings rely on non-evidence-based, passive modalities, low dosage of exercise, and minimal use of progressive overload principles. Moreover, these therapeutic rehabilitation settings neglect the evidence regarding the benefit of strength interventions on populations spanning from: high performing athletes, older women with sarcopenia, individuals with chronic low back pain, and individuals with cerebral palsy.

COVID-19 issues related to pediatric neuropsychology and inpatient rehabilitation – challenges to usual care and solutions during the pandemic

Objective: To describe the challenges related to COVID-19 affecting pediatric neuropsychologists practicing in inpatient brain injury rehabilitation settings, and offer solutions focused on face-to-face care and telehealth.Methods: A group of pediatric neuropsychologists from 12 pediatric rehabilitation units in North America and 2 in South America have met regularly since COVID-19 stay-at-home orders were initiated in many parts of the world. This group discussed challenges to clinical care and collaboratively problem-solvedsolutions.Results: Three primary challenges to usual care were identified, these include difficulty providing 1) neurobehavioral and cognitive assessments; 2) psychoeducation for caregivers and rapport building; and 3) return to academic instruction and home. Solutions during the pandemic for the first two areas focus on the varying service provision models that include 1) face-to-face care with personal protective equipment (PPE) and social distancing and 2) provision of care via remote methods, with a focus on telehealth. During the pandemic,neuropsychologists generally combine components of both the face-to-face and remote care models. Solutions to the final challenge focus on issues specific to returning to academic instruction and home after an inpatient stay.Conclusions: By considering components of in-person and telehealth models of patient care during the pandemic, neuropsychologists successfully serve patients within the rehabilitation setting, as well as the patient’s family who may be limited in their ability to be physically present due to childcare, illness, work-related demands, or hospital restrictions.

Applying the Sport Commitment Model to Sport Injury Rehabilitation.

Sustaining effort and persistence throughout injury rehabilitation are common goals for sport health care professionals. Considerable research in the sport domain has explored the issue of commitment to sport, as well as what predicts or influences an athlete's continued desire and resolve to continue participation. Scanlan and colleagues developed the sport commitment model (SCM) that places enjoyment as central construct influencing athletes' commitment. According to the model, perceptions of enjoyment, personal investments, involvement opportunities, attractive alternatives, social constraints, and social support should predict an athlete's level of sport commitment. One could argue the same may be true for commitment to sport injury rehabilitation. By applying the SCM to sport injury rehabilitation, practitioners may be able to enhance an athlete's commitment to their rehabilitation, prolong adherence, and increase other positive outcomes, such as increased enjoyment, motivation, and successful return to competition. The purpose of this pilot study was to explore the applicability of the SCM to the injury rehabilitation setting. Correlational design was used. Division I, intercollegiate athletic training room. 51 injured intercollegiate male and female athletes, 5 certified athletic trainers, and 8 senior, athletic training students. At the approximate midpoint of each athlete's injury rehabilitation, participants completed SCM measures. Certified athletic trainers and senior athletic training students independently assessed each injured athlete on effort, energy, and intensity during rehabilitation sessions. Rehabilitation commitment, enjoyment, investments, attractive alternatives, social constraints, perceived costs, and rehabilitation behaviors. Higher perceptions of investments predicted rehabilitation commitment. However, none of the SCM determinants predicted athletic trainer-rated rehabilitation behaviors. Future research should continue to explore commitment constructs in relation to rehabilitation motivation.

Feasibility of National Institutes of Health Toolbox Cognition Battery in pediatric brain injury rehabilitation settings.

Cognitive impairments are a devastating consequence of acquired brain injury (ABI) in children. Current pediatric tools for assessing cognitive impairments are generally time intensive and applicable only to a restricted age span. The National Institutes of Health Toolbox-Cognition Battery (NIHTB-CB) is a standardized, tablet-based cognitive assessment that has been normed across the life span in the general population and validated in adults with brain injuries. However, its clinical utility and validity has not yet been demonstrated in pediatric patients with brain injuries. The current study examines the feasibility of NIHTB-CB administration in both a pediatric inpatient and day treatment rehabilitation setting. The NIHTB-CB was attempted in 40 children with ABI aged 4-18 years within 1 year of injury in pediatric rehabilitation settings. Of the 40 participants tested, 38 (95%) were able to complete the full battery and 28 were able to complete it in 1 session. The average time to complete the NIHTB-CB for our sample was 40.2 min. Barriers to completion included both external (scheduling conflicts) and internal (fatigue, attention, and behavioral) limitations. Cohort results are consistent with expected impairments following ABI. This study demonstrates the feasibility of using the NIHTB-CB in postacute pediatric inpatient rehabilitation and day-treatment clinical settings following ABI. The NIHTB-CB has the potential to provide a quick, standardized assessment of cognitive function during the rehabilitation process. Further longitudinal studies of NIHTB-CB using larger samples will be needed to determine its validity, test-retest capabilities, and clinical utility. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Supplemental Material for Feasibility of National Institutes of Health Toolbox Cognition Battery in Pediatric Brain Injury Rehabilitation Settings

Supplemental Material for Feasibility of National Institutes of Health Toolbox Cognition Battery in Pediatric Brain Injury Rehabilitation Settings

The Lived Experience and Patient-reported Benefits of Yoga Participation in an Inpatient Brain Injury Rehabilitation Setting.

Context:The multifactorial benefits of yoga have been well documented in the literature, with the integration of yoga therapy into healthcare being an emerging field. In general, yoga therapy programs are utilized in the community as an adjunct to other therapy. At present, limited rehabilitation units routinely incorporate integrative therapy options within a hospital environment.Aims:The aim of this study is to explore the lived experience and patient-reported benefits of yoga in an inpatient brain injury rehabilitation setting.Settings and Design:Thirty-one participants were recruited to the study after voluntarily participating in a yoga class within an inpatient brain injury rehabilitation unit of a major metropolitan hospital. Yoga sessions were held weekly for 60 min and consisted of a modified Hatha yoga style. This was a mixed-methods, quasi-experimental one-group pretest–posttest study.Methodology:Quantitative data were collected to measure perceptions of relaxation and well-being before and after yoga classes, along with the satisfaction of the class. Semi-structured interviews were utilized to collect qualitative data of experiences and perceptions associated with yoga participation.Statistical Analysis Used:Thematic analysis was completed for qualitative data. Quantitative data were analyzed using nonparametric statistical methods, and descriptive statistics were also provided.Results:The benefits described by participants are reported in this paper. These include improved relaxation, physical well-being, emotional well-being, being present, and self-awareness.Conclusions:This study describes the personal benefits experienced from regular yoga participation within an inpatient rehabilitation setting.

Using audit and feedback to increase clinician adherence to clinical practice guidelines in brain injury rehabilitation: A before and after study.

ObjectiveThis study evaluated whether frequent (fortnightly) audit and feedback cycles over a sustained period of time (>12 months) increased clinician adherence to recommended guidelines in acquired brain injury rehabilitation.DesignA before and after study design.SettingA metropolitan inpatient brain injury rehabilitation unit.ParticipantsClinicians; medical, nursing and allied health staff.InterventionsFortnightly cycles of audit and feedback for 14 months. Each fortnight, medical file and observational audits were completed against 114 clinical indicators.Main outcome measureAdherence to guideline indicators before and after intervention, calculated by proportions, Mann-Whitney U and Chi square analysis.ResultsClinical and statistical significant improvements in median clinical indicator adherence were found immediately following the audit and feedback program from 38.8% (95% CI 34.3 to 44.4) to 83.6% (95% CI 81.8 to 88.5). Three months after cessation of the intervention, median adherence had decreased from 82.3% to 76.6% (95% CI 72.7 to 83.3, p<0.01). Findings suggest that there are individual indicators which are more amenable to change using an audit and feedback program.ConclusionA fortnightly audit and feedback program increased clinicians’ adherence to guideline recommendations in an inpatient acquired brain injury rehabilitation setting. We propose future studies build on the evidence-based method used in the present study to determine effectiveness and develop an implementation toolkit for scale-up.

Experience of Robotic Exoskeleton Use at Four Spinal Cord Injury Model Systems Centers.

Refinement of robotic exoskeletons for overground walking is progressing rapidly. We describe clinicians' experiences, evaluations, and training strategies using robotic exoskeletons in spinal cord injury rehabilitation and wellness settings and describe clinicians' perceptions of exoskeleton benefits and risks and developments that would enhance utility. We convened focus groups at 4 spinal cord injury model system centers. A court reporter took verbatim notes and provided a transcript. Research staff used a thematic coding approach to summarize discussions. Thirty clinicians participated in focus groups. They reported using exoskeletons primarily in outpatient and wellness settings; 1 center used exoskeletons during inpatient rehabilitation. A typical episode of outpatient exoskeleton therapy comprises 20 to 30 sessions and at least 2 staff members are involved in each session. Treatment focuses on standing, stepping, and gait training; therapists measure progress with standardized assessments. Beyond improved gait, participants attributed physiological, psychological, and social benefits to exoskeleton use. Potential risks included falls, skin irritation, and disappointed expectations. Participants identified enhancements that would be of value including greater durability and adjustability, lighter weight, 1-hand controls, ability to navigate stairs and uneven surfaces, and ability to balance without upper extremity support. Each spinal cord injury model system center had shared and distinct practices in terms of how it integrates robotic exoskeletons into physical therapy services. There is currently little evidence to guide integration of exoskeletons into rehabilitation therapy services and a pressing need to generate evidence to guide practice and to inform patients' expectations as more devices enter the market.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A231).

Patient perceptions of participation in group-based rehabilitation in an inpatient brain injury rehabilitation setting

ObjectivesThe use of groups is common in healthcare. There is a paucity of research which captures patient experiences of group participation. The aims of this study were to explore the perceptions and experiences of people with traumatic brain injury (TBI) about their participation in inpatient occupational therapy rehabilitation groups. MethodA phenomenological approach guided the study. Patients with a TBI who were participating in an inpatient occupational therapy group program were recruited. Data were collected through semi-structured interviews and analysed using content analysis. ResultsFifteen participants consented to the study. Three themes emerged from the data; 1) feeling normal, comfortable and connected; 2) learning by doing, seeing and sharing and; 3) practicalities of groups. Participants highlighted that groups facilitated opportunities to practice skills and prepared them for the real world. Opportunities for interaction and support were also emphasised as positive by participants. ConclusionPerceptions of patients about participation in groups were generally positive, and as such a consumer-focused approach to healthcare would support the use of occupational therapy groups in TBI rehabilitation. Practice implicationsRecommendations from the perspectives of patients include consideration of the selection of group participants, and meeting individual needs and goals within a group setting.

An examination of patient characteristics that contribute to falls in the inpatient traumatic brain injury rehabilitation setting

Purpose: To examine patient characteristics that contribute to falls in the inpatient traumatic brain injury (TBI) rehabilitation setting.Method: A three-round modified Delphi technique that engaged a multidisciplinary panel of 11 health experts was used. Group median score and disagreement index were used to measure agreement between participants about patient characteristics that contribute to falls.Results: All panel members participated in each questionnaire round. Several factors (such as, a fall since admission to hospital, cognitive impairment and motor impairment) were interpreted as contributing to falls in the TBI rehabilitation setting; but others were not (such as, antecedent falls and medication class). Some salient themes identified in participants’ comments include: (1) the need to differentiate between what is an activity (e.g., mobility) and impairment (e.g., ataxic gait)-based falls risk factor; (2) over the course of a 24-h day and inpatient rehabilitation stay, a patient’s risk of falling is not linear; and (3) Functional Independence Measure and predictors of TBI severity have varied sensitivity in predicting falls.Conclusions: In the TBI rehabilitation setting, falls result from a combination of many patient factors. Some factors are believed to be more relevant at different time points over a 24-h day and, at particular times during the course of a patient’s rehabilitation. The utility and statistical significance of risk factor of falls are both important concepts when determining their clinical relevance.Implications for RehabilitationClinicians should be mindful that the rehabilitation context can present unique falls risk factors, some of which emerge at different times during a patient’s rehabilitation.Over the course of a patient’s rehabilitation their risk of falling is not linear; therefore, rehabilitation clinicians should undertake periodic falls risk screening.The utility value and statistical significance of falls risk factors are both important aspects to consider when determining their clinical utility.

Holistic Practice in Traumatic Brain Injury Rehabilitation: Perspectives of Health Practitioners.

Given that the literature suggests there are various (and often contradictory) interpretations of holistic practice in brain injury rehabilitation and multiple complexities in its implementation (including complex setting, discipline, and client-base factors), this study aimed to examine the experiences of practitioners in their conceptualization and delivery of holistic practice in their respective settings. Nineteen health practitioners purposively sampled from an extensive Brain Injury Network in Queensland, Australia participated in individual interviews. A systematic text analysis process using Leximancer qualitative analysis program was undertaken, followed by manual thematic analysis to develop overarching themes. The findings from this study have identified several items for future inter-professional development that will not only benefit the practitioners working in brain injury rehabilitation settings, but the patients and their families as well.

National Collegiate Athletic Association Division I Certified Athletic Trainers' Perceptions of the Benefits of Sport Psychology Services.

Certified athletic trainers (ATs) are responsible for integrating relevant professionals into the rehabilitation team to assist with the holistic care of injured athletes. To explore National Collegiate Athletic Association Division I (DI) ATs' experience with sport psychology consultants (SPCs), willingness to encourage athletes to use SPCs for injury rehabilitation, and perceptions of the benefits of sport psychology services. Quantitative study. A Web-based survey was administered to a national sample of DI ATs. A total of 659 (341 men, 318 women) ATs completed the survey. Athletic trainers' experience with SPCs, willingness to encourage athletes to seek sport psychology services, and perceptions of the benefits of those services in injury-rehabilitation settings were self-reported using a rating scale that ranged from 1 (never or not at all) to 5 (definitely or extremely). Logistic regression revealed that the availability of SPCs, previous encouragement to athletes to seek sport psychology services, and previous positive interactions with SPCs predicted the ATs' willingness to encourage athletes to use these services (P < .0001). The services ATs rated the highest for injury rehabilitation were managing anxiety and emotion, improving coping techniques, and building confidence (ie, confidence in returning to sport and building confidence). Chi-square analyses indicated that female ATs' ratings of perceived benefits were higher (P ≤ .001) than those of male ATs, and the ratings of ATs who were likely to encourage the use of SPCs were higher (P ≤ .001) than those who were unlikely to encourage SPC service use. Athletic trainers in our study who had previous positive SPC experiences were most likely to use SPCs and their services during the injury-rehabilitation process. Possible implications are offered for how ATs interested in sport psychology services might call on SPCs to complement their work with injured athletes.

A Case-control Study Examining the Characteristics of Patients who Fall in an Inpatient Traumatic Brain Injury Rehabilitation Setting.

The purpose of the study was to describe the characteristics of patients who fall in the inpatient traumatic brain injury (TBI) rehabilitation setting. Specialized inpatient TBI rehabilitation unit. Fifty-four patients with history of falls and 55 nonequivalent patients without history of falls. Retrospective nonequivalent case-control study. The Functional Independence Measure, Glasgow Coma Scale, Westmead Post-traumatic Amnesia Scale, demographic and functional characteristics, and behavior and medication variables. No significant difference between patients with and without history of falls for age, sex, medication class or total number of medications administered on admission, and median admission Westmead Post-traumatic Amnesia Scale score was observed. Patients with history of falls had a significantly longer duration of post-traumatic amnesia, rehabilitation length of stay, and lower mean total admission Functional Independence Measure score and median Glasgow Coma Scale score at the time of injury. Patients with history of falls were more than 10 times more likely than patients without history of falls to require assistance on admission for activities of daily living, transfers, and continence/toileting. Neurobehaviors including noncompliance and anosognosia were significantly associated with patients with history of falls. A patient in the rehabilitation setting with a more severe TBI characterized by multisystem impairments is at an increased risk of falling, whereas some traditional fall risk factors were not associated with patients who fall. Rehabilitation settings should consider cohort-specific fall risk profiling. The Ontario STRATIFY Falls Risk Screening Tool is perhaps not the best tool to screen for falls in this inpatient population.

Reliability and validity of daily physical activity measures during inpatient spinal cord injury rehabilitation

Objectives:To assess the test–retest reliability and convergent validity of daily physical activity measures during inpatient spinal cord injury rehabilitation.Design:Observational study.Setting:Two inpatient spinal cord injury rehabilitation centres.Subjects:Participants (n = 106) were recruited from consecutive admissions to rehabilitation.Methods:Physical activity during inpatient spinal cord injury rehabilitation stay was recorded on two days via (1) wrist accelerometer, (2) hip accelerometer if ambulatory, and (3) self-report (Physical Activity Recall Assessment for People with Spinal Cord Injury questionnaire). Spearman’s correlations and Bland–Altman plots were utilized for test–retest reliability. Correlations between physical activity measures and clinical measures (functional independence, hand function, and ambulation) were performed.Results:Correlations for physical activity measures between Day 1 and Day 2 were moderate to high (ρ = 0.53–0.89). Bland–Altman plots showed minimal bias and more within-subject differences in more active individuals and wide limits of agreement. None of these three physical activity measures correlated with one another. A moderate correlation was found between wrist accelerometry counts and grip strength (ρ = 0.58) and between step counts and measures of ambulation (ρ = 0.62). Functional independence was related to wrist accelerometry (ρ = 0.70) and step counts (ρ = 0.56), but not with self-report.Conclusion:The test–retest reliability and convergent validity of the instrumented measures suggest that wrist and hip accelerometers are appropriate tools for use in research studies of daily physical activity in the spinal cord injury rehabilitation setting but are too variable for individual use.

A preliminary evaluation of the interpersonal music-communication competence scales

ABSTRACTWith the aim to develop and test a reliable and valid measure of communicative competencies in music for use in acquired brain injury rehabilitation settings, the interpersonal music-communication competence scale (IMCCS) was constructed, adapted from the interpersonal communication competence scale. Fifteen participants with medium to severe acquired brain injury, one music therapist and two blinded raters were involved in testing the IMCCS-Participant, the IMCCS-Therapist and the IMCCS-Rater versions of the scale. Before and after 20 music therapy sessions, each participant performed four music-based improvisational exercises in 1:1 sessions with the therapist (dialogue with the therapist, follow the musical ideas of the therapist, maintain musical phrases while therapist intentionally interrupt/challenge, and free improvisation with the therapist). Immediately following these improvisations, the participants and therapist completed the IMCCS. Two blinded raters completed the IMCCS-Rater after viewing video recordings of the exercises. Results revealed that the IMCCS-Therapist has good internal consistency (α = .89), the IMCCS-Participant has excellent internal consistency (α = .93), and the IMCCS-Rater has excellent internal consistency (α = .90). The two raters’ scores correlated significantly (r(26) = .54 to .73, p < .004), and a Cohen’s kappa analysis indicated a good agreement (Kw = .60). In addition, the correlation between the IMCCS-Rater and IMCCS-Therapist scores was adequate (r = .64, p = .005). All scales have satisfactory internal consistency and inter-rater reliability. These findings suggest that the IMCCS is a reliable measure of interpersonal communication competencies in music for people with acquired brain injury.

The characteristics of falls in an inpatient traumatic brain injury rehabilitation setting.

To describe the nature of falls in an inpatient traumatic brain injury rehabilitation setting. Falls are the most frequently recorded patient safety incident in the inpatient context. However, higher rates of falls are reported in rehabilitation settings compared to acute care settings. In the rehabilitation setting, patients with a traumatic brain injury have been identified as at a high risk of falling. However to date, research into the nature of falls involving this patient population is limited. Five-year retrospective cohort study design. Falls data from an inpatient traumatic brain injury rehabilitation unit were retrieved from the NSW Ministry of Health Incident Information Management System and patient clinical notes; nursing shift data were retrieved from the local rostering system. The fall rate was 5·18 per 1000 patient bed days. Over a 24-hour period falls (n = 103) occurred in a trimodal pattern. The median fall free period after admission was 14 days and 22% of traumatic brain injury patients had at least one fall. 53% of falls occurred in the patient's bedroom and 57% were attributed to loss of balance. At time of fall, 93% of fallers had impaired mobility and 85% required assistance for transfers. Falls within inpatient traumatic brain injury rehabilitation are a significant and complex clinical issue. While many patients continued to be at risk of falling several months after admission, a repeat faller's first fall occurred earlier in their admission than a single faller's. Generic falls prevention measures are insufficient for preventing falls in the brain injury rehabilitation population. Falls prevention initiatives should target times of high patient activity and situations where there is decreased nursing capacity to observe patients. Rehabilitation clinicians need to be mindful that a patient's risk of falling is not static and in fact, may increase over time.

Falls and fallers in traumatic brain injury (TBI) rehabilitation settings: an integrative review

Purpose: To critically appraise the research literature on the nature of falls and fallers in traumatic brain injury (TBI) rehabilitation settings. Method: An integrative review of the literature using thematic analysis was undertaken. Papers identified via a systematic search strategy were independently appraised by two reviewers. A data extraction instrument was developed to record results and to aid identification of themes in the literature. Critical Appraisal Skills Programme instruments were utilised to conduct a methodological critique of the papers included. Results: Thirteen studies were identified as having between 4% and 100% TBI patients in their study cohorts. From these papers, up to 71% of falls took place in a patient’s bedroom occurring in peaks and troughs over a 24-h period. With some divergent results, nine themes were identified describing faller characteristics including: (1) functional mobility impairments; (2) dizziness; (3) bladder and bowel dysfunction; (4) certain medications and number of medications prescribed; (5) executive functioning; (6) patient age; (7) fear of falling; (8) coma length following TBI; and (9) Functional Independence Measure (FIM™) total score, subscale scores and particular individual items. Conclusions: Being a multifactorial phenomenon, falls are a complex clinical issue. Despite the heterogeneity of diagnosis related groups (DRGs) in the included studies, TBI patients were identified as a high falls risk patient population in several studies.Implications for RehabilitationDue to multisystem impairments, falls in the traumatic brain injury (TBI) rehabilitation context are a multifactorial and significant clinical issue.When interpreting and generalising results from research into falls, clinicians need to be mindful that falls and faller characteristics may be dependent on study setting and patient population.There is need for context specific research into faller characteristics following a TBI; particularly in relation to post-traumatic amnesia.

Occupational therapists' use of advocacy in brain injury rehabilitation settings.

Occupational therapists working in brain injury rehabilitation are required to use the skill of advocacy to ensure that people with a brain injury have the right to engage in their chosen occupations. However, no studies were found exploring the use of advocacy by occupational therapists working in brain injury rehabilitation. To investigate how occupational therapists working in brain injury rehabilitation defined and implemented the skill of advocacy when working with clients. Interpretative phenomenological analysis was used to guide planning, data collection and analysis. Thirteen occupational therapists from six NSW metropolitan, regional and rural brain injury rehabilitation units participated in semi-structured interviews. All interviews were transcribed and member-checked prior to in-depth idiographic, inductive and interrogative analysis of each transcript. Participants identified the key elements of advocacy as the representation and education of clients and significant others. They indicated that all brain injury rehabilitation workers used advocacy when working with their clients, but were unable to identify unique ways that occupational therapists used advocacy when compared with other brain injury rehabilitation staff. However, they all felt that occupational therapists were well suited to advocate for clients in brain injury rehabilitation settings. Although participants had difficulty identifying unique ways in which occupational therapists used advocacy in brain injury rehabilitation settings, they all agreed that advocacy was an important skill for occupational therapists to develop and implement.