Clea C. Evans

Therapeutic alliance in post-acute brain injury rehabilitation: Predictors of strength of alliance and impact of alliance on outcome

Primary objective: To determine factors that influence the strength of therapeutic alliance for patients with traumatic brain injury (TBI) attending post-acute brain injury rehabilitation (PABIR) and to examine the association of therapeutic alliance with outcome after PABIR. Research design: Prospective cohort study. Methods and procedures: The study sample consisted of 69 of 95 patients with TBI admitted to the PABIR programme during the study period. Demographic and injury severity data were abstracted from medical records or obtained through interview. Study questionnaires (the modified California Psychotherapy Alliance Scales–patient, family and clinician forms; the Prigatano Alliance Scale; the Awareness Questionnaire; the Center for Epidemiologic Studies–Depression scale; and the Family Assessment Device–General Functioning Scale) were obtained within 2 weeks of patient admission to the PABIR programme. Main outcomes and results: Study outcomes were functional status (Disability Rating Scale), programme completion and employment status at discharge from PABIR. Higher levels of family discord were associated with poorer therapeutic alliance. Greater discrepancies between family and clinician ratings of patient functioning were associated with poorer therapeutic alliance and poorer effort in therapies. Poor participation was predictive of programme dropout. Productivity status at discharge was predicted by functional status at admission and degree of therapeutic alliance. Conclusions: Findings indicate that family perceptions and family functioning are important determinants of therapeutic alliance for patients in PABIR. These results indicate that therapists in PABIR programmes should address family perceptions and functioning to facilitate patient bonding with the programme.

EMERGENCE FROM MINIMALLY CONSCIOUS STATE: INSIGHTS FROM EVALUATION OF POSTTRAUMATIC CONFUSION

Background: Guidelines for defining the minimally conscious state (MCS) specify behaviors that characterize emergence, including “reliable and consistent” functional communication (accurate yes/no responding). Guidelines were developed by consensus because of lack of empirical data. Objective: To evaluate the utility of the operational threshold for emergence from posttraumatic MCS, by determining yes/no accuracy to questions of varied difficulty, including simple orientation questions, using all items from the Yes/No Subscale of the Mississippi Aphasia Screening Test. Method: Prospective observational study of a cohort of responsive patients recovering from traumatic brain injury in an acute inpatient brain injury rehabilitation program. Results: Of the 629 observations from 144 participants, name recognition was the easiest yes/no question, with nonconfused individuals responding with 100% accuracy, whereas only 75% to 78% of confused participants on initial evaluation answered this question correctly. Generalized Estimating Equations analysis revealed that confused participants were more likely to respond inaccurately to all yes/no questions. Nonconfused participants had a reduction in odds of inaccuracy ranging from 45.6% to 99.7% (p = 0.001 to 0.02) depending on the type of yes/no question. Conclusions: Accuracy for simple orientation yes/no questions remains challenging for responsive patients in early recovery from traumatic brain injury. Although name recognition questions are relatively easier than other types of yes/no questions, including situational orientation questions, confused patients still may answer these incorrectly. Results suggest the operational threshold for yes/no response accuracy as a diagnostic criterion for emergence from the minimally conscious state should be revisited, with particular consideration of the type of yes/no questions and the requisite accuracy threshold for responses.

Prospective Evaluation of the Nature, Course, and Impact of Acute Sleep Abnormality After Traumatic Brain Injury

OBJECTIVE To prospectively characterize the prevalence, course, and impact of acute sleep abnormality among traumatic brain injury (TBI) neurorehabilitation admissions. DESIGN Prospective observational study. SETTING Freestanding rehabilitation hospital. PARTICIPANTS Primarily severe TBI (median emergency department Glasgow Coma Scale [GCS] score=7; N=205) patients who were mostly men (71%) and white (68%) were evaluated during acute neurorehabilitation. INTERVENTIONS None. MAIN OUTCOME MEASURE Delirium Rating Scale-Revised-98 (DelRS-R98) was administered weekly throughout rehabilitation hospitalization. DelRS-R98 item 1 was used to classify severity of sleep-wake cycle disturbance (SWCD) as none, mild, moderate, or severe. SWCD ratings were analyzed both serially and at 1 month postinjury. RESULTS For the entire sample, 66% (mild to severe) had SWCD at 1 month postinjury. The course of the SWCD using a subset (n=152) revealed that 84% had SWCD on rehabilitation admission, with 63% having moderate to severe ratings (median, 24d postinjury). By the third serial exam (median, 35d postinjury), 59% remained with SWCD, and 28% had moderate to severe ratings. Using general linear modeling and adjusting for age, emergency department GCS score, and days postinjury, presence of moderate to severe SWCD at 1 month postinjury made significant contributions in predicting duration of posttraumatic amnesia (P<.01) and rehabilitation hospital length of stay (P<.01). CONCLUSIONS Results suggest that sleep abnormalities after TBI are prevalent and decrease over time. However, a high percent remained with SWCD throughout the course of rehabilitation intervention. Given the brevity of inpatient neurorehabilitation, future studies may explore targeting SWCD to improve early outcomes, such as cognitive functioning and economic impact, after TBI.

Self-esteem in an acute stroke rehabilitation sample: a control group comparison:

Objective: To compare ratings of self-esteem and depressive mood in a sample of stroke survivors in an acute inpatient rehabilitation setting to those of a matched control group. Design: Stroke survivors (n = 80) were matched on age and education to a group of neurologically intact community-dwelling control participants. Between-group analysis compared mean ratings of self-esteem and depressive measures. Within-group correlational analyses explored the relationship between self-esteem and mood. Between-group comparison of the correlations between self-esteem and mood explored differences in the strength of association between these constructs. Regression analyses explored the relationship of self-esteem measures after controlling for depressive mood. Main measures: Visual Analogue Self-Esteem Scale, Rosenberg Self-Esteem Scale, Geriatric Depression Scale. Results: Stroke survivors rated significantly lower mean levels of self-esteem on the Visual Analogue Self-Esteem Scale (37 versus 41) and the Rosenberg Self-Esteem Scale (21 versus 24) than the control group. Stroke survivors also rated higher mean levels of depressive mood on the Geriatric Depression Scale (9 versus 6). Significantly higher correlations between self-esteem and mood ratings were noted in the stroke group than in the control group. Lower self-esteem ratings do not appear to be a byproduct of depressive mood. Conclusions: Self-esteem is negatively impacted by stroke and is strongly, but independently, associated with depressive mood. Clinicians may better facilitate the emotional adjustment of the survivor by considering this facet of psychological impact and intervening to address self-esteem.

Serial yes/no reliability after traumatic brain injury: implications regarding the operational criteria for emergence from the minimally conscious state

Background: Published guidelines for defining the “minimally conscious state” (MCS) included behaviours that characterise emergence, specifically “reliable and consistent” functional interactive communication (accurate yes/no responding) and functional use of objects. Guidelines were developed by consensus because of the lack of empirical data to guide definitions. Criticism emerged that individuals with severely impaired cognition would have difficulty achieving the requisite threshold of accuracy and consistency proposed to demonstrate emergence from MCS. Objective: To determine the utility of the operational threshold for emergence from post-traumatic MCS, by evaluating a measure of yes/no accuracy (Cognitive Test for Delirium, auditory processing subtest (CTD-AP).) Methods: Prospective, consecutive cohort of responsive patients recovering from traumatic brain injury (TBI), including a subset meeting criteria for MCS at neurorehabilitation admission who improved and were able to undergo the study protocol. Participants were evaluated at least weekly, and given the CTD-AP to assess yes/no responding. Results: Of the 1434 observations from 336 participants, 767 observations yielded inaccurate yes/no responses. 75 participants (22%) never attained consistently accurate yes/no responses at any time during their hospitalisation. Generalised estimating equations analysis revealed that confused participants were more likely to respond inaccurately to yes/no questions. Further, the subset of individuals who were in MCS on rehabilitation admission and improved, were also more likely to respond inaccurately to yes/no questions. Conclusions: Consistent yes/no accuracy is uncommon among responsive patients in early recovery from TBI. These results suggest that the operational threshold for yes/no response accuracy as a diagnostic criterion for emergence from MCS should be revisited.

Evaluation of an interdisciplinary team intervention to improve therapeutic alliance in post-acute brain injury rehabilitation.

ObjectiveEvaluate an intervention to improve an alliance between an interdisciplinary team and clients with traumatic brain injury attending post–acute brain injury rehabilitation. DesignProspective design, 2 consecutive samples—historical control (CNT) and treatment (TX). MethodsSample of 104 clients (69 CNT, 35 TX) admitted to post–acute brain injury rehabilitation completed admit/discharge questionnaires. ResultsThe TX group had higher functional status at discharge than the CNT group. Stronger team alliance was associated with program completion, return to productivity, stronger client alliance, less family discord, and fewer depressive symptoms. ConclusionsFindings provide direction for a larger study examining the effectiveness of this intervention to improve outcome after traumatic brain injury.

Multilevel modeling of self-esteem change during acute inpatient stroke rehabilitation.

OBJECTIVE To explore self-esteem change during inpatient stroke rehabilitation and moderators of change. RESEARCH METHOD One hundred twenty survivors of stroke serially completed the State Self-Esteem Scale (SSES) during inpatient rehabilitation, as well as measures of mood and perceived recovery as potential moderators of change. Age, gender, prior stroke, prestroke depression, stroke laterality, and admission Functional Independence Measure (FIM) self-care, mobility, and cognitive scores were also included as moderators. RESULTS Multilevel modeling of the repeated administrations of the SSES indicated that self-esteem significantly improved during rehabilitation. Female gender, left hemisphere stroke, prior stroke, and lower admission FIM cognitive scores were associated with lower self-esteem ratings at admission, but only age and admission FIM self-care and mobility scores were associated with self-esteem change. Older individuals showed less self-esteem improvement than younger individuals, and higher self-care and mobility scores at admission were associated with greater self-esteem improvement. While mood change significantly covaried with self-esteem, the rate of mood change did not appear to influence rate of self-esteem change. Greater improvement in self-esteem over time was related to lower levels of perceived recovery, but this was likely because of the relationship between perceived recovery and self-esteem at rehabilitation admission. IMPLICATIONS These results suggest that self-esteem improves during inpatient rehabilitation, and this change may be partially dependent on functional status. Implications for facilitating self-esteem change by the clinician are discussed, as well as future research directions.

Self-esteem stability and depressive symptoms in acute stroke rehabilitation: methodological and conceptual expansion.

OBJECTIVES Explore the relationship of self-esteem level, self-esteem stability, and other moderating variables with depressive symptoms in acute stroke rehabilitation. MEASURES One hundred twenty participants completed measures of state self-esteem, perceived recovery, hospitalization-based hassles, impairment-related distress, and tendency to overgeneralize negative self-connotations of bad events. Self-report of depressive symptoms was collected at admission and on discharge. Four regression analyses explored the relationship of self-esteem level and stability and each of 4 moderating variables (perceived recovery, hassles, impairment-related distress, and overgeneralization) with depressive symptoms at discharge. RESULTS Analyses indicated significant 3-way interactions in the 4 regression models. In general, individuals with unstable high self-esteem endorsed greater depressive symptoms under conditions of vulnerability (e.g., lower perceived recovery) than did individuals with stable high self-esteem. Under conditions of vulnerability, participants with stable low self-esteem indicated the highest levels of depressive symptoms. IMPLICATIONS Self-esteem level and stability interact with psychological, environmental, and stroke-specific variables to predict depressive symptoms at discharge from stroke rehabilitation. This suggests the viability of self-esteem stability in exploring depressive symptoms in this setting and the complexity of emotional adjustment early after stroke.

Posttraumatic Confusion Predicts Patient Cooperation During Traumatic Brain Injury Rehabilitation

ABSTRACTScant research has examined the relationship between posttraumatic confusion (PTC) and cooperation during rehabilitation from moderate to severe traumatic brain injury. In this study, PTC and cooperation were examined in a prospective cohort of 74 inpatients with traumatic Brain Injury. Confusion was measured using the Confusion Assessment Protocol. Cooperation was rated on a 0–100 scale by rehabilitation therapists. Using multiple regression analysis, PTC significantly predicted cooperation (R2 = 0.33, P < 0.001). Age at injury, education, days since injury, and Glasgow Come Scale scores were not significant predictors. Bivariate analyses indicated that four PTC symptoms significantly predicted poorer cooperation: daytime hypersomnolence (&rgr; = −0.42, P < 0.001), agitation (&rgr; = −0.39, P = 0.001), psychosis (&rgr; = −0.39, P = 0.001), and cognitive impairment (&rgr; = −0.24, P = 0.04). Results provide empirical support that PTC is associated with poorer cooperation and empirical justification for interventions to manage confusion during early recovery from traumatic brain injury.

The Relationship Between Sleep-Wake Cycle Disturbance and Trajectory of Cognitive Recovery During Acute Traumatic Brain Injury.

Objective:Following traumatic brain injury, both sleep dysfunction and cognitive impairment are common. Unfortunately, little is known regarding the potential associations between these 2 symptoms during acute recovery. This study sought to prospectively examine the relationship between ratings of sleep dysfunction and serial cognitive assessments among traumatic brain injury acute neurorehabilitation admissions. Methods:Participants were consecutive admissions to a free-standing rehabilitation hospital following moderate to severe traumatic brain injury (Median Emergency Department Glasgow Coma Scale = 7). Participants were assessed for sleep-wake cycle disturbance (SWCD) and cognitive functioning at admission and with subsequent weekly examinations. Participants were grouped on the basis of presence (SWCD+) or absence (SWCD−) of sleep dysfunction for each examination; groups were equivalent on demographic and injury variables. Individual Growth Curve modeling was used to examine course of Cognitive Test for Delirium performance across examinations. Results:Individual Growth Curve modeling revealed a significant interaction between examination number (ie, time) and SWCD group (&bgr; = −4.03, P < .001) on total Cognitive Test for Delirium score. The SWCD+ ratings on later examinations were predicted to result in lower Cognitive Test for Delirium scores and greater cognitive impairment over time. Conclusions:This study has implications for improving neurorehabilitation treatment, as targeting sleep dysfunction for early intervention may facilitate cognitive recovery.