Emmah Doig

Patterns of community integration 2-5 years post-discharge from brain injury rehabilitation

Outcome after traumatic brain injury (TBI) is characterized by a high degree of variability which has often been difficult to capture in traditional outcome studies. The purpose of this study was to describe patterns of community integration 2-5 years after TBI. Participants were 208 patients admitted to a Brain Injury Rehabilitation Unit between 1991-1995 in Brisbane, Australia. The design comprised retrospective data collection and questionnaire follow-up by mail. Mean follow-up was 3.5 years. Demographic, injury severity and functional status variables were retrieved from hospital records. Community integration was assessed using the Community Integration Questionnaire (CIQ), and vocational status measured by a self administered questionnaire. Data was analysed using cluster analysis which divided the data into meaningful subsets. Based on the CIQ subscale scores of home, social and productive integration, a three cluster solution was selected, with groups labelled as working (n = 78), balanced (n = 46) and poorly integrated (n = 84). Although 38% of the sample returned to a high level of productive activity and 22% achieved a balanced lifestyle, overall community integration was poor for the remainder. This poorly integrated group had more severe injury characterized by longer periods of acute care and post-traumatic amnesia (PTA) and greater functional disability on discharge. These findings have implications for service delivery prior to and during the process of reintegration after brain injury.

Objective and behavioural assessment of the emergence from post-traumatic amnesia (PTA).

Primary objective: To determine the profile of resolution of typical PTA behaviours and describe new learning and improvements in self-care during PTA. Research design: Prospective longitudinal study monitoring PTA status, functional learning and behaviours on a daily basis. Methods and procedures: Participants were 69 inpatients with traumatic brain injury who were in PTA. PTA was assessed using the Westmead or Oxford PTA assessments. Functional learning capability was assessed using a routine set of daily tasks and behaviour was assessed using an observational checklist. Data was analysed using descriptive statistics. Main outcomes and results: Challenging behaviours that are typically associated with PTA, such as agitation, aggression and wandering resolved in the early stages of PTA and incidence rates of these behaviours were less than 20%. Independence in self-care and bowel and bladder continence emerged later during resolution of PTA. New learning in functional situations was demonstrated by patients in PTA. Conclusions: It is feasible to begin active rehabilitation focused on functional skills-based learning with patients in the later stages of PTA. Formal assessment of typically observed behaviours during PTA may complement memory-based PTA assessments in determining emergence from PTA.

Evaluation of an outpatient, peer group intervention for people with acquired brain injury based on the ICF 'Environment' dimension.

Purpose. This study aimed to evaluate the effectiveness of an intervention based on the ICF ‘Environment’ dimension for enhancing the well-being and psychosocial outcomes of patients with acquired brain injury in an outpatient (day hospital) setting. Method. A mixed methodology cohort study comparing an intervention group with an historical non-intervention group using pre- and post-intervention and follow-up measures. The 6-week group intervention involved participants and their significant others. Pre- and post-intervention data from the intervention group and the non-intervention group were compared using 2 × 2 analyses of variance for five standardised outcome measures. Semi-structured interviews with intervention participants and significant others were used to provide qualitative feedback. Results. A significant group by time interaction was found for level of community integration on the Sydney Psychosocial Reintegration Scale and depression scores on the Hospital Anxiety and Depression Scale, with greater improvements for the intervention group compared with the non-intervention group. No other significant differences between groups were found. Gains in community integration were maintained by the intervention group at 1-month follow-up. Qualitative feedback from participants indicated the value of: sharing experiences, the group content, goal setting, comparing with others and the group processes. Conclusions. The Environment-focused intervention was useful in improving patient outcomes in terms of better self-reported community integration.

Goal-directed outpatient rehabilitation following TBI: A pilot study of programme effectiveness and comparison of outcomes in home and day hospital settings

Primary objective: To determine (i) the effectiveness of a goal-directed, environment-focused occupational therapy intervention and (ii) to compare rehabilitation gains across a day hospital (outpatient) setting and home setting. Research design: Repeated measures cross-over design with pre–post test measures and a baseline control period, random allocation to a treatment setting sequence and an independent outcome assessor who was blinded to treatment sequence. Methods and procedures: Descriptive and non-parametric comparative analyses employed. Fourteen participants with severe traumatic brain injury completed a 12 week outpatient occupational therapy programme. The programme was directed by the participants chosen goals, which were established using a client-centred, structured, goal-planning process. Outcome measures included Goal attainment scaling, the Canadian Occupational Performance Measure, the Sydney Psychosocial Reintegration Scale, the Mayo-Portland Adaptability Index, the Craig Hospital Inventory of Environmental Factors and self-rated satisfaction with therapy. Main outcomes and results: The therapy programme resulted in significant improvements in goal attainment, occupational performance, psychosocial reintegration and ability and adjustment levels, compared with baseline. Differences in gains made in home vs day hospital settings were not statistically significant, with the exception of higher levels of patient satisfaction with therapy at home. Conclusions: To assist further with decision-making about where to conduct therapy, further research is needed to compare the outcomes and determine the cost effectiveness of therapy at home and in day hospital settings.

Comparison of rehabilitation outcomes in day hospital and home settings for people with acquired brain injury - a systematic review.

Purpose. To conduct a systematic literature review that identifies and summarises the findings of studies that have compared the outcomes of outpatient, brain injury rehabilitation programmes conducted in real-life home settings and day hospital clinic settings. Method. A systematic search, using specific inclusion and exclusion criteria, of English language electronic databases, as well as manual search of reference lists of identified articles. Each study was evaluated and rated using 11 methodological criteria. The findings are summarised. Results. Database searches, using key terms, initially yielded 4484 articles. Of these articles, 17 articles were included in the review and rated according to methodological quality. The majority of studies indicated that the outcomes of rehabilitation programmes conducted in home settings are at least equivalent to rehabilitation conducted in day hospital and outpatient settings for people with acquired brain injury. Most identified studies (15/17) were with groups of people with a diagnosis of stroke, primarily over the age of 65 years. Assessments of impairment or activity limitation were primarily used to reflect outcomes and no studies used participation or goal-based outcome measures. Conclusions. The available studies indicate that outcomes of outpatient rehabilitation programmes delivered at home, of short-term duration (mostly 3 months) for people with stroke recently discharged from hospital, are at least equivalent to day hospital-based outpatient rehabilitation programme outcomes. However, there have been no controlled studies designed to investigate the influence of therapy context (home and clinic settings) on outcomes for people receiving outpatient neurological rehabilitation. Furthermore, investigations of the efficacy of community-based rehabilitation with younger people with brain injuries, caused by mechanisms other than stroke, are required.

Development of self-awareness after severe traumatic brain injury through participation in occupation-based rehabilitation: mixed-methods analysis of a case series

OBJECTIVE. We examined participation in goal planning and development of self-awareness for people with impaired self-awareness after traumatic brain injury. METHOD. We performed a mixed-methods study of 8 participants recently discharged from inpatient rehabilitation. Self-awareness was measured using discrepancy between self and significant other ratings on the Mayo-Portland Adaptability Index (MPAI-4) at four time points. We calculated effect size to evaluate the change in MPAI-4 discrepancy over time. RESULTS. Seven participants identified their own goals. We found a large reduction in mean MPAI-4 discrepancy (M = 8.57, SD = 6.59, N = 7, d = 1.08) in the first 6 wk and a further small reduction (M = 5.33, SD = 9.09, N = 6, d = 0.45) in the second 6 wk of intervention. Case data indicated that 7 participants demonstrated some growth in self-awareness. CONCLUSION. Engagement in occupation-based, goal-directed rehabilitation appeared to foster awareness of injury-related changes to varying extents.

Development and construct validation of the Client-Centredness of Goal Setting (C-COGS) scale

Abstract Background: Client-centred philosophy is integral to occupational therapy practice and client-centred goal planning is considered fundamental to rehabilitation. Evaluation of whether goal-planning practices are client-centred requires an understanding of the client’s perspective about goal-planning processes and practices. The Client-Centredness of Goal Setting (C-COGS) was developed for use by practitioners who seek to be more client-centred and who require a scale to guide and evaluate individually orientated practice, especially with adults with cognitive impairment related to acquired brain injury. Aims: To describe development of the C-COGS scale and examine its construct validity. Material and methods: The C-COGS was administered to 42 participants with acquired brain injury after multidisciplinary goal planning. C-COGS scores were correlated with the Canadian Occupational Performance Measure (COPM) importance scores, and measures of therapeutic alliance, motivation, and global functioning to establish construct validity. Results: The C-COGS scale has three subscales evaluating goal alignment, goal planning participation, and client-centredness of goals. The C-COGS subscale items demonstrated moderately significant correlations with scales measuring similar constructs. Conclusion: Findings provide preliminary evidence to support the construct validity of the C-COGS scale, which is intended to be used to evaluate and reflect on client-centred goal planning in clinical practice, and to highlight factors contributing to best practice rehabilitation.

Group-based delivery of interventions in traumatic brain injury rehabilitation: a scoping review

Abstract Purpose: Whilst there are potential advantages of group-based interventions in rehabilitation, facilitation of groups for patients following traumatic brain injury (TBI) has challenges due to the complexity of impairments experienced. This paper aims to review the literature concerning therapy groups within TBI rehabilitation. Method: A scoping review with systematic searching of relevant databases and review of reference lists of included studies was conducted. Key search terms included brain injury, group and rehabilitation OR therapy OR intervention. Studies were included if at least some participants had a TBI diagnosis and they investigated rehabilitation interventions conducted in a group setting. Articles were collated, summarised and key findings are presented. Results: The total number of included articles was 99. The results indicated group interventions are widely practised in TBI rehabilitation. Existing research consists mostly of pre–post intervention studies addressing cognitive impairments with outpatient participants. Most studies have identified significant positive changes on some targeted outcome measures suggesting group interventions are effective. Conclusions: Studies of the effectiveness of interventions targeting ‘real-world’ activities and participation-based goals are under-represented in the TBI rehabilitation literature. Further research investigating the effectiveness of group processes and the perceptions of patients and clinicians is warranted to guide clinical practice. Implications for Rehabilitation Group-based interventions are common in TBI rehabilitation, usually targeting cognitive skills and impairments. The majority of studies demonstrated positive changes pre–post group interventions on some outcome measures. Few studies directly compare the outcome of an intervention delivered in a group setting to the same intervention delivered in an individual setting. Patients perceive group interventions to be beneficial for sharing experiences and reducing isolation, receiving help and feedback and, assisting with adjustment and adaptation to life after TBI, however, this research is limited. Greater emphasis on group-delivered interventions that target ‘real world’ activities, or participation may be beneficial with this population. Further research regarding consumer experiences and processes that facilitate effective group interventions in TBI rehabilitation is recommended.

Goal setting approaches and principles used in rehabilitation for people with acquired brain injury: A systematic scoping review

Abstract Primary objective: To identify goal setting approaches used with people with acquired brain injury (ABI) in the working age range. Methods: Database searches were conducted in Medline (via Ovid) (1960–May 2014), CINAHL (1982–May 2014), Cochrane Library (1996–May 2014) and PsycINFO (1840–May 2014). Systematic scoping review of databases identified studies that described or evaluated goal setting approaches, which were classified as informal or formal. Methodological quality appraisal was completed with all studies that evaluated a goal setting approach. Key practice principles were extracted from evaluation studies using a content analytic approach to identify key themes. Results: Of the full text articles included (n = 86), 62 described a goal setting approach and 24 evaluated a goal setting approach. Formal goal setting approaches were used in 77% of studies. The most common practice principles extracted describe goal setting in ABI rehabilitation as being client-centred, collaborative, measurable and realistic and as incorporating proximal goals or providing a link to therapy. Conclusion: Use of formal goal setting approaches appears more prevalent in research studies compared with routine clinical practice. There is a strong theme in the literature that client-centredness and collaboration are necessary components of effective goal setting.

Remediation of social communication impairments following traumatic brain injury using metacognitive strategy intervention: a pilot study

ABSTRACT Objective: To perform a pilot study to evaluate whether a novel metacognitive, goal-based intervention improved and maintained the social communication skills of adults with traumatic brain injury (TBI). Method: Eight community-dwelling participants with TBI completed three study phases: (1) baseline, (2) eight-week intervention targeting social communication impairments and (3) follow-up. Participants completed the Profile of Pragmatic Impairment in Communication (PPIC), LaTrobe Communication Questionnaire (LCQ) and Goal Attainment Scaling (GAS) at the commencement of baseline phase, pre- and post-intervention and completion of the follow-up phase. During the intervention programme phase, participants attended two 1-hour therapy sessions (one individual; one group) per week focusing on remediating impaired social communication skills using metacognitive strategy intervention and goal-based therapy. Results: Variable changes in PPIC feature-summary scores were observed post-intervention. A non-significant improvement in LCQ scores was also observed. There was a significant increase in GAS goal T-scores following the intervention, with six of the eight participants achieving or exceeding their expected level of performance on all goals. Conclusion: A goal-driven, metacognitive approach to intervention may assist individuals with TBI to achieve their personal social communication goals, with benefits reported by participants and observable during conversations. Further research is required.