Jennifer Fleming

Cluster analysis of self-awareness levels in adults with traumatic brain injury and relationship to outcome

The purpose of this study was to investigate the relationship between self-awareness, emotional distress, motivation, and outcome in adults with severe traumatic brain injury. A sample of 55 patients were selected from 120 consecutive patients with severe traumatic brain injury admitted to the rehabilitation unit of a large metropolitan public hospital. Subjects received multi disciplinary inpatient rehabilitation and different types of outpatient rehabilitation and community-based services according to availability and need. Measures used In the cluster analysis were the Patient Competency Rating Scale, Self-Awareness of Deficits Interview, Head Injury Behavior Scale, Change Assessment Questionnaire, the Beck Depression Inventory, and Beck Anxiety Inventory; outcome measures were the Disability Rating Scale, Community Integration Questionnaire, and Sickness Impact Profile. A three-cluster solution was selected, with groups labeled as high self-awareness (n=23), low self-awareness (n=23), and good recovery (n=8). The high self-awareness cluster had significantly higher levels of self-awareness, motivation, and emotional distress than the low self-awareness cluster but did not differ significantly in outcome. Self-awareness after brain injury is associated with greater motivation to change behavior and higher levels of depression and anxiety; however, it was not clear that this heightened motivation actually led to any improvement in outcome. Rehabilitation timing and approach may need to be tailored to match the Individuals level of self-awareness, motivation, and emotional distress

Prediction of community integration and vocational outcome 2-5 years after traumatic brain injury rehabilitation in Australia

OBJECTIVES To predict community integration and vocational outcomes 2-5 years after traumatic brain injury (TBI). DESIGN Multivariate correlational design incorporating retrospective data collection and questionnaire follow-up. METHODS Four hundred and forty six patients admitted to a Head Injury Unit between 1991 and 1995 were contacted. Data on predictor variables (demographic, injury severity and functional) were retrieved from hospital records. Community integration and vocational outcome was assessed by self-administered questionnaire. Two hundred and nine patients/carers completed and returned the questionnaires. Mean follow-up was 3.5 years. Data were analysed by descriptive statistics, multiple regression and discriminant analysis using SPSS. RESULTS Community integration was predicted by age, disability level and cognition. Length of PTA, cognition, disability levels, GCS, functional status, length of acute stay and prior occupation discriminated those who returned to work. A total of 46.5% returned to work with 74.5% in the same or similar jobs. CONCLUSION Long term outcomes post-TBI can be predicted by demographic, injury severity and functional status variables.

Prospective memory rehabilitation for adults with traumatic brain injury: A compensatory training programme

Primary objective: To describe a prospective memory rehabilitation programme based on a compensatory training approach and report the results of three case studies. Research design: Programme evaluation using pre- and post-intervention assessments and telephone follow-up. Methods and procedures: Three participants with traumatic brain injury completed 8 weeks of training with 1–2 hour individual sessions. Assessments were formal prospective memory assessment, self-report and measures of diary use. Experimental interventions: Intervention aimed to identify potential barriers, establish self-awareness of memory deficits, introduce a customized compensatory tool, a cueing system and organizational strategies. A significant other was involved in training to assist generalization. Main outcomes and results: All three participants improved on formal prospective memory assessment and demonstrated successful diary use after the programme. Self-report of prospective memory failure fluctuated and may reflect increased self-awareness. Conclusion: A compensatory approach may be useful in improving prospective memory performance following TBI.

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.

The relative importance of metacognitive skills, emotional status, and executive function in psychosocial adjustment following acquired brain injury

ObjectivesTo examine the interrelationships between metacognitive skills and measures of emotional status and executive function following acquired brain injury (ABI), and examine their relative importance to psychosocial outcomes. DesignA cross-sectional multicentre study employing correlational and multiple regression analyses. ParticipantsSixty-seven adults with ABI living in the community, on average 4.4 years (SD = 4.7) postinjury. MeasuresSydney Psychosocial Reintegration Scale, Self-Awareness of Deficits Interview, Self-Regulation Skills Interview, Hospital Anxiety Depression Scale, Beck Hopelessness Scale, and standardized measures of executive function. ResultsMetacognitive skills correlated with level of hopelessness and executive measures of idea generation and error self-regulation. The best predictor of psychosocial outcome was depressive symptoms, with specific outcomes additionally related to error self-regulation and intellectual awareness. ConclusionsThe findings highlight the need to evaluate interventions targeting depression and metacognitive skills to improve psychosocial outcomes.

A review of awareness interventions in brain injury rehabilitation

Unawareness related to brain injury has implications for participation in rehabilitation, functional outcomes, and the emotional well-being of clients. Addressing disorders of awareness is an integral component of many rehabilitation programmes, and a review of the literature identified a range of awareness interventions that include holistic milieu-oriented neuropsychological programmes, psychotherapy, compensatory and facilitatory approaches, structured experiences, direct feedback, videotaped feedback, confrontational techniques, cognitive therapy, group therapy, game formats and behavioural intervention. These approaches are examined in terms of their theoretical bases and research evidence. A distinction is made between intervention approaches for unawareness due to neurocognitive factors and approaches for unawareness due to psychological factors. The socio-cultural context of unawareness is a third factor presented in a biopsychosocial framework to guide clinical decisions about awareness interventions. The ethical and methodological concerns associated with research on awareness interventions are discussed. The main considerations relate to the embedded nature of awareness interventions within rehabilitation programmes, the need for individually tailored interventions, differing responses according to the nature of unawareness, and the risk of eliciting emotional distress in some clients.

A qualitative study of the transition from hospital to home for individuals with acquired brain injury and their family caregivers

Primary Objective: To explore the transition experiences from hospital to home of a purposive sample of individuals with acquired brain injury (ABI). Research Design: Phenomenological, qualitative design. Methods and Procedures: Semi-structured interviews were conducted with 13 individuals with ABI (mean time since discharge = 15.2 months) and 11 family caregivers. Each interview was recorded, transcribed verbatim and then inductively analyzed. Results: Through the inductive analysis process, a summary coding framework was developed that included that following eight main categories: the hospital experience; the transition process; the role of family caregivers; post-discharge services; friendship networks and community involvement; meaningful activities and time management; physical and psychological wellbeing; and barriers and facilitators. Conclusions: The results of the study provide valuable insights into the lived experiences of participants and provide evidence to support the existence of a distinct transition phase within the ABI rehabilitation continuum; additional to and closely associated with the acute, post-acute and community integration phases.

A Longitudinal Study of Self-Awareness: Functional Deficits Underestimated by Persons with Brain Injury

A longitudinal study of 55 adults with severe traumatic brain injury (TBI) investigated the areas of function for which they lacked self-awareness of their level of competency. Data were collected at 3 and 12 months post-injury using the Patient Competency Rating Scale. Self-awareness was measured by comparing patient self-ratings with the ratings of an informant. The results were consistent with previous studies, indicating that self-awareness was most impaired for activities with a large cognitive and socioemotional component, and least impaired for basic activities of daily living, memory activities, and overt emotional responses. For most areas of function that were overestimated at 3 months post-injury, self-awareness subsequently improved during the first year after injury.

Self-Awareness of Deficits following Acquired Brain Injury: Considerations for Rehabilitation

Limitations in self-awareness of deficits after acquired brain injury can hamper client participation in rehabilitation programmes. The concept of self-awareness encompasses awareness of brain injury related deficits, an appreciation of the functional consequences of deficits, and the ability to translate that information into realistic goals. A literature review suggests that the development of self-awareness can be associated with emotional distress in the individual. Self-awareness and emotional adjustment factors may both affect behavioural change in the individual, which may influence outcome. The widely held belief that self-awareness is necessary for successful outcomes from rehabilitation requires further investigation.

The transition from hospital to home for individuals with acquired brain injury: a literature review and research recommendations.

Purpose. To review the literature relating to the transition from hospital to home for individuals with acquired brain injury (ABI) and make recommendations concerning the future direction of transition-specific research. Method. Relevant research articles were identified through searching existing database systems and by reviewing the reference lists of identified articles. Only articles in which the results directly related to individuals with ABI from the time of discharge to 1 year post-discharge were included in the review. Results/discussion. A total of 50 articles were identified as meeting the criteria for inclusion in the review. The methodological quality of included articles was evaluated using a set of specific criteria. The articles were classified into the following categories: (i) The perspectives of individuals with ABI and their caregivers; (ii) outcomes for individuals with ABI following transition; (iii) post-discharge services; and (iv) transitional living services/programmes. The majority of articles were based on samples of individuals with stroke, typically aged over 65 years. A common theme identified in the review was that the transition from hospital to home is typically perceived as an exciting yet difficult period for individuals and their families and as such, post-discharge support is critical. Conclusion. Further ABI transition-specific research is necessary in order to: (i) Develop a comprehensive theoretical framework of the transition phase; and (ii) facilitate both the validation of current intervention strategies and the development of innovative/tailored intervention approaches.