Sven Stapert

Coping styles in relation to cognitive rehabilitation and quality of life after brain injury.

This study investigated the changes in coping styles of patients with acquired brain injury who underwent cognitive rehabilitation, and the effects of these changes on their quality of life. Participants were 110 patients in the chronic phase post-injury, who underwent outpatient cognitive rehabilitation according to current guidelines and standards. Coping style (Utrecht Coping List) was measured at the start of rehabilitation (T0) and repeated at least 5 months later (T1). Coping style was related to quality of life measured at T1 (Life Satisfaction Questionnaire and Stroke-Adapted Sickness Impact Profile). Results indicated that active problem-focused coping styles decreased and passive emotion-focused coping styles increased significantly between T0 and T1. Furthermore, the study showed that increases in active problem-focused coping styles and decreases in passive emotion-focused coping styles predicted a higher quality of life in the long term. These changes in coping styles are adaptive for the adjustment process in the chronic phase post-injury. Overall however, most participants showed maladaptive changes in coping styles. Implications for cognitive rehabilitation are therefore discussed.

About the Distinction between Working Memory and Short-Term Memory

The theoretical concepts short-term memory (STM) and working memory (WM) have been used to refer to the maintenance and the maintenance plus manipulation of information, respectively. Although they are conceptually different, the use of the terms STM and WM in literature is not always strict. STM and WM are different theoretical concepts that are assumed to reflect different cognitive functions. However, correlational studies have not been able to separate both constructs consistently and there is evidence for a large or even complete overlap. The emerging view from neurobiological studies is partly different, although there are conceptual problems troubling the interpretation of findings. In this regard, there is a crucial role for the tasks that are used to measure STM or WM (simple and complex span tasks, respectively) and for the cognitive load reflected by factors like attention and processing speed that may covary between and within these tasks. These conceptual issues are discussed based on several abstract models for the relation between STM and WM.

The adaptation process following acute onset disability: an interactive two-dimensional approach applied to acquired brain injury

Objective: To describe a new model of the adaptation process following acquired brain injury, based on the patient’s goals, the patient’s abilities and the emotional response to the changes and the possible discrepancy between goals and achievements. Background: The process of adaptation after acquired brain injury is characterized by a continuous interaction of two processes: achieving maximal restoration of function and adjusting to the alterations and losses that occur in the various domains of functioning. Consequently, adaptation requires a balanced mix of restoration-oriented coping and loss-oriented coping. The commonly used framework to explain adaptation and coping, ‘The Theory of Stress and Coping’ of Lazarus and Folkman, does not capture this interactive duality. Relevant theories: This model additionally considers theories concerned with self-regulation of behaviour, self-awareness and self-efficacy, and with the setting and achievement of goals. The two-dimensional model: Our model proposes the simultaneous and continuous interaction of two pathways; goal pursuit (short term and long term) or revision as a result of success and failure in reducing distance between current state and expected future state and an affective response that is generated by the experienced goal-performance discrepancies. This affective response, in turn, influences the goals set. This two-dimensional representation covers the processes mentioned above: restoration of function and consideration of long-term limitations. We propose that adaptation centres on readjustment of long-term goals to new achievable but desired and important goals, and that this adjustment underlies re-establishing emotional stability. We discuss how the proposed model is related to actual rehabilitation practice.

Coping following acquired brain injury: predictors and correlates

Objective:To examine the determinants and correlates of coping styles in the chronic phase following acquired brain injury. Design:Chart review. Setting:Outpatient rehabilitation center. Participants:One hundred thirty-six persons with an acquired brain injury who were more than 6 months postinjury. Measures:Utrecht Coping List, Symptom Checklist 90, Stroop Color Word Test, and the 15-Word Learning Test. Results:Neuropsychological performance did not influence the use of coping styles. Persons with higher levels of educational attainment most often reported active problem-focused coping styles. Persons with a long time period since injury most often used passive reactions. More use of passive coping styles and less seeking of social support contributed significantly to higher levels of subjective complaints. Conclusions:Cognitive functions do not influence coping style. Passive emotion-focused coping styles in the chronic phase after injury are maladaptive. These findings emphasize the importance of training of adaptive coping styles as rehabilitation targets in the chronic phase, especially for persons with lower educational attainment.

S-100B Concentration Is Not Related to Neurocognitive Performance in the First Month after Mild Traumatic Brain Injury.

The serum concentration of S-100B is reported to reflect the severity of brain damage. The purpose of this study was to determine whether elevated serum S-100B concentrations were related to neuropsychological test performance of patients in the subacute phase of recovery from mild traumatic brain injury (TBI). S-100B concentrations were measured in blood samples taken within 6 h after TBI. Serum S-100B was estimated using an immunoluminometric assay. Cognitive speed and memory were assessed with neuropsychological tests at a median of 13 days (range 7–21 days) after injury. The two groups, formed on a median split of initial serum S-100B concentrations (> or <0.22 µg/l) did not differ in age or education. The neuropsychological performance of the TBI patients was also compared with that of a healthy control group. Cognitive speed and memory performance of mild TBI patients were inferior compared to those of healthy subjects. There were no significant differences within the TBI group when serum S-100B concentration was taken into consideration. The findings suggest that serum S-100B levels after mild TBI are not predictive of neuropsychological performance in the subacute stage of recovery.

Neurocognitive fitness in the sub-acute stage after mild TBI: the effect of age.

Objective: Age is assumed to be a negative prognostic factor in recovery from moderate-to-severe traumatic brain injury (TBI). Little is known on cognitive performance after mild TBI in relation to age in the sub-acute stage after injury. Method: Ninety-nine mild TBI subjects (age 15–75) were compared with 91 healthy control subjects (age 14–74) in a case-control design. Patients were matched on age, sex and level of education, with control subjects. Mean interval between injury and cognitive assessment was 13 days. Neurocognitive test battery contained tests of verbal memory, selective attention, general speed of information processing and verbal fluency. Results: An overall effect was found of a single mild TBI on neurocognitive performance in the sub-acute stage after injury. Age did not add significantly to the effect of mild TBI on cognitive functioning. Conclusion: Patients suffering from mild TBI are characterized by subtle neurocognitive deficits in the weeks directly following the trauma. The notion that elderly subjects have a worse outcome in the sub-acute period after mild TBI is at least not in line with the results of this study.

Life goal attainment in the adaptation process after acquired brain injury: the influence of self-efficacy and of flexibility and tenacity in goal pursuit

Objective: To investigate attainment of important life goals and to examine whether self-efficacy, tenacity in goal pursuit and flexibility in goal adjustment contribute to adaptation by affecting levels of emotional distress and quality of life in patients with newly acquired brain injury. Methods: Data were collected from a prospective clinical cohort study of 148 patients assessed after discharge home (mean time since injury = 15 weeks) and one year later. At follow-up, attainment of life goals (set at baseline) and satisfaction with attainment was scored (10-point scale) and patients were asked how they adjusted unattained goals. Emotional distress was measured with the Hospital Anxiety and Depression Scale (HADS), quality of life with the Life Satisfaction Questionnaire (LiSat-9), self-efficacy with the TBI Self-efficacy Questionnaire (SEsx) and tenacity and flexibility with the Assimilative/Accommodative Coping Questionnaire (AACQ). Random effects regression analyses and structural equation modelling were used. Results: In total, only 13 % of initial life goals were achieved in one year. Patients who maintained efforts to reach their original goals had higher average levels of tenacity, but did not differ in level of self-efficacy compared with patients that disengaged. Patients with higher self-efficacy were more successful in attaining important life goals, which correlated with higher quality of life. Patients with higher self-efficacy, higher tenacity in goal pursuit, and higher flexibility in goal adjustment were less emotionally distressed, again correlating with higher quality of life. Conclusions: To optimise adaptation it seems appropriate to promote self-efficacy and both tenacity and flexibility during rehabilitation treatment.

Influence of Self-Efficacy and Coping on Quality of Life and Social Participation After Acquired Brain Injury: A 1-Year Follow-Up Study

OBJECTIVES To investigate the relations linking self-efficacy and coping to quality of life (QOL) and social participation and what effect self-efficacy, changes in self-efficacy, and coping style have on long-term QOL and social participation. DESIGN Prospective clinical cohort study. SETTING General hospitals, rehabilitation centers. PARTICIPANTS Patients with newly acquired brain injury (ABI) (N=148) were assessed at baseline (start outpatient rehabilitation or discharge hospital/inpatient rehabilitation; mean time since injury, 15wk) and 1 year later (mean time since injury, 67wk). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES QOL was measured with the EuroQuol 5D (the EQ-5D index and the EQ-5D visual analog scale [EQ VAS]) and the 9-item Life Satisfaction Questionnaire (LiSat-9), social participation with the modified Frenchay Activities Index, coping with the Coping Inventory for Stressful Situations, and self-efficacy with the Traumatic Brain Injury Self-efficacy Questionnaire. RESULTS At baseline, self-efficacy moderated the effect of emotion-oriented coping on the EQ-5D index and of avoidance coping on the EQ VAS. Self-efficacy mediated the relation between emotion-oriented coping and LiSat-9. An increase in self-efficacy over time predicted better scores on the EQ-5D index (β=.30), the EQ VAS (β=.49), and LiSat-9 (β=.44) at follow-up. In addition, higher initial self-efficacy (β=.40) predicted higher LiSat-9 scores at follow-up; higher initial emotion-oriented coping (β=-.23) predicted lower EQ VAS scores at follow-up. Higher modified Frenchay Activities Index scores at follow-up were predicted by higher self-efficacy (β=.19) and higher task-oriented coping (β=.14) at baseline (combined R(2)=5.1%). CONCLUSIONS Self-efficacy and coping predict long-term QOL but seem less important in long-term social participation. High self-efficacy protects against the negative effect of emotion-oriented coping. Enhancing self-efficacy in the early stage after ABI may have beneficial long-term effects.

Psychometric properties of the Coping Inventory for Stressful Situations (CISS) in patients with acquired brain injury

Information on the psychometric properties of the Coping Inventory for Stressful Situations (CISS) in acquired brain injury (ABI) is currently unavailable. Therefore, we investigated the construct and discriminant, convergent, and divergent validity of the CISS in a Dutch adult sample with newly ABI (N = 139). Patients were recruited at the start of outpatient neurorehabilitation (time since diagnosis ≤ 4 months) or after discharge home from hospital or inpatient neurorehabilitation. The original 3-factor solution of the CISS (Task-Oriented, Emotion-Oriented, Avoidance) showed a borderline fit, which slightly improved after removal of 3 problematic items. We found borderline support for a 4-factor model. Internal consistency was good. Discriminant validity was only partial as we found a moderate correlation between the Task-Oriented and Avoidance scales. Emotion-Oriented Coping correlated strongly with the anxiety and depression subscale of the Hospital Anxiety and Depression Scale. Of the 2 scales of the Assimilative/Accommodative Coping Questionnaire, Tenacious Goal Pursuit correlated strongest with Task-Oriented Coping, whereas Flexible Goal Adjustment correlated negatively with Emotion-Oriented Coping. In summary, the psychometric properties of the CISS in patients with ABI ranged from acceptable to good. The classical 3-factor structure is appropriate, but some items might be problematic in patients with ABI. Replication of the restricted 3-factor model in larger samples is needed, together with further exploration of discriminant validity and the relationship of the CISS with other coping measures, but for now we recommend using the original CISS in patients with ABI.

How flexible is coping after acquired brain injury? A 1-year prospective study investigating coping patterns and influence of self-efficacy, executive functioning and self-awareness

OBJECTIVES To investigate coping flexibility in patients with newly acquired brain injury and to investigate the influence of problem type, self-efficacy, self-awareness and self-reported executive functions on coping flexibility. METHODS Data were collected from a prospective clinical cohort study of 136 patients assessed after discharge home (mean time since injury = 15 weeks) and 1 year later. Situation-specific coping was measured by asking patients to complete the Coping Inventory for Stressful Situations (CISS) for 3 acquired brain injury (ABI)-related situations, which were then categorized into problem types (physical, cognitive, emotional, behavioural, communication, other). Coping consistency (number of strategies used throughout every situation) and variability (range in frequency of use of strategies over situations) were measured. Random effects regression analyses were used. RESULTS Patients used more task-oriented coping for cognitive compared with physical problems. Coping variability was limited. Reliance on emotion-oriented coping decreased over time. Higher self-efficacy correlated with increased task-oriented and avoidance coping and decreased emotion-oriented coping. Greater self-reported problems in executive function correlated with greater consistency in task-oriented and emotion-oriented strategies. CONCLUSION Patients with acquired brain injury rely on a defined set of coping options across situations and time. High self-efficacy increases active coping. Subjective executive dysfunction might hamper effective strategy selection.