The development of the therapeutic working alliance, patients' awareness and their compliance during the process of brain injury rehabilitation

Purpose: To examine the development and interaction of the therapeutic alliance, patients' compliance and awareness during the process of brain injury rehabilitation and the role of demographic and injury related variables in this process. Subjects were 86 patients who underwent a holistic neuropsychological outpatient rehabilitation programme. Patients had suffered a traumatic brain injury (n = 27), a cerebrovascular accident (n = 49) or another neurological insult (n = 10).

Measures: The therapeutic alliance between clients and their primary therapists, clients' awareness and their compliance were rated four times during the 14-week rehabilitation programme. The therapeutic alliance was rated by both clients and therapist using the Working Alliance Inventory (WAI), awareness and compliance were rated by the therapists.

Results: The development of the process measures over time is described in the article. Clients' and therapists' perspectives on their alliance tended to converge over time. Clients' experience of their emotional bond with their therapist added as much to the prediction of clients' awareness as the localization of their brain injury. Clients' awareness was related to their compliance and mediated the impact of the therapeutic alliance on their compliance.

Discussion: A good working alliance is the basis of successful rehabilitative work. The article discusses therapeutic implications of the results.     

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.     

Psychotherapy with brain injury survivors: an investigation of the challenges encountered by clinicians and their modifications to therapeutic practice

Objective: The aim of this study is to elicit practitioners' views and experiences of the challenges to forming a therapeutic alliance with brain injury survivors, with a view to informing current psychotherapeutic practice. Methods: The present research utilised the data-display method, a qualitative technique, to examine the questionnaire responses of 21 psychologists who provide forms of psychotherapy for brain injury survivors at rehabilitation units in the UK. An anonymous postal return questionnaire was used for data collection. Results: The main challenges to forming a working alliance comprised a range of cognitive, behavioural and emotional sequelae. A combination of educational, psychosocial and cognitive strategies were identified as being most effective in addressing the challenges encountered. Conclusions: A qualitative research approach has proved useful in identifying challenges to the formation of a working alliance and also the modifications to psychotherapeutic practice these challenges have engendered.     

The relationship between working memory, processing speed, verbal comprehension and FAS performance following traumatic brain injury

Primary objective: To investigate the relationship of working memory, processing speed and verbal comprehension with FAS performance in individuals who had sustained a traumatic brain injury (TBI).

Methods and procedure: Sixty-three patients with a TBI were grouped according to the presence of impaired verbal fluency performance and then compared on a number of cognitive and demographic variables.

Results: Following a TBI, working memory and processing speed had the greatest influence on verbal fluency performance. For those individuals who have not sustained a TBI, education, verbal intelligence, working memory and speed of information processing were related to FAS performance.

Conclusions: The findings of the study indicate that FAS performance was related to verbal intelligence, working memory ability, attention and speed of information processing. The results further suggest that different variables are related to FAS performance following a TBI as compared with control group performances.     

The role of serum testosterone and TBI in the in-patient rehabilitation setting

Objectives: To explore the relationship between serum testosterone levels, age, length of stay, admission, discharge and changes in functional capacity over time among patients with traumatic brain injury treated in a rehabilitation hospital.

Design: This study used a nonrandomized chart review of 54 males, consecutively admitted to a brain injury rehabilitation hospital.

Methods: The charts of 54 males consecutively admitted to a brain injury rehabilitation unit between the periods of December 2004 and May 2005 were included in this study. Individuals were included in this study if they were 18 years of age or older, had suffered a traumatic brain injury, undergone admission and discharge, functional independence measure (FIM) testing and had received a serum testosterone level check within one to seven days from admission.

Main outcome and results: The main outcome measure of this study was the FIM changes over time, as compared with admission testosterone levels. Low serum testosterone levels on admission to the in-patient rehabilitation unit were associated with longer lengths of stay, lower average admission FIM scores, less improvement in FIM scores, and a lower FIM efficiency. Although not statistically significant, individuals presenting to our unit with low testosterone levels, on average, stayed 26 days longer than did those with normal levels. Age and the presence of multi-trauma did not appear to be factors associated with serum testosterone levels. Changes in discharge cognitive FIM scores between the two groups approached statistical significance (p = 0.06).

Conclusion: This pilot study suggests that testosterone levels may be important in the recovery of patients with traumatic brain injury, treated at an in-patient rehabilitation hospital.     

Cognitive rehabilitation after severe traumatic brain injury: a pilot programme of goal planning and outdoor adventure course participation

Primary objective: To describe and evaluate a pilot community based rehabilitation programme for severe brain injury. Research design: A prospective repeated-measures design with a single convenience sample was conducted. Methods and procedures: Eleven participants with a history of severe brain injury completed the programme, which featured an outdoor adventure course, skill development and goal-based learning. In the first stage, practical activities facilitated the development of social skills, group cohesiveness and community integration. The second stage was a 9-day outdoor adventure course, which included physically challenging activities such as camping, bushwalking, abseiling, caving and high rope work. The third stage encouraged individuals to work on the personal goals they had developed. Main outcomes and results: Over 80% of stated goals were achieved; suggesting that such a programme may be effective in enabling clients to attain specified goals. Conclusions: The programme shows promise as a form of community rehabilitation.     

The adversarial alliance: Developing therapeutic relationships between families and the team in brain injury rehabilitation

Families of individuals who have survived brain injuries experience significant distress, and may resist accepting their relative's neurobehavioural deficits. Staff who work with brain-injured patients and their relatives are charged with the seemingly paradoxical task of helping families support rehabilitative efforts and be goal-oriented, while simultaneously communicating often negative realities about prognosis. In the midst of what may be an intermittently conflict-laden relationship, families and staff must become synergistically involved in a therapeutic partnership. This paper defines aspects of this 'adversarial alliance' which is often established between families and staff. The relationship between patient discharge outcome and perceived family stress and satisfaction with the rehabilitation programme was reviewed. Data analyses yielded the following conclusions: families evaluated retrospectively to have been 'highly stressed' were also perceived to experience more conflict with the rehabilitation team; family stress was related to poorer adjustment to the patient's disability (at admission); greater family/team conflict correlated with lower cognitive and physical functioning at admission, longer length of stay, younger patient age, and lower programme satisfaction. Implications for programme development and treatment guidelines are discussed.     

Subjective outcome of brain injury rehabilitation in relation to the therapeutic working alliance, client compliance and awareness

OBJECTIVE: To investigate the relationship between working alliance, compliance, awareness and subjective outcome of brain injury rehabilitation. Subjects were 86 patients who were clients in an holistic neuropsychological outpatient rehabilitation programme. They had suffered a traumatic brain injury (n = 27), a cerebrovascular accident (n = 49) or some other neurological insult (n = 10). MEASURES: The therapeutic alliance, clients' awareness and their compliance were rated four times during the 14-week rehabilitation programme. The therapeutic alliance was rated by both clients and therapist using the Working Alliance Inventory (WAI), awareness and compliance were rated by the therapists. Clients completed the European Brain Injury Questionnaire (EBIQ) at programme start and end. Clients and therapists rated the overall success of their collaboration at programme end. RESULTS: Clients' experience of a good emotional bond between themselves and therapists in mid-therapy was predictive for the reduction of clients' report of depressive symptoms on the EBIQ depression sub-scale (R = 0.68, n = 43, p < 0.001). Good compliance early in the programme was predictive of changes on the EBIQ. Improvement of awareness was related to the amplification of depressive symptoms (r = -0.27, n = 56, p < 0.05). CONCLUSIONS: Brain injury rehabilitation should be seen as a dynamic process that develops between clients and therapists. Future research should further investigate the relationship between process and outcome and how the therapeutic process can be optimized.     

创伤性脑损伤后认知功能障碍的临床治疗研究

目的探讨盐酸多奈哌齐对创伤性脑损伤（TBI）后认知功能障碍的干预作用及其对TBI临床预后的影响。方法将TBI后合并认知障碍患者86例,随机分成治疗组和对照组,治疗组应用盐酸多奈哌齐10mg,每日一次服用;对照组应用吡拉西坦0．8g,每日三次服用。两组的治疗周期为12周。治疗前及治疗后,分别应用简明精神状态检测量表（MMSE）、国人修订成人韦氏智利量表（WAIS—RC）和格拉斯哥预后评分（GOS）来评价疗效。结果治疗后12周两组MMSE和WAIS—RC评分均较治疗前提高（P〈0．05）。治疗后12周,治疗组MMSE和WAIS—RC评分较对照组高（P〈0．05）,治疗组预后优良率优于对照组（P〈0．05）。结论盐酸多奈哌齐对TBI后认知障碍有积极治疗作用,并能改善其预后。     

Cognitive appraisal accuracy moderates the relationship between injury severity and psychosocial outcomes in traumatic brain injury

Objective:Traumatic brain injury (TBI) frequently results in significant changes in physical, cognitive and emotional status. Outcomes after TBI may be related to accurate appraisal of these changes. This study examined the relationship between cognitive appraisal accuracy and psychosocial outcomes in TBI survivors.

Methods: Participants were male and female TBI survivors (n = 103) who were at least 6 months post-injury and a family member of each survivor. Appraisal accuracy was assessed using self- and observer-report measures of perceived cognitive difficulties. Family members also completed a measure of psychosocial function. Hierarchical regression techniques were used to determine whether cognitive appraisal accuracy accounted for a significant proportion of variance in psychosocial outcomes.

Results:Study findingsindicated cognitive appraisal accuracy moderated the relationship between injury severity and aspects of psychosocial function.

Conclusions:The results suggest that brain injury outcomes may be improved when an individual is able to accurately assess limitations.     

Changes in fMRI activation following rehabilitation of reading and visual processing deficits in subjects with traumatic brain injury

In this case series fMRI was used to examine activation patterns during presentation of a reading comprehension (RC) task in three adult subjects with a history of severe traumatic brain injury (TBI). These subjects received cognitive rehabilitation therapy (CRT) for visual processing and acquired reading deficits. fMRI and neuropsychological testing occurred pre- and post-rehabilitation. The study's objective was to evaluate the neurobiological changes using fMRI occurring with CRT and to compare these results to repeat fMRI in matched control subjects. While improvements in neuropsychological testing occurred post-CRT, diffuse and variable activation patterns in the subjects with TBI were still demonstrated when compared to the control subjects repeat imaging. Multiple networks exist to accomplish the complex task of sentence reading and rehabilitation of the cognitive components of reading, such as visual processing; in subjects with TBI, can alter the activation pattern demonstrated during reading comprehension in subjects many years post-injury. This is the first demonstration of changes in network activation patterns post-CRT in patients with severe, chronic TBI on an fMRI task shown to have imaging stability in a normal control sample.     

重型颅脑损伤后Pim-3的表达与细胞凋亡关系的研究

目的探讨颅脑损伤后Pim-3的表达及其与细胞凋亡的关系。方法48只大鼠随机分为实验组与对照组。实验组大鼠制作重型颅脑损伤模型,对照组大鼠予以假手术处理,两组大鼠分别在伤后6、24、72h及7d免疫组化sP法检测Pim-3蛋白表达、TUNEL法检测细胞凋亡。结果重型颅脑损伤后大鼠脑组织Pim-3蛋白水平、细胞凋亡水平均较对照组明显升高,并在伤后24h达到高峰,7d后开始下降。结论Pim-3可能在颅脑损伤后细胞凋亡中起重要作用。     

The prognostic and therapeutic importance of changes in the CSF during the acute stage of brain injury

Summary This research deals with the gaseous and biochemical changes in the cerebrospinal fluid and their effects on the cerebral blood flow and metabolic rates in the acute stage of brain injury.The results have shown that the lactacidosis in the CSF is of importance for prognosis and therapy, because of its central position in the course of pathophysiological mechanisms after a traumatic brain injury. Thus the lactate concentration in the CSF does give early information about the further clinical course. CSF acidosis itself can be influenced in a favourable way by intrathecal therapy with sodium bicarbonate.We like to thank Prof. Dr. F. Mundinger, head of the Department for Stereotaxie and Neuronuclear Medicin as well Prof. Dr. W. E. Zimmermann, head of the Lung Function Research Unit of the Surgical University Clinic of Freiburg i. B. for their cooperation and assistance.     

重型颅脑损伤后FT_3、FT_4、TSH水平变化和预后关系

目的 研究重型颅脑损伤后内分泌功能紊乱与预后关系。方法 对27例重型颅脑损伤病人的FT_3、FT_4、TSH水平利用放射免疫方法进行动态观察。结果 治疗后FT_3、FT_4、TSH下降不明显,病情预后好,FT_3、FT_4、TSH变化与GCS评分关系不大。结论 血清FT_3、FT_4、TSH水平,可作为重型颅脑损伤患者临床疗效和预后的判断指标。     

重型颅脑损伤患者继发转氨酶异常与预后关系分析

目的探讨重型颅脑损伤后继发转氨酶异常与预后关系。方法对117例重型颅脑损伤患者抽血检查谷丙转氨酶（AIJT）、谷草转氨酶（AST），按化验结果分为转氨酶升高组和转氨酶正常组。转氨酶升高组包括ALT〉50U／L和（或）AST〉50U／L。分析两组间GOS预后良好率和死亡率区别；同时比较转氨酶升高组中不同GOS预后评分的ALT、AST水平。结果转氨酶升高组预后良好率低于转氨酶正常组（x2=4．71，P〈0．05），而死亡率高于转氨酶正常组（x2=5．42，P〈0．05）。转氨酶升高组中ALT、AST水平与GOS预后明显相关，且转氨酶水平越高，预后越差。结论重型颅脑损伤常致转氨酶异常，转氨酶升高水平与预后密切相关，监测及保护肝功能有利改善患者预后。     

The relationship between cortical injury and brain tumour report of two cases and review of the literature

Summary We report on two cases of brain tumour and discuss the possible relationship to previous cortical trauma. The first patient, a 67-year-old male patient developed a glioblastoma at the same site of an open shell-splinter injury of the brain after a latency of 48 years. The second patient, a 55-year-old male, had a malignant anaplastic astrocytoma in the right frontal lobe 10 years after clipping of an aneurysm of the anterior communicating artery. Both cases fulfill the criteria of Zülch [52] for the correlation between cortical trauma and tumour. We believe that the development of a brain tumour following a cortical injury is very rare, although possible. Probably the brain must display some form of predisposing genetic alteration for a tumour to develop following a cortical injury.     

颅脑损伤患者血流动力学指标与住院转归相关性研究

目的:研究颅脑损伤（traumatic brain injury, TBI）患者EV1000血流动力学指标与住院转归的相关性,了解TBI患者术中血流动力学参数变化特点及EV1000血流动力学监测的临床意义。方法:回顾性分析首都医科大学附属北京天坛医院2018年2月—2019年12月于全身麻醉下行颅内血肿清除术的TBI患...     

Benign paroxysmal positional vertigo as the cause of dizziness in patients after severe traumatic brain injury: diagnosis and treatment

Objectives: To identify patients with benign paroxysmal positional vertigo (BPPV) among patients with severe traumatic brain injury (TBI) and to evaluate the effectiveness of the Particle Repositioning Maneouvre (PRM).

Design and methods: Eighteen months prospective study of 150 consecutive patients with severe TBI referred to an in-patients rehabilitation department.

Interventions: A structured interview emphasizing the possible presence of vertigo followed by a detailed neuro-otological examination. Patients diagnosed with BPPV were immediately treated with the PRM.

Main outcomes and results: BPPV diagnosis was based on a positive Dix-Hallpike positional test. PRM efficacy was determined by repeating the positional test 1 or 2 weeks after treatment. Twenty out of 150 (13.3%) patients complained about positional vertigo. The diagnosis of BPPV was confirmed in 10 patients. Signs and symptoms were completely relieved in six patients after a single PRM, while the other four patients needed repeated treatment for complete resolution of BPPV.

Conclusions: About half of the patients with severe TBI who complain about positional vertigo suffer from BPPV. These patients can be efficiently treated by physical maneouvres improving the rehabilitation outcome.     

颅脑损伤后血浆内皮素-1与经颅超声多谱勒的相关性研究

目的 探讨颅脑损伤后血浆内皮素－1（ET－1）水平的变化与经颅超声多谱勒（TCD）的关系。方法 动态测定33例成年颅脑损伤病人血浆ET－1水平的变化，同时地TCD检查以判定脑血管痉挛。结果 （１）伤后6-8d,13-15d血浆ET－1与血管痉挛呈明显正相关9r=0.533,P=0.002;r=0.423,P=0.02)，以伤后6－8d为著，ET－1水平高的时间与脑血管痉挛发生的时间一致。（2）伤后6－8d，发生血管痉挛者血浆ET－1水平明显高于无血管痉挛者（P＜0．05）。重度血管痉挛者血浆ET－1水平也高于轻度血管痉挛者，但未达到明显水平（＝0．134）。（3）伤后13－15d，血管痉挛者血浆ET－1水平较无血管痉挛者已无显著差异（P＝0．589），而重度血管痉挛者血浆ET－1水平明显高于无血管痉挛者（P＝0．0006＞结论 血浆ET－1水平和血管痉挛的发生和程度相关，其和TCD匀可以反映脑血管痉挛发生和严重程度；抗ET治疗，可以减轻或防止迟发性缺血性脑损害。     

The association between post-concussion symptoms and health-related quality of life in patients with mild traumatic brain injury

A subset of mild traumatic brain injury (mTBI) patients experience post-concussion symptoms. When a cluster of post-concussion symptoms persists for over three months, it is referred to as post-concussion syndrome (PCS). Little is known about the association between PCS and Health-Related Quality of Life (HRQoL) after mTBI. The aims of this study were to assess the implications of PCS on HRQoL six months after mTBI and the relationship between PCS and HRQoL domains. A prospective observational cohort study was conducted among a sample of mTBI patients. Follow-up postal questionnaires at six months after emergency department (ED) admission included socio-demographic information, the Rivermead Post-Concussion Symptoms Questionnaire (RPQ), and HRQoL measured with the 36-item Short-Form Health Survey (SF-36) and the Perceived Quality of Life Scale (PQoL). In total, 731 mTBI patients were included, of whom 38.7% were classified as suffering from PCS. Patients with PCS had significantly lower scores on all SF-36 domains, lower physical and mental component summary scores and lower mean PQoL scores compared to patients without PCS. All items of the RPQ were negatively correlated to all SF-36 domains and PQoL subscale scores, indicating that reporting problems on any of the RPQ symptoms was associated with a decrease on different aspects of an individuals’ HRQoL. To conclude, PCS is common following mTBI and patients with PCS have a considerably lower HRQoL. A better understanding of the relationship between PCS and HRQoL and possible mediating factors in this relationship could improve intervention strategies, the recovery process for mTBI patients and benchmarking.