Boredom in patients with acquired brain injuries during inpatient rehabilitation: a scoping review

Abstract

Purpose: Boredom may impede engagement in inpatient rehabilitation following an acquired brain injury. This review aimed to: (1) describe the experience and (2) quantify the incidence of boredom; (3) identify measurement tools used to quantify boredom; (4) summarize factors contributing to boredom, and (5) outline evidence-based interventions shown to reduce boredom during inpatient rehabilitation.

Methods: Two researchers independently screened publications retrieved from electronic database searches. Publications presenting patient, carer or staff data relating to boredom in inpatients with acquired brain injuries were included.

Results: Two thousand four hundred and ninety-nine references were retrieved, 88 full texts were reviewed, with 24 studies included. The majority of studies reported qualitative data indicating boredom to be a common experience of patients with acquired brain injuries (n?=?14 studies +1 review). The incidence of boredom post acquired brain injury is unknown. Personal and organizational factors and the physical environment may contribute to boredom (n?=?11 studies +2 reviews). Qualitative work (n?=?9 studies) indicates that use of the creative-arts or exposure to environmental enrichment may help alleviate boredom in patients with acquired brain injuries during inpatient rehabilitation.

Conclusion: Further mixed-methods research is required to establish the incidence of and contributing factors to boredom in patients with acquired brain injuries undergoing rehabilitation. Understanding this will help inform future research aimed at improving patient engagement in inpatient rehabilitation.

• Implications for rehabilitation

• Boredom is commonly reported by hospitalised patients with ABI to negatively affect their rehabilitation yet the scope of the problem has not been measured.

• Boredom is a complex phenomenon, likely influenced by a number of personal and environmental factors that are not fully understood in this population.

• Through a better understanding of boredom, interventions may be developed to improve patient engagement in inpatient rehabilitation programs.

     

Prophylaxis of venous thromboembolism during early inpatient rehabilitation after acquired brain injury: how guidelines change management

Purpose. To establish guidelines for prophylaxis of venous thromboembolism (VTE) in younger adults undergoing early inpatient rehabilitation following acquired brain injury (ABI).

Method. A two-phase (phase 1: retrospective; phase 2: prospective) observational study was carried out involving patients admitted to an inpatient neurological rehabilitation unit during a 40-month period. In phase 1, VTE prophylaxis was prescribed on an ad hoc basis. In phase 2, prophylaxis was considered in accordance with guidelines agreed locally. The prescribing behaviour in each phase of the study was compared using a VTE risk stratification tool based on expert opinion and a review of the literature.

Results. Data were obtained on 94 patients in phase 1 and 23 patients in phase 2. During phase 1, the prophylactic prescribing behaviour of the referring hospitals and our unit after admission were similar ( p = 0.13). In phase 2, our prescribing behaviour had changed compared with that of the referring hospitals, with a significant increase in the proportion of patients on appropriate treatment ( p = 0.01) and a decrease in the numbers under-treated ( p = 0.002). We were also significantly less likely to under-treat ( p = 0.005) and more likely to over-treat ( p = 0.004) after admission during phase 2 compared with phase 1, whilst practice was variable in patients at moderate risk.

Conclusions. Guidelines modify behaviour. They must stratify risk, particularly to avoid inconsistencies in the management of patients at moderate risk. There is a need to establish national guidelines for VTE prophylaxis during early inpatient rehabilitation after ABI; these guidelines should include a risk stratification tool.     

Prophylaxis of venous thromboembolism during early inpatient rehabilitation after acquired brain injury: How guidelines change management

Purpose.?To establish guidelines for prophylaxis of venous thromboembolism (VTE) in younger adults undergoing early inpatient rehabilitation following acquired brain injury (ABI).

Method.?A two-phase (phase 1: retrospective; phase 2: prospective) observational study was carried out involving patients admitted to an inpatient neurological rehabilitation unit during a 40-month period. In phase 1, VTE prophylaxis was prescribed on an ad hoc basis. In phase 2, prophylaxis was considered in accordance with guidelines agreed locally. The prescribing behaviour in each phase of the study was compared using a VTE risk stratification tool based on expert opinion and a review of the literature.

Results.?Data were obtained on 94 patients in phase 1 and 23 patients in phase 2. During phase 1, the prophylactic prescribing behaviour of the referring hospitals and our unit after admission were similar ( p = 0.13). In phase 2, our prescribing behaviour had changed compared with that of the referring hospitals, with a significant increase in the proportion of patients on appropriate treatment ( p = 0.01) and a decrease in the numbers under-treated ( p = 0.002). We were also significantly less likely to under-treat ( p = 0.005) and more likely to over-treat ( p = 0.004) after admission during phase 2 compared with phase 1, whilst practice was variable in patients at moderate risk.

Conclusions.?Guidelines modify behaviour. They must stratify risk, particularly to avoid inconsistencies in the management of patients at moderate risk. There is a need to establish national guidelines for VTE prophylaxis during early inpatient rehabilitation after ABI; these guidelines should include a risk stratification tool.     

Sustaining employment after vocational rehabilitation in acquired brain injury

Purpose.?To explore factors affecting sustaining employment in people with acquired brain injury (ABI).

Method.?A multiple case study approach using semi-structured interviews in eight cases (29 individuals). Each case included an individual with ABI, a family member, a job coach and a co-worker (triangulation). The eight individuals with ABI had completed vocational rehabilitation and were purposively selected based on whether they had sustained employment (4) or not (4).

Results.?Similarity between pre-injury work or leisure interest and post-injury work, unconditional motivation, insight and the ability to cope with cognitive and behavioural sequelae were beneficial in sustaining employment. Post-injury instances of poor cognitive or behavioural function did not necessarily affect sustained employment. The vocational rehabilitation programme was beneficial in building up confidence, providing continued follow up and providing co-worker ‘twins’ in the work place. Employers with a personal experience of disability helped individuals with ABI to sustain employment.

Conclusions.?Similarities between pre-injury work or leisure interests and post-injury work improved motivation. Factors associated with sustained employment were insightful, unconditional, internal motivation providing an ability to cope, confidence provided by ongoing vocational rehabilitation support through job coaches, supportive co-workers and employers with a personal experience of disability. People with ABI can be outstanding employees.     

Motivation in rehabilitation and acquired brain injury: can theory help us understand it?

Background: In acquired brain injury (ABI) populations, low motivation to engage in rehabilitation is associated with poor rehabilitation outcomes. Motivation in ABI is thought to be influenced by internal and external factors. This is consistent with Self-determination Theory, which posits that motivation is intrinsic and extrinsic. This paper discusses the benefit of using Self-determination Theory to guide measurement of motivation in ABI.

Methods: Using a narrative review of the Self-determination Theory literature and clinical rehabilitation research, this paper discusses the unique role intrinsic and extrinsic motivation has in healthcare settings and the importance of understanding both when providing rehabilitation in ABI.

Results: Based on the extant literature, it is possible that two independently developed measures of motivation for ABI populations, the Brain Injury Rehabilitation Trust Motivation Questionnaire-Self and the Motivation for Traumatic Brain Injury Rehabilitation Questionnaire, may assess intrinsic and extrinsic motivation, respectively.

Conclusion: Intrinsic and extrinsic motivation in ABI may be two equally important but independent factors that could provide a comprehensive understanding of motivation in individuals with ABI. This increased understanding could help facilitate behavioural approaches in rehabilitation.

• Implications for Rehabilitation

• Conceptualization of motivation in ABI would benefit from drawing upon Self-determination Theory.

• External factors of motivation such as the therapeutic environment or social support should be carefully considered in rehabilitation in order to increase engagement.

• Assessing motivation as a dual rather than a global construct may provide more precise information about the extent to which a patient is motivated.

     

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

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.

     

Sleep and agitation during subacute traumatic brain injury rehabilitation: A scoping review

BackgroundSleep disturbance and agitation are frequent conditions during the subacute period of recovery in moderate to severe traumatic brain injury (TBI). Clarity is needed regarding the association between the two conditions to improve fundamental nursing care.AimThe aim of our scoping review was to identify the evidence for potential associations between sleep disturbance and agitation during subacute inpatient rehabilitation of adult patients with moderate to severe TBI.DesignWe conducted a five-step scoping review.MethodsSources of evidence were PubMed, CINAHL, PsycINFO, Cochrane, and Web of Science databases. Eligibility criteria were as follows: English or Scandinavian language articles describing sleep and/or agitation during inpatient rehabilitation of adult patients with moderate to severe TBI and published in the period 2000–2019.ResultsWe identified 152 articles of which we included six. The included articles were all affiliated with the USA using quantitative methodology. The association between sleep disturbance and agitation is highly complex, with disturbed sleep affecting cognitive and emotional functions. Sleep disturbance was associated with posttraumatic amnesia (PTA)/posttraumatic confusional state, cognitive function, and agitation. Our review suggested a bidirectional association between these symptoms during early TBI rehabilitation. We inferred that improved sleep might be a contributing factor to the resolution of PTA, cognitive impairment, and agitation.ConclusionThe association between sleep disturbance and agitation is still undetermined, but we assume that improved sleep may protect against neuropsychiatric problems in patients with moderate to severe TBI. Larger controlled interventional studies are needed to provide the evidence of modifiable factors for improving sleep during inpatient TBI rehabilitation. Owing to the current lack of publications, it is probably too early to perform a systematic review on the topic.Relevance to clinical practiceWe recommend systematic implementation of sleep hygiene during inpatient rehabilitation of patients with TBI to reduce PTA, agitation, and long-term neuropsychiatric problems.     

创伤性颅脑损伤康复治疗患者相关因素的回顾性分析

目的了解接受康复治疗的创伤性颅脑损伤(TBI)患者的一般情况、康复治疗时间、并发症等情况。方法回顾性分析北京博爱医院神经康复科1993年9月~2004年7月入院的所有TBI病例。结果共有280例TBI住院患者,平均发病年龄(33.1±11.4)岁,男女比为4.28∶1,职业构成以机关干部为主(占34.6%),报销方式也以公费医疗最多(占71.1%)。受伤原因以交通事故为主(占66.4%)。入院时距离受伤日期10 d~6年,平均288 d,在伤后3月内入院行康复治疗者占25.0%。继发癫痫者占15.7%,住院期间发现有脑积水者占18.9%。结论目前我国因TBI住院康复治疗的群体主要为城市男性居民、享受公费医疗待遇者;TBI急性期和亚急性期的康复流程体系也有待建立和完善。     

Vision rehabilitation interventions following mild traumatic brain injury: a scoping review

Purpose: To broadly examine the literature to identify vision interventions following mild traumatic brain injury. Objectives are to identify: (1) evidence-informed interventions for individuals with visual dysfunction after mild traumatic brain injury; (2) professions providing these interventions; (3) gaps in the literature and areas for further research.

Methods: A scoping review was conducted of four electronic databases of peer-reviewed literature from the databases earliest records to June 2017. Articles were included if the study population was mild traumatic brain injury/concussion and a vision rehabilitation intervention was tested. Two independent reviewers screened articles for inclusion, extracted data, and identified themes.

Results: The initial search identified 3111 records. Following exclusions, 22 articles were included in the final review. Nine studies evaluated optical devices, such as corrective spectacles, contact lenses, prisms, or binasal occlusion. Two studies assessed vision therapy. Ten studies examined vision therapy using optical devices. One study investigated hyperbaric oxygen therapy. Optometrists performed these interventions in most of the studies. Future research should address quality appraisal of this literature, interventions that include older adult and pediatric populations, and interdisciplinary interventions.

Conclusions: There are promising interventions for vision deficits following mild traumatic brain injury. However, there are multiple gaps in the literature that should be addressed by future research.

• Implications for Rehabilitation

• Mild traumatic brain injury may result in visual deficits that can contribute to poor concentration, headaches, fatigue, problems reading, difficulties engaging in meaningful daily activities, and overall reduced quality of life.

• Promising interventions for vision rehabilitation following mild traumatic brain injury include the use of optical devices (e.g., prism glasses), vision or oculomotor therapy (e.g., targeted exercises to train eye movements), and a combination of optical devices and vision therapy.

• Rehabilitation Professionals (e.g., optometrists, occupational therapists, physiotherapists) have an important role in screening for vision impairments, recommending referrals appropriately to vision specialists, and/or assessing and treating functional vision deficits in individuals with mild traumatic brain injury.

     

Non-pharmacological rehabilitation interventions for concussion in children: a scoping review

Purpose: To summarise the extent, nature, and quality of current scholarly literature related to non-pharmacological, rehabilitation interventions following concussion, or mild traumatic brain injury in children.

Methods: An electronic search was conducted from 1987 to 24 October 2017. Studies were included if they met the following criteria: (1) full text, peer reviewed, and written in English, (2) original research, (3) diagnosed concussion or mild traumatic brain injury, (4) described the evaluation of an intervention, (5) the outcome was a concussion impairment, and (6) the mean/median age was under 19. Quality assessment using the Down’s and Black criteria was conducted.

Results: Twenty-six studies published between 2001 and 2017 were identified. Interventions included rest, active rehabilitation, exercise, vestibular, oculomotor, cervicospinal therapy, education, early intervention, telephone counselling, mobile health application, Web-based Self-Management program, multimodal physical therapy, cognitive behavioural therapy, transcranial direct current stimulation, and acupuncture. The quality assessments ranged from poor to good.

Conclusions: The literature describing interventions following concussion in children is scarce. While both positive and negative results were obtained, there were methodological concerns in most studies limiting the ability to draw conclusions. Interventions incorporating aerobic exercise show promise as a concussion management strategy.

• Implications for rehabilitation

• Few studies have examined rehabilitation interventions for youth following concussion.

• Research ranging from rest to exercise highlights the uncertainty of the field.

• Low quality research limits the generalizability of results.

• The use of physical activity appears to be an emerging area of interest.

• Individualised, aerobic exercise should be used as part of clinical management.

     

Technology to encourage meaningful activities following brain injury

Abstract

Background: Cognitive and behavioural difficulties after acquired brain injury (ABI) may lead to reduced engagement in leisure and social activities. Increasing participation is a goal of neuropsychological rehabilitation and assistive and behaviour change technology can play an important role in this. Focus groups and interviews were conductive with brain injury rehabilitation stakeholders (n = 24): people with ABI (n = 9), family members (n = 3) and care providers (n = 12) in order to understand the barriers to engaging in meaningful activities and what helps to overcome these barriers. A collaborative thematic analysis was performed by a multi-disciplinary research team using an approach based on Grounded Theory.

Results: Four central, interlinked, barriers were found: Access, Cognitive Difficulties, Anticipation (of Physical or Cognitive Difficulties) and Motivation. To overcome these barriers, participants cited themes such as External Motivation from both Other People and Technology, Maintaining Momentum and different aspects of Being Planful.

Conclusions: The results point to future directions for the purposeful development of effective assistive technology for this user group. Technology that is social, persuasive, adapts to individual needs and supports people to plan activities are likely to be particularly useful within neuropsychological rehabilitation.

• Implications For Rehabilitation

• Adults with ABI and their carers describe problems accessing activities, cognitive difficulties, anticipationof physical or cognitive difficulties and low motivation as the key barriers to undertaking meaningfulactivities.

• Current solutions are external prompting, maintaining momentum and being planful.

• This detailed qualitative analysis of a diverse group of carers and service users allows insight into theassistive technologies that could aid rehabilitation.

     

重型闭合性颅脑损伤患者早期康复疗效观察

目的观察重症监护室中重型闭合性颅脑损伤患者早期康复的疗效。方法将118 例重型闭合性颅脑损伤患者分为治疗组和对照组各59例,对照组接受呼吸康复、压疮预防、泌尿系护理,治疗组在此基础上进行肢体神经功能康复、认知功能康复比较两组患者治疗前后的Glasgow昏迷量表(GCS)、Fugl Mayer量表评定(FMA)、日常生活活动能力(ADL)测评、残疾分级量表(DRS)测评和简易精神状态检查表(MMSE)评分。结果治疗组患者的GCS、FMA(上肢)、ADL和DRS评分较对照组有显著性差异( P <0.05),MMSE评分无显著性差异( P >0.05)。结论早期康复治疗可以改善重型闭合性颅脑损伤患者的神经功能,认知功能的改善短期内不明显。     

重型颅脑损伤患者医院感染的调查分析及预防

目的探讨重型颅脑损伤患者医院感染的临床特点与预防措施。方法对640例重型颅脑损伤患者医院感染情况进行回顾性分析(包括感染部位、细菌培养、药敏试验等),并结合医院实际情况提出预防对策。结果640例重型颅脑损伤患者医院感染98例,感染率为15．31％,显著高于同期医院平均感染率(4．08）。感染部位分布：呼吸道最高,为15．16％,其次为泌尿道感染9．69％。感染病原体主要是革兰氏阴性菌占58．93%,其中以铜绿假单孢菌、大肠埃希菌为主,敏感抗生素为亚胺培能;其次是真菌占32．14％,敏感抗生素为氟康唑;革兰氏阳性菌占8．93%,其中以金黄色葡萄球菌为主,敏感抗生素为万古霉素。结论重型颅脑损伤患者是易发医院感染的主要高危人群。通过严格病房管理、消毒隔离、无菌操作及合理使用抗生素,有利于控制医院感染的发生。     

心理韧性改善脑外伤康复效果的系统综述

目的 系统综述心理韧性在改善脑外伤康复效果中的作用。方法 通过主题词检索方式,在PubMed、ScienceDirect、知网、万方、维普数据库检索心理韧性干预在改善脑外伤康复效果中作用的相关文献,检索时间建库至2021年12月31日。经筛选从文献中提取研究、国家、研究对象、研究设计、干预频率、干预效果、康复影响和影响因素,并采用PEDro量表进行方法学质量评价。结果 共获得有效文献6篇,主要集中在心理韧性干预在改善脑外伤患者的身体功能、创伤后应激障碍、心理功能和社会适应方面的研究。结论 心理韧性干预可减少患者的身体症状和创伤后应激障碍,促进心理功能恢复,使患者保持乐观的态度,采取灵活的应对方式,积极适应社会。     

重型闭合性颅脑损伤患者的康复临床研究

目的：研究重型闭合性颅脑损伤住院患者综合康复治疗的效果以及影响因素。方法：对住院的69例重型颅脑损伤患者进行综合康复治疗，采用Glasgow昏迷量表（GCS）、日常生活能力（ADL）、残疾分级量表（DRS）、简易精神状态检查表（MMSE）等评定疗效并进行统计学分析。结果：本组病例的年龄、病程、治疗时间、GCS、昏迷时间等均有较大差异，其中GCS评分明显受昏迷时间的影响（P＜0．001）；患者的日常生活能力、认知能力和残疾水平均有较大程度的改善（P＜0．001）；手术组认知功能的恢复较非手术组明显（P＜0．05）；日常生活能力的恢复主要受损伤严重程度（GCS评分）和治疗时间的影响（P＜0．05）；认知功能的恢复除受GCS影响外（P＜0．01），病程短恢复好（P＜0．05）。结论：临床综合康复治疗对于重型闭合性颅脑损伤患者各种功能的恢复具有肯定的效果，日常生活能力和认知能力的恢复受颅脑损伤程度的影响、脑损伤患者认知功能的康复体系有待加强。     

Using participatory action research in community-based rehabilitation for people with acquired brain injury: from service provision to partnership with Aboriginal communities

Purpose.?Community-based rehabilitation (CBR) developed in response to delivery of rehabilitation services to people with disability in developing countries, and appears appropriate to address rehabilitation needs of rural and remote populations, including Australian Aboriginal People with acquired brain injury (ABI). This article will describe participatory action research (PAR) as a vehicle for exploring and translating the CBR model within a mainstream brain injury rehabilitation service in Queensland, Australia.

Method.?PAR was conducted with two self-selected remote Aboriginal communities in Far North Queensland. Key components to this project were the employment of a local Aboriginal worker, facilitating community engagement and consultation. PAR elements of planning, action and review were conducted through individual and group meetings and activities within the communities across a 3-year period.

Results.?The project has facilitated expansion and change within the current brain injury rehabilitation service model in line with CBR philosophical foundations, including community development and partnership as a desirable way of engaging with key stakeholders.

Conclusions.?The focus on community consultation through PAR and the development of community partnerships has increased the cultural competency of the rehabilitation service, the capacity of participating communities and of the sector to respond in ways that are valued and owned by Aboriginal People with brain injury, their families and communities.     

脑外伤后认知障碍社区康复的可行性研究

目的：了解认知康复服务的需求，有关专业人士的认知康复知识水平以及他们对创新性认知康复的态度和接受程度，以便帮助制定认知障碍社区康复计划。方法：采用自行设计的结构式问卷调查表，155名神经外科医生、康复科医生、康复治疗师、护士等接受了问卷调查。结果：95．4％的调查对象认为在中国有必要开展脑外伤后的认知障碍康复。按康复的重要性需要优先考虑的前4个问题为：语言能力、记亿力、定向力、注意力；脑外伤后康复场所的重要性依次为：家庭、医院、社区；三种康复训练方法的重要性依次为：面对面方式、电脑辅助方式、网上远程指导方式。家庭是首选的康复场所、“面对面”是主要康复方式。康复训练方式与康复场所之间存在良好的相关关系，即相对于其他训练方式，在家庭或医院人们更愿意选择“面对面”训练；对于远程指导而言，在家中则比医院能更好地发挥作用。结论：①认知康复服务正在快速发展并获得有关专业人士的大力支持；②“面对面”训练仍是认知康复主要跟务方式；③在家中开展认知康复远程指导也是一项合适的服务选择，以家庭为基础的康复是社区康复的重要内容，网上和／或远程指导的认知康复服务值得大力提倡；④需进一步探讨创新性认知康复服务方式的有效性和实用性。