On the road again after traumatic brain injury: driver safety and behaviour following on-road assessment and rehabilitation

Purpose: To examine pre- and post-injury self-reported driver behaviour and safety in individuals with traumatic brain injury (TBI) who returned to driving after occupational therapy driver assessment and on-road rehabilitation. Method: A self-report questionnaire, administered at an average of 4.5 years after completing an on-road driver assessment, documenting pre- and post-injury crash rates, near-crashes, frequency of driving, distances driven, driving conditions avoided and navigation skills, was completed by 106 participants, who had either passed the initial driver assessment (pass group n?=?74), or required driver rehabilitation, prior to subsequent assessments (rehabilitation group n?=?32). Results: No significant difference was found between pre- and post-injury crash rates. Compared to pre-injury, 36.8% of drivers reported limiting driving time, 40.6% drove more slowly, 41.5% reported greater difficulty with navigating and 20.0% reported more near-crashes. The rehabilitation group (with greater injury severity) was significantly more likely to drive less frequently, shorter distances, avoid: driving with passengers, busy traffic, night and freeway driving than the pass group. Conclusions: Many drivers with moderate/severe TBI who completed a driver assessment and rehabilitation program at least 3 months post-injury, reported modifying their driving behaviour, and did not report more crashes compared to pre-injury. On-road driver training and training in navigation may be important interventions in driver rehabilitation programs.

• Implications for Rehabilitation

• Driver assessment and on-road retraining are important aspects of rehabilitation following traumatic brain injury.

• Many drivers with moderate/severe TBI, reported modifying their driving behaviour to compensate for ongoing impairment and continued to drive safely in the longer term.

• Navigational difficulties were commonly experienced following TBI, suggesting that training in navigation may be an important aspect of driver rehabilitation.

     

Client and family engagement in rehabilitation research: a framework for health care organizations

Purpose: To describe the development and implementation of an organizational framework for client and family-centered research.

Method: Case report.

Results: While patient-centered care is now well established, patient-centered research remains underdeveloped. This is particularly true at the organizational level (e.g., hospital based research institutes). In this paper we describe the development of an organizational framework for client and family centered research at Holland Bloorview Kids Rehabilitation Hospital in Toronto, Canada.

Conclusion: It is our hope that, by sharing our framework other research institutions can learn from our experience and develop their own research patient/client/family engagement programs.

• Implications for rehabilitation

• Family engagement in rehabilitation research

• ?Rehabilitation research is crucial to the development and improvement of rehabilitative care.

• ?The relevance, appropriateness, and accountability of research to patients, clients and families could be improved.

• ?Engaging clients and families as partners in all aspects of the research process is one way to address this problem.

• ?In this paper, we describe a framework for engaging clients and families in research at the organizational level.

     

Patients’ perspectives on aerobic exercise early after stroke

Purpose: To describe patient perspectives of aerobic exercise during inpatient stroke rehabilitation, including their self-efficacy and beliefs towards exercise, as well as their perceptions of barriers. Method: A survey was conducted at three Canadian rehabilitation centres to evaluate individuals’ (N?=?33) self-efficacy and outcome expectations for exercise. In addition, patient perceptions of other people recovering from stroke, social support, and aerobic exercise as part of rehabilitation were assessed. Results: Thirty-two people completed the survey. Of these, 97% were willing to participate in aerobic exercise 5.9?±?8.8 days after admission to inpatient rehabilitation. While outcome expectations for exercise were high, participants reported lower self-efficacy for exercise. Patients reported barriers related to the ability to perform exercise (other health problems (i.e., arthritis), not being able to follow instructions and physical impairments) more often than safety concerns (fear of falling). The lack of support from a spouse and family were commonly identified, as was a lack of information on how to perform aerobic exercise. Conclusion: Patients with stroke are willing to participate in aerobic exercise within a week after admission to inpatient rehabilitation. However, they perceive a lack of ability to perform aerobic exercise, social support from family and information as barriers.

• Implications for rehabilitation

• Aerobic exercise is recognized as part of comprehensive stroke rehabilitation.

• There is a need to better understand patient perspectives to develop and implement more effective interventions early after stroke.

• Patients lack confidence in their ability to overcome barriers early after stroke.

• Patients are concerned with their ability to perform exercise, fall risk, lack of support from a spouse and family, and limited information on aerobic exercise.

• There is a need to reinforce education with practical experience in structured aerobic exercise programs that show patients and caregivers how to manage disability and complex health needs.

     

Caregivers’ experiences with the selection and use of assistive technology

Qualitative data from a mixed-methods clinical trial are used to examine caregivers’ experiences with the selection and use of assistive technology to facilitate care recipients’ independence. Through a thematic analysis of interviews from 27 caregivers, three broad themes were identified. “A partial peace of mind” described the generally positive psychological impacts from assistive technology, mainly reduced stress and a shift in caregiving labour from physical tasks to a monitoring role. “Working together” explored the caregivers’ experiences of receiving assistive technology and the sense of collaboration felt by caregivers during the intervention process. Finally, “Overcoming barriers“ addressed two impediments to accessing assistive technology: lack of funding and appointment wait times for service providers. The findings suggest that assistive technology provision by prescribers plays a beneficial role in the lives of caregivers, but access to such benefits can be hampered by contextual constraints.

• Implications for rehabilitation

• The study findings have a number of implications for rehabilitation practice:

• Family caregivers can be instrumental in determining what assistive technology is needed and then procured. Their involvement in the selection process is desirable because assistive technology may have both positive and negative impacts on them, and they themselves may use the devices chosen.

• Involving family caregivers as more active partners in the process of assistive technology provision may represent a greater time investment in the short term, but may contribute to better long-term outcomes for care recipients and caregivers as well.

• Limited access to funding and long appointment wait times are potential barriers to obtaining necessary assistive technologies.

     

A comprehensive assessment of family caregivers of stroke survivors during inpatient rehabilitation

Abstract

Purpose: Stroke caregivers have been identified as a group at high risk for poor outcomes as a result of the suddenness of stroke and a potentially high level of care needed due to significant functional limitations of the patient. However, there is little research on the assessment of family members who will assume the caregiving role prior to patient discharge from rehabilitation. The purpose of this article is to delineate critical assessment domains identified by a subset of spousal stroke caregivers. Methods: Semi-structured interviews were conducted pre- and post-discharge from rehabilitation as part of a larger study that focused on identifying caregiver and stroke survivor needs as they transitioned home from inpatient rehabilitation. For this study, two semi-structured interviews with 14 spousal caregivers were analyzed using grounded theory methods. Results: Long-term stroke survivor outcomes were dependent upon the commitment, capacity and preparedness of the family caregiver. Twelve domains of assessment were identified and presented. Conclusions: A comprehensive, systematic caregiver assessment to understand the caregiver’s concerns about stroke should be conducted during rehabilitation to help the team to develop a plan to address unmet needs and better prepare family caregivers to take on the caregiving role.

• Implications for Rehabilitation

• Stroke is a sudden event that often leaves stroke survivors and their families in crisis.

• The needs of stroke family caregivers are not often systematically assessed as part of inpatient rehabilitation.

• Long-term stroke survivor outcomes are dependent upon the commitment, capacity and preparedness of the family caregiver.

• Stroke caregiver assessment should include the commitment, capacity and preparedness to provide care, and the overall impact of stroke in order to develop discharge plans that will adequately address the needs of the stroke survivor/caregiver dyad.

     

Family caregiving of individuals with traumatic brain injury in Botswana

Background The impairments that affect survivors of TBI impact the person’s independence, and family members frequently have to take on a caregiver role. This study examined the experience of caregiving for individuals with TBI in Botswana and its impact on psychological distress in caregivers. Methods Using a mixed methods study design, qualitative data from semi-structured interviews were thematically analyzed and triangulated with data regarding functional status from the Structured Head Injury Outcome Questionnaire and the Hospital Anxiety and Depression Scale (HADS). Results The study included 26 participants with moderate to severe TBI, and a total of 18 caregivers were recruited. Caregivers commonly reported receiving limited information regarding their relatives’ injuries and management methods. Heavy caregiving demands were placed on them, with little support from the healthcare system. A significant proportion of caregivers experienced anxiety and depression, which was associated with lower functional independence in their injured relative. Somewhat more spouses than parents reported clinically significant anxiety levels. Other consequences of caregiving included social isolation and limited support from the wider community as well as financial difficulties. Despite these stresses caregivers tended to accept their caregiving role. Cultural factors such devotion to their families and faith and belief in God moderated burden and distress. Conclusions Carers of individuals with TBI in Botswana face significant challenges. Rehabilitation efforts need to take these into account. Specifically, more information and support needs to be provided to survivors and their families. Psychological, economic and health needs of the care providers also should be addressed in the planning of rehabilitation interventions.

• Implications for Rehabilitation

• Caregivers of individuals with TBI in under-resourced countries carry much of the burden of care, face many challenges and experience significant stress.

• More information and support needs to be provided to survivors of TBI and their families in countries such as Botswana in a culturally sensitive manner.

• Psychological, economic and health needs also need to be addressed in the planning of rehabilitation interventions, which are currently non-existent in Botswana.

     

Targeted rehabilitation reduces visual dependency and improves balance in severe traumatic brain injury: a case study

Purpose: To further understand the mechanisms underlying gait impairment following traumatic brain injury.

Case report: A 58-year-old man presented with marked unsteadiness and motion sensitivity following a severe traumatic brain injury. He underwent a 6-week inpatient rehabilitation program focused on re-weighting and subsequently re-integrating ascending interoceptive information, by gradual reduction of maladaptive visual fixation techniques. We report clinical neurological outcomes and measures of functional outcome, as well as an objective assessment of visual dependency (the rod and disk test) at baseline and after the rehabilitation.

Results: Clinically, the patient had gait unsteadiness exacerbated by visual motion. A significant reduction in visual dependency occurred with tailored multi-disciplinary rehabilitation via gradual removal of visual fixation strategies that the patient had developed to maintain balance (t-test; p?Conclusions: We highlight the importance of visual dependency in the generation of maladaptive gait strategies following brain injury. Our data suggest assessing and treating visual dependency to be an important component of gait rehabilitation after traumatic brain injury.

• Implications for rehabilitation

• Whilst gait disturbance in TBI is multifactorial, abnormal visual dependency may be important but under-recognised component of the disorder.

• Visual dependency can be easily and objectively assessed by the bedside in patients using a dynamic rod and disc test.

• Tailored rehabilitation with gradual reduction of maladaptive visual fixation can reduce visual dependency and contribute to improved gait and balance following TBI.

     

Pediatric SCI/D caregiver mental health and family dynamics in Colombia,South America

Objective: This study examined the connections between family dynamics and the mental health of caregivers of youth with spinal cord injuries/disorders (SCI/D) caregivers from Colombia, South America. It was hypothesized that lower family functioning would be associated with poorer caregiver mental health. Methods: A cross-sectional study of self-report data collected from caregivers through the Hospital Universatario Hernando Moncaleano Perdomo in Neiva, Colombia. Thirty caregivers of children with SCI/D from Nevia, Colombia who were a primary caregiver for ≥3 months, providing care for an individual who was ≥6 months post-injury/diagnosis, familiar with the patient’s history, and without neurological or psychiatric conditions. Caregivers’ average age was 41.30 years (SD?=?10.98), and 90% were female. Caregivers completed Spanish versions of instruments assessing their own mental health and family dynamics. Results: Family dynamics explained 43.2% of the variance in caregiver burden and 50.1% of the variance in satisfaction with life, although family dynamics were not significantly associated with caregiver depression in the overall analysis. Family satisfaction was the only family dynamics variable to yield a significant unique association with any index of caregiver mental health (satisfaction with life). Conclusions: If similar findings emerge in future intervention research, interventions for pediatric SCI/D caregivers in Colombia and other similar global regions could benefit from including techniques to improve family dynamics, especially family satisfaction, given the strong potentially reciprocal connection between these dynamics and caregiver mental health.

• Implications of Rehabilitation

• The degree of disability resulting from SCI/D can vary greatly depending on the severity and level of the lesion, though permanent impairment is often present that profoundly impacts both physical and psychological functioning.

• Very little is known about the impact of pediatric SCI/D in developing countries, despite the high rates of injury reported in these areas.

• Family interventions could contribute significantly to the lives of children with SCI/D and their families.

     

Co-construction of an Internet-based intervention for older assistive technology users and their family caregivers: stakeholders’ perceptions

Abstract

Purpose: Providing care to older adults using assistive technology can be challenging for family caregivers. To inform the development of an Internet-based intervention, this study aimed to identify older assistive technology users and family caregivers’ needs related to assistive technology procurement, and to explore how to offer remote support through an Internet-based intervention.

Methods: Based on an iterative user-centered design approach, 30 semi-structured interviews were conducted with stakeholders about their experiences with assistive technology procurement/attribution and their perceptions of a proposed intervention. A modified content analysis approach was used, with a mix of emerging and a priori concepts.

Results: Participants view assistive technology procurement as an ongoing cyclical process, with potential unmet needs at key moments before and after assistive technology procurement. Assistive technology user-family caregiver dyads needs focus on assistive technology information, access, assistive technology-person-context match, training and support. While participants felt there were benefits to the proposed intervention they also identified potential implementation barriers.

Conclusion: Assistive technology Internet-based interventions dedicated to family caregivers should ensure systematic and tailored follow-up while integrating some form of human support. This study guides the prototype design of the proposed intervention towards a graded support approach, empowering assistive technology users and family caregivers to resolve assistive technology-related challenges.

• Implication for rehabilitation

• Providing home-based care to older adults using assistive technology (e.g., mobility aids, communication aids) can be challenging for family caregivers.

• Using a user-centered design approach, an Internet-based intervention is under development to support older assistive technology users and their family caregivers.

• Through interviews with diverse stakeholders, this study explores unmet needs related to assistive technology procurement and perceptions about the proposed intervention.

     

Characteristics and functional outcomes of brain injury caused by physical assault in Canada: a population-based study from an inpatient rehabilitation setting

Abstract

Purpose: To investigate the characteristics and inpatient rehabilitation outcomes of persons who sustained a traumatic brain injury (TBI) resulting from physical assault – a form of intentional TBI – and compare these outcomes to those of persons with TBI resulting from other aetiologies. Method: A prospective population-based cohort study using inpatient rehabilitation data from Canadian population-based administrative databases for the fiscal years 2001–2006. Outcome measures were measures of functional independence (motor and cognitive), as measured by the FIM? Instrument, and discharge destinations. Results: Characteristics associated with intentional TBI were being male, younger in age and unemployed; living alone and having a greater likelihood of alcohol/drug abuse prior to admission. The intentional TBI group showed poorer total functional gains at discharge from inpatient rehabilitation. Multivariate regression analyses showed that persons with intentional injury were less likely to be discharged home. Conclusions: Persons with TBI from physical assault are a distinct clinical group in Canadian inpatient rehabilitation settings. These findings can support clinicians in determining proper assessment, management, discharge planning and post-rehabilitation care that target specific needs of persons with TBI resulting from physical assault.

• Implications for Rehabilitation

• Clinicians should have appropriate training to properly assess the mental health status of this patient group.

• Inpatient rehabilitation facilities should be prepared to provide services targeting psychosocial, substance abuse and interpersonal relationship issues to persons with a TBI from physical assault while patients are still within a hospital setting.

• Follow-up clinical care and community support services are warranted for those with intentional TBIs, including provision of occupational rehabilitation services, such as vocational rehabilitation.

• The discharge team should be responsible for ensuring appropriate discharge to community in the absence of family or other advocates on behalf of the patient.

     

Work-related difficulties in patients with traumatic brain injury: a systematic review on predictors and associated factors

Purpose: To address the content of work-related difficulties and explore which variables are associated to or determinants of these difficulties in persons that suffered from Traumatic Brain Injury (TBI). Method: Papers published between 1993 and February 2015 were included. Quality was judged as poor, acceptable, good or excellent. Determinants were extracted from longitudinal data, associated variables from cross-sectional data; variables were grouped by similarity. Evidence was judged as strong if the same results were reported by two or more good studies; limited if reported by one good and some acceptable studies. Results: Forty-two papers were selected (25,756 patients). Work-related difficulties were referred as unemployment, job instability or job cessation. Strong evidence of impact was found for: low educational level, pre-injury unemployment, Glasgow Coma Scale score and TBI severity, length of stay in acute and rehabilitation settings, lower Functional Independence Measure scores and presence of cognitive disturbances. Discussion: Evidence on the effect of rehabilitation interventions on TBI patients’ work-related difficulties exists, but is poorly measured. Future studies should address the sustainability of holistic and tailored interventions targeting employees, employers and workplaces and aimed to reduce the gap between work duties and worker’s abilities, using appropriate assessment instruments measuring difficulties in work activities.

• Implications for rehabilitation

• Traumatic Brain Injury (TBI) primarily affects young persons of working age causing a broad range of motor, sensory and cognitive impairments. A combination of variables related both to pre-morbid and to injury-related factors predict and are associated to work-related difficulties.

• While demographic and injury characteristics cannot be modified, some TBI outcomes (e.g. cognitive impairments or functional status) may be addressed by specific rehabilitative interventions: the knowledge of the specific work-related difficulties of TBI patients is of importance to tailor rehabilitation programs that maximize vocational outcomes.

• Rehabilitation researchers should give attention to vocational issues and use assessment instruments addressing the difficulties in work-related activities, in order to demonstrate the benefits of rehabilitative interventions on TBI patients’ ability to work.

     

Family members’ needs and experiences of driving disruption over time following an acquired brain injury: an evolving issue

Purpose: Family members often assume the role of driver for individuals who are not driving post-acquired brain injury (ABI). Given that return to driving can be unpredictable and uncertain, the impact of driving disruption on family members may vary at different stages post-injury. This study aims to understand the needs and experiences of family members over time during driving disruption following an ABI.

Method: A qualitative prospective longitudinal research design was used with semi-structured interviews at recruitment to study, 3 and 6 months later.

Results: Fourteen family members completed 41 interviews. The longitudinal data revealed four phases of driving disruption: (1) Wait and see, (2) Holding onto a quick fix, (3) No way out, and (4) Resolution and adjustment. The phases described a process of building tension and a need for support and resolution over time.

Conclusions: Holding onto a quick fix is a pivotal phase whereby supports, such as engagement in realistic goal setting, are essential to facilitate family members’ resolution of driving disruption issues. Family members who see no way out might not actively seek help and these points to a need for long-term and regular follow-ups. Future research can explore ways to support family members at these key times.

• Implications for rehabilitation

• Health professionals need to facilitate the process of fostering hope in family members to set realistic expectations of return to driving and the duration of driving disruption.

• It is necessary to follow-up with family members even years after ABI as the issue of driving disruption could escalate to be a crisis and family members might not actively seek help.

• Health professionals can consider both practical support for facilitating transport and emotional support when addressing the issue of driving disruption with family members.

     

Problems in functioning after a mild traumatic brain injury within the ICF framework: the patient perspective using focus groups

Purpose: To describe problems in body functions, activities, and participation and the influence of environmental factors as experienced after mild traumatic brain injury (TBI), using the ICF framework. To compare our findings with the Brief and Comprehensive ICF Core Sets for TBI. Methods: Six focus-group interviews were performed with 17 participants (nine women, eight men, age ranged from 22 to 55 years) within the context of an outpatient rehabilitation programme for patients with mild TBI. The interviews were transcribed verbatim and analysed using the ICF. Results: One-hundred and eight second-level categories derived from the interview text, showing a large diversity of TBI-related problems in functioning. Problems in cognitive and emotional functions, energy and drive, and in carrying out daily routine and work, were frequently reported. All ICF categories reported with high-to-moderate frequencies were present in the Brief ICF Core Set and 84% in the Comprehensive ICF Core Set. The reported environmental factors mainly concerned aspects of health and social security systems, social network and attitudes towards the injured person. Conclusions: This study confirms the diversity of problems and the environmental factors that have an impact on post-injury functioning of patients with mild TBI.

Implications for Rehabilitation

• Disabilities related to cognitive and emotional functions, energy and drive, and carrying out daily routine and work should be addressed in rehabilitation of people with mild traumatic brain injury (TBI).

• Attention should be given to environmental facilitators and barriers for activities and participation.

• Participation in everyday life after a mild TBI, including social- and work-participation, constitutes a challenge where multidisciplinary rehabilitation efforts should be considered.

• The Brief Core Set does not attain all frequently observed categories of functioning among people with mild TBI.

     

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.

     

Exploring strategies used to deliver physical activity experiences to Veterans with a physical disability

Abstract

Purpose: Physical activity is an important method of rehabilitation used to promote positive physical and psychosocial outcomes among military personnel, including Veterans, with a physical disability. However, minimal research has explored physical activity program implementation strategies, particularly how these strategies may foster positive rehabilitation outcomes, and quality participation experiences among Veterans post-injury. The purpose of the current study is to document strategies used to deliver physical activity programs to Veterans with a physical disability.

Research methods: Semi-structured interviews were conducted with program staff from three Veteran physical activity programs, and program documentation was collected. Data were analyzed using a thematic analysis.

Results: Four themes were identified representing strategies used for delivering physical activity programming: (1) foster social connections; (2) challenge participants; (3) tailor programs and outcomes to match participant needs; and (4) include knowledgeable coaches/instructors.

Conclusions: The study provides researchers and practitioners (e.g., rehabilitation professionals, program facilitators, coaches) with evidence of strategies for delivering physical activity programming for Veterans post-injury, thus assisting with future program development and evaluation. The findings also provide preliminary insight regarding the potential relationships between physical activity programming and elements of quality participation.

• Implications for Rehabilitation

• Physical activity is a popular method of rehabilitation for military personnel post-injury.

• Findings highlight four strategies used to deliver physical activity experiences to Veterans with a physical disability.

• Strategies highlighted provide insight as to how rehabilitation specialists can promote quality experiences for Veterans with a physical disability during physical activity programming.

     

Traumatic brain injury resiliency model: a conceptual model to guide rehabilitation research and practice

Abstract

There is a growing trend in traumatic brain injury (TBI) rehabilitation, and research, to focus on the processes of adaptation following the injury. Resiliency is an umbrella term describing the range of personal protective factors, environmental supports and resources, as well as self-regulatory processes, engaged in response to adversity. An affective, cognitive, and behavioural self-regulatory process model of resiliency in the workplace was adapted to suit the TBI context. Through a narrative review of the literature pertaining to brain injury rehabilitation, participation, and resilience, we substantiated the model, and explained how resiliency can frame research on life experiences following the injury. TBI represents a cascading adversity as the injury and subsequent life experiences (e.g., job loss) shape adaptation. Resiliency is shaped by: personal characteristics (e.g., hope, social functioning, self-awareness, memory, spirituality, coping, and self-efficacy), environmental resources/supports (e.g., services and social support), and self-regulatory processes that lead to the resiliency-related outcomes, which we suggest involve re-engaging in activities, adapting participation, and reconstructing identity. This conceptual model outlines and defines the factors and processes operating and contributing to resiliency following TBI. Recommendations for future research are outlined.

• Implications for rehabilitation

• Investigating resiliency processes can move the traumatic brain injury field beyond examining individual traits and protective factors, to transactional processes that influence participation experiences and opportunities over time.

• The Traumatic Brain Injury Resiliency Model can be used to frame the targets and desired outcomes of rehabilitation interventions, such as self-regulatory processes or environmental supports known to enhance resiliency.

• Studying resiliency will help to shift the paradigms of traumatic brain injury research, and rehabilitation practice, to a focus on life experiences and adaptation, helping individuals, clinicians, and families consider processes of positive change, rather than focusing solely on adversity.

     

“The complaining women”: health professionals’ perceptions on patients with fibromyalgia in Spain

Purpose: The aim of this study is twofold: (1) to explore health service providers’ perceptions regarding fibromyalgia patients in Spain and (2) to analyze possible consequences of these perceptions in terms of how health service providers construct the disease and treat their patients.

Design: Qualitative study.

Subjects/Patients: Twelve health service providers (eight men, four women) involved in the care of fibromyalgia patients. Providers were from different disciplines and included general practitioners, rheumatologists, occupational doctors, psychologists, psychiatrists, physiotherapists and behavioral specialists from Spain.

Method: We performed individual semistructured interviews, which were recorded and transcribed to conduct a qualitative content analysis supported by Atlas.ti-7.

Results: We identified three categories from the interviews: (1) the fibromyalgia patient prototype: the complaining woman, (2) fibromyalgia is considered a women’s health issue, but male patients are a privileged minority, and (3) health professionals’ attitudes toward fibromyalgia patients: are they really suffering or pretending?

Conclusion: The uncertainty surrounding fibromyalgia together with the fact that those affected are primarily women, seem to influence professional practice in terms of lack of recognition of Fibromyalgia as a severe disease. Increased training of all health professionals is essential to improving the support and attention given to patients suffering from fibromyalgia.

• Implications for rehabilitation

• Fibromyalgia

• ??In order to improve fibromyalgia patients´ attention, health providers should learn how to assist patients without prejudices.

• ??Training programs for health providers should include sensitization about the severity of fibromyalgia.

• ??Health providers should be aware of the existence of stereotypes about women suffering from fibromyalgia.

• ??Fibromyalgia protocols should give skills to health providers to avoid offering a gender-biased attention to patients.