Reduced community integration in persons following traumatic brain injury,as measured on the community integration measure: An exploratory analysis

Purpose.?To explore the community integration of individuals who had suffered a Traumatic Brain Injury (TBI) and compare this to members of the general public.

Method.?An independent groups design explored differences in three groups' levels of community integration. These groups consisted of ten survivors of TBI, ten male and ten female controls and were measured using The Community Integration Measure (CIM). All participants were resident in Northern Ireland (NI). The brain injured participants were drawn from a Belfast-based social skills programme.

Results.?Mann-Whitney U tests showed a statistically significant difference between female controls and brain-injured individuals (U = 26.50, N₁ = 10, N₂ = 10, p = 0.037, one-tailed).

Conclusion.?Females were more integrated into their communities than males, who were, in turn, more integrated than brain injured individuals. It would appear that brain injury survivors are doubly disadvantaged. Their gender (mainly male), and the injury itself, conspire to reduce their integration within the wider community.     

Developing a comprehensive framework of community integration for people with acquired brain injury: a conceptual analysis

Purpose: Despite increasing emphasis on the importance of community integration as an outcome for acquired brain injury (ABI), there is still no consensus on the definition of community integration. The aim of this study was to complete a concept analysis of community integration in people with ABI.

Materials and methods: The method of concept clarification was used to guide concept analysis of community integration based on a literature review. Articles were included if they explored community integration in people with ABI. Data extraction was performed by the initial coding of (1) the definition of community integration used in the articles, (2) attributes of community integration recognized in the articles’ findings, and (3) the process of community integration. This information was synthesized to develop a model of community integration.

Results: Thirty-three articles were identified that met the inclusion criteria. The construct of community integration was found to be a non-linear process reflecting recovery over time, sequential goals, and transitions. Community integration was found to encompass six components including: independence, sense of belonging, adjustment, having a place to live, involved in a meaningful occupational activity, and being socially connected into the community. Antecedents to community integration included individual, injury-related, environmental, and societal factors.

Conclusion: The findings of this concept analysis suggest that the concept of community integration is more diverse than previously recognized. New measures and rehabilitation plans capturing all attributes of community integration are needed in clinical practice.

• Implications for rehabilitation

• Understanding of perceptions and lived experiences of people with acquired brain injury through this analysis provides basis to ensure rehabilitation meets patients’ needs.

• This model highlights the need for clinicians to be aware and assess the role of antecedents as well as the attributes of community integration itself to ensure all aspects are addressed in in a manner that will enhance the recovery and improve the level of integration into the community.

• The finding that community integration is a non-linear process also highlights the need for rehabilitation professionals to review and revise plans over time in response to a person’s changing circumstances and recovery journey.

• This analysis provides the groundwork for an operational model of community integration for the development of a measure of community integration that assesses all six attributes revealed in this review not recognized in previous frameworks.

     

Home or away? Community rehabilitation following traumatic brain injury: a case report

Background and Purpose . A case report of AJ, a 25 year old man who had a severe traumatic brain injury and required ongoing rehabilitation. This study illustrates that community based rehabilitation can be the medium of choice to meet a client's rehabilitation needs. Method . 3 separated episodes of rehabilitation were given over a two year period. Meaningful goals were negotiated with client and main carer throughout; the supportive and effective care system provided by his family allowed abilities to be maintained and progress between sessions and episodes of care. Results . Goals were achieved in each rehabilitation episode, maintained and progressed in each treatment break, with incremental reduction in levels of dependency for AJ, and improvement in quality of life for him and his family. Conclusion . With a specialist professional team and good support network, the community is the environment of choice for rehabilitation of severely brain injured clients. Copyright © 2008 John Wiley & Sons, Ltd.     

Path tree analysis as a tool for describing motor recovery following acquired brain injury: an exploratory study

Purpose. Knowledge of the likely sequence of motor recovery following brain injury has obvious usefulness within rehabilitation. Research has tended to focus on establishing the linearity of the recovery sequence. This study aimed to ascertain the usefulness of path tree analysis as a graphical means of exploring inter-subject variation in routes followed during motor recovery.

Method. Data were collected via physiotherapist questionnaire, ascertaining recovery sequence of 14 motor milestones across 80 adults with severe traumatic brain injury (TBI). An adapted version of the Rivermead Mobility Index (RMI) was used. Data were analysed to establish inter-subject agreement regarding recovery sequence. A path tree diagram was then composed to explore inter-subject variation.

Results. Putative order of recovery for the 14 motor milestones appeared to have face validity. Guttman coefficients of reproducibility ((0.954) and scalability (0.948) were good, suggesting intrinsic order. Composition of a path tree suggested considerable variation in recovery paths between individuals, with 34 combinations of test items being evident.

Conclusions. Motor recovery following severe TBI follows a distinct pattern, but path tree analysis emphasises the variety of routes which individuals can follow. Additional research should ascertain the scope of this method to document the natural history of the recovery process.     

Utility of the Croatian translation of the community integration questionnaire-revised in a sample of adults with moderate to severe traumatic brain injury

Purpose: To examine the utility of the Community Integration Questionnaire-Revised, translated into Croatian, in a sample of adults with moderate to severe traumatic brain injury.

Method: The Community Integration Questionnaire-Revised was administered to a sample of 88 adults with traumatic brain injury and to a control sample matched by gender, age and education. Participants with traumatic brain injury were divided into four subgroups according to injury severity.

Results: The internal consistency of the Community Integration Questionnaire-Revised was satisfactory. The differences between the group with traumatic brain injury and the control group were statistically significant for the overall Community Integration Questionnaire-Revised score, as well as for all the subscales apart from the Home Integration subscale. The community Integration Questionnaire-Revised score varied significantly for subgroups with different severity of traumatic brain injury.

Conclusions: The results show that the Croatian translation of the Community Integration Questionnaire-Revised is useful in assessing participation in adults with traumatic brain injury and confirm previous findings that severity of injury predicts community integration. Results of the new Electronic Social Networking scale indicate that persons who are more active on electronic social networks report better results for other domains of community integration, especially social activities.

• Implications for rehabilitation

• The Croatian translation of the Community Integration Questionnaire-Revised is a valid tool for long-term assessment of participation in various domains in persons with moderate to severe traumatic brain injury

• Persons with traumatic brain injury who are more active in the use of electronic social networking are also more integrated into social and productivity domains.

• Targeted training in the use of new technologies could enhance participation after traumatic brain injury.

     

Experiences of patients with traumatic brain injury and their carers during transition from in-patient rehabilitation to the community: a qualitative study

Purpose: To explore the experiences of individuals who have had a severe traumatic brain injury (TBI) and their carers in the first month post-discharge from in-patient rehabilitation into living in the community.

Method: Using a qualitative approach underpinned by critical realism, we explored the narratives of 10 patients and nine carers using semi-structured interviews approximately one month post-discharge. Thematic analysis was carried out independently by two researchers.

Results: Firstly, perceptions of support were mixed but many patients and carers felt unsupported in the inpatient phase, during transitions between units and when preparing for discharge. Secondly, they struggled to accept a new reality of changed abilities, loss of roles and loss of autonomy. Thirdly, early experiences post-discharge exacerbated fears for the future.

Conclusions: Most patients and carers struggled to identify a cohesive plan that supported their transition to living in the community. Access to services required much persistence on the part of carers and tended to be short-term, and therefore did not meet their long-term needs. We propose the need for a case manager to be involved at an early stage of their rehabilitation and act as a key point for information and access to on-going rehabilitation and other support services.

• Implications for Rehabilitation

• Traumatic Brain Injury (TBI) is a major cause of long-term disability. It can affect all areas of daily life and significantly reduce quality of life for both patient and carer.

• Professionals appear to underestimate the change in abilities and impact on daily life once patients return home. Community services maintain a short-term focus, whereas patients and carers want to look further ahead – this dissonance adds to anxiety.

• The study’s findings on service fragmentation indicate an urgent need for better integration within health services and across health, social care and voluntary sectors.

• A link person/case manager who oversees the patient journey from admission onwards would help improve integrated care and ensure the patient, and carer, are at the center of service provision.

     

Contemporary view on neuromonitoring following severe traumatic brain injury

Evolving brain damage following traumatic brain injury (TBI) is strongly influenced by complex pathophysiologic cascades including local as well as systemic influences. To successfully prevent secondary progression of the primary damage we must actively search and identify secondary insults e.g. hypoxia, hypotension, uncontrolled hyperventilation, anemia, and hypoglycemia, which are known to aggravate existing brain damage. For this, we must rely on specific cerebral monitoring. Only then can we unmask changes which otherwise would remain hidden, and prevent adequate intensive care treatment. Apart from intracranial pressure (ICP) and calculated cerebral perfusion pressure (CPP), extended neuromonitoring (SjvO₂, ptiO₂, microdialysis, transcranial Doppler sonography, electrocorticography) also allows us to define individual pathologic ICP and CPP levels. This, in turn, will support our therapeutic decision-making and also allow a more individualized and flexible treatment concept for each patient. For this, however, we need to learn to integrate several dimensions with their own possible treatment options into a complete picture. The present review summarizes the current understanding of extended neuromonitoring to guide therapeutic interventions with the aim of improving intensive care treatment following severe TBI, which is the basis for ameliorated outcome.     

Return to work following traumatic brain injury: trends and challenges

Purpose. The aim of this paper is to present the current knowledge regarding return to work (RTW) following traumatic brain injury (TBI).

Method. Based on a Medline search, the authors reviewed the current TBI rehabilitation literature regarding (a) predictive factors for successful RTW, and (b) current concepts in rehabilitative strategies for successful RTW.

Results. The functional consequences to the victim of traumatic brain injury (TBI) can be severe. Intensive rehabilitative efforts typically emphasize the early phase and address mainly the accompanying functional deficits in the realm of basic activities of daily living and mobility. An otherwise successful medical rehabilitation may end unsuccessfully because of the failure to return to work, with profound consequences to the individual and family, both economic and psychosocial. Even mild TBI may cause lasting problems in tasks calling for sustained attention. There appears to be a complex interaction between pre-morbid characteristics, injury factors, post injury impairments, personal and environmental factors in TBI patients, which influences RTW outcomes in ways that make prediction difficult. Injury severity and lack of self-awareness appear to be the most significant indicators of failure to RTW. Several medical, psychosocial and rehabilitative therapies are currently being implemented in rehabilitation settings which improve the chances of returning to work.

Conclusion. Accurate prediction of whether a particular TBI patient will successfully return to work is not feasible, with RTW rates in the 12 - 70% range. A significant proportion of TBI patients, including those who are severely injured, are able to return to productive employment if sufficient and appropriate effort is invested. A comprehensive approach - medical and psychosocial - eventually entailing adequate vocational rehabilitation with supported employment can improve outcomes.     

Return to work following traumatic brain injury: Trends and challenges

Purpose. The aim of this paper is to present the current knowledge regarding return to work (RTW) following traumatic brain injury (TBI).

Method. Based on a Medline search, the authors reviewed the current TBI rehabilitation literature regarding (a) predictive factors for successful RTW, and (b) current concepts in rehabilitative strategies for successful RTW.

Results. The functional consequences to the victim of traumatic brain injury (TBI) can be severe. Intensive rehabilitative efforts typically emphasize the early phase and address mainly the accompanying functional deficits in the realm of basic activities of daily living and mobility. An otherwise successful medical rehabilitation may end unsuccessfully because of the failure to return to work, with profound consequences to the individual and family, both economic and psychosocial. Even mild TBI may cause lasting problems in tasks calling for sustained attention. There appears to be a complex interaction between pre-morbid characteristics, injury factors, post injury impairments, personal and environmental factors in TBI patients, which influences RTW outcomes in ways that make prediction difficult. Injury severity and lack of self-awareness appear to be the most significant indicators of failure to RTW. Several medical, psychosocial and rehabilitative therapies are currently being implemented in rehabilitation settings which improve the chances of returning to work.

Conclusion. Accurate prediction of whether a particular TBI patient will successfully return to work is not feasible, with RTW rates in the 12 – 70% range. A significant proportion of TBI patients, including those who are severely injured, are able to return to productive employment if sufficient and appropriate effort is invested. A comprehensive approach – medical and psychosocial – eventually entailing adequate vocational rehabilitation with supported employment can improve outcomes.     

Path tree analysis as a tool for describing motor recovery following acquired brain injury: An exploratory study

Purpose. Knowledge of the likely sequence of motor recovery following brain injury has obvious usefulness within rehabilitation. Research has tended to focus on establishing the linearity of the recovery sequence. This study aimed to ascertain the usefulness of path tree analysis as a graphical means of exploring inter-subject variation in routes followed during motor recovery.

Method. Data were collected via physiotherapist questionnaire, ascertaining recovery sequence of 14 motor milestones across 80 adults with severe traumatic brain injury (TBI). An adapted version of the Rivermead Mobility Index (RMI) was used. Data were analysed to establish inter-subject agreement regarding recovery sequence. A path tree diagram was then composed to explore inter-subject variation.

Results. Putative order of recovery for the 14 motor milestones appeared to have face validity. Guttman coefficients of reproducibility ((0.954) and scalability (0.948) were good, suggesting intrinsic order. Composition of a path tree suggested considerable variation in recovery paths between individuals, with 34 combinations of test items being evident.

Conclusions. Motor recovery following severe TBI follows a distinct pattern, but path tree analysis emphasises the variety of routes which individuals can follow. Additional research should ascertain the scope of this method to document the natural history of the recovery process.     

Community integration and life satisfaction among individuals with spinal cord injury living in the community after receiving institutional care in Bangladesh

Purpose: This study reports level of community integration and life satisfaction among individuals who sustained traumatic spinal cord injuries, received institutional rehabilitation care services, and went back to live in the community in Bangladesh. It examines the impact of type of injury, demographic characteristics, socio-economic profile, and secondary health conditions on community integration and life satisfaction and explores the association between these two measures.

Method: Individuals with spinal cord injury were telephone interviewed by the Centre for the Rehabilitation of the Paralysed, Bangladesh from February to June of 2014. Data were collected from the subjects on type of injury, demographic and socio-economic profile, and secondary health conditions. The outcome measures were determined by using two validated tools – Community Integration Questionnaire and Life Satisfaction 9 Questionnaire.

Results: Total community integration and life satisfaction scores were 15.09 and 3.69, respectively. A significant positive relationship between community integration and life satisfaction was revealed. Type of injury, gender, and age were found to be significant predictors of both community integration and life satisfaction scores. Higher education was significantly related to community integration and life satisfaction scores.

Conclusion: Participants scored low in total community integration and life satisfaction, suggesting there is a great need to develop interventions by governmental and non-governmental organizations to better integrate individuals with spinal cord injury in the community.

• Implications for Rehabilitation

• Government and non-government organizations should offer disability friendly public transportation facilities for individuals with spinal cord injury so that they can return to education, resume employment, and involve in social activities.

• Entrepreneurs and businesses should develop assistive devices featuring low technology, considering the rural structure and housing conditions in Bangladesh. Innovations being made in assistive technology should be supported by subsidies and grants.

• They should also plan to offer injury appropriate employment opportunities for individuals who suffer major injuries like spinal cord injury in Bangladesh.

• Housing facilities with accessible bathrooms, kitchens and stairs should be designed and offered for this population to improve their ability to self-care and decrease the dependence on caregivers for household tasks such as – cooking meals and taking care of children.

     

脑疏宁对大鼠颅脑创伤后神经功能影响的实验研究

目的评价中药脑疏宁对创伤性脑损伤 (TBI)后神经功能的保护作用。方法按Feeney自由落体撞击法造成TBI模型 ,通过木条行走实验评价伤后大鼠的神经功能恢复情况 ,并在伤后不同时间点观察脑组织含水量及病理改变。结果伤后 1周内大鼠完成木条行走作业的能力明显受损。经脑疏宁治疗后 ,TBI大鼠神经功能明显改善 ,脑组织含水量及病理改变减轻。结论中药脑疏宁可以促进颅脑损伤后神经功能的恢复 ,可能与早期减轻脑水肿、保护脑组织有关。     

Return to productivity following traumatic brain injury: Cognitive,psychological, physical,spiritual, and environmental correlates

Purpose.The purpose of this study was to investigate the determinants and correlates of return to productivity (RTP) defined here as return to paid employment and/or school four years following traumatic brain injury (TBI).

Method.Participants included 46 people with TBI, part of a prospective, cohort study, and 14 friend/family member controls all employed and/or in school at time of injury or inception into the study. Variables were selected for investigation based on two models of recovery. Demographic and injury severity data including time to recover free recall were collected at time of injury, on admission to a trauma unit. Data on other variables (neuropsychological, psychological, physical, spiritual, environmental) were collected concurrent with productivity status at a mean of 4.3 years post-TBI.

Results.Time to recover free recall (measured acutely), neuropsychological status, pain severity, depression, and the use of maladaptive coping behaviours were all related to productivity status (p < 0.05). When these variables were entered into exploratory, planned hierarchical logistic regression models time to free recall, pain, and maladaptive coping remained in the models with depression only dropping out because of the high correlation with pain (r > 0.80).

Conclusions.Injury severity (time to free recall), physical status (pain), and psychological status (depression, coping) are important to understanding differences in productivity outcomes. Addressing pain, depression and coping in rehabilitation programs may have a positive impact on outcomes.     

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。     

Magnetic resonance imaging changes in the pituitary gland following acute traumatic brain injury

OBJECTIVE: The objective was to study the anatomical changes in the pituitary gland following acute moderate or severe traumatic brain injury (TBI). DESIGN: Retrospective, observational, case-control study. SETTING: Neurosciences Critical Care Unit of a university hospital. PATIENTS: Forty-one patients with moderate or severe TBI who underwent magnetic resonance imaging (MRI) during the acute phase (less than seven days) of TBI. MRI scans of 43 normal healthy volunteers were used as controls. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patient demographics, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Injury Severity Score (ISS), post-resuscitation Glasgow Coma Score (GCS), Glasgow Outcome Score (GOS), mean intracranial pressure (ICP), mean cerebral perfusion pressure (CPP), computed tomography (CT) data, pituitary gland volumes and structural lesions in the pituitary on MRI scans. The pituitary glands were significantly enlarged in the TBI group (the median and interquartile range were as follows: cases 672 mm3 (range 601-783 mm3) and controls 552 mm3 (range 445-620 mm3); p value<0.0001). APACHE II, GCS, GOS and ICP were not significantly correlated with the pituitary volume. Twelve of the 41 cases (30%) demonstrated focal changes in the pituitary gland (haemorrhage/haemorrhagic infarction (n=5), swollen gland with bulging superior margin (n=5), heterogeneous signal intensities in the anterior lobe (n=2) and partial transection of the infundibular stalk (n=1). CONCLUSIONS: Acute TBI is associated with pituitary gland enlargement with specific lesions, which are seen in approximately 30% of patients. MRI of the pituitary may provide useful information about the mechanisms involved in post-traumatic hypopituitarism.     

Isolated bilateral,large, basal ganglia haemorrhage following a traumatic brain injury: A case report

Traumatic basal ganglia haemorrhage is rarely seen in clinical practice. Bilateral basal ganglia hematoma without any other cerebral lesions due to trauma is extremely uncommon and has been reported only in a few cases. Although the mechanisms of this condition are unclear, haemorrhagic contusions are thought to arise as a consequence of a shearing strain on cranial blood vessels due to high-velocity forces at the time of the injury. Here we describe a 63-year-old female patient with an isolated bilateral, large, basal ganglia haemorrhage secondary to a road traffic accident. The patient was promptly diagnosed and conservatively treated and had fully recovered after two months.     

创伤性颅脑损伤后神经细胞凋亡的研究

目的：通过对创伤性颅脑损伤后神经细胞凋亡的研究，了解人脑创伤后脑组织中凋亡发生的情况及其所起的作用。方法：采用末端脱氧核苷酸转移酶介导的d-UTP生物素标记法(TUNEL法)检测细胞凋亡。同时显微镜观察病理切片。结果：66．7％出现TUNEL阳性，TUNEL阳性与阴性患者间的GCS评分(t=-2.88，P=O．01)、受伤时间(t=2．14，P=0．049)有显著差异。TUNEL阳性与阴性患者间性别、年龄、预后无显著差异。结论：人脑创伤后脑组织中存在凋亡，且与患者的病情严重程度及病程相关。其在颅脑创伤的病理过程中有一定作用，但只是颅脑损伤后复杂病理过程中的一种表现，即创伤后神经细胞死亡的一种方式。     

高压氧治疗对创伤性脑损伤大鼠认知功能的影响

目的:观察高压氧治疗对脑损伤大鼠认知功能的影响及海马区CCL2及其受体CCR2的表达变化。方法:75只成年雄性SD大鼠按数字表法随机分为假手术组(Sham组)、脑外伤组(TBI组)和高压氧治疗组(HBOT组),每组各25只。HBOT组和TBI组均采用Feeney自由落体法制作脑外伤模型,HBOT组每天进行HBO治疗;Sham组暴露硬脑膜不予打击。运用Morris水迷宫测试认知功能;荧光免疫双标检测海马CA1区CCL2和CCR2的表达。实时定量PCR测定损伤侧海马CCL2和CCR2mRNA的表达情况。结果:Morris水迷宫测试结果显示,HBOT组高压氧治疗后7d、14d和21d平均潜伏期下降,同时穿越平台次数增多,与TBI组相比,差异均有显著性意义(P0.05);免疫荧光双染法检测显示,大鼠TBI后海马CA1区CCL2主要表达在星形胶质细胞,CCR2主要表达在神经元;实时定量PCR显示,脑损伤后3—21d损伤侧海马CCL2 mRNA、CCR2 mRNA水平明显上升,差异有显著性意义;高压氧治疗后海马CCL2 mRNA明显下降,与TBI组相比,7d组、14d组及21d组差异有显著性意义(P0.05)。高压氧治疗7d、14d后海马CCR2 mRNA明显下降,与TBI组相比,7d组及14d组差异有显著性意义(P0.05)。结论:HBO治疗可以改善创伤性脑损伤大鼠认知功能,其机制可能与海马CCL2/CCR2表达下调有关。