Community reintegration following acquired brain injury

Objective: To evaluate the interventions and strategies used to enable transition from acute care or post-acute rehabilitation to the community following brain injury.

Methods and main outcomes: A systematic review of the literature from 1980-2005 was conducted focusing on ABI rehabilitation. Five major aspects of community reintegration, including: independence and social integration, caregiver burden, satisfaction with quality of life, productivity and return to driving were considered.

Results: With the exception of one, the majority of interventions are supported by only limited evidence, denoting an absence of randomized controlled trials (RCTs) in the literature. Of 38 studies evaluated for this review, only one RCT was found. That RCT provided moderate evidence that behavioural management, coupled with caregiver education, did not help to improve caregiver burden. Conclusions: Further research, using an interventional approach, is required to advance the evidence base of reintegration into the community following brain injury.     

Management of heterotopic ossification and venous thromboembolism following acquired brain injury

Objective: To evaluate the effectiveness of interventional strategies for the common complications of heterotopic ossification (HO) and venous thromboembolism (VTE) following acquired brain injury (ABI).

Methods and main outcomes: A systematic review of the literature from 1980-2005 was conducted focusing on interventions for HO and VTE in the ABI population. Nineteen studies examining a variety of treatment approaches were evaluated.

Results: The majority of interventions are supported by limited evidence, defined as an absence of randomized controlled trials (RCTs). All of the treatment approaches for HO are supported with limited evidence. For VTE, there is moderate evidence, defined as at least one positive RCT, indicating that low-molecular-weight heparin is more effective than low-dose unfractionated heparin in preventing VTE, low-molecular-weight heparin is as effective and safe as unfractionated heparin for the prevention of pulmonary thromboembolism, low-molecular-weight heparin combined with compression stockings is more effective than compression stockings alone for the prevention of VTE and intermittent pneumatic compression devices are as effective as low-molecular-weight heparin for the prevention of VTE.

Conclusions: There are a variety of intervention and prophylactic strategies that have been postulated to treat and reduce the incidence of these complications, with the goal of improving rehabilitation outcomes. It is therefore important to investigate the efficacy of these treatment strategies to provide guidance for clinical practice based on the best available evidence.     

Post-traumatic seizure disorder following acquired brain injury

Objective: The present study aimed to evaluate the effectiveness of prophylactic anticonvulsant pharmacological strategies for the prevention of seizure disorders following acquired brain injury (ABI) to provide guidance for clinical practice based on the best available evidence.

Methods and main outcomes: A systematic review of the literature from 1980-2005 was conducted focusing on treatment interventions available for post-traumatic seizures following ABI. The evidence for the efficacy of a given intervention was ranked as strong (supported by at least two randomized controlled trials (RCTs), moderate (supported by a single RCT), or limited (supported by other types of studies in the absence of RCTs).

Results: Based on a previous meta-analysis and the findings of this review, there is strong evidence that prophylactic anticonvulsant therapy decreases the occurrence of early seizures but only within the first week post-injury. Moreover, the evidence indicates that prophylactic anticonvulsant therapy does not decrease the incidence of seizure onset more than one week post-injury. In children, there is moderate evidence that prophylactic phenytoin does not reduce the incidence of early or late seizures. The efficacy of anticonvulsants after the development of seizures has not been specifically studied in ABI.

Conclusions: Prophylactic anti-convulsants are effective in reducing seizures in the first week post-injury in adults. However, they do not reduce the occurrence of seizures after the first week.     

Behavioural interventions for children and adults with behaviour disorders after TBI: a systematic review of the evidence

Objective: To systematically review the evidence for the effectiveness of behavioural interventions for children and adults with behaviour disorders after TBI.

Design: Using a variety of search procedures, 65 studies were identified. This literature was reviewed using a set of questions about participants, interventions, outcomes and research methods.

Participants: The 65 studies included 172 experimental participants, including children and adults.

Interventions: A number of specific intervention procedures were used, falling into three general categories: traditional contingency management, positive behaviour interventions and supports and combined.

Results: All of the studies reported improvements in behavioural functioning.

Conclusions: Behavioural intervention, not otherwise specified, can be considered a treatment guideline for children and adults with behaviour disorders after TBI. Both traditional contingency management procedures and positive behaviour support procedures can be said to be evidence-based treatment options. However, a variety of methodological concerns block stronger conclusions.     

'Participate to learn': a promising practice for community ABI rehabilitation

Objective: To identify best practices and promising practices to enhance participation in meaningful and productive activities.

Method: An electronic search of the ABI rehabilitation research literature since 1990 yielded 974 articles of which 30 focused on interventions that targeted participation and evaluated effectiveness using direct measures of participation. Three reviewers rated these articles according to the standards set out by the Centre for Reviews and Dissemination. Following the systematic review, an interpretive review of the same articles was completed.

Results: Only three studies were rated as strong. No best practices were identified. Three promising practices found some support. The interpretive review suggested 'Participate to learn' as a useful rehabilitation model. The model rests on roles as goals, learning by experience in real-life contexts and the use of personal and environmental support to enable participation.

Conclusions: 'Participate to learn' is both a credible rehabilitation model and deserving of more study.     

The efficacy of acquired brain injury rehabilitation

OBJECTIVE: The purpose of this review was to investigate the efficacy of rehabilitation interventions in acquired brain injury (ABI) rehabilitation to provide guidance for clinical practice based on the best available evidence. METHODS AND MAIN OUTCOMES: A systematic review of the literature from 1980-2005 was conducted focusing on rehabilitation interventions for ABI. The efficacy of a given intervention was classified as strong (supported by at least two randomized controlled trials (RCTs)), moderate (supported by a single RCT), or limited (supported by other types of studies in the absence of RCTs). RESULTS: The majority of interventions were only supported by limited evidence. However, there is moderate evidence that inpatient rehabilitation results in successful return to work and return to duty for the majority of military service members, increasing the intensity of rehabilitation reduces length of stay and improves short-term functional outcomes, and that direct patient involvement in neurorehabilitation goal setting results in significant improvements in reaching and maintaining those goals. CONCLUSIONS: There is a need for studies of improved methodological quality into ABI rehabilitation.     

A systematic review of treatments for mild traumatic brain injury

Objectives: To assess the effectiveness of interventions for mild traumatic brain injury (MTBI) in adults as found in the literature.

Research design: Systematic review of the literature.

Methods: Six electronic databases and 18 journals within the brain injury field were manually searched between the years 1980-2003. References from articles were scanned for further literature. Studies that met broad inclusion criteria were subjected to a formal test of relevance. Those found to be relevant were qualitatively tested for their methodological soundness.

Results: One thousand and fifty-five studies were initially identified and 163 were assessed using the relevance tool, yielding 20 studies for review. Four categories of interventions were identified: Pharmacotherapy, Cognitive Rehabilitation, Patient Education and Other. The majority of studies were weak, however there is evidence to support the effectiveness of patient education interventions.

Conclusions: There are few rigorous studies evaluating treatment of MTBI. Limitations of the current literature are presented.     

Rehabilitation outcomes of cardiac and non-cardiac anoxic brain injury: a single institution experience

Objective: To compare the functional outcomes of patients with anoxic brain injury (ABI) due to cardiac and non-cardiac aetiologies.

Design: Retrospective chart review over 4 years.

Setting: Freestanding rehabilitation hospital.

Participants: Thirteen patients with cardiac ABI and 13 patients with non-cardiac ABI.

Intervention: Comprehensive, multi-disciplinary inpatient rehabilitation services.

Main outcome measures: Rehabilitation hospital length of stay (LOS) and cost; Functional Independence Measure (FIM) scores and its various sub-sets on admission and discharge; FIM efficiency and change; and discharge disposition.

Results: Patients with cardiac ABI were similar in gender and ethnicity when compared to patients with non-cardiac ABI but were older (average age 52 vs 42) with a higher percentage of cardiac patients married (77% vs 39%). No statistically significant differences were found between the two groups on all sub-sets of the FIM on admission and discharge as well as the different FIM efficiencies. However, there was a trend for the cardiac ABI patients to have a greater efficiency in improving mobility during rehabilitation when compared to non-cardiac ABI patients. The rehabilitation hospital LOS was ∼28 days less for patients with cardiac ABI (41.49 vs 69.84 days), but this difference was not statistically significant (p = 0.26). The mean rehabilitation cost for patients with cardiac ABI was ∼ $14 000 less than that for those with non-cardiac ABI ($44 181 vs $58 187). This difference was not statistically significant (p = 0.15). Cardiac ABI patients were more likely to be discharged directly to home from rehabilitation when compared to non-cardiac ABI patients (p = 0.06).

Conclusion: This pilot study demonstrates some differences in the recovery patterns of patients with ABI who had a cardiac aetiology and those who had non-cardiac aetiologies. While both groups experienced similar progress during rehabilitation, those with cardiac ABI made gains with a shorter LOS and less rehabilitation costs when compared to non-cardiac ABI patients. These data suggest a trend towards greater cost and length of stay for patients with ABI who had non-cardiac aetiologies.     

Functional outcomes following anoxic brain injury: a comparison with traumatic brain injury

Primary objective: To compare the functional outcomes of patients with anoxic brain injury (ABI) and patients with traumatic brain injury (TBI) following inpatient rehabilitation.

Research design: Retrospective chart review.

Methods and procedures: Data on 68 patients with brain injury (34 with ABI and 34 with TBI) were collected.

Main outcomes and results: The ABI and TBI groups were demographically similar, except that patients with ABI were more likely to be married. Both groups significantly improved their function and were similar upon discharge. For the ABI group, there were trends toward a shorter length of stay, increased total FIM efficiency and decreased cost of stay when compared with the TBI group. The patients with ABI tended to be discharged to a sub-acute rehabilitation facility more than those in the TBI group.

Conclusions: This study is important because it shows that patients with ABI benefit from inpatient rehabilitation and made significant functional gains comparable to the gains of patients with TBI.     

Comparability of Mayo-Portland Adaptability Inventory ratings by staff, significant others and people with acquired brain injury

Objectives: To determine the internal consistency, reliability and comparability of the Mayo-Portland Adaptability Inventory (MPAI-4) and sub-scales completed by people with acquired brain injury (ABI), family and significant others (SO) and rehabilitation staff.

Subjects: 134 people with ABI consecutively seen for outpatient rehabilitation evaluation.

Method: MPAI-4 protocols based on independent ratings by the people with ABI undergoing evaluation, SO and rehabilitation staff were submitted to Rasch Facets analysis to determine the internal consistency of the overall measure and sub-scales (Ability, Adjustment and Participation indices) for each rater group and for a composite measure based on all rater groups. Rater agreement for individual items was also examined.

Results: Rasch indicators of internal consistency were entirely within acceptable limits for 3-rater composite full scale and sub-scale measures; these indicators were generally within acceptable limits for measures based on a single rater group. Item agreement was generally acceptable; disagreements suggested various sources of bias for specific rater groups.

Conclusions: The MPAI-4 possesses satisfactory internal consistency regardless of rating source. A composite measure based on ratings made independently by people with ABI, SO and staff may serve as a 'gold standard' for research purposes. In the clinical setting, assessment of varying perspectives and biases may not only best represent outcome as evaluated by all parties involved but be essential to developing effective rehabilitation plans.     

Cognitive interventions post acquired brain injury

Objective: Cognitive rehabilitation represents a substantial portion of rehabilitative efforts put forth in increasing independence following an acquired brain injury. Main outcomes and results: This review examined four major areas of cognitive therapy including: attention/concentration, learning and memory, executive functioning, and general cognitive rehabilitation approaches. In total, 64 studies were evaluated throughout the four major areas, which provided the evidence-base for 18 conclusions. The majority of the conclusions were based on moderate and limited evidence, however three strong and one conflicting conclusions were made.

Conclusions: Future research should explore functional outcome measures and long-term effects of treatment interventions through follow-up.     

Predictors of family system functioning after brain injury

Objectives: To identify predictors of family system functioning after acquired brain injury (ABI).

Research design: Retrospective design.

Methods and procedures: Data on ABI-related impairments, level of awareness, neuropsychological functioning, caregiver strain and family system functioning were extracted from the files of 66 individuals with ABI and 148 family members who had enrolled in a community-based support programme.

Main outcomes and results: Individuals with ABI, mothers, spouses, siblings and the family as a unit reported significant distress in family functioning compared to the norm. Higher caregiver strain and client gender (i.e. female) were predictive of poorer family system functioning. Neither ABI impairments nor neuropsychological variables were correlated with family functioning.

Conclusions: The effects of ABI extend beyond the injured person and primary caregiver. The need for a family systems approach to family intervention after ABI is supported. Implications for practice and future research are discussed.     

Incidence of concussion in contact sports: a systematic review of the evidence

Primary objective: To estimate incidence of concussion in contact sports.

Research design: Systematic review of the literature on concussion in contact sports.

Methods and procedures: MEDLINE was searched from 1985-2000. Older articles cited in retrieved articles were also reviewed. Articles meeting the inclusion/exclusion criteria were critically appraised for methodologic quality. The incidence of concussion was recalculated in some cases.

Results: Twenty-three out of 63 identified articles were accepted to estimate the risk of concussion. Overall, ice hockey and rugby have the highest incidence of concussion and soccer has the lowest. Male boxers and female taekwondo participants have the highest frequency of concussion at the recreational level.

Conclusions: There are few good studies on the incidence of concussion and limited information on the risk of concussion for females in contact sports. Some common methodological problems were also identified in this literature with the hope of improving future studies.     

A qualitative study of the transition from hospital to home for individuals with acquired brain injury and their family caregivers

Primary Objective: To explore the transition experiences from hospital to home of a purposive sample of individuals with acquired brain injury (ABI).

Research Design: Phenomenological, qualitative design.

Methods and Procedures: Semi-structured interviews were conducted with 13 individuals with ABI (mean time since discharge = 15.2 months) and 11 family caregivers. Each interview was recorded, transcribed verbatim and then inductively analyzed.

Results: Through the inductive analysis process, a summary coding framework was developed that included that following eight main categories: the hospital experience; the transition process; the role of family caregivers; post-discharge services; friendship networks and community involvement; meaningful activities and time management; physical and psychological wellbeing; and barriers and facilitators.

Conclusions: The results of the study provide valuable insights into the lived experiences of participants and provide evidence to support the existence of a distinct transition phase within the ABI rehabilitation continuum; additional to and closely associated with the acute, post-acute and community integration phases.     

Self-concept and quality of life following acquired brain injury: a pilot investigation

Objective: To investigate through pilot exploration the relationships between depression, self-concept and perceived quality of life (QoL) in post-acute patients with acquired brain injury (ABI).

Methods: Nineteen patients with ABI were administered the Beck Depression Inventory-II and the Quality of Life Inventory, along with the Tennessee Self-Concept Scale-2 and the Head Injury Semantic Differential Scale, measures of self-concept. The relationships between these measures were explored using correlational analyses.

Results: Ratings of self-concept were correlated with perceived QoL, suggesting that poorer view of self was associated with lower subjective QoL. Additionally, depressive symptoms were associated with lower QoL ratings, consistent with previous research.

Conclusions: These results suggest that intra-personal variables, such as self-concept and depression, impact the perceived QoL of the ABI survivor. Future research exploring the mediating effects of these variables on QoL may clarify this relationship and may aid in developing more effective interventions for these individuals.     

Achieving a successful and sustainable return to the workforce after ABI: a client-centred approach

Primary objective: This paper describes the approach used by the Victorian Acquired Brain Injury (ABI) specialist team of CRS Australia (formerly Commonwealth Rehabilitation Service) to facilitate participation in the workforce for its clients. The approach and results achieved are compared and contrasted with other models nationally and internationally.

Method and procedures: This two part study involves a survey of the specialist team members regarding use and efficacy of assessment and intervention strategies and data mining of closed case files to identify predictors of sustainable employment outcomes for people with ABI.

Main outcomes and results: CRS Australia's results compare favourably with other published results (50% achieved a minimum of 13 weeks open employment compared to population estimates of 38-46.5%). Results were achieved with people with mild, moderate and severe injury. Assessments and interventions that correlate with successful employment outcome are described.

Conclusions: A client-centred approach, combining specialist ABI expertise, skilled assessment and practical workplace-based interventions results in favourable employment outcome rates.     

Assessment of family needs following acquired brain injury in Saskatchewan

Primary objective: The objective was to learn what the family members of individuals with acquired brain injury (ABI) perceived as important needs and to what extent these needs are being met.

Methods and procedures: Sixty-six individuals who care for someone with an ABI and who receive service from the Saskatchewan South ABI Outreach Team completed the Family Needs Questionnaire (FNQ).

Main outcomes: An analysis of the importance ratings found that the most important needs were related to health information. Most needs perceived as unmet were related to emotional support.

Conclusions: Caregivers indicated that having honest, accurate comprehensive information regarding the ABI survivor is important. Respondents also indicated that approximately one-half of the needs have gone unmet or only partly met. This study highlights the importance for service providers to assess family needs in order to minimize distress in caregivers, maintenance of the well being of whom is integral in the support of the person with ABI.     

Rehabilitation implications of non-traumatic subarachnoid haemorrhage

Objective: Subarachnoid haemorrhage (SAH) remains an important cause of stroke in the rehabilitation population, whose incidence has not been changed by pre-morbid medical treatment. The understanding of the pathophysiological changes that occur after SAH has been more clearly defined, therefore the treatment and outcomes of these patients have undergone drastic changes over the past few years. The purpose of this review is to update and familiarize the rehabilitation professional on the state of the art treatment and common complications associated with this disease and how this may affect the rehabilitation programme. Also, the current literature on the outcomes of these patients will be reviewed to help advise the rehabilitation professional on potential predictors.

Data sources: Literature review.

Study selection: Articles of relevance to the current management of SAH.

Data extraction: Information that was deemed significant in the understanding of the pathophysiology, treatment and results of outcomes in patients with SAH.

Data synthesis: Subarachnoid haemorrhage (SAH) is the one sub-type of stroke whose incidence has not declined. Due to advances in medical care, mortality rate is on the decline. Outcomes data was analysed to look for common predictors for this patient population.

Conclusions: While the incidence of SAH has not declined, improving medical treatment has reduced mortality. The rehabilitation professional should be familiar with the latest advances, potential complications and likely outcomes in order to plan the most appropriate therapy course for these patients.