Including children in family-focused acquired brain injury rehabilitation: a national survey of rehabilitation staff practice

OBJECTIVE: To establish whether rehabilitation staff work regularly with child relatives of adults with acquired brain injury to involve them in their family member's rehabilitation. To explore factors influencing rehabilitation staff's decisions about involving child relatives. DESIGN: A cross-sectional postal survey design was used for the main study. Questionnaire packs were sent to rehabilitation staff, followed by a reminder letter one week later. Non-responders received a follow-up pack after three weeks.A prospective design was used with a subsample of participants who re-completed the questionnaire one month later. SUBJECTS: Participants were 393 multidisciplinary staff working in rehabilitation services for adults with acquired brain injury throughout the UK. MAIN MEASURES: A questionnaire based on the theory of planned behaviour was designed specially for the purposes of the study. RESULTS: A response rate of 67% (n=263) was obtained. Few respondents (19%, n=50) reported carrying out work with child relatives. Perceived behavioural control (e.g. access to training, resources and support) significantly predicted staff's intention to work with child relatives, and whether they carried this out. Staff's attitudes towards work with child relatives also significantly predicted intentions. Other influential factors were anxiety, training, work setting and perceptions of colleagues' attitudes. CONCLUSIONS: Little work is carried out with child relatives by acquired brain injury rehabilitation staff, influenced by several factors. A priority in addressing this is to provide staff training.     

Linguistic difficulties in children and adolescents after acquired brain injury: A retrospective study

Objective: The purpose of this study was to focus on two linguistic abilities, word retrieval (expressive language) and comprehension of vocabulary and grammar (receptive language), as well as to investigate to what extent long-term problems exist in these areas in children following traumatic brain injury. Methods: Two groups of children were studied retrospectively: twenty-four children with traumatic brain injury (TBI) and twenty-one children diagnosed with brain tumour. All children had been referred to the rehabilitation team for assessment. The children were between four and seventeen years old when assessed, with the assessments performed at least one year after the injury or brain tumour diagnosis. An established set of tests regarding word retrieval and comprehension of vocabulary and grammar was used, and the results were compared with normative test data. Results: In both clinical groups, significantly more children scored lower than the designated "normal" score than in the normative sample on tests measuring confrontation naming and phonological word retrieval. In addition, in the brain tumour group, more children demonstrated significantly lower results than normal performance on a test for semantic word retrieval. In the TBI group, significantly more children scored below the normal value on tests of word and grammatical comprehension when compared to the normative sample.Conclusions: This study confirms that word retrieval is an area of deficit in many children with acquired brain injuries one year or more after the injury occurred. The study also indicates that children with TBI may have persistent deficits in comprehension of both vocabulary and grammar.     

Oculomotor rehabilitation in acquired brain injury: a case series

OBJECTIVE: To investigate the effects of systematic, oculomotor rehabilitation on basic versional ocular motility, as well as reading eye movements, in subjects with acquired brain injury, using objective eye movement recording and subjective rating of reading ability. DESIGN: Case series. SETTING: Clinical research laboratory. PARTICIPANTS: Two men with acquired brain injury: one with traumatic brain injury and one with stroke. INTERVENTIONS: Versional oculomotor training was performed for 1 hour, twice weekly for 8 weeks. There were 2 feedback modes of training: normal internal oculomotor visual feedback alone (4wk), or that feedback in conjunction with external oculomotor auditory feedback (4wk). Testing was conducted before and after training.Main outcome measures Objective outcome measures included both basic eye movement parameters (fixational accuracy, saccadic gain and latency, pursuit gain, mean saccade frequency ratio for simulated reading), and reading eye movement parameters (words per minute, grade level equivalent, fixations per 100 words, regressions per 100 words, percentage of reading comprehension, duration of fixation in seconds). Subjective outcome measures included the subject's ability to read based on the responses to the reading rating-scale questionnaire. RESULTS: Both subjects improved objectively in terms of basic versional oculomotor accuracy and reading ability. These findings concurred with their subjective impressions. CONCLUSIONS: This case series provides objective documentation of the positive effects of oculomotor rehabilitation on basic ocular motility and reading ability in selected cases with acquired brain injury, thus suggesting the need for a larger clinical trial in this area.     

Effective rehabilitation for children and adolescents with brain injury: evaluating and disseminating the evidence

OBJECTIVE: To develop and evaluate literature reviews of the effectiveness of rehabilitation interventions for children with brain injury. DESIGN: We wrote 6 research summaries, which were evaluated by study participants. SETTING: Community. PARTICIPANTS: A convenience sample that included 18 parents of children with brain injury, 18 service providers, and 12 insurance industry representatives. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Questionnaire designed for the evaluation of printed material. RESULTS: Few articles were found that focused on evaluation of rehabilitation interventions for children with brain injury. Study participants were representative of a broad range of educational and professional backgrounds. Before reading the research summaries, service providers reported greater familiarity with the topics than did parents and insurance representatives. Despite this finding, there were no significant between-group differences in the format, content, and impact ratings provided by the 3 participant groups. CONCLUSIONS: Research summaries written in a clear, straightforward manner are appropriate for people with different educational and professional backgrounds. Further research into the effectiveness of rehabilitation interventions is needed to support informed decision-making that results in the best outcomes for children with brain injury.     

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.     

Recovery of ambulation during inpatient rehabilitation: physical therapist prognosis for children and adolescents with traumatic brain injury

BACKGROUND AND PURPOSE: Evidence to guide physical therapist prognosis for recovery of the ability to ambulate in children and adolescents with traumatic brain injury (TBI) is limited. The aim of this study was to delineate a predictive model and determine the value of key demographic and clinical variables in establishing a prognosis for ambulation without the assistance of a device or person over 15.24 m on a flat, level surface following inpatient rehabilitation. SUBJECTS AND METHODS: For this retrospective study, a consecutive series of 95 children and adolescents with TBI (aged 2-18 years) admitted to an inpatient rehabilitation program was assessed using information from medical records. A multiple logistic regression analysis was conducted to identify predictors for ambulation at the time of discharge from the rehabilitation setting. RESULTS: Fifty-six percent of the children achieved ambulation at discharge. Lower-extremity hypertonicity (measured on physical therapist examination as resistance to passive stretch), brain injury severity, and lower-extremity injury together were predictors of the ability to ambulate. DISCUSSION AND CONCLUSION: Impairment and injury-related variables were important in predicting a minimal level of unassisted ambulation after discharge from inpatient rehabilitation. Awareness of predictors of recovery of the ability to ambulate that are gathered as part of a physical therapist's examination may assist in developing a prognosis for ambulation and in establishment of an appropriate plan of care.     

Fitting back in: adolescents returning to school after severe acquired brain injury

Purpose. To explore the experiences of Australian adolescents with severe acquired brain injury (ABI) and their families as the adolescent returned to school. In particular, to understand the influence of services and support on the school return.

Method. In-depth interviews conducted over a two-year period with families who had an adolescent with a recent severe ABI (mean age 15 years, 11 months) analysed using a grounded theory approach.

Results. Two critical phases for adolescents returning to school post ABI were identified: organizing the school return and being back at school.Experience in these phases was influenced by length of school absence, extent of noticeable and hidden problems and school response to the students' return post injury. The central concept characterizing experience was the challenge of fitting back in. Some adolescents fitted back in adequately and continued school participation. Those that did not fit in tried again by revisiting the organizing phase, re-evaluated their school experience and either continued or left school.

Conclusions. Adolescents with ABI faced the challenge of fitting back in when they returned to school. This was either facilitated or hindered by the extent and quality of organization, communication and support from parents, schoolteachers and the rehabilitation team.     

Beyond restoration to transformation: positive outcomes in the rehabilitation of acquired brain injury

OBJECTIVES: This paper compares the situation of the person with acquired brain injury to that of the people of Israel in the sixth century BCE (before the current era) during the period of exile in Babylon. Both situations are characterized by traumatic multiple losses, and a struggle to regain a sense of identity: personal, national or spiritual. Evidence from the literature on both brain injury rehabilitation and from the Hebrew Scriptures indicates that models of restoration of function and transformation of suffering have been applied to both situations. The relative strengths and weaknesses of these models are considered, and it is argued that models of transformation of suffering have much to offer, especially in the longer term psychotherapeutic rehabilitation of people with acquired brain injury, when restoration of function has reached its limits.     

A scoping review of the working alliance in acquired brain injury rehabilitation

Purpose: The aim was to review the empirical literature to determine the nature and breadth of research into the working alliance in acquired brain injury (ABI) rehabilitation.

Methods: A scoping review was conducted, beginning with a systematic search of relevant databases using key search terms. Studies with a focus on the role of the working alliance in shaping rehabilitation outcomes, and factors influencing perceptions of the working alliance were included and key information extracted.

Results: A total of 10 quantitative studies met inclusion criteria. In most studies, ratings of the working alliance were compared with other process variables or outcome measures. The working alliance was linked to positive activity and participation outcomes, including return to work, school, and driving. Client related factors such as age, level of education and approach to rehabilitation tasks were associated with client and therapist perceptions of the working alliance.

Conclusions: The working alliance emerged as a complex process that interacts with many factors and processes at play in the rehabilitation environment. Notwithstanding the limitations of the research base, findings indicate that enhancement of the working alliance may indeed influence rehabilitation outcomes. Allowing time for the development of the working alliance, and consideration of factors such as therapist skill, may support therapists to strengthen their alliances in ABI rehabilitation.

• Implications for Rehabilitation

• Allowing time for the development of the working alliance has the potential to enhance the alliance and thereby influence rehabilitation outcomes.

• Factors such as the client’s age and level of education may influence the strength of the working alliance, and hence, awareness of these factors may assist clinicians in maintaining strong alliances with all clients.

• A strong working alliance is possible in the presence of client cognitive impairment, however, the skill of the therapist may be important in managing the potential impact of cognitive impairment on the working alliance.

     

Self-awareness assessment during cognitive rehabilitation in children with acquired brain injury: a feasibility study and proposed model of child anosognosia

Abstract

Purpose: To compare three ways of assessing self-awareness in children with traumatic brain injury (TBI) and to propose a model of child anosognosia. Method: Five single cases of children with severe TBI, aged 8–14, undergoing metacognitive training. Awareness was assessed using three different measures: two measures of metacognitive knowledge/intellectual awareness (a questionnaire and illustrated stories where child characters have everyday problems related to their executive dysfunction) and one measure of on-line/emergent awareness (post-task appraisal of task difficulty). Results: All three measures showed good feasibility. Analysis of awareness deficit scores indicated large variability (1–100%). Three children showed dissociated scores. Conclusions: Based on these results, we propose a model of child self-awareness and anosognosia and a framework for awareness assessment for rehabilitation purposes. The model emphasizes (1) the role of on-line error detection in the construction of autobiographical memories that allow a child to build a self-knowledge of his/her strengths and difficulties; (2) the multiple components of awareness that need to be assessed separately; (3) the implications for rehabilitation: errorless versus error-based learning, rehabilitation approaches based on metacognition, rationale for rehabilitation intervention based on child’s age and impaired awareness component, ethical and developmental consideration of confrontational methods.

• Implications for Rehabilitation

• Self-awareness has multiple components that need to be assessed separately, to better adapt cognitive rehabilitation.

• Using questionnaires and discrepancy scores are not sufficient to assess awareness, because it does not include on-line error detection, which can be massively impaired in children, especially those with impaired executive functions.

• On-line error detection is important to promote and error-based learning is useful to allow a child to build a self-knowledge of his/her strengths and difficulties, in the absence of severe episodic memory problems.

• Metacognitive trainings may not be appropriate for younger children who have age appropriate developmentally immature self-awareness, nor for patients with brain injury if they suffer anosognosia because of their brain injury.

     

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.

     

Early community outreach intervention in children with acquired brain injury

Ten patients with acquired brain injury were recruited over an 18 month period in the south-western health care region of Sweden in order to evaluate the costs and effectiveness of a multidisciplinary community outreach intervention programme. An experienced multidisciplinary project team was involved and patients underwent detailed functional, cognitive and motor assessments following initial contact within two weeks of injury, within six weeks of injury and at a 12-month follow-up. An individualized counselling programme was also offered. Of an expected recruitment number of 50 patients (based on epidemiological and population based figures) 10 children were reached, evaluated and followed; eight patients with traumatic brain injury (five severe, two moderate and one mild), and two patients with non-traumatic brain injury (both severe). At follow-up there was a significant improvement in motor function. No significant changes were seen in other areas of functional assessment or on neuropsychological measures although there were mild improvements in communication and behaviour functions. The financial costs per patient in the programme were deemed relatively modest compared with cost estimates of shorter-term in-patient rehabilitation. Time intensive interventions included supporting caregivers and school staff and the direct and indirect patient interventions were shown to enhance support and promote active involvement of local services.     

Efficacy of leisure intervention groups in rehabilitation of people with an acquired brain injury

Abstract

Purpose: To determine whether participation in a week-long residential leisure intervention program targeting individuals with an acquired brain injury (ABI) improved the leisure satisfaction, self-esteem and quality of life (QOL) of participants. The program included leisure awareness, leisure resources, social interaction skills and leisure activity skills. Method: Using a pre- and post-intervention design leisure satisfaction, self-esteem and QOL were assessed prior to, immediately following and at three months post program. Data were analyzed using Wilcoxon signed-rank tests. Results: Participants were eight men and four women aged between 19 and 49 years who were recent clients of a rural Brain Injury Rehabilitation Service. The majority (7/12) had acquired their ABI more than two years previously, and for most (10/12) the cause was trauma. Program participants showed clinically important and statistically significant improvements in leisure satisfaction (p?=?0.002), self-esteem (p?=?0.03) and QOL (p?=?0.02 to 0.008 for four domains of the World Health Organisation Quality of Life – Bref scale) three months post program. Conclusion: Adults with an ABI participating in leisure education programs can experience improvements in leisure satisfaction, self-esteem and QOL following the program. The findings suggest that active leisure intervention programs should be included in the ongoing rehabilitative care of adults with an ABI.

• Implications for Rehabilitation

• Leisure participation, leisure satisfaction and social integration can be seriously compromised following an acquired brain injury (ABI).

• Engagement in leisure activities has positive effects on physical and mental health and is increasingly recognised as an important determinant of quality of life (QOL) for people with ABI.

• Participation in a short-term intensive leisure intervention program can improve leisure satisfaction, self-esteem and QOL.

• Active leisure intervention programs should be included in the ongoing rehabilitation and reintegration of adults with ABI.

     

Reflex and non-reflex elements of hypertonia in triceps surae muscles following acquired brain injury: implications for rehabilitation

Background : Following adult onset acquired brain injury, the triceps surae muscles tend to become shortened and exhibit increased resistance to passive lengthening; a phenomenon that has been termed 'hypertonia'. Spasticity (velocity dependent tonic reflex hyper-excitability) has traditionally been considered a major component of hypertonia. In addition, unmodulated descending excitatory influences on the alpha motorneurone pool may result in inappropriate or excessive muscle activity (dystonia). Non-reflex changes, secondary to the brain injury, and as a consequence of subsequent immobility, also take place in the passive and active elements of the muscle. These non-reflex changes affect the stiffness and extensibility of the musculo-tendinous unit. Atrophy of muscle fibres combines with collagen proliferation to produce increased muscle stiffness. This may be compounded by increased actin-myosin cross-bridge linkages, which are thought to be associated with reduced rates of cross-bridge detachment. Prolonged immobilization in a shortened position results in a loss of sarcomeres in series. Arthrogenic changes associated with disuse include remodelling of dense connective tissue and intra-articular adhesions. Conclusion : Decreased muscle extensibility may be exacerbated by muscle overactivity. Consideration of all of the potential factors contributing to hypertonia of the triceps surae muscle will assist clinicians to identify appropriate intervention strategies, which may facilitate better treatment outcomes.     

Using video-capture virtual reality for children with acquired brain injury

Objective.?To assess the use of a video-capture projected VR system for children with acquired brain injury (ABI), and to compare their performance to that of matched healthy controls.

Subjects.?Thirty-three children (age range: 6–11.4 years) were divided into two groups: 17 children with ABI and 16 controls matched for age, gender and maternal education.

Methods.?Participants experienced three video-captured virtual environments and completed the SFQ child at the end of each specific environment. Participants with ABI experienced three virtual reality (VR) sessions over a period of 10 days. Attention was evaluated using the TEA-Ch. Upper extremity motor abilities were evaluated with the Melbourne Assessment, and self-care abilities were evaluated with the PEDI.

Results.?The video-capture projected system differentiated between the performance of children with ABI and control participants. There was a correlation between VR performance and some attention factors and self-care abilities. No significant correlations were found between performance in the Melbourne assessment and performance within VR.

Conclusions.?The results highlight the potential of the video-capture virtual reality as a tool in the rehabilitation process of children with ABI.