The effect of access to a designated interdisciplinary post-acute rehabilitation service on participant outcomes after brain injury.

OBJECTIVE: This study aimed to determine the influence of participation in a designated acquired brain injury (ABI) transitional rehabilitation service (ABI TRS) on outcome, in the context of a historical comparison group (HIST). Design: A cohort study, with retrospective comparison. Participants: 187 persons with ABI. Measures: The Depression, Anxiety and Stress Scale (DASS-21), Mayo-Portland Adaptability Index (MPAI-4) and Sydney Psychosocial and Reintegration Scale (SPRS) were completed at discharge and 3 months after discharge. Participation in the ABI TRS involved interdisciplinary rehabilitation, 2-4 times per week, for 3 months after hospital discharge. Results: There was evidence that at 3 months, participants with ABI TRS showed stabilized psychological wellbeing, and improvements in MPAI-4 ability and participation scores; in addition to improvements in SPRS occupational activity and living skills scores. Conclusion: A designated ABI TRS may improve the transition from hospital to home, and could form an important part of the brain injury rehabilitation continuum, between the inpatient and community setting.

The nature of occupational gaps and relationship with mood, psychosocial functioning and self-discrepancy after severe traumatic brain injury.

Purpose: To examine the nature of occupational gaps and desired re-engagement following severe traumatic brain injury (TBI), and the relationship to mood, self-discrepancy, and psychosocial functioning.Materials and methods: Fifty-nine adults with severe TBI (73% male, M age = 36.50, SD = 12.54) were administered measures of past, current, and desired occupations (Occupational Gaps Questionnaire), mood (Depression Stress and Anxiety Scale - 21), and self-discrepancy (Head Injury Semantic Differential Scale - version 3). Psychosocial functioning was rated by relatives on the Sydney Psychosocial Reintegration Questionnaire.Results: Participants reported that they engaged in significantly fewer occupations than prior to their injury (p < 0.001). Further, they participated in fewer occupations than they desired (p < 0.001). Desired re-engagement was identified for 18 of the 30 occupations (e.g., working, sports, managing personal finances, and supporting others). A higher number of these re-engagement gaps was significantly related to greater anxiety (r = 0.30, p < 0.05) and lower psychosocial functioning (r = -0.29, p < 0.05). A mediation analysis revealed that re-engagement gaps were indirectly related to self-discrepancy through an association with anxiety.Conclusions: Occupational gaps are commonly experienced after severe traumatic brain injury. Lack of engagement in desired occupations is associated with greater anxiety and poorer psychosocial functioning. Anxiety regarding these gaps may contribute to negative comparisons between one's pre-injury and post-injury self. Identification of occupational gaps and their psychological impact may guide the focus of client-centred rehabilitation approaches.Implications for RehabilitationGaps between current activity engagement (i.e., post injury) and desired activity engagement are commonly experienced after severe traumatic brain injury.Greater desired re-engagement gaps (i.e., when individuals report they are not completing activities that they would like to do) are associated with greater anxiety and poorer psychosocial functioning.Individuals who are unable to re-engage in desired activities are more likely to experience anxiety, which in turn may contribute to negative self-discrepancy.It may be beneficial to explore the personal meaning of changes in occupation after traumatic brain injury.

Domain-specific deficits in self-awareness and relationship to psychosocial outcomes after severe traumatic brain injury.

Purpose: To investigate the evidence for domain-specific deficits in self-awareness on the Patient Competency Rating Scale (PCRS) and the relationship to psychosocial outcomes after severe traumatic brain injury (TBI).Methods: Fifty-six adults with severe TBI (75% males, M age =36.96, SD = 12.96), and 50 age- and gender-matched controls (72% male, M age =34.12, SD = 11.43) were administered the PCRS self-report form, and the Depression, Anxiety, Stress Scales. Relatives of TBI and control participants completed the PCRS informant version. Relatives of the TBI group also completed the Sydney Psychosocial Rating Scale.Results: A within-group analysis indicated that self-awareness varied according to PCRS domain (p <.01). Relative to their own profile, TBI participants displayed significantly poorer self-awareness on the activities of daily living (ADLs) domain than on the interpersonal and emotional domains (p < 0.01). Further, TBI participants displayed significantly poorer self-awareness of ADLs than controls (p < 0.001), but there were no significant between-group differences in other domains. Hierarchical regression analyses revealed that poorer self-awareness of cognitive difficulties was related to lower occupational functioning (p = 0.01), whereas poorer self-awareness of difficulties with ADLs was related to lower independent living skills (p < 0.001).Conclusions: The results provide only limited support for domain-specific deficits in self-awareness after severe TBI, with impairment most evident for ADLs. Poorer self-awareness in the ADLs and cognitive domains were associated with lower independence and occupational functioning, respectively. The findings highlight the potential benefits of targeting self-awareness related to difficulties with ADLs in the rehabilitation of people with severe TBI.Implications for rehabilitationPeople with severe traumatic brain injury had poorest self-awareness of difficulties regarding activities of daily living, which was related to less independenceDifficulties with complex activities of daily living were more likely to be under-reported than difficulties with basic self-careIt may be beneficial to target self-awareness of difficulties relating to complex activities of daily living in rehabilitation.

Personality characteristics and cognitive appraisals associated with self-discrepancy after severe traumatic brain injury.

Although changes to self-identity or self-discrepancy are common after severe traumatic brain injury (TBI), the mechanisms underlying these changes are poorly understood. This study aimed to examine the influence of personality characteristics and cognitive appraisals on self-discrepancy. Participants were 51 adults (74% male) with severe TBI (M age = 36.22 years; SD = 12.65) who were on average 34 months (SD = 40.29) post-injury. They completed self-report measures of personality style (optimism and defensiveness), cognitive appraisals (threat appraisals, rumination and reflection and perceived coping resources), and self-discrepancy (Head Injury Semantic Differential Scale - III). Correlation analyses identified that higher levels of optimism, defensiveness and perceived coping resources were significantly associated with more positive self-discrepancy (r = .29-.47, p < .05), whereas higher threat appraisals and rumination were significantly related to more negative self- discrepancy (r = -.50-.57, p < .001). After controlling for personality characteristics, cognitive appraisals significantly accounted for self-discrepancy (R2 change = .15). Moreover, rumination significantly mediated the relationship between optimism and self-discrepancy. In summary, cognitive appraisals were found to be related to self-discrepancy, independent of personality characteristics. Rumination in particular may be an important target of psychological intervention for individuals experiencing negative self-discrepancy.

Self-focused processing after severe traumatic brain injury: Relationship to neurocognitive functioning and mood symptoms.

OBJECTIVE: To investigate the impact of neurocognitive functioning on the self-focused processing styles of rumination and reflection, and the relationship to mood symptoms after severe traumatic brain injury (TBI). DESIGN: A cross-sectional design with a between-group component comparing self-focused processing styles and mood symptoms of adults with TBI and age- and gender-matched controls. METHOD: Fifty-two participants with severe TBI (75% male, M age = 36.56, SD = 12.39) completed cognitive tests of attention, memory, executive functioning and the Awareness Questionnaire, Reflection and Rumination Questionnaire (RRQ), and Depression, Anxiety, and Stress Scales (DASS - 21). Fifty age- and gender-matched controls completed the RRQ and DASS-21. RESULTS: TBI participants reported significantly greater mood symptoms than controls (p < .05); however, levels of rumination and reflection did not significantly differ. TBI participants high on both reflection and rumination had significantly greater mood symptoms than those with high reflection and low rumination (p < .001). Higher levels of rumination and reflection were associated with better working memory and immediate and delayed verbal memory (r = .36-.43, p < .01). Higher levels of rumination were also associated with greater verbal fluency, self-awareness, and mood symptoms (r = .36-.70, p < .01). CONCLUSIONS: Individuals with better memory functioning may be more likely to engage in self-focused processing after severe TBI. Reflection without ruminative tendencies is more adaptive for mental health than reflection with rumination. PRACTITIONER POINTS: Individuals with severe TBI report more mood symptoms than non-injured controls but do not differ on self-focused processing. Poorer memory function is related to lower levels of rumination and reflection. Reflection without ruminative tendencies is adaptive for mental health after severe TBI. Individuals with greater self-awareness and ruminative tendencies are at increased risk of mental health problems following severe TBI. LIMITATIONS: Rumination and reflection were assessed using a self-report measure which assumes that people with severe TBI are able to reliably report on self-focused processing styles. The direction of associations between self-focused processing, self-awareness, and mood symptoms could not be determined due to the cross-sectional design.

Relationship Between Neurocognitive Function and Self-Discrepancy After Severe Traumatic Brain Injury.

OBJECTIVE: Individuals with traumatic brain injury (TBI) often make unfavorable comparisons between their preinjury and postinjury selves. Although it is known that negative "self-discrepancy" is related to poorer emotional adjustment, the impact of neurocognitive function on self-discrepancy is unclear. This study aimed to investigate the relationship between current neurocognitive function (attention, memory, executive function, and self-awareness) and self-discrepancy after severe TBI. DESIGN: Fifty-four adults with severe TBI were recruited from outpatient and community rehabilitation services and completed measures of self-discrepancy (Head Injury Semantic Differential Scale-III) and self-awareness (Awareness Questionnaire) and a battery of standardized tests of attention, memory, and executive functions. RESULTS: More negative self-discrepancy was significantly associated with greater self-awareness (r = -0.40, P < .001) and better performance on tests of immediate memory (r = -0.43, P < .01), working memory (r = -0.35, P < .05), and verbal fluency (r = -0.34, P < .05). Self-awareness was the only neurocognitive factor significantly and uniquely related to self-discrepancy, accounting for 8.6% of the variance (P < .05). Furthermore, self-awareness was found to partially mediate the relationship between immediate memory and self-discrepancy. CONCLUSION: Better neurocognitive function is related to more negative self-discrepancy. These findings improve understanding of the process of identity reconstruction following TBI.

Efficacy of Telerehabilitation for Adults With Traumatic Brain Injury: A Systematic Review.

OBJECTIVE: To identify and appraise studies evaluating the efficacy of telerehabilitation for adults with traumatic brain injury (TBI). METHODS: A systematic search of Cochrane Library, MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and PsycINFO databases was conducted from January 1980 to April 23, 2017, for studies evaluating the efficacy of telerehabilitation for adults with TBI. Two reviewers independently assessed articles for eligibility and rated methodological quality using 16 criteria related to internal validity, descriptive, and statistical characteristics. RESULTS: The review yielded 13 eligible studies, including 10 randomized controlled trials and 3 pre-/postgroup studies (n ≥ 10). These evaluated the feasibility and/or efficacy of telephone-based (10 studies) and Internet-based (3 studies) interventions. Overall, the evidence of efficacy was somewhat mixed. The most common study design evaluated the efficacy of telephone-based interventions relative to usual care, for which 4 of 5 randomized controlled trials reported positive effects at postintervention (d = 0.28-0.51). For these studies, improvements in global functioning, posttraumatic symptoms and sleep quality, and depressive symptoms were reported. The feasibility of Internet-based interventions was generally supported; however, the efficacy could not be determined because of insufficient studies. CONCLUSIONS: Structured telephone interventions were found to be effective for improving particular outcomes following TBI. Controlled studies of Internet-based therapy and comparisons of the clinical and cost-effectiveness of in-person and telerehabilitation formats are recommended for future research.

Do People With Severe Traumatic Brain Injury Benefit From Making Errors? A Randomized Controlled Trial of Error-Based and Errorless Learning.

BACKGROUND: Errorless learning (ELL) and error-based learning (EBL) are commonly used approaches to rehabilitation for people with traumatic brain injury (TBI). However, it is unknown whether making errors is beneficial in the learning process to promote skills generalization after severe TBI. OBJECTIVE: To compare the efficacy of ELL and EBL for improving skills generalization, self-awareness, behavioral competency, and psychosocial functioning after severe TBI. METHOD: A total of 54 adults (79% male; mean age = 38.0 years, SD = 13.4) with severe TBI were randomly allocated to ELL or EBL and received 8 × 1.5-hour therapy sessions that involved meal preparation and other goal-directed activities. The primary outcome was total errors on the Cooking Task (near-transfer). Secondary outcome measures included the Zoo Map Test (far-transfer), Awareness Questionnaire, Patient Competency Rating Scale, Sydney Psychosocial Reintegration Scale, and Care and Needs Scale. RESULTS: Controlling for baseline performance and years of education, participants in the EBL group made significantly fewer errors at postintervention (mean = 36.25; 95% CI = 32.5-40.0) than ELL participants (mean = 42.57; 95% CI = 38.8-46.3). EBL participants also demonstrated greater self-awareness and behavioral competency at postintervention than ELL participants ( P < .05). There were no significant differences on other secondary outcomes ( P > .05), or at the 6-month follow-up assessment. CONCLUSION: EBL was found to be more effective than ELL for enhancing skills generalization on a task related to training and improving self-awareness and behavioral competency.

Cognitive Deficits Underlying Error Behavior on a Naturalistic Task after Severe Traumatic Brain Injury.

People with severe traumatic brain injury (TBI) often make errors on everyday tasks that compromise their safety and independence. Such errors potentially arise from the breakdown or failure of multiple cognitive processes. This study aimed to investigate cognitive deficits underlying error behavior on a home-based version of the Cooking Task (HBCT) following TBI. Participants included 45 adults (9 females, 36 males) with severe TBI aged 18-64 years (M = 37.91, SD = 13.43). Participants were administered the HBCT in their home kitchens, with audiovisual recordings taken to enable scoring of total errors and error subtypes (Omissions, Additions, Estimations, Substitutions, Commentary/Questions, Dangerous Behavior, Goal Achievement). Participants also completed a battery of neuropsychological tests, including the Trail Making Test, Hopkins Verbal Learning Test-Revised, Digit Span, Zoo Map test, Modified Stroop Test, and Hayling Sentence Completion Test. After controlling for cooking experience, greater Omissions and Estimation errors, lack of goal achievement, and longer completion time were significantly associated with poorer attention, memory, and executive functioning. These findings indicate that errors on naturalistic tasks arise from deficits in multiple cognitive domains. Assessment of error behavior in a real life setting provides insight into individuals' functional abilities which can guide rehabilitation planning and lifestyle support.

The Impact of Traumatic Brain Injury on Self-Identity: A Systematic Review of the Evidence for Self-Concept Changes.

OBJECTIVES: This review systematically appraised the evidence for changes to self-identity after traumatic brain injury (TBI) in adults and investigated associations between self-concept changes and neurocognitive and psychosocial functioning. METHODS: Systematic searches of 4 databases (PsycINFO, PubMed, CINAHL, and Cochrane Systematic Review Database) were undertaken from January 1983 to July 2014. Empirical studies were included if they used a quantitative measure of pre-/postinjury changes in self-concept after TBI or compared levels of self-concept between TBI and control participants. RESULTS: Fifteen studies met the review criteria and, despite methodological differences, provided mostly evidence of negative changes to self-concept. However, stability in self-concept and positive changes to sense of self were also reported in some studies. Furthermore, levels of self-esteem and personality characteristics did not significantly differ between participants with TBI and orthopedic/trauma controls. Negative self-concept changes were associated with emotional distress in 3 studies. CONCLUSIONS: People with TBI most commonly experience negative changes in self-identity; however, such changes are also reported after other traumatic events or injuries. Greater consistency in measurement of self-identity change and use of longitudinal designs is recommended to improve understanding of factors contributing to self-concept changes after TBI and to guide clinical interventions.

Long-term functional outcomes and academic-occupational status in implanted children after 10 to 14 years of cochlear implant use.

OBJECTIVES: To assess a group of consecutively implanted children over 10 years after implantation with regard to implant device use and function, speech perception, and speech intelligibility outcomes; and to document current academic or occupational status. STUDY DESIGN: A prospective longitudinal study assessing device function, device use, speech perception, speech intelligibility, and academic/occupational status of implanted deaf children. SETTING: Pediatric tertiary referral center for cochlear implantation. METHODS: The auditory performance and speech intelligibility development of 30 profoundly deaf children were rated before cochlear implantation and at 5 and 10 years after implantation using the Categories of Auditory Performance and the Speech Intelligibility Rating. The academic and/or occupational status of the participants after 10 years of implant experience was documented. All children received a Nucleus multichannel cochlear implant between the ages of 2.5 and 11 years (mean age at implantation, 5.2 yr). Implant experience ranged from 10 to 14 years of use. RESULTS: After 10 years of implant experience, 26 subjects (87%) reported that they always wore their device; 2 subjects (7%), frequently; and 1 subject (3%), occasionally. Only one child had discontinued use of his device. After 10 years of implant use, 26 (87%) of the children understood a conversation without lip reading and 18 (60%) used the telephone with a familiar speaker. Ten years after implantation, 23 (77%) of the subjects used speech intelligible to an average listener or a listener with little experience of a deaf person's speech. One-third to one-half of the implanted children continued to demonstrate improvements at 5 to 10 years of implant use. Of the 30 implanted children, 8 (26.7%) experienced nine device failures. The length of time from identification of the first faulty electrode to reimplant surgery ranged from 2 weeks to 5.5 years, as several failures were gradual or intermittent. However, all children were successfully reimplanted. At the end of the study (10-14 yr after implantation), 19 subjects were in secondary school for children aged 11 to 16 years: 6 were in mainstream schools, 7 were in specialist hearing-impaired units attached to a mainstream secondary school, and 6 were in schools for the deaf. Of the remaining 11 subjects, 4 were in college studying vocational subjects, 2 were in a university studying for a bachelor's degree, 3 were working full-time, 1 was working and going to a university part-time, and 1 was a full-time mother of two young children. CONCLUSION: All but 1 of the 30 implanted children continue using their devices 10 to 14 years after implantation, showing significant progress in speech perception and production. Device failure was frequent, but successful reimplantation occurred in all cases. One-third to one-half of the implanted children in this study continued to demonstrate improvements at 5 to 10 years of implant use. All children are studying or working and are actively involved in their local communities. The results suggest that cochlear implantation provides long-term communication benefit to profoundly deaf children that does not plateau for some subjects even after reimplantation. This study further indicates that cochlear implant centers need the structure and funding to provide long-term support, counseling, audiologic follow-up, rehabilitation, and device monitoring to implanted children.