Efficacy and acceptability of a home-based, family-inclusive intervention for veterans with TBI: A randomized controlled trial.

OBJECTIVE: Traumatic brain injury (TBI) often undermines community re-integration, impairs functioning and produces other symptoms. This study tested an innovative programme for veterans with TBI, the Veterans' In-home Programme (VIP), delivered in veterans' homes, involving a family member and targeting the environment (social and physical) to promote community re-integration, mitigate difficulty with the most troubling TBI symptoms and facilitate daily functioning. SETTING: Interviews and intervention sessions were conducted in homes or by telephone. PARTICIPANTS: Eighty-one veterans with TBI at a VA polytrauma programme and a key family member. DESIGN: This was a 2-group randomized controlled trial. Control-group participants received usual-care enhanced by two attention-control telephone calls. Follow-up interviews occurred up to 4 months after baseline interview. MAIN MEASURES: VIP's efficacy was evaluated using measures of community re-integration, target outcomes reflecting veterans' self-identified problems and self-rated functional competence. RESULTS: At follow-up, VIP participants had significantly higher community re-integration scores and less difficulty managing targeted outcomes, compared to controls. Self-rated functional competence did not differ between groups. In addition, VIP's acceptability was high. CONCLUSION: A home-based, family-inclusive service for veterans with TBI shows promise for improving meaningful outcomes and warrants further research and clinical application.

Exploration of Individual and Family Factors Related to Community Reintegration in Veterans With Traumatic Brain Injury.

BACKGROUND: Community reintegration (CR) poses a major problem for military veterans who have experienced a traumatic brain injury (TBI). Factors contributing to CR after TBI are poorly understood. OBJECTIVE: To address the gap in knowledge, an ecological framework was used to explore individual and family factors related to CR. DESIGN: Baseline data from an intervention study with 83 veterans with primarily mild to moderate TBI were analyzed. Instruments measured CR, depressive symptoms, physical health, quality of the relationship with the family member, and sociodemographics. Posttraumatic stress disorder and TBI characteristics were determined through record review. RESULTS: Five variables that exhibited significant bivariate relationships with CR (veteran rating of quality of relationship, physical functioning, bodily pain, posttraumatic stress disorder diagnosis, and depressive symptoms) were entered into hierarchical regression analysis. In the final analysis, the five variables together accounted for 35% of the variance, but only depression was a significant predictor of CR, with more depressed veterans exhibiting lower CR. CONCLUSIONS: Efforts to support CR of Veterans with TBI should carefully assess and target depression, a modifiable factor.

Rating competency in everyday activities in patients with TBI: clinical insights from a close look at patient-family differences.

PURPOSE: Families of patients with traumatic brain injury (TBI) often perceive patients' functional capabilities differently from patients themselves. Research documents inconsistent findings regarding direction of differences. Differences have implications for family support and are germane to clinicians' treatment planning during rehabilitation. We compared two analytic approaches to patient-family differences in ratings of 30 functional tasks: (a) comparing patients' and families' mean scores in domains derived from factor analysis versus (b) examining differences on a task-by-task basis. METHOD: In-home interviews were conducted with 83 outpatients with TBI at a Veteran Affairs polytrauma clinic and for each a family member, using the Patient Competency Rating Scale with both. RESULTS: Principal components analysis identified three functional domains--cognitive, interpersonal/emotional and physical--with significant patient-family differences in the cognitive domain only (family competency ratings were higher). By contrast, task-by-task examination showed significant veteran-family differences in 12 items, mostly in interpersonal/emotional functioning, with mixed directions of differences. The task-by-task approach thus revealed a different picture of patient-family differences than examination by functional domains. CONCLUSIONS: Grouping tasks by domains may obscure important differences in functional ratings. Examination of patient-family differences by task has clinical applications for helping patients and families to manage TBI symptoms and for treatment planning. IMPLICATIONS FOR REHABILITATION: Differences in functional capacity ratings by patients with TBI and their family members are not well understood, with past research demonstrating inconsistencies in direction of difference. Differences in ratings may affect family relationships and may inform clinicians' treatment plans. The study showed that different approaches to analyzing the same data yield two distinct pictures of patient-family differences. Examining patient-family differences by specific tasks is clinically meaningful. The Competency Rating Scale could be used as a clinical tool with patients and families. Its use may improve family understanding of the patient's strengths and struggles and also guide treatment planning.

A Randomized Controlled Trial to Evaluate the Veterans' In-home Program for Military Veterans With Traumatic Brain Injury and Their Families: Report on Impact for Family Members.

BACKGROUND: Traumatic brain injury (TBI) creates many challenges for families as well as for patients. Few intervention studies have considered both the needs of the person with TBI and his or her family and included both in the intervention process. To address this gap, we designed an innovative intervention for veterans with TBI and families-the Veterans' In-home Program (VIP)-targeting veterans' environment, delivered in veterans' homes, and involving their families. OBJECTIVES: To determine whether the VIP is more effective than standard outpatient clinic care in improving family members' well-being in 3 domains (depressive symptoms, burden, and satisfaction) and to assess its acceptability to family members. DESIGN: In this randomized controlled trial, 81 dyads (veteran/family member) were randomly assigned to VIP or an enhanced usual care control condition. Randomization occurred after the baseline interview. Follow-up interviews occurred 3-4 months after baseline, and the interviewer was blinded to group assignment. SETTING: Interviews and intervention sessions were conducted in veterans' homes or by telephone. PARTICIPANTS: A total of 81 veterans with TBI recruited from a Veterans Affairs (VA) polytrauma program and a key family member for each participated. Of the 81 family members, 63 completed the follow-up interview. INTERVENTION: The VIP, guided by the person-environment fit model, consisted of 6 home visits and 2 telephone calls delivered by occupational therapists over a 3- to 4-month period. Family members were invited to participate in the 6 home sessions. MAIN OUTCOME MEASURES: Family member well-being was operationally defined as depressive symptomatology, caregiver burden, and caregiver satisfaction 3-4 months after baseline. Acceptability was operationally defined through 3 indicators. RESULTS: Family members in the VIP showed significantly lower depressive symptom scores and lower burden scores when compared to controls at follow-up. Satisfaction with caregiving did not differ between groups. Family members' acceptance of the intervention was high. CONCLUSIONS: VIP represents the first evidence-based intervention that considers both the veteran with TBI and the family. VIP had a significant impact on family member well-being and thus addresses a large gap in previous research and services for families of veterans with TBI.