Children's, parents', and teachers' experiences of the feasibility of a telerehabilitation intervention for children with acquired brain injury in the chronic phase - a qualitative study of acceptability and participation in the Child In Context Intervention (CICI).

BACKGROUND: This is a qualitative feasibility study of the Child in Context Intervention (CICI). The CICI is an individualized, goal-oriented and home-based tele-rehabilitation intervention which targets everyday functioning of children (6-16 years) with acquired brain injury in the chronic stage, and their families, one year or more after insult, who have ongoing challenges (physical, cognitive, behavioral, social and/or psychological). The aim of this study is to better understand how children, parents and teachers experienced participation and acceptability; to develop knowledge about the mechanisms of change, and to explore how the CICI was tailored to the context. METHODS: Six families and schools participated in the intervention, which comprised seven tele-rehabilitation sessions in which the child and parent participated, one in-person parent seminar and four digital school meetings. A multidisciplinary team delivered the intervention to 23 participants over a 4- to 5-month period. The intervention involved psychoeducation about targeted acquired brain injury-related problems, such as fatigue, pain, or social challenges. All but one consented to participate in the current digital interview study. The data were analyzed using content analysis. RESULTS: The experience of participation and acceptability varied among the children. Attendance was consistently high; the child participants felt mostly listened to and could influence goal setting and strategies. However, engaging and motivating the child participants proved somewhat challenging. The parents found the CICI rewarding, useful and relevant. However, they had different experiences regarding which intervention component they perceived as most helpful. Some argued in favor of the 'whole intervention', while others highlighted new knowledge, SMART goals or the school collaboration. The teachers found the intervention acceptable and useful but wanted a better meeting plan. They had difficulties in finding time for meetings, emphasized the involvement of school leaders, and appreciated the digital format. CONCLUSIONS: Overall, the intervention was perceived as acceptable, and the participants felt that the various intervention components contributed to improvements. The CICI's flexibility facilitated tailoring to different contexts based on the children's functional level. The digital format saved time and provided flexibility regarding the amount of attendance but limited full participation from children with more severe cognitive impairments. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04186182.

The effects of vestibular rehabilitation on dizziness and balance problems in patients after traumatic brain injury: a randomized controlled trial.

OBJECTIVE:: To investigate the effects of group-based vestibular rehabilitation in patients with traumatic brain injury. DESIGN:: A single-blind randomized controlled trial. SETTING:: University Hospital (recruitment and baseline assessments) and Metropolitan University (experimental intervention). SUBJECTS:: A total of 65 patients (45 women) with mild-to-moderate traumatic brain injury (mean age 39.4 ± 13.0 years) were randomly assigned to intervention ( n = 33) or control group ( n = 32). INTERVENTION:: Group-based vestibular rehabilitation for eight weeks. Participants were tested at baseline (3.5 ± 2.1 months after injury) and at two post-intervention follow-ups (2.7 ± 0.8 and 4.4 ± 1.0 months after baseline testing). MAIN MEASURES:: Primary outcome: Dizziness Handicap Inventory. Secondary outcome: High-Level Mobility Assessment Tool. Other outcomes: Vertigo Symptom Scale; Rivermead Post-concussion Symptoms Questionnaire; Hospital Anxiety and Depression Scale; and Balance Error Scoring System. Between-group differences were analyzed with a linear mixed-model analysis for repeated measurements. RESULTS:: At baseline, no group differences were revealed (personal factors, clinical characteristics and outcome measures). At the first follow-up, statistically significant mean differences in favor of the intervention were found in the primary (-8.7, 95% confidence interval (CI): -16.6 to -0.9) and secondary outcomes (3.7 points, 95% CI: 1.4-6.0). At the second follow-up, no significant between-group differences were found. No significant between-group differences in the other outcomes were found at the two follow-ups. CONCLUSION:: The intervention appeared to speed up recovery for patients with dizziness and balance problems after traumatic brain injury. However, the benefits had dissipated two months after the end of the intervention.

Functional level during the first 2 years after moderate and severe traumatic brain injury.

BACKGROUND: Long-term outcomes after TBI are examined to a large extent, but longitudinal studies with more than 1-year follow-up time after injury have been fewer in number. The course of recovery may vary due to a number of factors and it is still somewhat unclear which factors are contributing. AIM: The aim of this study was to describe the functional level at four time points up to 24 months after traumatic brain injury (TBI) and to evaluate the predictive impact of pre-injury and injury-related factors. DESIGN: A cohort study. SETTING: Outpatient. POPULATION: Sixty-five patients with moderate (n = 21) or severe (n = 44) TBI. METHODS: The patients with TBI were examined with Functional Independence Measure (FIM) and Glasgow Outcome Scale Extended (GOSE) at 3 months, 12 months and 24 months after injury. Possible predictors were analysed in a regression model using FIM total score at 24 months as the outcome measure. RESULTS: FIM scores improved significantly from rehabilitation unit discharge to 24 months after injury, with peak levels at 3 and 24 months after injury (p < 0.001), for the whole TBI group and the group with severe TBI. The moderate TBI group did not show significant FIM score improvement during this time period. GOSE scores for the whole group and the moderate group improved significantly over time, but the severe group did not. FIM at admission to the rehabilitation unit and GCS score at admission to the rehabilitation unit were closest to being significant predictors of FIM total scores 24 months after injury (B = 0.265 and 2.883, R(2 )= 0.39, p = 0.073, p = 0.081). CONCLUSION: FIM levels improved during the period from rehabilitation unit discharge to 3 months follow-up; thereafter, there was a 'plateauing' of recovery. In contrast, GOSE 'plateauing' of recovery was at 12 months. CLINICAL REHABILITATION IMPACT: The study results may indicate that two of the most used outcome measures in TBI research are more relevant for assessment of the functional recovery in a sub-acute phase than in later stages of TBI recovery.

Community integration 2 years after moderate and severe traumatic brain injury.

OBJECTIVE: The aim of this study was to examine community integration by the Community Integration Questionnaire (CIQ) 2 years after injury in a divided TBI sample of moderately and severely injured patients. The second aim was to identify social-demographic, injury-related and rehabilitation associated predictors of CIQ. DESIGN: A cohort study. SETTING: Outpatient follow-up. PARTICIPANTS: Fifty-seven patients with moderate (n = 21) or severe (n = 36) TBI were examined with the Community Integration Questionnaire (CIQ) at 2 years after injury. Possible predictors were analysed in a regression model using CIQ total score at 2 years as the outcome measure. MAIN OUTCOME MEASURES: The Community Integration Questionnaire. RESULTS: At 2 years follow-up, there was significant difference between the moderately and severely injured patients in the productivity scores (p < 0.003), while difference in the total CIQ scores approached the significance level (p = 0.074). Significant predictors of a higher CIQ score were living with a spouse, higher Glasgow Coma Scale (GCS) in the acute phase, shorter Post-Traumatic Amnesia (PTA), longer rehabilitation stay (LOS) and use of rehabilitation service. Use of rehabilitation service (B = 7.766) and living with a spouse (B = 4.251) had the largest influence. This means that living with a spouse, better score on the GCS scale, shorter PTA, longer LOS and use of rehabilitation service after discharge equated to better community integration 2 years after TBI Conclusions: Two years after TBI the moderately injured patients have a higher productivity level than the severely injured patients. Marital status, injury severity and rehabilitation after injury were associated with community integration 2 years after TBI.

Rehabilitation for children with chronic acquired brain injury in the Child in Context Intervention (CICI) study: study protocol for a randomized controlled trial.

BACKGROUND: Pediatric acquired brain injury (pABI) is associated with long-term cognitive, behavioral, social, and emotional problems, which may affect the quality of life, school, and family functioning. Yet, there is a lack of evidence-based community-centered rehabilitation programs for chronic pABI and these children do not systematically receive comprehensive rehabilitation. The Child In Context Intervention (CICI) study is a pragmatic randomized controlled trial (RCT) for children with chronic pABI, which aims to evaluate the effectiveness of an individualized and goal-oriented intervention targeting everyday functioning of the child and family. METHODS: Children aged 6-16 years with MRI/CT-verified intracranial abnormalities will be included in the CICI study if they have persistent self- or parent-reported cognitive, emotional, and/or behavioral challenges 1 year or more after insult and attend school regularly. A total of 70 families will be randomized 1:1 to an intervention or a control group. The intervention consists of seven family sessions, one parent seminar, and four school sessions delivered over approximately 6 months. The parent seminar will be held in person, and the other sessions will mainly be video based. The children's and families' self-reported major challenges in everyday life will be targeted using SMART goals. Evidence-based strategies, when available, will be applied to achieve the goals, combined with psychoeducation. Goal attainment scaling (GAS) will be used to evaluate goal attainment. Data is collected at baseline and after approximately 6 and 9 months. External assessors are blinded to group allocation. Primary outcomes are parent-reported brain injury symptoms in children and parenting self-efficacy at 9 months of follow-up. Secondary outcomes include child-reported brain injury symptoms, quality of life, executive functioning in daily life, parent emotional symptoms, family functioning, and unmet family health care needs. A process evaluation will be conducted. DISCUSSION: The current study provides an innovative approach to rehabilitation for children in the chronic phase of ABI and their families. This complex intervention may contribute to the development of evidence-based, high-quality rehabilitation for a large patient group, which is underrepresented in clinical research. It may also improve collaboration between specialized rehabilitation facilities, schools, and local health care services. Inclusion for the trial started in April 2021. TRIAL REGISTRATION: ClinicalTrials.gov NCT04798859 . Registered on March 15, 2021.

Functional level during sub-acute rehabilitation after traumatic brain injury: course and predictors of outcome.

OBJECTIVES: To describe the functional level during sub-acute rehabilitation after moderate and severe traumatic brain injury (TBI) and to evaluate the impact of pre-injury and injury-related factors as predictors of early recovery. MATERIAL AND METHODS: A prospective study of 55 patients with moderate (n = 21) and severe (n = 34) TBI who received specialized, inpatient rehabilitation. Functional level was assessed by the FIM. Possible predictors were analysed in a regression model using FIM total score at discharge as outcome. RESULTS: At discharge from sub-acute rehabilitation, on average 53 (+/-24) days post-injury, 57% of moderate TBI patients and 91% of severe TBI patients were still disabled with a FIM score < 126. The disability was mild (FIM 109-126) in 95% with moderate TBI and in 62% with severe TBI. The disability was severe (FIM < 72) in 24% with severe TBI. Only one patient did not improve. Predictors of functional level at discharge from rehabilitation were Glasgow Coma Scale (GCS) score at rehabilitation admission (B = 5.991), FIM total score at rehabilitation admission (B = 0.393), length of stay (LOS) in the rehabilitation unit (B = 0.264) and length of Post-Traumatic Amnesia (PTA) (B = -0.120). Together, these predictors explained 86% of variance of FIM total scores at discharge. CONCLUSION: Less than half of moderate TBI patients reached a normal functional level at discharge from sub-acute rehabilitation. A short PTA period, a high GCS score and FIM score at admission to rehabilitation and a longer stay in the rehabilitation unit were positive predictors of functional level at discharge.

Self and near relative ratings of functional level one year after traumatic brain injury.

PURPOSE: To quantify traumatic brain injury (TBI) patients' perceptions of own function by the Patient Competency Rating Scale (PCRS) one year after injury, and to examine self-awareness of functional deficits by comparing PCRS ratings from patients (PCRS-P) and PCRS ratings from near relatives (PCRS-R), and to identify predictors of awareness deficits. METHOD: A cohort of 50 severe (n = 33) and moderate (n = 17) TBI patients. Awareness of deficits was investigated by subtracting PCRS relative ratings from PCRS patient ratings. Predictors of PCRS ratings and differences were assessed by stepwise multiple regression analyses. RESULTS: The average patient PCRS sum score was 122/150 (95% CI = 115; 129) as compared to a sum score of 117/150 (95% CI = 110; 125), given by their relatives (p = 0.93). The patients scored themselves slightly higher than their relatives in the domains of activities of daily living (ADL) and cognitive function (p < 0.001, p < 0.001). Regression analyses showed that Glasgow Coma Scale (GCS)score at admission to rehabilitation was the strongest predictor of patient PCRS (B = 3.314, p = 0.008). The strongest predictor of differences between patient and relative PCRS was GCS acute (B = -3.530, p = 0.001). CONCLUSIONS: TBI patients demonstrated a slight "awareness gap" in ADL and cognitive function. Low GCS in the acute phase and high age were the strongest predictors of self- awareness deficits.

Does an early onset and continuous chain of rehabilitation improve the long-term functional outcome of patients with severe traumatic brain injury?

There are currently no international guidelines regarding treatment in the early rehabilitation phase for persons with severe traumatic brain injury (TBI), and only a few studies have investigated the effect of integrating rehabilitation into acute TBI care. The aim of the study was to evaluate whether a continuous chain of rehabilitation that begins with the acute phase could improve the functional outcome of severe TBI patients, compared to a broken chain of rehabilitation that starts in the sub-acute phase of TBI. A total of 61 surviving patients with severe TBI were included in a quasi-experimental study conducted at the Level I trauma center in Eastern Norway. In the study, 31 patients were in the early rehabilitation group (Group A) and 30 patients were in the delayed rehabilitation group (Group B). The functional outcomes were assessed 12 months post-injury with the Glasgow Outcome Scale Extended (GOSE) and the Disability Rating Scale (DRS). A favorable outcome (GOSE 6-8) occurred in 71% of the patients from Group A versus 37% in Group B (p=0.007). The DRS score was significantly better in Group A (p=0.03). The ordinal logistic regression analysis was used to quantify the relationship between the type of rehabilitation chain and the GOSE. A better GOSE outcome was found in patients from Group A (unadjusted OR 3.25 and adjusted OR 2.78, respectively). These results support the hypothesis that better functional outcome occurs in patients who receive early onset and a continuous chain of rehabilitation.