Characteristics and Concerns of Caregivers of Adults With Traumatic Brain Injury.

OBJECTIVE: To describe the characteristics of caregivers of adults with traumatic brain injury (TBI) and their concerns in the first months after community discharge of the TBI survivor. DESIGN: Secondary analysis of data collected during a parallel-group randomized controlled trial. SETTING: Community. PARTICIPANTS: A total of 153 consecutively enrolled caregivers of adults with moderate to severe TBI discharged to the community following acute and/or rehabilitation care at a Level I trauma center with 71 caregivers in the treatment group identifying concerns as part of the intervention procedures. MAIN MEASURES: Caregiver demographics, caregiver-survivor relationship characteristics, caregiver activity changes, and concerns targeted by caregivers for education and problem-solving via biweekly phone calls. RESULTS: Thirty-nine percent of caregivers were spouses and 35% parents. Sixty-five percent lived in the same house as the survivor preinjury with 86% in touch daily to several times per week. Concerns targeted by more than one-third of caregivers related to managing their emotional adjustment, strategies for getting things done, managing survivor emotions and behaviors, and engaging in healthful habits. CONCLUSIONS: Caregivers of TBI survivors targeted personal concerns relating to their own emotional adjustment and participation as well as concerns relating to symptoms and recovery of the TBI survivor to address through education and problem-solving.

A Telehealth Approach to Caregiver Self-Management Following Traumatic Brain Injury: A Randomized Controlled Trial.

OBJECTIVE: To determine whether a telephone-based, individualized education and mentored problem-solving intervention would improve outcomes for caregivers of persons with traumatic brain injury (TBI). DESIGN: Parallel group, randomized controlled trial with blinded outcome assessment. SETTING: General community. PARTICIPANTS: A total of 153 caregivers (mean age = 49.7 years; 82% female; 54% spouses/partners, 35% parents) of persons with moderate to severe TBI who received acute and/or rehabilitation care at a level I trauma center. Eighty-two percent of participants were evaluated at 6-month follow-up. INTERVENTION: Individualized education and mentored problem-solving intervention focused on caregivers' primary concerns delivered via up to 10 telephone calls at 2-week intervals. MAIN OUTCOME MEASURES: Composite of Bakas Caregiving Outcomes Scale (BCOS) and Brief Symptom Inventory (BSI-18) at 6 months post-TBI survivor discharge. Secondary measures included the Brief COPE. RESULTS: Caregivers in the treatment arm scored higher on the BCOS-BSI composite (P = .032), with more active coping (P = .020) and less emotional venting (P = .028) as measured by the Brief COPE. CONCLUSIONS: An individualized education and mentored problem-solving approach delivered via telephone in the first few months following community discharge of the TBI survivor resulted in better caregiver outcomes than usual care. Consideration should be given to using this approach to augment the limited support typically offered to caregivers.

Special Issue on Occupational Therapy for Adults With Traumatic Brain Injury.

Awareness of the incidence and consequences of traumatic brain injury (TBI) has increased in recent years, along with interest in knowing how best to treat this complex condition. This editorial provides an overview of the various factors that contribute to the complexity of TBI and introduces the six systematic reviews and one qualitative study included in this special issue of the American Journal of Occupational Therapy focusing on interventions for TBI from an occupational therapy perspective. Issues with the generation and interpretation of research evidence are discussed, along with the importance of valuing clinician expertise and client perspectives along with research findings in implementing evidence-based and evidence-informed practice.

Effectiveness of Occupation- and Activity-Based Interventions to Improve Everyday Activities and Social Participation for People With Traumatic Brain Injury: A Systematic Review.

This systematic review presents research on the effectiveness of occupation- and activity-based interventions to improve everyday activities and areas of occupation and social participation for people with traumatic brain injury (TBI). Nineteen studies identified through a comprehensive database search were reviewed and synthesized into five themes: (1) multidisciplinary and interdisciplinary treatment approaches, (2) community-based rehabilitation programs, (3) treatment approaches using client-centered goals and relevant contexts, (4) social skills training and peer mentoring interventions, and (5) community mobility interventions. Evidence supports the use of multidisciplinary and interdisciplinary approaches across a variety of settings, with no single treatment approach or setting clearly superior to another. The specific contributions of occupational therapy practitioners and the nature of occupational therapy interventions have not been well studied, making it difficult to determine the extent to which occupation- and activity-based interventions provided by occupational therapy practitioners improve occupational performance and social participation after TBI.

Capstone projects as scholarship of application in entry-level occupational therapy education.

Capstone projects are integrative student learning experiences used in higher education. This article describes the value and merit of capstone projects as scholarship of application within an entry-level occupational therapy education program. The capstone process is outlined and roles and responsibilities of student, faculty members, and community mentors described. Summative curricular evaluation from 5 years of capstone projects indicated that project characteristics and objectives aligned with the theory and desired outcomes of applied scholarship in the areas of student learning, faculty practice and development, and community service. Challenges identified can further inform development of the capstone experience in occupational therapy education.

Robot-assisted therapy for long-term upper-limb impairment after stroke.

BACKGROUND: Effective rehabilitative therapies are needed for patients with long-term deficits after stroke. METHODS: In this multicenter, randomized, controlled trial involving 127 patients with moderate-to-severe upper-limb impairment 6 months or more after a stroke, we randomly assigned 49 patients to receive intensive robot-assisted therapy, 50 to receive intensive comparison therapy, and 28 to receive usual care. Therapy consisted of 36 1-hour sessions over a period of 12 weeks. The primary outcome was a change in motor function, as measured on the Fugl-Meyer Assessment of Sensorimotor Recovery after Stroke, at 12 weeks. Secondary outcomes were scores on the Wolf Motor Function Test and the Stroke Impact Scale. Secondary analyses assessed the treatment effect at 36 weeks. RESULTS: At 12 weeks, the mean Fugl-Meyer score for patients receiving robot-assisted therapy was better than that for patients receiving usual care (difference, 2.17 points; 95% confidence interval [CI], -0.23 to 4.58) and worse than that for patients receiving intensive comparison therapy (difference, -0.14 points; 95% CI, -2.94 to 2.65), but the differences were not significant. The results on the Stroke Impact Scale were significantly better for patients receiving robot-assisted therapy than for those receiving usual care (difference, 7.64 points; 95% CI, 2.03 to 13.24). No other treatment comparisons were significant at 12 weeks. Secondary analyses showed that at 36 weeks, robot-assisted therapy significantly improved the Fugl-Meyer score (difference, 2.88 points; 95% CI, 0.57 to 5.18) and the time on the Wolf Motor Function Test (difference, -8.10 seconds; 95% CI, -13.61 to -2.60) as compared with usual care but not with intensive therapy. No serious adverse events were reported. CONCLUSIONS: In patients with long-term upper-limb deficits after stroke, robot-assisted therapy did not significantly improve motor function at 12 weeks, as compared with usual care or intensive therapy. In secondary analyses, robot-assisted therapy improved outcomes over 36 weeks as compared with usual care but not with intensive therapy. (ClinicalTrials.gov number, NCT00372411.)

Benefits of exercise maintenance after traumatic brain injury.

OBJECTIVE: To examine the effect of exercise intervention on exercise maintenance, depression, quality of life, and mental health at 6 months for people with traumatic brain injury (TBI) with at least mild depression. DESIGN: Treatment group participants were assessed at baseline, after a 10-week exercise intervention, and 6 months after completion of the intervention. SETTING: Community. PARTICIPANTS: Participants (N=40) with self-reported TBI from 6 months to 5 years prior to study enrollment and a score of 5 or greater on the Patient Health Questionnaire-9. INTERVENTIONS: Ten-week exercise intervention program consisting of supervised weekly 60-minute sessions and unsupervised 30 minutes of aerobic exercises 4 times each week. Telephone follow-up was conducted every 2 weeks for an additional 6 months to promote exercise maintenance for individuals randomized to the intervention group. MAIN OUTCOME MEASURE: Beck Depression Inventory (BDI) comparing participant outcomes over time. Post hoc analyses included comparison among those who exercised more or less than 90 minutes per week. RESULTS: Participants reduced their scores on the BDI from baseline to 10 weeks and maintained improvement over time. Many participants (48%) demonstrated increased physical activity at 6 months compared with baseline. Those who exercised more than 90 minutes had lower scores on the BDI at the 10-week and 6-month assessments and reported higher perceived quality of life and mental health. CONCLUSIONS: Exercise may contribute to improvement in mood and quality of life for people with TBI and should be considered as part of the approach to depression treatment.

Neurobehavioural symptoms 1 year after traumatic brain injury: a preliminary study of the relationship between race/ethnicity and symptoms.

OBJECTIVE: To investigate whether White, African American and Hispanic individuals with a traumatic brain injury (TBI) express differences in neurobehavioural symptoms at 1 year post-injury after adjusting for demographic and injury characteristics. DESIGN: Retrospective study. PARTICIPANTS: One thousand, three hundred and thirty-nine individuals from the TBI Model Systems National Database with primarily moderate-to-severe TBI (978 White, 288 African American and 73 Hispanic) hospitalized between 1996 and 2001. MAIN OUTCOME MEASURES: Neurobehavioural Functioning Inventory (NFI) at 1 year post-injury. RESULTS: There were significant differences in NFI scores among the races/ethnicities for the depression, somatic, memory/attention, communication and motor subscales, after adjusting for demographic and injury characteristics; there were not significant differences in the aggression sub-scale. Hispanics had higher levels of symptom reporting than African Americans and Whites, while differences between African Americans and Whites were not significant. CONCLUSIONS: Hispanics scored significantly higher than Whites and African Americans on the sub-scales of the NFI, indicating more problems in these areas. Future research should focus on identifying factors that may contribute to the difference between the groups and treatment interventions should be implemented accordingly.

Impact of traumatic brain injury on participation in leisure activities.

OBJECTIVE: To determine how participation in leisure activities for people with traumatic brain injury (TBI) changes from before injury to 1 year after injury. DESIGN: Prospective evaluation of leisure participation at 1 year after TBI. SETTING: Level I trauma center. PARTICIPANTS: Rehabilitation inpatients (mean age, 35.3 years; 77% male; 77% white) with moderate to severe TBI (N=160). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Functional Status Examination. RESULTS: At 1 year after injury, 81% had not returned to preinjury levels of leisure participation. Activities most frequently discontinued included partying, drug and alcohol use, and various sports. The activity most often reported as new after injury was watching television. Of the small fraction who returned to preinjury levels, 70% did so within 4 months of injury. Sixty percent of those who did not return to preinjury levels were moderately to severely bothered by the changes. CONCLUSIONS: At 1 year after injury, many TBI survivors engage in a reduced number of leisure activities, which are more sedentary and less social, with a substantial fraction dissatisfied with these changes. While discontinuing some activities may be viewed as a positive change, there are few new ones to replace them.

Return to driving within 5 years of moderate-severe traumatic brain injury.

PRIMARY OBJECTIVE: To examine return to driving and variables associated with that activity in a longitudinal database. RESEARCH DESIGN: Retrospective analysis of a large, national database. METHODS AND PROCEDURES: The sample was comprised of people with predominantly moderate-severe traumatic brain injury (TBI) enrolled in the TBI Model System national database at 16 centres and followed at 1 (n = 5942), 2 (n = 4628) and 5 (n = 2324) years after injury. MAIN OUTCOMES AND RESULTS: Respondents were classified as driving or not driving at each follow-up interval. Five years after injury, half the sample had returned to driving. Those with less severe injuries were quicker to return to driving, but, by 5 years, severity was not a factor. Those who were driving expressed a higher life satisfaction. Functional status at rehabilitation discharge, age at injury, race, pre-injury residence, pre-injury employment status and education level were associated with the odds of a person driving. CONCLUSIONS: Half of those with a moderate-severe TBI return to driving within 5 years and most of those within 1 year of injury. Driving is associated with increased life satisfaction. There are multiple factors that contribute to return to driving that do not relate to actual driving ability.

Accuracy of mild traumatic brain injury diagnosis.

OBJECTIVE: To determine how often emergency department (ED) patients meeting the Centers for Disease Control and Prevention (CDC) mild traumatic brain injury (TBI) criteria were diagnosed with a mild TBI by the ED physician. DESIGN: Prospective identification of cases of mild TBI in the ED by study personnel using scripted interviews and medical record data was compared with retrospective review of ED medical record documentation of mild TBI. SETTING: EDs of a level I trauma center and an academic nontrauma hospital. PARTICIPANTS: Prospective cohort of subjects (N=197; mean age, 32.6 y; 70% men) with arrival at the ED within 48 hours of injury, Glasgow Coma Scale score of 13 to 15, and injury circumstances, alteration of consciousness, and memory dysfunction consistent with the CDC mild TBI definition. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: ED medical record documentation of mild TBI. RESULTS: Fifty-six percent of mild TBI cases identified by study personnel did not have a documented mild TBI-related diagnosis in the ED record. The greatest agreement between study personnel and ED physicians for positive mild TBI-related findings was for loss of consciousness (72% vs 65%) with the greatest discrepancy for confusion (94% vs 28%). CONCLUSIONS: The diagnosis of mild TBI was frequently absent from ED medical records despite patients reporting findings consistent with a mild TBI diagnosis when interviewed by study personnel. Asking a few targeted questions of ED patients with likely mechanisms of injury that could result in mild TBI could begin to improve diagnosis and, in turn, begin to improve patient management and the accuracy of estimates of mild TBI incidence.

State of the occupational therapy workforce: results of a national study.

OBJECTIVE: This study determined the current status of the occupational therapy workforce in the United States with a demand-based report using current job data. METHOD: A 31-question survey was sent to rehabilitation administrators and managers from a proportional random sample of 556 facilities that hire occupational therapy practitioners in 29 states. Data were collected from November 2005 to February 2006 using structured mailing and follow-up procedures. RESULTS: The response rate was 55%. The vacancy rate was 8.9% for occupational therapists and 7.7% for occupational therapy assistants. Forty-five percent of respondents predicted an increase in occupational therapy positions in the next 2 years, and 30% predicted an increase in occupational therapy assistant positions. Sixty-seven percent reported difficulty hiring occupational therapists, and 62% reported difficulty hiring occupational therapy assistants. DISCUSSION: This study identifies a serious shortage of occupational therapy practitioners at a time when predictions of workforce demands continue to grow.

Experiences of living with non-cancer-related lymphedema: implications for clinical practice.

Lymphedema is a chronic medical condition caused by lymphatic insufficiency that can lead to extreme swelling and susceptibility to infection. Physical and psychosocial effects of the condition can have a significant impact on an individual's life and level of participation. Research about experiences of individuals living with lymphedema has focused primarily on women with breast cancer, yet individuals with non-cancer-related lymphedema are a distinct group. In this study, the authors used qualitative description to explore the experience of 7 individuals living with advanced and complicated cases of lymphedema who had been treated in an inpatient setting. Findings reveal the extensive impact lymphedema has on those who live with it. Participants spoke of difficulty finding a correct diagnosis and effective treatment, the importance of their inpatient experiences, and the challenges of daily self-management. The authors make recommendations to increase lymphedema awareness, promote inpatient treatment programs, and create effective self-management techniques.

Gaining insight into patients' perspectives on participation in home management activities after traumatic brain injury.

OBJECTIVE: This study investigated performance of home management activities 1 year after traumatic brain injury (TBI), as reported on the Functional Status Examination. METHOD: Home management performance of 164 rehabilitation inpatients (mean age 35.4 years, 77% men, 75% white) with moderate to severe TBI was examined in relation to demographics, injury severity, neuropsychological functioning, and living situation. RESULTS: Fifty-nine percent reported more difficulty or more assistance with home management at 1 year. Nonperformance of individual activities before injury ranged from 16% to 76%. Age (p= .001), living situation after injury (p = .002), and neuropsychological function at 1 year (p = .001) were associated with more limited home management performance after injury as compared to premorbid function. CONCLUSIONS: Home management is challenging 1 year after TBI, especially for older adults and those with greater cognitive impairments. Accurate preinjury information is needed to determine the nature and extent of subsequent losses, guide treatment planning and interventions, and characterize recovery of function.

Assessment of unilateral neglect in stroke: Simplification and structuring of test items.

STATEMENT OF CONTEXT: Unilateral neglect is a complex impairment that is common after stroke and limits occupational performance. Sensitive assessment of unilateral neglect is critical for planning treatment and ensuring safe community discharge. CRITICAL REFLECTION ON PRACTICE: This reflection describes unexpected findings in the assessment of neglect with two individuals in the acute phase of recovery post stroke. When trialing a new activity based test battery, we observed few neglect behaviors during test tasks despite observation of multiple neglect behaviors outside of the testing situation. Upon reflection, we better understood how simplification and structuring of test items and environments could impact the observation and assessment of neglect behaviors. IMPLICATIONS FOR PRACTICE: This practice analysis further supports the use of multiple assessments when evaluating unilateral neglect and specifically encourages the inclusion of assessment methods that maintain the complexity of everyday tasks and environments.

The role of habit in recurrent pressure ulcers following spinal cord injury.

BACKGROUND: Despite the existence of numerous prevention strategies, pressure ulcers remain highly prevalent in those with spinal cord injury (SCI). The concept of habit, broadly defined, may help understand the persistence of this problem and offer strategies for its mitigation by occupational therapy. AIM: The aim of this paper is to describe the relationship between habits established prior to sustaining an SCI and post-injury habits that impacted on pressure ulcer risk. METHODS: Secondary analysis of qualitative data collected during an ethnographic study of community-dwelling adults with SCI. RESULTS: Participants' habits appeared to substantially affect their risk of developing pressure ulcers. Habits established before incurring the SCI either facilitated or hindered the acquisition of new habits intended to prevent pressure ulcers. CONCLUSIONS: An understanding of the individual's pre-existing habits may be important when designing a rehabilitation programme intended to minimize risk of pressure ulcer development following SCI. Habit-change strategies could be used to supplement education in pressure ulcer prevention techniques. SIGNIFICANCE: Occupational therapists have a longstanding interest in habit. A more comprehensive understanding of this concept may provide important insights into the persistence and management of pressure ulcers following SCI.

Occupational therapy workforce needs: a model for demand-based studies.

PURPOSE: To provide a model for assessing occupational therapy workforce needs by using a demand-based approach to determine current workforce status in the Northwest region. Regional information may have implications for addressing national occupational therapy service needs. METHOD: A questionnaire was sent to a proportional random sample of 234 facilities that hire occupational therapy practitioners. Data were collected in July-August 2003 using structured mailing and follow-up procedures. RESULTS: Response rate was 79%. Twenty-four percent reported occupational therapy vacancies and 11% occupational therapy assistant vacancies; 48% predicted an increase in occupational therapy positions in the next 2 years and 41% an increase in occupational therapy assistant positions. Sixty-three percent of respondents reported difficulty in hiring. DISCUSSION: This study identifies an occupational therapy workforce shortage in the Northwest. Management of a shortage is critical, for even short-term adjustments could lead to permanent changes in service provision. This study demonstrates the importance of current information on the status of the national workforce and serves as a model for future studies.

Supports and barriers as experienced by individuals with vision loss from diabetes.

PURPOSE: The purpose of this study was to explore the perceived environmental supports and barriers to daily functioning for people with low vision due to diabetic retinopathy and the adaptive strategies used by these individuals to improve person-environment fit. METHOD: The researchers used a qualitative descriptive approach with eight participants with low vision as a result of diabetic retinopathy. Data collection methods included semi-structured interviews, observation of participants' home environments and focus group discussions. RESULTS: Participants described aspects of the physical environment, the social environment and psychological adjustment as important in adapting to vision loss and diabetes. Four themes emerged from the data analysis: "It's a Complicated Life", "The World Isn't Accessible", "Making it Work" and "Learning to be Blind". CONCLUSIONS: Physical and social environmental influences on functioning are complex. Adaptation to vision loss is an ongoing process that may be aided by peer interactions and more community-based rehabilitation. To best rehabilitate people with low vision due to diabetic retinopathy, the influence of both the physical and social environment along with psychological adaptation need to be considered. Periodic rehabilitation, interventions taking place in community settings and the formal inclusion of peers in the rehabilitation process may be indicated. Implications for Rehabilitation Consideration of the social as well as the physical environment is essential in the rehabilitation of people with low vision due to diabetic retinopathy. Adaptation to vision loss by those with diabetic retinopathy is complicated by the fact that diabetes is a systemic disease that affects multiple body systems. Psychological adaptation to vision loss is characterized by cycles of grieving and acceptance, which affects readiness for rehabilitation. Alternative approaches to rehabilitation may be indicated for people with low vision due to diabetic retinopathy, including periodic intervention over time and the inclusion of peers in the rehabilitation process.