Community resource facilitation use by ethnic minority groups with traumatic brain injury in the Midwestern United States.

OBJECTIVE: This study surveyed the use of community-based resource facilitation (RF) services by ethnic minority survivors of traumatic brain injury (TBI) living in the Midwestern United States. METHOD: Past records of RF use by survivors of TBI were reviewed. Demographics and patterns of RF use across 3 ethnic groups were documented. Reported barriers to community integration related to ethnic identity were identified using Chi-square test of independence. RESULTS: Ethnic minority survivors were less likely to use RF services than white survivors. Caucasian women and men utilized RF services at similar rates, whereas more African American men and Latina women used RF services. Caucasians received information about RF from a greater variety of sources than ethnic minority survivors. Ethnic identity was significantly associated with greater reported needs for TBI awareness. CONCLUSIONS: A pattern of differential RF use by survivors from ethnic minority groups was noted, suggesting potential socio-cultural influences on help-seeking behavior after TBI. These factors should be considered to develop more accessible and equitable strategies of RF service referral and support. Future investigations of cultural perspectives of TBI and injury-related services may improve understanding of the likelihood and necessity of community-based RF service use by diverse populations.

The impact of resource facilitation on recidivism for individuals with traumatic brain injury: A pilot, non-randomized controlled study.

OBJECTIVE: Research has shown that as many as 60% of adults in the criminal justice system have a history of traumatic brain injury (TBI), but the examination of effective interventions to reduce recidivism has only just begun. The present study explored the extent to which resource facilitation (RF) may decrease recidivism among those individuals with TBI. METHODS: Over a 2-year period, a prospective, non-randomized controlled study was conducted that included 1,504 justice-involved individuals exiting the Indiana Department of Corrections (IDOC). Participants were screened for a history of TBI as they entered parole or community corrections, with 211 (14%) offenders screening positive for moderate-to-severe TBI. Thirty-one of the 211 offenders offered RF chose to participate in the intervention, while 180 declined and served as the comparison group. RESULTS: Participants in RF were found to recidivate significantly less often at 6 and 12 months post-release when looking at rearrests or return to incarceration combined between the two groups. CONCLUSION: Our findings suggest that the increased risk for reincarceration in those individuals with TBI could be mitigated by the use of RF.

Recommendations for Prescribing Opioids for People With Traumatic Brain Injury.

Our objective was to make recommendations intended to reduce the rate of opioid misuse and overdose for a particularly high-risk group of people with traumatic brain injury (TBI). A consensus process conducted with TBI researchers and expert practitioners developed practical recommendations to inform prescribing of opioids for people with TBI. After determining key general principles for prescribing opioids for people with TBI, 6 TBI-specific recommendations were developed, 1 for acute pain in the agitated patient with TBI, 3 recommendations to be considered before prescribing an opioid, and 2 for follow-up and use by mental health and substance use disorder providers. While there is much needed research to examine the relationship between opioid misuse and TBI, the present recommendations provide at least some clinical considerations that might serve to prevent further deaths among a high-risk group.

Provision of resource facilitation services for individuals with acquired brain injury across the United States: results of a 2018 resource facilitator provider survey.

OBJECTIVE: Resource Facilitation is a lesser-known service line within the field of brain injury rehabilitation and has been described as similar to case management, care coordination, and neuronavigation. The purpose of this project was to evaluate current Resource Facilitation programs and provide a comprehensive summary of program characteristics to work toward a common definition of Resource Facilitation services and inform future program development and evaluation frameworks. MATERIALS AND METHODS: An online survey was sent to all known Resource Facilitation programs in the US (N = 70). DATA COLLECTION: Completed through Survey Monkey including information related to program history, structure, population served, and outcomes measurement. STATISTICALANALYSIS: Descriptive statistical analyses were applied. RESULTS: Twenty-four of the 70 programs completed the survey, resulting in a 34% completion rate. This snapshot of the current definitions and activities demonstrated high variability across programs regarding structure, funding, eligibility, and data collection. Only 33% of programs reported having a program evaluation system. CONCLUSIONS: This project provided a comprehensive summary of Resource Facilitation program characteristics and associated outcome metrics. The findings may be used to begin the formulation of a common definition of Resource Facilitation services, a program evaluation framework, and aid in establishing a common data set across programs.

Evidence-Based Cognitive Rehabilitation: Systematic Review of the Literature From 2009 Through 2014.

OBJECTIVES: To conduct an updated, systematic review of the clinical literature, classify studies based on the strength of research design, and derive consensual, evidence-based clinical recommendations for cognitive rehabilitation of people with traumatic brain injury (TBI) or stroke. DATA SOURCES: Online PubMed and print journal searches identified citations for 250 articles published from 2009 through 2014. STUDY SELECTION: Selected for inclusion were 186 articles after initial screening. Fifty articles were initially excluded (24 focusing on patients without neurologic diagnoses, pediatric patients, or other patients with neurologic diagnoses, 10 noncognitive interventions, 13 descriptive protocols or studies, 3 nontreatment studies). Fifteen articles were excluded after complete review (1 other neurologic diagnosis, 2 nontreatment studies, 1 qualitative study, 4 descriptive articles, 7 secondary analyses). 121 studies were fully reviewed. DATA EXTRACTION: Articles were reviewed by the Cognitive Rehabilitation Task Force (CRTF) members according to specific criteria for study design and quality, and classified as providing class I, class II, or class III evidence. Articles were assigned to 1 of 6 possible categories (based on interventions for attention, vision and neglect, language and communication skills, memory, executive function, or comprehensive-integrated interventions). DATA SYNTHESIS: Of 121 studies, 41 were rated as class I, 3 as class Ia, 14 as class II, and 63 as class III. Recommendations were derived by CRTF consensus from the relative strengths of the evidence, based on the decision rules applied in prior reviews. CONCLUSIONS: CRTF has now evaluated 491 articles (109 class I or Ia, 68 class II, and 314 class III) and makes 29 recommendations for evidence-based practice of cognitive rehabilitation (9 Practice Standards, 9 Practice Guidelines, 11 Practice Options). Evidence supports Practice Standards for (1) attention deficits after TBI or stroke; (2) visual scanning for neglect after right-hemisphere stroke; (3) compensatory strategies for mild memory deficits; (4) language deficits after left-hemisphere stroke; (5) social-communication deficits after TBI; (6) metacognitive strategy training for deficits in executive functioning; and (7) comprehensive-holistic neuropsychological rehabilitation to reduce cognitive and functional disability after TBI or stroke.

Models of brain injury vocational rehabilitation: The evidence for resource facilitation from efficacy to effectiveness.

BACKGROUND: Resource Facilitation (RF) is an intervention developed to improve return to work (RTW) following brain injury. RF is an individualized treatment specializing in connecting patients and caregivers with community-based resources and services to mitigate barriers to return to work. OBJECTIVES: Examine the effectiveness of the RHI RF program for a clinical prospective cohort of participants referred to this program from the State Vocational Rehabilitation agency. METHODS: Participants were 243 participants with data drawn from the two sources: 33 from previous randomized controlled trial (RCT) control groups who did not receive RF and 210 from clinical patients discharged from the RHI RF program. RESULTS: At discharge from RF, a greater proportion of the treatment group obtained employment than the control group [X2 (1)  = 5.39, p = 0.018]. When controlling for baseline level of disability, treatment group significantly predicted employment outcome (Wald = 4.52, p = 0.033) and participants in the treatment group were 2.3 times more likely to return to work than controls. CONCLUSIONS: Previous RCTs have studied the RHI RF model and demonstrated significant efficacy. The findings from the present study are consistent with the employment rates found in the previous RCT's following RF, and also provide initial support for the clinical effectiveness of RF.

Replication of a Prospective Randomized Controlled Trial of Resource Facilitation to Improve Return to Work and School After Brain Injury.

OBJECTIVE: To determine the extent to which previous findings on the effectiveness of resource facilitation to impact return to work and school could be replicated. DESIGN: Randomized controlled trial. SETTING: Outpatient rehabilitation clinic. PARTICIPANTS: Outpatients with acquired brain injury (N=44). INTERVENTION: Fifteen months of resource facilitation services. MAIN OUTCOME MEASURES: A revised version of the Vocational Independence Scale and the Mayo-Portland Adaptability Inventory-4 Participation Index. RESULTS: Participants randomized to the resource facilitation group demonstrated a significant advantage in terms of rate and timing of return to productive community-based work relative to control participants. When examining only return to competitive work (and not return to school), 69% of the resource facilitation group was able to return compared with 50% of the control participants. Analyses of measures of participation in household and community activities revealed that both groups improved significantly over the 15-month study period, but no significant advantage for either group was demonstrated. CONCLUSIONS: This study replicates the positive impact of resource facilitation in improving productive community-based activity, including competitive employment and volunteering in the community.

Traumatic Brain Injury in Indiana's Correctional System: Prevalence and Recidivism.

This article identified rates of traumatic brain injury (TBI) and recidivism among people incarcerated or exiting incarceration in Indiana using data from different sectors of the incarcerated population. This article was a collaboration between the rehabilitation hospital of Indiana and both the Indiana Department of Correction (IDOC) and the problem-solving courts of Marion County, resulting in two distinct screening samples. Participants in the IDOC sample (N = 2,791) were screened over a period of 2 years and 4 months. Participants in the specialty courts sample (N = 189) were screened between August and October 2016. The rates of moderate-to-severe TBI in the samples were highly variable and ranged from 13% to 86%, higher than in the general population. Recidivism rates for those with TBI were significantly higher than among participants without TBI at 6 and 12 months postrelease. Formerly incarcerated people from the IDOC sample reporting a moderate-to-severe TBI were nearly two times more likely to return to incarceration within 1 year of release.

Brain injury coping skills group: a preventative intervention for patients with brain injury and their caregivers.

OBJECTIVE: To determine whether training in coping strategies will improve psychologic functioning and self-efficacy in survivors of brain injury (BI) and caregivers. DESIGN: Randomized controlled pilot study with measurements at baseline, postintervention, and 3-month follow-up. SETTING: Postacute rehabilitation clinic. PARTICIPANTS: Survivors of BI (n=20) and caregivers (n=20). INTERVENTIONS: The Brain Injury Coping Skills Group is a 12-session, manualized, cognitive-behavioral treatment (CBT) group providing psychoeducation, support, and coping skills training. Effects of this preventative intervention were examined on emotional functioning and perceived self-efficacy (PSE). MAIN OUTCOME MEASURES: Brief Symptom Inventory-18 (BSI-18) and Brain Injury Coping Skills Questionnaire. RESULTS: Analyses revealed that the Brain Injury Coping Skills group showed significantly improved PSE compared with the control group immediately posttreatment (F=14.16; P=.001) and maintained this over time. PSE assessed posttreatment predicted global distress at 3-month follow-up across groups (rho=-.46). No differences between treatment and control groups were apparent on the BSI-18 posttreatment. However, the control group showed increased emotional distress at 3-month follow-up while the Brain Injury Coping Skills group remained stable over time. CONCLUSIONS: Few CBT studies have included survivors of BI and caregivers together in group treatment or included a control group. No prior studies have examined the role of PSE specifically. Prior intervention studies show inconsistent effects on emotional functioning, raising questions regarding the role of intervening variables. This study offers a new conceptualization that PSE may moderate longer-term emotional adjustment after brain injury. Results indicate that PSE is an important and modifiable factor in helping persons better adjust to BI.

Prospective randomized controlled trial of resource facilitation on community participation and vocational outcome following brain injury.

OBJECTIVE: To examine the impact of resource facilitation (RF) on return to work, participation in home and community activities, and depression. PARTICIPANTS: Twenty-two people with acquired brain injury (mean age = 43 years; mean education = 13.3 years). DESIGN: A prospective randomized controlled trial of RF compared with standard care. All participants received standard follow-up services, but participants in the RF group were also assigned a resource facilitator to assist them in returning to work. RESULTS: Participation increased significantly for both groups (F = 60.65, P < .0001), but the interaction between groups and time demonstrated greater improvement for the RF group relative to controls (F = 9.11, P < .007). Also, 64% of the RF group was employed at follow-up compared with 36% of the control group (Wald-Wolfkowitz z = -3.277, P < .0001). No significant differences were found between groups on measures of depression. CONCLUSION: Resource facilitation services that have a clear focus on return to work may have a substantial impact on participation and unemployment after brain injury.

Initial validation of a brief provisional diagnostic scale for delirium.

PRIMARY OBJECTIVE: The Delirium Diagnostic Tool-Provisional (DDT-Pro) is a newly developed provisional diagnostic tool for delirium presented here. This study evaluated its accuracy and validity in a population of participants with acquired brain injury (ABI). RESEARCH DESIGN: Cross-sectional study. METHODS: Thirty-six patients with ABI, including traumatic brain injury (TBI; n = 29) and intraparenchymal haemorrhage (ICH; n = 7) were assessed at admission to inpatient rehabilitation using the DDT-Pro, the Delirium Rating Scale-Revised 98 (DRS-R98) and DSM-IV-TR diagnostic criteria for delirium. RESULTS: Using receiver operating characteristic (ROC) analysis, the estimate of accuracy, the area under the curve (AUC), was 0.994, and the DDT-Pro accurately classified 35/36 (97%) observations vs the DSM-IV-TR gold standard. The DDT-Pro correlated well with the DRS-R98 both in terms of raw score (r = -0.913, p < 0.0001) and estimates of the duration of delirium (r = 0.975, p < 0.0001). CONCLUSIONS: The DDT-Pro is supported as a measure of delirium following ABI. Further validation in ABI and other medical populations is recommended.

Mortality Secondary to Unintentional Poisoning after Inpatient Rehabilitation among Individuals with Moderate to Severe Traumatic Brain Injury.

Studies have shown reduced life expectancy following moderate-severe traumatic brain injury (TBI) with death from unintentional poisoning (UP) being 11 times higher following TBI than in the general population. The characteristics of those who die of unintentional poisoning are compared with the characteristics of those who die of other causes (OC) in a retrospective cohort who received inpatient rehabilitation following TBI and enrolled in the TBI Model Systems National Database between 1989 and 2017 (n = 15,835 cases with 2,238 deaths recorded). Seventy-eight cases (3.5%) of deaths were the result of UP, 76% were the result of OC, and 20.5% were from an unknown cause. Among the UP deaths, 90% involved drugs (of these, 67% involved narcotic drugs and 14% involved psychostimulants), and 8% involved alcohol. Age-adjusted risk for UP death was associated with: white/non-Hispanic race/ethnicity, living alone, non-institutionalization, pre- and post-injury illicit drug use and alcohol/drug problem use, any alcohol use at last follow-up, better Functional Independence MeasureTM (FIM) scores, history of arrest, moderate disability (vs. severe disability or good recovery), less supervision needed, and greater anxiety. Adults who receive inpatient rehabilitation for TBI who die from UP are distinguishable from those who die of OC. Factors such as pre-injury substance use in the context of functional independence may be regarded as targets for prevention and/or intervention to reduce substance use and substance-related mortality among survivors of moderate-severe TBI. The current findings may have implications for medical care, surveillance, prevention, and health promotion.

Awareness of activity limitations and prediction of performance in patients with brain injuries and orthopedic disorders.

The aim of this study was to compare the accuracy of performance predictions in experimental tasks with patients' awareness of activity limitations. Participants were 24 patients with brain injuries (i.e., traumatic brain injury and cerebrovascular disorders) and 22 patients with orthopedic disorders. Prediction of performance was examined in a memory task (word list learning) and a motor task (finger tapping). Awareness of activity limitations was measured by comparing patients' self-ratings and staff ratings in the Patient Competency Rating Scale (PCRS). Results for the PCRS showed that patients with orthopedic disorders underestimated and patients with brain injuries (i.e., patients with TBI) overestimated their level of functioning in the total scale and the social/emotional subscale in comparison to staff ratings. Both patient groups agreed with staff ratings in physical/basic self-care items. In the predicted performance tasks a similar pattern could be observed: None of the groups showed an overestimation of performance in the motor task, whereas patients with brain injuries overestimated their competency in the memory task. However, the agreement between both awareness measures (PCRS, predicted performance) was only low, which indicates that they might measure different aspects or levels of self-awareness.

Awareness of activity limitations, goal setting and rehabilitation outcome in patients with brain injuries.

PRIMARY OBJECTIVE: To examine the relationship between self-awareness, goal setting ability (i.e. ability to set realistic goals) and performance/outcome in a cognitive task and for rehabilitation. RESEARCH DESIGN: Regression analyses were conducted to compare the predictive power of self-awareness and demographic/neuropsychological variables on goal setting ability and performance/outcome. METHODS AND PROCEDURES: Self-awareness of 63 patients with brain injuries was measured by direct clinicians' rating and the difference between patient and staff ratings in a questionnaire. RESULTS: The awareness measures predicted 32% of the variance for goal setting ability in the rehabilitation context but only 4% of the goal setting variance in the cognitive task. Similarly, self-awareness predicted 33% of the variance for rehabilitation outcome but only 5% of the performance in the cognitive task. CONCLUSIONS: Self-awareness seems to be related to goal setting ability and outcome in a long-term rehabilitation process but less in short-term experimental tasks.

Development and exploratory analysis of the Neurorehabilitation Program Styles Survey.

OBJECTIVE: To develop a survey instrument that assesses implementation of key components of outpatient neurorehabilitation programs and test the capacity of this instrument to differentiate between rehabilitation approaches. DESIGN: The Neurorehabilitation Program Styles Survey (NPSS) was administered to 18 outpatient facilities: 10 specialized and 8 discipline-specific outpatient neurorehabilitation programs. Scores were compared between types of programs using independent samples t tests. RESULTS: The NPSS showed good reliability and contrasted groups validity, significantly differentiating between types of programs. CONCLUSIONS: The NPSS holds considerable promise as a tool for distinguishing among different types of brain injury programs, and for assessing the differential effectiveness of specialized versus discipline-specific outpatient brain rehabilitation programs. Future research on the NPSS will assess the stability of the instrument over time, its content validity, and capacity to differentiate the full continuum of neurorehabilitation programs.