Exploring the goals and outcomes of adults with severe acquired brain injury participating in an extended inpatient brain injury rehabilitation unit in Australia.

PURPOSE: To explore the rehabilitation goals and evaluate goal attainment outcomes of people with severe acquired brain injury (ABI), and investigate the relationship between goal engagement and goal attainment. MATERIALS AND METHODS: Mixed-methods cohort study with twenty-nine adults with severe ABI in Australia. Demographic data, goal statements and pre-post program Goal Attainment Scale scores as well as Goal Engagement Scale scores were collected. Goals were coded using inductive content analysis and categorised by ICF component and domain. Goal attainment within ICF categories was described and compared using descriptive statistics. Pre-post program change in goal attainment was evaluated using Wilcoxon signed rank tests and correlations between goal engagement and attainment was explored using Spearman's (rho). RESULTS: 94% of 320 goals were categorised as ICF Activity and Participation. There was significant improvement in goal attainment between admission and discharge (z=-0.47, p < 0.01). There was no significant relationship between goal engagement and goal attainment however there was a positive association between engagement in goal setting at admission and discharge.Conclusions: This interdisciplinary, inpatient rehabilitation program underpinned by key-worker facilitated person-centred, role-based goal setting resulted in goal attainment in chosen goals, which were primarily activity and participation-focused.

Goal setting is a core rehabilitation practice and service delivery models that facilitate collaborative goal setting which engages patients, their significant others and health professionals as a team are necessary to enable person-centred care.Role-based goal setting effectively engaged patients with acquired brain injury and their families, facilitating goal setting and the formation of activity and participation-focused rehabilitation goals in this extended rehabilitation setting.

The Priority Goals and Underlying Impairments Contributing to Goal-Related Problems of People with Parkinson's Disease Receiving a Community-Based Rehabilitation Program.

Background: Goal setting is a core rehabilitation practice in Parkinson's disease (PD). Targeting therapy towards specific goals leads to greater improvements in performance and psychosocial outcomes. Goal setting in PD is feasible, and although the nature of goals has been described in previous studies, the underlying impairments related to goals have not been described. Understanding the nature of goals ensures that interventions for people with PD are aligned with their needs and priorities. Understanding the underlying impairments highlights which symptoms have the biggest impact on daily life and is necessary for planning appropriate interventions to target them. Aim: To describe the nature of the goals of people with PD; the underlying impairments related to goals; and to compare differences between high and low priority goals. Method: Deductive content analysis was used to map goal statements to the international classification of function (ICF) activity and participation category and to map therapist field notes detailing the primary underlying impairment to the ICF Body Functions category. These results were then compared across goal priority rankings. Results: 88 goals of 22 people with PD were analysed. We found that people with PD set diverse goals across all chapters of the ICF Activity and Participation category, with "self-care" goals making up the highest proportion of goals. The primary underlying impairment related to the goals was predominantly related to impairments in "mental functions" under the Body Functions category. Regardless of goal priority, most goal-related underlying impairments were found to be in the "mental functions" category. Conclusion: The goals of this sample of community-dwelling people with PD highlight their diverse needs and priorities. These findings indicate that nonmotor symptoms, namely, executive dysfunction and amotivation most commonly impact the performance of and participation in activities of greatest importance to people with PD. This trial is registered with ACTRN12621001483842.

Capacity building for providers of cognitive rehabilitation in Queensland: a needs analysis survey.

Background Cognitive rehabilitation of people with traumatic brain injury is a complex and challenging area of practice. Practitioners working in cognitive rehabilitation require ongoing training to stay abreast of new research and best practice interventions. A needs analysis was conducted to inform the development of a capacity building program for cognitive rehabilitation providers. Methods A cross-sectional online survey of providers of cognitive rehabilitation services in Queensland collected data on demographic information, perceptions of knowledge, skills and confidence in cognitive rehabilitation, previously completed training, desired training opportunities and delivery methods, and barriers and facilitators to engaging in training. Results The 103 respondents included 67 occupational therapists, 17 speech pathologists, 12 psychologists and seven social workers with a broad range of practice experience. Participants perceived a need for further training, with executive function and functional cognition the most desired topics. The number of topics previously trained on was significantly correlated with levels of knowledge, skills and confidence (P Conclusion Cognitive rehabilitation providers in Queensland reported a need for further training, delivered flexibly, with a focus on managing complex cognitive impairments.

Pilot evaluation of a digital approach to occupational therapy home assessments: acceptability and efficiency compared with usual practice in a hospital.

INTRODUCTION: Pre-discharge home assessments by occupational therapists facilitate safe and timely discharge from hospital and are associated with better health outcomes. Digital technology offers the potential to reduce duplication of documentation and improve communication and sharing of home assessment findings. OBJECTIVE: This quality improvement project evaluated time-cost; clinician satisfaction and confidence; and acceptability of the use of a digital approach to home assessments. METHODS: A prospective, cross-sectional design was used to compare usual practice with the digital approach across two sub-acute wards in a large metropolitan hospital in Queensland, Australia. Time to document and conduct home assessments as well as clinician satisfaction and confidence were compared using descriptive statistics. Clinician perspectives about the home assessment approaches were collected through a survey and analyzed using content analysis. RESULTS: Home assessment and documentation time were significantly lower for the home assessments conducted using the digital approach compared with usual practice assessments. Clinician satisfaction with using digital technology was higher. CONCLUSIONS: The introduction of this simple technology reduced clinicians' time to conduct home assessments and document home assessment reports. The project was well received by occupational therapy clinicians. SPANISH ABSTRACT: http://links.lww.com/IJEBH/A187.

The perspectives of participants with traumatic brain injury on prospective memory rehabilitation incorporating compensatory and metacognitive skills training.

OBJECTIVE: Patient feedback is rarely gathered systematically in cognitive rehabilitation research. This study examined the perceptions and experiences of people with traumatic brain injury (TBI) who participated in a trial of a 6-session educational program for the rehabilitation of prospective memory (PM) impairment. METHODS: A mixed methods design was used with 47 participants with TBI who completed a compensatory strategy training program (COMP) or COMP plus metacognitive strategy training program (COMP-MST) delivered by an occupational therapist. Data were collected via a participant survey, extracts from progress notes, and audiotaped discussions about learnings from the program during the final session. RESULTS: Participants from both programs were highly satisfied and perceived improvements in everyday PM performance post-intervention. Elements that were highly valued include setting individualised client-centred goals, repetitive training of strategy use, establishing habits and routines, and receiving experiential, verbal, and written feedback.Changes including more therapy sessions were recommended. CONCLUSIONS: Both the COMP and COMP-MST programs were perceived as effective by participants with TBI in improving their PM performance in everyday life using compensatory strategies such as assistive technology. PRACTICE IMPLICATIONS: Routine collection of patient feedback on cognitive rehabilitation can provide valuable information to support person-centred implementation of clinical practice guidelines.

Planning for Change: Co-Designing Implementation Strategies to Improve the Use of Sensory Approaches in an Acute Psychiatric Unit.

Implementing sensory approaches in psychiatric units has proven challenging. This multi-staged study involved qualitative interviews (n = 7) with mental health care staff in an acute psychiatric ward to identify the local factors influencing use of sensory approaches, and co-design implementation strategies with key stakeholders to improve their use. Using framework analysis, results revealed that the use of sensory approaches were hindered by: inadequate access to sensory resources/equipment; lack of time; lack of staff knowledge; and belief that sensory approaches are not effective or part of staff's role. To address identified barriers a systematic theory-informed method was used to co-design implementation strategies to improve the use of sensory approaches.

Efficacy and Feasibility of the CO-OP Approach in Parkinson's Disease: RCT Study Protocol.

Background. Parkinson's disease (PD) leads to cognitive dysfunction which limits participation and occupational performance. Cognitive Orientation to Daily Occupational Performance (CO-OP) approach is effective in other adult neurological populations and warrants investigation in PD. Purpose. To describe a study protocol evaluating the preliminary efficacy and feasibility of CO-OP approach in PD. Method. A randomised controlled trial (RCT) with adults with PD was assigned to either: CO-OP training-intensive (CO-OP-I, 20 sessions) or waitlist control (WLC) followed by CO-OP-standard (CO-OP-S, 10 sessions). Outcomes. Occupational performance and satisfaction of adults with PD in chosen goals. Measures will be obtained at baseline, post-intervention, and 3-month follow-up. Implications. As the first RCT focused on CO-OP in PD, this trial will provide evidence for the potential of this approach in PD and lay the groundwork for future large-scale trials. Trial Registration. Australian New Zealand Clinical Trials registry, ACTRN12621001483842. Registered November 1, 2021; retrospectively registered 3 months after commencement.

Normalising interdisciplinary role-based goal setting in inpatient brain injury rehabilitation: reflections and recommendations of clinicians.

PURPOSE: Person-centred goal setting with people with brain injury, by interdisciplinary teams has benefits including improved communication between patients, families and clinicians, person-centred care, and improved engagement in rehabilitation. Exploring the experiences of team members who have adopted interdisciplinary, person-centred goal setting may assist in understanding what is needed to implement this complex, core component of rehabilitation practice. This study explored experiences of clinicians working in an extended inpatient brain injury rehabilitation unit about implementing a role-based goal planning approach within an interdisciplinary team. MATERIALS AND METHODS: Semi-structured interviews with 13 clinicians working at the rehabilitation unit explored their experiences about the cognitive participation and collective actions required to carry out the practice, with data analysed using inductive content analysis guided by Normalisation Process Theory. RESULTS: Three primary themes were identified: putting the person at the centre, accepting the mind-shift to participation focused goals and working collaboratively. CONCLUSIONS: This study has elucidated some key processes that occurred and were necessary to carry out goal setting. A mind-shift towards holistic, participation-focussed goal setting was described as "unlearning" discipline-specific goal setting. Development and ownership by the team, acceptance of team members and willingness to share, and structured processes and resources were necessary.IMPLICATIONS FOR REHABILITATIONNormalising interdisciplinary role-based goal setting in multi-professional teams requires a mind-shift away from traditional, discipline-specific goal setting.Implementation of interdisciplinary, collaborative team goal setting within health service settings requires collective actions including collaborative working by team members, structured processes including organised time for collaborative team and family meetings, practical resources and training to support processes.Clinicians perceived the goal setting approach to put the person at the centre resulting in a deep understanding of the person, shared understanding, and motivation for rehabilitation.

Navigating the application of new innovations: Establishing an indocyanine green lymphography clinic in Australia.

Translation of evidence into practice in healthcare is challenging, particularly with new innovations. Indocyanine Green (ICG) lymphography is a novel innovation where the superficial lymphatics are imaged to provide information about lymphoedema diagnosis and to guide individualised therapy for a person's long-term chronic management of lymphoedema, supporting care across the continuum to the community setting. Despite the unique information ICG lymphography provides, the technology itself is complex and highly specialised and currently has limited adoption in clinical practice. This paper sought to determine the barriers and enablers to establishing an ICG lymphography clinic within an outpatient lymphoedema service by exploring staff perceptions and experiences. An interpretive descriptive design was used with semi-structured interviews of key staff participants from a quaternary public hospital six months after ICG lymphography clinic establishment. An interview guide was developed, underpinned by the Consolidated Framework for Implementation Research (CFIR), to guide the inquiry. Interview data were transcribed, inductively coded and analysed to identify themes. All eligible management, clinical and ancillary staff were included (N = 8). Four key themes were identified from the data as essential to implementation success. These were support is critical for implementation; beliefs about the technology; practicalities are achievable; and sustainability for ongoing success. Themes were found to be interrelated and centred around support from staff and the organisation as a critical process facilitator. The study demonstrated an ICG lymphography clinic can be successfully established as part of an outpatient lymphoedema service. Key enablers related to positive staff attitudes and beliefs about ICG lymphography and its application. Future implementation sites may consider that although the complexity of this innovation creates process challenges, the use of an implementation framework can assist in identifying determinants of success for effective implementation to practice.

Efficacy of Prospective Memory Rehabilitation Plus Metacognitive Skills Training for Adults With Traumatic Brain Injury: A Randomized Controlled Trial.

BACKGROUND: Prospective memory (PM) failure can limit independence and productivity following traumatic brain injury (TBI). Compensatory strategy use may ameliorate the effect of PM impairment on daily life but requires sufficient self-awareness. Metacognitive skills training (MST) can facilitate self-awareness and strategy use and may improve the efficacy of PM rehabilitation. OBJECTIVE: To evaluate the effectiveness of compensatory strategy training (COMP) with an MST component (COMP-MST) for reducing everyday PM failure and improving psychosocial integration in adults with moderate-severe TBI, compared to COMP alone and a control condition. Secondary aims were to evaluate the effect of training on psychometric PM test scores, strategy use, self-awareness, and level of care. METHODS: Assessor and participant-blinded randomized controlled trial with 52 participants (77% male, mean age = 39.0. SD = 13.6) allocated to 3 groups: COMP-MST, COMP, and waitlist control. Interventions were delivered over 6 weekly sessions. Measures were collected pre- and post-intervention and 3-month follow-up. Data were analyzed using unstructured linear mixed-effects modeling for repeated measures and planned contrasts between time-points for each group. RESULTS: The models showed no significant differences between the groups on primary or secondary outcome measures. Significant pre-post intervention improvements were found for significant other's ratings of everyday PM failure for both intervention groups but not the control group, with medium to large effect sizes. Clinically relevant improvements on primary outcomes were found for participants across all 3 groups. CONCLUSIONS: This study found no significant benefits of combining MST with COMP for improving everyday PM and psychosocial integration. CLINICAL TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry https://www.anzctr.org.au/ ACTRN12615000996561.

Improving self-awareness of prospective memory function after TBI using experiential feedback on a board game activity: An observational study.

This study investigated whether experiential and video feedback on performance of prospective memory (PM) tasks embedded within a board game activity improved self-awareness of PM function in adults with moderate-severe traumatic brain injury. An observational pre-post study design with 26 participants from a larger trial of a 6-session PM rehabilitation programme. Sessions 3 and 4 included a board game activity with embedded time-, event-, and activity-based PM tasks. Verbal feedback was provided by therapists during the game and video feedback afterwards. Self-ratings of performance were used to divide the sample into under-estimators (n = 7), accurate estimators (n = 9) and over-estimators (n = 10) of actual PM performance. The discrepancy between self- and therapist ratings of PM performance was measured before and after the game, and following video feedback, and compared between timepoints using non-parametric statistics. Post-task self-evaluations were more accurate than pre-task self-evaluations for the under- and over-estimator groups. Under-estimators showed significant improvement in accuracy of ratings for activity-based PM. Over-estimators showed improvement for event-based PM. Further improvements after video feedback were not significant. The board game activity provided a vehicle for experiential feedback and a means of engaging both those with impaired self-awareness and heightened self-awareness of PM in cognitive rehabilitation.

Student-resourced service delivery of occupational therapy rehabilitation groups: patient, clinician and student perspectives about the ingredients for success.

BACKGROUND: A number of innovative models of student practice placements are emerging due to pressures on universities to provide quality practice placements and on health services to deliver rehabilitation efficiently, safely and cost-effectively. The student-resourced service delivery (SRSD) group program is one such model in occupational therapy. There is a paucity of research evidence to guide services in planning, implementing and evaluating the SRSD model. OBJECTIVE: The study aimed to explore and identify the factors that key stakeholders perceived as contributing to the successful development and implementation of the occupational therapy student-resourced service delivery group programs. METHODS: Participants in this multi-site study were rehabilitation inpatients, clinicians, Clinical Education Liaison Managers and students completing practice placement in the student-resourced service delivery group program. Data were collected using face-to-face semi-structured interviews and focus groups. RESULTS: A total of 83 participants consented to the study. Four themes emerged from the data. Planning needs to be an iterative process that commences before and continues during the program. Support processes need to be established for students and clinicians during and across placements. The creation of an engaging, client-relevant and graded group dynamic is critical for success. Establishing a culture whereby groups are valued by the clients, therapy and multidisciplinary teams is important. CONCLUSIONS: The above-mentioned factors were perceived as contributing to successful operationalisation of a student-resourced service delivery group program, and may be helpful when developing student-resourced service delivery professional practice placements in other settings.IMPLICATIONS FOR REHABILITATIONStudent-resourced service delivery of groups are one way to achieve additional professional practice placements for students and delivery of therapy services for patients.Ongoing investment for planning and preparation, provision of continual support for students, a culture of valuing groups and students, and creating a group dynamic that engages group participants were perceived by stakeholders as key ingredients for successful implementation of the student-resourced service delivery group model.Clinicians and educators are encouraged to use the perceived success factors identified in this study as a resource for future student-resourced service delivery program development.

It was just mind blowing to be honest: a qualitative phenomenological study exploring cancer survivor's experiences of indocyanine green lymphography used to inform lymphedema therapy management.

PURPOSE: A diagnosis of secondary lymphedema following cancer treatment can necessitate lifelong therapy. Indocyanine green (ICG) lymphography is a technique for visualising lymphatics to enable individualised lymphedema diagnosis, staging and therapy prescription. The participant experience of undergoing the procedure and the impact of imaging findings on lymphedema management is unknown. This study aimed to explore participant's experiences of ICG lymphography to inform cancer-related lymphedema therapy. METHODS: A qualitative phenomenological study was conducted using semi-structured interviews with 17 adult participants who had undergone ICG lymphography for stage 0 to 2 upper or lower limb secondary cancer-related lymphedema (International Society of Lymphology, Lymphology 53(1):3-10, 2020). RESULTS: Seventeen participants were included in the study ranging in age from 36 to 78 years (M = 53.8 years), the majority had a primary diagnosis of breast cancer (N = 7) or melanoma (N = 7). Three overarching themes emerged. Firstly, describing the experience of the ICG lymphography procedure. Secondly, the new knowledge explained symptoms and tailored treatment. Participants reflected on how seeing their lymphatic system helped in understanding about their lymphedema symptoms and guided changes towards more individualised lymphedema management. The final theme described the internal impact of self-knowledge, which included impacts of the new information on empowerment and motivation to self-manage participant's condition as well as their feelings. CONCLUSIONS: ICG lymphography had beneficial impacts on participant's understanding of their lymphedema symptoms and often led to changes in management, positive outcomes in response to management changes and peace of mind about management plans, leading to feeling more empowered to self-manage their condition.

Evaluation of an occupation-based metacognitive intervention targeting awareness, executive function and goal-related outcomes after traumatic brain injury using single-case experimental design methodology.

Self-awareness is commonly impaired after traumatic brain injury and impacts on rehabilitation engagement and community re-integration outcomes. Interventions which incorporate metacognitive strategy instruction have the potential to improve rehabilitation engagement and outcomes. This study aimed to determine whether an occupation-based intervention incorporating metacognitive strategy instruction resulted in goal achievement and improved online awareness and executive function performance during goal-related tasks. A single-case experimental design using a multiple-baseline design across behaviours was used with two participants with severe traumatic brain injury to evaluate the effectiveness of the 6-week intervention. Repeated measures of goal-related performance, percentage of self-corrected errors and executive function were made via independent analysis of video footage and documentation logs. Data analysis involved 2SD bandwidth analysis and overlap data, reliable change index and evaluation of goal achievement across phases. There were improvements in self-corrected errors for one participant, which were maintained. Significant reductions in anxiety (RCI = ±5.98) were evident for both participants, with a significant reduction in stress (RCI = ±7.05) for one participant following the intervention. The occupation-based intervention incorporating metacognitive strategy instruction led to improvements compared to baseline performance in some targeted goals, online awareness and executive function performance during goal-related tasks and reduced stress and anxiety.

Concordance between the Awareness Questionnaire and Self-Awareness of Deficits Interview for identifying impaired self-awareness in individuals with traumatic brain injury in the community.

OBJECTIVE: To investigate concordance between the Awareness Questionnaire (AQ) and Self-Awareness of Deficits Interview (SADI) for identifying impaired self-awareness in the community after traumatic brain injury. DESIGN: A retrospective file audit was conducted to retrieve data on the AQ and SADI for participants with traumatic brain injury involved in previous studies on community-based outcomes. Concordance between the AQ and SADI was examined using receiver operating characteristic curves for different scores on each measure. PARTICIPANTS: A total of 80 individuals with moderate-to-severe traumatic brain injury (81% male, mean age 2.25 years, standard deviation (SD) 11.5 years) living in the community. METHODS: Participants were administered the AQ and SADI and their significant other completed the AQ and SADI checklist. RESULTS: Consistency of classification of impaired self-awareness between the AQ and SADI was high (i.e. 80-84%) based on scores reflecting good sensitivity and specificity. Corresponding scores on the 2 measures and rates of impaired self-awareness were as follows: SADI > 3~AQ discrepancy > 4 (45-48% with impaired self-awareness); SADI > 4~AQ discrepancy > 9 (26-34% with impaired self-awareness); SADI > 5~AQ discrepancy >12 (13-26% with impaired self-awareness). CONCLUSION: The AQ and SADI yielded consistent information regarding the presence of impaired self-awareness in community-based individuals with traumatic brain injury. The choice of measure may depend on how the tool is being used to guide rehabilitation planning.

Refining a clinical practice framework to engage clients with brain injury in goal setting.

BACKGROUND/AIM: Client-centred goal setting is fundamental to occupational therapy practice and has been increasingly embraced by all rehabilitation practioners. Goal setting in clinical practice is a highly individualised process and may be more challenging with people with acquired brain injury. However, research examining practice is limited. We developed the Client-Centred Goal Setting Practice Framework to explain how client-centred goals are developed in brain injury rehabilitation. This framework was based on interview data and may reflect practitioner's theoretical knowledge rather than goal setting processes used in routine practice. The aims of this study were to explore the application of the framework to every-day practice, examine the extent to which goal setting was client-centred and refine the framework. METHODS: A mixed methods approach was employed. Participants were community dwelling clients with ABI and their practitioners, drawn from a hospital outpatient service and community private practices. The communication exchange between practitioners and clients during routine goal setting was audio-recorded, transcribed verbatim and analysed using framework analysis. Quantitative measures evaluated the client-centredness of goals. RESULTS: A total of 65 goal setting sessions with 36 clients and 17 practitioners (n = 8 occupational therapists) were analysed. The three goal setting phases of the framework and associated processes and strategies were represented. The 'establishing trust' process was interwoven throughout all phases and an additional strategy, 'social connection' was identified. CONCLUSION: The framework provides preliminary evidence about the core processes and strategies which uses establishing trust to engage clients with ABI in goal setting, and may be a useful tool to guide client-centred goal setting practice in similar services.

Patient perceptions of participation in group-based rehabilitation in an inpatient brain injury rehabilitation setting.

OBJECTIVES: The use of groups is common in healthcare. There is a paucity of research which captures patient experiences of group participation. The aims of this study were to explore the perceptions and experiences of people with traumatic brain injury (TBI) about their participation in inpatient occupational therapy rehabilitation groups. METHOD: A phenomenological approach guided the study. Patients with a TBI who were participating in an inpatient occupational therapy group program were recruited. Data were collected through semi-structured interviews and analysed using content analysis. RESULTS: Fifteen participants consented to the study. Three themes emerged from the data; 1) feeling normal, comfortable and connected; 2) learning by doing, seeing and sharing and; 3) practicalities of groups. Participants highlighted that groups facilitated opportunities to practice skills and prepared them for the real world. Opportunities for interaction and support were also emphasised as positive by participants. CONCLUSION: Perceptions of patients about participation in groups were generally positive, and as such a consumer-focused approach to healthcare would support the use of occupational therapy groups in TBI rehabilitation. PRACTICE IMPLICATIONS: Recommendations from the perspectives of patients include consideration of the selection of group participants, and meeting individual needs and goals within a group setting.

Rehabilitation goal setting with community dwelling adults with acquired brain injury: a theoretical framework derived from clinicians' reflections on practice.

PURPOSE: The aim of this study was to explore clinicians' experiences of implementing goal setting with community dwelling clients with acquired brain injury, to develop a goal setting practice framework. METHOD: Grounded theory methodology was employed. Clinicians, representing six disciplines across seven services, were recruited and interviewed until theoretical saturation was achieved. A total of 22 clinicians were interviewed. RESULTS: A theoretical framework was developed to explain how clinicians support clients to actively engage in goal setting in routine practice. The framework incorporates three phases: a needs identification phase, a goal operationalisation phase, and an intervention phase. Contextual factors, including personal and environmental influences, also affect how clinicians and clients engage in this process. Clinicians use additional strategies to support clients with impaired self-awareness. These include structured communication and metacognitive strategies to operationalise goals. For clients with emotional distress, clinicians provide additional time and intervention directed at new identity development. CONCLUSIONS: The goal setting practice framework may guide clinician's understanding of how to engage in client-centred goal setting in brain injury rehabilitation. There is a predilection towards a client-centred goal setting approach in the community setting, however, contextual factors can inhibit implementation of this approach. Implications for Rehabilitation The theoretical framework describes processes used to develop achievable client-centred goals with people with brain injury. Building rapport is a core strategy to engage clients with brain injury in goal setting. Clients with self-awareness impairment benefit from additional metacognitive strategies to participate in goal setting. Clients with emotional distress may need additional time for new identity development.

The occurrence of early impaired self-awareness after traumatic brain injury and its relationship with emotional distress and psychosocial functioning.

OBJECTIVE: To describe the occurrence of impaired self-awareness (ISA) after traumatic brain injury (TBI) and its association with emotional distress and psychosocial functioning following discharge. DESIGN: Prospective cohort design with data collection at discharge and 1-, 3- and 6-month follow-up. PARTICIPANTS: 81 adults with TBI. MEASURES: Self-awareness was measured using a discrepancy score generated from the Mayo-Portland Adaptability Index (MPAI-4) Ability subscale, and significant other's ratings of Item 20 on the MPAI-4. Other measures were the Depression Anxiety Stress Scale-21 and Sydney Psychosocial and Reintegration Scale. RESULTS: The discrepancy score method identified more cases of ISA than the single-item rating by significant others. Using discrepancy scores, the occurrence of ISA was 69.1% at discharge, and for those remaining in the study 6 months later, it was 54.3%. Better self-awareness was associated with greater anxiety at discharge, and stress at discharge, 3 and 6 months later, and better psychosocial functioning at all time points. Participants with ISA had significantly poorer relationships at 6 months post-discharge after controlling for injury severity. CONCLUSION: Whilst self-awareness is associated with greater stress in patients with TBI, it is also associated with better outcomes, indicating the importance of targeting ISA in rehabilitation.

Remediation of social communication impairments following traumatic brain injury using metacognitive strategy intervention: a pilot study.

OBJECTIVE: To perform a pilot study to evaluate whether a novel metacognitive, goal-based intervention improved and maintained the social communication skills of adults with traumatic brain injury (TBI). METHOD: Eight community-dwelling participants with TBI completed three study phases: (1) baseline, (2) eight-week intervention targeting social communication impairments and (3) follow-up. Participants completed the Profile of Pragmatic Impairment in Communication (PPIC), LaTrobe Communication Questionnaire (LCQ) and Goal Attainment Scaling (GAS) at the commencement of baseline phase, pre- and post-intervention and completion of the follow-up phase. During the intervention programme phase, participants attended two 1-hour therapy sessions (one individual; one group) per week focusing on remediating impaired social communication skills using metacognitive strategy intervention and goal-based therapy. RESULTS: Variable changes in PPIC feature-summary scores were observed post-intervention. A non-significant improvement in LCQ scores was also observed. There was a significant increase in GAS goal T-scores following the intervention, with six of the eight participants achieving or exceeding their expected level of performance on all goals. CONCLUSION: A goal-driven, metacognitive approach to intervention may assist individuals with TBI to achieve their personal social communication goals, with benefits reported by participants and observable during conversations. Further research is required.