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13. Community Reintegration Following Acquired Brain Injury

Shannon Janzen MSc, Pavlina Faltynek MSc, Andreea Lee BSc, Corbin Lippert BScN, Joshua Wiener BSc, Magdalena Mirkowski MSc MScOT OT Reg.(Ont.), Robert Teasell MD FRCPC

Abbreviations

ABI         Acquired Brain Injury

ADL        Activities of Daily Living

GCS        Glasgow Coma Scale

HADS     Hospital and Anxiety Depression Scale

PCT        Prospective Controlled Trial

QoL        Quality of Life

RCT        Randomized Controlled Trial

TBI          Traumatic Brain Injury

Key Points


Group-based therapy may improve independent living and social integration post ABI.

Certain cognitive rehabilitation interventions may improve independence and social integration post ABI.

Peer mentoring may not improve social integration post ABI.

Various community-based rehabilitation programs may improve independence and social integration post ABI.

Various multimodal interventions may or may not improve independence or social integration post ABI.

Multi-faceted rehabilitation, coping skills training, and support-based interventions may improve self-efficacy and/or perceived quality of life post ABI.

Virtual reality training may not be effective in improving employment outcomes compared to conventional psychoeducation post ABI.

Cognitive rehabilitation therapy may not be effective for improving employment rates post ABI.

Simulated educational experiences may be helpful for predicting an individual’s readiness to return to school post ABI.

Mentoring may be effective for improving employment and education rates post ABI.

Community-based vocational rehabilitation may improve employment rates post ABI.

Resource facilitation may improve employment rates post ABI.

Various multimodal interventions may improve employability post ABI.

Multidisciplinary neurorehabilitation may increase the number of individuals that return to driving post ABI.

Remote support groups (video or telephone) and problem-solving therapy may improve outcomes in caregivers of individuals post ABI.

Educational interventions may improve certain outcomes in caregivers of individuals post ABI.

Various multimodal interventions may benefit caregivers of individuals post ABI.

Introduction

Community reintegration is the ultimate goal of acquired brain injury (ABI) rehabilitation. However, contrary to expectations, community reintegration post ABI is multifaceted and can therefore be a challenging hurdle to overcome for both patients and their caregivers. The transition back into the community from acute care or post-acute rehabilitation requires diverse supports within the community, often for extended periods of time. Returning to a full range of activities in the community can prove difficult for individuals post brain injury and their families.  Rehabilitation interventions primarily focus on restoring independence and social integration. While many individuals may acquire an ABI at a young age, there is also merit for a focus to be on vocational (professional and academic) rehabilitation. The impact of ABI on interpersonal relationships and leisure roles may be equally challenging, which overall is mirrored in the literature by the number of multimodal interventions for community reintegration post ABI.

Given that ABI is a relatively significant disabler of an otherwise healthy, young, and productive portion of the population, returning to independence and productivity is of utmost importance. For those individuals who had not yet developed certain skills and abilities or achieved autonomous living prior to the injury, habilitation, rather than rehabilitation, is the primary focus. Individuals may need to learn or relearn basic activities of daily living (ADL) and appropriate social behaviours, and complete primary or secondary schooling before considering vocational options.

It should be noted that the evaluation of clinical work in this area may not lend itself well to a randomized controlled trial (RCT), due to the individualized nature of community rehabilitation protocols. This module reviews the available evidence pertaining to aspects of community reintegration following ABI, and is broken down into sections focusing on interventions for either the ABI individual or the caregiver.

13.1 Independence and Social Integration

Establishing independence and strong social networks post ABI can be challenging. Independence is a broad category that includes the ability to satisfy personal needs and carry out basic ADLs. Social integration includes a broad group of experiences related to social interaction and perception. Indicators of social integration include recreational and community involvement, interpersonal interactions, and relationships. It has been reported that post ABI, a third of individuals are dissatisfied with their level of independence, social lives, and interpersonal relationships (Larsson et al., 2013).

Reduced independence can negatively impact the ability of a post-ABI individual to maintain and build relationships; persons who have experienced ABI and limited independence reported having fewer close relationships and less social contact (Johnson & Davis, 1998). Individuals with ABI often face isolation and a lack of social support, and also report lower self-esteem and perceived sex appeal (Johnson & Davis, 1998; Kreuter et al., 1998; Kreutzer & Zasler, 1989). Rehabilitation is important for improving ADL performance and social perception and interaction by targeting cognitive needs, psychosocial needs, and transitional living using diverse treatment methods. Due to the unique combination of needs each individual has, multiple interventions can be provided in combination. Individuals who engage in rehabilitation – whether it is community-based, in-home care, or a residential transitional living program – have been found to experience improvements in productivity, social integration, and ADLs (Hopman et al., 2012).

13.1.1 Group-Based Interventions

Key Points

Group-based therapy may improve independent living and social integration post ABI.

Group-based therapy provides an opportunity for individuals to undergo rehabilitation while also integrating the individual into a social setting. Social interaction through brain injury support groups can provide individuals with a sense of belonging and reduce feelings of isolation. Social interaction within the treatment group can help prepare the individual with an ABI for social settings outside of a treatment environment.

Discussion

In current literature, group-based therapy has been offered in both home and assisted-living settings for individuals with ABI. Sloan et al. (2012) reported that group-based therapy resulted in improvements in community integration for individuals living in a disability-specific setting and in home-like settings, although the former group required higher levels of support. The authors explained that carers may provide more assistance than is needed and reduce the patients’ level of independence.

For participants living in their home, social integration can be difficult. Johnson & Davis (1998) matched post-ABI individuals with healthy community members and found that the relationship led to increased social interaction in participants with ABI. The results of this study relied heavily on the community volunteers’ ability to create a relationship with the individual who had an ABI in a short period of time, therefore careful selection of community volunteers is essential. Future studies could report different results if their selection process is altered.

Two studies used a general group-based intervention program. Gerber & Garagaro (2015) demonstrated that participants showed improved community integration, which had a positive effect on their caregiver’s burden. Feeney et al. (2001) reported that most individuals provided with general community support were still living in the community three years later. Both general programs benefited the participants, but it is difficult to compare their effect due to the lack of definitive protocol.

Group-based therapies may be effective in improving social integration but there is also evidence that group therapy s in a disability specific setting may reduce independence. To better evaluate the efficacy of group-based therapy, RCTs and studies with more standardized protocols are needed.

Conclusions

There is level 4 evidence that a general group-based rehabilitation program may improve independent living and community integration post ABI.

There is level 2 evidence that the Community Approach to Participation in a home-like setting may improve independent living post ABI compared to disability-specific settings. Both settings may improve social integration.

There is level 4 evidence that pairing individuals who have ABI with community members may increase their frequency of social contact.

13.1.2 Cognitive Interventions

Key Points

Certain cognitive rehabilitation interventions may improve independence and social integration post ABI.

Cognitive impairment following ABI can contribute to chronic disability (Cicerone et al., 2004). As cognitive rehabilitation can reduce functional disability and recovery time (Barman et al., 2016), it is imperative that rehabilitation effectively targets cognition to improve independence with daily functioning and social integration. Current cognitive therapies focus on behavioural retraining, self-awareness, or general cognitive function (Table 13.2).

Discussion

Cognitive interventions may increase independence by re-establishing pre-injury behaviours. Behavioural retraining has been shown to be effective for improving target behaviours following ABI (Carnevale, 1996; Giles et al., 1997), which includes both a specific program called the Natural-Setting Behaviour Management Program (Carnevale, 1996) and an undefined behavioural training program (Giles et al. 1997).

The effect of cognitive interventions for social integration has been evaluated by two studies. A prospective controlled trial found that intensive cognitive training was twice as likely as standard neurorehabilitation to improve social integration (Cicerone et al., 2004). Contrary to intensive cognitive training, self-awareness training did not improve social integration compared to conventional therapy (Goverover et al., 2007). This could be due to individuals becoming more aware of their social separation from the general community as a result of receiving the training. Self-awareness training did, however, improve participants’ awareness of disability, motor and process skills, as well as self-regulation skills (Goverover et al., 2007). It appears that behavioural training and intensive cognitive training positively influence independence and social integration.

Conclusions

There is level 4 evidence that behavioural training programs may improve target behaviours in individuals post ABI.

There is level 1b evidence that self-awareness training may not improve social integration compared to conventional therapy in individuals post ABI.

There is level 2 evidence that intensive cognitive rehabilitation may improve social integration compared to standard neurorehabilitation in individuals post ABI.

13.1.3 Mentorship

Key Points

Peer mentoring may not improve social integration post ABI.

Mentorship is widely recognized as an effective approach for the rehabilitation of many sequelae arising as a result of injury (Hanks et al., 2012). Unlike support groups, mentorship provides a more personalized approach to rehabilitation (Hibbard et al., 2002). The individualized support offered by a mentor may be beneficial for helping an individual with an ABI reintegrate into the community. Relevant studies are presented in Table 13.3.

Discussion

There are conflicting results regarding the effect of mentorship on the social reintegration of individuals with an ABI. Struchen et al. (2011) reported a significant improvement in perceived social support in individuals who received mentorship compared to those who did not, however no significant differences were found between groups in terms of social integration, social network size, or social activity level. Similarly, Hanks et al. (2012) also found that, compared to individuals without a mentor, mentees did not demonstrate significantly different levels of community integration following intervention.

Hibbard et al. (2002) conducted a post-test and reported that mentorship had little impact on social support, even though the majority of participants reported that the program improved their quality of life. However, there were other positive effects, including general agreement between studies that mentorship improved coping ability in individuals post ABI (Hanks et al., 2012; Hibbard et al., 2002). Struchen et al. (2011) reported a significantly higher likeliness of depression in individuals with a mentor compared to those without. Therefore, while mentorship may be effective for improving coping and quality of life following ABI, there is also the possibility that it could be associated with depression.

Conclusions

There is level 2 evidence that peer mentoring may not improve social integration compared to no mentorship in individuals post ABI.

13.1.4 Community Rehabilitation

Key Points

Various community-based rehabilitation programs may improve independence and social integration post ABI.

Community rehabilitation involves the provision of rehabilitation to individuals either in their homes or communities (Hopman et al., 2012). Community rehabilitation relies on the participation of diverse services, including educational, government, non-government, vocational, and other social services. Improving the efficacy of community rehabilitation has become increasingly more important because time spent in inpatient rehabilitation programs is decreasing (Sander, 2002). Studies examining the effect of community rehabilitation for independence and social integration are presented in Table 13.4.

Discussion

There are several different approaches to community rehabilitation. Three studies used a variety of approaches with the Community Integration Questionnaire as an outcome measure and found that transitional living compared to community-based rehabilitation, attending a brain injury drop in clinic compared to not attending, and community-based intensive life skill training, improved outcomes (social integration and productivity subscales) on the questionnaire (Hopman et al., 2012; McLean et al., 2012; Wheeler et al., 2007)}. While transitional living may improve community integration compared to community-based rehabilitation, Hopman et al. (2012) found that community-based rehabilitation was more effective for improving independence with performing activities than transitional-living. This difference may exist because patients in transitional living settings may become dependent on their caregiver. Occupational therapy and early-onset continuous rehabilitation were also found to improve independent living skills and ADLs in individuals with ABI (Lippert-Gruner et al., 2002; Trombly et al., 1998).

Social support is another important aspect of community reintegration. McLean et al. (2012) found that while participants attending a drop-in centre were successfully integrating into the community, they had low levels of perceived social support. Some community-based interventions may be less effective than others because they are unable to affect many personal, environmental, or social factors involved in social isolation (McLean et al., 2012). To improve research on this topic, RCTs evaluating the effectiveness of community-based rehabilitation are needed, as well as the use of standardized interventions between studies.

Conclusions

There is level 3 evidence that brain injury drop-in centres may improve social participation compared to not attending a centre in individuals post ABI.

There is level 2 evidence that transitional living may improve social integration compared to community-based rehabilitation in individuals post ABI, and community-based rehabilitation may improve independence with activities compared to transitional living. Both may improve activities of daily living and social participation.

There is level 2 evidence that intensive community-based life skills training may improve independence with activities compared to no intervention in individuals post ABI.

There is level 4 evidence that occupational therapy and early-onset continuous rehabilitation may improve independent living skills and activities of daily living in individuals post ABI.

13.1.5 Multimodal Interventions

Therapies may be evaluated in combination or comparatively to determine treatment effects. Multimodal therapies can target multiple deficits in an individual with an ABI using a single program by combining multiple interventions. This is particularly beneficial for social reintegration since there is often a compounding effect arising from multiple impairments which can prevent an individual from successfully reintegrating into the community (Powell et al., 2002).

Discussion

Multidisciplinary rehabilitation was found to be effective for improving home integration, but not social integration or independence with performing activities, compared to those not receiving the intervention (Goranson et al., 2003). Multidisciplinary rehabilitation, including a combination of cognitive and physical training, in comparison to an information treatment (a booklet of resources) resulted in significantly higher Barthel Index scores, indicating improved ADL performance (Powell et al., 2002; Waehrens & Fisher, 2007). Waehrens & Fisher (2007) also found improved ADL performance in patients receiving inpatient neurorehabilitation.

A single RCT evaluated the use of telephone-delivered cognitive and educational training. The authors found that there was no improvement in mental and physical well-being or independence compared to usual care (Bell et al., 2011). The authors identified that there were baseline differences between the participants at different sites, but despite initial differences, improvement did not differ between sites. A potential reason contributing to the lack of effectiveness of this treatment is that participants did not feel comfortable receiving counselling using a telephone (Bell et al., 2011).

Lastly, one high level RCT examined if the delivery of feedback on functional task performance could influence self-awareness and other outcomes (Schmidt et al., 2013). The authors found that delivering feedback via video and verbally significantly improved self-awareness compared to verbal or experiential feedback alone. However, there were no significant differences between groups regarding measures of depression (Schmidt et al., 2013).

Conclusions

There is level 2 evidence that a multimodal telephone intervention may not improve independence with activities of daily living in comparison to usual care in individuals post ABI.

There is level 2 evidence that multidisciplinary rehabilitation may improve performance on activities of daily living compared to an information treatment in individuals post ABI.

There is level 2 evidence that multidisciplinary rehabilitation may not improve social integration and independence with activities compared to no multidisciplinary rehabilitation in individuals post ABI.

13.2 Life Satisfaction and Quality of Life

Key Points

Multi-faceted rehabilitation, coping skills training, and support-based interventions may improve self-efficacy and/or perceived quality of life post ABI.

Life satisfaction is regarded as an important indicator of the efficacy of a rehabilitative intervention. Compared to healthy individuals, those with ABI have reported less satisfaction in multiple aspects of life (Atay et al., 2016; Jacobsson & Lexell, 2013b). Quality of life (QoL) is a subjective measure that takes many factors into account, including but not restricted to: health and functioning, psychological and material well-being, and social functioning (Mailhan et al., 2005). Other factors such as cognitive functioning, physical functioning, sexual functioning, vocational outcomes, and perception have been related to QoL outcomes (Esbjörnsson et al., 2013; Forslund et al., 2013; Jacobsson & Lexell, 2013b; Sander et al., 2013). As perception influences health related QoL, some individuals may have greater awareness of their obstacles and less denial of their limitations based on their level of impairment. This awareness may influence their anxiety, depression, and life satisfaction. Satisfaction with QoL is a complex concept and its definition and validity can vary due to its subjectivity. Studies examining life satisfaction in ABI populations are presented in Table 13.6.

Discussion

Having a social support group is an important component in improving an individual’s life satisfaction after ABI (Atay et al., 2016; Jacobsson & Lexell, 2013a; Vandiver & Christofero-Snider, 2000 ). Armengol (1999) demonstrated that social support groups focusing on education, coping training, and goal setting resulted in positive changes to measures of hopelessness, which can lead to a greater sense of control and empowerment. Vandiver and Christofero-Snider (2000 ) found similar results in individuals who actively participated in a brain injury club; participants’ self-efficacy and sense of personal competency improved as a result of planning, organizing, and implementing club events (Vandiver & Christofero-Snider, 2000 ). Self-efficacy was also improved by participating in a Brain Injury Coping Skills training program, based on cognitive behavioural therapy principles, compared to individuals who did not receive training (Backhaus et al., 2010). Additionally, this training was found to reduce feelings of emotional distress (Backhaus et al., 2010).

After an intensive cognitive rehabilitation program involving cognitive, emotional, interpersonal, and functional interventions, Cicerone et al. (2008) found that participants had higher self-efficacy and perceived QoL than those receiving standard neurorehabilitation. Similarly, a comprehensive case management program for substance abuse and ABI was compared to standard care, with the case management group demonstrating significantly higher satisfaction with life scores following treatment(Heinemann et al., 2004). Cusick et al. (2003) evaluated whether services provided through Colorado’s Medicaid Programme improved psychosocial outcomes, and reported that individuals receiving services compared to those who did not had significantly reduced mental health problems, but there were  no significant differences between groups in terms of satisfaction with life (Cusick et al., 2003).

Conclusions

There is level 3 evidence that the Colorado Medicaid Programme may reduce mental health problems compared to individuals not receiving this service, but may not improve life satisfaction, in individuals post ABI.

There is level 2 evidence that a Brain Injury Coping Skills training program may improve perceived self-efficacy and reduce emotional distress compared to no training in individuals post ABI.

There is level 1b evidence that intensive cognitive rehabilitation therapy may improve self-efficacy and perceived quality of life compared to standard neurorehabilitation in individuals post ABI.

There is level 2 evidence that comprehensive case management may improve life satisfaction compared to standard care for individuals with substance abuse problems post ABI.

There is level 4 evidence that support group programs may improve self-efficacy and feelings of hopelessness in individuals post ABI.

13.3 Vocational Rehabilitation and Productivity

13.3.1 Technology

Key Points

Virtual reality training may not be effective in improving employment outcomes compared to conventional psychoeducation post ABI.

Although technology may be beneficial to the rehabilitation process, few studies currently exist which examine technological interventions for vocational rehabilitation following ABI (Table 13.7).

Discussion

Unfortunately, studies evaluating the effect of technology on vocational rehabilitation to date are limited. Man et al. (2013) reported greater improvements in employment outcomes in participants receiving artificial intelligence virtual reality training compared to individuals receiving a conventional psychoeducational programme, although this difference was not statistically significant.(Man et al., 2013). It is difficult to make any definitive conclusions regarding the effect of technology for improving vocational outcomes in ABI populations due to the limited number of studies examining this topic.

Conclusions

There is level 2 evidence that virtual reality training may not improve employment outcomes compared to a conventional psychoeducational programme in individuals post ABI, although both interventions may improve employment outcomes.

13.3.2 Cognitive Interventions

Key Points

Cognitive rehabilitation therapy may not be effective for improving employment rates post ABI.

Cognitive interventions are some of the most commonly studied rehabilitative interventions for individuals with ABI due to the high prevalence of cognitive impairments within this clinical population (Vanderploeg et al., 2008). Cognitive impairments can reduce or eliminate vocational options that an individual with an ABI has depending on severity, therefore it is imperative that vocational rehabilitation includes a cognitive rehabilitation component.

Discussion

Vanderploeg et al. (2008) compared two different treatment approaches for vocational rehabilitation, cognitive-didactic therapy and functional-experiential rehabilitation therapy. After one year of cognitive-didactic therapy, over one third of participants had returned to work, but this was similar to participants in the functional treatment arm (Vanderploeg et al., 2008). Salazar et al. (2000) evaluated the effect of an in-hospital cognitive rehabilitation program compared to a limited home rehabilitation program on return to employment and fitness for military duty. There were no significant differences between groups in terms of the number of participants who returned to work or were fit for active duty (Salazar et al., 2000). Although there was no difference between the treatment and control groups, Salazar et al. (2000) reported high employment rates (90% and 94%, respectively); this was likely due to the study having been conducted  during the acute phase of recovery, which may have reduced the potential impact that the intervention could have had due to spontaneous recovery. While more research is needed to confirm this, based on current research, cognitive training does not seem effective for improving rates of employment compared to conventional therapies.

Conclusions

There is level 1b evidence that cognitive-didactic therapy may not be more effective than functional-experiential rehabilitation therapy for return to work in individuals post ABI.

There is level 1b evidence that intensive hospital-based cognitive rehabilitation may not improve return to work compared to  limited home-based rehabilitation in individuals post ABI.

13.3.3 Educational Interventions

Key Points

Simulated educational experiences may be helpful for predicting an individual’s readiness to return to school post ABI.

Educational interventions provide individuals with an ABI an opportunity to learn more about the potential challenges encountered following a brain injury, as well as resources that are available to them. Few studies currently exist which examine educational interventions for vocational rehabilitation following ABI (Table 13.9).

Discussion

Individuals interested in returning to post-secondary education following ABI can face many potential challenges. MacLennan & MacLennan (2008) assessed a simulated college experience and its ability to predict college performance and success. Both participants who performed poorly did not return to school, while one participant who was successful in the program did return to school. One participant specifically chose not to return to school after the simulated lectures despite initially insisting that he would. The experience may have reduced his unawareness or denial of impairment. Exposing individuals with ABI to a simulated college experience may help the individual in making a more informed decision about pursuing further education, however more higher-level and larger studies are needed to evaluate the effectiveness of this program as well as other educational interventions.

Conclusions

There is level 4 evidence that a stimulated college experience may predict readiness for post-secondary education in individuals post ABI.

13.3.4 Mentorship

Key Points

Mentoring may be effective for improving employment and education rates post ABI.

Mentorship provides an individual with a trained mentor or peer to help with the transition to living with an ABI. Mentorship has been effective in people with an ABI, particularly in terms of educating the individual about the resources and methods available to assist them in pursuing their vocational goals (Kolakowsky-Hayner et al., 2012). Mentorship is also useful for providing an individualized approach to achieve the desired employment outcomes.

Discussion

Kolakowsky-Hayner et al. (2012) evaluated a community-based mentoring program using a sample of participants mostly comprised of individuals with TBI. The authors reported that trained mentors helped most of the program participants return to work or school. . Of the 35 individuals who did not complete the program, more than half dropped out because they were not interested in pursuing an educational or vocational goal through the program. The mentorship also increased participants’ community integration and independence, functional performance, and adaptability (Kolakowsky-Hayner et al., 2012). Mentorship may be effective for increasing post-ABI vocational performance, but supporting research is currently limited.

Conclusions

There is level 4 evidence that a community-based mentoring program may be beneficial for helping individuals with ABI return to work or school.

13.3.5 Community Rehabilitation

Key Points

Community-based vocational rehabilitation may improve employment rates post ABI.

Community rehabilitation involves the provision of rehabilitation to individuals either in their homes or communities (Hopman et al., 2012). Community rehabilitation relies on the participation of diverse services, including educational, government, non-government, vocational, and other social services. Improving the efficacy of community rehabilitation has become increasingly more important because time spent in inpatient rehabilitation programs is decreasing (Sander, 2002). Studies examining the effect of community rehabilitation for vocational rehabilitation are presented in Table 13.11.

Discussion

Community rehabilitation provides an opportunity for individuals to reintegrate themselves gradually into the community. Two studies looked at the effectiveness of a work/school re-entry program. The first study by Klonoff et al. (1998) found that more than half of the participants were employed after the program, although a minority of participants returned to the same pre-injury level of work or school. Individuals with strong patient and family working alliance, work eagerness, and more severe injuries were found to have favourable outcomes. Subsequently, Klonoff et al. (2001) again reported that at 20 week follow-up, a minority of individuals returned to work in the same field and at the same pre-injury capacity.

The Community Based Training Program was evaluated in a single study. The program was completed by 58% of participants, and of those, more than half were competitively employed. Those who completed the program often had a longer length of disability and longer employment pre-injury (Wall et al., 1998). Longer employment prior to injury may be associated with an older population in the study, indicating that younger individuals with a shorter pre-injury employment history may have recovered more quickly. In a different study, the effect of a comprehensive brain injury day treatment program was evaluated, which showed no significant improvement in vocational independence at one year follow-up compared to at the end of the program (Malec & Moessner, 2000).

To meet vocational goals post ABI, access to employment services may be essential.. In a study by Gamble & Moore (2003), significantly more individuals who received supported employment services were employed compared to those who did not receive support. The authors also observed that those who did not have access to employment services had a higher average income and worked more hours each week. Buffington & Malec (1997) saw 40% of their participants placed in jobs at 3 months, and at 1 year 70% of the participants were placed. The authors also reported that early onset vocational training (<12 mo) is more effective than later onset training. Community-based rehabilitation may be effective in improving vocational outcomes post ABI stroke, but a lack of control groups in most studies to date makes it difficult to accurately determine treatment effects.

Conclusions

There is level 4 evidence that community-based programs may improve return to work in individuals post ABI.

There is level 2 evidence that supported employment services may improve return to work compared to not receiving these services in individuals post ABI.

13.3.6 Resource Facilitation

Key Points

Resource facilitation may improve employment rates post ABI.

Resource facilitators provide support for transitioning back into the community for individuals with an ABI. They provide a comprehensive explanation of available resources for individuals with an ABI, as well as how to access them  (Trexler et al., 2010). Part of their focus is to assist with vocational goals when desired by the individual.

Discussion

Currently, there remains limited research focused on resource facilitation in the ABI population. However, two studies have found that substantially more participants who received aid from a resource facilitator returned to work compared to standard care (Radford et al., 2013; Trexler et al., 2010). Trexler et al. (2010) also found that community participation increased when employment increased, potentially because work increases one’s motivation to become involved in the community again. Alternatively, it may be that individuals who return to work are more independent and therefore better able to participate in the community than those who are not employed. Resource facilitation appears to have a positive impact on achieving vocational goals for individuals with an ABI.

Conclusions

There is level 2 evidence that a resource facilitator may improve return to work compared to standard care in individuals post ABI.

13.3.7 Multimodal Interventions

Key Points

Various multimodal interventions may improve employability post ABI.

Individuals with an ABI often experience multiple challenges, including psychological and physiological, that may prevent them from returning to work. Multimodal therapies provide an opportunity for individuals with an ABI to receive therapy for multiple areas of need in a single program. Targeting multiple problems with a single program could assist individuals return to their vocation sooner than if receiving singular therapies.

Discussion

Most multimodal studies have evaluated the effect of combining multiple interventions rather than comparing different interventions. There was, however, one study that compared and combined three different rehabilitation approaches (Malec & Degiorgio, 2002). Vocational services were provided either alone, with community reintegration, or with comprehensive day treatment. Employment rates were 77% or higher in each group, but none of the treatments were found to be more effective than the others (Malec & Degiorgio, 2002).

There are several multimodal rehabilitation programs available for people with an ABI. The service of accompaniment and follow-up to employment (SPASE) program, the French evaluation, retraining, social and vocational unit (UEROS) program, Mayo Clinic Comprehensive Day Treatment Programme, Brain Integration Programme, Come Back Programme, and Program Without Walls all reported favourable improvements in vocational outcomes following program completion, though conclusions cannot be made regarding which one is most effective as no studies have compared one to another (Bergquist et al., 2012; Bonneterre et al., 2013; Cogné et al., 2017; De Kort et al., 2002; Geurtsen et al., 2008; O’Neill et al., 2004). In addition to improved vocational outcomes, the UEROS and Come Back Programme improved independence (Cogné et al., 2017; De Kort et al., 2002). The Brain Integration Programme also reported increased independence, as well as less depressive symptoms a year after treatment (Geurtsen et al., 2008). Though it has been thought that increased independence and societal awareness post ABI may lead to increased emotional burden, the decrease in depressive symptoms along with an increase in independence suggest otherwise. However, a follow-up study of the Brain Integration Programme reported that from 1-3 years post discharge, more individuals were employed, but less were living independently (Geurtsen et al., 2008). Though this program is effective in increasing employability, it may not have lasting effects on independence.

General inpatient or outpatient rehabilitation programs may also be effective for improving employment outcomes. Trexler et al. (2016) reported that access to a multidisciplinary team led to an increase in employment and independence compared to standard outpatient care. Similarly, inpatient rehabilitation may also improve return to work post ABI; Walker et al. (2006) found that 39% of individuals were employed at 1-year post injury following rehabilitation. Though there is less research on general multidisciplinary rehabilitation programs, it seems that they also have a positive effect on employability post ABI.

Some factors that increase whether an individual has a successful return to work trajectory include independence, workplace support, and higher Functional Independence Measure and Barthel Index scores (Bergquist et al., 2012; Bonneterre et al., 2013; Walker et al., 2006; Watanabe, 2013). Walker et al. (2006) also found that type of occupation may influence employment outcomes; participants who worked in professional or management roles were more likely to return to work compared to skilled trade or manual workers.

Conclusions

There is level 2 evidence that the Evaluation, Retraining, Social, and Vocational Unit (UEROS) program may improve return to work in individuals post ABI.

There is level 3 evidence that the Program Without Walls may improve employment rates and incomes compared to traditional vocational rehabilitation in individuals post ABI.

There is level 4 evidence that the Come Back Programme, Brain Integration Programme, Mayo Clinic Comprehensive Day Treatment Program, and service of accompaniment and follow-up to employment may improve return to work post ABI.

There is level 1b evidence that multidisciplinary outpatient rehabilitation may improve return to work and vocational independence in individuals post ABI.

There is level 2 evidence that inpatient rehabilitation may improve return to work in individuals post ABI.

There is level 2 evidence that vocational services alone may not be more effective than vocational services paired with either community reintegration or comprehensive day treatment for return to work in individuals post ABI.

13.4 Return to Driving

Key Points

Multidisciplinary neurorehabilitation may increase the number of individuals that return to driving post ABI.

For those who have an ABI, the inability to drive is one of the most challenging consequences because it is often seen as a key determinant of an individual’s level of social engagement and general independence (Lane & Benoit, 2011). Individuals with an ABI often return to driving in an effort to feel independent, even if they are not fit to do so (Leon-Carrion et al., 2005; Liddle et al., 2011, 2012). Driving a motor vehicle requires good functionality across multiple domains which may have been impaired by the injury, including perception, cognition, communication, and coordination. In particular, driving depends on functional vision, rapid reliable responses, attentiveness despite distractions, and quick decision making. Individuals with an ABI may have difficulty driving due to deficits in monitoring simultaneous inputs (Formisano et al., 2005; Masson et al., 2013; Ortoleva et al., 2012) and anticipating dangerous situations (van Zomeren et al., 1987). Adjusting to post-injury abilities can also be an issue among returning drivers, as some individuals are less likely to modify their driving style and behaviour following ABI, particularly younger male drivers (Labbe et al., 2014). All of these factors contribute to the increased likelihood that individuals with an ABI will be involved in more accidents than the general population (Bivona et al., 2012; Formisano et al., 2005), reinforcing the need for effective driver rehabilitation therapies.

Discussion

Participation in a multidisciplinary neurorehabilitation program has been shown to improve driving as well as driving-related impairments, and thus may increase the rate of individuals returning to driving following ABI (Leon-Carrion et al., 2005; Perumparaichallai et al., 2014). After treatment, 54% to 71% of participants returned to driving, though one study found that 30% were driving upon admission to rehabilitation despite not being fit to do so (Leon-Carrion et al., 2005). Performance on tests of visual attention, working memory, processing speed, and task switching were correlated with return to driving (Perumparaichallai et al., 2014). Specifically, those who resumed driving scored higher on the Functional Independence and Assessment Measures than those who did not resume (Cullen et al., 2014; Hawley, 2001; Leon-Carrion et al., 2005).

Conclusions

There is level 4 evidence that multidisciplinary neurorehabilitation may improve return to driving in individuals post ABI.

13.5 Caregiving and Caregiver Burden

13.5.1 Interventions of Support or Cognitive-Behavioural Interventions

Key Points

Remote support groups (video or telephone) and problem-solving therapy may improve outcomes in caregivers of individuals post ABI.

The need for social relationships and support systems for caregivers has been reported in many studies. Caregivers who receive less social support typically feel more burdened and isolated (Chronister et al., 2016; Coy et al., 2013; Davis et al., 2009; Liu et al., 2015; Manskow et al., 2015; Stevens et al., 2013). Interventions of support directly address this need by providing group or individual support sessions.

Discussion

Support groups provide an opportunity for caregivers to learn from and converse with other caregivers. Acorn (1995) found that weekly support groups did not aid in improving mental well-being, including coping, self-esteem, and life satisfaction. However, in another study it was found that participants of a videoconferencing support group program, assessed through a qualitative study, reported that the sessions were helpful for managing emotions (Damianakis et al., 2016). Additionally, caregivers attending a telephone support program reported less burden and distress than those attending an on-site support group (Brown et al., 1999). Current literature suggests that remote support groups  ̶  via video or telephone  ̶  can have a positive influence on caregivers of individuals with an ABI.

Rivera et al. (2008) compared caregivers who received problem-solving therapy or education to those who received only education. The treatment group showed significant decreases in depression, health complaints, and dysfunctional problem solving, but no treatment and time interactions were found for caregiver well-being or burden (Rivera et al., 2008). Problem solving therapy training may be a beneficial intervention for improving certain caregiver outcomes.

Conclusions

There is level 2 evidence that problem-solving therapy may improve depression, health complaints, and dysfunctional problem solving, but not well-being or burden, compared to an educational program in caregivers of individuals with ABI.

There is level 2 evidence that telephone support groups may reduce burden and distress compared to traditional on-site support groups in caregivers of individuals with ABI.

There is level 4 evidence that on-site support groups may not improve well-being in caregivers of individuals post ABI.

13.5.2 Educational Interventions

Key Points

Educational interventions may improve certain outcomes in caregivers of individuals post ABI.

Education and access to information have been found to have a positive effect on caregiver burden. Caregivers regard health information support as a valuable resource, particularly in the early stages of TBI care (Calvete & de Arroyabe, 2012; Liu et al., 2015). When these resources are unavailable or inaccessible, it can negatively impact caregiver mental health. Doyle et al. (2013) revealed that most unmet caregiver needs – resulting in anxiety and depression – revolved around a lack of health information regarding the patient and ABI.

Discussion

Several studies examined whether an educational intervention was effective for reducing caregiver depression. Fortune et al. (2016) provided educational modules on a variety of different topics for caregivers of individuals with ABI and reported that it did not improve caregiver depression or anxiety in comparison to wait-list control participants, but there were significant improvements in caregiver strain and perceived criticism. Morris (2001) found that providing educational material to caregivers did not impact caregiver depression or anxiety. From these two studies educational interventions do not appear to have a beneficial impact on caregiver depression, although they may have positive impacts on other caregiver outcomes. Contrary to this one study (Sinnakaruppan et al., 2005) did show that education can have a positive effect on one measure of depression (General Health Questionnaire), however, these effects were not seen on the HADS measure within the same study and should be interpreted with caution.

Two studies provided rehabilitation to the individual with an ABI as well as educational intervention for the caregiver. Goodwin et al. (2016) reported that caregiver strain improved following intervention, as demonstrated by improved scores on two subscales on the carer strain index. However, Carnevale et al. (2002) found that there was no difference in family stress or potential burnout post education and behavioral management training compared to caregivers just receiving education.

The method of education delivery is also important to consider. It has been reported that the distribution of educational material alone may not have as significant an impact as educational programs (Morris, 2001).

Conclusions

There is level 2 evidence that educational training programs may improve strain and perceived criticism compared to wait-list controls in caregivers of individuals post ABI.

There is level 2 evidence that providing education to a caregiver as well as rehabilitation for the individual with an ABI may not be more effective for improving family stress or burnout risk compared to education alone in caregivers of individuals post ABI.

There is level 2 evidence that educational training programs may not improve depression and anxiety compared to wait-list controls in caregivers of individuals post ABI.

13.5.3 Multimodal Interventions

Key Points

Various multimodal interventions may benefit caregivers of individuals post ABI.

Therapies may be evaluated in combination or comparatively to determine treatment effects. Commonly, studies combine educational and support interventions into a single treatment program to improve caregiver outcomes. This is particularly beneficial because caregivers face diverse challenges, and a multimodal intervention can target more areas than a singular intervention program.

Discussion

Smith et al. (2006) found that home-based community rehabilitation services for the individual with an ABI resulted in more favourable outcomes for carers in terms of fulfilled family needs and family functioning when compared to traditional outpatient services. Bowen et al. (2001) compared timing of intervention and found that early access to a multidisciplinary team was more effective for informing caregivers but did not reduce levels of distress compared to late access. However, both late and early access were significantly more effective than no access to the support team. It is imperative that caregivers be made aware of available services, as it has been shown to help caregivers feel better prepared for the future and feel less distressed (Bowen et al., 2001).

Kreutzer et al. (2009) studied families who participated in a Brain Injury Family Intervention program that focused on cognitive behavioural therapy and education on family dynamics (e.g., managing stress). The authors found that family members benefited in terms of meeting needs and overcoming service obstacles, although the program did not strongly improve their family functioning, life satisfaction, or psychological well-being. In a more recent study of the same intervention, Kreutzer et al. (2015) reported that the program significantly reduced caregiver burden and improved met family needs and satisfaction with services relative to pre-treatment.

Powell et al. (2016) reported that caregivers receiving a telehealth self-management intervention, comprised of education and mentored problem-solving, showed improved coping ability and psychological well-being, when compared to usual care. In a follow-up to this study, Powell et al. (2017) reported that 6 months post ABI, caregivers were able to increase their involvement in recreational and professional endeavors. At this time, continuing concerns presented by caregivers included emotional adjustment, time management, and creating healthy habits (Powell et al., 2017).

Conclusions

There is level 4 evidence that the Brain Injury Family Intervention may improve met family needs and satisfaction with services and reduce burden in caregivers of individuals post ABI.

There is level 1b evidence that a telehealth self-management program combining education and mentored problem-solving may improve coping and psychological well-being compared to usual care in caregivers of individuals post ABI.

There is level 3 evidence that community-based rehabilitation for the individual with an ABI may be more effective than traditional outpatient services in benefiting caregivers of individuals post ABI by improving levels of met family needs and family dysfunction.

There is level 2 evidence that early or late access to a head injury team intervention may reduce distress compared to no intervention in caregivers of individuals post ABI.

13.6 Conclusions

Based on the studies above, multimodal interventions appear to have the strongest evidence for community reintegration post ABI. As social integration encompasses many different aspects of life and functioning, multimodal interventions can provide the broadest support for these components. A multitude of studies comprised of having a diverse care team to address both physical and psychological needs when re-entering the community. Newer areas of interest and research included topics such as mentorship and resource facilitation.

With regards to caregiver burden, many studies were added for ERABI Version 12. These studies examined the effects of care giving for those with ABI on their support team. The majority of interventions involved psychological support and access to resources.

Summary


There is level 4 evidence that a general group-based rehabilitation program may improve independent living and community integration post ABI.

There is level 2 evidence that the Community Approach to Participation in a home-like setting may improve independent living post ABI compared to disability-specific settings. Both settings may improve social integration.

There is level 4 evidence that pairing individuals who have ABI with community members may increase their frequency of social contact.

There is level 4 evidence that behavioural training programs may improve target behaviours in individuals post ABI.

There is level 1b evidence that self-awareness training may not improve social integration compared to conventional therapy in individuals post ABI.

There is level 2 evidence that intensive cognitive rehabilitation may improve social integration compared to standard neurorehabilitation in individuals post ABI.

There is level 2 evidence that peer mentoring may not improve social integration compared to no mentorship in individuals post ABI.

There is level 3 evidence that brain injury drop-in centres may improve social participation compared to not attending a centre in individuals post ABI.

There is level 2 evidence that transitional living may improve social integration compared to community-based rehabilitation in individuals post ABI, and community-based rehabilitation may improve independence with activities compared to transitional living. Both may improve activities of daily living and social participation.

There is level 2 evidence that intensive community-based life skills training may improve independence with activities compared to no intervention in individuals post ABI.

There is level 4 evidence that occupational therapy and early-onset continuous rehabilitation may improve independent living skills and activities of daily living in individuals post ABI.

There is level 2 evidence that a multimodal telephone intervention may not improve independence with activities of daily living in comparison to usual care in individuals post ABI.

There is level 2 evidence that multidisciplinary rehabilitation may improve performance on activities of daily living compared to an information treatment in individuals post ABI.

There is level 2 evidence that multidisciplinary rehabilitation may not improve social integration and independence with activities compared to no multidisciplinary rehabilitation in individuals post ABI.

There is level 3 evidence that the Colorado Medicaid Programme may reduce mental health problems compared to individuals not receiving this service, but may not improve life satisfaction, in individuals post ABI.

There is level 2 evidence that a Brain Injury Coping Skills training program may improve perceived self-efficacy and reduce emotional distress compared to no training in individuals post ABI.

There is level 1b evidence that intensive cognitive rehabilitation therapy may improve self-efficacy and perceived quality of life compared to standard neurorehabilitation in individuals post ABI.

There is level 2 evidence that comprehensive case management may improve life satisfaction compared to standard care for individuals with substance abuse problems post ABI.

There is level 4 evidence that support group programs may improve self-efficacy and feelings of hopelessness in individuals post ABI.

There is level 2 evidence that virtual reality training may not improve employment outcomes compared to a conventional psychoeducational programme in individuals post ABI, although both interventions may improve employment outcomes.

There is level 1b evidence that cognitive-didactic therapy may not be more effective than functional-experiential rehabilitation therapy for return to work in individuals post ABI.

There is level 1b evidence that intensive hospital-based cognitive rehabilitation may not improve return to work compared to limited home-based rehabilitation in individuals post ABI.

There is level 4 evidence that a stimulated college experience may predict readiness for post-secondary education in individuals post ABI.

There is level 4 evidence that a community-based mentoring program may be beneficial for helping individuals with ABI return to work or school.

There is level 4 evidence that community-based programs may improve return to work in individuals post ABI.

There is level 2 evidence that supported employment services may improve return to work compared to not receiving these services in individuals post ABI.

There is level 2 evidence that a resource facilitator may improve return to work compared to standard care in individuals post ABI.

There is level 2 evidence that the Evaluation, Retraining, Social, and Vocational Unit (UEROS) program may improve return to work in individuals post ABI.

There is level 3 evidence that the Program Without Walls may improve employment rates and incomes compared to traditional vocational rehabilitation in individuals post ABI.

There is level 4 evidence that the Come Back Programme, Brain Integration Programme, Mayo Clinic Comprehensive Day Treatment Program, and SPASE may improve return to work post ABI.

There is level 1b evidence that multidisciplinary outpatient rehabilitation may improve return to work and vocational independence in individuals post ABI.

There is level 2 evidence that inpatient rehabilitation may improve return to work in individuals post ABI.

There is level 2 evidence that vocational services alone may not be more effective than vocational services paired with either community reintegration or comprehensive day treatment for return to work in individuals post ABI.

There is level 4 evidence that multidisciplinary neurorehabilitation may improve return to driving in individuals post ABI.

There is level 2 evidence that problem-solving therapy may improve depression, health complaints, and dysfunctional problem solving, but not well-being or burden, compared to an educational program in caregivers of individuals with ABI.

There is level 2 evidence that telephone support groups may reduce burden and distress compared to traditional on-site support groups in caregivers of individuals with ABI.

There is level 4 evidence that on-site support groups may not improve well-being in caregivers of individuals post ABI.

There is level 2 evidence that educational training programs may improve strain and perceived criticism compared to wait-list controls in caregivers of individuals post ABI.

There is level 2 evidence that providing education to a caregiver as well as rehabilitation for the individual with an ABI may not be more effective for improving family stress or burnout risk compared to education alone in caregivers of individuals post ABI.

There is level 2 evidence that educational training programs may not improve depression and anxiety compared to wait-list controls in caregivers of individuals post ABI.

There is level 4 evidence that the Brain Injury Family Intervention may improve met family needs and satisfaction with services and reduce burden in caregivers of individuals post ABI.

There is level 1b evidence that a telehealth self-management program combining education and mentored problem-solving may improve coping and psychological well-being compared to usual care in caregivers of individuals post ABI.

There is level 3 evidence that community-based rehabilitation for the individual with an ABI may be more effective than traditional outpatient services in benefiting caregivers of individuals post ABI by improving levels of met family needs and family dysfunction.

There is level 2 evidence that early or late access to a head injury team intervention may reduce distress compared to no intervention in caregivers of individuals post ABI.

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