1. Identifying Barriers Affecting Participatory and Social Function After Traumatic Brain Injury Rehabilitation
Norazlina A Aziz, MBBS1,2; Allison Foster PhD1; Richard Seemann MBChB1
1ABI Rehabilitation New Zealand, Auckland, New Zealand
2Hospital Tuanku Ja’afar Seremban, N Sembilan, Malaysia
Introduction
Methods
The goal of rehabilitation after severe traumatic brain injury (TBI) is usually aimed for individuals to achieve the highest level of independent functions for participation in the home and social environment. Their ability to return to their life roles and participation in the community as near to the pre-injury levels are important measures of the effectiveness of the inpatient TBI rehabilitation services. Recent studies of TBI rehabilitation have evaluated the treatment outcomes in term of improvements on return to work (1, 2), living situation (3, 4), and independent transport use (5). However, social participation outcomes have not been looked at in detail previously. Clinical audits have shown that a majority of clients continue to improve after discharge from our inpatient TBI rehabilitation facility, while some struggle with their community participation. This study was intended to characterise these patterns more fully while also identifying possible barriers for integrating back to community.
A consecutive sample of 60 clients meeting criteria were assessed with the Mayo-Portland Participation Index (M2PI; 6) by a clinician upon discharge from a national rehabilitation centre for TBI in New Zealand. Clients were excluded if they were minimally responsive or not able to be contacted via phone calls. The M2PI was completed again by the client or a family member via a telephone call with the researcher after discharge. Additionally, respondents were asked in an open-ended way to describe any issues or challenges faced by the client.
Results 50 60 40
100
Best outcomes
Worst outcomes
mean
+1 SD
-1 SD
M2PI T-scores
20 out of 60 clients (33%) deteriorated from 41.5 (±5.3) at discharge to 51.5 (±6.5) at follow-up.
Discharge
Follow-up
27 out of 60 clients (45%) had no change from 42.9 (±5.2) at discharge to 43.9 (±5.9) at follow-up.
13 out of 60 clients (22%) improved from 44.2 (±6.4) at discharge to 27.8 (±16.9) at follow-up.
At discharge, the mean M2PI score was 42.7 (standard deviation [SD]=5.5), indicating better-than-average participation relative to the reference population of adults with brain injury; at follow-up (117 days post-discharge; SD=52), the mean M2PI was 42.9 (SD=12.8).
Among this group, 67% of clients’ M2PI scores stayed the same (within 5 points) or improved at follow-up relative to discharge. However, there were 33% of clients whose discharge M2PI scores deteriorated by at least 5 points at follow-up.
Only 3 clients deteriorated into severe limitations.
Clients who reported post-discharge issues in the following categories # %
Clients who worsened (N=20)
Physical issues 8
40%
Mood problems 9
45%
Behaviour issues 3
15%
Cognitive problems 5
25%
Fatigue issues
Clients who stayed the same or improved (N=40) 15
38% 4
10% 8%
22% 11
28%
Domains with the greatest degree of worsening were social contact and leisure/recreation. 45% of these clients also reported mood problems as a factor, in contrast to only 10% of the clients who maintained or improved their participatory gains after discharge.
Areas of deterioration were in social contact, leisure / recreation, and residence.
Discussion
Mood problems appear to be a barrier to societal participation after discharge from inpatient TBI rehabilitation for a sizable minority of clients. Perhaps unsurprisingly, this is reflected most strongly by difficulties with social and leisure activities.
This suggests that providers may be able to improve positive participatory outcomes after TBI by identifying/treating mood problems during inpatient rehabilitation programmes and providing education to support post-discharge outcomes.  
What interventions during inpatient rehabilitation can maximise community participation after discharge?
References
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Keyser-Marcus LA, Bricout JC, Wehman P, Campbell LR, Cifu DX, Englander J, High W, Zafonte RD. Acute predictors of return to employment after traumatic brain injury: a longitudinal follow-up. Arch Phys Med Rehabil. 2002;83:
Nalder E, Fleming J, Foster M, Cornwell P, Shields C, Khan A. Identifying factors associated with perceived success in the transition from hospital to home after brain injury. J Head Trauma Rehabil. 2012;27(2):
Olver JH, Ponsford JL, Curran CA. Outcome following traumatic brain injury: a comparison between 2 and 5 years after injury. Brain Inj. 1996;10(11):
Nalder E, Fleming J, Cornwell P, Foster M, Haines T. Factors associated with the occurrence of sentinel events during transition from hospital to home for individuals with traumatic brain injury. J Rehabil Med ;44:
Malec JF. The Mayo-Portland Participation Index: A brief and psychometrically sound measure of brain injury outcome. Arch Phys Med Rehabil. 2004;85(12):
Poster presented at the 10th Congress of the International Society of Physical and Rehabilitation Medicine ; Kuala Lumpur, Malaysia; 29 May – 2 June, 2016.
Data were gathered incidental to standard service delivery through ABI Rehabilitation New Zealand, Ltd. Views and/or conclusions in this report are those of the author(s) and may not reflect the position of funding or governmental agencies.
ABI Rehabilitation
New Zealand Ltd.
(Auckland)
(Wellington)