Community integration after severe traumatic brain injury in adults.
ABSTRACT Despite being the main cause of death and disability in young adults, traumatic brain injury (TBI) is a rather neglected epidemic. Community integration of persons with TBI was, until recently, insufficiently informed by clinical research.
To bridge the gap between rehabilitation and community re-entry, the first task is to assess the person, using TBI-specific outcome measures. The second task is to provide re-entry programs, the effectiveness of which is assessed by those measures, using well designed studies. There are very few such studies. However, there are some effective comprehensive programs and others which are specifically targeted dealing mainly with return to work, behavior, and family issues. The complex psychological and environmental components of the disability require individualized and often long-term care.
For persons with severe TBI trying to achieve the best possible community integration a new semiology is required, not just limited to medical care, but also involving social and psychological care that is tailored to the needs of each individual and family, living within his/her environment. Currently, only a minority benefit from well validated programs.
- SourceAvailable from: Dominic Pérennou[Show abstract] [Hide abstract]
ABSTRACT: To analyse usefulness of the SPASE programme, a coordinated facility programme to assist traumatic brain injury (TBI) persons in returning to work and retaining their job in the ordinary work environment. A retrospective study including 100 subjects aged over 18 who had suffered traumatic brain injury (GOS 1 or 2). The criterion for return to work (RTW) success was the ability to return to the job he/she had before the accident or to a new professional activity. Factors associated with RTW success were at short-term (2-3 years): the presence of significant workplace support OR=15.1 [3.7-61.7], the presence of physical disabilities OR=0.32 [0.12-0.87] or serious traumatic brain injury OR=0.22 [0.07-0.66]. At medium-term (over 3 years) these factors were: significant workplace support OR=3.9 [1.3-11.3] and presence of mental illness OR=0.15 [0.03-0.7]. This study suggests that a case coordination vocational programme may facilitate the return and maintain to work of TBI persons. It reveals that the workplace support is a key factor for job retention in the medium-term.Annals of physical and rehabilitation medicine 10/2013;
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ABSTRACT: Participation in community life is a major challenge for most people with psychiatric and/or cognitive disabilities. Current assessments of participation lack a theoretical basis. However, the new International Classification of Functioning, Disability and Health (ICF) provides a relevant framework. The present study used an ICF-derived assessment tool to activity limitations and participation restrictions in two groups of participants with disabilities linked to schizophrenia or traumatic brain injury respectively. Twenty-six items (related to six ICF sections) were selected by reviewing the literature and gathering the clinician's opinions and representatives of patient associations. These items, yielded an ordinal rating of activity limitations, participation restrictions and contextual factors (social support, attitudes and, systems & politics). Special attention was paid to contextual and environmental factors. The final checklist (called the Grid for Measurements of Activity and Participation, G-MAP) was administered to 16 participants with traumatic brain injury (the TBI group) and 15 participants with schizophrenic disorders (the SD group). Psychometric assessments of cognition and, neurobehavioural, psychological and psychosocial functioning were also performed. The internal consistencies for activity limitations (Cronbach's alpha coefficient=0.89) and participation restriction (Cronbach's alpha coefficient=0.89) were satisfactory. We did not observe any significant differences between the two groups in terms of the psychometric test results. The G-MAP scores demonstrated that the two groups were confronted with the same limitations in self care, domestic life, leisure and community life (i.e., the intergroup differences were not statistically significant in Mann-Whitney tests). However, interpersonal relationships and economic and social productivity appeared to be more severely limited in the SD group than in the TBI group. Similarly, participation restrictions in domestic life, interpersonal relationships and economic and social productivity were more severe in the SD group than in the TBI group. G-MAP is a useful, feasible, relevant tool for performing a detailed, individualized assessment of participation restrictions in people with psychiatric and/or cognitive disabilities.Annals of physical and rehabilitation medicine 12/2013;
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ABSTRACT: To explore the scope, reliability and validity of community integration measures for older adults following traumatic brain injury (TBI). A search of peer reviewed articles in English from 1990 -April 2011 was conducted using the EbscoHealth and Scopus databases. Search terms included were community integration, traumatic brain injury or TBI, 65 plus or older adults, and assessment. Forty-three eligible articles were identified, with 11 selected for full review using a standardized critical review method. Common community integration measures were identified and ranked for relevance and psychometric properties. Of the eligible articles (43) studies reporting community integration outcomes post TBI were identified and critically reviewed. Older adults' community integration needs post TBI from high quality studies were summarized. There is a relative lack of evidence pertaining to older adults post TBI, but indicators are that older adults have poorer outcomes than their younger counterparts. The Community Integration Questionnaire (CIQ) is the most widely used community integration measurement tool used in research for people with TBI. Due to some limitations many studies have used the CIQ in conjunction with other measures to better quantify and/or monitor changes in community integration. Enhancing integration of older adults following TBI into their community of choice, with particular emphasis on social integration and quality of life, ought to be a primary rehabilitation goal. However, more research is needed to inform best practice guidelines to meet the needs of this growing TBI population. It is recommended that subjective tools like quality of life measures are employed, in conjunction with well established community integration measures such as the CIQ, during the assessment process.Archives of physical medicine and rehabilitation 09/2013; · 2.18 Impact Factor
Community integration after severe traumatic brain injury
Jean-Luc Truellea, Patrick Fayolb, Miche `le Montreuilcand Mathilde Chevignardd,e
Traumatic brain injury (TBI) is a major cause of death
and of disability, particularly in persons under 40 years of
age. There are around 6.2 million Europeans with TBI-
related disability. However, TBI is in many ways a ‘silent
epidemic’, particularly for the so-called ‘chronic phase’.
The long-term physical and, moreover, cognitive/
emotional impairments and the resulting limitations of
daily-life activities affect the person’s self-image, coping
strategies, and community reintegration .
Bridging the gap between medical care/rehabilitation
and community integration means changing semio-
logy from a medical-oriented healthcare perspective
Community integration has been defined by three main
areas: employment, independent living, and social
The purpose of this study is to review recent advances in
the field of community integration after severe TBI in
adults. A literature search was performed in PubMed
Two major issues emerged: diagnosis, evaluation, out-
come measures; and targeted and holistic programs
addressing community integration.
Assessment of community integration and
quality of life: validated outcome measures
and predictive factors
Malec [2??] identified methodological and ethical issues
in TBI clinical research. The goal of evidence-based
medicine (EBM) is to develop a scientific basis for
choosing interventions that will benefit individuals with
defined characteristics. The randomized controlled trial
(RCT) is the gold standard for EBM methodology. Inter-
ventions in TBI rehabilitation may be appropriately
studied within a social model of disability. Ethical
practice requires not only scientific evidence for an
intervention, but also best practices recommended by
professional traditions and consensus, and the indivi-
dual’s known needs and evolving situation [3,4].
The integrated biopsychosocial approach represents a
significant challenge for the evaluation and development
aDepartment of Neurological Rehabilitation, Raymond
Poincare ´ University Hospital, Garches,bService de
psychore ´habilitation Centre hospitalier Esquirol, rue du
Dr Marcland, Limoges,cLaboratoire de
psychopathologie et de neuropsychologie, Universite ´
Paris 8, rue de la Liberte ´, Saint-Denis Cedex,
dRehabilitation Department for Children with Acquired
Brain Injury, Ho ˆpital National de Saint-Maurice, rue du
Val d’Osne, Saint-Maurice andeUniversite ´ Pierre et
Marie Curie, Paris 10, France
Correspondence to Professor Jean-Luc Truelle, MD,
Department of Neurological Rehabilitation, Raymond
Poincare ´ University Hospital, 92380 Garches, France
Tel: +33 1 42 08 67 88; Mobile: þ33 6 22 84 77 65;
fax: +33 1 47 10 70 73;
Current Opinion in Neurology 2010, 23:688–694
Purpose of review
Despite being the main cause of death and disability in young adults, traumatic brain
injury (TBI) is a rather neglected epidemic. Community integration of persons with TBI
was, until recently, insufficiently informed by clinical research.
To bridge the gap between rehabilitation and community re-entry, the first task is to
assess theperson, using TBI-specific outcome measures. The second task is to provide
designed studies. There are very few such studies. However, there are some effective
comprehensive programs and others which are specifically targeted dealing mainly with
return to work, behavior, and family issues. The complex psychological and
environmental components of the disability require individualized and often long-term
For persons with severe TBI trying to achieve the best possible community integration a
new semiology is required, not just limited to medical care, but also involving social and
psychological care that is tailored to the needs of each individual and family, living within
his/her environment. Currently, only a minority benefit from well validated programs.
community integration, health-related quality of life, long-term outcome, rehabilitation
programs, traumatic brain injury
Curr Opin Neurol 23:688–694
? 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
1350-7540 ? 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsDOI:10.1097/WCO.0b013e3283404258
of TBI re-entry programs. Their assessment needs vali-
dated scales which are specific to the chronic phase, and
commonly used in TBI. Examples are the Community
Integration Questionnaire (CIQ) , the Mayo-Portland
Adaptability Inventory (MPAI-4) , the Glasgow Out-
come Scale Extended (GOSE) , and the European
Brain Injury Society (EBIS) document . In addition,
the International Classification of Functioning, Disabil-
ity, and Health (ICF)  offers a taxonomic tool for
conceptualizing and codifying symptoms and barriers
to community participation, and allocating resources.
Increasingly, outcome assessment incorporates the sub-
jective opinion of the person with TBI and of his/her
family. Self-awareness may be assessed by the Patient
Competency Rating Scale (PCRS) [10??], mood and
behavior by the Hospital Anxiety and Depression Scale
(HADS) . The ultimate goal of community integ-
ration is health-related quality of life (HRQOL), and the
unique TBI-specific HRQOL scale, QOLIBRI, has now
been validated in six languages [12?].
programs aimed at community reintegration is the accred-
itation process of The Commission on Accreditation of
Rehabilitation Facilities (CARF). CARF is a nonprofit
American/Canadianorganization which has assessed more
than 500 programs in North America and in Europe .
Predictive factors of community integration
Older age at injury, years after injury [14?,15??,16??],
dynamic assessment of learning ability , coma length,
Barthel Index score, hospital discharge destination, and
preinjury community integration [18?] are usually
reported as the major determinants of postinjury
Prigatano , psychosocial variables play a crucial role,
namely, motivation (a desire for, and personal engage-
tance of the handicapping consequences of TBI; suffi-
cient emotional stabilization; and social and family
environment, particularly a supportive partner and ident-
ified and committed professionals.
The five best predictors or HRQOL (measured by
QOLIBRI) in the community integration period are
depression, amount of help needed, health complaints,
anxiety, and GOSE score [12?].
Community integration targeted programs
Although the major part of motor and cognitive recovery
takes place during the first year, persons with severe TBI
can improve after injury for many years [21?].
Targeted programs aiming at improving various physical,
cognitive and behavioural impairments may increase
Physical therapy interventions
Physical disability, in severe TBI, can be a major obstacle
here by coordinating other health professionals. He/she is
confronted with a range of problems, such as epilepsy,
oro-pharyngeal and bladder/bowel dysfunction, move-
ment and balance disorders, spasticity, orthopedic issues,
pain, and frequent comorbidities in those vulnerable
patients. Recovering mobility is a main challenge. It often
requires long-term rehabilitative maintenance, and may
involve a wheelchair, and assistive devices, for facilitating
independent functioning in the community .
Various specific neuropsychological rehabilitation pro-
grams, focused on divided attention [23?], metacognitive
skills training  or self-awareness  can improve the
targeted skill, but with little transfer to nontrained skills
or independence in everyday life. This is a recurring
problem in neuropsychological rehabilitation in the
chronic phase [26??].
Wilson et al. [26??] demonstrated the efficiency of
electronic devices to compensate memory deficits. For
Culley and Evans , mobile phone and text messages
use improved memorization of rehabilitation goals. Infor-
mation provision on TBI programs is increasingly web-
Behavioral and emotional dysfunction, the major
predictor of low community integration and poor
Two literature reviews [29?,30??] reported very few stu-
dies meeting level I requirements. Cognitive/behavior
Community integration post-TBI in adults Truelle et al.
? Use validated and TBI-specific measures of com-
munity integration and HRQOL.
? When elaborating program studies, participant
characteristics and program content have to be
? Promote best practice in research, including RCT,
single-case experimental design, and consensus
? Long-term follow-up and quality assurance are
based on individual needs, hopes and life situation.
? Promote community-based, holistic and multidisci-
plinary programs, with continuity of care and TBI-
therapy and comprehensive holistic re-entry programs
improve behavioral problems. Serotoninergic antidepress-
ants are the best option for depression. Methylphenidate
[31?] and rivastigmine  improve information proces-
increased after TBI [33?].
Traumatic brain injury limitations on communication,
insight, and self-awareness are an obstacle to insight-
based psychotherapies. Cognitive/behavior therapy and
family therapy are increasingly used. Therapy may
address existential issues such as mourning the loss of
the preinjury hopes and aspirations [29?,30??].
Alcohol and drug addictions are frequent and have a
deleterious effect in TBI. Surprisingly, many physicians
fail toscreenforsubstanceabuse.Furthermore, Westetal.
[34?] showed that 40% of those who diagnosed substance
Ponsford et al. [35?] demonstrated the positive effect of
motivational interviewing, together with an information
booklet on reducing alcohol consumption.
Return to work
Return to work (RTW) is one of the main challenges
following severe TBI [12?,36,37?,38??]. The most signifi-
cant predictors of a successful RTW are better marital
and pretraumatic work status, higher education level,
socio-economic status, and current income, less severe
injury, shorter hospitalization length, being a Caucasian,
and HRQOL [12?,36,37?].
Fadyl and McPherson [38??] identified three approaches
to vocational rehabilitation: work skills rehabilitation,
guided work trials and assisted placement with tran-
sitional job support; individual placement model of
supported employment with on-the-job coaching and
unlimited intervention time and extent; and a case man-
agement model, with early intervention and continuity of
care, and coordination with other rehabilitation services.
The third approach was the most effective, and Fadyl
et al. noted the importance of the therapeutic alliance
with a skilled practitioner.
Wrona [39?] described the vocational rehabilitation pro-
cess in the state of Washington. Forty-four per cent of
persons with severe TBI received vocational rehabilita-
tion, including 65% who returned to work or were con-
sidered as employable. Vocational rehabilitation was pro-
vided in four phases: early intervention involving
employee, employer, physician and vocational counselor;
assessment of ability to work; retraining plan; and plan
implementation. RTW may be full or part-time, shel-
teredwork,or volunteer activity. Ouellet etal. [40?] noted
that the volunteer group included the most severely
injured, and those with a longer delay after injury. One
key to successful RTW is the belief on the part of service
providers that employability is related to the right type,
level, and intensity of support when efforts are made to
help people locate workplaces inwhich their skills will be
valued and their limitations accommodated [41??].
Return to driving
Hemianopia, epilepsy, inattention, aggression, and sub-
stance abuse may all lead to inability to drive, thus
impeding employability, social relationships, indepen-
dence, and self-image. Severely injured patients should
have a driving assessment, including neuropsychological
examination, a simulator test, and an on-road driving test
Sport, leisure, culture, and spirituality
Sportscanbeamajor promoter ofcommunityintegration,
especially for those without severe physical damage. For
the most severely injured, other nonsporting leisure
activities may improve familial and social reintegration.
The choice of activity is typically based on previous life
experience, and the wishes and abilities of the person
with TBI . Better mental health is known to be
associated with membership of a religious group. Positive
spiritual experiences and willingness to forgive are
related to better physical health .
Traumatic brain injury veterans often sustain blast injury
with sensory impairment, pain, reduced motivation,
emotional dysfunction, substance abuse, and impaired
family dynamics [45?]. The Assisted Living Pilot Project
at the Defense and Veterans Brain Injury Center-Johns-
town combines traditional services with telemedicine-
teleconferencing and embedded research on outcomes
and interventions [46?].
Community integration holistic programs
A systematic review, from 1990 to 2008 (Geurtsen et al.
[47??]), of comprehensive re-entry programs after severe
acquired brain injury (ABI) yielded two RCTs, five con-
trolled comparative studies, and six uncontrolled longi-
tudinal cohort studies. Those studies showed a reduction
in psychosocial problems, better community integration
and work participation, more so for day-treatment pro-
grams than for residential programs and for neurobeha-
vioural interventions. Overall, there were methodological
intervention characteristics. The author highlighted the
importance of an integrated multidisciplinary team, and
found that community-based therapy is as effective as
residential programs. Some programs use the goal attain-
ment approach, which provides subjective satisfaction,
Trauma and rehabilitation
Altman et al. [49??] carried out a retrospective analysis
of a community-based postacute brain injury rehabi-
litation on 489 persons with TBI, compared to 114
who were discharged early, prior to program completion.
Significant differences in favor of the former were found
on MPAI-4 (P<0.0001). Gracey et al.  propose a
model of the change process in rehabilitation called the
Y-shape model focused on level of participation but
also on the personal meaning of this to the person
Case management was initially developed in the USA to
facilitate cost-effective rehabilitation. In this approach,
one person (the case manager) is given responsibility to
formulate a plan of intervention, identify the many
services likely to be needed by the brain injured person,
and then help the patient navigate through the maze of
services. Studies by Cope  demonstrated that effi-
cient case management led to shorter inpatient rehabi-
litation stays, and improved rehabilitation outcomes.
Case management is developing in Europe. The British
Association of Brain Injury Case Managers (BABICM)
has now developed a competency framework to assure
quality, and help the professional development of the
case manager [52?].
Impact on family, caregiver stress and
The family has two characteristics: it is caregiver and it
Traumatic brain injury affects the whole family. Several
studies indicate persisting and significant levels of
depression, anxiety, and somatic symptoms. Higher care-
giver distress was associated with caring for survivors who
had worse functional status, received more supervision,
and used alcohol excessively [53?].
Traumatic brain injury family associations are an import-
ant part of the service network, and provide peer groups,
mutual help, and counseling. Regional associations are
often grouped in a national union, which may accrue
political power, and convince public authorities to pay
attention to this ‘silent epidemic’, and to give financial
support for integration programs.
Sex and partnership
Complaints of sexual dysfunction are related to isolation,
emotional and behavioral change, and impaired com-
munication, rather than physical/organic difficulties.
Nevertheless, unsatisfied sexual desire, coupled with
impulsivity, reduced empathy, and difficulty in under-
standing social situations can explain the (relatively
infrequent) sexual assault or aggression. The partner of
the injured person, often a woman, may sustain a heavy
responsibilities. There is a high risk of divorce with a
divorce rate of 58% five years following injury. Managing
sexual issues, especially in residential facilities, is very
challenging for staff, and requires patient-centred care,
with a respect for emotional needs, while balancing an
individual’s rights and limitation of liberty necessitated
by the risk of violence. For female patients pregnancy is
a difficult challenge, requiring reliable contraception
and/or mature decision founded on the ability of the
couple to bring up children [52?,54].
Professional training and concerns
A well trained, experienced, open-minded, and motiv-
ated professional is a key element in a TBI re-entry
program. US and European master classes and university
courses with practical exercises and in-facility courses are
Whatever the compensation system, the physician, the
psychologist, and others, for example, the occupational
therapist, play a major role. TBI requires a thorough
assessment of cognitive/behavior sequelae, family needs,
and functional consequences such as loss of employment.
TBI care, and a solicitor trained in injury compensation
The patient and the life project
Over time, the impact of the initial severity and of the
biomedical aspects decreases, whereas the impact of the
psychological and social/environmental aspects increases.
TBI is particularly common as a result of road traffic
accidents in adolescents and young adults and comes at a
issues regarding independence, work and relationships.
Asking patients for their subjective opinion is crucial in
prioritizing therapeutic goals, taking into account their
personal needs, values and hopes. It also facilitates the
therapeutic alliance, thus helping the participant to build
a new life, in his/her own cultural, familial, social and
environmental context [12?,55?,56?,57].
Continuum of care
One critical issue is transition between early rehabilita-
tion and community integration. At that transition, TBI
persons are still often left alone with their families,
without significant clinical support, leading often to psy-
chosocial deterioration. To address this issue, a transi-
tional program was created, in France, with four aims:
evaluation, retraining, social/vocational orientation, and
follow-up (UEROS). Each of the 32 UEROS comprises a
Community integration post-TBI in adults Truelle et al.
multidisciplinary team providing support for 6 months to
acquired brain injuries, mainly TBI (67%), and long-term
assessment and follow-up. Out of 395 ABI patients, 68%
were moderately or severely disabled at admission. Two
years after discharge, 33% returned to their own accom-
modation and 49% to some kind of work. Apart from the
mandatory continuity of care all the way through, there is
a need for TBI-specific networks, if possible in the same
geographic area [55?],
Do the services meet the needs?
Lefebvre et al.  interviewed persons with TBI,
families and professionals and found that services were
considered to be inadequate, as follows: information,
communication planning, resources coordination and
coherent support, feedback in progress and issues, and
access to medical records; financial protection, work
adaptation and how to access care in psychological crises;
recognition of the need for family and caregiver training
and support, peer groups and associations; and continuity
of care, awareness and access to TBI-specific programs.
For persons with severe TBI trying to achieve the best
possible community integration a new semiology is
required, not just limited to medical care, but also invol-
ving social and psychological care that is tailored to the
needs of each individual and family living within his/her
environment [18?]. Community-based holistic, interdis-
ciplinary, and TBI-specific programs are needed, and
outcomes must be rigorously assessed by effective
measures. There are currently too few services to meet
the needs of all those whohave suffered a TBI, especially
in the long term [53?].
We would like to thank Dr Neil Brooks for our common work on TBI
projects on behalf of the European Brain Injury Society, and for
including his helpful advice on this paper, Professor Klaus von Wild
who induced me to focus our main common investment on community
integration of persons with TBI, Professor Philippe Azouvi for our fruitful
collaboration about the persons with TBI that I take care of in his
department, Christophe Coupe ´ who gathered the numerous papers,
Michel Onillon (ADEF-re ´sidences) for his contribution to community
integration of adults with TBI.
The authors report neither conflict of interest, nor any funding or
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
Additional references related to this topic can also be found in the Current
World Literature section in this issue (pp. 711–713).
of special interest
of outstanding interest
Tagliaferri F, Compagnone C, Korsic M, et al. A systematic review of brain
injury epidemiology in Europe. Acta Neurochir (Wien) 2006; 148:255–268.
This study represents an outstanding contribution to the place of evidence-based
medicine and randomized controlled studies in TBI. However, in the absence of
strong evidence, the ethical practice of brain injury rehabilitation also requires an
awareness of current best practices recommended by professional traditions and
consensus in individual care. He insists on the social/environmental aspects of
disability when targeting the interventions.
Malec JF. Ethical and evidence-based practice in brain injury rehabilitation.
Neuropsychol Rehabil 2009; 19:790–806.
Hart T. Treatment definition in complex rehabilitation interventions. Neuro-
psychol Rehabil 2009; 6:824–840.
The Congressional Brain Injury Task Force. The 2008 International Confer-
ence on Behavioral Health and Traumatic Brain Injury: report to Congress on
improving the care of wounded warriors now. Clin Psychol 2009; 8:1283–
A comparative examination. Am J Phys Med Rehabil 1994; 73:103–111.
Malec JF, Lezak MD. Manual for the Mayo-Portland Adaptability Inventory.
WilsonJT,Pettigrew LE,Teasdale GM. Structured interviews for theGlasgow
Outcome Scale and the extended Glasgow Outcome Scale: guidelines for
their use. J Neurotrauma 1998; 15:573–585.
Brooks DN, Truelle JL, et al. The E. B. I. S. document (European Brain Injury
Society). In: Brooks DN, Truelle JL, editors. Head injury evaluation chart.
Ezanville, France: LADAPT; 1994. pp. 1–32. ; www.ebissociety.org.
Koskinen S, Hokkinen EM, Sarajuuri J, Alaranta H. Applicability of the ICF
checklist to traumatically brain injured patients in postacute rehabilitation
settings. J Rehabil Med 2007; 39:467–472.
PCRS is the most used and accurate scale of anosognosia with two question-
naires to do with the patient and with the significant other. Anosognosia is one of
the major obstacles to community integration.
Prigatano GP. Anosognosia: clinical and ethical considerations. Curr Opin
Neurol 2009; 22:606–611.
11 Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta
Psychiatrica Scand 1983; 67:361–370.
Truelle JL, Koskinen S, Hawthorne G, et al. Quality of life after traumatic brain
injury: the clinical use of the QOLIBRI, a novel disease-specific instrument.
Brain Injury 2010; 24:1272–1291.
This study presents the first TBI-specific HRQOL instrument via a 37 item self-
report questionnaire, to be filled-out in 12 min (the most severely injured need the
help of an examiner), and validated by the international QOLIBRI Task Force in six
languages and six more in progress.
13 Commission on Accreditation of Rehabilitation Facilities. Medical rehabilita-
tion standards manual; 2005 www.carf.org.
Senathi-Raja D, Ponsford J, Scho ¨nberger MJ. Impact of age on long-term
cognitive function after traumatic brain injury. Neuropsychology 2010;
After maximum spontaneous recovery from TBI, poorer cognitive functioning
appears to be associated with both older age at the time of injury and increased
Ponsford J, Scho ¨nberger M. Family functioning and emotional state two and
five years after traumatic brain injury. J Int Neuropsychol Soc 2010; 16:306–
This long-term study showed that both TBI participants and their relatives had
elevated rates of anxiety and depression, with little difference at 2 and 5 years after
injury. These findings indicate the need for long-term support of families with a
Sendroy-Terrill M, Whiteneck GG, Brooks CA. Aging with traumatic brain
injury: cross-sectional follow-up of people receiving inpatient rehabilitation
over more than 3 decades. Arch Phys Med Rehabil 2010; 91:489–497.
The initial severity of the TBI is a stronger predictor of most outcomes than either
the years after injury or the age at injury. Nevertheless, these last two factors
predict decline in physical and cognitive functioning, in social participation, and in
perceived environmental barriers.
ability improves outcome prediction following acquired brain injury. Brain
Injury 2009; 23:278–290.
Willemse van-Son A, Ribbers G, Hop W, Stam H. Community integration
following moderate to severe traumatic brain injury: a logitudinal issue.
J Rehabil Med 2009; 41:521–527.
Age, Barthel Index scores, hospital dischargedestination,and preinjury community
integration scores were the major determinants of community integration
36 months after injury.
19 Ben-Yishay Y, Daniels-Zide E. Diller lecture: outcomes after holistic rehabi-
litation. Rehabil Psychol 2000; 2:112–129.
20 Prigatano GP. Work, love, and play after brain injury. Bull Menninger Clin
Trauma and rehabilitation
6-15 years after traumatic brain injuries in northern Sweden. Acta Neurol
Scand 2009; 120:389–391.
Individuals with a TBI can achieve and maintain a high degree of functioning many
years after the injury. Increasing age and a greater injury severity contributed to
their long-term disability.
22 Sullivan KJ. Therapy interventions for mobility impairments and motor skill
acquisition after TBI. In: Zasler N, Katz D, Zafonte R, editors. Brain injury
medicine. New York: Demos Publisher; 2007. pp. 929–946.
Couillet J, Soury S, Lebornec G, et al. Rehabilitation of divided attention after
severe traumatic brain injury: a randomised trial. Neuropsychol Rehabil 2010;
Very well designed study showing a positive effect on divided attention rehabilita-
tion but without significant transfer in the long term on activities of daily life.
24 Ownsworth T, Quinn H, Fleming J, et al. Error self-regulation following
traumatic brain injury: a single case study evaluation of metacognitive skills
training and behavioural practice interventions. Neuropsychol Rehabil 2010;
25 Lundquist A, Linnros H, Ornelius H, Samuelsson K. Improved self-awareness
and coping strategies for patients with acquired brain injury: a group therapy
programme. Brain Injury 2010; 24:823–832.
Wilson B, Gracey F, Evans J, Bateman A. Neuropsychological rehabilitation:
theories, models, therapy and outcome. Wilson B, editor. Cambridge, UK:
Cambridge University Press; 2009.
This book presents a holistic approach to understanding and working with the
population with acquired brain injury by integrating evidence-based treatment with
clinical judgment and patient-centred goals.
27 Culley C, Evans JJ. SMS text messaging as a means of increasing recall of
therapy goals in brain injury rehabilitation: a single-blind within-subjects trial.
Neuropsychol Rehabil 2010; 20:103–119.
28 Newby G, Groom C. Evaluating the usability of a single UK community
acquired brain injury (ABI) rehabilitation service website: implications for
research methodology and website design. Neuropsychol Rehabil 2010;
Fann JR, Jones AL, Dikmen SS, et al. Depression treatment preferences after
traumatic brain injury: a systematic review. J Head Trauma Rehabil 2009;
The challenge concerns one of the major obstacles to community integration. This
up-to-date literature review shows the paucity of RCT. Serotoninergic antidepres-
sants and cognitive/behavioral interventions appear to have the best preliminary
evidence for treating depression following TBI.
Cattelani R, Zettin M, Zoccolotti P. Rehabilitation treatments for adults with
behavioral and psychosocial disorders following acquired brain injury: a
systematic review. Neuropsychol Rev 2010; 20:52–58.
This literature review on 63 studies in ABI emphasizes the efficiency of cognitive/
behavior therapy and moreover of comprehensive holistic rehabilitation programs
in psychosocial functioning.
SivanM,Neumann V,KentR,etal.Pharmacotherapyfor treatment ofattention
deficits after nonprogressive acquired brain injury. A systematic review. Clin
Rehabil 2010; 24:110–121.
Although there is lack of robust evidence to recommend the routine use of
medication to improve attention after traumatic brain injury and stroke, the existing
evidence indicates potential for benefit in some patents.
32 Silver JM, Koumaras B, Meng X, et al. Long-term effects of rivastigmine
capsules in patients with traumatic brain injury. Brain Injury 2009; 23:123–
Tsiouris JA. Pharmacotherapy for aggressive behaviours in persons with
intellectual disabilities: treatment or mistreatment? J Intellect Disabil Res
Antipsychotic drugs should be given with caution, considering their adverse
effects in TBI.
Professional neglect of alcohol and drug problems.
West S, Luck R, Capps C, et al. Alcohol/other drug problems screening and
intervention by rehabilitation physicians. Alcohol Treat Q 2009; 23:280–293.
A well designed RCT showing the positive effect of a simple method of interview
and information as compared to usual treatment to reduce alcohol use in persons
Ponsford J, Twedly L, Lee N. Investigation of a brief intervention to minimize
alcohol use following traumatic brain injury. Brain Impair 2010; 11:198–199.
36 Gary KW, Arango-Lasprilla JC, Ketchum JM, et al. Racial differences in
employment outcome after traumatic brain injury at 1, 2, and 5 years after
injury. Arch Phys Med Rehabil 2009; 90:1699–1707.
Tsaousides T, Warshowsky A, Ashman TA, et al. The relationship between
employment-related self-efficacy and quality of life following traumatic brain
injury. Rehabil Psychol 2009; 54:299–305.
Theinterest ofthisstudyistotakeinto account thesubjective opinion oftheworker
on his/her working efficacy and of his/her QOL to improve the employability.
Fadyl JK, McPherson KM. Approaches to vocational rehabilitation after trau-
matic brain injury: a review of the evidence. J Head Trauma Rehabil 2009;
This is a systematic and critical review on the effectiveness, strengths and
weaknesses of vocational rehabilitation. Three broad categories of vocational
rehabilitation are identified: program-based job skills training and placement
assistance, individual placement model of supported employment, and case
coordinated rehabilitation. In the absence of definitive evidence regarding
efficacy, the author suggests a framework to evaluate which of the approaches
available would be most suitable for the particular individual or population of
Wrona RM. Disability and return to work outcomes after traumatic brain injury:
results from the Washington State Industrial Insurance Fund. Disabil Rehabil
A thorough description of a stage by stage process of return to work and of a State
Ouellet M, Morin CM, Lavoie A. Volunteer work and psychological health
following traumatic brain injury. J Head Trauma Rehabil 2009; 24:262–
This study shows the interest of volunteer work in community integration for
numerous severely injured.
Wehman P, Gentry T, West M, Arango-Lasprilla JC. Community integration:
current issues in cognitive and vocational rehabilitation for individuals with
ABI. J Rehabil Res Dev 2009; 46:909–918.
The problemsare not just cognitive or emotional but spill overinto community living
and vocational issues. The main interest of this study is the thorough reflections on
the background of community integration.
42 Kneipp S, Rubin A. Clinical driving assessment.
Zafonte R, editors. Brain injury medicine. New York: Demos Publisher;
2007. pp. 1091–1097.
In: Zasler N, Katz D,
43 Bier N, Dutil E, Couture M. Factors affecting leisure participation after a
traumatic brain injury: an exploratory study. J Head Trauma Rehabil 2009;
44 Johnstone B, Yoon DP, Rupright J, Reid-Arndt S. Relationships among
spiritual beliefs, religious practices, congregational support and health for
individuals with traumatic brain injury. Brain Injury 2009; 23:411–419.
Kennedy CH, Moore JL, editors. Military neuropsychology. New York: Spring-
er Publishing Co; 2010. pp. 101–125.
Given the increasing number of warriors sustaining blast injury including TBI, the
author emphasizes the complexity of symptomatology and of care for both physical
and emotional consequences and of the implications for their community integra-
Hoffman SW, Shesko K, Harrison CR. Enhanced neurorehabilitation techni-
ques in the DVBIC Assisted Living Pilot Project. NeuroRehabilitation 2010;
A comprehensive model dedicated to warriors which enhances the knowledge of
various targeted and comprehensive programs.
Geurtsen GJ, van Heugten CM, Martina JD, Geurts ACH. Comprehensive
rehabilitation programmes in the chronic phase after severe brain injury: a
systematic review. J Rehabil Med 2010; 42:97–110.
The most recently achieved literature review from 1990 to 2008 of the compre-
hensive rehabilitation and re-entry programs showing few RCT but positive effects
on community integration.
48 Doig E, Fleming J, Tooth L. Patterns of community integration 2–5 years
postdischarge from brain injury rehabilitation. Brain Injury 2001; 15:747–
Altman IM, Swick S, Parrott D, Malec JF. Effectiveness of community-
based rehabilitation after traumatic brain injury for 489 programs com-
pleters compared to those precipitously discharged. Brain Impair 2010;
This retrospective study grouped seven centers and 489 persons with TBI with a
control group. At 12-month follow-up, program completers had a higher score for
the full MPAI-4, the Abilities, Adjustment, and Participation indexes (all scores at
50 Gracey F, Evans J, Malley D. Capturing process and outcome in complex
rehabilitation interventions: a ‘Y-shape’ model. Neuropsychol Rehabil 2009;
51 Cope ND. Managing the impossible: getting better results in returning
catastrophically injured people to work. J Workers Compensation 2009;
Despite the heterogeneity of the population served which explains the difficulty of
assessing its effectiveness, case management is developing and integrates, under
the leadership of the case manager, all the interventions needed by one person
British Association of Brain Injury Case Managers (BABICM) Competency
Framework for Brain Injury Case Managers. 2010. www.babicm.org
Community integration post-TBI in adults Truelle et al.
Kreutzer JS, Rapport LJ, Marwitz JH, et al. Caregivers’ well being after
traumatic brain injury: a multicenter prospective investigation. Arch Phys
Med Rehabil 2009; 90:939–946.
Depression, anxiety, and somatic symptoms are common among caregivers.
Findings substantiate the importance of clinical care systems addressing the
needs of caregivers in the long term as well as survivors.
54 Johnson C, Knight C, Alderman N. Challenges associated with the definition
and assessment of inappropriate sexual behaviour amongst individuals with
an acquired neurological impairment. Brain Injury 2006; 20:687–693.
This work presents the French experience of community integration after TBI and
emphasizes French innovations to do with transitional units, TBI-specific tools and
programs, and family involvement.
Truelle J, von Wild K, Onillon M, Montreuil M. Social reintegration of traumatic
brain injured: the French experience. Asian J Neurosurg 2010; 5:24–31.
O’Callaghan AM, McAllister L, Wilson L. Sixteen years on: has quality of care
for rural and noncompensable traumatic brain injury clients improved? Aust J
Rural Health 2009; 17:119–123.
This review focuses on two factors that influence client access to care following
head injury, namely the degree of rurality of a client’s home town and the funding
model to which they are allocated.
57 Weed R, Berens D. Life care planning after traumatic brain injury. In: Zasler N,
Katz D, Zafonte R, editors. Brain injury medicine. New York: Demos Medical
Publishing; 2007. pp. 1223–1240.
58 Lefebvre H, Pelchat D, Levert M. Interdisciplinary family intervention program:
a partnership among health professionals, traumatic brain injury patients, and
caregiving relatives. J Trauma Nurs 2007; 14:100–113.
Trauma and rehabilitation