Evaluating Brain-in-Hand for adults with an acquired brain injury

Over one million people live with the long-term consequences of acquired brain injury (ABI). Individuals with ABI may find it difficult to self-manage the effects of injury and it is important to provide them with the skills to live independently. Many smart technologies exist to aid rehabilitation, but there is limited technology available to support self-management. Brain-in-Hand (BiH) is a smartphone application that was specifically engineered to support the management of persistent emotional and behavioural problems, which are commonly seen following ABI. However, it has not been systematically evaluated in this population. The aim of this thesis was to understand the perspectives and experiences of people with ABI and healthcare professionals after using BiH. A systematic review was conducted to highlight the level of evidence available for smart technologies in the ABI population, and determine the effectiveness of technologies compared to usual care/other technologies on independence and functional outcomes. The review included six randomised controlled trials that utilised a range of technology interventions (e.g., smartphone, iPad, Neuropage). All included a measure of goal attainment/function, however none measured independence or fatigue. Only one measured quality of life and participation. The review highlighted a lack of studies focusing on some of the hidden consequences of ABI such as lack of independence, fatigue, anxiety and poor participation. An engagement study was conducted with stakeholders (n=50) (including people with ABI, carers and professionals), to explore their views and opinions of BiH, and identify some of the barriers and facilitators to its use. A mixed methods approach was used (focus groups, questionnaires, and presentations) to obtain feedback. Stakeholders identified areas that BiH could potentially target such a memory and managing routine. They also highlighted some of the barriers to use such as smartphone competency, lack of interest in technology, and not seeing a personal use for BiH. These findings informed the design of the subsequent case studies. An n-of-1 mixed method case study design was used. All ABI participants were provided with BiH for 12 months. Data were collected using questionnaires (at baseline, 6 and 12 months post-intervention) and semi-structured interviews (at six months post-intervention) with ABI participants and healthcare professionals. Questionnaire data were used to determine whether BiH had any effect on functional outcomes, mood, fatigue, participation, quality of life and cognition of ABI participants. The interviews aimed to explore the barriers and facilitators associated with the use of BiH. These were thematically analysed using a framework informed by the Behaviour Change Wheel (BCW) and International Classification of Functioning, Disability and Health (ICF). A feasibility health economics evaluation was also conducted. The quantitative findings showed that BiH had no effect on mood, functional independence, participation, quality of life, fatigue, or quality of life. However, there was a significant increase in goal attainment over the first six months. There was also a slight improvement in cognitive function. An overarching theme of context (personal/environmental factors) was identified as a key factor influencing the use and effectiveness of BiH. The four subthemes were: 1) insight and self-awareness following injury and its impact on BiH use; 2) patient and therapist support/training to use BiH; 3) motivation to use BiH and achieve goals; 4) technology specific barriers/facilitators. Having a sufficient level of insight, appropriate support (set up, training, monitoring etc.), and motivation appeared to facilitate BiH use. The health economics evaluation identified potential cost drivers as therapist appointments and the cost of BiH. It was feasible to collect this data from the ABI population. Contextual factors need to be considered when implementing BiH, or similar technology interventions in the ABI population. Personal and environmental factors play a key role in the use and effectiveness of BiH. It is important to identify important barriers and facilitators early in the implementation process, to guide the development of BiH for ABI, and its wider applicability to other long-term neurological conditions. Additional research is required to determine its effectiveness in the ABI population. BiH has the potential to be a valuable tool in community rehabilitation by facilitating independent living for people with ABI and providing a way to self-monitor and manage their fatigue/anxiety

A systematic review of personal smart technologies used to improve outcomes in adults with acquired brain injuries

Objective:This review aimed to determine the effectiveness of personal smart technologies on outcomes in adults with acquired brain injury.Data sources:A systematic literature search was conducted on 30 May 2019. Twelve electronic databases, grey literature databases, PROSPERO, reference list and author citations were searched.Methods:Randomised controlled trials were included if personal smart technology was used to improve independence, goal attainment/function, fatigue or quality of life in adults with acquired brain injury. Data were extracted using a bespoke form and the TIDieR checklist. Studies were graded using the PEDro scale to assess quality of reporting. Meta-analysis was conducted across four studies.Results:Six studies met the inclusion criteria, generating a total of 244 participants. All studies were of high quality (PEDro ⩾ 6). Interventions included personal digital assistant, smartphone app, mobile phone messaging, Neuropage and an iPad. Reporting of intervention tailoring for individual needs was inconsistent. All studies measured goal attainment/function but none measured independence or fatigue. One study (n = 42) reported a significant increase in memory-specific goal attainment (p = 0.0001) and retrospective memory function (p = 0.042) in favour of the intervention. Another study (n = 8) reported a significant increase in social participation in favour of the intervention (p = 0.01). However, our meta-analyses found no significant effect of personal smart technology on goal attainment, cognitive or psychological function.Conclusion:At present, there is insufficient evidence to support the clinical benefit of personal smart technologies to improve outcomes in acquired brain injury. Researchers need to conduct more randomised studies to evaluate these interventions and measure their potential effects/harms

Describing return to work after stroke : a feasibility trial of 12-month outcomes

Objective: Stroke is the greatest cause of disability in adults. A quarter of strokes in the UK affect people of working age, yet under half of them return to work after stroke. There has been little investigation into what constitutes “return to work” following stroke. The aim of this study is to describe the work metrics of stroke survivor participants in a feasibility randomized controlled trial of an early stroke specific vocational rehabilitation intervention. Methods: Retrospective analysis of trial data. Metrics on work status, working hours, workplace accommodations and costs were extracted from trial out - comes gathered by postal questionnaire at 3, 6, and 12 months’ post-randomization for 46 stroke participants in a feasibility randomized controlled trial. Participants were randomized to receive vocational rehabilitation (intervention) or usual care (control). Results: Two-thirds ( n = 29; 63%) of participants re - turned to work at some point in the 12 months following stroke. Participants took a mean of 90 days to return to work. Most returned to the same role with an existing employer. Only one-third of participants who were employed full-time at stroke onset were working full-time at 12 months post-stroke. Most participants experienced a reduction in pre-stroke earnings. Workplace accommodations were more common among intervention group participants. More intervention participants than control participants reported satisfaction with work at both 6 and 12 months post-randomization. Conclusion: This study illustrates the heterogeneous nature of return to work and the dramatic impact of stroke on work status, working hours and income. Longitudinal research should explore the socioeconomic legacy of stroke and include clear definitions of work and accurate measures of working hours and income from all sources

A study of mapping usual care and unmet need for vocational rehabilitation and psychological support following major trauma in five health districts in the UK

Traumatic injuries in working age adults are a global public health problem. Traumatic injury or ‘major trauma’ describes serious and often multiple injuries where there is a strong possibility of death or disability1 (e.g. traumatic brain injuries, complex fractures). Survivors of such injuries may experience physical, social, and psychological problems, such as pain, fatigue, depression and anxiety, or hidden disabilities, such as cognitive problems. A significant number of people experiencing trauma have residual problems affecting their ability to return to, and remain in, work2, 3. Therefore, it is important that rehabilitation to support these individuals is available long-term and addresses all issues

Patient perspectives on key outcomes for vocational rehabilitation interventions following traumatic injury

Returning to work after traumatic injury can have a range of benefits, but there is currently little research that incorporates patient perspectives to identify outcomes of vocational rehabilitation interventions that are important to survivors. Trauma survivors (n = 17) participated in in-depth semi-structured interviews or focus groups exploring outcomes that were important to them for recovery and return to work. Data were analysed using thematic analysis. Participants identified a range of outcomes that they considered important and necessary to facilitate a successful and sustainable return to work: physical and psychological recovery, purposeful life engagement, managing expectations of recovery, managing expectations about return to work, and employers’ expectations. Our participants advocated for a multifaceted and biopsychosocial understanding of recovery and outcomes that need to be captured for vocational rehabilitation interventions. Implications for practice and research are discussed, and recommendations are given based on the findings

Vocational rehabilitation to enhance return to work after trauma (ROWTATE): protocol for a non-randomised single-arm mixed-methods feasibility study

BackgroundTraumatic injuries are common amongst working age adults. Survivors often experience physical and psychological problems, reduced quality of life and difficulty returning to work. Vocational rehabilitation improves work outcomes for a range of conditions but evidence of effectiveness for those with traumatic injuries is lacking. This study assesses feasibility of delivering a vocational rehabilitation intervention to enhance return to work and improve quality of life and wellbeing in people with at least moderate trauma to inform design of a definitive randomised controlled trial (RCT).MethodsNon-randomised, single arm, multi-centre mixed-methods feasibility study with nested case studies and qualitative study. The case studies comprise interviews, observations of clinical contacts and review of clinical records. The qualitative study comprises interviews and/or focus groups. Participants will be recruited from two UK major trauma centres. Participants will comprise 40 patients aged 16-69 with an injury severity score of >8 who will receive the intervention and complete questionnaires. Interviews will be conducted with 10 patients and their occupational therapists (OTs), clinical psychologists (CPs), employers and commissioners of rehabilitation services. Fidelity will be assessed in up to six patients by observations of OT and CP – patient contacts, review of patient records and intervention case report forms. OT and CP training will be evaluated using questionnaires and competence to deliver the intervention assessed using a team objected structured clinical examination and written task. Patients participating in and those declining participation in the study will be invited to take part in interviews/focus groups to explore barriers and facilitators to recruitment and retention. Outcomes include recruitment and retention rates, intervention fidelity, OT and CP competence to deliver the intervention, experiences of delivering or receiving the intervention and factors likely to influence definitive trial delivery.Discussion Effective vocational rehabilitation interventions to enhance return to work amongst trauma patients are urgently needed because return to work is often delayed, with detrimental effects on health, financial stability, healthcare resource use and wider society. This protocol describes a feasibility study delivering a complex intervention to enhance return to work in those with at least moderate trauma

Understanding how stroke telerehabilitation works and for whom to inform recommendations for practice: The TELSTAR study protocol

Telerehabilitation (TR) shows promise as a method of remote service delivery, yet there is little guidance to inform implementation in the context of the National Health Service (NHS) in England. This paper presents the protocol for a realist synthesis study aiming to investigate how TR can be implemented to support the provision of high quality, equitable community-based stroke rehabilitation and under what conditions. Using a realist approach, we will synthesise information from: 1) a comprehensive evidence review; 2) qualitative interviews with clinicians (n≤30), and patient-family carer dyads (n≤60), from three purposively selected community stroke rehabilitation services in England. Working groups including rehabilitation professionals, service users and policy makers will co-develop actionable recommendations. Insights from the review and the interviews will be synthesised to test and refine programme theories that explain how TR works and for whom in clinical practice and draw key messages for service implementation. This protocol highlights the need to improve our understanding of TR implementation in the context of multidisciplinary, community-based stroke service provision. We suggest the use of realist methodology and co-production to inform evidence-based recommendations which consider the needs and priorities of clinicians and people affected by stroke

Factors affecting the delivery and acceptability of the ROWTATE telehealth vocational rehabilitation intervention for traumatic injury survivors: a mixed-methods study

Background: Returning to work after traumatic injury can be problematic. We developed a vocational telerehabilitation (VR) intervention for trauma survivors, delivered by trained occupational therapists (OTs) and clinical psychologists (CPs), and explored factors affecting delivery and acceptability in a feasibility study. Methods: Surveys pre- (5 OTs, 2 CPs) and post-training (3 OTs, 1 CP); interviews pre- (5 OTs, 2 CPs) and post-intervention (4 trauma survivors, 4 OTs, 2 CPs). Mean survey scores for 14 theoretical domains identified telerehabilitation barriers (score ≤ 3.5) and facilitators (score ≥ 5). Interviews were transcribed and thematically analysed. Results: Surveys: pre-training, the only barrier was therapists’ intentions to use telerehabilitation (mean = 3.40 ± 0.23), post-training, 13/14 domains were facilitators. Interviews: barriers/facilitators included environmental context/resources (e.g., technology, patient engagement, privacy/disruptions, travel and access); beliefs about capabilities (e.g., building rapport, complex assessments, knowledge/confidence, third-party feedback and communication style); optimism (e.g., impossible assessments, novel working methods, perceived importance and patient/therapist reluctance) and social/professional role/identity (e.g., therapeutic methods). Training and experience of intervention delivery addressed some barriers and increased facilitators. The intervention was acceptable to trauma survivors and therapists. Conclusion: Despite training and experience in intervention delivery, some barriers remained. Providing some face-to-face delivery where necessary may address certain barriers, but strategies are required to address other barriers

Informing evaluation of a smartphone application for people with acquired brain injury: a stakeholder engagement study

Background Brain in Hand is a smartphone application (app) that allows users to create structured diaries with problems and solutions, attach reminders, record task completion and has a symptom monitoring system. Brain in Hand was designed to support people with psychological problems, and encourage behaviour monitoring and change. The aim of this paper is to describe the process of exploring the barriers and enablers for the uptake and use of Brain in Hand in clinical practice, identify potential adaptations of the app for use with people with acquired brain injury (ABI), and determine whether the behaviour change wheel can be used as a model for engagement. Methods We identified stakeholders: ABI survivors and carers, National Health Service and private healthcare professionals, and engaged with them via focus groups, conference presentations, small group discussions, and through questionnaires. The results were evaluated using the behaviour change wheel and descriptive statistics of questionnaire responses. Results We engaged with 20 ABI survivors, 5 carers, 25 professionals, 41 questionnaires were completed by stakeholders. Comments made during group discussions were supported by questionnaire results. Enablers included smartphone competency (capability), personalisation of app (opportunity), and identifying perceived need (motivation). Barriers included a physical and cognitive inability to use smartphone (capability), potential cost and reliability of technology (opportunity), and no desire to use technology or change from existing strategies (motivation). The stakeholders identified potential uses and changes to the app, which were not easily mapped onto the behaviour change wheel, e.g. monitoring fatigue levels, method of logging task completion, and editing the diary on their smartphone. Conclusions The study identified that both ABI survivors and therapists could see a use for Brain in Hand, but wanted users to be able to personalise it themselves to address individual user needs, e.g. monitoring activity levels. The behaviour change wheel is a useful tool when designing and evaluating engagement activities as it addresses most aspects of implementation, however additional categories may be needed to explore the specific features of assistive technology interventions, e.g. technical functions

Evaluating Brain-in-Hand for adults with an acquired brain injury

Over one million people live with the long-term consequences of acquired brain injury (ABI). Individuals with ABI may find it difficult to self-manage the effects of injury and it is important to provide them with the skills to live independently. Many smart technologies exist to aid rehabilitation, but there is limited technology available to support self-management. Brain-in-Hand (BiH) is a smartphone application that was specifically engineered to support the management of persistent emotional and behavioural problems, which are commonly seen following ABI. However, it has not been systematically evaluated in this population. The aim of this thesis was to understand the perspectives and experiences of people with ABI and healthcare professionals after using BiH. A systematic review was conducted to highlight the level of evidence available for smart technologies in the ABI population, and determine the effectiveness of technologies compared to usual care/other technologies on independence and functional outcomes. The review included six randomised controlled trials that utilised a range of technology interventions (e.g., smartphone, iPad, Neuropage). All included a measure of goal attainment/function, however none measured independence or fatigue. Only one measured quality of life and participation. The review highlighted a lack of studies focusing on some of the hidden consequences of ABI such as lack of independence, fatigue, anxiety and poor participation. An engagement study was conducted with stakeholders (n=50) (including people with ABI, carers and professionals), to explore their views and opinions of BiH, and identify some of the barriers and facilitators to its use. A mixed methods approach was used (focus groups, questionnaires, and presentations) to obtain feedback. Stakeholders identified areas that BiH could potentially target such a memory and managing routine. They also highlighted some of the barriers to use such as smartphone competency, lack of interest in technology, and not seeing a personal use for BiH. These findings informed the design of the subsequent case studies. An n-of-1 mixed method case study design was used. All ABI participants were provided with BiH for 12 months. Data were collected using questionnaires (at baseline, 6 and 12 months post-intervention) and semi-structured interviews (at six months post-intervention) with ABI participants and healthcare professionals. Questionnaire data were used to determine whether BiH had any effect on functional outcomes, mood, fatigue, participation, quality of life and cognition of ABI participants. The interviews aimed to explore the barriers and facilitators associated with the use of BiH. These were thematically analysed using a framework informed by the Behaviour Change Wheel (BCW) and International Classification of Functioning, Disability and Health (ICF). A feasibility health economics evaluation was also conducted. The quantitative findings showed that BiH had no effect on mood, functional independence, participation, quality of life, fatigue, or quality of life. However, there was a significant increase in goal attainment over the first six months. There was also a slight improvement in cognitive function. An overarching theme of context (personal/environmental factors) was identified as a key factor influencing the use and effectiveness of BiH. The four subthemes were: 1) insight and self-awareness following injury and its impact on BiH use; 2) patient and therapist support/training to use BiH; 3) motivation to use BiH and achieve goals; 4) technology specific barriers/facilitators. Having a sufficient level of insight, appropriate support (set up, training, monitoring etc.), and motivation appeared to facilitate BiH use. The health economics evaluation identified potential cost drivers as therapist appointments and the cost of BiH. It was feasible to collect this data from the ABI population. Contextual factors need to be considered when implementing BiH, or similar technology interventions in the ABI population. Personal and environmental factors play a key role in the use and effectiveness of BiH. It is important to identify important barriers and facilitators early in the implementation process, to guide the development of BiH for ABI, and its wider applicability to other long-term neurological conditions. Additional research is required to determine its effectiveness in the ABI population. BiH has the potential to be a valuable tool in community rehabilitation by facilitating independent living for people with ABI and providing a way to self-monitor and manage their fatigue/anxiety