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Background: Case management (CM) aims to facilitate access to and integration of health care and social services. We investigated the feasibility and effectiveness of CM., Methods: Randomized controlled trial with 219 patients and 114 caregivers randomly allocated to CM (109/59) or care as usual (110/55). CM was based on early and continuous online monitoring of problems and needs. Outcomes were assessed every 6 months with the Hospital Anxiety and Depression Scale (HADS). Secondary outcome domains were participant restrictions, life satisfaction, self-efficacy, caregiver burden, and needs. Multilevel modeling was used. Feasibility aspects were protocol delivery, participants' and case managers' satisfaction, and factors affecting implementation., Results: There were no significant differences between groups. Participation restrictions and unmet needs decreased in both groups within 6 months. Monitoring was successful in 38, and 10 participants asked the CM for support. CM consisted mostly of providing information., Discussion: CM based on early and continuous online monitoring does not have benefit in identifying and addressing problems early after relatively mild injury. Unsuccessful monitoring may have hindered access to the case manager and prevented us from evaluating CM as a complex intervention. It remains a challenge to early identify those who could benefit from care coordination.

Background: Detecting cognitive impairments early after stroke is essential for appropriate referrals. Although recommended in stroke guidelines, early cognitive screening is not always implemented. We assessed whether the Montreal Cognitive Assessment (MoCA) adds diagnostic value compared to clinical observation alone. In addition, discharge destinations for stroke patients with and without cognitive deficits detected with the screening tool or the treatment team were explored., Methods: Forty-four stroke patients were screened with the MoCA during stroke unit admission. Their charts were studied for cognitive impairments reported by the stroke care team, who were blinded to screening scores. Proportions of detected cognitive deficits were compared between screening (score <26) and patient charts. Discharge destination distribution (home vs. rehabilitation) was explored., Results: The proportion of cognitively impaired patients indicated by the MoCA (84%) and reported in patients' charts (25%) differed significantly ( p  < 0.001). The distribution of discharge destination did not suggest an association with the detection of cognitive deficits by the treatment team or the cognitive screening., Conclusions: The MoCA detects more cognitive deficits than clinical impression alone, emphasizing the importance of standard screening for cognitive impairments in acute stroke patients. Ultimately, systematic screening may enhance discharge planning and improve long-term outcomes.

Objective: To determine whether cognitive learning potential measured with the dynamic Wisconsin Card Sorting Test has added value in predicting rehabilitation outcome in elderly patients post-stroke after controlling for age, ADL independence at admission, global cognitive functioning and depressive symptoms., Methods: Participants were patients with stroke admitted to a geriatric rehabilitation unit. ADL independence (Barthel Index) at discharge was used as measure for rehabilitation outcome. Predictor variables included age, ADL independence at admission, global cognitive functioning (Montreal Cognitive Assessment), depressive symptoms (Geriatric Depression Scale) and cognitive learning potential measured with the dWCST., Results: Thirty participants were included. Bivariate analyses showed that rehabilitation outcome was significantly correlated with ADL independence at admission ( r  = 0.443, p  = 0.014) and global cognitive functioning ( r  = 0.491, p  = 0.006). Regression analyses showed that the dWCST was not an independent predictor of rehabilitation outcome. ADL independence at admission was the only significant predictor of rehabilitation outcome (beta = 0.480, p  = 0.007)., Conclusions: Cognitive learning potential, measured with the dWCST has no added value in predicting rehabilitation outcome in elderly patients post-stroke. ADL independence at admission was the only significant predictor of rehabilitation outcome., Registration Number Netherlands Trial Register: Trial NL7947.

Objective : Although the long-term consequences of acquired brain injury are frequent and diverse, care and support over the longer term is an under-addressed issue. This study aims to identify the perceived needs of people with acquired brain injury and their partners. Methods : Interviews with four focus groups of people with brain injury (n = 17) and three partner groups (n = 19) were audio- and videotaped, transcribed verbatim and analyzed using inductive content analysis. Results : Needs were perceived on the intrapersonal, social, healthcare and societal levels, focusing on three themes: 1) Adaptation to changes, including awareness of consequences, acceptance, role changes and dealing with these; 2) Understanding from relatives/friends, professionals, institutions and society; 3) Timely, individualized care, involving information, transition to home, searching for support, peer support and support for partner/family. Discussion : The variety and complexity of needs show that people with brain injury and their partners need to find a new balance in order to live a fulfilling life despite the consequences of brain injury. The overarching need for continuity of care from the transition to home onwards provides important implications for supporting the process of learning how to live well with brain injury.

Objectives : To systematically review literature on efficacy of amantadine on behavior (irritability/aggression/agitation, emotional lability, apathy, impairment of executive functioning), participation, quality-of-life (QoL), and safety, in patients with acquired brain injury (ABI). Amantadine is widely used clinically, so comprehensive information on efficacy, participation, QoL and safety is relevant. Methods : We used PRISMA Guidelines. We searched PubMed/EMBASE/CINAHL (last search 28-8-2018) Two independent reviewers performed selection and data-extraction. Quality of studies was assessed, using CONSORT and Quality Assessment Tool for Quantitative Studies (QATFQS). Results : Eleven out of 500 studies were included. Of five RCTs, two reported significant effects on irritability/aggression, and one no effect. One RCT on cognition no effect. One prospective cohort study showed a significant effect on executive functioning. One retrospective study was inconclusive. One single-case experimental design (SCED) study reported significant effect on apathy and three case-reports indicated effects on behavior. QoL and societal participation were not measured. No safety issues emerged. Conclusion : Amantadine may be efficacious on irritability and aggression after ABI. Amantadine is a safe drug in the presence of adequate creatinine clearance. Future studies should use designs, suitable for the heterogeneous ABI population, like randomized SCEDs, and should include the effect on societal participation and QoL.

Background: A minority of patients with mild traumatic brain injury (mTBI) experience a persistent symptom complex also known as post-concussion syndrome. Explanations for this syndrome are still lacking., Objective: To investigate if the fear avoidance model, including catastrophizing thoughts and fear avoidance behaviour, poses a possible biopsychosocial explanation for lingering symptoms and delay in recovery after traumatic brain injury (TBI) with special focus on mTBI., Design: Cross-sectional study., Participants: 48 patients with TBI, of which 31 patients with mTBI, had persistent symptoms (mean time since injury 48.2 months); 92% of the entire sample fulfilled the criteria for post-concussion syndrome., Outcome Variables: catastrophizing, fear-avoidance, depression and post-concussion symptoms., Results: High levels of catastrophizing were found in 10% and high levels of fear avoidance behaviour were found in 35%. Catastrophizing, fear avoidance behaviour, depressive symptoms and post-concussion symptoms correlated significantly with each other (p < 0.05)., Conclusion: The fear-avoidance model proposes a possible explanation for persistent symptoms. Validation and normative data are needed for suitable measures of catastrophizing and fear avoidance of post-concussion symptoms after TBI. Longitudinal prospective cohort studies are needed to establish its causal and explanatory nature.

Primary Objective: To determine whether patients with stroke who have a good functional outcome show awareness of memory functioning and whether over- and under-estimation of memory performance are differentially related to neuropsychological performance., Research Design: Prospective cohort study., Methods and Procedures: The Barrow Neurological Institute Screen for Higher Cerebral Functions and a brief neuropsychological assessment were used to evaluate language, orientation, attention, visuospatial problem-solving, perception, reasoning, executive functioning, memory, affect and awareness of memory functioning. As for the latter, the patient's estimate of memory functioning was compared with his or her actual memory performance. Patients were divided into three groups: good-estimators (estimated performance = actual performance), over-estimators (estimated performance > actual performance) and under-estimators (estimated performance < actual performance)., Main Outcomes and Results: In total, 54 patients with stroke were included, of whom 27 patients were classified as good-estimators, 19 as over-estimators and eight as under-estimators. Compared to good-estimators, over-estimators had significantly lower scores for all cognitive domains. Under-estimators had significantly poorer affect compared to good-estimators., Conclusions: These preliminary results suggest that over- and under-estimation of memory functioning can be observed in patients with stroke who have a good functional outcome and that they may reflect distinct underlying neuropsychological processes.

Primary Objective: To determine clinicians' views on learning ability in brain injury rehabilitation., Research Design: Online survey., Methods and Procedures: An online survey was sent to physicians, psychologists and therapists of three Dutch organizations for neuropsychology or rehabilitation. The survey enquired (1) whether clinicians take learning ability into account; (2) about factors influencing learning ability; and (3) about assessment tools used to assess learning ability., Main Outcomes and Results: Thirty-seven physicians, 83 psychologists and 43 therapists completed the online survey. In total, 93% of respondents reported that they take learning ability into account when making a prognosis. The most frequently mentioned factors influencing learning ability were cognition, awareness of deficits and motivation. Learning ability was mainly determined by means of cognitive and memory tests and observations during therapy., Conclusions: This study demonstrates that a patient's learning ability may be influenced by not only cognition but also by motivation and awareness of deficits. Structured and standardized assessment of these factors may be suggested for standard use in clinical practice. More research is needed about the influence these factors have on the learning process.

Objective: To provide recommendations for the successful implementation of Assistive Technology (AT) in cognitive rehabilitation by investigating the attitudes towards AT of professionals, individuals with acquired brain injury (ABI) and their caregivers in two exploratory studies., Method: A total of 147 professionals in cognitive rehabilitation filled out a web-based survey. Fifteen patients with ABI and 14 caregivers were interviewed., Results: Most professionals were willing to use AT in the future, although only 27% used AT currently in a treatment setting. Professionals with AT experience were more positive than those without about the potential of AT and their own ability to use it in their treatment programmes. Most patients and caregivers were positive about using AT in the future, still, only a minority currently used AT. Refusal to reimburse AT devices by health insurance companies appeared an important barrier for a more widespread use., Conclusions: Although enthusiasm about AT was evident in both studies, a lack of progress in the implementation of AT was noted. This could be improved by promoting knowledge and hands-on experience of professionals who work in rehabilitation centres. More evidence on the efficacy of AT is required to improve coverage of AT devices by insurance companies.

Objective: To examine the effects of a residential community reintegration programme for patients with psychosocial problems due to acquired chronic brain injury on caregivers' emotional burden and family functioning., Design: A prospective cohort study with waiting list control and 1-year follow-up., Subjects: Forty-one caregivers of which 28 female. Mean age was 48 ± 8.3 years and 33 caregivers were parents., Intervention: A structured residential treatment programme was offered to the patients directed at domestic life, work, leisure time and social interactions., Measures: The Involvement Evaluation Questionnaire for Brain Injury (IEQ-BI) for emotional burden, the General Health Questionnaire (GHQ) for psychological health and the Family Assessment Device (FAD) for family functioning were used., Results: There was an overall significant effect of Time for all outcome measures (MANOVA T(2 )= 9.1, F(15,317) = 64.1, p = 0.000). The effect sizes were moderate for three IEQ-BI sub-scales (partial η(2 )= 0.12-0.17) and small for two sub-scales (partial η(2 )= 0.05-0.09). The effect size for GHQ was moderate (partial η(2 )= 0.11). As for FAD no significant time effects were present (partial η(2 )= 0.00-0.04)., Conclusions: Emotional burden and psychological health of the caregivers improved significantly when patients with acquired brain injury and psychosocial problems followed a residential community reintegration programme. Family dynamics remained stable.

Purpose: To assess the effectiveness of a residential community reintegration programme for participants with chronic sequelae of severe acquired brain injury that hamper community functioning., Design: Prospective cohort study., Subjects: Twenty-four participants with acquired brain injury (traumatic n = 18; stroke n = 3, tumour n = 2, encephalitis n = 1). Participants had impaired illness awareness, alcohol and drug problems and/or behavioural problems., Intervention: A skills-oriented programme with modules related to independent living, work, social and emotional well-being., Methods: The Community Integration Questionnaire, CES-Depression, EuroQOL, Employability Rating Scale, living situation and work status were scored at the start (T0), end of treatment (T1) and 1-year follow-up (T2)., Results: Significant effects on the majority of outcome measures were present at T1. Employability significantly improved at T2 and living independently rose from 42% to over 70%. Participants working increased from 38% to 58% and the hours of work per week increased from 8 to 15., Conclusion: The Brain Integration Programme led to a sustained reduction in experienced problems and improved community integration. It is concluded that even participants with complex problems due to severe brain injury who got stuck in life could improve their social participation and emotional well-being through a residential community reintegration programme.

Objective: To investigate the long-term (2-15 years) functional outcome of children and young adults who received an early intensive neurorehabilitation programme (EINP) after a prolonged period of unconsciousness due to severe brain injury; to differentiate between traumatic brain injury (TBI) and non-traumatic brain injury (nTBI); and to compare the results on two different outcome scales: the Disability Rating Scale (DRS) and the Glasgow Outcome Scale Extended (GOSE)., Subjects: One hundred and forty-five patients, who were admitted to EINP between December 1987 and January 2001., Outcome Measures: The Post-Acute Level of Consciousness scale (PALOC-s), the DRS, including categorized scores (DRScat), and the GOSE., Results: The long-term functional level of 90 patients could be determined, of whom 25 were deceased. The mean DRS-score of the surviving patients was 6.8 (SD = 6.6); the mean score on the GOSE was 4.5 (SD = 1.7). There was a significant difference in the outcome amongst traumatic and non-traumatic patients (t88 = 4.21; p < 0.01). The correlation between the DRS and the GOSE was high (Spearman rho = 0.85; p < 0.01), as well as the correlation between the categorized scores of the DRS and the GOSE (Spearman rho = 0.81; p < 0.01). The distribution of outcome scores on the DRScat is more diverse than on the GOSE. Especially item 7 of the DRS, measuring functional independence, showed considerable variance in discriminating between different outcome levels., Conclusions: More patients with TBI than expected reached a (semi-) independent level of functioning, indicating a possible effect of EINP. Patients suffering from nTBI did not demonstrate these outcome levels. Only a few patients stayed in a vegetative state for more than a couple of years. In this cohort of severe brain-injured young people, the DRS offered the best investigative possibilities for long-term level of functioning.

Objective: The purpose of the present study was to evaluate progress in neuropsychological performance in children and adolescents with severe paediatric traumatic brain injury (TBI), from admission to the rehabilitation centre up to 3-12 years after the trauma., Methods: Children and adolescents (n = 31, mean age at injury 11.8 years, SD = 3.8; at follow-up 18.8 years; SD = 4.5) who all had suffered a TBI participated. A comprehensive neuropsychological test battery was administered at the start of rehabilitation (T1), around discharge (T2) and in the long-term (at least 3 years after rehabilitation; T3). T1 and T2 were clinical assessments; T3 was executed as a follow-up measurement for this study., Results: At T1 and T2, most problems were in the domains of attention, memory and executive functioning. At the start of rehabilitation most deficits were with performal intelligence (61%); at discharge (mean length of stay 411 days) considerably less children had severe deficits on the intelligence domain (23%). At long-term follow-up, most problems were in the domains attention, mental speed and memory. From admission to discharge 42% of the children improved on two or more cognitive tests; from discharge to follow-up this percentage was 13%., Conclusions: In this unique study a clinical cohort of children with severe TBI was followed for many years after injury. Most cognitive deficits were found in the early phase of rehabilitation. Most children did improve on cognitive functioning (40%) during the first year after their injury, whereas at follow-up most children had not changed. At follow-up, more than half of the children (54%) attended a regular school or had a regular job, corresponding to their age and pre-morbid functioning.