Background: Ventilator-associated pneumonia is a major cause of morbidity and mortality for patients in an intensive care unit. Once present, ventilator-associated pneumonia is known to increase the duration of mechanical ventilation, time in the intensive care unit, and length of hospital stay. Patients with acquired brain injury are commonly admitted to the intensive care unit and considered to be at a high risk for the development of respiratory complications such as ventilator-associated pneumonia, which could potentially impact on the intensive care unit costs and outcomes. Respiratory physiotherapy is often provided to prevent and/or treat ventilator-associated pneumonia in patients with acquired brain injury. The theoretical rationale of the respiratory physiotherapy is to improve airway clearance and enhance ventilation which may reduce the incidence of pulmonary infections and thus ventilator-associated pneumonia, and may in turn decrease the duration of mechanical ventilation, prevent the need for tracheostomy and hence result in reduced costs and shorter hospital stay. Although respiratory physiotherapy may be beneficial in reversing or preventing ventilator-associated pneumonia, to date there are no data concerning the effectiveness of respiratory physiotherapy in patients with acquired brain injury. Hence from an evidence-based perspective, at present there is no justification for the role of respiratory physiotherapy in the management of patients with acquired brain injury in the intensive care unit. Aim: This two-part, prospective randomised controlled trial aimed to investigate the effect of regular prophylactic respiratory physiotherapy on the incidence of ventilator-associated pneumonia, duration of mechanical ventilation, and length of intensive care unit stay in adults with acquired brain injury, as compared to a control group (Part A). / The second part of the study (Part B) randomised those subjects from Part A who developed a ventilatorassociated pneumonia into a treatment or control group to establish if the provision of a regimen of regular respiratory physiotherapy influenced the outcome of ventilator-associated pneumonia. Additionally, this study also aimed to provide the first description of the financial costs of respiratory physiotherapy time in providing interventions to patients with acquired brain injury in the intensive care unit and investigated the cost effectiveness of respiratory physiotherapy interventions in decreasing the incidence of ventilator-associated pneumonia, duration of mechanical ventilation and length of intensive care unit stay. Subjects: 144 adult patients with acquired brain injury admitted with a Glasgow Coma Scale of nine or less, requiring intracranial pressure monitoring, and invasive ventilatory support for greater than 24 hours, were randomised to a treatment group or a control group. Methods: For subjects randomised to the treatment groups, the regimen of respiratory physiotherapy treatment was repeated six times per 24-hour period and continued until the subject was weaned from mechanical ventilatory support. Each respiratory physiotherapy intervention of 30 minute duration comprised a regimen of positioning, manual hyperinflation and suctioning. In both Parts A and B, the control group received standard nursing and medical care but no respiratory physiotherapy interventions. Results: Consent was obtained for 144 subjects, with 72 randomised for treatment in Part A. Part A groups were comparable with respect to demographic variables, with the exception of body mass index and gender distribution. / Using intention to treat philosophy, there were no significant differences for incidence of ventilator-associated pneumonia [Treatment Group 14/72 (19.4%) vs. Control 19/72 (26.4%); p = 0.32], duration of mechanical ventilation (hr) [172.8 vs. 206.3); p = 0.18], or length of intensive care unit stay (hr) [224.2 vs. 256.4; p = 0.22]. For subjects with acquired brain injury receiving this prophylactic regimen of respiratory physiotherapy in the intensive care unit, in an attempt to prevent ventilator-associated pneumonia, the cost of physiotherapy was $487 per subject. Comparatively the intensive care unit mechanical ventilation bed day cost was $33,380 per subject. The cost of Part A respiratory physiotherapy time for Treatment Group 1 was 1.7 per cent of the cost of subject's intensive care unit mechanical ventilation bed days. Thirty-three subjects (22.9%) from Part A developed ventilator-associated pneumonia, and were transferred to Part B and re-randomised, 17 to the Treatment Group 3. Part B groups were comparable with respect to demographic variables. No significant differences were detected in the dependent variables for Part B of the study, with similar duration of mechanical ventilation (hr) [342.0 vs. 351.0); p = 0. 89], and length of ICU stay (hr) [384.7 vs. 397.9; p = 0.84] noted. In those subjects with acquired brain injury in whom ventilator-associated pneumonia developed, the regimen of respiratory physiotherapy for the remaining duration of mechanical ventilation following diagnosis of ventilator-associated pneumonia costed an average of $788. Comparatively the intensive care unit bed day cost for the period of mechanical ventilation was $43,865. The cost of Part B respiratory physiotherapy time for Treatment Group 3 was 1.8 per cent of the cost of their intensive care unit mechanical ventilation bed days. / Subjects with a ventilator-associated pneumonia were significantly younger, were admitted with a lower Glasgow coma scale, and more likely to have been admitted with a chest injury than subjects without a ventilator-associated pneumonia. Duration of mechanical ventilation and length of intensive care unit stay were significantly increased in subjects with ventilatorassociated pneumonia, but length of hospital stay was not significantly different. Significant differences in the costs of respiratory physiotherapy and intensive care unit mechanical ventilation bed day costs were evident between those subjects with ventilator-associated pneumonia as compared to those without ventilator-associated pneumonia. For subjects with ventilator-associated pneumonia, the respiratory physiotherapy time cost was $1,029 per subject, compared to $510 for subjects without ventilator-associated pneumonia. The intensive care unit mechanical ventilation bed day cost for subjects with ventilator-associated pneumonia was $61,092 per subject, and $25,142 for those without a ventilator-associated pneumonia, giving an incremental health cost of $35,950 per episode of ventilatorassociated pneumonia. No significant differences were evident in the cost of respiratory physiotherapy as a per cent of the cost of their intensive care unit mechanical ventilation bed days, with findings of 1.4 per cent in those with ventilator-associated pneumonia and 1.1 per cent in those without ventilator-associated pneumonia. / Conclusion: Use of a regular prophylactic respiratory physiotherapy regimen comprising of positioning, manual hyperinflation and suctioning, in addition to routine medical and nursing care, did not appear to prevent ventilator-associated pneumonia, reduce length of ventilation or intensive care unit stay in adults with acquired brain injury. Furthermore, in those acquired brain injury subjects with ventilator-associated pneumonia, regular respiratory physiotherapy did not appear to expedite recovery in terms of reducing length of ventilation or intensive care unit stay. It can be concluded from the findings of this study that the presence of ventilator-associated pneumonia has a significant influence on morbidity and costs in subjects with acquired brain injury. Whilst statistically significant results were not found with clinical variables, it is suggested that the provision of a prophylactic respiratory physiotherapy regimen costing $487 per subject is a worthwhile investment in attempts to avoid the incremental health cost of $35,950 per episode of ventilator-associated pneumonia. In subjects with ventilator-associated pneumonia it is concluded that the cost of respiratory physiotherapy would not appear to be justified in attempts to reduce the duration of mechanical ventilation.

Acquired Brain Injury (ABI) can cause balance and mobility deficits with activity and participation limitations. Repetitive Functional Task Practice (RFTP), currently best practice to promote recovery, is often not delivered at an adequate volume due to limited resources. This case series looked at the feasibility of treating community-dwelling people with ABI, in a group format, thus allowing economical, intense rehabilitation. Four participants attended for four weeks, three days/week, 4.25 hours/day. One-to-one and semi-supervised therapy was delivered with one therapist and one assistant. 89.51 minutes of RFTP and 134.82 minutes of total physical therapeutic activity was delivered per day. Participant satisfaction was good. All participants improved on some clinical measures. Three participants improved single and dual-task balance measures. This project established feasibility, allowed the formation of guiding principles for and supported the value of future research and development of this ABI Boot Camp model. / February 2016

Aims: Acquired Brain Injury (ABI) is often researched from a reductionist perspective, focusing on pathology and dysfunction (Olney & Kim, 2001). More recently there has been a call towards taking a person-centred, global approach; questioning old ‘assumptions’ about what is currently known, and incorporating the views of the patient (Hill, 1999). This qualitative research study aimed to make a further contribution to the evidence-base by investigating the experience of adjusting to life after ABI. Method: Six participants, (two female, four male) aged 26-49, who had experienced a severe ABI an average of 31 months previously, were interviewed using a semistructured schedule. Interpretative Phenomenological Analysis (IPA) was employed to analyse the transcripts. Results: Five master themes emerged from the participants’ accounts: Experiencing a loss of control; Observed changes as a threat to identity; Being displaced by the injury: Feeling unchanged in a changed world; Attempts at managing a threatened identity, and Enable me don’t disable me: The role of support in recovery. Implications: Clinical implications were considered within Bronfenbrenner’s (1979, 2004) Ecological Systems Theoretical Framework. Within the Microsystems (the individual’s immediate systems such as their body, home and work) participants described a struggle to make sense of their perceived loss of control of their body and brain. They described the importance of making sense of these changes. Clinically there is a potential role for professionals to facilitate how people make sense of their experiences, perhaps moving away from reductionist explanations, which appeared to prevent participants from having hope to influence change. From a Macrosystemic level (the individual’s social, cultural and political systems) the participants felt they were less valued and as a result, judged by society and by political systems. Participants’ accounts suggested that they wanted to continue to contribute and be valuable in society. An implication therefore is for professionals involved to take more a political stance in influencing how we currently conceptualise people after brain injury, focusing on enablement rather than disablement.

Few studies have explored emotion processing abilities in children following Acquired Brain Injury (ABI). This study develops previous research in this area by exploring emotion processing skills in children with focal ABI, using eye tracking technology. It was hypothesised that children with focal ABI would demonstrate impaired emotion recognition abilities relative to a control group and that, similar to adult eye tracking studies, they would show an atypical pattern of eye moments when viewing faces. Sixteen participants with focal ABI (10-16 years) and 27 healthy controls (10-16 years) completed one novel and one adapted visual emotion processing task, presented using a T120 Tobii eye-tracker. The eye-tracker measured eye-movement fixations in three areas of interest (AOIs; eyes, nose, mouth), as participants viewed the stimuli. Emotion perception accuracy was recorded. All participants from the ABI group also completed neuropsychological assessment of their immediate visual memory, visual attention, visuospatial abilities, and everyday executive function. The results of the study showed no significant difference in accuracy between the ABI and control groups. However, on average children with ABI appeared slightly less accurate than the control group in both emotion recognition tasks. Within-subjects analysis revealed no effect of lesion location and laterality or age at lesion onset upon emotion recognition accuracy. Eye tracking analysis showed that children within the ABI group presented with an atypical pattern of eye movements relative to the control group, demonstrating significantly greater fixation times within the eye region, when viewing disgusted, fearful angry and happy faces. The ABI group also showed reduced mean percentage fixation duration within the nose and mouth regions, relative to controls. Furthermore, it was observed that the ABI group took longer on average to give an accurate response to sad, disgusted, happy and surprised faces and this difference reached statistical significance for the accurate recognition of happy and surprised faces. It is suggested that the atypical fixation patterns noted within the ABI group, may represent a difficulty with dividing visual attention rapidly across the whole of the face. This slowing may have an impact upon functioning in everyday social situations, where rapid processing and appraisal of emotion is thought to be particularly important. It is therefore suggested that eye tracking technology may be a valuable method for the identification of subtle difficulties in facial emotion processing, following focal ABI in childhood, and may also have an application in the rehabilitation of these difficulties in future.

Acquired brain injury (ABI) and long-term neurological conditions (such as multiple sclerosis, Parkinson’s disease), are major causes of disability in the UK, and can lead to significant physical, cognitive, neuro-behavioural, psychological and social difficulties for sufferers. Individuals affected by an ABI or neurological conditions commonly report difficulties around emotional adjustment, reduced attention, mental control, and self-efficacy and their health-related quality of life also often appears to be much reduced. Whilst conventional neuro-rehabilitation has tended to address physical and cognitive impairments and deficits rather than psychological sequelae, recently a growing trend for more holistic approaches appears to have emerged (e.g., Wilson et al., 2000, 2013). Amongst these approaches, mindfulness-based interventions (collectively known as MBIs) have sought to address this gap in terms of therapeutic intervention. There is a growing body of research evidence pointing to the utility of MBIs in the rehabilitation and support of these populations in improving perceived quality of life and increasing self-management of these conditions. However, the research still remains limited and debate persists in terms of the conceptual and theoretical framework of mindfulness. The present study sought to evaluate the effectiveness of an adapted, short-form MBI group programme for a mixed population of patients (n = 22) currently offered in a local neuro-rehabilitation service. A specific pre-post control group design was adopted in order to investigate whether the intervention produced improvements in mindfulness skills, and whether these would in turn lead to improvements in measures associated with self-efficacy and perceived quality of life. Results indicated participants completing the MBI group programme showed significantly higher mean scores across measures of mindfulness. The results also indicated that these improvements were predictive of improvements across self-efficacy and quality of life measures, with large effect sizes observed. The findings would appear to support the research hypothesis that a suitably modified MBI is beneficial for a mixed ABI population. Findings, study limitations, clinical relevance and implications, as well as methodological and theoretical considerations and directions for future research are discussed in light of the main research questions.