Authors: Anthony H. Lequerica, PhD; Michael Williams, PhD; Irene Ward, DPT
During acute hospitalization after brain injury, individuals receive critical, life-saving care aimed at maximizing health. Once medically stable, patients may be transferred to a rehabilitation facility where there is a greater focus on functional gains to maximize independence and prepare patients for community reintegration.
The rehabilitation setting typically requires greater effort and volition on the part of the brain injury survivor as they progress through intensive rehabilitation therapies that may involve physical therapy, occupational therapy, and speech-language pathology, therapeutic recreation, rehabilitation psychology and neuropsychology services, and other therapeutic interventions delivered by the rehabilitation staff. With lengths of stay becoming shorter over the years, therapeutic engagement is an important consideration to maximize the patient’s ability to benefit from services during their rehabilitation stay. Engagement can continue to hold prominence as individuals transition to outpatient therapies or other rehabilitation programs in the community. In this article, we will review some of the prior research regarding barriers and facilitators of engagement and present an updated conceptual model that may provide a useful visual reference for understanding engagement as a phenomenon within the context of brain injury rehabilitation.
Engagement in rehabilitation has been defined previously as a “deliberate effort and commitment to working toward the goals of rehabilitation interventions, typically demonstrated through active, effortful participation in therapies and cooperation with treatment providers”1. Therapeutic engagement in rehabilitation has been demonstrated to be an important predictor of functional outcomes, with poorer engagement found to be associated with lower functional gains and longer length of stay2,3. Presented here is an updated model (see Figure 1) from one that was previously published 1. In some ways, this model has been simplified.
However, some contributing factors have been added for consideration as contextual issues that can influence various elements in the model. Some of these issues are affected by brain injury sequelae (i.e., post-traumatic amnesia, cognitive deficits, disinhibition, agitation, emotional distress, and pain) that can pose barriers to engagement in rehabilitation and negatively influence outcomes. The duration of post-traumatic amnesia, or the acute period of confusion following a traumatic brain injury is an indicator of injury severity that has been inversely linked to therapy engagement 2,4. Disinhibition and agitated behaviors that are often observed during the early phase of recovery have also been shown to be associated with engagement in rehabilitation, and an indirect effect of agitation on rehabilitation progress has been demonstrated with engagement as the mediator 5.
Even after individuals emerge from the acute period of confusion, residual cognitive deficits can pose barriers to engagement. Williams and colleagues (2021) demonstrated positive relationships between engagement and various cognitive domains6. Notably, executive functioning, delayed memory, and processing speed had the strongest bivariate relationships with therapy engagement.
Executive functioning is a prominent cognitive domain with respect to engagement as it captures self-regulatory behaviors and cognitive abilities. Relatedly, impaired self-awareness (or awareness of deficits) is an important factor in recovery affecting therapeutic engagement. Toglia & Kirk (2000) comprehensively detailed awareness of deficits after TBI, which highlighted the metacognitive/executive functioning aspects of self-awareness 7.
Arnould and colleagues (2016) expanded the conceptual understanding of awareness deficits to include other problematic behavior changes (i.e., impulsivity and apathy) while maintaining connection to executive control and adding neuroanatomical correlates pertinent for individuals after brain injury 8. Impaired self-awareness is likely to affect the perceived need depicted in the conceptual model. However, even when awareness of deficits is not impaired, it may not always be intuitive how therapy activities will be of benefit. Not understanding how therapeutic activities will be beneficial has been cited as a barrier to rehabilitation in exercise-based interventions 9. Shared decision making (SDM) is a dynamic process that “involves patient engagement through patient education, which arms the patients with the necessary knowledge needed to make informed decisions regarding their health” or potential benefits to treatment 10.
Rehabilitation therapists may need to employ creative ways such as the use of decision aids or include patient’s families to explain the evidence to patients with limited health literacy or cognitive capacity 10. Rehabilitation therapists working with individuals with brain injury reported frequently tailoring their therapy tasks to be meaningful to patients and in line with their goals in order to enhance engagement 11. Therapy activities that are decontextualized or removed from a real-world context, may require therapists to take extra time to help patients understand the connection between a therapeutic exercise and the anticipated benefit to everyday functioning. In addition to executive dysfunction, poor memory functioning can present as lack of follow through with unsupervised, independent practice. The bivariate relationship between processing speed and therapy engagement found in previous research6 may reflect an overarching attentional component whereby a lack of engagement may arise from high distractibility or reduced arousal.
In addition to pharmacological interventions, modification to the therapy environment can play an important role in minimizing distraction or creating a therapy space tailored to the needs of the brain injury survivor. See Table 1 for barriers to engagement in the recovery and rehabilitation process as well as considerations for addressing these barriers.
Emotional status is connected to engagement and requires careful consideration. Apathy is inversely related to therapy engagement6,12. However, the cognitive drivers for low engagement could also affect level of apathy in other life areas. Individuals with brain injury may have a complex combination of anosognosia (lack of awareness of deficits as described earlier) and denial (lack of acceptance or acknowledgement), the latter of which represents a psychological coping mechanism 13,14. Denial of illness is an important predictor of engagement 15. A rehabilitation psychologist is often charged with assisting rehabilitation patients as they begin the process of adjustment to disability. As awareness of deficits increases, emotional distress may also increase. Findings have been mixed with regard to the relationship between rehabilitation engagement and self-reported psychological symptoms of depression and anxiety. Although Ramanathan-Elion and colleagues (2016) found an inverse bivariate relationship, depression was not a relevant predictor of engagement in the full model controlling for other facilitators and barriers 15. Individual differences in the manifestation of depressive symptoms is likely an important consideration as common concomitants of depression such as apathy and reduced motivation have been shown to be associated with engagement 12,16. Further study is needed in this area regarding potential self-referent cognitions regarding self-esteem and adjustment to disability that may affect the perceived self-efficacy factors in the proposed model of engagement.
General anxiety was not related to engagement in a study by Williams and colleagues 6 although pain-related anxiety was inversely linked with level of therapy engagement in the same study sample 17. The fear-avoidance model of pain suggests a person will avoid activities that cause pain, which can include physical rehabilitation activities 18. Moderate to large associations between pain-related fear (trigger for avoidance) and disability has been demonstrated for people with acute or chronic pain 19. Physical pain may hamper engagement in rehabilitation activities by limiting range of motion or task persistence in the moment. Managing pain through pharmacological and non-pharmacological means should be included in a comprehensive plan that includes addressing any associated anticipatory pain-related anxiety that may interfere with rehabilitation therapies. The conceptual model component of perceived risk may include a fear of pain or discomfort as well as a fear of personal injury resulting from active participation in therapy exercises. Other contextual factors in the model such as trust in the therapist can play an important role in rehabilitation engagement on a number of levels such as minimizing the fear associated with perceived risks and providing a general openness to cooperation.
Rehabilitation therapists often walk a fine line between challenging individuals toward advancement, while not overwhelming them, and also supporting a sense of self-efficacy even in the face of perceived failures by providing encouragement and validation. In the model, engagement is shown to occur when effort is applied which may be affected by one’s capacity to initiate. Once the patient is engaged in the therapeutic activity, the ongoing analysis of experience may lead to a reassessment of the outcome expectancies which will persist as long as there is energy to participate, the experience is tolerated, and the goal has not yet been achieved. Individual differences may be observed with regard to the degree of importance one places on each of the factors depicted in the model. Rehabilitation therapists often encounter a wide variety of individuals with brain injury sequelae that may differentially affect the perceptions and outcome expectancies. For some individuals with greater cognitive impairment, ability to follow commands or behavioral disturbance may play a greater role in engagement. Another important consideration is that culturally and linguistically diverse individuals may have different ideas and values regarding health care, independence, and personal control that can affect motivation to participate 20,21. For example, the concept of active participation in one’s own treatment, while an important ingredient in the rehabilitation setting, may be a foreign concept to many individuals 22. Culturally humble approaches within a patient centered framework are important as a step toward minimizing racial/ethnic disparities in functional outcomes.
In the original engagement model proposed by Lequerica and Kortte (2010), engagement was described as a complex concept that involved one’s interaction with their environment1. This concept of engagement as a process was reflected in review by Bright, Kayes, Worrall & McPherson (2015) which concluded that engagement is a multi-dimensional construct, comprising both a co-constructed process and a patient state 23. This conceptualization highlights the therapeutic dyad where the patient and therapist both play a role in cultivating a therapeutic relationship where engagement can be maximized. While the cognitive process model presented here is more patient-centered, further research is needed within the context of brain injury rehabilitation to examine the dynamic nature of the dyadic interaction and develop tailored interventions that can improve rehabilitation outcomes. To encourage ongoing research and consideration for clinical use, a listing of some engagement measures is provided in Table 2.
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Anthony H. Lequerica, PhD, is a Senior Research Scientist at Kessler Foundation’s Center for TBI Research and a Research Associate Professor at Rutgers – New Jersey Medical School in the Department of Physical Medicine and Rehabilitation. As Director of the Brain and Behavioral Outcomes Lab, his research focuses on cultural and sociodemographic factors affecting brain injury rehabilitation outcomes. He is Co-Chair of the Inclusion, Diversity, Equity, and Accessibility Special Interest Group within the Traumatic Brain Injury Model Systems sponsored by the National Institute on Disability, Independent Living, and Rehabilitation Research. He is a Staff Neuropsychologist at Kessler Institute for Rehabilitation where he provides neuropsychological services to Spanish-speakers with a variety of neurological conditions. He has over 50 peer-reviewed publications and has given numerous presentations across the U.S. and abroad to researchers, health care professionals, and individuals with brain injury and their families.
Michael W. Williams, PhD, is an Assistant Professor in the Department of Psychology at the University of Houston. As a faculty member in the doctoral clinical psychology program, he mentors graduate students in research. He leads the Measurement and Intervention for Neuropsychological Disorders (MIND) lab, which focuses on improving patient centered outcomes for individuals with a brain injury. His research examines neuropsychological characteristics (e.g., cognition, mood, pain) that are associated with long-term functional outcomes (e.g., independence, return to work, etc.) to identify novel targets of intervention and to develop tailored interventions for optimizing medical rehabilitation and functional recovery. His research is actively funded by the Brain Injury Association of America as well as the National Institute on Disability, Independent Living, and Rehabilitation Research. He is a licensed psychologist and serves on the item writing committee for the Association of State and Provincial Psychology Boards to develop questions for the Examination in Professional Practice of Psychology (EPPP) Part 1.
Irene Gorzelany Ward, PT, DPT, is board certified specialist in Neurologic Physical Therapy since 2006 with 21 years of clinical experience in working with adults with acquired brain injury. Irene engages in clinical research through her current role as the research coordinator for the Brain Injury Program at the Kessler Institute for Rehabilitation. She is the Principal Investigator for a Knowledge Translation Project involving High Intensity Gait Training in the Brain Injury Program. Irene is an adjunct instructor on evidence based practice techniques for the Physical Therapy Program at Seton Hall University and a Clinical Assistant Professor for Rutgers- New Jersey Medical School. Irene is the Director of Knowledge Synthesis on the Board of Directors for the Academy of Neurologic Physical Therapy of the American Physical Therapy Association.