Observational Study Medicine ® OPEN The impact of COVID-19 on home, social, and productivity integration of people with chronic traumatic brain injury or stroke living in the community ∗ Alejandro García-Rudolph, PhDa,b,c, , Joan Saurí, PhDa,b,c, Blanca Cegarra, MSca,b,c, Eloy Opisso, PhDa,b,c, Josep María Tormos, PhDa,b,c, Dietmar Frey, PhDd, Vince Istvan Madai, PhDd,e,f, Montserrat Bernabeu, MDa,b,c Abstract Compare community integration of people with stroke or traumatic brain injury (TBI) living in the community before and during the coronavirus severe acute respiratory syndrome coronavirus 2 disease (COVID-19) when stratifying by injury: participants with stroke (G1) and with TBI (G2); by functional independence in activities of daily living: independent (G3) and dependent (G4); by age: participants younger than 54 (G5) and older than 54 (G6); and by gender: female (G7) and male (G8) participants. Prospective observational cohort study In-person follow-up visits (before COVID-19 outbreak) to a rehabilitation hospital in Spain and on-line during COVID-19. Community dwelling adults (≥18 years) with chronic stroke or TBI. Community integration questionnaire (CIQ) the total-CIQ as well as the subscale domains (ie, home-CIQ, social-CIQ, productivity CIQ) were compared before and during COVID-19 using the Wilcoxon ranked test or paired t test when appropriate reporting Cohen effect sizes (d). The functional independence measure was used to assess functional independence in activities of daily living. Two hundred four participants, 51.4% with stroke and 48.6% with TBI assessed on-line between June 2020 and April 2021 were compared to their own in-person assessments performed before COVID-19. When analyzing total-CIQ, G1 (d = 0.231), G2 (d = 0.240), G3 (d = 0.285), G5 (d = 0.276), G6 (d = 0.199), G7 (d = 0.245), and G8 (d = 0.210) significantly decreased their scores during COVID-19, meanwhile G4 was the only group with no significant differences before and during COVID-19. In productivity-CIQ, G1 (d = 0.197), G4 (d = 0.215), G6 (d = 0.300), and G8 (d = 0.210) significantly increased their scores, meanwhile no significant differences were observed in G2, G3, G5, and G7. In social-CIQ, all groups significantly decreased their scores: G1 (d = 0.348), G2 (d = 0.372), G3 (d = 0.437), G4 (d = 0.253), G5 (d = 0.394), G6 (d = 0.319), G7 (d = 0.355), and G8 (d = 0.365). In home-CIQ only G6 (d = 0.229) significantly decreased, no significant differences were observed in any of the other groups. The largest effect sizes were observed in total-CIQ for G3, in productivity-CIQ for G6, in social-CIQ for G3 and in home-CIQ for G6 (medium effect sizes). Stratifying participants by injury, functionality, age or gender allowed identifying specific CIQ subtotals where remote support may be provided addressing them. Editor: Wen-Jun Tu. This research was partially funded by H2020 Personalised Medicine by Predictive Modeling in Stroke for better Quality of Life (PRECISE4Q) Grant No. 777107 and by PARTICIPA: Overcoming barriers to social participation in individuals with disabilities (Institut Guttmann). The authors have no conflicts of interest to disclose. Supplemental Digital Content is available for this article. The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request. a Department of Research and Innovation, Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, Badalona, Barcelona, Spain, b Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain, c Fundació Institut d’Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Barcelona, Spain, d Charité Lab for Artificial Intelligence in Medicine – CLAIM, Charité - Universitätsmedizin Berlin, Berlin, Germany, e QUEST Center for Transforming Biomedical Research, Berlin Institute of Health (BIH), Charité - Universitätsmedizin Berlin, Berlin, Germany, f School of Computing and Digital Technology, Faculty of Computing, Engineering and the Built Environment, Birmingham City University, Birmingham, United Kingdom. ∗ Correspondence: Alejandro García-Rudolph, Department of Research and Innovation, Institut Guttmann – Hospital de Neurorehabilitació, Cami Can Ruti s/n 08916 Badalona, Barcelona, Spain (e-mail: alejandropablogarcia@gmail.com). Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc. This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite this article: García-Rudolph A, Saurí J, Cegarra B, Opisso E, Tormos JM, Frey D, Madai VI, Bernabeu M. The impact of COVID-19 on home, social, and productivity integration of people with chronic traumatic brain injury or stroke living in the community. Medicine 2022;101:8(e28695). Received: 26 June 2021 / Received in final form: 11 December 2021 / Accepted: 3 January 2022 http://dx.doi.org/10.1097/MD.0000000000028695 1 García-Rudolph et al. Medicine (2022) 101:8 Medicine Abbreviations: ADLs = activities of daily living, CI = community integration, CIQ = community integration questionnaire, COVID- 19 = coronavirus disease 2019, FIM = functional independence measure, SMS = short message service, TBI = traumatic brain injury. Keywords: community integration, coronavirus disease 2019, stroke, traumatic brain injury 1. Introduction differences, a recent study conducted in Spain concluded that the social impact of COVID-19 on general population was worse in Stroke is a leading cause of disability worldwide, affecting an women (33% of women and 17% of men experiencing anxiety increasing number of people at working-age[1] it places special and depression)[32] but little is known about sex differences in demands on rehabilitation services and re-integration into people with disabilities. society.[2] Community re-integration and participation are goals We hypothesized that the identification of specific groups (eg, in many policy documents, but also complex processes that have older participants, individuals with lower level of independence been previously reported to require healthcare professionals’ in ADLs) in any of the 3 specific major areas (home integration; support.[3] social integration; or productive activities) would be useful for Similarly, traumatic brain injury (TBI) represents the greatest providing specialized support interventions remotely conducted contributor to disability among all trauma-related injuries.[4] by rehabilitation professionals. Despite the fact that community integration (CI) is a hallmark Therefore, this study aims at objectively compare CI, consider- goal of rehabilitation, there is a notable gap in our understanding ing its 3 major areas (home, social, and productive activities) of of factors that contribute to diminished CI within TBI people with chronic stroke or TBI living in the community before populations.[5] and during the outbreak of COVID-19. When stratifying by injury: CI is defined as one’s active participation into 3 major areas: participants with stroke (G1) and with TBI (G2); by functional home integration as an active participation of the individual in independence in ADLs: independent (G3) and dependent (G4); by the operations of the home; social integration as participation in a age: participants younger than 54 (G5) and older than 54 (G6); and variety of activities outside the home, for example, social events; by gender: female (G7) and male (G8) participants. and productive activities such as employment, and educational and/or volunteer activities.[6] Previous longitudinal studies are consistent in concluding that 2. Methods older persons with TBI had lower CI levels as compared to younger ones. Consistent results were reported at 1 year follow-up[7–9] at 3 2.1. Study design years,[10] between 2 and 5 years[11] or between 3 to 15 years.[12] We conducted a retrospective observational study enrolling Functional independence was also previously reported as signifi- people with stroke or TBI who were living in the community and cant predictor of CI at 3 years postinjury[10] or at 1 year.[13] responded an online assessment. The individuals with stroke or Women appeared to outperform men in overall CI in previous TBI were selected from the electronical health records of a research,[14] for example, in home activities[12] but research rehabilitation hospital from a Mediterranean setting in Spain addressing CI from a sex perspective is scarce and required.[15] (Institut Guttmann - Hospital de Neurorehabilitació - Barcelona). Similarly, in stroke survivors, older individuals have been Only participants registered in the hospital’s electronical health extensively reported to experience lower levels of integration into records with the CIQ (CI questionnaire)[33] assessment previously the community compared to younger ones in several longitudinal performed in-person (during a follow-up visit before COVID-19 studies.[16–19] Independence in activities of daily living (ADLs) outbreak) to the hospital’s Psychosocial Unit were included in the was also found as significant predictor of long-term CI (eg,[16,20]). study. Recruitment period for the online questionnaire was from In relation to sex differences, women appear to experience worse June 2020 to April 2021. functional outcomes[21] and greater participation restrictions[22] This study conforms to the Strengthening the Reporting of with higher prevalence of depression.[23] Ayis et al[24] recently Observational Studies in Epidemiology Guidelines.[34] reported that severe depression symptoms in women (up to 5 The data that support the findings of this study are available years poststroke) were double than in men. from the corresponding author upon reasonable request. The coronavirus disease 2019 (COVID-19)[25] represents nowadays (May 2021) an international health emergency 2.2. Participants without precedents in terms of its health, economic, and organizational effects on people’s lives.[26] Spain has been one Eligible participants were living in the community with the of the most affected countries in the world in terms of absolute diagnosis of stroke or TBI (at the moment of online assessment number of diagnosed cases.[27] On March 13, 2020, the were aged ≥18), with electronical health records including Government declared a national state of alarm, including complete data. measures of national lockdown, confinement of the population, Participants were excluded for the following reasons: diagnosis and restricted mobility[28] (legally effective on March 15). of concomitant comorbidity (eg, brain tumors), more than 3 years Recent research involving general population during COVID- since in-person assessment to COVID-19 lockdown date (March 19 pointed out that older people may experience more stress and 15, 2020), more than 3 years since in-person functional fear, and that forced isolation may have a severe impact on their independence assessment to online CIQ assessment, not fluent psychological well-being.[29,30] Meanwhile other findings sug- in Spanish or other communication issues. gested that older adults may be able to cope well with the The Psychosocial Unit performs follow-up on CIQ every emergency.[31] These conflicting results indicate the need of 3 years. Therefore, every eligible participant was contacted as further research analyzing differences by age. In relation to sex part of the routine clinical follow-up. 2 García-Rudolph et al. Medicine (2022) 101:8 www.md-journal.com Participants answered their follow-up online assessments ranked test or paired t test when appropriate. The Shapiro–Wilk within at most 10 days since contacted, therefore all were test was used to assess normality, Levene test for homogeneity of completed between June 2020 and April 2021. Consequently, variances and Cohen d to assess effects sizes (small effect size participants completed the online measures analyzed in this study [d = .1], medium [d = .3], and large effect size [d = .5]). as part of a virtual visit involving other assessments (eg, the Craig Handicap Assessment and Reporting Technique.[35] 2.6. Ethical considerations A specific written informed consent was not required for 2.3. Online assessment participants to be included in this study, in accordance with The online assessment was implemented during COVID-19 the local legislation and institutional requirements. Nevertheless lockdown in order to provide a remote follow-up service. The at admission participants provide written informed consent to be online assessment includes the same questionnaires as when included in research studies addressed by the hospital. The participants were assessed in-person (before COVID-19 out- authors confirm that this study is compliant with the break) as follow-up visits. Each participant received the online Helsinki Declaration of 1975, as revised in 2008 and it was assessment by means of a short message service (SMS) sent to the approved by the Ethics Committee of Clinical Research of the participant’s mobile phone. This SMS is sent by the professional hospital. from the psychosocial unit in charge of the participants’ online follow-up. In this work we applied the Spanish validated version 3. Results of the CIQ.[36] It yields 3 domains which examine home integration (denoted in this work as home-CIQ), social The initial number of eligible participants, considering the integration (denoted in this work as social-CIQ) and productive procedure described in Section 2.2. was n = 237. Three activities (denoted in this work as productivity CIQ), as detailed participants presented another disabling condition (anoxia and in Table S1, Supplemental Digital Content, http://links.lww.com/ brain tumors) and 2 of them were not fluent in Spanish. Two MD2/A903. This version has been used in previous brain injury hundred thirty-two received the SMS in their mobile phones, 6 research.[37] (2.6%) did not complete the CIQ assessment, 18 (7.7%) were The CIQ is a recognized measure for examining CI following assessed in-person more than 3 years before the COVID-19 brain injury and is the most widely used CI measurement tool lockdown date and 4 (1.7%) had more than 3 years since in- used in research for people with TBI[38] also extensively used to person FIM assessment to online CIQ assessment. A detailed assess CI in individuals with stroke.[16] Psychometric properties flowchart is presented in Figure S1, Supplemental Digital were evaluated for the Spanish-language version of the CIQ. Content, http://links.lww.com/MD2/A902. Internal consistency was considered adequate and similar to that Consequently, a total of 204 individuals were included in the found by the authors of the original English version (.70 vs study, 105 individuals with stroke (51.4%) and 99 with TBI .76).[33] The social integration and productive activity subscales (48.6%). were positively related to similar constructs in the Craig Table 1 presents their demographics and clinical character- Handicap Assessment and Reporting Technique.[36] istics. The mean time since injury to online assessment was 9.88 ± 7.02 years for participants with stroke and 13.64 ± 7.04 years for participants with TBI. The mean time since CIQ in-person 2.4. Clinical and demographic variables assessment to CIQ online assessment was 2.00 ± 0.49 and 2.19 ± Demographics (age, sex, years of education, marital status), 0.76 years, respectively. The mean time since lockdown (March severity of the injury by means of the National Institutes of 15) to online assessment was 0.67 ± 0.28 years and 0.65 ± 0.29 Health Stroke Scale[39] and the Glasgow Coma Scale,[40] as well years, respectively. Participants with stroke were older: 57.46 ± as time since onset of the injury, were collected from the hospital’s 10.21 and 47.33 ± 11.87, respectively at the moment of online electronical health records. The functional independence measure assessment. (FIM)[41] was used to assess independence in ADLs. The hospital’s interdisciplinary stroke and TBI rehabilitation 3.1. Stratification by injury: participants with stroke teams comprise the following professionals with expertise in rehabilitation: neurologist, physiatrist, physiotherapist, occupa- Table 2 presents comparisons before and during COVID-19 for tional therapist, speech and language therapist, neuropsycholo- individuals with stroke (G1), (n = 105, 51.4%) gist, and nurse. Trained therapists recorded admission and For G1 in this section and for G2 in the next section we discharge FIM scores, and are systematically reviewed as part of compared home-CIQ, social-CIQ, productivity-CIQ, and total- our formal rehabilitation program. CIQ but we also compared all CIQ individual items comprising A cutoff value of motor FIM <61 was used to stratify each domain. Nevertheless, individual items were not reported to dependent and independent performance in ADLs as in previous psychometrically measure any valid or reliable construct in the research.[42] original English version[33] neither in the Spanish validated version.[36] Therefore the specific items comparisons are included in Tables 2 and 3 only as additional information. 2.5. Statistical analyses No significant differences were observed in home-CIQ, All statistical analyses were performed in R-v4.05 (64 bits) meanwhile social-CIQ significantly decreased (d = 0.348), (Vienna, Austria),[43] level of significance was set at P = .05. productivity-CIQ significantly increased (d = 0.197), and Descriptive statistics were used for demographic and clinical total-CIQ significantly decreased (d = 0.231). characteristics of participants. Responses to CIQ were compared The specific item with the highest effect size was travel out before COVID-19 outbreak and during it using the Wilcoxon home (d = 0.388). 3 García-Rudolph et al. Medicine (2022) 101:8 Medicine Table 1 Comparison of demographics and clinical characteristics of individuals with stroke (n = 105) and traumatic brain injury (n = 99). Variables Stroke (N = 105) TBI (N = 99) P Sex (%) .035 Male 61.0 74.7 Female 39.0 25.3 Age at the moment of injury in years, mean (SD) 47.58 (10.19) 33.68 (14.83) <.001 Age at the moment of online assessment, mean (SD) 57.46 (10.21) 47.33 (11.87) <.001 Age <65 at the moment of online assessment (%) 77.1 89.9 .015 Age ranges at the moment of online assessment (%) <.001 18–30 1.9 4.0 31–45 9.5 53.5 46–60 49.5 25.3 61–75 37.1 16.2 76+ 1.9 1.0 Time (in yr) since lockdown (March 14) to CIQ online assessment, mean (SD) 0.67 (0.28) 0.65 (0.29) .556 Time (in yr) since CIQ in-person assessment to CIQ online assessment, mean (SD) 2.00 (0.49) 2.19 (0.76) .232 Time (in yr) since in-person CIQ assessment to lockdown (March 14), mean (SD) 1.32 (0.58) 1.54 (0.79) .076 Time (in yr) since injury to online assessment, mean (SD) 9.88 (7.02) 13.64 (7.04) <.001 Time (range in yr) since injury to online assessment (%) <.001 3–6 42.9 23.2 7–12 33.3 29.3 13–18 20.0 22.2 19+ 3.8 25.3 Time (in yr) since injury to lockdown assessment, mean (SD) 9.20 (7.04) 12.99 (7.06) <.001 Severity at the moment of injury (%) .642 Mild 12.8 14.6 Moderately severe and severe 87.2 85.4 FIM in-person assessment, mean (SD) Cognitive FIM 28.61 (7.71) 27.01 (8.65) .201 Motor FIM 65.81 (22.30) 69.34 (28.41) .004 Total FIM 94.42 (27.94) 96.35 (36.22) .032 Time (in yr) since FIM in-person assessment to the CIQ online assessment, mean (SD) 2.13 (0.70) 2.29 (0.96) .278 Years of education at the moment of online assessment (%) .011 Read and write (<2 yr) 9.5 3.0 Primary (2–5 yr) 27.6 39.4 Secondary (6–12 yr) 42.9 27.3 Higher (>13 yr) 20.0 30.3 Marital status. Married (%) 80.0 34.3 <.001 Location where participants were living at the moment of answering the online assessment (%) .223 Barcelona 78.1 73.7 Girona 11.4 9.1 Tarragona 8.6 9.1 Lerida 1.9 8.1 CIQ assessment (in person) Home-CIQ 4.06 (3.07) 5.20 (3.64) .032 Social-CIQ 6.73 (2.16) 6.95 (2.46) .288 Productivity-CIQ 0.47 (1.11) 1.29 (1.66) <.001 Total-CIQ 11.26 (4.52) 13.44 (6.67) .009 CIQ assessment (online) Home-CIQ 3.91 (3.17) 4.87 (3.66) .075 Social-CIQ 5.81 (2.33) 6.11 (2.56) .274 Productivity-CIQ 0.77 (1.50) 1.63 (1.90) <.001 Total-CIQ 10.50 (5.12) 12.60 (6.71) .020 All characteristics are presented as percentages (%), unless otherwise indicated. CIQ = community integration questionnaire, FIM = functional independence measure, SD = standard deviation, TBI = traumatic brain injury. Bold value indicates level of significance was set at P = .05 3.2. Stratification by injury: participants with TBI The specific item with the highest effect size was housework Table 3 presents comparisons before and during COVID-19 for (d = 0.311). individuals with TBI (G2), (n = 99, 48.6%). No significant differences were observed in home-CIQ neither 3.3. Stratification by functional independence, age, and sex in productivity-CIQ, meanwhile social-CIQ significantly de- Table 4 presents comparisons before and during COVID-19 for creased (d = 0.372) as well as total-CIQ (d = 0.240). independent participants (G3), (n = 144, 70.6%), dependent 4 García-Rudolph et al. Medicine (2022) 101:8 www.md-journal.com Table 2 Paired comparisons for pre-COVID assessments and during COVID for participants with stroke (n = 105) (G1). COVID Median Mean (SD) S–W test (P) Wilcoxon test/t test (P) Effects sizes (d) Groceries Before 1.00 1.30 (0.71) <.001 .199 0.125 During 1.00 1.23 (0.76) <.001 Prepare meals Before 0.00 0.66 (0.88) <.001 .636 0.046 During 0.00 0.63 (0.84) <.001 Housework Before 0.00 0.66 (0.81) <.001 .0356 0.205 During 0.00 0.55 (0.71) <.001 Plans social Before 1.00 0.80 (0.75) <.001 .324 0.092 During 1.00 0.86 (0.80) <.001 Personal finances Before 0.00 0.64 (0.81) <.001 .832 0.0206 During 0.00 0.65 (0.82) <.001 Home-CIQ Before 4.00 4.06 (3.07) <.001 .197 0.125 During 3.00 3.91 (3.17) <.001 Leisure activities Before 1.00 1.10 (0.63) <.001 <.001 0.358 During 1.00 0.84 (0.59) <.001 Visit friends Before 1.00 1.12 (0.63) <.001 .004 0.275 During 1.00 0.93 (0.64) <.001 Leisure with others Before 2.00 1.48 (0.65) <.001 .368 0.087 During 2.00 1.41 (0.68) <.001 Best friend Before 2.00 1.24 (0.98) <.001 .245 0.113 During 2.00 1.12 (1.00) <.001 Travel out home Before 2.00 1.79 (0.47) <.001 <.001 0.388 During 2.00 1.50 (0.72) <.001 Social-CIQ Before 7.00 6.73 (2.16) <.001 <.001 0.348 During 6.00 5.81 (2.33) <.001 Work situation Before 0.00 0.26 (0.52) <.001 .344 0.092 During 0.00 0.21 (0.43) <.001 Training situation Before 0.00 0.09 (0.28) <.001 .012 0.243 During 0.00 0.19 (0.42) <.001 Volunteer situation Before 0.00 0.09 (0.37) <.001 .849 0.018 During 0.00 0.10 (0.35) <.001 Productivity-CIQ Before 0.00 0.47 (1.11) <.001 .043 0.197 During 0.00 0.77 (1.50) <.001 ∗ ∗∗ Total-CIQ Before 12.00 11.26 (4.52) .190 .017 0.231 During 10.00 10.50 (5.12) .230 CIQ = community integration questionnaire, COVID = coronavirus disease, SD = standard deviation, S–W test = Shapiro–Wilk test. ∗ Levene test P = .622 the variances are not significantly different, indicating that the assumption of homogeneity has been met. ∗∗ t test: t = 2.406, df = 104, P-value = .01789. Bold value indicates level of significance was set at P = .05 participants (G4) (n = 60, 29.4%), participants younger than 54 well as total-CIQ (d = 0.236) and productivity-CIQ significant- (G5) (n = 111, 54.4%), older than 55 (G6) (n = 93, 45.6%), ly increased (d = 0.210). women (G7) (n = 66, 32.4%), and men (G8) (n = 138, 67.6%). Table 5 presents the summarization of results considering all In G3 no significant differences were observed in home- stratifications, by injury (G1 and G2), functional independence CIQ neither in productivity-CIQ, meanwhile social-CIQ signifi- (G3 and G4), age (G5 and G6), and sex (G7 and G8), also cantly decreased (d = 0.437) as well as total-CIQ (d = presented as bar graphs in Figure 1. 0.285). In G4 no significant differences were observed in home-CIQ 4. Discussion neither in total-CIQ, meanwhile social-CIQ significantly de- creased (d = 0.253) and productivity-CIQ significantly in- Given that the literature concerning COVID-19 is emerging, to creased (d = 0.215). our best knowledge no authors have addressed the virus’ impact In G5 no significant differences were observed in home-CIQ from a CI perspective addressing home, social and productivity neither in productivity-CIQ, meanwhile social-CIQ significantly activities on people with chronic stroke or TBI living in the decreased (d = 0.394) as well as total-CIQ (d = 0.276). community. We hypothesized that the identification of specific In G6 home-CIQ significantly decreased (d = 0.229), as well groups (eg, older participants, individuals with lower level of as social-CIQ (d = 0.319) and total-CIQ (d = 0.199), mean- independence in ADLs) in any of the 3 specific major areas (home while productivity-CIQ significantly increased (d = 0.300). integration, social integration, or productive activities) would be In G7 no significant differences were observed in home-CIQ, useful to specialized support interventions remotely conducted by neither in productivity-CIQ, meanwhile social-CIQ significantly rehabilitation professionals. decreased (d = 0.355) as well as total-CIQ (d = 0.245). We found that the older age group (G6) significantly reduced In G8 no significant differences were observed in home-CIQ, their participation in home activities, being this the only group meanwhile social-CIQ significantly decreased (d = 0.365), as who did. We also found that this older group significantly 5 García-Rudolph et al. Medicine (2022) 101:8 Medicine Table 3 Paired comparisons for pre-COVID assessments and during COVID for participants with traumatic brain injury (n = 99) (G2). COVID Median Mean (SD) S–W test (P) Wilcoxon test/t test (P) Effects sizes (d) Groceries Before 2.00 1.47 (0.79) <.001 .012 0.243 During 2.00 1.36 (0.81) <.001 Prepare meals Before 1.00 1.05 (0.93) <.001 .437 0.075 During 1.00 1.00 (0.93) <.001 Housework Before 1.00 1.03 (0.86) <.001 .001 0.311 During 1.00 0.82 (0.85) <.001 Plans social Before 1.00 0.94 (0.83) <.001 .759 0.029 During 1.00 0.96 (0.84) <.001 Personal finances Before 0.00 0.71 (0.85) <.001 .718 0.035 During 0.00 0.73 (0.85) <.001 Home-CIQ Before 6.00 5.20 (3.64) <.001 .112 0.154 During 5.00 4.87 (3.66) <.001 Leisure activities Before 1.00 1.13 (0.65) <.001 .057 0.185 During 1.00 0.99 (0.63) <.001 Visit friends Before 1.00 1.26 (0.68) <.001 .002 0.296 During 1.00 1.02 (0.64) <.001 Leisure with others Before 2.00 1.60 (0.57) <.001 .057 0.185 During 2.00 1.47 (0.63) <.001 Best friend Before 2.00 1.21 (0.98) <.001 .324 0.096 During 2.00 1.11 (1.00) <.001 Travel out home Before 2.00 1.75 (0.59) <.001 .003 0.283 During 2.00 1.52 (0.80) <.001 Social-CIQ Before 7.00 6.95 (2.46) <.001 <.001 0.372 During 7.00 6.11 (2.56) <.001 Work situation Before 0.00 0.63 (0.82) <.001 .946 0.001 During 0.00 0.62 (0.83) <.001 Training situation Before 0.00 0.28 (0.50) <.001 1.00 During 0.00 0.28 (0.50) <.001 Volunteer situation Before 0.00 0.16 (0.49) <.001 .490 0.060 During 0.00 0.20 (0.51) <.001 Productivity-CIQ Before 0.00 1.29 (1.66) <.001 .077 0.172 During 0.00 1.63 (1.90) <.001 Total CIQ Before 15.00 13.44 (6.68) <.001 .013 0.240 During 14.00 12.61 (6.71) <.001 CIQ = community integration questionnaire, COVID = coronavirus disease, SD = standard deviation, S–W test = Shapiro–Wilk test. Bold value indicates level of significance was set at P = .05 increased their productivity activities, as well as the individuals health seemed to be more affected when economic conditions with lower level of independence (G4), men (G8), and individuals worsened during the pandemic. Also, women reported greater with stroke (G1). Meanwhile, the younger group (G5), concern for their personal finances.[32] Our results, showing a individuals with TBI (G2), participants who were independent nonsignificant increase in their productivity scores, suggest a in ADLs (G3) and women (G7) did not increase their productivity remote timely age-appropriate (directly mostly to younger during COVID-19. women) provision of educational or training information. In Remarkably, the cutoff value of 55 years old is also observed in Table S2, Supplemental Digital Content, http://links.lww.com/ men’s median age, it was 55 (44–64) years, (as presented in MD2/A904 we compared men and women in relation to home- Table S2, Supplemental Digital Content, http://links.lww.com/ CIQ, social-CIQ, productivity-CIQ, and total-CIQ showing no MD2/A904) meanwhile women’s was 49 (42–57). Median age of significant differences between them. participants with motor FIM <61 was also 55 (44–64) meanwhile This lack of support seems not to be related to the time since median age was 52 (43–60) for those with motor FIM >61. injury, a qualitative study of stroke survivors who were aged 20 Median age of participants with stroke was 57 (51–64) and for to 61 years old and up to 9 years after stroke (in our case it was participants with TBI was 44 (39–54). 9.88 ± 7.02 years) reported their inability to fulfil their role In relation to young participants, previous studies from expectations and feelings of isolation or helplessness. Similarly nonpandemic times reported that young adults with stroke for women with TBI, as reported in previous research, health encounter substantially greater difficulties reintegrating into their service providers and policymakers should recognize the long- social roles compared to older adults.[44] A study including only term health and social needs of women with TBI and address women aged 18 to 50 years old has also highlighted the young societal factors that result in financial and structural barriers, to stroke survivors’ unmet needs, including a lack of access to age- ensure access to needed services.[46] appropriate information, inadequate professional support re- A recent survey[47] conducted during the ongoing COVID-19 garding life skills training, limited dialogue with healthcare pandemic on 47 individuals in the chronic phase of moderate– professionals and underuse of peer learning to support the severe TBI, concluded that healthcare providers should look for continual reintegration process.[45] Besides, women’s mental ways to provide tailored education and reduce social isolation for 6 García-Rudolph et al. Medicine (2022) 101:8 www.md-journal.com Table 4 Paired comparisons for pre-COVID and during COVID assessments. Group Measures COVID Median Mean (SD) S–W test (P) Wilcoxon test/t test (P) Effects sizes (d) Motor FIM > 61 (n = 144) (G3) Home-CIQ Before 6.00 6.08 (2.84) <.001 .066 0.179 During 6.00 5.82 (2.99) <.001 Social-CIQ Before 8.00 7.29 (2.07) <.001 <.001 0.437 During 7.00 6.42 (2.33) <.001 Productivity-CIQ Before 0.00 1.11 (1.57) <.001 .055 0.187 During 0.00 1.39 (1.81) <.001 Total-CIQ Before 14.00 14.47 (5.01) .024 .003 0.285 During 14.00 13.64 (5.42) .040 Motor FIM  61 (n = 60) (G4) Home-CIQ Before 1.00 1.10 (1.56) <.001 .477 0.069 During 0.00 0.90 (1.28) <.001 Social-CIQ Before 6.00 5.75 (2.49) <.001 .009 0.253 During 5.00 4.83 (2.37) <.001 Productivity-CIQ Before 0.00 0.28 (0.94) <.001 .0273 0.215 During 0.00 0.70 (1.53) <.001 Total-CIQ Before 7.00 7.13 (3.85) .060 .155 0.189 During 6.00 6.43 (4.05) .003 Age  54 (n = 111) (G5) Home-CIQ Before 6.00 5.21 (3.58) <.001 .524 0.064 During 5.00 5.07 (3.61) <.001 Social-CIQ Before 8.00 7.17 (2.37) <.001 <.001 0.394 During 7.00 6.29 (2.63) <.001 Productivity-CIQ Before 0.00 1.21 (1.64) <.001 .328 0.095 During 0.00 1.37 (1.81) <.001 Total-CIQ Before 14.00 13.59 (6.20) .003 .004 0.276 During 14.00 12.73 (6.48) <.001 Age ≥55 (n = 93) (G6) Home-CIQ Before 4.00 3.90 (3.04) <.001 .018 0.229 During 3.00 3.55 (3.04) <.001 Social-CIQ Before 7.00 6.44 (2.16) <.001 .002 0.319 During 6.00 5.56 (2.15) <.001 Productivity-CIQ Before 0.00 0.46 (1.09) <.001 .002 0.300 During 0.00 0.97 (1.67) <.001 Total-CIQ Before 11.00 10.81 (4.81) .125 .041 0.199 During 10.00 10.08 (5.10) .227 Female (n = 66) (G7) Home-CIQ Before 5.50 5.02 (3.52) <.001 .126 0.149 During 5.00 4.70 (3.49) <.001 Social-CIQ Before 8.00 7.21 (2.14) <.001 <.001 0.355 During 6.00 6.02 (2.33) <.001 Productivity-CIQ Before 0.00 0.89 (1.44) <.001 .098 0.161 During 0.00 1.27 (1.76) <.001 Total-CIQ Before 14.00 13.12 (5.65) .215 .0117 0.245 During 13.00 11.98 (5.85) .092 Male (n = 138) (G8) Home-CIQ Before 4.00 4.42 (3.33) <.001 .161 0.136 During 4.00 4.22 (3.42) <.001 Social-CIQ Before 7.00 6.66 (2.36) <.001 <.001 0.365 During 6.00 5.93 (2.50) <.001 Productivity-CIQ Before 0.00 0.86 (1.48) <.001 .030 0.210 During 0.00 1.14 (1.76) <.001 Total-CIQ Before 12.00 11.93 (5.80) .009 .015 0.236 During 11.00 11.30 (6.11) .002 CIQ = community integration questionnaire, COVID = coronavirus disease, FIM = functional independence measure, SD = standard deviation, S–W test = Shapiro–Wilk test. Bold value indicates level of significance was set at P = .05 individuals with disability. They discuss a number of direct Spain.[49] The main needs and difficulties experienced by Spanish suggestions from participant responses. people with disabilities and their families were reported and Pisano et al[48] recently analyzed COVID-19 impact on concluded that the pandemic had a negative impact in all of the individuals with aphasia, remarking that global attention is main 5 analyzed areas (employment, education, health, social currently focused on clinical populations who, prior to COVID- services, and other basic rights). These results are in accordance 19 were followed-up in rehabilitation services, but the impor- with ours. We further analyzed the impact on all CIQ individual tance of also considering the individuals with chronic TBI or items, as well as stratified the participants considering for stroke living in the community needs to be highlighted. example their level of functional independence in ADLs. The Spanish Government recently reported the largest study in In our results, G4 was the only group with no significant relation to the impact of COVID-19 on people with disabilities in differences in total-CIQ before and during COVID-19. Their 7 García-Rudolph et al. Medicine (2022) 101:8 Medicine Table 5 Summarization of results for pre-COVID and during COVID assessments. Stratification Group Home-CIQ Social-CIQ Productivity-CIQ Total-CIQ Injury Stroke (G1) = ↓ ↑ ↓ TBI (G2) = ↓ = ↓ Functionality Motor FIM > 61 points (G3) = ↓ = ↓ Motor FIM  61 points (G4) = ↓ ↑ = Age  54 years (G5) = ↓ = ↓ ≥55 years (G6) ↓ ↓ ↑ ↓ Sex Female (G7) = ↓ = ↓ Male (G8) = ↓ ↑ ↓ CIQ = community integration questionnaire, COVID = coronavirus disease, FIM = functional independence measure, TBI = traumatic brain injury. ↓ indicates that the item significantly decreased during COVID. ↑ indicates that the item significantly increased during COVID. = indicates that no significant differences were found when comparing the (sub)total before and during COVID. Figure 1. Community integration questionnaire subtotals and total for each stratification (by injury, functional independence, age, and sex) before and during COVID-19. COVID-19 = coronavirus disease 2019. 8 García-Rudolph et al. Medicine (2022) 101:8 www.md-journal.com situation means living with several restrictions on participation may create bias; if the participants have a doubt, researcher with or without pandemic situation. In this sense, the figure of cannot clear it immediately. In our case, participants already the personal assistant can be recommended as a facilitator of knew the questionnaires, because they have already answered empowerment, independent living, and the promotion of them during previous in-person follow-up visits. community participation.[50] Another limitation to mention is that in this work we did not G3 significantly decreased their total-CIQ with the highest use the revised CIQ version which includes an added subscale effect size, also showing the largest social-CIQ decrease. As that assesses use of social media to integrate virtually,[60] which mindfulness training has been recently reported to play a key role would have been quite useful given the stay at home requirements in alleviating the negative impact related to an individual’s imposed during COVID-19. Nevertheless this revised version was boredom proneness, intervention with home-based mindfulness recently published (2016) and to our best knowledge there is not training might be specially beneficial to them.[51] a validated Spanish version of it. G5 did not significantly increase productivity-CIQ meanwhile Future work includes a stratification of stroke participants on G6 not only significantly increased their productivity, they were those with and without aphasia for comparison with Pisano the group with the highest effect size. Therefore, productivity- et al.[48] Further future analysis will address the impact of other related psychological interventions can be recommended to G5. social factors (eg, finances, family support, educational level). As For example, self-regulation, which integrates management of shown in Table S2, Supplemental Digital Content, http://links. internal (ie, attention, emotion, motivation) and external (ie, lww.com/MD2/A904 40.9% of women completed high educa- environment, support, time) factors. Forms of self-regulation tion meanwhile only 17.4% of men did. In spite of women’s interventions include cognitive-behavior therapy, coherence higher educational level there were no significant differences in therapy, and acceptance-based behavior therapy.[52] productive-CIQ between men and women before COVID-19 For G6 self-affirmation theory interventions can be remotely neither during it (as shown in Table S2, Supplemental Digital applied in order to promote motivation through maintaining Content, http://links.lww.com/MD2/A904), but men significant- positive perceptions of one’s competence and identity.[53] ly increased their productive-CIQ score during COVID-19 G7 have not significantly increased productivity-CIQ mean- meanwhile women didn’t, suggesting future further analysis in while G8 did. Recent findings have established an increase in relation to such factors. procrastination among students in higher education during COVID-19.[54] Additionally, the nature of online learning from 5. Conclusions home further encourages procrastination as students not only We analyzed for the first time the virus’ impact from a CI need to exert higher levels of self-control to overcome isolated perspective addressing home, social and productivity activities on learning and the challenges of online learning,[55] they must also people with chronic stroke or TBI living in the community. resist distractions present at home (eg, television and social Stratifying participants by injury, functionality, age or gender media). Furthermore, the increase in procrastination may be allowed identifying specific highly impacted CIQ subtotals and attributed to the heightened levels of uncertainty in the items where remote specialized support can be provided to pandemic.[54] In these cases, remote Reality Therapy based address them. interventions can be recommended. Reality therapy helps individuals understand and accept that they are responsible for the consequences of their choices.[56] Psycho-educational training Author contributions sessions that are based upon reality therapy concepts have been Conceptualization: Joan Sauri, Blanca Cegarra, Josep Maria proven to be an effective way to reduce academic procrastination Tormos. behavior[57] shown effective in women with disabilities.[58] Data curation: Alejandro Garcia-Rudolph. Formal analysis: Alejandro Garcia-Rudolph. 4.1. Limitations to generalizability and future directions Funding acquisition: Dietmar Frey, Vince Istvan Madai. Investigation: Alejandro Garcia-Rudolph, Eloy Opisso. The data was collected from individuals living in the community Methodology: Alejandro Garcia-Rudolph, Joan Sauri, Blanca but who had been previously undertaken rehabilitation in 1 single Cegarra. tertiary center from a restricted geographical location (Catalonia, Project administration: Eloy Opisso, Josep Maria Tormos, with more than 70% from Barcelona). Therefore the generaliza- Dietmar Frey, Vince Istvan Madai, Montserrat Bernabeu. tion of these results should be considered carefully. Nevertheless, Resources: Eloy Opisso. assessments by means of standardized tools (CIQ, FIM) allow for Software: Alejandro Garcia-Rudolph, Eloy Opisso. similar comparative studies and the restricted physical locations Supervision: Joan Sauri, Eloy Opisso, Josep Maria Tormos, allowed for controlled variability in regional pandemic circum- Vince Istvan Madai, Montserrat Bernabeu. stances. Validation: Blanca Cegarra. Given that the pandemic is evolving, there will also be need for Visualization: Blanca Cegarra, Eloy Opisso. ongoing surveillance as to how to support individuals with stroke Writing – original draft: Alejandro Garcia-Rudolph. or TBI at each stage and across additional geographic regions. Writing – review & editing: Alejandro Garcia-Rudolph, Blanca Male gender accounts for 61% of participants with stroke and Cegarra, Eloy Opisso, Josep Maria Tormos, Dietmar Frey, 74% of participants with TBI, suggesting a sex bias, nevertheless, Vince Istvan Madai, Montserrat Bernabeu. the proportion is similar to recent studies in similar settings.[42] Several cons have been reported[59] regarding online assess- References ments such as: the researcher cannot determine questionnaire [1] Törnbom K, Lundälv J, Sunnerhagen KS. Long-term participation 7–8 filling time and participants may abandon the survey giving years after stroke: experiences of people in working-age. PLoS One partial data; the participant can take his own time to fill form; it 2019;14:e0213447. 9 García-Rudolph et al. Medicine (2022) 101:8 Medicine [2] Katan M, Luft A. Global burden of stroke. Semin Neurol 2018;38:208– [26] WHO 2021. World Health Organization. Weekly epidemiological 11. update on COVID-19. Available at: https://www.who.int/publications/ [3] Palstam A, Törnbom M, Sunnerhagen KS. Experiences of returning to m/item/weekly-epidemiological-update-on-covid-19—25-may-2021. work and maintaining work 7 to 8 years after a stroke: a qualitative Accessed May 25, 2021. interview study in Sweden. BMJ Open 2018;8:e021182. [27] Domínguez-Gil B, Coll E, Fernández-Ruiz M, et al. COVID-19 in Spain: [4] Dewan MC, Rattani A, Gupta S, et al. Estimating the global incidence of transplantation in the midst of the pandemic. Am J Transplant traumatic brain injury. J Neurosurg 2018;1–18. doi: 10.3171/2017.10. 2020;20:2593–8. JNS17352. [28] Laxe S, Ferri J, Juárez-Belaunde A, Ríos-Lago M, Rodríguez-Duarte R, [5] Binder AS, Lancaster K, Lengenfelder J, Chiaravalloti ND, Genova HM. Murie-Fernández M. Neurorehabilitation in the times of Covid-19: Community integration in traumatic brain injury: the contributing factor insights from the Spanish Neurorehabilitation Society (SENR). Brain Inj of affect recognition deficits. J Int Neuropsychol Soc 2019;25:890–5. 2020;34:1691–2. [6] Lama S, Damkliang J, Kitrungrote L. Community integration after [29] Dubey S, Biswas P, Ghosh R, et al. Psychosocial impact of COVID-19. traumatic brain injury and related factors: a study in the Nepalese Diabetes Metab Syndr 2020;14:779–88. context. SAGE Open Nurs 2020;doi:10.1177/2377960820981788. [30] Morrow-Howell N, Galucia N, Swinford E. Recovering from the [7] Arango-Lasprilla JC, Rosenthal M, Deluca J, Cifu DX, Hanks R, COVID-19 pandemic: a focus on older adults. J Aging Soc Policy Komaroff E. Functional outcomes from inpatient rehabilitation after 2020;32:526–35. traumatic brain injury: how do Hispanics fare? Arch Phys Med Rehabil [31] López J, Perez-Rojo G, Noriega C, et al. Psychological well-being among 2007;88:11–8. older adults during the COVID-19 outbreak: a comparative study of the [8] Harrison-Felix C, Zafonte R, Mann N, Dijkers M, Englander J, Kreutzer young–old and the old–old adults. Int Psychogeriatr 2020;32:1365–70. J. Brain injury as a result of violence: preliminary findings from the [32] Jacques-Aviñó C, López-Jiménez T, Medina-Perucha L, et al. Gender- traumatic brain injury model systems. Arch Phys Med Rehabil based approach on the social impact and mental health in Spain during 1998;79:730–7. COVID-19 lockdown: a cross-sectional study. BMJ Open 2020;10: [9] Bogner JA, Corrigan JD, Mysiw WJ, Clinchot D, Fugate L. A comparison e044617. of substance abuse and violence in the prediction of long-term [33] Willer B, Ottenbacher KJ, Coad ML. The community integration rehabilitation outcomes after traumatic brain injury. Arch Phys Med questionnaire: a comparative examination”. Am J Phys Med Rehabil Rehabil 2001;82:571–7. 1994;73:103–10. [10] Willemse-van Son AH, Ribbers GM, Hop WC, Stam HJ. Community [34] STROBE Enhancing the Quality and Transparency of health Research. integration following moderate to severe traumatic brain injury: a Statement – Checklist of items that should be included in reports of longitudinal investigation. J Rehabil Med 2009;41:521–7. cohort studies. Available at: https://www.equator-network.org/. [11] Fleming J, Tooth L, Hassell M, Chan W. Prediction of community Accessed June 5, 2021 integration and vocational outcome 2–5 years after traumatic brain [35] Whiteneck GG, Charlifue SW, Gerhart KA, Overholser JD, Richardson injury rehabilitation in Australia. Brain Inj 1999;13:417–31. GN. Quantifying handicap: a new measure of long-term rehabilitation [12] Winkler D, Unsworth C, Sloan S. Factors that lead to successful outcomes. Arch Phys Med Rehabil 1992;73:519–26. community integration following severe traumatic brain injury. J Head [36] Rintala DH, Novy DM, Garza HM, Young ME, High WMJr, Chiou- Trauma Rehabil 2006;21:8–21. Tan FY. Psychometric properties of a Spanish-language version of the [13] Rosenthal P, Dijkers M, Harrison-Felix C, et al. Impact of minority status community integration questionnaire (CIQ). Rehabil Psychol on functional outcome and community integration following traumatic 2002;47:144–64. brain injury. J Head Trauma Rehabil 1996;11:40–57. [37] Aza A, Verdugo MÁ, Orgaz MB, Andelic N, Fernández M, Forslund [14] Niemeier JP, Perrin PB, Holcomb MG, et al. Gender differences in MV. The predictors of proxy- and self-reported quality of life among awareness and outcomes during acute traumatic brain injury recovery. J individuals with acquired brain injury. Disabil Rehabil 2020;1–13. doi: Womens Health (Larchmt) 2014;23:573–80. 10.1080/09638288.2020.1803426. [15] Gupte R, Brooks W, Vukas R, Pierce J, Harris J. Sex differences in [38] Ritchie L, Wright-St Clair VA, Keogh J, Gray M. Community integration traumatic brain injury: what we know and what we should know. J after traumatic brain injury: a systematic review of the clinical Neurotrauma 2019;36:3063–91. implications of measurement and service provision for older adults. [16] Matos I, Fernandes A, Maso I, et al. Investigating predictors of Arch Phys Med Rehabil 2014;95:163–74. community integration in individuals after stroke in a residential setting: [39] Williams LS, Yilmaz EY, Lopez-Yunez AM. Retrospective assessment of a longitutinal study. PLoS One 2020;15:e0233015. initial stroke severity with the NIH Stroke Scale. Stroke 2000;31:858–62. [17] Elloker T, Rhoda A, Arowoiya A, Lawal IU. Factors predicting [40] Teasdale G, Jennett B. Assessment of coma and impaired consciousness. community participation in patients living with stroke, in the Western A practical scale. Lancet 1974;2:81–4. Cape, South Africa. Disabil Rehabil 2019;41:2640–7. [41] Linacre JM, Heinemann AW, Wright BD, Granger CV, Hamilton BB. [18] Tse T, Douglas J, Lentin P, et al. Reduction in retained activity The structure and stability of the functional independence measure. Arch participation is associated with depressive symptoms 3 months after mild Phys Med Rehabil 1994;75:127–32. stroke: an observational cohort study. J Rehabil Med 2017;49:120–7. [42] Scrutinio D, Lanzillo B, Guida P, et al. Development and validation of a [19] Obeme A, Mapayi B, Johnson O, Agunbiade T, Emechete A. Community predictive model for functional outcome after stroke rehabilitation: the reintegration in stroke survivors: relationship with motor function and Maugeri Model. Stroke 2017;48:3308–15. depression. Hong Kong Physiother J 2013;31:69–74. [43] The R Project for Statistical Computing. R version 4.0.5 (Shake and [20] Verberne DPJ, Post MWM, Köhler S, Carey LM, Visser-Meily JMA, van Throw). Available at: https://cran.r-project.org/src/base/R-4. Accessed Heugten CM. Course of social participation in the first 2 years after June 5, 2021 stroke and its associations with demographic and stroke-related factors. [44] Lo SHS, Chau JPC, Choi KC, et al. Promoting community reintegration Neurorehabil Neural Repair 2018;32:821–33. using narratives and skills building for young adults with stroke: a [21] Persky RW, Turtzo LC, McCullough LD. Stroke in women: disparities protocol for a randomised controlled trial. BMC Neurol 2021;21:3. and outcomes. Curr Cardiol Rep 2010;12:6–13. [45] Leahy DM, Desmond D, Coughlan T, O’Neill D, Collins DR. Stroke in [22] Phan HT, Blizzard CL, Reeves MJ, et al. Factors contributing to sex young women: an interpretative phenomenological analysis. J Health differences in functional outcomes and participation after stroke. Psychol 2016;21:669–78. Neurology 2018;90:e1945–53. [46] Toor GK, Harris JE, Escobar M, et al. Long-term health service outcomes [23] Poynter B, Shuman M, Diaz-Granados N, Kapral M, Grace SL, Stewart among women with traumatic brain injury. Arch Phys Med Rehabil DE. Sex differences in the prevalence of post-stroke depression: a 2016;97(Suppl 2):S54–63. systematic review. Psychosomatics 2009;50:563–9. [47] Morrow EL, Patel NN, Duff MC. Disability and the COVID-19 [24] Ayis SA, Rudd AG, Ayerbe L, Wolfe CDA. Sex differences in trajectories pandemic: a survey of individuals with traumatic brain injury. Arch Phys of depression symptoms and associations with 10-year mortality in Med Rehabil 2021;102:1075–83. patients with stroke: the South London Stroke Register. Eur J Neurol [48] Pisano F, Giachero A, Rugiero C, Calati M, Marangolo P. Does COVID- 2019;26:872–9. 19 impact less on post-stroke aphasia? This is not the case. Front Psychol [25] Cao J, Tu WJ, Cheng W, et al. Clinical features and short-term outcomes 2020;11:564717. of 102 patients with coronavirus disease 2019 in Wuhan, China. Clin [49] García Goikoetxea I, et al. El impacto de la pandemia COVID-19 en las Infect Dis 2020;71:748–55. personas con discapacidad. Principales necesidades y dificultades que 10 García-Rudolph et al. Medicine (2022) 101:8 www.md-journal.com afrontan las personas con discapacidad y sus familias a causa de la criss [55] Hong JC, Lee YF, Ye JH. Procrastination predicts online self-regulated del COVID-19. 2021;Real Patronato sobre Discapacidad; Ministerio de learning and online learning ineffectiveness during the coronavirus Derechos Sociales y Agenda 2030, lockdown. Pers Individ Differ 2021;174:110673. [50] Von Granitz H, Reine I, Sonnander K, Winblad U. Do personal [56] Wubbolding RE, Brickell J, Imhof L, et al. Reality therapy: a global assistance activities promote participation for persons with disabilities in perspective. Int J Adv Couns 2004;26:219–28. Sweden? Disabil Rehabil 2017;39:2512–21. [57] Çelik ÇB, Odacı H. Psycho-educational group intervention based on [51] Yan L, Gan Y, Ding X, Wu J, Duan H. The relationship between reality therapy to cope with academic procrastination. J Ration Emot perceived stress and emotional distress during the COVID-19 outbreak: Cogn Behav Ther Vol 2017;36:220–33. effects of boredom proneness and coping style. J Anxiety Disord [58] Bahram AH, Taklavi S, Narimani M. Reality therapy on fear of negative 2021;77:102328. evaluation and defensive self-expression in women with imposter [52] Eerdea W, Klingsieck KB. Overcoming procrastination? A meta-analysis syndrome. Middle East J Disabil Stud 2020;10:45–145. of intervention studies. Educ Res Rev 2018;25:73–85. [59] Siva Durga M, Narayan KA. Strengths and weakness of online surveys. [53] Sherman DK, Cohen GL. The psychology of self-defense: self-affirmation IOSR J Humanit Soc Sci 2019;24:31–8. theory. Adv Exp Soc Psychol 2006;38:183–242. [60] Callaway L, Winkler D, Tippett A, Herd N, Miglioroni C, Willer B. The [54] Lim AJ, Javadpour S. Into the unknown: uncertainty and procrastination community integration questionnaire revised: Australian normative data in students from a life history perspective. Front Psychol 2021; and measurement of electronic social networking. Aust Occup Ther J 12:717380. 2016;63:143–53. 11