Factors Affecting Participation in Physical Therapy During Posttraumatic Amnesia

Narrative Discourse Intervention for Patients in Posttraumatic Amnesia: A Feasibility Study

PURPOSE

Recent INCOG 2.0 guidelines for posttraumatic amnesia (PTA) recommend commencing multidisciplinary functional intervention for patients who do not demonstrate severe behavioral disturbance. This pilot feasibility study aimed to determine if people with traumatic brain injury (TBI) could engage in a narrative discourse intervention during PTA.

METHOD

A narrative discourse intervention was developed based on existing evidence for discourse treatment and allied health treatments with patients in PTA. The study setting was a TBI-specific facility. Participants were screened on ward admission for PTA status and received daily discourse intervention comprising a story retell with visual supports and self-generated task during PTA. Measures included the Pittsburgh Rehabilitation Participation Scale (PRPS), the Agitated Behavior Scale (ABS), number of sessions attended, length of session, narrative organization, and patient enjoyment of sessions.

RESULTS

Ten patients participated in this pilot study, in a total of 56 sessions overall. Average session duration was approximately 25 min. Participation (PRPS) scores ranged from 3 to 5 (good to very good), and agitation scores were mostly within normal limits on the ABS. Narrative samples produced with picture supports were more organized than self-generated samples. Participants reported enjoying sessions.

CONCLUSIONS

Discourse intervention conducted in the early PTA recovery period was feasible for this cohort, within a specialized TBI setting. Future research is required to examine the feasibility of intervention with patients in PTA in other settings, and the potential efficacy of narrative discourse intervention during PTA.

Recovery patterns of body functions and activities of daily living performance across the progression and resolution of posttraumatic amnesia

OBJECTIVE

Posttraumatic amnesia (PTA) following a traumatic brain injury (TBI) is characterized by multiple cognitive and behavioral changes including memory impairment and disorientation. This study aimed to measure changes and relationships between key body functions and activities of daily living (ADL) performance throughout PTA progression and resolution.

METHOD

A longitudinal observational study was conducted with 24 participants in PTA. PTA was measured daily with the Westmead PTA Scale (WPTAS). As participants achieved a new score on the WPTAS, measures of agitation, attention, balance, visual perception, visual motor and ADL performance were taken. The data were analyzed descriptively and significant improvements in functions were identified using Friedman´s rank tests with post-hoc testing. Relationships between variables were examined using Spearman's rank order correlations.

RESULTS

As PTA resolved, there were gradual and significant improvements in all variables except for visual motor performance. Attention was significantly better when scoring >8-9 on the WPTAS. There were significant correlations between body functions and ADL performance at different timepoints.

CONCLUSION

Understanding these gradual and interrelated improvements of functions during PTA may facilitate more precise assessment and earlier introduction of interventions to enhance patient outcomes.

Family experiences of supporting a relative with agitation during early recovery after traumatic brain injury

During the early recovery period after traumatic brain injury (TBI), referred to as post-traumatic amnesia (PTA), approximately 44% of individuals may exhibit agitated behaviours. Agitation can impede recovery and poses a significant management challenge for healthcare services. As families provide significant support for their injured relatives during this time, this study aimed to explore the family's experience during PTA to better understand their role in agitation management. There were 20 qualitative semi-structured interviews conducted with 24 family members of patients exhibiting agitation during early TBI recovery (75% female, aged 30-71 years), predominantly parents (n = 12), spouses (n = 7) and children (n = 3). The interviews explored the family's experience of supporting their relative exhibiting agitation during PTA. The interviews were analyzed using reflexive thematic analysis, which revealed three key themes: family contributions to patient care, expectations of the health care service and supporting families to support patients. This study emphasized the significant role of families in managing agitation during early TBI recovery and highlighted that families who are well-informed and well-supported have the potential to minimize their relative's agitation during PTA, which may reduce the burden on healthcare staff and promote patient recovery.

Effectiveness of Non-Pharmacological Interventions for Agitation during Post-Traumatic Amnesia following Traumatic Brain Injury: A Systematic Review

Agitation is common in the early recovery period following traumatic brain injury (TBI), known as post-traumatic amnesia (PTA). Non-pharmacological interventions are frequently used to manage agitation, yet their efficacy is largely unknown. This systematic review aims to synthesize current evidence on the effectiveness of non-pharmacological interventions for agitation during PTA in adults with TBI. Key databases searched included MEDLINE Ovid SP interface, PubMed, CINAHL, Excerpta Medica Database, PsycINFO and CENTRAL, with additional online reviewing of key journals and clinical trial registries to identify published or unpublished studies up to May 2020. Eligible studies included participants aged 16 years and older, showing agitated behaviours during PTA. Any non-pharmacological interventions for reducing agitation were considered, with any comparator accepted. Eligible studies were critically appraised for methodological quality using Joanna Briggs Institute Critical Appraisal Instruments and findings were reported in narrative form. Twelve studies were included in the review: two randomized cross-over trials, three quasi-experimental studies, four cases series and three case reports. Non-pharmacological interventions were music therapy, behavioural strategies and environmental modifications, physical restraints and electroconvulsive therapy. Key methodological concerns included absence of a control group, a lack of formalised agitation measurement and inconsistent concomitant use of pharmacology. Interventions involving music therapy had the highest level of evidence, although study quality was generally low to moderate. Further research is needed to evaluate non-pharmacological interventions for reducing agitation during PTA after TBI.Systematic review registration number: PROSPERO (CRD42020186802), registered May 2020.

Effectiveness of Non-Pharmacological Interventions for Agitation during Post-Traumatic Amnesia following Traumatic Brain Injury: A Systematic Review

Agitation is common in the early recovery period following traumatic brain injury (TBI), known as post-traumatic amnesia (PTA). Non-pharmacological interventions are frequently used to manage agitation, yet their efficacy is largely unknown. This systematic review aims to synthesize current evidence on the effectiveness of non-pharmacological interventions for agitation during PTA in adults with TBI. Key databases searched included MEDLINE Ovid SP interface, PubMed, CINAHL, Excerpta Medica Database, PsycINFO and CENTRAL, with additional online reviewing of key journals and clinical trial registries to identify published or unpublished studies up to May 2020. Eligible studies included participants aged 16 years and older, showing agitated behaviours during PTA. Any non-pharmacological interventions for reducing agitation were considered, with any comparator accepted. Eligible studies were critically appraised for methodological quality using Joanna Briggs Institute Critical Appraisal Instruments and findings were reported in narrative form. Twelve studies were included in the review: two randomized cross-over trials, three quasi-experimental studies, four cases series and three case reports. Non-pharmacological interventions were music therapy, behavioural strategies and environmental modifications, physical restraints and electroconvulsive therapy. Key methodological concerns included absence of a control group, a lack of formalised agitation measurement and inconsistent concomitant use of pharmacology. Interventions involving music therapy had the highest level of evidence, although study quality was generally low to moderate. Further research is needed to evaluate non-pharmacological interventions for reducing agitation during PTA after TBI.

Systematic review registration number: PROSPERO (CRD42020186802), registered May 2020.

Factors Associated With Physical Therapy Engagement During the Period of Posttraumatic Amnesia

BACKGROUND AND PURPOSE

Physical therapy is important in the management of traumatic brain injury (TBI) and associated multitrauma. Providing therapy during the posttraumatic amnesia (PTA) phase is challenging, given that hallmark features including confusion, amnesia, agitation, and fatigue may impede the person's ability to engage in and benefit from rehabilitation. To date, there is little empirical evidence to guide the provision of therapy during PTA. This observational study aimed to explore the frequency, duration, location, and engagement of physical therapy provision during PTA and the impact of cognition, agitation, and fatigue.

SUMMARY OF KEY POINTS

The majority of patients were found to meaningfully engage and participate in physical therapy for the majority of sessions. Only a small proportion were unable to participate in physical therapy. Patient refusal and fatigue were identified as the most prominent barriers to rehabilitation. Despite fatigue and agitation reaching clinical levels, therapy could still successfully proceed on most occasions.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Physical therapy is feasible during the acute recovery stages after TBI. Current results support the notion that therapy should commence early to minimize secondary complications and promote the recovery of mobility. A patient-centered therapeutic model that tailors the therapeutic approach to meet the individual's current physical and fluctuating cognitive capabilities may be most suited for this population. Clinicians working with people after TBI need experience in understanding and managing the cognitive limitations and associated symptoms of PTA to optimize the provision of therapy. These findings could inform guidelines for the management of patients in PTA.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A368).