Validation of a neurobehavioral functioning inventory for adults with traumatic brain injury

Using the St Andrew's - Swansea Neurobehavioural Outcome Scale (SASNOS) to determine prevalence and predictors of neurobehavioural disability amongst survivors with traumatic brain injury in the community

Studies using the St Andrew's - Swansea Neurobehavioural Outcome Scale (SASNOS) confirm neurobehavioural disability (NBD) is highly prevalent in inpatient Neurobehavioural Rehabilitation and Stroke samples. However, a recent study amongst a Danish community sample of acquired brain injury survivors found a relative paucity of NBD symptoms; and when symptoms were present, they tended to be of mild severity. The current observational study employed the SASNOS to explore prevalence of NBD in survivors with traumatic brain injury (TBI) living in the community, the extent of survivors' self-awareness of NBD symptoms, and constructed prediction models of NBD. A de-identified data set was compiled, comprising data for 97 TBI survivors (74.2% men, mean time since injury 2.8 years). In addition to SASNOS self- and proxy-ratings, various demographic, clinical and injury-related characteristics were captured. NBD was found to be highly characteristic, although severity varied depending on subtype. Statistical comparison of self- and proxy-ratings did not support reduced self awareness regarding NBD, whereas treating the problem as one of inter-rater reliability suggested this was an issue. Executive impairment, depressed mood and sex were especially prognostic of NBD. Reasons accounting for differences in NBD between the community samples are discussed and recommendations for future research made.

A Double-Blind Placebo-Controlled, Randomized Trial of Divalproex Sodium for Posttraumatic Irritability Greater Than 1 Year After Mild to Moderate Traumatic Brain Injury

OBJECTIVE

Posttraumatic irritability after traumatic brain injury (TBI) may become a chronic problem and contribute to impaired everyday function, either alone or in combination with alcohol use disorder. The authors hypothesized that divalproex sodium (VPA) would improve posttraumatic irritability and result in lessened alcohol use.

METHODS

This randomized, placebo-controlled double-blind clinical trial recruited participants with an index TBI occurring 1 or more years prior to enrollment, a history of alcohol use disorder, and posttraumatic irritability corroborated by a knowledgeable informant. An 8-item subset of the Agitated Behavior Scale served as the primary outcome measure of VPA efficacy. Doses of VPA were titrated to standard serum concentrations of 50 µg/ml to 100 µg/ml.

RESULTS

Forty-eight persons completed this clinical trial (VPA, N=22; placebo, N=26). At baseline, participants rated their posttraumatic irritability as less severe than did their informants (p<0.05). During the trial, informants reported significant and sustained reduction of posttraumatic irritability (p=0.03) in the study participants. Biweekly averages during drug exposure confirmed this (p<0.03, Cohen's d=0.44). Treatment efficacy was not related to measures of anxiety, posttraumatic stress disorder, sedation, or veteran versus nonveteran status. Alcohol use did not change as a result of treatment. There were no serious adverse events.

CONCLUSIONS

This study demonstrated an effect of VPA on posttraumatic irritability, and VPA was well tolerated. Further definition of treatment efficacy and safety requires a large-scale multisite trial, using a randomized, double-blind placebo-controlled design.

Home-based (virtual) rehabilitation improves motor and cognitive function for stroke patients: a randomized controlled trial of the Elements (EDNA-22) system

Background

Home-based rehabilitation of arm function is a significant gap in service provision for adult stroke. The EDNA-22 tablet is a portable virtual rehabilitation-based system that provides a viable option for home-based rehabilitation using a suite of tailored movement tasks, and performance monitoring via cloud computing data storage. The study reported here aimed to compare use of the EDNA system with an active control (Graded Repetitive Arm Supplementary Program—GRASP training) group using a parallel RCT design.

Methods

Of 19 originally randomized, 17 acute-care patients with upper-extremity dysfunction following unilateral stroke completed training in either the treatment (n = 10) or active control groups (n = 7), each receiving 8-weeks of in-home training involving 30-min sessions scheduled 3–4 times weekly. Performance was assessed across motor, cognitive and functional behaviour in the home. Primary motor measures, collected by a blinded assessor, were the Box and Blocks Task (BBT) and 9-Hole Pegboard Test (9HPT), and for cognition the Montreal Cognitive Assessment (MoCA). Functional behaviour was assessed using the Stroke Impact Scale (SIS) and Neurobehavioural Functioning Inventory (NFI).

Results

One participant from each group withdrew for personal reasons. No adverse events were reported. Results showed a significant and large improvement in performance on the BBT for the more-affected hand in the EDNA training group, only (g = 0.90). There was a mild-to-moderate effect of training on the 9HPT for EDNA (g = 0.55) and control (g = 0.42) groups, again for the more affected hand. In relation to cognition, performance on the MoCA improved for the EDNA group (g = 0.70). Finally, the EDNA group showed moderate (but non-significant) improvement in functional behaviour on the SIS (g = 0.57) and NFI (g = 0.49).

Conclusion

A short course of home-based training using the EDNA-22 system can yield significant gains in motor and cognitive performance, over and above an active control training that also targets upper-limb function. Intriguingly, these changes in performance were corroborated only tentatively in the reports of caregivers. We suggest that future research consider how the implementation of home-based rehabilitation technology can be optimized. We contend that self-administered digitally-enhanced training needs to become part of the health literacy of all stakeholders who are impacted by stroke and other acquired brain injuries.

Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) Number: ACTRN12619001557123. Registered 12 November 2019, http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378298&isReview=true

Assessing the Effects of Healthy and Neuropathological Aging on Personality with the Iowa Scales of Personality Change

Personality changes in older adults with brain disease may be confounded by effects of normal aging. In this cross-sectional study, ratings with the Iowa Scales of Personality Change for 62 healthy older adults (OA-H, aged 60+) were compared to matched older adults with brain diseases (OA-BD). OA-H did not show any significant personality changes from middle age to older adulthood. However, between 10% and 20% of OA-H developed a disturbance in Lack of Stamina, Inflexibility, Lability, and Lack of Insight. Otherwise, the pattern of findings suggesting normal aging effects on personality disturbances in clinical groups are generally minimal.

Impaired self-awareness after traumatic brain injury: A systematic review. Part 2. Consequences and predictors of poor self-awareness

BACKGROUND

Impaired self-awareness (ISA) has frequently been found both frequent and deleterious in patients with moderate to severe traumatic brain injury (TBI).

OBJECTIVES

This is the second of a two-part systematic review on ISA after TBI, focusing on the consequences and predictors of ISA after TBI.

METHODS

Following the PRISMA guidelines, 95 articles meeting the inclusion criteria were included; 46 were specifically related to this second part of the review.

RESULTS

Among 16 studies that investigated the effect of ISA on outcome, most (n=13) found poor self-awareness associated with poor rehabilitation, functional, social and vocational outcome and with increased burden on relatives. Multiple factors have been found associated with increased frequency of ISA. ISA was found significantly related to injury severity in 8 of 10 studies, impaired executive functions in 12 of 15 studies, and poor social cognition in 3 studies, but paradoxically inverse associations were repeatedly found between self-awareness and emotional status (11 of 12 studies). Finally, although research in the field is still scarce, ISA seems associated with a dysfunction within brain networks involving the anterior cingulate cortex, anterior insula and fronto-parietal control network.

CONCLUSIONS

ISA is a complex and multifaceted disorder associated with poor rehabilitation outcome, severe injuries, and deficits of executive functions and social cognition but has an inverse association with mood impairments.

The psychometric measures to assess aggressive dimension following traumatic brain injury: A review

BACKGROUND

higher level of aggression and antisocial behavior are frequent following head trauma, due to specific brain alterations. Many tests are used to assess this aspect. A descriptive review was conducted on the main tests used to detect the appearance of aggressive dimensions following traumatic brain injury.

REVIEW SUMMARY

we searched on PubMed and Web of Science databases and screening references of included studies and review articles for additional citations. From initial 723 publications, only 7 met our search criteria. Findings showed that various psychometric tools are used to assess aggressiveness and its subdomains, following head trauma.

CONCLUSIONS

further investigation are necessary to clarify whether these tools ensure a reliable diagnosis in order to make an early intervention and reduce violent behavior and its development.

Are spousal partner perceptions of continuity and discontinuity within the relationship linked to the symptoms of acquired brain injury?

PURPOSE

Some partners experience their relationship with a person with brain injury as the continuation of a loving pre-injury relationship (continuity), but others feel that the pre-injury relationship has been lost and replaced with something very different (discontinuity). This study provided a quantitative test of claims arising from qualitative research that certain symptoms of the injury might contribute to the experience of discontinuity - specifically, lack of emotional warmth, reduced social interaction and aggression.

METHODS

Fifty-three partners providing care to someone with brain injury completed questionnaires assessing continuity/discontinuity and a range of symptoms (emotional warmth, conversational ability, aggression, depression, somatic complaints, cognition, communication, aggression, and physical disability).

RESULTS

Discontinuity was significantly correlated with all symptom variables except physical disability but, in a multiple regression, only the measures of emotional warmth, conversation, aggression, and depression made a significant unique contribution.

CONCLUSIONS

Discontinuity has been linked with relationship dissatisfaction and dysfunction, greater burden and distress, and a less person-centred approach to the provision of care. Identifying which symptoms contribute to discontinuity may enable partners to be more effectively supported in terms of how they make sense of and react to those symptoms, so that a greater sense of continuity may be retained.Implications for rehabilitationIn a marriage/partnership after brain injury, some people struggle to maintain the loving relationship they shared with the person with the brain injury before the injury. This has an impact on the psychological wellbeing of the couple and on the quality of care provided.Certain symptoms of the brain injury may make it more difficult to maintain the loving pre-injury relationship.These include aggression, depression, a lack of emotional warmth within the relationship, and more general difficulties in making conversation.Caregivers dealing with these symptoms may need extra support in making sense of, and coming to terms with, these changes.

Rivastigmine Transdermal Patch Treatment for Moderate to Severe Cognitive Impairment in Veterans with Traumatic Brain Injury (RiVET Study): A Randomized Clinical Trial

Cognitive impairment is common in veterans with histories of traumatic brain injury (TBI). Cholinergic deficits have been hypothesized as contributors to this impairment. We report the effects of cholinesterase inhibitor rivastigmine transdermal patch treatment in veterans with TBI and post-traumatic memory impairment. Our objective was to evaluate the efficacy and safety of a 9.5 mg/24 h (10 cm²) rivastigmine patch in veterans of military conflicts with persistent moderate to severe memory impairment at least 12 weeks after TBI. This randomized, outpatient, double-blind, placebo-controlled 12-week trial with an exploratory double-blind phase of an additional 14 weeks was conducted at 5 VA Medical Centers, among veterans with closed, non-penetrating TBI who met or exceeded modified American Congress of Rehabilitation Medicine criteria for mild TBI with verbal memory deficits, as assessed by the Hopkins Verbal Learning Test, Revised (HVLT-R). Patients were randomized 1:1 to rivastigmine or matching placebo patches after a 1-week single-blind, placebo run-in phase. At randomization, patients received 4.6 mg/24 h rivastigmine patches or matching placebo increased to a 9.5 mg/24 h patch after 4 weeks. The primary efficacy outcome measure was the proportion of participants who had at least a five-word improvement on the HVLT-R Total Recall Index (Trials 1-3). A total of 3671 participants were pre-screened, of whom 257 (7.0%) were screened; 96 (37%) randomized, and 94 included in study analyses. Responder rates were 40.8% (20 of 49) and 51.1% (23 of 45) in the rivastigmine and placebo groups, respectively (p = 0.41). A mixed-effect model including treatment, time, and treatment-by-time interaction indicated no significant difference in treatment effect over time between the groups (p = 0.24). Overall, there were no significant differences in changes for all secondary outcomes between the rivastigmine and placebo groups. The most commonly observed adverse events were application site reactions. This trial provides the largest sample to date of veterans with TBI and post-traumatic memory deficits enrolled in a pharmacological trial. Trial Registration: clinicaltrials.gov Identifier: NCT01670526.

The effect of severe traumatic brain injury on social cognition, emotion regulation, and mood

This chapter provides a review of the emotional and psychosocial consequences of moderate to severe traumatic brain injury (TBI). Many of the disorders affecting socioemotional function arise from damage to frontotemporal systems, exacerbated by white matter injury. They include disorders of social cognition, such as the ability to recognize emotions in others, the ability to attribute mental states to others, and the ability to experience empathy. Patients with TBI also often have disorders of emotion regulation. Disorders of drive or apathy can manifest across cognitive, emotional, and behavioral domains. Likewise, disorders of control can lead to dysregulated emotions and behavior. Other disorders, such as loss of self-awareness, are also implicated in poor psychosocial recovery. Finally, this chapter overviews psychiatric disorders associated with TBI, especially anxiety and depression. For each kind of disorder, the nature of the disorder and its prevalence, as well as theoretical considerations and impact on every day functions, are reviewed.

Factors associated with utilization of emotion and personality instruments among neuropsychologists

Historically, assessment of emotion and personality functioning was not emphasized by clinical neuropsychologists, who instead focused almost exclusively on the evaluation of cognitive functioning. This study examined current practices regarding clinical neuropsychologists' usage of instruments for assessing emotion and personality, along with factors that may mediate their choice of measures and their beliefs about evaluating emotion and personality. Participants were 117 board-certified neuropsychologists as recognized by the American Board of Professional Psychology (ABPP-CN), many of whom had been practicing for over 20 years (39%). Participants generally indicated that examining emotion and personality is essential to evaluations. There was variability among participants as to whether assessment of emotion and personality functioning is challenging, as well as whether or not clinical interview was better suited than instruments. Patients' lack of self-awareness, purposeful over- and under-exaggeration, and lack of sensitivity and specificity of the assessment instruments for neurologic disorders/conditions were identified as the greatest challenges in this area of assessment. Results of the survey suggest that further advancement in the construction and availability of emotion/personality instruments is necessary.

Interventions that support adults with brain injuries, learning disabilities and autistic spectrum disorders in dating or romantic relationships: a systematic review

PURPOSE

To evaluate the current evidence on dating interventions, their theoretical underpinnings and effectiveness for adult neuro-atypical populations.

METHODS

A literature search was completed using CINAHL, Communication Source, PsycARTICLES, PsycINFO, SocINDEX, MEDLINE, Embase, AMED and EMB Reviews (all), for English-language, peer-reviewed studies into interventions for relationships or dating among adults with acquired brain injuries (ABI), learning disabilities or autistic spectrum disorder (ASD). Demographic data and intervention details were extracted for all included studies. Standard checklists were used for methodological quality and intervention description. Narrative synthesis for studies rating above poor quality.

RESULTS

A total of 11 studies (13 articles) were eligible, ABI (n = 6), learning disability (n = 4), ASD (n = 1). These comprised five comparison or control group studies, two pre-post studies and four case studies. The methodological quality was varied, but intervention descriptions were generally poor. While all studies reported positive outcomes, firm conclusions on their effectiveness are difficult due to the high number of before-after analyses and variation in content and outcome measures used.

CONCLUSIONS

More high-quality studies are needed to assess the effectiveness of interventions. Also, greater consensus is needed on the key behaviors for dating and relationships and the measures to assess these.IMPLICATIONS FOR REHABILITATIONIntimate relationships are important to quality of life, but challenging for many people in neuro-atypical populations.There are a small number of researched interventions to support dating or marital relationships among adults with ABI, ASD or learning disabilities.Rehabilitation professionals should ask about dating and relationships and support people if this area is identified as important.Rehabilitation professionals should consider different interventions for dating skills and marital relationships.

Neurobehavioral Initiation and Motivation Problems After Acquired Brain Injury

Motivation is a primary and permanent source of human behavior and adaptation. Motivational deficits, along with deficiencies in initiation, frequently occur in individuals with acquired brain injury (ABI). These neurobehavioral problems are associated with consequences at the participation level: patients are reluctant to engage in rehabilitation, and their subsequent social reintegration is often at risk. The same problems may also become a heavy burden for the families of individuals with ABI. In the present paper, we will critically review both the current definitions and the instruments used to measure motivational disorders following ABI. We will also describe the neural system underlying motivation and its impairments. What emerges is the need to develop specific rehabilitative treatments, still absent at the moment, with the ultimate aim of ensuring a better quality of life for both the patients and their proxies.

Evaluation of a Brief, Skill-Building, Supportive, and Educational Intervention for Couples After Brain Injury

OBJECTIVE

To examine the effectiveness of an intervention (Therapeutic Couples Intervention, TCI) designed to improve relationship quality for couples after acquired brain injury.

SETTING

Outpatient brain injury rehabilitation center.

PARTICIPANTS

Persons with brain injury (n = 75) and their intimate partners (n = 75).

DESIGN

Two-arm parallel, randomized, controlled trial with wait-listed control.

METHODS

Composed of 5 to 6 2-hour sessions, the TCI is a manualized, treatment program designed to enhance relationship quality by addressing issues and concerns most often identified by persons with brain injury and their partners.

MAIN MEASURE

Revised Dyadic Adjustment Scale completed by the persons with brain injury and their partners.

RESULTS

Persons with brain injury and their partners in the treatment group showed an improvement in relationship quality, both compared with their own baseline values and the control group.

CONCLUSIONS

Investigation provided evidence that a curriculum-based education, skill-building, and supportive intervention can benefit couples for up to 3 months after treatment. Additional research is needed to ascertain the long-term benefits of intervention and the efficacy of alternative delivery methods (eg, Internet, telephone, and group).

Assessing aggression following Acquired Brain Injury (ABI): a systematic review of assessment measures

Objective: To conduct a systematic review to identify and examine the reliability and validity of standardized measures used to assess aggression in people with ABI. Data sources: Systematic searches of PsychInfo, Medline, Embase, PubMed and CINAHL databases along with hand searching of gray literature and review articles. Study selection: Studies were included if the sample had an ABI, and the measure included assessment of aggression. Data extraction: Sample and measure characteristics and psychometric properties were extracted. Measure quality was assessed using the COSMIN checklist. Data synthesis: Of 5,100 abstracts screened, 78 were reviewed in full against the inclusion and exclusion criteria, and 25 articles met the criteria for analysis. Included articles assessed the psychometric properties of 17 different measures of aggression in adults with ABI. Quality of evidence was often low. Four measures (MBPC-1990R, NFI, SASNOS and KSMS) demonstrated positive evidence of at least one psychometric property with good quality evidence. Conclusions: Although a large number of general measures were available, there are few measures that only assess post-ABI aggression, and many are not well-validated. Future research should assess the psychometric properties of these measures.

Loss of friendship following traumatic brain injury: A model grounded in the experience of adults with severe injury

Relationships make important contributions to wellbeing and maintenance of self-worth. For those who sustain traumatic brain injury (TBI), life is frequently characterized by declining interpersonal relationships. The aim of this study was to understand the post-injury experience of friendship from the perspective of adults with severe TBI. Participants were 23 adults who had sustained severe TBI on average 10 years earlier; the majority was between 25 and 45 years old. The experience of friendship was explored using a convergent mixed methods design (quantitative self-report measures and in-depth interviews). Qualitative analysis of interview transcripts employed open and focussed coding to reveal themes and categories. Participants nominated on average 3.35 (SD 2.19) friends. When paid carers and family members were excluded, the mean dropped to 1.52 (SD 1.38). Exploratory correlations between number of friends and quality of life, depression and strong-tie support revealed significant associations of moderate to large effects. The post-injury experience of friendship was broadly conceptualized as "going downhill" with four overlapping phases: losing contact, being misunderstood, wanting to share and hanging on. Participants' stories illustrated how rehabilitation can focus on friendship by supporting established relationships and facilitating access to activities that afford interpersonal encounters and opportunities to share experiences.

Measuring Neurobehavioral Disabilities Among Severe Brain Injury Survivors: Reports of Survivors and Proxies in the Chronic Phase

Background: Neurobehavioral disability (NBD) has a major influence on long-term psychosocial outcome following acquired brain injury, as it affects not only the survivor of the brain injury, but the whole family.

Objectives: To investigate (1) the frequency of NBD among survivors of severe brain injury measured by the Danish version of the St Andrew's-Swansea Neurobehavioural Outcome Scale (SASNOS) rated by patients and proxies, (2) factors associated with NBD, and (3) concordance between reports of NBD completed by patients and proxies.

Methods: SASNOS was administered at an outpatient unit as a part of a follow-up assessment after discharge from intensive neurorehabilitation. SASNOS consists of five factors describing the following domains: Interpersonal Behavior, Cognition, Aggression, Inhibition and Communication, and both the patient and a proxy were asked to complete the questionnaire. Data collection was conducted over a period of 2 years, and 32 patients and 31 proxies completed the questionnaire. Mean time since injury was 19.4 months (10.0 SD). Most patients were male (68.8%), and most proxies were female (58.1%). Most of the patients had suffered a traumatic brain injury (68.8%).

Results: A fourth of this patient group reported themselves below the normal range on the major domains of Interpersonal Behavior and Cognition. Significant associations between proxies' reports and time since injury, cohabitant status, and the patient's score on the Extended Glasgow Outcome Scale were found. Furthermore, significant differences were found between patient and proxy ratings. Proxies rated patients as having fewer problems on the Interpersonal Behavior domain, and more problems in relation to Cognition. Cognition was the only domain, where patients rated themselves higher indicating fewer problems, compared with their proxies. On both the Aggression and Communication domains, proxies rated patients higher indicating fewer problems than the patients themselves.

Conclusion: Danish brain injury survivors experienced NBD as measured by SASNOS. Differences were found between patient and proxy ratings in relation to Cognition and Interpersonal Behavior. The NBDs identified can affect the survivor's ability to reintegrate and participate in activities of daily living, emphasizing how a systematic assessment is required.

Measuring Neurobehavioral Functioning in People With Traumatic Brain Injury: Rasch Analysis of Neurobehavioral Functioning Inventory

OBJECTIVE

To examine internal construct validity of the Neurobehavioral Functioning Inventory (NFI) by applying Rasch analysis.

SETTING

An outpatient rehabilitation program trial in New Zealand employing a goal-setting intervention in people with traumatic brain injury (TBI).

PARTICIPANTS

One hundred eight people (mean age = 46 years; 73% male) between 6 months and 5 years post-TBI.

DESIGN

Rasch analysis of the NFI (Partial Credit Model).

RESULTS

Three NFI subscales were not unidimensional and at least 4 items in each subscale had disordered response categories. Two items showed differential item functioning by age, 1 item by educational attainment, and 2 items were found to misfit the overall construct. These items were excluded from the total score calculation. The revised scale fit the Rasch model and supported the internal construct validity of the NFI.

CONCLUSIONS

Current scoring of the NFI subscales for people with TBI in New Zealand does not meet the requirements of the Rasch model. The revised version of NFI can improve the interpretation of scores but should be further tested with people with TBI in other settings.

Perceived personality change after traumatic brain injury II: comparing participant and informant perspectives

OBJECTIVE

The objective of this paper was to correlate informant personality change (PC) judgements following moderate-severe traumatic brain injury with quantitative neurobehavioural measures and to contrast the neurobehavioural correlates of informant and participant judgements of PC.

PARTICIPANTS

Informant-participant pairs were recruited from a medico-legal clinic passing effort tests (N = 31) and a National Health Service clinic (N = 40).

MEASURES

Participants were assessed on Wechsler tests of general ability, tests of executive functioning (Zoo Map and Fluency) and emotional distress (Beck Depression Inventory-FastScreen, Hospital Anxiety and Depression Scale and State-Trait Anger Expression Inventory-II). Informants' expressed emotion towards participants was assessed with the family questionnaire. Both completed the DEX, the Frontal and Social Behavior Questionnaire and PC ratings.

RESULTS

The correlates of participant and informant ratings of participant PC partially overlapped. For example, participant self-reported PC was associated with self-reported dysexecutive symptoms and emotional distress. In contrast, informant report of participant PC was associated with lower perceived emotional recognition and empathy, informant report of dysexecutive symptoms and high informant expressed emotion.

CONCLUSIONS

It is argued that whilst researchers aim to exhaustively quantify specific neurobehavioural changes and their clusters, partially overlapping subsets of these changes evoke the PC judgements of participants and informants. The clinical implications of this are briefly considered.

Prevalence of suicidal behaviour following traumatic brain injury: Longitudinal follow-up data from the NIDRR Traumatic Brain Injury Model Systems

OBJECTIVE

This study utilized the Traumatic Brain Injury Model Systems (TBIMS) National Database to examine the prevalence of depression and suicidal behaviour in a large cohort of patients who sustained moderate-to-severe TBI.

METHOD

Participants presented to a TBIMS acute care hospital within 72 hours of injury and received acute care and comprehensive rehabilitation in a TBIMS designated brain injury inpatient rehabilitation programme. Depression and suicidal ideation were measured with the Patient Health Questionnaire (PHQ-9). Self-reported suicide attempts during the past year were recorded at each follow-up examination, at 1, 2, 3, 10, 15 and 20 years post-injury.

RESULTS

Throughout the 20 years of follow-up, rates of depression ranged from 24.8-28.1%, suicidal ideation ranged from 7.0-10.1% and suicide attempts (past year) ranged from 0.8-1.7%. Participants who endorsed depression and/or suicidal behaviour at year 1 demonstrated consistently elevated rates of depression and suicidal behaviour 5 years after TBI.

CONCLUSION

Compared to the general population, individuals with TBI are at greater risk for depression and suicidal behaviour many years after TBI. The significant psychiatric symptoms evidenced by individuals with TBI highlight the need for routine screening and mental health treatment in this population.

Updates and Current Perspectives of Psychiatric Assessments after Traumatic Brain Injury: A Systematic Review

Neuropsychological and psychiatric disorders represent a major concern and cause of disabilities after the trauma, contributing to worse recovery after traumatic brain injury (TBI). However, the lack of well-defined parameters to evaluate patient's psychiatric disorders leads to a wide range of diagnoses and symptoms. The aim of this study was to perform a review of literature in order to gather data of the most common scales and inventories used to assess and diagnose depression, anxiety, and posttraumatic stress disorder (PTSD) after TBI. We conducted a literature search via MEDLINE, PubMed, and Web of Science. We included reviews, systematic reviews, and meta-analysis studies, and we used the following keywords: "traumatic brain injury OR TBI," "depression OR depressive disorder," "anxiety," and "posttraumatic stress disorder OR PTSD." From 610 titles, a total of 68 systematic reviews or meta-analysis were included in the section "Results" of this review: depression (n = 32), anxiety (n = 9), and PTSD (n = 27). Depression after TBI is a more established condition, with more homogeneous studies. Anxiety and PTSD disorders have been studied in a heterogeneous way, usually as comorbidity with other psychiatric disorders. Some scales and inventories designed for the general community may not be appropriate for patients with TBI.

The evaluation of behavioural changes in brain-injured patients: SOFMER recommendations for clinical practice

Behavioural changes are the main cause of difficulties in interpersonal relationships and social integration among traumatic brain injury (TBI) patients. The Société française de médecine physique et réadaptation (SOFMER) decided to develop recommendations for the treatment and care provision for these problem under the auspices of the French health authority, the Haute Autorité de la santé (HAS). Assessment of behaviour is essential to describe, understand and define situations, assess any change and suggest lines for intervention. The relationship of these behavioural changes with the brain lesion is likewise of crucial importance in legal and forensic expertise.

AIMS

Using a literature review and expert opinions, the aim was to define the optimal conditions for the collection of data on behavioural changes in individuals having sustained brain trauma, to identify the situations in which they arise, to review the instruments available, and to suggest lines of intervention.

METHODS

A literature search identified 981 articles, among which 122 on the target subject were selected and analysed in detail and confronted with the experience of professionals and user representatives. A first draft of the recommendations was produced by the working group, and then submitted to a review group for opinions and complements.

RESULTS

The literature on this subject is heterogeneous, and presents low levels of evidence. No article enabled the development of recommendations above the "expert opinion" level. After prior clarification of the aims of the evaluation, it is recommended first to carefully describe the changes in behaviour, from patient and third-person narratives, and where possible from direct observations. The information enabling the description of the phenomena occurring should be collected by different individuals (multi-source evaluation): the patient, his or her close circle, and professionals with different training backgrounds (multidisciplinary evaluation). The analysis of triggering or associated factors requires an assessment of cognitive functions and any neurological pathology (seizures). After confrontation and synthesis, the information should be completed using one or several behavioural scales, which provide objectivity and reproducibility. The main generic and specific scales are presented, with their advantages, drawbacks and validation references. The group did not wish to recommend any one of them in particular.

CONCLUSION

The evaluation of behavioural changes is essential, since without it a therapeutic strategy and appropriate orientation cannot be implemented. The emphasis should be put on contextualised, multi-source and multidisciplinary evaluation, including validated behavioural scales. In this area, nevertheless, evaluation is still restricted by several methodological limitations. Further research is needed to improve the standardisation of data collection and the psychometric properties of the instruments. A European harmonisation of these procedures is also greatly needed.

Emotional and behavioral dyscontrol after traumatic brain injury

Emotional and behavioral dyscontrol are relatively common neuropsychiatric sequelae of traumatic brain injury and present substantial challenges to recovery and community participation. Among the most problematic and functionally disruptive of these types of behaviors are pathologic laughing and crying, affective lability, irritability, disinhibition, and aggression. Managing these problems effectively requires an understanding of their phenomenology, epidemiology, and clinical evaluation. This article reviews these issues and provides clinicians with brief and practical suggestions for the management of emotional and behavioral dyscontrol.

Distress of the Caregiver in Acquired Brain Injury: Positive aspects of care to moderate the effects of psychological problems

Acquired brain injury (ABI) causes numerous problems, including cognitive and personality changes, which can be quite stressful for caregivers. In this study, we aimed to adapt an instrument to measure caregivers’ distress, the Relative Version of the Head Injury Behaviour Scale (HIBS; Godfrey et al., 2003) to the Spanish language and to determine whether the positive aspects of caregiving moderate the effects of the psychological problems of ABI on caregivers’ distress. Moderation analyses indicated that positive aspects of caregiving involving one's outlook on life reduced the association between psychological problems and caregivers’ distress. The findings suggest that although the caregiver role is a source of distress, this role can also become a source of satisfaction, actually contributing to reducing caregivers’ distress. The importance of promoting the positive aspects of caregiving in rehabilitation programmes is discussed.

Factors associated with strain in carers of people with traumatic brain injury

OBJECTIVE

To explore factors associated with strain in carers of patients with traumatic brain injury.

DESIGN

Cross-sectional cohort study.

PARTICIPANTS

Forty-eight carers of patients with traumatic brain injury admitted to a neurosurgical unit over a 9-year period were assessed an average of 9.3 years after injury.

MEASURES

Caregiver Strain Index (CSI), Neurobehavioral Functioning Inventory (NFI), Glasgow Outcome Scale (GOS), Virginia Prediction Tree Score, and carer and patient demographics.

PROCEDURE

Carers were assessed via postal survey for levels of strain using the CSI and for their perception of the patients' disabilities using the NFI.

RESULTS

Elevated levels of strain were found in 42% of carers. Using logistic regression, outcome as rated by the patients' general practitioner on the GOS and all subscales of the NFI (except Somatic) explained 41% to 57% of the variance in strain and predicted group membership correctly in 72.9% of cases. No individual variable contributed significantly to the explained variance in the model.

CONCLUSION

A number of factors appear to combine to result in feelings of strain, but the GOS could be used as a crude screening tool. Interventions for cognitive, behavioral, and emotional difficulties may be most useful for carers.

Patient Characterization Protocols for Psychophysiological Studies of Traumatic Brain Injury and Post-TBI Psychiatric Disorders

Psychophysiological investigations of traumatic brain injury (TBI) are being conducted for several reasons, including the objective of learning more about the underlying physiological mechanisms of the pathological processes that can be initiated by a head injury. Additional goals include the development of objective physiologically based measures that can be used to monitor the response to treatment and to identify minimally symptomatic individuals who are at risk of delayed-onset neuropsychiatric disorders following injury. Research programs studying TBI search for relationships between psychophysiological measures, particularly ERP (event-related potential) component properties (e.g., timing, amplitude, scalp distribution), and a participant's clinical condition. Moreover, the complex relationships between brain injury and psychiatric disorders are receiving increased research attention, and ERP technologies are making contributions to this effort. This review has two objectives supporting such research efforts. The first is to review evidence indicating that TBI is a significant risk factor for post-injury neuropsychiatric disorders. The second objective is to introduce ERP researchers who are not familiar with neuropsychiatric assessment to the instruments that are available for characterizing TBI, post-concussion syndrome, and psychiatric disorders. Specific recommendations within this very large literature are made. We have proceeded on the assumption that, as is typically the case in an ERP laboratory, the investigators are not clinically qualified and that they will not have access to participant medical records.

Rehabilitation Approaches to the Management of Aggressive Behaviour Disorders after Acquired Brain Injury

Symptoms of neurobehavioural disability acquired through brain injury, especially aggression, are associated with severe social handicap. Differences in terminology have resulted in varying estimates, but aggressive behaviour disorder appears to be characteristic of survivors at some point in their recovery journey. This paper provides a brief review regarding the prevalence, development and causes of aggression associated with acquired brain injury (ABI), and what can be done to help manage them. The advantages of using standardised measures conceptualised for ABI in the assessment and formulation of aggressive behaviour disorders are especially highlighted. A range of treatment methods and the evidence base relating to these are described. The contribution of pharmacological therapies, cognitive behavioural therapy and behavioural interventions are explored. It is argued that the strongest evidence base is associated with behaviour therapy, especially when carried out in the context of neurobehavioural rehabilitation, and two case studies are described to illustrate the clinical advantages of interventions derived from operant theory. Comparative lack of ABI experts trained in the management of post-acute behaviour disorders remains a limiting factor.

A health and wellness intervention for those with moderate to severe traumatic brain injury: a randomized controlled trial

OBJECTIVES

To assess the efficacy of a standardized 12-week health and wellness group intervention for those with moderate to severe traumatic brain injury (TBI).

STUDY DESIGN

Randomized controlled trial.

PARTICIPANTS

Seventy-four individuals with moderate to severe TBI recruited from the outpatient program at a rehabilitation hospital, a Veterans Affairs Medical Center, and the community.

METHOD

Eligible participants were randomized to treatment (health and wellness therapy group) or wait-list control (treatment, n = 37; wait-list, n = 37). The primary outcome was the Health Promoting Lifestyle Profile-II.

RESULTS

The results of the mixed-model repeated-measures analysis indicated no differences between treatment and control groups engaging in activities to increase their health and well-being.

CONCLUSIONS

Findings did not support the efficacy of the intervention. Results may have been impacted by the wide variability of individualized health and wellness goals selected by group members, the structure and/or content of the group, and/or the outcome measures selected.

Diagnosis and Treatment of Depression Following Traumatic Brain Injury

Depression is one of the most common psychiatric diagnoses among individuals with traumatic brain injury (TBI). Prevalence of post-TBI depression (PTBID) ranges from 12 to 60% and is generally higher than rates reported in the general population. The wide range in reported rates is attributed to methodological variability across studies, including measurement and sampling differences. Several systematic reviews have been published in the past 5 years, reporting on outcomes for depression across different classes of interventions, including pharmacological, biomedical and behavioural. The consensus across reviews is that more research is necessary to develop evidence-based practice guidelines. The present narrative review synthesises the findings of previous studies, focusing on the nature of the interventions, the eligibility criteria for inclusion and the assessment of outcome. Pharmacological studies are generally more rigorous methodologically, but provide mixed findings. Other biomedical interventions are only at the initial stages of research development, including case and pilot studies. The results of behavioural studies are positive regarding improvements in mood. However, the number of efficacy studies of behavioural interventions for depression is extremely limited. Recommendations for designing interventions are provided.

Neurobehavioural symptoms 1 year after traumatic brain injury: a preliminary study of the relationship between race/ethnicity and symptoms

OBJECTIVE

To investigate whether White, African American and Hispanic individuals with a traumatic brain injury (TBI) express differences in neurobehavioural symptoms at 1 year post-injury after adjusting for demographic and injury characteristics.

DESIGN

Retrospective study.

PARTICIPANTS

One thousand, three hundred and thirty-nine individuals from the TBI Model Systems National Database with primarily moderate-to-severe TBI (978 White, 288 African American and 73 Hispanic) hospitalized between 1996 and 2001.

MAIN OUTCOME MEASURES

Neurobehavioural Functioning Inventory (NFI) at 1 year post-injury.

RESULTS

There were significant differences in NFI scores among the races/ethnicities for the depression, somatic, memory/attention, communication and motor subscales, after adjusting for demographic and injury characteristics; there were not significant differences in the aggression sub-scale. Hispanics had higher levels of symptom reporting than African Americans and Whites, while differences between African Americans and Whites were not significant.

CONCLUSIONS

Hispanics scored significantly higher than Whites and African Americans on the sub-scales of the NFI, indicating more problems in these areas. Future research should focus on identifying factors that may contribute to the difference between the groups and treatment interventions should be implemented accordingly.

Clinical electrophysiologic assessments and mild traumatic brain injury: state-of-the-science and implications for clinical practice

Conventional and quantitative electroencephalography (EEG and qEEG, respectively) may enhance clinical diagnosis and treatment planning provided to persons with mild traumatic brain injury (mTBI) and postconcussive symptoms. Effective and appropriate use of EEG and qEEG in this context requires expert-level knowledge of these technologies, mTBI, and the differential diagnosis for postconcussive symptoms. A practical and brief review from the perspective of a clinician-scientist engaged principally in the care and study of persons with mTBI therefore may be of use and value to other clinicians and scientists interested in these matters. Toward that end, this article offers an overview of the current applications of conventional EEG and qEEG to the study and clinical evaluation of persons with mTBI. The clinical case definition of TBI, the differential diagnosis of post-injury neuropsychiatric disturbances, and the typical course of recovery following mTBI are reviewed. With this background and context, the strengths and limitations of the literature describing EEG and qEEG studies in this population are considered. The implications of this review on the applications of these electrophysiologic assessments to the clinical evaluation of persons with mTBI and postconcussive symptoms are then considered. Finally, suggestions are offered regarding the design of future studies using these technologies in this population. Although this review may be of interest and value to professionals engaged in clinical or research electrophysiology in their daily work, it is intended to serve more immediately the needs of clinicians less familiar with these types of clinical electrophysiologic assessments.

Fatigue after traumatic brain injury: Association with neuroendocrine, sleep, depression and other factors

OBJECTIVE

Define associations between post-traumatic brain injury (TBI) fatigue and abnormalities in neuroendocrine axes, sleep, mood, cognition and physical functioning.

DESIGN

Survey.

SETTING

Large community hospital-based rehabilitation centre.

PARTICIPANTS

Convenience sample of 119 individuals at least 1 year post-TBI.

OUTCOME MEASURES

Multidimensional Assessment of Fatigue (MAF); Fatigue Severity Scale (FSS); neuroendocrine assessments-growth hormone (GH) reserve, thyroid, cortisol and testosterone levels; visual analogue pain rating; Pittsburgh Sleep Quality Index; Beck Depression Inventory-II; Disability Rating Scale; Craig Handicap Assessment and Reporting Technique; Neurobehavioural Functioning Inventory.

RESULTS

Fifty-three per cent reported fatigue on the MAF and one-third on the FSS; 65% were found to have moderate/severe GH deficiency; 64% had adrenal insufficiency (low fasting cortisol); 12% had central hypothyroidism; and 15% of men had testosterone deficiency. Pituitary dysfunction did not correlate with fatigue or other symptoms. Predictors of MAF total scores were female gender, depression, pain and self-assessed memory deficits. Predictors of FSS scores were depression, self-assessed motor deficits and anti-depressant usage.

CONCLUSIONS

Robust correlates of fatigue were gender, depression, pain and memory and motor dysfunction. Investigation of post-TBI fatigue should include screening for depression, pain and sleep disturbance. There was no correlation between pituitary dysfunction and fatigue; however, the relatively high prevalence of hypothyroidism and adrenal dysfunction suggests screening for these hormone deficiencies.

Evaluation and Management of Posttraumatic Cognitive Impairments

Psychiatrists are increasingly called upon to care for individuals with cognitive, emotional, and behavioral disturbances after TBI, especially in settings serving military service personnel and Veterans. In both the early and late post-injury periods, cognitive impairments contribute to disability among persons with TBI and are potentially substantial sources of suffering for persons with TBI and their families. In this article, the differential diagnosis, evaluation, and management of posttraumatic cognitive complaints is reviewed. The importance of pre-treatment evaluation as well as consideration of non-cognitive contributors to cognitive problems and functional limitations is emphasized first. The course of recovery after TBI, framed as a progression through posttraumatic encephalopathy, is reviewed next and used to anchor the evaluation and treatment of posttraumatic cognitive impairments in relation to injury severity as well as time post-injury. Finally, pharmacologic and rehabilitative interventions that may facilitate cognitive and functional recovery at each stage of posttraumatic encephalopathy are presented.

Measuring perceived difficulty in post-acute brain injury rehabilitation: The Sister Kenny Symptom Management Scale

PRIMARY OBJECTIVE

Patients' perceptions of difficulty managing symptoms contribute to disability after brain injury. This study introduces the Sister Kenny Symptom Management Scale (KSMS) and reports on its factor structure, reliability, validity and clinical value.

METHOD

Archived data from (overlapping) samples of patients with brain injuries of mixed aetiologies, seen at an outpatient clinic over 16 years were used in development and validation studies of the KSMS. Comparison measures included the Profile of Mood States (POMS), neuropsychological test scores and employment.

RESULTS

Factor analysis of 34 items (n = 328) identified five sub-scales with satisfactory internal consistency and test-re-test stability representing difficulty with executive functions, language, recent memory, aggressive behaviour and physical symptoms. A pattern of correlations (n = 336) with Profile of Mood States (POMS) sub-scales of similar and different content supported the concurrent validity of KSMS sub-scales. Only the Memory sub-scale correlated with its test index. The Language score and test index approached significance. The Executive sub-scale did not. Hierarchical regression analysis (n = 102) that included ratings of mood and symptom management showed that employment after discharge was only predicted by post-treatment ratings of difficulty with cognitive functions.

CONCLUSION

Self-assessments of difficulty managing symptoms can be reliably assessed and may contribute to understanding patients' disability, treatment response and future prospects.

The effect of internet-based cognitive rehabilitation in persons with memory impairments after severe traumatic brain injury

PRIMARY OBJECTIVE

The current study examined whether cognitive rehabilitation delivered over the Internet was associated with improvements in functioning.

RESEARCH DESIGN

A total of 14 individuals with medically documented traumatic brain injury completed this study. Participants completed 30 sessions of an active calendar acquisition intervention and 30 sessions of a control diary intervention in a cross-over study design for a total of 60 online sessions. All sessions were completed using an instant messaging system via the Internet. Measures of cognitive functioning, ratings of memory and mood and frequency of use of common memory and cognitive compensation techniques were gathered from participants and family members.

MAIN OUTCOMES AND RESULTS

There were no significant differences between the active and control conditions on the primary outcome measure of memory functioning. However, significant improvements in use of compensatory strategies as well as family reports of improved memory and mood were observed following completion of all sessions. Individuals with less use of compensatory strategies at baseline were significantly less likely to complete the study.

CONCLUSIONS

These results suggest that the Internet may be an effective delivering mechanism for compensatory cognitive rehabilitation, particularly among individuals who are already utilizing some basic compensatory strategies.