Socratic guided feedback therapy after acquired brain injury: A multicenter randomized controlled trial to evaluate effects on self-awareness

Impaired self-awareness after acquired brain injury (ABI) challenges neuropsychological rehabilitation. The current study aimed to compare the effects of Socratic Guided Feedback therapy to usual care in a multicenter randomized controlled trial with 64 participants with reduced self-awareness after ABI. The objectives were to study the effects on (1) self-awareness and (2) motivation for and participation in therapy, mood, quality of life, and social participation. Patients were recruited from rehabilitation centres in The Netherlands and Belgium. They were 50.8 (±16) years old and 2.7 months (±1.8) post-injury at baseline. Session duration ranged from 20-60 minutes and the number of sessions ranged from 1 to 162 sessions. Self-awareness increased over time in both groups. Between 9 and 12 months after baseline measurement, self-awareness (Patient Competency Rating Scale discrepancy score between patient and significant other) improved in the experimental group and deteriorated in care as usual. No significant differences were found on secondary outcome measures. In conclusion, Socratic Guided Feedback therapy is as effective as care as usual but provides a structure for therapists. We recommend further investigation of the added value of Socratic Guided Feedback therapy in later follow-up measurements, group therapy settings, and on other outcome domains such as caregiver burden.

An eHealth intervention for patients with a low socioeconomic position during their waiting period preceding cardiac rehabilitation: a randomized feasibility study

Aims

Cardiac rehabilitation (CR) shows lower effectiveness and higher dropouts among people with a low socioeconomic position (SEP) compared to those with a high SEP. This study evaluated an eHealth intervention aimed at supporting patients with a low SEP during their waiting period preceding CR.

Methods and results

Participants with a low SEP in their waiting period before CR were randomized into an intervention group, receiving guidance videos, patient narratives, and practical tips, or into a control group. We evaluated adherence (usage metrics), acceptance (modified Usefulness, Satisfaction, and Ease of use questionnaire), and changes in feelings of certainty and guidance between the waiting period's start and end. Semi-structured interviews provided complementary insights. The study involved 41 participants [median interquartile range (IQR) age 62 (14) years; 33 males], with 21 participants allocated to the intervention group, using the eHealth intervention for a median (IQR) duration of 16 (10) days, using it on a median (IQR) of 100% (25) of these days, and viewing 88% of the available messages. Key adherence themes were daily routine compatibility and curiosity. Acceptance rates were 86% for usability, 67% for satisfaction, and 43% for usefulness. No significant effects on certainty and guidance were observed, but qualitative data suggested that the intervention helped to inform and set expectations.

Conclusion

The study found the eHealth intervention feasible for cardiac patients with a low SEP, with good adherence, usability, and satisfaction. However, it showed no effect on feelings of certainty and guidance. Through further optimization of its content, the intervention holds promise to improve emotional resilience during the waiting period.

Registration

This trial is registered as follows: 'Evaluation of a Preparatory eHealth Intervention to Support Cardiac Patients During Their Waiting Period (PReCARE)' at ClinicalTrials.gov (NCT05698121, https://clinicaltrials.gov/study/NCT05698121).

Serious Game with Electromyography Feedback and Physical Therapy in Young Children with Unilateral Spastic Cerebral Palsy and Equinus Gait: A Prospective Open-Label Study

The clinical effects of a serious game with electromyography feedback (EMGs_SG) and physical therapy (PT) was investigated prospectively in children with unilateral spastic cerebral palsy (USCP). An additional aim was to better understand the influence of muscle shortening on function. Thirty children with USCP (age 7.6 ± 2.1 years) received four weeks of EMGs_SG sessions 2×/week including repetitive, active alternating training of dorsi- and plantar flexors in a seated position. In addition, each child received usual PT treatment ≤ 2×/week, involving plantar flexor stretching and command strengthening on dorsi- and plantar flexors. Five-Step Assessment parameters, including preferred gait velocity (normalized by height); plantar flexor extensibility (XV1); angle of catch (XV3); maximal active ankle dorsiflexion (XA); and derived coefficients of shortening, spasticity, and weakness for both soleus and gastrosoleus complex (GSC) were compared pre and post treatment (t-tests). Correlations were explored between the various coefficients and gait velocities at baseline. After four weeks of EMGs_SG + PT, there was an increase in normalized gait velocity from 0.72 ± 0.13 to 0.77 ± 0.13 m/s (p = 0.025, d = 0.43), a decrease in coefficients of shortening (soleus, 0.10 ± 0.07 pre vs. 0.07 ± 0.08 post, p = 0.004, d = 0.57; GSC 0.16 ± 0.08 vs. 0.13 ± 0.08, p = 0.003, d = 0.58), spasticity (soleus 0.14 ± 0.06 vs. 0.12 ± 0.07, p = 0.02, d = 0.46), and weakness (soleus 0.14 ± 0.07 vs. 0.11 ± 0.07, p = 0.005, d = 0.55). At baseline, normalized gait velocity correlated with the coefficient of GSC shortening (R = -0.43, p = 0.02). Four weeks of EMGs_SG and PT were associated with improved gait velocity and decreased plantar flexor shortening. A randomized controlled trial comparing EMGs_SG and conventional PT is needed.

Development and Psychometric Evaluation of the Motivation for Healing Scale in Patients with Cancer

Introduction

This study was conducted to develop and validate a Motivation for Healing Scale (MHS) in Cancer.

Methods

in this methodological study, the MHS draft was developed based on the approach of Waltz and colleagues using existing scales and concept analysis. The psychometric features, including face validity (qualitative and quantitative), content validity (qualitative and quantitative), structural validity (exploratory and confirmatory factors), and construct validity (convergent and discriminant validity) were assessed. Finally, the reliability was evaluated using internal consistency, and stability.

Results

Based on the results of the qualitative phase, an initial item pool was generated with 55 items, Exploratory and confirmatory factor analyses were performed on the data collected from 404 patients. 25 Items were excluded during the psychometric evaluation phases. Reliability assessment and internal consistency assessment revealed that Cronbach's alpha value of the 25-item MHS was 0.912. The results of intraclass correlation coefficient (0.93, 95% CI: 0.86- 0.96) showed the stability was strong.

Conclution

The 25-item MHS is a valid and reliable scale for the assessment of motivation for healing in patients with cancer.

Developing post-stroke psychometric properties for an Adherence to rehabilitation regimen scale: A sequential exploratory mixed-method study

INTRODUCTION

Adherence to rehabilitation in patients post-stroke plays a significant role in the effectiveness of rehabilitation and patient recovery. This study aimed to design and determine the psychometric properties of a scale for measuring adherence to the rehabilitation regimen in patients post-stroke in the Iranian community.

METHODS

The present study used a sequential exploratory mixed method and was conducted in two phases (phase one qualitative and phase two quantitative). Participants in the first phase were patients post-stroke, caregivers, and rehabilitation team members (n=20). The second phase was conducted on patients post-stroke (n=198), and the psychometric steps, including face, content, and construct validity, as well as reliability, were assessed.

RESULTS

The Adherence to Rehabilitation Regimen Scale (ARRS)was designed with 26 items and four factors of participation: 1) physical exercises, 2) following prescribed regimens, 3) performing the activities of daily living, and 4) psychological follow-up. The internal consistency was 0.96 by calculating Cronbach's alpha coefficient. The Interclass Correlation Coefficient was 0.99 with a confidence interval of 0.96-0.99.

CONCLUSION

The scale measuring adherence to the rehabilitation regimen in patients post-stroke has optimal psychometric properties. Therefore, as the first specific scale to measure the degree of rehabilitation regimen adherence in patients post-stroke, this tool may be beneficial for other rehabilitation programs interested in managing and improving program adherence.

Mood, Activity Participation, and Leisure Engagement Satisfaction (MAPLES): results from a randomised controlled pilot feasibility trial for low mood in acquired brain injury

BACKGROUND

Acquired brain injury (ABI) is linked to increased depression risk. Existing therapies for depression in ABI (e.g., cognitive behavioural therapy) have mixed efficacy. Behavioural activation (BA), an intervention that encourages engaging in positively reinforcing activities, shows promise. The primary aims were to assess feasibility, acceptability, and potential efficacy of two 8-week BA groups.

METHODS

Adults (≥ 18 years) recruited from local ABI services, charities, and self-referral via social media were randomised to condition. The Activity Planning group (AP; "traditional" BA) trained participants to plan reinforcing activities over 8 weeks. The Activity Engagement group (AE; "experiential" BA) encouraged engagement in positive activities within session only. Both BA groups were compared to an 8-week Waitlist group (WL). The primary outcomes, feasibility and acceptability, were assessed via recruitment, retention, attendance, and qualitative feedback on groups. The secondary outcome, potential efficacy, was assessed via blinded assessments of self-reported activity levels, depression, and anxiety (at pre- and post-intervention and 1 month follow-up) and were compared across trial arms. Data were collected in-person and remotely due to COVID-19.

RESULTS

N = 60 participants were randomised to AP (randomised n = 22; total n = 29), AE (randomised n = 22; total n = 28), or re-randomised following WL (total n = 16). Whether in-person or remote, AP and AE were rated as similarly enjoyable and helpful. In exploring efficacy, 58.33% of AP members had clinically meaningful activity level improvements, relative to 50% AE and 38.5% WL. Both AP and AE groups had depression reductions relative to WL, but only AP participants demonstrated anxiety reductions relative to AE and WL. AP participants noted benefits of learning strategies to increase activities and learning from other group members. AE participants valued social discussion and choice in selecting in-session activities.

CONCLUSIONS

Both in-person and remote group BA were feasible and acceptable in ABI. Though both traditional and experiential BA may be effective, these may have different mechanisms.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03874650. Protocol version 2.3, May 26 2020.

Game-supported cognitive strategy training for slowed information processing speed after acquired brain injury: study protocol for a randomised controlled trial

INTRODUCTION

Many individuals with acquired brain injury tend to experience problems with slowed information processing speed (IPS). A potentially beneficial and cost-effective supplement for cognitive rehabilitation of impaired IPS may be the implementation of serious gaming that focuses on compensatory learning as part of cognitive training. However, most digital platforms used during cognitive rehabilitation focus on restoring cognitive function and evidence for skill transfer from digital practice to everyday life is lacking. This study aims to investigate the efficacy of a game-supported cognitive strategy training. The training combines a well-validated time pressure management cognitive strategy training, targeting slowed IPS, with a novel game and a mobile application. The game-supported training focuses on the generalisation of strategy-use to untrained tasks in everyday life.

METHODS AND ANALYSIS

The study is designed as a randomised controlled trial in which the experimental group (Karman Line - Tempo module: an 8-week game-supported cognitive strategy training) will be compared with an active control group (CogniPlus training: an 8-week computerised cognitive function training). Data from 60 individuals with acquired brain injury (30 per group, ages between 16 and 75) will be collected at baseline (T0), post-treatment (T1) and at 3-month follow-up (T2). The primary outcome measure is an objective assessment of compensatory strategy use in an untrained experimental task. The secondary outcome is the attainment of trained and untrained treatment goals assessed by goal attainment scaling. Pre-training and post-training data will be analysed using a 2×2 repeated measure analysis of variance.

ETHICS AND DISSEMINATION

This study has been approved by the medical review ethics committee CMO Region Arnhem and Nijmegen (NL74818.091.20) and is registered in the Netherlands Trial Register. Research findings will be published in peer-reviewed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

NL9437; The Netherlands Trial Register.

A scoping review to identify process and outcome measures used in acceptance and commitment therapy research, with adults with acquired neurological conditions

BACKGROUND

Acceptance and Commitment Therapy interventions are increasing in use in neurological populations. There is a lack of information on the measures available.

PURPOSE

To identify and classify the measures used in Acceptance and Commitment Therapy research studies with adults with acquired neurological conditions.

METHODS

PRISMA-ScR guided scoping review. MEDLINE, PsycInfo and CINAHL databases searched (up to date 29/06/2022) with forward and backward searching. All study types included. Extraction of Acceptance and Commitment Therapy process-of-change and health-related outcome measures. Outcomes coded using the Core Outcome Measures in Effectiveness Trials (COMET) taxonomy.

RESULTS

Three hundred and thirty three papers found on searching. Fifty four studies included and 136 measurement tools extracted. Conditions included multiple sclerosis, traumatic brain injury and stroke. Thirty-eight studies measured processes of change, with 32 measures extracted. The process measure most often used was the Acceptance and Action Questionnaire (n = 21 studies). One hundred and four health-related outcome measures extracted. Measures exploring quality of life, health status, anxiety and depression occurred most frequently, and were used in all included neurological conditions. COMET domains most frequently coded were emotional functioning/well-being (n = 50), physical functioning (n = 32), role functioning (n = 22) and psychiatric (n = 22).

CONCLUSIONS

This study provides a resource to support future identification of candidate measures. This could aid development of a Core Outcome Set to support both research and clinical practice. Further research to identify the most appropriate and relevant targets and tools for use in these populations should include expert consensus, patient, carer and public involvement and psychometric examination of measures.

Cross-cultural adaptation and validation of the Motivation in Stroke Patients for Rehabilitation Scale in Chinese hospitalized older adults with stroke

OBJECTS

To translate, cross-culturally adapt, and validate the Motivation in Stroke Patients for Rehabilitation Scale (MORE) questionnaire in Chinese hospitalized older adults with stroke.

METHODS

The Chinese version of the MORE was produced following Brislin's guidelines. The psychometric properties of the MORE were evaluated among 420 eligible patients.

RESULTS

The Cronbach's alpha coefficient of the Chinese version of the MORE scale was 0.983, and the content validity index (S-CVI) was 0.94, with good reliability. Exploratory factor analysis showed a single-factor structure that explained 78.01% of the total variance, and the confirmatory factor analysis model had a good fit index (X²/df=2.97; NFI =0.93; CFI=0.96; TFI=0.95; IFI=0.96).

CONCLUSION

The MORE presented acceptable validity and reliability and could be used in Chinese hospitalized older adults with stroke.

Development and validation of new evaluation scale for measuring stroke patients' motivation for rehabilitation in rehabilitation wards

OBJECTIVE

This study aimed to develop the Motivation in stroke patients for rehabilitation scale (MORE scale), following the Consensus-based standards for the selection of health measurement instruments (COSMIN).

METHOD

Study participants included rehabilitation professionals working at the convalescent rehabilitation hospital and stroke patients admitted to the hospital. The original MORE scale was developed from an item pool, which was created through discussions of nine rehabilitation professionals. After the content validity of the scale was verified using the Delphi method with 61 rehabilitation professionals and 22 stroke patients, the scale's validity and reliability were examined for 201 stroke patients. The construct validity of the scale was investigated using exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and item response theory analysis. Cronbach's alpha confirmed its internal consistency. Regarding convergent, discriminant, and criterion validity, Spearman's rho was calculated between the MORE scale and the Apathy Scale (AS), Self-rating Depression Scale (SDS), and Visual Analogue Scale (VAS), which rates the subjective feelings of motivation.

RESULTS

Using the Delphi method, 17 items were incorporated into the MORE scale. According to EFA and CFA, a one-factor model was suggested. All MORE scale items demonstrated satisfactory item response, with item slopes ranging from 0.811 to 2.142, and item difficulty parameters ranging from -3.203 to 0.522. Cronbach's alpha was 0.948. Regarding test-retest reliability, a moderate correlation was found between scores at the beginning and one month after hospitalization (rho = 0.612. p < 0.001). The MORE scale showed significant correlation with AS (rho = -0.536, p < 0.001), SDS (rho = -0.347, p < 0.001), and VAS (rho = 0.536, p < 0.001), confirming the convergent, discriminant, and criterion validity, respectively.

CONCLUSIONS

The MORE scale was verified as a valid and reliable scale for evaluating stroke patients' motivation for rehabilitation.

Motivation for Rehabilitation in Patients With Subacute Stroke: A Qualitative Study

Background: Motivation is essential for patients with subacute stroke undergoing intensive rehabilitation. Although it is known that motivation induces behavioral changes toward rehabilitation, detailed description has been lacking. Motivation can be intrinsic or extrinsic; however, it is unclear which type of factors mainly motivates patients' daily rehabilitation.

Purpose: This study aimed to examine the factors influencing patients' motivation and to explore the behavioral changes induced by motivation, especially age-related differences.

Method: Twenty participants (mean age 65.8 years [standard deviation 13.7]) who had a subacute stroke and underwent rehabilitation at a convalescent hospital were recruited using convenience sampling. Semi-structured interviews were conducted by an occupational therapist with an interview topic guide regarding factors influencing motivation and how it affects behavioral change. Interviews were recorded, transcribed to text, and analyzed by three occupational therapists using thematic analysis. The participants were divided into two groups: aged patients (aged ≥ 65 years) and middle-aged patients (aged < 65 years), and data were analyzed according to the groups. This study was conducted according to the consolidated criteria for reporting qualitative research.

Results: Seven core categories were identified as factors influencing patients' motivation: patients' goals, experiences of success and failure, physical condition and cognitive function, resilience, influence of rehabilitation professionals, relationships between patients, and patients' supporters. The first four and last three core categories were further classified as personal and social-relationship factors, respectively. The categories related to intrinsic motivation such as enjoyment of rehabilitation itself were not derived. In both age-groups, motivation affected the frequency of self-training and activity in daily lives. In some aged patients, however, high motivation restrained their self-training to conserve their physical strength for rehabilitation by professionals. Some aged patients do not express their high motivation through their facial expressions and conversations compared to middle-aged patients; therefore, motivation is not always observable in aged patients.

Conclusions: Interventions tailored to extrinsic factors are important for maintaining patients' motivation. Observational evaluation may lead to mislabeling of their motivation, especially for aged patients. Rehabilitation professionals should use validated evaluation scales or patients' narratives to assess patients' motivation.

Use of conversational agents in rehabilitation following brain injury, disease, or stroke: a scoping review protocol

OBJECTIVE

The objective of the review is to identify peer-reviewed literature reporting the design and use of conversational agents in rehabilitation for adults with brain injury, disease, or stroke.

INTRODUCTION

Rehabilitation for adults with brain injury, disease, or stroke provides goal-directed care to overcome functional impairments and reduced independence. However, recovery can be impacted due to rehabilitation being time-limited. New therapy approaches supporting rehabilitation and self-management are warranted. Conversational agents provide personal computer-based dialogues that can be designed to meet the specific needs of clients. Interacting with a conversational agent may support rehabilitation for clients with brain injury, disease, or stroke.

INCLUSION CRITERIA

Studies that report the design or use of conversational agents in rehabilitation for adults aged over 18 years with brain injury, disease, or stroke will be considered for inclusion. Research settings may include hospitals, community settings, and homes. Eligible study types are peer-reviewed research protocols, prototype development papers, and pilot and clinical trials.

METHODS

Primary sourcing databases (MEDLINE [Ovid], Scopus, ProQuest [all databases], Web of Science) and gray literature sources will be searched with no date limitations. Only studies published in English will be considered due to feasibility limitations. Two independent reviewers will screen the retrieved papers by title and abstract, and the selected papers by full-text review. Any disagreements will be resolved by an objective arbitrator. Data to be extracted and analyzed from included papers will include details of participants, concept, context, and the study design. Results will be presented narratively and in tabular format.

Effectiveness of a Visual Imagery Training Program to Improve Prospective Memory in Older Adults with and without Mild Cognitive Impairment: A Randomized Controlled Study

Prospective memory (PM) problems in aging and, to a greater extent, in mild cognitive impairment (MCI), compromise functional independence. This study examined the effectiveness of a cognitive training program based on visual imagery to improve PM among older adults with and without MCI. Participants were older adults, 24 with MCI and 24 cognitively healthy (HOA). Half of them (12 MCI and 12 HOA) were randomly assigned to the PM training program, the other half to the no-training control group. All participants also completed a pre- and post-test evaluation, including neuropsychological tests, questionnaires, and the Ecological Test of Prospective Memory (TEMP). There was no significant effect of the intervention on the TEMP total, event-based or time-based scores for either the MCI or HOA groups. However, the trained MCI group committed fewer false alarms (i.e., more efficient identification of prospective cues) in the event-based condition of the TEMP at post-test. On the other hand, all trained participants performed better than control participants on retrospective memory tests, which suggests that visual imagery-based training is more effective to improve retrospective memory than PM. Possible explanations for these results are explored.

Scoping Review on the Concept of Patient Motivation and Practical Tools to Assess it

BACKGROUND

In this scoping review, the concept of patients' motivation and the tools that have been designed to measure this concept in clinical settings are presented.

MATERIALS AND METHODS

Arksey and O'Malley's framework was used in conducting the current scoping review. Google Scholar, PubMed, Scopus, and Web of Science databases were searched for relevant English articles published between January 1995 and January 2020 using the keywords motivation and tool, and their synonyms. Out of 2820 articles, 34 articles were chosen and were entered into the final analysis. Definitions of patients' motivation were determined using Kyngäs et al., content analysis method.

RESULTS

The findings showed that new tools had been developed in 38% of the studies and other studies had revised or translated existing questionnaires. Moreover, 62% of the tools were used to measure patient motivation in mental disorders. Most of the studies did not clearly define the concept of patient motivation in the clinical environment. The findings of content analysis outlined the 3 categories of motivation determinant factors, decisions, and behaviors that determine overall levels of motivations and its consequences.

CONCLUSIONS

Motivation is a dynamic concept and is a result of internal and external motives that lead to decisions and behaviors. There are limited tools for measuring motivation in clinical settings. This addresses the need to design specific tools in various diseases, especially chronic diseases. By the concept defined in this study, it is possible to design a short tool with general application that can be used in all diseases.

Distinguishing TBI Malingering and Fatigue Using Event-Related Potentials

Abstract. Poorer-than-expected performance on cognitive-behavioral tasks may indicate malingering, or it could be an outcome of fatigue, resulting in false positives when suboptimal task performance is used to flag individuals feigning or exaggerating symptoms of traumatic brain injury (TBI). The primary goal of this study was to examine the P3 event-related potentials (ERP) and behavioral outcomes associated with TBI malingering and fatigue, in order to distinguish between them. A secondary goal was to determine if history of TBI (hTBI) is associated with differences in fatigue, ERPs, or performance on a short-term memory task. Participants completed the Mental Fatigue and Related Symptoms (SR-MF) questionnaire and were interviewed to assess TBI history, then they completed a computerized “old/new” (match-mismatch) task while ERPs were recorded, under three conditions: Normal, Malinger, and Fatigue. Participants reported mild fatigue at the end of study, with no difference between individuals reporting a history of TBI ( n = 32) and healthy controls ( n = 47). Fatigue was associated with prolonged P3 latency but was otherwise indistinguishable from Normal. In contrast, Malinger was clearly distinguished from Normal by significantly lower accuracy, longer reaction times, reduced P3 amplitude on Match trials, and a smaller old/new ERP effect. Individuals with a history of TBI reported clinical levels of fatigue at baseline but did not differ significantly from healthy controls on any behavioral or ERP measure. The results support the use of behavioral and ERP measures to identify malingering, without concern over confounding effects of mild subjective fatigue, including mild fatigue induced by testing.

Mood, Activity Participation, and Leisure Engagement Satisfaction (MAPLES): a randomised controlled pilot feasibility trial for low mood in acquired brain injury

Background

Acquired brain injury (ABI) affects approximately 79.3 million individuals annually and is linked with elevated rates of depression and low mood. Existing methods for treating depression in ABI have shown mixed efficacy. Behavioural activation (BA) is a potentially promising intervention. Its premise is that individuals with low mood avoid planning and engaging in activities due to low expectations of a positive outcome. Consequently, their exposure to positive reinforcement is reduced, exacerbating low mood. BA aims to break this cycle by encouraging activity planning and engagement. It is unknown whether cognitive demands of traditional BA may undermine efficacy in ABI. Here, we assess the feasibility and acceptability of two groups designed to increase activity engagement. In the activity planning group (traditional BA), the importance of meaningful and positive activity will be discussed and participants encouraged to plan/engage in activities in everyday life. The activity engagement group (experiential BA) instead focuses on engagement in positive experiences (crafts, games, discussion) within the group. The primary aims are to evaluate the feasibility and acceptability of the two groups in ABI. A secondary aim is to explore relative efficacy of the groups compared to an equivalent period of waitlist controls.

Method

This study outlines a parallel-arm pilot feasibility trial for individuals with low mood and ABI that compares a traditional vs experiential BA group vs waitlist controls. Adults (≥ 18 years) will be recruited from local ABI services and randomised to condition. Feasibility and acceptability will be assessed via recruitment, retention, attendance and participant feedback. Groups will be compared (pre- and post-intervention and 1 month follow-up) by assessing self-reported activity engagement. Secondary outcomes include self-report measures of depression, anxiety, post-traumatic distress related to the ABI, motivation, participation and sense of control over one’s life.

Ethics and dissemination

The trial has been approved by the Health Research Authority of the NHS in the UK (East of England—Cambridge Central, REF 18/EE/0305). Results will inform future research on interventions for mood in ABI and be disseminated broadly via peer-reviewed journals, conference presentations and social media.

Trial registration

ClinicalTrials.gov, NCT03874650 pre-results. Protocol version 2.1, March 5, 2019

The Impact of Socio-environmental Barriers on the Process of Engagement in Cardiac Rehabilitation Programs

Cardiac rehabilitation (CR) is a multi-disciplinary intervention designed to stabilise, slow, or reverse CVD, restore health following a cardiac event and facilitate the prevention of further events. The Model of Therapeutic Engagement (MTE) is a comprehensive conceptual model for explaining the process of engagement in rehabilitation. Of concern is that the role of socio-environmental factors is absent from explaining individual engagement in the MTE. There is also a lack of prospective studies investigating the impact of socio-environmental barriers on engagement in CR programs over time. This study aimed to expand the MTE, by illuminating the role of socio-environmental barriers in a three-stage process of engagement in CR programs. A prospective study was conducted, with 217 individuals recruited from the Cardiology Ward in the Gold Coast University Hospital (GCUH) and the Robina Cardiac Rehabilitation Centre. The collected data were examined using a structural equation model that added socio-environmental factors into the MTE, using multi-group analyses. In this study, we found that socio-environmental factors were not associated with intention to engage in the CR program, but were related to actual attendance and maintenance of participation in CR programs. Knowing how these socio-environmental barriers affect the process of engagement at different stages may help to tailor more accessible CR programs for the population.

Factors affecting adherence to rehabilitation in Iranian stroke patients: A qualitative study

Adherence to rehabilitation has significant effects on patient outcomes. This study aimed to explore factors affecting adherence to rehabilitation in Iranian stroke patients. This is a descriptive, qualitative study. This study was conducted in 2018. Participants were stroke patients, family members, and rehabilitation team members-20 in total. They were purposively recruited from Rofaideh inpatient rehabilitation center in Tehran, and the outpatient physiotherapy center of Poursina hospital in Rasht. Data collection was performed through semistructured interviews and was continued up to data saturation. Data were analyzed by content analysis technique. Factors affecting adherence to rehabilitation in stroke patients were categorized into four main categories, namely patients-related, rehabilitation team, rehabilitation systems, and insurance and social support systems factors. Health care providers can promote patients' adherence to rehabilitation, involvement in the process of treatment, and their quality of life through broadening patients' knowledge about rehabilitation effectiveness, strengthening communication with health care providers, and adequate insurance and social support.

The Process of Patient Engagement in Outpatient Cardiac Rehabilitation Programs

The primary aim of this study was to test the causal structure of the model of therapeutic engagement (MTE) for the first time, to examine whether the model assists in understanding the process of patient engagement in cardiac rehabilitation (CR) programs. This study used a prospective design, following up patients from the Gold Coast University Hospital Cardiology ward who attended Robina Cardiac Rehabilitation Clinic. A structural equation model of the interactions among the proposed variables within the three stages of the MTE (intention to engage in CR programs, CR initiation, and sustained engagement) revealed significant relationships among these variables in a dataset of 101 patients who attended a CR program. However, no relationship was discerned between outcome expectancies and patient intention to engage in CR. Patients’ willingness to consider the treatment also mediated the relationship between perceived self-efficacy and patient intention to engage in CR. These findings help clarify the process proposed by Lequerica and Kortte (2010) in the context of patient engagement in CR programs. The findings also reveal information on how patients engage in CR programs. Importantly, this provides new information for healthcare providers, enabling them to more effectively engage patients according to their stage of engagement.

Assessing Patient Motivation for Treatment: A Systematic Review of Available Tools, Their Measurement Properties, and Conceptual Definition

BACKGROUND AND PURPOSE

Motivation is often reported by clinicians and researchers as a key factor related to treatment and health outcomes. This systematic review aims to (a) Identify and critically appraise tools that measure patient motivation for treatment and (b) determine how these tools define and evaluate motivation.

METHODS

Library databases and the search engine Google Scholar were examined. Identified tools measuring patient motivation for treatment and reported measurement properties were selected.

RESULTS

14 peer-reviewed articles covering 12 different tools made the final selection. Quality was assessed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) and a new measure checklist. Reliability evidence was predominantly estimated using internal consistency; validity evidence was limited, and responsiveness was seldom examined. Overall, quality ratings were poor or inadequately reported and serious methodological limitations were identified. A lack of conceptual foundation quality ratings as tools did not apply a theory related to motivation or have a clear definition of the construct of patient motivation.

CONCLUSIONS

A significant gap exists of available tools with adequate measurement properties that use relevant theoretical frameworks.

Feasibility of Aerobic Exercise in the Subacute Phase of Recovery From Traumatic Brain Injury: A Case Series

BACKGROUND AND PURPOSE

Aerobic exercise is as important for individuals with traumatic brain injury (TBI) as for the general population; however, the approach to aerobic training may require some adaptation. The objective of the trial program was to examine the feasibility of introducing aerobic physical exercise programs into the subacute phase of multidisciplinary rehabilitation from moderate to severe TBI, which includes computerized cognitive training.

CASE DESCRIPTION

Five individuals undergoing inpatient rehabilitation with moderate or severe TBIs who also have concomitant physical injuries. All of these individuals were in the subacute phase of recovery from TBIs.

INTERVENTION

An 8-week progressive aerobic physical exercise program. Participants were monitored to ensure that they could both adhere to and tolerate the exercise program. In addition to the physical exercise, individuals were undergoing their standard rehabilitation procedures that included cognitive training. Neuropsychological testing was performed to gain an understanding of each individual's cognitive function.

OUTCOMES

Participants adhered to both aerobic exercise and cognitive training. Poor correlations were noted between heart rate reserve and ratings of perceived effort. Two minor adverse events were reported.

DISCUSSION

Despite concomitant physical injuries and cognitive impairments, progressive aerobic exercise programs seem feasible and well tolerated in subacute rehabilitation from moderate to severe TBI. Findings highlight the difficulty in measuring exercise intensity in this population.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A235).

Motivation in rehabilitation and acquired brain injury: can theory help us understand it?

Background: In acquired brain injury (ABI) populations, low motivation to engage in rehabilitation is associated with poor rehabilitation outcomes. Motivation in ABI is thought to be influenced by internal and external factors. This is consistent with Self-determination Theory, which posits that motivation is intrinsic and extrinsic. This paper discusses the benefit of using Self-determination Theory to guide measurement of motivation in ABI. Methods: Using a narrative review of the Self-determination Theory literature and clinical rehabilitation research, this paper discusses the unique role intrinsic and extrinsic motivation has in healthcare settings and the importance of understanding both when providing rehabilitation in ABI. Results: Based on the extant literature, it is possible that two independently developed measures of motivation for ABI populations, the Brain Injury Rehabilitation Trust Motivation Questionnaire-Self and the Motivation for Traumatic Brain Injury Rehabilitation Questionnaire, may assess intrinsic and extrinsic motivation, respectively. Conclusion: Intrinsic and extrinsic motivation in ABI may be two equally important but independent factors that could provide a comprehensive understanding of motivation in individuals with ABI. This increased understanding could help facilitate behavioural approaches in rehabilitation. Implications for Rehabilitation Conceptualization of motivation in ABI would benefit from drawing upon Self-determination Theory. External factors of motivation such as the therapeutic environment or social support should be carefully considered in rehabilitation in order to increase engagement. Assessing motivation as a dual rather than a global construct may provide more precise information about the extent to which a patient is motivated.

Fitness training for cardiorespiratory conditioning after traumatic brain injury

BACKGROUND

Reduced cardiorespiratory fitness (cardiorespiratory deconditioning) is a common consequence of traumatic brain injury (TBI). Fitness training may be implemented to address this impairment.

OBJECTIVES

The primary objective of this updated review was to evaluate whether fitness training improves cardiorespiratory fitness in people who have sustained a TBI. The secondary objectives were to evaluate whether fitness training improves body function and structure (physical and cognitive impairments, psychological responses resulting from the injury), activity limitations and participation restrictions in people who have sustained a TBI as well as to evaluate its safety, acceptance, feasibility and suitability.

SEARCH METHODS

We searched 10 electronic databases (the Cochrane Injuries Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Embase; PubMed (MEDLINE); CINAHL; AMED; SPORTDiscus; PsycINFO; PEDro and PsycBITE) and the International Clinical Trials Registry Platform for relevant trials. In addition we screened reference lists from systematic reviews related to the topic that we identified from our search, and from the included studies, and contacted trialists to identify further studies. The search was run in August 2017.

SELECTION CRITERIA

Randomised controlled studies with TBI participants were eligible if they compared an exercise programme incorporating cardiorespiratory fitness training to usual care, a non-exercise intervention, or no intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently screened the search results, extracted data and assessed bias. We contacted all trialists for additional information. We calculated mean difference (MD) or standardised mean difference (SMD) and 95% confidence intervals (CI) for continuous data, and odds ratio with 95% CI for dichotomous data. We pooled data when there were sufficient studies with homogeneity.

MAIN RESULTS

Two new studies incorporating 96 participants were identified in this update and were added to the six previously included studies. A total of eight studies incorporating 399 participants are included in the updated review. The participants were primarily men aged in their mid-thirties who had sustained a severe TBI. No studies included children. The studies were clinically diverse with regard to the interventions, time postinjury and the outcome measures used. At the end of intervention, the mean difference in peak power output was 35.47 watts (W) in favour of fitness training (MD 35.47 W, 95% CI 2.53 to 68.41 W; 3 studies, 67 participants; low-quality evidence). The CIs include both a possible clinically important effect and a possible negligible effect, and there was moderate heterogeneity among the studies.Five of the secondary outcomes had sufficient data at the end of intervention to enable meta-analysis: body composition (SMD 0.29 standard deviations (favouring control), 95% CI -0.22 to 0.79; 2 studies, 61 participants; low-quality evidence), strength (SMD -0.02 (favouring control), 95% CI -0.86 to 0.83; 2 studies, 23 participants; very low-quality evidence), fatigue (SMD -0.32 (favouring fitness training), 95% CI -0.90 to 0.26; 3 studies, 130 participants; very low-quality evidence), depression (SMD -0.43 (favouring fitness training), 95% CI -0.92 to 0.06; 4 studies, 220 participants; very low-quality evidence), and neuromotor function (MD 0.01 m (favouring fitness training), 95% CI -0.25 to 0.27; 2 studies, 109 participants; moderate-quality evidence). It was uncertain whether fitness training was more or less effective at improving these secondary outcomes compared to the control interventions. Quality of life was assessed in three trials, but we did not pool the data because of substantial heterogeneity. Five of the eight included studies had no dropouts from their intervention group and no adverse events were reported in any study.

AUTHORS' CONCLUSIONS

There is low-quality evidence that fitness training is effective at improving cardiorespiratory deconditioning after TBI; there is insufficient evidence to draw any definitive conclusions about the other outcomes. Whilst the intervention appears to be accepted by people with TBI, and there is no evidence of harm, more adequately powered and well-designed studies are required to determine a more precise estimate of the effect on cardiorespiratory fitness, as well as the effects across a range of important outcome measures and in people with different characteristics (e.g. children). In the absence of high quality evidence, clinicians may be guided by pre-exercise screening checklists to ensure the person with traumatic brain injury is safe to exercise, and set training parameters using guidelines established by the American College of Sports Medicine for people who have suffered a brain injury.

Outcome Measures for Persons With Moderate to Severe Traumatic Brain Injury: Recommendations From the American Physical Therapy Association Academy of Neurologic Physical Therapy TBI EDGE Task Force

BACKGROUND AND PURPOSE

The use of standardized outcome measures (OMs) is essential in assessing the effectiveness of physical therapy (PT) interventions. The purposes of this article are (1) to describe the process used by the TBI EDGE task force to assess the psychometrics and clinical utility of OMs used with individuals with moderate to severe traumatic brain injury (TBI); (2) to describe the consensus recommendations for OM use in clinical practice, research, and professional (entry-level) PT education; and (3) to make recommendations for future work.

METHODS

An 8-member task force used a modified Delphi process to develop recommendations on the selection of OMs for individuals with TBI. A 4-point rating scale was used to make recommendations based on practice setting and level of ambulation. Recommendations for appropriateness for research use and inclusion in entry-level education were also provided.

RESULTS

The TBI EDGE task force reviewed 88 OMs across the International Classification of Functioning, Disability, and Health (ICF) domains: 15 measured body functions/structure only, 21 measured activity only, 23 measured participation only, and 29 OMs covered more than 1 ICF domain.

DISCUSSION AND CONCLUSIONS

Recommendations made by the TBI EDGE task force provide clinicians, researchers, and educators with guidance for the selection of OMs. The use of these recommendations may facilitate identification of appropriate OMs in the population with moderate to severe TBI. TBI EDGE task force recommendations can be used by clinicians, researchers, and educators when selecting OMs for their respective needs. Future efforts to update the recommendations are warranted in order to ensure that recommendations remain current and applicable.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A140).

Investigating the relationship between reduced self-awareness of falls risk, rehabilitation engagement and falls in older adults

The present study aimed to investigate whether self-awareness of falls risk is associated with rehabilitation engagement, motivation for rehabilitation, and number of falls after hospital discharge. The sample comprised 91 older adults (M_age=77.97, SD=8.04) undergoing inpatient rehabilitation. The Self-Awareness of Falls Risk Measure (SAFRM) was used to measure different aspects of self-awareness. The treating physiotherapist and occupational therapist rated the patient's engagement in rehabilitation and the patient reported his/her motivation for treatment. Falls information was collected from the patient and significant other once a month for three months following hospital discharge. Significant correlations were found between physiotherapist-rated engagement and intellectual (r_s=-0.22, p<0.05) and anticipatory awareness (r_s=-0.24, p<0.05). Occupational therapist-rated engagement and patient-reported motivation for rehabilitation was correlated with emergent awareness (r_s=-0.38 and -0.31, p<0.05, respectively) and overall self-awareness (r_s=-0.31 and -0.26, p<0.05, respectively). Regression analyses indicated that overall self-awareness provided a unique contribution to occupational therapist-rated engagement when controlling for age, gender, cognition and functional ability. Falls were reported by 29.9% of participants, however, self-awareness did not differ significantly between fallers and non-fallers. The findings suggest that self-awareness of falls risk is associated with rehabilitation engagement and motivation. Therefore, improving patient self-awareness of falls risk may increase engagement in therapy leading to better patient outcomes.

MMPI-2 Predictors of Academic Performance

This report describes relationships between MMPI-2 validity and clinical scale scores and four different measures of academic performance (high school GPA, cumulative college GPA, classroom attendance, standardized course grade). A total of 435 MMPI-2 profiles were provided by college students enrolled in various undergraduate psychology courses. Elevations on the F, Pd, Sc, Ma, and Si scales were associated with academic performance difficulties. The number of elevated MMPI-2 scales was found to be significantly related to high school and college GPA. The profile mean elevation was also correlated significantly with high school and college GPA. Efforts were also made to quantify the severity of risk posed to academic performance by particular MMPI-2 attributes. Only about 7.5% of participants reported a cumulative college GPA that was less than or equal to 2.5, but this risk was tripled (22.6%) among participants with F scale elevations (T> 59). About 15.4% of the total sample attended class less than 60% of the time, while only about half (7.4%) of those generating low Pd scores showed equal levels of absenteeism. Simple MMPI-2 interpretive guidelines are provided for the identification of students at elevated risk for academic difficulty. The practical and theoretical implications of these results were discussed within the context of a broader literature involving the use of psychological inventories to identify cognitive and academic functioning deficits.

Cognitive and psychological flexibility after a traumatic brain injury and the implications for treatment in acceptance-based therapies: A conceptual review

This paper provides a selective review of cognitive and psychological flexibility in the context of treatment for psychological distress after traumatic brain injury, with a focus on acceptance-based therapies. Cognitive flexibility is a component of executive function that is referred to mostly in the context of neuropsychological research and practice. Psychological flexibility, from a clinical psychology perspective, is linked to health and well-being and is an identified treatment outcome for therapies such as acceptance and commitment therapy (ACT). There are a number of overlaps between the constructs. They both manifest in the ability to change behaviour (either a thought or an action) in response to environmental change, with similarities in neural substrate and mental processes. Impairments in both show a strong association with psychopathology. People with a traumatic brain injury (TBI) often suffer impairments in their cognitive flexibility as a result of damage to areas controlling executive processes but have a positive response to therapies that promote psychological flexibility. Overall, psychological flexibility appears a more overarching construct and cognitive flexibility may be a subcomponent of it but not necessarily a pre-requisite. Further research into therapies which claim to improve psychological flexibility, such as ACT, needs to be undertaken in TBI populations in order to clarify its utility in this group.

Further validation of the Motivation for Traumatic Brain Injury Rehabilitation Questionnaire (MOT-Q) in patients with acquired brain injury

The Motivation for Traumatic Brain Injury Rehabilitation Questionnaire (MOT-Q) evaluates motivation for rehabilitation in four subscales: Interest in rehabilitation, Lack of anger, Lack of denial, and Reliance on professional help. The objective of this study was to further validate the MOT-Q in 122 inpatients and 92 outpatients with acquired brain injury (ABI). The main measures were motivation for rehabilitation (MOT-Q), self-awareness (Patient Competency Rating Scale), and treatment motivation (Visual Analogue Scale). The MOT-Q showed adequate feasibility in terms of few items with missing responses and few undecided responses. We found no floor or ceiling effects, and significant item-total MOT-Q correlations for 29 of 31 items. Internal consistency was good for the MOT-Q total and acceptable to good for the subscales. The MOT-Q scores were significantly intercorrelated except for the subscales Lack of denial and Reliance on professional help in the inpatient group. The MOT-Q total and subscales were significantly associated with treatment motivation. The Lack of denial subscale showed no significant association with treatment motivation and no to moderate significant associations with self-awareness. In conclusion, the overall MOT-Q is a valid instrument to assess motivation for rehabilitation in patients with ABI. Further research is needed to examine the validity of the subscales.

Traumatic brain injury, boredom and depression

Traumatic brain injury (TBI) often presents with co-morbid depression and elevated levels of boredom. We explored the relationship between boredom and depression in a group of mild (n = 38), moderate-to-severe TBI patients (n = 14) and healthy controls (n = 88), who completed the Beck Depression Inventory and Boredom Proneness Scales as part of a larger study. Results showed that the relationship between boredom and depression was strongest in moderate-to-severe TBI patients. We explored two boredom proneness factors that index an individual's need for external or internal stimulation. Results indicated that the need for external stimulation was the critical driver in the relation between boredom and depression. Once again, this relationship was strongest in the moderate-to-severe TBI group. These results suggest that one common factor underlying boredom and depression is the need for stimulation from the external environment and, presumably, a failure to satisfy that need-a disconnection felt most strongly in moderate-to-severe TBI.

Psychometric properties and feasibility of instruments used to assess awareness of deficits after acquired brain injury: a systematic review

BACKGROUND

Unawareness of deficits after acquired brain injury (ABI) is often reported in the clinic. Several methods have been developed to measure a patient's awareness of deficits after ABI; however, no criterion standard currently exists to measure this phenomenon.

OBJECTIVE

To review all instruments for measuring awareness of deficits and evaluate their psychometric and conceptual properties as well as their feasibility.

METHODS

Systematic literature search for available awareness measurement instruments used in experimental ABI studies. Instruments were divided into the following 4 assessment methods: clinician ratings, structured interviews, performance-based discrepancy, and self-other rating discrepancy methods. The quality of the instruments was evaluated.

RESULTS

The literature search identified 39 instruments and 8 of these were selected. The following 3 instruments stood out in terms of quality: Self-Awareness of Deficits Interview, Patient Competency Rating Scale, and Awareness Questionnaire.

CONCLUSION

Although these quantitative instruments are useful tools in research, they have limited utility in the clinic because they only measure intellectual awareness. Therefore, in addition to these instruments, qualitative tools should also be used to gain a complete view of a patient's awareness problem.

Acceptance and Commitment Therapy (ACT) for Psychological Adjustment after Traumatic Brain Injury: Reporting the Protocol for a Randomised Controlled Trial

Following a severe traumatic brain injury (TBI) there is a complex presentation of psychological symptoms which may impact on recovery. Validated treatments addressing these symptoms for this group of people are limited. This article reports on the protocol for a single-centre, two-armed, Phase II Randomised Control Trial (RCT) to address the adjustment process following a severe TBI. Participants will be recruited from Liverpool Brain Injury Rehabilitation Unit and randomly allocated to one of two groups, Acceptance and Commitment Therapy (ACT) or an active control (Befriending). The active treatment group utilises the six core processes of ACT with the intention of increasing participation and psychological flexibility and reducing psychological distress. A number of primary and secondary outcome measures, administered at assessment, post-treatment and 1-month follow-up, will be used to assess clinical outcomes. The publication of the protocol before the trial results are available addresses fidelity criterion (intervention design) for RCTs. This ensures transparency in the RCT and that it meets the guidelines according to the CONSORT statement. The protocol has also been registered on the Australian New Zealand Clinical Trials Registry ACTRN12610000851066.

Circuit class therapy can provide a fitness training stimulus for adults with severe traumatic brain injury: a randomised trial within an observational study

QUESTIONS

Can circuit class therapy provide sufficient exercise dosage (at least 20 minutes at ≥ 50% heart rate reserve or total caloric expenditure ≥ 300 kilocalories) to induce a cardiorespiratory fitness effect in adults with traumatic brain injury? Can feedback from heart rate monitors influence exercise intensity?

DESIGN

Randomised controlled trial within an observational study.

PARTICIPANTS

Fifty-three people with severe traumatic brain injury, of whom 40 progressed into the trial.

INTERVENTION

All participants undertook circuit class therapy. Participants allocated to the experimental group received exercise intensity feedback from a heart rate monitor and the control group received no feedback.

OUTCOME MEASURES

Proportion of participants exercising at ≥ 50% heart rate reserve for at least 20 minutes or expending ≥ 300 kilocalories during circuit class therapy. The primary outcome measure for the trial was the time spent in the heart rate training zone (ie, at ≥ 50% heart rate reserve) during the intervention and re-assessment periods.

RESULTS

Circuit class therapy provided sufficient cardiorespiratory exercise dosage for 28% (95% CI 18 to 42) of the cohort according to the heart rate reserve criteria and 62% (95% CI 49 to 74) according to the caloric criteria. Feedback did not increase the time in the training zone during the intervention (mean difference 4.8 minutes, 95% CI -1.4 to 10.9) or re-assessment (1.9 minutes, -4.4 to 8.3) periods.

CONCLUSION

The low intensity, long duration structure of circuit class therapy can provide sufficient exercise dosage for a fitness training effect for 62% of people with traumatic brain injury. Feedback from heart rate monitors does not necessarily influence exercise intensity.

TRIAL REGISTRATION

ACTRN12607000522415.

Prospective memory rehabilitation based on visual imagery techniques

Despite the frequency of prospective memory (PM) problems in the traumatic brain injury (TBI) population, there are only a few rehabilitation programmes that have been specifically designed to address this issue, other than those using external compensatory strategies. In the present study, a PM rehabilitation programme based on visual imagery techniques expected to strengthen the cue-action association was developed. Ten moderate to severe chronic TBI patients learned to create a mental image representing the association between a prospective cue and an intended action within progressively more complex and naturalistic PM tasks. We hypothesised that compared to TBI patients (n = 20) who received a short session of education (control condition), TBI patients in the rehabilitation group would exhibit a greater improvement on the event-based than on the time-based condition of a PM ecological task. Results revealed however that this programme was similarly beneficial for both conditions. TBI patients in the rehabilitation group and their relatives also reported less everyday PM failures following the programme, which suggests generalisation. The PM improvement appears to be specific since results on cognitive control tasks remained similar. Therefore, visual imagery techniques appear to improve PM functioning by strengthening the memory trace of the intentions and inducing an automatic recall of the intentions.

Influence of history of brain disease or brain trauma on psychopathological abnormality in young male in Korea : analysis of multiphasic personal inventory test

OBJECTIVE

The purpose of this study is to confirm whether brain disease or brain trauma actually affect psychopathology in young male group in Korea.

METHODS

The authors manually reviewed the result of Korean military multiphasic personal inventory (KMPI) in the examination of conscription in Korea from January 2008 to May 2010. There were total 237 young males in this review. Normal volunteers group (n=150) was composed of those who do not have history of brain disease or brain trauma. Brain disease group (n=33) was consisted of those with history of brain disease. Brain trauma group (n=54) was consisted of those with history of brain trauma. The results of KMPI in each group were compared.

RESULTS

Abnormal results of KMPI were found in both brain disease and trauma groups. In the brain disease group, higher tendencies of faking bad response, anxiety, depression, somatization, personality disorder, schizophrenic and paranoid psychopathy was observed and compared to the normal volunteers group. In the brain trauma group, higher tendencies of faking-good, depression, somatization and personality disorder was observed and compared to the normal volunteers group.

CONCLUSION

Young male with history of brain disease or brain trauma may have higher tendencies to have abnormal results of multiphasic personal inventory test compared to young male without history of brain disease or brain trauma, suggesting that damaged brain may cause psychopathology in young male group in Korea.

Indicators of complicated mild TBI predict MMPI-2 scores after 23 years

PRIMARY OBJECTIVE

Research suggests that post-concussive syndrome may become persistent after mild traumatic brain injury (mTBI). The aim of this study was to investigate determinants of subjective complaints, characteristic for post-concussive syndrome, 23 years after mTBI.

RESEARCH DESIGN

The study was a follow-up after a prospective head injury study at a general hospital in Norway.

METHODS AND PROCEDURES

Ninety-seven patients were assessed with the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) 23 years after sustaining primarily mTBI.

MAIN OUTCOMES AND RESULTS

A good overall outcome was found with scores close to the normative mean, average length of education and normal employment rate. However, the patients that sustained complicated mTBI showed somewhat more pathological scores, well-matched with mild post-concussive syndrome. The most important predictors of poor outcome were a combination of post-traumatic amnesia >30 minutes and EEG pathology within 24 hours after TBI. No influence of pre- and post-injury risk factors on current MMPI-2 profiles was found.

CONCLUSIONS

The results are in line with previous research findings and support the notion of potentially differential impact of uncomplicated vs. complicated mTBI. The findings suggest that complicated mTBI may cause subtle chronic symptoms typical of post-concussive syndrome.

MMPI-2 profiles 23 years after paediatric mild traumatic brain injury

PRIMARY OBJECTIVE

Research suggest that post-concussive syndrome after mild traumatic brain injury (mTBI) is more common than chronic cognitive impairment. The aim of this study was to investigate very long-term outcome of subjective complaints after paediatric mTBI.

RESEARCH DESIGN

The study was a follow-up 23 years after a prospective head injury study at a general hospital in Norway.

METHODS AND PROCEDURES

Forty-one patients were assessed with the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) 23 years after sustaining mTBI as children.

MAIN OUTCOMES AND RESULTS

A good overall outcome was found with scores close to the normative mean, average length of education and normal employment rate. However, the children that sustained complicated mTBI showed slightly more pathological scores, typical for mild post-concussive syndrome. The most important predictors of poor outcome were skull fracture and a combination of post-traumatic amnesia > 30 minutes and EEG pathology within 24 hours after TBI. No influence of pre- and post-injury risk factors on current MMPI-2 profiles was evident.

CONCLUSIONS

The results give support for the notion of potentially differential impact of uncomplicated vs complicated mTBI. The findings suggest that children and adolescents sustaining complicated mTBI may be at risk of developing subtle chronic symptoms typical of post-concussive syndrome.

Fitness training for cardiorespiratory conditioning after traumatic brain injury

BACKGROUND

Cardiorespiratory deconditioning is a common sequelae after traumatic brain injury (TBI). Clinically, fitness training is implemented to address this impairment, however this intervention has not been subject to rigorous review.

OBJECTIVES

The primary objective was to evaluate whether fitness training improves cardiorespiratory fitness in people who have sustained a TBI.

SEARCH STRATEGY

We searched ten electronic databases (Cochrane Injuries Group Trials Register; Cochrane Central Register of Controlled Trials (CENTRAL); EMBASE; PubMed (MEDLINE); CINAHL; AMED; SPORTDiscus; PsycINFO; PEDro and PsycBITE) and two clinical trials registers (TrialsCentral and Current Controlled Trials). The last search was August 2007. In addition we screened reference lists from included studies and contacted trialists to identify further studies.

SELECTION CRITERIA

Randomised controlled studies with TBI participants were eligible if they compared an exercise programme incorporating cardiorespiratory fitness training to usual care, a non-exercise intervention or no intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently screened the search output, extracted data and assessed quality. All trialists were contacted for additional information. Mean difference and 95% confidence intervals (CI) were calculated for continuous data and risk difference or odds ratio and 95% CI were calculated for dichotomous data. Data were pooled when there were sufficient studies with clinical and statistical homogeneity.

MAIN RESULTS

Six studies, incorporating 303 participants, were included. The participants were primarily males, in their mid thirties who had sustained a severe TBI. The studies were clinically diverse with regard to the interventions, time post-injury and the outcome measures used; therefore, the primary outcome could not be pooled. Three of the six studies indirectly assessed change in cardiorespiratory fitness after fitness training using the peak power output obtained during cycle ergometry (either at volitional fatigue or at a predetermined endpoint, that is, a percentage of predicted heart rate maximum). Cardiorespiratory fitness was improved after fitness training in one study (mean difference 59 watts, 95% CI 24 to 94), whilst there was no significant improvement in the other two studies. Four of the six studies had no drop-outs from their intervention group and no adverse events were reported in any study.

AUTHORS' CONCLUSIONS

There is insufficient evidence to draw any definitive conclusions about the effects of fitness training on cardiorespiratory fitness. Whilst it appears to be a safe and accepted intervention for people with TBI, more adequately powered and well-designed studies are required to determine the effects across a range of outcome measures.

An exploratory study of mental representations for rehabilitation based upon the Theory of Planned Behaviour

This study explores whether mental representations based upon the Theory of Planned Behaviour (TPB) can predict engagement in rehabilitation after acquired brain injury (ABI). A scale was developed to measure: treatment outcome beliefs, perceived barriers, subjective norm, and control cognitions. Other adjustment factors that are often seen as important in predicting engagement, e.g., denial and anger, were also measured using the Motivation for Traumatic Brain Injury Questionnaire (MOT-Q). Clinicians also provided ratings of patient's engagement in rehabilitation which was used as the measure of actual behaviour. The scales were administered to 40 participants with ABI who were a mean of 14 months post-injury. The new scale showed good internal reliability, and regression analyses demonstrated that "treatment outcome beliefs" were the main aspects of TPB that predicted engagement. Control beliefs and adjustment factors added very little to the variance in engagement that was already explained by TPB. However, the amount of variance that was explained by TPB was small and it is suggested that other volitional factors need to be considered in order to predict engagement more accurately. This study thus constitutes a first exploration of mental representations about rehabilitation after ABI using TPB. It suggests a theoretical model that may help clinicians to formulate lack of engagement. It also suggests that addressing patients' beliefs about the benefits of undertaking rehabilitation may prove fruitful in increasing engagement.

The influence of cultural background on motivation for and participation in rehabilitation and outcome following traumatic brain injury

AIMS

To compare motivation for and participation in rehabilitation, outcome, and distress over role changes in persons with traumatic brain injury (TBI) from the dominant English-speaking culture in Australia versus those from minority culturally and linguistically diverse (CALD) backgrounds.

MAIN MEASURES

Motivation for Traumatic Brain Injury Rehabilitation Questionnaire; Craig Handicap Assessment Reporting Technique.

PARTICIPANTS

Two groups of persons with TBI, 38 of English-speaking backgrounds and 32 of CALD backgrounds.

RESULTS

Groups had similar education and preinjury employment status, both showed positive attitudes toward rehabilitation and participated equally in rehabilitation. However, CALD participants showed poorer outcomes in several domains, including postinjury employment status, cognitive independence, mobility and social integration, and showed greater distress about changes in ability to perform certain life roles.

CONCLUSIONS

Differences in outcome and levels of distress over role changes may occur in those from CALD backgrounds following TBI, independent of socioeconomic background and access to rehabilitation. There is a need to further investigate possible reasons for this, including beliefs, coping style, and emotional response to injury.