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Carrier SL, Ponsford J, McKay A. Family experiences of supporting a relative with agitation during early recovery after traumatic brain injury. Neuropsychol Rehabil 2024; 34:510-534. [PMID: 37332244 DOI: 10.1080/09602011.2023.2219064] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 05/23/2023] [Indexed: 06/20/2023]
Abstract
During the early recovery period after traumatic brain injury (TBI), referred to as post-traumatic amnesia (PTA), approximately 44% of individuals may exhibit agitated behaviours. Agitation can impede recovery and poses a significant management challenge for healthcare services. As families provide significant support for their injured relatives during this time, this study aimed to explore the family's experience during PTA to better understand their role in agitation management. There were 20 qualitative semi-structured interviews conducted with 24 family members of patients exhibiting agitation during early TBI recovery (75% female, aged 30-71 years), predominantly parents (n = 12), spouses (n = 7) and children (n = 3). The interviews explored the family's experience of supporting their relative exhibiting agitation during PTA. The interviews were analyzed using reflexive thematic analysis, which revealed three key themes: family contributions to patient care, expectations of the health care service and supporting families to support patients. This study emphasized the significant role of families in managing agitation during early TBI recovery and highlighted that families who are well-informed and well-supported have the potential to minimize their relative's agitation during PTA, which may reduce the burden on healthcare staff and promote patient recovery.
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Affiliation(s)
- Sarah L Carrier
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia
| | - Jennie Ponsford
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia
- Rehabilitation and Mental Health Division, Epworth Healthcare, Melbourne, Australia
| | - Adam McKay
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia
- Rehabilitation and Mental Health Division, Epworth Healthcare, Melbourne, Australia
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Pauli E, Debecker I, Hund-Georgiadis M. Functional independence and agitation outcomes following inpatient rehabilitation after structural brain injury: A retrospective cohort study. Neuropsychol Rehabil 2024:1-18. [PMID: 38502714 DOI: 10.1080/09602011.2024.2328871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 02/23/2024] [Indexed: 03/21/2024]
Abstract
The study's purpose was to analyze outcomes of patients with severe behavioural disturbances after acquired brain injury (ABI) in order to identify predictors of discharge destination from a specialized unit (SU) of a Swiss neurorehabilitation facility. Retrospective analysis of 85 patients. Potential predictors of the main outcome discharge destination were assessed with a correlation analysis. The Agitation Behaviour Scale (ABS), Functional Independence Measure (FIM), length of stay (LOS) and pre-living situation were tested in a logistic regression analysis. Twenty-nine patients were institutionalized and 56 patients went home. Discharge destination was significantly correlated to ABS score at discharge from SU (rs = -.33, p = .002), total FIM score on admission to the SU (rs = .25, p = .022), total FIM score at discharge from the SU (rs = .37, p < .001), LOS at the SU (rs = -.36, p = .001), and LOS after discharge of the SU (rs = .36, p = .001). Multivariate analysis showed that FIM scores at discharge (OR = 1.03, p = .008), and LOS at SU (OR = 0.98, p = .017) predicted discharge destination significantly. FIM or LOS may be important predictors in planning discharge destination in patients with severe behavioural disturbances. Further prospective studies are critically needed to better understand the complexity of interactions amongst important predictive factors.
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Affiliation(s)
- Elena Pauli
- REHAB Basel, Clinic for Neurorehabilitation and Paraplegiology, Basel, Switzerland
| | - Isabelle Debecker
- REHAB Basel, Clinic for Neurorehabilitation and Paraplegiology, Basel, Switzerland
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Hocking J, Maeder A, Powers D, Perimal-Lewis L, Dodd B, Lange B. Mixed methods, single case design, feasibility trial of a motivational conversational agent for rehabilitation for adults with traumatic brain injury. Clin Rehabil 2024; 38:322-336. [PMID: 38058144 PMCID: PMC10829423 DOI: 10.1177/02692155231216615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 11/02/2023] [Indexed: 12/08/2023]
Abstract
OBJECTIVE Rehabilitation for adults with traumatic brain injury (TBI) incorporates client-centred goal-setting and motivational support to achieve goals. However, face-to-face rehabilitation is time-limited. New therapy approaches which leverage care are warranted. Conversational agents (CAs) offer a human-computer interface with which a person can converse. This study tested the feasibility, usability and acceptability of using a novel CA - RehabChat - alongside brain injury rehabilitation. DESIGN Mixed methods, single case design, feasibility pilot trial. SETTING Ambulatory and community brain injury rehabilitation. PARTICIPANTS Adults with TBI receiving brain injury rehabilitation and clinicians providing this care. INTERVENTION Following 1:1 training, client-clinician dyads used RehabChat for two weeks alongside usual care. MAIN MEASURES Pre-post clinical measures (Motivation for Traumatic Brain Injury Rehabilitation Questionnaire, Rehabilitation Therapy Engagement Scale, Brain Injury Rehabilitation Trust Motivation Questionnaire-Relative, Brain Injury Rehabilitation Trust Motivation Questionnaire-Self) repeated measures (Hospital Anxiety and Depression Scale, researcher-developed wellbeing screening questions); and post-intervention (System Usability Scale (SUS), semi-structured 1:1 interview). RESULTS Six participants (two clients and four clinicians) completed training. Two client-clinician dyads completed the intervention. Two other clinicians used RehabChat in a mock client-clinician session. SUS scores indicated good usability. Client well-being did not deteriorate. No adverse events were experienced. Interviews indicated RehabChat was feasible, acceptable and easy to use; and supported motivation, goal-setting and completing practice activities. CONCLUSIONS RehabChat was feasible and acceptable to use alongside usual ambulatory and community brain injury rehabilitation, had good usability and supported client needs. Further testing of RehabChat with a larger cohort for longer duration is warranted.
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Affiliation(s)
- Judith Hocking
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Anthony Maeder
- Flinders Digital Health Research Centre, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - David Powers
- College of Science and Engineering, Flinders University, Adelaide, South Australia, Australia
| | - Lua Perimal-Lewis
- College of Science and Engineering, Flinders University, Adelaide, South Australia, Australia
| | - Beverley Dodd
- South Australian Brain Injury Rehabilitation Services, Adelaide, South Australia, Australia
| | - Belinda Lange
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
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Block H, Bellon M, Hunter SC, George S. Barriers and enablers to managing challenging behaviours after traumatic brain injury in the acute hospital setting: a qualitative study. BMC Health Serv Res 2023; 23:1266. [PMID: 37974214 PMCID: PMC10655469 DOI: 10.1186/s12913-023-10279-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Challenging behaviours after traumatic brain injury (TBI) in the acute setting are associated with risk of harm to the patient and staff, delays in commencing rehabilitation and increased length of hospital stay. Few guidelines exist to inform practice in acute settings, and specialist services providing multi-disciplinary expertise for TBI behaviour management are predominantly based in subacute inpatient services. This study aims to investigate acute and subacute staff perspectives of barriers and enablers to effectively managing challenging behaviours after TBI in acute hospital settings. METHODS Qualitative focus groups were conducted with 28 staff (17 from acute setting, 11 from subacute setting) across two sites who had experience working with patients with TBI. Data were analysed using inductive-deductive reflexive thematic analysis. Data were applied to the constructs of the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to generate themes representing barriers and enablers to managing challenging behaviours after TBI in the acute hospital setting. RESULTS Four barriers and three enablers were identified. Barriers include (1) Difficulties with clinical decision making; (2) Concerns for risks to staff and patients; (3) Hospital environment; (4) Intensive resources are required. Enablers were (1) Experienced staff with practical skills; (2) Incorporating person-centred care; and (3) Supportive teams. CONCLUSION These findings can inform pre-implementation planning for future improvements to TBI behaviour management in acute hospital settings. Difficulties with clinical decision making, concerns for risks of injury, the hospital environment and lack of resources are major challenges. Implementation strategies developed to address barriers will need to be trialled, with multi-disciplinary team approaches, and tailored to the acute setting.
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Affiliation(s)
- Heather Block
- Caring Futures Institute, College of Nursing and Health Science, Flinders University, Adelaide, Australia.
- Division of Allied Health, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, Australia.
| | - Michelle Bellon
- Caring Futures Institute, College of Nursing and Health Science, Flinders University, Adelaide, Australia
| | - Sarah C Hunter
- Caring Futures Institute, College of Nursing and Health Science, Flinders University, Adelaide, Australia
| | - Stacey George
- Caring Futures Institute, College of Nursing and Health Science, Flinders University, Adelaide, Australia
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Block H, George S, Hunter SC, Bellon M. Family experiences of the management of challenging behaviours after traumatic brain injury in the acute hospital setting. Disabil Rehabil 2023:1-10. [PMID: 37970816 DOI: 10.1080/09638288.2023.2280081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE This study explored experiences of the management of challenging behaviours after traumatic brain injury (TBI) in the acute hospital setting from the perspectives of family members. MATERIALS AND METHODS A qualitative, interpretive phenomenological approach was adopted involving semi-structured interviews with 10 family members. Interviews were transcribed and analysed using thematic analysis, with Ecological Systems Theory applied as a guiding framework to discuss findings and implications for practice. RESULTS Four primary themes were identified: 1) The hospital environment; 2) Hospital staffing; 3) Identifying and preventing triggers, and 4) Family support and information. CONCLUSIONS This qualitative study highlights the need for further information, education, and support to families of patients with TBI in the acute setting. Further research investigating the implementation of best practice approaches for managing challenging behaviours practice in acute settings is needed to overcome the barriers of the hospital environment, inexperienced and inconsistent staffing, and difficulties identifying triggers within the acute hospital setting, experienced by families. Approaches for family involvement in behaviour management strategies, and facilitation of communication for people with TBI in the acute setting requires exploration.
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Affiliation(s)
- Heather Block
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
- Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Stacey George
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Sarah C Hunter
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Michelle Bellon
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
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Carrier SL, Ponsford J, McKay A. Managing agitation during early recovery following traumatic brain injury: qualitative interviews with clinicians. Disabil Rehabil 2023; 45:3686-3695. [PMID: 36282105 DOI: 10.1080/09638288.2022.2135771] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 10/02/2022] [Accepted: 10/09/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Agitated behaviours pose a significant challenge during early recovery following traumatic brain injury (TBI). This study aimed to gain a deeper understanding of how clinicians worldwide manage post-TBI agitation. Understanding the factors that influence how clinicians manage agitation can help inform the use of consistent and effective management strategies for reducing agitation in TBI care. METHODS Using a qualitative design, semi-structured interviews were conducted with 33 clinicians (58% female, aged 23-71 years) from 16 countries who had experience working with agitated patients. The interviews explored the approaches used to manage agitation during early TBI recovery. RESULTS Interviews were analysed using thematic analysis. The central theme of the interviews was the effective management of agitation, consisting of three sub-themes: managing the safety of staff and patients, reducing triggers for agitation, and implementing behavioural principles for managing agitation. Two overarching themes influenced the effective management of agitation: clinician-related factors and systemic factors. CONCLUSIONS This study highlighted key approaches for effective agitation management during early TBI recovery, as described by clinicians working with these patients worldwide. There were similarities in the strategies described, although there were many challenges that impeded the consistent implementation of such strategies in TBI care settings. IMPLICATIONS FOR REHABILITATIONEffective management of agitation during early traumatic brain injury (TBI) recovery continues to pose a significant challenge for clinicians worldwide.Healthcare services may improve the management of agitation by involving the patient's family in care delivery and implementing low-cost less-restrictive non-pharmacological interventions to reduce reliance on pharmacological interventions.Proactively addressing and removing potential sources of agitation (patient-related and environmental) may help reduce the risk of agitation occurring.The use of simple behaviour management strategies may be effective for reducing agitation, but strategies need to be implemented consistently and the approach should be flexible and tailored to the patient.Clinicians should develop an understanding of a patient's premorbid behaviours and interests to best inform the management approach.Management of agitation may be improved by increasing clinicians' agency in responding to agitated behaviours, through the provision of information and resources, ongoing training and skill development, supervision and support.
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Affiliation(s)
- Sarah L Carrier
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia
| | - Jennie Ponsford
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia
- Rehabilitation and Mental Health Division, Epworth Healthcare, Melbourne, Australia
| | - Adam McKay
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia
- Rehabilitation and Mental Health Division, Epworth Healthcare, Melbourne, Australia
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Race NS, Moschonas EH, Cheng JP, Bondi CO, Kline AE. Antipsychotic Drugs: The Antithesis to Neurorehabilitation in Models of Pre-Clinical Traumatic Brain Injury. Neurotrauma Rep 2023; 4:724-735. [PMID: 37928134 PMCID: PMC10621671 DOI: 10.1089/neur.2023.0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Sixty-nine million traumatic brain injuries (TBIs) are reported worldwide each year, and, of those, close to 3 million occur in the United States. In addition to neurobehavioral and cognitive deficits, TBI induces other maladaptive behaviors, such as agitation and aggression, which must be managed for safe, accurate assessment and effective treatment of the patient. The use of antipsychotic drugs (APDs) in TBI is supported by some expert guidelines, which suggests that they are an important part of the pharmacological armamentarium to be used in the management of agitation. Despite the advantages of APDs after TBI, there are significant disadvantages that may not be fully appreciated clinically during decision making because of the lack of a readily available updated compendium. Hence, the aim of this review is to integrate the existing findings and present the current state of APD use in pre-clinical models of TBI. The studies discussed were identified through PubMed and the University of Pittsburgh Library System search strategies and reveal that APDs, particularly those with dopamine2 (D2) receptor antagonism, generally impair the recovery process in rodents of both sexes and, in some instances, attenuate the potential benefits of neurorehabilitation. We believe that the compilation of findings represented by this exhaustive review of pre-clinical TBI + APD models can serve as a convenient source for guiding informed decisions by critical care clinicians and physiatrists contemplating APD use for patients exhibiting agitation.
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Affiliation(s)
- Nicholas S. Race
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Association of Academic Physiatrists Rehabilitation Medicine Scientist Training Program, Owings Mills, Maryland, USA
| | - Eleni H. Moschonas
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Neurobiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeffrey P. Cheng
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Corina O. Bondi
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Neurobiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anthony E. Kline
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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8
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Hoover GL, Whitehair VC. Agitation after traumatic brain injury: a review of current and future concepts in diagnosis and management. Neurol Res 2023; 45:884-892. [PMID: 32706643 DOI: 10.1080/01616412.2020.1797374] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 07/14/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Agitation and aggression are common following traumatic brain injury. The challenges related to these disorders affect all stages of recovery, from the acute hospital to the community setting. The aim of this literature review is to provide an updated overview of the current state of post-traumatic agitation research. METHODS We performed a PubMed literature review which included recent confirmatory and novel research as well as classic and historical studies to integrate past and future concepts. RESULTS Areas explored include the personal and societal effects of post-traumatic agitation, methods for defining and diagnosing several neurobehavioral disorders, and pathophysiology and management of agitation and aggression. Target areas for future study are identified and discussed. DISCUSSION While much progress has been made in understanding post-traumatic agitation, there remain several key areas that require further elucidation to support the care and treatment for people with traumatic brain injury.
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Affiliation(s)
- Gary L Hoover
- Department of Physical Medicine and Rehabilitation, MetroHealth System, Cleveland, OH, USA
- Department of Physical Medicine and Rehabilitation, Case Western Reserve University, Cleveland, OH, USA
| | - Victoria C Whitehair
- Department of Physical Medicine and Rehabilitation, MetroHealth System, Cleveland, OH, USA
- Department of Physical Medicine and Rehabilitation, Case Western Reserve University, Cleveland, OH, USA
- Cleveland FES Center, Cleveland, OH, USA
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Factor Structure of the Agitated Behavior Scale in Traumatic Brain Injury During Posttraumatic Amnesia. J Head Trauma Rehabil 2023; 38:E56-E64. [PMID: 36594864 DOI: 10.1097/htr.0000000000000787] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To investigate the factor structure of the Agitated Behavior Scale (ABS) in patients with traumatic brain injury (TBI) in posttraumatic amnesia (PTA). SETTING Inpatient TBI rehabilitation ward in Victoria, Australia. PARTICIPANTS A total of 364 patients aged 16 to 92 years meeting diagnostic criteria for TBI and PTA admitted between September 2013 and October 2020. DESIGN Retrospective cohort study utilizing electronic medical record data. MAIN MEASURES The ABS and the Westmead Post-Traumatic Amnesia Scale (WPTAS). RESULTS Exploratory factor analysis uncovered 2 moderately correlated underlying factors (0.52), labeled Restlessness and Aggression/Lability. Two items failed to demonstrate sufficiently large loadings on either factor. Both factors demonstrated adequate reliability (Cronbach α = 0.87 and 0.81 for Restlessness and Aggression/Lability, respectively). Linear regression indicated that higher WPTAS scores were associated with lower levels of Restlessness (β = -.14, P < .001), supporting construct validity. Conversely, WPTAS scores were not significantly associated with Aggression/Lability (β = -.12, P = .08). Subgroup analysis indicated that a history of mood disorder was associated with greater severity of Aggression/Lability (P = .02). Confirmatory factor analysis indicated superior fit of the identified 2-factor solution when compared with previously explored 1-, 2-, 3-, and 4-factor structures. CONCLUSION This study suggests that the latent structure of the ABS is best explained by a single construct of agitation with 2 discrete facets reflecting Restlessness and Aggression/Lability. These subscales may be used in clinical practice to evaluate the severity of different aspects of agitated behavior, inform treatment decisions, and judge the efficacy of interventions over time. Further research is required to explain low factor loadings demonstrated by 2 items.
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Phyland RK, McKay A, Olver J, Walterfang M, Hopwood M, Ponsford M, Ponsford JL. Use of Olanzapine to Treat Agitation in Traumatic Brain Injury: A Series of N-of-One Trials. J Neurotrauma 2023; 40:33-51. [PMID: 35833454 DOI: 10.1089/neu.2022.0139] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Agitation is common during post-traumatic amnesia (PTA) following traumatic brain injury (TBI) and is associated with risk of harm to patients and caregivers. Antipsychotics are frequently used to manage agitation in early TBI recovery despite limited evidence to support their efficacy, safety, and impact upon patient outcomes. The sedating and cognitive side effects of these agents are theorized to exacerbate confusion during PTA, leading to prolonged PTA duration and increased agitation. This study, conducted in a subacute inpatient rehabilitation setting, describes the results of a double-blind, randomized, placebo-controlled trial investigating the efficacy of olanzapine for agitation management during PTA, analyzed as an n-of-1 series. Group comparisons were additionally conducted, examining level of agitation; number of agitated days; agitation at discharge, duration, and depth of PTA; length of hospitalization; cognitive outcome; adverse events; and rescue medication use. Eleven agitated participants in PTA (mean [M] age = 39.82 years, standard deviation [SD] = 20.06; mean time post-injury = 46.09 days, SD = 32.75) received oral olanzapine (n = 5) or placebo (n = 6) for the duration of PTA, beginning at a dose of 5 mg/day and titrated every 3 to 4 days to a maximum dose of 20 mg/day. All participants received recommended environmental management for agitation. A significant decrease in agitation with moderate to very large effect (Tau-U effect size = 0.37-0.86) was observed for three of five participants receiving olanzapine, while no significant reduction in agitation over the PTA period was observed for any participant receiving placebo. Effective olanzapine dose ranged from 5-20 mg. Response to treatment was characterized by lower level of agitation and response to treatment within 3 days. In group analyses, participants receiving olanzapine demonstrated poorer orientation and memory during PTA with large effect size (olanzapine, mean = 9.32, SD = 0.69; placebo, M = 10.68, SD = 0.30; p = .009, d = -2.16), and a trend toward longer PTA duration with large effect size (olanzapine, M = 71.96 days, SD = 20.31; placebo, M = 47.50 days, SD = 11.27; p = 0.072, d = 1.26). No further group comparisons were statistically significant. These results suggest that olanzapine can be effective in reducing agitation during PTA, but not universally so. Importantly, administration of olanzapine during PTA may lead to increased patient confusion, possibly prolonging PTA. When utilizing olanzapine, physicians must therefore balance the possible advantages of agitation management with the possibility that the patient may never respond to the medication and may experience increased confusion, longer PTA and potentially poorer outcomes. Further high-quality research is required to support these findings and the efficacy and outcomes associated with the use of any pharmacological agent for the management of agitation during the PTA period.
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Affiliation(s)
- Ruby K Phyland
- Monash Epworth Rehabilitation Research Center, Melbourne, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne Australia
| | - Adam McKay
- Monash Epworth Rehabilitation Research Center, Melbourne, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne Australia.,Division of Rehabilitation and Mental Health, Epworth HealthCare, Melbourne, Australia
| | - John Olver
- Department of Rehabilitation Medicine, Epworth HealthCare, Melbourne, Australia.,Epworth Monash Rehabilitation Medicine Research Unit, Epworth HealthCare, Melbourne, Australia
| | - Mark Walterfang
- Department of Psychiatry, University of Melbourne, Melbourne, Australia.,Royal Melbourne Hospital, Melbourne, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne, Melbourne, Australia.,Albert Road Clinic Professorial Psychiatry Unit, University of Melbourne, Melbourne, Australia
| | - Michael Ponsford
- Department of Rehabilitation Medicine, Epworth HealthCare, Melbourne, Australia.,Epworth Monash Rehabilitation Medicine Research Unit, Epworth HealthCare, Melbourne, Australia
| | - Jennie L Ponsford
- Monash Epworth Rehabilitation Research Center, Melbourne, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne Australia
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Carrier SL, Ponsford J, Phyland RK, Hicks AJ, McKay A. Effectiveness of Non-Pharmacological Interventions for Agitation during Post-Traumatic Amnesia following Traumatic Brain Injury: A Systematic Review. Neuropsychol Rev 2022; 33:374-392. [PMID: 35687261 PMCID: PMC10148768 DOI: 10.1007/s11065-022-09544-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 05/15/2022] [Indexed: 02/03/2023]
Abstract
Agitation is common in the early recovery period following traumatic brain injury (TBI), known as post-traumatic amnesia (PTA). Non-pharmacological interventions are frequently used to manage agitation, yet their efficacy is largely unknown. This systematic review aims to synthesize current evidence on the effectiveness of non-pharmacological interventions for agitation during PTA in adults with TBI. Key databases searched included MEDLINE Ovid SP interface, PubMed, CINAHL, Excerpta Medica Database, PsycINFO and CENTRAL, with additional online reviewing of key journals and clinical trial registries to identify published or unpublished studies up to May 2020. Eligible studies included participants aged 16 years and older, showing agitated behaviours during PTA. Any non-pharmacological interventions for reducing agitation were considered, with any comparator accepted. Eligible studies were critically appraised for methodological quality using Joanna Briggs Institute Critical Appraisal Instruments and findings were reported in narrative form. Twelve studies were included in the review: two randomized cross-over trials, three quasi-experimental studies, four cases series and three case reports. Non-pharmacological interventions were music therapy, behavioural strategies and environmental modifications, physical restraints and electroconvulsive therapy. Key methodological concerns included absence of a control group, a lack of formalised agitation measurement and inconsistent concomitant use of pharmacology. Interventions involving music therapy had the highest level of evidence, although study quality was generally low to moderate. Further research is needed to evaluate non-pharmacological interventions for reducing agitation during PTA after TBI.Systematic review registration number: PROSPERO (CRD42020186802), registered May 2020.
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Affiliation(s)
- Sarah L Carrier
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia. .,Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia.
| | - Jennie Ponsford
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia.,Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia.,Rehabilitation and Mental Health Division, Epworth Healthcare, Melbourne, Australia
| | - Ruby K Phyland
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia.,Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia
| | - Amelia J Hicks
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia.,Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia
| | - Adam McKay
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia.,Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia.,Rehabilitation and Mental Health Division, Epworth Healthcare, Melbourne, Australia
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12
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Carrier SL, Ponsford J, Phyland RK, Hicks AJ, McKay A. Effectiveness of Non-Pharmacological Interventions for Agitation during Post-Traumatic Amnesia following Traumatic Brain Injury: A Systematic Review. Neuropsychol Rev 2022. [DOI: https://doi:10.1007/s11065-022-09544-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AbstractAgitation is common in the early recovery period following traumatic brain injury (TBI), known as post-traumatic amnesia (PTA). Non-pharmacological interventions are frequently used to manage agitation, yet their efficacy is largely unknown. This systematic review aims to synthesize current evidence on the effectiveness of non-pharmacological interventions for agitation during PTA in adults with TBI. Key databases searched included MEDLINE Ovid SP interface, PubMed, CINAHL, Excerpta Medica Database, PsycINFO and CENTRAL, with additional online reviewing of key journals and clinical trial registries to identify published or unpublished studies up to May 2020. Eligible studies included participants aged 16 years and older, showing agitated behaviours during PTA. Any non-pharmacological interventions for reducing agitation were considered, with any comparator accepted. Eligible studies were critically appraised for methodological quality using Joanna Briggs Institute Critical Appraisal Instruments and findings were reported in narrative form. Twelve studies were included in the review: two randomized cross-over trials, three quasi-experimental studies, four cases series and three case reports. Non-pharmacological interventions were music therapy, behavioural strategies and environmental modifications, physical restraints and electroconvulsive therapy. Key methodological concerns included absence of a control group, a lack of formalised agitation measurement and inconsistent concomitant use of pharmacology. Interventions involving music therapy had the highest level of evidence, although study quality was generally low to moderate. Further research is needed to evaluate non-pharmacological interventions for reducing agitation during PTA after TBI.Systematic review registration number: PROSPERO (CRD42020186802), registered May 2020.
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Abstract
OBJECTIVES Post-traumatic amnesia (PTA) is a transient period of recovery following traumatic brain injury (TBI) characterised by disorientation, amnesia, and cognitive disturbance. Agitation is common during PTA and presents as a barrier to patient outcome. A relationship between cognitive impairment and agitation has been observed. This prospective study aimed to examine the different aspects of cognition associated with agitation. METHODS The sample comprised 82 participants (75.61% male) admitted to an inpatient rehabilitation hospital in PTA. All patients had sustained moderate to extremely severe brain injury as assessed using the Westmead Post-Traumatic Amnesia Scale (WPTAS) (mean duration = 42.30 days, SD = 35.10). Participants were assessed daily using the Agitated Behaviour Scale and WPTAS as part of routine clinical practice during PTA. The Confusion Assessment Protocol was administered two to three times per week until passed criterion was achieved (mean number assessments = 3.13, SD = 3.76). Multilevel mixed modelling was used to investigate the association between aspects of cognition and agitation using performance on items of mental control, orientation, memory free recall, memory recognition, vigilance, and auditory comprehension. RESULTS Findings showed that improvement in orientation was significantly associated with lower agitation levels. A nonsignificant trend was observed between improved recognition memory and lower agitation. CONCLUSIONS Current findings suggest that the presence of disorientation in PTA may interfere with a patient's ability to understand and engage with the environment, which in turn results in agitated behaviours. Interventions aimed at maximizing orientation may serve to minimize agitation during PTA.
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Parker TD, Rees R, Rajagopal S, Griffin C, Goodliffe L, Dilley M, Jenkins PO. Post-traumatic amnesia. Pract Neurol 2021; 22:129-137. [PMID: 34906998 DOI: 10.1136/practneurol-2021-003056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2021] [Indexed: 11/03/2022]
Abstract
Post-traumatic amnesia is the transient state of altered brain function that may follow a traumatic brain injury. At a practical level, an individual has emerged from post-traumatic amnesia when he or she is fully orientated and with return of continuous memory. However, the clinical manifestations are often more complex, with numerous cognitive domains commonly affected, as well as behaviour. In the acute setting, post-traumatic amnesia may easily go unrecognised; this is problematic as it has important implications for both immediate management and for longer-term prognosis. We therefore recommend its careful clinical assessment and prospective evaluation using validated tools. Patients in post-traumatic amnesia who have behavioural disturbance can be particularly challenging to manage. Behavioural and environmental measures form the mainstay of its treatment while avoiding pharmacological interventions where possible, as they may worsen agitation. Patients need assessing regularly to determine their need for further rehabilitation and to facilitate safe discharge planning.
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Affiliation(s)
- Thomas D Parker
- Atkinson Morley Neuroscience Unit, St George's University Hospitals NHS Foundation Trust, London, UK.,Department of Brain Sciences, Imperial College London, London, UK
| | - Richard Rees
- Atkinson Morley Neuroscience Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sangeerthana Rajagopal
- Atkinson Morley Neuroscience Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Colette Griffin
- Atkinson Morley Neuroscience Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Luke Goodliffe
- Atkinson Morley Neuroscience Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Michael Dilley
- Atkinson Morley Neuroscience Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Peter Owen Jenkins
- Atkinson Morley Neuroscience Unit, St George's University Hospitals NHS Foundation Trust, London, UK
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Phyland RK, Ponsford JL, Carrier SL, Hicks AJ, McKay A. Agitated Behaviors following Traumatic Brain Injury: A Systematic Review and Meta-Analysis of Prevalence by Post-Traumatic Amnesia Status, Hospital Setting, and Agitated Behavior Type. J Neurotrauma 2021; 38:3047-3067. [PMID: 34435884 DOI: 10.1089/neu.2021.0257] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Agitation is a common behavioral problem following traumatic brain injury (TBI); however, the precise proportion of patients who experience agitation in the early stages of recovery is unknown. The aim of this systematic review and meta-analysis was to evaluate the prevalence of agitation in TBI patients undergoing inpatient care, and whether this prevalence differed by post-traumatic amnesia (PTA) status and setting (acute and rehabilitation). We also aimed to describe the prevalence of sub-types of agitated behavior (disinhibited, aggressive, and emotionally labile). We searched five databases and one clinical trials register, with additional review of websites and key journals to identify any relevant records up to July 2020. We included studies describing the proportion of hospitalized TBI patients age 16 years or older demonstrating agitated behavior. We included comparative studies with and without concurrent controls, randomized controlled trials, pseudo-randomized controlled trials, and case series. Methodological quality was critically appraised using a Joanna Briggs Institute checklist. Sixteen studies met eligibility criteria, with a total of 5592 participants. The pooled prevalence of agitation was 31.73% (95% confidence interval [CI], 25.25%-39.00%) during inpatient care (acute and rehabilitation), 32.23% (95% CI, 27.13%-37.80%) during rehabilitative care and 44.06% (95% CI, 36.15%-52.28%) for inpatients in PTA specifically. Disinhibited behaviors were the most common. There was substantial heterogeneity between studies. Additional high-quality research featuring large samples, frequent and long-term measurement of agitation, use of validated scales, and consideration of variables such as PTA status will further improve estimates of agitation prevalence following TBI.
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Affiliation(s)
- Ruby K Phyland
- Monash Epworth Rehabilitation Research Center, Melbourne, Victoria, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Jennie L Ponsford
- Monash Epworth Rehabilitation Research Center, Melbourne, Victoria, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Sarah L Carrier
- Monash Epworth Rehabilitation Research Center, Melbourne, Victoria, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Amelia J Hicks
- Monash Epworth Rehabilitation Research Center, Melbourne, Victoria, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Adam McKay
- Monash Epworth Rehabilitation Research Center, Melbourne, Victoria, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia.,Division of Rehabilitation and Mental Health, Epworth HealthCare, Melbourne, Victoria, Australia
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16
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The Use of Atypical Antipsychotics for Managing Agitation After Traumatic Brain Injury. J Head Trauma Rehabil 2021; 36:149-155. [PMID: 32898031 DOI: 10.1097/htr.0000000000000614] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE This study examined the use of antipsychotics for managing agitation during posttraumatic amnesia (PTA) after traumatic brain injury (TBI) and its relationship with agitated behavior. DESIGN Observational prospective study with correlational design. SETTING Inpatient rehabilitation hospital for TBI. PARTICIPANTS A total of 125 consecutive admissions who were in PTA and had moderate-severe TBI. MEASURES Antipsychotic use was compared with agitation levels as measured by the total scores on the Agitated Behavior Scale (ABS). RESULTS Atypical antipsychotics were used in one-third of participants to manage agitation. Antipsychotic use was more common in participants with high levels of global agitation; however, there were many on antipsychotics who had mild or even no agitation according to the ABS. Uncontrolled observational data found no reduction in agitation after antipsychotic commencement or dose increase. CONCLUSIONS Antipsychotics are commonly used to manage agitation after TBI despite limited evidence of efficacy. Agitation should be formally monitored in PTA to ensure antipsychotics are used to manage more severe agitation and for evaluating treatment response. Research is needed to understand why prescribers are using antipsychotics when agitation is mild or below clinical thresholds.
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Carrier SL, Hicks AJ, Ponsford J, McKay A. Managing agitation during early recovery in adults with traumatic brain injury: An international survey. Ann Phys Rehabil Med 2021; 64:101532. [PMID: 33933690 DOI: 10.1016/j.rehab.2021.101532] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 02/01/2021] [Accepted: 02/26/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Managing agitation is a significant challenge in the early stages of recovery after traumatic brain injury (TBI), and research investigating current practice during this period is lacking. OBJECTIVES This study examined how clinicians worldwide conceptualise, measure and manage agitation during early TBI recovery. METHODS A cross-sectional anonymous online survey was distributed via email, newsletters, conferences and social media to clinicians involved in early TBI care worldwide. Respondents were 331 clinicians (66% female) from 34 countries worldwide who worked in inpatient and outpatient settings in disciplines including medicine, nursing and allied health. Participants had an average of 13 years' clinical experience working specifically with an adult TBI population. RESULTS Agitated behaviour was commonly defined as aggression and restlessness. Three quarters of clinicians reported that their services measure agitation, and clinicians in North America more frequently use standardised assessment tools. Common non-pharmacological approaches used across all regions surveyed included providing familiarising information (85%) and environmental cues (82%), managing patients in single rooms (81%) and reducing noise levels (80%). Most clinicians (90%) reported pharmacology use, particularly atypical antipsychotic agents. Clinicians' mean rating of confidence in managing agitation was 7 out of 10 (10 being excellent) and was higher for services that provided staff with written guidelines for agitation management. Only half of clinicians reported sufficient training for managing agitation and 52% were satisfied with current agitation management practices. CONCLUSIONS Despite high rates of agitation measurement and management, many clinicians reported dissatisfaction with current agitation management and insufficient training. This study supports the development of international guidelines and training to ensure consistent and effective agitation management in early TBI care.
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Affiliation(s)
- Sarah L Carrier
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia; Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia.
| | - Amelia J Hicks
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia; Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia
| | - Jennie Ponsford
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia; Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia; Rehabilitation and Mental Health Division, Epworth Healthcare, Melbourne, Australia
| | - Adam McKay
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia; Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia; Rehabilitation and Mental Health Division, Epworth Healthcare, Melbourne, Australia
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Williams MW, Rapport LJ, Sander AM, Parker HA. Pain anxiety and rehabilitation outcomes after acquired brain injury. Brain Inj 2020; 35:32-40. [PMID: 33347375 DOI: 10.1080/02699052.2020.1859614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Purpose: The purpose of this study was to examine pain anxiety after acquired brain injury (ABI) and its relationship to rehabilitation outcomes.Materials and Method: Participants consisted of 89 adults with an ABI participating in outpatient rehabilitation therapy. They completed a battery of neuropsychological tests at baseline along with surveys of mood, health-related self-efficacy, and pain anxiety. Separately, occupational therapists assessed basic and instrumental activities of daily living (ADLs) as well as therapy engagement across treatment after the sixth session.Results: Individuals who reported high pain anxiety had fewer years of formal education, lower self-efficacy, and more emotional distress than those with low pain anxiety. Although Blacks were about half (56%) of the study sample, they comprised the majority (73.1%) of individuals in the high pain anxiety group. Pain anxiety was negatively related to therapy engagement. Moderation analysis using linear regression indicated that pain anxiety moderated the influence of self-efficacy on basic ADLs.Conclusions: Pain anxiety, particularly when high, is negatively associated with rehabilitation outcomes for individuals with ABI. Among those with high pain anxiety, health-related self-efficacy is an important resilience characteristic to improve functional outcomes. In rehabilitation therapy, pain anxiety provides a novel intervention target to enhance ABI recovery.
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Affiliation(s)
- Michael W Williams
- Department of Psychology, Wayne State University, Detroit, MI, USA.,Department of Psychology, University of Houston, Houston, TX, USA
| | - Lisa J Rapport
- Department of Psychology, Wayne State University, Detroit, MI, USA
| | - Angelle M Sander
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA.,Brain Injury Research Center, TIRR Memorial Hermann, Houston, TX, USA
| | - Hillary A Parker
- Department of Psychology, Wayne State University, Detroit, MI, USA.,Neurology, Mount Carmel Health System, Columbus, OH, USA
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Carrier SL, Hicks AJ, Ponsford JL, McKay A. Effectiveness of non-pharmacological interventions for managing agitation during post-traumatic amnesia following traumatic brain injury: a systematic review protocol. JBI Evid Synth 2020; 19:499-512. [PMID: 33165180 DOI: 10.11124/jbies-20-00216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE To synthesize current evidence on the effects and harms of non-pharmacological interventions for managing agitation during post-traumatic amnesia in adults who have sustained a traumatic brain injury. INTRODUCTION Agitation is one of the most disruptive and clinically significant sequelae observed during post-traumatic amnesia. Patients who experience agitation during this period demonstrate reduced engagement in rehabilitation and poorer long-term functional outcomes. Agitation also poses a risk to staff and patient safety. Research for the effects of pharmacological intervention for managing agitation during this period is inconclusive. Thus, synthesis of the research for non-pharmacological interventions for reducing agitation during post-traumatic amnesia is essential for improving long-term outcomes for survivors of traumatic brain injury. INCLUSION CRITERIA Studies will be considered if they include participants aged 16 years and older who exhibit agitated behaviors during post-traumatic amnesia after sustaining a traumatic brain injury (irrespective of severity or mechanism). Studies will be considered if they evaluate any non-pharmacological intervention for reducing agitation, with all types of comparators accepted. Primary outcomes of interest include a change in agitation severity and any adverse effects. METHODS Key information sources include MEDLINE Ovid SP interface, PubMed, CINAHL, Excerpta Medica Database, PsycINFO, and Cochrane CENTRAL. Studies published in English will be included, irrespective of publication year. Two independent reviewers will be involved in study selection and data extraction. Eligible studies will be critically appraised for methodological quality. Studies will be pooled with statistical meta-analysis where possible; otherwise findings will be reported in narrative form. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42020186802.
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Affiliation(s)
- Sarah L Carrier
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Vic, Australia.,Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Vic, Australia
| | - Amelia J Hicks
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Vic, Australia.,Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Vic, Australia
| | - Jennie L Ponsford
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Vic, Australia.,Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Vic, Australia.,Rehabilitation and Mental Health Division, Epworth Healthcare, Melbourne, Vic, Australia
| | - Adam McKay
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Vic, Australia.,Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Vic, Australia.,Rehabilitation and Mental Health Division, Epworth Healthcare, Melbourne, Vic, Australia
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20
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Role of LCF scale as an outcome prognostic index in patients with traumatic brain injury. Neurol Sci 2020; 42:2747-2752. [PMID: 33123923 DOI: 10.1007/s10072-020-04852-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 10/22/2020] [Indexed: 10/23/2022]
Abstract
The disabling effects of traumatic brain injuries (TBI) present a significant healthcare concern to developed countries. In order to achieve a reliable prognosis, validated assessment scales are used to monitor the cognitive outcome, like the Level of Cognitive Functioning Scale, or the overall functional outcome, namely the Functional Independence Measure and Glasgow Outcome Scale. The aim of our study was to evaluate the role of Level of Cognitive Functioning Scale (LCF) as an outcome prognostic index in patients with TBI. MATERIALS AND METHODS Fifty-four patients with TBI with a mean age of 44.9 years (SD 20.915) were enrolled in this retrospective study. Patients were evaluated at admission and at discharge using the Glasgow Outcome Scale, Functional Independence Measure, and Level of Cognitive Functioning Scale. The Glasgow Outcome Scale was also implemented at 6 months after discharge (OUTCOME.GOS), whereas the LCF was used twice a week throughout hospitalization. For our purpose, we named LCF at admission LCFa, whereas permanence in the same LCF value (number of days), LCFaL. RESULTS Δ.GOS, Δ.FIM (Δ = difference between value at discharge and at admission), and OUTCOME.GOS were significantly affected by age, length of stay, LCFa, and LCFaL. CONCLUSION The LCF can give a valuable indication to the prognosis of patients with TBI besides monitoring changes in cognitive function. This allows for individual rehabilitation plan, and long-term management strategies could be developed more quickly upon patient's discharge. Consequently, valuable healthcare and social care resources could be assigned correctly.
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Factors Affecting Participation in Physical Therapy During Posttraumatic Amnesia. Arch Phys Med Rehabil 2020; 102:378-385. [PMID: 32745545 DOI: 10.1016/j.apmr.2020.06.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 06/16/2020] [Accepted: 06/30/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To examine the effect of agitation, cognitive impairment, fatigue, and pain on physical therapy participation and outcomes during posttraumatic amnesia (PTA) after traumatic brain injury (TBI). DESIGN Prospective longitudinal study. SETTING Inpatient rehabilitation hospital. PARTICIPANTS Participants (N=77) with moderate-to-severe TBI who were deemed to be experiencing PTA using the Westmead Post-Traumatic Amnesia Scale. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The Pittsburgh Rehabilitation Participation Scale and time in therapy (min) were recorded twice daily after routine physical therapy sessions during PTA. The FIM-motor (select items related to physical therapy) score rated on admission and after emergence from PTA was used to calculate FIM-motor change. RESULTS Agitation was associated with lower participation in therapy. The presence of agitation and pain both predicted lower FIM-motor change at emergence from PTA. Higher levels of cognitive impairment and fatigue were also associated with lower participation and less time in therapy. CONCLUSIONS The presence of agitation, fatigue, pain, and cognitive impairment impede rehabilitation success during PTA. This study strengthens the case for implementing environmental and behavioral recommendations, such as conducting therapy earlier in the day within a familiar space (ie, on the ward) and tailoring session duration to patient needs. This is with the aim of minimizing fatigue, agitation, and pain, while promoting cognitive recovery and arousal during PTA to maximize physical gains. Further research is warranted to examine the factors associated with rehabilitation success across other therapeutic disciplines.
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22
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Phyland RK, McKay A, Olver J, Walterfang M, Hopwood M, Hicks AJ, Mortimer D, Ponsford JL. Use of olanzapine to treat agitation in traumatic brain injury: study protocol for a randomised controlled trial. Trials 2020; 21:662. [PMID: 32690072 PMCID: PMC7370410 DOI: 10.1186/s13063-020-04553-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 06/23/2020] [Indexed: 11/24/2022] Open
Abstract
Background Agitation is common in the early stages of recovery from traumatic brain injury (TBI), when patients are in post-traumatic amnesia (PTA). Agitation is associated with risk of harm to patients and caregivers. Recent guidelines recommend that agitation during PTA is managed using environmental modifications. Agitation is also frequently treated pharmacologically, with the use of atypical antipsychotics such as olanzapine among the most common. This is despite a lack of well-designed studies to support the use of antipsychotics within this context. This study will be a double-blind, placebo-controlled randomised controlled trial. We will examine the efficacy, safety, cost-effectiveness and outcomes associated with the use of olanzapine for reducing agitation in patients in PTA following TBI over and above recommended environmental management. Methods Fifty-eight TBI rehabilitation inpatients who are in PTA and are agitated will receive olanzapine or placebo for the duration of PTA. All participants will additionally receive optimal environmental management for agitation. Measures of agitation, PTA and health will be undertaken at baseline. Treatment administration will begin at a dose of 5 mg daily and may be escalated to a maximum dose of 20 mg per day. Throughout the treatment period, agitation and PTA will be measured daily, and adverse events monitored weekly. Efficacy will be assessed by treatment group comparison of average Agitated Behaviour Scale scores during PTA. Participants will cease treatment upon emergence from PTA. Agitation levels will continue to be monitored for a further 2 weeks, post-treatment measures of health will be undertaken and cognitive and functional status will be assessed. Level of agitation and functional health will be assessed at hospital discharge. At 3 months post-discharge, functional outcomes and health service utilisation will be measured. Discussion This trial will provide crucial evidence to inform the management of agitation in patients in PTA following TBI. It will provide guidance as to whether olanzapine reduces agitation over and above recommended environmental management or conversely whether it increases or prolongs agitation and PTA, increases length of inpatient hospitalisation and impacts longer term cognitive and functional outcomes. It will also speak to the safety and cost-effectiveness of olanzapine use in this population. Trial registration ANZCTR ACTRN12619000284167. Registered on 25 February 2019
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Affiliation(s)
- Ruby K Phyland
- Monash Epworth Rehabilitation Research Centre, 185-187 Hoddle Street, Richmond, Victoria, 3121, Australia. .,School of Psychological Sciences, Monash University, 18 Innovation Walk, Clayton Campus, Wellington Road, Clayton, Victoria, 3800, Australia. .,Turner Institute for Brain and Mental Health, Monash University, Level 5, 18 Innovation Walk, Clayton Campus, Clayton, Victoria, 3800, Australia.
| | - Adam McKay
- Monash Epworth Rehabilitation Research Centre, 185-187 Hoddle Street, Richmond, Victoria, 3121, Australia.,School of Psychological Sciences, Monash University, 18 Innovation Walk, Clayton Campus, Wellington Road, Clayton, Victoria, 3800, Australia.,Turner Institute for Brain and Mental Health, Monash University, Level 5, 18 Innovation Walk, Clayton Campus, Clayton, Victoria, 3800, Australia.,Department of Psychology, Epworth HealthCare, 29 Erin Street, Richmond, Victoria, 3121, Australia
| | - John Olver
- Rehabilitation Medicine, Epworth HealthCare, 89 Bridge Rd, Richmond, Victoria, 3121, Australia
| | - Mark Walterfang
- Department of Psychiatry, University of Melbourne, Royal Melbourne Hospital, Level 1 North Block, Grattan Street, Parkville, Victoria, 3052, Australia.,Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria, 3050, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, 30 Royal Parade, Parkville, Victoria, 3052, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne, Royal Melbourne Hospital, Level 1 North Block, Grattan Street, Parkville, Victoria, 3052, Australia.,Albert Road Clinic Professorial Psychiatry Unit, University of Melbourne, 31 Albert Rd, Melbourne, Victoria, 3004, Australia
| | - Amelia J Hicks
- Monash Epworth Rehabilitation Research Centre, 185-187 Hoddle Street, Richmond, Victoria, 3121, Australia.,School of Psychological Sciences, Monash University, 18 Innovation Walk, Clayton Campus, Wellington Road, Clayton, Victoria, 3800, Australia.,Turner Institute for Brain and Mental Health, Monash University, Level 5, 18 Innovation Walk, Clayton Campus, Clayton, Victoria, 3800, Australia
| | - Duncan Mortimer
- Centre for Health Economics, Monash Business School, Monash University, Building H, Level 5, Caulfield Campus, Clayton, Victoria, 3145, Australia
| | - Jennie L Ponsford
- Monash Epworth Rehabilitation Research Centre, 185-187 Hoddle Street, Richmond, Victoria, 3121, Australia.,School of Psychological Sciences, Monash University, 18 Innovation Walk, Clayton Campus, Wellington Road, Clayton, Victoria, 3800, Australia.,Turner Institute for Brain and Mental Health, Monash University, Level 5, 18 Innovation Walk, Clayton Campus, Clayton, Victoria, 3800, Australia
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Kwak EH, Wi S, Kim M, Pyo S, Shin YK, Oh KJ, Han K, Kim YW, Cho SR. Factors affecting cognition and emotion in patients with traumatic brain injury. NeuroRehabilitation 2020; 46:369-379. [PMID: 32310194 PMCID: PMC7306897 DOI: 10.3233/nre-192893] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cognitive and emotional disturbances are common serious issues in patients with traumatic brain injury (TBI). However, predictors associated with neuropsychological functions were not consistent. OBJECTIVE To investigate factors affecting cognition and emotion in patients with TBI, we evaluated executive function, memory, and emotion based on injury severity and lesion location. METHODS Neuropsychological outcomes of 80 TBI patients were evaluated via Wisconsin Card Sorting Test (WCST), Color Trail Test (CTT), Controlled Oral Word Association Test (COWAT), Everyday Memory Questionnaire (EMQ), Geriatric Depression Scale (GDS), State-Trait Anxiety Inventory (STAI), and Agitated Behavior Scale (ABS). WCST, CTT, and COWAT assessed executive function; EMQ assessed everyday memory; and GDS, STAI, and ABS assessed emotion. Patients were categorized according to lateralization of lesion and existence of frontal lobe injury. RESULTS Patients with longer duration of loss of consciousness (LOC) showed more severe deficits in everyday memory and agitated behaviors. The frontal lesion group showed poorer performance in executive function and higher agitation than the non-frontal lesion group. Patients with bilateral frontal lesion showed greater deficits in executive function and were more depressed than unilateral frontal lesion groups. Especially in those unilateral frontal lesion groups, right side frontal lesion group was worse on executive function than left side frontal lesion group. CONCLUSIONS Duration of LOC and lesion location are main parameters affecting executive function, everyday memory, and emotion in neuropsychological outcomes following TBI, suggesting that these parameters need to be considered for cognitive rehabilitation interventions.
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Affiliation(s)
- Eun Hee Kwak
- Department and Research Institute of Rehabilitation Medicine, Yonsei University Medical Center, Seoul, Korea.,Department of Psychology, Yonsei University, Seoul, Korea
| | - Soohyun Wi
- Department and Research Institute of Rehabilitation Medicine, Yonsei University Medical Center, Seoul, Korea.,Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - MinGi Kim
- Department and Research Institute of Rehabilitation Medicine, Yonsei University Medical Center, Seoul, Korea.,Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Soonil Pyo
- Department and Research Institute of Rehabilitation Medicine, Yonsei University Medical Center, Seoul, Korea.,Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon-Kyum Shin
- Department and Research Institute of Rehabilitation Medicine, Yonsei University Medical Center, Seoul, Korea.,Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Ja Oh
- Department of Psychology, Yonsei University, Seoul, Korea
| | - Kyunghun Han
- Division of Sport science, Pusan National University, Busan, Korea
| | - Yong Wook Kim
- Department and Research Institute of Rehabilitation Medicine, Yonsei University Medical Center, Seoul, Korea
| | - Sung-Rae Cho
- Department and Research Institute of Rehabilitation Medicine, Yonsei University Medical Center, Seoul, Korea.,Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea.,Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea.,Graduate Program of Nano Science and Technology, Yonsei University College of Medicine, Seoul, Korea
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24
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Zarshenas S, Colantonio A, Horn SD, Jaglal S, Jacob B, Cullen N. Occupational and Physical Therapy Activities and Level of Effort in Patients With Traumatic Brain Injury: Association With Functional Outcomes. PM R 2019; 12:339-348. [PMID: 31600430 DOI: 10.1002/pmrj.12260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 09/17/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Although some attention has been given to the association of functional outcomes with rehabilitation intensity, the evidence is still sparse in this field. OBJECTIVE To investigate the effect of inpatient rehabilitation (IR) on discharge cognitive and motor function and the association of time spent in occupational and physical therapy and level of effort with cognitive and motor function in patients with traumatic brain injury (TBI). DESIGN Secondary analysis of TBI-Practice Based Evidence dataset. SETTINGS Inpatient rehabilitation. PARTICIPANTS One hundred forty-nine patients with TBI who were consecutively admitted for IR between 2008 and 2011 in Ontario, Canada. INTERVENTIONS Not applicable. MAIN OUTCOME MEASUREMENTS Admission and discharge Functional Independence Measure-Rasch Cognitive and Motor Scores. RESULTS Patients showed significant improvement in cognitive and motor function from admission to discharge (P < .0001). After controlling for confounding factors, discharge FIM-Rasch cognitive and motor scores were not associated with either level of effort or time spent in physical therapy activities. Discharge motor, but not cognitive function, was associated with more time spent in the complex (β = 0.20, confidence interval [CI] 0.005, 0.05) and less time spent in simple OT activities (β = -0.13, CI -0.13, -0.01). CONCLUSION This study provides valuable information for clinicians about the effectiveness of IR on the improvement of motor and cognitive outcomes and the importance of considering the amount of time spent in activities based on their level of complexity rather than the total time of therapy to improve motor outcomes in this population. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Sareh Zarshenas
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada.,University Health Network, Toronto Rehabilitation Institute, University Centre, Toronto, Canada
| | - Angela Colantonio
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada.,University Health Network, Toronto Rehabilitation Institute, University Centre, Toronto, Canada.,Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Susan D Horn
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake, UT
| | - Susan Jaglal
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada.,University Health Network, Toronto Rehabilitation Institute, University Centre, Toronto, Canada
| | - Binu Jacob
- University Health Network, Toronto Rehabilitation Institute, University Centre, Toronto, Canada
| | - Nora Cullen
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada.,University Health Network, Toronto Rehabilitation Institute, University Centre, Toronto, Canada
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Economic Evaluation of Activities of Daily Living Retraining During Posttraumatic Amnesia for Inpatient Rehabilitation Following Severe Traumatic Brain Injury. Arch Phys Med Rehabil 2019; 100:648-655. [DOI: 10.1016/j.apmr.2018.08.184] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 08/14/2018] [Accepted: 08/18/2018] [Indexed: 11/21/2022]
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Agitated Behavior and Activities of Daily Living Retraining During Posttraumatic Amnesia. J Head Trauma Rehabil 2018; 33:317-325. [DOI: 10.1097/htr.0000000000000363] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hicks AJ, Clay FJ, Hopwood M, James AC, Jayaram M, Batty R, Perry LA, Ponsford JL. Efficacy and Harms of Pharmacological Interventions for Neurobehavioral Symptoms in Post-Traumatic Amnesia after Traumatic Brain Injury: A Systematic Review. J Neurotrauma 2018; 35:2755-2775. [PMID: 29969935 DOI: 10.1089/neu.2018.5738] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Many individuals in post-traumatic amnesia (PTA) following traumatic brain injury (TBI) experience neurobehavioral symptoms (NBS) in addition to disorientation and amnesia. These symptoms are associated with low rehabilitation engagement, self-inflicted harm, and risk of violence. The aim of this systematic review was to evaluate the efficacy and harms of pharmacological interventions for NBS in PTA following TBI in adults. Studies in English published before December 2017 were reviewed. Six databases were searched, with additional hand searching of key journals, clinical trials registries, and international drug regulators. Evidence quality was assessed using Joanna Briggs Institute Critical Appraisal Instruments. Thirteen studies were identified: three randomized controlled trials (RCTs), three cohort studies, and seven case series. In the RCTs, neither amantadine nor sertraline reduced NBS. Less rigorous studies reported reduced NBS in patients administered haloperidol, ziprasidone, carbamazepine, amitriptyline, desipramine, and varied neuroleptics. There is a paucity of well-designed, adequately powered and controlled studies of pharmacological interventions for NBS in PTA. More research is needed to provide evidence-based treatment recommendations and improve care.
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Affiliation(s)
- Amelia J Hicks
- 1 Monash-Epworth Rehabilitation Research Centre, Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Fiona J Clay
- 2 Department of Psychiatry, University of Melbourne, Melbourne, Australia .,3 Department of Forensic Medicine, Monash University, Southbank, Melbourne, Australia .,4 Professorial Psychiatry Unit, Albert Road Clinic, Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Malcolm Hopwood
- 2 Department of Psychiatry, University of Melbourne, Melbourne, Australia .,4 Professorial Psychiatry Unit, Albert Road Clinic, Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Amelia C James
- 1 Monash-Epworth Rehabilitation Research Centre, Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Mahesh Jayaram
- 2 Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Rachel Batty
- 2 Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Luke A Perry
- 2 Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Jennie L Ponsford
- 1 Monash-Epworth Rehabilitation Research Centre, Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, Melbourne, Australia
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McKay A, Love J, Trevena-Peters J, Gracey J, Ponsford J. The relationship between agitation and impairments of orientation and memory during the PTA period after traumatic brain injury. Neuropsychol Rehabil 2018; 30:579-590. [DOI: 10.1080/09602011.2018.1479276] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Adam McKay
- School of Psychological Sciences, Monash University, Melbourne, Australia
- Monash-Epworth Rehabilitation Research Centre, Melbourne, Australia
- Department of Psychology, Epworth HealthCare, Melbourne, Australia
| | - Jasmine Love
- School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Jessica Trevena-Peters
- School of Psychological Sciences, Monash University, Melbourne, Australia
- Monash-Epworth Rehabilitation Research Centre, Melbourne, Australia
| | - Jacinta Gracey
- Department of Psychology, Epworth HealthCare, Melbourne, Australia
| | - Jennie Ponsford
- School of Psychological Sciences, Monash University, Melbourne, Australia
- Monash-Epworth Rehabilitation Research Centre, Melbourne, Australia
- National Trauma Research Institute, Melbourne, Australia
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Trevena-Peters J, McKay A, Spitz G, Suda R, Renison B, Ponsford J. Efficacy of Activities of Daily Living Retraining During Posttraumatic Amnesia: A Randomized Controlled Trial. Arch Phys Med Rehabil 2018; 99:329-337.e2. [DOI: 10.1016/j.apmr.2017.08.486] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 08/15/2017] [Accepted: 08/23/2017] [Indexed: 10/18/2022]
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Hicks AJ, Clay FJ, Hopwood M, Jayaram M, Batty R, Ponsford JL. Efficacy and harms of pharmacological interventions for neurobehavioral symptoms in post traumatic amnesia after traumatic brain injury: a systematic review and meta-analysis protocol. JBI DATABASE OF SYSTEMATIC REVIEWS AND IMPLEMENTATION REPORTS 2017; 15:2890-2912. [PMID: 29219873 DOI: 10.11124/jbisrir-2017-003430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
REVIEW OBJECTIVE/QUESTION The objective of this systematic review is to synthesize the best available evidence on the effectiveness and harms of pharmacotherapy as compared to all types of comparators for the management of neurobehavioral symptoms in post-traumatic amnesia in adults aged 16 years and over who have sustained a traumatic brain injury. This review forms part of a larger project which aims to gather the evidence for the pharmacological treatment of neurobehavioral symptoms post traumatic brain injury as a prelude to the development of a clinical guideline.
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Affiliation(s)
- Amelia J Hicks
- Monash-Epworth Rehabilitation Research Centre, Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Fiona J Clay
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
- Department of Forensic Medicine, Monash University, Southbank, Australia
- The Australian Centre for Evidence-Based Primary Health Care, Community Care: a Joanna Briggs Institute Centre of Excellence, Adelaide, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
- Professorial Psychiatry Unit, Albert Road Clinic, Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Mahesh Jayaram
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Rachel Batty
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Jennie L Ponsford
- Monash-Epworth Rehabilitation Research Centre, Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, Melbourne, Australia
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Putrino D, Zanders H, Hamilton T, Rykman A, Lee P, Edwards DJ. Patient Engagement Is Related to Impairment Reduction During Digital Game-Based Therapy in Stroke. Games Health J 2017; 6:295-302. [PMID: 28910162 DOI: 10.1089/g4h.2016.0108] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Upper limb impairment in the chronic phase of stroke recovery is persistent, disabling, and difficult to treat. The objectives of this study were to determine whether therapeutic enjoyment is related to clinical improvement after upper limb rehabilitation and to assess the feasibility of a therapy gaming system. MATERIALS AND METHODS Ten chronic stroke survivors with persistent upper limb impairment were enrolled in the study. Upper limb impairment was evaluated by using the Fugl-Meyer Assessment of Upper Extremity Function (FMA-UE). The Physical Activity Enjoyment Scale (PACES) assessed the level of therapy enjoyment, and the System Usability Scale (SUS) measured the ease of operation of the game. Upper limb therapy involved 30 minutes of novel digital gaming therapy, three times per week, for 6 weeks. RESULTS The average improvement in the FMA-UE after the digital gaming therapy was 2.8 (±2.1) points. Participants scored the digital gaming system as having good usability (SUS: 72 ± 7.9), and the physical activity as enjoyable (PACES: 65.8 ± 10.6). There was a strong positive correlation between improvement in the FMA-UE score and the PACES (Spearman's Rho = 0.84; P < 0.002). CONCLUSION This pilot study demonstrates the feasibility and potential for improvements in upper limb motor function by using digital gaming in the chronic stroke patient population. The positive correlation found between therapy enjoyment and clinical gains highlights the importance of engagement in therapy to optimize outcomes in chronic stroke survivors.
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Affiliation(s)
- David Putrino
- 1 Telemedicine and Virtual Rehabilitation Laboratory, Burke Medical Research Institute , White Plains, New York.,2 Department of Rehabilitation Medicine, Weill Cornell Medicine , New York, New York.,6 Department of Rehabilitation Medicine, Icahn School of Medicine , at Mount Sinai, New York, New York
| | - Helma Zanders
- 3 Brain Stimulation and Robotics Laboratory, Burke Medical Research Institute , White Plains, New York
| | - Taya Hamilton
- 1 Telemedicine and Virtual Rehabilitation Laboratory, Burke Medical Research Institute , White Plains, New York
| | - Avrielle Rykman
- 3 Brain Stimulation and Robotics Laboratory, Burke Medical Research Institute , White Plains, New York
| | - Peter Lee
- 3 Brain Stimulation and Robotics Laboratory, Burke Medical Research Institute , White Plains, New York
| | - Dylan J Edwards
- 3 Brain Stimulation and Robotics Laboratory, Burke Medical Research Institute , White Plains, New York.,4 Neurology Department, Weill Cornell Medicine , New York, New York.,5 School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
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Moessner A, Malec JF, Beveridge S, Reddy CC, Huffman T, Marton J, Schmerzler AJ. Preliminary evaluation of a measure for reliable assessment of need for constant visual observation in adults with traumatic brain injury. Brain Inj 2016; 30:1343-1349. [PMID: 27715319 DOI: 10.1080/02699052.2016.1193629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PRIMARY OBJECTIVE To develop and provide initial validation of a measure for accurately determining the need for Constant Visual Observation (CVO) in patients with traumatic brain injury (TBI) admitted to inpatient rehabilitation. RESEARCH DESIGN Rating scale development and evaluation through Rasch analysis and assessment of concurrent validity. METHODS AND PROCEDURES One hundred and thirty-four individuals with moderate-severe TBI were studied in seven inpatient brain rehabilitation units associated with the National Institute for Disability, Independent Living and Rehabilitation Research (NIDILRR) TBI Model System. Participants were rated on the preliminary version of the CVO Needs Assessment scale (CVONA) and, by independent raters, on the Levels of Risk (LoR) and Supervision Rating Scale (SRS) at four time points during inpatient rehabilitation: admission, Days 2-3, Days 5-6 and Days 8-9. OUTCOMES AND RESULTS After pruning misfitting items, the CVONA showed satisfactory internal consistency (Person Reliability = 0.85-0.88) across time points. With reference to the LoR and SRS, low false negative rates (sensitivity > 90%) were associated with moderate-to-high false positive rates (29-56%). CONCLUSIONS The CVONA may be a useful objective metric to complement clinical judgement regarding the need for CVO; however, further prospective study is desirable to further assess its utility in identifying at-risk patients, reducing adverse events and decreasing CVO costs.
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Affiliation(s)
- Anne Moessner
- a Mayo Clinic Department of Physical Medicine & Rehabilitation , Rochester , MN , USA
| | - James F Malec
- b Physical Medicine and Rehabilitation , Indiana University School of Medicine and Rehabilitation Hospital of Indiana , Indianapolis , IN , USA
| | - Scott Beveridge
- c UPMC Mercy Hospital Rehabilitation Institute , Pittsburgh , PA , USA
| | | | - Tracy Huffman
- d The Ohio State University Wexner Medical Center , Columbus , OH , USA
| | - Julia Marton
- e Department of Rehabilitation , Baylor Institute for Rehabilitation-Dallas Campus , Dallas , TX , USA
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Aadal L, Mortensen J, Nielsen JF. Monitoring Agitated Behavior After acquired Brain Injury: Onset, Duration, Intensity, and Nursing Shift Variation. Rehabil Nurs 2015; 41:289-97. [PMID: 26542895 DOI: 10.1002/rnj.251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2015] [Indexed: 11/11/2022]
Abstract
PURPOSE To describe the onset, duration, intensity, and nursing shift variation of agitated behavior in patients with acquired brain injury (ABI) at a rehabilitation hospital. DESIGN Prospective descriptive study. METHODS A total of 11 patients with agitated behavior were included. Agitated behavior was registered with the Agitated Behavior Scale (ABS). The nurse or therapist allocated the individual patient assessed ABS during each shift. Intensity of agitated behavior was tested using exact test. A within-subject shift effect was analyzed with repeated-measure ANOVA. FINDINGS The onset of agitated behavior was at a median of 14 (1-28) days from admission. Seven patients remained agitated beyond 3 weeks from onset. Severe intensity of agitation was observed in 86 of 453 nursing shifts. Differences in agitated behavior between day, evening, and night shifts were found, F(2.20) = 7.90, p = .008, with tendencies of increased agitated behavior in day and evening shifts compared to night shifts. CONCLUSION Agitated behavior had a late onset, was severe, and long-lasting in the present sample of patients. CLINICAL RELEVANCE The study increases awareness on the potential challenge of agitated behavior in patients with ABI.
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Affiliation(s)
- Lena Aadal
- Hammel Neurorehabilitation and Research Centre, Hammel, Denmark.
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Seel RT, Corrigan JD, Dijkers MP, Barrett RS, Bogner J, Smout RJ, Garmoe W, Horn SD. Patient Effort in Traumatic Brain Injury Inpatient Rehabilitation: Course and Associations With Age, Brain Injury Severity, and Time Postinjury. Arch Phys Med Rehabil 2015. [PMID: 26212400 DOI: 10.1016/j.apmr.2014.10.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To describe patients' level of effort in occupational, physical, and speech therapy sessions during traumatic brain injury (TBI) inpatient rehabilitation and to evaluate how age, injury severity, cognitive impairment, and time are associated with effort. DESIGN Prospective, multicenter, longitudinal cohort study. SETTING Acute TBI rehabilitation programs. PARTICIPANTS Patients (N=1946) receiving 138,555 therapy sessions. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Effort in rehabilitation sessions rated on the Rehabilitation Intensity of Therapy Scale, FIM, Comprehensive Severity Index brain injury severity score, posttraumatic amnesia (PTA), and Agitated Behavior Scale (ABS). RESULTS The Rehabilitation Intensity of Therapy Scale effort ratings in individual therapy sessions closely conformed to a normative distribution for all 3 disciplines. Mean Rehabilitation Intensity of Therapy Scale ratings for patients' therapy sessions were higher in the discharge week than in the admission week (P<.001). For patients who completed 2, 3, or 4 weeks of rehabilitation, differences in effort ratings (P<.001) were observed between 5 subgroups stratified by admission FIM cognitive scores and over time. In linear mixed-effects modeling, age and Comprehensive Severity Index brain injury severity score at admission, days from injury to rehabilitation admission, days from admission, and daily ratings of PTA and ABS score were predictors of level of effort (P<.0001). CONCLUSIONS Patients' level of effort can be observed and reliably rated in the TBI inpatient rehabilitation setting using the Rehabilitation Intensity of Therapy Scale. Patients who sustain TBI show varying levels of effort in rehabilitation therapy sessions, with effort tending to increase over the stay. PTA and agitated behavior are primary risk factors that substantially reduce patient effort in therapies.
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Affiliation(s)
- Ronald T Seel
- Crawford Research Institute, Shepherd Center, Atlanta, GA.
| | - John D Corrigan
- Department of Physical Medicine and Rehabilitation, Ohio State University, Columbus, OH
| | - Marcel P Dijkers
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryan S Barrett
- Institute for Clinical Outcomes Research, International Severity Information Systems, Salt Lake City, UT
| | - Jennifer Bogner
- Department of Physical Medicine and Rehabilitation, Ohio State University, Columbus, OH
| | - Randall J Smout
- Institute for Clinical Outcomes Research, International Severity Information Systems, Salt Lake City, UT
| | - William Garmoe
- Medstar National Rehabilitation Hospital, Washington, DC
| | - Susan D Horn
- Institute for Clinical Outcomes Research, International Severity Information Systems, Salt Lake City, UT
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Horn SD, Corrigan JD, Beaulieu CL, Bogner J, Barrett RS, Giuffrida CG, Ryser DK, Cooper K, Carroll DM, Deutscher D. Traumatic Brain Injury Patient, Injury, Therapy, and Ancillary Treatments Associated With Outcomes at Discharge and 9 Months Postdischarge. Arch Phys Med Rehabil 2015; 96:S304-29. [PMID: 26212406 PMCID: PMC4517296 DOI: 10.1016/j.apmr.2014.11.030] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Revised: 10/28/2014] [Accepted: 11/20/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To examine associations of patient and injury characteristics, inpatient rehabilitation therapy activities, and neurotropic medications with outcomes at discharge and 9 months postdischarge for patients with traumatic brain injury (TBI). DESIGN Prospective, longitudinal observational study. SETTING Inpatient rehabilitation centers. PARTICIPANTS Consecutive patients (N=2130) enrolled between 2008 and 2011, admitted for inpatient rehabilitation after an index TBI injury. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Rehabilitation length of stay, discharge to home, and FIM at discharge and 9 months postdischarge. RESULTS The admission FIM cognitive score was used to create 5 relatively homogeneous subgroups for subsequent analysis of treatment outcomes. Within each subgroup, significant associations were found between outcomes and patient and injury characteristics, time spent in therapy activities, and medications used. Patient and injury characteristics explained on average 35.7% of the variation in discharge outcomes and 22.3% in 9-month outcomes. Adding time spent and level of effort in therapy activities and percentage of stay using specific medications explained approximately 20% more variation for discharge outcomes and 12.9% for 9-month outcomes. After patient, injury, and treatment characteristics were used to predict outcomes, center differences added only approximately 1.9% additional variance explained. CONCLUSIONS At discharge, greater effort during therapy sessions, time spent in more complex therapy activities, and use of specific medications were associated with better outcomes for patients in all admission FIM cognitive subgroups. At 9 months postdischarge, similar but less pervasive associations were observed for therapy activities, but not classes of medications. Further research is warranted to examine more specific combinations of therapy activities and medications that are associated with better outcomes.
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Affiliation(s)
- Susan D Horn
- Institute for Clinical Outcomes Research, International Severity Information Systems, Salt Lake City, UT.
| | - John D Corrigan
- Department of Physical Medicine and Rehabilitation, Ohio State University, Columbus, OH
| | | | - Jennifer Bogner
- Department of Physical Medicine and Rehabilitation, Ohio State University, Columbus, OH
| | - Ryan S Barrett
- Institute for Clinical Outcomes Research, International Severity Information Systems, Salt Lake City, UT
| | | | - David K Ryser
- Neuro Specialty Rehabilitation Unit, Intermountain Medical Center, Salt Lake City, UT
| | - Kelli Cooper
- Neuro Specialty Rehabilitation Unit, Intermountain Medical Center, Salt Lake City, UT
| | - Deborah M Carroll
- Neuro Specialty Rehabilitation Unit, Intermountain Medical Center, Salt Lake City, UT
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Bogner J, Barrett RS, Hammond FM, Horn SD, Corrigan JD, Rosenthal J, Beaulieu CL, Waszkiewicz M, Shea T, Reddin CJ, Cullen N, Giuffrida CG, Young J, Garmoe W. Predictors of Agitated Behavior During Inpatient Rehabilitation for Traumatic Brain Injury. Arch Phys Med Rehabil 2015. [DOI: 10.1016/j.apmr.2015.04.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Rettke H, Geschwindner HM, van den Heuvel WJA. Assessment of Patient Participation in Physical Rehabilitation Activities: An Integrative Review. Rehabil Nurs 2015; 40:209-23. [DOI: 10.1002/rnj.157] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2014] [Indexed: 11/12/2022]
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Bower J, Catroppa C, Grocke D, Shoemark H. Music therapy for early cognitive rehabilitation post-childhood TBI: an intrinsic mixed methods case study. Dev Neurorehabil 2014; 17:339-46. [PMID: 23815784 DOI: 10.3109/17518423.2013.778910] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The primary aim of this case study was to explore the behavioural changes of a paediatric patient in post-traumatic amnesia (PTA) during a music therapy session. A secondary objective was to measure the effect of the music therapy intervention on agitation. METHOD Video data from pre, during and post-music therapy sessions were collected and analysed using video micro-analysis and the Agitated Behaviour Scale. RESULTS The participant displayed four discrete categories of behaviours: Neutral, Acceptance, Recruitment and Rejection. Further analysis revealed brief but consistent and repeated periods of awareness and responsiveness to the live singing of familiar songs, which were classified as Islands of Awareness. Song offered an Environment of Potential to maximise these periods of emerging consciousness. The quantitative data analysis yielded inconclusive results in determining if music therapy was effective in reducing agitation during and immediately post the music therapy sessions. CONCLUSION The process of micro-analysis illuminated four discrete participant behaviours not apparent in the immediate clinical setting. The results of this case suggest that the use of familiar song as a music therapy intervention may harness early patient responsiveness to foster cognitive rehabilitation in the early acute phase post-TBI.
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Affiliation(s)
- Janeen Bower
- Music Therapy Department, The Royal Children's Hospital Melbourne , Flemington Rd, Parkville, VIC , Australia
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Gion T, Leclaire-Thoma A. Delirium in the Brain-Injured Patient. Rehabil Nurs 2014; 39:232-9. [DOI: 10.1002/rnj.128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2013] [Indexed: 11/10/2022]
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Ponsford J, Janzen S, McIntyre A, Bayley M, Velikonja D, Tate R. INCOG Recommendations for Management of Cognition Following Traumatic Brain Injury, Part I. J Head Trauma Rehabil 2014; 29:307-20. [DOI: 10.1097/htr.0000000000000074] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gialanella B, Ferlucci C, Monguzzi V, Prometti P. Determinants of functional outcome in hip fracture patients: the role of specific neuropsychiatric symptoms. Disabil Rehabil 2014; 37:517-22. [PMID: 24963835 DOI: 10.3109/09638288.2014.932446] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Bernardo Gialanella
- Operative Unit for Recovery and Functional Rehabilitation, Scientific Institute of Lumezzane , Fondazione Salvatore Maugeri, IRCCS, Lumezzane , Italy
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Janzen S, McIntyre A, Meyer M, Sequeira K, Teasell R. The management of agitation among inpatients in a brain injury rehabilitation unit. Brain Inj 2014; 28:318-22. [DOI: 10.3109/02699052.2013.860478] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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McClanachan NJ, Gesch J, Wuthapanich N, Fleming J, Kuys SS. Feasibility of gaming console exercise and its effect on endurance, gait and balance in people with an acquired brain injury. Brain Inj 2013; 27:1402-8. [PMID: 24102295 DOI: 10.3109/02699052.2013.823654] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine feasibility of gaming console exercise and its effect on endurance, gait and balance in people following acquired brain injury (ABI). METHOD Twenty-one people following ABI were recruited to an 8-week randomized cross-over trial where 4 weeks of gaming console exercise in addition to usual therapy and 4 weeks of usual therapy alone were received. Feasibility measures included compliance, session duration and adverse events. Measures included endurance measured using a 6-minute walk test, spatiotemporal gait parameters (GAITRite) and balance using Balance Outcome Measure for Elder Rehabilitation (BOOMER). Motivation was measured using the Change Assessment Questionnaire. RESULTS Compliance with gaming console exercise was high (99%), the majority of sessions reached duration target (82%) and there were no adverse events. There were small, though non-significant increases in 6-minute walk distance (18 metres, 95% CI = -33 to 69), gait speed (0.11 m s(-1), 95% CI = -0.18 to 0.29) and balance compared to after usual therapy after gaming console exercise. CONCLUSIONS Gaming console exercise appears feasible in people with ABI. Four weeks of gaming console exercise in addition to usual therapy appears to result in similar improvements in endurance, gait and balance compared to usual therapy alone and may enhance active engagement in therapy.
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Affiliation(s)
- Nelson J McClanachan
- School of Health and Rehabilitation Sciences, University of Queensland , Australia
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Dvorkin AY, Pacini S, Hsu N, Larson EB. Treatment challenges with profound behaviour disturbance after traumatic brain injury: A case report. Brain Inj 2013; 27:957-61. [DOI: 10.3109/02699052.2013.793399] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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McNett M, Sarver W, Wilczewski P. The prevalence, treatment and outcomes of agitation among patients with brain injury admitted to acute care units. Brain Inj 2012; 26:1155-62. [PMID: 22642404 DOI: 10.3109/02699052.2012.667587] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE Agitation occurs in 70% of patients hospitalized with traumatic brain injury (TBI) and has adverse effects on length of stay and functional outcomes. Treatment involves pharmacological and behavioural interventions. Much research on TBI agitation has been conducted in intensive care or rehabilitation settings. This study aimed to identify agitation prevalence, treatment and outcomes among patients with TBI on acute care wards. METHODS Data abstracted from the trauma registry and medical records of adult patients with TBI admitted to an acute care ward within a Level I trauma centre over 12 months. FINDINGS From 219 patients, at least one agitation behaviour was present in 41% (n = 90) of patients. Clinically significant agitation was present in 8% (n = 18) of patients. Agitation behaviours included impulsiveness (30%), pulling at devices (21%) and decreased attention span (16%). Common interventions were reorientation (33%), constant supervision (32%) and benzodiazepines (30%). Agitated patients had longer length of stay (p < 0.001) and were less likely to be discharged home. Physical restraints, constant supervision, redirection, reorientation and environmental modifications were associated with agitation (p < 0.001). IMPLICATIONS Management of agitation among patients with TBI on acute care wards can present challenges to healthcare staff. Innovative approaches are needed to promote outcomes using available resources.
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Affiliation(s)
- Molly McNett
- MetroHealth Medical Centre, Cleveland, OH 44109, USA.
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Nott MT, Chapparo C, Heard R, Baguley IJ. Patterns of agitated behaviour during acute brain injury rehabilitation. Brain Inj 2011; 24:1214-21. [PMID: 20715891 DOI: 10.3109/02699052.2010.506858] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To monitor daily shift-by-shift changes in agitated behaviour during adult brain injury rehabilitation. DESIGN A prospective, descriptive study. METHODS Eight participants were monitored daily for up to 28 days. The Agitated Behaviour Scale (ABS) evaluated behaviour during three nursing shifts (morning, afternoon, night). Severity of agitation, peak intensity and concomitant behaviours were calculated. Shift differences and patterns of behavioural changes were analysed. RESULTS Four hundred and seven recordings were taken with the ABS. All participants demonstrated multiple agitated behaviours (between 3-13 concomitant behaviours per person); the most common behaviours were representative of the ABS Disinhibition sub-scale. Weekly peak intensity ranged from 14-55 on the ABS. Mean ABS scores were highest during the afternoon shift and lowest at night. Improved cognition was associated with resolving agitated behaviour; while persistent agitated behaviour was associated with low levels of cognition. Minimal agitated behaviour was observed in participants who emerged from post-traumatic amnesia. CONCLUSIONS Agitated behaviour during acute brain injury rehabilitation has a complex clinical presentation. High levels of agitation observed during the afternoon shift may be associated with low levels of structured activities available at that time, higher levels of environmental stimuli during visiting times and increased cognitive fatigue. Lower cognitive ability was related to consistently higher levels of agitated behaviour and vice-versa.
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Affiliation(s)
- Melissa T Nott
- Brain Injury Rehabilitation Service, Westmead Hospital, Wentworthville, NSW, Australia.
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Pangilinan PH, Giacoletti-Argento A, Shellhaas R, Hurvitz EA, Hornyak JE. Neuropharmacology in Pediatric Brain Injury: A Review. PM R 2010; 2:1127-40. [DOI: 10.1016/j.pmrj.2010.07.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Revised: 06/16/2010] [Accepted: 07/05/2010] [Indexed: 11/28/2022]
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Goldshtrom Y, Knorr G, Goldshtrom I. Rhythmic exercises in rehabilitation of TBI patients: a case report. J Bodyw Mov Ther 2009; 14:336-45. [PMID: 20850040 DOI: 10.1016/j.jbmt.2009.06.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Revised: 05/20/2009] [Accepted: 06/05/2009] [Indexed: 12/31/2022]
Abstract
SUMMARY Patients who have sustained traumatic brain injury (TBI) often present with a multiplicity of dysfunctions making rehabilitation challenging. Patients who have taken part in studies of rehabilitation exercises that incorporated monotonous timed auditory cues (using a metronome) following cerebrovascular events demonstrated improvement in gait and motor functions. The purpose of this case report is to describe the efficacy of Rhythmic Exercises with Auditory Cues (REAC) to improve functions in a patient, years after their traumatic brain injury. METHODS A single case report of a 24-year-old female patient, nine years post hemispherectomy following TBI that resulted in right hemiparesis. The patient was taught to perform REAC exercises at home. These exercises were designed to activate the body while Alternating hands and feet Bilaterally with Cross-midline movements for a short Duration while synchronizing the movements with a metronome as a Rhythm regulator. Outcome measurements included gait and functional assessment and cognitive and psychological instrument scores that were compared pre and post treatment. Clinical improvement was observed in the patient's gait pattern with reduced hip hiking motion and increased cadence. There was a decrease in spasticity in the right arm and leg with some isolated volitional movements of the hand and fingers returning. She also regained sensation in her right arm and leg. Cognitive improvement was demonstrated by increased IQ scores from 78 to 94.
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Affiliation(s)
- Yigal Goldshtrom
- Pillar of Light, Physical Therapy, Address 37-03 Berdan Ave, Fair Lawn, NJ 07410, USA.
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