Cognitive Behavioral Therapy for Sleep Disturbance and Fatigue Following Acquired Brain Injury: Predictors of Treatment Response

Clinician perspectives on cognitive behavioral therapy and health education for sleep disturbance and fatigue after acquired brain injury: A qualitative study

Sleep disturbance and fatigue are persistent, clinically significant problems for many with acquired brain injury (ABI). A recent randomized controlled trial (RCT) demonstrated that cognitive and behavioral therapy tailored for post-ABI sleep and fatigue (CBT-SF) produced larger and faster effects compared to an active health education (HE) control intervention. The current study aimed to qualitatively explore the perspectives of the six clinicians, all clinical neuropsychologists, who delivered the CBT-SF and HE interventions to 126 individuals with ABI in the RCT. One-on-one semi-structured interviews were conducted, and transcripts were analyzed using reflexive thematic analysis. Seven themes were generated, encompassing client-related factors (Client Awareness and Readiness as Precursors to Engagement and Navigating Client Differences Throughout Treatment) and clinician-related factors that influenced treatment delivery (Building on Pre-Existing Expertise and Strengths and Challenges of Delivering a Manualized Intervention), as well as other themes directly related to treatment delivery itself (Challenges and Successes Relating to Client Engagement, CBT Strategies That Work, and Navigating Practical Considerations in Treatment Delivery). The findings reinforce the value of psychoeducation and cognitive-behavioral strategies for managing sleep and fatigue problems after ABI. They also provide valuable insights to guide the translation of CBT-SF from an RCT to real-world clinical practice.

Understanding participant experiences of cognitive behavioural therapy and health education for sleep disturbance and fatigue after acquired brain injury: a qualitative study

PURPOSE

A recent randomised controlled trial demonstrated the efficacy of a cognitive behavioural therapy intervention for sleep disturbance and fatigue (CBT-SF) after acquired brain injury (ABI), leading to more rapid improvement than an active health education (HE) control intervention. This study qualitatively examined participants' experiences of receiving the CBT-SF and HE interventions.

MATERIALS AND METHODS

20 individuals with ABI shared their experiences with the interventions through semi-structured interviews, with transcripts analysed using reflexive thematic analysis.

RESULTS

We identified eight themes, organised into a narrative spanning the start of treatment (Coming Into Therapy), through the process of change (Acceptance, Taking Control, and It's Hard Work) and helpful intervention elements (Building Knowledge and Skills and Facilitating Factors), to life post-treatment (Maintaining Improvements and Overall Intervention Outcomes). Treatment helped participants accept their sleep and fatigue problems as enduring consequences of a brain injury, while empowering them to regain control by learning strategies to manage their symptoms, which they continued to use post-treatment.

CONCLUSIONS

This qualitative study reinforces the value of the CBT-SF and HE interventions for sleep and fatigue problems after ABI. Findings contribute to our understanding of the mechanisms driving change within these interventions and raise important considerations for clinical translation.

Predictors of Response to Cognitive Behavioral Therapy for Sleep Disturbance and Fatigue After Acquired Brain Injury: A Secondary Analysis of a Randomized Controlled Trial

OBJECTIVE

To investigate factors associated with response to cognitive behavioral therapy for sleep disturbance and fatigue (CBT-SF) in individuals with acquired brain injury.

DESIGN

Participants took part in a parent randomized controlled trial comparing an 8-week CBT-SF program with a health education control, face-to-face or via videoconferencing, and adapted for cognitive impairments. They were assessed at baseline, posttreatment, 2 months posttreatment, and 4 months posttreatment. A secondary analysis was conducted to identify which demographic, injury-related, neuropsychological, and pretreatment variables, as well as mode of treatment delivery, were associated with response to CBT-SF.

SETTING

Community dwelling.

PARTICIPANTS

Eighty-six participants (N=86) with a traumatic brain injury (TBI) or stroke who received CBT-SF in a parent randomized controlled trial.

INTERVENTIONS

CBT-SF.

MAIN OUTCOME MEASURES

Pittsburgh Sleep Quality Index and Fatigue Severity Scale.

RESULTS

Greater improvements in sleep after CBT-SF were associated with higher baseline sleep disturbance, less time since injury, and telehealth mode of delivery. Larger reductions in fatigue were associated with less time since injury and higher education. Injury type (TBI and stroke) and cognitive variables were not associated with treatment outcomes.

CONCLUSIONS

These findings highlight that an adapted CBT-SF intervention can be equally effective for individuals with TBI and stroke; however, gains are greater earlier after injury. Although individuals with severe symptoms at baseline show the greatest benefit, the intervention can be effective across a range of symptom presentations.

Features of Structured, One-to-One Videoconference Interventions That Actively Engage People in the Management of Their Chronic Conditions: Scoping Review

BACKGROUND

A dramatic increase in the use of videoconferencing occurred as a response to the COVID-19 pandemic, including delivery of chronic disease management programs. With this increase, clients' openness to and confidence in receiving any type of telehealth care has dramatically improved. However, the rapidity of the response was accomplished with little time to learn from existing knowledge and research.

OBJECTIVE

The purpose of this scoping review was to identify features, barriers, and facilitators of synchronous videoconference interventions that actively engage clients in the management of chronic conditions.

METHODS

Using scoping review methodology, MEDLINE, CINAHL, and 6 other databases were searched from 2003 onward. The included studies reported on structured, one-on-one, synchronous videoconferencing interventions that actively engaged adults in the management of their chronic conditions at home. Studies reporting assessment or routine care were excluded. Extracted text data were analyzed using thematic analysis and published taxonomies.

RESULTS

The 33 included articles reported on 25 distinct programs. Most programs targeted people with neurological conditions (10/25, 40%) or cancer (7/25, 28%). Analysis using the Taxonomy of Every Day Self-Management Strategies and the Behavior Change Technique Taxonomy version 1 identified common program content and behavior change strategies. However, distinct differences were evident based on whether program objectives were to improve physical activity or function (7/25, 28%) or mental health (7/25, 28%). Incorporating healthy behaviors was addressed in all programs designed to improve physical activity or function, whereas only 14% (1/7) of the programs targeting mental health covered content about healthy lifestyles. Managing emotional distress and social interaction were commonly discussed in programs with objectives of improving mental health (6/25, 24% and 4/25, 16%, respectively) but not in programs aiming at physical function (2/25, 8% and 0%, respectively). In total, 13 types of behavior change strategies were identified in the 25 programs. The top 3 types of strategies applied in programs intent on improving physical activity or function were feedback and monitoring, goals and planning, and social support, in contrast to shaping knowledge, regulation, and identity in programs with the goal of improving mental health. The findings suggest that chronic condition interventions continue to neglect evidence that exercise and strong relationships improve both physical and mental health. Videoconference interventions were seen as feasible and acceptable to clients. Challenges were mostly technology related: clients' comfort, technology literacy, access to hardware and the internet, and technical breakdowns and issues. Only 15% (5/33) of the studies explicitly described compliance with health information or privacy protection regulations.

CONCLUSIONS

Videoconferencing is a feasible and acceptable delivery format to engage clients in managing their conditions at home. Future program development could reduce siloed approaches by adding less used content and behavior change strategies. Addressing client privacy and technology issues should be priorities.

Randomized controlled trial of cognitive behavioral therapy versus health education for sleep disturbance and fatigue following stroke and traumatic brain injury

OBJECTIVE

Evaluate efficacy of cognitive behavioural therapy for sleep and fatigue adapted for brain injury relative to health education control in alleviating sleep disturbance and fatigue after acquired brain injury.

DESIGN

Parallel groups randomized controlled trial.

SUBJECTS

126 community dwelling adults with stroke or traumatic brain injury.

METHODS

Participants were randomized 2:1 to receive 8-weeks of cognitive behavioural therapy for sleep and fatigue (n = 86) or health education (n = 40). The Pittsburgh Sleep Quality Index was assessed pre- and post-treatment, and 2 and 4-months post-treatment, with secondary measures of insomnia, fatigue, sleepiness, mood, quality of life, activity levels, self-efficacy, and actigraphy.

RESULTS

Both groups showed improved sleep by 4-month follow-up. However, cognitive behavioural therapy for sleep and fatigue had significantly larger and more rapid improvements than health education immediately post-treatment (β = -1.50, p < 0.001, 95% confidence interval -2.35 to -0.64). There were no significant between-groups differences in fatigue; however, cognitive behavioural therapy for sleep and fatigue showed within-group gains on both fatigue measures immediately post-treatment and over time (β = -0.29, p = 0.047, 95% confidence interval -0.58 to -0.01). Health education had delayed improvements at 4-month follow-up on 1 fatigue measure.

CONCLUSIONS

Both cognitive behavioural therapy for sleep and fatigue and health education led to improvement in sleep and fatigue; however, effects were larger and more rapid for cognitive behavioural therapy for sleep and fatigue immediately post-treatment. This supports the efficacy of cognitive behavioural therapy for sleep and fatigue in acquired brain injury but also highlights that health education may result in delayed improvements in symptoms. ANZCTR Trial registration numbers: 1261700087830; 12617000879369.

Symptom clusters and network analysis in patients with gynecologic cancer undergoing chemotherapy: A cross-sectional study

Objective

This study aimed to explore the complex relationships among symptoms and symptom clusters in patients with gynecologic cancer receiving chemotherapy using symptom network analysis, and to identify core symptoms and core symptom clusters.

Methods

A cross-sectional study was conducted at the Affiliated Hospital of Jiangnan University from December 2023 to June 2024, including 221 patients with gynecologic tumors. Participants completed demographic and clinical information questionnaires and the Chinese version of the MD Anderson Symptom Inventory (MDASI-C). Univariate analysis and multiple linear regression were used to screen covariates, exploratory factor analysis to determine symptom clusters, and network analysis to identify core symptoms and core symptom clusters.

Results

A total of 221 patients were included, with an average age of 58.73 years (SD = 11.50). Fatigue (n = 197, 89.1%) and lack of appetite (n = 192, 86.9%) were the most common symptoms, while fatigue (mean = 4.17, SD = 2.07) and distress (mean = 3.43, SD = 2.20) were the most severe symptoms. Several distinct symptom clusters were identified: sickness behavior, gastrointestinal, psychological, and side-effect clusters. In the constructed network, fatigue emerged as the most central symptom (rs = 1.28), while the sickness behavior cluster was identified as the most central symptom cluster (rs = 1.11).

Conclusions

Patients with gynecologic cancer undergoing chemotherapy commonly experience a range of symptoms. Our findings suggest that targeted interventions focusing on the sickness behavior symptom cluster may help reduce the overall symptom burden and assist caregivers in developing more effective symptom management strategies.

A Preliminary Investigation of Stakeholders' Perspectives on Cognitive Fatigue After Childhood Brain Injury

BACKGROUND

Cognitive fatigue after childhood acquired brain injury (ABI) is known to negatively impact engagement in typical academic and social activities, yet limited evidence is available to inform speech-language pathologists' (SLPs') clinical practices. The purpose of this research study was to explore stakeholders' perspectives on cognitive fatigue for children with ABI to inform future directions for clinicians and researchers.

METHOD

Twelve parents of children with traumatic brain injury and 35 SLPs participated in an online survey with 33 and 49 questions, respectively, including participant characteristics and perspectives on cognitive fatigue.

RESULTS

Parents reported being between "somewhat" and "highly aware" about cognitive fatigue, whereas SLPs reported being between "neither aware or not aware" and "somewhat aware." Parents reported being between "somewhat comfortable" and "very comfortable," whereas SLPs reported being between "neither comfortable or uncomfortable" and "somewhat comfortable" addressing cognitive fatigue in children with ABI. SLPs "somewhat" to "strongly" agreed that cognitive fatigue for children with ABI was within their scope of practice. Parents and SLPs reported accommodations and strategies useful to managing cognitive fatigue in children with brain injury, as well as factors that worsen and lessen cognitive fatigue.

CONCLUSIONS

While additional foundational and translation research is needed, the perspectives of parents and SLPs begin to address a critical gap in SLPs' assessment and management of cognitive fatigue in children with ABI.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24216576.

Clinical Updates in Mild Traumatic Brain Injury (Concussion)

Traumatic brain injury (TBI) affects > 3 million people in the United States annually. Although the number of deaths related to severe TBIs has stabalized, mild TBIs, often termed concussions, are increasing. As evidence indicates that a significant proportion of these mild injuries are associated with long-lasting functional deficits that impact work performance, social integration, and may predispose to later cognitive decline, it is important that we (a) recognize these injuries, (b) identify those at highest risk of poor recovery, and (c) initiate appropriate treatments promptly. We discuss the epidemiology of TBI, the most common persistent symptoms, and treatment approaches.

A short add-on sleep intervention in the rehabilitation of individuals with acquired brain injury: A randomized controlled trial

BACKGROUND

Sleep disturbances are common after acquired brain injury (ABI) and have a negative impact on functioning.

OBJECTIVE

This study examines whether a short add-on therapy for sleep disturbances in individuals with ABI is effective in addition to rehabilitation treatment as usual.

METHODS

In the randomized-controlled study, 54 adults with ABI and self-reported sleep disturbances receiving outpatient rehabilitation services were randomized in two groups: one receiving a sleep intervention (based on cognitive behavioural therapy for insomnia (CBT-I)) in addition to their rehabilitation treatment (CBT-I + TAU group) and one receiving treatment as usual (TAU). The primary outcome was sleep quality, measured with the Pittsburgh Sleep Quality Index (PSQI). Secondary outcomes included measures of anxiety, depression, fatigue and dysfunctional beliefs and attitudes about sleep.

RESULTS

The short add-on sleep therapy resulted in improvements in sleep quality in the CBT-I + TAU group as compared to the TAU group (ES = 0.924). Furthermore, the CBT-I + TAU group reported less dysfunctional beliefs and attitudes about sleep and were better able to cope with fatigue compared to the TAU group.

CONCLUSIONS

The application of this short add-on sleep intervention could be implemented in neuropsychological rehabilitation settings.

Cognitive behavioural therapy versus health education for sleep disturbance and fatigue after acquired brain injury: A pilot randomised trial

BACKGROUND

Sleep disturbance and fatigue are highly prevalent after acquired brain injury (ABI) and are associated with poor functional outcomes. Cognitive behavioural therapy (CBT) is a promising treatment for sleep and fatigue problems after ABI, although comparison with an active control is needed to establish efficacy.

OBJECTIVES

We compared CBT for sleep disturbance and fatigue (CBT-SF) with a health education (HE) intervention to control for non-specific therapy effects.

METHODS

In a parallel-group, pilot randomised controlled trial, 51 individuals with traumatic brain injury (n = 22) and stroke (n = 29) and clinically significant sleep and/or fatigue problems were randomised 2:1 to 8 weeks of a CBT-SF (n = 34) or HE intervention (n = 17), both adapted for cognitive impairments. Participants were assessed at baseline, post-treatment, and 2 and 4 months post-treatment. The primary outcome was the Pittsburgh Sleep Quality Index; secondary outcomes included measures of fatigue, sleepiness, mood, quality of life, activity levels, self-efficacy and actigraphy sleep measures.

RESULTS

The CBT-SF led to significantly greater improvements in sleep quality as compared with HE, during treatment and at 2 months [95% confidence interval (CI) -24.83; -7.71], as well as significant reductions in fatigue maintained at all time points, which were not evident with HE (95% CI -1.86; 0.23). HE led to delayed improvement in sleep quality at 4 months post-treatment and in depression (95% CI -1.37; -0.09) at 2 months post-treatment. CBT-SF led to significant gains in self-efficacy (95% CI 0.15; 0.53) and mental health (95% CI 1.82; 65.06).

CONCLUSIONS

CBT-SF can be an effective treatment option for sleep disturbance and fatigue after ABI, over and above HE. HE may provide delayed benefit for sleep, possibly by improving mood.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry: ACTRN12617000879369 (registered 15/06/2017) and ACTRN12617000878370 (registered 15/06/2017).