INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part V: Memory

I thought it would be difficult, but this is actually something I can do - experiences with Virtual Reality-based cognitive training in persons with TBI

INTRODUCTION

Virtual reality (VR) has been suggested as a promising technology for delivering cognitive training to persons with traumatic brain injury (TBI), as it can provide situations resembling everyday activities. Studies have demonstrated that persons with TBI manage utilizing VR in clinical settings; however, no studies have investigated VR use in home settings. The aim of this study was to explore how persons with TBI experience utilizing VR for rehabilitation at home and how they experience VR as cognitive training.

METHODS

Individual qualitative interviews were conducted with ten persons with TBI, aged 18-65. Participants had experience using VR, as they were recruited from the intervention group in a randomized controlled trial investigating VR in cognitive training. The data were analyzed using thematic analysis.

RESULTS

Participants highlighted the importance of creating new routines when fitting VR into everyday life. They addressed how being in a virtual world contributes to their motivation for cognitive training. Three themes were developed: 'Fitting VR-training into everyday life', 'Navigating through change' and 'Being in two worlds at the same time'.

CONCLUSION

This study shows that participants experienced VR as motivating, engaging, and easy to use, regardless of prior experiences with VR. The participants demonstrated how they included VR in everyday life by creating new routines when they performed cognitive training. Therewere few reports of adverse events. However, some experienced that VR had a negative impact on their energy level. Participants described the importance of therapeutic involvement for individual tailoring of the intervention.

Rebuilding the self through valued action and group connections after acquired brain injury: Participant perspectives of the VaLiANT group intervention

Effective interventions that facilitate adjustment following acquired brain injury (ABI) are needed to improve long-term outcomes and meaningful reengagement in life. VaLiANT is an 8-week group intervention that combines cognitive rehabilitation with Acceptance and Commitment therapy to improve valued living, wellbeing, and adjustment. This study explored participant experiences of VaLiANT to optimize its ongoing development. This included characterization of individually meaningful treatment outcomes, mechanisms of action, and intervention acceptability. Qualitative interviews and quantitative ratings were collected from 39 ABI survivors (Mage = 52, SD = 15; 54% stroke) following their participation in VaLiANT. Participants reported diverse outcomes which resulted in three themes being generated following reflexive thematic analysis. "A fuller toolkit for life with brain injury" indicated increased strategy usage and better daily functioning; "The value of connection and belonging" captured the importance of social experiences in shaping recovery; and "Finding the me I can be" represented cognitive, behavioural, and emotional aspects of identity reconstruction post-ABI. The content and delivery of the intervention were rated highly but participants desired greater follow-up and tailoring of the intervention. Overall, VaLiANT appears to facilitate adjustment through several mechanisms, but greater intervention individualization and dosage may be required to enhance the treatment impact.

Ageing with Traumatic Brain Injury: Long-Term Cognition and Wellbeing

Whether and how traumatic brain injury (TBI) impacts ageing in the decades post-injury remains a matter of debate, partly due to a lack of controlled studies. This study examined the long-term impact of TBI on cognition and wellbeing in middle-aged and older adults and explored the relationship between age, cognition, and wellbeing, compared with a non-TBI control group. Cross-sectional data from 143 participants aged ≥40 with moderate-severe TBI (6-33 years post-injury; mean age 59.64) were compared with 71 non-TBI controls (mean age 62.10) group matched on age, gender, and premorbid IQ. Individuals with significant confounding comorbidities were excluded. A battery of neuropsychological tests and wellbeing measures (emotional distress, sleep, health-related quality of life [HRQoL]) was administered. Older age and TBI were each independently associated with poorer cognition across multiple domains (p < 0.05). The relationship between verbal learning and memory impairment post-TBI differed between age groups: individuals with TBI in their 40s-60s performed significantly worse than same-aged controls on verbal story acquisition (B = 0.09, p = 0.040, 95% confidence interval [CI] [0.004, 0.17]) and recall (B = 0.12, p = 0.009, 95% CI [0.03, 0.21]), and verbal wordlist recall (B = 0.11, p = 0.007, 95% CI [0.03, 0.19]). In comparison, no significant group differences in verbal memory emerged for ages 70-90. The TBI group reported greater emotional distress (B = 3.55, p < 0.001, 95% CI [1.73, 5.37]), poorer sleep quality (B = 1.07, p = 0.016, 95% CI [0.20, 1.94]), and poorer physical HRQoL (B = -4.26, p = 0.003, 95% CI [-7.08, -1.43]) than controls at all ages. Poorer physical HRQoL was related to poorer cognition post-TBI (p < 0.05). Our results challenge the notion that TBI exacerbates ageing. Moderate-severe TBI resulted in significant long-term impairments in cognition and wellbeing, with verbal learning and memory more impaired during middle-adulthood but not older adulthood compared to controls. TBI was not associated with changes to wellbeing with ageing. Intervention for verbal memory deficits in middle-aged adults with TBI is important, along with wider long-term supports for cognition, wellbeing, and activity participation in all individuals with TBI.

Development and Pilot Implementation of a Theory-Based Cognitive Rehabilitation Protocol for Adults With Chronic Cognitive Complaints After Mild Traumatic Brain Injury

PURPOSE

The aim of this study was to describe the development of and pilot feasibility outcomes for a strategy-based, brief, intensive cognitive rehabilitation intervention delivered to U.S. service members and veterans with mild traumatic brain injury in a recently completed 3-year pragmatic clinical trial: Symptom-Targeted Approach to Rehabilitation for Concussion (STAR-C).

METHOD

To develop STAR-C, we used the Rehabilitation Treatment Specification System to identify core elements and principles from a previous randomized clinical trial of cognitive rehabilitation, and incorporated principles of neuroplasticity (e.g., high-dose spaced practice of personally meaningful tasks), best clinical practices (e.g., client-centered goal setting), health psychology (e.g., a focus on self-efficacy and motivation), and community-based participation research (e.g., the protocol was co-designed by clinicians and researchers). Treatment was based on a resource-allocation theory of everyday cognitive challenges, which predicted that automatic strategy use would reduce cognitive demands of everyday activities and therefore reduce cognitive symptoms. Treatment was delivered by speech-language pathologists (SLPs) and occupational therapists (OTs), using a protocol that included a problem-focused intake questionnaire, manualized treatment, and clinician resources. Therapy was delivered individually in six to 10 virtual or in-person sessions over 3-4 weeks. Therapy focused on desired changes in function, scaled using Goal Attainment Scaling.

RESULTS

Trained SLPs and OTs delivered STAR-C to 53 U.S. service members and veterans, with treatment fidelity > 95%. Participants and clinicians rated STAR-C as acceptable, feasible, and appropriate, and most participants attained and maintained targets.

CONCLUSION

STAR-C appears to be a feasible method for improving everyday cognitive performance and efficacy should be tested in a controlled study.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.28222613.

A Mixed Methods Evaluation of Implementation Outcomes of a Self-Regulation Strategy for Health Education: Perspectives of Clinicians and Older Adults With and Without Traumatic Brain Injury

PURPOSE

Effective self-management is key for older adults with and without traumatic brain injury (TBI) to maintain their health, safety, and independence. Self-regulation is one method of promoting self-management. However, it is essential to examine effective methods of self-regulation interventions to maximize the use of such health promotion.

METHOD

Forty-one older adults (19 with TBI; 22 without TBI) participated in an in-person or telepractice health education intervention for fall prevention with 15 speech-language pathology student clinicians. The intervention was a self-regulation strategy, mental contrasting with implementation intentions (MCII), for promoting fall prevention. This mixed methods study explored treatment adherence and evaluated implementation outcomes through acceptability, appropriateness, feasibility, modifications to treatment, and therapist adherence and client participation.

RESULTS

All participants demonstrated some behavior change. Participants without TBI evaluated the MCII protocol as more acceptable, F(1, 39) = 5.88, p = .018; appropriate, F(1, 39) = 5.34, p = .023; and feasible, F(1, 39) = 9.56, p = .003, than participants with TBI, although all ratings were perceived as neutral or positive. From clinician data, protocol adherence, F(1, 39) = 1.57, p = .22, and client participation, F(1, 39) = 0.10, p = .92, were similar across injury groups, but participants with TBI required more fidelity-consistent modifications to treatment, F(1, 39) = 6.88, p = .012. There were no differences between settings except that those in telepractice had more client participation, F(1, 39) = 21.02, p < .001. Clinicians felt MCII was equally appropriate for both groups in all settings, acceptability: F(1, 48) = 0.082, p = .78; appropriateness: F(1, 48) = 0.554, p = .46; feasibility: F(1, 48) = 0.197, p = .66.

CONCLUSION

MCII may be a feasible tool to provide health education as it offers enough structure and individualization to be considered appropriate and relevant for older adults, and for novice clinicians to administer and modify as needed based on client needs.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.28074443.

The processing of verbal memories after traumatic brain injury

Objective: Memory dysfunction is a persistent cognitive symptom following traumatic brain injury (TBI), negatively impacting capacity for independent living and productivity. Traditional scoring of neuropsychological memory tests does not allow for differentiation of specific impairments of encoding, consolidation and/or retrieval, or the potential impact of strategy deficits. Method: The current study examined performance of 142 moderate-to-severe TBI participants and 68 demographically matched healthy controls on the Rey Auditory Verbal Learning Test (RAVLT) using Item Specific Data Analysis (ISDA) and strategy use analyses. Results: Results revealed significantly greater impairments in encoding, consolidation, and retrieval in TBI participants, compared to controls. Encoding deficits significantly explained the most variance in the long-delayed recall of TBI participants, followed by consolidation, and then retrieval. Participants with TBI showed a reduced ability to spontaneously apply strategies during learning, evident in decreased subjective clusters and increased word omissions, compared to controls. No difference was found between groups in passive learning strategy application, shown through serial clustering. Spontaneous strategy measures both uniquely accounted for variance in the encoding ability of TBI participants. Conclusions: These findings highlight the potential value in using ISDA and strategy use measures to assess RAVLT results to better characterize individual memory profiles and inform rehabilitative interventions.

Errorless Learning for Everyday Functioning in Adults With Brain Injury: A Scoping Review

BACKGROUND

Errorless learning is an intervention technique used in acquired brain injury (ABI) rehabilitation. To support the use of this intervention within occupational therapy practice, it is important to know how errorless learning has been applied to (re)train daily functions.

OBJECTIVES

To describe the empirical literature on errorless learning applied to everyday functioning in adults with ABI.

METHOD

A scoping review was conducted with systematic searching of four databases (i.e., AMED, CINAHL, MEDLINE, PsycINFO) and screening by independent reviewers.

FINDINGS

41 experiments from 34 papers met eligibility criteria. Errorless learning has been heterogeneously delineated, described, and applied. Operationalization of everyday functioning has been poorly reported, and mostly applied to technology use and instrumental activities of daily living.

IMPLICATIONS

Greater clarity and detail of errorless learning interventions are required, and more research is needed on its applications to everyday functioning.

Multicenter Evaluation of Memory Remediation in Traumatic Brain Injury With Donepezil: A Randomized Controlled Trial

Memory impairments are common chronic and functionally important consequences of traumatic brain injury (TBI). Among patients with persistent verbal memory impairments due to TBI-related cholinergic deficits, donepezil (an acetylcholinesterase inhibitor) may improve these and related problems. The Multicenter Evaluation of Memory Remediation in TBI with Donepezil (MEMRI-TBI-D) study, a four-site, randomized, parallel-group, double-blind, placebo-controlled, 10-week clinical trial, evaluated the efficacy of donepezil on verbal memory impairments, co-occurring cognitive and noncognitive neuropsychiatric problems, and functional status among persons with severe, persistent, and functionally limiting verbal memory problems at least 6 months after mild, moderate, or severe TBI. Efficacy, safety, and tolerability measures were assessed. Seventy-five participants were randomly assigned to donepezil (N=37) and placebo (N=38) groups. In both modified intent-to-treat and per-protocol analyses, donepezil significantly improved memory (i.e., verbal learning, as measured by the Hopkins Verbal Learning Test-Revised Total Trials 1-3, the primary outcome measure) when compared with placebo. Treatment-responder rates in the donepezil and placebo groups were 42% and 18%, respectively, yielding a number needed to treat of 3.5. Among donepezil responders, delayed recall and processing speed also improved significantly. Treatment-emergent adverse event rates for donepezil and placebo were 46% and 8%, respectively, and mild or moderate (85%); diarrhea and nausea were significantly more common in the donepezil group, yielding a number needed to harm of 6.25 and a likelihood to be helped or harmed ratio of 1.79. These results suggest that donepezil is an efficacious treatment for severe, persistent memory impairments after predominantly severe TBI, with a relatively favorable safety and tolerability profile.

Delivery of Neuropsychological Interventions for Adult and Older Adult Clinical Populations: An Australian Expert Working Group Clinical Guidance Paper

Delivery of neuropsychological interventions addressing the cognitive, psychological, and behavioural consequences of brain conditions is increasingly recognised as an important, if not essential, skill set for clinical neuropsychologists. It has the potential to add substantial value and impact to our role across clinical settings. However, there are numerous approaches to neuropsychological intervention, requiring different sets of skills, and with varying levels of supporting evidence across different diagnostic groups. This clinical guidance paper provides an overview of considerations and recommendations to help guide selection, delivery, and implementation of neuropsychological interventions for adults and older adults. We aimed to provide a useful source of information and guidance for clinicians, health service managers, policy-makers, educators, and researchers regarding the value and impact of such interventions. Considerations and recommendations were developed by an expert working group of neuropsychologists in Australia, based on relevant evidence and consensus opinion in consultation with members of a national clinical neuropsychology body. While the considerations and recommendations sit within the Australian context, many have international relevance. We include (i) principles important for neuropsychological intervention delivery (e.g. being based on biopsychosocial case formulation and person-centred goals); (ii) a description of clinical competencies important for effective intervention delivery; (iii) a summary of relevant evidence in three key cohorts: acquired brain injury, psychiatric disorders, and older adults, focusing on interventions with sound evidence for improving activity and participation outcomes; (iv) an overview of considerations for sustainable implementation of neuropsychological interventions as 'core business'; and finally, (v) a call to action.

Factors Influencing Speech-Language Pathology Referral and Utilization in Mild Traumatic Brain Injury: An Exploratory Analysis

PURPOSE

Speech-language pathologists provide important services to people recovering from mild traumatic brain injury (mTBI), also called concussion, although they may be underutilized in outpatient care. Because health care providers face challenges in selecting assessments to efficiently describe patient needs, the purpose of this study was to describe factors related to patients receiving speech-language pathology services after mTBI, as well as how assessments predict amount of services received.

METHOD

In this retrospective chart review study, demographic factors, injury characteristics, and assessment scores were extracted from medical records of patients aged 14-65 years receiving services for recent (within 6 months) mTBI at an outpatient specialty clinic. The Post-Concussion Symptom Scale (PCSS), Montreal Cognitive Assessment, Standardized Assessment of Concussion, and a newly developed self-report measure of cognitive-communication function-the Cognitive-Communication Referral Indicator for Concussion (CCoRI-C)-were used as dependent variables to predict speech-language pathology service referral. For those referred, Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and Behavior Rating Inventory of Executive Function (BRIEF) scores were added as dependent variables predicting speech-language pathology dosage.

RESULTS

A total of 132 patient charts met inclusion and exclusion criteria. In addition to CCoRI-C and PCSS symptoms, receiving imaging, being injured in a motor vehicle crash, experiencing loss of consciousness, and being of female sex were related to speech-language pathology referrals. Of the 77 patients referred for speech-language pathology care, higher CCoRI-C, PCSS, BRIEF, RBANS total, and RBANS visuospatial scores were associated with recommended speech-language pathology dosage. Only the CCoRI-C, BRIEF-Adult Version (BRIEF-A) Behavioral Regulation, and BRIEF-A Metacognition were associated with actual number of speech-language pathology sessions attended.

CONCLUSIONS

Cognitive-communication symptoms and executive function may be important to planning speech-language pathology rehabilitative episodes of care for people with mTBI. Future work should continue to evaluate how assessments augment demographic and injury characteristics in decision making for both referral to and use of speech-language pathology services after mTBI.

Long-Term Effects of Intensive Rehabilitation on Memory Functions in Acquired Brain-Damaged Patients

OBJECTIVE

Memory difficulties after brain injury are a frequent and concerning outcome, affecting a wide range of daily activities, employment, and social reintegration. Despite the importance of functional memory capacities throughout life, most studies examined the short-term effects of memory interventions in brain-damaged patients who underwent a rehabilitation program. In the present study, we investigated the long-term outcomes and intensity of memory interventions in acquired (traumatic brain injury [TBI] and non-TBI) brain-damaged patients who participated in an intensive cognitive rehabilitation program and either suffered or did not suffer from memory impairments.

METHOD

We measured pre-post-treatment memory performance of patiients (N = 24) suffering from memory deficits in four common and validated memory tasks (e.g. ROCFT). We compared them to other acquired brain injury patients treated at the same rehabilitation facility who did not suffer from memory impairments (N = 16).

RESULTS

Patients with memory deficits showed long-term improvements in three out of four tasks, while patients without memory deficits showed memory enhancements in only one task. In addition, rehabilitation intensity and type of brain damage predicted the extent of the memory change over time.

DISCUSSION

Long-term improvements in objective memory measures can be observed in patients suffering from brain injury. These improvements can be enhanced by intensifying the treatment program. Findings also suggest that these memory improvements are more pronounced in non-TBI than TBI patients. We discuss the implications of these results in designing optimal memory rehabilitation interventions.

Cognitive Rehabilitation for Adults with a History of Traumatic Brain Injury

Cognitive rehabilitation following traumatic brain injury (TBI) involves a targeted, individualized approach to address deficits in attention, memory, executive functions, and/or other cognitive domains. This overview highlights the importance of thorough assessment to inform cognitive rehabilitation, a multidimensional approach, and current best practices in intervention strategies. It provides exemplar compensatory strategies for each cognitive domain. In addition to broad clinical practice guidelines, it also addresses unique considerations that may be warranted in some subgroups with TBI. Finally, outcome measurement is summarized.

Reduced on-line speech gesture integration during multimodal language processing in adults with moderate-severe traumatic brain injury: Evidence from eye-tracking

BACKGROUND

Language is multimodal and situated in rich visual contexts. Language is also incremental, unfolding moment-to-moment in real time, yet few studies have examined how spoken language interacts with gesture and visual context during multimodal language processing. Gesture is a rich communication cue that is integrally related to speech and often depicts concrete referents from the visual world. Using eye-tracking in an adapted visual world paradigm, we examined how participants with and without moderate-severe traumatic brain injury (TBI) use gesture to resolve temporary referential ambiguity.

METHODS

Participants viewed a screen with four objects and one video. The speaker in the video produced sentences (e.g., "The girl will eat the very good sandwich"), paired with either a meaningful gesture (e.g., sandwich-holding gesture) or a meaningless grooming movement (e.g., arm scratch) at the verb "will eat." We measured participants' gaze to the target object (e.g., sandwich), a semantic competitor (e.g., apple), and two unrelated distractors (e.g., piano, guitar) during the critical window between movement onset in the gesture modality and onset of the spoken referent in speech.

RESULTS

Both participants with and without TBI were more likely to fixate the target when the speaker produced a gesture compared to a grooming movement; however, relative to non-injured participants, the effect was significantly attenuated in the TBI group.

DISCUSSION

We demonstrated evidence of reduced speech-gesture integration in participants with TBI relative to non-injured peers. This study advances our understanding of the communicative abilities of adults with TBI and could lead to a more mechanistic account of the communication difficulties adults with TBI experience in rich communication contexts that require the processing and integration of multiple co-occurring cues. This work has the potential to increase the ecological validity of language assessment and provide insights into the cognitive and neural mechanisms that support multimodal language processing.

INTIMASY-TBI Guideline: Optimization of INTIMAcy, SexualitY, and Relationships Among Adults With Traumatic Brain Injury

INTRODUCTION

Traumatic brain injury (TBI) can negatively impact intimacy, relationships, and sexual functioning through changes in physical, endocrine, cognitive, behavioral, and emotional function. Without intervention, diminished intimacy and/or sexual functioning in individuals with TBI may persist. Although most health care professionals agree that sexuality and intimacy in relationships are significant concerns and should be addressed in rehabilitation, these concerns are not typically discussed during rehabilitation and discharge planning for people with TBI. To address this gap, an expert panel of North American clinicians and researchers convened to develop evidence-informed recommendations to assist clinicians in providing a framework and guidance on how clinicians can support individuals after TBI.

METHODS

A systematic search of multiple databases was conducted to identify relevant evidence published from 2010 to 2023. The INTIMASY-TBI Expert Panel developed recommendations for optimizing discussions and interventions related to intimacy and sexuality for people with TBI in rehabilitation and community-based programs. For each recommendation, the experts evaluated the evidence by examining the study design and quality to determine the level of evidence.

RESULTS

A total of 12 recommendations were developed that address the following topic areas: (1) interprofessional team training, (2) early education on the effects of TBI on intimacy, relationships, and sexuality, (3) creating individualized interventions, (4) education, assessment, and management of the causes of sexual dysfunction, and (5) providing written materials and relationship coaching to persons with TBI and their partners. Two recommendations were supported by Level A evidence, 1 was supported by Level B evidence, and 9 were supported by Level C (consensus of the INTIMASY-TBI Expert Panel) evidence. A decision algorithm was developed to assist clinicians in navigating through the recommendations.

CONCLUSION

The INTIMASY-TBI Guideline is one of the first comprehensive clinical practice guidelines to offer strategies to trained clinicians to discuss the physical, psychosocial, behavioral, and emotional aspects of intimacy and sexuality with persons with TBI.

Lessons Learned From Moving to Living Guidelines-The Canadian Clinical Practice Guideline for the Rehabilitation of Adults With Moderate-to-Severe TBI

OBJECTIVE

It is often challenging for providers to remain up to date with best practices gleaned from clinical research. Consequently, patients may receive inappropriate, suboptimal, and costly care. Living clinical practice guidelines (CPGs) maintain the methodological rigor of traditional CPGs but are continuously updated in response to new research findings, changes in clinical practice, and emerging evidence. The objective of this initiative was to discuss the lessons learned from the transformation of the Canadian Clinical Practice Guideline for the Rehabilitation of Adults with Traumatic Brain Injury (CAN-TBI) from a traditional guideline update model to a living guideline model.

DESIGN

The CAN-TBI Guideline provides evidence-based rehabilitative care recommendations for individuals who have sustained a TBI. The Guideline is divided into 2 sections: Section I, which provides guidance on the components of the optimal TBI rehabilitation system, and Section II, which focuses on the assessment and rehabilitation of brain injury sequelae. A comprehensive outline of the living guideline process is presented.

RESULTS

The CAN-TBI living guideline process has yielded 351 recommendations organized within 21 domains. Currently, 30 recommendations are supported by level A evidence, 81 recommendations are supported by level B evidence, and 240 consensus-based recommendations (level C evidence) comprise 68% of the CAN-TBI Guideline.

CONCLUSION

Given the increasing volume of research published on moderate-to-severe TBI rehabilitation, the CAN-TBI living guideline process allows for real-time integration of emerging evidence in response to the fastest-growing topics, ensuring that practitioners have access to the most current and relevant recommendations.

Equity considerations in clinical practice guidelines for traumatic brain injury and the criminal justice system: A systematic review

BACKGROUND

Traumatic brain injury (TBI) is disproportionately prevalent among individuals who intersect or are involved with the criminal justice system (CJS). In the absence of appropriate care, TBI-related impairments, intersecting social determinants of health, and the lack of TBI awareness in CJS settings can lead to lengthened sentences, serious disciplinary charges, and recidivism. However, evidence suggests that most clinical practice guidelines (CPGs) overlook equity and consequently, the needs of disadvantaged groups. As such, this review addressed the research question "To what extent are (1) intersections with the CJS considered in CPGs for TBI, (2) TBI considered in CPGs for CJS, and (3) equity considered in CPGs for CJS?".

METHODS AND FINDINGS

CPGs were identified from electronic databases (MEDLINE, Embase, CINAHL, PsycINFO), targeted websites, Google Search, and reference lists of identified CPGs on November 2021 and March 2023 (CPGs for TBI) and May 2022 and March 2023 (CPGs for CJS). Only CPGs for TBI or CPGs for CJS were included. We calculated the proportion of CPGs that included TBI- or CJS-specific content, conducted a qualitative content analysis to understand how evidence regarding TBI and the CJS was integrated in the CPGs, and utilised equity assessment tools to understand if and how equity was considered. Fifty-seven CPGs for TBI and 6 CPGs for CJS were included in this review. Fourteen CPGs for TBI included information relevant to the CJS, but only 1 made a concrete recommendation to consider legal implications during vocational evaluation in the forensic context. Two CPGs for CJS acknowledged the prevalence of TBI among individuals in prison and one specifically recommended considering TBI during health assessments. Both CPGs for TBI and CPGs for CJS provided evidence specific to a single facet of the CJS, predominantly in policing and corrections. The use of equity best practices and the involvement of disadvantaged groups in the development process were lacking among CPGs for CJS. We acknowledge limitations of the review, including that our searches were conducted in English language and thus, we may have missed other non-English language CPGs in this review. We further recognise that we are unable to comment on evidence that is not integrated in the CPGs, as we did not systematically search for research on individuals with TBI who intersect with the CJS, outside of CPGs.

CONCLUSIONS

Findings from this review provide the foundation to consider CJS involvement in CPGs for TBI and to advance equity in CPGs for CJS. Conducting research, including investigating the process of screening for TBI with individuals who intersect with all facets of the CJS, and utilizing equity assessment tools in guideline development are critical steps to enhance equity in healthcare for this disadvantaged group.

Meta-analysis of Cognitive Rehabilitation Interventions in Veterans and Service Members With Traumatic Brain Injuries

MAIN OBJECTIVE

Cognitive difficulties are some of the most frequently experienced symptoms following mild-to-moderate traumatic brain injuries (TBIs). There is meta-analytic evidence that cognitive rehabilitation improves cognitive functioning after TBI in nonveteran populations but not specifically within the veteran and service member (V/SM) population. The purpose of the current meta-analysis was to examine the effect of cognitive rehabilitation interventions for V/SMs with a history of mild-to-moderate TBI.

DESIGN AND MAIN MEASURES

This meta-analysis was preregistered with PROSPERO (CRD42021262902) and used the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist for reporting guidelines. Inclusion criteria required studies to have (1) randomized controlled trials; (2) used adult participants (aged 18 years or older) who were US veterans or active-duty service members who had a history of mild-to-moderate TBI; (3) cognitive rehabilitation treatments designed to improve cognition and/or everyday functioning; (4) used objective neuropsychological testing as a primary outcome measure; and (5) been published in English. At least 2 reviewers independently screened all identified abstracts and full-text articles and coded demographic and effect size data. The final search was run on February 24, 2023, using 4 databases (PubMed, PsycINFO, Web of Science, and Google Scholar). Study quality and bias were examined using the revised Cochrane Risk-of-Bias Tool for Randomized Trials.

RESULTS

We identified 8 articles meeting full criteria (total participants = 564; 97% of whom had a history of mild TBI). Compared with control groups, participants showed a small, but significant, improvement in overall objective neuropsychological functioning after cognitive rehabilitation interventions. Interventions focusing on teaching strategies had a larger effect size than did those focusing on drill-and-practice approaches for both objective neuropsychological test performance and performance-based measures of functional capacity.

CONCLUSION

There is evidence of cognitive improvement in V/SMs with TBI histories after participation in cognitive rehabilitation. Clinician-administered interventions focusing on teaching strategies may yield the greatest cognitive improvement in this population.

Advances in Neurorehabilitation: Strategies and Outcomes for Traumatic Brain Injury Recovery

Traumatic brain injury (TBI) consists of an external physical force that causes brain function impairment or pathology and globally affects 50 million people each year, with a cost of 400 billion US dollars. Clinical presentation of TBI can occur in many forms, and patients usually require prolonged hospital care and lifelong rehabilitation, which leads to an impact on the quality of life. For this narrative review, no particular method was used to extract data. With the aid of health descriptors and Medical Subject Heading (MeSH) terms, a search was thoroughly conducted in databases such as PubMed and Google Scholar. After the application of exclusion and inclusion criteria, a total of 146 articles were effectively used for this review. Results indicate that rehabilitation after TBI happens through neuroplasticity, which combines neural regeneration and functional reorganization. The role of technology, including artificial intelligence, virtual reality, robotics, computer interface, and neuromodulation, is to impact rehabilitation and life quality improvement significantly. Pharmacological intervention, however, did not result in any benefit when compared to standard care and still needs further research. It is possible to conclude that, given the high and diverse degree of disability associated with TBI, rehabilitation interventions should be precocious and tailored according to the individual's needs in order to achieve the best possible results. An interdisciplinary patient-centered care health team and well-oriented family members should be involved in every stage. Lastly, strategies must be adequate, well-planned, and communicated to patients and caregivers to attain higher functional outcomes.

AppReminders - a pilot feasibility randomized controlled trial of a memory aid app for people with acquired brain injury

Mobile phone reminding apps can be used by people with acquired brain injury (ABI) to compensate for memory impairments. This pilot feasibility trial aimed to establish the feasibility of a randomized controlled trial comparing reminder apps in an ABI community treatment setting. Adults with ABI and memory difficulty who completed the three-week baseline were randomized (n = 29) and allocated to Google Calendar or ApplTree app. Those who attended an intervention session (n = 21) watched a 30-minute video tutorial of the app then completed reminder setting assignments to ensure they could use the app. Guidance was given if needed from a clinician or researcher. Those who passed the app assignments (n = 19) completed a three-week follow up. Recruitment was lower than target (n = 50), retention rate was 65.5%, adherence rate was 73.7%. Qualitative feedback highlighted issues that may impact usability of reminding apps introduced within community brain injury rehabilitation. Feasibility results indicate a full trial would require 72 participants to demonstrate the minimally clinically important efficacy difference between apps, should a difference exist. Most participants (19 of 21) given an app could learn to use it with the short tutorial. Design features implemented in ApplTree have potential to improve the uptake and utility of reminding apps.

Use of Social Media Data Mining to Examine Needs, Concerns, and Experiences of People With Traumatic Brain Injury

PURPOSE

Given the limited availability of topic-specific resources, many people turn to anonymous social media platforms such as Reddit to seek information and connect to others with similar experiences and needs. Mining of such data can therefore identify unmet needs within the community and allow speech-language pathologists to incorporate clients' real-life insights into clinical practices.

METHOD

A mixed-method analysis was performed on 3,648 traumatic brain injury (TBI) subreddit posts created between 2013 and 2021. Sentiment analysis was used to determine the sentiment expressed in each post; topic modeling and qualitative content analysis were used to uncover the main topics discussed across posts. Subgroup analyses were conducted based on injury severity, chronicity, and whether the post was authored by a person with TBI or a close other.

RESULTS

There was no significant difference between the number of posts with positive sentiment and the number of posts with negative sentiment. Comparisons between subgroups showed significantly higher positive sentiment in posts by or about people with moderate-to-severe TBI (compared to mild TBI) and who were more than 1 month postinjury (compared to less than 1 month). Posts by close others had significantly higher positive sentiment than posts by people with TBI. Topic modeling identified three meta-themes: Recovery, Symptoms, and Medical Care. Qualitative content analysis further revealed that returning to productivity and life as well as sharing recovery tips were the primary focus under the Recovery theme. Symptom-related posts often discussed symptom management and validation of experiences. The Medical Care theme encompassed concerns regarding diagnosis, medication, and treatment.

CONCLUSIONS

Concerns and needs shift over time following TBI, and they extend beyond health and functioning to participation in meaningful daily activities. The findings can inform the development of tailored educational resources and rehabilitative approaches, facilitating recovery and community building for individuals with TBI.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24881340.

Memory and Traumatic Brain Injury: Assessment and Management Practices of Speech-Language Pathologists

PURPOSE

Memory impairments are among the most commonly reported deficits and among the most frequent rehabilitation targets for individuals with traumatic brain injury (TBI). Memory and learning are also critical for rehabilitation success and broader long-term outcomes. Speech-language pathologists (SLPs) play a central role in memory management for individuals with TBI across the continuum of care. Yet, little is known about the current practice patterns of SLPs for post-TBI memory disorders. This study aims to examine the clinical management of memory disorders in adults with TBI by SLPs and identify opportunities to improve post-TBI memory outcomes.

METHOD

SLPs from across the continuum of care were recruited to complete an online survey. The survey assessed key practice areas specific to memory and memory disorders post-TBI, including education and training, knowledge and confidence, and assessment and treatment patterns.

RESULTS

Surveys from 155 SLPs were analyzed. Results revealed that TBI-specific training remains low in the field. Respondents varied in their practice patterns in assessing and treating memory disorders. Most SLPs do not appear to have access to appropriate standardized assessments to measure unique forms of memory. Respondents also reported a range of barriers and opportunities to advance memory outcomes following TBI and provided suggestions of areas in which they would like to see more basic and clinical research.

CONCLUSIONS

These findings establish a baseline of the current practices for clinical management of memory impairment in adults with TBI by SLPs. Improved opportunities for clinician training, the development of a single tool to assess multiple forms of memory, better access to existing memory assessments, and implementation of evidence-based interventions promise to lead to improved memory outcomes for individuals with TBI.

The perspectives of participants with traumatic brain injury on prospective memory rehabilitation incorporating compensatory and metacognitive skills training

OBJECTIVE

Patient feedback is rarely gathered systematically in cognitive rehabilitation research. This study examined the perceptions and experiences of people with traumatic brain injury (TBI) who participated in a trial of a 6-session educational program for the rehabilitation of prospective memory (PM) impairment.

METHODS

A mixed methods design was used with 47 participants with TBI who completed a compensatory strategy training program (COMP) or COMP plus metacognitive strategy training program (COMP-MST) delivered by an occupational therapist. Data were collected via a participant survey, extracts from progress notes, and audiotaped discussions about learnings from the program during the final session.

RESULTS

Participants from both programs were highly satisfied and perceived improvements in everyday PM performance post-intervention. Elements that were highly valued include setting individualised client-centred goals, repetitive training of strategy use, establishing habits and routines, and receiving experiential, verbal, and written feedback.Changes including more therapy sessions were recommended.

CONCLUSIONS

Both the COMP and COMP-MST programs were perceived as effective by participants with TBI in improving their PM performance in everyday life using compensatory strategies such as assistive technology.

PRACTICE IMPLICATIONS

Routine collection of patient feedback on cognitive rehabilitation can provide valuable information to support person-centred implementation of clinical practice guidelines.

Equity considerations in clinical practice guidelines for traumatic brain injury and homelessness: a systematic review

Background

Clinical practice guidelines (CPGs) predominantly prioritise treatment and cost-effectiveness, which encourages a universal approach that may not address the circumstances of disadvantaged groups. We aimed to advance equity and quality of care for individuals experiencing homelessness and traumatic brain injury (TBI) by assessing the extent to which homelessness and TBI are integrated in CPGs for TBI and CPGs for homelessness, respectively, and the extent to which equity, including consideration of disadvantaged populations and the PROGRESS-Plus framework, is considered in these CPGs.

Methods

For this systematic review, CPGs for TBI or homelessness were identified from electronic databases (MEDLINE, Embase, CINAHL, PsycINFO), targeted websites, Google Search, and reference lists of eligible CPGs on November 16, 2021 and March 16, 2023. The proportion of CPGs that integrated evidence regarding TBI and homelessness was identified and qualitative content analysis was conducted to understand how homelessness is integrated in CPGs for TBI and vice versa. Equity assessment tools were utilised to understand the extent to which equity was considered in these CPGs. This review is registered with PROSPERO (CRD42021287696).

Findings

Fifty-eight CPGs for TBI and two CPGs for homelessness met inclusion criteria. Only three CPGs for TBI integrated evidence regarding homelessness by recognizing the prevalence of TBI in individuals experiencing homelessness and identifying housing as a consideration in the assessment and management of TBI. The two CPGs for homelessness acknowledged TBI as prevalent and recognised individuals experiencing TBI and homelessness as a disadvantaged population that should be prioritised in guideline development. Equity was rarely considered in the content and development of CPGs for TBI.

Interpretation

Considerations for equity in CPGs for homelessness and TBI are lacking. To ensure that CPGs reflect and address the needs of individuals experiencing homelessness and TBI, we have identified several guideline development priorities. Namely, there is a need to integrate evidence regarding homelessness and TBI in CPGs for TBI and CPGs for homelessness, respectively and engage disadvantaged populations in all stages of guideline development. Further, this review highlights an urgent need to conduct research focused on and with disadvantaged populations.

Funding

Canada Research Chairs Program (2019-00019) and the Ontario Ministry of Health and Long-Term Care (Grant #725A).

COVCOG: Immediate and long-term cognitive improvement after cognitive versus emotion management psychoeducation programs - a randomized trial in covid patients with neuropsychological difficulties

BACKGROUND

Cognitive difficulties are a frequent complaint in long COVID and persist for more than a year post- infection. There is a lack of evidence-based data on effective intervention strategies. Non-pharmacological intervention programs that are used with other neurological populations have not yet been the subject of controlled trials. COVCOG is a multicentric, randomized trial comparing cognitive intervention and a cognitive-behavioural counselling.

METHODS/DESIGN

Patients with long covid are selected and recruited at least three months post-infection. Patients are randomised in a 1:1 ratio into the cognitive (neuropsychological psychoeducation) and affective (emotion management with cognitive-behavioural counselling) intervention arms. The inclusion of 130 patients is planned. The cognitive intervention includes psycho-educational modules on fatigue and sleep, attention and working memory, executive functions and long-term memory. The affective intervention includes modules on emotion recognition and communication, uncertainty management and behavioral activation. The main objective is to reduce cognitive complaints 2 months after the intervention. A Follow-up is also planned at 8 months.

DISCUSSION

Given the long-term effects of Covid on cognition and the negative effects of cognitive impairment on quality of life and social participation, it is important to determine whether low-dose, non-pharmacological interventions can be effective. The trial will determine which of the usual types of intervention is the most effective.

TRIAL REGISTRATION

Clinicaltrials.gov Number: NCT05167266 (21/12/ 2021).

Protection of Mice from Controlled Cortical Impact Injury by Food Additive Glyceryl Tribenzoate

Despite intense investigations, no effective therapy is available to halt the pathogenesis of traumatic brain injury (TBI), a major health concern, which sometimes leads to long-term neurological disability, especially in war veterans and young adults. This study highlights the use of glyceryl tribenzoate (GTB), a flavoring ingredient, in ameliorating the disease process of controlled cortical impact (CCI)-induced TBI in mice. Oral administration of GTB decreased the activation of microglia and astrocytes to inhibit the expression of inducible nitric oxide synthase (iNOS) in hippocampus and cortex of TBI mice. Accordingly, GTB treatment protected and/or restored synaptic maturation in the hippocampus of TBI mice as revealed by the status of PSD-95, NR-2A and GluR1. Furthermore, oral GTB also reduced the size of lesion cavity in the brain of TBI mice. Finally, GTB treatment improved locomotor functions and protected spatial learning and memory in TBI mice. These results outline a novel neuroprotective property of GTB which may be beneficial in treatment of TBI.

INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part II: Attention and Information Processing Speed

INTRODUCTION

Moderate to severe traumatic brain injury (MS-TBI) commonly causes disruption in aspects of attention due to its diffuse nature and injury to frontotemporal and midbrain reticular activating systems. Attentional impairments are a common focus of cognitive rehabilitation, and increased awareness of evidence is needed to facilitate informed clinical practice.

METHODS

An expert panel of clinicians/researchers (known as INCOG) reviewed evidence published from 2014 and developed updated guidelines for the management of attention in adults, as well as a decision-making algorithm, and an audit tool for review of clinical practice.

RESULTS

This update incorporated 27 studies and made 11 recommendations. Two new recommendations regarding transcranial stimulation and an herbal supplement were made. Five were updated from INCOG 2014 and 4 were unchanged. The team recommends screening for and addressing factors contributing to attentional problems, including hearing, vision, fatigue, sleep-wake disturbance, anxiety, depression, pain, substance use, and medication. Metacognitive strategy training focused on everyday activities is recommended for individuals with mild-moderate attentional impairments. Practice on de-contextualized computer-based attentional tasks is not recommended because of lack of evidence of generalization, but direct training on everyday tasks, including dual tasks or dealing with background noise, may lead to gains for performance of those tasks. Potential usefulness of environmental modifications is also discussed. There is insufficient evidence to support mindfulness-based meditation, periodic alerting, or noninvasive brain stimulation for alleviating attentional impairments. Of pharmacological interventions, methylphenidate is recommended to improve information processing speed. Amantadine may facilitate arousal in comatose or vegetative patients but does not enhance performance on attentional measures over the longer term. The antioxidant Chinese herbal supplement MLC901 (NeuroAiD IITM) may enhance selective attention in individuals with mild-moderate TBI.

CONCLUSION

Evidence for interventions to improve attention after TBI is slowly growing. However, more controlled trials are needed, especially evaluating behavioral or nonpharmacological interventions for attention.

INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury: Methods, Overview, and Principles

INTRODUCTION

Moderate to severe traumatic brain injury (TBI) results in complex cognitive sequelae. Despite hundreds of clinical trials in cognitive rehabilitation, the translation of these findings into clinical practice remains a challenge. Clinical practice guidelines are one solution. The objective of this initiative was to reconvene the international group of cognitive researchers and clinicians (known as INCOG) to develop INCOG 2.0: Guidelines for Cognitive Rehabilitation Following TBI.

METHODS

The guidelines adaptation and development cycle was used to update the recommendations and derive new ones. The team met virtually and reviewed the literature published since the original INCOG (2014) to update the recommendations and decision algorithms. The team then prioritized the recommendations for implementation and modified the audit tool accordingly to allow for the evaluation of adherence to best practices.

RESULTS

In total, the INCOG update contains 80 recommendations (25 level A, 15 level B, and 40 level C) of which 27 are new. Recommendations developed for posttraumatic amnesia, attention, memory, executive function and cognitive-communication are outlined in other articles, whereas this article focuses on the overarching principles of care for which there are 38 recommendations pertaining to: assessment (10 recommendations), principles of cognitive rehabilitation (6 recommendations), medications to enhance cognition (10 recommendations), teleassessment (5 recommendations), and telerehabilitation intervention (7 recommendations). One recommendation was supported by level A evidence, 7 by level B evidence, and all remaining recommendations were level C evidence. New to INCOG are recommendations for telehealth-delivered cognitive assessment and rehabilitation. Evidence-based clinical algorithms and audit tools for evaluating the state of current practice are also provided.

CONCLUSIONS

Evidence-based cognitive rehabilitation guided by these recommendations should be offered to individuals with TBI. Despite the advancements in TBI rehabilitation research, further high-quality studies are needed to better understand the role of cognitive rehabilitation in improving patient outcomes after TBI.