Cognitive and behavioral impairment in traumatic brain injury related to outcome and return to work

Research Priorities in Neuropalliative Care: A Consensus Statement From the International Neuropalliative Care Society

Importance

The integration of palliative care in neurology, or neuropalliative care, is an emerging area of practice focused on holistically improving quality of life and reducing the burden of suffering for people living with serious neurologic disease and their care partners. Major neurology and palliative care societies have recognized the need to advance primary and specialty palliative care services for people with neurologic disease. However, research to support this work is in its early stages.

Observations

The International Neuropalliative Care Society Research Committee convened an interdisciplinary panel of experts, including clinicians, scientists, people with neurologic disease, and care partners, to identify priority research areas for the advancement of neuropalliative care as a field. Three priority areas highlighted in this review include (1) patient- and care partner-centered symptoms and outcomes specific to neurologic illness and tools for their assessment, (2) development of effective neuropalliative care interventions and delivery models, and (3) methods to support the ability to foster, deliver, and measure goal-concordant care over time.

Conclusions and Relevance

This Special Communication outlines some of the most pressing neuropalliative care research needs, the advancement of which will best serve patients of all ages living with serious neurologic diseases and their care partners. Research funding mechanisms are needed to support and sustain impactful work in this field.

Gamma frequency connectivity in frontostriatal networks associated with social preference is reduced with traumatic brain injury

Among the myriad of complications associated with traumatic brain injury (TBI), impairments in social behaviors and cognition have emerged as a significant area of concern. Animal models of social behavior are necessary to explore the underlying brain mechanisms contributing to chronic social impairments following brain injury. Here, we utilize large-scale brain recordings of local field potentials to identify neural signatures linked with social preference deficits following frontal brain injury. We used a controlled cortical impact model of TBI to create a severe bilateral injury centered on the prefrontal cortex. Behavior (social preference and locomotion) and brain activity (power and coherence) during a three-chamber social preference task were compared between sham and injured animals. Sham rats preferred to spend time with a social conspecific over an inanimate object. An analysis of local field oscillations showed that social preference was associated with a significant increase in coherence in gamma frequency band across widespread brain regions in these animals. Animals with a frontal TBI showed a significant reduction in this social preference, visiting an inanimate object more frequently and for more time. Reflecting these changes in social behavior, these animals also showed a significant reduction in gamma frequency (25-60 Hz) coherence associated with social preference.

Neurocognitive Intraindividual Variability in Veterans with Mild Traumatic Brain Injury History and Posttraumatic Stress Disorder

OBJECTIVE

Veterans with a history of blast-related mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) may be at risk for greater cognitive concerns and worse functional outcomes compared to those with either condition in isolation. However, traditional neuropsychological assessment approaches have yielded equivocal results in these populations. The present study examined an alternative method for detecting subtle cognitive inefficiencies: neurocognitive intraindividual variability (IIV), a measure of within-person performance consistency.

METHOD

Participants were 79 male Veterans with a history of blast-related mTBI and current PTSD (mTBI/PTSD group; n = 54) or neither diagnosis (controls; n = 25). Mean T-scores and IIV scores were calculated from neuropsychological measures of attention and speed of information processing (A/SoP) as well as executive functioning (EF).

RESULTS

Global IIV was significantly higher in the mTBI/PTSD group compared to controls (p = .047, Cohen's d = 0.49). At the domain level, larger effect sizes were observed for EF IIV (Cohen's d = 0.46) compared to A/SoP IIV (d = 0.32), although neither were statistically significant. Within the mTBI/PTSD group, higher Global IIV was associated with worse self-reported executive dysfunction, psychological quality of life, and cognitive post-concussive symptoms; at the domain level, these clinical outcomes were generally associated with greater A/SoP IIV (but not EF IIV).

CONCLUSION

Findings extend previous investigations of neurocognitive IIV in individuals with a history of mTBI across PTSD status. Among Veterans with a history of mTBI and comorbid PTSD, neurocognitive variability may be a better indicator of self-reported cognitive inefficiencies and Veteran experience of daily cognitive functioning than mean neuropsychological performances.

Approachability and Sensory Changes Following Mild Traumatic Brain Injury in Pigs

BACKGROUND/OBJECTIVES

Traumatic brain injury (TBI) is a global healthcare concern affecting millions, with wide-ranging symptoms including sensory and behavioral changes that can persist long-term. Due to similarities with human brain cytoarchitecture and inflammation, minipig models are advantageous for translational TBI research. However, gaps in knowledge exist regarding their behavioral and sensory sequelae following injury.

METHODS

Therefore, in this study, we assessed changes in approachability using a forced human approach task (FHAT) and mechanical nociception using the von Frey test in adult male and female Yucatan minipigs for up to one week following a sham or central fluid percussion injury (cFPI). Specifically, the FHAT assessed each animal's response to a forced interaction with either a known or unknown experimenter. To evaluate changes in nociceptive sensory sensitivity, von Frey monofilaments ranging from 0.008 to 300 g of force were applied to the pinna of the ear or base of the tail.

RESULTS

We found that forced approachability was affected by experimenter familiarity as well as cFPI in a sex-specific manner at subacute timepoints. We also found reductions in sensitivity following cFPI on the ear in male minipigs and on the tail in female minipigs.

CONCLUSION

Overall, the current study demonstrates that cFPI produces both behavioral and sensory changes in minipigs up to one-week post-injury.

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.

Mild traumatic brain injury caused by workplace violence in a US workers' compensation system

OBJECTIVES

Approximately 81% of traumatic brain injury cases are considered to be mild (mTBI), but few studies have reviewed mTBI caused by workplace violence (WPV). This study aimed to (1) determine the incidence of mTBI secondary to WPV in a statewide workers' compensation system using International Classification of Disease codes and (2) analyse and compare factors associated with return-to-work outcomes between WPV mTBI cases versus other mechanisms.

METHODS

Using a retrospective cohort of claims data from the California Workers' Compensation Information System during 2015-2019, cases with a return-to-work date were classified as WPV if the injury description contained keywords such as assault, gunpoint, harassed, intimidated, punch, threat, robbery, violent or verbal abuse.

RESULTS

Of the 14 089 mTBI claims analysed in this study, 11.2% were caused by WPV. When comparing WPV to non-WPV claims, the variables with statistically significant (p≤0.001) differences were age, income, industry and job class. There were no significant differences between groups for leave duration. In a linear mixed model, the variable of interest (WPV) was not associated with recovery duration after adjusting for other factors.

CONCLUSION

To our knowledge, this is the first study to examine WPV mTBI claims in the USA. The findings suggest that the public administration, education and healthcare and social services industries are at higher risk for WPV mTBI. WPV and job class were the only modifiable factors in the model and therefore should be the focus of additional research.

Factors associated with self-awareness impairment in an inpatient brain injury rehabilitation cohort

BACKGROUND

Self-awareness impairment is common following acquired brain injury and can impact rehabilitation outcomes. Knowledge of factors associated with impaired self-awareness may assist with rehabilitation planning.

OBJECTIVES

To identify factors associated with self-awareness and determine predictors of self-awareness impairment for adults with traumatic brain injury (TBI) and stroke.

DESIGN AND METHODS

A retrospective cohort study of rehabilitation inpatients was conducted by medical record audit. Self-awareness was measured using the Self-awareness of Deficits Interview (SADI). Relationships between SADI scores and demographic and clinical variables were identified with non-parametric statistics. Predictors of SADI scores were identified using ordinal regression analyses for TBI and stroke groups.

RESULTS

Participants were 149 adults (18-70 years) with TBI (n = 110) and stroke (n = 39). For TBI, longer post-traumatic amnesia (PTA), lower functional cognition/communication, and behaviors of concern (BoC) were significantly associated with higher SADI scores (i.e. impaired self-awareness). For stroke, lower functional cognition/communication and motor scores were associated with higher SADI scores. Impaired self-awareness was predicted by PTA duration, acute length of stay and presence of BoC for the TBI group, and by functional cognition/communication for the stroke group.

CONCLUSION

Different factors were associated with impaired self-awareness for individuals with TBI and stroke during inpatient rehabilitation.

Risk factors and service gaps affecting a sustainable work: a qualitative multi-stakeholder analysis in the context of persons with acquired brain injury living in Switzerland

INTRODUCTION

Along with the social and economic challenges posed by an aging society, creating work conditions that allow persons to stay healthy and work into old age has become a major task of Western societies. Retaining employment after returning to work is particularly difficult for individuals with a disability, as evidenced by the high rate of premature labor market dropout. Individuals with acquired brain injury (ABI) exemplify this challenge, as it often impairs cognitive, technical, and interpersonal abilities that are crucial in today's labor market. To effectively support these individuals, vocational integration practitioners require comprehensive knowledge of risk factors for premature labor market dropout and effective strategies for sustainable work.

OBJECTIVE

This study aimed to identify perceived risk factors and related service gaps regarding sustainable work for people with ABI, as reported by affected individuals, employers, vocational integration professionals, and health professionals.

METHODS

Secondary data analysis. Data that was originally collected through seven focus groups and two interviews with persons with ABI, 15 interviews with employers, and 13 interviews with vocational integration and health professionals in the context of the project 'Sustainable employment' was re-analysed thematically.

RESULTS

Two major themes of risk factors were identified: (1) person-related factors (including the subthemes: post-ABI impairments; lack of understanding of post-ABI impairments; poor health management) and (2) environment-related factors (including the subthemes: challenges related to the service structure; insufficient knowledge and education about ABI; challenges at the workplace; difficulties in private life). While stakeholders noted the variety of the currently available services, they particularly pointed to the missing long-term monitoring and counseling services for persons with ABI following the initial return-to-work, reflecting a major challenge for sustainable work. An overarching gap related to the fragmentation of the service structure and the lack of case coordination along the working life.

CONCLUSIONS

Multiple stakeholders emphasized the importance of empowering individuals, ensuring easy access to professional support, and providing a suitable work environment to address key risk factors and facilitate sustainable work for individuals with ABI. Continuous coaching, long-term monitoring and counseling following return-to-work, were identified as potential strategies to achieve these goals.

The contribution of executive functions to the process of return to work after brain injury: A systematic review

Acquired brain injury (ABI) is a worldwide public health issue for its high prevalence rate and the disability it produces. The consequences of ABI, including cognitive deficits, may impact return to work. This review focuses on the association between executive functions (EFs) and return to work after ABI. A systematic review of the literature between 1998 and 2023 was conducted following PRISMA guidelines. The articles were retrieved from the Pubmed, Medline and Web of Science databases. A total of 49 studies were finally selected. Impairments of EF were consistently shown to have a negative impact on return to work after an ABI. There is evidence that specific executive functions and neurobehavioral variables may affect return to work Studies showed a significant theoretical and methodological heterogeneity, representing an important limitation to understand the relation between EFs and work. There is a robust association between EFs and return to work after brain injury. Findings in this systematic review raise the need for further research on the role of specific EF profiles in the process of returning to work after brain damage.

A literature review of outcome and treatment options after acquired brain injury: Suggestions for adult offenders using knowledge from the general population

BACKGROUND

Acquired brain injury (ABI) is a major health problem, often with negative effects on behaviour and mental health as well as cognition. Prevalence of ABI is exceptionally high among offenders and increases their re-offending risk. Information on risk factors for ABI and its outcomes among offenders that could guide effective treatment for them is, nevertheless, scarce and dispersed. However, there is a more substantial literature about the general population that could inform work with brain-injured offenders, especially when selecting for samples or subgroups with similar relevant characteristics, such as lower socio-economic status (SES), pre-injury lower tested intelligence score (<85) and pre-injury mental health problems.

AIMS

To explore brain injury data from non-offender samples of otherwise similar socio-economic and mental health and ability characteristics to offenders then, first, to describe their untreated outcomes and, secondly, outcomes after frequently used interventions in these circumstances, noting factors associated with their effectiveness.

METHOD

Three databases were systematically searched for the years 2010-2022; first, using terms for brain injury or damage and cognitive (dys)function, mental health or quality of life. Second, in a separate search, we used these terms and terms for interventions and rehabilitation. In the second review, studies were selected for clear, distinguishable data on age, sex, SES and lifestyle factors to facilitate inferences for offenders. A narrative analytical approach was adopted for both reviews.

RESULTS

Samples with characteristics that are typical in offender groups, including lower SES, lower pre-injury intelligence quotient (<85), prior cognitive impairments and prior mental health problems, had poorer cognitive and behavioural outcomes following ABI than those without such additional problems, together with lower treatment adherence. With respect to treatment, adequate motivation and self-awareness were associated with better cognitive and behavioural outcomes than when these were low or absent, regardless of the outcome measured.

CONCLUSIONS

More complex pre-injury mental health problems and social disadvantages typical of offenders are associated with poorer post-brain injury recovery. This paper adds to practical knowledge by bringing together work that follows specific outcome trajectories. Overall, succesful ABI-interventions in the general population that aim at pre-injury difficulties comparable to those seen among offenders, show that personalising injury-specific treatments and taking account of these difficulties, maximised positive outcomes.

A window into the reality of families living long term with challenging behaviours after a TBI

Challenging behaviours are a long-term burden for people with traumatic brain injury (TBI) and their families. Families frequently shoulder the responsibility alone, but little is known about the strategies they use to manage these behaviours. This study aimed to 1) identify the coping strategies used by people with TBI living in the community and their family caregivers to manage challenging behaviours; and 2) describe the similarities and differences between strategies used by people with TBI and caregivers. In this qualitative descriptive design, individual semi-structured interviews were conducted with adults with TBI and their caregivers and were inductively analyzed. The sample included 10 dyads and two triads, totalling 12 caregivers (8 women) and 14 individuals with TBI (6 women; 21.71 ± 10.84 years post-injury). Participants' strategies were proactive (prevention), reactive (response), or retroactive (aftercare). Most strategies were described by caregivers. Some of them were effective and lasting, others not, reflecting how they adapted their approaches over time. Families put in place various strategies in their life's journey, such as giving feedback or adapting the environment. Despite these strategies supporting long-term community living, the need for ongoing support is underscored, as crises may still occur, impacting families' quality of life.

The dual reality of challenging behaviours: Overlapping and distinct perspectives of individuals with TBI and their caregivers

Challenging behaviours significantly impact the lives of people with traumatic brain injury (TBI) and their family caregivers. However, these behaviours are rarely defined from the perspectives of both individuals, a necessary step to developing interventions targeting meaningful goals for individuals and caregivers. This study aimed to (1) explore and confirm the perspective of individuals with TBI living in the community and their family caregivers on behaviours they consider challenging and, (2) identify overlapping or distinct views on challenging behaviours. A qualitative descriptive design was used. Twelve caregivers (8 females; 59.67 ± 11.64 years old) and 14 participants with mild-severe TBI (6 females; 43.21 ± 10.98 years old; time post-injury: 21.71 ± 10.84 years) were interviewed (10 dyads and two triads). Data were analysed using inductive qualitative analysis. Challenging behaviours most frequently reported by all participants were aggressive/impulsive behaviours, inappropriate social behaviours, and behavioural manifestations of cognitive impairments. Overlapping perspectives were identified regarding aggressive behaviours. Distinctions exist as inappropriate social behaviours and cognitive difficulties were mainly reported by caregivers. Our results confirm that perspectives may vary between dyad members. Interventions should include dyad inputs to formulate goals that are significant to the person with TBI and their caregiver.

The Role of Neuropsychology in Traumatic Brain Injury: Comprehensive Literature Review

Traumatic brain injury (TBI) is a major public health concern, often leading to significant behavioral and cognitive changes with subsequent impairment in daily functioning and personal interactions. The management of TBI involves a multidisciplinary approach. Neuropsychology has emerged as a critical discipline in assessing, diagnosing, treating, and rehabilitating individuals with TBI. Successful management also requires careful consideration of the patient's cognitive status. Therefore, clinicians must have a comprehensive understanding of the overall clinical picture of the patient at the cognitive and physical level. The primary aim of this research is to explore the role of neuropsychology in TBI management and rehabilitation thoroughly while providing an updated review of the literature. Various neuropsychological assessment tools used to evaluate cognitive functioning in individuals with TBI will be discussed in addition to their validity, reliability, and usefulness in identifying cognitive deficits and developing individualized treatment plans. The findings in this article will have significant implications on the clinical practice of neuropsychology in TBI patients, highlighting the importance of neuropsychological assessment in optimizing the management of this population. The need for increased awareness of neuropsychology among health care professionals, especially in the acute hospital setting, is growing along with the increase in diagnosis of TBI and its complications. Adequate understanding of the complex interplay between cognitive, emotional, and behavioral factors in TBI can inform the development of new interventions and treatment strategies, making it equally as important for patients and their families.

Cerebral microhaemorrhage count is related to processing speed, but not level of symptom reporting, independently of age, psychological status and premorbid functioning, after first-ever mild traumatic brain injury

Cerebral microhaemorrhage is a commonly identified neuropathological consequence of mild traumatic brain injury (mTBI) and can be identified in vivo using susceptibility weighted imaging (SWI). This study aimed to determine whether SWI-detected microhaemorrhages are more common in individuals after a single, first-ever, mTBI event relative to trauma controls (TC) and to investigate whether a linear relationship exists between microhaemorrhage numbers and cognition or symptom reporting in the post-acute period after injury, independently of age, psychological status and premorbid level of functioning. Microhaemorrhagic lesions were identified by expert clinical examination of SWI for 78 premorbidly healthy adult participants who were admitted to hospital after a traumatic injury and had suffered a first-ever mTBI (n = 47) or no head strike (n = 31). Participants underwent objective cognitive examination of processing speed, attention, memory, and executive function as well as self-reported post-concussion symptomatology. Bootstrapping analyses were used as data were not normally distributed. Analyses revealed that the mTBI group had significantly more microhaemorrhages than the TC group (Cohen's d = 0.559). These lesions were only evident in 28% of individuals. The mTBI participants demonstrated a significant linear association between number of microhaemorrhages and processing speed, independently of age, psychological status, or premorbid level of functioning. This study shows that a single mTBI causes cerebral microhaemorrhages to occur in a minority of premorbidly healthy individuals. Greater microhaemorrhage count is independently associated with slower processing speed, but not symptom reporting, during the post-acute injury period.

Moderate-Severe TBI as a Progressive Disorder: Patterns and Predictors of Cognitive Declines in the Chronic Stages of Injury

BACKGROUND

Moderate-severe traumatic brain injury (TBI) has been associated with progressive cognitive decline in the chronic injury stages in a small number of studies.

OBJECTIVE

This study aimed to (i) replicate our previous findings of decline from 1 to 3+ years post-injury in a larger, non-overlapping sample and (ii) extend these findings by examining the proportion of decliners in 2 earlier time windows, and by investigating novel predictors of decline.

METHODS

N = 48 patients with moderate-severe TBI underwent neuropsychological assessment at 2, 5, 12 months, and 30+ months post-injury. We employed the Reliable Change Index (RCI) to evaluate decline, stability and improvement across time and logistic regression to identify predictors of decline (demographic/cognitive reserve; injury-related).

RESULTS

The proportions of patients showing decline were: 12.5% (2-5 months post-injury), 17% (5-12 months post-injury), and 27% (12-30+ months post-injury). Measures of verbal retrieval were most sensitive to decline. Of the predictors, only left progressive hippocampal volume loss from 5 to 12 months post-injury significantly predicted cognitive decline from 12 to 30+ months post-injury.

CONCLUSIONS

Identical to our previous study, 27% of patients declined from 12 to 30+ months post-injury. Additionally, we found that the further from injury, the greater the proportion of patients declining. Importantly, earlier progressive hippocampal volume loss predicted later cognitive decline. Taken together, the findings highlight the need for ongoing research and treatment that target these deleterious mechanisms affecting patients in the chronic stages of moderate-severe TBI.

A meaningful everyday life experienced by adults with acquired neurological impairments: A scoping review

OBJECTIVE

This scoping review explores the characteristics of a meaningful life appraised by adults living with an acquired neurological impairment.

INTRODUCTION

Limitations in function, activity or participation following a neurological injury or disease imposes comprehensive changes on the every-day life of the affected person and close relatives. Including patients' perception of a meaningful life is pivotal to facilitate motivation and individualize rehabilitation efforts to address the patients' wishes, hopes, needs, and preferences. Surprisingly, only little research has been devoted to illuminating what a meaningful life is from the impaired person's perspective. Hence, a scoping review of existing knowledge is needed to facilitate person-centered high-quality rehabilitation and research initiatives.

INCLUSION CRITERIA

All studies, published in English or Scandinavian languages describing a meaningful life as experienced by adult persons with neurological impairment were included. No search date range filter was selected.

METHODS

This review followed the Joanna Briggs Institute (JBI) methodology for scoping reviews according to a published protocol. A three-step search strategy was conducted in the databases PubMed, Cinahl, PsycINFO and Embase. At least two independent researchers conducted inclusions and exclusions, data extraction, and analyses. Covidence software was used to manage the information.

FINDINGS

We identified 307 studies. Of these, 20 were included and quality assessed. Findings are reported in accordance with the PRISMA- SCR checklist and descriptively presented mapped in three main domains and 10 ten sub-domains.

CONCLUSION

Current literature conveys no clear definition or perception of what a meaningful life is. However, across the 20 included studies, the following main characteristics were stepped forward as particularly significant for adults living with an acquired neurological impairment in regard to achieving a meaningful life: i) to be part of meaningful relationships and meaningful activities; ii) to become confident with one's perceived identity.

The relationship between cognition and white matter tract damage after mild traumatic brain injury in a premorbidly healthy, hospitalised adult cohort during the post-acute period

Introduction

Recent developments in neuroimaging techniques enable increasingly sensitive consideration of the cognitive impact of damage to white matter tract (WMT) microstructural organisation after mild traumatic brain injury (mTBI).

Objective

This study investigated the relationship between WMT microstructural properties and cognitive performance.

Participants setting and design

Using an observational design, a group of 26 premorbidly healthy adults with mTBI and a group of 20 premorbidly healthy trauma control (TC) participants who were well-matched on age, sex, premorbid functioning and a range of physical, psychological and trauma-related variables, were recruited following hospital admission for traumatic injury.

Main measures

All participants underwent comprehensive unblinded neuropsychological examination and structural neuroimaging as outpatients 6-10 weeks after injury. Neuropsychological examination included measures of speed of processing, attention, memory, executive function, affective state, pain, fatigue and self-reported outcome. The WMT microstructural properties were estimated using both diffusion tensor imaging (DTI) and neurite orientation dispersion and density imaging (NODDI) modelling techniques. Tract properties were compared between the corpus callosum, inferior longitudinal fasciculus, uncinate fasciculus, anterior corona radiata and three segmented sections of the superior longitudinal fasciculus.

Results

For the TC group, in all investigated tracts, with the exception of the uncinate fasciculus, two DTI metrics (fractional anisotropy and apparent diffusion coefficient) and one NODDI metric (intra-cellular volume fraction) revealed expected predictive linear relationships between extent of WMT microstructural organisation and processing speed, memory and executive function. The mTBI group showed a strikingly different pattern relative to the TC group, with no relationships evident between WMT microstructural organisation and cognition on most tracts.

Conclusion

These findings indicate that the predictive relationship that normally exists in adults between WMT microstructural organisation and cognition, is significantly disrupted 6-10 weeks after mTBI and suggests that WMT microstructural organisation and cognitive function have disparate recovery trajectories.

Protocol for Safety and Efficacy of MLC901 (NeuroAiD II) in Patients With Moderate Traumatic Brain Injury: A Randomized Double-Blind Placebo-Controlled Trial (ANDROMEDA)

BACKGROUND AND OBJECTIVES

Traumatic brain injury (TBI) remains a leading cause of death and disability, affecting approximately 69 million individuals each year worldwide. A significant portion of TBI research has focused on treatments for neuroprotection and/or neurorecovery, with most failing to transition to successful clinical applications despite promising animal/in vitro study results. MLC901 (NeuroAiD II), with origins from a traditional Chinese medicine, has been shown to exhibit both neuroprotective and neuroregenerative properties in in vitro and animal studies for stroke and TBI. Clinical trials have demonstrated its safety with significant improvements in some functional outcome and cognitive domain measures. The objective of this study is to determine the efficacy and safety of MLC901 (NeuroAiD II) vs placebo in adult patients with moderate TBI.

METHODS

This is a multicenter randomized double-blind placebo-controlled trial that aims to enroll 120 adult patients with moderate TBI receiving standard of care in 2 arms: MLC901 vs placebo for a treatment period of 6 months with a further follow-up of 3 months. The total duration of the study is 9 months. The primary end point is Glasgow Outcome Scale Extended (GOS-E) at 6 months. Other assessments include mortality at 6 months, GOS-E, Glasgow Coma Scale, Montreal Cognitive Assessment Filipino Version, Frontal Assessment Battery Conflicting Instructions and Go-No-Go, Rivermead Post-Concussion Symptom Questionnaire, Barthel Index, Hospital Anxiety and Depression Scale, and Health related Quality of life (EQ-5D) at 1, 3, 6, and 9 months. Cerebral swelling at baseline and at 1 and 2 weeks will also be documented. Adverse events and drug compliance will also be monitored.

EXPECTED OUTCOMES

We expect to find a significant improvement in functional and cognitive outcomes in patients who were given MLC901.

DISCUSSION

Previous studies on the effect of MLC901 in adult patients with moderate TBI showed positive results; However, these studies are limited by the small number of patients. This study will establish a more definitive role of MLC901 in improving functional and cognitive outcomes in patients with moderate TBI.

Development and feasibility testing of a psychoeducational tool to support the return to work (RTW) of individuals with traumatic brain injury (TBI): The RTW after TBI app

To document the development and clinician evaluation of a psychoeducational and support tool: the return to work after traumatic brain injury app (RTW after TBI app). Co-design of the app involved the collaboration of traumatic brain injury (TBI) /vocational rehabilitation (VR) expert researchers (n = 4) and lived experience co-designers (individuals with TBI who had previously returned to work; n = 4). Twelve TBI/VR clinician reviewers then evaluated the app. Content analysis of TBI/VR clinician reviewers' interviews revealed four themes: content, usability (functional ease of use), utility (applicability to RTW after TBI) and suggestions for improvements. All clinicians reported that they would use the RTW after TBI app in their clinical practice. Although several aspects were reported to potentially limit the app's appropriateness for some TBI clients, many feasible improvements were suggested to address limitations. These improvements aim to increase the utility of the app with a wider range of clients and extend its use to other settings. Future research should evaluate, in a clinical trial, the efficacy of the RTW after TBI app in supporting individuals with TBI and their vocational providers and optimizing RTW success.

Facial affect recognition in context in adults with and without TBI

Introduction

Several studies have reported impaired emotion recognition in adults with traumatic brain injury (TBI), but studies have two major design features that limit application of results to real-world contexts: (1) participants choose from among lists of basic emotions, rather than generating emotion labels, and (2) images are typically presented in isolation rather than in context. To address these limitations, we created an open-labeling task with faces shown alone or in real-life scenes, to more closely approximate how adults with TBI label facial emotions beyond the lab.

Methods

Participants were 55 adults (29 female) with moderate to severe TBI and 55 uninjured comparison peers, individually matched for race, sex, and age. Participants viewed 60 photographs of faces, either alone or in the pictured person's real-life context, and were asked what that person was feeling. We calculated the percent of responses that were standard forced-choice-task options, and also used sentiment intensity analysis to compare verbal responses between the two groups. We tracked eye movements for a subset of participants, to explore whether gaze duration or number of fixations helped explain any group differences in labels.

Results

Over 50% of responses in both groups were words other than basic emotions on standard affect tasks, highlighting the importance of eliciting open-ended responses. Valence of labels by participants with TBI was attenuated relative to valence of Comparison group labels, i.e., TBI group responses were less positive to positive images and the same was true for negative images, although the TBI group responses had higher lexical diversity. There were no significant differences in gaze duration or number of fixations between groups.

Discussion

Results revealed qualitative differences in affect labels between adults with and without TBI that would not have emerged on standard forced-choice tasks. Verbal differences did not appear to be attributable to differences in gaze patterns, leaving open the question of mechanisms of atypical affect processing in adults with TBI.

Persistent Changes in Mechanical Nociception in Rats With Traumatic Brain Injury Involving Polytrauma

Traumatic brain injury (TBI) survivors often experience debilitating consequences. Due to the high impact nature of TBI, patients often experience concomitant peripheral injuries (ie, polytrauma). A common, yet often overlooked, comorbidity of TBI is chronic pain. Therefore, this study investigated how common concomitant peripheral injuries (ie, femoral fracture and muscle crush) can affect long-term behavioral and structural TBI outcomes with a particular focus on nociception. Rats were randomly assigned to 1 of 4 groups: polytrauma (POLY; ie, fracture + muscle crush + TBI), peripheral injury (PERI; ie, fracture + muscle crush + sham TBI), TBI (ie, sham fracture + sham muscle crush + TBI), and sham-injured (SHAM; ie, sham fracture + sham muscle crush + sham TBI). Rats underwent behavioral testing at 3-, 6-, and 11-weeks postinjury, and were then euthanized for postmortem magnetic resonance imaging (MRI). POLY rats had a persisting increase in pain sensitivity compared to all groups on the von Frey test. MRI revealed that POLY rats also had abnormalities in the cortical and subcortical brain structures involved in nociceptive processing. These findings have important implications and provide a foundation for future studies to determine the underlying mechanisms and potential treatment strategies for chronic pain in TBI survivors. PERSPECTIVE: Rats with TBI and concomitant peripheral trauma displayed chronic nociceptive pain and MRI images also revealed damaged brain structures/pathways that are involved in chronic pain development. This study highlights the importance of polytrauma and the affected brain regions for developing chronic pain.

Wants and needs for involvement experienced by relatives of patients with an acquired brain injury: a scoping review

OBJECTIVE

The objective of this scoping review was to identify and map the breadth of available evidence on relatives' wants and needs for involvement in the care of patients with an acquired brain injury.

INTRODUCTION

Acquired brain injuries often occur suddenly and unexpectedly. Experiencing an acquired brain injury has major consequences, not only for the patients-due to the devastating impact on their physical, cognitive, social, and psychological well-being-but also for the relatives who may need to take on a lifelong role as a carer. Research has cited some benefits of involving relatives in the care of patients, including positive effects on the patients' health outcomes; however, there are few studies showing how relatives can be involved.

INCLUSION CRITERIA

Studies that defined or assessed relatives' wants and needs for involvement in the care of patients with an acquired brain injury in all settings were included. Studies were included if they described any kind of wants and needs for involvement experienced from the perspective of relatives. The review considered all study designs, except for literature reviews.

METHODS

The JBI methodology for conducting a scoping review was employed in accordance with an a priori published protocol. An extensive search was conducted in MEDLINE (PubMed), CINAHL (EBSCO), and Embase (Ovid). Gray literature was searched using Grey Matters and BASE. The initial search was conducted in February 2020 and updated in September 2021. This review was limited to studies published in English, German, or Scandinavian languages since January 2010. The data were extracted using a data extraction tool (authors, year of publication, country of origin, setting, study methods, and findings related to wants and needs for involvement) created by the authors. The review findings are reported as a descriptive summary, with tables and figures supporting the data.

RESULTS

The search identified 3854 studies, 31 of which were included. The studies were published between 2010 and 2021, and were conducted across 9 countries. In total, 16 studies applied a qualitative study design, 4 studies used a descriptive approach, 4 studies used a quantitative research design, 4 studies reported using a mixed methods design, and 3 studies employed a multi-methods design. The studies were conducted across a variety of settings, ranging from acute care to home. The international literature on the involvement of relatives of patients with acquired brain injuries comprises multiple published studies on different aspects of the topic and within various care contexts. The findings identified few studies describing wants and needs experienced by relatives in relation to involvement in the patient's disease trajectory.

CONCLUSIONS

The findings show that relatives' wants and needs are primarily related to information and communication, but are also related to collaboration with health care professionals. The findings illustrate that the complexity of involvement is comprehensive, with multiple aspects to consider.

Effects of Neurofeedback on Cognitive Function, Productive Activity, and Quality of Life in Patients With Traumatic Brain Injury: A Randomized Controlled Trial

BACKGROUND

Cognitive impairment is common in patients with traumatic brain injury (TBI). Studies that have examined the effectiveness of neurofeedback (NFB) on cognitive function following TBI have had poor study designs and small sample sizes.

OBJECTIVES

This randomized controlled trial assessed the effects of low-resolution tomography Z-score NFB (LZNFB) and theta/beta NFB on cognitive impairment, return to productive activity, and quality of life in patients with TBI.

METHODS

We randomly assigned 87 patients with TBI with cognitive impairment to LZNFB, theta/beta NFB, or usual care (UC) groups. Patients in both NFB groups received weekly 60-minute treatment for 10 weeks, and those in the control group received UC and telephone interviews for 10 weeks. The primary outcome was cognitive function as measured by performance on cognitive tasks; the secondary outcomes included productive activity and quality of life based on the Community Integration Questionnaire-revised (CIQ-R) and the Quality of Life after Brain Injury (QOLIBRI), respectively, at baseline and immediately after the last intervention.

RESULTS

The LZNFB group exhibited significantly greater improvements in immediate recall, delayed recall, recognition memory, and selective attention compared with the UC group; the theta/beta NFB group exhibited improvements in only immediate memory and selective attention (P < .05). The total CIQ-R scores of the LZNFB group after treatment were significantly improved than those of the UC group were.

CONCLUSION

Consecutive LZNFB achieved therapeutic effects in memory, attention, and productive activity, whereas theta/beta NFB improved memory and attention in patients with TBI.This trial was prospectively registered at ClinicalTrial.gov (registration number: NCT03515317; https://clinicaltrials.gov/ct2/show/NCT03515317).

Long-term work quality of patients with mild traumatic brain injury: The associations with postconcussion symptoms

Return to work (RTW) has always been a determinant functional outcome in patients with mild traumatic brain injury (MTBI). However, the quality of long-term RTW was still unclear. This study thus aims to examine long-term work quality and to reveal its associating factors. A total of 110 patients with MTBI was prospectively recruited. Post-concussion symptoms (PCS) and RTW were evaluated by the Checklist of Post-Concussion Symptoms (CPCS) and Work Quality Index (WQI) respectively at one-week and long-term evaluation (M = 2.90 years, SD = 1.29) post-injury. Only 16% of patients can successfully RTW at one-week post-injury, while 69% of patients have retained their jobs at long-term evaluations. Importantly, 12% of patients had to work under the adverse impacts of PCS at one-week after MTBI, and long-term WQI was significantly associated with PCS at one-week post-injury. Almost 1/3 of patients still had unfavorable long-term work quality even though they could return to work. Thus, a careful evaluation of the early PCS endorsement and work quality for patients with MTBI is merited.

The cognitive status of chronic subdural hematoma patients after treatment: an exploratory study

OBJECTIVE

Chronic subdural hematoma (CSDH) is a common neurological condition, often affecting the elderly. Cognitive impairment is frequently observed at presentation. However, the course and longer term aspects of the cognitive status of CSDH patients are unknown. In this study, we aim to explore the cognitive status of CSDH patients after treatment.

METHODS

An exploratory study in which CSDH patients were assessed 3 months after treatment and compared to healthy controls. A total of 56 CSDH patients (age 72.1 SD ± 10.8 years with 43 [77%] males) and 60 healthy controls were included (age 67.5 ± SD 4.8 with 34 [57%] males). Cognitive testing was performed using the Telephonic Interview of Cognitive Status-modified (TICS-m), a 12-item questionnaire in which a total of 50 points can be obtained on several cognitive domains.

RESULTS

Median time between treatment and cognitive testing was 93 days (range 76-139). TICS-m scores of CSDH patients were significantly lower than healthy controls, after adjusting for age and sex: mean score 34.6 (95% CI: 33.6-35.9) vs. 39.6 (95% CI: 38.5-40.7), p value < 0.001. More than half (54%) of CSDH patients have cognitive scores at follow-up that correspond with cognitive impairment.

CONCLUSION

A large number of CSDH patients show significantly worse cognitive status 3 months after treatment compared to healthy controls. This finding underlines the importance of increased awareness for impaired cognition after CSDH. Further research on this topic is warranted.

Predictors of Social Participation Outcome after Traumatic Brain Injury Differ According to Rehabilitation Pathways

Social participation (SP) is one of many objectives in the rehabilitation of patients with traumatic brain injury (TBI). Studies on predictors of SP specific to post-acute universally accessible specialized rehabilitation pathways following TBI are scarce. Our objectives were to: 1) characterize SP, as well as a set of pre-injury, injury-related, and post-injury variables in individuals participating in inpatient-outpatient or outpatient rehabilitation pathways within a universally accessible and organized trauma continuum of care; and 2) examine the ability of pre-injury, injury-related, and post-injury variables in predicting SP outcome after TBI according to rehabilitation path. Participants (N = 372) were adults admitted to an inpatient-outpatient rehabilitation pathway or an outpatient rehabilitation pathway after sustaining a TBI between 2016 and 2020, and for whom Mayo-Portland Adaptability Intentory-4 (MPAI-4) outcomes were prospectively obtained at the start and end of rehabilitation. Additional data was collected from medical files. For both rehabilitation pathways, predicted SP outcome was MPAI-4 Participation score at discharge from outpatient rehabilitation. Multiple regression models investigated the predictive value of each variable for SP outcome, separately for each care pathway. Main findings show that for the inpatient-outpatient sample, three variables (education years, MPAI-4 Ability and Adjustment scores at rehabilitation intake) significantly predicted SP outcome, with the regression model accounting for 49% of the variance. For the outpatient sample, five variables (pre-morbid hypertension and mental health diagnosis, total indirect rehabilitation hours received, MPAI-4 Abilities and Adjustment scores at rehabilitation intake) significantly predicted SP outcome, with the regression model accounting for 47% of the variance. In conclusion, different pre-morbid and post-injury variables are involved in predicting SP, depending on the rehabilitation path followed. The predictive value of those variables could help clinicians identify patients more likely of showing poorer SP at discharge and who may require additional or different interventions.

Exploring employment following traumatic brain injury in persons who completed an insurer funded vocational rehabilitation program in Australia

PURPOSE

To extend the authors' previous research by investigating the maintenance of work performance over time and the long-term experience of employment following traumatic brain injury (TBI).

MATERIALS AND METHODS

Semi-structured interviews were conducted with a sample of 72 individuals with predominantly severe TBI, up to 10-years post-injury. Thematic analysis of transcribed interviews was conducted.

RESULTS

Four key themes were identified: brain injury influences on work performance and long-term employment; factors optimising long-term employment; and need for compromise and acceptance, which all impacted the final theme, quality of life outcome. While TBI-related difficulties such as fatigue, cognitive, and emotional difficulties still impacted work many years post-injury, work modifications and employer and vocational rehabilitation (VR) support were important factors optimising long-term employment. The timing of return to work (RTW) was also an important and potentially modifiable factor influencing work performance, which appeared to have long-term effects on the maintenance of employment. Support for acceptance of altered career goals is needed.

CONCLUSION

Findings support the need for early VR to facilitate employer contact, to maximise adjustment and preparation time before RTW, to educate both employees and employers and to implement work modifications to support continuing employment after TBI.Implications for rehabilitationThe maintenance of employment following TBI is of critical importance for financial independence, psychological and social well-being, and improved quality of life.Injury-related difficulties still impact work performance many years after injury requiring individuals with TBI to continue working in modified roles and for reduced hours over the long-term.Ongoing VR and employer support is needed to facilitate long-term work modifications and compensatory strategies to support work performance.Early VR involvement to facilitate employer contact and maximise adjustment and preparation time before returning to work is necessary to avoid the negative and potentially dire consequences of returning too early.Psychological support to facilitate acceptance of role changes and career compromises is also important.

The experience of employers of individuals with traumatic brain injury

OBJECTIVES

To understand the experience of employers of individuals with traumatic brain injury (TBI) who have received comprehensive vocational rehabilitation (VR), the factors involved in supporting an individual with TBI to return to work (RTW), and the support needs of employers.

METHODS

12 employers completed semi-structured interviews, which were recorded, transcribed, and analysed thematically.

RESULTS

Five main themes were identified: challenges and impact on employer, managing employee post-injury changes, looking after employee wellbeing, managing conflicting emotions, and utilizing sources of support. Although employers received support with operational challenges, findings suggest they were not prepared for the emotional journey. While they struggled to support employees through the difficult process of realizing they could no longer perform at their pre-injury level, employers strove to find appropriate roles and ensure wellbeing for their injured employees. Despite employers' endeavours, they felt this process was demoralizing for some employees.

CONCLUSIONS

Advising employers on operational as well as emotional support needs of both employees and employers is an ongoing challenge for VR providers. Although unsupportive employers were not well-represented in this sample, the study highlights the challenges faced and strategies used by employers who have a strong personal investment in the successful RTW of their employees.

"It's been a long hard road": challenges faced in the first three years following traumatic brain injury

PURPOSE

There is limited qualitative research exploring challenges experienced following severe traumatic brain injury (TBI). We investigated challenges to recovery identified by individuals who sustained severe TBI three years earlier or their close others (COs), as well as suggestions for managing these challenges.

MATERIALS AND METHODS

Nine participants with TBI and 16 COs completed semi-structured interviews. Using reflexive thematic analysis, challenges were identified across several timeframes (i.e., at the injury, acute care, inpatient rehabilitation, outpatient rehabilitation, and at home/other location).

RESULTS

Challenges experienced across all timeframes included: lack of information and poor communication, pre-existing conditions, missed injuries, and issues with medical staff, and continuity of care. From acute care onwards, there were TBI-related consequences, issues with coping and emotional adjustment, negative outlook, insufficient treatment, lack of support for COs, and issues with compensation and funding for rehabilitation needs. Some challenges were unique to a specific timeframe (e.g., over-stimulating ward setting during acute care, and limited or unsupportive families once injured individuals went home). Suggestions for managing some of the challenges were provided (e.g., information provision, having peer supports).

CONCLUSION

Suggestions should be considered to promote successful outcomes following severe TBI.IMPLICATIONS FOR REHABILITATIONRecovery following a severe traumatic brain injury can be hindered by challenges, such as poor communication, limited information provision, injury-related consequences, limited services and emotional support for the injured individual and their Close Others, and a need for education of the broader community about traumatic brain injury.Suggestions for managing these challenges (e.g., peer supports; services closer to home) could be used to inform clinical guidelines that could be used in a rehabilitation context.These suggestions ultimately aim to improve the post-injury experience and outcomes of individuals with traumatic brain injury and their Close Others.

Unequal neurorehabilitation trajectories - a longitudinal case study combining field structures with social Class-Based Capital Conversion

Inequalities in illness, service provision, and outcomes are well documented in the Nordic universal welfare state. The ways in which inequalities are produced during illness recovery trajectories remain largely unknown. Long-term brain injury rehabilitation in this context provides a window into veiled aspects of inequality and the underlying mechanisms. We examine inequality empirically by combing framing field structures with the classed abilities of families to mobilise capital after a severe acquired brain injury (severe ABI). Using a Bourdieuan theoretical framework, informed by the concepts of field, doxa, cultural health capital (CHC), and rehabilitation capital (RC), we designed a longitudinal case study encompassing professional records, observations, and interviews that tracked and analysed subjects' trajectories. We found that families' consistent accumulation and conversion of capital was crucial after a severe ABI because of the multifaceted rehabilitation process involving many different field specific agendas and doxas. This study supplements previous concepts (CHC and RC) developed in a health care context by including other rehabilitation contexts. These disparities in forms of capital amongst social classes result in winners and losers and were reflected in the rehabilitation trajectories of the young adults, characterised by continuity on one extreme and broken trajectories on the other.

Memory and Executive Functions Subserving Judgments of Learning: Cognitive Reorganization After Traumatic Brain Injury

We investigated relationships between psychometric measures of memory, executive functions (EFs), and task-based measures of Judgments of Learning (JOLs) in individuals with and without Traumatic Brain Injury (TBI), to study functional reorganization after TBI. We hypothesized that, in controls, accuracy of immediate JOLs would be associated with short-term memory and EFs (but not long-term memory, LTM), while accuracy of delayed JOLs would be associated primarily with LTM. We hypothesized that those with good recovery from TBI would demonstrate functional reorganization of the relationships between memory, EFs, and JOLs. Eighteen individuals with TBI and 18 matched controls completed eight neuropsychological tests of memory and EFs. They studied word-pairs, made immediate and delayed JOLs, and took a cued-recall test for the studied word-pairs. Stepwise regression and Lasso analyses generated a predictive model of JOL accuracy for each group. Accuracy of immediate JOLs in controls was predicted by short-term memory, inhibition, switching, and cognitive fluency, while accuracy of delayed JOLs was predicted by verbal recall. In individuals with TBI, inhibition predicted immediate JOL accuracy and switching predicted delayed JOL accuracy. Cognitive reorganization in those with good long-term recovery from TBI may account for the ability to make JOLs with accuracy similar to controls.

Factors associated with sustaining work after an acquired brain injury: a scoping review

PURPOSE

Maintaining work in the long term represents a major challenge for people with acquired brain injury (ABI) as evidenced by a high rate of premature labour market dropouts. The present study aimed to compile factors associated with working in the long term after sustaining an ABI.

MATERIALS AND METHODS

We carried out a scoping review synthesizing quantitative and qualitative research conducted between 2000 and 2021. Databases searched comprised PubMed, CINAHL Complete, PsycINFO, Scopus, and Web of Science.

RESULTS

Ten quantitative and nine qualitative studies were included, all but one from high-resource countries. Quantitative research predominantly comprised longitudinal follow-ups on individuals' work status several years post ABI onset, showing an effect of injury-related and sociodemographic factors. Qualitative studies mostly dealt with work maintenance and revealed a key role of cognitive difficulties, psychological personal factors (e.g., adequate coping strategies) and environmental factors (e.g., flexible work schedules, supportive colleagues).

CONCLUSIONS

The factors identified in our review should receive particular attention in vocational integration and job retention programs to support work participation of people with ABI in the long term. There is a need for measures that regularly monitor and promote a good match between individuals and their work environment.Implications for RehabilitationPeople with acquired brain injury (ABI) often have long-lasting and invisible injury-related difficulties that hamper their labour market participation.Factors identified as positively associated with working in the long term, such as coping strategies and self-awareness, should be strengthened.Future interventions should educate affected persons, employers and health care professionals about long-lasting injury-related difficulties and promote a supportive work environment for people with ABI.Prolonged availability of vocational services could be beneficial for supporting work maintenance of people with ABI.

Crosstalk among N6-methyladenosine modification and RNAs in central nervous system injuries

Central nervous system (CNS) injuries, including traumatic brain injury (TBI), intracerebral hemorrhage (ICH) and ischemic stroke, are the most common cause of death and disability around the world. As the most common modification on ribonucleic acids (RNAs), N6-methyladenosine (m6A) modification has recently attracted great attentions due to its functions in determining the fate of RNAs through changes in splicing, translation, degradation and stability. A large number of studies have suggested that m6A modification played an important role in brain development and involved in many neurological disorders, particularly in CNS injuries. It has been proposed that m6A modification could improve neurological impairment, inhibit apoptosis, suppress inflammation, reduce pyroptosis and attenuate ferroptosis in CNS injuries via different molecules including phosphatase and tensin homolog (PTEN), NLR family pyrin domain containing 3 (NLRP3), B-cell lymphoma 2 (Bcl-2), glutathione peroxidase 4 (GPX4), and long non-coding RNA (lncRNA). Therefore, m6A modification showed great promise as potential targets in CNS injuries. In this article, we present a review highlighting the role of m6A modification in CNS injuries. Hence, on the basis of these properties and effects, m6A modification may be developed as therapeutic agents for CNS injury patients.

Predictive Factors of Return Home and Return to Work for Intensive Care Unit Survivors after Traumatic Brain Injury with a Follow-up Period of 2 Years

Intensive care unit (ICU) survivors after traumatic brain injury (TBI) frequently have serious disabilities with subsequent difficulty in reintegration into society. We aimed to investigate outcomes for ICU survivors after moderate to severe TBI (msTBI) and to identify predictive factors of return home (RH) and return to work (RTW). This single-center retrospective cohort study was conducted on all trauma patients admitted to the emergency ICU of our hospital between 2013 and 2017. Of these patients, adult (age ≥ 18 years) msTBI patients with head Abbreviated Injury Scale ≥ 3 were extracted. We performed univariate/multivariate logistic regression analyses to explore the predictive factors of RH and RTW. Among a total of 146 ICU survivors after msTBI, 107 were included (median follow-up period: 26 months). The RH and RTW rates were 78% and 35%, respectively. Multivariate analyses revealed that the predictive factors of RH were age < 65 years (P < 0.001), HR < 76 bpm (P = 0.015), platelet count ≥ 19 × 10⁴/μL (P = 0.0037), D-dimer < 26 μg/mL (P = 0.034), and Glasgow Coma Scale (GCS) score > 8 (P = 0.0015). Similarly, the predictive factors of RTW were age < 65 years (P < 0.001) and GCS score > 8 (P = 0.0039). This study revealed that “age” and “GCS score on admission” affected RH and RTW for ICU survivors after msTBI.

Life goals as a driving force in traumatic brain injury rehabilitation: a longitudinal dyadic perspective

BACKGROUND

Traumatic brain injury significantly impacts survivors and their families. Rehabilitation following traumatic brain injury is often complex due to the physical, psychological, and socio-economic problems survivors face. Life goals are considered a motivational factor in rehabilitation.

OBJECTIVE

The aim was to explore expectations, problems, and strategies for goal setting in survivors of traumatic brain injury and their family caregivers for one-year during rehabilitation.

METHODS

A longitudinal qualitative study using dyadic interviews with survivors and family caregivers was carried out at three time points during the first year following traumatic brain injury. Data was analyzed according to Braun and Clarke's thematic analysis.

RESULTS

Eight survivors of traumatic brain injury and their family caregivers completed 24 interviews. Three themes and one sub-theme were identified: 1) life goals as a driving force (subtheme: dyadic discrepancies and conflicts); 2) conflicts between specific, measurable, achievable, realistic, and timed (SMART) goals and life goals; and 3) changing perceptions of the impact of impairments.

CONCLUSIONS

Life goals are important motivation in the rehabilitation process. Health care professionals must integrate life goals and rehabilitation goals (i.e. SMART goals) to decrease barriers and survivor ambivalence about rehabilitation. Involving both survivors and family caregivers in goal setting increases rehabilitation success.

Social problem solving and trait socioemotional abilities in ambulatory stroke patients

INTRODUCTION

Stroke has been associated with sociocognitive impairment, so far well documented for emotion recognition and Theory of Mind. However, more complex abilities, such as social problem solving, which directly facilitate appropriate behavior in social situations have been neglected in previous research.

METHOD

The present study aimed to address this gap by focusing on performance-based social problem solving abilities and self-reported socioemotional abilities (i.e., empathy and alexithymia) in outpatient stroke patients (n = 36) compared to a group of healthy controls (n = 36) equivalent on age, gender, and education. In further analyses, potential lateralization effects and correlations between social problem solving/socioemotional functioning and demographic and clinical data were investigated.

RESULTS

In the main analyses, patients were impaired in their ability to freely generate appropriate solutions for challenging interpersonal situations depicted in written scenarios but performed on a comparable level as healthy controls when they had to choose the optimal solution presented amidst a range of less optimal options. While showing difficulty in identifying the awkward elements in the scenarios, the patient group nevertheless rated the degree of discomfort attributed to these elements on a level comparable to the control group. On the self-report measures, stroke patients reported overall higher degrees of alexithymia (i.e., an inability to describe and identify one's own and other persons´ emotions) and more personal distress in response to other individuals´ emotional suffering as assessed by self-report.

CONCLUSIONS

The present results suggest that stroke is associated with a broad impact on socioemotional and social problem solving abilities. As difficulties in social problem solving might be associated with increased psychosocial burden they ought to be addressed in stroke rehabilitation.

What is a meaningful life for persons with acquired neurological impairments? A scoping review protocol

OBJECTIVE

This scoping review explores the constitution of a meaningful life as perceived by adults with acquired neurological impairment following an injury or a disease.

INTRODUCTION

A neurological injury or disease imposes extensive life changes on the affected person and his or her close relatives. Including the patients' perception of a meaningful life is crucial to facilitate adjustment of any rehabilitation initiatives to the patients' wishes, hopes, needs, and preferences. Even so, the descriptions and common traits of a meaningful life from the impaired person's perspective are scarcely covered in the literature. Hence, a scoping review of existing knowledge is needed to facilitate quality rehabilitation and research initiatives.

INCLUSION CRITERIA

All studies, regardless of their design, are included provided they describe a meaningful life as considered or experienced by persons aged 18 years or more with neurological impairment.

METHODS

A PICo framework defines the search algorithms used in the databases MEDLINE, Cinahl, PsycINFO and Embase. Using Covidence, the scoping review systematically organizes the identified articles to provide a broad description of the study phenomenon. Furthermore, titles, abstracts, and full-text articles are screened independently by two reviewers to determine if they meet the inclusion criteria. In case of disagreement, a third and fourth reviewer are consulted. The scoping will be reported according to the PRISMA- SCR checklist.

Traumatic brain injury-induced submissive behavior in rats: link to depression and anxiety

Traumatic brain injury (TBI) affects millions of people worldwide, many of whom are affected with post-TBI mood disorders or behavioral changes, including aggression or social withdrawal. Diminished functionality can persist for decades after TBI and delay rehabilitation and resumption of employment. It has been established that there is a relationship between these mental disorders and brain injury. However, the etiology and causal relationships behind these conditions are poorly understood. Rodent models provide a helpful tool for researching mood disorders and social impairment due to their natural tendencies to form social hierarchies. Here, we present a rat model of mental complications after TBI using a suite of behavioral tests to examine the causal relationships between changes in social behavior, including aggressive, hierarchical, depressive, and anxious behavior. For this purpose, we used multivariate analysis to identify causal relationships between the above post-TBI psychiatric sequelae. We performed statistical analysis using principal component analysis, discriminant analysis, and correlation analysis, and built a model to predict dominant-submissive behavior based on the behavioral tests. This model displayed a predictive accuracy of 93.3% for determining dominant-submissive behavior in experimental groups. Machine learning algorithms determined that in rats, aggression is not a principal prognostic factor for dominant-submissive behavior. Alternatively, dominant-submissive behavior is determined solely by the rats' depressive-anxious state and exploratory activity. We expect the causal approach used in this study will guide future studies into mood conditions and behavioral changes following TBI.

Virtual-Reality Performance-Based Assessment of Cognitive Functions in Adult Patients With Acquired Brain Injury: A Scoping Review

Individuals with acquired brain injury (ABI) commonly present with impairments in cognitive abilities. As these competencies seem to be predictive of patients' abilities to reintegrate into the everyday settings, it is crucial to assess them properly. However, previous research has indicated that patients may perform relatively well on standard tests of cognitive functioning, but may nonetheless encounter significant difficulties in organizing and executing everyday tasks. In order to overcome this issue, virtual reality (VR) methods have been introduced in clinical practice with the aim of creating assessments that simulate real-world activities and thus, provide a clearer picture of patients' functioning in everyday settings. This review offers an overview of VR assessment tools described in the scientific literature between 2010 and 2019. Overall, 38 relevant records describing 31 different tools were found. Among these tools, 16 assessed executive functions and prospective memory, while the other 15 assessed visuo-spatial abilities. Although promising results have been reported, our analysis indicated that about half of the tools deliver tasks that differ from everyday activities, thus limiting the generalizability of patients' performance to the real-world. Moreover, a variety of methodological shortfalls related to study Internal and External Validity have been highlighted, which hamper the possibility of drawing definite recommendations on tool choice. These limitations suggest the importance of putting considerable efforts into the improvement or development of VR tools for patients with ABI for both research and clinical purposes, considering the great potential of this form of assessment.

Who are relatives? Young adults, relatives and professionals' perceptions of relatives during the rehabilitation of young adults with a severe acquired brain injury

PURPOSE

This paper explores the perception of "relatives" during the rehabilitation of young adults with severe acquired brain injury (SABI).

METHODS

This longitudinal qualitative study followed eight young adults with a SABI from hospital discharge to a year and a half after discharge. The design encompassed professional records, interviews, and surveys, including a name generator list completed by the young adults and focus group interviews with both their families and professionals. We apply a sociological theoretical framework concerning friendship, and we employ social network analysis (SNA) methodology to capture, visualise, and analyse the young adults' significant social relations.

RESULTS

Social relations engaged as relatives during rehabilitation are to a large extent determined by the perceptions of professionals and the parents of the young adult. These perceptions contain a limited number of social relations, with priority given to biological and juridical ties. This might reflect the reduced social support available for the young adult, who initially had a much larger social network.

CONCLUSION

The authors suggest a professional rethinking of who "relatives" are as well as considering these social ties as dynamic. Implications for rehabilitationRehabilitation professionals must be aware of and pay attention to differing perceptions that exist as to who qualifies as significant social relations in order to reconsider the practical implementation of relative involvement.The perception of who relatives are during the rehabilitation process should be reconsidered and extended to include who the young adult perceive as significant social relations.Relatives are not a fixed entity and should be considered dynamically throughout the rehabilitation process.Social relations of the young adult must to a larger extent be considered during rehabilitation to prevent social isolation in the long run.

Shades of Rage: Applying the Process Model of Emotion Regulation to Managing Anger After Brain Injury

Uncontrollable anger is common following an acquired brain injury (ABI), with impaired emotion regulation (ER) being one of the main contributors. Existing psychological interventions appear moderately effective, though studies typically include limitations such as small sample sizes, issues of long-term efficacy, and standardization of content. While ER has been a popular research field, the study of ER for anger management after ABI is less well investigated, and contains few interventions based on the widely used Process Model of ER. This review surveys the efficacy of ER strategies in individuals with ABI, and proposes a novel research design for future interventions. Recommendations are made about: strategy number and type, shared decision-making, approaches to data analysis, and mode of delivery.

Clinical and Psychological Factors Associated With Return to Work Among United States Diplomats Who Sustained a Work-Related Injury While on Assignment in Havana, Cuba

OBJECTIVE

To determine factors associated with return to work in US diplomats injured during a work assignment in Cuba.

METHODS

In this case series work ability was determined at each visit. Questionnaires used included the Symptom Score Questionnaire, Beck Anxiety Inventory, Beck Depression Inventory, Quality-of-Life Inventory, and Patient Health Questionnaire.

RESULTS

Of the 45 employees referred to Occupational Medicine, the mean age was 42.5 years, 60% were men, 68% were never out of work, 22% were out of work for some period, and 15% remain out of work. Vestibular, cognitive, hearing, sleep, and visual symptoms, and a higher initial symptom score were significantly associated with work inability while psychiatric symptoms were not.

CONCLUSIONS

This exposure resulted in prolonged illness with cognitive impairment and other clinical manifestations associated with work inability.

Prevalence of suicidal ideation and suicide attempt among patients with traumatic brain injury: A meta-analysis

BACKGROUND

Suicidality is common among patients with traumatic brain injury (TBI). This meta-analysis aimed to assess the prevalence of suicidal ideation (SI) and suicide attempt (SA) in TBI patients.

METHODS

Databases including PubMed, Cochrane Library, Embase, CINAHL, Web of Science, PsycINFO, China National Knowledge Infrastructure (CNKI), VIP, WanFang Data, and Chinese Biomedical Literature Database (CBM) were searched for relevant literature from inception to 9th January 2021. Random effects models were used to estimate the prevalence of SI and SA. The methodological quality of the included studies was assessed using the modified Newcastle-Ottawa Scale. Subgroup analysis was performed based on the geographical location of the institutions.

RESULTS

A total of 16 studies involving 1,146,271 patients with TBI were included in our meta-analysis. The prevalence of SI and SA were 19.1% (95% CI 13.6-24.6%) and 2.1% (95% CI 1.8-2.4%), respectively, while the prevalence of SA in Asian and non-Asian countries were 2.0% (95% CI 0.3-3.7%) and 2.0% (95% CI 1.6-2.3%). Meta-regression analyses revealed that the publication year and age were positively associated, while the geographical location of the institution and sample size were negatively associated with the pooled prevalence of SI. On the other hand, the geographical location of the institution, sample size and age were negatively associated with the pooled prevalence of SA.

LIMITATIONS

The overall heterogeneity between studies was high.

CONCLUSION

SI and SA are common among TBI patients. Therefore, targeted preventive measures are paramount to manage TBI-related suicide.

"Manoeuvring in uncharted waters - a balancing act": A qualitative exploration of treatment and improvement after mild traumatic brain injury

Background: Individuals who have sustained mild traumatic brain injury (mTBI) with a protracted course of recovery may experience long-lasting somatic, cognitive, and emotional symptoms affecting activities of daily living. There is limited knowledge regarding individuals' lived experiences with treatments and advice provided.Purpose: To explore how individuals with mTBI describe and make sense of their injury, recovery process, and their experiences with various treatment approaches.Methods: Eight participants with mTBI were recruited from the intervention group in an ongoing randomized controlled trial regarding return-to-work. They were interviewed once after treatment delivery using a qualitative hermeneutical approach. Thematic analysis was applied, and findings are discussed in light of a salutogenic theory.Results: Participants expressed uncertainty regarding conflicting advice they received in the early phase of recovery. Three main themes were developed: (1) "Ambiguity and hope"; (2) "Uncertainty concerning activity and rest"; and (3) "To become the person I used to be vs. to become a new version of myself."Conclusion: The findings showed that the participants experienced both uncertainty and hope for further recovery. The recovery process is challenged by the variability of TBI symptoms that affects participation in everyday life, as well as the conflicting advice received by the participants.

Rehabilitation interventions after traumatic brain injury: a scoping review

PURPOSE

To (1) identify interventional research topics in traumatic brain injury (TBI) rehabilitation, (2) describe potential knowledge gaps, and (3) uncover further needs for interventional TBI rehabilitation research for patients and families.

METHOD

We searched three databases (2006-2019) and screened 1552 non-duplicate articles. Titles and abstracts were screened for relevance, yielding 754 articles for full-text review. Of these, 425 were included, as relevant to the purpose of the scoping review.

FINDINGS

Among articles on TBI rehabilitation, the majority (71.8%) applied quantitative methodology; of these only 19.7% were randomized controlled trials. Severe TBI was described more often than mild/moderate TBI populations. Hospital vs community/home rehabilitation was 55.1% vs 37.2%; rehabilitation at workplace/school was described in only 4.5% articles, while in 7.2% the setting was undisclosed. Of 83 articles describing work/education, only 14 were in a work/school context. An additional focus in the work/education articles was activities of daily living (n = 28), cognition (n = 33) and emotions (n = 23), few targeted family or network.

CONCLUSION

The main attention of interventional TBI rehabilitation studies has been on severe TBI and long-term rehabilitation. Gaps identified were rehabilitation of mild/moderate TBI populations, older populations, acute/sub-phase rehabilitation, return to work issues and studies including the family.Implications for rehabilitationA substantial number of interventional studies exist to guide long-term rehabilitation after traumatic brain injury with focus on daily life, physical, emotional and cognitive functioning.We recommend a stronger focus in the clinic on the following groups; people with mild/moderate traumatic brain injury, people in the acute and sub-acute phase, and older people with traumatic brain injury.Issues that target challenges returning to work should be addressed, while they are of importance to patients and families.Emphasis should be put on continuity of care and peer-support.

Effects of Cognitive Reserve on Cognition in Individuals With Central Nervous System Disease

Cognitive reserve (CR) has been proposed to account for functional outcome differences in brain pathology and its clinical manifestations. The purpose of our paper is to systematically review the effects of CR on cognitive outcomes in individuals with neurodegenerative and structural CNS diseases. We performed a systematic search of PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and PsychInfo using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Seventeen studies met the predetermined inclusion criteria and were selected for review. Education level was the most commonly used measure for CR, and various neuropsychological tests were used to measure cognitive outcomes. Regardless of the CNS disease of the individuals, almost all of the studies reported a positive association between CR and cognitive outcomes when they were evaluated cross-sectionally. However, when evaluated longitudinally, CR had either no effect on, or a negative association with, cognitive outcomes. Based on studies across a broad spectrum of CNS diseases, our findings suggest that CR may serve as a predictor of cognitive outcomes in individuals with CNS diseases. However, studies to date are limited by a lack of imaging analyses and standardized assessment strategies. The ability to use a standardized measure to assess the longitudinal effects of CR may allow for the development of more targeted treatment methods, resulting in improved disease outcomes for individuals.

Family involvement in the treatment of patients with an acquired brain injury or malignant brain tumor: a scoping review protocol

OBJECTIVE

The objective of this review is to scope the evidence on the wants and needs of families with regards to their level of involvement in treatment for patients with an acquired brain injury or malignant brain tumor.

INTRODUCTION

Severe acquired brain injury and malignant brain tumor are diseases occurring unexpectedly and suddenly. Sustaining a severe acquired brain injury or malignant brain tumor has major consequences for patients and their relatives because of its devastating impact on physical, cognitive, social, and psychological well-being. The neurocognitive deficits have been shown to put strain on families in particular.

INCLUSION CRITERIA

This scoping review will consider studies involving relatives (≥18 years) of patients (≥18 years) with severe acquired brain injury or malignant brain tumor (WHO grade 3 and 4) from different settings (municipalities, primary care, health care centers, hospital, and long-term care institutions). Studies will be included if they describe any kind of involvement by relatives, and the review will consider all study designs, regardless of their rigor.

METHODS

Indexed and gray literature in English, Scandinavian, or German from January 2010 to the present will be considered. The searches will be conducted using bibliographic databases. Studies will be independently screened according to the inclusion criteria by two reviewers based on title, abstract, and full text. In case of disagreement, a third and fourth reviewer will be consulted. A customized data extraction form will be used to extract data from the included studies. The results will be presented in tabular form, accompanied by a narrative summary related to the objective of the present scoping review.

The functional indexes of RBCs and microcirculation in the traumatic brain injury with the action of 2-ethil-6-methil-3-hydroxypiridin succinate

RESEARCH AIM

To study the RBCs functional and metabolic parameters and the microcirculatory brain structure at traumatic brain injury (TBI) under the action of 2-ethyl-6-methyl-3-hydroxypyridine succinate.

METHODS

A closed TBI was modeled by the free fall of a load on the parietooccipital regions of head. We made studies of the influence of 2-ethil-6-methil-3-hydroxipiridin succinate on aggregation and electrophoretic mobility of RBCs, catalase activity, malonic dialdehyde concentration, adenosine triphosphate and 2.3-biphosphoglycerate (2.3 - BPG) concentrations in RBCs. The state of parenchyma and microcirculatory brain mainstream in post-traumatic period of TBI have been studied on micro-preparations.

RESULTS

The use of 2-ethyl-6-methyl-3-hydroxypyridine succinate under conditions of head injury leads to a decrease in MDA concentration and in aggregation of RBCs, to an increase in the 2.3-BPG concentration and RBC electrophoretic mobility compared to the control (group value). The most pronounced changes under the action of 2-ethyl-6-methyl-3-hydroxypyridine succinate were observed 3-7 days after the TBI. Significant indicators of the restoration of the microvasculature and brain tissue provoked by the use of 2-ethyl-6-methyl-3-hydroxypyridine succinate of were evident from the 7th day unlike the control group, where the restoration of structural morphological parameters was observed only on the 12th day of the post-traumatic period. Fast recovery of blood flow under the action of 2-ethyl-6-methyl-3-hydroxypyridine succinate ensured effective restoration of neurons and glia in comparison with the control group.

CONCLUSIONS

Early and long-term cytoprotective correction intensifies the oxygen transport function of the blood, prevents and / or reduces disorders of microvessels, neurons and glia in the post-traumatic period, thereby provides correction of hypoxic state and drives to the restoration of brain tissues homeostasis.

Factors associated with employment stability following traumatic brain injury, in a sample who have received comprehensive vocational rehabilitation

PURPOSE

To quantify employment stability of individuals with traumatic brain injury (TBI) who received comprehensive vocational rehabilitation (VR) using different measures to identify difficulties experienced and factors associated with employment stability.

MATERIALS AND METHODS

72 individuals with predominantly moderate-severe TBI were interviewed. Neuropsychological assessment scores were collected. Three employment stability measures were used: number of post-injury employers, duration with employer and average weekly hours. Descriptive and predictive analyses were performed.

RESULTS

90.2% remained employed at time of interview (Mean = 4.83 years post-injury). However, participants worked significantly fewer hours, 63.9% had changed roles or employers at least once and only 51% achieved their pre-injury level of responsibility. 61% reported a high level of employer support. Self-reported difficulties included physical sequelae, memory problems and fatigue. Post-injury testing found impaired memory (34.4%) and processing speed (49.2%). After accounting for time since injury, demographic and employment variables (older age, male gender, higher pre-injury skill-level, higher level of employer support), higher level of injury-related difficulties and lower level of cognitive function significantly predicted employment stability.

CONCLUSION

Injury-related difficulties impact employment long-term, necessitating ongoing work modifications. Individualised VR is important, not only to facilitate return to work but to support long-term employment stability after TBI.Implications for rehabilitationBeing male was associated with working more hours, and having faster processing speed, lower levels of fatigue and ongoing physical sequelae were associated with a longer duration with the same employer.Initial return to work is often the first step on a long journey as injury-related difficulties can continue to impact work in the-long term and require lasting modifications to duties and working hours.VR should include ongoing follow-up to facilitate work modifications and support both the employer and the employee in adjusting to these.VR should be individualised to support the impact of the unique cognitive and physical limitations experienced by each individual with TBI, based on the needs and employment demands of each workplace.

Computer-Mediated Communication in Adults With and Without Moderate-to-Severe Traumatic Brain Injury: Survey of Social Media Use

BACKGROUND

Individuals with a history of traumatic brain injury (TBI) report fewer social contacts, less social participation, and more social isolation than noninjured peers. Cognitive-communication disabilities may prevent individuals with TBI from accessing the opportunities for social connection afforded by computer-mediated communication, as individuals with TBI report lower overall usage of social media than noninjured peers and substantial challenges with accessibility and usability. Although adaptations for individuals with motor and sensory impairments exist to support social media use, there have been no parallel advances to support individuals with cognitive disabilities, such as those exhibited by some people with TBI. In this study, we take a preliminary step in the development process by learning more about patterns of social media use in individuals with TBI as well as their input and priorities for developing social media adaptations.

OBJECTIVE

This study aims to characterize how and why adults with TBI use social media and computer-mediated communication platforms, to evaluate changes in computer-mediated communication after brain injury, and to elicit suggestions from individuals with TBI to improve access to social media after injury.

METHODS

We conducted a web-based survey of 53 individuals with a chronic history of moderate-to-severe TBI and a demographically matched group of 51 noninjured comparison peers.

RESULTS

More than 90% of participants in both groups had an account on at least one computer-mediated communication platform, with Facebook and Facebook Messenger being the most popular platforms in both groups. Participants with and without a history of TBI reported that they use Facebook more passively than actively and reported that they most frequently maintain web-based relationships with close friends and family members. However, participants with TBI reported less frequently than noninjured comparison participants that they use synchronous videoconferencing platforms, are connected with acquaintances on the web, or use social media as a gateway for offline social connection (eg, to find events). Of the participants with TBI, 23% (12/53) reported a change in their patterns of social media use caused by brain injury and listed concerns about accessibility, safety, and usability as major barriers.

CONCLUSIONS

Although individuals with TBI maintain social media accounts to the same extent as healthy comparisons, some may not use them in a way that promotes social connection. Thus, it is important to design social media adaptations that address the needs and priorities of individuals with TBI, so they can also reap the benefits of social connectedness offered by these platforms. By considering computer-mediated communication as part of individuals' broader social health, we may be able to increase web-based participation in a way that is meaningful, positive, and beneficial to broader social life.