Changes in sexual functioning following traumatic brain injury: An overview on a neglected issue

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.

Early traumatic experiences are linked to hypersexual behavior and erectile dysfunction in men through the mediation of body uneasiness and general psychopathology

BACKGROUND

Childhood traumatic experiences have been associated with hypersexuality and sexual dysfunctions. However, the mediators of the interactions between these variables should be clarified in men.

AIM

This study aimed to investigate the interaction of early traumatic experiences, psychopathology, and sexuality with respect to erectile dysfunction (ED) and hypersexual behavior. The hypothesized model expected that traumatic experiences would be associated with hypersexual behavior and reduced sexual functioning through the mediation of body uneasiness and psychological distress.

METHODS

The study was cross-sectional and observational. A total of 317 men were enrolled. Male patients with a primary complaint of ED and an indication for psychiatry referral represented the clinical sample (n = 116; mean ± SD age, 42.82 ± 16.89 years). Clinical classification was assessed with the Structured Interview on Erectile Dysfunction. The second sample (n = 201, 30.82 ± 11.94 years) was recruited from the general population. All participants were administered the following questionnaires: Brief Symptom Inventory, Childhood Trauma Questionnaire-Short Form, Hypersexual Behavior Inventory, Body Uneasiness Test-A, and 5-item International Index of Erectile Function.

OUTCOMES

Psychopathology and sexual functioning were assessed by a dimensional approach, and a multivariate model was computed by structural equation model analysis.

RESULTS

When compared with the sample from the general population, the clinical sample exhibited a higher prevalence of early traumatic experiences, as measured by scores on the Childhood Trauma Questionnaire-Short Form (45.08 ± 14.25 vs 39.03 ± 10.22, F = 17.63, P < .001), and a higher tendency to engage in hypersexual behaviors (34.63 ± 13.55 vs 30.79 ± 12.44, F = 6.97, P < .01). Structural equation model analysis showed excellent fit indices indicating that early traumatic experiences predicted hypersexual behaviors and ED through the exacerbating mediating effect of body uneasiness and psychopathology.

CLINICAL IMPLICATIONS

Clinicians should not limit their attention to the behavioral level when assessing sexual dysfunction in men; rather, they should also consider the complex psychopathologic consequences of childhood trauma. Integrated treatments that address the potential presence of childhood trauma with its wider psychological correlates (eg, emotion dysregulation, body uneasiness) might improve treatment response.

STRENGTHS AND LIMITATIONS

The study reports novel data on the relationship among childhood maltreatment, male sexuality, and psychopathologic mediators with a dimensional assessment. However, the assessment was cross-sectional, and causality was mainly derived from previous studies.

CONCLUSION

The present study enriches the current literature, strengthening the hypothesis that childhood traumatic experiences significantly shape development and sexuality. Body uneasiness and psychopathology can both tax sexual functioning, as assessed by erectile functioning or hypersexuality.

Virtual reality-based attention training in patients with neurological damage: A pilot study

Virtual Reality has been shown to be a valid tool to assess cognitive functions in an ecologically valid way. However, evidence regarding its effectiveness as a treatment option for cognitive rehabilitation has been limited. Furthermore, its potential to facilitate the transfer of training effects to patients' everyday life is still poorly studied. This study aimed to evaluate the efficacy of a VR-based attention training and its transfer to attentional functioning in everyday life. Nineteen inpatients with neurological disorders and attentional deficits underwent daily 30-min VR training sessions over a two-week period. Attentional functions were assessed before and after the training period using several computerized tests, two self-constructed behavioral tasks, and a questionnaire assessing patients' subjective attentional functioning. Pre-Post-analyses show significant decreases in reaction times in the computerized alertness and selective attention tests. Transfer to the behavioral tasks and self-report data could not be observed. Despite the specificity of the changes, confounding effects cannot entirely be ruled out due to the lack of a control group. Results suggest that training was effective in improving attentional functioning along neuropsychological measures, but did not elicit transfer to an ecologically valid or subjective level. Implications for the future development of VR interventions are discussed.

Experience of adapted cognitive behaviour therapy to address sexuality problems after traumatic brain injury: A qualitative study

Although sexuality has been shown to be negatively impacted in up to half of individuals who sustain traumatic brain injury (TBI), few studies have sought to evaluate the efficacy of targeted interventions. Gaining insight into the participant experience of undergoing treatment for post-TBI sexuality changes is a crucial aspect of intervention evaluation. This study aimed to investigate participants with TBI experience of undergoing eight sessions of a novel CBT intervention designed to help both couples and singles improve sexual wellbeing after TBI. Eight participants (50% male) with moderate-severe TBI, and a mean age of 46.38-years (SD = 13.54), completed a qualitative interview. A six-phase reflexive thematic analysis approach was used. Despite variability in participant characteristics, the findings suggested that participants with TBI experience reflected that of a positive treatment journey characterized by high levels of enjoyment and satisfaction. Key themes identified included contextual factors that preceded treatment, factors that facilitated treatment engagement, outcomes derived from the treatment experience, and feedback provided on reflection. The results not only provide an enriched understanding of the client experience of the intervention but provide corroborating preliminary evidence of efficacy for this novel CBT intervention in addressing complex and persistent sexuality problems after TBI.

Co-designing for behavioural change: understanding barriers and enablers to addressing sexuality after traumatic brain injury and mapping intervention strategies in a multi-disciplinary rehabilitation unit

Background Persistent changes in sexuality often follow traumatic brain injury (TBI). However, health professionals remain reticent about discussing sexuality and have reported barriers including uncertainties around whose role it is and limited educational and institutional support. This study employed a co-design and implementation process, aiming to promote team-wide behavioural change, whereby health professionals at a TBI rehabilitation unit would attempt to address sexuality with patients routinely. Methods Focus group sessions with multidisciplinary health professionals were conducted to identify barriers and enablers to behavioural change, identify areas for development, and co-design intervention options. Implementation deliverables were then finalised and provided to the team. The Theoretical Domains Framework was used to map factors influencing behaviours and the Behaviour Change Wheel was used to map interventions. Thematic analysis was used to further analyse barrier themes. Results Thirty-five barriers and eight enablers falling within 12 theoretical domains to behavioural change were identified. Thematic analysis revealed highly correlated barriers in initiating and sustaining change. Nine co-designed intervention options aligned with five intervention functions of the Behaviour Change Wheel, resulting in six final implementation deliverables. Conclusions Barriers were highly interrelated, influencing the approach to implementation deliverables. Simultaneously addressing multiple barriers could potentially alleviate discomfort associated with discussing sexuality. Concerns around initiating change were related to confidence in achieving sustainable changes. Achieving change requires organisational and team-level environmental restructuring and enablement. The next step involves evaluating the effectiveness of the co-design and implementation process in driving behavioural change and potential impacts on patient satisfaction and sexuality outcomes.

An exploration of women's sexual and reproductive health following traumatic brain injury

AIMS AND OBJECTIVES

To develop a gendered understanding of sexual and reproductive health for Australian women following traumatic brain injury.

BACKGROUND

The intersection of socialised normative expectations of sexuality and sexual health, and being a woman with a disability, can lead to inequity and a misconception that a woman with a disability is asexual.

DESIGN

An equal weighting concurrent mixed methods design.

METHODS

Twenty women participated in conversational interviews and 49 women completed an online survey. Equal priority was given to both qualitative and quantitative data which were collected concurrently. A separate analysis of data was performed and was later merged. This paper follows the Good Reporting of a Mixed Methods Study guidelines for reporting mixed methods research.

RESULTS

Women reported changes in menstruation, reproduction, and sexual activity. Results identified that following traumatic brain injury, routine reproductive, and sexual health screening were neglected. Women revealed a personal reticence to discuss sexual health in a holistic sense and appeared more comfortable discussing reproductive health rather than sex for pleasure. Additionally, they perceived there was a reticence by clinicians to discuss sexual health as part of their rehabilitation.

CONCLUSIONS

Shifting the focus to be on women's health through periodic comprehensive health assessments is essential to the delivery of holistic health care. These results can inform the provision of sexual health, sexual safety, and sexual assertiveness education and training for women and girls within a rehabilitation framework and would be a way of addressing what women in this study identified as an unmet need.

RELEVANCE TO CLINICAL PRACTICE

Reproductive and sexual health are important elements of routine comprehensive health screening for women. Nurses are well positioned to begin discussions regarding sexual agency, sexual, and reproductive health to ensure person-centred care.

Sexuality >1 year after brain injury rehabilitation: A cross-sectional study in Sweden

PURPOSE

This study investigates whether Acquired Brain Injury (ABI) is associated with changes in sexual function and satisfaction and how such changes are experienced, focusing on invisible impairments after ABI.

MATERIALS AND METHODS

A study-specific questionnaire was distributed in 2018-2019. The sample included individuals aged 20-90 years diagnosed with ABI due to subarachnoid hemorrhage (SAH), trauma, infection, or anoxia (ischemic stroke and intracerebral hemorrhage excluded), who participated in brain injury rehabilitation in Sweden, 2014-2016. Chi-square and Logistic regression analyses were used.

RESULTS

The study consists of 250 participants (response rate was 40%). Among participants 78% (194/250) had resumed sexual life. Participants reporting sexual changes also experienced more consequences related to ABI. Those with decreased sexual desire (63%, 148/234) reported more ABI consequences, including decreased memory (86% vs 65%, p = 0.000), decreased concentration ability (82% vs 65%, p = 0.003), and increased tiredness (91% vs 70%, p = 0.000) compared to those with intact desire. Such consequences can be invisible to others.

CONCLUSION

Visible impairments are known to impact sexual functions and satisfaction after ABI. Our results show how invisible impairments also have a great impact. From a biopsychosocial perspective, these results imply that individuals should receive sexual rehabilitation, irrespective of ABI impairment.

Urogenital dysfunction following neurotrauma

PURPOSE OF REVIEW

Trauma affecting the nervous system can have widespread consequences, depending on the location and severity of injury. The sensorimotor and cognitive deficits due to neurotrauma have been studied extensively. Although the overall mortality due to neurotrauma has reduced, the disability and morbidity due to neurotrauma has not significantly reduced and focus on urogenital disturbances in these patients has been limited. This article reviews the limited evidence and scientific literature on this topic.

RECENT FINDINGS

Lower urinary tract symptoms are commonly reported in patients with neurotrauma, both acutely and over the long term. Multiple medical and surgical approaches are available for managing bladder dysfunction in these patients. Sexual dysfunction and changes in sexual behaviour are reported by patients with neurotrauma and are usually multifactorial. Treatment options for sexual dysfunction are available and their management requires a holistic approach.

SUMMARY

Urogenital dysfunction contributes significantly to the overall functional outcome and impaired quality of life in patients with neurotrauma. A better understanding of the mechanisms behind the urogenital abnormalities is needed for efficient management and treatment.

Pregnancy After Concussion: A Clarion Call for Attention?

OBJECTIVE

Emerging research shows that women who sustain a mild traumatic brain injury, also termed concussion, have a higher risk of menstrual irregularities and sexual dysfunctions. However, no research exists on how these reproductive disruptions affect women's subsequent pregnancies. The objective of this study was to evaluate pregnancy outcomes after concussion in a cohort of reproductive-aged women (aged 18-45 years), 24 months post-injury. We hypothesized that, compared with their extremity-injured peers in the same cohort, women with concussion will have lower incidence of pregnancies.

SETTING

Emergency department of a level 1 trauma center.

PARTICIPANTS

Women of reproductive age (aged 18-45 years) seeking care for concussion or extremity injury.

DESIGN

Longitudinal cohort study that used data collected at 3 distinct time points: t0, baseline: an original cohort of 245 women recruited in January to July 2017 for exposure assessment; t1, 6(+4) weeks post-injury: evaluation of self-reported postinjury menstrual and sexual changes for subgroup analyses-data collected in March to September 2017 ( n = 135); t2, 24 months post-injury: March 2020 chart review for documentation of pregnancies/pregnancy-related events ( N = 245).

MAIN MEASURE

Poisson regression estimates used to model the incidence rate (IR) of pregnancies, comparing concussion with extremity injury.

RESULTS

We reviewed the charts of 254 women from the t0 cohort. After excluding 9 patients who were either deceased or missing relevant data, we had the 245 (96.5%) charts of 102 concussed and 143 extremity-injured study participants. After adjusting for race and obstetric history, women with concussion had 80% lower incidence of pregnancies than their extremity-injured peers (adjusted [adj] IR = 0.20; 95% CI: 0.07-0.59; P = .003). When we excluded women who were using birth control, the IR of pregnancy for women with concussions was 76% lower than for those who had sustained extremity injuries (adj IR = 0.24; 95% CI: 0.07-0.81; P = .02). Pregnancy incidence remained consistently lower for concussed women in additional sensitivity analyses excluding assault/domestic violence victims and those with a prior/new concussion at t0 and t2. Subgroup analyses of the 135 women who had experienced menstrual and/or sexual dysfunctions at t1 showed 84% reduced incidence of pregnancy for women with concussions compared with those who had sustained an extremity injury (adj IR = 0.16; 95% CI: 0.04-0.73; P = .02).

CONCLUSION AND RELEVANCE

Our study potentially serves as a clarion call to understand the long-term reproductive effects of female concussions.

Evaluating a Novel Treatment Adapting a Cognitive Behaviour Therapy Approach for Sexuality Problems after Traumatic Brain Injury: A Single Case Design with Nonconcurrent Multiple Baselines

There has been little progress in development of evidence-based interventions to improve sexuality outcomes for individuals with traumatic brain injury (TBI). This study aimed to evaluate the preliminary efficacy of an individualised intervention using a cognitive behaviour therapy (CBT) framework to treat sexuality problems after TBI. A nonconcurrent multiple baseline single-case design with 8-week follow-up and randomisation to multiple baseline lengths (3, 4, or 6 weeks) was repeated across nine participants (five female) with complicated mild–severe TBI (mean age = 46.44 years (SD = 12.67), mean post-traumatic amnesia = 29.14 days (SD = 29.76), mean time post-injury = 6.56 years (median = 2.50 years, SD = 10.11)). Treatment comprised eight weekly, individual sessions, combining behavioural, cognitive, and educational strategies to address diverse sexuality problems. Clinical psychologists adopted a flexible, patient-centred, and goal-orientated approach whilst following a treatment guide and accommodating TBI-related impairments. Target behaviour was subjective ratings of satisfaction with sexuality, measured three times weekly. Secondary outcomes included measures of sexuality, mood, self-esteem, and participation. Goal attainment scaling (GAS) was used to measure personally meaningful goals. Preliminary support was shown for intervention effectiveness, with most cases demonstrating sustained improvements in subjective sexuality satisfaction and GAS goal attainment. Based on the current findings, larger clinical trials are warranted.

Systemic inflammation in traumatic brain injury predicts poor cognitive function

BACKGROUND

Traumatic brain injury (TBI) impairs cognitive function. Systemic inflammation plays important role in cognitive deficits. It remains unclear if systemic inflammation in TBI is associated with poor cognitive function.

METHODS

From January 2018 to December 2020, two groups of subjects were recruited: patients with TBI (n = 120), and healthy control (n = 120), followed up to 3 months. Blood was collected from TBI patients and healthy control, and serum inflammatory cytokines including interferon-α (IFN-α), interleukin-1β (IL-1β), IL-6, IL-8, IL-10, and tumor necrosis factor-α (TNF-α) were measured at baseline and end of 3 months. Multivariate regression was used for analysis for the relationship between cognitive function and inflammatory cytokines.

RESULTS

Inflammatory cytokines were higher in patients with brain injury and remained high at end of 3 months. Some cytokines such as IFN-α, IL-1β, IL-6, and TNF-α were associated with worsening memory and predicted poor performance.

CONCLUSION

Systemic inflammation in patients with TBI predicts poor cognitive function.

Reply to van den Broek et al. Comment on "Laratta et al. Marital Stability and Quality of Couple Relationships after Acquired Brain Injury: A Two-Year Follow-Up Clinical Study. Healthcare 2021, 9, 283"

We thank van den Broek et al. [...].

Improving motor and cognitive recovery following severe traumatic brain injury using advanced emotional audio-video stimulation: Lessons from a case report

RATIONALE

It is estimated that about 6 million people suffer from severe traumatic brain injury (TBI) each year (73 cases per 100,000 people). TBI may affect emotional, sensory-motor, cognitive, and psychological functions with a consequent worsening of both patient and his/her caregiver's quality of life. In recent years, technological innovations allowed the development of new, advanced sensory stimulation systems, such as Neurowave, to further stimulate residual cognitive abilities and, at the same time, evaluate residual cognition.

PATIENT CONCERN

An 69-year-old Italian man entered our neurorehabilitation unit with a diagnosis of minimally conscious state following severe TBI. He breathed spontaneously via tracheostomy and was fed via percutaneous gastrostomy. At the neurological examination, the patient showed severe tetraparesis as he showed fluctuating alertness and responsiveness to external stimuli and opened the eyes without stimulation.

DIAGNOSIS

Patient was affected by subarachnoid hemorrhage and frontotemporal bilateral hematoma, which were surgically treated with decompressive craniotomy and subsequent cranioplasty about 6 months before.

INTERVENTIONS

The patient underwent a neuropsychological and clinical evaluation before (T0) and after a conventional rehabilitation cycle (T1), and after a Neurowave emotional stimulation-supported rehabilitative cycle (T2).

OUTCOMES

Following conventional rehabilitation (T1), the patient achieved a partial improvement in behavioral responsiveness; there was also a mild improvement in the caregiver's distress. Conversely, Neurowave emotional stimulation session determined (at T2) a significant improvement of the patient's behavioral responsiveness, cognition, and in the caregiver's distress. The P300 recording in response to the NES showed a significant change of P300 magnitude and latency.

DISCUSSION

Our data suggest that emotional-integrated sensory stimulation using adequate visual stimuli represents a beneficial, complementary rehabilitative treatment for patients in minimally conscious state following a severe TBI. This may occur because stimuli with emotional salience can provide a reliable motivational resource to stimulate motor and cognitive recovery following severe TBI.

Resilience and Sexuality After Concussion in Women

Background

Previous findings from our group show that in the acute (ie, 6–10 weeks) post-injury period, women with concussions have a 70% greater risk of sexual dysfunction than those with extremity injuries. There are currently limited treatment options for the clinical management of concussions. Resilience is a protective, modifiable psychological construct that has been shown to improve concussion-related sequelae. To date, however, no research has evaluated how resilience impacts sexuality outcomes after concussion in women.

Aim

Evaluate if resilience offers protection against negative sexuality outcomes in a cohort of reproductive, aged women with a concussion, seeking care in the Emergency Department of a Level-1 Trauma Center. We hypothesized that women with low resilience will be more likely to experience negative impacts on sexuality and that increasing levels of resilience will be associated with more positive sexuality outcomes.

Methods

Secondary data analyses.

Measures

Resilience was evaluated with the Resilience Scale (RS), and the Brain Injury Questionnaire for Sexuality (BIQS) was used for sexuality.

Results

Of the 299 participants recruited for the parent study, 80 with concussion had complete follow-up data and were included in these secondary analyses. Less than half (42.5%; n = 34) had low resilience (score≤130 on the RS), and the remaining 46 (57.5%) had high resilience (score>130 on the RS). In crude linear regression models, 1-unit increase in resilience was associated with a 4% increase in sexuality outcomes (β = 0.04, 95% CI:0.01, 0.05; P = .008). The effect estimate remained similar in post-concussion-symptom-adjusted models (β = 0.03, 95% CI:0.002, 0.06; P = .03). Mood-adjusted models showed a statistically significant interaction term (P < .0001). After stratifying by mood, findings showed that unit increases in resilience were associated with a 6% increase in sexuality outcomes for women in the high risk mood group (HADS score ≥11; PCS-adjusted β = 0.06, 95% CI:0.02, 0.11; P = .009).

Conclusion

Longitudinal studies are needed to evaluate how these improvements in resilience translate to patient recovery measures following concussion.

Anto-Ocrah M, Oktapodas Feiler M, Pukall C, et al. Resilience and Sexuality After Concussion in Women. Sex Med 2021;9:100297.

Altered sexual function after central neurological system trauma is reflective of region of injury; brain vs spinal cord

OBJECTIVE

To compare and contrast the contributory effects of traumatic brain injury (TBI) and spinal cord injury (SCI) on sexual function and social relationship opportunities, hypothesizing that patterns of change in sexual function would follow etiology.

DESIGN

Cross-sectional, case-matched survey of community living individuals with TBI, SCI or both (termed dual diagnosis).

PARTICIPANTS

Consecutive sample of participants with TBI (n = 25), SCI (n = 24) and dual diagnosis (n = 28), an average 3.6 years post-rehabilitation discharge.

METHODS

Participants were interviewed using a modified version of the 'Sexuality after Spinal Injury Questionnaire.'

RESULTS

Almost all respondents (97%) perceived adverse post-injury change in their experience of neurosexual function and/or social relationships. Physiological aspects of sexual function (e.g., erection, orgasm) were most affected by SCI whereas social relationships appeared more affected by TBI. People with dual diagnoses exhibited a combination of features. Participants with SCI (with or without TBI) were significantly more likely to have their concerns about sexual function discussed during rehabilitation than the TBI group.

CONCLUSION

TBI and SCI produce predictable impacts upon sexual function following injury, the impact of which were less frequently addressed during inpatient rehabilitation for those with TBI.

Factors Influencing Burden in Spouse-Caregivers of Patients with Chronic-Acquired Brain Injury

In this cross-sectional study, we assess associated factors of burden in spouse-caregivers of patients with acquired brain injury (ABI) in the chronic phase. 35 spouse-caregivers (71% female, mean age ± SD: 55.7 ± 11.1y) of patients with mild/moderate ABI (29% female, mean age ± SD: 57.5 ± 10.7y), admitted to the intensive rehabilitation unit of the Institute S. Anna (Crotone, Italy) between January 2013 and December 2017, were contacted 2 years postinjury and asked to complete a series of questionnaires. The outcome measure was the Caregiver Burden Inventory (CBI) test, while several demographical and clinical data were considered as predictive factors. Two years after injury, a high level of burden was reported in 34.2% of spouse-caregivers. Stepwise multiple linear regression analyses revealed that caring for a patient with more severe disability (as measured by the Barthel Index scale) and the family life cycle (from the initial phase of engagement to marriage with adult children) explain the vast majority of variance for higher caregiver burden. The functional clinical status and the stages through which a family may pass over time were identified as areas in which the spouse-caregiver of ABI patients experienced high levels of burden in the chronic phase.

Social cognition in patients with acquired brain lesions: An overview on an under-reported problem

Social cognition (SC) consists of mental representations of interpersonal relationships, which are used flexibly by the individual to promote functional social behaviors and achieve the goals. SC is a multidimensional construct and is supported by the activity of distributed neural networks in which different cortical and subcortical regions of the brain are involved. The review aims to evaluate the current literature on SC taking into account how it is compromised in acquired brain injury. Studies performed between 2010 and 2019 and fulfilling the selected criteria were searched on PubMed, Scopus, Cochrane and Web of Sciences databases. Impairment of SC is a neglected but common consequence of ABI, often leading to disordered interpersonal functioning and poor regulation of personal behavior with impaired social adaptation and quality of life of both the patient and his/her family. This review supports the idea that SC could have an important role in the management of neurological patients by both clinicians and caregivers.

Traumatic Brain Injury and Sexuality: User Experience Study of an Information Toolkit

Background

After having sustained a traumatic brain injury (TBI), individuals are at risk of functional impairments in information processing, abstract reasoning, executive functioning, attention, and memory. This affects different aspects of communicative functioning. Specific strategies can be adopted to improve the provision of health information to individuals with TBI, including the development of written materials and nonwritten media.

Objective

A user-centered design was adopted to codevelop four audiovisual presentations, a double-sided information sheet, and a checklist aimed at informing individuals about post-TBI sexuality. The last phase of the project was the assessment of the user experience of the information toolkit, based on the User Experience Honeycomb model.

Methods

Overall, two small group discussions and one individual semistructured interview were conducted with individuals with moderate to severe TBI.

Results

The participants mentioned that the toolkit was easily usable and would have fulfilled a need for information on post-TBI sexuality during or after rehabilitation. They mostly agreed that the minimalist visual content was well-organized, attractive, and relevant. The information was easily located, the tools were accessible in terms of reading and visibility, and the content was also considered credible.

Conclusions

Aspects such as usability, usefulness, desirability, accessibility, credibility, and findability of information were viewed positively by the participants. Further piloting of the toolkit is recommended to explore its effects on the awareness of the potential sexual repercussions of TBI in individuals and partners.

Mild traumatic brain injury/concussion and female sexuality, a scoping review of the literature

BACKGROUND

The American Congress of Rehabilitation Medicine (ACRM) in 2010 called for more head injury research on gender disparities to bridge the gender gap for the short-and long-term effects of TBI, including sexual and reproductive outcomes. In this paper, we review the state of the literature before and after the ACRM announcement, and evaluate how research teams have considered females and mildly injured TBI(mTBI)/concussion groups in post-TBI-related changes in sexual functioning.

METHODS

The research question for this scoping review was "what is the state of the literature in the evaluation of post-TBI sexual changes for women, and individuals with mTBI?" Using the 2010 ACRM call for action as a line of demarcation, we compared our findings before and after the 2010 announcement.

RESULTS

We identified 9 research studies that addressed sexual functioning changes in females and mTBI/concussion groups. Four of the nine were published before the 2010 ACRM announcement, and five were published after. The representation of female research participants increased steadily over the 28-year timespan. The proportion of individuals with mTBI included in the post-2010 era was higher than the earlier time period. Consistently, women with mTBI reported more adverse sexual outcomes compared to male cohorts, orthopaedic, and non-injured comparison groups. This observation persisted regardless of recruitment site (rehabilitation center/Emergency Department (ED)/Community) or time of outcome assessment (acute versus chronic). The findings also remained despite the heterogeneity of survey questionnaires used to evaluate sexual functioning outcomes. Excluding the most recent 2019 study, none of the research groups compared the findings by TBI severity, making it difficult to fully understand how concussion-related sexual changes compare to more severe forms of the head injury. The long term impacts of the sexual changes, such as infertility and relationship discord were also absent across all studies; even though most evaluated outcomes chronically (some as far out as 20 years post injury).

CONCLUSION

The number of publications in the era before the ACRM call for action and afterwards were almost identical. In order to tailor interventions for the appropriate groups of TBI patients, more neurosexuality research is needed to increase awareness of the importance of sexuality as a health outcome for individuals with neurodisabilities.

Co-creation of a post-traumatic brain injury sexuality information toolkit: a patient-oriented project

AIM

Different studies and two clinical practice guidelines emphasize the necessity to provide patients undergoing rehabilitation with information about commonly occurring changes in sexuality following traumatic brain injury (TBI). The purpose of this study was to co-create information resources for individuals with moderate to severe TBI and their partners to consult during rehabilitation.

METHODS

An iterative user-centered design was used, combining focus group and individual interviews. A convenience sample of individuals with TBI and life partners was constituted.

RESULTS

The needs and expectations of these participants in terms of form and content of an information toolkit on post-TBI sexuality were explored. The subjects that matched the interests and needs of participants were numerous and supported by the literature. Contrasting with existing written resources, the participants' views oriented the creation process toward the development of a toolkit including five audiovisual presentations, a double-sided information sheet, and a checklist.

CONCLUSIONS

A similar approach of co-creation could be used to develop other information packs aimed at patients with other disabilities. The created material is expected to be a usable and useful tool for individuals with TBI, which can support clinicians in addressing the subject of sexuality.Implications for rehabilitationThe central role held by individuals with moderate to severe traumatic brain injury, in identifying the sexuality related topics to be addressed and the form of resources to be created, led to a better understanding of their needs.This patient-centered research brought solutions to difficulties related to the understanding of health information, prevalent among patients.This patient-oriented project highlights the necessity for adequacy between the health information provided by rehabilitation professionals and the capacity of their patients' to seek for, process, and understand its content.

Effects of robotic neurorehabilitation through lokomat plus virtual reality on cognitive function in patients with traumatic brain injury: A retrospective case-control study

Background: Traumatic brain injury (TBI) is a clinical condition characterized by damage due to a mechanical physical event, which has a devastating impact on both the patient and his/her family. The purpose of this study is to evaluate the effects of robotic neurorehabilitation using Lokomat with virtual reality (VR) on attention processes and executive functions in patients with TBI.Materials and Methods: This is a retrospective case-control study. Fifty-six TBI patients have been included in the analysis, using an electronic recovery data system. The enrolled patients were divided into two groups: the experimental group (LPG) underwent rehabilitation training with Lokomat Pro, equipped with a VR screen, whereas the control group (LNG) performed rehabilitation training using Lokomat Nanos, without VR. The two groups matched for age, sex, education, brain lesions, interval from TBI. The rehabilitation protocol consisted of a total of 40 training sessions.Results: LPG and LNG had a significant improvement in mood and in the perception of physical well-being. However, only the LPG had a significant improvement in global cognitive, executive and attention functions. Furthermore, LPG presented a significant enhancement of the quality of life, with regard to the perception of the mental and physical state.Conclusion: Our study supports the idea that Lokomat is a useful tool in the rehabilitation of patients with TBI; in particular, the integration of the VR device can implement the cognitive and behavioral functions of TBI patients, enhancing also their physical and mental well-being.

[Sexual dysfunctions after traumatic brain injury: Systematic review of the literature]

BACKGROUND

Sexual dysfunction (SD) is common in the general population, up to 50% in women and with no clearly defined prevalence in men but up to 30% in erectile dysfunction. Sexual dysfunctions (SD) are common after a traumatic brain injury (TBI) but remain underrated in clinical practice, yet it is a crucial aspect of the person with consequences for the relationship with the other, psychological wellbeing and quality of life.

OBJECTIVE

To determine, through a systematic literature review, the epidemiology, assessment tools and treatment of SD in the TBI population.

SOURCES

(keywords, languages): Medline, COCHRANE and OVID databases were used with specific keywords (MeSH), combined with Boolean operators: "sexual dysfunction", "sexuality", "erectile dysfunction" and "traumatic brain injury".

STUDY SELECTION

Only studies published in French or English, and with full-text available, have been included. Articles have been independently reviewed and extracted.

RESULTS

Of the 199 articles reviewed after exclusion of duplicates, 86 articles were reviewed in their full text. A total of 40 studies were included in the final analysis. After TBI, 6% to 83% of patients report SD: decreased frequency of sexual intercourse (47-62%), desire and/or arousal (24-86%), erectile dysfunction (24,2-57%), difficulties with orgasm (29-40%), inappropriate sexual behaviour (8,9%). There is no consensus method for evaluating SD in this population, with 16 tools identified. Among them, only two questionnaires were validated in this population, the Brain Injury Questionnary of Sexuality - not validated in French - and the Overt Behavior Scale, the latter being intended for the evaluation of sexual behaviour disorders. Several factors are significantly and positively associated with SD: age (P≤0.01), severity of TBI (P≤0.002), depression (P<0.001), anxiety (P<0.001), and fatigue (P=0.042). Others are negatively associated: time since injury (P=0.01), perceived physical health status (P<0.001) and social participation (P<0.001). There is little data on the treatment of SD outside of case studies.

LIMITS

Quantitative analysis could not be performed due to differences in the studies included in their design, evaluation tools, choice of TBI severity criteria, and post-TBI timeframes. Four unavailable articles could not be consulted.

CONCLUSION

SD are common after TBI but remain poorly evaluated in clinical practice, despite their impact on patients and their partners. Their evaluation and treatment should be part of the overall management of patients after TBI. Nevertheless, there is currently no validated tool in French to evaluate these SD, nor are there any guidelines on their treatment.

Improving Cognitive Function after Traumatic Brain Injury: A Clinical Trial on the Potential Use of the Semi-Immersive Virtual Reality

Traumatic brain injury (TBI) is the most common cause of long-term disability and death among young adults, and it represents an enormous socioeconomic and healthcare burden. Our purpose is to evaluate the effects of a virtual reality training with BTs-Nirvana (BTs-N) on the recovery of cognitive functions in TBI subjects, using the interactive semi-immersive program. One hundred patients with TBI were enrolled in this study and randomized into either the Traditional Cognitive Rehabilitation Group (TCRG: n = 50) or the Virtual Reality Training Group (VRTG: n = 50). The VRTG underwent a VRT with BTs-N, whereas the TCRG received a standard cognitive treatment. Each treatment session lasted 60 minutes and was repeated three times a week for 8 weeks. All of the patients were evaluated by a specific psychometric battery before (T0) and immediately (T1) after the end of the training. VRTG and TCRG had a significant improvement in cognitive functioning and in mood, but only VRTG presented with a significant increase in cognitive flexibility and shifting skills and in selective attention. In conclusion, our results suggest that VR may be a useful and effective approach for the rehabilitation of patients with TBI, leading to better cognitive and behavioral outcomes.

Risk of female sexual dysfunction following concussion in women of reproductive age

Objectives: Traumatic Brain Injury (TBI) has frequently been associated with changes in sexual functioning. The TBI and sexuality literature, however, has limited generalizability to concussed females, who often use the emergency department (ED) as their first line of care after head injury. Primary Objective: The primary objective of this study was to evaluate the impact of concussions on female sexual functioning. Secondary Objective: Secondarily, we evaluated if concussed women with sexual dysfunction also report more post-concussion symptoms (PCS) and/or mood changes. Research Design: This was a prospective cohort, with outcomes assessed at 6-10 weeks after ED enrollment. Methods and Procedures: Sexual dysfunction was defined as ≤ 45 on the Brain Injury Questionnaire on Sexuality (BIQS). The Rivermead Post-concussion Symptoms Questionnaire (RPQ) and the Hospital Anxiety and Depression Scale (HADS) assessed PCS and post-injury mood, respectively. Main Outcomes & Results: Eighty-nine eumenorrheic females (8-14 menstrual cycles/year) completed the study; 31(36%) had concussions, and 55(64%) were extremity injured. Concussed women had 70% increased risk of sexual dysfunction (adj.RR:1.70, 95% CI: 1.04,2.76; p = .03) versus extremity injured. Of clinical relevance, concussed women with sexual dysfunction also reported more PCS symptoms (adj.β = 5.5, 95% CI: -6.7,18.2; p = .37) and mood scores (adj.β = 8.0; 95% CI: -0.4, 16.4; p = .06). Conclusions: This study highlights the need for more research and interventions for one of the fastest growing subgroups within the TBI population.