Ecological validity of the Dysexecutive Questionnaire: Results from the PariS-TBI study

The 20-item dysexecutive questionnaire after severe traumatic brain injury: Distribution of the total score and its significance

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01437683..

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.

Use of smartphones and tablets after acquired brain injury to support cognition

OBJECTIVES

To describe the use of mobile devices after acquired brain injury (ABI), from the perspectives of injured individuals and significant others, and to examine factors associated with mobile device use for cognition.

METHODS

Cross-sectional study with 50 adults with moderate/severe traumatic brain injury or stroke (42% women; mean of 50.7 years old, 4.6 years post-ABI), and 24 significant others. Participants completed questionnaires on mobile technology, cognitive functioning and the impact of technology.

RESULTS

Of 45/50 adults with ABI who owned a smartphone/tablet, 31% reported difficulties in using their device post-injury, 44% had received support, and 46% were interested in further training. Significant others reported motor/visual impairments and the fear of becoming dependent on technology as barriers for mobile device use, and 65% mentioned that their injured relative needed additional support. Mobile device use for cognition was common (64%), predicted in a regression model by lower subjective memory and more positive perception of the psychosocial impacts of technology, and also associated in univariate analyses with younger age, lower executive functioning, and greater use of memory strategies.

CONCLUSION

Using mobile devices for cognition is common post-ABI but remains challenging for a significant proportion. Developing training approaches may help supporting technology use.

Cross-cultural adaptation and validation of the cooking task to the French-Canadian context: assessing the impact of executive function disorders through cooking activities

BACKGROUND

Acquired brain injury (ABI) often leads to deficits in executive functioning (EF) which is responsible for severe and longstanding disabilities in activities of daily living. The "Cooking Task" (CT), an ecological test of EF involving multi-tasking, was developed in France and exhibits excellent psychometric properties but has not yet been adapted and validated for the French-Canadian context.

OBJECTIVES

Conduct a cross-cultural adaptation and validation of the CT for the French-Canadian context.

METHODS

The CT was translated and adapted by a committee of experts and was validated.

RESULTS

Adaptation-changes were made to the language (e.g., cartable vs classeur), the materials (e.g., measuring cup vs scale), and the measuring units (e.g., ml/cups vs grams). Validation-Preliminary analyses were conducted on 24 participants with an ABI and 17 controls. Construct convergent validity: The French-Canadian-CT discriminates between ABI and control total score on the CT and on most error type categories. Construct known-group validity: French-Canadian-CT scores correlated with another measure of EF deficits (Dysexecutive Questionnaire and Six Elements Task). Inter-rater reliability score for the total error was high (ICC= .84) and results were similar to those obtained for the France-CT.

CONTRIBUTIONS

This study will provide a new ecologically valid tool for clinicians in Canada.

Outcome of severe COVID-19: spotlight on fatigue, fatigability, multidomain complaints and pattern of cognitive deficits in a case series without prior brain dysfunction and without COVID-19-related stroke and/or cardiac arrest

BACKGROUND

Population-wide surveys and large-scale investigations highlighted the presence of cognitive deficits in the acute and postacute stages of severe COVID-19; a few studies documented their occurrence in cases without prior or COVID-19-related brain damage. The evolution of cognitive deficits in the latter population and their relationship to the post-COVID-19 fatigue syndrome are poorly understood.

CASE PRESENTATION

We report the outcome at 12 months after severe COVID-19 involving an intensive care unit stay and mechanical ventilation in six (five Caucasian and one Asian) patients (age range: 53-71 years, mean age 61.7 ± 6.5 years) without history of prior brain dysfunction and without stroke and/or cardiac arrest during or after COVID-19. All patients reported pervading mental and physical fatigue as well as numerous multidomain complaints, which impacted everyday life. Individual patients described mental fatigability, apathy, and/or anxiety. Standardized neuropsychological tests revealed isolated symptoms of cognitive dysfunction or performance at the lower limit of the norm in the attentional, executive, and/or working memory domains in four of the six patients. Somatic scales documented dyspnoea, muscle weakness, olfactory disorder, and/or minor sleep problems in some, but not all, patients.

CONCLUSION

Fatigue, fatigability, multidomain complaints, cognitive difficulties, or dysfunction, as well as isolated neurobehavioral and/or psychiatric and/or somatic symptoms, tend to occur in the aftermath of severe COVID-19 and persist at 12 months, even in the absence of prior and/or COVID-19-related brain damage. This clinical situation, which impacts everyday life, calls for a detailed investigation of patients' complaints, its neural underpinning, and an elaboration of specific rehabilitation programs.

Ecological validity in neurocognitive assessment: Systematized review, content analysis, and proposal of an instrument

OBJECTIVES

The main objectives of this study are to identify the dimensions of Ecological Validity (EV) within the definitions of this concept, understand how they are operationalized in neurocognitive tests, and propose a checklist for EV attributes in neurocognitive tests.

METHOD

A systematized review was combined with content analysis of the selected papers, using the inductive method. We analyzed 82 studies on the EV of neurocognitive tests, 19 literature reviews and 63 empirical studies. Based on this review, we identified the relevant criteria for evaluating EV.

RESULTS

EV is a multidimensional concept with two main dimensions: representativeness and generalization. Representativeness involves the subdimensions simplicity-complexity and artificial-natural and several criteria organized on a continuum from low EV to high EV. Generalization is dependent on representativeness and is influenced by different cognitive and non-cognitive factors. We propose six stages for operationalizing EV, from defining the objectives of the neurocognitive assessment to the methodology for scoring and interpreting the results.

CONCLUSION

This systematized review helps to operationalize the concept of EV by providing a tool for evaluating and improving EV while developing new tests. Further studies with a longitudinal design can compare the predictive value of tests with higher versus lower EV-checklist scores.Key pointsQuestion: Understand the definition of EV, its dimensions and subdimensions, how EV is operationalized in neurocognitive tests and propose a checklist for the EV attributes of neurocognitive tests.Findings: The primary findings were that representativeness and generalization are the main dimensions of EV. Representativeness involves several subdimensions, whereas generalization is dependent on representativeness and is influenced by cognitive and non-cognitive factors. We provided an EV-checklist organized into six parts.Importance: The EV-checklist can be used to guide the development of ecologically valid neurocognitive tests and/or assess the EV of existing ones.Next steps: Examine the predictive value of tests that have higher EV-checklist scores.

Exploring the Multidimensional Participation of Adults Living in the Community in the Chronic Phase following Acquired Brain Injury

This exploratory study aimed to examine multiple aspects of the participation of adults in the chronic phase following acquired brain injury (ABI), considering different disability levels. Our study included 25 adults ≥6 months after ABI (predominantly stroke), living at home, without severe cognitive decline. Primary measures included the Canadian Occupational Performance Measure (subjective participation) and the Mayo-Portland Adaptability Inventory-4 Participation Index (objective participation). The results indicated subjective participation problems in all of the International Classification of Functioning, Disability and Health participation domains. In addition, objective participation was reported as most limited in the areas of leisure and recreational activities, residence, and employment. Both subjective and objective participation profiles varied according to the disability level except for the social and leisure areas, which were found to be similar across all subgroups. However, only partial compatibility was found between the subjective and objective participation aspects. To conclude, our findings indicated that chronic ABI survivors report a variety of subjective and objective participation concerns that varied according to their disability levels. Moreover, the incongruity between the participation aspects suggests that the level of limitation may not necessarily correspond to the importance of a particular participation area. This highlights the need for comprehensive assessments to determine unique individual participation profiles in order to facilitate client-centered interventions supporting the rehabilitation of community-dwelling ABI survivors.

Differences in daily life executive functioning between people with autism and people with schizophrenia

This is a comparative analysis of everyday executive functioning between individuals with Autism Spectrum Disorder (ASD), Schizophrenia Spectrum Disorders (SSD) and controls using Dysexecutive Questionnaire-Spanish (DEX-Sp), to identify patterns of difficulties. Also we assessed the relationship between EF and adaptive behavior as measured by the Vineland Adaptive Behavioral Scale-II. Common areas of everyday executive functions were established as problematic in individuals with ASD and SSD related to Disinhibition and Apathy, while Disorganization and Impulsivity was gravely affected in ASD group only. The degree of Dysexecutive Syndrome was predictive of adaptive behavior in ASD group only. These suggest that DEX-Sp could be a useful tool in differentiating areas of strength and weaknesses in clinical groups such as ASD and SDD.

A Performance-Based Teleintervention for Adults in the Chronic Stage after Acquired Brain Injury: An Exploratory Pilot Randomized Controlled Crossover Study

This pilot study aimed to investigate the initial effect of a remotely delivered performance-based client-centered intervention on activity performance and participation among adults in the chronic phase after acquired brain injury (ABI). Sixteen participants living at home with little to no assistance in basic daily activities were allocated into intervention or waitlist control groups. Assessments were conducted at the baseline, after the 3-month intervention/wait period, and at a 3-month follow-up. The primary outcomes were activity performance using the Canadian Occupational Performance Measure (COPM) and the Performance Quality Rating Scale (PQRS) and participation using the Mayo-Portland Adaptability Inventory-4 (MPAI-4). The intervention included weekly videoconferencing sessions using the Cognitive Orientation to Daily Occupational Performance approach (tele-CO-OP). The participants identified five functional goals, of which three were directly addressed. Wilcoxon signed-ranks test results showed no significant improvements in the control group at the end of the 3-month wait period. Pooled data from both groups showed significant improvements in COPM scores for trained and untrained goals following the intervention. Significant improvements were also found in the PQRS and MPAI-4 scores. Improvements were partially maintained at follow-up. Our preliminary results suggest that tele-CO-OP may positively impact the lives of adults after ABI who are coping with long-term disability.

The prevalence, predictors, associated symptoms, and outcomes of social disinhibition following moderate-to-severe TBI: A scoping review of quantitative evidence

The present study aimed to map existing quantitative evidence of research related to the nature of social disinhibition following moderate-to-severe traumatic brain injury (TBI), with a specific focus on its prevalence, predictors, associated symptoms and outcomes in studies that met minimal methodological criteria. We conducted a scoping review of the literature following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) extension for Scoping Reviews (PRISMA-ScR). Seventeen peer-reviewed articles including 1440 participants met the inclusion criteria and were included in the qualitative synthesis. Results of the study indicate that social disinhibition is a common and significant consequence of moderate-to-severe TBI with its prevalence estimates ranging from 21% to 32%. Inappropriate sexual behavior appears to be more prevalent in men and younger survivors. Rule-breaking/perseverative errors in fluency tests are significantly associated with social disinhibition. The perceived burden of caregivers of people with TBI is a very common outcome. An interesting finding was an association between higher social disinhibition and higher emotional empathy levels. However, similarly to many potential predictors, this was only found in a single study and therefore requires further investigation. Some common methodological flaws are discussed, such as the use of non-probability sampling, lack of sample size justification or not including a control group. Due to the heterogeneity of measures used to assess social disinhibition in the reviewed articles, conducting a meta-analysis was not possible. In conclusion, social disinhibition is a significant consequence of moderate-to-severe TBI, as it impacts both the TBI survivor and their family/caregivers. The present study extends the scope of the prior overview by offering a clearer picture of social disinhibition after surviving moderate-to-severe TBI, as it focuses on studies with strong methodology and validated measures. It also assesses potential predictors other than executive dysfunction, such as demographics and injury characteristics.

A review of executive functioning challenges and strengths in autistic adults

Objective: There has been a steady rise in research characterizing executive functioning (EF) impairments in autistic individuals but limited research investigating EF strengths. This review provides a summary of current EF research in autistic adults with a focus on EF challenges and strengths and potential sources of heterogeneity in research findings. New avenues for addressing gaps in our understanding of EF strengths are proposed.Method: A review of the EF literature was conducted. One hundred twenty-four studies of inhibition, working memory, cognitive flexibility, fluency, planning, decision-making, and subjective measures of EF in autistic adults were included.Results: Autistic adults with average intellectual functioning demonstrate difficulties with cognitive flexibility, phonemic fluency, and working memory. Strengths in planning, decision-making, and semantic verbal fluency were evident in some but not all studies. Findings regarding inhibition are inconclusive. Key findings across each EF domain are discussed and sources of potential heterogeneity across studies were evaluated. The type of measure used appears to contribute to heterogeneous findings. Subjective EF measures revealed more consistent findings of deficits in autistic adults than objective EF measures.Conclusions: Research reveals areas of EF weaknesses as well as strengths in autistic adults. Unlike EF challenges, EF strengths are not well understood. Future research identifying EF strengths is needed to improve services and supports for autistic adults. Further investigation of potential factors that interact with or constrain EF such as comorbid disorders, verbal ability, sensory processing, and other factors specific to autism will be critical to move the field forward and increase understanding of how EF is related to everyday functioning in autistic adults.

Relationships between neuropsychological impairments and functional outcome eight years after severe traumatic brain injury: Results from the PariS-TBI study

BACKGROUND/OBJECTIVES

The objective was to assess the relationships between neuropsychological impairments, functional outcome and life satisfaction in a longitudinal study of patients after a severe traumatic brain injury (TBI) (PariS-TBI study).

PATIENTS

Out of 243 survivors, 86 were evaluated 8 years post-injury. They did not significantly differ from patients lost-to-follow up except for the latter being more frequently students or unemployed before the injury.

METHODS

Outcome measures included the Glasgow Outcome Scale-Extended (GOS-E), a functional independence questionnaire, employment, mood, fatigue and satisfaction with life. Neuropsychological outcome was assessed by two ways: performance-based outcome measures, using neuropsychological tests and patient and relative-based measures.

RESULTS

Neuropsychological measures were not significantly related to initial injury severity nor to gender, but were significantly related to age and education. After statistical correction for multiple comparisons, cognitive testing and cognitive questionnaires were significantly correlated with most outcome measures. By contrast, satisfaction with life was only related with patient-rated questionnaires. A regression analysis showed that the Trail-Making-Test-A was the best predictor of functional outcome, in addition to education duration.

CONCLUSIONS

Cognitive measures, particularly slowed information processing speed, were significant indicators of functional outcome at a long-term post-injury, beyond and above demographics or injury severity measures.

Psychometric properties of the Dysexecutive Questionnaire (DEX): a study with Brazilian older adults

Abstract This study aimed to verify the psychometric properties of the Dysexecutive Questionnaire (DEX) through exploratory factor analysis (EFA), evidence of reliability, and convergent validity, in a sample of neurologically preserved older adults. Participants were 345 older adults who answered, in addition to DEX, a sociodemographic and clinical questionnaire, the Mini-Mental State Examination (MMSE), and two verbal fluency tasks. The EFA was conducted through Parallel Analysis based on the generation of a polychoric correlation matrix, as well as Pearson’s correlation between the DEX scores, age, education, MMSE, and verbal fluency tasks. According to the EFA, the extraction of two factors (“Inhibition” and “Social Regulation and Planning”) was suggested and DEX was negatively associated with age and MMSE. In conclusion, DEX presented a satisfactory factorial structure for older adults, which can be considered a reliable self-report measure for complaints of executive functions.

Validation of the Neuropsychological Assessment Battery Screening Module (NAB-SM) in patients with traumatic brain injury

This study cross-validates the screening module of the Neuropsychological Assessment Battery (NAB-SM) with a battery of well validated neuropsychological tests (Convergent Validity Test Battery: CVTB) in a Traumatic Brain Injury (TBI) population. Forty-four participants with "mild-complicated" to "severe" TBI were recruited from a cohort of patients attending an outpatient clinic at a UK major trauma center. The NAB-SM Total Index score and an abbreviated short-form, from which a TBI Index was derived, both showed good classification accuracy in predicting impairment as measured by the CVTB mean score. These indices also accurately identified impairment as defined by the base rate of low scores across individual CVTB indices measuring mental processing speed, working memory, memory and executive functioning. The NAB-SM and its derived TBI index therefore have significant utility as a cognitive screening tool for use in either inpatient (acute) or outpatient TBI populations.

Potential for recovery between 4 and 8 years after a severe traumatic brain injury. Data from the PariS-TBI longitudinal study

BACKGROUND

Severe traumatic brain injury (TBI) is a leading cause of complex and persistent disability. Yet, long-term change in global functioning and determinants of this change remain unclear.

OBJECTIVES

This study aimed to assess change in global functioning in the long-term after severe TBI and factors associated with the change.

METHODS

This was a prospective observational study of an inception cohort of adults with severe TBI in the Paris area (PariS-TBI). Outcome was assessed at 1, 4 and 8 years post-injury. For the included participants (n=257), change in global outcome between 4 and 8 years was evaluated with the Glasgow Outcome Scale Extended (GOSE) score, and its association with pre-injury, injury-related and post-injury variables was tested with univariate and multivariable analyses.

RESULTS

More than half of the 73 participants evaluated at both 4 and 8 years showed global improvement (of at least one point) in GOSE score and an improvement in mood, executive function, and subjective complaints. On univariate analysis, none of the pre-injury, injury or post-injury variables were associated with GOSE score change between 4 and 8 years, except for GOSE score at 4 years (rho=-0.24, P=0.04). On multivariable analysis, probability of increased GOSE score was associated with more years of education (odds ratio 1.18 [95% confidence interval 1.02-1.37], P=0.03). The change in GOSE score was significantly correlated with change in Hospital Anxiety Depression Scale score between 4 and 8 years (rho=-0.42, P<0.001).

CONCLUSIONS

Most participants with severe TBI in the present sample showed a late improvement (4 to 8 years post-injury) in global functioning. Of the socio-demographic and injury-related factors, only more years of education was associated with improvement in global functioning. Decreased anxiety and depression symptoms were associated with improved global functioning. Targeting interventions to enhance resilience may be the most effective in the long-term after severe TBI.

Implications of Unconnected Micro, Molecular, and Molar Level Research in Psychology: The Case of Executive Functions, Self-Regulation, and External Regulation

The proliferation of research production in Psychology as a science has been increasing exponentially. This situation leads to the necessity of organizing the research production into different levels of analysis that make it possible to delimit each research domain. The objective of this analysis is to clearly distinguish the different levels of research: micro-analysis, molecular, and molar. Each level is presented, along with an analysis of its benefits and limitations. Next, this analysis is applied to the topics of Executive Functions, Self-Regulation, and External Regulation. Conclusions, limitations, and implications for future research are offered, with a view toward a better connection of research production across the different levels, and an allusion to ethical considerations.

Posttraumatic Stress Disorder and executive dysfunction among children and adolescents: A Latent Profile Analysis

Background/Objective

The current study aimed to examine the relationship between Posttraumatic Stress Disorder (PTSD) symptoms and executive dysfunction in children and adolescents after psychological trauma.

Method

Participants were 13,438 of children and adolescents aged 6 to 18 years exposed to the 2008 Wenchuan earthquake. PTSD and dysexecutive symptoms were assessed using the UCLA PTSD Reaction Index for Children and the Self-Report Dysexecutive Questionnaire. Latent Profile Analysis (LPA) was conducted using Mplus version 7.4. Subgroup differences in trauma exposure and quality of life were calculated using ANCOVA.

Results

A 4-class parallel model was found to best describe latent PTSD symptom profiles and executive dysfunction. Individuals in higher symptom groups showed more trauma exposure and lower quality of life.

Conclusions

This LPA study shed light on the relationship between PTSD and executive dysfunction symptoms in children and adolescents. The correlation between PTSD and executive dysfunction was maintained after individual differences were taken into consideration. Our findings provide a new view on how PTSD relates to executive dysfunction and several suggestions for treating child and adolescent PTSD patients.

Long-term cognitive disability after traumatic brain injury: Contribution of the DEX relative questionnaires

Executive functions are high-level cognitive processes commonly impaired after severe traumatic brain injury (sTBI), which may be associated with persistent anosognosia. The dysexecutive questionnaire (DEX) was designed to assess different domains of executive functioning in daily life. Two versions of the DEX exist (DEX-S completed by the patient, DEX-O completed by a relative) to compare cognitive complaints and patient's awareness. This work was aimed at studying the relevance of DEX-O for assessing daily-life limitations, the persistence of anosognosia and its association with global disability (GOSE) and magnetic resonance imaging (MRI) markers of brain alterations. Sixty-three patients (and relatives) were included within 63.4 months (±20.7) after sTBI. DEX-S and DEX-O scores were significantly positively correlated. We obtained significant correlations between DEX-S and episodic memory and phasic alert but not with executive assessment, GOSE and diffusion MRI markers. DEX-O was significantly correlated with executive function, episodic memory, attention (phasic alert sustained and divided attention), with the GOSE and the volume of the body of the corpus callosum (MRI marker). Anosognosia score (DEX-O minus DEX-S) correlated with mean diffusivity measure. These results highlight the clinical interest of DEX-O in assessing long-term disability.

A Detailed Overview of Long-Term Outcomes in Severe Traumatic Brain Injury Eight Years Post-injury

Background and aims: Severe traumatic brain injury is a leading cause of acquired persistent disabilities, and represents an important health and economic burden. However, the determinants of long-term outcome have rarely been systematically studied in a prospective longitudinal study of a homogeneous group of patients suffering exclusively from severe TBI

Methods: Prospective observational study of an inception cohort of adult patients with severe traumatic brain injury in the Parisian area (PariS-TBI). Outcome was assessed with face-to-face interview 8 years after Traumatic Brain Injury, focusing on impairments, activity limitations, and participation restriction.

Results: Five hundred and four patients were included between 2005 and 2007. At 8-year follow-up, 261 patients were deceased, 128 were lost to follow-up, 22 refused to participate, and 86 were finally evaluated. Age, gender, initial injury severity did not significantly differ between evaluated patients and lost to follow-up, but the latter were more frequently students or unemployed. Mean age was 41.9 (SD 13.6), 79% were male, median initial Glasgow Coma Scale Score was 6. The most frequent somatic complaints concerned balance (47.5%), motricity (31%), and headaches (36%), but these were less frequent than cognitive complaints (Memory 71%, Slowness 68%, Concentration 67%). According to the Hospital Anxiety and Depression Scale (HADS), 25 % had a score >8 for anxiety and 23.7% for depression. According to the Extended Glasgow Outcome Scale, 19.8% remained severely disabled, 46.5% moderately disabled, 33.7% had a good recovery. Older age, longer education duration, lower functional status upon intensive care discharge, and more severe 8-year dysexecutive problems were significantly associated with a lower Extended Glasgow Outcome Scale score in multivariable analysis. At 8 years, 48.7% of patients were employed in a productive job. Of those, 38% declared a salary loss since traumatic brain injury. Unemployment was significantly associated with lower 1-year GOSE score and more severe 8-year dysexecutive problems.

Conclusions: These results from an inception cohort study highlight the fact that long-term outcome after severe TBI is determined by a complex combination of injury-related, demographic and neuropsychological factors. Long after the injury, persisting impairments still interfere with social integration, and participation.

Late Functional Changes Post-Severe Traumatic Brain Injury Are Related to Community Reentry Support: Results From the PariS-TBI Cohort

OBJECTIVES

To explore late functional changes after a traumatic brain injury and their relation to patients' characteristics and reentry support.

DESIGN

Prospective follow-up of an inception cohort of adults with severe traumatic brain injury recruited in 2005-2007 in the Parisian area, France. One and 4-year assessments were performed by trained neuropsychologists. One-to-4-year change in the Glasgow Outcome Scale-Extended defined 3 groups: "improvement," "stability," and "worsening." Relationships between these groups and patients' characteristics were analyzed.

RESULTS

Among 504 recruited patients and 245 four-year survivors, 93 participated in both evaluations. Overall Glasgow Outcome Scale-Extended improved by 0.4. Forty percent of the sample improved, 44% were stable, and 16% worsened. Being in a more unfavorable group was related to preinjury alcohol abuse and to higher anxiety and depression at 4 years. Attendance to a specialized community reentry unit was related to higher chances of being in the "improvement" group in univariate analyses and after adjustment for age, time to follow command, preinjury alcohol and occupation, and mood disorders (adjusted odds ratio [OR] = 4.6 [1.1-20]).

CONCLUSION

Late functional changes were related to psychosocial variables and to reentry support. The effect of reentry support on late recovery needs to be confirmed by further investigations.

Return to work after severe traumatic brain injury: a national study with a one-year follow-up of neurocognitive and behavioural outcomes

The objectives were to investigate the frequency of return-to-work (RTW) one year after severe traumatic brain injury (sTBI: Glasgow Coma Scale, GCS 3-8) and to identify which demographic and injury-related characteristics and neurocognitive factors are associated with RTW. This study is part of a prospective national study on sTBI conducted in all four Norwegian Trauma Referral Centres, including patients aged >15 years over a period of three years (n = 378). For the purpose of this study, only pre-employed individuals of working age (16 to 67 years) were investigated for RTW (n = 143), and of these, 104 participants underwent neuropsychological testing. Measures of acute injury severity, neuropsychological composite scores (Memory, Processing Speed, Executive Functions) at the one-year follow-up, and the Behaviour Rating Inventory of Executive Functions (patient- and relative reports) were explored as predictors of RTW. The frequency of RTW was 54.5%. Multivariate logistic regression analyses identified younger age, shorter length of stay in intensive care, better Processing Speed scores, and lower levels of metacognitive difficulties as rated by relatives as significant predictors of RTW. Findings support the importance of neuropsychological measures in predicting long-term RTW and highlight the need to address neurocognitive and behavioural difficulties to improve RTW after sTBI.

Self-awareness four years after severe traumatic brain injury: discordance between the patient’s and relative’s complaints. Results from the PariS-TBI study

Objective:

To evaluate the patient’s awareness of his or her difficulties in the chronic phase of severe traumatic brain injury (TBI) and to determine the factors related to poor awareness.

Design/Setting/Subjects:

This study was part of a larger prospective inception cohort study of patients with severe TBI in the Parisian region (PariS-TBI study).

Intervention/Main measures:

Evaluation was carried out at four years and included the Brain Injury Complaint Questionnaire (BICoQ) completed by the patient and his or her relative as well as the evaluation of impairments, disability and quality of life.

Results:

A total of 90 patient-relative pairs were included. Lack of awareness was measured using the unawareness index that corresponded to the number of discordant results between the patient and relative in the direction of under evaluation of difficulties by the patient. The only significant relationship found with lack of awareness was the subjective burden perceived by the relative (Zarit Burden Inventory) ( r = 0.5; P < 0.00001). There was no significant relationship between lack of awareness and injury severity, pre-injury socio-demographic data, cognitive impairments, mood disorders, functional independence (Barthel index), global disability (Glasgow Outcome Scale), return to work at four years or quality of life (Quality Of Life after Brain Injury scale (QOLIBRI)).

Conclusion:

Lack of awareness four years post severe TBI was not related to the severity of the initial trauma, sociodemographic data, the severity of impairments, limitations of activity and participation, or the patient’s quality of life. However, poor awareness did significantly influence the weight of the burden perceived by the relative.

Psychometric properties of the French version of the Rating Scale of Attentional Behaviour

The Rating Scale of Attentional Behaviour (RSAB) was devised by Ponsford and Kinsella to assess the impact of attentional impairments on everyday behaviour. The scale includes 14 items. The objective of this study was to assess the psychometric properties of a French translation of the RSAB. A sample of 196 healthy participants and 27 patients with chronic acquired brain injury was included. For healthy participants, both self and a relative's ratings were independently recorded. For the patients, a therapist's rating was obtained in addition. The scale showed good internal consistency. A mild significant effect of education duration was found in the healthy control group. Principal component analysis in healthy participants (self-assessment) yielded three underlying factors accounting for 58.2% of the variance. The scale was able to adequately discriminate patients from healthy controls. The area under the ROC curve was 0.76 both for self- and proxy ratings. In the patient group, the item related to fatigue was the one that obtained the highest ranking. RSAB ratings were poorly related to neuropsychological testing, but proxy ratings were significantly correlated with other questionnaires assessing cognitive failures, mood and fatigue.

Employment outcome four years after a severe traumatic brain injury: results of the Paris severe traumatic brain injury study

OBJECTIVE

To describe employment outcome four years after a severe traumatic brain injury by the assessment of individual patients' preinjury sociodemographic data, injury-related and postinjury factors.

DESIGN

A prospective, multicenter inception cohort of 133 adult patients in the Paris area (France) who had received a severe traumatic brain injury were followed up postinjury at one and four years. Sociodemographic data, factors related to injury severity and one-year functional and cognitive outcomes were prospectively collected.

METHODS

The main outcome measure was employment status. Potential predictors of employment status were assessed by univariate and multivariate analysis.

RESULTS

At the four-year follow-up, 38% of patients were in paid employment. The following factors were independent predictors of unemployment: being unemployed or studying before traumatic brain injury, traumatic brain injury severity (i.e., a lower Glasgow Coma Scale score upon admission and a longer stay in intensive care) and a lower one-year Glasgow Outcome Scale-Extended score.

CONCLUSION

This study confirmed the low rate of long-term employment amongst patients after a severe traumatic brain injury. The results illustrated the multiple determinants of employment outcome and suggested that students who had received a traumatic brain injury were particularly likely to be unemployed, thus we propose that they may require specific support to help them find work. Implications for rehabilitation Traumatic brain injury is a leading cause of persistent disablity and can associate cognitive, emotional, physical and sensory impairments, which often result in quality-of-life reduction and job loss. Predictors of post-traumatic brain injury unemployment and job loss remains unclear in the particular population of severe traumatic brain injury patients. The present study highlights the post-traumatic brain injury student population require a close follow-up and vocational rehabilitation. The study suggests that return to work post-severe traumatic brain injury is frequently unstable and workers often experience difficulties that caregivers have to consider.

Negative impact of litigation procedures on patient outcomes four years after severe traumatic brain injury: results from the PariS-traumatic brain injury study

PURPOSE

To analyze the effect of litigation procedures on long-term outcomes in severe traumatic brain injury.

MATERIALS AND METHODS

Prospective observational follow-up of an inception cohort including 504 adults with severe traumatic brain injury recruited in 2005-2007 in the Parisian area, France, with initial, one- and four-year outcomes measures.

RESULTS

Four years after the traumatic brain injury, 147 patients, out of 257 who survived the acute phase, were assessed. Among these patients, 53 patients declared being litigants and 78 nonlitigants (litigation status was unknown in 16 cases). Sociodemographic characteristics, type of injury and initial severity did not differ significantly between litigants and nonlitigants, except for Injury Severity Score (worse in litigants) and the proportion of road traffic accidents (higher in litigants). One- and four-year outcomes were significantly worse in litigants for autonomy, participation, psychiatric and cognitive function but not quality of life (measured with the Glasgow Outcome Scale-Extended, the working activity status, the Brain Injury Community Rehabilitation Outcome, the Hospital Anxiety and Depression scale, the Neurobehavioral Rating Scale-revised and the Quality of Life after Brain Injury, respectively). Multivariate analyses highlighted litigation procedure as an independent significant predictor of lower autonomy, participation and psychiatric function and tended to predict lower cognitive function, but not lower quality of life, after adjustment for pretrauma characteristics, Injury Severity Score, road traffic accidents and work-related accident status.

CONCLUSIONS

Patients with severe traumatic brain injury have a worse prognosis when involved in a litigation procedure and require special attention in clinical practice. Implications for rehabilitation The influence of litigation procedure on health and social outcomes in severe traumatic brain injury is a major issue that entail numerous levels of complexities. A wide range of interactions and factors related to the prolonged process of litigation against a third party may influence recovery. Results from the PariS-Traumatic Brain Injury study suggest that patients with a severe Traumatic Brain Injury who are involved in a litigation procedure within French jurisdiction compensation scheme have a worse prognosis than patients who do not. Health professionals should be aware of the potential adverse effects of litigation procedures on recovery, and provide appropriate interventions and information to patients and families in such cases.