Assessment and treatment of mental fatigue after a traumatic brain injury

A study protocol for risk stratification in children with concussion (RSiCC): Theoretical framework, design, and methods

Research shows that one in five children will experience a concussion by age 16. Compared to adults, children experience longer and more severe postconcussive symptoms (PCS), with severity and duration varying considerably among children and complicating management of these patients. Persistent PCS can result in increased school absenteeism, social isolation, and psychological distress. Although early PCS diagnosis and access to evidence-based interventions are strongly linked to positive health and academic outcomes, symptom severity and duration are not fully explained by acute post-injury symptoms. Prior research has focused on the role of neuroinflammation in mediating PCS and associated fatigue; however relationship between inflammatory biomarkers and PCS severity, has not examined longitudinally. To identify which children are at high risk for persistent PCS and poor health, academic, and social outcomes, research tracking PCS trajectories and describing school-based impacts across the entire first year postinjury is critically needed. This study will 1) define novel PCS trajectory typologies in a racially/ethnically diverse population of 500 children with concussion (11-17 years, near equal distribution by sex), 2) identify associations between these typologies and patterns of inflammatory biomarkers and genetic variants, 3) develop a risk stratification model to identify children at risk for persistent PCS; and 4) gain unique insights and describe PCS impact, including fatigue, on longer-term academic and social outcomes. We will be the first to use NIH's symptom science model and patient-reported outcomes to explore the patterns of fatigue and other physical, cognitive, psychological, emotional and academic responses to concussion in children over a full year. Our model will enable clinicians and educators to identify children most at risk for poor long-term health, social, and academic outcomes after concussion. This work is critical to meeting our long-term goal of developing personalized concussion symptom-management strategies to improve outcomes and reduce disparities in the health and quality of life of children.

Widespread White Matter Abnormalities in Concussed Athletes Detected by 7T Diffusion Magnetic Resonance Imaging

Sports-related concussions may cause white matter injuries and persistent post-concussive symptoms (PPCS). We hypothesized that athletes with PPCS would have neurocognitive impairments and white matter abnormalities that could be revealed by advanced neuroimaging using ultra-high field strength diffusion tensor (DTI) and diffusion kurtosis (DKI) imaging metrics and cerebrospinal fluid (CSF) biomarkers. A cohort of athletes with PPCS severity limiting the ability to work/study and participate in sport school and/or social activities for ≥6 months completed 7T magnetic resonance imaging (MRI) (morphological T1-weighed volumetry, DTI and DKI), extensive neuropsychological testing, symptom rating, and CSF biomarker sampling. Twenty-two athletes with PPCS and 22 controls were included. Concussed athletes performed below norms and significantly lower than controls on all but one of the psychometric neuropsychology tests. Supratentorial white and gray matter, as well as hippocampal volumes did not differ between concussed athletes and controls. However, of the 72 examined white matter tracts, 16% of DTI and 35% of DKI metrics (in total 28%) were significantly different between concussed athletes and controls. DKI fractional anisotropy and axial kurtosis were increased, and DKI radial diffusivity and radial kurtosis decreased in concussed athletes when compared with controls. CSF neurofilament light (NfL; an axonal injury marker), although not glial fibrillary acidic protein, correlated with several diffusion metrics. In this first 7T DTI and DKI study investigating PPCS, widespread microstructural alterations were observed in the white matter, correlating with CSF markers of axonal injury. More white matter changes were observed using DKI than using DTI. These white matter alterations may indicate persistent pathophysiological processes following concussion in sport.

Feasibility of a novel blended-care intervention for fatigue after acquired brain injury: a pilot study of the Tied by Tiredness intervention

PURPOSE

Evidence-based treatments for fatigue after brain injury are scarce and often not personalized. An approach to foster personalization is Experience Sampling Methodology (ESM), consisting of repeated daily measurements of fatigue and related factors in daily life. We investigated the feasibility and usability of a novel six-week ESM-based intervention for fatigue after brain injury.

MATERIALS AND METHODS

Ten individuals with acquired brain injury (six men; four women) aged between 36-70 years (M = 53.3, SD = 12.9) used a mHealth application for three days each week during six-weeks; seven completed the intervention. Momentary fatigue, activities, mood, worrying, and social context were assessed with ESM and participants received weekly personalized feedback by a therapist..

RESULTS

56% of ESM-questionnaires (568/1008) were completed, providing detailed insights into individual fatigue patterns. No statistically significant decrease in response rate was found over the course of treatment. Qualitative feedback from participants revealed increased insight into factors underlying fatigue, and no problems with treatment duration or difficulties using the app. Five participants showed a decline in fatigue level during treatment.

CONCLUSIONS

This pilot study provides initial support for the feasibility and usability of this novel blended-care intervention, aimed at alleviating fatigue through personalized feedback and treatment strategies.

Validation of the Scandinavian guidelines for minor and moderate head trauma in children: protocol for a pragmatic, prospective, observational, multicentre cohort study

INTRODUCTION

Mild traumatic brain injury is common in children and it can be challenging to accurately identify those in need of urgent medical intervention. The Scandinavian guidelines for management of minor and moderate head trauma in children, the Scandinavian Neurotrauma Committee guideline 2016 (SNC16), were developed to aid in risk stratification and decision-making in Scandinavian emergency departments (EDs). This guideline has been validated externally with encouraging results, but internal validation in the intended healthcare system is warranted prior to broad clinical implementation.

OBJECTIVE

We aim to validate the diagnostic accuracy of the SNC16 to predict clinically important intracranial injuries (CIII) in paediatric patients suffering from blunt head trauma, assessed in EDs in Sweden and Norway.

METHODS AND ANALYSIS

This is a prospective, pragmatic, observational cohort study. Children (aged 0-17 years) with blunt head trauma, presenting with a Glasgow Coma Scale of 9-15 within 24 hours postinjury at an ED in 1 of the 16 participating hospitals, are eligible for inclusion. Included patients are assessed and managed according to the clinical management routines of each hospital. Data elements for risk stratification are collected in an electronic case report form by the examining doctor. The primary outcome is defined as CIII within 1 week of injury. Secondary outcomes of importance include traumatic CT findings, neurosurgery and 3-month outcome. Diagnostic accuracy of the SNC16 to predict endpoints will be assessed by point estimate and 95% CIs for sensitivity, specificity, likelihood ratio, negative predictive value and positive predictive value.

ETHICS AND DISSEMINATION

The study is approved by the ethical board in both Sweden and Norway. Results from this validation will be published in scientific journals, and a tailored development and implementation process will follow if the SNC16 is found safe and effective.

TRIAL REGISTRATION NUMBER

NCT05964764.

Fatigue in patients with acquired brain damage

Fatigue is a complex, multidimensional syndrome that is prevalent in patients with acquired brain damage and has a negative impact on the neurorehabilitation process. It presents from early stages after the injury, and may persist over time, regardless of whether sequelae have resolved. Fatigue is conditioned by upper neuronal circuits, and is defined as an abnormal perception of overexertion. Its prevalence ranges from 29% to 77% after stroke, from 18% to 75% after traumatic brain injury, and from 47% to 97% after brain tumours. Fatigue is associated with factors including female sex, advanced age, dysfunctional families, history of specific health conditions, functional status (eg, fatigue prior to injury), comorbidities, mood, secondary disability, and the use of certain drugs. Assessment of fatigue is fundamentally based on such scales as the Fatigue Severity Scale (FSS). Advances have recently been made in imaging techniques for its diagnosis, such as in functional MRI. Regarding treatment, no specific pharmacological treatment currently exists; however, positive results have been reported for some conventional neurorehabilitation therapies, such as bright light therapy, neurofeedback, electrical stimulation, and transcranial magnetic stimulation. This review aims to assist neurorehabilitation professionals to recognise modifiable factors associated with fatigue and to describe the treatments available to reduce its negative effect on patients.

Efficient assessment of brain fog and fatigue: Development of the Fatigue and Altered Cognition Scale (FACs)

Debilitating symptoms of fatigue and accompanying "brain fog" are observed among patients with various chronic health conditions. Unfortunately, an efficient and psychometrically sound instrument to assess these co-occurring symptoms is unavailable. Here, we report the development and initial psychometric properties of the Fatigue and Altered Cognition Scale (the FACs), a measure of self-reported central fatigue and brain fog. Traumatic brain injury (TBI) was chosen to model and develop the FACs due to research team expertise and established links between TBI and the symptom complex. Potential items were generated by researchers and clinicians with experience treating these symptoms, drawing from relevant literature and review of patient responses to measures from past and current TBI studies. The 20 candidate items for the FACs-ten each to assess altered cognition (i.e., brain fog) and central fatigue-were formatted on an electronic visual analogue response scale (eVAS) via an online survey. Demographic information and history of TBI were obtained. A total of 519 participants consented and provided usable data (average age = 40.23 years; 73% female), 204 of whom self-reported a history of TBI (75% reported mild TBI). Internal consistency and reliability values were calculated. Confirmatory factor analysis (CFA) examined the presumed two-factor structure of the FACs and a one-factor solution for comparison. A measurement invariance test of the two latent constructs (altered cognition, fatigue) among participants with and without TBI was conducted. All items demonstrated normal distribution. Cronbach's alpha coefficients indicated good internal consistency for both factors (α's = .95). Omega reliability values were favorable (α's = .95). CFA supported the presumed two-factor model and item loadings which outperformed the one-factor model. Measurement invariance found the two-factor structure was consistent between the two groups. Implications of these findings, study limitations, and potential use of the FACs in clinical research and practice are discussed.

Co-design of a therapeutic virtual reality tool to increase awareness and self-management of cognitive fatigue after traumatic brain injury

PURPOSE

The symptom of cognitive fatigue is reported as one of the longest lasting and most debilitating symptoms of traumatic brain injury (TBI). Virtual reality may be one of the most suitable technologies for neurorehabilitation, able to integrate evidence-based neuroscientific principles into motivating rehabilitation simulations. The purpose of this study was to seek perspectives of individuals with lived experience of TBI and experienced rehabilitation clinicians in the co-design of a novel technology-based tool for cognitive fatigue after TBI.

MATERIALS AND METHOD

Co-design focus groups with a sample of clinicians and individuals with lived experience of TBI were used to identify the design parameters. A prototype was developed using inter-disciplinary design iterations. Focus groups were repeated with participants testing the prototype. Qualitative data were analysed using a general inductive approach.

RESULTS

Feasibility of VR in this population was well tolerated. The focus groups guided development of domains including environment, tasks, level progression, outcome measures and considerations about clinical implementation of VR.

CONCLUSIONS

By merging advancements in VR science with a translational approach, a co-designed virtual reality tool to increase awareness and self-management of cognitive fatigue has been developed, suitable for use in persons with TBI.Implications for rehabilitationImmersive virtual reality tools show promise for addressing awareness of cognitive fatigue after traumatic brain injury in rehabilitation settings.Early engagement with consumers is recommended to produce a usable rehabilitation product.

Exploring physical and biological manifestations of burnout and post-traumatic stress disorder symptoms in healthcare workers: a scoping review protocol

INTRODUCTION

The COVID-19 pandemic has strained the mental and physical well-being of healthcare workers (HCW). Increased work-related stress and limited resources have increased symptoms of anxiety, depression, insomnia and post-traumatic stress disorder (PTSD) in this population. Stress-related disorders have been strongly associated with long-term consequences, including cardiometabolic disorders, endocrine disorders and premature mortality. This scoping review aims to explore available literature on burnout, PTSD, and other mental health-associated symptoms in HCW to synthesise relationships with physiological and biological biomarkers that may be associated with increased risk of disease, creating an opportunity to summarise current biomarker knowledge and identify gaps in this literature.

METHODS AND ANALYSIS

This scoping review uses the Arksey and O'Malley six-step scoping review methodology framework. The research team will select appropriate primary sources using a search strategy developed in collaboration with a health sciences librarian. Three reviewers will initially screen the title and abstracts obtained from the literature searches, and two reviewers will conduct independent reviews of full-text studies for inclusion. The research team will be reviewing literature focusing on which burnout and/or PTSD-associated physiological and biological biomarkers have been studied, the methodologies used to study them and the correlations between the biomarkers and HCW experiencing burnout/PTSD. Data extraction forms will be completed by two reviewers for included studies and will guide literature synthesis and analysis to determine common themes.

ETHICS AND DISSEMINATION

This review does not require ethical approval. We expect results from this scoping review to identify gaps in the literature and encourage future research regarding improving biological and physiological biomarker research in HCW. Preliminary results and general themes will be communicated back to stakeholders. Results will be disseminated through peer-reviewed publications, policy briefs and conferences as well as presented to stakeholders to an effort to invest in HCW mental and physical health.

Exploring Physical and Biological Manifestations of Burnout and Post-Traumatic Stress Disorder Symptoms in Healthcare Workers: A Scoping Review Protocol

Introduction

The COVID-19 pandemic has strained the mental and physical well-being of healthcare workers (HCW). Increased work-related stress and limited resources has increased symptoms of anxiety, depression, insomnia, and post-traumatic stress disorder (PTSD) in this population. Stress-related disorders have been strongly associated with long-term consequences including cardiometabolic disorders, endocrine disorders and premature mortality. This scoping review aims to explore available literature on burnout, PTSD, and other mental health-associated symptoms in HCW to synthesize relationships with physiological and biological biomarkers that may be associated with increased risk of disease, creating an opportunity to summarize current biomarker knowledge and identify gaps in this literature.

Methods and Analysis

This scoping review uses the Arksey and O'Malley six-step scoping review methodology framework. The research team will select appropriate primary sources using a search strategy developed in collaboration with a health sciences librarian. Three reviewers will initially screen the title and abstracts obtained from the literature searches, and two reviewers will conduct independent reviews of full-text studies for inclusion. The research team will be reviewing literature focusing on which burnout and/or PTSD-associated physiological and biological biomarkers have been studied, the methodologies used to study them and the correlations between the biomarkers and HCW experiencing burnout/PTSD. Data extraction forms will be completed by two reviewers for included studies and will guide literature synthesis and analysis to determine common themes.

Ethics and Dissemination

This review does not require ethical approval. We expect results from this scoping review to identify gaps in the literature and encourage future research regarding improving biologic and physiologic biomarker research in HCW. Preliminary results and general themes will be communicated back to stakeholders. Results will be disseminated through peer-reviewed publications, policy briefs, and conferences, as well as presented to stakeholders to an effort to invest in HCW mental and physical health.

Strengths and Limitations of This Study

This will be the first scoping review to assess the current understanding of the biologic and physiological impact of burnout on healthcare workers. The target population is restricted to healthcare workers; however, identified research gaps may be used to guide future studies in other high-burnout occupations and industries.This scoping review will be guided by the Arksey and O'Malley six-step methodological framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review checklist.Both peer reviewed manuscript and pre-prints/abstracts will be evaluated, but studies that have not been peer reviewed will be notated in the summary table. Conference abstracts are excluded.Preliminary and final themes and results identified by this scoping review will be communicated to stakeholders, including hospital staff and HCW, to ensure agreement with our interpretation and to convey knowledge gained with our population of interest.This review will advance the field's current understanding of mechanisms connecting the burnout and pathogenic stress to biologic and physiologic outcomes in healthcare workers and provide researchers with gaps in the literature to inform opportunities for future research.

"My head feels like it has gone through a mixer" - a qualitative interview study on recovery 1 year after aneurysmal subarachnoid hemorrhage

PURPOSE

To describe patients' perceived and expected recovery 1 year after aneurysmal subarachnoid hemorrhage (aSAH).

MATERIALS AND METHODS

Semi-structured interviews were conducted with 16 persons 1 year after aSAH. Inductive manifest qualitative content analysis was used.

RESULTS

The analysis resulted in two categories and seven subcategories. The category "A spectrum of varying experiences of recovery" includes four subcategories describing physical recovery, mental recovery, alterations in social life, and perceived possibilities to return to normality. Some informants felt that life was almost as before, while others described a completely different life, including a new view of self, altered relationships, not being able to return to work, and effects on personal finances. The category "A spectrum of reflections and expectations of recovery" comprises three subcategories depicturing that expectations of recovery were influenced by existential thoughts, describing what they based own expectations of recovery on, and how expectations from others influenced them.

CONCLUSIONS

aSAH was perceived as a life-changing event. The changes impacted on informants' view of self and relationships, and they perceived new barriers in their living conditions. Lack of information on expected recovery was expressed and expectations of recovery were at times unrealistic.IMPLICATIONS FOR REHABILITATIONContracting an aneurysmal subarachnoid hemorrhage (aSAH) is a life-changing event with possible impact on a variety of areas in daily life.There is a need for improved information to aSAH survivors and their significant others on the course of the recovery and possible long-term consequences.aSAH survivors may need assistance to balance unrealistic expectations on recovery.

Segregation over time in functional networks in prefrontal cortex for individuals suffering from pathological fatigue after traumatic brain injury

Pathological fatigue is present when fatigue is perceived to continually interfere with everyday life. Pathological fatigue has been linked with a dysfunction in the cortico-striatal-thalamic circuits. Previous studies have investigated measures of functional connectivity, such as modularity to quantify levels of segregation. However, previous results have shown both increases and decreases in segregation for pathological fatigue. There are multiple factors why previous studies might have differing results, including: (i) Does the functional connectivity of patients with pathological fatigue display more segregation or integration compared to healthy controls? (ii) Do network properties differ depending on whether patients with pathological fatigue perform a task compared to periods of rest? (iii) Are the brain networks of patients with pathological fatigue and healthy controls differently affected by prolonged cognitive activity? We recruited individuals suffering from pathological fatigue after mild traumatic brain injury (n = 20) and age-matched healthy controls (n = 20) to perform cognitive tasks for 2.5 h. We used functional near-infrared spectroscopy (fNIRS) to assess hemodynamic changes in the frontal cortex. The participants had a resting state session before and after the cognitive test session. Cognitive testing included the Digit Symbol Coding test at the beginning and the end of the procedure to measure processing speed. We conducted an exploratory network analysis on these resting state and Digit Symbol Coding sessions with no a priori hypothesis relating to how patients and controls differ in their functional networks since previous research has found results in both directions. Our result showed a Group vs. Time interaction (p = 0.026, η_p² = 0.137), with a post hoc test revealing that the TBI patients developed higher modularity toward the end of the cognitive test session. This work helps to identify how functional networks differ under pathological fatigue compared to healthy controls. Further, it shows how the functional networks dynamically change over time as the patient performs tasks over a time scale that affect their fatigue level.

Fatigue in patients with acquired brain damage

Fatigue is a complex, multidimensional syndrome that is prevalent in patients with acquired brain damage and has a negative impact on the neurorehabilitation process. It presents from early stages after the injury, and may persist over time, regardless of whether sequelae have resolved. Fatigue is conditioned by upper neuronal circuits, and is defined as an abnormal perception of overexertion. Its prevalence ranges from 29% to 77% after stroke, from 18% to 75% after traumatic brain injury, and from 47% to 97% after brain tumours. Fatigue is associated with factors including female sex, advanced age, dysfunctional families, history of specific health conditions, functional status (eg, fatigue prior to injury), comorbidities, mood, secondary disability, and the use of certain drugs. Assessment of fatigue is fundamentally based on such scales as the Fatigue Severity Scale (FSS). Advances have recently been made in imaging techniques for its diagnosis, such as in functional MRI. Regarding treatment, no specific pharmacological treatment currently exists; however, positive results have been reported for some conventional neurorehabilitation therapies, such as bright light therapy, neurofeedback, electrical stimulation, and transcranial magnetic stimulation. This review aims to assist neurorehabilitation professionals to recognise modifiable factors associated with fatigue and to describe the treatments available to reduce its negative effect on patients.

Predictors of disability in adolescents and young adults with acquired brain injury after the acute phase

AIM

To develop and validate a prediction model for disability among young patients with acquired brain injury (ABI) after the acute phase.

METHODS

Within a nationwide cohort of 446 15-30-year-old ABI-patients, we predicted disability in terms of Glasgow Outcome Scale - Extended (GOS-E) <7 12 months after baseline assessment in outpatient neurorehabilitation clinics. We studied 22 potential predictors covering demographic and medical factors, clinical tests, and self-reported fatigue and alcohol/drug consumption. The model was developed using multivariable logistic regression analysis and validated by 5-fold cross-validation and geographical validation. The model's performance was assessed by receiver operating characteristic curves and calibration plots.

RESULTS

Baseline assessment took place a median of 12 months post-ABI. Low GOS-E (range 1-8 (best)) and Functional Independence Measure (range 18-126 (best)) along with high mental fatigue (range 4-20 (worst)) predicted disability. The model showed high validity and performance with an area under the curve of 0.82 (95% confidence interval (CI) 0.77, 0.87) in the cross-validation and 0.81 (95% CI 0.73, 0.88) in the geographical validation.

CONCLUSION

We developed and validated a parsimonious model which effectively predicted disability. The model may be useful to guide decision-making in outpatient neurorehabilitation clinics treating young patients with ABI.

Managing fatigue after an acquired brain injury: a pilot randomised controlled trial and qualitative investigation

Background/Aims

Fatigue after brain injury is common and enduring, and rehabilitation improves patient understanding and strategy development. The aim of this study was to determine whether therapy supporting fatigue management can be provided economically in groups to inpatients undertaking rehabilitation.

Methods

A mixed-methods study was undertaken, including a pilot randomised control trial and a parallel qualitative investigation. A total of 78 adult inpatients with moderate to severe acquired brain injury were recruited to the study; 40 were allocated to routine usual care and 38 were allocated to the intervention, which consisted of routine usual care plus four group therapy sessions that took place over 2 weeks, run by an experienced occupational therapist. Participants were aged between 18 and 65 years and were considered to be able to manage learning in a group setting. Outcome measures were collected at baseline and at the end of the therapy intervention (Barrow Neurological Institute Fatigue Scale, Quality of Life after Brain Injury questionnaire and a Fatigue Knowledge questionnaire assessing knowledge related to the aims of the education modules). A qualitative study was conducted after the quantitative investigation in the form of patient interviews. A total of 10 patients were interviewed to discuss their fatigue journey and impressions of receiving fatigue management therapy in a group.

Results

A repeated measures analysis of variance with time as a within-subject factor and group as a between-subjects factor showed no interaction effect of group × time for fatigue, quality of life or acquisition of knowledge; however, knowledge improved over time, irrespective of group allocation (P<0.01). Although most participants found the group work satisfactory in terms of overall knowledge development, a number would have preferred to address their specific fatigue issues in an individual session. Participants described a confusing journey understanding fatigue symptoms before therapy, but reported an improved understanding and acquiring management strategies after receiving the educational therapy sessions.

Conclusions

Education regarding fatigue following brain injury can be provided successfully to inpatients receiving rehabilitation in group settings. However, it may be important to build in an additional individual therapy session to address each patient's individual issues and queries.

Understanding the relationship between cognitive performance and function in daily life after traumatic brain injury

OBJECTIVE

Cognitive impairment is a key cause of disability after traumatic brain injury (TBI) but relationships with overall functioning in daily life are often modest. The aim is to examine cognition at different levels of function and identify domains associated with disability.

METHODS

1554 patients with mild-to-severe TBI were assessed at 6 months post injury on the Glasgow Outcome Scale-Extended (GOSE), the Short Form-12v2 and a battery of cognitive tests. Outcomes across GOSE categories were compared using analysis of covariance adjusting for age, sex and education.

RESULTS

Overall effect sizes were small to medium, and greatest for tests involving processing speed (ηp 2 0.057-0.067) and learning and memory (ηp 2 0.048-0.052). Deficits in cognitive performance were particularly evident in patients who were dependent (GOSE 3 or 4) or who were unable to participate in one or more major life activities (GOSE 5). At higher levels of function (GOSE 6-8), cognitive performance was surprisingly similar across categories. There were decreases in performance even in patients reporting complete recovery without significant symptoms. Medium to large effect sizes were present for summary measures of cognition (ηp 2 0.111), mental health (ηp 2 0.131) and physical health (ηp 2 0.252).

CONCLUSIONS

This large-scale study provides novel insights into cognitive performance at different levels of disability and highlights the importance of processing speed in function in daily life. At upper levels of outcome, any influence of cognition on overall function is markedly attenuated and differences in mental health are salient.

A tool for measuring burden in activities and participation of clients with acquired brain injury: the FINAH-instrument

PRIMARY OBJECTIVE

The objective of this study was to design an instrument to screen for burden in the daily life of both the client with acquired brain injury (ABI) and their nonprofessional caregiver.

RESEARCH DESIGN

Exploratory research Methods and Procedures: Based on a survey amongst stakeholder organizations, the FINAH-instrument is designed as a digital self-assessment questionnaire, based on ICF-framework. A test survey of the FINAH instrument is conducted on both clients, nonprofessional caregivers and healthcare professionals.

MAIN OUTCOMES AND RESULTS

The relative burden per item for clients and nonprofessional caregivers is most prominent in the domains of fatigue, cognitive and emotional consequences, self-care and mobility. The estimation of burden for clients and nonprofessional caregiver by healthcare professionals showed an overall 65% correct estimation by the healthcare professional. 19% of the items showed underestimation of burden, while 16% showed overestimation.

CONCLUSIONS

These results show that FINAH can ameliorate the estimation of the health care professional on the self-assessed burden of clients and nonprofessional caregivers, thus substantiating a more client-centred approach.

Reward presentation reduces on-task fatigue in traumatic brain injury

While cognitive fatigue is experienced by up to 80% of individuals with traumatic brain injury (TBI), little is known about its neural underpinnings. We previously hypothesized that presentation of rewarding outcomes leads to cognitive fatigue reduction and activation of the striatum, a brain region shown to be associated with cognitive fatigue in clinical populations and processing of rewarding outcomes. We have demonstrated this in individuals with multiple sclerosis. Here, we tested this hypothesis in individuals with TBI. Twenty-one individuals with TBI and 24 healthy participants underwent functional magnetic resonance imaging. Participants performed a task during which they were presented with 1) the Outcome condition where they were exposed to monetary rewards, and 2) the No Outcome condition that served as the control condition and was not associated with monetary rewards. In accordance with our hypothesis, results showed that attainment of rewarding outcomes leads to cognitive fatigue reduction in individuals with TBI, as well as activation of the striatum. Specifically, we observed a significant group by condition interaction on fatigue scores driven by the TBI group reporting lower levels of fatigue after the Outcome condition. fMRI data revealed a significant main-effect of condition in regions previously implicated in outcome processing, while a significant group by condition interaction was observed in the left ventral striatum as revealed by a priori region of interest analysis. Results suggest that a salient motivator can significantly reduce fatigue and that outcome presentation leads to increased activation of the ventral striatum in TBI. These findings can inform the development of future non-pharmacological cognitive fatigue treatment methods and contribute to the growing body of evidence showing the association between cognitive fatigue and the striatum.

Measuring Fatigue in TBI: Development of the TBI-QOL Fatigue Item Bank and Short Form

OBJECTIVE

To develop a traumatic brain injury (TBI)-specific, item response theory (IRT)-calibrated Fatigue item bank, short form, and computer adaptive test (CAT) as part of the Traumatic Brain Injury-Quality of Life (TBI-QOL) measurement system.

SETTING

Five TBI Model Systems rehabilitation centers in the US PARTICIPANTS:: Adults with complicated mild, moderate, or severe TBI confirmed by medical record review.

DESIGN

Cross-sectional field testing via phone or in-person interview.

MAIN MEASURES

TBI-QOL Fatigue item bank, short form, and CAT.

RESULTS

A total of 590 adults with TBI completed 95 preliminary fatigue items, including 86 items from the Patient-Reported Outcomes Measurement Information System (PROMIS) and 9 items from the Quality of Life in Neurological Disorders (Neuro-QOL) system. Through 4 iterations of factor analysis, 22 items were deleted for reasons such as local item dependence, misfit, and low item-total correlations. Graded response model IRT analyses were conducted on the 73-item set, and Stocking-Lord equating was used to transform the item parameters to the PROMIS (general population) metric. A short form and CAT, which demonstrate similar reliability to the full item bank, were developed. Test-retest reliability of the CAT was established in an independent sample (Pearson's r and intraclass correlation coefficient = 0.82 [95% confidence interval: 0.72-0.88]).

CONCLUSIONS

The TBI-QOL Fatigue item bank, short form, and CAT provide rehabilitation researchers and clinicians with TBI-optimized tools for assessment of the patient-reported experience and impact of fatigue on individuals with TBI.

Randomized Controlled Trials of Rehabilitation Services in the Post-acute Phase of Moderate and Severe Traumatic Brain Injury - A Systematic Review

Background and aims: There is a gap in knowledge regarding effective rehabilitation service delivery in the post-acute phase after traumatic brain injury (TBI). Recently, Gutenbrunner et al. proposed a classification system for health-related rehabilitation services (International Classification System for Service Organization in Health-related Rehabilitation, ICSO-R) that could be useful for contrasting and comparing rehabilitation services. The ICSO-R describes the dimensions of Provision (i.e., context of delivered services), Funding (i.e., sources of income and refunding), and Delivery (i.e., mode, structure and intensity) at the meso-level of services.

We aim to:

-Provide an overview of randomized, controlled trials (RCTs) with rehabilitation service relevance provided to patients with moderate and severe TBI in the post-acute phase using the ICSO-R as a framework; and

-Evaluate the extent to which the provision, funding and delivery dimensions of rehabilitation services were addressed and differed between the intervention arms in these studies.

Materials and methods: A systematic literature search was performed in OVID MEDLINE, EMBASE, CINHAL, PsychINFO, and CENTRAL, including multidisciplinary rehabilitation interventions with RCT designs and service relevance targeting moderate and severe TBI in the post-acute phase.

Results: 23 studies with 4,644 TBI patients were included. More than two-thirds of the studies were conducted in a hospital-based rehabilitation setting. The contrast in Context between the intervention arms often co-varied with Resources. The funding of the services was explicitly described in only one study. Aspects of the Delivery dimension were described in all of the studies, and the Mode of Production, Intensity, Aspects of Time and Peer Support were contrasted in the intervention arms in several of the studies. A wide variety of outcome measures were applied often covering Body function, as well as the Activities and Participation domains of the International Classification of Functioning, Disability, and Health (ICF).

Conclusion: Aspects of service organization and resources as well as delivery may clearly influence outcome of rehabilitation. Presently, lack of uniformity of data and collection methods, the heterogeneity of structures and processes of rehabilitation services, and a lack of common outcome measurements make comparisons between the studies difficult. Standardized descriptions of services by ICSO-R, offer the possibility to improve comparability in the future and thus enhance the relevance of rehabilitation studies.

Physiological and pathological covariates of persistent concussion-related fatigue: results from two regression methodologies

BACKGROUND

Fatigue severity in persons with mild traumatic brain injury (mTBI) has received little research attention, despite its typically positively skewed nature. Investigation of covariates across a range of fatigue severity may provide insight into important contributors.

OBJECTIVE

To assess the relative significance of a priori-hypothesized covariates of physiological and pathological (mental and physical) fatigue in persons with mTBI/concussion, applying ordinary least squares (OLS) and quantile regression (QR) approaches.

METHODS

We conducted a cross-sectional investigation in 80 participants with mTBI/concussion (mean age 45.4 ± 10.1 years, 59% male). The fatigue severity scale (FSS) was used as an outcome measure. Predictors of this outcome, grouped into physiological and pathological models of fatigue were assessed using OLS and QR.

RESULTS

The mean total FSS score was 46.13 ± 14.59, and the median was 49 (interquartile range 37-57), demonstrating positive skewness. Fatigue severity was associated with variables within the mental, psychological and psychiatric domains at different levels of the fatigue score distribution.

CONCLUSION

Results highlighted that some covariates had a significant impact on the FSS total score at non-central parts of its distribution, while others exhibited significant impact across the entire distribution. Addressing covariates of fatigue across the severity continuum can enhance research and clinical management.

Rehabilitation Assessment and Management of Neurosensory Deficits After Traumatic Brain Injury in the Polytrauma Veteran

Neurosensory deficits after traumatic brain injury can frequently lead to disability; therefore, diagnosis and treatment are important. Posttraumatic headaches typically resemble migraines and are managed similarly, but adjuvant physical therapy may be beneficial. Sleep-related issues are treated pharmacologically based on the specific sleep-related complaint. Fatigue is difficult to treat; cognitive behavioral therapy and aquatic therapy can be beneficial. Additionally, methylphenidate and modafinil have been used. Peripheral and central vestibular dysfunction causes dizziness and balance dysfunction, and the mainstay of treatment is vestibular physical therapy. Visual dysfunction incorporates numerous different diagnoses, which are frequently treated with specific rehabilitation programs.