A need for improved training interventions for the remediation of impairments in social functioning following brain injury

Recovery after traumatic brain injury: An integrative review of the role of social factors on postinjury outcomes

This research is an integrative review of the literature on social factors in TBI outcomes. It examines how such factors have been framed in TBI models, the social experience of people post-injury, and the evidence for effective social interventions. Evidence suggests that even when physical functioning has improved after injury, there is a lingering social distress that leaves individuals isolated and functionally impaired. A novel hypothesis is proposed to explain why these difficulties persist. This hypothesis draws from existing biopsychosocial models of TBI recovery, including those prominent in neuropsychology. It is argued that the social component of several TBI outcome models is too narrowly defined. This potentially has the effect of focusing efforts on the individual and their social skills or abilities as opposed to the seeking improvements at the level of the community. Evidence for and against this hypothesis is considered. This evaluation supports the idea that TBI outcomes are subject to a wider range of post injury social factors than is typically recognized, and that these factors are dynamic rather than static. Inspired by this hypothesis, this review proposes that social interventions for TBI should be adjusted to suit the stage of recovery.

Perspectives on Primary Blast Injury of the Brain: Translational Insights Into Non-inertial Low-Intensity Blast Injury

Most traumatic brain injuries (TBIs) during military deployment or training are clinically "mild" and frequently caused by non-impact blast exposures. Experimental models were developed to reproduce the biological consequences of high-intensity blasts causing moderate to severe brain injuries. However, the pathophysiological mechanisms of low-intensity blast (LIB)-induced neurological deficits have been understudied. This review provides perspectives on primary blast-induced mild TBI models and discusses translational aspects of LIB exposures as defined by standardized physical parameters including overpressure, impulse, and shock wave velocity. Our mouse LIB-exposure model, which reproduces deployment-related scenarios of open-field blast (OFB), caused neurobehavioral changes, including reduced exploratory activities, elevated anxiety-like levels, impaired nesting behavior, and compromised spatial reference learning and memory. These functional impairments associate with subcellular and ultrastructural neuropathological changes, such as myelinated axonal damage, synaptic alterations, and mitochondrial abnormalities occurring in the absence of gross- or cellular damage. Biochemically, we observed dysfunctional mitochondrial pathways that led to elevated oxidative stress, impaired fission-fusion dynamics, diminished mitophagy, decreased oxidative phosphorylation, and compensated cell respiration-relevant enzyme activity. LIB also induced increased levels of total tau, phosphorylated tau, and amyloid β peptide, suggesting initiation of signaling cascades leading to neurodegeneration. We also compare translational aspects of OFB findings to alternative blast injury models. By scoping relevant recent research findings, we provide recommendations for future preclinical studies to better reflect military-operational and clinical realities. Overall, better alignment of preclinical models with clinical observations and experience related to military injuries will facilitate development of more precise diagnosis, clinical evaluation, treatment, and rehabilitation.

Application of neuropsychology and imaging to brain injury and use of the integrative cognitive rehabilitation psychotherapy model

BACKGROUND

An early approach to cognitive rehabilitation therapy (CRT) was developed based on A. R. Luria's theory of brain function. Expanding upon this approach, the Integrative Cognitive Rehabilitation Psychotherapy model (ICRP) was advanced.

OBJECTIVE

To describe the ICRP approach to treatment of clients post brain injury and provide a comprehensive list of evaluation tools to determine the client's abilities and needs. Finally, to provide a link between CRT and functional imaging studies designed to improve rehabilitation efforts.

METHODS

History of cognitive rehabilitation and neuropsychological testing is reviewed and description of cognitive, academic, psychiatric, and substance abuse tools are provided. Cognitive and emotional treatment techniques are fully described. Additionally, a method of determining the client's stage of recovery and pertinent functional imaging studies is detailed.

RESULTS

Authors have been able to provide a set of tools and techniques to use in comprehensive treatment of clients with brain injury.

CONCLUSIONS

Inclusive treatment which is outlined in the ICRP model is optimal for the client's recovery and return to a full and satisfying life post brain injury. The model provides a framework for neuropsychologists to integrate issues that tend to co-occur in clients living with brain injury into a unified treatment plan.

Theory of mind in adults with traumatic brain injury: A meta-analysis

Studies of abnormal theory of mind (ToM) performance in adult patients with traumatic brain injury (TBI) have reported inconsistent results. Therefore, we conducted a meta-analysis to characterize ToM performance in adult patients with TBI. Random-effects models were employed to estimate the overall effect size and the differential effect sizes across different ToM aspects. Based on a sample of 28 studies (1031 patients and 865 healthy controls), the meta-analytic findings revealed that ToM was significantly impaired in adult patients with TBI compared to healthy controls (g = -1.13). Besides, patients with TBI showed significant impairments in individual ToM tasks, as well as for different stimulus modes and contents involved in these ToM tasks. A meta-regression indicated a positive association between ToM performance and Glasgow Coma Scale score. The results of the current meta-analysis suggest that the performance in ToM tasks may be a good predictor of functional outcomes in adults with TBI, which is important for the identification of targets for cognitive interventions and the development of useful training intervention programs.

Establishing 'proof of concept' for a social cognition group treatment program (SIFT IT) after traumatic brain injury: two case studies

OBJECTIVE

Social cognitive deficits are prevalent after traumatic brain injury (TBI). Despite this, few remediation studies exist. This study aimed to demonstrate 'proof of concept' for a novel group treatment that comprehensively targeted the core processes of social cognition.

DESIGN

Pre-post case study with two participants, "Greg" and "Aaron", living with severe TBI, with three assessment time points.

METHOD

Participants were screened at baseline to confirm social cognitive deficits: Greg exhibited difficulties with emotion perception and detecting hints; Aaron with detecting sarcasm and hints. Both reported everyday social problems. Participants then completed the 14-week group treatment program (SIFT IT). Feasibility and outcome measures were repeated post-group and at three-month follow-up.

RESULTS

The study procedure was implemented with 100% assessment and 89% SIFT IT session attendance, albeit with a lack of proxy-report measures. Both participants described procedures as acceptable, although suggested more group participants could be beneficial. They both demonstrated reliable improvements (RCI > 1.96) on relevant social cognitive measures. Qualitative feedback corroborated findings: Greg reported generalization of therapeutic gains, Aaron reported increased self-awareness but nominal generalization.

CONCLUSION

Feasibility and limited efficacy outcomes established 'proof of concept' of SIFT IT. Findings will inform the study protocol for a larger randomized-controlled trial.

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.

Training emotional recognition in a child with acquired brain injury: A single case study

Emotional processing is affected by childhood brain injury. Ineffective emotional processing and poor understanding of social cues affect the development of social relationships leading to social isolation and a poorer quality of life in the long-term. Facial expression recognition is a non-verbal social cue that is used to interpret the thoughts and feelings of others. Children with brain injury have shown deficits identifying even basic emotions from facial expression, yet few intervention studies have explored how to develop facial expression recognition in children with brain injury. Enhancing the ability to recognize and interpret facial expressions for these children would have implications for their emotional processing and social-emotional behavior. In this paper we report on a short single case study intervention to increase facial expression recognition using the Facial Affect Recognition training (FAR) for a 10-year-old-child with brain injury. Following intervention, there was not only an increase in facial expression recognition but also changes in social-emotional behavior indicating some generalization to other contexts. The results suggest that rehabilitation of emotional processing difficulties may indeed be possible, and further intervention studies aimed at developing these skills in children with brain injury are warranted.

Default Mode Network Connectivity Predicts Emotion Recognition and Social Integration After Traumatic Brain Injury

Moderate-severe traumatic brain injury (TBI) may result in difficulty with emotion recognition, which has negative implications for social functioning. As aspects of social cognition have been linked to resting-state functional connectivity (RSFC) in the default mode network (DMN), we sought to determine whether DMN connectivity strength predicts emotion recognition and level of social integration in TBI. To this end, we examined emotion recognition ability of 21 individuals with TBI and 27 healthy controls in relation to RSFC between DMN regions. Across all participants, decreased emotion recognition ability was related to increased connectivity between dorsomedial prefrontal cortex (dmPFC) and temporal regions (temporal pole and parahippocampal gyrus). Furthermore, within the TBI group, connectivity between dmPFC and parahippocampal gyrus predicted level of social integration on the Community Integration Questionnaire, an important index of post-injury social functioning in TBI. This finding was not explained by emotion recognition ability, indicating that DMN connectivity predicts social functioning independent of emotion recognition. These results advance our understanding of the neural underpinnings of emotional and social processes in both healthy and injured brains, and suggest that RSFC may be an important marker of social outcomes in individuals with TBI.

Measuring conversations after acquired brain injury in 30 minutes or less: a comparison of two pragmatic rating scales

Primary objective: This study compared the reliability, validity and feasibility of the Pragmatics Rating Scale (PRS) to the Profile of Pragmatic Impairment in Communication (PPIC). It was hypothesized that the PRS would have equivalent reliability and validity and superior feasibility. Research design: A correlational pilot study design was implemented. Methods and procedures: Participants were 15 adults with a history of ABI, who provided two conversation samples each, and 15 adults with no history of ABI, who provided one conversation sample each. Two clinicians used the PRS and PPIC to rate each conversation sample. Main outcomes and results: The results of the PRS showed good discriminative validity between the ABI and non-ABI group, adequate construct validity with the PPIC and the La Trobe Communication Questionnaire, superior interrater reliability to the PPIC, and good test-retest reliability. Also, the PRS demonstrated higher clinical feasibility than the PPIC as measured by mean completion time per sample and ratings on a clinical feasibility survey. Conclusions: These results supported our hypotheses that the PRS is sensitive to aspects of social communication often impaired by ABI, without the feasibility drawbacks of a more complex rating scale.

Rehabilitation of social cognition impairment after traumatic brain injury: A systematic review

INTRODUCTION

Many studies have described the presence of difficulty processing and generating social behaviour in patients who have suffered a traumatic brain injury (TBI). These difficulties in social cognition (SC) deteriorate personal relationships in the family, at work, or in the community. However, therapeutic programmes aiming to improve SC continue to be an outstanding issue in clinical practice. We performed a systematic review of the existing literature on the recovery of SC in patients with TBI, assessing the methodological quality of the included studies and the therapeutic effectiveness of the rehabilitation strategies used.

DEVELOPMENT

We performed a bibliographic search of papers published before June 2018 in the Medline/PubMed, Google Scholar, PsycINFO, and ClinicalTrials.gov databases. Of the 198 potentially relevant articles, 10 met our eligibility criteria. Two of the authors independently and blindly assessed the methodological quality of these studies using the PEDro scale.

CONCLUSIONS

The articles included in this systematic review essentially studied the effect of different interventions aimed at the rehabilitation of SC in patients with chronic TBIs. The analysis showed adequate methodological quality and an acceptable level of evidence. Future research should analyse the effect of these interventions in patients with TBIs in the sub- and post-acute phases.

Treatment of social cognition impairments in patients with traumatic brain injury: a critical review

Objective: The aim of this study is to review published research on treatment of social cognition impairments in patients with traumatic brain injury (TBI).Methods: Following the PRISMA guidelines, a PubMed literature search was conducted, followed by a manual search in recently published papers. Main criteria for selection were that patients had sustained a TBI, and that social cognition was the main target of treatment. A total of 16 papers and three reviews were selected and included in the present review.Results: Five studies (including three randomized controlled trials (RCT)) addressed facial affect recognition, one study specifically addressed emotional prosody, two RCTs used a combination of treatment strategies addressing social perception deficits. Six studies, including two RCTs, addressed social communication skills or theory of mind. Finally, two RCTs reported the effectiveness of a more global approach, addressing multiple domains of social cognition, such as emotion perception, social skills training, and theory of mind.Discussion/conclusion: Although there has been much less research on treatment of social cognition in patients with TBI as compared with psychiatric conditions, the findings reported in the present review are encouraging. Further multicenter large-scale RCTs are needed, with special emphasis on the generalization of treatment effects to social skills in everyday life.

Sex differences in response to emotion recognition training after traumatic brain injury

OBJECTIVE

To examine sex differences in the effectiveness of a Stories intervention for teaching affect recognition in people with a traumatic brain injury (TBI).

SETTING

Post-acute rehabilitation facilities.

PARTICIPANTS

203 participants (53 women and 150 men) with moderate to severe TBI were screened. 71 were eligible and randomized to one of three treatment conditions: two affect recognition conditions and an active control (cognition). This paper examines sex differences between the Stories intervention (n = 23, 5 women and 18 men) and the cognitive treatment control (n = 24, 8 women and 16 men).

DESIGN

Randomized controlled trial with immediate, 3- and 6-month follow-up post-tests. Interventions were 9 hours of computer-based training with a therapist.

MEASURES

Facial Affect Recognition (DANVA2-AF); Emotional Inference from Stories Test (EIST).

RESULTS

A significant treatment effect was observed for the Stories intervention for women, who demonstrated and maintained improved facial affect recognition. In contrast, males in our sample did not benefit from the Stories intervention.

CONCLUSION

This positive finding for the Stories intervention for females contrasts with our conclusions in a previous paper, where an analysis collapsed across sex did not reveal an overall effectiveness of the Stories intervention. This intervention warrants further research and development.

Social Cognition Deficits: Current Position and Future Directions for Neuropsychological Interventions in Cerebrovascular Disease

Neuropsychological assessments of cognitive dysfunction in cerebrovascular illness commonly target basic cognitive functions involving aspects of memory, attention, language, praxis, and number processing. Here, I highlight the clinical importance of often-neglected social cognition functions. These functions recruit a widely distributed neural network, making them vulnerable in most cerebrovascular diseases. Sociocognitive deficits underlie most of the problematic social conduct observed in patients and are associated with more negative clinical outcomes (compared to nonsocial cognitive deficits). In clinical settings, social cognition deficits are normally gleaned from collateral information from caregivers or from indirect inferences made from patients' performance on standard nonsocial cognitive tests. Information from these sources is however inadequate. I discuss key social cognition functions, focusing initially on deficits in emotion perception and theory of mind, two areas that have gained sizeable attention in neuroscientific research, and then extend the discussion into relatively new, less covered but crucial functions involving empathic behaviour, social awareness, social judgements, and social decision making. These functions are frequently impaired following neurological change. At present, a wide range of psychometrically robust social cognition tests is available, and this review also makes the case for their inclusion in neuropsychological assessments.

Facial emotion recognition in patients with focal and diffuse axonal injury

OBJECTIVE

Facial emotion recognition impairment has been well documented in patients with traumatic brain injury. Studies exploring the neural substrates involved in such deficits have implicated specific grey matter structures (e.g. orbitofrontal regions), as well as diffuse white matter damage. Our study aims to clarify whether different types of injuries (i.e. focal vs. diffuse) will lead to different types of impairments on facial emotion recognition tasks, as no study has directly compared these patients.

METHODS

The present study examined performance and response patterns on a facial emotion recognition task in 14 participants with diffuse axonal injury (DAI), 14 with focal injury (FI) and 22 healthy controls.

RESULTS

We found that, overall, participants with FI and DAI performed more poorly than controls on the facial emotion recognition task. Further, we observed comparable emotion recognition performance in participants with FI and DAI, despite differences in the nature and distribution of their lesions. However, the rating response pattern between the patient groups was different.

CONCLUSION

This is the first study to show that pure DAI, without gross focal lesions, can independently lead to facial emotion recognition deficits and that rating patterns differ depending on the type and location of trauma.

Reducing anger outbursts after a severe TBI: a single-case study

Anger outbursts constitute a frequent behavioural issue after a traumatic brain injury (TBI) and have a strong negative impact on the social outcomes resulting from the TBI. However, few studies have examined the efficacy of specific intervention strategies to reduce the frequency and intensity of anger outbursts. We therefore performed a single-case study on this topic by administering two successive and complementary psychological interventions with an AB design with maintenance (first intervention) and an AC design with maintenance plus a one-month follow-up (second intervention) to a patient with a severe TBI. Whereas the first intervention focused on improving the recognition and expression of basic emotions, the second consisted of a self-regulation programme, including various features such as psychoeducation about self-control strategies, relaxation and assertiveness training that aimed to establish adequate behaviours, which were further promoted by an implementation intentions strategy in the patient's daily life. The results indicated that all interventions resulted in a reduced frequency and intensity of anger outbursts, and the data upheld the specificity of these effects. In addition, a meta-analytic integration of the effects of both interventions on the outcomes indicated a medium effect size. Further research is needed on other patients who experience long-standing anger outbursts to examine whether the observed gains can be replicated, sustained on a longer-term basis and improved.

Social Cognitive Interventions in Neuropsychiatric Patients: A Meta-Analysis

Social cognitive deficits are common in neuropsychiatric disorders. Given the proximity of social cognition (SC) to everyday functioning, many intervention studies (including targeted, comprehensive, and broad-based approaches) have focussed on SC. The aim of this paper was to quantitatively meta-analyse the efficacy of SC interventions in adult neuropsychiatric patients. Databases Pubmed, PsycINFO, Web of Knowledge, and Embase were searched for controlled SC intervention studies published between 01-01-2003 and 01-01-2016. Forty-one studies, comprising 1,508 patients with schizophrenia, autism spectrum disorders, or acquired brain injury were included. Outcome measures evaluated emotion perception (EP), social perception (SP), Theory of Mind (ToM), and social functioning (SF). The meta-analyses showed that interventions were effective in improving SC (Cohen'sd=.71). Interventions targeting one specific SC function were found to be most effective (d=.89), followed by broad-based interventions, targeting non-SC domains in addition to SC (d=.65), and comprehensive interventions, that target multiple SC processes (d=.61). Targeted interventions were especially effective in improving EP and ToM. Comprehensive interventions were able to ameliorate EP, ToM, and SF. Broad-based interventions were especially effective in improving SF, but also showed effects on EP and ToM.

Non pharmacological treatments for psychological and behavioural disorders following traumatic brain injury (TBI). A systematic literature review and expert opinion leading to recommendations

INTRODUCTION

The non pharmacological approach is an important issue in the treatment of psychological and behavioural disorders in traumatic brain injury (TBI) patients. It remains nevertheless insufficiently known and defined. The objective of this work was to develop precise recommendations for caregivers and relatives.

METHOD

The elaboration of these guidelines followed the procedure validated by the French health authority for good practice recommendations, close to the Prisma statement, involving a systematic, critical review of the literature and the expert opinions of the French Society of Physical Medicine and Rehabilitation (SOFMER) group.

RESULTS

458 articles were identified, among which 98 were selected for their relevance to the theme of the research. None of the studies reached the highest level of evidence. Fifteen controlled studies reached a relatively high level of evidence (level 2); other studies were case series or expert opinions, and other articles again were reviews of the literature and theoretical points of view. The holistic approach structured into programmes, cognitive-behavioural therapy, and family and systemic therapy, despite the low levels of proof, are recommended in first intention at all stages in the evolution of TBI. Relational and adaptive approaches, rehabilitation and vocational approaches, and psychoanalytical therapies may be useful, provided that therapists are familiar with and trained in traumatic brain injury.

CONCLUSION

Despite the small number of publications and a low level of proof, a number of recommendations for the non-pharmacological approach to psychological and behavioural disorders in TBI is proposed by the consensus conference of experts. Scientific research in this domain is needed to confirm and complete these first recommendations.

Rehabilitation of executive function and social cognition impairments after brain injury

PURPOSE OF REVIEW

Brain injury is a major cause of long-term disability. Executive and social cognition sequelae are associated with poor outcome. This review examines recent evidence on the efficacy of rehabilitation in these areas.

RECENT FINDINGS

Accumulating evidence shows that interventions that work with patients on developing insight and strategies to offset executive impairments can produce significant benefits. Training of specific capacities, such as working memory, holds some promise, but more needs to be known about effect generalization. Evidence on social cognition rehabilitation following brain injury is sparse. Although there are some encouraging early results, more information on the clinical significance of change for everyday function is required.

SUMMARY

Rehabilitation in these areas is inherently difficult but vital if outcomes are to improve. Significant gains have been reported, and further work applying appropriate methods is urgently required.

Effect of psychological interventions on depressive symptoms in long-term rehabilitation after an acquired brain injury: a systematic review and meta-analysis

OBJECTIVE

To summarize empirical studies on the effectiveness of psychological interventions in long-term rehabilitation after an acquired brain injury (ABI) in reducing depressive symptoms.

DATA SOURCES

A systematic literature search was conducted on MEDLINE, PsycINFO, Embase, and CINAHL to identify articles published between January 1990 and October 2011. Search terms included the 3 concepts (1) "brain injur*" or "stroke," (2) "psychotherap*" or "therapy" or "intervention" or "rehabilitation," and (3) "depress*."

STUDY SELECTION

Studies evaluating psychological interventions in patients after ABI were included. Time since injury was on average more than 1 year. Trials reported data on validated depression questionnaires before and after the psychological intervention.

DATA EXTRACTION

Two independent reviewers extracted information from the sample, the intervention, and the outcome of the included studies and calculated effect sizes (ESs) from depression questionnaires. Thirteen studies were included in a pre-post analysis. Seven studies were eligible for a meta-analysis of ESs in active interventions and control conditions.

DATA SYNTHESIS

Pre-post ESs were significant in 4 of 13 studies. The overall ES of .69 (95% confidence interval [CI], .29-1.09) suggests a medium effectiveness of psychological interventions on depressive symptoms compared with control conditions. Moderator analysis of the number of sessions and adequate randomization procedure did not show significant ES differences between strata. Studies with adequate randomization did not, however, suggest the effectiveness of psychological interventions on depressive symptoms after ABI.

CONCLUSIONS

Psychological interventions are a promising treatment option for depressive symptoms in long-term rehabilitation after ABI. Since only a few adequately randomized controlled trials (RCTs) exist, more RCTs are required to confirm this initial finding.