Telephone Problem Solving for Service Members with Mild Traumatic Brain Injury: A Randomized, Clinical Trial

How completely are randomized controlled trials of non-pharmacological interventions following concussion reported? A systematic review

PURPOSE

The study aimed to examine the reporting completeness of randomized controlled trials (RCTs) of non-pharmacological interventions following concussion.

METHODS

We searched MEDLINE, Embase, PsycInfo, CINAHL, and Web of Science up to May 2022. Two reviewers independently screened studies and assessed reporting completeness using the Template for Intervention Description and Replication (TIDieR), Consensus on Exercise Reporting Template (CERT), and international Consensus on Therapeutic Exercise aNd Training (i-CONTENT) checklists. Additional information was sought my study authors where reporting was incomplete. Risk of bias (ROB) was assessed with the Cochrane ROB-2 Tool. RCTs examining non-pharmacological interventions following concussion.

RESULTS

We included 89 RCTs (n = 53 high ROB) examining 11 different interventions for concussion: sub-symptom threshold aerobic exercise, cervicovestibular therapy, physical/cognitive rest, vision therapy, education, psychotherapy, hyperbaric oxygen therapy, transcranial magnetic stimulation, blue light therapy, osteopathic manipulation, and head/neck cooling. Median scores were: TIDieR 9/12 (75%; interquartile range (IQR) = 5; range: 5-12), CERT 17/19 (89%; IQR = 2; range: 10-19), and i-CONTENT 6/7 (86%; IQR = 1; range: 5-7). Percentage of studies completely reporting all items was TIDieR 35% (31/89), CERT 24% (5/21), and i-CONTENT 10% (2/21). Studies were more completely reported after publication of TIDieR (t87 = 2.08; p = 0.04) and CERT (t19 = 2.72; p = 0.01). Reporting completeness was not strongly associated with journal impact factor (TIDieR: rs = 0.27; p = 0.01; CERT: rs = -0.44; p = 0.06; i-CONTENT: rs = -0.17; p = 0.48) or ROB (TIDieR: rs = 0.11; p = 0.31; CERT: rs = 0.04; p = 0.86; i-CONTENT: rs = 0.12; p = 0.60).

CONCLUSION

RCTs of non-pharmacological interventions following concussion demonstrate moderate to good reporting completeness, but are often missing key components, particularly modifications, motivational strategies, and qualified supervisor. Reporting completeness improved after TIDieR and CERT publication, but publication in highly cited journals and low ROB do not guarantee reporting completeness.

Level of Evidence of Telehealth Rehabilitation and Behavioral Health Services for Traumatic Brain Injury: A Scoping Review

Traumatic brain injury (TBI) can result in significant impairments in functioning associated with partial or permanent disabilities. Examining the evidence for domain-specific telehealth interventions is necessary to guide the development of effective clinical and research programs for this population. The present scoping review characterizes the level of evidence across a range of TBI-related disabilities and impairments. A literature search was performed across comprehensive databases using search terms related to TBI, rehabilitation, telehealth, and outcome. A total of 19 publications from 17 studies met inclusion criteria. Articles focused on telehealth interventions to improve global, cognitive, emotional, and physical functioning post-TBI. Levels of evidence ranged from 1 to 4 across domains, with predominantly experimental designs (level 1). Outcomes demonstrating improvement or benefit from telehealth treatments were reported across all functional domains (50-80% of studies). Results highlight the potential of telehealth interventions across the span of comprehensive interdisciplinary rehabilitation care. Expanded research is needed on remote treatment options for physical symptoms, for subgroups within TBI populations (i.e., mild TBI, military populations), as well as on remote and hybrid comprehensive rehabilitation programs.

Effectiveness of telehealth interventions among traumatic brain injury survivors: A systematic review and meta-analysis

INTRODUCTION

Traumatic brain injury (TBI) represents a major cause of death and disability worldwide. Brain damage is associated with physical and psychological difficulties among TBI survivors. Diverse face-to-face and telehealth programs exist to help survivors cope with these burdens. However, the effectiveness of telehealth interventions among TBI survivors remains inconclusive.

METHODS

A systematic review and meta-analysis of randomized control trials were conducted. Relevant full-text articles were retrieved from seven databases, from database inception to January 2022, including Academic Search Complete, CINAHL, EMBASE, Cochrane, MEDLINE, PubMed, and Web of Science. Bias was assessed with the revised Cochrane risk-of-bias tool for randomized trials. A meta-analysis was performed using a random-effects model to calculate the pooled effect size of telehealth interventions for TBI survivors. STATA 16.0 was used for statistical analysis.

RESULTS

In total, 17 studies (N = 3158) applying telehealth interventions among TBI survivors were included in the analysis. Telehealth interventions decreased neurobehavioural symptom (standardized mean difference: -0.13; 95% confidence interval [CI]: -0.36 to 0.10), reduce depression (standardized mean difference: -0.32; 95% CI: -0.79 to 0.14), and increase symptom management self-efficacy (standardized mean difference: 0.22; 95% CI: 0.02-0.42).

DISCUSSION

Telehealth interventions are promising avenues for healthcare delivery due to advances in technology and information. Telehealth programs may represent windows of opportunity, combining traditional treatment with rehabilitation to increase symptom management self-efficacy among TBI patients during recovery. Future telehealth programs can focus on developing the contents of telehealth modules based on evidence from this study.

Effects of a telerehabilitation-based exercise program in patients with systemic sclerosis

BACKGROUND

This study aimed to evaluate the effect of telerehabilitation-based exercise programs in systemic sclerosis (SSc) patients.

METHODS

Forty-six SSc patients were randomly separated into two groups as telerehabilitation and control. Videos comprising clinical Pilates-based exercises were designed and uploaded to YouTube™ for the telerehabilitation group by physiotherapists. A video interview was conducted with the SSc patients once a week and an exercise program was performed twice daily for 8 weeks in the telerehabilitation group. The same exercise programs were printed on paper brochures and patients were instructed on their application in the form of a home exercise program to be continued for 8 weeks in the control group. Pain, fatigue, quality of life, sleep, physical activity, anxiety, and depression were assessed in all patients at the beginning and end of the study.

RESULTS

The clinical and demographic characteristics were similar in both groups (p > 0.05). Fatigue, pain, anxiety, and depression decreased in both groups, while quality of life and sleep quality increased after the exercise program (p < 0.05). However, the improvements in the telerehabilitation group were statistically more significant than in the control group for all studied parameters (p < 0.05).

CONCLUSION

The results of our study demonstrate the superior efficacy of telerehabilitation-based treatment programs over home exercise programs, hence, we suggest widespread use of this innovative treatment program in SSc patients.

Effectiveness of interventions for the improvement of mental health and well-being post-concussion: a systematic review

OBJECTIVE

To identify and assess the effectiveness and quality of interventions targeted at improving mental health, well-being, and psychosocial impairments post-concussion.

DATA SOURCES

EBSCOHost, SPORTSDiscus, PsychINFO, Medline (Web of Science), PubMed, and Embase databases.

REVIEW METHODS

This systematic review is reported in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement in exercise, rehabilitation, sport medicine and sports science (PERSiST). Articles were included if they: (1) were randomized controlled trials or repeated measures pre-posttest study designs, (2) reported mild traumatic brain injury (mTBI) or concussion injury, and (3) evaluated interventions targeting mental health, well-being, and psychosocial impairments post-injury.

RESULTS

Twenty-three studies were included which evaluated interventions targeting mental health, well-being, and psychosocial impairments post-concussion. Interventions included cognitive rehabilitation (n = 7), psychotherapy (n = 7), psychoeducational (n = 3), neurocognitive training (n = 4), neurocognitive training combined with cognitive rehabilitation (n = 1), and psychotherapy combined with cognitive rehabilitation (n = 1). The seven (100%) cognitive rehabilitation intervention studies and four of the five (80%) neurocognitive training intervention studies observed significant improvements in mental health and well-being outcomes.

CONCLUSIONS

Cognitive rehabilitation and neurocognitive training may be the most effective interventions for mental health and well-being impairments post-concussion. Researchers and clinicians should continue to explore the effectiveness of these interventions, specifically in populations most impacted by concussion (i.e. athletes).

Occupational Therapy Practice Guidelines for Adults With Traumatic Brain Injury

IMPORTANCE

Occupational therapy practitioners are uniquely qualified to address the occupational needs of people with traumatic brain injury (TBI) and their caregivers to maximize participation, health, and well-being.

OBJECTIVE

These Practice Guidelines are informed by systematic reviews of the effectiveness of interventions that address impairments and skills to improve the occupational performance of people with TBI, as well as interventions for caregivers of people with TBI. The purpose of these guidelines is to summarize the current evidence available to assist clinicians' clinical decision-making in providing interventions for people with TBI and their caregivers.

METHOD

We reviewed six systematic reviews and synthesized the results into clinical recommendations to be used in occupational therapy clinical practice.

RESULTS

Sixty-two articles served as the basis for the clinical recommendations.

CONCLUSIONS AND RECOMMENDATIONS

Strong to moderate evidence supports multimodal sensory stimulation, unimodal auditory stimulation, physical activity, virtual reality, cognitive interventions, vision therapy, goal-focused interventions, individual and group training and education, and caregiver supports. Occupational therapy practitioners should incorporate these interventions into individual and group sessions to maximize recovery and promote occupational participation. Additional interventions are also available, based on emerging evidence and expert opinion, including prevention approaches, complexity of injury, and the use of occupation-based performance assessments. What This Article Adds: These Practice Guidelines provide a summary of evidence in clinical recommendations tables supporting occupational therapy interventions that address impairments resulting from and skills to improve occupational performance after TBI. The guidelines also include case study examples and evidence graphics for practitioners to use to support clinical reasoning when selecting interventions that address the goals of the person with TBI and their caregiver's needs.

Feasibility and acceptability of a brief intervention to improve mild traumatic brain injury recovery: Problem-solving training-concussion

OBJECTIVE

Mild traumatic brain injuries (mTBIs) are common among Veterans. Although the majority of neurobehavioral symptoms resolve following mTBI, studies with Veteran samples demonstrate a high frequency and chronicity of neurobehavioral complaints (e.g., difficulties with attention, frustration tolerance) often attributed to mTBI. Recent opinions suggest the primacy of mental health treatment, and existing mTBI practice guidelines promote patient-centered intervention beginning in primary care (PC). However, trial evidence regarding effective clinical management in PC is lacking. This study evaluated the feasibility and acceptability of a brief, PC-based problem-solving intervention to reduce psychological distress and neurobehavioral complaints.

RESEARCH METHOD/DESIGN

Mixed method open clinical trial of 12 combat Veterans with a history of mTBI, chronic neurobehavioral complaints, and psychological distress. Measures included qualitative and quantitative indicators of feasibility (recruitment and retention metrics, interview feedback), patient acceptability (treatment satisfaction, perceived effectiveness), and change in psychological distress as measured by the Brief Symptom Inventory-18.

RESULTS

The protocol was successfully delivered via in-person and telehealth treatment modalities (4.3 sessions attended on average; 58% completed the full protocol). Patient interview data suggested that treatment content was personally relevant, and patients were satisfied with their experience. Treatment completers described the intervention as helpful and reported corresponding reductions in psychological distress (ES = 1.8). Dropout was influenced by the onset of the COVID-19 pandemic.

CONCLUSIONS/IMPLICATIONS

Further study with a more diverse, randomized sample is warranted. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Associations between risky alcohol use, disability, and problem-solving impairment among Veterans with Gulf War Illness: Secondary data analysis of a randomized clinical trial

OBJECTIVE

Gulf War Illness (GWI) and alcohol use are both major sources of disability among Gulf War Veterans. The goal of this secondary data analysis was to examine associations between risky alcohol use, problem-solving impairment, and disability among Veterans in a randomized clinical trial of problem-solving treatment (PST) for GWI. We examined cross-sectional associations and conducted longitudinal analyses to test if alcohol use moderated treatment outcome of PST.

METHODS

Participants were 268 United States military Veterans with GWI randomized to PST or a control intervention. Participants were assessed at four timepoints. Measures included the World Health Organization Disability Assessment Schedule 2.0 (WHO-DAS 2.0), Problem Solving Inventory (PSI), and Alcohol Use Disorders Identification Test-Concise (AUDIT-C). We conducted multivariate regression (cross-sectional) and mixed model analyses (longitudinal) with separate models for WHO-DAS 2.0 and PSI. All models included AUDIT-C and household income. This analysis was pre-registered on the Open Science Framework.

RESULTS

Cross-sectional analyses revealed a significant negative association with small effect size between AUDIT-C and WHO-DAS 2.0 (p = 0.006; f² = 0.05); worse disability was associated with less risky alcohol use. There was no evidence that risky alcohol use moderated effects of PST on disability or PSI.

CONCLUSION

If replicated, the cross-sectional findings suggest high levels of disability may deter heavy drinking among Veterans with GWI. We did not find evidence that risky alcohol use moderated treatment outcome of PST for GWI. More research is needed to identify moderators of GWI interventions and to understand risky drinking among Veterans with complex health problems.

Cognitive and Behavioral Digital Health Interventions for People with Traumatic Brain Injury and Their Caregivers: A Systematic Review

Traumatic brain injury (TBI) leads to cognitive linguistic deficits that significantly impact on quality of life and well-being. Digital health offers timely access to specialized services; however, there are few synthesized reviews in this field. This review evaluates and synthesizes reports of digital health interventions in TBI rehabilitation and caregiver education. Systematic searches of nine databases (PsycINFO, MEDLINE, CINAHL, Embase, Cochrane Library, Scopus, Web of Science Core Collection, speechBITE, and PsycBITE) were conducted from database inception to February 2022. Studies were included of interventions where the primary treatment focus (> 50%) was on improving communication, social, psychological or cognitive skills of people with TBI and/or communication partners. Data on participants, characteristics of the interventions, outcome measures and findings were collected. Risk of bias was accounted for through methodological quality assessments (PEDro-P and PEDro+, Risk of Bias in N-of-1 Trials) and intervention description. Qualitative data was analyzed using thematic synthesis. Forty-four articles met eligibility criteria: 20 randomized controlled trials, three single-case experimental designs, six non-randomized controlled trials, nine case series studies, and two case studies. Studies comprised 3666 people with TBI and 213 carers. Methodological quality was varied and intervention description was poor. Most interventions were delivered via a single digital modality (e.g., telephone), with few using a combination of modalities. Five interventions used co-design with key stakeholders. Digital health interventions for people with TBI and their caregivers are feasible and all studies reported positive outcomes; however, few included blind assessors. Improved methodological rigor, clearly described intervention characteristics and consistent outcome measurement is recommended. Further research is needed regarding multi-modal digital health interventions.

Implementation of telehealth and hybrid service delivery of interdisciplinary rehabilitation for military populations with traumatic brain injury

BACKGROUND

The COVID-19 pandemic necessitated the implementation of telehealth and hybrid service delivery models and provided an opportunity to study the impact of this care model in military populations with history of traumatic brain injury (TBI).

OBJECTIVE

To present telehealth service utilization rates across rehabilitation specialties, treatment outcome indicators, and patient satisfaction outcomes from a retrospective clinical sample.

METHODS

The study sample consists of 34 patients who underwent telehealth/hybrid Intensive Outpatient Programming (IOP) at a major rehabilitation hospital. Retrospective chart review and clinical data extraction were performed. A historical cohort receiving in-person care was used as a comparison group. Statistical analyses included partial correlations, mixed method analysis of variance (ANOVA), and independent sample t-tests.

RESULTS

Medical, behavioral health, physical, occupational, and speech-language therapy providers exhibited similar rates of telehealth service delivery (35 to 41% of all sessions). No significant association was found between percent telehealth sessions and the global treatment outcome indicator. Comparison of treatment effects across cohorts revealed similar benefits of IOP. No between-group differences were noted in satisfaction ratings.

CONCLUSION

The comparable treatment-related gains and reports of positive patient experience support the use of a telehealth and hybrid delivery model for military service members and veterans with TBI.

Enhanced education for adult patients with persistent post-concussion headaches: a randomized controlled trial

Aim & Patients

We conducted a randomized clinical trial to determine if an e-learning intervention can enhance recovery in adult patients with persistent post-concussion headaches (PPCH).

Materials & Methods

The intervention consisted of three e-learning modules administered at baseline, 6 and 12 weeks. Data were collected on symptoms, community integration, quality of life and healthcare utilization at baseline and 12-week follow-up. ANCOVA was conducted to compare changes.

Results

No statistically significant difference was observed on symptoms although we observed a trend toward reduced healthcare utilization and improved quality of life in the intervention group.

Conclusion

E-learning modules for patients experiencing PPCH warrant further investigation with data on participant compliance and measures focusing on simpler short-term outcomes.Clinical Trial Registration: NCT03391583 (ClinicalTrials.gov).

Cognitive Interventions to Improve a Specific Cognitive Impairment for Adults With TBI (June 2013-October 2020)

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on cognitive interventions to improve a specific cognitive impairment for adults with TBI.

Resilience Interventions Conducted in Western and Eastern Countries-A Systematic Review

Previous research has demonstrated the efficacy of psychological interventions to foster resilience. However, little is known about whether the cultural context in which resilience interventions are implemented affects their efficacy on mental health. Studies performed in Western (k = 175) and Eastern countries (k = 46) regarding different aspects of interventions (setting, mode of delivery, target population, underlying theoretical approach, duration, control group design) and their efficacy on resilience, anxiety, depressive symptoms, quality of life, perceived stress, and social support were compared. Interventions in Eastern countries were longer in duration and tended to be more often conducted in group settings with a focus on family caregivers. We found evidence for larger effect sizes of resilience interventions in Eastern countries for improving resilience (standardized mean difference [SMD] = 0.48, 95% confidence interval [CI] 0.28 to 0.67; p < 0.0001; 43 studies; 6248 participants; I2 = 97.4%). Intercultural differences should receive more attention in resilience intervention research. Future studies could directly compare interventions in different cultural contexts to explain possible underlying causes for differences in their efficacy on mental health outcomes.

Treatment of Psychiatric Problems After Traumatic Brain Injury

Psychiatric sequelae of traumatic brain injury (TBI) can cause significant and often chronic impairment in functioning and quality of life; however, their phenomenological and mechanistic complexities continue to present significant treatment challenges. The clinical presentation is often an amalgam of syndromes and co-occurring symptoms that require a highly nuanced and systematic approach to treatment. Although few randomized controlled trials have tested treatments for psychiatric problems after TBI and the synthesis of results continues to be compromised by the heterogeneity of study populations, small samples, and differing inclusion criteria and outcome measures, an increasing body of literature supports evidence-based treatment strategies. We provide a narrative review of pharmacological, psychoeducational/behavioral, and neuromodulation treatments for psychiatric conditions in adults with TBI and discuss known or postulated mechanisms of action for these treatment approaches. Where data are available, we focus on randomized controlled trials and large case series in which a psychiatric condition provides both a selection criterion and a primary or secondary outcome. We conclude by proposing directions for future research, particularly the need for novel neuropharmacological, behavioral, and neurophysiological studies and pragmatic trials of multicomponent and adaptive models that will increase understanding of the mechanisms underlying post-TBI psychiatric disorders and accelerate dissemination and implementation of effective person-centered care.

Neuropsychiatric Treatment for Mild Traumatic Brain Injury: Nonpharmacological Approaches

Postconcussive symptoms following mild traumatic brain injury (mTBI)/concussion are common, disabling, and challenging to manage. Patients can experience a range of symptoms (e.g., mood disturbance, headaches, insomnia, vestibular symptoms, and cognitive dysfunction), and neuropsychiatric management relies heavily on nonpharmacological and multidisciplinary approaches. This article presents an overview of current nonpharmacological strategies for postconcussive symptoms including psychoeducation; psychotherapy; vestibular, visual, and physical therapies; cognitive rehabilitation; as well as more novel approaches, such as neuromodulation. Ultimately, treatment and management of mTBI should begin early with appropriate psychoeducation/counseling, and be tailored based on core symptoms and individual goals.

Role of the Treatment of Post-Concussion Syndrome in Preventing Long-Term Sequela Like Depression: A Systematic Review of the Randomized Controlled Trials

Traumatic brain injury of any severity can result in post-concussion syndrome (PCS). Although the post-concussive symptoms are complex, there is an emerging scientific consensus regarding the initiation of the treatment for these symptoms to improve quality of life and prevent long-term effects. The objective of this systematic review is to assess the comprehensive interventions used for the PCS and it aims to appraise if these interventions could prevent the development of depression as a complication. This research has used randomized controlled trials (RCTs) that evaluate the treatment of PCS and its effect on long-term complications like depression. We searched PubMed/MEDLINE, PubMed Central, Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE from January 1, 2016 to May 31, 2021 for our literature search. A quality check was conducted on the identified studies using the Cochrane risk of bias quality assessment tool (modified Cochrane RoB 2). In total, we included 11 RCTs and used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines for the reporting of this systematic review. Most of the studies reinforced early initiation of the treatment by providing education to the patients and conducting their risk assessment. Strong evidence for the multidisciplinary treatment consisting of cognitive-behavioral therapy, psychoeducation, and physiotherapy is emphasized by some studies. More studies with a longer follow-up period are required to assess the effectiveness of intervention more accurately on depression. Regardless, this study will discuss guidelines and provide direction to physicians. It will help in developing future guidelines by addressing the clinical gaps in the implementation of these guidelines.

The effectiveness of cognitive behaviour therapy for reducing anxiety symptoms following traumatic brain injury: A meta-analysis and systematic review

BACKGROUND

Anxiety is a common neuropsychological sequela following traumatic brain injury (TBI). Cognitive Behaviour Therapy (CBT) is a recommended, first-line intervention for anxiety disorders in the non-TBI clinical population, however its effectiveness after TBI remains unclear and findings are inconsistent.

OBJECTIVE

There are no current meta-analyses exploring the efficacy of CBT as an intervention for anxiety symptoms following TBI, using controlled trials. The aim of the current study, therefore, was to systematically review and synthesize the evidence from controlled trials for the effectiveness of CBT for anxiety, specifically within the TBI population.

METHOD

Three electronic databases (Web of Science, PubMed and PsycInfo) were searched and a systematic review of intervention studies utilising CBT and anxiety related outcome measures in a TBI population was performed through searching three electronic databases. Studies were further evaluated for quality of evidence based on Reichow's (2011) quality appraisal tool. Baseline and outcome data were extracted from the 10 controlled trials that met the inclusion criteria, and effect sizes were calculated.

RESULTS

A random effects meta-analysis identified a small overall effect size (Cohen's d) of d = -0.26 (95%CI -0.41 to -0.11) of CBT interventions reducing anxiety symptoms following TBI.

CONCLUSIONS

This meta-analysis tentatively supports the view that CBT interventions may be effective in reducing anxiety symptoms in some patients following TBI, however the effect sizes are smaller than those reported for non-TBI clinical populations. Clinical implications and limitations of the current meta-analysis are discussed.

Improving transition from inpatient rehabilitation following traumatic brain injury: Protocol for the BRITE pragmatic comparative effectiveness trial

Moderate to severe traumatic brain injury (TBI) is a common cause of long-term disability. Due to challenges that include inconsistent access to follow-up care, persons with TBI being discharged from inpatient rehabilitation facilities (IRFs) are at risk for rehospitalization, poor reintegration into the community, family stress, and other unfavorable outcomes resulting from unmet needs. In a six-center randomized pragmatic comparative effectiveness study, the BRITE trial (Brain Injury Rehabilitation: Improving the Transition Experience, ClinicalTrials.govNCT03422276), we compare the effectiveness of two existing methods for transition from IRF to community living or long-term nursing care. The Rehabilitation Discharge Plan (RDP) includes patient/family education and referrals for continued care. The Rehabilitation Transition Plan (RTP) provides RDP plus individualized, manualized care management via phone or videoconference, for 6 months. Nine hundred patients will be randomized (1:1) to RDP or RTP, with caregivers also invited to participate and contribute caregiver-reported outcomes. Extensive stakeholder input, including active participation of persons with TBI and their families, has informed all aspects of trial design and implementation planning. We hypothesize that RTP will result in better patient- and caregiver-reported outcomes (societal participation, quality of life, caregiver well-being) and more efficient use of healthcare resources at 6-months (primary outcome) and 12-months post-discharge, compared to RDP alone. Planned analyses will explore which participants benefit most from each transition model. With few exclusion criteria and other pragmatic features, the findings of this trial are expected to have a broad impact on improving transitions from inpatient TBI rehabilitation. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT03422276.

Therapeutic benefits of pharmacologic and nonpharmacologic treatments for depressive symptoms after traumatic brain injury: a systematic review and network meta-analysis

BACKGROUND

Depression is a common morbidity after traumatic brain injury. This network meta-analysis investigated the efficacy and tolerability of pharmacologic and nonpharmacologic interventions for depression after traumatic brain injury.

METHODS

We extracted randomized controlled trials examining pharmacologic or nonpharmacologic interventions with placebo- or active-controlled designs from PubMed, the Cochrane Library and ScienceDirect, from inception to October 30, 2018. We based study selection and extraction of a predefined list of variables on the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines, and conducted meta-analysis procedures using random effects modelling. Primary outcomes were changes in depressive symptom severity after pharmacologic or nonpharmacologic treatment; the secondary outcome was tolerability, reflected in overall patient dropout rates.

RESULTS

Our analysis of 27 randomized controlled trials (10 pharmacologic, total n = 483, mean age = 37.9 yr; 17 nonpharmacologic, total n = 1083, mean age = 38.0 yr) showed that methylphenidate had significantly superior efficacy compared to placebo or control (standardized mean difference -0.91, 95% confidence interval [CI] -1.49 to -0.33). Sertraline was associated with significantly lower tolerability (i.e., a higher dropout rate) compared to placebo or control (odds ratio 2.65, 95% CI 1.27 to 5.54). No nonpharmacologic treatment was more effective than the others, and we found no significant differences in tolerability (i.e., dropout rates) among the nonpharmacologic treatments.

LIMITATIONS

Heterogeneity in participant characteristics (e.g., comorbidities), study designs (e.g., trial duration) and psychopathology assessment tools, as well as small trial numbers for some treatment arms, could have been confounders.

CONCLUSION

The present network meta-analysis suggests that methylphenidate might be the best pharmacologic intervention for depressive symptoms related to traumatic brain injury. None of the nonpharmacologic interventions was associated with better improvement in depressive symptoms than the others or than control conditions. None of the pharmacologic or nonpharmacologic treatments had inferior tolerability compared to placebo or controls except for sertraline, which had significantly lower tolerability than placebo.

Cognitive and psychological interventions for the reduction of post-concussion symptoms in patients with mild traumatic brain injury: a systematic review

OBJECTIVE

To evaluate the effects of cognitive and psychological interventions for the reduction of post-concussion symptoms (PCS) in patients with mild traumatic brain injury (MTBI).

DATA SOURCES

The databases of CINAHL, Medline, PubMed, PsycINFO, Web of Science, and Cochrane Database of Systematic Reviews.

REVIEW METHODS

Meta-analysis was conducted for randomized-controlled trials that have included an assessment of PCS using the Rivermead Post-concussion Symptoms Questionnaire as primary outcomes by calculating the mean difference/standardized mean difference using fixed/random effect models as appropriate.

RESULTS

Systematic review with the date of the last search in Mar 2018 yielded 16080 articles, 17 articles including 3081 participants were included in the final review. Interventions included psychoeducation (n = 8), telephone problem-solving treatment (n = 4), individual-based cognitive behavioral therapy (n = 4), and cognitive training (n = 1). No intervention is effective in reducing PCS at 3 to 6 months follow-up, however, an overall small effect size was found in pooled functional outcomes at 6 months.

CONCLUSIONS

There was no effect on symptom reduction at 3 to 6 months for PCS interventions but improved functional outcomes were shown for patients with MTBI at 6 months. Long-lasting effects of interventions at 12 months or after were not studied.

"Moving Forward with Life": Acceptability of a Brief Alcohol Reduction Intervention for People Receiving Antiretroviral Therapy in South Africa

Background: In South Africa, interventions are needed to address the impact of hazardous drinking on antiretroviral therapy among people living with HIV (PLWH). Participant feedback about these interventions can identify ways to enhance their acceptability. We interviewed participants in a randomized controlled trial of a brief motivational interviewing and problem-solving therapy (MI-PST) intervention about their perceptions of this alcohol-reduction intervention. Methods: The trial was conducted in HIV treatment clinics operating from six hospitals in the Tshwane region of South Africa. We conducted qualitative in-depth interviews with a random selection of participants. Twenty-four participants were interviewed after the final intervention session and 25 at the six-month follow up. Results: Participants believed that it was acceptable to offer PLWH, an alcohol reduction intervention during HIV treatment. They described how the MI-PST intervention had helped them reduce their alcohol consumption. Intervention components providing information on the health benefits of reduced consumption and building problem-solving and coping skills were perceived as most beneficial. Despite these perceived benefits, participants suggested minor modifications to the dosage, content, and delivery of the intervention for greater acceptability and impact. Conclusions: Findings highlight the acceptability and usefulness of this MI-PST intervention for facilitating reductions in alcohol consumption among PLWH.

Activity Performance, Participation, and Quality of Life Among Adults in the Chronic Stage After Acquired Brain Injury-The Feasibility of an Occupation-Based Telerehabilitation Intervention

Objective: Acquired brain injury (ABI) is a leading cause of long-term disability. This calls for effective and accessible interventions to support participation in the community over time. One promising avenue to answer this need is telerehabilitation. Prior to conducting a larger trial, the main objective of this pilot study is to explore the feasibility, acceptability, and preliminary efficacy of a metacognitive occupation-based intervention in a telerehabilitation format with adults and older adults in the chronic phase after ABI.

Methods: Five community dwelling participants (ages 65–72), 6–10 months post-ABI, with scores 2–4 on the modified Rankin scale and without dementia, completed the teleintervention. The intervention included ~10 weekly videoconferencing sessions administered by an occupational therapist using the Cognitive Orientation to Daily Occupational Performance approach. Each participant defined five functional goals and three were trained and two were not trained during the intervention. Evaluations were conducted at pre, post, and 3-month follow-up. The primary outcome measures included activity performance (The Canadian Occupational Performance Measure; COPM), participation (the Mayo-Portland Adaptability Inventory-4 Participation Index; MPAI-4-P), and quality of life (QoL) (stroke impact scale; SIS). Other measures included a feedback interview, satisfaction questionnaire, field notes, and a treatment fidelity checklist.

Results: The teleintervention was found to be feasible and the participants expressed a high degree of satisfaction with the intervention and the technology use. A Wilcoxon Signed-Ranks test indicated statistically significant improvements post intervention in COPM performance (z = −2.023, p = 0.043) and satisfaction (z = −2.023, p = 0.043) ratings. Additionally, clinically significant improvements (≥2 points) in both performance and satisfaction with performance were found for each participant in at least three of their five defined functional goals. Trends toward significant improvement were found in MPAI-4-P ratings post intervention (z = −1.826, p = 0.068). Furthermore, clinically significant improvements (≥15 points) post intervention were found for each participant in some subscales of the SIS. Results were partially maintained at 3-month follow-up.

Conclusions: This pilot study demonstrated the feasibility of a metacognitive occupation-based telerehabilitation intervention and its potential benefits in activity performance, participation, and QoL for older adults coping with long-term disability following ABI.

Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03048708.

Clinical and cost-effectiveness of teen online problem-solving for adolescents who have survived an acquired brain injury in the UK: protocol for a randomised, controlled feasibility study (TOPS-UK)

INTRODUCTION

Paediatric acquired brain injury is a leading cause of mortality in children in the UK. Improved treatment during the acute phase has led to increased survival rates, although with life-long morbidity in terms of social and emotional functioning. This is the protocol for a feasibility randomised controlled trial with an embedded qualitative study and feasibility economic evaluation. If feasible, a later definitive trial will test the effectiveness and cost-effectiveness of an online intervention to enhance problem solving ability versus treatment as usual.

METHODS AND ANALYSIS

Twenty-five adolescents and their families identified by primary or secondary care clinicians at participating UK National Health Service Trusts will be recruited and individually randomised in a 1:1 ratio to receive the online intervention or treatment as usual. Participants will be followed up by online questionnaires 17 weeks after randomisation to capture acceptability of the study and intervention and resource use data. Qualitative interviews will capture participants' and clinicians' experiences of the study.

ETHICS AND DISSEMINATION

This study has been granted ethical approval by the South West-Exeter Research Ethics Committee (ref 17/SW/0083). Results will be disseminated via peer-reviewed publications and will inform the design of a larger trial.

TRIAL REGISTRATION NUMBER

ISRCTN10906069.

Efficacy of Telerehabilitation for Adults With Traumatic Brain Injury: A Systematic Review

OBJECTIVE

To identify and appraise studies evaluating the efficacy of telerehabilitation for adults with traumatic brain injury (TBI).

METHODS

A systematic search of Cochrane Library, MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and PsycINFO databases was conducted from January 1980 to April 23, 2017, for studies evaluating the efficacy of telerehabilitation for adults with TBI. Two reviewers independently assessed articles for eligibility and rated methodological quality using 16 criteria related to internal validity, descriptive, and statistical characteristics.

RESULTS

The review yielded 13 eligible studies, including 10 randomized controlled trials and 3 pre-/postgroup studies (n ≥ 10). These evaluated the feasibility and/or efficacy of telephone-based (10 studies) and Internet-based (3 studies) interventions. Overall, the evidence of efficacy was somewhat mixed. The most common study design evaluated the efficacy of telephone-based interventions relative to usual care, for which 4 of 5 randomized controlled trials reported positive effects at postintervention (d = 0.28-0.51). For these studies, improvements in global functioning, posttraumatic symptoms and sleep quality, and depressive symptoms were reported. The feasibility of Internet-based interventions was generally supported; however, the efficacy could not be determined because of insufficient studies.

CONCLUSIONS

Structured telephone interventions were found to be effective for improving particular outcomes following TBI. Controlled studies of Internet-based therapy and comparisons of the clinical and cost-effectiveness of in-person and telerehabilitation formats are recommended for future research.

Psychological Intervention in Traumatic Brain Injury Patients

Objective

To provide a brief and comprehensive summary of recent research regarding psychological interventions for patients surviving a traumatic brain injury.

Methods

A bibliographical search was performed in PubMed, Cochrane Library, PsycNET, Scopus, ResearchGate, and Google Scholar online databases. Analysis included distribution by year of publication, age stage of participants (paediatric, adult), location of the research team, study design, type of intervention, and main outcome variables.

Results

The initial search eliciting 1541 citations was reduced to 62 relevant papers. Most publications had adult samples (88.7%). The United States outstands as the country with more research (58.1%); Latin America countries provided no results. Cognitive behavioural therapy (CBT) was the most widely used approach for treatment of (sub)clinical mental disturbances (41.9%). Neuropsychological interventions were scarce (4.8%). Outcome measures included psychiatric disorders (e.g., posttraumatic stress disorder (PTSD), depression, and anxiety) (37.1%), postconcussive symptoms (16.1%), cognitive and functional deficits (48.1%), and social and psychological dimensions (62.9%).

Conclusions

CBT outstands as the preferred therapeutic approach for treating behavioural and emotional disturbances. Also, other related therapies such as dialectical behaviour, mindfulness, and acceptance and commitment therapies have been proposed, and probably in the years to come, more literature regarding their effectiveness will be available. On the other hand, evidence showed that interventions from the field of neuropsychology are minimal if compared with its contribution to assessment. Future research should be aimed at performing studies on more diverse populations (e.g., nonmilitary communities and paediatric and Latin American populations) and at controlling designs to examine the therapeutic efficacy of psychotherapeutic and neurocognitive rehabilitation interventions and compare amelioration by injury severity, age of patients, and clinical profile, in the hopes of creating better guidelines for practitioners.

Apps and Mobile Health Technology in Rehabilitation: The Good, the Bad, and the Unknown

Although there is disparity in access to mobile health (mHealth) services among people with disabilities, several smartphone and tablet-based mHealth applications are available that may affect the care of patients in rehabilitation medicine. This article reviews the current evidence for and breadth of application-based mHealth interventions in rehabilitation medicine, including comprehensive self-management mHealth services; weight management mHealth services; diagnosis-specific mHealth services for individuals with brain, spinal cord, musculoskeletal, or other injury types; and nonmedical services to improve community and social integration.

Risk of Posttraumatic Stress Disorder and Major Depression in Civilian Patients After Mild Traumatic Brain Injury: A TRACK-TBI Study

IMPORTANCE

Traumatic brain injury (TBI) has been associated with adverse mental health outcomes, such as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), but little is known about factors that modify risk for these psychiatric sequelae, particularly in the civilian sector.

OBJECTIVE

To ascertain prevalence of and risk factors for PTSD and MDD among patients evaluated in the emergency department for mild TBI (mTBI).

DESIGN, SETTING, AND PARTICIPANTS

Prospective longitudinal cohort study (February 2014 to May 2018). Posttraumatic stress disorder and MDD symptoms were assessed using the PTSD Checklist for DSM-5 and the Patient Health Questionnaire-9 Item. Risk factors evaluated included preinjury and injury characteristics. Propensity score weights-adjusted multivariable logistic regression models were performed to assess associations with PTSD and MDD. A total of 1155 patients with mTBI (Glasgow Coma Scale score, 13-15) and 230 patients with nonhead orthopedic trauma injuries 17 years and older seen in 11 US hospitals with level 1 trauma centers were included in this study.

MAIN OUTCOMES AND MEASURES

Probable PTSD (PTSD Checklist for DSM-5 score, ≥33) and MDD (Patient Health Questionnaire-9 Item score, ≥15) at 3, 6, and 12 months postinjury.

RESULTS

Participants were 1155 patients (752 men [65.1%]; mean [SD] age, 40.5 [17.2] years) with mTBI and 230 patients (155 men [67.4%]; mean [SD] age, 40.4 [15.6] years) with nonhead orthopedic trauma injuries. Weights-adjusted prevalence of PTSD and/or MDD in the mTBI vs orthopedic trauma comparison groups at 3 months was 20.0% (SE, 1.4%) vs 8.7% (SE, 2.2%) (P < .001) and at 6 months was 21.2% (SE, 1.5%) vs 12.1% (SE, 3.2%) (P = .03). Risk factors for probable PTSD at 6 months after mTBI included less education (adjusted odds ratio, 0.89; 95% CI, 0.82-0.97 per year), being black (adjusted odds ratio, 5.11; 95% CI, 2.89-9.05), self-reported psychiatric history (adjusted odds ratio, 3.57; 95% CI, 2.09-6.09), and injury resulting from assault or other violence (adjusted odds ratio, 3.43; 95% CI, 1.56-7.54). Risk factors for probable MDD after mTBI were similar with the exception that cause of injury was not associated with increased risk.

CONCLUSIONS AND RELEVANCE

After mTBI, some individuals, on the basis of education, race/ethnicity, history of mental health problems, and cause of injury were at substantially increased risk of PTSD and/or MDD. These findings should influence recognition of at-risk individuals and inform efforts at surveillance, follow-up, and intervention.

Early Clinical Predictors of 5-Year Outcome After Concussive Blast Traumatic Brain Injury

Importance

The long-term clinical effects of wartime traumatic brain injuries (TBIs), most of which are mild, remain incompletely described. Current medical disability cost estimates from world conflicts continually surpass projections. Additional information regarding long-term functional trajectory is needed to reduce this extensive public health burden.

Objectives

To examine 5-year clinical outcomes leveraging existing clinical data collected at 1 year after injury in the same patients and to identify early risk factors for long-term disability.

Design, Setting, and Participants

This prospective, longitudinal study enrolled active-duty US military after concussive blast injury (n = 50) in the acute to subacute stage and combat-deployed control individuals (n = 44) in Afghanistan or after medical evacuation to Germany from November 1, 2008, through July 1, 2013. One- and 5-year clinical evaluations were completed in the United States. All concussive blast injuries met the Department of Defense definition of mild, uncomplicated TBI. In-person clinical evaluations included standardized evaluations for neurobehavior, neuropsychological performance, and mental health burden that were essentially identical to the evaluations completed at 1-year follow-up. Data were analyzed from October 1 through November 30, 2016.

Main Outcomes and Measures

Changes in the in-person standardized evaluations for neurobehavior, neuropsychological performance, and mental health burden from the 1- to 5-year follow-up. Predictive modeling was used to identify early risk factors for long-term disability.

Results

Among the 94 participants (87 men [93%] and 7 women [7%]; mean [SD] age, 34 [8] years), global disability, satisfaction with life, neurobehavioral symptom severity, psychiatric symptom severity, and sleep impairment were significantly worse in patients with concussive blast TBI compared with combat-deployed controls, whereas performance on cognitive measures was no different between groups at the 5-year evaluation. Logistic regression on the dichotomized Extended Glasgow Outcome Scale (GOS-E) at 5 years as a measure of overall disability identified brain injury diagnosis, preinjury intelligence, motor strength, verbal fluency, and neurobehavioral symptom severity at 1 year as risk factors for a poor outcome at 5 years, with an area under the curve of 0.92 indicating excellent prediction strength. Thirty-six of 50 patients with concussive blast TBI (72%) had a decline in the GOS-E from the 1- to 5-year evaluations, in contrast with only 5 of 44 combat-deployed controls (11%). Worsening of symptoms in concussive blast TBI was also observed on measures of posttraumatic stress disorder and depression. Service members with concussive blast TBI experienced evolution, not resolution, of symptoms from the 1- to 5-year outcomes.

Conclusions and Relevance

Considerable decline was observed in military service members with concussive blast TBI when comparing 1- and 5-year clinical outcomes. These results advocate for new treatment strategies to combat the long-term and extremely costly effect of these wartime injuries.

Impact of Telephone-Based Problem-Solving Treatment on the Use of Medical and Psychological Services in the Military

OBJECTIVE

To explore the impact of problem-solving treatment (PST) for mild traumatic brain injury in active duty service members on the use of medical and psychological services.

PARTICIPANTS

Service members who had a mild traumatic brain injury during their last deployment and enrolled in the CONcussion Treatment After Combat Trauma (CONTACT) study.

DESIGN

Secondary analysis of a randomized clinical trial. Participants were assigned to telephone-based PST, or e-mailed or mailed education only over the course of 6 months.

MAIN MEASURE

Self-reported health service utilization from months 4 through 6 and 10 through 12 after initiation of treatment, using the Cornell Service Index.

RESULTS

In months 4 to 6, participants receiving PST had 6.17 times the odds of an emergency department visit or hospitalization than those receiving education only (95% confidence interval = 1.92-19.8; P value = .0023). These estimates, however, were not significant using a conservative Bonferroni correction (P value threshold < .0014). There were no other significant differences for other medical or psychological services received in months 4 to 6 or 10 to 12.

CONCLUSION

Telephone-based PST was designed to complement clinical care, and this study showed that it may increase emergency department utilization. Future evaluations of PST with more accurate and complete measures of health service utilization are needed.

Economic evaluation of telephone-based concussion management for combat-related mild traumatic brain injury

Introduction Mild traumatic brain injury (mTBI) is an unfortunately common repercussion of military service in a combat zone. The CONTACT study tested an individualized telephone support intervention employing problem solving therapy (PST) for mTBI in soldiers recently returned from deployment. We sought to determine the cost effectiveness of this intervention from a military healthcare system perspective. Methods We conducted an intent-to-treat post-hoc analysis by building a decision analytic model that evaluated the choice between using PST or education only (EO). The model included cost-minimization and cost-effectiveness analyses. The incremental cost-effectiveness ratios (ICERs) were calculated as the differences in costs of PST versus EO relative to the differences in the outcomes of participants. Results The PST intervention resulted in an annual per-enrolee cost of $1027 (95% CI: $836 to $1248), while EO costs were $32 (95% CI: $25 to $39), resulting in a net incremental cost of $996 per enrolee (95% CI: $806 to $1,217). The ICERs were $68,658/QALY based on EQ-5D (95% CI: -$463,535 to $596,661) and $49,284/QALY based on SF-6D (95% CI: $26,971 to $159,309). Estimates of treatment costs in a real-world setting were accompanied by substantially lower ICERs that are within accepted thresholds for willingness-to-pay. Discussion Although the intervention had short-term benefits sufficient to yield acceptable ICERs, there was no long-term effect of PST over EO observed in the study. Consequently, we suggest that future studies examine the use of low-cost approaches, such as booster relapse-prevention calls, that may lead to a sustained treatment benefit for this population.