Self-Awareness and Neurobehavioral Outcomes, 5 Years or More After Moderate to Severe Brain Injury

Aberrant error monitoring in traumatic brain injuries: A meta-analysis of event-related potential studies

OBJECTIVE

Although individuals with traumatic brain injuries (TBI) often manifest altered error monitoring, evidence using event-related potentials (ERPs) to index these cortical processes is inconsistent. Therefore, this meta-analysis study aimed to comprehensively compare the error-related negativity (ERN) and error positivity (Pe) between individuals with TBI and healthy controls (HC) from the existing literature.

METHODS

Literature search was performed using PubMed/MEDLINE, Web of Science, and Cochrane Library. The effect sizes (Hedges' g) in the comparisons of ERN and Pe amplitudes between TBI and HC groups were employed by a random-effect, inverse-variance weighted model. The effects of age, TBI severity and experimental tasks on both ERP components were also examined.

RESULTS

Random-effect models showed decreased ERN (g = 0.361, p = 0.010), but intact Pe (g = 0.105, p = 0.443), in those with TBI compared to HC. A further analysis revealed that the adult patients (g = 0.326, p = 0.038), but not the youth patients, showed significant reduction of ERN as compared to the HC. However, we did not find moderating effects of TBI severity and experimental paradigms on either ERN or Pe.

CONCLUSIONS

ERN and Pe reflect separate neurophysiological mechanisms and different aspects of error monitoring in TBI. Our findings suggest that attenuated ERN amplitude may be an electrophysiological parameter of error monitoring deficits in TBI.

Profiling self-awareness in brain injury rehabilitation: A mixed methods study

ABSTRACTImpaired self-awareness impacts outcomes for individuals with brain injury. Self-awareness is a complex construct, with little known about how its presentation differs across diagnostic groups, or how brain injury-related changes are expressed by individuals in the early phase post-brain injury. This study aims to identify differences and similarities in patterns of self-awareness between patients with different brain injury diagnoses, and provide a clinical account of how individuals with ABI describe changes to themselves arising from brain injury. This is a mixed methods retrospective cohort study involving an audit of medical files that included extraction of data from the Self-Awareness of Deficits Interview. Quantitative and qualitative techniques were used to analyse data from 173 participants. Individuals identified a range of brain injury-related impairments across domains, with greatest difficulty noted with linking impairments to functional implications and setting realistic goals. There were similarities and distinct differences in the expression of changes across diagnostic groups. Two main themes that aligned with self-awareness theory were identified from the data: 1/ Development of self-awareness; and 2/ Dimensions of self-awareness. These interrelated themes demonstrated the multifaceted nature of the clinical presentation of self-awareness, and highlight the need for an individualized approach to cognitive rehabilitation.

A systematic literature review of the impact of impaired self-awareness on the process of rehabilitation in acquired brain injury

BACKGROUND

Impaired self-awareness (ISA) is common in individuals with an acquired brain injury (ABI) and can lead to reduced awareness of one's difficulties. Previous reviews have found that ISA impacts on functional outcomes in rehabilitation. However, to date there has not been a systematic literature review which examines how ISA impacts on the process of rehabilitation in ABI populations.

METHOD

A literature search was conducted using several databases in May 2024, including Academic Search Premier, CINAHL, MEDLINE, APA PsycARTICLES and APA PsycINFO. Seventeen articles were selected for the review and were analyzed using Narrative Synthesis.

RESULTS

Four themes arose from the findings, including goal setting, treatment adherence, engagement and willingness to change and time spent in hospital. ISA was found to impact on the value adult ABI participants placed in rehabilitation, which decreased treatment compliance, motivation, and engagement. ISA also impacted on goal setting and behavior and resulted in a longer length of time spent in hospital.

CONCLUSION

This review emphasizes the impact of ISA on various aspects/processes of rehabilitation in ABI and provides considerations of how clinicians might adapt interventions to manage these difficulties.

Factors associated with self-awareness impairment in an inpatient brain injury rehabilitation cohort

BACKGROUND

Self-awareness impairment is common following acquired brain injury and can impact rehabilitation outcomes. Knowledge of factors associated with impaired self-awareness may assist with rehabilitation planning.

OBJECTIVES

To identify factors associated with self-awareness and determine predictors of self-awareness impairment for adults with traumatic brain injury (TBI) and stroke.

DESIGN AND METHODS

A retrospective cohort study of rehabilitation inpatients was conducted by medical record audit. Self-awareness was measured using the Self-awareness of Deficits Interview (SADI). Relationships between SADI scores and demographic and clinical variables were identified with non-parametric statistics. Predictors of SADI scores were identified using ordinal regression analyses for TBI and stroke groups.

RESULTS

Participants were 149 adults (18-70 years) with TBI (n = 110) and stroke (n = 39). For TBI, longer post-traumatic amnesia (PTA), lower functional cognition/communication, and behaviors of concern (BoC) were significantly associated with higher SADI scores (i.e. impaired self-awareness). For stroke, lower functional cognition/communication and motor scores were associated with higher SADI scores. Impaired self-awareness was predicted by PTA duration, acute length of stay and presence of BoC for the TBI group, and by functional cognition/communication for the stroke group.

CONCLUSION

Different factors were associated with impaired self-awareness for individuals with TBI and stroke during inpatient rehabilitation.

Components of self-awareness affecting caregiver burden: a long-term follow-up study

OBJECTIVE

Studies utilizing the discrepancy model of the Mayo-Portland Adaptability Inventory-4 (MPAI-4) have commonly used the cognitive and physical domains to estimate self-awareness. This study included other aspects of self-awareness such as awareness of one's social and emotional status and daily functioning to explore their effects on caregiver burden for ABI survivors.

METHODS

We studied 64 patient-caregiver pairs up to 29 years post-discharge from a holistic, milieu-oriented outpatient neurorehabilitation program. Discrepancy scores between ABI survivors' and caregivers' reports on the MPAI-4 subscales (i.e. Abilities, Adjustment, and Participation) and Total Score were used to determine self-awareness. Caregiver burden was measured using the Zarit Burden Interview (ZBI).

RESULTS

Exploratory linear regression analyses revealed that caregiver burden derived from the ZBI was predicted by the discrepancy scores generated from the Abilities (p < 0.0001), Adjustment (p < 0.01), Participation subscales (p = 0.01), and Total Score (p < 0.001), respectively. Among the exploratory models generated, the Total Score model had the highest predictive value (R2 = .33) for caregiver burden.

CONCLUSIONS

Measures of self-awareness should be comprehensive by considering diverse components of self-awareness. Increasing ABI survivors' self-awareness in different domains has the potential to effectively alleviate caregiver burden.

Disinhibited and angry: Investigating the relationship between social disinhibition and the components of aggression following severe TBI

Social disinhibition and aggression share many similarities. But unlike with aggression, research evidence about social disinhibition following severe traumatic brain injury (TBI) is limited and treatments are missing. Establishing the association between aggression and social disinhibition would facilitate a better conceptualization of these disorders. This study aimed to determine the relationship between social disinhibition and aggression following severe TBI.In this case-control study, 25 individuals with severe TBI and 25 control participants completed the Buss-Perry Aggression Questionnaire (BPAQ), Frontal Systems Behaviour Scale (FrSBe), and Social Disinhibition Interview (SDI).Hierarchical multiple regression analyses revealed that, when controlling for covariates, the inclusion of BPAQ Anger in the model led to a 13% increase in proportion of explained variance of social disinhibition (Adjusted R2 increased from .243 to .363, p < .005). BPAQ Anger was not a significant predictor of SDI scores. Similarly, BPAQ Physical aggression scores did not contribute to the prediction of FrSBe Disinhibition or SDI scores.In conclusion, higher levels of self-reported anger (but no other components of aggression) are associated with higher levels of self-reported social disinhibition. While these findings have potential implications for the treatment of social disinhibition, further research into the possible relationship with aggression should be conducted.

Action control and selection in social disinhibition following severe TBI: a pavlovian-to-instrumental transfer and outcome devaluation study

INTRODUCTION

Social disinhibition is a significant sequela of severe traumatic brain injury (TBI). Some research suggests that it could reflect a deficiency in goal-directed behavior. The current study aimed to test whether these inappropriate behaviors tend to be deficient in goal-directed control, that is, triggered more by environmental stimuli than by the known consequences of their actions.

METHOD

We used a between-group design with 25 adult participants with severe TBI, and 27 control participants. Social disinhibition was measured using Frontal Systems Behavior Scale and Social Disinhibition Interview. Changes in reward-related goal-directed behavior were evaluated using a computer-based task in which we assessed the influence of cues predicting reward and of reward devaluation on choice performance.

RESULTS

We found no difference in the levels of social disinhibition between the TBI and control groups and, using mixed two-way ANCOVAs, no overall effect of the stimuli or outcome devaluation. However, after combing these groups and splitting them based on their disinhibition levels, a significant interaction between group (High vs Low disinhibition) and reward type (Valued vs Devalued) in sensitivity to outcome devaluation test (F = 5.99, p = .01, ηp2 = .13) appeared. Comparing with the baseline rate of responding, the Low disinhibition group decreased their responding to devalued and increased their responding to still-valued outcomes. In contrast, the High disinhibition group showed the opposite pattern of choice performance.

CONCLUSIONS

It appears that people with clinical levels of social disinhibition are both prone to outcome-response priming effects and insensitive to changes in the value of the consequences of their actions, that is, despite evidence they were aware of the reduction in the value of their actions's outcomes, people with high-level disinhibition kept performing those actions. This pattern has the hallmarks of a habit suggesting their disinhibition reflects a loss of executive control.

Self-Awareness and therapeutic alliance in speech-language treatment of traumatic brain injury

Purpose: To investigate the relationships among client self-awareness, client perception of the therapeutic alliance, and speech-language pathologist (SLP) communicative self-awareness in dyads of SLPs and traumatic brain injury (TBI) clients.Method: Nineteen SLP-TBI client dyads (N = 38) engaged in the same collaborative therapy task. At baseline, client self-awareness and client perception of the therapeutic alliance was assessed. SLP communicative self-awareness was measured by 1) a prediction/reflection questionnaire about their own communicative behaviour, administered pre- and post-treatment sessions, and 2) self-evaluation during a novel procedure using video review within three hours after the session.Result: Client self-awareness was not associated with client perceptions of the therapeutic alliance. Client perceptions of the therapeutic alliance were related to specific communicative intentions of the SLP. Regarding SLP communicative self-awareness, SLPs predicted their primary communication modality with 66% accuracy. The video review procedure yielded more detailed SLP communicative self-awareness ratings and was completed within real-world clinical settings.Conclusion: TBI client self-awareness may not impact the establishment of a strong therapeutic alliance between SLP and client. The finding that specific communicative intentions of the SLP were related to client perception of the therapeutic alliance should prompt further efforts to measure SLP communicative intentions and behaviours during TBI treatment sessions.

Intentional Self-Harm Among US Veterans With Traumatic Brain Injury or Posttraumatic Stress Disorder: Retrospective Cohort Study From 2008 to 2017

BACKGROUND

Veterans with a history of traumatic brain injury (TBI) and/or posttraumatic stress disorder (PTSD) may be at increased risk of suicide attempts and other forms of intentional self-harm as compared to veterans without TBI or PTSD.

OBJECTIVE

Using administrative data from the US Veterans Health Administration (VHA), we studied associations between TBI and PTSD diagnoses, and subsequent diagnoses of intentional self-harm among US veterans who used VHA health care between 2008 and 2017.

METHODS

All veterans with encounters or hospitalizations for intentional self-harm were assigned "index dates" corresponding to the date of the first related visit; among those without intentional self-harm, we randomly selected a date from among the veteran's health care encounters to match the distribution of case index dates over the 10-year period. We then examined the prevalence of TBI and PTSD diagnoses within the 5-year period prior to veterans' index dates. TBI, PTSD, and intentional self-harm were identified using International Classification of Diseases diagnosis and external cause of injury codes from inpatient and outpatient VHA encounters. We stratified analyses by veterans' average yearly VHA utilization in the 5-year period before their index date (low, medium, or high). Variations in prevalence and odds of intentional self-harm diagnoses were compared by veterans' prior TBI and PTSD diagnosis status (TBI only, PTSD only, and comorbid TBI/PTSD) for each VHA utilization stratum. Multivariable models adjusted for age, sex, race, ethnicity, marital status, Department of Veterans Affairs service-connection status, and Charlson Comorbidity Index scores.

RESULTS

About 6.7 million veterans with at least two VHA visits in the 5-year period before their index dates were included in the analyses; 86,644 had at least one intentional self-harm diagnosis during the study period. During the periods prior to veterans' index dates, 93,866 were diagnosed with TBI only; 892,420 with PTSD only; and 102,549 with comorbid TBI/PTSD. Across all three VHA utilization strata, the prevalence of intentional self-harm diagnoses was higher among veterans diagnosed with TBI, PTSD, or TBI/PTSD than among veterans with neither diagnosis. The observed difference was most pronounced among veterans in the high VHA utilization stratum. The prevalence of intentional self-harm was six times higher among those with comorbid TBI/PTSD (6778/58,295, 11.63%) than among veterans with neither TBI nor PTSD (21,979/1,144,991, 1.92%). Adjusted odds ratios suggested that, after accounting for potential confounders, veterans with TBI, PTSD, or comorbid TBI/PTSD had higher odds of self-harm compared to veterans without these diagnoses. Among veterans with high VHA utilization, those with comorbid TBI/PTSD were 4.26 (95% CI 4.15-4.38) times more likely to receive diagnoses for intentional self-harm than veterans with neither diagnosis. This pattern was similar for veterans with low and medium VHA utilization.

CONCLUSIONS

Veterans with TBI and/or PTSD diagnoses, compared to those with neither diagnosis, were substantially more likely to be subsequently diagnosed with intentional self-harm between 2008 and 2017. These associations were most pronounced among veterans who used VHA health care most frequently. These findings suggest a need for suicide prevention efforts targeted at veterans with these diagnoses.

Understanding the Barriers of Implementing a Self-Awareness Assessment in Occupational Therapy Practice within a Brain Injury Population: An Exploratory Study

Background

Self-awareness is seldom formally assessed by occupational therapists among individuals with traumatic brain injury (TBI). However, impaired self-awareness is prevalent and has a significant impact on rehabilitation outcomes. There is a need to understand clinician perspectives on self-awareness assessments and promote evidence-based practice in clinical settings.

Aims

(1) Explore how an education session impacts knowledge and use of self-awareness assessments in occupational therapists working with people with TBI; (2) Understand the barriers that occupational therapists experience when assessing self-awareness in clinical practice.

Materials and Methods

A single-group pre-post session design with an integrated knowledge translation approach was used. Occupational therapists working in neurorehabilitation were recruited from two rehabilitation centres through convenience sampling. Participants completed questionnaires before, after, and three months following an education session about the Self-Awareness of Deficits (SADI) assessment.

Results

14 occupational therapists participated in this study. A statistically significant increase in knowledge and confidence in using the SADI was observed both post-session and at 3-month follow-up.

Conclusion

Targeted and ongoing education promotes confidence and knowledge retention among occupational therapists. Further research should explore strategies to promote behaviour change. Significance. The barriers identified in this study can provide insights for knowledge translation across clinical contexts.

Assessment of communication competence in acquired communication disorders: A systematic scoping review

PURPOSE

Individuals with acquired communication disorders (ACDs) experience reduced ability to participate independently in activities of daily life, and maintain interpersonal relationships and psychosocial wellbeing. Communication interventions are designed to optimise communication competence in personally relevant everyday activities. However, the assessment tools speech-language pathologists (SLPs) typically utilise to evaluate communication competence in everyday life are not ideal. To explore the range and availability of assessments used in research to examine functional communication in adults with ACDs.

METHOD

Five databases (Medline, CINAHL, EMBASE, SCOPUS and PsycINFO) were searched to identify assessment or intervention studies evaluating functional communication in adults with ACDs. Functional communication tools utilised in each study were identified. Extracted tools were categorised according to type, target population, consideration of multimodal communication, person-specificity, consideration of context, availability, administration/analysis time and availability of normative/psychometric data.

RESULT

Forty functional communication assessment tools were included. Just over half the tools were performance-based (n = 25), examined different modes of communication (n = 26) and/or considered context (n = 23). Only 14 tools were person-specific. Many of the most comprehensive tools were out of print or considered excessively time consuming to administer and analyse.

CONCLUSION

A paucity of accessible, time-efficient yet comprehensive tools to assess functional communication in ACDs may limit clinical practice and client outcomes. More versatile functional communication assessments incorporating individualised contexts, and the use of modern communication technologies are recommended.

Interaction between APOE ɛ4 and Age Is Associated with Emotional Distress One Year after Moderate-Severe Traumatic Brain Injury

Emotional distress is common following moderate-severe traumatic brain injury (TBI) and is associated with poorer post-injury outcomes. Previously investigated sociodemographic, psychological, and injury-related factors account for only a small proportion of variance in post-TBI emotional distress, highlighting a need to consider other factors such as genetic factors. The apolipoprotein E gene (APOE) has been commonly studied in the TBI literature, with the ɛ4 allele linked to worse neuronal repair and recovery. Few studies have investigated the potential relationship between APOE ɛ4 and emotional distress after moderate-severe TBI, and results have been varied. We examined whether APOE ɛ4 was associated with emotional distress 1 year following moderate-severe TBI, and whether this relationship was moderated by age, sex, and TBI severity (as indexed by the duration of post-traumatic amnesia [PTA]). Moderate-severe TBI survivors provided saliva samples following inpatient admission to a TBI rehabilitation hospital. They completed a self-report measure of emotional distress, the Hospital Anxiety and Depression Scale (HADS), at a follow-up interview ∼1 year post-injury. Complete genetic and follow-up data were available for 441 moderate-severe TBI survivors (mean age = 39.42 years; 75% male). We constructed a linear regression model that included APOE ɛ4 carriage status (carrier vs. non-carrier) and interactions with age, sex, and TBI severity (APOE × age, APOE × sex, APOE × age × sex, and APOE × PTA duration) to predict total score on the HADS, while covarying for the main effects of age, sex, PTA duration, and previous head injury. There was a significant main effect of APOE ɛ4, whereby ɛ4 carriers reported less emotional distress than non-carriers (p = 0.04). However, we also found a significant interaction with age such that APOE ɛ4 carriers reported increasingly greater emotional distress with older age compared with non-carriers (p = 0.01). A sensitivity analysis (n = 306) suggested that the APOE × age interaction, and main effects of age and previous head injury, were not unique to individuals with pre-injury mental health problems (n = 136). However, the main effect of APOE ɛ4 was no longer significant when individuals with pre-injury mental health problems were removed. Our findings highlight the importance of considering moderation of genetic associations, suggesting that APOE ɛ4 may be a risk factor for emotional distress specifically among older survivors of moderate-severe TBI. If these findings can be independently replicated, APOE ɛ4 carriage status, interpreted in the context of age, could be incorporated into risk prediction models of emotional distress after moderate-severe TBI, enhancing targeted early detection and intervention efforts.

Anosognosia in moderate-to-severe traumatic brain injury: A review of prevalence, clinical correlates, and diversity considerations

METHOD

A comprehensive search of peer-reviewed articles was conducted from September to November 2020 using Google Scholar and PubMed databases. Key terms included "anosognosia," "self-awareness," "traumatic brain injury," and variants thereof. Our search was restricted to articles published in English within the last 25 years, although a few historical articles were included due to scientific merit. Articles were chosen based on methodological quality, inclusion of solely or predominantly msevTBI sample, and relevance to the current topic.

CONCLUSIONS

Anosognosia is a multifaceted and domain-specific construct that affects the majority of those with msevTBI. It is related to TBI severity, injuries in right-hemispheric and cortical midline regions, specific aspects of executive function, psychological function, and cultural factors. We offer pragmatic advice for clinicians working with this population and discuss implications for the field regarding "best practices" of anosognosia assessment and intervention.

Smart Assistive Technology for Cooking for People With Cognitive Impairments Following a Traumatic Brain Injury: User Experience Study

Background

User experience (UX), including usability, should be formally assessed multiple times throughout the development process to optimize the acceptability and integration of a new technology before implementing it within the home environment of people living with cognitive impairments.

Objective

The aim of this study is to identify UX issues, notably usability issues, and factors to consider for the future implementation of the COOK (Cognitive Orthosis for Cooking) within the home of individuals with traumatic brain injury (TBI) to identify modifications to improve the technology.

Methods

This study comprised two rounds of UX evaluations, including extensive usability testing, which were completed in a laboratory context: 3 sessions with 5 experts and, after improvement of COOK, 2 sessions with 10 participants with TBI. Each session included the use of scenarios and questionnaires on UX and usability.

Results

Both rounds demonstrated good usability outcomes and hedonic qualities. Various usability issues were identified by participants, such as navigation inconsistencies, technical bugs, and the need for more feedback. Factors to consider in the future implementation of COOK were also mentioned by participants with TBI, including environmental (eg, space available and presence of pets) and personal factors (eg, level of comfort with technology, presence of visual deficits, and preferences).

Conclusions

By evaluating UX, including usability, various times throughout the development process and including experts and end users, our research team was able to develop a technology that was perceived as usable, pleasant, and well-designed. This research is an example of how and when people with cognitive impairments (ie, people with TBI) can be involved in evaluating the UX of new technology.

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

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

Clinical perspectives on delivering a Positive Behaviour Support intervention for challenging behaviours following acquired brain injury

Challenging behaviours are distressing sequelae for people with acquired brain injury (ABI) and their families. Positive Behaviour Support (PBS) is a collaborative approach focussing on improving quality of life for individuals with ABI presenting with challenging behaviours. This qualitative study explored clinicians' experiences of a 12-month intervention (PBS+PLUS) for adults with ABI and their family/carers. Semi-structured interviews were conducted with eight clinicians trained in neuropsychology (n = 5), occupational therapy (n = 3), speech pathology (n = 2), with two clinicians trained in two of these disciplines. Interviews were analysed through reflexive thematic analysis. Three themes were identified: Shifting clinical identity; Working as equals; Adapting to the environment. Participants experienced PBS+PLUS as a difficult approach to learn but one which enhanced overt client communication and comfort with their clinical fallibility. PBS+PLUS involved giving clients equal status in the clinician-client relationship which for some clients and families was challenging. Finally, PBS+PLUS was perceived as problematic to implement in some work settings (e.g., involving high staff turnover). Clinicians' recommendations for future implementation included thorough training and supervision and early setting of client expectations. With increasing interest in PBS to address challenging behaviours after ABI, these findings will guide PBS+PLUS translation for community clinicians.

Caregivers' perspectives of the challenges faced with survivors of traumatic brain injury: A scoping review

INTRODUCTION

Traumatic Brain Injury (TBI) has wide-ranging neuropsychological, physical, social and financial implications. The impact on caregivers of moderate to severe TBI survivors, particularly in low- and middle-income countries, is under-investigated.

AIM

Identify and describe the experiences of caregivers' of moderate to severe TBI survivors postdischarge from healthcare facilities.

METHODS

A scoping review was conducted utilising seven electronic databases. Two reviewers screened articles using eligibly criteria related to setting (postdischarge), caregiving (informal), age of TBI survivors (>  18 years) and injury severity (moderate-severe). Studies published in English between 1999 -2018 were included.

RESULTS

Fourteen articles met the inclusion criteria. Articles reporting on the same sample were merged during data charting. The final analyses included 11 articles comprised of qualitative, quantitative and mixed-methods studies. Ten themes were identified: psychological distress, social functioning, financial burden, family experiences, coping strategies, access to services, time burdens and physical, cognitive and behavioural difficulties. Characteristics of caregivers and TBI survivors were also reported.

CONCLUSION

Caregivers of moderate to severe TBI survivors experience challenges in various life domains, and there is limited research concerning caregivers in low- and middle-income countries. Future research should focus on understanding more nuanced experiences across various environments, which may increase comprehensive, flexible and long-term support.

The journey is just as important as the destination-Digital neuropsychological assessment provides performance stability measures in patients with acquired brain injury

BACKGROUND

Cognitive performances on neuropsychological paper-and-pencil tests are generally evaluated quantitatively by examining a final score (e.g., total duration). Digital tests allow for a quantitative evaluation of "how" a patient attained a final score, which opens the possibility to assess more subtle cognitive impairment even when final scores are evaluated as normal. We assessed performance stability (i.e., the number of fluctuations in test performance) to investigate (1) differences in performance stability between patients with acquired brain injury (ABI) and healthy controls; (2) the added value of performance stability measures in patients with ABI; and (3) the relation between performance stability and cognitive complaints in daily life in patients with ABI.

METHODS

We administered three digital neuropsychological tests (Rey Auditory Verbal Learning Test, Trail Making Test, Stroop Colour and Word Test) and the Cognitive Complaints-Participation (CoCo-P) inventory in patients with ABI (n = 161) and healthy controls (n = 91).

RESULTS

Patients with ABI fluctuated more in their performance on all tests, when compared to healthy controls. Furthermore, 4-15% of patients who performed inside normal range on the conventional final scores were outside normal range on the performance stability measures. The performance stability measures, nor the conventional final scores, were associated with cognitive complaints in daily life.

CONCLUSIONS

Stability in test performance of patients was clearly dissociable from healthy controls, and may assess additional cognitive weaknesses which might not be observed or objectified with paper-and-pencil tests. More research is needed for developing measures better associated with cognitive complaints.

New insights into neural networks of error monitoring and clinical implications: a systematic review of ERP studies in neurological diseases

Error monitoring allows for the efficient performance of goal-directed behaviors and successful learning. Furthermore, error monitoring as a metacognitive ability may play a crucial role for neuropsychological interventions, such as rehabilitation. In the past decades, research has suggested two electrophysiological markers for error monitoring: the error-related negativity (ERN) and the error positivity (Pe), thought to reflect, respectively, error detection and error awareness. Studies on several neurological diseases have investigated the alteration of the ERN and the Pe, but these findings have not been summarized. Accordingly, a systematic review was conducted to understand what neurological conditions present alterations of error monitoring event-related potentials and their relation with clinical measures. Overall, ERN tended to be reduced in most neurological conditions while results related to Pe integrity are less clear. ERN and Pe were found to be associated with several measures of clinical severity. Additionally, we explored the contribution of different brain structures to neural networks underlying error monitoring, further elaborating on the domain-specificity of error processing and clinical implications of findings. In conclusion, electrophysiological signatures of error monitoring could be reliable measures of neurological dysfunction and a robust tool in neuropsychological rehabilitation.

A population study on the epidemiology and outcome of brain injuries in intensive care

BACKGROUND

Traumatic Brain Injury (TBI) is characterized by a highly heterogenous profile in terms of pathophysiology, clinical presentation and outcome.

OBJECTIVE

This is the first population study investigating the epidemiology and outcomes of moderate-to-severe TBI in Cyprus. Patients treated in the Intensive Care Unit (ICU) of Nicosia General Hospital, the only Level 1 Trauma Centre in the country, were recruited between January 2013 and December 2016.

METHODS

This was an observational cohort study, using longitudinal methods and six-month follow-up. Patients (N = 203) diagnosed with TBI were classified by the Glasgow Coma Scale at the Emergency Department as moderate or severe.

RESULTS

Compared to international multicentre studies, the current cohort demonstrates a different case mix that includes older age, more motor vehicle collisions and lower mortality rates. There was a significantly higher proportion of injured males. Females were significantly older than males. There were no sex differences in the type, severity or place of injury. Sex did not yield differences in mortality or outcomes or on injury indices predicting outcomes. In contrast, older age was a predictor of higher mortality rates and worse outcomes.

CONCLUSION

Trends as described in the study emphasize the importance of continuous evaluation of TBI epidemiology and outcome in different countries.

Awareness of deficit following traumatic brain injury: A systematic review of current methods of assessment

Background: Awareness of deficit plays an important role in adjustment following a brain injury and has been noted to impact on engagement with and outcome of rehabilitation. However, there are challenges associated with the assessment of awareness. Aim: To systematically review all instruments used to assess intellectual awareness of deficits following Traumatic Brain Injury (TBI) in adults, and evaluate instrument characteristics (e.g., the format and focus of measures of awareness) and assessment methods adopted. Results: Thirty-four studies, all rated as fair to good quality, were identified and within these twenty-three different assessment tools were adopted. The most common method of assessment was patient-proxy discrepancy, with three frequently used instruments employed in a total of 22 of the 34 studies. Across studies, variability was noted regarding the type of assessment method dependent on various sample demographics (e.g., age of sample) and injury characteristics (e.g., time post injury). Conclusions: There is no consensus on the preferred instrument to assess intellectual awareness of deficits after TBI. Continued instrument development should attempt to incorporate multiple perspectives and assessment should take into account demographic and injury-related factors. An insightful avenue for future research would be to determine which factors are likely to impact awareness measurement.

Psychological status and role of caregivers in the neuro-rehabilitation of patients with severe Acquired Brain Injury (ABI)

OBJECTIVE

To investigate the relationships between (a) the psychological status of the caregiver, (b) the specific features of caregiving as perceived by the cognitive therapist in neuro-rehabilitation, (c) the caregivers' subjective approach to neuro-rehabilitation, and (d) the functional outcome of the patient.

METHODS

Twenty-four patients with severe acquired brain injury and their 24 caregivers participated in this observational study. Caregivers underwent a psychological assessment examining emotional distress, burden and family strain; their subjective approach to neuro-rehabilitation has been evaluated by two specific answers. The patients' cognitive therapists responded to an ad-hoc questionnaire, namely the "Caregiving Impact on Neuro-Rehabilitation Scale" (CINRS), evaluating the features (i.e., amount and quality) of caregiving. Finally, the functional outcome of the patient was assessed through standardized scales of disability and cognitive functioning.

RESULTS

The caregivers' psychological well-being was associated to the features of caregiving, to the subjective approach to neuro-rehabilitation, and to the functional recovery of their loved ones. A better caregivers' approach to neuro-rehabilitation was also associated to an overall positive impact of caregiving in neuro-rehabilitation and to a better functional outcome of the patients.

CONCLUSIONS

We posited a virtuous circle involving caregivers within the neuro-rehabilitation process, according to which the caregivers' psychological well-being could be strictly associated to a better level of caregiving and to a better functional outcome of the patients that, in turn, could positively influence the caregivers' psychological well-being. Although preliminary, these results suggest a specific psycho-educational intervention, aimed at improving the caregivers' psychological well-being and at facilitating their caring of the loved one.

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.

Self-Awareness Moderates the Association Between Executive Dysfunction and Functional Independence After Acquired Brain Injury

OBJECTIVE

Impaired self-awareness (SA) is a common symptom after suffering acquired brain injury (ABI) which interferes with patient's rehabilitation and their functional independence. SA is associated with executive function and declarative memory, two cognitive functions that are related to participants' daily living functionality. Through this observational study, we aim to explore whether SA may play a moderator role in the relation between these two cognitive processes and functional independence.

METHOD

A sample of 69 participants with ABI completed a neuropsychological assessment focused on executive function and declarative memory which also included a measure of SA and functional independence. Two separated linear models were performed including functional independence, SA, and two neuropsychological factors (declarative memory and executive function) derived from a previous principal component analysis.

RESULTS

Moderation analysis show a significant interaction between SA and executive function, reflecting an association between lower executive functioning and poorer functional outcome, only in participants with low levels of SA. Notwithstanding, declarative memory do not show a significant interaction with SA, even though higher declarative memory scores were associated with better functional independence.

CONCLUSIONS

SA seems to play a moderator effect between executive function, but not declarative memory, and functional independence. Accordingly, participants with executive deficits and low levels of SA might benefit from receiving specific SA interventions in the first instance, which would in turn positively impact on their functional independence.

Neuroimaging and Psychometric Assessment of Mild Cognitive Impairment After Traumatic Brain Injury

Traumatic brain injury (TBI) can be serious partly due to the challenges of assessing and treating its neurocognitive and affective sequelae. The effects of a single TBI may persist for years and can limit patients’ activities due to somatic complaints (headaches, vertigo, sleep disturbances, nausea, light or sound sensitivity), affective sequelae (post-traumatic depressive symptoms, anxiety, irritability, emotional instability) and mild cognitive impairment (MCI, including social cognition disturbances, attention deficits, information processing speed decreases, memory degradation and executive dysfunction). Despite a growing amount of research, study comparison and knowledge synthesis in this field are problematic due to TBI heterogeneity and factors like injury mechanism, age at or time since injury. The relative lack of standardization in neuropsychological assessment strategies for quantifying sequelae adds to these challenges, and the proper administration of neuropsychological testing relative to the relationship between TBI, MCI and neuroimaging has not been reviewed satisfactorily. Social cognition impairments after TBI (e.g., disturbed emotion recognition, theory of mind impairment, altered self-awareness) and their neuroimaging correlates have not been explored thoroughly. This review consolidates recent findings on the cognitive and affective consequences of TBI in relation to neuropsychological testing strategies, to neurobiological and neuroimaging correlates, and to patient age at and assessment time after injury. All cognitive domains recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are reviewed, including social cognition, complex attention, learning and memory, executive function, language and perceptual-motor function. Affect and effort are additionally discussed owing to their relationships to cognition and to their potentially confounding effects. Our findings highlight non-negligible cognitive and affective impairments following TBI, their gravity often increasing with injury severity. Future research should study (A) language, executive and perceptual-motor function (whose evolution post-TBI remains under-explored), (B) the effects of age at and time since injury, and (C) cognitive impairment severity as a function of injury severity. Such efforts should aim to develop and standardize batteries for cognitive subdomains—rather than only domains—with high ecological validity. Additionally, they should utilize multivariate techniques like factor analysis and related methods to clarify which cognitive subdomains or components are indeed measured by standardized tests.

Metacognitive knowledge and functional outcomes in adults with acquired brain injury: A meta-analysis

Pronounced difficulties in functional outcomes often follow acquired brain injury (ABI), and may be due, in part, to deficits in metacognitive knowledge (being unaware of one's cognitive strengths and limitations). A meta-analytic review of the literature investigating the relationship between metacognitive knowledge and functional outcomes in ABI is timely, particularly given the presence of apparently inconsistent findings. Twenty-two articles revealed two distinct methods of measuring metacognitive knowledge: (1) absolute (the degree of inaccurate self-appraisal regardless of whether the error tends towards under- or over-confident estimations) and (2) relative (the degree and the direction of the inaccuracy) discrepancy. Separate meta-analyses were conducted for absolute and relative discrepancy studies to assess the relationship between metacognitive knowledge and functional outcomes (affect-related quality of life, family and community integration, and work outcomes). The pattern of results found suggested that better metacognitive knowledge is related to better overall functional outcomes, but the relationship may differ depending on the outcome domain. These findings generally support the importance of focusing on metacognitive knowledge to improve outcomes following ABI. Nonetheless, the relatively small effect sizes observed suggest that other predictors of functional outcome should be investigated, including other subdomains of metacognition.

CoCo - participation: The development and clinical use of a novel inventory measuring cognitive complaints in daily life

Cognitive difficulties can be subtle and only come to light when patients return home from inpatient care and start to participate in society. Subjective cognitive complaints often interfere with participation, hence capturing cognitive complaints systematically is important. We developed a patient- and relative-reported measure to assess cognitive complaints during daily life activities across the memory, attention and executive domain for patients with acquired brain injury (ABI). The inventory Cognitive Complaints - Participation (CoCo-P) was created based on a literature review, consultations with experts, semi-structured interviews with patients, and a quantitative study. The inventory was administered to patients with ABI (n = 46), their relatives (n = 33) and healthy controls (n = 102) to finalize the inventory. We examined the reported complaints per daily life activity and cognitive domain of patients and healthy controls, and we compared the patients' and relatives' reports. The majority of patients (87-96%) experienced cognitive complaints, mostly related to attention, at work/education, during leisure activities, and in contact with family/friends and community. Patients reported more cognitive complaints than relatives. The CoCo-P seems appropriate to capture cognitive complaints in daily life in patients with mild ABI. Additional research is needed in terms of reliability and validity.

The Use of Computed Tomography Perfusion on Admission to Predict Outcomes in Surgical and Nonsurgical Traumatic Brain Injury Patients

Introduction: The objective of this study was to investigate if data obtained from a computed tomography (CT) perfusion study on admission could correlate to outcomes for the patient, including the patient’s length of stay in the hospital and their initial and final Glasgow Coma Scale (GCS), as well as the modified Rankin Scale (mRS) on discharge. We present an initial subset of patients fulfilling the inclusion criteria: over the age of 18 with mild, moderate, or severe traumatic brain injury (TBI). Patients admitted with a diagnosis of TBI had CT perfusion studies performed within 48 hours of admission. GCS, length of stay, mRS, and discharge location were tracked, along with the patient’s course of hospitalization. Initial results and discussion on the utility of CT perfusion for predicting outcomes are presented.

Methods: Patients exhibiting mild, moderate, or severe TBI were assessed using CT perfusion within 48 hours of admission from January to July 2019 at the Arrowhead Regional Medical Center (ARMC). The neurosurgery census and patient records were assessed for progression of outcomes. Data obtained from the perfusion scans were correlated to patient outcomes to evaluate the utility of CT perfusion in predicting outcomes in surgical and nonsurgical TBI patients.

Results: Preliminary data were obtained on six patients exhibiting TBI, ranging from mild to severe. The mean GCS of our patient cohort on admission was eight, with the most common mechanism of injury found to be falls (50%) and motor vehicle accidents (50%). Cerebral blood volume (CBV) seemed to increase with Rankin value (Pearson's correlations coefficient = 0.43 but was statistically insignificant (P = 0.21)). Cerebral blood flow (CBF) was found to be correlated with CBV, and both increased with Rankin score (Pearson's correlation coefficient = 0.56) but were statistically insignificant (P = 0.27). These results suggest that with a larger sample size, CBV and CBF may be correlated to patient outcome.

Conclusion: Although more data is needed, preliminary results suggest that with larger patient populations, CT perfusion may provide information that can be correlated clinically to patient outcomes. This study shows that CBF and CBV may serve as useful indicators for prognostication of TBI patients.

The effect of subjective perception of cognition on emotional functioning in adults with long-term neurological and neuropsychiatric disorders

Purpose: To examine effects of subjective perception and objective status of cognition on emotional functioning in a sample of adults with long-term neurological and neuropsychiatric disorders.Method: N = 65. Subjective measures were derived from the self-ratings on the Problem Checklist (PCL) from the HI-FI; the objective status was represented by combined externally standardised scores on neuropsychological tests across three cognitive domains: verbal memory, executive functioning, and psychomotor speed.Results: No relationship was found between self-ratings of cognitive competence and performance on neuropsychological tests. Based on the results of the multiple regression analysis, approximately 40% of the variability in emotional functioning was explained by self-perceived cognitive and physical competence, while the addition of objective measures of cognition increased predictive capacity by only 1.3%. The awareness scores were calculated as the difference between objective performance scores and self-ratings of cognition. Overall, the sample demonstrated a tendency towards low awareness of cognitive deficits. Patients who overestimated cognitive deficits self-rated emotional functioning at a significantly lower level, while those with average or low awareness of deficits were equally emotionally content.Conclusions: Self-perception of competence, rather than objective level of functioning influence emotional well-being and quality of life in individuals with long-term disabilities in our study.IMPLICATIONS FOR REHABILITATIONCognitive deficits are common consequences of neurological dysfunction.This study shows that self-perception of cognitive competence, rather than objective level of cognitive functioning has critical influence on emotional well-being and perceived quality of life.An addition of psychotherapeutic intervention directed at alleviation of self-perception bias is likely to improve emotional well-being and enhance efficiency of rehabilitation efforts in patients with long-term disabilities due to neurological disorders.Based on our findings, patients with long-term disabilities could benefit from psychotherapy to improve their self-perception and quality of life.

Clinical utility of neuropsychological tests for employment outcomes in persons with cognitive impairment after moderate to severe traumatic brain injury

OBJECTIVE

To retrospectively examine the clinical utility of neuropsychological tests (NPTs) for predicting employment outcomes in persons with cognitive impairment after moderate to severe traumatic brain injury (TBI).

METHODS

132 individuals of working age with cognitive impairment after moderate to severe TBI were classified into three groups by employment status: competitive employment (CE); supported employment (SE); and unemployed (UE). NPT scores were compared among groups. Using multinomial logistic regression with group allocation as the dependent variable, significant variables were identified, and receiver operating characteristic (ROC) curves were calculated.

RESULTS

Comparison of NPT results among the three groups showed significant differences for all NPTs (all items, p < 0.01). Using multinomial logistic regression analysis, Rivermead Behavioral Memory Test (RBMT) and Behavioral Assessment of the Dysexecutive Syndrome from CE versus SE and Trail Making Test-B and RBMT from SE versus UE were identified. ROC curve analysis indicated small to moderate accuracy (area under the curve, 0.63-0.84).

CONCLUSION

NPT scores can predict future employment status in patients with cognitive impairment after TBI. These findings may lead to improved clinical assessments when providing work support. Future research should consider occupational categories, managerial categories, and types of re-employment.

Relationship between social cognition and social behaviour following traumatic brain injury

Objective: To present an overview of studies that investigated associations between social cognition functions (social cue perception, empathy, understanding intentions) and social behaviour or social outcome following traumatic brain injury (TBI).Methods: The literature search was conducted in the Medline, PsycInfo, Cochrane Library and Web of Science databases. Main criteria for selection were that the participants were adult persons with TBI, social cognition as well as social behaviour or social outcome post-TBI was assessed and correlations between social cognition and social behaviour or outcome were reported. Average correlations were calculated based on weighted summation of the correlations from the individual studies.Results: Of the 511 publications identified in the search, 13 were selected. Ten of these assessed emotion recognition, six assessed understanding of intentions and two assessed empathy. Average correlations between social cognition performance and post-injury social behaviour or outcome were significant for each of the three social cognition functions; poorer performance was associated with poorer outcome. Effect sizes varied from small to moderate (understanding intentions) to moderate (emotion recognition) to large (empathy).Conclusions: The associations were in line with models of social cognition and proposals that impairments in social cognition may underlie social behaviour difficulties and poor social outcome following TBI.

Effectiveness and feasibility of Socratic feedback to increase awareness of deficits in patients with acquired brain injury: Four single-case experimental design (SCED) studies

OBJECTIVE

To investigate the effectiveness and feasibility of a Socratic feedback programme to improve awareness of deficits in patients with acquired brain injury (ABI).

SETTING

Rehabilitation centre.

PARTICIPANTS

Four patients with ABI with awareness problems.

DESIGN

A series of single-case experimental design studies with random intervention starting points (A-B + maintenance design).

MAIN MEASURES

Rate of trainer-feedback and self-control behaviour on everyday tasks, patient competency rating scale (PCRS), self-regulating skills interview (SRSI), hospital anxiety and depression scale.

RESULTS

All patients needed less trainer feedback, the change was significant in 3 out of 4. One patient increased in overt self-corrective behaviour. SRSI performance increased in all patients (medium to strong effect size), and PCRS performance increased in two patients (medium and strong effect size). Mood and anxiety levels were elevated in one patient at the beginning of the training and decreased to normal levels at the end of the training. The feasibility of the programme was scored 9 out of 10.

CONCLUSIONS

The Socratic feedback method is a promising intervention for improving awareness of deficits in patients with ABI. Controlled studies with larger populations are needed to draw more solid conclusions about the effect of this method.

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

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

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

Objective:

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

Design/Setting/Subjects:

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

Intervention/Main measures:

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

Results:

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

Conclusion:

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

Subjective complaints after acquired brain injury: presentation of the Brain Injury Complaint Questionnaire (BICoQ)

The objective of the present study was to present a new complaint questionnaire designed to assess a wide range of difficulties commonly reported by patients with acquired brain injury. Patients (n =  619) had been referred to a community re-entry service at a chronic stage after brain injury, mainly traumatic brain injury (TBI). The Brain Injury Complaint Questionnaire (BICoQ) includes 25 questions in the following domains: cognition, behavior, fatigue and sleep, mood, and somatic problems. A self and a proxy questionnaire were given. An additional question was given to the relative, about the patient's awareness of his difficulties. The questionnaires had a good internal coherence, as measured with Cronbach's alpha. The most frequent complaints were, in decreasing order, mental slowness, memory troubles, fatigue, concentration difficulties, anxiety, and dual tasking problems. Principal component analysis with varimax rotation yielded six underlying factors explaining 50.5% of total variance: somatic concerns, cognition, and lack of drive, lack of control, psycholinguistic disorders, mood, and mental fatigue/slowness. About 52% of patients reported fewer complaints than their proxy, suggesting lack of awareness. The total complaint scores were not significantly correlated with any injury severity measure, but were significantly correlated with disability and poorer quality of life (Note: only factor 2 [cognition/lack of drive] was significantly related to disability.) The BICoQ is a simple scale that can be used in addition to traditional clinical and cognitive assessment measures, and to assess awareness of everyday life problems.

Rehabilitation of emergent awareness of errors post traumatic brain injury: A pilot intervention

Impaired awareness of errors is common following traumatic brain injury (TBI) and can be a barrier to successful rehabilitation. The objective of this study was to develop and evaluate a computer-based intervention programme aimed at improving error awareness in individuals with TBI. A further aim was to explore its effects on metacognitive awareness and variability of performance. Participants were 11 individuals with TBI and impaired error awareness who performed a sustained attention task twice-weekly for four weeks. The intervention consisted of audio-visual feedback-on-errors during the sustained attention task. Six participants received audio-visual feedback-on-error, five did not receive feedback. Emergent and metacognitive awareness were measured pre- and post-intervention. Between-groups comparisons of emergent awareness from pre- to post-intervention showed that audio-visual feedback-on-error improved emergent awareness compared to no feedback-on-error. Some changes in metacognitive awareness of executive behaviours as a result of feedback were observed. Audio-visual feedback-on-error improved emergent awareness in individuals with TBI following a four-week/eight-session intervention. This improvement was not observed in the no-feedback group. This pilot intervention is not a stand-alone treatment but it has potential to be usefully incorporated into cognitive or clinical rehabilitation programmes to improve emergent awareness.

Social Behavior and Impairments in Social Cognition Following Traumatic Brain Injury

OBJECTIVES

The negative effect of changes in social behavior following traumatic brain injury (TBI) are known, but much less is known about the neuropsychological impairments that may underlie and predict these changes. The current study investigated possible associations between post-injury behavior and neuropsychological competencies of emotion recognition, understanding intentions, and response selection, that have been proposed as important for social functioning.

METHODS

Forty participants with TBI and 32 matched healthy participants completed a battery of tests assessing the three functions of interest. In addition, self- and proxy reports of pre- and post-injury behavior, mood, and community integration were collected.

RESULTS

The TBI group performed significantly poorer than the comparison group on all tasks of emotion recognition, understanding intention, and on one task of response selection. Ratings of current behavior suggested significant changes in the TBI group relative to before the injury and showed significantly poorer community integration and interpersonal behavior than the comparison group. Of the three functions considered, emotion recognition was associated with both post-injury behavior and community integration and this association could not be fully explained by injury severity, time since injury, or education.

CONCLUSIONS

The current study confirmed earlier findings of associations between emotion recognition and post-TBI behavior, providing partial evidence for models proposing emotion recognition as one of the pre-requisites for adequate social functioning. (JINS, 2017, 23, 400-411).

Does history of substance use disorder predict acute traumatic brain injury rehabilitation outcomes?

BACKGROUND/OBJECTIVE

The study explored whether premorbid substance use disorder (SUD) predicts acute traumatic brain injury (TBI) outcomes.

METHODS

143 participants with moderate (34.2%) and severe (65.8%) TBI were enrolled at two Level 1 trauma center inpatient brain injury rehabilitation units. Acute outcomes were measured with the Disability Rating Scale (DRS), the FIMTM; self and informant ratings of the Patient Competency Rating Scale (PCRS); self and family rating of the Frontal Systems Behavioral Scale (FrSBe), and the Neurobehavioral Rating Scale-Revised (NRS-R).

RESULTS

Hierarchical linear modeling revealed that SUD history significantly predicted trajectories of PCRS clinician ratings, PCRS self-family and PCRS self-clinician discrepancy scores, and more negative FrSBE family ratings. These findings indicate comparatively greater post-injury executive functions (EF) impairments, particularly self-awareness (SA) of injury-related deficits, for those with SUD history. No significant SUD*time interaction effect was found for FIM or NRS-R scores.

CONCLUSIONS

SUD history and TBI are associated with impaired SA and EF but their co-occurrence is not a consistent predictor of acute post-injury functional outcomes. Pre-morbid patient characteristics and rater expectations and biases may moderate associations between SA and recovery after TBI.

Quality of life after brain injury (QOLIBRI): Italian validation of the proxy version

To validate the proxy version of the Quality of Life after Brain Injury (QOLIBRI) questionnaire to utilize caregivers for comparison and to evaluate the correspondence between patients' self-perceived and caregivers' perception of patients' Health-Related Quality of Life (HRQoL). Ninety-two patients with severe TBI and their main caregivers were enrolled. Patients' and caregivers' HRQoL was assessed by the Patient-QOLIBRI (Pt-QOLIBRI) and the Proxy-QOLIBRI (Pro-QOLIBRI), respectively. The Pro-QOLIBRI is a modified version of the QOLIBRI to investigate caregivers' perception of patients' HRQoL (Pro-QOLIBRIpatient-centered), and their degree of satisfaction and botheredness (Pro-QOLIBRIcaregiver centered). The patients' disability and their social reintegration was investigated by means of Glasgow Outcome Scale Extended and Community Integration Questionnaire. Pro-QOLIBRI has good internal consistency and homogeneity. There was also positive correlation between the level of satisfaction measured by Pro-QOLIBRI but not by Pt-QOLIBRI, and the disability severity and social integration of the patients. The comparison between the Pt-QOLIBRI and Pro-QOLIBRI confirmed the usefulness of the Pro-QOLIBRI, especially the caregiver-centered version, to predict the social reintegration of survivors. To our knowledge this is the first study that correlates the HRQoL of survivors, as self-perceived and as perceived by the caregivers with social reintegration.

A Qualitative Study of Sleep-Wake Disturbance Among Veterans With Post-Acute Moderate to Severe Traumatic Brain Injury

OBJECTIVE

Examine sleep-wake disturbance (SWD) characteristics, factors, consequences, and management strategies from the perspective of veterans with chronic stage, moderate/severe traumatic brain injury (TBI).

SETTING

VA Medical Center, Rocky Mountain.

US PARTICIPANTS

Nineteen male veterans with post-acute TBI and SWD in the VA Health Administration.

DESIGN

Qualitative descriptive.

MEASURES

Semistructured interviews, Ohio State University TBI-Identification Method, Insomnia Severity Index.

RESULTS

Two main dimensions emerged: "Messed up sleep" and Surviving and Managing SWD. Sleep-wake disturbance has long-term multidimensional features, etiology, consequences, and practice implications. Although SWD may not be consistently discussed with providers, the problem appears to be pervasive in many aspects of the lives of the informants. Difficulty falling asleep, frequent awakenings, and poor sleep quality were common symptoms that were described as intrusive, isolating, and difficult to self-manage. Veterans discussed a host of physical symptoms, mental health issues, environmental, and behavioral factors that contributed to SWD. Medications, sleep apnea treatment, and self-imposed isolation were frequent management strategies. Veterans expressed a willingness to try new approaches and work with providers.

CONCLUSION

Sleep-wake disturbance among veterans with chronic stage TBI is a multidimensional phenomenon with interplay between comorbidities, contributing factors, effects on functioning, and sleep management strategies. Implications for practice include early and routine evaluation, monitoring, and treatment of SWD. Research is needed to test interventions that address SWD and common TBI comorbidities.

Impact of the Birkman Method Assessment on Pharmacy Student Self-Confidence, Self-Perceptions, and Self-Awareness

Objective. To identify changes in pharmacy student self-confidence, self-perceptions, and self-awareness after completing the Birkman Method assessment and training program. Methods. Survey tools were developed to evaluate students at baseline and following the co-curricular Birkman Method program. Following IRB approval, students participating in the Birkman Method program were recruited for enrollment in this survey-based study. Results. Student self-confidence was high at baseline (mean=4 out of 5) and did not significantly change after Birkman Method testing and training. Self-perceptions regarding usual and stressed communication style and behaviors and behavioral needs under stress changed significantly after Birkman Method testing and training for these endpoints. The Birkman Method intervention resulted in a significant improvement in self-awareness, as indicated by a mean self-perception accuracy score increase of 1.6 points (95% CI: 1.3-1.9). Conclusions. A Birkman Method assessment and training program is an effective self-assessment tool for students, and may be useful for accomplishing Accreditation Council for Pharmacy Education (ACPE) 2016 Standard 4 affective domain elements, particularly self-awareness.

Discrepancies among Measures of Executive Functioning in a Subsample of Young Adult Survivors of Childhood Brain Tumor: Associations with Treatment Intensity

OBJECTIVES

Treatments for childhood brain tumors (BT) confer substantial risks to neurological development and contribute to neuropsychological deficits in young adulthood. Evidence suggests that individuals who experience more significant neurological insult may lack insight into their neurocognitive limitations. The present study compared survivor, mother, and performance-based estimates of executive functioning (EF), and their associations with treatment intensity history in a subsample of young adult survivors of childhood BTs.

METHODS

Thirty-four survivors (52.9% female), aged 18 to 30 years (M=23.5; SD=3.4), 16.1 years post-diagnosis (SD=5.9), were administered self-report and performance-based EF measures. Mothers also rated survivor EF skills. Survivors were classified by treatment intensity history into Minimal, Average/Moderate, or Intensive/Most-Intensive groups. Discrepancies among survivor, mother, and performance-based EF estimates were compared.

RESULTS

Survivor-reported and performance-based measures were not correlated, although significant associations were found between mother-reported and performance measures. Survivors in the Intensive/Most-Intensive treatment group evidenced the greatest score discrepancies, reporting less executive dysfunction relative to mother-reported F(2,31)=7.81, p.05).

CONCLUSIONS

There may be a lack of agreement among survivor, mother, and performance-based estimates of EF skills in young adult survivors of childhood BT, and these discrepancies may be associated with treatment intensity history. Neuropsychologists should use a multi-method, multi-reporter approach to assessment of EF in this population. Providers also should be aware of these discrepancies as they may be a barrier to intervention efforts. (JINS, 2016, 22, 900-910).