Affective state and community integration after traumatic brain injury

Training to Reconnect with Emotional Awareness Therapy (TREAT): A Randomized Controlled Trial in Participants with Traumatic Brain Injury

OBJECTIVE

To examine the efficacy of an intervention, training to reconnect with emotional awareness therapy (TREAT) at improving alexithymia, emotion dysregulation, anxiety, depression, anger and global positive and negative affect in participants with traumatic brain injury (TBI).

SETTING

Outpatient brain injury rehabilitation center PARTICIPANTS: : Adult participants, who were on average 11.37 years post-complicated mild to severe TBI and also had elevated alexithymia (n=44), who were randomized to immediate treatment (TREAT; n=20) or waitlist control (WLC=24).

DESIGN

Randomized, waitlist control trial with 3-month follow-up.

INTERVENTION

Eight session, structured training program that teaches emotional awareness and discrete labeling of emotions.

OUTCOME MEASURES

Toronto Alexithymia Scale-20 (TAS-20), Levels of Emotional Awareness Scale (LEAS), Difficulty with Emotion Regulation Scale (DERS), General Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9); State-Trait Anger Expression Inventory (STAXI), Positive and Negative Affect Schedule (PANAS); and Patient Global Impression of Change (PGIC).

RESULTS

Thirty-four participants completed the study per protocol. Compared to WLC participants (n=16) who had not yet received the intervention, TREAT participants (n=18) had significantly less alexithymia, emotion dysregulation, anxiety, and depression (all p's<.05) within approximately one week of completing the intervention. Before/after results from the pooled sample (n=34) showed significant improvements, immediately and 3 months after the intervention, on all outcomes except the STAXI and the Positive Affect subscale of the PANAS. On the PGIC, a noticeable change in global emotional function and quality of life was reported by 80%. Intent-to-Treat (ITT) analyses (n=38) revealed similar results to the per protocol sample.

CONCLUSIONS

Findings support the efficacy of TREAT for reducing alexithymia and emotion dysregulation in individuals with chronic TBI. While outcomes were also promising for anxiety and depression, more research using attention-control designs are warranted to control for the attention received during treatment.

Alexithymia Prevalence, Characterization, and Associations With Emotional Functioning and Life Satisfaction: A Traumatic Brain Injury Model System Study

OBJECTIVES

Alexithymia an emotional processing deficit that interferes with a person's ability to recognize, express, and differentiate emotional states. Study objectives were to (1) determine rates of elevated alexithymia among people with moderate-to-severe traumatic brain injury (TBI) 1-year post-injury, (2) identify demographic and injury-related variables associated with high versus low-average levels of alexithymia, and (3) examine associations among alexithymia with other aspects of emotional functioning and life satisfaction.

SETTING

Data were collected during follow-up interviews across four TBI Model System (TBIMS) centers.

PARTICIPANTS

The sample consisted of 196 participants with moderate-to-severe TBI enrolled in the TBIMS. They were predominately male (77%), White (69%), and had no history of pre-injury mental health treatment (66.3%).

DESIGN

Cross-sectional survey data were obtained at study enrollment and 1-year post-injury.

MAIN MEASURES

Toronto Alexithymia Scale-20 (TAS-20) as well as measures of anger, aggression, hostility, emotional dysregulation, post-traumatic stress, anxiety, depression, resilience and life satisfaction. Sociodemographic information, behavioral health history and injury-related variables were also included.

RESULTS

High levels of alexithymia (TAS-20 score > 1.5 standard deviation above the normative mean) were observed for 14.3%. Compared to individuals with low/average levels of alexithymia, the high alexithymia group tended to have lower levels of education. At 1-year follow-up, high TAS-20 scores were strongly associated with emotional dysregulation and post-traumatic stress; moderately associated with anger, hostility, depression, anxiety, lower resilience and lower satisfaction with life; and weakly associated with aggression.

CONCLUSION

These findings provide further evidence that alexithymia is associated with poor emotional functioning and life satisfaction after TBI. Longitudinal studies are needed to determine if alexithymia is a risk factor that precipitates and predicts worse emotional outcomes in the TBI population. This line of work is important for informing treatment targets that could prevent or reduce of psychological distress after TBI.

The effect of self-reported balance confidence on community integration after brain injury: an observational study

OBJECTIVE

To evaluate the correlation between self-reported balance confidence and community integration related to home management for community-dwelling adults with acquired brain injury (ABI).

METHODS

This is a study of 141 participants over the age of 18 with a history of ABI, living in the community, who completed an online survey. The survey included a series of demographic questions followed by the Activities-Specific Balance Confidence Scale (ABC) and the Home Integration subscale of the Community Integration Questionnaire (CIQ-H).

RESULTS

Data from 119 completed surveys were included in the analysis. Significant positive correlations were found between the ABC and the CIQ-H total scores (rs = 0.241, p = 0.008). There was no significant difference between CIQ-H total scores in individuals by injury type (traumatic vs non-traumatic) or by level of severity (mild, moderate, severe) (p > 0.05). There was no significant difference between ABC total scores by injury type (p > 0.05).

CONCLUSIONS

Higher levels of balance confidence may be associated with improved community integration related to home management for individuals with traumatic and non-traumatic BI. This study's results support future research to evaluate the integration of strategies to improve balance confidence as a component of interdisciplinary assessment and rehabilitation to maximize community integration in community-dwelling adults with ABI.

Social integration: A concept analysis

BACKGROUND

In recent decades, social isolation has been increasingly linked to serious health conditions. However, social integration (SI) is a complex concept that has not been systematically explored or defined in nursing. It is essential for nurses and healthcare providers to have a clearer concept of SI to better provide holistic care to support optimal health.

PURPOSE

This concept analysis aimed to clarify the concept of SI in health research and to identify attributes, antecedents, and consequences of the concept of SI to enhance understanding of the concept and its implications for human health.

METHODS

Walker and Avant's framework was used as the methodology for the concept analysis of SI. A literature search using PubMed, CINAHL, and Embase databases on SI was conducted with keywords: "integration," "social integration," "social relationships," "social participation," "community integration," "socialization." Studies included in the search were published from 2001 to 2021.

RESULTS

SI is affected by multidimensional individual, societal, and environmental factors. Defining attributes are productive activities, social relationships, community engagement, and leisure activities. SI is effective in promoting multiple aspects of health as well as healthy aging and overall well-being.

CONCLUSION

The analysis contributes to a comprehensive and fundamental understanding of SI and contributes to helping nurses better understand patients' circumstances that promote or inhibit SI. This knowledge will support the development of interventions that support optimal health and well-being, in assisting patients to remain integrated or reintegrate into society during and following an illness or injury.

Social isolation after acquired brain injury: Exploring the relationship between network size, functional support, loneliness and mental health

Social isolation can be a consequence of acquired brain injury (ABI). Few studies have examined the relationship between social isolation and mental health after ABI. In this cross-sectional and case-control study, we compared 51 ABI survivors and 51 matched healthy controls on measures of social isolation (network size, social support and loneliness) mental health and mental health problems. We explored the relationship between structural, functional and subjective components of social isolation and examined whether they were associated with mental health outcomes. No group differences were found on size of the network and perceived social support. The ABI group exhibited marginally higher levels of loneliness. The ABI group presented higher levels of depression, lower levels of quality of life and emotional wellbeing. In both groups, perception of social support was inversely related to subjective experience of loneliness. The relationship between network size and loneliness was only significant in the ABI group. Only loneliness significantly predicted quality of life, emotional wellbeing, depression and anxiety in people with brain injury. The relationship between social isolation variables in ABI is discussed, as well as the theoretical and clinical implications of focusing on loneliness to improve mental health after brain injury.

Anxiety Trajectories the First 10 Years Following a Traumatic Brain Injury (TBI): A TBI Model Systems Study

OBJECTIVE

Determine anxiety trajectories and predictors up to 10 years post-traumatic brain injury (TBI).

DESIGN

Prospective longitudinal, observational study.

SETTING

Inpatient rehabilitation centers.

PARTICIPANTS

2,836 participants with moderate to severe TBI enrolled in the TBI Model Systems National Database who had ≥2 anxiety data collection points.

MAIN OUTCOME MEASURE

Generalized Anxiety Disorder-7 (GAD-7) at 1, 2, 5, and 10-year follow-ups.

RESULTS

Linear mixed models showed higher GAD-7 scores were associated with Black race (p<.001), public insurance (p<.001), pre-injury mental health treatment (p<.001), 2 additional TBIs with loss of consciousness (LOC) (p=.003), violent injury (p=.047), and more years post-TBI (p=.023). An interaction between follow-up year and age was also related to GAD-7 scores (p=.006). A latent class mixed model identified three anxiety trajectories: low-stable (n=2,195), high-increasing (n=289), and high-decreasing (n=352). The high-increasing and high-decreasing groups had ≥mild GAD-7 scores up to 10 years. Compared to the low-stable group, the high-decreasing group was more likely to be Black (OR=2.25), have public insurance (OR=2.13), have had pre-injury mental health treatment (OR=1.77), and have had 2 prior TBIs (OR=3.16).

CONCLUSIONS

A substantial minority of participants had anxiety symptoms that either increased (10%) or decreased (13%) over 10 years, but never decreased below mild anxiety. Risk factors of anxiety included indicators of socioeconomic disadvantage (public insurance) and racial inequities (Black race) as well as having had pre-injury mental health treatment and two prior TBIs. Awareness of these risk factors may lead to identifying and proactively referring susceptible individuals to mental health services.

The relationship between vocal affect recognition and psychosocial functioning for people with moderate to severe traumatic brain injury: a systematic review

The purpose of this review was to explore how vocal affect recognition deficits impact the psychosocial functioning of people with moderate to severe traumatic brain injury (TBI). A systematic review following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines was conducted, whereby six databases were searched, with additional hand searching of key journals also completed. The search identified 1847 records after duplicates were removed, and 1749 were excluded through title and abstract screening. After full text screening of 65 peer-reviewed articles published between January 1999 and August 2019, only five met inclusion criteria. The methodological quality of selected studies was assessed using the Mixed Methods Appraisal Tool (MMAT) Version 2018 with a fair level of agreement reached. A narrative synthesis of the results was completed, exploring vocal affect recognition and psychosocial functioning of people with moderate to severe TBI, including aspects of social cognition (i.e., empathy; Theory of Mind) and social behaviour. Results of the review were limited by a paucity of research in this area, a lack of high-level evidence, and wide variation in the outcome measures used. More rigorous study designs are required to establish more conclusive evidence regarding the degree and direction of the association between vocal affect recognition and aspects of psychosocial functioning. This review is registered with Prospero.

A Scoping Review of Predictors of Community Integration Following Traumatic Brain Injury: A Search for Meaningful Associations

OBJECTIVE

The purpose of this scoping review was to identify predictors of community integration for adults with traumatic brain injury.

DATA SOURCES

We searched the PubMed and PsycINFO databases and reviewed references of included studies. We selected studies exploring multiple components of community integration, including instrumental activities of daily living, leisure activities, and social activities. A total of 53 studies were included.

DATA EXTRACTION

We extracted data on sample size and sample characteristics (stage of injury and recovery, severity) and examined predictor variables, outcome measures for community integration, and significant findings, reported as correlations.

DATA SYNTHESIS

We found that the predictors of community integration fell into 4 categories: demographics, injury characteristics, disability and impairments, and environmental factors. There was large variability in reported relationships for demographics (r = 0.01-0.43), injury characteristics (r = 0.01-0.58), disability/functional impairments (r = 0.003-0.98) and environmental factors (r = 0.11-0.58). Cognition, disability, mobility/physical functioning, mood, social support, and length of posttraumatic amnesia had the strongest relationships with community integration outcomes.

CONCLUSIONS

Strategies for the management of cognitive, physical, and emotional functioning, and building and training a strong support system, may facilitate community integration outcomes. Additional work is warranted to further explore the discrepancies found among studies.

Domains and dimensions of community participation following traumatic brain injury

PRIMARY OBJECTIVE

To examine patterns of community participation, as well as the relationship among community participation outcomes and time since injury, impairments, environmental factors, and enfranchisement in adults with traumatic brain injury (TBI).

RESEARCH DESIGN

Cross-sectional study of a sample of 61 adults with TBI.

METHODS AND PROCEDURES

We administered the Participation Measure- 3 Domains 4 Dimensions to examine community participation in the three domains (productivity, community activities, and social participation) using four dimensions (diversity of activities, frequency, difficulty, and desire for change).

MAIN RESULTS AND OUTCOMES

All dimensions of community participation seem to be impaired following TBI, as evidenced by scores in the lower half of the available range. Most impaired was social participation (frequency: M = 10.0, SD = 3.4, possible range 0-24; difficulty: M=  11.3, SD = 3.2, possible range 4-16). Correlational analyses revealed that depression (r = 0.51), environmental factors (r = 0.51), and enfranchisement (r = 0.42), seem to play an important role in community participation outcomes, and may be potential targets for intervention. Results did not vary based on time since injury.

CONCLUSION

Our results suggest that depression, environmental factors, and enfranchisement may be important considerations for future interventions aiming to promote management of identified barriers.

Participation differences by age and depression 5 years after moderate-to-severe traumatic brain injury

Participation restrictions, including restrictions in employment, recreational activities, and social interactions, and depression are common after traumatic brain injury (TBI) and can profoundly affect individuals. Participation and depression demonstrate complex relationships with each other and over time as individuals age. This study (1) identified differences in participation between different age groups; (2) determined if participation differed between those with and without clinically significant depressive symptoms within each age group; and (3) determined the effect of the interaction between age groups and the presence or absence of clinically significant depressive symptoms on participation in community-dwelling adults with a moderate-to-severe TBI. Results indicate that, among community-dwelling adults 5 years post-TBI, there are significant differences in participation between age groups across the lifespan, with younger adults generally having higher levels of participation. Individuals with clinically significant depressive symptoms participate less than individuals without it within the same age group, except for adults over 65 years-old. For the productivity domain, age interacted with depressive symptoms, such that the presence of clinically significant depressive symptoms was associated with a larger difference in productivity in early-to-middle adulthood. Based on these findings, depression should be considered when providing interventions for participation and vice versa.

Mapping global evidence on strategies and interventions in neurotrauma and road traffic collisions prevention: a scoping review protocol

INTRODUCTION

Neurotrauma is an important global health problem. This 'silent epidemic' is a major cause of death and disability in adolescents and young adults, with significant societal and economic impacts. Globally, the largest cause of neurotrauma is road traffic collisions (RTCs). Neurotrauma and RTCs are largely preventable, and many preventative strategies and interventions have been established and implemented over the last decades, particularly in high-income countries. However, these approaches may not be applicable globally, due to variations in environment, resources, population, culture and infrastructure. This paper outlines the protocol for a scoping review, which seeks to map the evidence on strategies and interventions in neurotrauma and RTCs prevention globally, and to ascertain contextual factors that influence their implementation.

METHODS AND ANALYSIS

This scoping review will use the established methodology by Arksey and O'Malley. Eligible studies will be identified from five electronic databases (MEDLINE, EMBASE, CINAHL, Global Health/EBSCO and Cochrane Database of Systematic Reviews) and grey literature sources. We will also carry out bibliographical and citation searching of included studies. A two-stage selection process, which involves screening of titles and abstracts, followed by full-text screening, will be used to determine eligible studies which will undergo data abstraction using a customised, piloted data extraction sheet. The extracted data will be presented using evidence mapping and a narrative summary.

ETHICS AND DISSEMINATION

Ethical approval is not required for this scoping review, which is the first step in a multiphase public health research project on the global prevention of neurotrauma. The final review will be submitted for publication to a scientific journal, and results will be presented at appropriate conferences, workshops and meetings. Protocol registered on 5 April 2019 with Open Science Framework (https://osf.io/s4zk3/).

Predicting the Trajectory of Participation After Traumatic Brain Injury: A Longitudinal Analysis

OBJECTIVE

To identify factors that predict trajectories of participation over the first 5 years after moderate to severe traumatic brain injury (TBI).

SETTING

TBI Model System Programs.

PARTICIPANTS

Community-dwelling individuals with TBI, 16 years of age or older (n = 1947).

DESIGN

Secondary analysis of a prospective, nonrandomly sampled, longitudinal data registry.

MAIN MEASURES

Participation Assessment with Recombined Tools-Objective (PART-O).

RESULTS

Age at injury and FIM Motor score predicted trajectory of participation over the first 5 years after moderate to severe TBI. Older age predicted generally worse participation overall as well as progressively worsening participation over time. Higher FIM Motor raised the predicted participation values, although it reduced the rate of improvement in participation scores over time. FIM Cognitive scores, race, depression, years of education, and living setting did not predict trajectory but did significantly influence participation consistently at all time points.

CONCLUSION

The trajectories of participation over the first 5 years after TBI can be predicted by age at injury and FIM Motor scores. These findings may enhance the ability of rehabilitation professionals to identify individuals at risk for poor participation after TBI and develop targeted interventions for optimizing involvement in life activities.

Examining Driving and Participation 5 Years After Traumatic Brain Injury

Participation is often considered a primary goal of traumatic brain injury (TBI) rehabilitation, but little is known about the influence of driving on participation after TBI. The objective of this study was to examine the independent contribution of driving status to participation at 5 years post TBI, after controlling for demographic, psychosocial, and functional factors. Participants ( N = 2,456) were community-dwelling individuals with moderate to severe TBI, age 18 to 65 at time of injury, and enrolled in the TBI Model Systems (TBIMS) National Database (NDB). Hierarchical linear regressions for the dependent variable of participation at 5 years post TBI were performed. Findings showed that driving was a highly significant independent predictor of participation and was a stronger relative predictor of participation than FIM® Cognitive, FIM® Motor, and depression. The independent contribution of driving to participation suggests the need to develop evidenced-based occupational therapy assessments and interventions that facilitate safe engagement in the occupation of driving to address the long-term goal of improved participation.

Affect and Incident Participation Restriction in Adults With Knee Osteoarthritis

OBJECTIVE

Participation restriction, common among people with knee osteoarthritis (OA), may be influenced by affect. We examined the risk of incident participation restriction over 84 months conferred by positive and negative affect among people with knee OA.

METHODS

Participants were from the Multicenter Osteoarthritis Study and had or were at high risk of knee OA. Participation restriction was measured using the Instrumental Role Limitation subscale of the Late-Life Disability Index, and affect was measured using the positive affect and depressed mood subscales of the Center for Epidemiologic Studies Depression Scale. Robust Poisson regression was used to calculate the risk of incident participation restriction over 84 months conferred by combinations of low and high positive and negative affect, adjusting for covariates.

RESULTS

Of 1,810 baseline participants (mean age 62.1 years, 56% female), 470 (26%) had incident participation restriction over 84 months. Participants with low positive affect had 20% greater risk of incident participation restriction than those with high positive affect; participants with high negative affect had 50% greater risk of incident participation restriction compared to those with low negative affect. Participants with both low positive and high negative affect had 80% greater risk of incident participation restriction compared to other combinations of positive and negative affect.

CONCLUSION

Low positive and high negative affect, both alone and in combination, increase the risk of participation restriction among adults with knee OA. Efforts aimed at preventing participation restriction in this population should consider these mood states.

The Effect of a Single Bout of Surfing on Exercise-Induced Affect

Exercise-induced affect (EIA) has been well documented and is often composed of positive affect, negative affect, tranquility, and fatigue. Research on EIA has focused on mainstream sports such as running, walking, or cycling; however, no research has evaluated the influence of action sports participation in activities such surfing on EIA. The current study examined the effect of a single 30-min surfing bout on EIA in 107 adult volunteers. An additional purpose was if change in affect was similar based on surfing history, surfing frequency, and surfing skill level. To assess EIA, each participant completed the Physical Activity Affect Scale (PAAS) prior to and immediately following the 30-min surf session. Dependent t-tests were used to examine differences between pre- and post-test EIA. For the secondary purpose, a change score (PAAS posttest-PAAS pretest) was computed for each subscale. One-way ANOVAs were performed to determine differences among comparisons of surfing history, surfing frequency, and surfing skill level, and the change score for each of the 4 subscales. EIA was significantly altered by surfing, with significant improvements in positive affect and tranquility, and significant reductions in negative affect and fatigue. There were no significant differences among surfing history, surfing frequency, and surfing skill level, and positive affect, negative affect or tranquility. However, there were significant differences between fatigue and surfing history, surfing frequency, and surfing skill level. The results indicate that a single 30-min surfing bout may provide positive benefits for the participant. Implications for future surfing research and EIA are discussed.

Exploring the relationship between boredom proneness and self-control in traumatic brain injury (TBI)

Characterized as an agitated state in which the individual is motivated to engage in their environment but all attempts to do so fail to satisfy, boredom represents a disengaged attentional state that is associated with negative affect and poor self-control. There have been anecdotal reports of increased levels of boredom post-traumatic brain injury (TBI). For the first time, we provide objective evidence that TBI patients do indeed experience higher levels of boredom proneness. Hierarchical regression analyses showed that the presence and severity of head injury were a significant positive predictor of levels of boredom proneness and a negative predictor of self-control. As with healthy controls, TBI patients showed a strong negative correlation between boredom proneness and self-control-those with lower levels of self-control exhibited higher levels of boredom proneness. This was despite the fact that our TBI patients reported higher overall levels of self-control (probably concomitant with their older mean age). The TBI patients also showed strong positive correlations between boredom proneness and measures of physical aggression and anger. Together, this suggests that patients with TBI may be more susceptible to increased levels of boredom proneness and other negative affective states that arise as a consequence of failures of self-control.