Experiences of individuals with acquired brain injury and their families interacting with community services: a systematic scoping review

PURPOSE

This scoping review aims to (1) synthesise the research findings on the experiences of individuals with acquired brain injuries, and their families, when interacting with, or accessing, community-based services and (2) identify where gaps in service provision may exist and their cause.

METHODS

A systematic search strategy was employed across multiple databases to identify all studies relating to the experiences of individuals with acquired brain injuries and their families when interacting with, or accessing, community-based services. Inclusion was assessed by at least two reviewers at each stage and data extraction was completed by one researcher and validity checked by another. A narrative synthesis was employed.

RESULTS

A total of 101 papers met the inclusion criteria with the narrative synthesis identifying three main themes of (1) unmet needs, (2) types of access, and (3) barriers to access.

CONCLUSIONS

The results identify that those with acquired brain injuries, and their families, experience significant difficulties interacting with community-based services and often do not receive appropriate access. Many barriers to access were identified including a lack of knowledge of the long-term effects of acquired brain injury amongst professionals working in health and social care services.Implications for rehabilitationBrain injury is a leading cause of disability worldwide with a range of physical, cognitive, emotional, and behavioural difficulties.It is important that service users and families are given appropriate information about the long-term difficulties associated with ABI so they are better informed about the types of support they may need upon discharge from hospital.Rehabilitation professionals need to ensure they have good level of knowledge of the difficulties associated with ABI to ensure appropriate access to services for individuals and their families.Understanding more about unmet needs allows community rehabilitation services to be tailored and person-centred.

Neurobiological Mechanisms Of Depression Following Traumatic Brain Injury

OBJECTIVE

Depression is among the most pervasive and debilitating neuropsychiatric sequelae experienced by patients following a traumatic brain injury (TBI). While the individual mechanisms underlying depression and TBI have been widely studied, the neurobiological bases of depression after TBI remain largely unknown. This article highlights the potential mechanisms of action implicated in depression after TBI.

RESULTS

We review putative mechanisms of action including neuroinflammation, neuroendocrine dysregulation, metabolic abnormalities, and neurotransmitter and circuitry dysfunction. We also identify the current limitations in the field and propose directions for future research.

CONCLUSION

An improved understanding of the underlying mechanisms will aid the development of precision-guided and personalized treatments for patients suffering from depression after TBI.

Brain Trauma, Glucocorticoids and Neuroinflammation: Dangerous Liaisons for the Hippocampus

Glucocorticoid-dependent mechanisms of inflammation-mediated distant hippocampal damage are discussed with a focus on the consequences of traumatic brain injury. The effects of glucocorticoids on specific neuronal populations in the hippocampus depend on their concentration, duration of exposure and cell type. Previous stress and elevated level of glucocorticoids prior to pro-inflammatory impact, as well as long-term though moderate elevation of glucocorticoids, may inflate pro-inflammatory effects. Glucocorticoid-mediated long-lasting neuronal circuit changes in the hippocampus after brain trauma are involved in late post-traumatic pathology development, such as epilepsy, depression and cognitive impairment. Complex and diverse actions of the hypothalamic–pituitary–adrenal axis on neuroinflammation may be essential for late post-traumatic pathology. These mechanisms are applicable to remote hippocampal damage occurring after other types of focal brain damage (stroke, epilepsy) or central nervous system diseases without obvious focal injury. Thus, the liaisons of excessive glucocorticoids/dysfunctional hypothalamic–pituitary–adrenal axis with neuroinflammation, dangerous to the hippocampus, may be crucial to distant hippocampal damage in many brain diseases. Taking into account that the hippocampus controls both the cognitive functions and the emotional state, further research on potential links between glucocorticoid signaling and inflammatory processes in the brain and respective mechanisms is vital.

Association between perceived distress and salivary cortisol in veterans with mTBI

Mild traumatic brain injury (mTBI) is one of the most common injuries experienced by Veterans and can frequently result in a variety of post-concussive symptoms. Post-concussive headaches (PCH), one of the most common symptoms, can persist for years after the injury occurred. The long-lasting impacts of PCH can be extremely distressing for Veterans, thus necessitating the need to find reliable biomarkers that directly relate to subjective feelings of distress. Yoga-based interventions have been shown to improve both subjective and objective markers of stress. Techniques used in yoga, such as the focus on releasing muscular tension, are also recommended as strategies for treating PCH. Thus, yoga-based interventions provide a unique context for the comparison of subjective and objective measures of distress in Veterans with PCH. In this secondary, exploratory analysis, we examined the relationship between perceived distress and cortisol in sixteen Veterans with mTBI and long-term PCH within the context of a yoga intervention feasibility study. The Visual Analogue Scale (VAS), a validated tool for measuring subjective distress, was administered to participants immediately before and after 75-min yoga classes, which occurred twice weekly over eight weeks. Participants also provided salivary cortisol (pre- and post-yoga) at in-person sessions (eight) to compare to changes in VAS scores. We found that VAS scores were significantly reduced within five of the eight assessed yoga classes, but there were no significant changes in cortisol levels. No significant correlations were found between VAS scores and salivary cortisol levels. When looking at how cortisol levels changed over time (i.e., over the series of eight yoga sessions), there was a significant downward trajectory in post-yoga cortisol, but not after taking pre-class cortisol into account (i.e., within yoga session cortisol change over time). Taken together, we found that subjective distress, but not cortisol was reduced by yoga classes. These data suggest that salivary cortisol did not match changes in perceived distress, thus emphasizing the ongoing challenges of relating subjective and objective measures.

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Perceived distress can negatively impact post-concussive symptoms.

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Efforts are needed to relate objective and subjective measures of distress.

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Subjective distress and salivary cortisol were examined within yoga sessions.

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Subjective distress, but not cortisol was reduced within 5 of 8 yoga classes.

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These data highlight the challenges of relating subjective and objective measures.

ASSOCIATION BETWEEN ALTERED CORTISOL PROFILES AND NEUROBEHAVIORAL IMPAIRMENT FOLLOWING mTBI IN COLLEGE STUDENTS

Mild Traumatic Brain Injury (mTBI) is the most common form of TBI, accounting for over 2.5 million TBI cases in the United States annually. Identification of easily obtainable biomarkers that track strongly with mTBI symptoms may improve our understanding of biological factors that contribute to mTBI symptom profiles and long-term outcomes. Notably, some individuals with mTBI exhibit circadian disruptions and elevated stress sensitivity, which in other clinical groups often correlate with disrupted secretion of cortisol, a glucocorticoid hormone that coordinates circadian and stress physiology. Here, we sought to determine whether cortisol profiles could serve as a biomarker to complement the assessment of neurobehavioral sequelae following mTBI. We partnered with our on-campus health clinic to recruit college students seeking medical care following mTBI (n=46) and compared this population to a well-matched non-injured student control group (n=44). We collected data at an initial visit (shortly after injury in mTBI subjects) and one week later. At each visit, we evaluated neurobehavioral function using the Automated Neuropsychological Assessment Metric (ANAM). Our subjects then provided cortisol samples through at-home saliva collection. We observed strong coherence between ANAM subjective and objective measures, indicating significant multidimensional impairment in those with mTBI. Further, female mTBI subjects exhibited diminished neurobehavioral function compared to males. Regardless of sex, decreased amplitude of diurnal cortisol and a blunted cortisol awakening response predicted mTBI symptom severity and neurobehavioral impairment. Taken together, these findings suggest that salivary cortisol profiles may be a sensitive biomarker for studying underlying biological factors that impact mTBI outcomes.

Cognitive disengagement and biological stress responses in early adolescence

Individual differences in biological responses to stress increase risk for the onset and exacerbation of health and psychiatric conditions. Biases in cognitive disengagement are hypothesized to underlie these individual differences in biological responses to stress. However, no studies have examined which cognitive disengagement bias has the strongest relation with biological responses to stress, and no studies have examined this relation during early adolescence, despite evidence that this is a critical developmental window in which patterns of cognition and biological responses to stress influence trajectories of health throughout life. The current study is the first to test whether difficulty disengaging attention versus working memory from valenced stimuli is associated with biological responses to stress in early adolescence. Youth between 11 and 13 years of age completed two computer-based tasks to assess biases in attention and working memory disengagement to valenced stimuli, and then completed a standardized psychosocial stressor. Consistent with expectations, attention and working memory disengagement biases were associated with stress responses of both the neuroendocrine and autonomic nervous systems, but bias valence and cognitive system influenced the directionality of results. These findings inform our understanding of cognitive mechanisms that influence biological stress reactivity.

Relationship between depression, community integration and life satisfaction following mild traumatic brain injury

Purpose: Compared to studies on moderate and severe traumatic brain injury (TBI), less literature exists concerning the consequences of mild traumatic brain injury (mTBI) on community integration and life satisfaction, especially in the early phase of recovery. Moreover, a better understanding of the variables that contribute to community integration and life satisfaction is still needed. The aim of the study was to assess the association of mood, fatigue and post-concussive symptoms with community integration and life satisfaction early following mTBI.Research method: A total of 85 participants aged between 18 and 61 years who sustained mTBI were included. Participants answered web-based questionnaires measuring anxiety and depression symptoms, fatigue, post-concussive symptoms, community integration and life satisfaction in the first three months post mTBI.Results: Post-concussive symptoms, fatigue and anxiety were not associated with community integration or life satisfaction. However, depressive symptoms were negatively associated with community integration and life satisfaction.Conclusions: Among all acute post-concussive symptoms following mTBI, depressive symptoms seem to have strongest relationship with community integration and life satisfaction. Acute psychological intervention targeting these symptoms is strongly recommended.

Accepting what we do not know: A need to improve professional understanding of brain Injury in the UK

Acquired brain injury (ABI) can lead to life-long changes and disability. The complex and extensive nature of behavioural, cognitive, executive, physical and psychological difficulties mean ABI survivors and their families may come into contact with a range of health and social care services as part of their long-term care. This study aimed to understand the ABI knowledge base of professionals across a range of organisations within the UK, and to identify areas for improvement. This was achieved through a mixed methods approach using a mixed methods questionnaire (117 participants) and qualitative semi-structured interviews about service experiences (31 participants) of professionals and service users (families and individuals with ABI). Participants included UK health and social care professionals, ABI specialists, ABI survivors and family members. Data were collected from February 2017 to April 2018. The results of the study identified a lack of knowledge and understanding of ABI among health and social care professionals in the UK, from those involved in acute care through to long-term community services. Poor knowledge was associated with a lack of understanding of "hidden" disabilities associated with ABI, a lack of empathy and a lack of knowledge regarding specific safeguarding. Health and social care professionals across a range of services could benefit in ABI-specific training to improve their knowledge and improve the service currently being provided to individuals with ABI and their families.

Minimally-invasive methods for examining biological changes in response to chronic stress: A scoping review

BACKGROUND

Nurse researchers are increasingly interested in incorporating biological indicators related to chronic stress, or repeated or constant exposure to psychological stressors. Minimally invasive collection methods may improve access to vulnerable populations.

OBJECTIVE

To map biological indicators measured through minimally invasive methods investigating biological changes in response to chronic stress.

DESIGN, DATA SOURCES, AND METHODS

The paper seeks to answer two questions: What are the characteristics of the minimally-invasive methods used to measure the biological correlates of chronic stress? What are the limitations regarding the use of the minimally-invasive methods and/or biological indicators identified above? Authors completed a scoping review following guidelines from the Joanna Briggs Institute Manual and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews. A literature search was completed in PubMed, PsycINFO, and Scopus. 2518 articles were screened and 145 studies were included. Data were extracted using a standardized extraction tool, compiled, and coded.

RESULTS

Studies included minimally-invasive methods to measure the hypothalamic-adrenal-pituitary axis (N = 173), immune and inflammatory markers (N = 118), and adult neurogenesis (N = 6). Cortisol was most frequently measured (N = 136), usually in saliva (N = 86). Studies included a variety of limitations for the methods and indicators, including concerns about timing and accuracy of collection, frequency of sampling, and controlling for acute stressors.

CONCLUSIONS

Nurse researchers have access to many minimally-invasive methods to measure altered biological processes related to chronic stress. A gap identified by this review is the paucity of minimally-invasive methods for investigating neurogenesis; the measurement of brain derived neurotrophic factor in plasma is a distal proxy and further research is needed to test the response of peripheral levels to psychosocial stress interventions. Additionally, while this scoping review allows nurse researchers to consider possible biological indicators to include in their research, future research is still needed on some of the basic premises of stress research, including agreement on the conceptualization of chronic stress.

The blockade of corticotropin-releasing factor 1 receptor attenuates anxiety-related symptoms and hypothalamus-pituitary-adrenal axis reactivity in mice with mild traumatic brain injury

Recent studies have shown that mild traumatic brain injury (mTBI) is associated with higher risk for anxiety-related disorders. Dysregulation in the hypothalamus-pituitary-adrenal (HPA) axis following mTBI has been proposed to be involved in the development of neurobehavioral abnormalities; however, the underlying mechanisms are largely unknown. The aim of this study was to determine whether the corticotropin-releasing-factor-1 (CRF-1) receptor is involved in the regulation of anxiety-related symptoms in a mouse model of mTBI. Animals with or without mTBI received intracerebroventricular injections of a CRF-1 receptor agonist (CRF; 0.01 nmol/mouse) or antagonist (antalarmin; 1 µg/mouse) for 5 days, and then the animals were subjected to anxiety tests (light-dark box and zero maze). The levels of adrenocorticotropic hormone and corticosterone, the most important markers of HPA axis, were also measured after behavioral tests. Our results indicated that mTBI-induced anxiety-related symptoms in mice through increased levels of adrenocorticotropic hormone and corticosterone, showing HPA axis hyperactivity. Interestingly, activation of CRF receptor by a subthreshold dose of CRF resulted in significant increases in anxiety-like behaviors and HPA axis response to stress, whereas blockade of CRF receptors by a subthreshold dose of antalarmin decreased anxiety-related symptoms and HPA axis response to stress in mTBI-induced mice. Collectively, these findings suggest that the CRF-1 receptor plays an important role in the regulation of anxiety-related behaviors following mTBI induction in mice and support the hypothesis that blockade of the CRF-1 receptor may be a promising therapeutic target for anxiety-related disorders in patients with TBI.

Modifying and Validating a Measure of Chronic Stress for People With Aphasia

PURPOSE

Chronic stress is likely a common experience among people with the language impairment of aphasia. Importantly, chronic stress reportedly alters the neural networks central to learning and memory-essential ingredients of aphasia rehabilitation. Before we can explore the influence of chronic stress on rehabilitation outcomes, we must be able to measure chronic stress in this population. The purpose of this study was to (a) modify a widely used measure of chronic stress (Perceived Stress Scale [PSS]; Cohen & Janicki-Deverts, 2012) to fit the communication needs of people with aphasia (PWA) and (b) validate the modified PSS (mPSS) with PWA.

METHOD

Following systematic modification of the PSS (with permission), 72 PWA completed the validation portion of the study. Each participant completed the mPSS, measures of depression, anxiety, and resilience, and provided a sample of the stress hormone cortisol extracted from the hair. Pearson's product-moment correlations were used to examine associations between mPSS scores and these measures. Approximately 30% of participants completed the mPSS 1 week later to establish test-retest reliability, analyzed using an interclass correlation coefficient.

RESULTS

Significant positive correlations were evident between the reports of chronic stress and depression and anxiety. In addition, a significant inverse correlation was found between reports of chronic stress and resilience. The mPSS also showed evidence of test-retest reliability. No association was found between mPSS score and cortisol level.

CONCLUSION

Although questions remain about the biological correlates of chronic stress in people with poststroke aphasia, significant associations between chronic stress and several psychosocial variables provide evidence of validity of this emerging measure of chronic stress.

Clinical and Biochemical Outcomes Following EEG Neurofeedback Training in Traumatic Brain Injury in the Context of Spontaneous Recovery

It has been found that reduction of posttraumatic stress symptoms is positively associated with the reduction of postconcussive symptoms. Cortisol is commonly used as a biomarker of stress. Understanding the role of posttraumatic stress and cortisol in symptom reduction has implication for neuropsychological rehabilitation particularly in the context of spontaneous recovery.

OBJECTIVE

The aim of the research was to study the effectiveness of EEG neurofeedback training on clinical symptoms, perceived stress, and cortisol in traumatic brain injury (TBI) patients in the context of spontaneous recovery.

METHODS

The design was an experimental longitudinal design with the pre-post comparison. The sample comprised 60 patients with the diagnosis of TBI-30 patients in the neurofeedback training (NFT) group and 30 patients in the treatment as usual group (TAU) group. Half of the patients were recruited within 6 months of injury to study the role of spontaneous recovery and the other half were recruited in the 12 to 18 months postinjury phase. Alpha-theta training was given to the NFT group over 20 sessions. Pre and post comparisons were made on clinical symptom rating, perceived stress, and serum cortisol levels.

RESULTS

The results indicate significant differences in symptom reporting and perceived stress between the NFT and TAU groups. Significant differences were also seen in cortisol levels with implications for the acute recovery phase.

CONCLUSION

Alpha-theta NFT has a beneficial effect on symptom reduction as well as perceived stress. It also has a beneficial effect on levels of serum cortisol, corroborating these findings.

Mindfulness-Based Versus Health Promotion Group Therapy After Traumatic Brain Injury

The current pre- and posttest intervention study is designed for individuals with chronic symptoms and stress associated with mild-to-moderate traumatic brain injury (TBI). The researchers' intent was to evaluate whether an 8-week mindfulness-based group therapy compared to health promotion active control group therapy reduces chronic stress, TBI symptoms, and depressive symptoms. Significant mean reductions in chronic stress and TBI depressive and general symptoms for individuals in the mindfulness group compared to the active control group were present, according to paired t test analyses. Further, while controlling for baseline scores, the mindfulness-based intervention group change score was greater compared to the control group using regression analyses. Results suggest that mindfulness-based group intervention for individuals with chronic difficulties after TBI is feasible and effective. Further study of this cost-effective and self-management approach to stress and symptom management is warranted and has the potential to be a broad-based intervention for early therapy after injury. [Journal of Psychosocial Nursing and Mental Health Services, 57(1), 26-33.].

Prevention Strategies in Post-TBI Depression in Older Adults: A Case Study

PURPOSE

The purpose of this study was to describe a theoretically focused intervention aimed toward chronic stress and depressive symptom management that is coordinated by a case manager and delivered within a home environment by the caregiver.

PRIMARY PRACTICE SETTING

Home care, community setting.

METHODS

A case study of an older adult with traumatic brain injury (TBI) secondary to a fall who had significant allostatic load at the time of his injury. "Allostatic load" is a theoretical construct that suggests the brain is experiencing chronic strain on its systems that flexibly respond to stressors. Sustained allostatic load can contribute to chronic conditions and poor outcomes.

FINDINGS

Through actions with the family as caregivers, the case manager was able to coordinate a structured home setting and gradual resumption of social activities for this older adult. Focus was on establishing structure, meaningful social interactions, and positive home experiences that maximized the older adult's interests and capacity and mitigated chronic stress. Gradually, the older adult returned to his preinjury capacity and lives independently within the family home.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

The case management process has the potential to mitigate stressors and improve depression management through family-focused care. Although there is limited guidance on prevention of depression, this approach resulted in attainment of safe home care, no hospital readmissions, and return to previous lifestyle for the older adult. This could be useful in the prevention of post-TBI depression.

Physiological emotional under-arousal in individuals with mild head injury

PRIMARY OBJECTIVES

This study examined the potential emotional sequelae following self-reported mild head injury (MHI; e.g. 'altered state of consciousness' [ASC]) in university students with a particular focus on arousal status and responsivity to experimental manipulation of arousal.

RESEARCH DESIGN

A quasi-experimental design (n = 91) was used to examine arousal status (self-reported and physiological indices) and response to manipulated arousal (i.e. induced psychosocial stress/activation; reduced activation/relaxation) between persons who acknowledged prior MHI and persons with no-MHI.

MAIN OUTCOME AND RESULTS

University students who self-reported MHI were physiologically under-aroused and less responsive to stressors (both laboratory and environmental) compared to their no-MHI cohort. Those with reported loss of consciousness demonstrated the most attenuated emotional arousal responses (i.e. flattened electrodermal responsivity) relative to those with only a reported ASC, followed by those with no-MHI.

CONCLUSIONS

The under-arousal in traumatic brain injury has been hypothesized to be associated with ventromedial prefrontal cortex disruption. This under-arousal may be mirrored in persons who self-report experiencing subtle head trauma. Students who reported MHI may be less able to physiologically respond and/or cognitively appraise stressful experiences as compared to their no-MHI cohort; and experience subtle persistent consequences despite the subtle nature of the reported head trauma.

Interpersonal relatedness and psychological functioning following traumatic brain injury: implications for marital and family therapists

Recovery from a mild-to-moderate traumatic brain injury (TBI) is a challenging process for injured persons and their families. Guided by attachment theory, we investigated whether relationship conflict, social support, or sense of belonging were associated with psychological functioning. Community-dwelling persons with TBI (N = 75) and their relatives/significant others (N = 74) were surveyed on relationship variables, functional status, and TBI symptom severity. Results from this cross-sectional study revealed that only sense of belonging was a significant predictor of postinjury psychological functioning, although interpersonal conflict approached significance. No relevant preinjury or injury-related variables impacted these relationships, except marital status. Our findings suggest that interventions targeting strengthening the injured persons' sense of belonging and lowering interpersonal conflict may benefit those living with TBI.

Chronic stress and fatigue-related quality of life after mild to moderate traumatic brain injury

OBJECTIVE

To determine relationships among chronic stress, fatigue-related quality of life (QOL-F), and related covariates after mild to moderate traumatic brain injury (TBI).

DESIGN

Observational and cross-sectional.

PARTICIPANTS

A total of 84 community-dwelling individuals with mild to moderate TBI recruited from multiple out patient rehabilitation clinics assessed on average 15 months after injury.

METHOD

Self-report surveys and chart abstraction.

MEASURES

Neurofunctional Behavioral Inventory, Perceived Stress Scale-14, Impact of Events Scale, McGill Pain Short-form Scale, and modified version of the Fatigue Impact Scale.

RESULTS

QOL-F was associated with somatic symptoms, perceived situational stress, but not with event-related stress (posttraumatic stress disorder symptoms) related to index TBI, preinjury demographic, or postinjury characteristics. Somatic symptoms and chronic situational stress accounted for 42% of the variance in QOL-F.

CONCLUSIONS

QOL-F in community-dwelling individuals with mild to moderate TBI is associated with chronic situational stress and somatic symptoms. Symptom management strategies may need to include general stress management to reduce fatigue burden and improve quality of life.

Mild traumatic brain injury: a Midwest survey of discharge teaching practices of emergency department nurses

Research indicates that the assessment and discharge teaching practices for persons with traumatic brain injury are more focused on ruling out severe brain injury and informing the person about "red flags" warranting a return visit to the medical provider. Our primary purpose was to determine the extent to which discharge practices were aligned with the Centers for Disease Control and Prevention guidelines contained within the Acute Concussion Evaluation care plan. Responses from 87 nurses (25.0% response rate) to a tailored survey were analyzed to determine emergency department nurses' discharge teaching practices for adults who experienced a mild traumatic brain injury (MTBI). Results indicated that nurses in general were focused on injury-specific information and less often provided information about MTBI, symptom management, or strategies for preventing future brain damage. System improvements are justified to provide injured persons with a clearly defined diagnosis and instructions for follow-up and symptom management.

Relationship between depression anxiety stress scale (DASS) and urinary hydroxyproline and proline concentrations in hospital workers

OBJECTIVES

Although increased reactive oxygen species (ROS) is caused by stress accelerates collagen degradation, there was no data on the relationship between stress and urinary hydroxyproline (Hyp) and proline (Pro), a good marker of collagen degradation. The purpose of this study was to evaluate the relationship between depression, anxiety, and stress (DAS) and concentrations of urinary Hyp and Pro.

METHODS

97 hospital employees aged 20 to 58 were asked to fill out comprehensive self-administrated questionnaires containing information about their medical history, lifestyle, length of the work year, shift-work and DAS. depression anxiety stress scale (DASS) was applied to evaluate chronic mental disorders. Urine samples were analyzed using high performance liquid chromatography (HPLC) with double derivatization for the assay of hydroxyproline and proline.

RESULTS

The mean value of Hyp and Pro concentration in all subjects was 194.1 ± 113.4 μmol/g and 568.2 ± 310.7 μmol/g. DASS values and urinary Pro concentrations were differentiated by sex (female > male, p < 0.05) and type of job (nurse > others, p < 0.05). In the stepwise multiple linear regressions, urinary Hyp and Pro concentrations were influenced by stress (Adjusted r2 = 0.051) and anxiety and job (Adjusted r2 = 0.199), respectively.

CONCLUSIONS

We found that stress and anxiety were correlated with urinary Hyp and Pro concentrations. To identifying a definite correlation, further study in large populations will be needed.

Association of daily stressors and salivary cortisol in spinal cord injury

OBJECTIVE

Examine the diurnal variation of salivary cortisol in adults with spinal cord injury (SCI) and the effect of stressors on cortisol and mood.

METHOD

Ecological momentary assessment (EMA) to capture cortisol, stress, and mood from 25 persons with SCI and 26 without SCI. Data were analyzed using linear mixed models.

RESULTS

There were no systematic differences between groups on missing data. Diurnal variation of cortisol of participants with SCI reflected an expected pattern. No significant group differences for cortisol diurnal pattern, stress, or mood; when group interactions were significant, results indicated lower cortisol reactivity to stress in participants with SCI. Stress had a significant impact on positive, negative and agitated moods.

CONCLUSIONS

Stress in daily life and its association with cortisol and mood were largely similar between persons with and without SCI. A key methodological contribution is the demonstration of using EMA to collect biological and behavioral data in the field from participants with SCI. The use of EMA in rehabilitation psychology research has great potential to advance our understanding of the dynamics of daily life with disability.

Psychological and biological correlates of fatigue after mild-to-moderate traumatic brain injury

Relationships between chronic perceived stress, cortisol response (area under the curve) and posttraumatic brain injury fatigue were examined with persons from outpatient settings. Seventy-five injured persons with traumatic brain injury and their relatives/significant others participated in this cross-sectional study. Using interviews and self-reported data from the Neurofunctional Behavioral Inventory, the Perceived Stress Scale, the Profile of Mood States-Fatigue subscale, the McGill Pain Scale, as well as self-collection of salivary cortisol over a 12-hour period (N = 50), we found that perceived chronic stress explained 40% of the variance in fatigue until depressive symptoms and pain were in the model. Hypocortisolemia was evident. Somatic symptom frequency and perceived chronic stress represented 50% of the variability in post-TBI fatigue. Fatigue and stress management interventions, as suggested in the Centers for Disease Control Acute Concussion guidelines, may be beneficial in reducing this common symptom.