Psychosexual consequences of traumatic brain injury: methodology and preliminary findings

Factors Contributing to Life-Change Adaptation in Family Caregivers of Community-Dwelling Individuals with Acquired Brain Injury

Acquired brain injury (ABI) is a public health issue that affects family caregivers, because individuals with ABI often require semi-permanent care and community support in daily living. Identifying the characteristics of family caregivers and individuals with ABI and examining life-change adaptation may provide valuable insights. The current study sought to explore the factors contributing to life-change adaptation in family caregivers of community-dwelling individuals with ABI. As a secondary analysis, a cross-sectional study was conducted using data obtained in a previous study of 1622 family caregivers in Japan. We hypothesized that life-change adaptation in family caregivers of individuals with ABI would also be related to family caregivers' characteristics and the characteristics of individuals with ABI. In total, 312 valid responses were analyzed using Poisson regression analysis. The results revealed that life-change adaptation in family caregivers of individuals with ABI was related to sex (prevalence ratio [PR]: 0.65, confidence interval [CI]: -0.819;-0.041) and mental health (PR: 2.04, CI: 0.354; 1.070) as family caregivers' characteristics, and topographical disorientation (PR: 1.51, CI: 0.017; 0.805) and loss of control over behavior (PR: 1.61, CI: 0.116; 0.830) as the characteristics of individuals with ABI, after adjusting for the effects of the caregiver's age, sex, and the duration of the caregiver's role. The current study expands existing knowledge and provides a deeper understanding to enhance the development of specific policies for improving caregiving services and supporting families.

A qualitative study on the attitudes and approaches of Australian clinicians in addressing sexuality after acquired brain injury

PURPOSE

Studies indicate that up to 50% of survivors of acquired brain injury (ABI) experience persistent changes in sexuality. However, research on clinicians' perspectives in addressing sexuality issues post-ABI is limited. This study explored the attitudes and approaches, barriers and facilitators, and training preferences of Australian clinicians in addressing sexuality in individuals post-ABI.

METHOD

Purposive sampling was used to recruit 20 Australian multi-disciplinary clinicians from a related survey study. Semi-structured interviews were conducted and qualitatively analysed using thematic analysis.

RESULTS

Three broad themes were identified: ABI results in multi-faceted changes in sexuality; there is a fundamental discomfort in talking about sexuality; and, strategies proposed by clinicians may help to improve sexuality support. Participants also provided suggestions for sexuality training, which they believed should start at university.

CONCLUSION

Most clinicians are aware of sexuality issues post-ABI but fail to adequately address sexuality in individuals post-ABI due to personal levels of discomfort, perpetuated by institutional factors. Therefore, participants believe that changes made at individual and institutional levels may increase sexuality support for individuals with ABI. However, further research on the causes and treatment of sexual problems and patient perspectives is required to provide the evidence-based guidelines and training programs that clinicians require.Implications for rehabilitationUp to half of individuals experience changes in sexuality after ABI that restrict quality of life and relationships.The consequences of ABI and their impacts on sexuality are understood by Australian clinicians but remain largely unaddressed due to individual discomfort, perpetuated by institutional factors.This study suggests that professional training targeted towards understanding, assessing and treating sexuality issues post-ABI may help to reduce the discomfort.Adjustments should also be made at individual, policy and procedural levels to ensure that sexuality is addressed within rehabilitation post-ABI.

Association of Concussion Symptoms With Testosterone Levels and Erectile Dysfunction in Former Professional US-Style Football Players

Question

Are professional US-style football players with a history of multiple concussion symptoms more likely to report indicators of low testosterone levels or erectile dysfunction (ED)?

Findings

In this cross-sectional study of 3409 former players, a monotonically increasing association was found between the number of concussion symptoms and the odds of reporting an indicator of low testosterone level and ED.

Meaning

Concussion symptoms among former football players were associated with low testosterone levels and ED indicators, suggesting that men with a history of head injury may benefit from discussions with their health care clinicians regarding these treatable outcomes.

Importance

Small studies suggest that head trauma in men may be associated with low testosterone levels and sexual dysfunction through mechanisms that likely include hypopituitarism secondary to ischemic injury and pituitary axonal tract damage. Athletes in contact sports may be at risk for pituitary insufficiencies or erectile dysfunction (ED) because of the high number of head traumas experienced during their careers. Whether multiple symptomatic concussive events are associated with later indicators of low testosterone levels and ED is unknown.

Objective

To explore the associations between concussion symptom history and participant-reported indicators of low testosterone levels and ED.

Design, Setting, and Participants

This cross-sectional study of former professional US-style football players was conducted in Boston, Massachusetts, from January 2015 to March 2017. Surveys on past football exposures, demographic factors, and current health conditions were sent via electronic and postal mail to participants within and outside of the United States. Analyses were conducted in Boston, Massachusetts; the data analysis began in March 2018 and additional analyses were performed through June 2019. Of the 13 720 male former players eligible to enroll who were contacted, 3506 (25.6%) responded.

Exposures

Concussion symptom score was calculated by summing the frequency with which participants reported 10 symptoms, such as loss of consciousness, disorientation, nausea, memory problems, and dizziness, at the time of football-related head injury.

Main Outcomes and Measures

Self-reported recommendations or prescriptions for low testosterone or ED medication served as indicators for testosterone insufficiency and ED.

Results

In 3409 former players (mean [SD] age, 52.5 [14.1] years), the prevalence of indicators of low testosterone levels and ED was 18.3% and 22.7%, respectively. The odds of reporting low testosterone levels or ED indicators were elevated for previously established risk factors (eg, diabetes, sleep apnea, and mood disorders). Models adjusted for demographic characteristics, football exposures, and current health factors showed a significant monotonically increasing association of concussion symptom score with the odds of reporting the low testosterone indicator (highest vs lowest quartile, odds ratio, 2.39; 95% CI, 1.79-3.19; P < .001). The ED indicator showed a similar association (highest quartile vs lowest, odds ratio, 1.72; 95% CI, 1.30-2.27; P < .001).

Conclusions and Relevance

Concussion symptoms at the time of injury among former football players were associated with current participant-reported low testosterone levels and ED indicators. These findings suggest that men with a history of head injury may benefit from discussions with their health care clinicians regarding testosterone deficiency and sexual dysfunction.

Co-creation of a post-traumatic brain injury sexuality information toolkit: a patient-oriented project

AIM

Different studies and two clinical practice guidelines emphasize the necessity to provide patients undergoing rehabilitation with information about commonly occurring changes in sexuality following traumatic brain injury (TBI). The purpose of this study was to co-create information resources for individuals with moderate to severe TBI and their partners to consult during rehabilitation.

METHODS

An iterative user-centered design was used, combining focus group and individual interviews. A convenience sample of individuals with TBI and life partners was constituted.

RESULTS

The needs and expectations of these participants in terms of form and content of an information toolkit on post-TBI sexuality were explored. The subjects that matched the interests and needs of participants were numerous and supported by the literature. Contrasting with existing written resources, the participants' views oriented the creation process toward the development of a toolkit including five audiovisual presentations, a double-sided information sheet, and a checklist.

CONCLUSIONS

A similar approach of co-creation could be used to develop other information packs aimed at patients with other disabilities. The created material is expected to be a usable and useful tool for individuals with TBI, which can support clinicians in addressing the subject of sexuality.Implications for rehabilitationThe central role held by individuals with moderate to severe traumatic brain injury, in identifying the sexuality related topics to be addressed and the form of resources to be created, led to a better understanding of their needs.This patient-centered research brought solutions to difficulties related to the understanding of health information, prevalent among patients.This patient-oriented project highlights the necessity for adequacy between the health information provided by rehabilitation professionals and the capacity of their patients' to seek for, process, and understand its content.

[Sexual dysfunctions after traumatic brain injury: Systematic review of the literature]

BACKGROUND

Sexual dysfunction (SD) is common in the general population, up to 50% in women and with no clearly defined prevalence in men but up to 30% in erectile dysfunction. Sexual dysfunctions (SD) are common after a traumatic brain injury (TBI) but remain underrated in clinical practice, yet it is a crucial aspect of the person with consequences for the relationship with the other, psychological wellbeing and quality of life.

OBJECTIVE

To determine, through a systematic literature review, the epidemiology, assessment tools and treatment of SD in the TBI population.

SOURCES

(keywords, languages): Medline, COCHRANE and OVID databases were used with specific keywords (MeSH), combined with Boolean operators: "sexual dysfunction", "sexuality", "erectile dysfunction" and "traumatic brain injury".

STUDY SELECTION

Only studies published in French or English, and with full-text available, have been included. Articles have been independently reviewed and extracted.

RESULTS

Of the 199 articles reviewed after exclusion of duplicates, 86 articles were reviewed in their full text. A total of 40 studies were included in the final analysis. After TBI, 6% to 83% of patients report SD: decreased frequency of sexual intercourse (47-62%), desire and/or arousal (24-86%), erectile dysfunction (24,2-57%), difficulties with orgasm (29-40%), inappropriate sexual behaviour (8,9%). There is no consensus method for evaluating SD in this population, with 16 tools identified. Among them, only two questionnaires were validated in this population, the Brain Injury Questionnary of Sexuality - not validated in French - and the Overt Behavior Scale, the latter being intended for the evaluation of sexual behaviour disorders. Several factors are significantly and positively associated with SD: age (P≤0.01), severity of TBI (P≤0.002), depression (P<0.001), anxiety (P<0.001), and fatigue (P=0.042). Others are negatively associated: time since injury (P=0.01), perceived physical health status (P<0.001) and social participation (P<0.001). There is little data on the treatment of SD outside of case studies.

LIMITS

Quantitative analysis could not be performed due to differences in the studies included in their design, evaluation tools, choice of TBI severity criteria, and post-TBI timeframes. Four unavailable articles could not be consulted.

CONCLUSION

SD are common after TBI but remain poorly evaluated in clinical practice, despite their impact on patients and their partners. Their evaluation and treatment should be part of the overall management of patients after TBI. Nevertheless, there is currently no validated tool in French to evaluate these SD, nor are there any guidelines on their treatment.

The long-term effects of childhood traumatic brain injury on adulthood relationship quality

PRIMARY OBJECTIVE

To investigated the long-term effect of childhood Traumatic Brain Injury (TBI) on adulthood Relationship Quality (RQ), examining injury severity, age of injury, and markers of prefrontal cortex (PFC) functioning, apathy, disinhibition, and executive dysfunction.

RESEARCH DESIGN

Longitudinal, between-subjects, cross-sectional design using retrospective and current data.

METHODS AND PROCEDURES

Participants (N = 169; 61 mild TBI (mTBI); 65 moderate to severe TBI (MSTBI); 43 orthopaedic injury (OI); Injury age: 1-17 years; Testing age: 18-31 years) completed a structured interview regarding their injury, demographic characteristics and RQ, the National Adults Reading Test, and Frontal Systems Behaviour Scale. Data were analyzed using IBM SPSS 25.

MAIN OUTCOMES AND RESULTS

Adults who had experienced childhood TBI had significantly poorer RQ than adults who had experienced childhood OI. Severity of TBI did not impact adulthood RQ. Earlier age of injury predicted reduced adulthood RQ in the MSTBI group. Greater PFC dysfunction predicted poorer RQ in adults with a history of childhood TBI. While elevated levels of apathy, disinhibition, and executive dysfunction were associated with poorer RQ, no individual marker had predictive value.

CONCLUSION

Experiencing a childhood TBI can have a long-term negative influence on adulthood RQ. Such RQ deficits can underpin reduced life satisfaction and increased health issues.

Changes in sexual functioning following traumatic brain injury: An overview on a neglected issue

Traumatic brain injury (TBI) is any damage to the skull and/or the brain and its frameworks due to an external force. Following TBI, patients may report cognitive, physiological and psychosocial changes with a devastating impact on important aspects of the patient's life, such as sexual functioning. Although sexual dysfunction (SD) occurs at a significantly greater frequency in individuals with TBI, it is not commonly assessed in the clinical setting and little information is available on this crucial aspect of patients' quality of life. As the number of people with TBI is on the rise, there is a need for better management of TBI problems, including SD, by providing information to patients and their caregivers to achieve sexual health, with a consequent increase in their quality of life. Discussing and treating sexual problems in TBI patients enters the framework of a holistic approach. The purpose of this narrative review is provide clinicians with information concerning changes in sexual functioning and relationships in individuals with TBI, for a better management of patient's functional outcomes and quality of life.

What is known about sexual health after pediatric acquired brain injury: A scoping review

BACKGROUND

Positive sexual development is a core task in the transition from childhood/adolescence to adulthood. Little is known about the extent of research addressing this topic after acquired brain injury (ABI).

OBJECTIVE

To identify publications (1980 to 2016) addressing positive sexual health among children/adolescents with ABI.

METHODS

A scoping review.

RESULTS

A search conducted using OVID and PubMed databases yielded 2021 citations with 28 publications meeting the inclusion criteria (six reviews, one expert account, 19 observational and two intervention studies). Teenagers with ABI reported poorer body image, feeling less sexually or physically attractive than sex and age matched non brain-damaged controls. The one study with findings on sexual orientation, reported 15% of adolescents with ABI identified as lesbian, gay or bisexual. Precocious puberty was a rare outcome from ABI, but the most common focus of the publications (14/28). Finally, two case studies (genital touching and classroom masturbation respectively) found that behavioral interventions were an effective means of extinguishing inappropriate sexual behaviour after childhood ABI.

CONCLUSIONS

Sexual health is a neglected area of research in post-ABI care for children/adolescents. A better understanding of the needs and challenges will help rehabilitation professionals and parents provide more informed and effective supports.

Aberrant Insula-Centered Functional Connectivity in Psychogenic Erectile Dysfunction Patients: A Resting-State fMRI Study

Most previous studies exploring the neural mechanism of psychogenic erectile dysfunction (pED) focused on brain activity under tasks. We suggest that the resting brain activity is equally important in pED studies, in that the patterns of spontaneous neural activities is independent of modalities of sensory input, therefore providing substantial information regarding the central mechanism of pED. Our previous study reported the altered baseline activity in right anterior insula (aINS) in pED patients. Also, the insula is a pivotal region in sexual behavior, which is suggested to be able to directly mediate erection. Therefore, the current study employed resting-state fMRI to examine alterations in functional connectivity (FC) of the aINS comparing pED patients with matched control subjects. After rigorous participant inclusion procedure, 27 pED patients and 27 healthy male controls were enrolled. Our results elucidated the disrupted homogeneity within the right aINS and aberrant connection patterns between the right aINS and the right dorsolateral prefrontal cortex (dlPFC), as well as the right aINS and the right temporoparietal junction (TPJ) respectively in pED group, as compared with the healthy controls. In conclusion, our results demonstrated the aberrant insula-centered FC in pED, which may be related to the abnormal representation of internal bodily state or needs in pED patients and thus further affect the inhibitory control in the sexual context. We hope that these findings may shed new light on the understanding of the central mechanism of pED.

Quality of relationship between veterans with traumatic brain injury and their family members

OBJECTIVES

The quality of the relationship between patients with many illnesses and their family members has been shown to affect the well-being of both. Yet, relationship quality has not been studied in traumatic brain injury (TBI), and giving and receiving aspects have not been distinguished. The present study of veterans with TBI examined associations between relationship quality and caregiver burden, satisfaction with caregiving, and veterans' competence in interpersonal functioning, rated by veterans and family members.

METHOD

In this cross-sectional study, 83 veterans and their family members were interviewed at home. Measures of quality of relationship, veterans' interpersonal competence and sociodemographics were collected for both, caregiver burden and satisfaction for family members only.

RESULTS

As predicted, veteran-rated Q_rel/Giving was associated with family-rated Q_rel/Receiving, and veteran-rated Q_rel/Receiving with family-rated Q_rel/Giving. Lower caregiver burden and higher caregiving satisfaction were associated with higher Q_rel/Receiving scores but not with Q_rel/Giving scores. Veterans' interpersonal competence was associated with total Q_rel as rated by either veterans or family members.

CONCLUSIONS

Relationship quality should be included in family research in TBI, and giving and receiving aspects should be differentiated. Findings suggest that lower caregiver burden and greater satisfaction should be more achievable by increasing caregivers' sense of benefits received from the relationship.

Experiences, attitudes, and needs related to sexuality and service delivery in individuals with traumatic brain injury

OBJECTIVE

To explore the experiences, attitudes, and needs related to service delivery regarding sexuality issues in individuals with traumatic brain injury (TBI).

METHODS

Community-dwelling individuals with TBI having completed a post-acute TBI rehabilitation program. The TBI sample consisted of 16 men (42.1%) and 22 women (57.9%), with an average age of 38.9 years (SD = 9.9) and 12.8 years of education (SD = 2.8). They were on average 2.6 years post-injury (SD = 1.4). Glasgow coma scale at admission was on average 12.6 (SD = 3.5). Participants completed a questionnaire adapted to individuals with TBI addressing experiences, attitudes, and needs regarding sexuality and service delivery.

RESULTS

Individuals with TBI reported a low frequency of specific discussions with their treating clinician(s) about sexual and reproductive health issues, as well as many unmet needs regarding sexuality. None of the participants considered discussion about these issues to be inappropriate. They reported more favourable attitudes towards discussing sexual health topics compared to actual service delivery with family physicians, general practitioners, psychologists, and other health care professionals (p's <  0.05).

CONCLUSIONS

Individuals with TBI desired more openness about discussing sexual concerns. Findings are discussed in terms of the clinical implications to meet the individuals' needs regarding sexual concerns after TBI.

A biopsychosocial analysis of sexuality in adult males and their partners after severe traumatic brain injury

PURPOSE

The primary aim of this study was to investigate changes in sexual function in males and their partners following severe TBI. Secondary aims of the study were to explore the relationship between selected sociodemographic, emotional/behavioural and sexual function variables.

METHODS

Twenty males with a history of severe TBI and 20 healthy controls (HC) and their respective partners were recruited. Sexual life was assessed with the Sexuality Evaluation Schedule Assessment Monitoring (SESAMO). Study participant level of self-awareness was evaluated by the Awareness Questionnaire, whereas their neuropsychiatric and psychopathological statuses were assessed by the NPI, the HAM-D and STAI.

RESULTS

A reduction in desire and frequency of sexual intercourse was found in all survivors and their partners. Moreover, higher levels of survivor depression correlated with lower partner harmony. Survivor feelings toward their partners gradually decreased over time, as did the ability to make decisions as a couple. The comparison with HC couples revealed that both survivors' and their partners' exaggerated the extent of disease.

CONCLUSIONS

After male severe TBI, men appear to have a reduced quality of their sexual life, which may be more a result of relationship dysfunction than a sexual performance deficit related to their brain injury history.

Sexual behavior and its correlates after traumatic brain injury

PURPOSE OF REVIEW

Traumatic brain injury (TBI) is one of the leading causes of permanent disability in young adults and is frequently accompanied by changes in sexual behaviors. Satisfying sexuality is an important factor for overall quality of life in people with disabilities. The purpose of this article is to review the studies evaluating the assessment, correlates and management of sexuality following TBI.

RECENT FINDINGS

The Brain Injury Questionnaire of Sexuality is the first validated questionnaire specifically developed for adults with TBI. A considerable amount of individuals with TBI show inappropriate sexual behaviors and sexual dysfunctions. Whereas inappropriate sexual behaviors are related to younger age, less social participation and more severe injuries, sexual dysfunctions show an association with higher fatigue, higher depression scores, less self-esteem and female sex. Healthcare professionals have suggested that because of discomfort at the individual or institutional level, sexual problems are often not sufficiently addressed and have suggested that a specialist should treat sexual problems.

SUMMARY

Although some important correlates of sexual problems could be identified, methodological differences across studies limit their comparability. Furthermore, there is an absence of evidence-based treatment strategies for addressing sexual problems. Therapeutic efforts should take into account the identified correlates of sexual problems following TBI.

Changes in sexual functioning from 6 to 12 months following traumatic brain injury: a prospective TBI model system multicenter study

OBJECTIVE

To investigate longitudinal changes in sexual functioning during the first year following moderate to severe traumatic brain injury (TBI).

DESIGN

Prospective cohort study.

SETTING

Community.

PARTICIPANTS

182 persons (53 women and 129 men) with moderate to severe TBI who were admitted to 1 of 6 participating TBI Model System centers and followed in the community at 6 and 12 months after injury.

MAIN MEASURES

Derogatis Interview for Sexual Functioning-Self-Report (DISF-SR); Global Sexual Satisfaction Index (GSSI).

RESULTS

Mean T-scores on the DISF-SR Arousal subscale demonstrated marginal improvement over time, with a 2.59-point increase (P = .05) from 6 to 12 months after injury. There were no significant differences over this 6-month period on the remaining DISF-SR subscales, including sexual cognition/fantasy, sexual behavior/experience, and orgasm. There was no significant change in satisfaction with sexual functioning on the GSSI from 6 months (72% satisfied) to 12 months (71% satisfied).

CONCLUSIONS AND IMPLICATIONS

Sexual function and satisfaction appears to be stable in those with moderate to severe TBI from 6 to 12 months after injury, with the exception of minimal improvement in arousal. These findings, to our knowledge, reflect the first evidence regarding prospective changes in sexual functioning in this population. Future research can go far to assist clinicians in treatment planning and managing patient expectations of recovery of sexual functioning after TBI.

Assessment of sexuality following traumatic brain injury: validation of the Brain Injury Questionnaire of Sexuality

BACKGROUND

The importance of effectively identifying and managing sexuality issues following acquired brain injury is being increasingly recognized within clinical and research domains. However, a tool specifically developed to measure sexuality following brain injury is yet to be validated.

OBJECTIVES

In this study, the reliability and validity of the Brain Injury Questionnaire of Sexuality (BIQS) was evaluated.

METHOD

Eight hundred and sixty-five people who had sustained traumatic brain injury participated in this study. All participants completed the BIQS, and a subsample also completed the Derogatis Interview for Sexual Functioning-Self-Report version (DISF-SR).

RESULTS

Exploratory factor analysis supported a 3-subscale structure of the BIQS, which aligns with contemporary conceptual models of sexuality in chronic disease. All subscales of the BIQS demonstrated very good internal consistency. Convergent and divergent validity of all BIQS subscales was also demonstrated.

CONCLUSIONS

Results from the study support the reliability and validity of the BIQS, which shows promise as a measurement tool for future traumatic brain injury sexuality research. Further validation work including evaluation for potential clinical applications is encouraged.

Factors associated with sexuality following traumatic brain injury

BACKGROUND

Previous research has demonstrated that sexuality is compromised following traumatic brain injury (TBI).

OBJECTIVES

The aim of this study was to determine the association between sexuality following TBI and demographic, injury-related, and postinjury variables (age, gender, time since injury, posttraumatic amnesia duration, independence in activities of daily activities (ADL), antidepressant use, depression, and self-esteem).

METHODS

Participants included 986 individuals with predominantly moderate to severe TBI, who completed the Brain Injury Questionnaire of Sexuality (BIQS), the Hospital Anxiety and Depression Scale, and the Rosenberg Self-Esteem Scale and an ADL assessment on 1 or more occasions, providing a total of 1673 assessments across 1, 2, 3, 5, 10, and 20 years postinjury.

RESULTS

Being depressed, older in age, at shorter time postinjury, and less independent in ADL significantly predicted poorer overall BIQS scores as well as the Sexual Functioning subscale score. Poorer Relationship Quality and Self-esteem scores on the BIQS were predicted by older age at injury and higher levels of depression. Lower Mood score on the BIQS was associated with shorter posttraumatic amnesia duration, younger age, and higher levels of depression. Self-esteem was associated positively with sexuality outcome.

CONCLUSIONS

Therapeutic interventions for sexuality need to focus on depression where indicated and self-esteem and address specific barriers to social participation and opportunities for sexual contact in individuals who are less independent in ADL.

Predictors of sexual functioning and satisfaction 1 year following traumatic brain injury: a TBI model systems multicenter study

OBJECTIVE

To investigate predictors of sexual functioning 1 year following traumatic brain injury (TBI).

DESIGN

Prospective cohort study.

SETTING

Community.

PARTICIPANTS

A total of 255 persons with TBI (187 males; 68 females) who had been treated at 1 of 6 TBI Model Systems inpatient rehabilitation units and were living in the community.

MAIN MEASURES

Derogatis Interview for Sexual Functioning-Self-Report (DISF-SR); Global Satisfaction With Sexual Functioning (Global Sexual Satisfaction Index); Participation Assessment With Recombined Tools-Objective; Patient Health Questionnaire-9.

RESULTS

Older age, female gender, and more severe injury were associated with greater sexual dysfunction 1 year following injury. As age increased from 24 to 49 years, the odds of sexual impairment increased more than 3-fold (95% confidence interval: 1.82-5.88). Females had a 2.5 increase in odds of sexual impairment compared with males (95% confidence interval: 1.23-5.26). Greater social participation was predictive of better sexual functioning. Dissatisfaction with sexual functioning was predicted by older age and depression.

CONCLUSIONS AND IMPLICATIONS

Older persons and females appear to be at greater risk for sexual dysfunction after TBI and may benefit from specialized assessment and treatment services. Relationships were identified between social participation and sexual function and between depression and sexual satisfaction that may serve as clinical indicators for further assessment and intervention. Further research is needed to elucidate these relationships and identify effective clinical approaches.

Talking about sex after traumatic brain injury: perceptions and experiences of multidisciplinary rehabilitation professionals

PURPOSE

Research indicates that although 50-60% of people who have had a traumatic brain injury (TBI) experience changes in sexual functioning, sexuality issues remain largely unaddressed in rehabilitation. This study aimed to explore rehabilitation professionals' perceptions and experiences of discussing sexuality with service-users who have had a TBI.

METHOD

Purposeful sampling was used to recruit 24 participants from two local National Health Service trusts and from a national charity. Four focus groups were conducted with pre-existing groups of professionals, using a semi-structured interview schedule. Focus group data were transcribed verbatim and analysed using thematic analysis.

RESULTS

Six main themes were derived from the analysis: (1) sexuality after TBI is a specialist issue; (2) sexuality is a sensitive subject; (3) practicalities of discussing sexuality; (4) roles and responsibilities; (5) dilemmas about risk and vulnerabilities; and (6) organisational and structural issues.

CONCLUSIONS

Our findings suggest that a more proactive approach to addressing sexuality issues be taken by incorporating sexuality into assessments and by having sexuality information available for service-users. Support for professionals is also needed in the form of the development of policy, on-going training and supervision. Implications for Rehabilitation Rehabilitation professionals find it difficult to deal with issues of sexuality following TBI, and the reasons for this are complex and interrelated. To provide holistic care, a more proactive approach to addressing sexuality issues should be taken. Professionals do not need to be an expert in sexual issues to open dialogue. Sexuality discussions should be incorporated into assessments, and written information should be available for service-users. Further training for professionals and organisational policy change is sometimes required to effectively deal with sexuality issues.

Sexual functioning 1 year after traumatic brain injury: findings from a prospective traumatic brain injury model systems collaborative study

OBJECTIVE

To investigate the incidence and types of sexual difficulties in men and women with traumatic brain injury (TBI) 1 year after injury, as well as their comfort level in discussing problems with health care professionals.

DESIGN

Prospective cohort study.

SETTING

Community.

PARTICIPANTS

Persons with TBI (N=223; 165 men and 58 women) who had been treated at 1 of 6 participating TBI Model Systems inpatient rehabilitation units and were living in the community.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Derogatis Interview for Sexual Functioning-self-report (DISF-SR); Global Sexual Satisfaction Index (GSSI); structured interview regarding changes in sexual functioning; and comfort level discussing sexuality with health care professionals.

RESULTS

Women with TBI scored significantly below the normative sample for all subscales of the DISF-SR, including sexual cognition/fantasy, arousal, sexual behavior/experience, and orgasm. Men scored significantly below the normative sample on all scales except arousal. Women reported greater dysfunction than men for sexual cognition/fantasy and arousal. Twenty-nine percent of participants reported dissatisfaction with sexual functioning on the GSSI, with a greater percentage of men reporting dissatisfaction. Sixty-eight percent of participants indicated that they would spontaneously raise issues of sexual difficulties with health care professionals, while the remainder would either bring it up only if directly asked or would not discuss it at all.

CONCLUSIONS

Sexual difficulties were present in a substantial portion of community-dwelling people with TBI at 1 year after injury. Educational interventions to increase awareness among people with TBI and rehabilitation professionals are warranted, as well as interventions to improve sexual functioning.

The young brain and concussion: imaging as a biomarker for diagnosis and prognosis

Concussion (mild traumatic brain injury (mTBI)) is a significant pediatric public health concern. Despite increased awareness, a comprehensive understanding of the acute and chronic effects of concussion on central nervous system structure and function remains incomplete. Here we review the definition, epidemiology, and sequelae of concussion within the developing brain, during childhood and adolescence, with current data derived from studies of pathophysiology and neuroimaging. These findings may contribute to a better understanding of the neurological consequences of traumatic brain injuries, which in turn, may lead to the development of brain biomarkers to improve identification, management and prognosis of pediatric patients suffering from concussion.

Addressing the Sexual Concerns of Persons With Traumatic Brain Injury in Rehabilitation Settings: A Framework for Action

Traumatic brain injury (TBI) impacts upon people's sexuality with 50% to 60% of persons reporting some level of disruption post-injury. However, only small proportions of patients/family members report that rehabilitation health professionals made inquiries about whether they had any sexual concerns. Rehabilitation programs have a responsibility to meet the challenge of addressing this important area of human functioning. An agency framework is described that provides a non-threatening, structured way for services to conceptualise, introduce or upgrade sexuality services in a manner that can be maintained over the long term. The framework contains an underlying philosophy of sexuality, five proposed modalities of service provision and detail of the underlying organisational structures that are required to provide sexuality services with consistency and effectiveness over the long term. Finally, organisational strategies that can be employed to implement the framework are discussed as well as suggestions about the sequencing of such strategies. By using the framework, rehabilitation services can put sexuality back onto their treatment agenda, as they seek to restore patients/clients with TBI to the “highest level of adaptation attainable” (World Health Organisation, 1996, p. 1) in all areas of their lives.

Exploring the impact of traumatic brain injury on the older couple: ‘Yes, but how much of it is age, I can’t tell you …’

PRIMARY OBJECTIVE

To qualitatively explore the partner relationships of older couples faced with traumatic brain injury (TBI).

RESEARCH DESIGN

Qualitative analysis comparing individuals with TBI and a comparison group.

METHODS AND PROCEDURES

Twenty-one individuals were interviewed using a semi-structured format focusing on various aspects of their partner relationship. A qualitative analysis of transcripts identified general themes.

MAIN OUTCOMES AND RESULTS

Variability of relationship experiences (relationship relatedness and persistence of the partnership) was shown across groups. Aspects of relationship commitment to the partnership were revealed. Many individuals with TBI and their partners attributed various relationship changes to ageing and age-related issues and not to the TBI.

CONCLUSIONS

These findings suggest that the effects of TBI are not clearly distinguished from age-related causes for change in the partners and their relationship. Older couples' experiences may be different from those of younger couples impacted by TBI, in the areas of sexuality, inter-personal support and role functions.

Advances in neuropharmacological rehabilitation for brain dysfunction

The use of pharmacological agents as rehabilitative tools following brain injury remains to some degree both a science and an art. Recent work in the area of the neural sciences has shed new light on the workings of basic CNS neurochemical systems and the use of pharmacologic agents in altering central neurophysiologic processes. The major central neurochemical systems are reviewed both anatomically and physiologically. An overview is provided of basic neuropharmacologic agents by class. Lastly, some of the newer neuropharmacological options for treatment of post-acute brain injury deficits are examined.

Challenges associated with the definition and assessment of inappropriate sexual behaviour amongst individuals with an acquired neurological impairment

The subject of Inappropriate Sexual Behaviour (ISB) amongst clients with neurological impairment, specifically Acquired Brain Injury (ABI) and dementia, has received limited coverage to date within the literature. This paper discusses some of the problems encountered in the definition and quantification of ISB, in particular the absence of standardized measurement tools to record ISB within an inpatient setting. Whilst ISB is reported to be less prevalent than other behavioural sequelae of brain injury or dementia, it is suggested that its impact on patients and carers can be significant. Ill-defined terminology and the absence of relevant assessment tools add to the specific challenges of understanding and managing ISB within a care or rehabilitation setting. As a result, it is argued that the subjective attitudes of staff and the culture of an institution can dominate the approach taken to dealing with ISB for these client groups.

Masculine role adherence and outcomes among men with traumatic brain injury

PRIMARY OBJECTIVE

Traumatic brain injury (TBI) is a significant health problem disproportionately affecting men and is often associated with changes in masculine role functioning in life domains such as vocational functioning, sexual and inter-personal functioning and personal independence. These changes could have serious implications for men's adjustment following injury. The aim of this study was to examine the relations among traditional masculine role adherence, psychosocial adjustment and rehabilitation outcomes in men with TBI.

RESEARCH DESIGN

A correlational design was chosen to examine the relations among variables. Spearman correlations and Wilcoxon Rank Sum tests were used to examine relationships between masculine role variables and outcome variables.

METHODS AND PROCEDURES

The study included 33 men with TBI who had been discharged from inpatient rehabilitation within 5 years. Participants completed surveys on traditional masculine gender role adherence and gender role conflict and additional data, including measures of functional outcome, life satisfaction, psychosocial outcomes and earnings, were obtained through the TBI Model System longitudinal data collection system.

MAIN OUTCOMES AND RESULTS

The results revealed significant associations between masculine role adherence and satisfaction with life, follow-up earnings and FIM change from admission to discharge.

CONCLUSIONS

In the current study, particular masculine role variables corresponded to different functional and psychological outcomes. Understanding these differences provides new directions for treatment and offers important information about aspects of traditional masculine roles that may enhance or hinder adjustment to injury.

Community reintegration following acquired brain injury

OBJECTIVE

To evaluate the interventions and strategies used to enable transition from acute care or post-acute rehabilitation to the community following brain injury.

METHODS AND MAIN OUTCOMES

A systematic review of the literature from 1980-2005 was conducted focusing on ABI rehabilitation. Five major aspects of community reintegration, including: independence and social integration, caregiver burden, satisfaction with quality of life, productivity and return to driving were considered.

RESULTS

With the exception of one, the majority of interventions are supported by only limited evidence, denoting an absence of randomized controlled trials (RCTs) in the literature. Of 38 studies evaluated for this review, only one RCT was found. That RCT provided moderate evidence that behavioural management, coupled with caregiver education, did not help to improve caregiver burden.

CONCLUSIONS

Further research, using an interventional approach, is required to advance the evidence base of reintegration into the community following brain injury.

Does dorsolateral prefrontal cortex (DLPFC) activation return to baseline when sexual stimuli cease?

A fundamental question in human sexuality regards the neural substrate underlying sexually-arousing representations. Lesion and neuroimaging studies suggest that dorsolateral pre-frontal cortex (DLPFC) plays an important role in regulating the processing of visual sexual stimulation. The aim of this Functional Near-Infrared Spectroscopy (fNIRS) study was to explore DLPFC structures involved in the processing of erotic and non-sexual films. fNIRS was used to image the evoked-cerebral blood oxygenation (CBO) response in 15 male and 15 female subjects. Our hypothesis is that a sexual stimulus would produce DLPFC activation during the period of direct stimulus perception ("on" period), and that this activation would continue after stimulus cessation ("off" period). A new paradigm was used to measure the relative oxygenated hemoglobin (oxyHb) concentrations in DLPFC while subjects viewed the two selected stimuli (Roman orgy and a non-sexual film clip), and also immediately following stimulus cessation. Viewing of the non-sexual stimulus produced no overshoot in DLPFC, whereas exposure to the erotic stimulus produced rapidly ascendant overshoot, which became even more pronounced following stimulus cessation. We also report on gender differences in the timing and intensity of DLPFC activation in response to a sexually explicit visual stimulus. We found evidence indicating that men experience greater and more rapid sexual arousal when exposed to erotic stimuli than do women. Our results point out that self-regulation of DLPFC activation is modulated by subjective arousal and that cognitive appraisal of the sexual stimulus (valence) plays a secondary role in this regulation.

Treatment of depression following traumatic brain injury

Depression is a common consequence of traumatic brain injury (TBI), and is a source of substantial distress and disability for persons with TBI and their families. This article offers a practical approach to the evaluation and treatment of this condition. Diagnostic and etiologic considerations relevant to this issue are reviewed first. Next, somatic therapies for posttraumatic depression, including antidepressant medications and electroconvulsive therapy, are discussed. Use of these therapies is also considered in the context of the common medical and neurological comorbidities among persons with TBI. Finally, psychosocial interventions relevant to the care of persons with posttraumatic depression are presented.

An Evaluation of Sex Education and Information Resources and Their Provision to Adults With Traumatic Brain Injury

OBJECTIVES

To evaluate sex education and information resources developed to address the sexual health concerns of persons with traumatic brain injury (TBI) and the means by which agencies have introduced this clinically sensitive program initiative.

DESIGN

A process evaluation methodology was used to assess program reach, participant satisfaction, program component usage, and quality of materials.

SUBJECTS

Two samples comprising multidisciplinary rehabilitation and disability staff (n = 37) from 36 brain injury agencies that had been utilizing the resources and 12 people with brain injury, respectively.

SETTINGS

A diverse range of rehabilitation and community brain injury agencies.

OUTCOME MEASURES

Two purpose-designed evaluation protocols for staff and consumers, respectively, and a readability analysis to assess the comprehensibility of program materials (eg, information sheets) for people with TBI.

RESULTS

Agencies strongly endorsed their role in addressing consumer sexual health concerns. Agencies generally used a selective rather than a universal approach to sex education, with an average of 10% of consumers within agency caseloads receiving some intervention within the previous 12 months. The 4 issues most frequently addressed in education programs were sexual dysfunction, how to meet people, what is sexuality, and sexual adjustment in the context of established preinjury relationships. Finally, the average reading age needed to comprehend the resources was higher than the recommended levels for communicating health information.

CONCLUSION

The sex education program resources have been positively evaluated by both rehabilitation and community agencies as a means of providing education and information to address the sexual health concerns of people with TBI.

Treatment of premature ejaculation after traumatic brain injury

Premature ejaculation (PE) is the most common male sexual disturbance occurring in the general community. Surveys of sexual dysfunction after traumatic brain injury (TBI) have identified that between 17-36% of males report a number of different post-injury ejaculatory problems, including PE. Whilst there are a number of studies that document effective treatment of PE in the general population, there have been no reports of treatment interventions for this problem amongst males with TBI. This paper reports on the assessment and successful treatment of PE in a young male with severe TBI. The treatment programme trialed combined pharmacotherapy (namely, the application of a topical anaesthetic), behavioural and educational approaches. The case report suggests that existing sex therapy techniques, albeit with modifications to compensate for motor sensory, cognitive and affect related injury sequelae, provide one option for the treatment of PE after TBI.

Sexual changes associated with traumatic brain injury

Findings from numerous outcome studies have suggested that people with traumatic brain injuries (TBI) experience relationship difficulties and changes in sexuality. However, there have been few investigations of these problems. This paper reports the results of a study of sexuality following TBI, which aimed to identify changes in sexual behaviour, affect, self-esteem, and relationship quality, and their inter-relationships. Two hundred and eight participants with moderate-to-severe TBI (69% males) completed a questionnaire 1-5 years post-injury. Their responses were compared with those of 150 controls, matched for age, gender, and education. Of TBI participants 36-54% reported: (1) A decrease in the importance of sexuality, opportunities, and frequency of engaging in sexual activities; (2) reduced sex drive; (3) a decline in their ability to give their partner sexual satisfaction and to engage in sexual intercourse; and (4) decreased enjoyment of sexual activity and ability to stay aroused and to climax. The frequencies of such negative changes were significantly higher than those reported by controls and far outweighed the frequency of increases on these dimensions. A significant proportion of TBI participants also reported decreased self-confidence, sex appeal, higher levels of depression, and decreased communication levels and relationship quality with their sexual partner. Factors associated with sexual problems in the TBI group are explored and implications of all findings discussed.