Rehabilitation of Communicative Abilities in Patients with a History of TBI: Behavioral Improvements and Cerebral Changes in Resting-State Activity

Can Narrative Skills Improve in Autism Spectrum Disorder? A Preliminary Study with Verbally Fluent Adolescents Receiving the Cognitive Pragmatic Treatment

Autism spectrum disorder (ASD) is a neurodevelopmental condition affecting social and communicative skills, including narrative ability, namely the description of real-life or fictive accounts of temporally and causally related events. With this study, we aimed to determine whether a communicative-pragmatic training, i.e., the version for adolescents of the Cognitive-Pragmatic Treatment, is effective in improving the narrative skills of 16 verbally fluent adolescents with ASD. We used a multilevel approach to assess pre- and post-training narrative production skills. Discourse analysis focused on micro- (i.e., mean length of utterance, complete sentences, omissions of morphosyntactic information) and macrolinguistic measures (i.e., cohesion, coherence errors, lexical informativeness). Results revealed a significant improvement in mean length of utterance and complete sentences and a decrease in cohesion errors. No significant change was found in the other narrative measures investigated. Our findings suggest that a pragmatically oriented training may be useful in improving grammatical efficiency in narrative production.

Resting-State Connectivity Changes After Goal-Oriented Attentional Self-Regulation Training in Veterans With Mild Traumatic Brain Injury: Preliminary Findings from a Randomized Controlled Trial

Mild traumatic brain injury (mTBI) can have lasting consequences on cognitive functioning and well-being. Goal-Oriented Attentional Self-Regulation (GOALS) training has been shown to improve attention and executive functioning, as well as emotional functioning, in veterans with chronic TBI. An ongoing clinical trial (NCT02920788) is further evaluating GOALS training, including underlying neural mechanisms of change. The present study aimed to examine training-induced neuroplasticity by resting-state functional connectivity (rsFC) changes in GOALS versus active control. Veterans with a history of mTBI ≥6 months post-injury (N = 33) were randomly assigned to GOALS (n = 19) or an intensity-matched active control group (Brain Health Education [BHE] training; n = 14). GOALS consists of attention regulation and problem solving applied to individually defined, relevant goals through a combination of group, individual, and home practice sessions. Participants underwent multi-band resting-state functional magnetic resonance imaging at baseline and post-intervention. Exploratory 2 × 2 mixed analyses of variance identified pre-to-post changes in seed-based connectivity for GOALS versus BHE in five significant clusters. GOALS versus BHE demonstrated a significant increase in right lateral pre-frontal cortex connectivity with the right frontal pole and right middle temporal gyrus, as well as increased posterior cingulate connectivity with the pre-central gyrus. Rostral pre-frontal cortex connectivity with the right precuneus and the right frontal pole decreased in GOALS versus BHE. These GOALS-related changes in rsFC point to potential neural mechanisms underlying the intervention. This training-induced neuroplasticity may play a role in improved cognitive and emotional functioning post-GOALS.

Update on the Efficacy of Cognitive Rehabilitation After Moderate to Severe Traumatic Brain Injury: A Scoping Review

OBJECTIVES

To identify, categorize, and analyze the methodological issues of cognitive rehabilitation of patients with moderate to severe traumatic brain injury and its efficacy.

DATA SOURCES

Pubmed and PsycINFO were searched for studies published between 2015 and 2021 using keywords for cognitive intervention and traumatic brain injury.

STUDY SELECTION

Two independent reviewers selected articles concerning cognitive rehabilitation for adults with traumatic brain injury. Of 458 studies, 97 full-text articles were assessed and 46 met the inclusion criteria.

DATA EXTRACTION

Data were analyzed by 1 reviewer according to criteria concerning the methodological quality of studies.

DATA SYNTHESIS

Results showed a large scope of 7 cognitive domains targeted by interventions, delivered mostly in individual sessions (83%) with an integrative cognitive approach (48%). Neuroimaging tools as a measure of outcome remained scarce, featuring in only 20% of studies. Forty-three studies reported significant effects of cognitive rehabilitation, among which 7 fulfilled a high methodological level of evidence.

CONCLUSIONS

Advances and shortcomings in cognitive rehabilitation have both been highlighted and led us to develop methodological key points for future studies. The choice of outcome measures, the selection of control interventions, and the use of combined rehabilitation should be investigated in further studies.

A cross-sectional study to assess pragmatic strengths and weaknesses in healthy ageing

Background

Ageing refers to the natural and physiological changes that individuals experience over the years. This process also involves modifications in terms of communicative-pragmatics, namely the ability to convey meanings in social contexts and to interact with other people using various expressive means, such as linguistic, extralinguistic and paralinguistic aspects of communication. Very few studies have provided a complete assessment of communicative-pragmatic performance in healthy ageing.

Methods

The aim of this study was to comprehensively assess communicative-pragmatic ability in three samples of 20 (N = 60) healthy adults, each belonging to a different age range (20–40, 65–75, 76–86 years old) and to compare their performance in order to observe any potential changes in their ability to communicate. We also explored the potential role of education and sex on the communicative-pragmatic abilities observed. The three age groups were evaluated with a between-study design by means of the Assessment Battery for Communication (ABaCo), a validated assessment tool characterised by five scales: linguistic, extralinguistic, paralinguistic, contextual and conversational.

Results

The results indicated that the pragmatic ability assessed by the ABaCo is poorer in older participants when compared to the younger ones (main effect of age group: F(2,56) = 9.097; p < .001). Specifically, significant differences were detected in tasks on the extralinguistic, paralinguistic and contextual scales. Whereas the data highlighted a significant role of education (F(1,56) = 4.713; p = .034), no sex-related differences were detected.

Conclusions

Our results suggest that the ageing process may also affect communicative-pragmatic ability and a comprehensive assessment of the components of such ability may help to better identify difficulties often experienced by older individuals in their daily life activities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03304-z.

Systematic Review of Discourse and Social Communication Interventions in Traumatic Brain Injury

PURPOSE

This study reviewed the current state of discourse and social communication interventions in traumatic brain injury (TBI) to provide clinically focused guidance about treatment efficacy, treatment approaches by TBI severity, treatment components, and treatment outcome measures.

METHOD

Searches were conducted in five electronic databases and reference lists of topical articles for discourse or social communication interventions in TBI published between 2012 and 2021. Search terms reflected three concepts: TBI, treatment, and cognitive-communication. Studies were evaluated for methodological quality using rating scales specific to study design.

RESULTS

Seven hundred sixty-seven records were identified, culminating in 21 studies for qualitative synthesis. All approaches resulted in improvement posttreatment, but durability and strength of evidence varied. Five treatment components were identified as "essential" for fostering change. Discourse approaches were generally more effective in mild-to-moderate TBI, whereas social communication approaches were more effective in moderate-to-severe TBI. Communication outcome measures were generally more sensitive to change than measures of other domains of functioning.

CONCLUSIONS

The evidence suggests that discourse and social communication treatments are promising for improving communication in TBI. Selection of treatment components and tailoring treatment to the individual are important clinical considerations. Use of at least two proximal outcome measures that evaluate the target behavior and extent of functional generalization may be advantageous. The field would benefit from additional, more rigorous treatment studies to provide a greater understanding of how best to treat cognitive-communicative impairments in people with TBI.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19233516.

Amplitude of low-frequency fluctuation may be an early predictor of delayed motor development due to neonatal hyperbilirubinemia: a fMRI study

BACKGROUND

Acute bilirubin encephalopathy or kernicterus is the worst consequence of brain damage caused by the elevation of total unbound serum bilirubin (TSB) in neonates. The present study aimed to visualize the characteristic brain regions of neonates with hyperbilirubinemia (HB) using functional magnetic resonance imaging (fMRI) and to measure the amplitude of low-frequency fluctuation (ALFF) values.

METHODS

This was a prospective cohort study, which included newborns with HB who were hospitalized at the Children's Hospital of Fudan University. The control group included neonates admitted with neonatal simple wet lung or pneumonia without neurological disease or brain injury. Newborns were divided into a severe hyperbilirubinemia group (SHB), moderate HB group, and control group based on TSB levels. The newborns completed routine MRI combined with fMRI scans and brainstem auditory evoked potentials (BAEPs) during their hospitalization.

RESULTS

A total of 251 newborns were included in this study. There were 45 patients in the SHB group, 65 in the HB group, and 141 in the control group. The average ALFF value in the basal ganglia region in the SHB group was the highest, which was greater than that in the HB and control groups (P<0.001). The ALFF increased with an increase in TSB concentration. Based on the results of the Bayley Scales of infant development assessment, we further found that the most significant difference in ALFF remained in the basal ganglia region between newborns with motor development scores above 70 (including 70) and below 70. Correlation analysis revealed a strong negative correlation between motor development scores and ALFF (r=-0.691, P<0.001). When ALFF alone was used to predict motor development, the sensitivity was 89%. When ALFF was combined with TSB and BEAP results, the area under the ROC curve was the largest (AUC =0.85). The sensitivity and specificity of the model were 67.86% and 90.77%, respectively.

CONCLUSIONS

The ALFF value may be able to serve as an early imaging biomarker and has a greater sensitivity than TSB or BAEP results in predicting long-term motor development (18 m) in HB.

Communication skills training pilot programme after traumatic brain injury: short and medium-term benefits

Objective: The study aimed to evaluate whether a pilot communication rehabilitation programme improves different communicative modalities in people who have sustained a moderate to severe TBI immediately following the training and at 3 months follow up.Methods: We have recruited 12 participants who had moderate-to-severe TBI. Subjects were randomly divided into two groups, EG and CG. We have assessed the groups before and after treatment and we have performed a follow-up three months later, through of the ABaCo. The EG followed a very structured programme. In the CG, a programme to stimulate communication through free conversation was carried out. Each programme consisted of 24 group sessions, of 1h30 min, twice a week, for 12 weeks.Results: Improvements were observed in both groups, although more evident in the EG. Both groups had better results in extralinguistic production. In the EG, there was still an improvement in the paralinguistic production and extralinguistic comprehension, after ending the training. These improvements persisted 3 months after ending the programme.Conclusion: The results demonstrated the effectiveness of the intervention of a structured pragmatic rehabilitation programme. However, the existence of a communication group based solely on conversation can also have positive results and should be implemented whenever a more specific intervention is not possible. In future research, it will be important to increase the sample size and involve caregivers in person and regularly in the EG programme.

Long-Term Effect of Cognitive Rehabilitation Regardless of Prerehabilitation Cognitive Status for Veterans with TBI

Persisting difficulties in executive functioning (EF) are common after traumatic brain injury (TBI). Cognitive rehabilitation can be effective, but the impact of pretreatment neurocognitive functioning on long term effects of rehabilitation is unknown. Because this information can impact treatment planning, we examined the relationship between prerehabilitation neurocognitive status and long-term effects of EF training. Archival data were drawn from a trial of Goal-Oriented Attentional Self-Regulation group-format EF training for Veterans with TBI [mild-severe; 11 years postinjury; 96% male, 32% nonwhite, 14.21 years education (SD 1.72), 41.13 years old (SD 11.39)]. Using prerehabilitation neurocognitive performance, participants were clustered into cognitive difficulty (CD) and cognitively normal (CN) groups. Six-plus months after EF rehabilitation training, participants completed a structured telephone interview and/or in-person cognitive/functional/emotional assessment using standardized measures of cognitive, daily, and emotional functioning frequently employed in TBI research. At 6+ months post-EF training compared to prerehabilitation, CD and CN improved in multiple cognitive (Overall Attention/EF: F(1,18) = 26.17, partial η² = .59; Total Memory: F(1,18) = 6.82, partial η² = .28) and functional domains (Goal Processing Scale [GPS] total score: F(1,15) = 6.71, partial η² = .31). CD improved more than CN on Learning and Memory functional domain [F(1,15) = 6.10, partial η² = .29]. Results of our small archival analysis raise the possibility that Veterans with chronic TBI may demonstrate long-term effects of EF training.

Cognitive Training Reorganizes Network Modularity in Traumatic Brain Injury

Background. Graph-theoretic approaches are increasingly popular for identifying the patterns of disrupted neural systems after traumatic brain injury (TBI). However, the patterns of neuroplasticity in brain organization after cognitive training in TBI are less well understood. Objective. We identified the patterns of training-induced neuroplasticity of the whole-brain network in TBI, using resting-state functional connectivity and graph theory. Methods. A total of 64 civilians and veterans with TBI were randomized into either a strategy-based cognitive training group (n = 33) or a knowledge-based training group (active control group; n = 31) for 8 weeks. The participants experienced mild to severe TBI without focal damage and persistent cognitive dysfunctions. A subset of participants complained of subclinical but residual psychiatric symptoms. We acquired their resting-state functional magnetic resonance imaging before training, immediately posttraining, and 3 months posttraining. From participants' resting-state networks, we obtained the modularity, participation coefficient, within-module connectivity, global efficiency, and local efficiency over multiple network densities. We next performed longitudinal analyses on those measures corrected for multiple comparisons across network densities using false discovery rate (FDR). Results. Relative to the knowledge-based training group, the strategy-based cognitive training group had reduced modularity and increased participation coefficient, global efficiency, and local efficiency over time (P_nodal < .05; q_FDR < 0.05). Brain behavior analysis revealed that the participation coefficient and global efficiency within the strategy-based cognitive training group correlated with trail-making scores in the context of training (P_nodal < .05; q_FDR < 0.05). Conclusions. Cognitive training reorganized modular networks in TBI over the whole brain. Graph-theoretic approaches may be useful in identifying a potential brain-based marker of training efficacy in TBI.

Do executive function and theory of mind predict pragmatic abilities following traumatic brain injury? An analysis of sincere, deceitful and ironic communicative acts

Quality of life and social integration are strongly influenced by the ability to communicate and previous research has shown that pragmatic ability can be specifically impaired in individuals with traumatic brain injury (TBI). In addition, TBI usually results in damage to the frontotemporal lobes with a consequent impairment of cognitive functions, i.e., attention, memory, executive function (EF) and theory of mind (ToM). The role of the underlying cognitive deficits in determining the communicative-pragmatic difficulties of an individual with TBI is not yet completely clear. This study examined the relationship between the ability to understand and produce various kinds of communicative acts, (i.e., sincere, deceitful and ironic) and the above-mentioned cognitive and ToM abilities following TBI. Thirty-five individuals with TBI and thirty-five healthy controls were given tasks assessing their ability to comprehend and produce sincere, deceitful and ironic communicative acts belonging to the linguistic and extralinguistic scales of the Assessment Battery for Communication (ABaCo), together with a series of EF and ToM tasks. The results showed that, when compared to healthy individuals, participants with TBI performed poorly overall in the comprehension and production of all the pragmatic phenomena investigated, (i.e., sincere, deceitful and ironic communicative acts), and they also exhibited impaired performance at the level of all the cognitive functions examined. Individuals with TBI also showed a decreasing trend in performance in dealing with sincere, deceitful and ironic communicative acts, on both the comprehension and production subscales of the linguistic and extralinguistic scales. Furthermore, a hierarchical regression analysis revealed that - in patients with TBI but not in the controls - EF had a significant effect on the comprehension of linguistic and extralinguistic irony only, while the percentage of explained variance increased with the inclusion of theory of mind. Indeed, ToM had a significant role in determining patients' performance in the extralinguistic production of sincere and deceitful communicative acts, linguistic and extralinguistic comprehension of deceit and the linguistic production of irony. However, with regard to the performance of patients with TBI in the various pragmatic tasks investigated, (i.e., sincere, deceitful and ironic communicative acts), EF was able to explain the pattern of patients' scores in the linguistic and extralinguistic comprehension but not in production ability. Furthermore, ToM seemed not to be able to explain the decreasing trend in the performance of patients in managing the various kinds of communicative acts investigated.

Communicative-pragmatic disorders in traumatic brain injury: The role of theory of mind and executive functions

Previous research has shown that communicative-pragmatic ability, as well as executive functions (EF) and Theory of Mind (ToM), may be impaired in individuals with traumatic brain injury (TBI). However, the role of such cognitive deficits in explaining communicative-pragmatic difficulty in TBI has still not been fully investigated. The study examined the relationship between EF (working memory, planning and flexibility) and ToM and communicative-pragmatic impairment in patients with TBI. 30 individuals with TBI and 30 healthy controls were assessed using the Assessment Battery of Communication (ABaCo), and a set of cognitive, EF and ToM, tasks. The results showed that TBI participants performed poorly in comprehension and production tasks in the ABaCo, using both linguistic and extralinguistic means of expression, and that they were impaired in EF and ToM abilities. Cognitive difficulties were able to predict the pragmatic performance of TBI individuals, with both executive functions and ToM contributing to explaining patients' scores on the ABaCo.

Cognitive Pragmatic Rehabilitation Program in Schizophrenia: A Single Case fMRI Study

Introduction. The present study was intended to evaluate the effects of a rehabilitative training, the Cognitive Pragmatic Treatment (CPT), aimed at improving communicative-pragmatic abilities and the related cognitive components, on the cerebral modifications of a single case patient diagnosed with schizophrenia. Methods. The patient underwent two functional magnetic resonance imaging (fMRI) sessions, before and after the treatment. In order to assess brain changes, we calculated the Amplitude of Low Frequency Fluctuation (ALFF) index of the resting-state fMRI signal, which is interpreted as reflecting the intensity of the spontaneous regional activity of the brain. Behavioural measures of the patient's communicative performance were also gathered before and after training and at follow-up. Results. The patient improved his communicative performance in almost all tests. Posttraining stronger ALFF signal emerged in the superior, inferior, and medial frontal gyri, as well as the superior temporal gyri. Conclusions. Even if based on a single case study, these preliminary results show functional changes at the cerebral level that seem to support the patient's behavioural improvements.

Abnormal structural and functional hypothalamic connectivity in mild traumatic brain injury

PURPOSE

To investigate whether there is imaging evidence of hypothalamic injury in patients with mild traumatic brain injury (MTBI), which is a major public health problem due to the high prevalence and difficulty in diagnosis and treatment.

MATERIALS AND METHODS

Twenty-four patients (mean age 34.2, range, 18-56 years) with symptomatic MTBI and 22 age-matched healthy controls (mean age 37.0, range 20-61 years) participated in the study. Diffusion kurtosis imaging was performed with diffusion-weighted images acquired along 30 gradient directions and three b-values (b = 0, 1000, 2000 s/mm² ) based on a twice-refocused spin-echo sequence with a 3T magnetic resonance imaging (MRI) scanner. Resting-state functional (f)MRI with standard echo planar imaging (EPI) were performed to localize the resting-state networks (RSN) and hypothalamic functional connectivity.

RESULTS

There were significantly reduced mean kurtosis (P = 0.0092) and radial kurtosis (P = 0.0078) in patients as compared to controls in the hypothalamus. Furthermore, there was a significant negative correlation (r = -0.675, P = 0.0007) between radial kurtosis in the hypothalamus and fatigue severity scale in patients. The MTBI group also showed disrupted hypothalamic RSNs, with significantly decreased positive connectivity in medial prefrontal cortex, inferior posterior parietal, and cingulate regions but increased connectivity in the peri-hypothalamic regions and cerebellum, together with significantly decreased negative RSNs in visual and bilateral premotor areas (cluster corrected P < 0.05).

CONCLUSION

Our results show disruption of functional and structural hypothalamic connectivity in patients with MTBI, and might further the understanding of an array of clinical symptoms in MTBI such as sleep disturbance and fatigue.

LEVEL OF EVIDENCE

2 J. Magn. Reson. Imaging 2017;45:1105-1112.