Experiences and Challenges Updating a Living Evidence-Based Review of Randomized Controlled Trials on Mental Health and Behavioral Disorders in Individuals With Moderate to Severe Traumatic Brain Injury.

OBJECTIVE: To describe experiences and challenges when updating a living evidence-based review database of randomized controlled trials (RCTs) on mental health and behavioral disorders in moderate to severe traumatic brain injury (MSTBI). METHOD: This commentary derives from our experience developing an extensive database of RCTs on MSTBI that has been conceptualized as a living evidence-based review. Our working group focused on mental health and behavior RCTs and reflected upon their experiences and challenges using the living systematic approach. We discuss challenges associated with metrics of study quality, injury etiology and severity, time post-injury, country of origin, and variability in outcome measures. RESULTS: RCTs were conducted almost solely in high income countries, with smaller sample sizes, and most conducted in the chronic phase post-TBI. Issues related to lack of transparency, unclear and incomplete reporting of injury severity, etiology, and time post-injury remain a concern and can lead to challenges associated with interpretation of results, validity, and reliability of the data. There was significant heterogeneity regarding the use of outcome measures and constructs, underscoring the need for standardization. CONCLUSION: Lack of standardization and incomplete reporting of injury characteristics makes it difficult to compare data between RCTs of MSTBI, perform meta-analyses, and generate evidence-based clinical recommendations.

Evidence-Based Review of Randomized Controlled Trials of Interventions for Mental Health Management Post-Moderate to Severe Traumatic Brain Injury.

OBJECTIVE: To present an evidence-based review of randomized controlled trials (RCTs) evaluating interventions for mental health post-moderate to severe traumatic brain injury (post-MSTBI), as part of an extensive database that has been conceptualized as a living systematic review. METHODS: Systematic searches were conducted for RCTs published in the English language in MEDLINE, PubMed, Scopus, CINAHL, EMBASE, and PsycINFO, up to and including December 2022, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The methodological quality of RCTs was assessed using the Physiotherapy Evidence Database scale, and the level of evidence was assigned using a modified Sackett scale. RESULTS: Eighty-seven RCTs examining mental health interventions and outcome measures post-MSTBI were included. These studies collectively enrolled 6471 participants. A total of 41 RCTs (47.1%) were conducted in the United States and 56 studies (64.4%) were published after 2010. A total of 62 RCTs (71.3%) examined nonpharmacological interventions and 25 RCTs (28.7%) examined pharmacological interventions. Effective pharmacological treatments included desipramine and cerebrolysin; methylphenidate and rivastigmine showed conflicting evidence. Cognitive behavioral therapy (CBT) was found to be effective for hopelessness, stress, and anxiety, compared to usual care; however, it may be as effective as supportive psychotherapy for depression. CBT combined with motivational interviewing may be as effective as CBT combined with nondirective counseling for depression, stress, and anxiety. Acceptance and commitment therapy was effective for anxiety, stress, and depression. Tai Chi, dance, and walking appeared to be effective for depression and stress, while other nonpharmacological treatments such as peer mentoring showed limited effectiveness. CONCLUSION: This evidence-based review provides a comprehensive overview of the research landscape of RCTs addressing mental health post-MSTBI. The findings from these RCTs may be valuable for health care professionals, researchers, and policymakers involved in the field of mental health and neurorehabilitation.

Evidence-Based Review of Randomized Controlled Trials of Interventions for the Management of Behavioral Issues in Individuals With Moderate to Severe Traumatic Brain Injury.

OBJECTIVE: To present an evidence-based review of randomized controlled trials (RCTs) evaluating interventions for the management of behavioral issues post moderate to severe traumatic brain injury (MSTBI), as part of an extensive database that has been conceptualized as a living systematic review. METHODS: Systematic searches were conducted in MEDLINE, PubMed, Scopus, CINAHL, EMBASE and PsycINFO, up to and including December 2022, for articles published in the English language, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The quality of RCT was assessed using the Physiotherapy Evidence Database (PEDro) scale, and level of evidence was assigned using a modified Sackett scale. RESULTS: Forty-six RCTs examining interventions and outcome measures related to behavioral issues post-MSTBI were included. These studies collectively enrolled 3,267 participants. The majority of RCTs were conducted in the United States (n = 27; 58.7%) and 28 (60.9%) were conducted after 2010. Of these, 27 RCTs examined non-pharmacological interventions and 19 examined pharmacological interventions. Effective pharmacological treatments included amantadine and dexmedetomidine. Effective non-pharmacological interventions included sensory stimulation in the acute phase, anger self-management programs, peer mentoring, problem-solving, and emotional regulation. Psychotherapy showed conflicting evidence. CONCLUSION: This evidence-based review provides a comprehensive overview of the research landscape of RCTs addressing behavior post-MSTBI. The findings from these RCTs may be valuable for health care professionals, researchers, and policymakers involved in the field of TBI and behavior.

INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury: Methods, Overview, and Principles.

INTRODUCTION: Moderate to severe traumatic brain injury (TBI) results in complex cognitive sequelae. Despite hundreds of clinical trials in cognitive rehabilitation, the translation of these findings into clinical practice remains a challenge. Clinical practice guidelines are one solution. The objective of this initiative was to reconvene the international group of cognitive researchers and clinicians (known as INCOG) to develop INCOG 2.0: Guidelines for Cognitive Rehabilitation Following TBI. METHODS: The guidelines adaptation and development cycle was used to update the recommendations and derive new ones. The team met virtually and reviewed the literature published since the original INCOG (2014) to update the recommendations and decision algorithms. The team then prioritized the recommendations for implementation and modified the audit tool accordingly to allow for the evaluation of adherence to best practices. RESULTS: In total, the INCOG update contains 80 recommendations (25 level A, 15 level B, and 40 level C) of which 27 are new. Recommendations developed for posttraumatic amnesia, attention, memory, executive function and cognitive-communication are outlined in other articles, whereas this article focuses on the overarching principles of care for which there are 38 recommendations pertaining to: assessment (10 recommendations), principles of cognitive rehabilitation (6 recommendations), medications to enhance cognition (10 recommendations), teleassessment (5 recommendations), and telerehabilitation intervention (7 recommendations). One recommendation was supported by level A evidence, 7 by level B evidence, and all remaining recommendations were level C evidence. New to INCOG are recommendations for telehealth-delivered cognitive assessment and rehabilitation. Evidence-based clinical algorithms and audit tools for evaluating the state of current practice are also provided. CONCLUSIONS: Evidence-based cognitive rehabilitation guided by these recommendations should be offered to individuals with TBI. Despite the advancements in TBI rehabilitation research, further high-quality studies are needed to better understand the role of cognitive rehabilitation in improving patient outcomes after TBI.

INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part II: Attention and Information Processing Speed.

INTRODUCTION: Moderate to severe traumatic brain injury (MS-TBI) commonly causes disruption in aspects of attention due to its diffuse nature and injury to frontotemporal and midbrain reticular activating systems. Attentional impairments are a common focus of cognitive rehabilitation, and increased awareness of evidence is needed to facilitate informed clinical practice. METHODS: An expert panel of clinicians/researchers (known as INCOG) reviewed evidence published from 2014 and developed updated guidelines for the management of attention in adults, as well as a decision-making algorithm, and an audit tool for review of clinical practice. RESULTS: This update incorporated 27 studies and made 11 recommendations. Two new recommendations regarding transcranial stimulation and an herbal supplement were made. Five were updated from INCOG 2014 and 4 were unchanged. The team recommends screening for and addressing factors contributing to attentional problems, including hearing, vision, fatigue, sleep-wake disturbance, anxiety, depression, pain, substance use, and medication. Metacognitive strategy training focused on everyday activities is recommended for individuals with mild-moderate attentional impairments. Practice on de-contextualized computer-based attentional tasks is not recommended because of lack of evidence of generalization, but direct training on everyday tasks, including dual tasks or dealing with background noise, may lead to gains for performance of those tasks. Potential usefulness of environmental modifications is also discussed. There is insufficient evidence to support mindfulness-based meditation, periodic alerting, or noninvasive brain stimulation for alleviating attentional impairments. Of pharmacological interventions, methylphenidate is recommended to improve information processing speed. Amantadine may facilitate arousal in comatose or vegetative patients but does not enhance performance on attentional measures over the longer term. The antioxidant Chinese herbal supplement MLC901 (NeuroAiD IITM) may enhance selective attention in individuals with mild-moderate TBI. CONCLUSION: Evidence for interventions to improve attention after TBI is slowly growing. However, more controlled trials are needed, especially evaluating behavioral or nonpharmacological interventions for attention.

INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part I: Posttraumatic Amnesia.

INTRODUCTION: Posttraumatic amnesia (PTA) is a common occurrence following moderate to severe traumatic brain injury (TBI) and emergence from coma. It is characterized by confusion, disorientation, retrograde and anterograde amnesia, poor attention and frequently, agitation. Clinicians and family need guidelines to support management practices during this phase. METHODS: An international team of researchers and clinicians (known as INCOG) met to update the INCOG guidelines for assessment and management of PTA. Previous recommendations and audit criteria were updated on the basis of review of the literature from 2014. RESULTS: Six management recommendations were made: 1 based on level A evidence, 2 on level B, and 3 on level C evidence. Since the first version of INCOG (2014), 3 recommendations were added: the remainder were modified. INCOG 2022 recommends that individuals should be assessed daily for PTA, using a validated tool (Westmead PTA Scale), until PTA resolution. To date, no cognitive or pharmacological treatments are known to reduce PTA duration. Agitation and confusion may be minimized by a variety of environmental adaptations including maintaining a quiet, safe, and consistent environment. The use of neuroleptic medications and benzodiazepines for agitation should be minimized and their impact on agitation and cognition monitored using standardized tools. Physical therapy and standardized activities of daily living training using procedural and errorless learning principles can be effective, but delivery should be tailored to concurrent levels of cognition, agitation, and fatigue. CONCLUSIONS: Stronger recommendations regarding assessment of PTA duration and effectiveness of activities of daily living training have been made. Evidence regarding optimal pharmacological and nonpharmacological management of confusion and agitation during PTA remains limited, with further research needed. These guidelines aim to enhance evidence-based care and maximize consistency of PTA management.

INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part V: Memory.

INTRODUCTION: Memory impairments affecting encoding, acquisition, and retrieval of information after moderate-to-severe traumatic brain injury (TBI) have debilitating and enduring functional consequences. The interventional research reviewed primarily focused on mild to severe memory impairments in episodic and prospective memory. As memory is a common focus of cognitive rehabilitation, clinicians should understand and use the latest evidence. Therefore, the INCOG ("International Cognitive") 2014 clinical practice guidelines were updated. METHODS: An expert panel of clinicians/researchers reviewed evidence published since 2014 and developed updated recommendations for intervention for memory impairments post-TBI, a decision-making algorithm, and an audit tool for review of clinical practice. RESULTS: The interventional research approaches for episodic and prospective memory from 2014 are synthesized into 8 recommendations (6 updated and 2 new). Six recommendations are based on level A evidence and 2 on level B. In summary, they include the efficacy of choosing individual or multiple internal compensatory strategies, which can be delivered in a structured or individualized program. Of the external compensatory strategies, which should be the primary strategy for severe memory impairment, electronic reminder systems such as smartphone technology are preferred, with technological advances increasing their viability over traditional systems. Furthermore, microprompting personal digital assistant technology is recommended to cue completion of complex tasks. Memory strategies should be taught using instruction that considers the individual's functional and contextual needs while constraining errors. Memory rehabilitation programs can be delivered in an individualized or mixed format using group instruction. Computer cognitive training should be conducted with therapist guidance. Limited evidence exists to suggest that acetylcholinesterase inhibitors improve memory, so trials should include measures to assess impact. The use of transcranial direct current stimulation (tDCS) is not recommended for memory rehabilitation. CONCLUSION: These recommendations for memory rehabilitation post-TBI reflect the current evidence and highlight the limitations of group instruction with heterogeneous populations of TBI. Further research is needed on the role of medications and tDCS to enhance memory.

A systematic review examining the effect of vitamin D supplementation on functional outcomes post-stroke.

OBJECTIVE: The objective of this systematic review was to explore the effect of vitamin D supplementation on functional outcomes (motor function, mobility, activities of daily living and stroke impairment) among individuals post-stroke (PROSPERO CRD42022296462). DATA SOURCES: MEDLINE, PsycINFO, EMBASE, and CINAHL were searched for all articles published up to March 5, 2023. METHODS: Only interventional studies assessing vitamin D supplementation compared to placebo or usual care in adult stroke patients were selected. After duplicate removal, 2912 studies were screened by two independent reviewers. A total of 43 studies underwent full text review; 10 studies met inclusion criteria (8 randomized controlled trials and 2 non-randomized studies of intervention). Data were extracted by two independent reviewers using Covidence software. Motor function (Brunnstrom Recovery Stage, Berg Balance Score), mobility (Functional Ambulation Category), activities of daily living (Barthel Index, Functional Independence Measure) and stroke impairment (modified Rankin Scale, National Institutes for Health Stroke Severity, Scandinavian Stroke Severity) were the outcome measures of interest reported in the included studies. RESULTS: In total, 691 patients were studied for which 11 of 13 outcome measures showed improvement with vitamin D supplementation. CONCLUSIONS: The majority of studies showed a statistical improvement in motor function, mobility, and stroke impairment with vitamin D supplementation; however, the evidence did not support an improvement in activities of daily living with treatment. Despite this, there may not be clinical significance. Strong, methodologically sound, randomized controlled trials are required to verify these findings.

Phenotypes and Endotypes in Asthma.

Asthma is a broadly encompassing diagnosis of airway inflammation with significant variability in presentation and response. Advances in molecular techniques and imaging have unraveled the delicate mechanistic tapestry responsible for the underlying inflammatory pathways in asthma. The elucidation of biomarkers and cellular components specific to these inflammatory pathways allowed for the categorization of asthma from generic phenotypes to more specific mechanistic endotypes, with two prominent subgroups emerging based on the level of Type 2 inflammation present - T2 high and T2 low (or non-T2). Sophisticated modeling and cluster analyses using a combination of clinical, physiologic, and biomarker parameters have permitted the identification of subendotypes within the broader T2 umbrella. This mechanistic-driven classification schema for asthma has dramatically altered the landscape of asthma management with the discovery and approval of targeted biologic therapies and has ushered in a new era of personalized precision medicine in asthma.

Tolerability of pharmacological agents in the treatment of headache following brain injury: a scoping review.

BACKGROUND: While systematic reviews have examined medication effectiveness for post-traumatic headache (PTH), they have not assessed tolerability. OBJECTIVE: To conduct a scoping review to characterize the adverse effects of pharmacotherapy for PTH. METHODS: CINAHL, CMA Infobase, Cochrane Library, Embase, Epistemonikos, MEDLINE, PEDro, PsycInfo, Scopus, SportDiscus, TRIP and the University of York Center for Reviews and Dissemination were searched. Studies meeting these criteria were included 1) English language, 2) involved humans with traumatic brain injury (TBI), 3) a medication for PTH was administered and 4) reported tolerability outcomes. Author(s), publication year, country of origin, study design, sample demographics, medication type, comparator, dose, treatment duration, adverse effect type and rate, discontinuation rate, and effectiveness outcomes were extracted. RESULTS: The search yielded 2941 records; 11 studies were included (n = 324 subjects). All subjects had mild TBI except for one with moderate TBI. The following therapies were examined 1) abortive (dihydroergotamine N = 1; metoclopramide N = 1; indomethacin N = 3), 2) prophylactic (divalproex sodium N = 1; amantadine N = 1; erenumab N = 2; amitriptyline N = 2). No serious adverse effects occurred. Observed adverse effects overlap with common symptoms of TBI. CONCLUSION: The unique needs of people with TBI must be considered when instituting pharmacotherapy. More studies specifically evaluating medication tolerability in PTH are needed.

An integrative review of adult patient-reported reasons for non-urgent use of the emergency department.

OBJECTIVE: To conduct an integrative review of the scientific literature to explore adult patient-reported reasons for using the emergency department (ED) non-urgently. METHOD: A literature search of CINAHL, Cochrane, Embase, PsycINFO, and MEDLINE was conducted with filters for humans, published January 1, 1990-September 1, 2021, and English language. Methodological quality was assessed using Critical Appraisal Skills Programme Qualitative Checklist for qualitative and National Institutes Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies for quantitative studies. Data was abstracted on study and sample characteristics, and themes/reasons for ED use. Cited reasons were coded using thematic analysis. RESULTS: Ninety-three studies met inclusion criteria. Seven themes were found: need to be risk averse with respect to the health issue; knowledge and awareness of alternative sources of care; dissatisfaction with primary care provider; satisfaction with ED; ED accessibility and convenience resulting in low access burden; referred to the ED by others; and relationships between patients and health care providers. DISCUSSION: This integrative review examined patient-reported reasons for attending the ED on a non-urgent basis. The results suggest that ED patients are heterogenous and many factors influence their decision-making. Considering the complexity with which patients live, treating them as a single entity may be problematic. Limiting excessive non-urgent visits likely requires a multi-pronged approach. CONCLUSION: For many ED patients, they have a very clear problem which needed to be addressed. Future studies should explore psychosocial factors driving decision-making (e.g., health literacy, health-related personal beliefs, stress and coping ability).

The hand diagram: A novel outcome measure following supercharged end-to-side anterior interosseous nerve to ulnar nerve transfer in severe compressive ulnar neuropathy.

BACKGROUND: With advances in the surgical management for severe ulnar neuropathy with the introduction of the super charged-end-to-side (SETS) anterior interosseous nerve (AIN) to ulnar nerve transfer, a simple and reliable outcome measure is required. There is currently not "one" standardized outcome measure used to represent and compare results. PURPOSE: To present the abduction hand diagram as a "novel", reproducible, and simple outcome measure for patients with severe ulnar neuropathy. STUDY DESIGN: Retrospective case series. METHODS: Nine patients with severe entrapment/compressive ulnar neuropathy at the elbow were reviewed. Clinical parameters included preoperative and postoperative abduction tracings, Medical Research Grade (MRC) muscle strength, key pinch strength, Disability of the Hand Arm and Shoulder (DASH) score, and crossed finger test. Electrodiagnostic data included change in compound muscle action potentials (CMAP) amplitude of the first dorsal interosseous (FDI), and abductor digiti minimi (ADM). Summary statistics were used for demographic and clinical data. RESULTS: Average follow-up was 22.8 ± 9.3 months. At 18-months of follow up, 44% had ADM MRC grade 3 strength or higher, mean key pinch strength improved to 72 ± 19.3%, and mean DASH was 33 ± 28.7. There was a mean increase of 16.7 ± 9.1 mm and 31.5 ± 12 mm in total and summed hand abduction tracing measurements respectively. CONCLUSIONS: Hand abduction tracings are a quantitative outcome measure to follow recovery over time for intrinsic hand function and can be used in patients with severe ulnar neuropathy following surgical intervention.

Evaluating the effectiveness of aquatic therapy on mobility, balance, and level of functional independence in stroke rehabilitation: a systematic review and meta-analysis.

OBJECTIVE: To meta-analyze and systematically review the effectiveness of aquatic therapy in improving mobility, balance, and functional independence after stroke. DATA SOURCES: Articles published in Medline, Embase, CINAHL, PsycINFO, and Scopus up to 20 August 2019. STUDY SELECTION: Studies met the following inclusion criteria: (1) English, (2) adult stroke population, (3) randomized or non-randomized prospectively controlled trial (RCT or PCT, respectively) study design, (4) the experimental group received >1 session of aquatic therapy, and (5) included a clinical outcome measure of mobility, balance, or functional independence. DATA EXTRACTION: Participant characteristics, treatment protocols, between-group outcomes, point measures, and measures of variability were extracted. Methodological quality was assessed using Physiotherapy Evidence Database (PEDro) tool, and pooled mean differences (MD) ± standard error and 95% confidence intervals (CI) were calculated for Functional Reach Test (FRT), Timed Up and Go Test (TUG), gait speed, and Berg Balance Scale (BBS). DATA SYNTHESIS: Nineteen studies (17 RCTs and 2 PCTs) with a mean sample size of 36 participants and mean PEDro score of 5.6 (range 4-8) were included. Aquatic therapy demonstrated statistically significant improvements over land therapy on FRT (MD = 3.511 ± 1.597; 95% CI: 0.381-6.642; P = 0.028), TUG (MD = 2.229 ± 0.513; 95% CI: 1.224-3.234; P < 0.001), gait speed (MD = 0.049 ± 0.023; 95% CI: 0.005-0.094; P = 0.030), and BBS (MD = 2.252 ± 0.552; 95% CI: 1.171-3.334; P < 0.001). CONCLUSIONS: While the effect of aquatic therapy on mobility and balance is statistically significant compared to land-based therapy, the clinical significance is less clear, highly variable, and outcome measure dependent.

Nonpharmacological rehabilitation interventions for motor and cognitive outcomes following pediatric stroke: a systematic review.

The aim of this review was to evaluate the evidence for nonpharmacological rehabilitation interventions for motor and cognitive impairment following pediatric stroke. A literature search was conducted using multiple scientific databases. Studies were included if (1) the study population was > 50% pediatric (< 18 years) stroke, (2) a diagnosis of stroke was explicitly stated, (3) there were ≥ 3 pediatric stroke participants included in the study sample, and (4) motor or cognitive outcome measures were used to assess effect of treatment. Levels of evidence were assigned to each study to determine the strength of the evidence for each intervention. A total of 18 articles met inclusion criteria. Most studies (N = 14) examined rehabilitation of the upper limb, with constraint-induced movement therapy (CIMT) as the most common intervention. Overall, the evidence supports the use of CIMT, forced use therapy, repetitive transcranial magnetic stimulation, functional electrical stimulation, and robotics, but suggests no beneficial effect of transcranial direct current stimulation. Very few studies assessed interventions for the lower limb (N = 1) or cognitive impairment (N = 3).Conclusion: Effective rehabilitation approaches are important for optimizing outcomes in children who have had a stroke. Although the number of published clinical trials has increased in recent years, little evidence-based guidance exists for this clinical population. What is Known: • Pediatric stroke is a significant cause of disability in children that is often associated with long-term motor and cognitive sequelae. • There is a need to establish a knowledge base regarding available evidence-based rehabilitation therapies for this clinical population. What is New: • Most studies examining interventions for motor function focus on upper limb rehabilitation, whereas few studies have investigated interventions for improving lower limb or cognitive impairment. • An important gap exists regarding evidence-based rehabilitative treatment approaches for pediatric stroke.

Referral patterns of stroke rehabilitation inpatients to a model system of outpatient services in Ontario, Canada: a 7-year retrospective analysis.

BACKGROUND: While several studies have tracked the care paths of patients in the early phases of stroke recovery, studies examining the transition from inpatient to outpatient rehabilitation are lacking. Examining this transition allows for improved understanding and refinement of the process whereby patients are referred and admitted to programs. The objective of this study was to examine the referral patterns of stroke rehabilitation inpatients to outpatient stroke therapy services, their demographics, and clinical profile. METHODS: This study examined patients who: (1) were admitted to an inpatient stroke rehabilitation unit between January 1, 2009 and March 1, 2016, (2) had a stroke diagnosis, (3) had an inpatient length of stay of > 1 day, and (4) lived within the geographical boundaries of the South West Local Health Integration Network which allowed them access to both hospital-based and home-based stroke rehabilitation outpatient programs. Patient data was collected from the National Rehabilitation Reporting System, as well as three hospital outpatient administrative databases. These databases were cross-referenced to determine each patient's pathway. Those referred to an outpatient therapy program, and those who attended the outpatient programs, were compared to those who were not, and did not, respectively. RESULTS: 1497 inpatients were included in the analysis. Upon discharge, 1037 (69.3%) of patients had an outpatient clinic, follow-up appointment scheduled; of those, 902 (87.0%) patients attended at least one outpatient clinic visit. 891 (59.5%) were referred to one of the interdisciplinary outpatient stroke rehabilitation programs; of those, an outpatient therapy program was attended by 80.9% of patients (n = 721). Of those receiving outpatient therapy services, the number of patients attending the in-hospital versus home-based program were equal, 360 and 361 individuals, respectively. CONCLUSION: This study allows for a better understanding of the transition between inpatient and outpatient stroke care. There is a paucity of this type of information in stroke rehabilitation literature to date. This study acts as a starting point in improving rehabilitation planning across the continuum of care.

Opioids and cerebral physiology in the acute management of traumatic brain injury: a systematic review.

BACKGROUND: Following traumatic brain injury (TBI), optimization of cerebral physiology is recommended to promote more favourable patient outcomes. Accompanying pain and agitation are commonly treated with sedative and analgesic agents, such as opioids. However, the impact of opioids on certain aspects of cerebral physiology is not well established. OBJECTIVE: To conduct a systematic review of the evidence on the effect of opioids on cerebral physiology in TBI during acute care. METHODS: A comprehensive literature search was conducted in five electronic databases for articles published in English up to November 2017. Studies were included if: (1) the study sample was human subjects with TBI; (2) the sample size was ≥3; (3) subjects were given an opioid during acute care; and (4) any measure of cerebral physiology was evaluated. Cerebral physiology measures were intracranial pressure (ICP), cerebral perfusion pressure (CPP), and mean arterial pressure (MAP). Subject and study characteristics, treatment protocol, and results were extracted from included studies. Randomized controlled trials were evaluated for methodological quality using the Physiotherapy Evidence Database tool. Levels of evidence were assigned using a modified Sackett scale. RESULTS: In total, 22 studies met inclusion criteria, from which six different opioids were identified: morphine, fentanyl, sufentanil, remifentanil, alfentanil, and phenoperidine. The evidence for individual opioids demonstrated equally either: (1) no effect on ICP, CPP, or MAP; or (2) an increase in ICP with associated decreases in CPP and MAP. In general, opioids administered by infusion resulted in the former outcome, whereas those given in bolus form resulted in the latter. There were no significant differences when comparing different opioids, with the exception of one study that found fentanyl was associated with lower ICP and CPP than morphine and sufentanil. There were no consistent results when comparing opioids to other non-opioid medications. CONCLUSION: Several studies have assessed the effect of opioids on cerebral physiology during the acute management of TBI, but there is considerable heterogeneity in terms of study methodology and findings. Opioids are beneficial in terms of analgesia and sedation, but bolus administration should be avoided to prevent additional or prolonged unfavourable alterations in cerebral physiology. Future studies should better elucidate the effects of different opioids as well as varying dosages in order to develop improved understanding as well as allow for tighter control of cerebral physiology. ABBREVIATIONS: CPP: Cerebral Perfusion Pressure, GCS: Glasgow Coma Scale, ICP: Intracranial Pressure, MAP: Mean Arterial Pressure, PEDro: Physiotherapy Evidence Database, RCT: Randomized Controlled Trial, TBI: Traumatic Brain Injury.

A mapping review of randomized controlled trials in the spinal cord injury research literature.

STUDY DESIGN: Mapping Review. OBJECTIVE: The objective of this study was to map out and characterize the quantity and quality of all published spinal cord injury (SCI) randomized controlled trials (RCTs) with respect to number, sample size, and methodological quality between January 1970 and December 2016. SETTING: Not applicable. METHODS: A literature search of multiple research databases was conducted. Studies adhering to the following criteria were included: the research design was an RCT; written in English; participants were >18 years; and the sample was >50% SCI. Data were extracted pertaining to author(s), year of publication, country of origin, initial and final sample size, intervention, and control. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) tool. Data was assessed overall and by each year of publication. RESULTS: In total, 466 RCTs were published 1971-2016 on 29 primary topic areas, with Bladder (n = 78, 16.7%) most common, followed by Pain (n = 54, 11.6%), and Lower Limb (n = 45, 9.7%). Studies were published in 172 unique journals, with the most common being Spinal Cord (n = 68, 14.6%). The most common producer of studies was the United States (n = 191, 41.0%). RCT publications increased linearly until 2012 when the rate tripled, resulting in 40.8% published 2012-2016. A total of 247 (59.4%) RCTs had <30 subjects; there was no change in sample size over time (p = 0.770). The overall mean PEDro score was 5.56 (1.68); scores improved from 5.0 (1.4) in 1976 to 6.3 (1.9) in 2016 (F = 2.230, p < 0.001). CONCLUSIONS: The number of SCI RCTs and their associated sample size remains low; however, methodological quality has improved over time.

Cognitive behavioural therapy for aggression among individuals with moderate to severe acquired brain injury: a systematic review and meta-analysis.

BACKGROUND: Aggression is common after an acquired brain injury (ABI). Cognitive behavioural therapy (CBT) is a form of psychotherapy, in which therapists help patients to identify their maladaptive behaviours. OBJECTIVE: The objective of this systematic review and meta-analysis was to evaluate the effectiveness of CBT interventions in treating aggression in an ABI population. METHODS: A systematic literature search was conducted using: PubMed/MEDLINE, CINAHL, EMBASE and PsycINFO from database inception to August 2016. English articles were included if: at least 50% of the study sample had a moderate to severe ABI, there were at least three adult human participants, and use of a CBT intervention for the treatment of aggression. RESULTS: Seven articles met inclusion criteria: one RCT, an RCT crossover and five pre-post trials. Of these, four articles were included in a pre-post meta-analysis for treatment efficacy on subscales of the State Trait Anger Expression Inventory (STAXI) and STAXI-2 outcome measures. The meta-analysis found CBT was effective in moderating the external behaviours of aggression, but not internal anger. CONCLUSION: The differences in outcomes may be related to the differential management of anger expression and anger suppression. CBT shows promise, but further studies with comparator groups are needed before conclusions about its efficacy can be made.

Pharmacological management of agitation among individuals with moderate to severe acquired brain injury: A systematic review.

OBJECTIVE: To conduct a systematic review examining the effectiveness of pharmacological management of agitation among individuals with acquired brain injury (ABI). DATA SOURCES: MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched for all relevant articles published in English from 1980 to January 2016. STUDY SELECTION: Studies were included for analysis all participants had moderate to severe ABI, n ≥ 3, and a pharmacological intervention was provided for the treatment of agitation and its effectiveness was assessed. DATA EXTRACTION: Data extracted included participant demographics, inclusion and exclusion criteria, study design, outcome measure(s), and results. Study quality was assessed using the Physiotherapy Evidence Database assessment scale for randomized controlled trials (RCTs). A level of evidence was assigned to each intervention using a modified Sackett scale. DATA SYNTHESIS: Among 165 retrieved studies, 19 met inclusion criteria. The included studies consisted of 6 RCTs and 13 observational studies. Antipsychotic medications were studied predominately (n = 6), followed by anticonvulsants (n = 4) and dopaminergic (n = 4), antidepressants (n = 3), and beta-blockers (n = 2). Dopaminergic medications, specifically amantadine, had the highest level of evidence (Level 1a). The antipsychotic lithium carbonate was shown to be effective but was not recommended for use due to high risk of neurotoxicity. CONCLUSIONS: Studies consistently demonstrated that pharmacological treatment was effective in reducing agitation post ABI; however, there was insufficient information to develop a conclusion due to the limited number of studies and overall weakness of evidence for each individual medication.