Efficacy of an Intensive Exposure Intervention for Individuals With Persistent Concussion Symptoms Following Concussion: A Concurrent Multiple Baseline Single-Case Experimental Design (SCED) Study.

OBJECTIVE: After a concussion, 1 in 3 patients report persistent symptoms and experience long-term consequences interfering with daily functioning, known as persistent concussion symptoms (PCS). Evidence suggests PCS is (partly) maintained by anxious thoughts about brain functioning, recovery, and experienced symptoms, leading to avoidance behaviors, which may prevent patients from meeting life demands. We aimed to investigate the efficacy of a newly developed intensive exposure intervention for individuals with PCS after concussion aimed to tackle avoidance behavior. SETTING: Participants took part in the intervention at the Maastricht University faculty. PARTICIPANTS: Four participants who experienced PCS after concussion partook in the exploratory study. Participants' age ranged between 20 and 32 (mean = 26.5, SD = 5.9) years, with an average length of time after the concussion of 9.8 months. DESIGN: A concurrent multiple-baseline single-case design was conducted. The baseline period (A phase) length was randomly determined across participants (3, 4, 5, or 6 weeks). The exposure intervention (B phase) was conducted by psychologists over a 4-week period and consisted of 3 stages: exploration (2 sessions), active exposure (12 sessions conducted over 1 week), and 2 booster sessions. MAIN MEASURES: Participants answered daily questions on a visual analog scale related to symptom experience, satisfaction with daily functioning, and degree of avoidance of feared activities. Additional outcomes included symptom severity, catastrophizing, fear of mental activity, anxiety, depression, and societal participation. RESULTS: Tau-U yielded significant effects (P < .05) for all participants on all measures when comparing baseline and intervention phases. The pooled standardized mean difference was high for all measures (symptom experience = 0.93, satisfaction of daily functioning = 1.86, and activity avoidance = -2.05). CONCLUSIONS: The results show efficacy of the newly developed intensive exposure treatment for PCS after concussion, which is based on the fear avoidance model. Replication in a larger heterogeneous sample is warranted and needed.

The bidirectional relationship between sleep and physical activity following traumatic brain injury.

Sleep and physical activity are both modifiable behavioural factors that are associated with better health and are potentially related. Following traumatic brain injury, damage to the brain caused by an external force, sleep disturbances are common. Exploring bidirectional relationships between sleep and physical activity might provide insight into whether increasing physical activity could decrease these sleep disturbances. The current study, therefore, examined inter- and intra-individual temporal associations between sleep and daytime physical activity in 64 people with traumatic brain injury reporting sleep problems or fatigue (47 males; mean age, 40 years). Sleep and physical activity were measured using actigraphy with corroborating sleep diaries over 14 consecutive days. Multilevel models were used to examine inter- and intra-individual associations between physical activity and sleep. Inter-individual variations showed that earlier bedtimes, earlier wake-up times and lower sleep efficiency were associated with more physical activity. Intra-individual temporal variations showed no significant association of daytime physical activity with sleep duration or continuity. However, shorter sleep time and less wake after sleep onset than usual were associated with more time spent in light-intensity activity the next day. Therefore, sleep may have more of an influence on physical activity than physical activity has on sleep in people with traumatic brain injury. In conclusion, the results do not confirm a potential beneficial effect of physical activity on sleep but suggest that improving sleep quality might be relevant to support of a physically active lifestyle in people with traumatic brain injury. Further research is necessary to confirm these results.

Does the fear avoidance model explain persistent symptoms after traumatic brain injury?

BACKGROUND: A minority of patients with mild traumatic brain injury (mTBI) experience a persistent symptom complex also known as post-concussion syndrome. Explanations for this syndrome are still lacking. OBJECTIVE: To investigate if the fear avoidance model, including catastrophizing thoughts and fear avoidance behaviour, poses a possible biopsychosocial explanation for lingering symptoms and delay in recovery after traumatic brain injury (TBI) with special focus on mTBI. DESIGN: Cross-sectional study. PARTICIPANTS: 48 patients with TBI, of which 31 patients with mTBI, had persistent symptoms (mean time since injury 48.2 months); 92% of the entire sample fulfilled the criteria for post-concussion syndrome. OUTCOME VARIABLES: catastrophizing, fear-avoidance, depression and post-concussion symptoms. RESULTS: High levels of catastrophizing were found in 10% and high levels of fear avoidance behaviour were found in 35%. Catastrophizing, fear avoidance behaviour, depressive symptoms and post-concussion symptoms correlated significantly with each other (p < 0.05). CONCLUSION: The fear-avoidance model proposes a possible explanation for persistent symptoms. Validation and normative data are needed for suitable measures of catastrophizing and fear avoidance of post-concussion symptoms after TBI. Longitudinal prospective cohort studies are needed to establish its causal and explanatory nature.

Explaining fatigue in multiple sclerosis: cross-validation of a biopsychosocial model.

Fatigue is a common and disabling symptom in patients with multiple sclerosis (MS), but its pathogenesis is still poorly understood and consequently evidence-based treatment options are limited. Bol et al. (J Behav Med 33(5):355-363, 2010) suggested a new model, which explains fatigue in MS from a biopsychosocial perspective, including cognitive-behavioral factors. For purposes of generalization to clinical practice, cross-validation of this model in another sample of 218 patients with MS was performed using structural equation modeling. Path analysis indicated a close and adequate global fit (RMSEA = 0.053 and CFI = 0.992). The cross-validated model indicates a significant role for disease severity, depression and a fear-avoidance cycle in explaining MS-related fatigue. Modifiable factors, such as depression and catastrophizing thoughts, propose targets for treatment options. Our findings are in line with recent evidence for the effectiveness of a new generation of cognitive behavioral therapy, including acceptance and mindfulness-based interventions, and provide a theoretical framework for treating fatigue in MS.

Psychometric properties of two instruments assessing catastrophizing and fear-avoidance behavior in mild traumatic brain injury.

OBJECTIVE: Psychometrically sound measures of catastrophizing about symptoms and fear avoidance behavior are needed to further applications of the fear-avoidance model in mild traumatic brain injury (mTBI) for research and clinical purposes. To this end, two questionnaires were adapted (minor), the Postconcussion Symptom Catastrophizing Scale (PCS-CS) and the Fear of Mental Activity Scale (FMA). This study aimed to investigate the factor structure, internal consistency, test-retest reliability, and concurrent and construct validity of two adapted questionnaires in a sample of participants with mTBI compared to participants with orthopedic injury and healthy adults. METHOD: One hundred eighty-five mTBI participants (40% female), 180 participants with orthopedic injury (55% female), and 116 healthy adults (55% female) participated in the study. All participants were assessed at two time points (2 weeks postinjury and 3 months) using self-reported questionnaires. Data were collected using online questionnaires. RESULTS: Findings indicated a three-factor model (magnification, rumination, helplessness) with a higher order factor (catastrophizing) for the PCS-CS and a two-factor model (activity avoidance and somatic focus) for the FMA. The results showed strong internal consistency, good test-retest reliability, and good concurrent and convergent validity for the PCS-CS and FMA across all samples. CONCLUSIONS: This study has shown that the PCS-CS and FMA are psychometrically sound instruments and can be considered for valid and reliable assessment of catastrophizing about postconcussion like symptoms and fear-avoidance beliefs about mental activities. These instruments can be used in research and clinical practice applications of the fear-avoidance model and add to explanations of prolonged recovery after mTBI. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Mental effort and recovery from task-induced fatigue in people with traumatic brain injury.

PURPOSE: This exploratory case-controlled study examined whether the same amount of effort leads to similar feelings of fatigue and whether feelings of fatigue decline at the same rate in people with traumatic brain injury (pwTBI) compared to controls. METHODS: Twenty pwTBI and 20 healthy controls (HC) completed an adaptive n-back task to induce fatigue and reported mental effort upon task completion and state-fatigue pre-task and several times during 30-minutes rest-period post-task. Task difficulty adapted to performance allowing both groups to invest substantial amounts of mental effort. RESULTS: Fatigue and effort levels were higher in pwTBI compared to controls. Multiple linear regression analyses showed that effort was positively related to post-task fatigue and this relationship did not differ between groups. Pre-task fatigue was the only predictor of post-task fatigue. Multilevel models showed no significant difference in decline of fatigue over the rest-period between groups. CONCLUSIONS: Excessive feelings of fatigue following TBI could not be explained by a higher vulnerability to the fatigue-inducing effects of mental effort needed to perform a specific task. In pwTBI pre-task fatigue levels might be more related to the complex demands of everyday life. Future studies should investigate recovery of fatigue and applications of this knowledge to rehabilitation interventions.Implications for rehabilitationPeople with TBI experience long-term fatigue as one of the most frequent and disabling symptoms and this long-term fatigue is a risk factor for development of secondary psychiatric symptoms such as depression or anxiety.Since people with TBI did not show a higher vulnerability to the fatigue-inducing effects of mental effort, fatigue following TBI might be better explained by the complex demands of everyday life such as external (environment) and internal (emotions) factors.Rehabilitation programs should be directed to this complex and highly individual interplay of fatigue in relation to other factors.

The adaptation process following acute onset disability: an interactive two-dimensional approach applied to acquired brain injury.

OBJECTIVE: To describe a new model of the adaptation process following acquired brain injury, based on the patient's goals, the patient's abilities and the emotional response to the changes and the possible discrepancy between goals and achievements. BACKGROUND: The process of adaptation after acquired brain injury is characterized by a continuous interaction of two processes: achieving maximal restoration of function and adjusting to the alterations and losses that occur in the various domains of functioning. Consequently, adaptation requires a balanced mix of restoration-oriented coping and loss-oriented coping. The commonly used framework to explain adaptation and coping, 'The Theory of Stress and Coping' of Lazarus and Folkman, does not capture this interactive duality. RELEVANT THEORIES: This model additionally considers theories concerned with self-regulation of behaviour, self-awareness and self-efficacy, and with the setting and achievement of goals. THE TWO-DIMENSIONAL MODEL: Our model proposes the simultaneous and continuous interaction of two pathways; goal pursuit (short term and long term) or revision as a result of success and failure in reducing distance between current state and expected future state and an affective response that is generated by the experienced goal-performance discrepancies. This affective response, in turn, influences the goals set. This two-dimensional representation covers the processes mentioned above: restoration of function and consideration of long-term limitations. We propose that adaptation centres on readjustment of long-term goals to new achievable but desired and important goals, and that this adjustment underlies re-establishing emotional stability. We discuss how the proposed model is related to actual rehabilitation practice.

Relevance of the Fear-Avoidance Model for Chronic Disability after Traumatic Brain Injury.

Previous studies convincingly suggest that the biopsychosocial fear-avoidance model (FAM) may be of added value in understanding chronic disability after traumatic brain injury (TBI). In this model, persistent symptoms occur as a result of catastrophizing and fear-avoidance regarding initial symptoms, leading to depression, reduced mental activity, and greater disability in daily functioning. This study examined the FAM in a large English-speaking TBI sample. A cross-sectional study was conducted in 117 individuals with complicated mild, moderate, or severe TBI at 1-5 years post-injury. Participants completed questionnaires assessing personal, injury-related, and psychological characteristics. Reliability, correlational, and regression analyses were performed. Main outcome measures of chronic disability were depression, disuse (e.g., fewer mental activities), and functional disability. The results revealed that all correlations suggested by the FAM were significant. Catastrophizing thoughts were positively associated with TBI-related symptoms and fear-avoidance thoughts. Main outcome measures were positively associated with fear-avoidance thoughts and TBI-related symptoms. Further, variables in the FAM were of additive value to personal, injury-related, and psychological variables in understanding chronic disability after TBI. The separate regression analyses for depression, fewer mental activities, and disability revealed "fear-avoidance thoughts" as the only consistent variable. In conclusion, this study shows the association of the FAM with chronic disability after TBI, which has implications for assessment and future management of the FAM in TBI in English-speaking countries. Longitudinal studies are warranted to further investigate and refine the model.

Measuring fatigue following acquired brain injury: A validation study of the Psychomotor Vigilance Test.

OBJECTIVE: To evaluate the construct validity of Psychomotor Vigilance Test performance for measuring fatigue in people with acquired brain injury. DESIGN: Observational cross-sectional study. PARTICIPANTS: Fifty-four people with acquired brain injury and 61 healthy controls. METHODS: Participants performed the Psychomotor Vigilance Test and reported momentary fatigue before and after this test and general fatigue. Associations between performance and fatigue in patients were tested by correlational and hierarchical multiple linear regression analyses, controlling for sleep quality, daytime sleepiness, and mood. RESULTS: Patients performed worse on the test compared with controls. Within the patient group, worse test performance was associated with increases in momentary post-test fatigue and general fatigue, indicating convergent validity, but also with daytime sleepiness, and mood complaints, indicating a lack of divergent validity. When controlling for sleepiness and mood, the association between performance and general fatigue was no longer significant, whereas the association between performance and post-test fatigue remained. CONCLUSION: Performance on the Psychomotor Vigilance Test cannot be used as a specific measure for fatigue, but it appears to be a more general measure of severity of symptoms including fatigue, mood, and sleepiness. Therefore, the Psychomotor Vigilance Test may be a useful measure to examine the effects of interventions aimed at reducing these symptoms.

Unraveling the Biopsychosocial Factors of Fatigue and Sleep Problems After Traumatic Brain Injury: Protocol for a Multicenter Longitudinal Cohort Study.

BACKGROUND: Fatigue and sleep problems are common after a traumatic brain injury (TBI) and are experienced as highly distressing symptoms, playing a significant role in the recovery trajectory, and they can drastically impact the quality of life and societal participation of the patient and their family and friends. However, the etiology and development of these symptoms are still uncertain. OBJECTIVE: The aim of this study is to examine the development of fatigue and sleep problems following moderate to severe TBI and to explore the changes in underlying biological (pain, brain damage), psychological (emotional state), and social (support family, participation) factors across time. METHODS: This study is a longitudinal multicenter observational cohort study with 4 measurement points (3, 6, 12, and 18 months postinjury) including subjective questionnaires and cognitive tasks, preceded by 7 nights of actigraphy combined with a sleep diary. Recruitment of 137 moderate to severe TBI patients presenting at emergency and neurology departments or rehabilitation centers across the Netherlands is anticipated. The evolution of fatigue and sleep problems following TBI and their association with possible underlying biological (pain, brain damage), psychological (emotional state), and social (support family, participation) factors will be examined. RESULTS: Recruitment of participants for this longitudinal cohort study started in October 2017, and the enrollment of participants is ongoing. The first results are expected at the end of 2020. CONCLUSIONS: To the authors' knowledge, this is the first study that examines the development of both post-TBI fatigue and sleep longitudinally within a biopsychosocial model in moderate to severe TBI using both subjective and objective measures. Identification of modifiable factors such as mood and psychosocial stressors may give direction to the development of interventions for fatigue and sleep problems post-TBI. TRIAL REGISTRATION: Netherlands Trial Register NTR7162; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=7162 (Archived by WebCite at http://www.webcitation.org/6z3mvNLuy). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/11295.

Psychometric properties of the Coping Inventory for Stressful Situations (CISS) in patients with acquired brain injury.

Information on the psychometric properties of the Coping Inventory for Stressful Situations (CISS) in acquired brain injury (ABI) is currently unavailable. Therefore, we investigated the construct and discriminant, convergent, and divergent validity of the CISS in a Dutch adult sample with newly ABI (N = 139). Patients were recruited at the start of outpatient neurorehabilitation (time since diagnosis ≤ 4 months) or after discharge home from hospital or inpatient neurorehabilitation. The original 3-factor solution of the CISS (Task-Oriented, Emotion-Oriented, Avoidance) showed a borderline fit, which slightly improved after removal of 3 problematic items. We found borderline support for a 4-factor model. Internal consistency was good. Discriminant validity was only partial as we found a moderate correlation between the Task-Oriented and Avoidance scales. Emotion-Oriented Coping correlated strongly with the anxiety and depression subscale of the Hospital Anxiety and Depression Scale. Of the 2 scales of the Assimilative/Accommodative Coping Questionnaire, Tenacious Goal Pursuit correlated strongest with Task-Oriented Coping, whereas Flexible Goal Adjustment correlated negatively with Emotion-Oriented Coping. In summary, the psychometric properties of the CISS in patients with ABI ranged from acceptable to good. The classical 3-factor structure is appropriate, but some items might be problematic in patients with ABI. Replication of the restricted 3-factor model in larger samples is needed, together with further exploration of discriminant validity and the relationship of the CISS with other coping measures, but for now we recommend using the original CISS in patients with ABI.