Intensive Multi-Disciplinary Outpatient Rehabilitation for Facilitating Return-to-Work after Acquired Brain Injury: A Case-Control Study.

OBJECTIVE: Return-to-work is often the most important objective of working-age patients with acquired brain injury, but is often difficult to achieve. There is a lack of evidence for effective treatment. This study aimed to assess the benefit of a multidisciplinary neurorehabilitation in a daytime hospital on return-to-work after an acquired brain injury. DESIGN: Retrospective case-control study. PATIENTS: Acquired brain injury patients between 18 and 65 years of age. METHODS: Two periods, before (n = 82 patients) and after (n = 89 patients) the implementation of a daytime hospital in our neuro-rehabilitation unit were compared. Patients followed in the daytime hospital received intensive, interdisciplinary, coordinated, individual and group-level physical, cognitive, and vocational rehabilitation. During the control period, patients received outpatient neurorehabilitation with less intensive treatment without interdisciplinary coordination. The main outcome was the proportion of patients returning to > 50% of their premorbid work activity. RESULTS: Fifty-five percent of patients were able to resume more than 50% of their premorbid work level in the daytime hospital period vs 41% in the control period (p = 0.076). CONCLUSION: Intensive and coordinated outpatient neurorehabilitation may facilitate return-to-work after an acquired brain injury.

Reducing anger outbursts after a severe TBI: a single-case study.

Anger outbursts constitute a frequent behavioural issue after a traumatic brain injury (TBI) and have a strong negative impact on the social outcomes resulting from the TBI. However, few studies have examined the efficacy of specific intervention strategies to reduce the frequency and intensity of anger outbursts. We therefore performed a single-case study on this topic by administering two successive and complementary psychological interventions with an AB design with maintenance (first intervention) and an AC design with maintenance plus a one-month follow-up (second intervention) to a patient with a severe TBI. Whereas the first intervention focused on improving the recognition and expression of basic emotions, the second consisted of a self-regulation programme, including various features such as psychoeducation about self-control strategies, relaxation and assertiveness training that aimed to establish adequate behaviours, which were further promoted by an implementation intentions strategy in the patient's daily life. The results indicated that all interventions resulted in a reduced frequency and intensity of anger outbursts, and the data upheld the specificity of these effects. In addition, a meta-analytic integration of the effects of both interventions on the outcomes indicated a medium effect size. Further research is needed on other patients who experience long-standing anger outbursts to examine whether the observed gains can be replicated, sustained on a longer-term basis and improved.

Effects of group psychotherapy on anger management following acquired brain injury.

OBJECTIVE: To assess the effects of an anger management group programme for patients with acquired brain injury (ABI) on self-reported anger and to identify specific effects of intervention components at different time-points. PARTICIPANTS: Twenty-six participants with ABI were randomized, 24 started the programme and 19 completed it. DESIGN: A paired-randomization was held following the first baseline (T0) and a second baseline (T1) was held several weeks later. One group (n = 8) started with an 8-week anger management programme followed by a 4-week intervention focusing on the psychosocial impact of brain injury. This order was reversed in the other group (n = 11). Assessment was carried-out every 4 weeks (T1-T4) during the 12-week intervention period. MAIN OUTCOME MEASURES: The Aggression Questionnaire-12, The State-Trait Anger and Expression Inventory-2 and The Multidimensional Anger Reaction Scale. RESULTS: Anger levels did not significantly change between T0 and T1, but decreased significantly at T4. Adaptive anger coping strategies also increased following intervention. Inwardly expressed anger decreased following the anger management programme compared to the psychosocial adjustment programme. CONCLUSIONS: Group psychotherapy may improve parameters of anger management in patients with ABI. However, specific effects of different components of the anger management programme merit further investigation.

Prefrontal transcranial direct current stimulation facilitates affective flexibility.

Performance on paradigms involving switching between emotional and non-emotional task-sets (affective flexibility) predicts emotion regulation abilities and is impaired in patients with different emotional disorders. A better understanding of how neurostimulation techniques such as transcranial direct current stimulation (tDCS) influence affective switching may provide support for the improvement of rehabilitation programs. In the current study healthy volunteers received anodal tDCS over the right dorsolateral prefrontal cortex (DLPFC), the left DLPFC or sham stimulation while performing an affective-switching task. Participants had to repeat or switch between facial judgments of emotional expressions (emotional task-set) or gender (non-emotional task-set). Right tDCS resulted in faster responses in the gender task only when it followed a judgment of emotion. These effects were not observed following left tDCS. Further, switching away from emotion was easier for the right compared to left tDCS group (reduced switch costs for gender), while switching away from gender toward emotion was easier for the left compared to the right group (reduced switch-costs for emotion). In sum, tDCS over the DLPFC may modulate affective flexibility and right stimulation may be particularly helpful to facilitate disengagement from emotional task-sets. The usefulness of tDCS-trained affective switching may be further investigated on larger therapeutic protocols targeting emotional disorders.

Emotion Regulation After Traumatic Brain Injury: Distinct Patterns of Sympathetic Activity During Anger Expression and Recognition.

OBJECTIVE: To assess psychological and psychophysiological correlates of emotion recognition and anger experience in participants with traumatic brain injury (TBI). PARTICIPANTS: Twenty participants with TBI presenting with anger problems and 22 healthy controls. PROCEDURES: Participants were administered tasks assessing emotion recognition (The French Evaluation Task) and anger expression (Anger regulation task). The latter, designed to elicit and modulate anger feelings through verbal recall of a self-experienced event, involved 4 recall conditions that followed a resting period: neutral, uninstructed anger recall, anger rumination, and anger reappraisal. MEASURES: Skin conductance levels during recall and a self-report anger questionnaire between each condition. RESULTS: In the TBI and control groups, self-reported anger was similarly modulated across emotion regulation conditions. However, only in the TBI group did skin conductance levels significantly increase between neutral and uninstructed anger recall conditions. CONCLUSIONS: Impaired emotion regulation in TBI participants could be related to increased levels of autonomic system activity during emotional experience. However, anger feelings in these participants can also be modulated with the use of emotion regulation strategies, including adaptive strategies such as reappraisal. Thus, promoting awareness and management of physiological activation and encouraging cognitive restructuring can be recommended as a component of interventions targeting emotion regulation in TBI patients.

Poststroke fatigue following minor infarcts: a prospective study.

OBJECTIVE: To explore the potential relationship between fatigue following strokes and poststroke mood, cognitive dysfunction, disability, and infarct site and to determine the predictive factors in the development of poststroke fatigue (PSF) following minor infarcts. METHODS: Ninety-nine functionally active patients aged less than 70 years with a first, nondisabling stroke (NIH Stroke Scale score ≤6 in acute phase and ≤3 after 6 months, modified Rankin Scale score ≤1 at 6 months) were assessed during the acute phase and then at 6 (T1) and 12 months (T2) after their stroke. Scores in the Fatigue Assessment Inventory were described and correlated to age, gender, neurologic and functional impairment, lesion site, mood scores, neuropsychological data, laboratory data, and quality of life at T1 and T2 using a multivariate logistic regression analysis in order to determine which variables recorded at T1 best predicted fatigue at T2. RESULT: As many as 30.5% of the patients at T1 and 34.7% at T2 (11.6% new cases between T1 and T2) reported fatigue. At both 6 and 12 months, there was a significant association between fatigue and a reduction in professional activity. Attentional-executive impairment, depression, and anxiety levels remained associated with PSF throughout this time period, underlining the critical role of these variables in the genesis of PSF. There was no significant association between the lesion site and PSF. CONCLUSION: This study suggests that attentional and executive impairment, as well as depression and anxiety, may play a critical role in the development of PSF.