Using hypnotic suggestion in the rehabilitation of working memory capacity after acquired brain injury: study protocol for a randomized controlled trial.

OBJECTIVES: Establishment of effective evidence-based interventions in rehabilitation of working memory (WM) deficits after acquired brain injury (ABI) is sorely needed. Despite robust evidence for the efficiency of clinical hypnosis in a wide range of clinical conditions, and improved understanding of mechanisms underlying its effects, the potential of clinical hypnosis in cognitive rehabilitation is underexplored. A recent study has shown large effects of hypnotic suggestion on WM capacity following ABI. This randomized controlled trial aims to evaluate and explore the replicability of these findings and examine the generalization of treatment effects. The study will also explore possible mechanisms of change. METHODS: Ninety patients will be recruited from the Sunnaas Rehabilitation Hospital. Inclusion criteria are nonprogressive ABI, minimum 12-month post-injury, ongoing WM deficits, and age between 18 and 67 years. Patients will be randomized to either (a) an intervention group receiving four weekly 1-h sessions with induction and hypnosis, (b) an active control group receiving four weekly 1-h sessions of induction and mindfulness, or (c) a passive control group without intervention. The targeted procedure consists of suggestions about enhancing WM functions, for example through the instantiation of preinjury WM capacity in the present using age regression or through visualizations of brain plasticity. The non-targeted suggestions contain no explicit mention of ABI- or WM-related abilities. Each participant will be assessed at baseline, immediately after intervention, and 6 months after baseline. The primary outcome is the WM index from WAIS-IV and self- and informant-reported WM subscale from BRIEF-A, a questionnaire exploring executive functioning in everyday life. Secondary outcomes include a cognitive composite score derived from tests measuring processing speed, executive functions, learning capacity and memory, and self-reported measures of emotional distress, quality of life, and community integration. Exploratory measures include self-rated ABI and WM-related self-efficacy. DISCUSSION: Rehabilitation of impaired WM after ABI has hitherto yielded limited transfer effects beyond the training material, i.e., improvement effects on everyday WM capacity, and clinical trials of new interventions are thus warranted. Long-standing empirical evidence demonstrates that hypnosis is an effective therapeutic technique in a wide range of conditions, and recent exploratory research has suggested a high efficacy of hypnosis in improving WM capacity in patients with ABI. However, these extraordinary findings need replication in studies applying scientifically rigorous designs. If successful, our ambition is to provide recommendations and materials to implement hypnotic suggestion as an adjunct treatment following ABI. Study findings may inform future studies exploring the use of clinical hypnosis in other areas of rehabilitation, such as mild TBI, and in other neurological conditions where WM deficit is prominent. TRIAL REGISTRATION: ClinicalTrials.gov NCT05287542. Registered on March 2022 PROTOCOL VERSION: Protocol version 2.0, December 2023.

Workplace Factors Associated With Return to Work After Mild-to-Moderate Traumatic Brain Injury.

OBJECTIVE: Sociodemographic and injury-related predictors for return to work (RTW) after mild-to-moderate traumatic brain injury (TBI) have been extensively explored. However, there is a knowledge gap regarding work-related predictors of RTW. The main aim of this study was to explore work-related predictors of work participation 6 and 12 months after mild-to-moderate TBI. SETTING: Data were collected at baseline 8 to 12 weeks after injury, and 3, 6, and 12 months after baseline, at a specialized TBI rehabilitation outpatient clinic at Oslo University Hospital, Oslo, Norway. PARTICIPANTS: Eligible patients had suffered a mild-to-moderate TBI 8 to 12 weeks previously, were employed 50% or more at time of injury, were between 18 and 60 years of age, and sick listed 50% or more at time of inclusion due to symptoms of TBI (based on the Rivermead Post-Concussion Symptoms Questionnaire). In total, 116 patients were included in a randomized controlled trial, of whom 113 were included in the 1-year analysis. DESIGN: Patients were originally included in a randomized controlled trial. There were no between-group differences in RTW after 1 year. Thus, the participants were evaluated as one cohort in this study. MAIN MEASURES: The primary outcome measure was work participation 1 year after study inclusion. Work-related predictors were chosen on the basis of previous research and expert opinion and entered into a multivariable linear regression model. The model controlled for sociodemographic and injury-related factors. RESULTS: The best-fitting model explained 25% of variation in work participation at 1 year. Significant predictors were predictability, quantitative demands and rewards (recognition) at the workplace, private or public employment, symptom burden at baseline, and sex. CONCLUSION: In this study, several work-related predictors outperformed some of the established sociodemographic and injury-related predictors of RTW after TBI, thus stressing the need for further focus and research on amendable predictors of RTW after mild-to-moderate TBI.

Systematic Monitoring of Cognition for Adults With Cerebral Palsy-The Rationale Behind the Development of the CPCog-Adult Follow-Up Protocol.

Cerebral palsy (CP) comprises a heterogeneous group of conditions recognized by disturbances of movement and posture and is caused by a non-progressive injury to the developing brain. Birth prevalence of CP is about 2-2.5 per 1,000 live births. Although the motor impairment is the hallmark of the diagnosis, individuals with CP often have other impairments, including cognitive ones. Cognitive impairments may affect communication, education, vocational opportunities, participation, and mental health. For many years, CP has been considered a "childhood disability," but the challenges continue through the life course, and health issues may worsen and new challenges may arise with age. This is particularly true for cognitive impairments, which may become more pronounced as the demands of life increase. For individuals with CP, there is no one-to-one correlation between cognition and functioning in other areas, and therefore, cognition must be individually assessed to determine what targeted interventions might be beneficial. To facilitate this for children with CP, a systematic follow-up protocol of cognition, the CPCog, has been implemented in Norway and Sweden. However, no such protocol currently exists for adults with CP. Such discontinuity in healthcare services that results from lack of follow-up of cognitive functioning and subsequent needs for adjustments and interventions makes transition from pediatric to adult healthcare services challenging. As a result, a protocol for the surveillance of cognition in adults with CP, the CPCog-Adult, has been developed. It includes assessment of verbal skills, non-verbal reasoning, visual-spatial perception, and executive functioning. It is recommended to perform these assessments at least once in young adulthood and once in the mid-fifties. This report describes the process of developing the CPCog-Adult, which has a three-fold purpose: (1) to provide equal access to healthcare services to enable the detection of cognitive impairments; (2) to provide interventions that increase educational and vocational participation, enhance quality of life, and prevent secondary impairments; and (3) to collect systematic data for research purposes. The consent-based registration of data in the well-established Swedish and Norwegian national CP registries will secure longitudinal data from childhood into adulthood.

Post-concussion symptoms three months after mild-to-moderate TBI: characteristics of sick-listed patients referred to specialized treatment and consequences of intracranial injury.

Objective: To present pre-injury, injury-related, work-related and post-injury characteristics, and to compare patients with and without traumatic intracranial abnormalities, in a treatment-seeking sample with persistent post-concussion symptoms (PPCS) after mild-to-moderate TBI.Methods: Cross-sectional design in the context of a specialized TBI outpatient clinic. Eligible patients were aged 18-60 years, employed ≥ 50% at time of injury, and sick listed ≥ 50% at inclusion due to PPCS. Data were collected 8-12 weeks after injury through review of medical records, semi-structured interviews, questionnaires, and neuropsychological screening.Results: The study included 116 patients, of whom 60% were women, and predominantly white-collar workers in full-time positions. Ninety-four percent had a mild TBI, and 23% had intracranial abnormalities. The full sample reported high somatic, emotional, and cognitive symptom burden, and decreased health-related quality of life. Patients with normal CT/MRI results reported higher overall symptom burden, while patients with intracranial abnormalities had worse memory function.Conclusion: Injury severity and traumatic intracranial radiological findings should not be the sole ground for planning of rehabilitation service provision in patients with PPCS, as subjective complaints do not necessarily co-vary with these variables.

Cognitive and vocational rehabilitation after mild-to-moderate traumatic brain injury: A randomised controlled trial.

BACKGROUND: Returning to work is often a primary rehabilitation goal after traumatic brain injury (TBI). However, the evidence base for treatment options regarding return to work (RTW) and stable work maintenance remains scarce. OBJECTIVE: This study aimed to examine the effect of a combined cognitive and vocational intervention on work-related outcomes after mild-to-moderate TBI. METHODS: In this study, we compared 6 months of a combined compensatory cognitive training and supported employment (CCT-SE) intervention with 6 months of treatment as usual (TAU) in a randomised controlled trial to examine the effect on time to RTW, work percentage, hours worked per week and work stability. Eligible patients were those with mild-to-moderate TBI who were employed ≥50% at the time of injury, 18 to 60 years old and sick-listed ≥50% at 8 to 12 weeks after injury due to post-concussion symptoms, assessed by the Rivermead Post Concussion Symptoms Questionnaire. Both treatments were provided at the outpatient TBI department at Oslo University Hospital, and follow-ups were conducted at 3, 6 and 12 months after inclusion. RESULTS: We included 116 individuals, 60 randomised to CCT-SE and 56 to TAU. The groups did not differ in characteristics at the 12-month follow-up. Overall, a high proportion had returned to work at 12 months (CCT-SE, 90%; TAU, 84%, P=0.40), and all except 3 were stably employed after the RTW. However, a significantly higher proportion of participants in the CCT-SE than TAU group had returned to stable employment at 3 months (81% vs. 60%, P=0.02). CONCLUSION: These results suggest that the CCT-SE intervention might help patients with mild-to-moderate TBI who are still sick-listed 8 to 12 weeks after injury in an earlier return to stable employment. However, the results should be replicated and a cost-benefit analysis performed before concluding.

Effectiveness of training with motion-controlled commercial video games on hand and arm function in young people with cerebral palsy: A systematic review and meta-analysis.

OBJECTIVE: To examine the effect of motion-controlled commercial video games compared with traditional occupational and physiotherapy methods for hand and arm function in persons of all ages with cerebral palsy. DATA SOURCES: A systematic literature search was conducted in Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, OTseeker and PEDro for randomized controlled trials involving persons with cerebral palsy using motion-controlled commercial video games as a training method for hand and arm function, compared with traditional therapy. STUDY SELECTION AND DATA EXTRACTION: Screening, data-extraction, risk of bias and quality assessment was carried out independently by 2 of the authors. The risk of bias of each study was assessed using the Cochrane Collaborations Risk of Bias Tool. The quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). DATA SYNTHESIS: Eight randomized controlled trials, with a total of 262 participants, were included. A random effects meta-analysis showed a statistically significant difference between the groups in favour of motion-controlled commercial video games. The quality of the evidence was, however, rated as very low. CONCLUSION: Despite a significantly greater improvement in hand and arm function in favour of motion-controlled commercial video games, the results of this review should be interpreted with caution with regards to high risk of bias and the low strength of evidence. There is a need for high-powered studies on the effectiveness of training with motion-controlled commercial video games for persons with cerebral palsy, especially in adults.

Polio and post-polio syndrome in non-Western immigrants: A new challenge for the healthcare system in Norway.

OBJECTIVE: To explore the health situation and identify specific health challenges in non-Western immigrants with polio in Norway, by comparing their status with Western immigrants with polio and native Norwegians with polio. DESIGN: A questionnaire covering demographics, polio history, life satisfaction, medical, psychological and social conditions was answered by 1,408 persons with polio, among them 34 immigrants from non-Western countries and 32 immigrants from Western countries. RESULTS: The non-Western immigrant polio group had a mean age of 46 years, were highly educated, reported high frequency of mental health problems and only one-third was working. Mean age for contracting polio was 2.8 years. Only 30% was hospitalized in the acute phase and 80% reported severe leg weakness. Use of a powered wheelchair was reported by 72%. Post-polio symptoms had started at a mean age of 31 years. The non-Western immigrant group reported more fatigue, pain and loneliness, and a high proportion reported insufficient assistance from the public health system. CONCLUSION: The group of non-Western immigrants with polio in Norway reported more health and social problems than the group of Western immigrants with polio or the native Norwegian group with polio, even though they were younger and more highly educated. Their complex psychological and social situation requires active intervention from the health system, and health professionals need extra skills to deal most effectively with their situation.

Associations between self and informant ratings of executive functioning and driver behaviour following acquired brain injury.

OBJECTIVES: To investigate self and informant ratings of everyday executive functions and their correlation with driving behaviour after acquired brain injury. METHODS: A 1-year follow-up study of 24 adults with stroke and 10 adults with traumatic brain injury deemed fit to drive after a multidisciplinary driving assessment. Baseline measures included neuropsychological tests and self and informant reports of everyday executive function (Behavior Rating of Executive Function; BRIEF-A). Follow-up measurements were the Swedish Driver Behaviour Questionnaire (DBQ) and Sunnaas Driving Pattern Questionnaire (SDPQ). RESULTS: Patients' ratings on the BRIEF-A were significantly associated with the DBQ at follow-up, whereas informants' ratings were not. Neither patients' nor informants' reports were associated with accident involvement or the use of compensatory driving strategies. No significant associations were found between level of awareness and driving parameters. CONCLUSION: Patients' reports of everyday executive functioning were more strongly associated with driving behaviour than were informants' reports. Future studies are warranted to explore how informant and patient reports can contribute to distinguishing safe from unsafe drivers among patient groups with impaired awareness of deficits.

Exploring associations between self-regulatory mechanisms and neuropsychological functioning and driver behaviour after brain injury.

The objective of this prospective one-year follow-up study was to explore the associations between self-regulatory mechanisms and neuropsychological tests as well as baseline and follow-up ratings of driver behaviour. The participants were a cohort of subjects with stroke and traumatic brain injury (TBI) who were found fit to drive after a multi-disciplinary driver assessment (baseline). Baseline measures included neuropsychological tests and ratings of self-regulatory mechanisms, i.e., executive functions (Behavior Rating Inventory of Executive Function-Adult Version; BRIEF-A) and impulsive personality traits (UPPS Impulsive Behavior Scale). The participants rated pre-injury driving behaviour on the Driver Behaviour Qestionnaire (DBQ) retrospectively at baseline and after one year of post-injury driving (follow-up). Better performance on neuropsychological tests was significantly associated with more post-injury DBQ Violations. The BRIEF-A main indexes were significantly associated with baseline and follow-up ratings of DBQ Mistakes and follow-up DBQ Inattention. UPPS (lack of) Perseverance was significantly associated with baseline DBQ Inattention, whereas UPPS Urgency was significantly associated with baseline DBQ Inexperience and post-injury DBQ Mistakes. There were no significant changes in DBQ ratings from baseline (pre-injury) to follow-up (post-injury). It was concluded that neuropsychological functioning and self-regulatory mechanisms are related to driver behaviour. Some aspects of driver behaviour do not necessarily change after brain injury, reflecting the influence of premorbid driving behaviour or impaired awareness of deficits on post-injury driving behaviour. Further evidence is required to predict the role of self-regulatory mechanisms on driver behaviour and crashes or near misses.

Behavioural ratings of self-regulatory mechanisms and driving behaviour after an acquired brain injury.

OBJECTIVE: To explore whether measurements of self-regulatory mechanisms and cognition predict driving behaviour after an acquired brain injury (ABI). DESIGN: Consecutive follow-up study. PARTICIPANTS: At baseline participants included 77 persons with stroke and 32 persons with a traumatic brain injury (TBI), all of whom completed a multidisciplinary driving assessment (MDA). A follow-up cohort of 34 persons that succeeded the MDA was included. Baseline measurements: Neuropsychological tests and measurements of self-regulatory mechanisms (BRIEF-A and UPPS Impulsive Behaviour Scale), driving behaviour (DBQ) and pre-injury driving characteristics (mileage, compensatory driving strategies and accident rates). Follow-up measurements: Post-injury driving characteristics were collected by mailed questionnaires from the participants who succeeded the MDA. METHODS: A MDA, which included a medical examination, neuropsychological testing and an on-road driving test, was considered in the decision for or against granting a driver's license. Self-regulatory mechanisms and driving behaviour were examined for research purposes only. RESULTS: At baseline, self-regulatory mechanisms were significantly associated to aberrant driving behaviour, but not with neuropsychological data or with the outcome of the on-road driving test. Aspects of self-regulation were associated to driving behaviour at follow-up. CONCLUSION: It is recommended that self-regulatory measurements should regularly be considered in the driving assessments after ABI.

Driving behaviour after brain injury: a follow-up of accident rate and driving patterns 6-9 years post-injury.

OBJECTIVE: A follow-up of accident rate and driving patterns of patients 6-9 years after brain injury. DESIGN: Postal questionnaire sent to patients with brain injury who were assessed consecutively in the period 1997-2000 and who were re-issued. SUBJECTS: A total of 93 persons, 69 men and 24 women, mean age 57 years, average 9 years post-injury, 65 persons with brain injury after cerebrovascular accidents and 28 with traumatic brain injury. METHODS: The questionnaire covered self-reported driving accidents pre- and post-injury, yearly distance driven, behaviour in traffic and self-reported care taken in driving. RESULTS: The cerebrovascular accident group had reduced their driving significantly post-injury and had also changed their driving patterns. No significant changes were found in distance driven and driving patterns for the group with traumatic brain injury. Compared with normative data, reported accidents post-injury in the cerebrovascular accident group showed no increased accident rate, while the accident rate in the traumatic brain injury-group was more than 2 times higher. CONCLUSION: Patients with traumatic brain injury represent a risk group for accidents post-injury, while those with brain injury after cerebrovascular accidents do not. Possible causes for this difference are discussed.