Interprofessional collaboration and communication to facilitate implementation of cognitive rehabilitation in persons with brain injury.

Cognitive rehabilitation encompasses therapeutic services directed at improving cognitive functioning and functional abilities in individuals with brain injury. The term cognitive rehabilitation, however, is often broadly defined, and interventions delivered by individual disciplines may vary in their conceptualizations. This paper, written by an interprofessional collaborative group of speech-language pathologists and rehabilitation psychologists/ neuropsychologists identifies challenges in interprofessional rehabilitation of cognitive problems as well as solutions for addressing those challenges. Specifically, the challenge of defining elements of cognitive rehabilitation is addressed with a recommendation for interprofessional training and development of a shared perspective; the problem of "siloed" care is addressed by recommendations for consistent and considerable efforts at interprofessional communication, use of shared language and emphasis on health literacy; and the challenge of access to collaborative care is addressed with the recommendation to increase utilization of telerehabilitation interventions. Our goal is to empower clinicians to not only turn to evidence-based practice to address patient needs, but to go further in implementing the evidence base by facilitating true collaborative interdisciplinary services via improved knowledge of best practice, and advocacy avenues within systems of care. Such an approach will maximize the ability of rehabilitation professionals to provide meaningful, person-centered interventions that will maximize patient outcomes.

The relationship between self-reported sleep disturbance and polysomnography in individuals with traumatic brain injury.

PRIMARY OBJECTIVE: To characterize sleep architecture and self-reported sleep quality, fatigue and daytime sleepiness in individuals with TBI. Possible relationships between sleep architecture and self-reported sleep quality, fatigue and daytime sleepiness were examined. METHODS: Forty-four community-dwelling adults with TBI completed the Pittsburgh Sleep Quality Index (PSQI), Multidimensional Assessment of Fatigue (MAF) and Epworth Sleepiness Scale (ESS). They underwent two nights of in-laboratory nocturnal polysomnography (NPSG). Pearson product-moment correlation coefficients and hierarchical linear regression was used to analyse the data. RESULTS: Based on the PSQI cut-off score of ≥ 10, 22 participants were characterized as poor sleepers. Twenty-seven participants met criteria for clinically significant fatigue as measured by the GFI of the MAF. Fourteen participants met criteria for excessive daytime sleepiness as measured by the ESS. Poor sleep quality was associated with poor sleep efficiency, short duration of stage 2 sleep and long duration of rapid eye movement sleep. There was little-to-no association between high levels of fatigue or daytime sleepiness with NPSG sleep parameters. CONCLUSIONS: A high proportion of the sample endorsed poor sleep quality, fatigue and daytime sleepiness. Those who reported poorer sleep quality evidenced a shorter proportion of time spent in stage 2 sleep. These findings suggest that disruptions in stage 2 sleep might underlie the symptoms of sleep disturbance experienced following TBI.

Evaluation of the short-term executive plus intervention for executive dysfunction after traumatic brain injury: a randomized controlled trial with minimization.

OBJECTIVE: To determine whether the Short-Term Executive Plus (STEP) cognitive rehabilitation program improves executive dysfunction after traumatic brain injury (TBI). DESIGN: Randomized, waitlist controlled trial with minimization and blinded outcome assessment. SETTING: Community. PARTICIPANTS: Participants with TBI and executive dysfunction (N=98; TBI severity 50% moderate/severe; mean time since injury ± SD, 12±14y; mean age ± SD, 45±14y; 62% women; 76% white). INTERVENTION: STEP program: 12 weeks (9h/wk) of group training in problem solving and emotional regulation and individual sessions of attention and compensatory strategies training. MAIN OUTCOME MEASURES: Factor analysis was used to create a composite executive function measure using the Problem Solving Inventory, Frontal Systems Behavior Scale, Behavioral Assessment of the Dysexecutive Syndrome, and Self-Awareness of Deficits Interview. Emotional regulation was assessed with the Difficulties in Emotion Regulation Scale. The primary attention measure was the Attention Rating and Monitoring Scale. Secondary measures included neuropsychological measures of executive function, attention, and memory and measures of affective distress, self-efficacy, social participation, and quality of life. RESULTS: Intention-to-treat mixed-effects analyses revealed significant treatment effects for the composite executive function measure (P=.008) and the Frontal Systems Behavior Scale (P=.049) and Problem Solving Inventory (P=.016). We found no between-group differences on the neuropsychological measures or on measures of attention, emotional regulation, self-awareness, affective distress, self-efficacy, participation, or quality of life. CONCLUSIONS: The STEP program is efficacious in improving self-reported post-TBI executive function and problem solving. Further research is needed to identify the roles of the different components of the intervention and its effectiveness with different TBI populations.

Comparison of cognitive behavioral therapy and supportive psychotherapy for the treatment of depression following traumatic brain injury: a randomized controlled trial.

OBJECTIVE: To determine the efficacy of 2 different interventions (cognitive behavioral therapy [CBT] and supportive psychotherapy [SPT]) to treat post-traumatic brain injury (TBI) depression. PARTICIPANTS: A sample of 77 community-dwelling individuals with a TBI, and a diagnosis of depression. Participants were randomized into treatment conditions either CBT or SPT and received up to 16 sessions of individual psychotherapy. MEASURES: Participants completed the Structured Clinical Interview for DSM-IV and self-report measures of depression (Beck Depression Inventory-Second Edition), anxiety (State-Trait Anxiety Inventory), perceived social support (Interpersonal Support Evaluation List), stressful life events (Life Experiences Survey), and quality of life (QOL) before beginning and immediately following treatment. RESULTS: No significant differences were found at baseline between CBT and SPT groups on demographic factors (sex, age, education, race, and time since injury) or baseline measures of depression, anxiety, participation, perceived social support, stressful life events, or QOL. Analyses of variance revealed significant time effects for the Beck Depression Inventory-Second Edition, State-Trait Anxiety Inventory, and QOL outcome measures but no group effects. Intention-to-treat mixed effects analyses did not find any significant difference in patterns of scores of the outcome measures between the CBT and SPT intervention groups. CONCLUSIONS: Both forms of psychotherapy were efficacious in improving diagnoses of depression and anxiety and reducing depressive symptoms. These findings suggest that in this sample of individuals with TBI, CBT was not more effective in treating depression than SPT, though further research is needed with larger sample sizes to identify different components of these interventions that may be effective with different TBI populations. ClinicalTrials.gov Identifier: NCT00211835.

Systematic review of interventions for fatigue after traumatic brain injury: a NIDRR traumatic brain injury model systems study.

OBJECTIVE: To conduct a systematic review of the evidence on interventions for posttraumatic brain injury fatigue (PTBIF). METHODS: Systematic searches of multiple databases for peer-reviewed studies published in English on interventions targeting PTBIF as a primary or secondary outcome through January 22, 2014. Reference sections were also reviewed to identify additional articles. Articles were rated using the 2011 American Academy of Neurology Classification of Evidence Scheme for therapeutic studies. RESULTS: The searches yielded 1526 articles. Nineteen articles met all inclusion criteria: 4 class I, 1 class II/III, 10 class III, and 4 class IV. Only 5 articles examined fatigue as a primary outcome. Interventions were pharmacological and psychological or involved physical activity, bright blue light, electroencephalographic biofeedback, or electrical stimulation. Only 2 interventions (modafinil and cognitive behavioral therapy with fatigue management) were evaluated in more than 1 study. CONCLUSIONS: Despite areas of promise, there is insufficient evidence to recommend or contraindicate any treatments of PTBIF. Modafinil is not likely to be effective for PTBIF. Piracetam may reduce it, as may bright blue light. Cognitive behavioral therapy deserves additional study. High-quality research incorporating appropriate definition and measurement of fatigue is required to explore the potential benefits of promising interventions, evaluate fatigue treatments shown to be effective in other populations, and develop new interventions for PTBIF.

An evidence-based review of cognitive rehabilitation in medical conditions affecting cognitive function.

OBJECTIVES: To perform a methodical review of the evidence available for the efficacy of cognitive rehabilitation in individuals with diagnosed medical conditions known to affect cognitive function, and to establish evidence-based recommendations for clinical practice, as appropriate. DATA SOURCES: Ovid Medline and PubMed literature searches were conducted using the terms cognition, cognitive, crossed with the terms rehabilitation, remediation, retraining, training, crossed with 11 medical diagnostic categories. Articles through December 2008 were accessed, with a resulting 2284 abstracts. STUDY SELECTION: A total of 211 articles were selected from initial abstract review. These articles were then assessed by committee members, with agreement of at least 2 members, using 9 exclusion and 3 inclusion criteria. A total of 34 remaining articles were submitted to full review. DATA EXTRACTION: Articles were reviewed under diagnostic categories using specific criteria recorded on structured data sheets. Classification was performed according to guidelines of the American Academy of Neurology, with agreement between 2 committee members necessary for final decisions. DATA SYNTHESIS: Of the 34 studies fully evaluated, 1 was rated as class I, 6 as class II, 2 as class III, and 25 as class IV. Evidence within each diagnostic area was synthesized for the formulation of Practice Standards, Practice Guidelines, and Practice Options, as possible. CONCLUSIONS: Two clinical practice recommendations were advanced, 1 each in the diagnostic areas of brain neoplasms and epilepsy/seizure disorders. Discussion included comments on the research status of the effectiveness of cognitive rehabilitation for cognitive deficits related to these medical conditions, as well as suggestions for future directions in research.

Self-reported head injury among refugee survivors of torture.

OBJECTIVE: To examine the prevalence of self-reported head injury among treatment-seeking refugee survivors of torture, a population at high risk for such injuries. PARTICIPANTS: A total of 488 survivors of torture accepted at a torture treatment clinic between January 1, 2008, and December 31, 2011. MAIN MEASURES: Harvard Trauma Questionnaire, incidence of head injury and resulting loss of consciousness (LOC), chief physical complaints, general health scale, indicators of torture severity (length of detention, sexual assault, and number of different persecution types). RESULTS: Of the 488 cases reviewed, 335 (69%) patients reported sustaining a blow to the head. Of the 335 with head injury, 185 (55%) reported LOC following the injury. Those who reported sustaining a head injury were significantly more likely to be men, to have a greater number of types of torture experiences, and report sleep disturbances and headaches as their primary medical complaints. CONCLUSIONS: The high rates of head injury and head injury followed by LOC among treatment-seeking survivors of torture indicates the need for torture treatment centers to assess for possible brain injury. Our findings suggest that patients with possible traumatic brain injury (TBI) may be at a higher risk of negative physical outcomes than those without possible TBI.

Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008.

OBJECTIVE: To update our clinical recommendations for cognitive rehabilitation of people with traumatic brain injury (TBI) and stroke, based on a systematic review of the literature from 2003 through 2008. DATA SOURCES: PubMed and Infotrieve literature searches were conducted using the terms attention, awareness, cognitive, communication, executive, language, memory, perception, problem solving, and/or reasoning combined with each of the following terms: rehabilitation, remediation, and training for articles published between 2003 and 2008. The task force initially identified citations for 198 published articles. STUDY SELECTION: One hundred forty-one articles were selected for inclusion after our initial screening. Twenty-nine studies were excluded after further detailed review. Excluded articles included 4 descriptive studies without data, 6 nontreatment studies, 7 experimental manipulations, 6 reviews, 1 single case study not related to TBI or stroke, 2 articles where the intervention was provided to caretakers, 1 article redacted by the journal, and 2 reanalyses of prior publications. We fully reviewed and evaluated 112 studies. DATA EXTRACTION: Articles were assigned to 1 of 6 categories reflecting the primary area of intervention: attention; vision and visuospatial functioning; language and communication skills; memory; executive functioning, problem solving and awareness; and comprehensive-holistic cognitive rehabilitation. Articles were abstracted and levels of evidence determined using specific criteria. DATA SYNTHESIS: Of the 112 studies, 14 were rated as class I, 5 as class Ia, 11 as class II, and 82 as class III. Evidence within each area of intervention was synthesized and recommendations for Practice Standards, Practice Guidelines, and Practice Options were made. CONCLUSIONS: There is substantial evidence to support interventions for attention, memory, social communication skills, executive function, and for comprehensive-holistic neuropsychologic rehabilitation after TBI. Evidence supports visuospatial rehabilitation after right hemisphere stroke, and interventions for aphasia and apraxia after left hemisphere stroke. Together with our prior reviews, we have evaluated a total of 370 interventions, including 65 class I or Ia studies. There is now sufficient information to support evidence-based protocols and implement empirically-supported treatments for cognitive disability after TBI and stroke.

Does gender influence cognitive outcome after traumatic brain injury?

The aim of this study was to determine whether males and females differ in post-acute cognitive outcome following traumatic brain injury (TBI). Performances of 83 men and 75 women with mild to severe TBI were compared on measures of cognitive functions typically impacted by TBI (i.e., processing speed, executive functioning, and memory). Participants completed selected subtests of the Cambridge Neuropsychological Test Automated Battery (CANTAB). Among the participants with mild TBI, women scored significantly higher than men on a test of visual memory. There were no other significant gender differences in cognitive outcomes. These findings overall suggest that cognitive outcome after TBI does not differ according to gender, with the possible exception of memory functioning. Further research is needed to replicate this finding and determine which moderating variables may impact on the relationship between gender and cognitive outcome after TBI.

A randomized controlled trial of sertraline for the treatment of depression in persons with traumatic brain injury.

OBJECTIVE: To examine the efficacy of sertraline in the treatment of depression after traumatic brain injury (TBI). DESIGN: Double-blind, randomized controlled trial. SETTING: Research center at a major urban medical center. PARTICIPANTS: Subjects were a referred and volunteer sample of 52 participants with TBI, a diagnosis of major depression disorder (MDD), and a score on the Hamilton Rating Scale for Depression (HAM-D) of 18 or greater. The majority of the sample was male (58%), had less than 14 years of education (73%), had incomes below $20,000 (82%), and were from minority backgrounds (75%). Approximately one third of the sample had mild brain injuries, and two thirds had moderate to severe brain injuries. The mean age was 47+/-11, and the mean time since injury was 17+/-14 years. One participant withdrew from the study because of side effects. INTERVENTION: Daily oral sertraline in doses starting at 25mg and increasing to therapeutic levels (up to 200mg) or placebo for 10 weeks. MAIN OUTCOME MEASURES: The HAM-D, the Beck Anxiety Inventory, and the Life-3 quality of life (QOL). RESULTS: No statistically significant differences were found at baseline between drug and placebo groups on baseline measures of depression (24.8+/-7.3 vs 27.7+/-7.0), anxiety (16.4+/-12.3 vs 24.0+/-14.9), or QOL (2.96+/-1.0 vs 2.9+/-0.9). The income level of those receiving placebo was significantly lower than those participants receiving medication. Analyses of covariance revealed significant changes from preintervention to posttreatment for all 3 outcome measures (P<.001) but no group effects. Random-effects modeling did not find any significant difference in patterns of scores of the outcome measures between the placebo and medication groups. CONCLUSIONS: Both groups showed improvements in mood, anxiety, and QOL, with 59% of the experimental group and 32% of the placebo group responding to the treatment, defined as a reduction of a person's HAM-D score by 50%.

Objective and subjective assessment of long-term community integration in minority groups following traumatic brain injury.

Previous studies that used objective measures of community integration found that in the first year after injury, minority groups with traumatic brain injury (TBI) exhibit lower levels of community integration than White participants. The objective of this study was to determine if this discrepancy persists beyond one year post injury, and if assessing subjective components of community integration helps understand these differences. Participants were 360 community dwelling adults with TBI including 29% from minority backgrounds. Mean time post injury was 8.66 years (SD = 9.94). Main outcome measure utilized was the Participation Objective Participation Subjective (POPS). Multiple regression indicated that minority status predicted levels of transportation use (p < 0.01), with white participants reporting less use, after controlling for demographic and injury variables. When looking at subjective indicators, minority status predicted levels of dissatisfaction with community, civic, life and leisure participation (p < 0.01), and total levels of participation (p < 0.0125), with White participants reporting significantly less dissatisfaction. Findings indicate that differences between minorities and white participants in objective aspects of community integration after one year post-injury are only evident in levels of transportation use. However, when looking at subjective indicators differences between groups are present in other areas. These findings underscore the importance of considering the consumer's subjective experience when providing services to minorities in a rehabilitation setting.

Self-inflicted traumatic brain injury: Characteristics and outcomes.

OBJECTIVE: To characterize the population of those receiving inpatient rehabilitation who sustained a traumatic brain injury (TBI) secondary to a suicide attempt and identify differences between such individuals and a demographically-matched control group (n = 230) of those whose TBIs were of an unintentional aetiology. METHOD: Analysed cases were identified from the TBI Model Systems National Database. Based on ICD-9-CM external cause-of-injury codes, 79 participants incurred a TBI secondary to a suicide attempt. An approximate 1 : 3 matched case-control (age, gender, race, injury year) design was chosen to make statistical comparisons. RESULTS: Those who sustained a TBI secondary to a suicide attempt had greater pre-existing psychiatric and psychosocial problems (substance use problems (p = 0.01) prior suicide attempt (p < 0.0001), psychiatric hospitalization (p = 0.014) and non-productive activity (p = 0.014)), required more resources during acute and rehabilitative hospitalizations (i.e. charges per day; p = 0.024, p = 0.047) and had greater disability at the time of discharge, even after controlling for injury severity (p = 0.022). CONCLUSION: Individuals who sustained TBIs secondary to a suicide attempt had increased pre-injury psychiatric and psychosocial problems and poorer outcomes at discharge than those who incurred unintentional injuries. For these individuals, acute and rehabilitation charges per day were higher and could not be accounted for by injury severity.

The relationship between employment-related self-efficacy and quality of life following traumatic brain injury.

OBJECTIVES: This study examines the relative contribution of employment-related and general self-efficacy to perceptions of quality of life (QoL) for individuals with traumatic brain injury. DESIGN: Correlational. SETTING: Community-based research and training center. PARTICIPANTS: 427 individuals with self-reported TBI under the age of 65 were included in analysis. MAIN OUTCOME MEASURE: Employment-related self-efficacy, general self-efficacy, perceived quality of life (PQoL), unmet important needs (UIN). RESULTS: Significant correlations were found between income, injury severity, age at injury, and employment and the QoL variables. In addition, employment-related and general self-efficacy correlated positively with both PQoL and UIN. Employment-related and general self-efficacy accounted for 16% of the variance in PQoL and 9.5% of the variance in UIN, over and above other variables traditionally associated with QoL. CONCLUSIONS: These findings highlight the importance of including subjective appraisals of employment, such as perceived self-efficacy at the workplace, in assessing QoL and successful return to work following TBI.

Neurobehavioral consequences of traumatic brain injury.

At least 1.4 million people die, or receive hospital or emergency care every year in the United States as a result of traumatic brain injury (TBI). Many more are treated in other settings or receive no treatment at all. Thus TBI is often unidentified, with subsequent cognitive, behavioral, emotional and physical sequelae that are not linked to the injury. Yet, over 5.3 million Americans live with TBI-related disabilities that interfere with their overall performance and social roles within the community. The pathophysiology and consequences of TBI are discussed, as are functional changes and psychiatric manifestations after TBI. Finally, implications and recommendations for clinical practice are reviewed, including the importance of screening for TBI.

Age- and education-matched comparison of aging HIV+ men who have sex with men to general population on common neuropsychological assessments.

Little is known about the impact of HIV and aging on cognitive functioning. This New York City cross-sectional study of aging HIV-positive gay and bisexual men assessed their neuropsychological state. Working memory and verbal abstract reasoning were relatively intact. After 55 years of age, attention abilities were impaired. Executive function impairment was present regardless of age and education. Results suggest the need for HIV-specific norms, and the use of neuropsychological assessments (i.e. baseline and over time) as a cost-effective way to assess HIV-related cognitive decline in developed and under-developed countries.

Construct validity of the posttraumatic stress disorder checklist in cancer survivors: analyses based on two samples.

The measurement of posttraumatic stress disorder (PTSD) is critically important for the identification and treatment of this disorder. The PTSD Checklist (PCL; F. W. Weathers and J. Ford, 1996) is a self-report measure that is increasingly used. In this study, the authors investigated the factorial validity of the PCL with data from 236 cancer survivors who received a bone marrow or stem cell transplantation. The authors examined the fit of these data with the clinical model of 3 symptom clusters for PTSD, as proposed in the Diagnostic and Statistical Manual of Mental Disorders, and alternative models tested in prior research. By using confirmatory factor analysis the authors found that a 4-first-order-factor model of PTSD provided the best fit. The relations of PTSD symptoms with sociodemographic and medical variables were also explored.

Brief report: Effects of exercise and self-affirmation intervention after traumatic brain injury.

BACKGROUND: Physical exercise has been proven to be an effective method for improving cognition and mood, but little is known about its benefits among individuals with traumatic brain injury. OBJECTIVE: This pilot study investigated the feasibility of a combined exercise and self-affirmation intervention (IntenSati) for enhancing cognition and mood in individuals with TBI. It was hypothesized that this intervention would improve individuals' cognition and mood following the completion of the program. METHOD: This intervention was held at an outpatient rehabilitation department in an urban medical center. A wait-list control design was conducted. Twenty-one adult participants-at least 12-months post-TBI-enrolled in the study. Twelve of them completed the study. Assessment was conducted at three time-points throughout the study using neuropsychological and self-report measures to evaluate participants' cognition and mood. Following initial evaluation, participants were assigned into either the immediate intervention group or the waitlist control group. During the intervention, participants attended the program twice a week over the course of 8 weeks. Debriefing was conducted following the completion of the program. RESULTS: Both independent t tests and paired t tests were utilized. Results indicated that the intervention group experienced less depressive symptoms following the completion of the IntenSati program compared to the waitlist control group. Participants also reported having less depressive symptoms, experienced more positive affect, and had a higher quality of life following the completion of the program. Moderate-to-large effect sizes were found on decrease in negative affect. However, results associated with cognitive benefits were mixed. The participants tolerated the program well and reported satisfaction with the program. CONCLUSIONS: Results from this study indicated that the IntenSati exercise program is a feasible and beneficial intervention for individuals with TBI as supported by the positive impact on their mood and quality of life.

Positive psychology in rehabilitation medicine: a brief report.

BACKGROUND: The field of positive psychology has grown exponentially within the last decade. To date, however, there have been few empirical initiatives to clarify the constructs within positive psychology as they relate to rehabilitation medicine. Character strengths, and in particular resilience, following neurological trauma are clinically observable within rehabilitation settings, and greater knowledge of the way in which these factors relate to treatment variables may allow for enhanced treatment conceptualization and planning. OBJECTIVE: The goal of this study was to explore the relationships between positive psychology constructs (character strengths, resilience, and positive mood) and rehabilitation-related variables (perceptions of functional ability post-injury and beliefs about treatment) within a baseline data set, a six-month follow-up data set, and longitudinally across time points. METHODS: Pearson correlations and supplementary multiple regression analyses were conducted within and across these time points from a starting sample of thirty-nine individuals with acquired brain injury (ABI) in an outpatient rehabilitation program. RESULTS: Positive psychology constructs were related to rehabilitation-related variables within the baseline data set, within the follow-up data set, and longitudinally between baseline positive psychology variables and follow-up rehabilitation-related data. CONCLUSIONS: These preliminary findings support relationships between character strengths, resilience, and positive mood states with perceptions of functional ability and expectations of treatment, respectively, which are primary factors in treatment success and quality of life outcomes in rehabilitation medicine settings. The results suggest the need for more research in this area, with an ultimate goal of incorporating positive psychology constructs into rehabilitation conceptualization and treatment planning.

Variability of respiration and sleep during polysomnography in individuals with TBI.

BACKGROUND: Obstructive sleep apnea (OSA) is commonly found in individuals with traumatic brain injury (TBI) and may exacerbate TBI-related symptoms. Nocturnal polysomnography (NPSG) is considered the gold standard for detecting the presence of sleep apnea. However, there is a limitation with its use known as the "first-night effect" (aberrant polysomnography findings on the first night in a sleep lab). OBJECTIVE: The primary objectives were to investigate the night-to-night consistency of diagnosing and classifying obstructive sleep apnea in individuals with TBI, and ascertain if individuals with TBI are prone to a first-night effect. METHODS: 47 community-dwelling adults with self-reported mild-to-severe TBI underwent two nights of in-laboratory NPSG to examine variability between the first and second night with regards to OSA diagnosis and severity as well as sleep architecture. RESULTS: OSA detection and severity were consistent from night-to-night in 89% of participants with TBI. Participants with TBI demonstrated longer REM latency on the first night compared to the second night of sleep study. CONCLUSIONS: These findings indicate that two nights of in-laboratory NPSG are generally consistent in reliably diagnosing OSA in individuals with TBI and that first-night effects are minimal. One night of NPSG has diagnostic utility in the evaluation of sleep disorders in individuals with TBI.