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.

Assessing the validity of Task Analysis as a quantitative tool to measure the efficacy of rehabilitation in brain injury.

BACKGROUND: Inpatient rehabilitation with patients who have sustained an acquired brain injury (ABI), including traumatic brain injury (TBI), focuses on improving performance in activities of daily living (ADLs). Although not studied to date in patients with ABI/TBI, Task Analysis (TA) integrates assessment and the prompting/cueing levels required to complete various tasks, with the goal to achieve effective skill acquisition and rehabilitation planning. TA has demonstrated efficacy in teaching life skills in individuals with developmental disabilities and in this study is applied to teaching ADL skills in ABI/TBI rehabilitation. PRIMARY OBJECTIVE: To validate the use of TA in measuring progress in teaching ADLs by comparing it with three common ADL measures: Functional Independence Measure, Barthel Index and Klein-Bell. METHODS: Twenty-four inpatients were administered the Functional Independence Measure (FIM), Barthel Index (BI) and the Klein-Bell ADL Scale (KB) TA within 72 hours of admission, at 4 weeks and within 72 hours of discharge, for showering and dressing tasks. A repeated measures ANOVA compared scores across the four measures, at three time points, for both tasks. CONCLUSION: Concurrent validity of TA in measuring improvements in the ADL tasks was established. Improvements were associated with reductions in supervision and disability levels. TA was shown to be an effective evaluation and teaching strategy during rehabilitation, with demonstrated reductions in disability and supervision levels.

Long-Term Health Service Outcomes Among Women With Traumatic Brain Injury.

OBJECTIVES: To (1) assess long-term health care service utilization and satisfaction with health care services among women with traumatic brain injury (W-TBI); (2) examine barriers that prevent W-TBI from receiving care when needed; and (3) understand the perceived supports available for W-TBI. DESIGN: Retrospective cohort study. SETTING: Community. PARTICIPANTS: W-TBI (n=105) 5 to 12 years postinjury and women without TBI (n=105) matched on age, education, and geographic location. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Pre- and postinjury data were collected using a questionnaire administered via a semistructured interview. Questions on health services utilization, satisfaction with and quality of services, barriers to receiving care, and perceived social support were from the Canadian Community Health Survey; additional questions on perceived social support were from another large-scale study of people with moderate to severe brain injury. RESULTS: Compared with women without TBI, W-TBI reported using more family physician and community health services. W-TBI reported that they did not receive care when needed (40%), particularly for emotional/mental health problems. Significantly more W-TBI reported financial and structural barriers. There were no significant differences in reported satisfaction with services between women with and without TBI. CONCLUSIONS: Health service providers and policymakers should recognize the long-term health and social needs of W-TBI and address societal factors that result in financial and structural barriers, to ensure access to needed services.

A knowledge translation intervention to enhance clinical application of a virtual reality system in stroke rehabilitation.

BACKGROUND: Despite increasing evidence for the effectiveness of virtual reality (VR)-based therapy in stroke rehabilitation, few knowledge translation (KT) resources exist to support clinical integration. KT interventions addressing known barriers and facilitators to VR use are required. When environmental barriers to VR integration are less amenable to change, KT interventions can target modifiable barriers related to therapist knowledge and skills. METHODS: A multi-faceted KT intervention was designed and implemented to support physical and occupational therapists in two stroke rehabilitation units in acquiring proficiency with use of the Interactive Exercise Rehabilitation System (IREX; GestureTek). The KT intervention consisted of interactive e-learning modules, hands-on workshops and experiential practice. Evaluation included the Assessing Determinants of Prospective Take Up of Virtual Reality (ADOPT-VR) Instrument and self-report confidence ratings of knowledge and skills pre- and post-study. Usability of the IREX was measured with the System Usability Scale (SUS). A focus group gathered therapist experiences. Frequency of IREX use was recorded for 6 months post-study. RESULTS: Eleven therapists delivered a total of 107 sessions of VR-based therapy to 34 clients with stroke. On the ADOPT-VR, significant pre-post improvements in therapist perceived behavioral control (p = 0.003), self-efficacy (p = 0.005) and facilitating conditions (p =0.019) related to VR use were observed. Therapist intention to use VR did not change. Knowledge and skills improved significantly following e-learning completion (p = 0.001) and was sustained 6 months post-study. Below average perceived usability of the IREX (19th percentile) was reported. Lack of time was the most frequently reported barrier to VR use. A decrease in frequency of perceived barriers to VR use was not significant (p = 0.159). Two therapists used the IREX sparingly in the 6 months following the study. Therapists reported that client motivation to engage with VR facilitated IREX use in practice but that environmental and IREX-specific barriers limited use. CONCLUSIONS: Despite increased knowledge and skills in VR use, the KT intervention did not alter the number of perceived barriers to VR use, intention to use or actual use of VR. Poor perceived system usability had an impact on integration of this particular VR system into clinical practice.

Updated clinical practice guidelines for concussion/mild traumatic brain injury and persistent symptoms.

OBJECTIVE: To introduce a set of revised guidelines for the management of mild traumatic brain injury (mTBI) and persistent symptoms following concussive injuries. QUALITY OF EVIDENCE: The Guidelines for Mild Traumatic Brain Injury and Persistent Symptoms were made available in March 2011 based on literature and information up to 2008. A search for new clinical practice guidelines addressing mTBI and a systematic review of the literature evaluating treatment of persistent symptoms was conducted. Healthcare professionals representing a range of disciplines from Canada and abroad attended a consensus conference to revise the original guidelines in light of new evidence. MAIN MESSAGE: A modified Delphi process was used to create 96 recommendations addressing the diagnosis and management of mTBI and persistent symptoms, including post-traumatic headache, sleep disturbances, mental health disorders, cognitive difficulties, vestibular and vision dysfunction, fatigue and return to activity/work/school. Numerous resources, tools and treatment algorithms were also included to aid implementation of the recommendations. CONCLUSION: The revised clinical practice guideline reflects the most current evidence and is recommended for use by clinicians who provide care to people who experience PPCS following mTBI.

INCOG recommendations for management of cognition following traumatic brain injury, part I: posttraumatic amnesia/delirium.

INTRODUCTION: After traumatic brain injury (TBI) and emergence from coma, the majority of people experience posttraumatic amnesia (PTA), characterized by confusion, disorientation, retrograde and anterograde amnesia, poor attention, and sometimes agitation and delusions. An international team of researchers and clinicians developed recommendations for assessment and management of PTA. METHODS: The experts met to select recommendations, then reviewed literature to ensure they were current. The team then prioritized recommendations for implementation and developed audit criteria to evaluate the adherence to the best practice recommendations. RESULTS: Evidence in support of assessment and management strategies during PTA is weak. It is recommended that duration of PTA be assessed prospectively using a validated tool. Consideration should also be given to use of a delirium assessment tool. No cognitive or pharmacological treatments are known to reduce PTA duration. Recommendations for environmental manipulations to reduce agitation during PTA are made. Minimizing use of neuroleptic medication is supported by animal research and 1 retrospective study. CONCLUSIONS: The duration of PTA is an important predictor of late outcome after TBI and should be monitored prospectively with a standardized tool. Neuroleptic medication should be avoided. There is a significant need for controlled studies evaluating the impact of therapy during PTA.

INCOG recommendations for management of cognition following traumatic brain injury, part V: memory.

INTRODUCTION: Traumatic brain injury results in complex cognitive sequelae. Impairments in memory are among the most common sequelae resulting in significant functional problems. An international team of researchers and clinicians (known as INCOG) was formed to develop recommendations for the management of impairments in memory. METHODS: The experts met to select appropriate recommendations and then reviewed available literature to ensure recommendations were current. Decision algorithms incorporating the recommendations based on inclusion and exclusion criteria of published trials were developed. The team then prioritized recommendations for implementation and developed audit criteria to evaluate adherence to the best practice recommendations. RESULTS: The recommendations for rehabilitation of memory impairments support the integration of internal and external compensatory strategies implemented using appropriate instructional techniques that consider functional relevance and important patient characteristics. Restorative strategies have regained significant popularity, given broader access to computer technology; however, evidence for efficacy of these techniques remains weak and the choice in using these should be guided by special considerations. CONCLUSION: There is good evidence for the integration of internal and external compensatory memory strategies that are implemented using instructional procedures for rehabilitation for memory impairments. The evidence for the efficacy of restorative strategies currently remains weak.

INCOG recommendations for management of cognition following traumatic brain injury, part II: attention and information processing speed.

INTRODUCTION: Traumatic brain injury, due to its diffuse nature and high frequency of injury to frontotemporal and midbrain reticular activating systems, may cause disruption in many aspects of attention: arousal, selective attention, speed of information processing, and strategic control of attention, including sustained attention, shifting and dividing of attention, and working memory. An international team of researchers and clinicians (known as INCOG) convened to develop recommendations for the management of attentional problems. METHODS: The experts selected recommendations from published guidelines and then reviewed literature to ensure that recommendations were current. Decision algorithms incorporating the recommendations based on inclusion and exclusion criteria of published trials were developed. The team then prioritized recommendations for implementation and developed audit criteria to evaluate adherence to these best practices. RESULTS: The recommendations and discussion highlight that metacognitive strategy training focused on functional everyday activities is appropriate. Appropriate use of dual task training, environmental modifications, and cognitive behavioral therapy is also discussed. There is insufficient evidence to support mindfulness meditation and practice on de-contextualized computer-based tasks for attention. Administration of the medication methylphenidate should be considered to improve information-processing speed. CONCLUSION: The INCOG recommendations for rehabilitation of attention provide up-to-date guidance for clinicians treating people with traumatic brain injury.

INCOG recommendations for management of cognition following traumatic brain injury, part III: executive function and self-awareness.

INTRODUCTION: Traumatic brain injury (TBI) results in complex cognitive (and other) sequelae. Impairments in executive function and self-awareness are among the most characteristic neuropsychological sequelae and can exert a profound effect on resuming previous life roles. An international group of researchers and clinicians (known as INCOG) convened to develop recommendations for interventions to improve impairments in executive functioning and self-awareness after TBI. METHODS: The team reviewed the available literature and ensured the recommendations were current. To promote implementation, the team developed decision algorithms incorporating the recommendations based on inclusion and exclusion criteria of published trials. The team then prioritized the recommendations for implementation and developed audit criteria to evaluate the adherence to the best practice recommendations. RESULTS: Intervention programs incorporating metacognitive strategy instruction for planning, problem-solving, and other cognitive-executive impairments have a solid evidence base. New evidence supports the use of strategies to specifically improve reasoning skills. Substantial support exists for use of direct corrective feedback to improve self-awareness. CONCLUSIONS: An increasing number of scientifically well-designed studies are available that demonstrate the effectiveness of a variety of interventions for the remediation of impairments in executive function and self-awareness after TBI.

Quality of guidelines for cognitive rehabilitation following traumatic brain injury.

INTRODUCTION: Cognitive rehabilitation following traumatic brain injury can aid in optimizing function, independence, and quality of life by addressing impairments in attention, executive function, cognitive communication, and memory. This study aimed to identify and evaluate the methodological quality of clinical practice guidelines for cognitive rehabilitation following traumatic brain injury. METHODS: Systematic searching of databases and Web sites was undertaken between January and March 2012 to identify freely available, English language clinical practice guidelines from 2002 onward. Eligible guidelines were evaluated using the validated Appraisal of Guidelines for Research and Evaluation II instrument. RESULTS: The 11 guidelines that met inclusion criteria were independently rated by 4 raters. Results of quality appraisal indicated that guidelines generally employed systematic search and appraisal methods and produced unambiguous, clearly identifiable recommendations. Conversely, only 1 guideline incorporated implementation and audit information, and there was poor reporting of processes for formulating, reviewing, and ensuring currency of recommendations and incorporating patient preferences. Intraclass correlation coefficients for agreement between raters showed high agreement (intraclass correlation coefficient > 0.80) for all guidelines except for 1 (moderate agreement; intraclass correlation coefficient = 0.76). CONCLUSION: Future guidelines should address identified limitations by providing implementation information and audit criteria, along with better reporting of guideline development processes and stakeholder engagement.

The relationship between coping styles and affective/behavioural symptoms among individuals with an acquired brain injury.

PRIMARY OBJECTIVE: To evaluate the impact of combined Axis I and II emotional profiles, demographic and psychosocial variables on coping responses in an Acquired Brain Injury (ABI) population using the Personality Assessment Inventory (PAI) and the Coping Response Inventory (CRI). RESEARCH DESIGN: This was a retrospective study examining the relationship between coping styles with affective, demographic and psychosocial variables using a multi-dimensional profile analysis. METHODS AND PROCEDURES: Participants completed the PAI and CRI during a regular clinical visit at the ABI Program (n = 100). Profile data was divided into seven established sub-types and analysed with coping responses. Traumatic (TBI; n = 78) and non-traumatic (n = 24) brain-injured individuals comprised the sample. MAIN OUTCOMES AND RESULTS: Previous findings were confirmed showing that highly symptomatic patients primarily use negative coping strategies. Also, affective symptoms, gender, relationship status, perceived stress and psychosocial supports mediate the use of different negative coping responses. Interesting, anxiety-based symptoms were associated with positive responses similar to asymptomatic ABI patients. CONCLUSIONS: Coping strategies adopted by brain-injured individuals are mediated by Axis I and II symptoms as well as psychosocial support, stress, marital status and gender. As a result, this has implications for developing treatment strategies.

Clinical practice guidelines for mild traumatic brain injury and persistent symptoms.

OBJECTIVE: To outline new guidelines for the management of mild traumatic brain injury (MTBI) and persistent postconcussive symptoms (PPCS) in order to provide information and direction to physicians managing patients' recovery from MTBI. QUALITY OF EVIDENCE: A search for existing clinical practice guidelines addressing MTBI and a systematic review of the literature evaluating treatment of PPCS were conducted. Because little guidance on the management of PPCS was found within the traumatic brain injury field, a second search was completed for clinical practice guidelines and systematic reviews that addressed management of these common symptoms in the general population. Health care professionals representing a range of disciplines from across Canada and abroad were brought together at an expert consensus conference to review the existing guidelines and evidence and to attempt to develop a comprehensive guideline for the management of MTBI and PPCS. MAIN MESSAGE: A modified Delphi process was used to create 71 recommendations that address the diagnosis and management of MTBI and PPCS. In addition, numerous resources and tools were included in the guideline to aid in the implementation of the recommendations. CONCLUSION: A clinical practice guideline was developed to aid health care professionals in implementing evidencebased, best-practice care for the challenging population of individuals who experience PPCS following MTBI.

Experiences of inpatient rehabilitation from the perspective of persons with acquired brain injury.

BACKGROUND: Perspectives of individuals with acquired brain injury (ABI) regarding inpatient rehabilitation experiences can inform patient-centered care; however, these voices are under-represented in the literature. PURPOSE: To explore the experiences, needs, and preferences of patients from an ABI inpatient rehabilitation program in Ontario. METHODS: Using an interpretive description approach, we interviewed 12 participants and analyzed the transcripts inductively to generate themes. FINDINGS: We identified three major themes: (1) Life Rerouted - participants felt their lives diverted due to ABI, with rehabilitation seen as a way to return to pre-injury life, (2) Autonomy within Rehab highlighted the perceived importance of personal autonomy in decision-making within rehabilitation, and (3) Life (and Recovery) Go On reflected an ongoing recovery process after discharge - leading to mixed emotions. An overall message, "re-establishing personal identity is important to the recovery process," reflected theories of biographical disruption and relational autonomy. IMPLICATIONS: Our findings provide a patient perspective for clinicians and administrators to consider. We found that ABI was significantly disruptive to personal identity - resulting in tensions in autonomy while attempting to reclaim a sense of identity. We suggest counseling services and strategies supporting post-injury adjustment, along with ways for rehabilitation professionals to enhance patient autonomy where possible.Implications for rehabilitationSustaining an ABI can significantly disrupt personal identity and sense of autonomy - especially as persons occupy the role of "patient" while in inpatient rehabilitation.Psychological support is recommended to address the impacts of ABI on patients' sense of identity, as well as on family members.Strategies of support might include, providing formal psychotherapy, as well as creating opportunities for patients and family members to discuss the changes they are experiencing, and to establish their personal narratives (e.g., through writing or art) or peer mentorship programs between discharged and current patients.Clinicians can enhance patient autonomy by increasing opportunities for communication with patients about choice; educating patients and family members on the rehabilitation team's decision-making process, and other methods that increase communication and provide consistent up-to-date information to patients and their family members.

Protocol for a living systematic review for the management of concussion in adults.

INTRODUCTION: Concussion/mild traumatic brain injury (mTBI) often presents initially with disabling symptoms that resolve, but for an unfortunate minority some of these symptoms may become prolonged. Although research into diagnosis and interventions for concussion is increasing, study quality overall remains low. A living systematic review that is updated as evidence becomes available is the ideal research activity to inform a living guideline targeting clinicians and patients. The purpose of this paper is to present the protocol of an ongoing living systematic review for the management of adult concussion that will inform living guidelines building off the Guideline for Concussion/Mild Traumatic Brain Injury and Persistent Symptoms: third Edition. METHODS AND ANALYSIS: The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol guidelines were followed in the reporting of this systematic review protocol. We are including English peer-reviewed observational studies, trials, qualitative studies, systematic reviews and clinical practice guidelines related to diagnosis/assessment or treatment of adult concussion. Future searches will be conducted at minimum every 6 months using the following databases: MEDLINE ALL, EMBASE, Cochrane, PsycInfo and CINAHL. The data are managed in the Covidence website. Screening, data extraction and risk-of-bias assessments are being done through multiple raters working independently. Multiple validated tools are being used to assess risk of bias, and the tool applied matches the document or study design (eg, Downs and Black Scale for healthcare interventions). Many concussion experts in various clinical disciplines from across North America have volunteered to examine the evidence in order to make recommendations for the living guidelines. ETHICS AND DISSEMINATION: No ethical approval is necessary because primary data are not collected. The results will be disseminated through peer-reviewed publications and on the living guidelines website once built. PROSPERO REGISTRATION NUMBER: CRD42022301786.

Quality of clinical practice guidelines for persons who have sustained mild traumatic brain injury.

BACKGROUND: Mild TBI is one of the most common neurological disorders occurring today. For individuals who experience persistent symptoms following mild TBI, consequences can include functional disability, stress and time away from one's occupation. The objective of the study was to evaluate the quality of clinical practice guidelines (CPGs) that include recommendations on the care of persons who have sustained mild TBI and associated persistent symptoms. METHODS: A minimum of four appraisers used the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument to evaluate seven CPGs found via a systematic search of bibliographic databases and internet resources. RESULTS: High AGREE scores were obtained for the domains Scope and Purpose and Clarity and Presentation. The CPGs fared less well on Rigour of Development, Stakeholder Involvement, Editorial Independence and Applicability. The number of recommendations addressing the care of persistent symptoms following mild TBI was meager, with the exception of military guidelines. CONCLUSIONS: There is considerable variability in the quality of guidelines addressing mild TBI and, overall, the CPGs reviewed score lower on Rigour of Development than CPGs for other medical conditions. There is a clear need for clinical guidance on the management of individuals who experience persistent symptoms following mild TBI.

Motivation in rehabilitation and acquired brain injury: can theory help us understand it?

Background: In acquired brain injury (ABI) populations, low motivation to engage in rehabilitation is associated with poor rehabilitation outcomes. Motivation in ABI is thought to be influenced by internal and external factors. This is consistent with Self-determination Theory, which posits that motivation is intrinsic and extrinsic. This paper discusses the benefit of using Self-determination Theory to guide measurement of motivation in ABI. Methods: Using a narrative review of the Self-determination Theory literature and clinical rehabilitation research, this paper discusses the unique role intrinsic and extrinsic motivation has in healthcare settings and the importance of understanding both when providing rehabilitation in ABI. Results: Based on the extant literature, it is possible that two independently developed measures of motivation for ABI populations, the Brain Injury Rehabilitation Trust Motivation Questionnaire-Self and the Motivation for Traumatic Brain Injury Rehabilitation Questionnaire, may assess intrinsic and extrinsic motivation, respectively. Conclusion: Intrinsic and extrinsic motivation in ABI may be two equally important but independent factors that could provide a comprehensive understanding of motivation in individuals with ABI. This increased understanding could help facilitate behavioural approaches in rehabilitation. Implications for Rehabilitation Conceptualization of motivation in ABI would benefit from drawing upon Self-determination Theory. External factors of motivation such as the therapeutic environment or social support should be carefully considered in rehabilitation in order to increase engagement. Assessing motivation as a dual rather than a global construct may provide more precise information about the extent to which a patient is motivated.