Rebuilding the self through valued action and group connections after acquired brain injury: Participant perspectives of the VaLiANT group intervention.

Effective interventions that facilitate adjustment following acquired brain injury (ABI) are needed to improve long-term outcomes and meaningful reengagement in life. VaLiANT is an 8-week group intervention that combines cognitive rehabilitation with Acceptance and Commitment therapy to improve valued living, wellbeing, and adjustment. This study explored participant experiences of VaLiANT to optimize its ongoing development. This included characterization of individually meaningful treatment outcomes, mechanisms of action, and intervention acceptability. Qualitative interviews and quantitative ratings were collected from 39 ABI survivors (Mage = 52, SD = 15; 54% stroke) following their participation in VaLiANT. Participants reported diverse outcomes which resulted in three themes being generated following reflexive thematic analysis. "A fuller toolkit for life with brain injury" indicated increased strategy usage and better daily functioning; "The value of connection and belonging" captured the importance of social experiences in shaping recovery; and "Finding the me I can be" represented cognitive, behavioural, and emotional aspects of identity reconstruction post-ABI. The content and delivery of the intervention were rated highly but participants desired greater follow-up and tailoring of the intervention. Overall, VaLiANT appears to facilitate adjustment through several mechanisms, but greater intervention individualization and dosage may be required to enhance the treatment impact.

A single-case experimental evaluation of a new group-based intervention to enhance adjustment to life with acquired brain injury: VaLiANT (valued living after neurological trauma).

Adjustment to life with acquired brain injury (ABI) requires self-identity and behaviour to be updated, incorporating injury-related changes. Identifying and enabling new values-consistent behaviours could facilitate this process. We evaluated the feasibility, acceptability, and preliminary efficacy of VaLiANT, a new group intervention that aims to enhance "valued living" following ABI. We used a non-concurrent multiple baseline single-case experimental design (SCED) with an 8-week follow-up phase and randomization to multiple baseline lengths (5-7 weeks). Eight participants (50% women, aged 26-65; 4 Stroke, 3 Traumatic Brain Injury, 1 Epilepsy) attended eight group sessions with assessments before, during, and after the group. Target behaviour was valued living, assessed weekly by the Valued Living Questionnaire. Secondary outcomes included measures of wellbeing, mood, psychological acceptance, self-efficacy regarding ABI consequences, cognitive complaints, and intervention acceptability. Target behaviour was analysed through visual and statistical analysis while secondary outcome data were analysed via reliable change indices and descriptive statistics. Target behaviour data displayed no convincing patterns of improvement. Reliable improvements were found for most participants on secondary outcomes, particularly subjective wellbeing and anxiety. Intervention delivery was feasible with high acceptability ratings. Further investigation of VaLiANT is warranted, based on the feasibility and acceptability of intervention delivery and signals of efficacy identified across adjustment-related secondary outcomes.

Effectiveness of Communication-specific Coping Intervention for adults with traumatic brain injury: preliminary results.

People with traumatic brain injury (TBI) describe everyday interactions as a long-term challenge frequently associated with ongoing stress. Communication-specific Coping Intervention (CommCope-I) is a new treatment developed to target coping in the context of communication breakdown. The intervention incorporates principles of cognitive behavioural therapy, self-coaching and context-sensitive social communication therapy. The purpose of this study was to examine the effectiveness of CommCope-I in a group of adults with severe TBI and ongoing functional communication difficulties. Participants were 13 adults with severe TBI (GCS = 3-8; mean age = 35.2 years; mean time post-injury = 7.6 years). The project involved three phases: (1) Control/pre-intervention wait phase (multiple assessments), (2) Treatment (6 weeks), and (3) Follow-up (12 weeks). Repeated measures ANOVA with planned pairwise comparisons were used to test the significance of change. Intervention elicited statistically significant improvements in communication-specific coping, functional communication and stress that were maintained for three months. Improved use of communication-specific coping strategies was evident in clinician blind ratings. Clients reported significant reduction in stress at the end of treatment and one and three months later. This intervention provides a promising means of improving communication-specific coping and reducing communication dysfunction and its negative consequences for people with TBI.

A scoping review of the nature and outcomes of extended rehabilitation programmes after very severe brain injury.

PRIMARY OBJECTIVE: Many adults with very severe acquired brain injury (ABI) do not receive adequate rehabilitation, limiting their recovery and leading to admission to inappropriate living environments. The aim of this scoping review was to map the existing literature relating to the nature and outcomes of rehabilitation programmes for adults experiencing prolonged recovery after very severe ABI. DESIGN: A comprehensive scoping of the literature was undertaken, including systematic searching of databases, grey literature, and hand searching. Eligible studies had to report on (a) extended rehabilitation for (b) adults with very severe ABI and complex support needs and describe (c) the outcomes of the intervention. RESULTS: From an initial total of 17,829 citations, 18 records were retained for review. Data extraction focused on (i) participant characteristics, (ii) programme information, and (iii) programme outcomes. Studies were characterised by substantial diversity. However, findings suggested that extended rehabilitation assisted participants to live more independently in more home-like environments and contributed towards significant savings in their lifetime care costs. CONCLUSIONS: Extended specialised rehabilitation can maximise the independence and participation of adults with very severe ABI. Advocacy is required to ensure that adults with very severe injuries have access to individually tailored, non-time-limited intervention programmes.

"I won't be around forever": Understanding the decision-making experiences of adults with severe TBI and their parents.

There is growing recognition of the right of all individuals, including those with cognitive impairment, to make decisions about their own lives. However, little is known about how the process of decision making is experienced after severe traumatic brain injury (TBI). This study used constructivist grounded theory to explore processes used by adults with severe TBI and their parents in making decisions about life after injury. Data consisted of 18 individual, in-depth interviews with four dyads (consisting of an individual with severe TBI and his or her parent). The overlying construct emerging from the data was a process of reimagining the future, which influenced how participants approached and participated in making decisions. In line with this construct, two central themes described processes of joint decision making within parent-adult child relationships after severe TBI over time: (1) making decisions with parental support, and (2) reducing parental involvement. These findings emphasise the complexity of supporting decision making after injury, and illustrate that both parents and their adult children with TBI use explicit and implicit strategies to facilitate increased participation in making decisions. This study also underscores the need for brain injury clinicians to consider the needs of parents who find themselves in this role.

'The biggest thing is trying to live for two people': Spousal experiences of supporting decision-making participation for partners with TBI.

PRIMARY OBJECTIVE: To understand how the spouses of individuals with severe TBI experience the process of supporting their partners with decision-making. DESIGN: This study adopted a constructivist grounded theory approach, with data consisting of in-depth interviews conducted with spouses over a 12-month period. Data were analysed through an iterative process of open and focused coding, identification of emergent categories and exploration of relationships between categories. PARTICIPANTS: Participants were four spouses of individuals with severe TBI (with moderate-severe disability). Spouses had shared committed relationships (marriage or domestic partnerships) for at least 4 years at initial interview. Three spouses were in relationships that had commenced following injury. MAIN OUTCOME AND RESULTS: Two main themes emerged from the data. The first identified the saliency of the relational space in which decision-making took place. The second revealed the complex nature of decision-making within the spousal relationship. CONCLUSIONS: Spouses experience decision-making as a complex multi-stage process underpinned by a number of relational factors. Increased understanding of this process can guide health professionals in their provision of support for couples in exploring decision-making participation after injury.

Using microbiological data to improve the use of antibiotics for respiratory tract infections: A protocol for an individual patient data meta-analysis.

BACKGROUND: Resistance to antibiotics is rising and threatens future antibiotic effectiveness. 'Antibiotic targeting' ensures patients who may benefit from antibiotics receive them, while being safely withheld from those who may not. Point-of-care tests may assist with antibiotic targeting by allowing primary care clinicians to establish if symptomatic patients have a viral, bacterial, combined, or no infection. However, because organisms can be harmlessly carried, it is important to know if the presence of the virus/bacteria is related to the illness for which the patient is being assessed. One way to do this is to look for associations with more severe/prolonged symptoms and test results. Previous research to answer this question for acute respiratory tract infections has given conflicting results with studies has not having enough participants to provide statistical confidence. AIM: To undertake a synthesis of IPD from both randomised controlled trials (RCTs) and observational cohort studies of respiratory tract infections (RTI) in order to investigate the prognostic value of microbiological data in addition to, or instead of, clinical symptoms and signs. METHODS: A systematic search of Cochrane Central Register of Controlled Trials, Ovid Medline and Ovid Embase will be carried out for studies of acute respiratory infection in primary care settings. The outcomes of interest are duration of disease, severity of disease, repeated consultation with new/worsening illness and complications requiring hospitalisation. Authors of eligible studies will be contacted to provide anonymised individual participant data. The data will be harmonised and aggregated. Multilevel regression analysis will be conducted to determine key outcome measures for different potential pathogens and whether these offer any additional information on prognosis beyond clinical symptoms and signs. TRIAL REGISTRATION: PROSPERO Registration number: CRD42023376769.

Spontaneous gestures influence strategy choices in problem solving.

Do gestures merely reflect problem-solving processes, or do they play a functional role in problem solving? We hypothesized that gestures highlight and structure perceptual-motor information, and thereby make such information more likely to be used in problem solving. Participants in two experiments solved problems requiring the prediction of gear movement, either with gesture allowed or with gesture prohibited. Such problems can be correctly solved using either a perceptual-motor strategy (simulation of gear movements) or an abstract strategy (the parity strategy). Participants in the gesture-allowed condition were more likely to use perceptual-motor strategies than were participants in the gesture-prohibited condition. Gesture promoted use of perceptual-motor strategies both for participants who talked aloud while solving the problems (Experiment 1) and for participants who solved the problems silently (Experiment 2). Thus, spontaneous gestures influence strategy choices in problem solving.

Does Integrating Cognitive and Psychological Interventions Enhance Wellbeing After Acquired Brain Injury? Study Protocol for a Phase II Randomized Controlled Trial of the VaLiANT (Valued Living After Neurological Trauma) Group Program.

Background and Objectives: Cognitive and emotional changes affect the majority of individuals with acquired brain injury (ABI) and are associated with poorer outcomes. The evidence for "siloed" rehabilitation approaches targeting cognition and mood separately remains mixed. Valued living (i.e., acting consistently with personal values) is associated with better psychological functioning and participation in work and other productive activities. Rehabilitation interventions that concurrently address cognitive and emotional barriers to valued living may therefore result in improved outcomes. VaLiANT (Valued Living After Neurological Trauma) is an 8-week group intervention developed by our team, which uniquely combines cognitive rehabilitation and psychological therapy to improve wellbeing and meaningful participation (i.e., valued living) following ABI. Method: This protocol describes the design and implementation of a Phase II parallel-group randomized controlled trial with blinded outcome assessors, to evaluate the potential efficacy of VaLiANT and the feasibility of a Phase III trial. Participants are adults with a history of ABI at least 3 months prior to study entry, who experience cognitive and/or emotional difficulties and associated reduced participation in valued activities. Random allocation to the treatment condition (8-week VaLiANT group program) or a usual care waitlist control condition occurs at a 2:1 treatment: control ratio. The primary outcome is wellbeing, measured by the Warwick-Edinburgh Mental Wellbeing Scale. Secondary outcomes include measures of valued living, mood, cognitive complaints, quality of life, community participation, post-traumatic growth, and self-efficacy. All measures are collected across three time points by blinded assessors (baseline, 8-week follow-up, 16-week follow-up). Trial feasibility will be evaluated against recruitment rates, drop-out rates, intervention acceptability, and treatment fidelity (manual adherence and therapist competence). Discussion: This trial will extend current knowledge on how to improve long-term outcomes following ABI by evaluating an innovative integrated, multi-domain approach to rehabilitation concurrently addressing cognitive and emotional barriers to participation in meaningful life roles.

Neuropsychiatric symptoms associated with cerebral small vessel disease: a systematic review and meta-analysis.

BACKGROUND: Cerebral small vessel disease, a common cause of vascular dementia, is often considered clinically silent before dementia or stroke become apparent. However, some individuals have subtle symptoms associated with acute MRI lesions. We aimed to determine whether neuropsychiatric and cognitive symptoms vary according to small vessel disease burden. METHODS: In this systematic review and meta-analysis, we searched MEDLINE, EMBASE, and PsycINFO for articles published in any language from database inception to Jan 24, 2020. We searched for studies assessing anxiety, apathy, delirium, emotional lability, fatigue, personality change, psychosis, dementia-related behavioural symptoms or cognitive symptoms (including subjective memory complaints), and radiological features of cerebral small vessel disease. We extracted reported odds ratios (OR), standardised mean differences (SMD), and correlations, stratified outcomes by disease severity or symptom presence or absence, and pooled data using random-effects meta-analyses, reporting adjusted findings when possible. We assessed the bias on included studies using the Risk of Bias for Non-randomized Studies tool. This study is registered with PROSPERO, CRD42018096673. FINDINGS: Of 7119 papers identified, 81 studies including 79 cohorts in total were eligible for inclusion (n=21 730 participants, mean age 69·2 years). Of these 81 studies, 45 (8120 participants) reported effect estimates. We found associations between worse white matter hyperintensity (WMH) severity and apathy (OR 1·41, 95% CI 1·05-1·89) and the adjusted SMD in apathy score between WMH severities was 0·38 (95% CI 0·15-0·61). Worse WMH severity was also associated with delirium (adjusted OR 2·9, 95% CI 1·12-7·55) and fatigue (unadjusted OR 1·63, 95% CI 1·20-2·22). WMHs were not consistently associated with subjective memory complaints (OR 1·34, 95% CI 0·61-2·94) and unadjusted SMD for WMH severity between these groups was 0·08 (95% CI -0·31 to 0·47). Anxiety, dementia-related behaviours, emotional lability, and psychosis were too varied or sparse for meta-analysis; these factors were reviewed narratively. Overall heterogeneity varied from 0% to 79%. Only five studies had a low risk of bias across all domains. INTERPRETATION: Apathy, fatigue, and delirium associated independently with worse WMH, whereas subjective cognitive complaints did not. The association of anxiety, dementia-related behaviours, emotional lability, and psychosis with cerebral small vessel disease require further investigation. These symptoms should be assessed longitudinally to improve early clinical detection of small vessel disease and enable prevention trials to happen early in the disease course, long before cognition declines. FUNDING: Chief Scientist Office of the Scottish Government, UK Dementia Research Institute, Fondation Leducq, Stroke Association Garfield-Weston Foundation, Alzheimer's Society, and National Health Service Research Scotland.

Long-term ability to interpret facial expression after traumatic brain injury and its relation to social integration.

There is considerable evidence that individuals with traumatic brain injury (TBI) experience problems interpreting the emotional state of others. However, the functional implications of these changes have not been fully investigated. A study of 13 individuals with severe TBI and an equal number of matched controls found that TBI participants had significantly more difficulty interpreting facial expression and matching emotions to social situations. A significant relationship was also established between social integration and ability to interpret facial expression for TBI participants. These results support the inclusion of therapy targeting this area within rehabilitation programs for individuals with TBI.

"I've never been a yes person": Decision-making participation and self-conceptualization after severe traumatic brain injury.

PURPOSE: Although adults who sustain a severe traumatic brain injury (TBI) require support to make decisions in their lives, little is known about their experience of this process. The aim of this study was to explore how participation in decision making contributes to self-conceptualization in adults with severe TBI. METHOD: We used constructivist grounded theory methods. Data included 20 in-depth interviews with adults with severe TBI. Through a process of constant comparison, analysis involved open and focused coding until clear categories emerged and data saturation was achieved. RESULTS: Self-conceptualization emerged as a complex and multifaceted process, as individuals with TBI aimed to reestablish a sense of autonomy. We describe a recursive relationship in which decision-making participation assists the dynamic construction of self, and self-concept contributes to the experience of making decisions. The role of an individual's social support network in acting as a bridge between participation and self-conceptualization is presented. CONCLUSIONS: Findings emphasize that contributing to decisions about one's own goals across a range of life areas can reinforce a positive self-concept. It is vital that supporters understand that participation in decision making provides a pathway to conceptualizing self and aim to maximize the person's participation in the decision-making process. Implications for Rehabilitation Previous research has identified that the experience of sustaining TBI has a significant impact on a person's conceptualization of self. This study identified that decision-making experiences play an important role in the ongoing process of self-conceptualization after injury. Decision-making experiences can reinforce a person's self-concept or lead them to revise (positively or negatively) their sense of self. By maximizing the person's decision-making participation, those around them can support them to develop positive self-attributes and contribute to shaping their future goals.

Whose decision is it anyway? How clinicians support decision-making participation after acquired brain injury.

PURPOSE: To raise professional awareness of factors that may influence the support offered by clinicians to people with acquired brain injury (ABI), and to consider the potential implications of these factors in terms of post-injury rehabilitation and living. METHOD: A review of the literature was conducted to identify factors that determine how clinicians provide support and influence opportunities for individuals with ABI to participate in decision making across the rehabilitation continuum. Clinical case studies are used to highlight two specific issues: (1) hidden assumptions on the part of the practitioner, and (2) perceptions of risk operating in clinical practice. RESULTS: There are a range of factors which may influence the decision-making support provided by clinicians and, ultimately, shape lifetime outcomes for individuals with ABI. A multidimensional framework may assist clinicians to identify relevant factors and consider their potential implications including those that influence how clinicians involved in supporting decision making approach this task. CONCLUSIONS: Participation in decision making is an undisputed human right and central to the provision of person-centred care. Further research is required to understand how clinical practice can maximise both opportunities and support for increased decision-making participation by individuals with ABI. IMPLICATIONS FOR REHABILITATION: There is an increasing focus on the rights of all individuals to be supported to participate in decision making about their life. A number of changes associated with ABI mean that individuals with ABI will require support with decision making. Clinicians have a critical role in providing this support over the course of the rehabilitation continuum. Clinicians need to be aware of the range of factors that may influence the decision-making support they provide. A multidimensional framework may be used by clinicians to identify influences on the decision-making support they provide.