Effectiveness of Non-Pharmacological Interventions for Agitation during Post-Traumatic Amnesia following Traumatic Brain Injury: A Systematic Review.

Agitation is common in the early recovery period following traumatic brain injury (TBI), known as post-traumatic amnesia (PTA). Non-pharmacological interventions are frequently used to manage agitation, yet their efficacy is largely unknown. This systematic review aims to synthesize current evidence on the effectiveness of non-pharmacological interventions for agitation during PTA in adults with TBI. Key databases searched included MEDLINE Ovid SP interface, PubMed, CINAHL, Excerpta Medica Database, PsycINFO and CENTRAL, with additional online reviewing of key journals and clinical trial registries to identify published or unpublished studies up to May 2020. Eligible studies included participants aged 16 years and older, showing agitated behaviours during PTA. Any non-pharmacological interventions for reducing agitation were considered, with any comparator accepted. Eligible studies were critically appraised for methodological quality using Joanna Briggs Institute Critical Appraisal Instruments and findings were reported in narrative form. Twelve studies were included in the review: two randomized cross-over trials, three quasi-experimental studies, four cases series and three case reports. Non-pharmacological interventions were music therapy, behavioural strategies and environmental modifications, physical restraints and electroconvulsive therapy. Key methodological concerns included absence of a control group, a lack of formalised agitation measurement and inconsistent concomitant use of pharmacology. Interventions involving music therapy had the highest level of evidence, although study quality was generally low to moderate. Further research is needed to evaluate non-pharmacological interventions for reducing agitation during PTA after TBI.Systematic review registration number: PROSPERO (CRD42020186802), registered May 2020.

Delivery of Neuropsychological Interventions for Adult and Older Adult Clinical Populations: An Australian Expert Working Group Clinical Guidance Paper.

Delivery of neuropsychological interventions addressing the cognitive, psychological, and behavioural consequences of brain conditions is increasingly recognised as an important, if not essential, skill set for clinical neuropsychologists. It has the potential to add substantial value and impact to our role across clinical settings. However, there are numerous approaches to neuropsychological intervention, requiring different sets of skills, and with varying levels of supporting evidence across different diagnostic groups. This clinical guidance paper provides an overview of considerations and recommendations to help guide selection, delivery, and implementation of neuropsychological interventions for adults and older adults. We aimed to provide a useful source of information and guidance for clinicians, health service managers, policy-makers, educators, and researchers regarding the value and impact of such interventions. Considerations and recommendations were developed by an expert working group of neuropsychologists in Australia, based on relevant evidence and consensus opinion in consultation with members of a national clinical neuropsychology body. While the considerations and recommendations sit within the Australian context, many have international relevance. We include (i) principles important for neuropsychological intervention delivery (e.g. being based on biopsychosocial case formulation and person-centred goals); (ii) a description of clinical competencies important for effective intervention delivery; (iii) a summary of relevant evidence in three key cohorts: acquired brain injury, psychiatric disorders, and older adults, focusing on interventions with sound evidence for improving activity and participation outcomes; (iv) an overview of considerations for sustainable implementation of neuropsychological interventions as 'core business'; and finally, (v) a call to action.

Factor Structure of the Agitated Behavior Scale in Traumatic Brain Injury During Posttraumatic Amnesia.

OBJECTIVE: To investigate the factor structure of the Agitated Behavior Scale (ABS) in patients with traumatic brain injury (TBI) in posttraumatic amnesia (PTA). SETTING: Inpatient TBI rehabilitation ward in Victoria, Australia. PARTICIPANTS: A total of 364 patients aged 16 to 92 years meeting diagnostic criteria for TBI and PTA admitted between September 2013 and October 2020. DESIGN: Retrospective cohort study utilizing electronic medical record data. MAIN MEASURES: The ABS and the Westmead Post-Traumatic Amnesia Scale (WPTAS). RESULTS: Exploratory factor analysis uncovered 2 moderately correlated underlying factors (0.52), labeled Restlessness and Aggression/Lability. Two items failed to demonstrate sufficiently large loadings on either factor. Both factors demonstrated adequate reliability (Cronbach α = 0.87 and 0.81 for Restlessness and Aggression/Lability, respectively). Linear regression indicated that higher WPTAS scores were associated with lower levels of Restlessness (ß = -.14, P < .001), supporting construct validity. Conversely, WPTAS scores were not significantly associated with Aggression/Lability (ß = -.12, P = .08). Subgroup analysis indicated that a history of mood disorder was associated with greater severity of Aggression/Lability (P = .02). Confirmatory factor analysis indicated superior fit of the identified 2-factor solution when compared with previously explored 1-, 2-, 3-, and 4-factor structures. CONCLUSION: This study suggests that the latent structure of the ABS is best explained by a single construct of agitation with 2 discrete facets reflecting Restlessness and Aggression/Lability. These subscales may be used in clinical practice to evaluate the severity of different aspects of agitated behavior, inform treatment decisions, and judge the efficacy of interventions over time. Further research is required to explain low factor loadings demonstrated by 2 items.

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.

Family experiences of supporting a relative with agitation during early recovery after traumatic brain injury.

During the early recovery period after traumatic brain injury (TBI), referred to as post-traumatic amnesia (PTA), approximately 44% of individuals may exhibit agitated behaviours. Agitation can impede recovery and poses a significant management challenge for healthcare services. As families provide significant support for their injured relatives during this time, this study aimed to explore the family's experience during PTA to better understand their role in agitation management. There were 20 qualitative semi-structured interviews conducted with 24 family members of patients exhibiting agitation during early TBI recovery (75% female, aged 30-71 years), predominantly parents (n = 12), spouses (n = 7) and children (n = 3). The interviews explored the family's experience of supporting their relative exhibiting agitation during PTA. The interviews were analyzed using reflexive thematic analysis, which revealed three key themes: family contributions to patient care, expectations of the health care service and supporting families to support patients. This study emphasized the significant role of families in managing agitation during early TBI recovery and highlighted that families who are well-informed and well-supported have the potential to minimize their relative's agitation during PTA, which may reduce the burden on healthcare staff and promote patient recovery.

Aspects of Cognitive Impairment Associated with Agitated Behaviour during Post-traumatic Amnesia.

OBJECTIVES: Post-traumatic amnesia (PTA) is a transient period of recovery following traumatic brain injury (TBI) characterised by disorientation, amnesia, and cognitive disturbance. Agitation is common during PTA and presents as a barrier to patient outcome. A relationship between cognitive impairment and agitation has been observed. This prospective study aimed to examine the different aspects of cognition associated with agitation. METHODS: The sample comprised 82 participants (75.61% male) admitted to an inpatient rehabilitation hospital in PTA. All patients had sustained moderate to extremely severe brain injury as assessed using the Westmead Post-Traumatic Amnesia Scale (WPTAS) (mean duration = 42.30 days, SD = 35.10). Participants were assessed daily using the Agitated Behaviour Scale and WPTAS as part of routine clinical practice during PTA. The Confusion Assessment Protocol was administered two to three times per week until passed criterion was achieved (mean number assessments = 3.13, SD = 3.76). Multilevel mixed modelling was used to investigate the association between aspects of cognition and agitation using performance on items of mental control, orientation, memory free recall, memory recognition, vigilance, and auditory comprehension. RESULTS: Findings showed that improvement in orientation was significantly associated with lower agitation levels. A nonsignificant trend was observed between improved recognition memory and lower agitation. CONCLUSIONS: Current findings suggest that the presence of disorientation in PTA may interfere with a patient's ability to understand and engage with the environment, which in turn results in agitated behaviours. Interventions aimed at maximizing orientation may serve to minimize agitation during PTA.

Factors Associated With Physical Therapy Engagement During the Period of Posttraumatic Amnesia.

BACKGROUND AND PURPOSE: Physical therapy is important in the management of traumatic brain injury (TBI) and associated multitrauma. Providing therapy during the posttraumatic amnesia (PTA) phase is challenging, given that hallmark features including confusion, amnesia, agitation, and fatigue may impede the person's ability to engage in and benefit from rehabilitation. To date, there is little empirical evidence to guide the provision of therapy during PTA. This observational study aimed to explore the frequency, duration, location, and engagement of physical therapy provision during PTA and the impact of cognition, agitation, and fatigue. SUMMARY OF KEY POINTS: The majority of patients were found to meaningfully engage and participate in physical therapy for the majority of sessions. Only a small proportion were unable to participate in physical therapy. Patient refusal and fatigue were identified as the most prominent barriers to rehabilitation. Despite fatigue and agitation reaching clinical levels, therapy could still successfully proceed on most occasions. RECOMMENDATIONS FOR CLINICAL PRACTICE: Physical therapy is feasible during the acute recovery stages after TBI. Current results support the notion that therapy should commence early to minimize secondary complications and promote the recovery of mobility. A patient-centered therapeutic model that tailors the therapeutic approach to meet the individual's current physical and fluctuating cognitive capabilities may be most suited for this population. Clinicians working with people after TBI need experience in understanding and managing the cognitive limitations and associated symptoms of PTA to optimize the provision of therapy. These findings could inform guidelines for the management of patients in PTA.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A368).

Cognitive Behavioral Therapy for Sleep Disturbance and Fatigue Following Acquired Brain Injury: Predictors of Treatment Response.

OBJECTIVE: To identify factors associated with treatment response to cognitive behavioral therapy for sleep disturbance and fatigue (CBT-SF) after acquired brain injury (ABI). SETTING: Community dwelling. PARTICIPANTS: Thirty participants with a traumatic brain injury or stroke randomized to receive CBT-SF in a parent randomized controlled trial. DESIGN: Participants took part in a parallel-groups, parent randomized controlled trial with blinded outcome assessment, comparing an 8-week CBT-SF program with an attentionally equivalent health education control. They were assessed at baseline, post-treatment, 2 months post-treatment, and 4 months post-treatment. The study was completed either face-to-face or via telehealth (videoconferencing). Following this trial, a secondary analysis of variables associated with treatment response to CBT-SF was conducted, including: demographic variables; injury-related variables; neuropsychological characteristics; pretreatment sleep disturbance, fatigue, depression, anxiety and pain; and mode of treatment delivery (face-to-face or telehealth). MAIN MEASURES: Pittsburgh Sleep Quality Index (PSQI) and Fatigue Severity Scale (FSS). RESULTS: Greater treatment response to CBT-SF at 4-month follow-up was associated with higher baseline sleep and fatigue symptoms. Reductions in fatigue on the FSS were also related to injury mechanism, where those with a traumatic brain injury had a more rapid and short-lasting improvement in fatigue, compared with those with stroke, who had a delayed but longer-term reduction in fatigue. Mode of treatment delivery did not significantly impact CBT-SF outcomes. CONCLUSION: Our findings highlight potential differences between fatigue trajectories in traumatic brain injury and stroke, and also provide preliminary support for the equivalence of face-to-face and telehealth delivery of CBT-SF in individuals with ABI.

Factors Affecting Participation in Physical Therapy During Posttraumatic Amnesia.

OBJECTIVES: To examine the effect of agitation, cognitive impairment, fatigue, and pain on physical therapy participation and outcomes during posttraumatic amnesia (PTA) after traumatic brain injury (TBI). DESIGN: Prospective longitudinal study. SETTING: Inpatient rehabilitation hospital. PARTICIPANTS: Participants (N=77) with moderate-to-severe TBI who were deemed to be experiencing PTA using the Westmead Post-Traumatic Amnesia Scale. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Pittsburgh Rehabilitation Participation Scale and time in therapy (min) were recorded twice daily after routine physical therapy sessions during PTA. The FIM-motor (select items related to physical therapy) score rated on admission and after emergence from PTA was used to calculate FIM-motor change. RESULTS: Agitation was associated with lower participation in therapy. The presence of agitation and pain both predicted lower FIM-motor change at emergence from PTA. Higher levels of cognitive impairment and fatigue were also associated with lower participation and less time in therapy. CONCLUSIONS: The presence of agitation, fatigue, pain, and cognitive impairment impede rehabilitation success during PTA. This study strengthens the case for implementing environmental and behavioral recommendations, such as conducting therapy earlier in the day within a familiar space (ie, on the ward) and tailoring session duration to patient needs. This is with the aim of minimizing fatigue, agitation, and pain, while promoting cognitive recovery and arousal during PTA to maximize physical gains. Further research is warranted to examine the factors associated with rehabilitation success across other therapeutic disciplines.

The Use of Atypical Antipsychotics for Managing Agitation After Traumatic Brain Injury.

OBJECTIVE: This study examined the use of antipsychotics for managing agitation during posttraumatic amnesia (PTA) after traumatic brain injury (TBI) and its relationship with agitated behavior. DESIGN: Observational prospective study with correlational design. SETTING: Inpatient rehabilitation hospital for TBI. PARTICIPANTS: A total of 125 consecutive admissions who were in PTA and had moderate-severe TBI. MEASURES: Antipsychotic use was compared with agitation levels as measured by the total scores on the Agitated Behavior Scale (ABS). RESULTS: Atypical antipsychotics were used in one-third of participants to manage agitation. Antipsychotic use was more common in participants with high levels of global agitation; however, there were many on antipsychotics who had mild or even no agitation according to the ABS. Uncontrolled observational data found no reduction in agitation after antipsychotic commencement or dose increase. CONCLUSIONS: Antipsychotics are commonly used to manage agitation after TBI despite limited evidence of efficacy. Agitation should be formally monitored in PTA to ensure antipsychotics are used to manage more severe agitation and for evaluating treatment response. Research is needed to understand why prescribers are using antipsychotics when agitation is mild or below clinical thresholds.

Comparing the Westmead Posttraumatic Amnesia Scale, Galveston Orientation and Amnesia Test, and Confusion Assessment Protocol as Measures of Acute Recovery Following Traumatic Brain Injury.

BACKGROUND: The duration of the acute period of recovery following traumatic brain injury (TBI) remains a widely used criterion for injury severity and clinical management. Consensus regarding its most appropriate definition and assessment method has yet to be established. OBJECTIVE: The present study compared the trajectory of recovery using 3 measures: the Westmead Post-Traumatic Amnesia Scale (WPTAS), the Galveston Orientation and Amnesia Test (GOAT), and the Confusion Assessment Protocol (CAP). Patterns of symptom recovery using the CAP were explored. PARTICIPANTS: Eighty-two participants with moderate to severe TBI in posttraumatic amnesia (PTA) on admission to an inpatient rehabilitation hospital. DESIGN: Prospective longitudinal study. OUTCOME MEASURES: Length of PTA (days), agreement between measures (%, κ coefficient), and pattern of symptom recovery. RESULTS: Participants emerged from PTA earliest on the CAP followed the GOAT, and last on the WPTAS. There was good agreement between the CAP and the GOAT as to PTA status, but both tests had poor agreement with the WPTAS. Of patients considered out of PTA on the CAP, the majority exhibited signs of amnesia on the WPTAS and one-third had clinical levels of agitation. CONCLUSION: The WPTAS identifies a later stage of PTA recovery that requires specialized management due to ongoing amnesia and agitation. The CAP and the GOAT are less sensitive to this extended period of PTA.

Factors Associated With Response to Adapted Cognitive Behavioral Therapy for Anxiety and Depression Following Traumatic Brain Injury.

BACKGROUND: Given the high frequency and significance of anxiety and depression following traumatic brain injury (TBI), there is a need to evaluate the efficacy of psychological interventions and to understand factors influencing response to such interventions. The present study investigated factors associated with positive response to cognitive behavioral therapy adapted for cognitive impairments (CBT-ABI) for individuals with anxiety and depression following TBI, including demographic and injury-related factors, pretreatment levels of anxiety and depression, working alliance, and change expectancy as predictors. METHODS: Participants were 45 individuals enrolled in an active treatment condition within a randomized controlled trial, examining the efficacy of a 9-session CBT-ABI program for anxiety and depression following TBI. These participants completed all CBT sessions. RESULTS: Mixed-effects regressions controlling for baseline anxiety and depression indicated that for anxiety, older age at injury, as well as higher level of baseline anxiety, was associated with greater symptom reduction. For depression, longer time since injury and higher expectancy for change, as well as higher baseline level of depression, were significantly associated with a greater reduction in depression symptoms. CONCLUSIONS: This study paves the way for more detailed studies of the therapeutic processes involved in alleviating anxiety and depression following TBI.

The relationship between agitation and impairments of orientation and memory during the PTA period after traumatic brain injury.

Agitation is common during the post-traumatic amnesia (PTA) period after traumatic brain injury (TBI), although our knowledge of what causes or predicts agitation is limited. The current study aimed to examine the association of agitation in PTA with the concurrent impairments in orientation and memory while controlling for covariates of agitation. Participants were 125 patients in PTA following moderate to extremely severe TBI recruited from an inpatient brain injury rehabilitation service who were assessed throughout PTA on the Agitated Behavior Scale (ABS) and the Westmead PTA Scale (WPTAS). Agitation was observed in 42.4% of participants (ABS score > 21), with disinhibited behaviours (e.g., distractibility and impulsivity) most common. Multilevel modelling found daily ABS scores to be associated with daily scores on the WPTAS but in a non-linear pattern. Analysis of covariates found that shorter time post-admission, younger age, presence of infection and higher antipsychotic doses were associated with higher ABS scores. These results support a relationship between agitation and the concurrent cognitive impairment during PTA. While a causal link cannot yet be inferred, management strategies that can potentially interfere with cognition (e.g., sedating medications, environmental changes) should be used cautiously in case they exacerbate agitation.

Economic Evaluation of Activities of Daily Living Retraining During Posttraumatic Amnesia for Inpatient Rehabilitation Following Severe Traumatic Brain Injury.

OBJECTIVE: To evaluate the cost-effectiveness of structured activities of daily living (ADL) retraining during posttraumatic amnesia (PTA) plus treatment as usual (TAU) vs TAU alone for inpatient rehabilitation following severe traumatic brain injury (TBI). DESIGN: Trial-based economic evaluation from a health-system perspective. SETTING: Inpatient rehabilitation center. PARTICIPANTS: Participants (N=104) admitted to rehabilitation and in PTA for >7 days following severe TBI. INTERVENTIONS: Structured ADL retraining during PTA plus TAU vs TAU alone. Structured ADL retraining was manualized to minimize the risk of agitation and maximize functional improvement, following principles of errorless and procedural learning and targeting individualized therapy goals. TAU included physiotherapy and/or speech therapy during PTA plus ADL retraining after PTA emergence. MAIN OUTCOME MEASURES: FIM total scores at baseline, PTA emergence, hospital discharge, or final follow-up (2mo postdischarge) where FIM total scores were calculated as the sum of 5 FIM motor self-care items and a FIM meal-preparation item. RESULTS: Structured ADL retraining during PTA significantly increased functional independence at PTA emergence (mean difference: 4.90, SE: 1.4, 95% confidence interval [CI]: 1.5, 8.3) and hospital discharge (mean difference: 5.22, SE: 1.4, 95% CI: 1.8, 8.7). Even in our most pessimistic scenario, structured ADL retraining was cost-saving as compared to TAU (mean: -$7762; 95% CI: -$8105, -$7419). Together, these results imply that structured ADL retraining dominates (less costly but no less effective) TAU when effectiveness is evaluated at PTA emergence and hospital discharge. CONCLUSIONS: Structured ADL retraining during PTA yields net cost-savings to the health system and offers a cost-effective means of increasing functional independence at PTA emergence and hospital discharge.

Activities of daily living retraining and goal attainment during posttraumatic amnesia.

It is uncertain whether therapy delivered during posttraumatic amnesia (PTA) following traumatic brain injury can be effective due to risk of agitation and poor learning capacity. This study used goal attainment scaling (GAS) to assess gains in activities of daily living (ADL) retraining during PTA. Occupational therapists' perspectives on goal setting and therapy delivery were also explored qualitatively. Forty-nine rehabilitation inpatients were provided with manualised ADL retraining following errorless and procedural learning principles during PTA. From 104 GAS goals, 90% were achieved at PTA emergence. GAS T-scores changed significantly (p < .001) from baseline (M = 26.94, SD = 4.90) to post-intervention (M = 61.44, SD = 11.45). Mean post-intervention T-scores correlated significantly (p < .001) with change in Functional Independence Measure scores. The four therapists reported that GAS was unfamiliar and time-consuming initially, although it aided goal-directed therapy and measurement of patient performance. Application of manualised skill retraining using errorless and procedural learning techniques was described as novel and challenging, but providing valuable structure. The intervention reportedly promoted therapeutic alliance, skill-building and meaningful time-use without elevating agitation, but fatigue impeded therapy. Overall, GAS captured positive individual change following ADL retraining during PTA and therapists indicated that the intervention and use of GAS was generally beneficial and feasible within clinical practice.

Cognitive behavioural therapy for post-stroke fatigue and sleep disturbance: a pilot randomised controlled trial with blind assessment.

The objective of this study was to evaluate the effectiveness of individual cognitive behavioural therapy (CBT) for post-stroke fatigue and sleep disturbance compared to treatment as usual (TAU). In a parallel two-group pilot randomised controlled trial of 15 participants, nine were allocated to eight weekly sessions of adapted CBT and six continued usual care rehabilitation. The primary outcome was the Fatigue Severity Scale (FSS-7) at two and four months from baseline. Secondary outcomes included measures of sleep, mood and quality of life. Outcomes were assessed by a rater who was blind to group membership. At the four-month endpoint, the CBT group demonstrated significantly reduced fatigue relative to TAU (FSS-7 mean difference: 1.92, 95% CI: 0.24 to 3.60). Significant group differences also emerged for sleep quality and depression, favouring the CBT group. Insomnia and physical quality of life improved immediately post-therapy but were no longer superior to TAU at follow-up. Overall, CBT is a promising treatment for improving post-stroke fatigue, sleep quality and depression. Gains were maintained for two months after therapy cessation and represented large treatment effects. These findings highlight the feasibility of the intervention and warrant extension to a phase III clinical trial.

Efficacy of Activities of Daily Living Retraining During Posttraumatic Amnesia: A Randomized Controlled Trial.

OBJECTIVE: To assess the efficacy of activities of daily living (ADL) retraining during posttraumatic amnesia (PTA) compared with ADL retraining commencing after emergence from PTA. DESIGN: Randomized controlled trial. SETTING: Inpatient rehabilitation center. PARTICIPANTS: Participants with severe TBI (N=104), admitted to rehabilitation and remaining in PTA for >7 days, were randomized to receive either treatment as usual (TAU) with daily ADL retraining (treatment), or TAU alone (physiotherapy and/or necessary speech therapy) during PTA. INTERVENTIONS: ADL retraining was manualized, followed errorless and procedural learning principles, and included individualized goals. Both groups received occupational therapy as usual after PTA. MAIN OUTCOME MEASURES: Primary outcome was the FIM completed at admission, PTA emergence, discharge, and 2-month follow-up. Secondary outcomes included length of rehabilitation inpatient stay, PTA duration, Agitated Behavior Scale scores, and Community Integration Questionnaire (CIQ) scores at follow-up. Groups did not significantly differ in baseline characteristics. RESULTS: On the primary outcome, FIM total change, random effects regression revealed a significant interaction of group and time (P<.01). The treatment group had greater improvement in FIM scores from baseline to PTA emergence, which was maintained at discharge, but not at follow-up. Twenty-seven percent more of the treatment group reliably changed on FIM scores at PTA emergence. Group differences in length of stay, PTA duration, agitation, and CIQ scores were not significant; however, TAU trended toward longer length of stay and PTA duration. CONCLUSIONS: Individuals in PTA can benefit from skill retraining.

Agitated Behavior and Activities of Daily Living Retraining During Posttraumatic Amnesia.

BACKGROUND: Patients in posttraumatic amnesia (PTA) may receive limited rehabilitation due to the risk of overstimulation and agitation. This assumption has not been tested. OBJECTIVE: To examine the relationship between agitated behavior and participation in therapy for retraining of activities of daily living (ADL) while in PTA. SETTING: Inpatient rehabilitation center. PARTICIPANTS: A total of 104 participants with severe traumatic brain injury, admitted to rehabilitation, in PTA of more than 7 days. INTERVENTION: ADL retraining during PTA followed errorless and procedural learning principles. DESIGN: Group comparison and regression modeling of patient agitation data from a randomized controlled trial comparing ADL retraining in PTA (treatment) versus no ADL retraining in PTA (treatment as usual, TAU). OUTCOME MEASURES: Agitation using the Agitated Behavior Scale. Therapy participation measured in minutes and missed sessions. RESULTS: There were no group differences in agitated behavior (average scores, peak scores, or number of clinically agitated days) between the treatment and TAU groups. For treated patients, there was no significant relationship between agitation and therapy participation (therapy minutes or missed ADL treatment sessions). CONCLUSIONS: This study demonstrated that agitation is not increased by delivery of structured ADL retraining during PTA and agitation did not limit therapy participation. This supports the consideration of active therapy during PTA.

Physical activity: perceptions of people with severe traumatic brain injury living in the community.

PRIMARY OBJECTIVE: Increasing physical activity (PA) among people with severe traumatic brain injury (TBI) represents an important long-term rehabilitation goal. To design effective interventions to promote PA, the factors associated with PA engagement post-TBI need to be understood. RESEARCH DESIGN: A qualitative study design was employed to investigate the factors influencing PA engagement in people with severe TBI living in the community. METHODS AND PROCEDURES: Face-to-face interviews were conducted with eight people with severe TBI three to five years post-injury. A constant comparative method of data collection and analysis was adopted. MAIN OUTCOMES AND RESULTS: Interviews were analysed using thematic analysis. Three themes were identified: continuance of self and PA (perception of self, stage of life, and PA normality), beliefs about PA (knowledge of PA and associated benefits), and purpose of PA engagement (reasons for being physically active). Lifelong PA habits and current life priorities impacted on PA engagement post-TBI and influenced whether TBI-associated impairments were considered as a barrier to PA. CONCLUSION: Among this group of people, PA engagement post-TBI was influenced by perceptions of lifelong PA habits and current life priorities. Interventions to increase PA need to address these perceptions and adapt PA to account for life priorities within the context of TBI-associated impairments.

Cognitive Behavior Therapy to Treat Sleep Disturbance and Fatigue After Traumatic Brain Injury: A Pilot Randomized Controlled Trial.

OBJECTIVE: To evaluate the efficacy of adapted cognitive behavioral therapy (CBT) for sleep disturbance and fatigue in individuals with traumatic brain injury (TBI). DESIGN: Parallel 2-group randomized controlled trial. SETTING: Outpatient therapy. PARTICIPANTS: Adults (N=24) with history of TBI and clinically significant sleep and/or fatigue complaints were randomly allocated to an 8-session adapted CBT intervention or a treatment as usual (TAU) condition. INTERVENTIONS: Cognitive behavior therapy. MAIN OUTCOME MEASURES: The primary outcome was the Pittsburgh Sleep Quality Index (PSQI) posttreatment and at 2-month follow-up. Secondary measures included the Insomnia Severity Index, Fatigue Severity Scale, Brief Fatigue Inventory (BFI), Epworth Sleepiness Scale, and Hospital Anxiety and Depression Scale. RESULTS: At follow-up, CBT recipients reported better sleep quality than those receiving TAU (PSQI mean difference, 4.85; 95% confidence interval [CI], 2.56-7.14). Daily fatigue levels were significantly reduced in the CBT group (BFI difference, 1.54; 95% CI, 0.66-2.42). Secondary improvements were significant for depression. Large within-group effect sizes were evident across measures (Hedges g=1.14-1.93), with maintenance of gains 2 months after therapy cessation. CONCLUSIONS: Adapted CBT produced greater and sustained improvements in sleep, daily fatigue levels, and depression compared with TAU. These pilot findings suggest that CBT is a promising treatment for sleep disturbance and fatigue after TBI.