The Impact of Complementary and Integrative Medicine Following Traumatic Brain Injury: A Scoping Review.

OBJECTIVE: To examine the evidence levels, study characteristics, and outcomes of nonpharmacologic complementary and integrative medicine (CIM) interventions in rehabilitation for individuals with traumatic brain injury (TBI). DATA SOURCES: MEDLINE (OvidSP), PubMed (NLM), EMBASE ( Embase.com ), CINAHL (EBSCO), PsycINFO (OvidSP), Cochrane Library (Wiley), and National Guidelines Clearinghouse databases were evaluated using PRISMA guidelines. The protocol was registered in INPLASY (protocol registration: INPLASY202160071). DATA EXTRACTION: Quantitative studies published between 1992 and 2020 investigating the efficacy of CIM for individuals with TBI of any severity, age, and outcome were included. Special diets, herbal and dietary supplements, and counseling/psychological interventions were excluded, as were studies with mixed samples if TBI data could not be extracted. A 2-level review comprised title/abstract screening, followed by full-text assessment by 2 independent reviewers. DATA SYNTHESIS: In total, 90 studies were included, with 57 001 patients in total. This total includes 2 retrospective studies with 17 475 and 37 045 patients. Of the 90 studies, 18 (20%) were randomized controlled trials (RCTs). The remainder included 20 quasi-experimental studies (2-group or 1-group pre/posttreatment comparison), 9 retrospective studies, 1 single-subject study design, 2 mixed-methods designs, and 40 case study/case reports. Guided by the American Academy of Neurology evidence levels, class II criteria were met by 61% of the RCTs. Included studies examined biofeedback/neurofeedback (40%), acupuncture (22%), yoga/tai chi (11%), meditation/mindfulness/relaxation (11%), and chiropractic/osteopathic manipulation (11%). The clinical outcomes evaluated across studies included physical impairments (62%), mental health (49%), cognitive impairments (39%), pain (31%), and activities of daily living/quality of life (28%). Additional descriptive statistics were summarized using narrative synthesis. Of the studies included for analyses, 97% reported overall positive benefits of CIM. CONCLUSION: Rigorous and well experimentally designed studies (including RCTs) are needed to confirm the initial evidence supporting the use of CIM found in the existing literature.

An overview of systematic reviews on the pharmacological randomized controlled trials for reducing intracranial pressure after traumatic brain injury.

BACKGROUND: There is a need for an overview of systematic reviews (SRs) examining randomized clinical trials (RCTs) of pharmacological interventions in the treatment of intracranial pressure (ICP) post-TBI. OBJECTIVES: To summarize pharmacological effectiveness in decreasing ICP in SRs with RCTs and evaluate study quality. METHODS: Comprehensive literature searches were conducted in MEDLINE, PubMed, EMBASE, PsycINFO, and Cochrane Library databases for English SRs through October 2020. Inclusion criteria were SRs with RCTs that examined pharmacological interventions to treat ICP in patients post-TBI. Data extracted were participant characteristics, pharmacological interventions, and ICP outcomes. Study quality was assessed with AMSTAR-2. RESULTS: Eleven SRs between 2003 and 2020 were included. AMSTAR-2 ratings revealed 3/11 SRs of high quality. Pharmacological interventions included hyperosmolars, neuroprotectives, anesthetics, sedatives, and analgesics. Study samples ranged from 7 to 1282 patients. Hyperosmolar agents and sedatives were beneficial in lowering elevated ICP. High bolus dose opioids had a more deleterious effect on ICP. Neuroprotective agents did not show any effects in ICP management. CONCLUSIONS: RCT sample sizes and findings in the SRs varied. A lack of detailed data syntheses was noted. AMSTAR-2 analysis revealed moderate to high quality in most SRs. Future SRs may focus on streamlined reporting of dosing and clearer clinical recommendations. PROSPERO-Registration: CRD42015017355.

Emotion regulation after acquired brain injury: a study of heart rate variability, attentional control, and psychophysiology.

Primary objective: To examine the efficacy of heart rate variability biofeedback (HRV-BF) to treat emotional dysregulation in persons with acquired brain injury. Design: A secondary analysis of a quasi-experimental study which enrolled 13 individuals with severe chronic acquired brain injury participating in a community-based programme. Response-to-treatment was measured with two HRV resonance indices (low frequency activity [LF] and low frequency/high frequency ratio [LF/HF]). Main outcome: Behavior Rating Inventory of Executive Function-informant report (emotional control subscale [EC]). Results: Results show significant correlation between LF and EC with higher LF activity associated with greater emotional control; the association between LF/HF pre-post-change score and EC is not statistically significant. A moderation model, however, demonstrates a significant influence of attention on the relation between LF/HF change and EC when attention level is high, with an increase in LF/HF activity associated with greater emotional control. Conclusions: HRV-BF is associated with large increases in HRV, and it appears to be useful for the treatment of emotional dysregulation in individuals with severe acquired brain injury. Attention training may enhance an individual's emotional control.

Overview of pharmacological interventions after traumatic brain injuries: impact on selected outcomes.

The purpose of this study was to conduct an overview of systematic reviews (SRs) to appraise the published evidence related to pharmacological interventions after traumatic brain injury (TBI). Searches were conducted with Medline, Embase, PsycINFO, Web of Science, PubMed. 780 retrieved SRs underwent a two-level screening to determine inclusion. Data extracted included participant characteristics, TBI severity, study design, pharmacological interventions, and outcomes. SRs were assessed for methodological quality by using the AMSTAR measurement tool. After removing duplicates, 166/780 SRs published between 1990-2017 were reviewed, 62 of which met inclusion criteria. More than 90 drugs and 22 substance-classes were extracted. Most medications were administered during the acute stage. Mild TBI was included in 3% of the SRs. Physiological outcomes comprised 45% of the SRs, primarily mortality. Activities of daily living (ADLs) outcomes constituted 22% of the SRs followed by cognition (13%) and psychological/behavioral outcomes (13%). Only 7% of the SRs assessed adverse events. Inconsistencies in definitions, methods, and heterogeneity of instruments used to measure treatment response were noted. Only a third of the SRs had high methodological quality. Most SRs had heterogeneous TBI samples, outcomes, or methodologies making it difficult to synthesize findings into recommended guidelines. This study demonstrated a need for adequately powered and rigorous randomized clinical trials (RCTs) to provide generalizable evidence on the effectiveness of pharmacologic interventions for TBI. PROSPERO Registration: CRD42015017355.

Mentorship in rehabilitation psychology: Attitudes and perspectives.

OBJECTIVE: To characterize how mentorship has been perceived, received, and practiced by individuals in the field of rehabilitation psychology across the career lifespan. METHOD: Current members of the American Psychological Association Division 22 (Rehabilitation Psychology) were invited to complete an electronic survey via REDCap assessing individual experiences and perspectives on mentorship. Thematic analysis was used to identify key constructs and themes. RESULTS: 39 participants (n = 25 mentors) completed the survey with valid responses. Participants spanned the career lifespan, ranging from predoctoral trainees to late-senior psychologists. Mentorship was generally perceived as helpful for both mentors and mentees. Several important qualities of mentors (e.g., availability, communication skills, self-disclosure, and emotional support) and mentees (e.g., flexibility, motivation, and openness to feedback) were identified. Among both groups, mentorship was viewed as especially beneficial for obtaining American Board of Professional Psychology (ABPP) board certification, which may reflect an aspect of mentoring unique to Division 22. Existing gaps in mentorship and key areas for improvement were also identified; access to mid- to late-career mentorship emerged as a notable gap in mentorship. Increased program structure, networking opportunities, and research mentorship were also identified as possible areas of growth. CONCLUSIONS: This study provides meaningful insights into mentorship within the field of rehabilitation psychology. Our findings demonstrate the value of mentorship across the career lifespan, and the beneficial role of mentorship in obtaining ABPP board certification. In addition, we identify key areas of growth that can inform and improve mentorship within the field. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Using a highly abbreviated California Verbal Learning Test-II to detect verbal memory deficits.

Multiple sclerosis (MS) is frequently accompanied by changes in verbal memory. We hypothesized that administering an abbreviated California Verbal Learning Test-II (CVLT-II) would detect verbal memory problems in MS accurately, thus serving as a potential screening tool. We performed receiver-operating-characteristic (ROC) analyses of three trials (trial 1, trial 2, and trial 1+2 combined) for raw data against standardized total scores. The results showed that at 1.5 standard deviations (SD) from the mean, the first two trials were 96.3% accurate, while at 2 SD from the mean, the first two trials combined were 97.5% accurate. We conclude that this study demonstrates than an abbreviated CVLT-II is a valid screening tool for verbal memory impairments.

Heart rate variability biofeedback, executive functioning and chronic brain injury.

PRIMARY OBJECTIVE: To determine if individuals with brain injury can modify heart rate variability (HRV) through biofeedback and, if so, enhance its pattern to improve emotional regulation and problem-solving ability. DESIGN: A quasi-experimental design with repeated measures was employed. Thirteen individuals aged 23-63 years with severe brain injury (13-40 years post-onset) participating in a community-based programme were enrolled. MAIN OUTCOMES: Response-to-treatment was measured with HRV indices, Behavior Rating Inventory of Executive Function (BRIEF-A-Informant) and attention/problem-solving tests. RESULTS: At post-treatment, HRV indices (Low Frequency/High Frequency [LF/HF] and coherence ratio) increased significantly. Increased LF/HF values during the second-half of a 10-minute session were associated with higher attention scores. Participants who scored better (by scoring lower) in informant ratings at pre-treatment had highest HRV scores at post-treatment. Accordingly, at post-treatment, families' ratings of participants' emotional control correlated with HRV indices; staffs' ratings of participants' working memory correlated with participants' HRV indices. Self-ratings of the BRIEF-A Task Monitoring scale at post-treatment correlated with family ratings at pre-treatment and post-treatment. CONCLUSIONS: Results demonstrate an association between regulation of emotions/cognition and HRV training. Individuals with severe, chronic brain injury can modify HRV through biofeedback. Future research should evaluate the efficacy of this approach for modifying behavioural problems.

Interferon and interferon-induced cytokines as markers of impending clinical progression in ANA+ individuals without a systemic autoimmune rheumatic disease diagnosis.

BACKGROUND: Elevated levels of interferons (IFNs) are a characteristic feature of systemic autoimmune rheumatic diseases (SARDs) and may be useful in predicting impending symptomatic progression in anti-nuclear antibody-positive (ANA+) individuals lacking a SARD diagnosis. Typically, these are measured by their effect on gene expression in the blood, which has limited their utility in clinical settings. Here, we assessed whether the measurement of serum IFN-α or selected IFN-induced cytokines accurately mirrors IFN-induced gene expression in ANA+ individuals and investigated their utility as biomarkers of clinical progression. METHODS: A total of 280 subjects were studied, including 50 ANA- healthy controls, 160 ANA+ individuals without a SARD diagnosis (96 asymptomatic, 64 with undifferentiated connective tissue disease), and 70 SARD patients. IFN-induced gene expression was measured by nanoString and cytokine levels by ELISA or Simoa. ANA+ individuals lacking a SARD diagnosis who had the new onset of SARD criteria over the subsequent 2 years were defined as progressors. RESULTS: Measurement of IFN-α levels by high-sensitivity ELISA or Simoa correlated much better with IFN-induced gene expression than measurement of CXCL-10 or Galectin-9 levels. Despite this, high CXCL-10 and Galectin-9 levels were better predictors of subsequent progression in ANA+ individuals than measures of IFN-α or IFN-induced gene expression with the optimal combination of predictive cytokines (CXCL-10 and IFN-α as measured by ELISA), resulting in a specificity and positive predictive value of 100%. CONCLUSION: Easily performed ELISA assays for CXCL-10 and IFN-α can be used to predict ANA+ individuals at high risk of imminent symptomatic progression.

The Utopia of Disability Inclusion in the Rehabilitation Sciences: An Insider's Perspective.

The inclusion of people with disabilities has historically been, and continues to be, challenging work. In the health professions, the practice of inclusion should promote and advance the dissemination of efforts to decrease the impact of societal and physical barriers on the lives of people with disability, as well as promote innovative approaches to effectively foster an inclusive society. In addition to a focus on concepts such as the intact abilities of people with disabilities and the facilitation of community participation, an important shift in inclusion-related research requires listening to the lived experience of individuals with disabilities. Listening to their lived experiences and including the valuable insights gleaned from their insider's perspective can enrich efforts to evaluate clinical and educational programs, define population needs, and set research agendas and rehabilitation goals. Building on seminal work from Tamara Dembo, Beatrice Wright, and Margaret Brown, this communication from the Disability Representation Task Force at the American Congress of Rehabilitation Medicine also explores how healthcare providers living with a disability can make a significant contribution to rehabilitation treatment by analyzing how their own experience applies to clinical practice.

Measuring personal growth in partners of persons with multiple sclerosis: A new scale.

OBJECTIVE: The purpose of this study was to describe the development and validation of a personal growth scale in caregiving partners of persons with multiple sclerosis (MS). METHOD: Two studies were conducted: one to identify possible constructs and items, and another to and examine the instrument's psychometric properties. Study 1 consisted of focus groups of 39 partners of patients with MS, expert reviews, and qualitative methodology for identifying themes. In Study 2, the items generated were administered to a new sample (N = 315), and the instrument's psychometric properties were assessed. RESULTS: Study 2 sample was suitable for principal component analysis (PCA), and PCA was performed with oblique rotation. A 6-component solution was deemed most parsimonious and interpretable. Subscales were formed and labeled as follows: Positivity, Appreciation, Acceptance, Insight, Independence, and Spirituality. Reliability analysis of the subscales showed acceptable to high internal consistency. A secondary PCA was performed on mean subscale scores. Five of the six subscales clustered together along one dimension, and the sixth, Spirituality, was found to be distinct as represented in a loading plot. This subscale was retained as an independent measure; the remaining subscale scores were summed to create a total score. Measures of convergent and discriminant validity evaluated against existing instruments yielded findings in the expected directions. CONCLUSIONS: The dimensionality and structure of personal growth in caregiving partners of persons with MS were delineated in a novel instrument. Future studies should confirm its structure, establish classification criteria, and standardize it as an assessment tool. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Efficacy and Use of Cloth Masks: A Scoping Review.

During the coronavirus disease 2019 (COVID-19) pandemic, there has been a global shortage of personal protective equipment (PPE). In this setting, cloth masks may play an important role in limiting disease transmission; however, current literature on the use of cloth masks remains inconclusive. This review aims to integrate current studies and guidelines to determine the efficacy and use of cloth masks in healthcare settings and/or the community. Evidence-based suggestions on the most effective use of cloth masks during a pandemic are presented. Embase, MEDLINE, and Google Scholar were searched on March 31, 2020, and updated on April 6, 2020. Studies reporting on the efficacy, usability, and accessibility of cloth masks were included. Additionally, a search of guidelines and recommendations on cloth mask usage was conducted through published material by international and national public health agencies. Nine articles were included in this review after full-text screening. The clinical efficacy of a face mask is determined by the filtration efficacy of the material, fit of the mask, and compliance to wearing the mask. Household fabrics such as cotton T-shirts and towels have some filtration efficacy and therefore potential for droplet retention and protection against virus-containing particles. However, the percentage of penetration in cloth masks is higher than surgical masks or N95 respirators. Cloth masks have limited inward protection in healthcare settings where viral exposure is high but may be beneficial for outward protection in low-risk settings and use by the general public where no other alternatives to medical masks are available.

Problem solving, biofeedback, and severe brain injury: The moderating role of positive affect.

OBJECTIVE: To examine how positive affect influences ability to benefit from heart rate variability (HRV) biofeedback treatment for individuals with severe brain injury. METHOD: Secondary data analysis of a nonrandomized experimental study that assessed the efficacy of biofeedback treatment for executive dysfunction in 13 individuals with chronic severe brain injury. RESULTS: Bivariate correlations between the predictors (levels of HRV and positive affect) and the outcome (change in Category Test errors) showed large effect sizes for higher levels of HRV coherence (r = -.495, p = .085) but not for positive affect (r = .069, p = .824). Although positive affect had a negligible effect on Category Test improvements by itself, positive affect played a moderating role that complemented the effect of HRV coherence. HRV coherence had a stronger effect on Category Test performance among those participants who demonstrated higher positive affect. A regression model was fit that included main effects for HRV coherence and positive affect, as well as their interaction. The interaction term was significant in a 1-tailed test (b = -3.902, SE = 1.914, p = .072). CONCLUSIONS: Participants who had the most positive emotions made the most gains in the HRV biofeedback training and performed better posttreatment on a test designed to measure problem-solving ability. Results indicate that positive affect can improve cognition, specifically mental flexibility and abstract thinking. Addressing factors that shape negative affect such as irrational beliefs and self-doubt is an important target for therapeutic intervention even in those with severe, chronic deficits. (PsycINFO Database Record

Screening Instruments for the Early Detection of Cognitive Impairment in Patients with Multiple Sclerosis.

BACKGROUND: Cognitive impairments are common in individuals with MS and adversely affect functioning. Early detection of cognitive impairment, therefore, would enable earlier, and possibly more effective, treatment. We sought to compare self-reports with a short neuropsychological test as possible screening tools for cognitive impairment. METHODS: One hundred patients with MS were tested with the Minimal Assessment of Cognitive Function in Multiple Sclerosis; z scores were used to derive the Cognitive Index (CI). Receiver operator characteristic curve analyses were performed, with criteria for impairment set at -1.5 and -2.0 SD below the mean. Scores from two self-reports (the Multiple Sclerosis Neuropsychological Screening Questionnaire-Patient Version and the Behavior Rating Inventory of Executive Function-Adult Version [BRIEF-A]) and a neuropsychological test (the Symbol Digit Modalities Test [SDMT]) were entered as test variables. Exploratory regression analyses were conducted with 1) CI and self-reports and 2) CI and the Problem-Solving Inventory (PSI). RESULTS: Classification accuracy was high or moderately high for SDMT when the criterion was -2.0 or -1.5 SD, respectively, but low for the self-reports. Hierarchical linear regression showed that the SDMT alone was the best predictor of cognitive impairment; adding the self-reports did not improve the model. Exploratory analyses indicated that certain self-reports (BRIEF-A, PSI) provided some explanatory power in separate models. CONCLUSIONS: The SDMT is a more accurate screening tool for cognitive impairment; however, self-reports provide additional information and may complement objective testing. Results suggest that screening for cognitive impairment may require a multidimensional approach.

Assessing the criterion validity of four highly abbreviated measures from the Minimal Assessment of Cognitive Function in Multiple Sclerosis (MACFIMS).

OBJECTIVE: Cognitive dysfunction is prevalent in multiple sclerosis. As self-reported cognitive functioning is unreliable, brief objective screening measures are needed. Utilizing widely used full-length neuropsychological tests, this study aimed to establish the criterion validity of highly abbreviated versions of the Brief Visuospatial Memory Test - Revised (BVMT-R), Symbol Digit Modalities Test (SDMT), Delis-Kaplan Executive Function System (D-KEFS) Sorting Test, and Controlled Oral Word Association Test (COWAT) in order to begin developing an MS-specific screening battery. METHOD: Participants from Holy Name Medical Center and the Kessler Foundation were administered one or more of these four measures. Using test-specific criterion to identify impairment at both -1.5 and -2.0 SD, receiver-operating-characteristic (ROC) analyses of BVMT-R Trial 1, Trial 2, and Trial 1 + 2 raw data (N = 286) were run to calculate the classification accuracy of the abbreviated version, as well as the sensitivity and specificity. The same methods were used for SDMT 30-s and 60-s (N = 321), D-KEFS Sorting Free Card Sort 1 (N = 120), and COWAT letters F and A (N = 298). RESULTS: Using these definitions of impairment, each analysis yielded high classification accuracy (89.3 to 94.3%). CONCLUSIONS: BVMT-R Trial 1, SDMT 30-s, D-KEFS Free Card Sort 1, and COWAT F possess good criterion validity in detecting impairment on their respective overall measure, capturing much of the same information as the full version. Along with the first two trials of the California Verbal Learning Test - Second Edition (CVLT-II), these five highly abbreviated measures may be used to develop a brief screening battery.

Depression levels and interferon treatment in people with multiple sclerosis.

Multiple sclerosis (MS) is the most common cause of neurologic disease in young and middle-aged adults, and 75% of patients are female. Nearly one in two patients with MS will experience clinically significant depression-approximately three times the prevalence rate in the general population. This study used a cross-sectional approach to examine the link between depression levels and use of interferon medications among individuals with MS. Data were collected from 694 patients of the Multiple Sclerosis Comprehensive Care Center at Holy Name Medical Center in Teaneck, New Jersey. Analysis of variance was used to compare depression scores between patients taking and not taking interferons. Regression analyses with depression scores as the dependent variable were also conducted. The Beck Depression Inventory (BDI) was reduced to a set of dimensions by principal components analysis. Two components were identified, reflecting somatic and cognitive symptoms. The results showed no significant relationship between depression levels and interferon treatment. Significant associations were observed between depression and both age and disability status, with younger, more disabled patients tending to be more depressed.

Cognitive and motor functioning in patients with multiple sclerosis: neuropsychological predictors of walking speed and falls.

While motor and cognitive impairments are common in Multiple Sclerosis (MS) patients, research concerning their relationship in this population has been limited. We aimed to evaluate cross-sectional associations between cognitive functions, walking speed, and falls in patients with MS. Through a retrospective chart review of 81 patients with MS, we examined whether measures of cognitive function predicted walking speed on the Timed 25-Foot Walk and self-reported fall frequency. Hierarchical linear regressions showed that after controlling for age, gender, and disease severity, slower processing speed and IQ predicted slower gait speed, while poorer verbal memory predicted increased frequency of falls. Moreover, a binary logistic regression showed that poorer verbal memory also predicted increased risk of multiple falls. Thus, specific cognitive functions are meaningfully related to mobility limitations in patients with MS. These findings suggest that risk assessment for gait decline and falls should include cognitive assessment in patients with MS.