A randomised control trial of walking to ameliorate brain injury fatigue: a NIDRR TBI model system centre-based study.

Fatigue is one of the most commonly reported sequelae after traumatic brain injury (TBI). This study evaluated the impact of a graduated physical activity programme on fatigue after TBI. Using a prospective randomised single-blind crossover design, 123 individuals with TBI, over the age of 18, were enrolled. Interventions included a home-based walking programme utilising a pedometer to track daily number of steps at increasing increments accompanied by tapered coaching calls over a 12-week period. Nutritional counselling with the same schedule of coaching calls served as the control condition. Main outcome measures included: the Global Fatigue Index (GFI), the Barrow Neurological Institute (BNI) Fatigue Scale Overall Severity Index Score, and the Multidimensional Fatigue Inventory (MFI). Step counts improved over time regardless of group assignment. The walking intervention led to a decrease in GFI, BNI Total, and MFI General scores. Participants reported less fatigue at the end of the active part of the intervention (24 weeks) and after a wash out period (36 weeks) as measured by the BNI Overall. The study suggests that walking can be used as an efficient and cost-effective tool to improve fatigue in persons who have sustained a TBI.

Challenges to be overcome using population-based sampling methods to recruit veterans for a study of post-traumatic stress disorder and traumatic brain injury.

BACKGROUND: Many investigators are interested in recruiting veterans from recent conflicts in Afghanistan and Iraq with Traumatic Brain Injury (TBI) and/or Post Traumatic Stress Disorder (PTSD). Researchers pursuing such studies may experience problems in recruiting sufficient numbers unless effective strategies are used. Currently, there is very little information on recruitment strategies for individuals with TBI and/or PTSD. It is known that groups of patients with medical conditions may be less likely to volunteer for clinical research. This study investigated the feasibility of recruiting veterans returning from recent military conflicts--Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF)--using a population-based sampling method. METHODS: Individuals were sampled from a previous epidemiological study. Three study sites focused on recruiting survey respondents (n = 445) who lived within a 60 mile radius of one of the sites. RESULTS: Overall, the successful recruitment of veterans using a population-based sampling method was dependent on the ability to contact potential participants following mass mailing. Study enrollment of participants with probable TBI and/or PTSD had a recruitment yield (enrolled/total identified) of 5.4%. We were able to contact 146 individuals, representing a contact rate of 33%. Sixty-six of the individuals contacted were screened. The major reasons for not screening included a stated lack of interest in the study (n = 37), a failure to answer screening calls after initial contact (n = 30), and an unwillingness or inability to travel to a study site (n = 10). Based on the phone screening, 36 veterans were eligible for the study. Twenty-four veterans were enrolled, (recruitment yield = 5.4%) and twelve were not enrolled for a variety of reasons. CONCLUSIONS: Our experience with a population-based sampling method for recruitment of recent combat veterans illustrates the challenges encountered, particularly contacting and screening potential participants. The screening and enrollment data will help guide recruitment for future studies using population-based methods.

Child-adolescent emergency psychiatry: addressing false positive admissions.

Current literature emphasizes the necessary and increasing role of the emergency department (ED) psychologist. This perspective paper will illustrate that the recent focus on an ED psychologist is necessary, but insufficient. Equally important, is an understanding of when a patient in a potential crisis does not require an ED admission, but rather an assessment that is made prior to the patient going to the ED. The essential role of an outpatient crisis team is vital in differentiating when an ED admission is indicated for a psychiatric crisis (true positive) and when an ED admission is not indicated for a psychiatric crisis (false positive). Evaluating crises prior to ED admissions accomplishes two critical healthcare objectives in a parallel process: 1) accurately assessing the proper level of care needed when a patient reports they are experiencing acute psychiatric symptoms (which may or may not necessitate emergency department level of care, and 2) reducing burden on an already over-extended ED when emergency care is not indicated. Our findings are uniquely drawn from a highly diverse youth patient population in Northern California, United States.

Burden of Care Implications and Association of Intracranial Hypertension With Extremely Severe Post-traumatic Amnesia After Traumatic Brain Injury: A 5-Year Retrospective Longitudinal Study.

Post-traumatic amnesia (PTA) is characterized by a state of disorientation and confusion following traumatic brain injury (TBI). Few studies have looked at the effect of prolonged PTA on the functional outcomes beyond 1 year post-injury. This study aims to evaluate the burden of care in individuals with extremely severe PTA (esPTA; PTA >28 days) from acute inpatient rehabilitation admission to 5 years post-injury as well as the association between intracranial hypertension (ICH; Intracranial pressure (ICP) ≥20 mmHg) and esPTA status. Three hundred and forty-two individuals with moderate to severe TBI enrolled in the Northern California TBI Model System (TBIMS) of Care were included in this study. The FIM® instrument was chosen as the outcome measurement as it is a widely used functional assessment in the rehabilitation community. Repeated measure ANOVA revealed greater burden of care based on FIM® total scores (p < 0.001) from admission to 5-year follow-up for the esPTA group compared to the non-esPTA group (PTA ≤ 28 days). Unlike the non-esPTA group where FIM® total score plateaued 1 year post-injury, FIM® total score continued to improve up to 2 years post-injury for the esPTA group. The odds of developing esPTA was ~3 times higher for individuals with ICH vs. individuals without ICH (p < 0.001). In conclusion, individuals with esPTA have increased short- and long-term burden of care and the presence of ICH during hospitalization increased the odds of experiencing esPTA. These results may help the rehabilitation team and family in planning care post rehabilitation discharge.

SCiPad: Effective Implementation of Telemedicine Using iPads with Individuals with Spinal Cord Injuries, a Case Series.

BACKGROUND: Individuals with spinal cord injury (SCI) must often travel long distances to see a rehabilitation specialist. While telemedicine (TM) for pressure ulcer management has been used in this population, real-time video telecommunication using iPad has never been described. OBJECTIVE: The objective of this study was to provide specialized care for persons with SCI through TM consultation expediently in order to address medical needs, manage secondary complications, and to improve quality of life (QoL) of individuals with SCI. METHODS: Ten individuals with SCI participated in the TM program using iPads for 6 months as a feasibility study at a single-center, county hospital. The participants contacted the project staff for SCI-related conditions and were then connected to an SCI-trained health-care provider within 24 hours via FaceTime. Main outcome measures included health-care utilization; QoL and psychosocial measures collected at baseline and at 6 months: Reintegration to Normal Living Index (RNLI), Life Satisfaction Index A (LSI-A), and Patient Health Questionnaire 9 (PHQ-9); and a Program Satisfaction Survey. RESULTS: Ten patients (seven with tetraplegia, three with paraplegia; eight males and two females) with an average age of 34.4 (18-54) years were enrolled. The average baseline and 6-month follow-up scores were RNLI-70.1 ± 19.7 and 74.7 ± 21.8, respectively; LSI-A-25.4 ± 7.4 and 26.4 ± 8.2, respectively; and PHQ-9 were 6.8 ± 7.2 and 8.6 ± 6.1, respectively. TM encounters included topics such as pain, bladder and skin management, medication changes, and lab results. The Program Satisfaction Survey yielded positive results with 100% of program completers stating they would recommend the program and would like to continue having TM. CONCLUSION: This is the first known successful project using iPad to provide TM in the SCI population. This study discusses the implementation of such a TM program in a health system including limitations. It describes the clinical viability of TM using iPads in the SCI population for care beyond that of just pressure ulcer management. This project provides evidence for using a tablet device like an iPad as an effective and efficient patient management tool.

Implicit and explicit self-esteem in remitted depressed patients.

BACKGROUND AND OBJECTIVES: Low self-esteem is a symptom of depression and depression vulnerability. Prior research on self-esteem has largely focused on implicit (ISE) and explicit self-esteem (ESE) as two separate constructs, missing their interaction. Therefore, the current study investigated the interaction between ISE and ESE in a depression-vulnerable group (remitted depressed patients; RDs), compared to never-depressed controls (ND). METHODS: Seventy-five RDs and 75 NDs participated in the study. To measure ESE, the Rosenberg Self-Esteem Scale (RSES) was used. The Implicit Association Test (IAT) and the Name Letter Preference Task (NLPT) were used to assess ISE. RESULTS: RDs reported lower ESE than NDs. However, the two groups did not differ on ISE. RDs exhibited a damaged self-esteem or a low-congruent self-esteem, similar to what has been found in currently depressed patients. Moreover, damaged self-esteem was associated with residual depressive symptoms. LIMITATIONS: The results need to be interpreted with care because the IAT and NLPT did not reveal the same associations with the clinical measures. CONCLUSIONS: Implicit and explicit self-esteem may be different constructs in depression and studying the combination is important. The present study provides evidence indicating that damaged self-esteem may be more detrimental than low congruent self-esteem.

Depression in Men and Women One Year Following Traumatic Brain Injury (TBI): A TBI Model Systems Study.

In the general population, females experience depression at significantly higher rates than males. Individuals with traumatic brain injury (TBI) are at substantially greater risk for depression compared to the overall population. Treatment of, and recovery from, TBI can be hindered by depression; comorbid TBI and depression can lead to adverse outcomes and negatively affect multiple aspects of individuals' lives. Gender differences in depression following TBI are not well understood, and relevant empirical findings have been mixed. Utilizing the Patient Health Questionnaire-9 (PHQ-9) 1 year after TBI, we examined whether women would experience more severe depressive symptoms, and would endorse higher levels of depression within each category of depression severity, than would men. Interestingly, and contrary to our hypothesis, men and women reported mild depression at equal rates; PHQ-9 total scores were slightly lower in women than in men. Men and women did not differ significantly in any PHQ-9 depression severity category. Item analyses, yielded significant gender differences on the following items: greater concentration difficulties (cognitive problems) in men and more sleep disturbances (psychosomatic issues) in women per uncorrected two-sample Z-test for proportions analyses; however, these results were not significant after the family-wise Bonferroni correction. Our results indicate that, in contrast to the general population, mild depression in persons with moderate to severe TBI may not be gender-specific. These findings underscore the need for early identification, active screening, and depression treatment equally for men and women to improve emotional well-being, promote recovery, and enhance quality of life following TBI.

The impact of depression on Veterans with PTSD and traumatic brain injury: a diffusion tensor imaging study.

A significant proportion of military personnel deployed in support of Operation Enduring Freedom and Operation Iraqi Freedom were exposed to war-zone events associated with traumatic brain injury (TBI), depression (DEP) and posttraumatic stress disorder (PTSD). The co-occurrence of TBI, PTSD and DEP in returning Veterans has recently increased research and clinical interest. This study tested the hypothesis that white matter abnormalities are further impacted by depression. Of particular relevance is the uncinate fasciculus (UF), which is a key fronto-temporal tract involved in mood regulation, and the cingulum; a tract that connects to the hippocampus involved in memory integration. Diffusion tensor imaging (DTI) was performed on 25 patients with a combination of PTSD, TBI and DEP and 20 patients with PTSD and TBI (no DEP). Microstructural changes of white matter were found in the cingulum and UF. Fractional anisotropy (FA) was lower in Veterans with DEP compared to those without DEP.

Shorter gaze duration for happy faces in current but not remitted depression: evidence from eye movements.

Cognitive theories of depression propose that depressed individuals preferentially attend to negative information and that such cognitive biases constitute important vulnerability and maintenance factors for the disorder. Most studies examined this bias by registration of response latencies. The present study employed a direct and continuous measurement of attentional processing for emotional stimuli by recording eye movements. Currently depressed (CD), remitted depressed (RD) and healthy control (HC) participants viewed slides presenting sad, angry, happy and neutral facial expressions. For each expression, four components of visual attention were analyzed: first fixation, maintained fixation, relative fixation frequency and glance duration. Results showed that healthy controls were characterized by longer gaze duration for happy faces compared to currently depressed individuals but not compared to remitted depressed individuals. Both patient groups (CD, RD) demonstrated longer maintained fixation (dwelling time) on all emotional faces compared to healthy controls. The present findings are in line with the presumption that depression is associated with a loss of elaborative processing of positive stimuli that characterizes healthy controls. Importantly, successful remission of depression (RD group) may result in positive attentional processing as no group differences were found between healthy controls and remitted patients on glance duration for happy faces.

Verbal and facial-emotional Stroop tasks reveal specific attentional interferences in sad mood.

Mood congruence refers to the tendency of individuals to attend to information more readily when it has the same emotional content as their current mood state. The aim of the present study was to ascertain whether attentional interference occurred for participants in sad mood states for emotionally relevant stimuli (mood-congruence), and to determine whether this interference occurred for both valenced words and valenced faces. A mood induction procedure was administered to 116 undergraduate females divided into two equal groups for the sad and happy mood condition. This study employed three versions of the Stroop task: color, verbal-emotional, and a facial-emotional Stroop. The two mood groups did not differ on the color Stroop. Significant group differences were found on the verbal-emotional Stroop for sad words with longer latencies for sad-induced participants. Main findings for the facial-emotional Stroop were that sad mood is associated with attentional interference for angry-threatening faces as well as longer latencies for neutral faces. Group differences were not found for positive stimuli. These findings confirm that sad mood is associated with attentional interference for mood-congruent stimuli in the verbal domain (sad words), but this mood-congruent effect does not necessarily apply to the visual domain (sad faces). Attentional interference for neutral faces suggests sad mood participants did not necessarily see valence-free faces. Attentional interference for threatening stimuli is often associated with anxiety; however, the current results show that threat is not an attentional interference observed exclusively in states of anxiety but also in sad mood.

Morphed emotional faces: emotion detection and misinterpretation in social anxiety.

The current study investigated detection and interpretation of emotional facial expressions in high socially anxious (HSA) individuals compared to non-anxious controls (NAC). A version of the morphed faces task was implemented to assess emotion onset perception, decoding accuracy and interpretation, either with time pressure (Restricted Viewing Task, RVT) or with unlimited viewing (Free Viewing Task, FVT). Twenty-seven HSA and 30 NAC viewed sequences of neutral faces slowly changing to full-intensity angry, happy, or disgust expressions. Participants were instructed to assign the expression as soon as possible to one of four given emotion categories (angry, contempt, disgust, or happy). While no group differences were found for emotion onset perception or decoding performance, the results suggest an interpretation bias in HSA. Under the RVT condition, HSA demonstrated a threat bias (disgust interpreted as contempt), contrasting the NAC's positive bias (disgust interpreted as happy). No group differences were found in the FVT. We suggest that socially anxious individuals tend to misinterpret facial expressions as threatening when they must do so quickly and efficiently, as in real life.

The psychophysiology of generalized anxiety disorder: 2. Effects of applied relaxation.

Muscle relaxation therapy assumes that generalized anxiety disorder (GAD) patients lack the ability to relax but can learn this in therapy. We tested this by randomizing 49 GAD patients to 12 weeks of Applied Relaxation (AR) or waiting. Before, during, and after treatment participants underwent relaxation tests. Before treatment, GAD patients were more worried than healthy controls (n=21) and had higher heart rates and lower end-tidal pCO2, but not higher muscle tension (A. Conrad, L. Isaac, & W.T. Roth, 2008). AR resulted in greater symptomatic improvement than waiting. However, 28% of the AR group dropped out of treatment and some patients relapsed at the 6-week follow-up. There was little evidence that AR participants learned to relax in therapy or that a reduction in anxiety was associated with a decrease in activation. We conclude that the clinical effects of AR in improving GAD symptoms are moderate at most and cannot be attributed to reducing muscle tension or autonomic activation.

The psychophysiology of generalized anxiety disorder: 1. Pretreatment characteristics.

Generalized anxiety disorder (GAD) patients have been reported to have more muscle tension than controls, which has provided a rationale for treating them with muscle relaxation therapies (MRT). We tested this rationale by comparing 49 GAD patients with 21 controls. Participants underwent 5-min relaxation tests, during which they either just sat quietly (QS) or sat quietly and tried to relax (R). GAD patients reported themselves to be more worried during the assessment than the controls, had higher heart rates and lower end-tidal pCO2, but not higher muscle tension as measured by multiple EMGs. QS and R did not differ on most psychological and physiological measures, indicating that intention to relax did not affect speed of relaxation. In the GAD group, self-reported anxiety was not associated with electromyographic or autonomic measures. We conclude that GAD is not necessarily characterized by chronic muscle tension, and that this rationale for MRT should be reconsidered.