Considering the Importance of Personal and Injury Factors Influencing Outcome After Traumatic Brain Injury.

OBJECTIVE: Given the high variability in traumatic brain injury (TBI) outcomes and relative lack of examination of the influence of noninjury factors on outcome, this study aimed to examine factors associated with functional outcome at 1 and 2 years after moderate to severe TBI, including both preinjury and injury-related factors. DESIGN: Observational cohort study. SETTING: Inpatient hospital recruitment with outpatient follow-up at 1 and 2 years post injury. PARTICIPANTS: Individuals with moderate to severe TBI were recruited prospectively into a Longitudinal Head Injury Outcome Study. Of the eligible 3253 individuals who were eligible, 1899 participants consented to the study (N=1899). MAIN OUTCOME MEASURE: Functional outcome was measured using the Glasgow Outcome Scale-Extended (GOS-E). RESULTS: 1476 participants (73.6% males) and 1365 participants (73% males) completed the GOS-E at 1 and 2 years post injury. They had a mean age at injury of 40 years and mean duration of post-traumatic amnesia (PTA) of 26 days. Good recovery, representing return to previous activities on the GOS-E (score 7-8), was present in 31% of participants at 1 year post injury and 33.5% at 2 years post injury. When predictor variables were entered into regression together, good outcome was significantly associated with not being from a culturally and linguistically diverse background and not having preinjury mental health or alcohol treatment, shorter PTA duration, and absence of limb injuries at both 1 and 2 years; higher education was also a significant predictor at 1 year post injury. CONCLUSIONS: Alongside consideration of injury severity, understanding and addressing preinjury factors is important to maximize outcomes.

Effectiveness of Pharmacotherapy for Depression after Adult Traumatic Brain Injury: an Umbrella Review.

Symptoms of depression are common following traumatic brain injury (TBI), impacting survivors' ability to return to work, participate in leisure activities, and placing strain on relationships. Depression symptoms post TBI are often managed with pharmacotherapy, however, there is little research evidence to guide clinical practice. There have been a number of recent systematic reviews examining pharmacotherapy for post TBI depression. The aim of this umbrella review was to synthesize systematic reviews and meta-analyses of the effectiveness of pharmacotherapy for the management of post TBI depression in adults. Eligible reviews examined any pharmacotherapy against any comparators, for the treatment of depression in adults who had sustained TBI. Seven databases were searched, with additional searching of online journals, Research Gate, Google Scholar and the TRIP Medical Database to identify published and unpublished systematic reviews and meta-analyses in English up to May 2020. A systematic review of primary studies available between March 2018 and May 2020 was also conducted. Evidence quality was assessed using Joanna Briggs Institute Critical Appraisal Instruments. The results are presented as a narrative synthesis. Twenty-two systematic reviews were identified, of which ten reviews contained a meta-analysis. No new primary studies were identified in the systematic review. There was insufficient high quality and methodologically rigorous evidence to recommend prescribing any specific drug or drug class for post TBI depression. The findings do show, however, that depression post TBI is responsive to pharmacotherapy in at least some individuals. Recommendations for primary studies, systematic reviews and advice for prescribers is provided. Review Registration PROSPERO (CRD42020184915).

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.

Stability and Change in Biopsychosocial Factors Associated With Fatigue 6 and 12 Months After Traumatic Brain Injury: An Exploratory Multilevel Study.

OBJECTIVE: To explore factors associated with stability and change in fatigue from 6 to 12 months following traumatic brain injury (TBI). SETTING: Combined in- and outpatient acute care and postacute rehabilitation settings. PARTICIPANTS: A total of 103 patients with confirmed intracranial injury were assessed 6 and/or 12 months following TBI. DESIGN: A prospective observational study with repeated measures at 2 time points, analyzed with a hybrid mixed-effects model. MAIN MEASURES: Primary outcomes were the fatigue factor derived from items from several fatigue patient-reported outcome measures (PROMs; Fatigue Severity Scale, Chalder Fatigue Scale, Giessen Subjective Complaints List-fatigue subscale, and Rivermead Post-Concussion Symptoms Questionnaire-fatigue item) Secondary outcomes were PROMs relating to pain, somatic and psychological distress, insomnia, sleepiness, personality traits, optimism, resilience, behavioral activation and inhibition, and loneliness, as well as neuropsychological measures. Demographic variables and injury severity characteristics were included as covariates. RESULTS: In multilevel regression, female sex, years of education, and 3 factors related to injury severity, somatic vulnerability, and psychosocial robustness were all significantly associated with variation in fatigue between subjects, and explained 61% of the variance in fatigue that was due to stable between-subject differences. Fatigue levels declined significantly over time. Changes in pain severity, somatic symptom burden, psychological distress, and behavioral inhibition were positively associated with changes in fatigue, explaining 22% of the variance in fatigue within subjects. CONCLUSIONS: The study demonstrated that several previously implicated factors show robust effects in distinguishing individuals with TBI on levels of fatigue, but only a few show additional within-subject associations across time. Pain severity, somatic symptom burden, psychological distress, and behavioral inhibition correlated with fatigue across time, implicating these factors as crucial targets for rehabilitation of patients with TBI who suffer from persistent fatigue.

"They just say how stupid I was for being conned". Cyberscams and acquired brain injury: A qualitative exploration of the lived experience of survivors and close others.

Individuals with acquired brain injury (ABI) may be vulnerable to cyberscams due to their cognitive and psychosocial impairments. However, the lived experiences of cyberscam survivors with ABI and their close others is not understood, and no effective intervention has been identified. This qualitative study aimed to explore the perspectives of cyberscam survivors with ABI (n = 7) and their close others (n = 6). Semi-structured interviews explored the scam experience, impacts, vulnerabilities and interventions. Reflexive thematic analysis of interview transcripts identified seven themes: "who is at the helm?: vulnerabilities," "the lure: scammer tactics," "scammers aboard: scam experience," "the discovery," "sinking in: impacts," "responding to the mayday: responses from others," and "lifesavers: suggestions for intervention." The journey towards scam victimisation was complex, and complicated by the ABI. Cyberscams contributed to substantial financial disadvantage, loss of trust and shame. ABI related impairments and social isolation reportedly increased scam vulnerability and interfered with intervention attempts by family and professionals. Confusion, denial and disbelief created further barriers to discovery. The practical and emotional impacts on both cyberscam survivors with ABI and their family members, and a lack of effective intervention, highlight the need for increased education and awareness in order to improve online safety for those with ABI.

Experience of adapted cognitive behaviour therapy to address sexuality problems after traumatic brain injury: A qualitative study.

Although sexuality has been shown to be negatively impacted in up to half of individuals who sustain traumatic brain injury (TBI), few studies have sought to evaluate the efficacy of targeted interventions. Gaining insight into the participant experience of undergoing treatment for post-TBI sexuality changes is a crucial aspect of intervention evaluation. This study aimed to investigate participants with TBI experience of undergoing eight sessions of a novel CBT intervention designed to help both couples and singles improve sexual wellbeing after TBI. Eight participants (50% male) with moderate-severe TBI, and a mean age of 46.38-years (SD = 13.54), completed a qualitative interview. A six-phase reflexive thematic analysis approach was used. Despite variability in participant characteristics, the findings suggested that participants with TBI experience reflected that of a positive treatment journey characterized by high levels of enjoyment and satisfaction. Key themes identified included contextual factors that preceded treatment, factors that facilitated treatment engagement, outcomes derived from the treatment experience, and feedback provided on reflection. The results not only provide an enriched understanding of the client experience of the intervention but provide corroborating preliminary evidence of efficacy for this novel CBT intervention in addressing complex and persistent sexuality problems after TBI.

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.

Evaluating telehealth delivery of a compensatory memory rehabilitation programme following stroke: A single-case experimental design.

Rehabilitation of memory remains an unmet need for many stroke survivors. Telehealth methods may provide a solution, however evidence supporting the efficacy of remotely-delivered therapy is needed. A non-concurrent multiple baseline design was used with randomized onset of intervention across five individuals with chronic stroke-related memory complaints. A six-week compensatory memory skills programme was delivered individually via internet videoconferencing. Target behaviours of frequencies of self-reported lapses of everyday and prospective memory were measured weekly across baseline, intervention, and follow-up phases. A secondary outcome of functional goal attainment was measured once per phase, with participants setting two personal rehabilitation goals. Data were analysed visually and statistically. Improvements in memory functioning were statistically significant on at least one measure of target behaviour for four out of five participants at intervention or follow-up. Visual evidence of level change indicated at least modest improvements for all participants by follow-up. All participants attained at least one functional goal by follow-up. High rates of treatment adherence and participant satisfaction were observed. Technological issues were minimal and did not impact content delivery or engagement. These results provide preliminary support for the efficacy of a telehealth-delivered rehabilitation programme in improving memory function and achieving memory-related goals for stroke survivors.

Survey on the experiences, attitudes, and training needs of Australian healthcare professionals related to sexuality and service delivery in individuals with acquired brain injury.

Following acquired brain injury (ABI), sexuality, self-esteem and practices are often negatively impacted. Whilst sexuality is recognized as an essential part of a person's life regardless of medical condition, it is poorly understood in the ABI rehabilitation context. This study examined current assessment and treatment practices for sexual health and wellbeing in ABI rehabilitation, including perceived barriers and facilitators to discussing sexuality with individuals after ABI. We also assessed the need for further education and training in this area. Two hundred and thirty-nine Australian healthcare professionals predominantly working with both traumatic brain injury (TBI) and stroke populations completed an online survey comprising thirty-four questions. The 12-item sexuality attitudes and beliefs survey (SABS) was included as an additional objective outcome measure. Findings suggest that healthcare professionals infrequently raise sexuality with individuals with ABI. Inadequate education and training, not knowing whose role it is and when to raise the topic, and the view that individuals with ABI will ask for the information were all identified as key barriers contributing to poor sexuality management after ABI. More education and training opportunities with greater access to resources are needed to facilitate the incorporation of sexuality into routine practice across the continuum of ABI care.

Acceptability of telehealth in post-stroke memory rehabilitation: A qualitative analysis.

Despite evidence of the efficacy of telerehabilitation post-stroke, uptake has lagged behind the development of available technology, slowed by low confidence in user experience. We aimed to explore the issue of acceptability by characterizing the experience of telerehabilitation for service providers and consumers of a memory rehabilitation program. Semi-structured interviews were conducted with nine clinicians (Mage = 33.29; SD = 7.37; range 25-44) and 25 stroke survivors with memory difficulties (Mage = 54.12; SD = 10.99; range 36-82) following a 6-week compensatory memory skills program delivered via in-home videoconferencing. Thematic analysis identified a range of perspectives under three overarching themes: (1) Content and Delivery; (2) Relationship and Connection; and (3) The Role and Benefits of Telerehabilitation. Reports from both respondent groups were overwhelmingly positive about the telerehabilitation experience and identified the benefits of increasing service availability. Videoconferencing technology was usable and occasional reliability issues were not a barrier. Users identified a range of benefits and challenges regarding communication, rapport building, and integration of rehabilitation in the home environment. Furthermore, most stroke survivors reported benefit from the intervention, via the acquisition of memory strategies and improved self-confidence through better understanding of their deficits. Overall, telerehabilitation of memory was acceptable to users.

Does cognitive decline occur decades after moderate to severe traumatic brain injury? A prospective controlled study.

This prospective controlled study examined long-term trajectories of neuropsychological performance in individuals with traumatic brain injury (TBI) compared to healthy controls, and the impact of IQ, age at injury, time since injury, and injury severity on change over time. Fifty-three individuals with moderate to severe TBI (60.37% male; M = 59.77 yrs, SD = 14.03), and 26 controls (46.15% male; M = 63.96 yrs, SD = 14.42) were studied prospectively (M = 12.72 yrs between assessments). Participants completed measures of premorbid IQ (Weschler Test of Adult Reading), processing speed (Digit Symbol Coding Test), working memory (Digit Span Backwards), memory (Rey Auditory Verbal Learning Test) and executive function (Trail Making Test Part B; Hayling Errors), at a mean of 10.62 yrs (Initial) and 23.91 yrs (Follow-Up) post injury. Individuals with TBI did not show a significantly greater decline in neuropsychological performance over time compared with demographically similar controls. There was no association between change over time with IQ, time since injury or injury severity. Being older at injury had a greater adverse impact on executive function at follow-up. In this small sample, a single moderate to severe TBI was not associated with ongoing cognitive decline up to three decades post injury. Changes in cognitive function were similar between the groups and likely reflect healthy aging.

The bidirectional relationship between sleep and physical activity following traumatic brain injury.

Sleep and physical activity are both modifiable behavioural factors that are associated with better health and are potentially related. Following traumatic brain injury, damage to the brain caused by an external force, sleep disturbances are common. Exploring bidirectional relationships between sleep and physical activity might provide insight into whether increasing physical activity could decrease these sleep disturbances. The current study, therefore, examined inter- and intra-individual temporal associations between sleep and daytime physical activity in 64 people with traumatic brain injury reporting sleep problems or fatigue (47 males; mean age, 40 years). Sleep and physical activity were measured using actigraphy with corroborating sleep diaries over 14 consecutive days. Multilevel models were used to examine inter- and intra-individual associations between physical activity and sleep. Inter-individual variations showed that earlier bedtimes, earlier wake-up times and lower sleep efficiency were associated with more physical activity. Intra-individual temporal variations showed no significant association of daytime physical activity with sleep duration or continuity. However, shorter sleep time and less wake after sleep onset than usual were associated with more time spent in light-intensity activity the next day. Therefore, sleep may have more of an influence on physical activity than physical activity has on sleep in people with traumatic brain injury. In conclusion, the results do not confirm a potential beneficial effect of physical activity on sleep but suggest that improving sleep quality might be relevant to support of a physically active lifestyle in people with traumatic brain injury. Further research is necessary to confirm these results.

Home-based light therapy for fatigue following acquired brain injury: a pilot randomized controlled trial.

BACKGROUND AND OBJECTIVES: Fatigue and sleep disturbance are debilitating problems following brain injury and there are no established treatments. Building on demonstrated efficacy of blue light delivered via a lightbox in reducing fatigue and daytime sleepiness after TBI, this study evaluated the efficacy of a novel in-home light intervention in alleviating fatigue, sleep disturbance, daytime sleepiness and depressive symptoms, and in improving psychomotor vigilance and participation in daily productive activity, following injury METHODS: The impact of exposure to a dynamic light intervention (Treatment) was compared to usual lighting (Control) in a randomized within-subject, crossover trial. Outcomes were fatigue (primary outcome), daytime sleepiness, sleep disturbance, insomnia symptoms, psychomotor vigilance, mood and activity levels. Participants (N = 24, M ± SDage = 44.3 ± 11.4) had mild-severe TBI or stroke > 3 months previously, and self-reported fatigue (Fatigue Severity Scale ≥ 4). Following 2-week baseline, participants completed each condition for 2 months in counter-balanced order, with 1-month follow-up. Treatment comprised daytime blue-enriched white light (CCT > 5000 K) and blue-depleted light (< 3000 K) 3 h prior to sleep. RESULTS: Random-effects mixed-model analysis showed no significantly greater change in fatigue on the Brief Fatigue Inventory during Treatment, but a medium effect size of improvement (p = .33, d = -0.42). There were significantly greater decreases in sleep disturbance (p = .004), insomnia symptoms (p = .036), reaction time (p = .004) and improvements in productive activity (p = .005) at end of Treatment relative to Control, with large effect sizes (d > 0.80). Changes in other outcomes were non-significant. CONCLUSIONS: This pilot study provides preliminary support for in-home dynamic light therapy to address sleep-related symptoms in acquired brain injury. TRIAL REGISTRATION: This trial was registered with the Australian and New Zealand Clinical Trials Registry on 13 June 2017, www.anzctr.org.au , ACTRN12617000866303.

Investigating feasibility and preliminary efficacy of a simulator-based driving intervention for people with acquired brain injury: A randomised controlled pilot study.

OBJECTIVE: To investigate the feasibility and preliminary efficacy of a driving simulator intervention on driving outcomes following acquired brain injury. DESIGN: Pilot randomised controlled trial. SETTING: Occupational therapy driver assessment and rehabilitation service. SUBJECTS: Individuals post-acquired brain injury aiming to return to driving. INTERVENTION: Eight sessions of simulated driver training over four weeks, in addition to usual care. Control: Usual care only. MAIN MEASURES: Feasibility outcomes: Participant recruitment and retention; data completeness; therapy attendance and fidelity; adverse events. Performance outcomes: on-road driving performance; Simulator Sickness Questionnaire; Brain Injury Driving Self-Awareness Measure and Driving Comfort Scale - Daytime, assessed at baseline and five weeks post-randomisation. RESULTS: Out of 523 individuals screened, 22 (4%) were recruited and randomised, with 20 completing their allocated group (n = 12 Simulator, n = 8 Usual Care). For those who completed training, session attendance was 100% with simulator sickness rated, on average, as mild. Six individuals (50%) in the Simulator group failed the on-road assessment, versus two (25%) in the Usual Care group (P = 0.373). On average, the Simulator group reported a positive change in confidence ratings (M = 5.77, SD = 13.96) compared to the Usual Care group, who reported a negative change (M = -6.97, SD = 8.47), P = 0.034. The Simulator group (M = 0.67, SD = 3.34) demonstrated no significant change in self-awareness relative to the Usual Care group (M = -0.83, SD = 1.83, P = 0.325). CONCLUSIONS: With adjustments to inclusion criteria and recruitment strategies, it may be feasible to deliver the intervention and conduct a larger trial. There is potential benefit of simulator training for improving driver confidence after acquired brain injury.

User experiences and perspectives of a driving simulator intervention for individuals with acquired brain injury: A qualitative study.

Driving a motor vehicle is a common rehabilitation goal following acquired brain injury (ABI). There is increasing interest in the use of driving simulators for driver rehabilitation post-ABI; however, there is still limited research demonstrating efficacy and acceptability. This study sought to examine the user experience of a driving simulator intervention for ABI survivors. Semi-structured interviews were conducted with 14 individuals, including 12 ABI survivors (42% male; Mean age = 53.92 years, SD age = 17.63) who completed the intervention, and 2 occupational therapist driver assessors who facilitated the intervention. Thematic analysis was adopted to analyse interview data. Findings suggest that individual differences (e.g., anxiety, previous experience) influenced participant response to training. The intervention allowed participants to practise various driving skills, re-familiarize themselves with the task of driving, and prepare for return to on-road driving within a safe environment. The intervention was perceived to be useful for enhancing driver self-awareness, autonomy, confidence and patience. Fidelity and simulator sickness were considered limitations of the simulator technology. Subjective accounts of the appropriateness of intervention components are also documented. Overall, the simulator intervention was reported to be a positive experience for participants. Themes emerging from this study can inform future driving simulator interventions for ABI survivors.

Pharmacotherapy for the Pseudobulbar Affect in Individuals Who Have Sustained a Traumatic Brain Injury: a Systematic Review.

Pseudobulbar affect is a debilitating condition that significantly reduces quality of life for many individuals following traumatic brain injury (TBI). It is characterized by embarrassing and often uncontrollable episodes of crying or laughter. The aim of this systematic review was to evaluate the effectiveness of pharmacotherapy as compared to all other comparators for the management of pseudobulbar affect in adults who have sustained TBI. Six databases were searched, with additional hand searching of journals, clinical trials registries and international drug regulators to identify published and unpublished studies in English up to June 2018. Studies were eligible for this review if they included adults who had sustained a medically confirmed TBI and presented with pseudobulbar affect. All pharmacotherapy and comparator interventions were considered for inclusion, and study design was not limited to randomised controlled trials. Evidence quality was assessed using Joanna Briggs Institute Critical Appraisal Instruments. Two quasi-experimental studies examining the effectiveness of dextrometamorphan/quinidine (DM/Q) were identified. These studies reported that DM/Q was effective in reducing symptoms of pseudobulbar affect and had a positive safety profile, over follow-up periods of 3 months (n = 87) and 12 months (n = 23). However, both studies were limited by lack of a control group and a high dropout rate. The findings of twelve case reports examining the effectiveness of DM/Q (n = 6) and anti-depressants (n = 6) are also discussed. Further research is required to determine which pharmacological interventions provide the best outcomes for individuals with pseudobulbar affect following TBI, with consideration given to side effect profiles and financial costs.

Postconcussive Symptoms Following Mild TBI and Extracranial Injury: What Are the Contributing Factors?

OBJECTIVES: Whether mild traumatic brain injury (mTBI) sustained by children results in persistent or recurrent symptoms, over and above those experienced by children who solely sustain mild extracranial injuries, remains debated. The current prospective longitudinal case-controlled study aimed to examine the relative influence of injury and noninjury factors on symptoms in preschool and primary school-aged children who sustained an mTBI or mild extracranial injury at least 8 month earlier. METHODS: Participants were 64 parents of children (31 mTBI, 33 trauma controls) who sustained injury between ages 2 and 12, whose postconcussive symptoms across the first 3-month postinjury have been previously described. The current study assessed postconcussive symptoms at 8 or more months postinjury (M = 24.3, SD = 8.4) and examined a range of injury and noninjury predictive factors. RESULTS: At or beyond 8-month postinjury, symptom numbers in the mTBI group were comparable with those of the group who sustained mild extracranial injury. Educational attainment of parents (below or above high-school attainment level) was the only predictor of symptoms at follow-up, with preexisting learning difficulties approaching significance as a predictor. CONCLUSIONS: While our earlier study found that mTBI was associated with symptoms at 3-month postinjury, follow-up at more than 8 months showed mTBI no longer predicted symptom reporting. While mTBI contributes significantly to the presence of symptoms in the first few months postinjury, researchers and healthcare practitioners in this field need to consider the potential impact of noninjury factors on persistent or recurrent symptoms after mTBI.

Predictors of Anxiety and Depression Symptom Improvement in CBT Adapted for Traumatic Brain Injury: Pre/Post-Injury and Therapy Process Factors.

OBJECTIVES: The current study examined the association of demographic/preinjury, injury-related, and cognitive behavior therapy (CBT) process variables, with anxiety and depression symptom change in traumatic brain injury (TBI)-adapted CBT (CBT-ABI). METHODS: The audio recordings of 177 CBT-ABI sessions representing 31 therapist-client dyads were assessed from the independent observer perspective on measures of working alliance, homework engagement, and therapist competency in using homework. RESULTS: Linear regressions showed that older client age, longer post-TBI recovery period, better executive functioning, higher levels of client homework engagement, as well as higher levels of therapist competence in reviewing homework were associated with greater improvement in anxiety and/or depression symptoms. CONCLUSIONS: CBT-ABI is a promising treatment for post-TBI depression and anxiety. The current study highlights how therapists can enhance CBT-ABI effectiveness, specifically: comprehensive facilitation of client homework engagement with emphasis on homework review, and accommodation of executive deficits. The current study also suggests that the role of client age and the length of post-TBI recovery period require further investigation.

Telehealth Delivery of Memory Rehabilitation Following Stroke.

OBJECTIVE: Rehabilitation of memory after stroke remains an unmet need. Telehealth delivery may overcome barriers to accessing rehabilitation services. METHOD: We conducted a non-randomized intervention trial to investigate feasibility and effectiveness of individual telehealth (internet videoconferencing) and face-to-face delivery methods for a six-week compensatory memory rehabilitation program. Supplementary analyses investigated non-inferiority to an existing group-based intervention, and the role of booster sessions in maintaining functional gains. The primary outcome measure was functional attainment of participants' goals. Secondary measures included subjective reports of lapses in everyday memory and prospective memory, reported use of internal and external memory strategies, and objective measures of memory functioning. RESULTS: Forty-six stroke survivors were allocated to telehealth and face-to-face intervention delivery conditions. Feasibility of delivery methods was supported, and participants in both conditions demonstrated treatment-related improvements in goal attainment, and key subjective outcomes of everyday memory, and prospective memory. Gains on these measures were maintained at six-week follow-up. Short-term gains in use of internal strategies were also seen. Non-inferiority to group-based delivery was established only on the primary measure for the telehealth delivery condition. Booster sessions were associated with greater maintenance of gains on subjective measures of everyday memory and prospective memory. CONCLUSIONS: This exploratory study supports the feasibility and potential effectiveness of telehealth options for remote delivery of compensatory memory skills training after a stroke. These results are also encouraging of a role for booster sessions in prolonging functional gains over time.

Understanding the Multidimensional Nature of Sexuality After Traumatic Brain Injury.

OBJECTIVE: To investigate the association of sexuality with sociodemographic (age, sex, education), medical (injury severity, time since injury), physical (fatigue, pain, independence), neuropsychological (memory, attention, executive function), psychological (depression, anxiety, self-esteem), and social participation factors after traumatic brain injury (TBI). DESIGN: Survey. Individuals with TBI completed measures at a mean average of 2.78 years post injury (range, 1-10.3y). SETTING: All participants were community based at the time of data collection. PARTICIPANTS: Eighty-four individuals with TBI consecutively recruited after discharge from rehabilitation and 88 age-, sex-, and education-matched controls with TBI recruited from the general community. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Brain Injury Questionnaire of Sexuality. RESULTS: Individuals with TBI performed significantly worse on sexuality, mood, and self-esteem measures than the control group without TBI, supporting previous findings. Research findings highlighted a range of significant correlations between sociodemographic, physical, neuropsychological, psychological, and social participation factors and sexuality outcomes after TBI. In the multiple regression model, older age, greater depression, and lower self-esteem were significant predictors of poorer sexuality post injury. Further analyses indicated that depression mediated the independent relationships between lower social participation and greater fatigue with a decline in sexuality after TBI. CONCLUSIONS: These findings support sexuality changes after TBI as a multidimensional construct, highlighting depression as a key mechanism through which other factors may affect sexual functioning. Further research is needed to target assessment and intervention services for sexuality problems after TBI.