"We can all relate": patient experience of an emotion-oriented group intervention after Acquired Brain Injury.

Introduction: Group interventions are carried out routinely across neuropsychological rehabilitation services, to improve understanding of brain injury and aspects of impairment. Treatment provided in a group modality can bring additional perceived benefits, such as co-operative learning. However, there are very few studies which explore patient perceptions and experiences of such interventions. In the present study we investigated the experience of attending a group-based educational intervention for the consequences of acquired brain injury (ABI), which had a strong focus on emotion and emotion regulation. Methods: Using qualitative semi-structured interviews (approximately 20 minutes), the study explores the lived experience of participating in the seven-session programme, the better to identify the perceived efficacy, salience and value of individual elements. Twenty participants with ABI took part in individual interviews, after completion of the group programme (the Brain Injury Solutions and Emotions Programme, BISEP). The study adopted a descriptive phenomenological philosophy, which focuses on lived experience to explore a phenomenon (i.e. the experience of BISEP). As regards methods, the study employed thematic analysis to cluster experiences into themes of meaning. Results: Five themes were identified: (1) 'Long term consequences and psychological needs', which related to the persistent nature of direct consequences of injury and adjustment, and how these result in a need for interventions such as BISEP. (2) 'Positive experiences of participating in the programme', referred to participants' overall experience of the programme and valued elements within it. The remaining themes referred to the programme as (3) a social milieu; (4) a place to learn; and (5) a place to promote positive emotional experiences. Discussion: Similar to previous studies, many people reported high acceptability and perceived value of the group programme, and its role in facilitating adjustment and understanding of injury. Of particular importance was the opportunity to socialise with people who "can all relate", in line with a growing emphasis on social rehabilitation. The findings especially highlight the relevance of emotion-focused group programmes for ABI, promoting emotion regulation, and practical tools that are delivered optimistically. Further implications for practice and future research include to focus on long term rehabilitation, a social milieu, and strategies to support adjustment.

Cognitive Processing Speed and Loneliness in Stroke Survivors: Insights from a Large-Scale Cohort Study.

OBJECTIVE: Loneliness, when prolonged, is associated with many deleterious effects and has been shown to be highly prevalent in those with a history of stroke, yet the cognitive mechanisms underpinning this phenomenon remain unclear. Therefore, the current study aims to investigate the extent to which cognitive factors, with specific focus on processing speed, are associated with loneliness in those with a history of stroke. METHOD: Utilizing data from the British Cohort Study, a nationally representative dataset, we conducted secondary data analysis. A total of 7,752 participants completed relevant questions related to health, social interactions, demographics, loneliness, and cognitive assessments. Among them, 47 had experienced a stroke ("stroke," n = 47), 5,545 reported other health conditions ("ill," n = 5,545), and 2,857 were deemed healthy ("healthy," n = 2,857). RESULTS: Consistent with previous research, our findings confirmed a positive correlation between stroke history and heightened loneliness. However, inferential analysis revealed that processing speed, alongside other cognitive factors, had a minimal impact on loneliness, with correlations too small to draw definitive conclusions. CONCLUSION: This study suggests that cognitive processing speed alone is not a robust predictor of loneliness in stroke survivors. Consequently, when developing interventions to combat loneliness in this population, it is crucial to consider a broader spectrum of factors, such as social engagement, emotional wellbeing, and interpersonal relationships. This underscores the imperative need for comprehensive assessments to better comprehend the multifaceted nature of loneliness and inform more effective intervention strategies.

The Measure of an Outcome: Comparing Norming and Stacking to Benchmark the Effectiveness of Brain Injury Rehabilitation Services.

Practitioners have a clinical, ethical, academic, and economic responsibility to dispassionately consider how effective their services are. Approaches to measure how "good" or "bad" healthcare is include clinical audit, satisfaction surveys, and routine outcome measurement. However, the process of comparing the clinical outcomes of a specific service against the 'best' services in the same specialism, also known as benchmarking, remains challenging, and it is unclear how it affects quality improvement. This paper piloted and compared two different approaches to benchmarking to assess clinical outcomes in neurorehabilitation. Norming involved comparing routine measures of clinical outcome with external validators. Stacking involved pooling and comparing internal data across several years. The analyses of routine clinical outcome data from 167 patients revealed significant differences in the patient characteristics of those admitted to the same service provider over time, but no differences in outcomes achieved when comparing with historical data or with external reference data. These findings illustrate the potential advantages and limitations of using stacking and norming to benchmark clinical outcomes, and how the results from each approach might be used to evaluate service effectiveness and inform quality improvement within the field of brain injury rehabilitation.

"Talk and Chalk": An emotion regulation intervention for anger after acquired brain injury.

Uncontrollable anger is a debilitating consequence of acquired brain injury (ABI). This proof-of-concept study investigated the preliminary efficacy of an emotion regulation intervention for managing post-ABI anger. A secondary objective was to determine which participant characteristics were related to intervention gains. With a pre-post intervention design and three-month follow-up, there were five individually administered meetings on Zoom, over a four-month period. 24 adults who had sustained an ABI were enrolled. Participants were mostly males, from 24 to 85 years old. A series of one-way repeated-measures ANOVAs were conducted to determine the intervention's efficacy, and Spearman's rho bivariate correlations for the association between participant characteristics and intervention gains. Significant differences were observed in external anger from baseline to post-treatment; there were no further changes from post-treatment to follow-up. Of the participant characteristics, only readiness to change and anxiety were correlated. The proposed intervention presents a brief, feasible, and preliminary efficacious alternative for regulating post-ABI anger. Intervention gains are associated with readiness to change and anxiety, which has important implications for clinical delivery.

A neurobehavioral therapy approach to the rehabilitation and support of persons with brain injury: Practice-based evidence from a UK charitable rehabilitation provider.

Background: The treatment and rehabilitation for people with acquired brain injury is continually evolving, with increasing recognition of the importance of approaches that adopt a multi-disciplinary biopsychosocial perspective focused on improving adjustment, social participation, and wellbeing. However, there is significant variability as to how such approaches are delivered, across the various stages of recovery, rehabilitation settings, and within different healthcare systems. Objective: This paper had three aims. The first was to describe the neurobehavioral therapy (NBT) approach to brain injury rehabilitation adopted in our charitable organization. The second aim was to report how the NBT approach evolved in response to changes in referral patterns, and patient needs within a broader, longer-term clinical pathway. The third aim was to assess the effectiveness of the NBT approach by analyzing outcome data. Methods: Retrospective analyses of standardized outcome data were completed to investigate the effectiveness of our approach. Case vignettes are provided to illustrate the key components of the approach. Results: Outcome data suggested that the approach is effective in delivering positive outcomes for patients. Furthermore, the data show differences in presentation between three clinical streams (restoration, compensation, and scaffolding) within the NBT approach. Conclusions: This paper describes the adaption of the 'traditional' neurobehavioral approach to brain injury rehabilitation into a model of delivery that can benefit a more diverse range of people living with the heterogenous and long-term consequences of brain injury.

Shades of Rage: Applying the Process Model of Emotion Regulation to Managing Anger After Brain Injury.

Uncontrollable anger is common following an acquired brain injury (ABI), with impaired emotion regulation (ER) being one of the main contributors. Existing psychological interventions appear moderately effective, though studies typically include limitations such as small sample sizes, issues of long-term efficacy, and standardization of content. While ER has been a popular research field, the study of ER for anger management after ABI is less well investigated, and contains few interventions based on the widely used Process Model of ER. This review surveys the efficacy of ER strategies in individuals with ABI, and proposes a novel research design for future interventions. Recommendations are made about: strategy number and type, shared decision-making, approaches to data analysis, and mode of delivery.

The neuropsychological outcomes of non-fatal strangulation in domestic and sexual violence: A systematic review.

This systematic review draws together evidence from the literature for the pathological, neurological, cognitive, psychological, and behavioural outcomes of non-fatal strangulation in domestic and sexual violence. A systematic search of PubMed, PsycINFO, CINHAL, Proquest, ASSIA, Web of Science, WestLaw, Open Grey, and Ethos was conducted, with no date limits set, to identify eligible studies. Thirty empirical, peer-reviewed studies were found which met the inclusion criteria. Pathological changes included arterial dissection and stroke. Neurological consequences included loss of consciousness, indicating at least mild acquired brain injury, seizures, motor and speech disorders, and paralysis. Psychological outcomes included PTSD, depression, suicidality, and dissociation. Cognitive and behavioural sequelae were described less frequently, but included memory loss, increased aggression, compliance, and lack of help-seeking. However, no studies used formal neuropsychological assessment: the majority were medical case studies or based on self-report. Furthermore, few authors were able to control for possible confounds, including other physical violence and existing psychosocial difficulties. There is therefore a need for further neuropsychological research, focusing on cognitive and behavioural outcomes, using standardized tools, and control groups where possible. This is urgent, given societal normalization of strangulation, and legal systems which often do not reflect the act's severity and its consequences.

Stroke Survivors Experience Elevated Levels of Loneliness: A Multi-Year Analysis of the National Survey for Wales.

OBJECTIVE: Despite clinical observation that stroke survivors frequently experience loneliness, there is no large-scale empirical evidence to support this observation. Therefore, the primary objective of this research was to provide the first large-scale and comprehensive estimate of loneliness in the stroke survivor population. METHOD: To address this issue, we completed two preregistered analyses of a nationally representative annual survey (N > 21,000). A two-phase approach was adopted combining both exploratory (Study 1) and confirmatory (Study 2) phases. The benefit of such an approach is that replication is built into the design, which considerably strengthens the inferences that can be made. RESULTS: Across two separate cohorts, the results consistently showed that human stroke survivors report higher levels of loneliness compared with healthy individuals, and this relationship could not be accounted for by demographic factors (e.g., age, sex) or objective measures of social isolation (e.g., marital status, number of household members). CONCLUSIONS: These findings demonstrate that elevated levels of loneliness poststroke are robust in that they replicate in large nationally representative samples and cannot be reduced to objective measures of social isolation. The work has clinical and societal relevance by suggesting that loneliness poststroke is unlikely to be adequately "treated" if only the quantity and not the quality of social experiences are considered.

The effectiveness of cognitive behaviour therapy for reducing anxiety symptoms following traumatic brain injury: A meta-analysis and systematic review.

BACKGROUND: Anxiety is a common neuropsychological sequela following traumatic brain injury (TBI). Cognitive Behaviour Therapy (CBT) is a recommended, first-line intervention for anxiety disorders in the non-TBI clinical population, however its effectiveness after TBI remains unclear and findings are inconsistent. OBJECTIVE: There are no current meta-analyses exploring the efficacy of CBT as an intervention for anxiety symptoms following TBI, using controlled trials. The aim of the current study, therefore, was to systematically review and synthesize the evidence from controlled trials for the effectiveness of CBT for anxiety, specifically within the TBI population. METHOD: Three electronic databases (Web of Science, PubMed and PsycInfo) were searched and a systematic review of intervention studies utilising CBT and anxiety related outcome measures in a TBI population was performed through searching three electronic databases. Studies were further evaluated for quality of evidence based on Reichow's (2011) quality appraisal tool. Baseline and outcome data were extracted from the 10 controlled trials that met the inclusion criteria, and effect sizes were calculated. RESULTS: A random effects meta-analysis identified a small overall effect size (Cohen's d) of d = -0.26 (95%CI -0.41 to -0.11) of CBT interventions reducing anxiety symptoms following TBI. CONCLUSIONS: This meta-analysis tentatively supports the view that CBT interventions may be effective in reducing anxiety symptoms in some patients following TBI, however the effect sizes are smaller than those reported for non-TBI clinical populations. Clinical implications and limitations of the current meta-analysis are discussed.

This time it's personal: reappraisal after acquired brain injury.

Reappraisal is a widely investigated emotion regulation strategy, often impaired in those with acquired brain injury (ABI). Little is known, however, about the tools to measure this capacity in patients, who may find traditional reappraisal tasks difficult. Fifty-five participants with ABI, and thirty-five healthy controls (HCs), completed reappraisal tasks with personal and impersonal emotion elicitation components, questionnaires measuring reappraisal (the ERQ-CA), and neuropsychological assessment. The main findings demonstrated that both groups produced more reappraisals, and rated their reappraisal ideas as more effective for personal stimuli. The ABI group were significantly faster to generate reappraisals for personal, compared to impersonal, stimuli. Yet, participants with ABI performed worse than HCs on the majority of reappraisal components, across both reappraisal tasks. Results of regression analyses revealed significant relationships between certain measures of cognitive control and certain reappraisal components, which varied for the personal and impersonal reappraisal task. Notably, while inhibition predicted aspects of reappraisal in both the ABI and HC group, working memory was only related to reappraisal in participants with ABI. The study suggests that personal context plays a key role in reappraisal, and proposes a model to better understand the role of cognitive control across the reappraisal process.

Building the bond: Predictors of the alliance in neurorehabilitation.

BACKGROUND: Neurorehabilitation services are often delivered through group psycho-education programmes. However, little is known about the therapeutic process at work during such sessions. The present study is the first to gain insight into the therapeutic alliance, during a seven-session group programme. In addition, cognitive, emotional, and demographic predictors of the alliance, and participants' feelings towards their group members, were investigated, together with predictors of patient engagement. METHODS: Forty-five participants with an acquired brain injury completed a series of questionnaires, and neuropsychological assessment, following group psycho-education. The group facilitator completed a parallel therapeutic alliance questionnaire, and rated participants' engagement. RESULTS: Results demonstrated that a strong alliance can be formed in seven group sessions. Notably, no demographic or cognitive factors appear to pose a barrier to developing a therapeutic alliance, nor to group attraction. CONCLUSION: High levels of depression, however, may be a challenge, and clinicians may need to tailor their clinical skills to ensure a good therapeutic relationship with such patients. To promote engagement, clinicians may also need to provide additional support to patients with lower levels of education, working memory, and episodic memory impairment.

Good things better? Reappraisal and discrete emotions in acquired brain injury.

There has been substantial interest in emotion after acquired brain injury (ABI), but less attention paid to emotion regulation (ER). Research has focused primarily on the ER strategy of reappraisal for regulating negative emotions, without distinguishing between classes of emotion, and there has been no attempt at exploring these differences in patients with ABI. The present study explored components of reappraisal, across classes of emotion, and their associated neuropsychological mechanisms. Thirty-five patients with ABI and twenty-two matched healthy control participants (HCs) completed two questionnaires, a battery of cognitive tasks, and an emotion regulation task (the Affective Story Recall Reappraisal task). Results suggest that those with ABI take longer, and generate fewer reappraisals than HCs across several discrete emotions. Notably, their ability to decrease emotional intensity did not differ significantly to HCs for negative emotions, but findings suggest that their reappraisals are less effective when up-regulating neutral emotions to positive. Working memory was the only significant predictor of the total number of reappraisals generated, and the time taken to produce a first reappraisal. Implications of these findings are discussed in the context of neuropsychological rehabilitation, including the role of the relatives in implementing and reinforcing micro-interventions.

The effectiveness of physical exercise as an intervention to reduce depressive symptoms following traumatic brain injury: A meta-analysis and systematic review.

Alongside the obvious health benefits, physical exercise has been shown to have a modest anti-depressant effect for people in the general population. To the authors' knowledge, there are no current literature reviews or meta-analyses available exploring this effect for people with a traumatic brain injury (TBI). A systematic review of intervention studies utilising physical exercise and mood outcome measures for a TBI population was performed in November 2016. Baseline and outcome data were extracted for the nine studies which met the inclusion criteria. Effect sizes were calculated for the three controlled trials and six uncontrolled trials and entered into the meta-analysis. Consistent with research in non-brain injury populations, the current meta-analysis identified a small to medium effect size of physical exercise on reducing depressive symptoms in people with a TBI. This would support further rigorous trials to provide additional evidence for the efficacy of physical exercise interventions for people with TBI. Limitations of the current meta-analysis and clinical implications are discussed.

Pharmacotherapy Effectiveness in Treating Depression After Traumatic Brain Injury: A Meta-Analysis.

OBJECTIVE: Depression is a highly prevalent neuropsychiatric sequela among individuals who have experienced traumatic brain injury (TBI). Despite its high prevalence, there continues to be conflicting evidence surrounding the efficacy of medication for treating depression post-TBI and whether different treatments have distinct effects. The aim of this study was to systematically review and synthesize the available evidence for the effectiveness of pharmacotherapy for depression following a TBI. METHODS: A meta-analysis was completed using several online databases (PubMed, National Institute of Health and Care Excellence, and Healthcare Databases Advanced Search) to search for clinical trials involving various pharmacological treatments for depression in patients with TBIs. Twelve studies met the inclusion criteria and were assessed using their sample size, treatment duration, treatment used, TBI severity, method of assessment, and medication response. Standardized mean difference effect sizes (Cohen's d) were calculated for each study using pre- and postintervention scores and pooled using a random effects model to produce a summary effect size. RESULTS: Fourteen effect sizes were calculated, and a mild to moderate pooled effect size (Cohen's d=-0.49, 95% CI: -0.96, -0.02, p=0.02) was found. Ten studies demonstrated effect sizes that were statistically significant, and four were nonsignificant. The weighted pooled effect size was higher for single-group design studies (Cohen's d=-1.35, 95% CI: -2.14, -0.56, N=5) compared with independent-group designs (Cohen's d=0.001, CI: -0.59, 0.58; N=9). CONCLUSIONS: This meta-analysis tentatively supports the view that pharmacological treatment may be effective in reducing depressive symptoms in those with depression following TBI. However, evidence from randomized controlled trials alone demonstrated no beneficial effect. The limitations are also discussed.

Association between cognitive impairments and obsessive-compulsive spectrum presentations following traumatic brain injury.

This study examined the association between self-reported obsessive-compulsive spectrum symptomatology and cognitive performance in a sample of patients with traumatic brain injury (TBI). Twenty-four adults with a moderate-severe TBI accessing a community brain injury rehabilitation service were recruited. Age ranged between 19 and 69 years. Participants completed a battery of neuropsychological tasks assessing memory, executive functioning, and speed of information processing. Self-report questionnaires assessing obsessive-compulsive (OC) symptoms and obsessive-compulsive personality disorder (OCPD) traits were also completed. Correlational analyses revealed that deficits in cognitive flexibility were associated with greater self-reported OC symptomatology and severity. Greater OC symptom severity was significantly related to poorer performance on a visual memory task. Verbal memory and speed of information processing impairments were unrelated to OC symptoms. Performance on tasks of memory, executive functioning, and speed of information processing were not associated with OCPD traits. Overall, results indicate that greater OC symptomatology and severity were associated with specific neuropsychological functions (i.e., cognitive flexibility, visual memory). OCPD personality traits were unrelated to cognitive performance. Further research is needed to examine the potential causal relationship and longer-term interactions between cognitive sequelae and obsessive-compulsive spectrum presentations post-TBI.

The potential role of relatives in designing person-centred assistive technologies (innovative practice).

The paper explores the important role of relatives in designing assistive technologies in collaboration with practitioners. A brief case study reports the collaborative design of a 24-hour clock to reduce the impact of visual-spatial impairment on a family member's ability to read time and prevent temporal disorientation.

Depression, memory and electroconvulsive therapy.

SummaryCurrent neuroscience suggests that although short-term memory difficulties frequently occur immediately after electroconvulsive therapy (ECT), longer-term problems are less common. However, gaps in our knowledge remain regarding longer-term cognitive problems after ECT, including memory function. Some of these relate to the complexities surrounding cognitive testing and interpretation of test results. An important question in clinical decision-making is why, despite current evidence suggesting long-term memory problems are less frequent, some patients still report subjective memory difficulties. To further advance clinical practice and the neuroscience surrounding post-ECT cognitive function, assessment of cognitive function, possibly including neuropsychological testing, should potentially become more routine as part of clinical practice.Declaration of interestNone.

Study protocol for a randomised pilot study of a computer-based, non-pharmacological cognitive intervention for motor slowing and motor fatigue in Parkinson's disease.

BACKGROUND: Parkinson's disease (PD) is a chronic, neurodegenerative disorder affecting over 137,000 people in the UK and an estimated five million people worldwide. Treatment typically involves long-term dopaminergic therapy, which improves motor symptoms, but is associated with dose-limiting side effects. Developing effective complementary, non-pharmacological interventions is of considerable importance. This paper presents the protocol for a three-arm pilot study to test the implementation of computer-based cognitive training that aims to produce improvements or maintenance of motor slower and motor fatigue symptoms in people with PD. The primary objective is to assess recruitment success and usability of external data capture devices during the intervention. The secondary objectives are to obtain estimates of variance and effect size for changes in primary and secondary outcome measures to inform sample size calculations and study design for a larger scale trial. METHODS: The study aims to recruit between 40 and 60 adults with early- to middle-stage PD (Hoehn and Yahr 1-3) from National Health Service (NHS) outpatients' clinics and support groups across North Wales, UK. Participants will be randomised to receive training over five sessions in either a spatial grid navigation task, a sequential subtraction task or a spatial memory task. Patient-centred outcome measures will include motor examination scores from part 3 of the UPDRS-III and data from movement kinematic and finger tapping tasks. DISCUSSION: The results of this study will provide information regarding the feasibility of conducting a larger randomised control trial of non-pharmacological cognitive interventions of motor symptoms in PD. TRIAL REGISTRATION: ISRCTN, ISRCTN12565492. Registered 4 April 2018-retrospectively registered, in accordance with the WHO Trial Registration Data Set.