Posttraumatic stress and pain-related anxiety among trauma-exposed adults with chronic pain in terms of opioid misuse and dependence.

Trauma-exposure and posttraumatic stress symptoms increase risk for opioid-related problems in the context of chronic pain. Yet, there has been little exploration of moderators of the posttraumatic stress-opioid misuse association. Pain-related anxiety, defined as worry about pain and the negative consequences of pain, has shown relations to both posttraumatic stress symptoms and opioid misuse, and it may moderate the association between posttraumatic stress symptoms and opioid misuse, as well as dependence. The current study examined the moderating role of pain-related anxiety on the relationship between posttraumatic stress symptoms and opioid misuse and dependence among 292 (71.6 % female, Mage = 38.03 years, SD = 10.93) trauma exposed adults with chronic pain. Results indicated that pain-related anxiety significantly moderated the observed relations, such that compared to those with low pain-related anxiety, the relationship between posttraumatic stress symptoms and opioid misuse and dependence was stronger for those with elevated pain-related anxiety. These results highlight the importance of assessing and targeting pain-related anxiety among this trauma-exposed segment of the chronic pain population with elevated posttraumatic stress symptoms.

Predictors of Missed Follow-up Visits in the National Traumatic Brain Injury Model Systems Cohort Study.

OBJECTIVE: To identify key variables that could predict risk of loss to follow-up (LTFU) in a nationally funded longitudinal database of persons with traumatic brain injury. DESIGN: Secondary analysis of a prospective longitudinal cohort study. SETTING: Traumatic Brain Injury Model System (TBIMS) Centers in the US. PARTICIPANTS: A total of 17,956 TBIMS participants (N=17,956) with interview status data available were included if eligible for 1-, 2-, 5-, 10-, 15-, or 20-year follow-ups between October 31, 1989, and September 30, 2020. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Follow-up data collection completion status at years 1, 2, 5, 10, 15, and 20. RESULTS: Information relevant to participants' history, injury characteristics, rehabilitation stay, and patterns of follow-up across 20 years were considered using a series of logistic regression models. Overall, LTFU rates were low (consistently <20%). The most robust predictors of LTFU across models were missed earlier follow-ups and demographic factors including Hispanic ethnicity, lower education, and lack of private health insurance. CONCLUSIONS: Efforts to retain participants in such social disadvantaged or minority groups are encouraged given their disproportionate rate of LTFU. Repeated attempts to reach participants after a previously missed assessment are beneficial because many participants that missed 1 or more follow-ups were later recovered.

Pre-Injury headache and post-traumatic headache in patients with mild traumatic brain injury: neuropsychological, psychiatric, and post-concussion symptom outcomes.

PRIMARY OBJECTIVE: Headache, both before and after injury, has been associated with worse outcome following mild traumatic brain injury (MTBI). This study examined whether three MTBI patient groups - no headache (reported no pre-/post-injury headache), pre-injury headache (reported pre-injury headache, nearly all of whom also reported post-injury headache), and post-traumatic headache only (denied pre-injury headache and reported post-injury headache) - differed in acute-to-subacute outcomes. RESEARCH DESIGN: Cross-sectional observational study. METHODS AND PROCEDURES: Patients within 21 days of a MTBI (n = 291) completed neuropsychological tests and questionnaires evaluating depression, anxiety, and post-concussion symptoms. MAIN OUTCOMES AND RESULTS: Neuropsychological test performances did not differ between headache groups. Participants with pre-injury headache and participants with post-traumatic headache only reported greater change in self-reported physical and cognitive symptoms than participants with no headache. Participants with pre-injury headache reported worse post-injury anxiety symptoms than participants with post-traumatic headache only. CONCLUSIONS: The pre-injury headache and post-traumatic headache only groups did not meaningfully differ in outcome within 21 days of MTBI, but they had worse physical and cognitive symptoms than participants with no headache. Future research should assess whether differences in outcome emerge further from injury and whether specific headache subtypes are differentially associated with outcome.

Post-Traumatic Headache is Associated with Worse Anxiety and Mood Symptoms in Adolescent Mild Traumatic Brain Injury.

This study examined the relationships between post-traumatic headache (PTH) and mental health symptoms after concussions to inform adolescent concussion management. Headache is the most common complaint following adolescent concussion. In this sample of 123 adolescents with concussion, there was a 5-fold increase in odds of clinically elevated anxiety, as well as increased mental health symptoms (anxiety, depression, anger, and disruptive behaviours), among adolescents with PTH relative to those without PTH. Adolescents with headache following concussions are vulnerable to worse mental health outcomes, particularly anxiety, and may benefit from routine monitoring of mental health symptoms for early detection and intervention.

Understanding loss to follow-up in a longitudinal study of people with traumatic brain injury.

OBJECTIVE: To examine factors related to attrition in a traumatic brain injury (TBI) study sample assessed up to 15 years after injury. PARTICIPANTS: One thousand twenty-eight participants with TBI who completed the year 1 follow-up assessment at a TBI Model Systems Center between 1992 and 2018. METHOD: Secondary analysis of data from a prospective longitudinal cohort study considering follow-up data collection completion status at years 1, 2, 5, 10, and 15. RESULTS: In univariable analyses, multiple factors were associated with loss to follow-up (LOFU) including being a member of a socially disadvantaged group, substance use history, residence, payor, cause of injury, and results of earlier follow-up attempts. In a multiple logistic regression analysis examining the prediction of follow-up condition at 10 or 15 years post-injury, only payor and race/ethnicity were significant predictors. Hispanic ethnicity was associated with higher odds of LOFU, and these participants often spoke Spanish and were born outside of the United States. CONCLUSIONS: The findings suggest a need to understand sociodemographic variables and their influence on participant attrition in longitudinal TBI research. With a better understanding of these predictors, procedures can be developed to address retention of participants who are identified as being at increased risk for study drop out.

Semantic Clustering During Verbal List Learning Is Associated With Employment Status in a Community Sample.

The ability to learn and remember verbal information is highly relevant to many work roles and environments, but we know little about the underlying cognitive mechanisms of those associations. This study examined the hypothesis that unemployment is associated with decreased spontaneous use of higher-order encoding strategies deployed during list learning and recall. Participants were 120 employed and 59 unemployed community-dwelling adults who completed the California Verbal Learning Test-Second Edition (CVLT-II) as part of a broader neuropsychological assessment. Standardized measures of semantic, serial, and subjective clustering were generated from the CVLT-II. After adjusting for data-driven covariates, a significant interaction emerged between employment status and clustering strategy, whereby participants in the employed group exhibited significantly higher scores on semantic clustering, but not serial or subjective clustering, than the unemployed group. The semantic clustering slope score was higher among the employed group and was positively associated with executive functions and declarative memory. These findings suggest that higher-order semantic organizational strategies during supraspan list learning may be relevant to maintaining gainful employment (e.g., mentally organizing work-related instructions and task lists). Future studies might examine semantic clustering in relation to employment changes and work performance, as well as the potential benefit of metacognitive interventions for learning and employment success.

Pain anxiety and rehabilitation outcomes after acquired brain injury.

Purpose: The purpose of this study was to examine pain anxiety after acquired brain injury (ABI) and its relationship to rehabilitation outcomes.Materials and Method: Participants consisted of 89 adults with an ABI participating in outpatient rehabilitation therapy. They completed a battery of neuropsychological tests at baseline along with surveys of mood, health-related self-efficacy, and pain anxiety. Separately, occupational therapists assessed basic and instrumental activities of daily living (ADLs) as well as therapy engagement across treatment after the sixth session.Results: Individuals who reported high pain anxiety had fewer years of formal education, lower self-efficacy, and more emotional distress than those with low pain anxiety. Although Blacks were about half (56%) of the study sample, they comprised the majority (73.1%) of individuals in the high pain anxiety group. Pain anxiety was negatively related to therapy engagement. Moderation analysis using linear regression indicated that pain anxiety moderated the influence of self-efficacy on basic ADLs.Conclusions: Pain anxiety, particularly when high, is negatively associated with rehabilitation outcomes for individuals with ABI. Among those with high pain anxiety, health-related self-efficacy is an important resilience characteristic to improve functional outcomes. In rehabilitation therapy, pain anxiety provides a novel intervention target to enhance ABI recovery.

Engagement in rehabilitation therapy and functional outcomes among individuals with acquired brain injuries.

Purpose: The purpose was to examine the role of therapy engagement as a potential mediator for the relationship between neuropsychological performance and functional outcomes. Materials and method: Participants were 94 adults with medically documented ABI recruited from three outpatient rehabilitation clinics at the start of occupational therapy. Participants (57% men) ranged from 18 to 82 in age, with the majority (81%) having completed 12 or more years of education. They completed a comprehensive neuropsychological assessment at baseline. Separately, occupational therapists (OTs) assessed functional independence and disability at baseline and follow up. The OTs also rated the participants' therapy engagement. Results: Therapy engagement predicted functional outcomes and mediated the relationship between neuropsychological performance and outcomes. Moreover, therapy engagement accounted for unique variance in functional outcome, even after accounting for education, comorbid health conditions, emotional distress, apathy, and baseline functional ability. Conclusions: Engagement in therapy is a crucial patient characteristic in successful rehabilitation outcome. Cognitive deficits associated with ABI undermine full engagement in rehabilitation therapy, which in turn diminishes potential gains made in therapy and functional recovery. Neuropsychological assessment can enhance rehabilitation outcomes by identifying characteristics that underlie therapy engagement, which can ultimately be used to maximize the effectiveness of individualized treatment plans. Implications for rehabilitation Neuropsychological assessment can identify cognitive abilities that are strongly related to functional outcomes during occupational therapy for acquired brain injury. Therapy engagement is an important pathway by which neuropsychological impairment predicts functional outcomes after acquired brain injuries.

Complicated versus uncomplicated mild traumatic brain injuries: A comparison of psychological, cognitive, and post-concussion symptom outcomes.

INTRODUCTION: A complicated mild traumatic brain injury (MTBI) is defined as mild by all clinical severity indicators but is complicated due to a traumatic intracranial abnormality visible on neuroimaging. Researchers have reported mixed findings regarding whether neuropsychological and functional outcomes following complicated MTBI are worse than, or similar to, outcomes following uncomplicated MTBI. This study examined patients referred from a Taiwanese emergency department to a neurosurgical outpatient clinic. Participants with complicated MTBI, uncomplicated MTBI, and those who did not undergo head computed tomography (CT) were compared on psychological, neuropsychological, and post-concussion symptom outcomes within 21 days of injury. METHOD: Participants with complicated MTBI (n = 42), uncomplicated MTBI (n = 77), and no head CT (n = 172) completed the Paced Auditory Serial Attention Test, Taiwanese Word Sequence Learning Test, a semantic Verbal Fluency Test, the Checklist of Post-Concussion Symptoms, and the Beck Depression and Anxiety Inventories. RESULTS: No significant differences were observed between groups on any measure. For individual post-concussion symptoms, dizziness, anxiety, and attention difficulty were endorsed more often after uncomplicated MTBIs, but these group differences were not significant after controlling for multiple comparisons. CONCLUSIONS: Participants with complicated MTBIs did not have worse acute or subacute outcomes than participants with uncomplicated MTBIs or no head CT. These results are consistent with many studies finding comparable outcomes between those with complicated and uncomplicated MTBIs. This study is limited by small sample size and minimal information on intracranial abnormalities, broadly categorizing groups based on positive or negative neuroimaging as opposed to specific lesion types and locations.

Validation of the 10-item Center for Epidemiologic Studies Depression Scale Post Stroke.

OBJECTIVE: To establish reliability and validity of the abbreviated (10-item) Center for Epidemiologic Studies Depression Scale (CESD-10) among individuals post stroke. METHOD: The psychometric properties of the CESD-10 were evaluated in 1219 adults with stroke admitted to an eligible inpatient rehabilitation facilities (n = 11) across 9 different states post stroke during 2005 to 2006. This study was a secondary data analysis of the existing publicly available clinical trial dataset, Stroke Recovery in Underserved Populations study. Reliability, validity, factory structure and item-level psychometrics of the CESD-10 were examined. In addition, the predictive accuracy of the CESD-10 was compared against the CESD-20 (criterion). RESULTS: The CESD-10 was highly correlated with the CESD-20 (r = 0.97). The CESD-10 had good internal reliability (Cronbach's α = 0.86). The CESD-20 and CESD-10 had similar accuracy in classifying individuals as depressed (Kappa = 0.85). CONCLUSION: The 10-item CESD is a valid measure of depression for individuals post stroke.

Pain Anxiety Symptoms Scale-20: An empirical evaluation of measurement invariance across race/ethnicity, sex, and pain.

Pain-related anxiety, defined as fear of pain and pain-related sensations, is a transdiagnostic individual difference factor associated with pain-related problems, addictive disorders, and physical impairment among nonclinical and clinical populations. Pain-related anxiety is most commonly measured using the Pain Anxiety Symptoms Scale-20 (PASS-20). It was hypothesized that the data would provide evidence for a higher order PASS-20 factor structure and this structure would be invariant across race/ethnicity and sex. Therefore, the current study examined measurement invariance of the PASS-20 across a large (n = 3,455) diverse sample (Mage = 21.49, SD = 4.24, 73.7% female, 33.5% Hispanic, 29.3% Asian/Pacific Islander, 22.4% White, and 14.8% Black/African American) of young adults. Results supported measurement invariance across all race/ethnicity and sex groups for the PASS-20 total score, but results were inconsistent for the lower order factors. The PASS-20 total score showed good internal consistency and evidence of convergent and divergent validity with established constructs. These results provide empirical support only for the higher order factor structure of the PASS-20 and support its use across race/ethnicity and sex. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The Discrepancy Between Cognitive Complaints and Neuropsychological Test Findings in Persons With Traumatic Brain Injury.

OBJECTIVE: To better identify variables related to discrepancies between subjective cognitive complaints and objective neuropsychological findings in persons with traumatic brain injury (TBI). SETTING: Three rehabilitation centers in the United States. PARTICIPANTS: In total, 504 community-dwelling adult survivors of TBI following discharge from inpatient rehabilitation. DESIGN: Prospective cohort observation study. MAIN MEASURES: Wechsler Adult Intelligence Scale, Fourth Edition, Digit Span; Rey Auditory Verbal Learning Test; Trail Making Test, Part B; Word Memory Test; Patient Health Questionnaire-9; Neurobehavioral Symptom Inventory; TBI-Quality of Life item bank. RESULTS: Statistical analyses revealed multiple factors associated with subjective-objective discrepancies in attention, memory, and executive functions. Depression was consistently associated with underestimation of cognitive abilities. However, subjective-objective discrepancies varied by cognitive domains in regard to other factors related to underestimation and overestimation of abilities. CONCLUSIONS: Reconciling and interpreting subjective-objective discrepancies regarding cognitive functions following TBI are important tasks for case conceptualization and treatment planning. Depression is an important patient characteristic to consider when discrepancy patterns indicate underestimation of cognitive abilities. This study highlights the importance of assessing mood, a modifiable patient characteristic, with self-report symptom inventories. Future studies are needed to connect these findings with TBI outcomes.

Systematic Review of Preinjury Mental Health Problems as a Vulnerability Factor for Worse Outcome After Sport-Related Concussion.

BACKGROUND: It is difficult to predict who will experience prolonged health problems after sustaining a sport-related concussion. PURPOSE: To synthesize the literature and conduct a gap analysis on the association between preinjury mental health problems and clinical outcome from sport-related concussion. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: Data sources were PubMed, PsycINFO, MEDLINE (and MEDLINE in Process), CINAHL, Cochrane Library, EMBASE, SPORTDiscus, Scopus, and Web of Science. Studies published before February 2019 that addressed preinjury mental health problems as a possible predictor of worse clinical outcome or clinical recovery from concussion were eligible for inclusion. RESULTS: Of 4013 studies screened, 358 full texts were reviewed, and 12 studies involving 3761 participants (n = 471 [12.5%] with preexisting mental health problems) were ultimately included. The participants with a preinjury history of mental health problems were at greater risk for having persistent symptoms or worse outcome in 9 of 12 studies. The studies had major methodological differences, and most studies were not focused on mental health as a primary predictor or prognostic factor. Rather, they included it as a secondary or tertiary predictor. The sample sizes with preinjury mental health problems in most studies were small or very small (ie, <25). The age of onset, type, course, severity, and duration of mental health problems were not defined. The extent to which mental health problems were present before the season, during baseline testing, was not reported. CONCLUSION: Preinjury mental health problems appear to confer risk for worse clinical outcome after sport-related concussion. Future research is needed to (1) examine this risk factor in large representative populations of middle school students, high school students, and collegiate athletes; (2) quantify the risk for each mental health condition; (3) understand the mechanisms underlying this increased risk; and (4) develop more refined treatment and rehabilitation approaches for these student-athletes.

Brief and cost-effective tool for assessing verbal learning in multiple sclerosis: Comparison of the Rey Auditory Verbal Learning Test (RAVLT) to the California Verbal Learning Test - II (CVLT-II).

BACKGROUND: The Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) is a common cognitive screening tool. However, administration and scoring can be time-consuming, and its use of proprietary subtests like the California Verbal Learning Test - II (CVLT-II) is financially limiting. Use of the non-proprietary Rey Auditory Verbal Learning Test (RAVLT) may be provide a valid alternative. OBJECTIVES: To compare the RAVLT and CVLT-II in terms of diagnostic accuracy for detecting cognitive impairment, and to determine optimal cut-scores for the RAVLT. METHODS: 100 participants with MS completed the five learning trials from the RAVLT and CVLT-II. Receiver operating characteristic analyses were used to compare the measures' sensitivities, specificities, positive predictive values (PPV) and negative predictive values (NPV), and to identify optimal cut-scores. RESULTS: Using a criterion of 1.5 SD below the normative sample mean, the RAVLT showed fair to good (κs = 0.21-0.41) agreement with the CVLT-II. A cut-score of 12 on Trials 1 + 2 of the RAVLT showed fair sensitivity (75%) and specificity (76%) and did not differ significantly from the CVLT-II (p > .05). CONCLUSIONS: Performance on initial learning trials of the RAVLT may provide a brief, valid, and cost-effective alternative to the CVLT-II for screening verbal learning impairments in MS.

Health literacy, sociodemographic factors, and cognitive training in the active study of older adults.

OBJECTIVE: Health literacy is critical for understanding information from health-care providers and correct use of medications and includes the capacity to filter other information in navigating health care systems. Older adults with low health literacy exhibit more chronic health conditions, worse physical functioning, and poorer mental health. This study examined the relationship between sociodemographic variables and health literacy, and the impact of cognitive training on change in health literacy over 10 years in older adults. METHODS: Participants (N = 2,802) aged 65 years and older completed assessments, including reading and numeracy health literacy items, as part of the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study. We evaluated baseline sociodemographic variables and change in health literacy over a 10-year period in individuals exposed to cognitive training in reasoning, processing speed, memory, or a no-contact control condition. RESULTS: Age, sex, race, education level, and general cognitive functioning at baseline were all associated with baseline health literacy in older adults. Predictors of change in health literacy over the 10-year follow-up were age, race, education level, general cognitive functioning, and neighborhood income; disparities in health literacy because of race attenuated over time, while the effect of age increased over time. Health literacy was generally stable across the ACTIVE intervention groups over 10 years. CONCLUSIONS: The present study showed important disparities in health literacy level and change over 10 years. Cognitive training did not significantly impact health literacy, suggesting that alternative approaches are needed to reduce the disparities.

Functional independence after acquired brain injury: Prospective effects of health self-efficacy and cognitive impairment.

OBJECTIVE: To examine how health self-efficacy and cognitive impairment severity relate to functional independence after acquired brain injury (ABI). DESIGN: Observational. SETTING: Outpatient rehabilitation hospital. PARTICIPANTS: Seventy-five adults with predominately stroke or traumatic brain injury who were beginning a course of occupational therapy. MAIN MEASURES: Health self-efficacy was assessed with the Self-Rated Abilities for Health Practices. Cognitive functioning was assessed via a composite z score of neuropsychological tests. Trait affectivity was assessed with the Positive and Negative Affect Schedule. Functional independence was assessed with the Barthel Index and Lawton Instrumental Activities of Daily Living Scale. RESULTS: Health self-efficacy correlated moderately with functional independence. A moderation threshold effect was detected that revealed for whom health self-efficacy predicted functional independence. Among participants with normal to mildly impaired cognition (>-2 z cognitive composite), health self-efficacy correlated positively with functional independence, which held after accounting for trait affectivity. In contrast, health self-efficacy was not correlated with functional independence among participants with greater impairment (<-2 z cognitive composite). CONCLUSIONS: Health self-efficacy predicts functional independence and may serve as a protective factor after ABI among individuals with relatively intact cognition. However, health self-efficacy does not predict functional independence among individuals with moderate or severe cognitive impairment, possibly due to limited self-awareness. This study extends the literature linking health self-efficacy with rehabilitation outcomes and reinforces the need for promoting self-management in ABI. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Clinical utility and psychometric properties of the Disability Rating Scale with individuals with traumatic brain injury.

This Rehabilitation Measures Database summary provides a review of the psychometric properties of the Disability Rating Scale (DRS) which is an observer-rated instrument designed to measure general functional disability in individuals with traumatic brain injury. A full review of the DRS as well as reviews of over 300 other instruments can be found at www.rehabmeasures.org. (PsycINFO Database Record

Rasch analysis of the coping inventory for stressful situations in individuals with moderate to severe traumatic brain injury.

OBJECTIVE: To evaluate psychometric properties of the Coping Inventory for Stressful Situations (CISS) in individuals with traumatic brain injury (TBI). DESIGN: Archival study using Rasch analysis. SETTING: Postacute rehabilitation hospital. PARTICIPANTS: Adults (N=331) 1 to 15 years after moderate to severe TBI, recruited consecutively. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: CISS. RESULTS: Indices of unidimensionality and model fit supported the scale's proposed multidimensional structure consisting of Task, Emotion, and Avoidant coping style; 3 unidimensional scales showed better fit than a single combined scale. The 3 scales met Rasch expectations of reliability and separation for persons and items, as well as adequate response category functioning. The scales were generally well targeted but showed some evidence of ceiling effect for Task, and floor effects for Emotion and Avoidant coping; item difficulties did not fully capture extreme ranges demonstrated by some participants, suggesting that measurement of coping after TBI on the CISS would be improved with additional items at low and high ranges of difficulty. Results were generally equivalent for cross-sectional groups representing short-term (1y), intermediate (2y), and long-term (5-15y). CONCLUSIONS: The CISS showed good psychometric properties as a measure of coping style among persons with moderate to severe TBI in acute and chronic phases of recovery, and showed evidence of multidimensionality as predicted by theory, consistent with 3 unidimensional scales. Added items tapping broader (or more accessible, less cognitively complex) ranges of coping responses would likely benefit the scale overall and improve correspondence with the response needs of people with TBI.

Psychosocial outcomes after traumatic brain injury: life satisfaction, community integration, and distress.

OBJECTIVE: To examine the relationship between life satisfaction, community integration, and emotional distress in adults with traumatic brain injury (TBI). METHOD: This was an archival study of a longitudinal data set on the outcome and recovery process of persons with TBI. Participants were 253 consecutive adults with mild complicated, moderate, and severe TBI who were enrolled in a large, longitudinal study of persons with TBI. Main measures included the Satisfaction with Life Scale, the Positive Affective and Negative Affective Schedule, the Craig Hospital Assessment and Reporting Technique Short-Form, the Community Integration Measure, and the Brief Symptom Inventory-18. RESULTS: The three-factor model adequately fit the data, and a higher-order model did not necessarily improve model fit but revealed significant relationships with first-order constructs and one second-order construct. CONCLUSIONS: Life satisfaction, community integration, and emotional distress were found to be related yet unique concepts in persons with TBI. Life satisfaction was positively related to community involvement and inversely related to emotional distress. Community integration was inversely related to emotional distress. In addition, these concepts are related to a higher-order concept of psychosocial status, a global representation of subjective and objective functioning. These findings demonstrate the interrelated and dynamic nature of psychosocial well-being after brain injury and highlight the need for integrative and holistic treatment plans.