A Transdiagnostic, Hierarchical Taxonomy of Psychopathology Following Traumatic Brain Injury (HiTOP-TBI).

Psychopathology, including depression, anxiety, and post-traumatic stress, is a significant yet inadequately addressed feature of moderate-severe traumatic brain injury (TBI). Progress in understanding and treating post-TBI psychopathology may be hindered by limitations associated with conventional diagnostic approaches, specifically the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD). The Hierarchical Taxonomy of Psychopathology (HiTOP) offers a promising, transdiagnostic alternative to psychiatric classification that may more effectively capture the experiences of individuals with TBI. However, HiTOP lacks validation in the TBI population. To address this gap, we administered a comprehensive questionnaire battery, including 56 scales assessing homogeneous symptom components and maladaptive traits within HiTOP, to 410 individuals with moderate-severe TBI. We evaluated the reliability and unidimensionality of each scale and revised those with psychometric problems. Using a top-down, exploratory latent variable approach (bass-ackwards modeling), we subsequently constructed a hierarchical model of psychopathological dimensions tailored to TBI. The results showed that, relative to norms, participants with moderate-severe TBI experienced greater problems in the established HiTOP internalizing and detachment spectra, but fewer problems with thought disorder and antagonism. Fourteen of the 56 scales demonstrated psychometric problems, which often appeared reflective of the TBI experience and associated disability. The Hierarchical Taxonomy of Psychopathology Following Traumatic Brain Injury (HiTOP-TBI) model encompassed broad internalizing and externalizing spectra, splitting into seven narrower dimensions: Detachment, Dysregulated Negative Emotionality, Somatic Symptoms, Compensatory and Phobic Reactions, Self-Harm and Psychoticism, Rigid Constraint, and Harmful Substance Use. This study presents the most comprehensive empirical classification of psychopathology after TBI to date. It introduces a novel, TBI-specific transdiagnostic questionnaire battery and model, which addresses the limitations of conventional DSM and ICD diagnoses. The empirical structure of psychopathology after TBI largely aligned with the established HiTOP model (e.g., a detachment spectrum). However, these constructs need to be interpreted in relation to the unique experiences associated with TBI (e.g., considering the injury's impact on the person's social functioning). By overcoming limitations of conventional diagnostic approaches, the HiTOP-TBI model has the potential to accelerate our understanding of the causes, correlates, consequences, and treatment of psychopathology after TBI.

The processing of verbal memories after traumatic brain injury.

Objective: Memory dysfunction is a persistent cognitive symptom following traumatic brain injury (TBI), negatively impacting capacity for independent living and productivity. Traditional scoring of neuropsychological memory tests does not allow for differentiation of specific impairments of encoding, consolidation and/or retrieval, or the potential impact of strategy deficits. Method: The current study examined performance of 142 moderate-to-severe TBI participants and 68 demographically matched healthy controls on the Rey Auditory Verbal Learning Test (RAVLT) using Item Specific Data Analysis (ISDA) and strategy use analyses. Results: Results revealed significantly greater impairments in encoding, consolidation, and retrieval in TBI participants, compared to controls. Encoding deficits significantly explained the most variance in the long-delayed recall of TBI participants, followed by consolidation, and then retrieval. Participants with TBI showed a reduced ability to spontaneously apply strategies during learning, evident in decreased subjective clusters and increased word omissions, compared to controls. No difference was found between groups in passive learning strategy application, shown through serial clustering. Spontaneous strategy measures both uniquely accounted for variance in the encoding ability of TBI participants. Conclusions: These findings highlight the potential value in using ISDA and strategy use measures to assess RAVLT results to better characterize individual memory profiles and inform rehabilitative interventions.

Biomarkers of Neurobiologic Recovery in Adults With Sport-Related Concussion.

Importance: Sport-related concussion (SRC), a form of mild traumatic brain injury, is a prevalent occurrence in collision sports. There are no well-established approaches for tracking neurobiologic recovery after SRC. Objective: To examine the levels of serum glial fibrillary acidic protein (GFAP) and neurofilament light (NfL) in Australian football athletes who experience SRC. Design, Setting, and Participants: A cohort study recruiting from April 10, 2021, to September 17, 2022, was conducted through the Victorian Amateur Football Association, Melbourne, Australia. Participants included adult Australian football players with or without SRC. Data analysis was performed from May 26, 2023, to March 27, 2024. Exposure: Sport-related concussion, defined as at least 1 observable sign and/or 2 or more symptoms. Main Outcomes and Measures: Primary outcomes were serum GFAP and NfL levels at 24 hours, and 1, 2, 4, 6, 8, 12, and 26 weeks. Secondary outcomes were symptoms, cognitive performance, and return to training times. Results: Eighty-one individuals with SRC (median age, 22.8 [IQR, 21.3-26.0] years; 89% male) and 56 control individuals (median age, 24.6 [IQR, 22.4-27.3] years; 96% male) completed a total of 945 of 1057 eligible testing sessions. Compared with control participants, those with SRC exhibited higher GFAP levels at 24 hours (mean difference [MD] in natural log, pg/mL, 0.66 [95% CI, 0.50-0.82]) and 4 weeks (MD, 0.17 [95% CI, 0.02-0.32]), and NfL from 1 to 12 weeks (1-week MD, 0.31 [95% CI, 0.12-0.51]; 2-week MD, 0.38 [95% CI, 0.19-0.58]; 4-week MD, 0.31 [95% CI, 0.12-0.51]; 6-week MD, 0.27 [95% CI, 0.07-0.47]; 8-week MD, 0.36 [95% CI, 0.15-0.56]; and 12-week MD, 0.25 [95% CI, 0.04-0.46]). Growth mixture modeling identified 2 GFAP subgroups: extreme prolonged (16%) and moderate transient (84%). For NfL, 3 subgroups were identified: extreme prolonged (7%), moderate prolonged (15%), and minimal or no change (78%). Individuals with SRC who reported loss of consciousness (LOC) (33% of SRC cases) had higher GFAP at 24 hours (MD, 1.01 [95% CI, 0.77-1.24]), 1 week (MD, 0.27 [95% CI, 0.06-0.49]), 2 weeks (MD, 0.21 [95% CI, 0.004-0.42]) and 4 weeks (MD, 0.34 [95% CI, 0.13-0.55]), and higher NfL from 1 week to 12 weeks (1-week MD, 0.73 [95% CI, 0.42-1.03]; 2-week MD, 0.91 [95% CI, 0.61-1.21]; 4-week MD, 0.90 [95% CI, 0.59-1.20]; 6-week MD, 0.81 [95% CI, 0.50-1.13]; 8-week MD, 0.73 [95% CI, 0.42-1.04]; and 12-week MD, 0.54 [95% CI, 0.22-0.85]) compared with SRC participants without LOC. Return to training times were longer in the GFAP extreme compared with moderate subgroup (incident rate ratio [IRR], 1.99 [95% CI, 1.69-2.34]; NfL extreme (IRR, 3.24 [95% CI, 2.63-3.97]) and moderate (IRR, 1.43 [95% CI, 1.18-1.72]) subgroups compared with the minimal subgroup, and for individuals with LOC compared with those without LOC (IRR, 1.65 [95% CI, 1.41-1.93]). Conclusions and Relevance: In this cohort study, a subset of SRC cases, particularly those with LOC, showed heightened and prolonged increases in GFAP and NfL levels, that persisted for at least 4 weeks. These findings suggest that serial biomarker measurement could identify such cases, guiding return to play decisions based on neurobiologic recovery. While further investigation is warranted, the association between prolonged biomarker elevations and LOC may support the use of more conservative return to play timelines for athletes with this clinical feature.

Accelerated Aging after Traumatic Brain Injury: An ENIGMA Multi-Cohort Mega-Analysis.

OBJECTIVE: The long-term consequences of traumatic brain injury (TBI) on brain structure remain uncertain. Given evidence that a single significant brain injury event increases the risk of dementia, brain-age estimation could provide a novel and efficient indexing of the long-term consequences of TBI. Brain-age procedures use predictive modeling to calculate brain-age scores for an individual using structural magnetic resonance imaging (MRI) data. Complicated mild, moderate, and severe TBI (cmsTBI) is associated with a higher predicted age difference (PAD), but the progression of PAD over time remains unclear. We sought to examine whether PAD increases as a function of time since injury (TSI) and if injury severity and sex interacted to influence this progression. METHODS: Through the ENIGMA Adult Moderate and Severe (AMS)-TBI working group, we examine the largest TBI sample to date (n = 343), along with controls, for a total sample size of n = 540, to replicate and extend prior findings in the study of TBI brain age. Cross-sectional T1w-MRI data were aggregated across 7 cohorts, and brain age was established using a similar brain age algorithm to prior work in TBI. RESULTS: Findings show that PAD widens with longer TSI, and there was evidence for differences between sexes in PAD, with men showing more advanced brain age. We did not find strong evidence supporting a link between PAD and cognitive performance. INTERPRETATION: This work provides evidence that changes in brain structure after cmsTBI are dynamic, with an initial period of change, followed by relative stability in brain morphometry, eventually leading to further changes in the decades after a single cmsTBI. ANN NEUROL 2024;96:365-377.

Co-designing positive behaviour support (PBS+PLUS) training resources: a qualitative study of people with ABI, close-others, and clinicians' experiences.

Background Challenging behaviours are often a significant difficulty faced following acquired brain injury (ABI), for which PBS+PLUS (a Positive Behaviour Support framework) is an effective intervention. Clinicians report experiencing a range of barriers to supporting behaviour change for individuals with ABI and require tailored resources to support the implementation of PBS+PLUS. This study aimed to describe the process of co-designing a PBS+PLUS intervention guidebook and podcast series together with individuals with ABI, close-others, and clinicians, and qualitatively examine co-design experiences. Methods The Knowledge-To-Action Framework was followed to support the translation of PBS+PLUS into clinical practice. Participants with ABI (n = 4), close-others (n = 7), and clinicians (n = 3) participated in focus groups contributing to the development of a PBS+PLUS intervention guidebook and podcast series. Following completion of the groups, qualitative interviews were conducted to understand participants' perspectives of the co-design experience. Transcripts were analysed using reflexive thematic analysis. Results Co-design processes are described, and participants provided practical suggestions for co-design and the dissemination of developed resources. Two core themes encapsulating four sub-themes were identified. Firstly, 'Esteeming Experiences ' described the person-driven approach of co-design whereby participants felt supported and connected with other contributors and facilitators through sharing their perspectives. Secondly, 'Empowerment ' reflected participants' increased confidence and skills in applying PBS+PLUS. Conclusions Overall, participants endorsed the therapeutic benefits of co-design engagement and high utility of PBS+PLUS resources. This study adds to the growing literature supporting the use of co-design methodology within clinical implementation, and is inclusive of individuals with ABI, close-others, and clinicians.

The Australian Traumatic Brain Injury Initiative: Review and Recommendations for Outcome Measures for Use With Adults and Children After Moderate-to-Severe Traumatic Brain Injury.

The Australian Traumatic Brain Injury Initiative (AUS-TBI) aims to select a set of measures to comprehensively predict and assess outcomes following moderate-to-severe traumatic brain injury (TBI) across Australia. The aim of this article was to report on the implementation and findings of an evidence-based consensus approach to develop AUS-TBI recommendations for outcome measures following adult and pediatric moderate-to-severe TBI. Following consultation with a panel of expert clinicians, Aboriginal and Torres Strait Islander representatives and a Living Experience group, and preliminary literature searches with a broader focus, a decision was made to focus on measures of mortality, everyday functional outcomes, and quality of life. Standardized searches of bibliographic databases were conducted through March 2022. Characteristics of 75 outcome measures were extracted from 1485 primary studies. Consensus meetings among the AUS-TBI Steering Committee, an expert panel of clinicians and researchers and a group of individuals with lived experience of TBI resulted in the production of a final list of 11 core outcome measures: the Functional Independence Measure (FIM); Glasgow Outcome Scale-Extended (GOS-E); Satisfaction With Life Scale (SWLS) (adult); mortality; EuroQol-5 Dimensions (EQ5D); Mayo-Portland Adaptability Inventory (MPAI); Return to Work /Study (adult and pediatric); Functional Independence Measure for Children (WEEFIM); Glasgow Outcome Scale Modified for Children (GOS-E PEDS); Paediatric Quality of Life Scale (PEDS-QL); and Strengths and Difficulties Questionnaire (pediatric). These 11 outcome measures will be included as common data elements in the AUS-TBI data dictionary. Review Registration PROSPERO (CRD42022290954).

The Australian Traumatic Brain Injury Initiative: Statement of Working Principles and Rapid Review of Methods to Define Data Dictionaries for Neurological Conditions.

The Australian Traumatic Brain Injury Initiative (AUS-TBI) aims to develop a health informatics approach to collect data predictive of outcomes for persons with moderate-severe TBI across Australia. Central to this approach is a data dictionary; however, no systematic reviews of methods to define and develop data dictionaries exist to-date. This rapid systematic review aimed to identify and characterize methods for designing data dictionaries to collect outcomes or variables in persons with neurological conditions. Database searches were conducted from inception through October 2021. Records were screened in two stages against set criteria to identify methods to define data dictionaries for neurological conditions (International Classification of Diseases, 11th Revision: 08, 22, and 23). Standardized data were extracted. Processes were checked at each stage by independent review of a random 25% of records. Consensus was reached through discussion where necessary. Thirty-nine initiatives were identified across 29 neurological conditions. No single established or recommended method for defining a data dictionary was identified. Nine initiatives conducted systematic reviews to collate information before implementing a consensus process. Thirty-seven initiatives consulted with end-users. Methods of consultation were "roundtable" discussion (n = 30); with facilitation (n = 16); that was iterative (n = 27); and frequently conducted in-person (n = 27). Researcher stakeholders were involved in all initiatives and clinicians in 25. Importantly, only six initiatives involved persons with lived experience of TBI and four involved carers. Methods for defining data dictionaries were variable and reporting is sparse. Our findings are instructive for AUS-TBI and can be used to further development of methods for defining data dictionaries.

When stroke survivors' self-ratings are inconsistent with the ratings of others: a cohort study examining biopsychosocial factors associated with impaired self-awareness of functional abilities.

Background Stroke survivors' self-ratings of functional abilities are often inconsistent with ratings assigned by others (e.g. clinicians), a phenomenon referred to as 'impaired self-awareness' (ISA). There is limited knowledge of the biopsychosocial contributors and consequences of post-stroke ISA measured across the rehabilitation journey. This multi-site cohort study explored biopsychosocial correlates of ISA during subacute rehabilitation (inpatient) and at 4 months post-discharge (community-dwelling). Methods Forty-five subacute stroke survivors participated (Age M (s.d.) = 71.5 (15.6), 56% female), and 38 were successfully followed-up. Self-assessments were compared to those of an independent rater (occupational therapist, close other) to calculate ISA at both time points. Survivors and raters completed additional cognitive, psychological and functional measures. Results Multivariate regression (multiple outcomes) identified associations between ISA during inpatient admission and poorer outcomes at follow-up, including poorer functional cognition, participation restriction, caregiver burden, and close other depression and anxiety. Regression models applied cross-sectionally, including one intended for correlated predictors, indicated associations between ISA during inpatient admission and younger age, male sex, poorer functional cognition, poorer rehabilitation engagement and less frequent use of non-productive coping (adjusted R 2 = 0.60). ISA at community follow-up was associated with poorer functional cognition and close other anxiety (adjusted R 2 = 0.66). Conclusions Associations between ISA and poorer outcomes across the rehabilitation journey highlight the clinical importance of ISA and the value of assessment and management approaches that consider the potential influence of numerous biological and psychosocial factors on ISA. Future studies should use larger sample sizes to confirm these results and determine the causal mechanisms of these relationships.

Co-developing 'The CyberABIlity Scale' to assess vulnerability to cyberscams for people with acquired brain injury: Delphi and cognitive interviews with clinicians and people with acquired brain injury.

Background Although individuals with acquired brain injury (ABI) may be vulnerable to cyberscams, the lack of existing measures documenting cybersafety behaviours in people with ABI limits our understanding of ABI-specific risk factors, the frequency of this problem, and the ability to evaluate evidence-based interventions. The CyberABIlity Scale was developed to assess vulnerability in people with ABI via self-rated statements and practical scam-identification tasks. This study aimed to develop and refine The CyberABIlity Scale through feedback from clinicians and people with ABI. Methods Scale feedback was collected via three rounds of clinician surveys (n = 14) using Delphi methods and two rounds of cognitive interviews with participants with ABI (n = 8). Following each round, feedback was quantitatively and qualitatively summarised, and revisions were made accordingly. Results Key revisions included removing 12 items deemed irrelevant. Instructions and rating scales were revised to improve clarity. Cognitive interviews identified 15 comprehension errors, with further revisions made to support response clarity for participants with ABI. Clinicians and participants with ABI endorsed the content and face validities of The CyberABIlity Scale . Conclusions Following further validation, The CyberABIlity Scale has the potential to be an effective screening measure for online vulnerability for people with ABI within clinical and research settings.

Co-designing for behavioural change: understanding barriers and enablers to addressing sexuality after traumatic brain injury and mapping intervention strategies in a multi-disciplinary rehabilitation unit.

Background Persistent changes in sexuality often follow traumatic brain injury (TBI). However, health professionals remain reticent about discussing sexuality and have reported barriers including uncertainties around whose role it is and limited educational and institutional support. This study employed a co-design and implementation process, aiming to promote team-wide behavioural change, whereby health professionals at a TBI rehabilitation unit would attempt to address sexuality with patients routinely. Methods Focus group sessions with multidisciplinary health professionals were conducted to identify barriers and enablers to behavioural change, identify areas for development, and co-design intervention options. Implementation deliverables were then finalised and provided to the team. The Theoretical Domains Framework was used to map factors influencing behaviours and the Behaviour Change Wheel was used to map interventions. Thematic analysis was used to further analyse barrier themes. Results Thirty-five barriers and eight enablers falling within 12 theoretical domains to behavioural change were identified. Thematic analysis revealed highly correlated barriers in initiating and sustaining change. Nine co-designed intervention options aligned with five intervention functions of the Behaviour Change Wheel, resulting in six final implementation deliverables. Conclusions Barriers were highly interrelated, influencing the approach to implementation deliverables. Simultaneously addressing multiple barriers could potentially alleviate discomfort associated with discussing sexuality. Concerns around initiating change were related to confidence in achieving sustainable changes. Achieving change requires organisational and team-level environmental restructuring and enablement. The next step involves evaluating the effectiveness of the co-design and implementation process in driving behavioural change and potential impacts on patient satisfaction and sexuality outcomes.

Implementation of activities of daily living retraining for individuals in post-traumatic amnesia.

Background Despite evidence of the efficacy of activities of daily living (ADL) retraining during post-traumatic amnesia (PTA) following traumatic brain injury (TBI), utilisation of this intervention in practice is unclear. Utilising an implementation science framework, the Consolidated Framework for Implementation Research, this study explored efforts to translate ADL retraining during PTA into the clinical practice of occupational therapists (OTs) working in TBI rehabilitation settings across Australia. Methods Participants were 44 OTs who attended a day-long training workshop that included knowledge and skill-based content regarding ADL retraining during PTA. Baseline and post-training ratings were completed including evaluation of workshop utility, and skill and knowledge-based competencies relevant to the intervention. Approximately 2 years later, nine trained OTs and two administrators were interviewed to explore the results of implementing the intervention. Results Overall, the training workshop was rated as being helpful and OT ratings of confidence (P P Conclusion Multiple barriers were identified in implementation of ADL retraining during PTA and require consideration to facilitate translation and promote best practice.

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.

Mental and Physical Health Comorbidities in Traumatic Brain Injury: A Non-TBI Controls Comparison.

OBJECTIVE: To examine whether aging with a TBI was associated with a greater burden of health-related comorbidities compared with a non-TBI control cohort and examine the associations between comorbidity burden, emotional outcomes, and health-related quality of life (HRQoL) after TBI across ages. DESIGN: Cross-sectional. SETTING: Research center or telephone. PARTICIPANTS: The study included 559 participants (NTBI=291, NControls=268). Participants with TBI were recruited during inpatient rehabilitation and had sustained a moderate-severe TBI 1-33 years previously. Non-TBI controls were a convenience sample recruited through advertisements in the community. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The number of cardiovascular, general physical health, and mental health comorbidities was compared between cohorts and age strata using Poisson regression. The relationships between comorbidities, age, emotional outcomes (Generalized Anxiety Disorder Scale-7, Patient Health Questionnaire-9), and HRQoL (PROMIS Global Health Measure) were examined with linear regression. Distinct subgroups of comorbidities were identified using latent class analysis. Associations between comorbidity classes with demographic and outcome variables were evaluated using multinomial logistic and linear regressions, respectively. RESULTS: TBI participants had a significantly higher comorbidity burden than controls, primarily driven by elevated rates of mental health disorders (RR=2.71, 95% confidence interval [1.37, 5.35]). Cardiovascular and physical health comorbidities were not elevated in the TBI group compared with controls. Both cohorts had 3 similar comorbidity subgroups, suggesting consistent patterns of co-occurring health conditions regardless of TBI exposure. Physical and mental health comorbidities were associated with elevated depression and anxiety symptoms and diminished HRQoL after TBI compared with controls. CONCLUSION: TBI was associated with greater mental, but not physical, health comorbidities in the decades after injury. However, physical and mental health comorbidities significantly affected emotional and HRQoL status after TBI, underscoring a greater need for long-term support for individuals with TBI coping with both physical and mental health comorbidities.

The impact of age on outcome 2 years after traumatic brain injury: Case control study.

BACKGROUND: Age is associated with outcome after traumatic brain injury (TBI). However, there are mixed findings across outcome domains and most studies lack controls. OBJECTIVES: This cross-sectional study examined the association between age group (15-24 years, 25-34 years, 35-44 years, 45-54 years, 55-64 years, and 65 years or more) and outcomes 2 years after TBI in independence in daily activities, driving, public transportation use, employment, leisure activities, social integration, relationships and emotional functioning, relative to healthy controls. It was hypothesized that older individuals with TBI would have significantly poorer outcomes than controls in all domains except anxiety and depression, for which it was expected they would show better outcomes. Global functional outcome (measured using the Glasgow Outcome Scale-Extended) was also examined, and we hypothesized that older adults would have poorer outcomes than younger adults. METHODS: Participants were 1897 individuals with TBI (mean, SD age 36.7, 17.7 years) who completed measures 2 years post-injury and 110 healthy controls (age 38.3, 17.5 years). RESULTS: Compared to controls, individuals with TBI were less independent in most activities of daily living, participated less in leisure activities and employment, and were more socially isolated, anxious and depressed (p < 0.001). Those who were older in age were disproportionately less likely to be independent in light domestic activities, shopping and driving; and participated less in occupational activities relative to controls. Functional outcome was significantly higher in the youngest age group than in all older age groups (p < 0.001), but the younger groups were more likely to report being socially isolated (p < 0.001), depressed (p = 0.005) and anxious (p = 0.02), and less likely to be married or in a relationship (p < 0.001). CONCLUSION: A greater focus is needed on addressing psychosocial issues in younger individuals with TBI, whereas those who are older may require more intensive therapy to maximise independence in activities of daily living and return to employment.

The Australian Traumatic Brain Injury Initiative: Systematic Review and Consensus Process to Determine the Predictive Value of Pre-existing Health Conditions for People with Moderate-Severe Traumatic Brain Injury.

The first aim of the Australian Traumatic Brain Injury Initiative (AUS-TBI) encompasses development of a set of measures that comprehensively predict outcomes for people with moderate-severe TBI across Australia. This process engaged diverse stakeholders and information sources across six areas: social, health, and clinical factors; biological markers; treatments; and longer-term outcomes. Here, we report the systematic review of pre-existing health conditions as predictors of outcome for people with moderate-severe TBI. Standardized searches were implemented across databases until March 31, 2022. English-language reports of studies evaluating association between pre-existing health conditions and clinical outcome in at least 10 patients with moderate-severe TBI were included. A predefined algorithm was used to assign a judgement of predictive value to each observed association. The list of identified pre-existing health conditions was then discussed with key stakeholders during a consensus meeting to determine the feasibility of incorporating them into standard care. The searches retrieved 22,217 records, of which 47 articles were included. The process led to identification of 88 unique health predictors (homologized to 21 predictor categories) of 55 outcomes (homologized to 19 outcome categories). Only pre-existing health conditions with high and moderate predictive values were discussed during the consensus meeting. Following the consensus meeting, 5 out of 11 were included (migraine, mental health conditions, ≥4 pre-existing health conditions, osteoporosis, and body mass index [BMI]) as common data elements in the AUS-TBI data dictionary. Upon further discussion, 3 additional pre-existing health conditions were included. These are pre-existing heart disease, frailty score, and previous incidence of TBI.

Cognitive and psychological dysfunction is present after a first seizure, prior to epilepsy diagnosis and treatment at a First Seizure Clinic.

OBJECTIVE: Neuropsychological comorbidities found in chronic epilepsy have also been reported earlier in the disease course. However, recurrent seizures, antiseizure medication (ASM), and adjustment to a chronic diagnosis remain potential confounds of this literature. It thus remains unclear whether these comorbidities are primary or secondary attributes of epilepsy. To capture individuals as close to disease onset as possible, we studied the cognitive and psychological functioning in adults after their first seizure, yet prior to epilepsy diagnosis and treatment. METHODS: Using a telehealth-based prospective design, we screened cognition, mood, and anxiety symptoms in adult patients referred to a First Seizure Clinic (FSC), who were over 18 years, English-speaking and not taking ASM. We screened cognition via telephone, and psychological symptoms via online questionnaires, all prior to the patients' diagnostic evaluation. Data were collected on 32 individuals subsequently diagnosed with epilepsy at the FSC, and 30 healthy controls from the community, who were matched to the epilepsy group for age, gender, and education. RESULTS: A multivariate analysis of variance revealed that the groups differed significantly on combined cognitive measures with a large effect size (F[1,56] = 5.75, p < 0.001, η2 = 0.45). Post-hoc analyses showed that performances on measures of verbal memory, working memory, and executive functions were significantly worse for the newly diagnosed epilepsy group than controls. The epilepsy group also exhibited higher rates of clinically significant depressive and anxiety symptoms. SIGNIFICANCE: Cognitive and psychological dysfunction is prevalent in people with epilepsy as early as the first seizure event, before the influence of diagnosis, ASM and recurrent seizures. Their neuropsychological profile parallels that seen in chronic epilepsy, showing that this dysfunction is already present at the very onset of the disease. The current study demonstrates the viability of telehealth neuropsychological screening for all new epilepsy cases. PLAIN LANGUAGE STATEMENT: The results of this study show, using telephone-based cognitive assessment and online questionnaires, that people with newly diagnosed epilepsy can experience problems with their thinking and memory skills, and low mood and anxiety, as early as after their first seizure. These issues are apparent at the very beginning of the disease, before an epilepsy diagnosis is made and before antiseizure medication is commenced, which suggests that they are due to the underlying brain disturbance, rather than the secondary effects of seizures, treatment, or lifestyle changes. Telehealth-screening of thinking skills and mental health for all new epilepsy cases is recommended to promote early management of such problems.

Addressing Cyberscams and Acquired Brain Injury ("I Desperately Need to Know What to Do"): Qualitative Exploration of Clinicians' and Service Providers' Perspectives.

BACKGROUND: People with acquired brain injury (ABI) may be more susceptible to scams owing to postinjury cognitive and psychosocial consequences. Cyberscams result in financial loss and debilitating psychological impacts such as shame and mistrust, interference with neurorehabilitation, and reduced independence. Despite these significant consequences, there are no psychological treatments to support cyberscam survivors. There is limited evidence regarding how the current workforce is addressing post-ABI cyberscams. OBJECTIVE: This study aims to understand the perspectives and needs of clinicians and service providers in addressing post-ABI cyberscams. METHODS: Overall, 20 multidisciplinary clinicians and service providers were recruited through purposive sampling across Australia. Semistructured interviews explored post-ABI scam experiences and vulnerabilities, treatments and their efficacy, and recommendations for future cybersafety recovery interventions. Reflexive thematic analysis was used. RESULTS: In total, 8 themes encompassing a biopsychosocial understanding of scam vulnerabilities and impacts were identified: "genuine lack of awareness: cognitive-executive difficulties"; "not coping with the loss of it all"; "needing trust and connection"; "strong reactions of trusted others"; "nothing structured to do"; "financial stress and independence"; "cyberability"; and "scammer persuasion." Each theme informed clinical recommendations including the need to provide psychological and cognitive support, enhance financial and cybersafety skills, promote meaningful social engagement, and foster collaboration between families and clinical support teams. CONCLUSIONS: The multifaceted range of scam vulnerabilities and impacts highlighted the need for individualized, comprehensive, and targeted treatments using a biopsychosocial approach to enable cyberscam recovery among people with ABI. These findings will guide the development of a co-designed intervention.

Altered grey matter structural covariance in chronic moderate-severe traumatic brain injury.

Traumatic brain injury (TBI) alters brain network connectivity. Structural covariance networks (SCNs) reflect morphological covariation between brain regions. SCNs may elucidate how altered brain network topology in TBI influences long-term outcomes. Here, we assessed whether SCN organisation is altered in individuals with chronic moderate-severe TBI (≥ 10 years post-injury) and associations with cognitive performance. This case-control study included fifty individuals with chronic moderate-severe TBI compared to 75 healthy controls recruited from an ongoing longitudinal head injury outcome study. SCNs were constructed using grey matter volume measurements from T1-weighted MRI images. Global and regional SCN organisation in relation to group membership and cognitive ability was examined using regression analyses. Globally, TBI participants had reduced small-worldness, longer characteristic path length, higher clustering, and higher modularity globally (p < 0.05). Regionally, TBI participants had greater betweenness centrality (p < 0.05) in frontal and central areas of the cortex. No significant associations were observed between global network measures and cognitive ability in participants with TBI (p > 0.05). Chronic moderate-severe TBI was associated with a shift towards a more segregated global network topology and altered organisation in frontal and central brain regions. There was no evidence that SCNs are associated with cognition.

The Australian Traumatic Brain Injury Initiative: Systematic Review of the Effect of Acute Interventions on Outcome for People With Moderate-Severe Traumatic Brain Injury.

The Australian Traumatic Brain Injury Initiative (AUS-TBI) is developing a data resource to enable improved outcome prediction for people with moderate-severe TBI (msTBI) across Australia. Fundamental to this resource is the collaboratively designed data dictionary. This systematic review and consultation aimed to identify acute interventions with potential to modify clinical outcomes for people after msTBI, for inclusion in a data dictionary. Standardized searches were implemented across bibliographic databases from inception through April 2022. English-language reports of randomized controlled trials (RCTs) evaluating any association between any acute intervention and clinical outcome in at least 100 patients with msTBI, were included. A predefined algorithm was used to assign a value to each observed association. Consultation with AUS-TBI clinicians and researchers formed the consensus process for interventions to be included in a single data dictionary. Searches retrieved 14,455 records, of which 124 full-length RCTs were screened, with 35 studies included. These studies evaluated 26 unique acute interventions across 21 unique clinical outcomes. Only 4 interventions were considered to have medium modifying value for any outcome from the review, with an additional 8 interventions agreed upon through the consensus process. The interventions with medium value were tranexamic acid and phenytoin, which had a positive effect on an outcome; and decompressive craniectomy surgery and hypothermia, which negatively affected outcomes. From the systematic review and consensus process, 12 interventions were identified as potential modifiers to be included in the AUS-TBI national data resource.

Providing rehabilitation services to major traumatic injury survivors in rural Australia: perspectives of rehabilitation practitioners and compensation claims managers.

PURPOSE: The delivery of healthcare services in rural locations can be challenging. From the perspectives of rural rehabilitation practitioners and compensation claims managers, this study explored the experience of providing and coordinating rehabilitation services for rural major traumatic injury survivors. MATERIALS AND METHODS: Semi-structured interviews with 14 rural rehabilitation practitioners and 10 compensation claims managers were transcribed, and reflexive thematic analysis was conducted. RESULTS: Six themes were identified (1) Challenges finding and connecting with rural services, (2) Factors relating to insurance claims management, (3) Managing the demand for services, (4) Good working relationships, (5) Limited training and support, and (6) Client resilience and community. System-related barriers included a lack of available search resources to find rural rehabilitation services, limited service/clinician availability and funding policies lacking the flexibility to meet rehabilitation needs in a rural context. Strong peer and interdisciplinary relationships were viewed as crucial facilitators, which rural practitioners were particularly adept at developing. CONCLUSIONS: Greater consideration of unique needs within rural contexts is required when developing service delivery models. Specifically, flexible and equitable funding policies; facilitating interdisciplinary connections, support and training for rehabilitation practitioners and compensation claims managers; and harnessing clients' resilience may improve the delivery of rural services.IMPLICATIONS FOR REHABILITATIONRural survivors of major traumatic injury often have ongoing health and rehabilitation needs and struggle to access required treatment services.Rehabilitation providers and compensation claims managers highlighted areas for improvement in rural areas, including resources for locating available services, funding the additional costs of rural service delivery, and greater service choice for clients.Building rural workforce capacity for treatment of major traumatic injury is needed, including improved clinician access to specialist training and support.Developing good working relationships between clients and clinicians, including interdisciplinary collaborations, and supporting client resilience and self-management should be promoted in future service delivery models.