Measuring behavioural disturbances exhibited by children and adolescents in post-traumatic amnesia: Development of a scale.

Behavioural disturbances are often observed, but (to our knowledge) not systematically assessed, in children who are in post-traumatic amnesia (PTA) following traumatic brain injury (TBI). Therefore, we aimed to develop a prototype scale that measures the full range of behavioural disturbances exhibited by school-aged children in PTA. Quantitative and qualitative feedback was collected via online surveys. First, experts (n = 7) evaluated the relevance and developmental appropriateness of 37 behavioural items, extracted from the scoping literature review. Second, clinicians (n = 20) evaluated the preliminary scale for its suitability (acceptability, feasibility and usability). Analyses included descriptive statistics and qualitative analyses. First, experts eliminated nine items, adjusted the wording of three retained items and categorised 18 of the remaining 28 items into one of eight categories. Ten items were not consistently categorised. All experts highlighted that the scale needed to be short and easy to administer. Hence, categorised items were bundled, arriving at an 18-item preliminary scale. Second, clinicians deemed the preliminary scale highly suitable, easy to implement and addressing a gap in current clinical practice. The layout of the scale and wording of three items was modified according to qualitative feedback, arriving at an 18-item prototype. To our knowledge, this is the first scale designed to assess the full range of behavioural disturbances in children in PTA. The scale has the potential to systematically assess behaviour and streamline documentation of behavioural recovery in this population, inform management and rehabilitation, track responses to interventions and facilitate discussion with affected families.

Association Between Anatomic and Clinical Indicators of Injury Severity After Moderate-Severe Traumatic Brain Injury: A Pilot Study Using Multiparametric Magnetic Resonance Imaging.

This study sought to identify whether an anatomical indicator of injury severity as measured by multiparametric magnetic resonance imaging (MRI) including magnetic resonance elastography (MRE), is predictive of a clinical measure of injury severity after moderate-severe traumatic brain injury (TBI). Nine individuals who were admitted to acute inpatient rehabilitation after moderate-to-severe TBI completed a comprehensive MRI protocol prior to discharge from rehabilitation, which included conventional MRI with diffusion tensor imaging (DTI). Of those, five of nine also underwent brain MRE to measure the brain parenchyma stiffness. Clinical severity of injury was measured by the length of post-traumatic amnesia (PTA). MRI-assessed non-hemorrhage contusion score and hemorrhage score, DTI-measured white matter fractional anisotropy, and MRE-measured lesion stiffness were all assessed. A higher hemorrhagic score was significantly associated with a longer length of PTA (p = 0.026). Participants with a longer PTA tended to have a higher non-hemorrhage contusion score and softer contusion lesions than the contralateral control side, although the small sample size did not allow for assessment of a significant association. To our knowledge, this is the first report applying MRI/MRE imaging protocol to quantitate altered brain anatomy after moderate-severe TBI and its association with PTA, a known clinical predictor of post-acute outcome. Future larger studies could lead to the development of prediction models that integrate clinical data with anatomical (MRI), structural (DTI), and mechanical (MRE) changes caused by TBI, to inform prognosis and care planning.

Post-traumatic amnesia: a scoping review & content analysis of behavioral disturbances.

OBJECTIVE: The aim of this scoping review was to identify behavioral disturbances exhibited by patients in post-traumatic amnesia (PTA). While behavioral disturbances are common in PTA, research into their presentation and standardized measures for their assessment are limited. DESIGN: The study protocol was registered with PROSPERO (CRD42021268275). A scoping review of databases was performed according to pre-determined criteria on 29 July 2021 and updated on 13 July 2022. A conventional content analysis was used to examine and categorize behavioral disturbances. RESULTS: Thirty papers met the inclusion criteria, of which 27 reported observations and/or scores obtained on behavioral scales, and 3 on clinician interviews and surveys. None focused exclusively on children. Agitation was the most frequently assessed behavior, and Agitated Behavior Scale was the most used instrument. Content analysis, however, bore eight broad behavioral categories: disinhibition, agitation, aggression, lability, lethargy/low mood, perceptual disturbances/psychotic symptoms, personality change and sleep disturbances. CONCLUSION: Our study revealed that while standardized assessments of behavior of patients in PTA are often limited to agitation, clinical descriptions include a range of behavioral disturbances. Our study highlights a significant gap in the systematic assessment of a wide range of behavioral disturbances observed in PTA.

Who enrolls and why? Examining center-specific underlying patterns behind enrollment: a New York City-based traumatic brain injury model systems study.

BACKGROUND: To elucidate the sociodemographic and study factors involved in enrollment in the Traumatic Brain Injury Model System (TBIMS) database, this study examined the effect of a variety of variables on enrollment at a local TBIMS center. METHODS: A sample of 654 individuals from the local TBIMS center was studied examining enrollment by age, gender, race, ethnicity, homelessness status at date of injury, history of homelessness, health insurance status, presence of social support, primary language, consenting in hospital or after discharge, and the need for an interpreter. Binary logistic regression was conducted to identify variables that predict center-based enrollment into TBIMS. RESULTS: Results demonstrated that older age was associated with decreasing enrollment (OR = 0.99, p = 0.01), needing an interpreter made enrollment less likely (OR = 0.33, p < 0.01), being primarily Spanish speaking predicted enrollment (OR = 3.20, p = 0.02), Hispanic ethnicity predicted enrollment (OR = 7.31, p = 0.03), and approaching individuals in the hospital predicted enrollment (OR = 6.94, p < 0.01). Here, OR denotes the odds ratio estimate from a logistic regression model and P denotes the corresponding p-value. CONCLUSIONS: These results can be useful in driving enrollment strategies at this center for other similar TBI research, and to contribute a representative TBI sample to the national database.

Associations of prior concussion severity with brain microstructure using mean apparent propagator magnetic resonance imaging.

Magnetic resonance imaging (MRI) diffusion studies have shown chronic microstructural tissue abnormalities in athletes with history of concussion, but with inconsistent findings. Concussions with post-traumatic amnesia (PTA) and/or loss of consciousness (LOC) have been connected to greater physiological injury. The novel mean apparent propagator (MAP) MRI is expected to be more sensitive to such tissue injury than the conventional diffusion tensor imaging. This study examined effects of prior concussion severity on microstructure with MAP-MRI. Collegiate-aged athletes (N = 111, 38 females; ≥6 months since most recent concussion, if present) completed semistructured interviews to determine the presence of prior concussion and associated injury characteristics, including PTA and LOC. MAP-MRI metrics (mean non-Gaussian diffusion [NG Mean], return-to-origin probability [RTOP], and mean square displacement [MSD]) were calculated from multi-shell diffusion data, then evaluated for associations with concussion severity through group comparisons in a primary model (athletes with/without prior concussion) and two secondary models (athletes with/without prior concussion with PTA and/or LOC, and athletes with/without prior concussion with LOC only). Bayesian multilevel modeling estimated models in regions of interest (ROI) in white matter and subcortical gray matter, separately. In gray matter, the primary model showed decreased NG Mean and RTOP in the bilateral pallidum and decreased NG Mean in the left putamen with prior concussion. In white matter, lower NG Mean with prior concussion was present in all ROI across all models and was further decreased with LOC. However, only prior concussion with LOC was associated with decreased RTOP and increased MSD across ROI. Exploratory analyses conducted separately in male and female athletes indicate associations in the primary model may differ by sex. Results suggest microstructural measures in gray matter are associated with a general history of concussion, while a severity-dependent association of prior concussion may exist in white matter.

Long-term resting EEG correlates of repetitive mild traumatic brain injury and loss of consciousness: alterations in alpha-beta power.

Objective: Long-term changes to EEG spectra after mild traumatic brain injury (mTBI, i.e., concussion) have been reported; however, the role of injury characteristics in long-term EEG changes is unclear. It is also unclear how any chronic EEG changes may underlie either subjective or objective cognitive difficulties, which might help explain the variability in recovery after mTBI. Methods: This study included resting-state high-density electroencephalography (EEG) and mTBI injury data from 340 service members and veterans collected on average 11 years after injury as well as measures of objective and subjective cognitive functioning. The average absolute power within standard bands was computed across 11 spatial regions of the scalp. To determine how variation in brain function was accounted for by injury characteristics and aspects of cognition, we used regression analyses to investigate how EEG power was predicted by mTBI history characteristics [number, number with post-traumatic amnesia and witnessed loss of consciousness (PTA + LOC), context of injury (combat or non-combat), potentially concussive blast exposures], subjective complaints (TBIQOL General Cognitive and Executive Function Concerns), and cognitive performance (NIH Toolbox Fluid Intelligence and premorbid IQ). Results: Post-traumatic amnesia (PTA) and loss of consciousness (LOC), poorer cognitive performance, and combat experience were associated with reduced power in beta frequencies. Executive function complaints, lower premorbid IQ, poorer cognitive performance, and higher psychological distress symptoms were associated with greater power of delta frequencies. Multiple regression confirmed the relationship between PTA + LOC, poor cognitive performance, cognitive complaints, and reduced power in beta frequencies and revealed that repetitive mTBI was associated with a higher power in alpha and beta frequencies. By contrast, neither dichotomous classification of the presence and absence of mTBI history nor blast exposures showed a relationship with EEG power variables. Conclusion: Long-term alterations in resting EEG spectra measures of brain function do not appear to reflect any lasting effect of a history of mTBI or blast exposures. However, power in higher frequencies reflects both injury characteristics and subjective and objective cognitive difficulties, while power in lower frequencies is related to cognitive functions and psychological distress associated with poor long-term outcomes after mTBI.

Network analysis of anxiety and depressive symptoms one year after traumatic brain injury.

We used network analysis to explore interrelationships between anxiety and depressive symptoms after traumatic brain injury (TBI). At one year post-injury, 882 adult civilians who received inpatient rehabilitation for moderate-severe TBI self-reported anxiety and depressive symptoms (Hospital Anxiety and Depression Scale). The severity of TBI was characterized acutely by the duration of post-traumatic amnesia (PTA), and TBI-related functional disability was rated by an examiner at one year post-injury using a structured interview (Glasgow Outcome Scale - Extended). We estimated two cross-sectional, partial correlation networks. In the first network, anxiety and depressive symptoms were densely interconnected yet formed three distinct, data-driven communities: Hyperarousal, Depression, and General Distress. Worrying thoughts and having difficulty relaxing were amongst the most central symptoms, showing strong connections with other symptoms within and between communities. In the second network, TBI severity was directly negatively associated with hyperarousal symptoms but indirectly positively associated with depressive symptoms via greater functional disability. The results highlight the potential utility of simultaneous, transdiagnostic assessment and treatment of anxiety and depressive symptoms after moderate-severe TBI. Worrying thoughts, having difficulty relaxing, and the experience of disability may be important targets for treatment, although future studies examining symptom dynamics within individuals and over time are required.

Prolonged duration of post-traumatic amnesia: A sensitive classification for predicting cognitive outcomes in children recovering from traumatic brain injury.

OBJECTIVE: A paucity of data exists regarding the duration of post-traumatic amnesia (PTA) as a predictor of cognitive functioning among children after traumatic brain injury (TBI). The study aimed to assess the relationship between PTA duration and areas of neurocognitive function among the pediatric population in the sub-acute phase of recovery and rehabilitation. METHODS: Data were collected from medical files on 103 children aged 5.5-16.5 hospitalized at a pediatric rehabilitation department with a diagnosis of moderate-severe TBI (msTBI) between the years 2004-2019. The Children Orientation and Amnesia Test was used to evaluate PTA duration. Measures of high-order cognitive abilities of attention and executive function were collected using the Test of Everyday Attention-Child version (TEA-Ch). RESULTS: Three PTA duration groups were assembled out of a cluster analysis: "Long PTA" (M = 21 days), "Very Long PTA" (M = 47 days), and "Extremely Long PTA" (M = 94 days). Analyses revealed that the "Long PTA" group preformed significantly better than the "Very Long PTA" and "Extremely Long PTA" groups on all TEA-Ch measures, that is, Selective Attention, Attentional Control Switching, and Sustained Attention. CONCLUSIONS: This study is the first to demonstrate that PTA duration is a useful predictor of high-order cognitive functions among children with msTBI in the sub-acute phase of recovery and rehabilitation. The findings emphasize the importance of using a more sensitive classification of prolonged PTA durations to improve outcome prediction and allocation of resources to those who can benefit most after severe brain injuries.

Use of Olanzapine to Treat Agitation in Traumatic Brain Injury: A Series of N-of-One Trials.

Agitation is common during post-traumatic amnesia (PTA) following traumatic brain injury (TBI) and is associated with risk of harm to patients and caregivers. Antipsychotics are frequently used to manage agitation in early TBI recovery despite limited evidence to support their efficacy, safety, and impact upon patient outcomes. The sedating and cognitive side effects of these agents are theorized to exacerbate confusion during PTA, leading to prolonged PTA duration and increased agitation. This study, conducted in a subacute inpatient rehabilitation setting, describes the results of a double-blind, randomized, placebo-controlled trial investigating the efficacy of olanzapine for agitation management during PTA, analyzed as an n-of-1 series. Group comparisons were additionally conducted, examining level of agitation; number of agitated days; agitation at discharge, duration, and depth of PTA; length of hospitalization; cognitive outcome; adverse events; and rescue medication use. Eleven agitated participants in PTA (mean [M] age = 39.82 years, standard deviation [SD] = 20.06; mean time post-injury = 46.09 days, SD = 32.75) received oral olanzapine (n = 5) or placebo (n = 6) for the duration of PTA, beginning at a dose of 5 mg/day and titrated every 3 to 4 days to a maximum dose of 20 mg/day. All participants received recommended environmental management for agitation. A significant decrease in agitation with moderate to very large effect (Tau-U effect size = 0.37-0.86) was observed for three of five participants receiving olanzapine, while no significant reduction in agitation over the PTA period was observed for any participant receiving placebo. Effective olanzapine dose ranged from 5-20 mg. Response to treatment was characterized by lower level of agitation and response to treatment within 3 days. In group analyses, participants receiving olanzapine demonstrated poorer orientation and memory during PTA with large effect size (olanzapine, mean = 9.32, SD = 0.69; placebo, M = 10.68, SD = 0.30; p = .009, d = -2.16), and a trend toward longer PTA duration with large effect size (olanzapine, M = 71.96 days, SD = 20.31; placebo, M = 47.50 days, SD = 11.27; p = 0.072, d = 1.26). No further group comparisons were statistically significant. These results suggest that olanzapine can be effective in reducing agitation during PTA, but not universally so. Importantly, administration of olanzapine during PTA may lead to increased patient confusion, possibly prolonging PTA. When utilizing olanzapine, physicians must therefore balance the possible advantages of agitation management with the possibility that the patient may never respond to the medication and may experience increased confusion, longer PTA and potentially poorer outcomes. Further high-quality research is required to support these findings and the efficacy and outcomes associated with the use of any pharmacological agent for the management of agitation during the PTA period.

Effectiveness of Non-Pharmacological Interventions for Agitation during Post-Traumatic Amnesia following Traumatic Brain Injury: A Systematic Review.

Agitation is common in the early recovery period following traumatic brain injury (TBI), known as post-traumatic amnesia (PTA). Non-pharmacological interventions are frequently used to manage agitation, yet their efficacy is largely unknown. This systematic review aims to synthesize current evidence on the effectiveness of non-pharmacological interventions for agitation during PTA in adults with TBI. Key databases searched included MEDLINE Ovid SP interface, PubMed, CINAHL, Excerpta Medica Database, PsycINFO and CENTRAL, with additional online reviewing of key journals and clinical trial registries to identify published or unpublished studies up to May 2020. Eligible studies included participants aged 16 years and older, showing agitated behaviours during PTA. Any non-pharmacological interventions for reducing agitation were considered, with any comparator accepted. Eligible studies were critically appraised for methodological quality using Joanna Briggs Institute Critical Appraisal Instruments and findings were reported in narrative form. Twelve studies were included in the review: two randomized cross-over trials, three quasi-experimental studies, four cases series and three case reports. Non-pharmacological interventions were music therapy, behavioural strategies and environmental modifications, physical restraints and electroconvulsive therapy. Key methodological concerns included absence of a control group, a lack of formalised agitation measurement and inconsistent concomitant use of pharmacology. Interventions involving music therapy had the highest level of evidence, although study quality was generally low to moderate. Further research is needed to evaluate non-pharmacological interventions for reducing agitation during PTA after TBI.Systematic review registration number: PROSPERO (CRD42020186802), registered May 2020.

The role of the Neuropsychologist across the stages of recovery from acquired brain injury: a summary from the pediatric rehabilitation Neuropsychology collaborative.

Neuropsychologists working in a pediatric neurorehabilitation setting provide care for children and adolescents with acquired brain injuries (ABI) and play a vital role on the interdisciplinary treatment team. This role draws on influences from the field of clinical neuropsychology and its pediatric subspecialty, as well as rehabilitation psychology. This combination of specialties is uniquely suited for working with ABI across the continuum of recovery. ABI recovery often involves a changing picture that spans across stages of recovery (e.g., disorders of consciousness, confusional state, acute cognitive impairment), where each stage presents with distinctive characteristics that warrant a specific evidence-based approach. Assessment and intervention are used reciprocally to inform diagnostics, treatment, and academic planning, and to support patient and family adjustment. Neuropsychologists work with the interdisciplinary teams to collect and integrate data related to brain injury recovery and use this data for treatment planning and clinical decision making. These approaches must often be adapted and adjusted in real time as patients recover, demanding a dynamic expertise that is currently not supported through formal training curriculum or practice guidelines. This paper outlines the roles and responsibilities of pediatric rehabilitation neuropsychologists across the stages of ABI recovery with the goal of increasing awareness in order to continue to develop and formalize this role.

Variables predictoras de la duración de la amnesia postraumática tras un traumatismo craneoencefálico / Predictors of the duration of post-traumatic amnesia following traumatic brain injury

Introducción: La duración de la amnesia postraumática (APT) ayuda a estimar el nivel de recuperación tras un traumatismo craneoencefálico (TCE). Sin embargo, apenas se dispone de información sobre qué variables sociodemográficas y clínicas influyen en su duración. Este estudio pretende identificarlas y crear un modelo predictivo que permita estimar el tiempo que un paciente tarda en emerger de la APT. Pacientes y métodos: La muestra estaba formada por 40 pacientes adultos en APT ingresados en un centro neurorrehabilitador. El 89,7% había sufrido un TCE grave; el 10,3% restante, un TCE moderado. Su estado cognitivo se valoró mediante el Galveston Orientation and Amnesia Test (GOAT) –escala que permite determinar en qué momento se puede considerar que un paciente emerge de la APT–. Resultados: Se encontró una ecuación de regresión (F = 8,511; p < 0,001; R2 = 0,415), en la que las siguientes variables (clasificadas por su orden de importancia) explicaron el 41,5% de la variabilidad observada en la duración de la APT: a) GOAT administrado a la llegada al centro neurorrehabilitador; b) años de formación reglada del paciente; y c) días que estuvo en APT antes de ingresar en el centro neurorrehabilitador. La ecuación de regresión derivada fue la siguiente: 104,284 + (–0,708 × GOAT-inicial) + (–4,124 × años formación reglada) + (0,219 × APT-hospital agudos). Conclusiones: El tiempo que un paciente tarda en emerger de la APT está condicionado por la puntuación que obtiene en el primer GOAT administrado al ingresar en el centro neurorrehabilitador, el nivel de estudios, y los días que permanece en APT entre el momento del TCE y el ingreso en el centro neurorrehabilitador.(AU)

Introduction: The duration of post-traumatic amnesia (PTA) helps estimate the level of recovery following traumatic brain injury (TBI). Yet, little information is available about which sociodemographic and clinical variables influence its duration. This study aims to identify them and create a predictive model that makes it possible to estimate the time it takes for a patient to emerge from PTA. Patients and methods: The sample consisted of 40 adult patients with PTA admitted to a neurorehabilitation centre. A total of 89.7% had suffered a severe TBI, whereas the remaining 10.3% had had a moderate TBI. Cognitive status was assessed using the Galveston Orientation and Amnesia Test (GOAT) – a scale for determining at what point a patient can be considered to be emerging from PTA. Results: A regression equation was found (F = 8.511; p < 0.001; R2 = 0.415), in which the following variables (ranked in order of importance) explained 41.5% of the variability observed in the duration of PTA: a) GOAT administered on arrival at the neurorehabilitation centre; b) years of formal education of the patient; and c) days with PTA prior to admission to the neurorehabilitation centre. The equation derived was as follows: 104.284 + (–0.708 × GOAT-initial) + (–4.124 × years formal education) + (0.219 × hospital acute-APT). Conclusions: The time it takes for a patient to emerge from PTA is conditioned by the score obtained in the first GOAT administered on admission to the neurorehabilitation centre, their level of education, and the number of days elapsed with PTA between occurrence of the TBI and admission to the neurorehabilitation centre.(AU)

Meeting the confused patient with confidence: perceived benefits of communication partner training in subacute TBI.

OBJECTIVE: This study aims to explore health professionals' perceived benefits of implementing Communication Partner Training (CPT) using Supported Conversation for Adults with Aphasia (SCA™) in a subacute rehabilitation setting with patients in post-traumatic confusional state (PTCS) after TBI. METHOD: The study was conducted in a clinical setting using a pre-post questionnaire design to explore change. One hundred and four interdisciplinary clinicians attended CPT in the SCA™ method and subsequent implementation support. Participants completed a questionnaire with both quantitative and qualitative questions before and after the training and implementation period. Data were analyzed using descriptive and inferential statistics and qualitative content analysis. RESULTS: Participants' perceived confidence and self-assessed ability to communicate with patients in PTCS significantly increased after CPT (p = 0.006). While participants still experienced communication challenges, they reported using CPT-related tools and strategies in their interactions. Participants found they could apply strategies to improve patients' comprehension of information and to confirm their understanding of patients' communication. However, using strategies to enhance patients' expressive abilities was perceived as more challenging. CONCLUSIONS: Training health professionals in CPT increase their confidence in managing communication with patients in PTCS. Further research is needed to evaluate the efficacy of CPT within a more rigorous research design.

Pathological Slow-Wave Activity and Impaired Working Memory Binding in Post-Traumatic Amnesia.

Associative binding is key to normal memory function and is transiently disrupted during periods of post-traumatic amnesia (PTA) following traumatic brain injury (TBI). Electrophysiological abnormalities, including low-frequency activity, are common following TBI. Here, we investigate associative memory binding during PTA and test the hypothesis that misbinding is caused by pathological slowing of brain activity disrupting cortical communication. Thirty acute moderate to severe TBI patients (25 males; 5 females) and 26 healthy controls (20 males; 6 females) were tested with a precision working memory paradigm requiring the association of object and location information. Electrophysiological effects of TBI were assessed using resting-state EEG in a subsample of 17 patients and 21 controls. PTA patients showed abnormalities in working memory function and made significantly more misbinding errors than patients who were not in PTA and controls. The distribution of localization responses was abnormally biased by the locations of nontarget items for patients in PTA, suggesting a specific impairment of object and location binding. Slow-wave activity was increased following TBI. Increases in the δ-α ratio indicative of an increase in low-frequency power specifically correlated with binding impairment in working memory. Connectivity changes in TBI did not correlate with binding impairment. Working memory and electrophysiological abnormalities normalized at 6 month follow-up. These results show that patients in PTA show high rates of misbinding that are associated with a pathological shift toward lower-frequency oscillations.SIGNIFICANCE STATEMENT How do we remember what was where? The mechanism by which information (e.g., object and location) is integrated in working memory is a central question for cognitive neuroscience. Following significant head injury, many patients will experience a period of post-traumatic amnesia (PTA) during which this associative binding is disrupted. This may be because of electrophysiological changes in the brain. Using a precision working memory test and resting-state EEG, we show that PTA patients demonstrate impaired binding ability, and this is associated with a shift toward slower-frequency activity on EEG. Abnormal EEG connectivity was observed but was not specific to PTA or binding ability. These findings contribute to both our mechanistic understanding of working memory binding and PTA pathophysiology.

Evaluation of post-traumatic stress disorder (PTSD) and related comorbidities in clinical studies.

Patients with traumatic brain injury (TBI) of varying severities are experiencing adverse outcomes during and after rehabilitation. Besides depression and anxiety, post-traumatic stress disorder (PTSD) is highly encountered in civilian and military populations. As more prospective and retrospective studies - focused on evaluating new or old psychological therapies in inpatient, outpatient, or controlled environments, targeting patients with PTSD with or without a history of TBI - are carried out, researchers are employing various scales to measure PTSD as well as other psychiatric diagnoses or cognitive impairments that might appear following TBI. We aimed to explore the literature published between January 2010 and October 2021 by querying three databases. Our preliminary results showed that several scales - such as the Clinician-Administered PTSD Scale (CAPS), the Posttraumatic Stress Disorder Checklist Military Version (PCL-M) as well as Specific Version (PCL-S), and Civilian Version (PCL-C) - have been frequently used for PTSD diagnosis and symptom severity. However, heterogeneity in the scales used when assessing and evaluating additional psychiatric comorbidities and cognitive impairments are due to the study aim and therapeutic approaches. Therefore, conducting an intervention focusing on post-TBI PTSD patients requires increased attention to patients' medical history in capturing multiple cognitive impairments and affected neuropsychological processes when designing the study and including validated instruments for measuring primary and secondary neuropsychological outcomes.

Post-traumatic Stress Disorder after Severe Traumatic Brain Injury: A Systematic Review.

OBJECTIVE: The review aimed to summarize the existing knowledge base regarding post-traumatic stress disorder after severe traumatic brain injury (TBI) and try to guide future research. METHOD: Web of Science, Scopus, and PubMed databases were used to identify original studies that explored the relationship between severe TBI and post-traumatic stress disorder. RESULTS: A total of 13 studies were included in the review. They have been examined in terms of potentially compatible and incompatible mechanisms, as well as of possible confounding factors in relation to the diagnosis of post-traumatic stress disorder after severe TBI. CONCLUSION: Only a few studies in the literature have addressed the present topic; therefore, the prevalence of post-traumatic stress disorder in patients with severe TBI still needs to be further investigated. In particular, future studies should be conducted only in severe TBI populations, considering their premorbid personality characteristics and their reactivity alteration. They should also obtain an accurate and appropriate assessment of post-traumatic stress disorder with clinical interviews as well as clarifying the role of post-traumatic amnesia in this population by incorporating control groups of patients.

Aspects of Cognitive Impairment Associated with Agitated Behaviour during Post-traumatic Amnesia.

OBJECTIVES: Post-traumatic amnesia (PTA) is a transient period of recovery following traumatic brain injury (TBI) characterised by disorientation, amnesia, and cognitive disturbance. Agitation is common during PTA and presents as a barrier to patient outcome. A relationship between cognitive impairment and agitation has been observed. This prospective study aimed to examine the different aspects of cognition associated with agitation. METHODS: The sample comprised 82 participants (75.61% male) admitted to an inpatient rehabilitation hospital in PTA. All patients had sustained moderate to extremely severe brain injury as assessed using the Westmead Post-Traumatic Amnesia Scale (WPTAS) (mean duration = 42.30 days, SD = 35.10). Participants were assessed daily using the Agitated Behaviour Scale and WPTAS as part of routine clinical practice during PTA. The Confusion Assessment Protocol was administered two to three times per week until passed criterion was achieved (mean number assessments = 3.13, SD = 3.76). Multilevel mixed modelling was used to investigate the association between aspects of cognition and agitation using performance on items of mental control, orientation, memory free recall, memory recognition, vigilance, and auditory comprehension. RESULTS: Findings showed that improvement in orientation was significantly associated with lower agitation levels. A nonsignificant trend was observed between improved recognition memory and lower agitation. CONCLUSIONS: Current findings suggest that the presence of disorientation in PTA may interfere with a patient's ability to understand and engage with the environment, which in turn results in agitated behaviours. Interventions aimed at maximizing orientation may serve to minimize agitation during PTA.

Intervención no farmacológica en la amnesia postraumática, una revisión sistemática / Non-pharmacological intervention in post-traumatic amnesia, a systematic review

Introducción: Las personas que sobreviven a un traumatismo craneoencefálico pueden presentar un estado transitorio de confusión y perturbación global del funcionamiento cognitivoconductual denominado amnesia postraumática. Objetivo: Describir las características, la calidad metodológica y los principales resultados de los estudios que han analizado el impacto de las intervenciones no farmacológicas en el tratamiento de los síntomas asociados a la amnesia postraumática. Pacientes y métodos: Siguiendo las directrices PRISMA, se realizó una búsqueda bibliográfica de los trabajos publicados en las bases de datos PubMed y PsycInfo durante los últimos 20 años (2000-2020). La calidad metodológica de los artículos se evaluó mediante la escala PEDro. Resultados: Tras aplicar los criterios de inclusión y exclusión, de los 1.036 artículos potencialmente interesantes, ocho cumplieron los criterios de elegibilidad; de estos, cuatro eran ensayos clínicos aleatorizados. Las intervenciones aplicadas se agruparon de la siguiente forma: reentrenamiento estructurado de las actividades de la vida diaria (cuatro estudios), programa de orientación a la realidad (dos estudios), sistema Perceive, Recall, Plan and Perform (un estudio) y aplicación terapéutica de la música (un estudio). Siete de los ocho artículos revisados mostraron resultados positivos o parcialmente positivos. Conclusiones: De acuerdo con los resultados obtenidos, hay indicios de que las intervenciones no farmacológicas tienen efectos positivos en la disminución de la sintomatología cognitivoconductual asociada a la amnesia postraumática.(AU)

Introduction: Survivors of traumatic brain injury may experience a transient state of confusion and global disturbance of cognitive-behavioural functioning called post-traumatic amnesia.Aim. To describe the characteristics, methodological quality and main results of studies that have analysed the impact of non-pharmacological interventions in the treatment of symptoms associated with post-traumatic amnesia. Patients and methods: Following the PRISMA guidelines, a literature search was carried out on papers published in the PubMed and PsycInfo databases over the last 20 years (2000-2020). The methodological quality of the articles was assessed using the PEDro scale. Results: After applying the inclusion and exclusion criteria, of the 1,036 potentially interesting articles, eight met the eligibility criteria, four of which were randomised clinical trials. The interventions applied were grouped as follows: structured retraining of activities of daily living (four studies), reality orientation programme (two studies), Perceive, Recall, Plan and Perform system (one study) and therapeutic application of music (one study). Seven of the eight articles reviewed showed positive or partially positive results. Conclusions: According to the results obtained, there is evidence that non-pharmacological interventions have positive effects on reducing the cognitive-behavioural signs and symptoms associated with post-traumatic amnesia.(AU)

Agitated Behaviors following Traumatic Brain Injury: A Systematic Review and Meta-Analysis of Prevalence by Post-Traumatic Amnesia Status, Hospital Setting, and Agitated Behavior Type.

Agitation is a common behavioral problem following traumatic brain injury (TBI); however, the precise proportion of patients who experience agitation in the early stages of recovery is unknown. The aim of this systematic review and meta-analysis was to evaluate the prevalence of agitation in TBI patients undergoing inpatient care, and whether this prevalence differed by post-traumatic amnesia (PTA) status and setting (acute and rehabilitation). We also aimed to describe the prevalence of sub-types of agitated behavior (disinhibited, aggressive, and emotionally labile). We searched five databases and one clinical trials register, with additional review of websites and key journals to identify any relevant records up to July 2020. We included studies describing the proportion of hospitalized TBI patients age 16 years or older demonstrating agitated behavior. We included comparative studies with and without concurrent controls, randomized controlled trials, pseudo-randomized controlled trials, and case series. Methodological quality was critically appraised using a Joanna Briggs Institute checklist. Sixteen studies met eligibility criteria, with a total of 5592 participants. The pooled prevalence of agitation was 31.73% (95% confidence interval [CI], 25.25%-39.00%) during inpatient care (acute and rehabilitation), 32.23% (95% CI, 27.13%-37.80%) during rehabilitative care and 44.06% (95% CI, 36.15%-52.28%) for inpatients in PTA specifically. Disinhibited behaviors were the most common. There was substantial heterogeneity between studies. Additional high-quality research featuring large samples, frequent and long-term measurement of agitation, use of validated scales, and consideration of variables such as PTA status will further improve estimates of agitation prevalence following TBI.

Duration of post-traumatic amnesia is uniquely associated with memory functioning in chronic moderate-to-severe traumatic brain injury.

BACKGROUND: Disrupted memory circuitry may contribute to post-traumatic amnesia (PTA) after traumatic brain injury (TBI). It is unclear whether duration of PTA (doPTA) uniquely impacts memory functioning in the chronic post-injury stage. OBJECTIVE: To examine the relationship between doPTA and memory functioning, independent of other cognitive abilities, in chronic moderate-to-severe TBI. METHODS: Participants were 82 individuals (median chronicity = 10.5 years) with available doPTA estimates and neuropsychological data. Composite memory, processing speed (PS), and executive functioning (EF) performance scores, as well as data on subjective memory (SM) beliefs, were extracted. DoPTA-memory associations were evaluated via linear modeling of doPTA with memory performance and clinical memory status (impaired/unimpaired), controlling for PS, EF, and demographic covariates. Interrelationships between doPTA, objective memory functioning, and SM were assessed. RESULTS: DoPTA was significantly related to memory performance, even after covariate adjustment. Impairment in memory, but not PS or EF, was associated with a history of longer doPTA. SM was associated with memory performance, but unrelated to doPTA. CONCLUSIONS: Findings suggest a specific association between doPTA-an acute injury phenomenon-and chronic memory deficits after TBI. Prospective studies are needed to understand how underlying mechanisms of PTA shape distinct outcome trajectories, particularly functional abilities related to memory processing.