Scoping Review of Opioid Use After Traumatic Brain Injury.

OBJECTIVE: To summarize the current literature to identify what research has been conducted, examine the approaches used, and determine what is presently known about prescription and nonprescription opioid receipts and use among individuals with traumatic brain injury (TBI). DATA SOURCES: The search strategy included the following: opioid; opiate; analgesics, opioid; opiate alkaloids; or opioid-related disorders; AND brain injury; brain injuries; brain injuries, traumatic; head injury; head injuries; head injuries, closed; head injuries, penetrating; brain concussion; diffuse axonal injury; diffuse axonal injuries; brain trauma/s; head trauma/s; concussion; craniocerebral trauma/s; or TBI. Filters included English and Adults (19+ years). Study Selection: Inclusion: English language, adults with stable TBI, and prescription opioid receipt or use after TBI. Exclusion: Animal models, populations with other acquired brain injury, acute TBI management, and non-peer-reviewed articles, theses, or conference abstracts. Multiple reviewers screened abstracts and full-text articles for eligibility. In total, 771 abstracts were screened, 183 full texts were reviewed, and 21 met eligibility criteria. Data Extraction: Relevant content was independently extracted by multiple observers, including authors, design, sample identification and data source/s, TBI severity, TBI assessment, opioid assessment, study population (demographics, N), military affiliation, comparison groups, date of data collection, and summary of findings. RESULTS: Studies were published between 1987 and 2019; most data were collected prior to 2015. The majority utilized administrative and electronic medical record data from the Department of Veterans Affairs and retrospective cohort designs, and most focused on prescription opioids. There were no studies evaluating interventions to reduce use of opioids in TBI populations. Preliminary findings suggest that prescription opioid receipt is strongly related to psychological symptoms, including comorbid depression, anxiety, and posttraumatic stress disorder. CONCLUSIONS: Despite increased awareness of opioid receipt and use following TBI, there is limited investigation on the examination of this issue. Future studies should include more varied patient populations as well as evaluate interventions to reduce opioid use following TBI.

Evaluation of a Brief, Skill-Building, Supportive, and Educational Intervention for Couples After Brain Injury.

OBJECTIVE: To examine the effectiveness of an intervention (Therapeutic Couples Intervention, TCI) designed to improve relationship quality for couples after acquired brain injury. SETTING: Outpatient brain injury rehabilitation center. PARTICIPANTS: Persons with brain injury (n = 75) and their intimate partners (n = 75). DESIGN: Two-arm parallel, randomized, controlled trial with wait-listed control. METHODS: Composed of 5 to 6 2-hour sessions, the TCI is a manualized, treatment program designed to enhance relationship quality by addressing issues and concerns most often identified by persons with brain injury and their partners. MAIN MEASURE: Revised Dyadic Adjustment Scale completed by the persons with brain injury and their partners. RESULTS: Persons with brain injury and their partners in the treatment group showed an improvement in relationship quality, both compared with their own baseline values and the control group. CONCLUSIONS: Investigation provided evidence that a curriculum-based education, skill-building, and supportive intervention can benefit couples for up to 3 months after treatment. Additional research is needed to ascertain the long-term benefits of intervention and the efficacy of alternative delivery methods (eg, Internet, telephone, and group).

A Randomized Controlled Pilot Study of a Manualized Intervention for Caregivers of Patients With Traumatic Brain Injury in Inpatient Rehabilitation.

OBJECTIVE: Investigate effectiveness of a 5-session manualized intervention for addressing needs of caregivers of persons in acute traumatic brain injury (TBI) rehabilitation. DESIGN: Prospective, pilot randomized controlled trial. SETTING: Inpatient brain injury rehabilitation unit, level 1 trauma center. PARTICIPANTS: Patients (N=93) with moderate-to-severe TBI and their family members were enrolled in the study with 42 randomized to the treatment group, 51 to the control group. INTERVENTION: Five-session manualized caregiver intervention with educational, stress and anxiety self-management, coping, and emotional support components. MAIN OUTCOME MEASURES: Family Needs Questionnaire-Revised, knowledge assessment, Zarit Family Burden Scale, and Brief Symptom Inventory-18 were collected at pretreatment, posttreatment, and 3-month follow-up. RESULTS: Treatment group caregivers showed an increase in met needs for emotional, instrumental, and professional support, and brain injury knowledge from baseline to posttreatment, whereas controls did not. Between-group differences were significant for only emotional support needs. Treatment effects were not sustained at 3-month follow-up. CONCLUSIONS: Caregivers of persons undergoing acute TBI rehabilitation may benefit from interventions that target their unique needs. Caregivers may require additional and longer-term supports to sustain treatment benefits.

Using Decision Tree Methodology to Predict Employment After Moderate to Severe Traumatic Brain Injury.

OBJECTIVE: To build decision tree prediction models for long-term employment outcomes of individuals after moderate to severe closed traumatic brain injury (TBI) and assess model accuracy in an independent sample. SETTING: TBI Model Systems Centers. PARTICIPANTS: TBI Model Systems National Database participants injured between January 1997 and January 2017 with moderate to severe closed TBI. Sample sizes were 7867 (year 1 postinjury), 6783 (year 2 postinjury), and 4927 (year 5 postinjury). DESIGN: Cross-sectional analyses using flexible classification tree methodology and validation using an independent subset of TBI Model Systems National Database participants. MAIN MEASURES: Competitive employment at 1, 2, and 5 years postinjury. RESULTS: In the final employment prediction models, posttraumatic amnesia duration was the most important predictor of employment in each outcome year. Additional variables consistently contributing were age, preinjury education, productivity, and occupational category. Generally, individuals spending fewer days in posttraumatic amnesia, who were competitively employed preinjury, and more highly educated had better outcomes. Predictability in test data sets ranged from a C-statistic of 0.72 (year 5; confidence interval: 0.68-0.76) to 0.77 (year 1; confidence interval: 0.74-0.80). CONCLUSION: An easy-to-use decision tree tool was created to provide prognostic information on long-term competitive employment outcomes in individuals with moderate to severe closed TBI. Length of posttraumatic amnesia, a clinical marker of injury severity, and preinjury education and employment status were the most important predictors.

Longitudinal Examination of Resilience After Traumatic Brain Injury: A Traumatic Brain Injury Model Systems Study.

OBJECTIVES: To evaluate (1) the trajectory of resilience during the first year after a moderate-severe traumatic brain injury (TBI); (2) factors associated with resilience at 3, 6, and 12 months postinjury; and (3) changing relationships over time between resilience and other factors. DESIGN: Longitudinal analysis of an observational cohort. SETTING: Five inpatient rehabilitation centers. PARTICIPANTS: Patients with TBI (N=195) enrolled in the resilience module of the TBI Model Systems study with data collected at 3-, 6-, and 12-month follow-up. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Connor-Davidson Resilience Scale. RESULTS: Initially, resilience levels appeared to be stable during the first year postinjury. Individual growth curve models were used to examine resilience over time in relation to demographic, psychosocial, and injury characteristics. After adjusting for these characteristics, resilience actually declined over time. Higher levels of resilience were related to nonminority status, absence of preinjury substance abuse, lower anxiety and disability level, and greater life satisfaction. CONCLUSIONS: Resilience is a construct that is relevant to understanding brain injury outcomes and has potential value in planning clinical interventions.

Family Needs on an Inpatient Brain Injury Rehabilitation Unit: A Quantitative Assessment.

OBJECTIVE: To examine the needs of family members in an inpatient setting and factors predicting extent to which needs are perceived as met. SETTING: University health system inpatient rehabilitation unit. PARTICIPANTS: Adult survivors of traumatic brain injury and family members (n = 85). DESIGN: Prospective, cross-sectional. MAIN MEASURE: Family Needs Questionnaire-Revised (FNQ-R). RESULTS: Needs related to the Health Information subscale were most frequently rated as met, whereas needs related to the Instrumental Support and Emotional Support subscales were most frequently rated as unmet. Predictors related to the FNQ-R included family income, gender, and ethnicity. For 4 of 6 subscales, white family members were more likely to rate needs as unmet than minority members. For 3 subscales, females were more likely to rate needs as unmet than males. Greater household income was associated with fewer met needs for 2 subscales. CONCLUSIONS: The ranking of met and unmet needs in the present study was remarkably similar to previous studies within and outside the United States. Clinicians should not assume that families with relatively higher incomes will experience fewer unmet needs. Through structured assessment, clinicians can reveal perceived needs that might have otherwise been unrecognized and facilitate appropriate supports. Findings provide direction for inpatient program development.

Efficacy of the resilience and adjustment intervention after traumatic brain injury: a randomized controlled trial.

OBJECTIVE: Examine a psychoeducational and skill-building intervention's effectiveness for individuals after traumatic brain injury (TBI), using a two-arm, parallel, randomized, controlled trial with wait-listed control. METHODS: The Resilience and Adjustment Intervention (RAI) targets adjustment challenges and emphasizes education, skill-building and psychological support. Overall, 160 outpatients were randomly assigned to a treatment or wait-list control (WLC) group. The manualized treatment was delivered in seven 1-h sessions. The Connor-Davidson Resilience Scale (CD-RISC) was the primary outcome measure. Secondary measures included the Mayo Portland Adaptability Inventory-4 (MPAI-4), Brief Symptom Inventory-18 (BSI-18) and 13-Item Stress Test. RESULTS: After adjusting for injury severity, education and time postinjury, the RAI group (N = 75) demonstrated a significantly greater increase in resilience (effect size = 1.03) compared to the WLC group (N = 73). Participants in the RAI group demonstrated more favourable scores on the MPAI-4 Adjustment and Ability Indices, BSI-18 and the 13-item Stress Test. However, only the CD-RISC and BSI-18 demonstrated a clinically significant difference. In addition, RAI participants demonstrated maintenance of gains from pre-treatment to 3-month follow-up; however, only the BSI-18 maintained a clinically significant difference. CONCLUSIONS: Investigation provided evidence that a resilience-focused intervention can improve psychological health and adjustment after TBI. Additional research is needed to ascertain the longer term benefits of intervention and the efficacy of alternative delivery methods (e.g., via telephone, Internet).

Relationship Stability After Traumatic Brain Injury Among Veterans and Service Members: A VA TBI Model Systems Study.

OBJECTIVE: To explore stability of relationships and predictors of change in relationship status 2 years following TBI/polytrauma. SETTING: Five Department of Veterans Affairs Polytrauma Rehabilitation Centers (VA PRCs). PARTICIPANTS: A total of 357 active duty service members and Veterans enrolled in the Veterans Affairs Polytrauma Rehabilitation Centers Traumatic Brain Injury Model Systems database with complete marital status information at 2 years postinjury. DESIGN: Prospective, longitudinal, multisite. MAIN MEASURES: Relationship status change was defined as change in marital status (single/never married; married; divorced/separated) at 2-year follow-up, compared with status at enrollment. RESULTS: At the time of enrollment, 134 participants (38%) were single/never married; 151 (42%) were married, and 72 (20%) were divorced/separated. Of those married at enrollment, 78% remained married at year 2 while 22% underwent negative change. Multivariable analyses revealed that age and education at the time of injury and mental health utilization prior to injury were significant predictors of relationship change. Among those who were single/divorced/separated at the time of enrollment, 87% remained so at year 2 while 13% underwent positive change. Injury during deployment significantly predicted positive relationship change. CONCLUSIONS: The unmalleable, preinjury characteristics identified may be used as potential triggers for education, prevention, surveillance, and couples therapy, if needed.

Resilience Following Traumatic Brain Injury: A Traumatic Brain Injury Model Systems Study.

OBJECTIVE: To examine resilience at 3 months after traumatic brain injury (TBI). DESIGN: Cross-sectional analysis of an ongoing observational cohort. SETTING: Five inpatient rehabilitation centers, with 3-month follow-up conducted primarily by telephone. PARTICIPANTS: Persons with TBI (N=160) enrolled in the resilience module of the TBI Model System study with 3-month follow-up completed. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Connor-Davidson Resilience Scale. RESULTS: Resilience scores were lower than those of the general population. A multivariable regression model, adjusting for other predictors, showed that higher education, absence of preinjury substance abuse, and less anxiety at follow-up were significantly related to greater resilience. CONCLUSIONS: Analysis suggests that lack of resilience may be an issue for some individuals after moderate to severe TBI. Identifying persons most likely at risk for low resilience may be useful in planning clinical interventions.

Theoretical Applications of Positive Psychology to Vocational Rehabilitation After Traumatic Brain Injury.

PURPOSE: Traumatic brain injury (TBI) produces broad-reaching and often persistent challenges that impact an individual's ability to engage in vocational productivity. Return to work (RTW) rates after TBI are markedly poor and the efficacy of current TBI vocational rehabilitation (VR) practices is unclear. Positive psychology, the practice of fostering positive emotions and traits, offers novel approaches that might enhance the effectiveness of existing TBI VR practices. This article assesses the potential relevance of positive psychology principles and practices to VR for clients recovering from TBI. METHODS: A literature search was conducted using the database resources of a large university hospital, including PubMed, ProQuest, PsycINFO, and Web of Science. Content from this search was reviewed and synthesized, including literature on VR for TBI, vocational applications of positive psychology, and general rehabilitation applications of positive psychology. RESULTS: Ten guiding principles for positively-informed TBI VR are proposed. Specific positive psychology measures and interventions for improving emotional, social, and cognitive functioning are identified and discussed as they might be applied to TBI VR. CONCLUSIONS: Theoretically, positive psychology principles and practices appear to be well suited to improving VR outcomes for individuals with TBI. In addition to examining the feasibility of incorporating positive psychology techniques, future research should examine the impact of positive psychology interventions on RTW rates, job satisfaction, job stability, and other vocational outcomes. With additional investigation, positive psychology measures and interventions may prove to be a beneficial compliment to existing VR practices.

Prevalence of traumatic brain injury in cocaine-dependent research volunteers.

BACKGROUND: There is a high prevalence of traumatic brain injury (TBI) among those with substance dependence. However, TBI often remains undiagnosed in these individuals, due to lack of routine screening in substance use treatment settings or due to overlap in some of the cognitive sequelae (eg impulsivity, disinhibition) of TBI and cocaine dependence. METHODS: The prevalence of self-reported mild to moderate TBI in a group of cocaine-dependent (n = 95) and a group of healthy volunteers (n = 75) enrolled at the same facility was assessed. Additionally, the relationship between TBI and clinically relevant correlates, including impulsivity, cocaine use history, and treatment outcome in the cocaine-dependent group was also examined. RESULTS: A higher proportion of individuals with cocaine dependence (29.5%) reported having suffered a TBI in their lifetime compared to controls (8%) on a Closed Head Injury scale. Among cocaine users, the average age of sustaining TBI was significantly lower than the age of initiating cocaine use. Presence of TBI was not associated with higher impulsivity on the Barratt Impulsiveness Scale-11 or self-reported years of cocaine use. No differences were noted on treatment outcome for cocaine dependence as measured by treatment effectiveness scores (TES) between cocaine users with TBI and their non-TBI counterparts. CONCLUSIONS: These results are the first to highlight the high prevalence of TBI among individuals with cocaine dependence. This study underscores the possible role of TBI history as a risk factor for onset of cocaine use, however, more research is needed to determine the impact of co-morbid TBI as a complicating factor in the substance abuse treatment setting.

Efficacy of the Brain Injury Family Intervention: Impact on Family Members.

OBJECTIVE: Examine the effectiveness of an intervention (Brain Injury Family Intervention) for family caregivers after acquired brain injury. RESEARCH DESIGN: Prospective, controlled repeated-measures design. METHODS: The Brain Injury Family Intervention was designed as a whole family approach to addressing needs, emphasizing education, skill building, and psychological support. One hundred eight families of outpatients were assigned to either a treatment or wait list control group. The manualized treatment focused on highly relevant topics (eg, common injury effects, coping with loss and change, communication, and stress management) and was composed of five 2-hour sessions with outcome measurement pretreatment, posttreatment, and at 3 months following. Outcome measures included the Family Needs Questionnaire, the Service Obstacles Scale, and the Zarit Burden Interview. RESULTS: Treatment group caregivers showed an increase in met needs, greater satisfaction with services, and reduced burden relative to pretesting, whereas controls did not. Between-group differences for Professional Support needs were identified. CONCLUSIONS: Investigation provided evidence that a curriculum-based education, skill-building, and support intervention can benefit caregivers for up to 3 months. Additional research is needed to ascertain the longer-term benefits of intervention and the efficacy of alternative delivery methods (eg, via telephone and the Internet).

Relationship Between Resilience, Adjustment, and Psychological Functioning After Traumatic Brain Injury: A Preliminary Report.

OBJECTIVE: To examine the relationship between resilience, psychological distress, adjustment, and community participation after traumatic brain injury (TBI). SETTING: Large university health system. PARTICIPANTS: Adult survivors of mild to severe TBI (N = 96). DESIGN: Descriptive, preliminary. MAIN MEASURES: The Connor-Davidson Resilience Scale (10-item version) was used to assess resilience, the Brief Symptom Inventory (BSI-18) was used to characterize psychological distress, and the Mayo-Portland Adaptability Index (MPAI-4) was used to measure ability, adjustment, and participation. RESULTS: Resilience scores were substantially lower than those of the general population. Significant relationships were found between resilience, psychological distress, and adjustment. Partial correlations (adjusting for the other MPAI-4 indices) showed significant correlation (P < .05) between MPAI-4 Adjustment and resilience. Partial correlations (adjusting for the other BSI-18 scales) also showed significance for Depression (P < .01) and resilience. Resilience scores differed significantly (P < .001) between individuals meeting BSI-18 caseness criteria for psychological distress (n = 55) and those not meeting criteria (n = 41). CONCLUSIONS: Individuals with TBI are at risk for low resilience, which was found to correlate with psychological distress and psychosocial maladjustment. Developing interventions to strengthen resilience skills has the potential to improve postinjury psychosocial adjustment, an important area for future research.

Relationships after TBI: a grounded research study.

BACKGROUND: While study on the emotional effects of traumatic brain injury (TBI) for individuals and caregivers has increased dramatically over the years, insufficient research has been performed on TBI's impact on the coupled relationship or the healing process successful couples go through following injury. As such, couples are left on their own to adjust to the complex challenges that TBI brings. METHODS: This qualitative study aims to develop a framework for conceptualizing and assessing couples after TBI. Additionally, it purposes to establish a foundation built upon the practises of successful couples that have subsisted TBI from which methods of treatment can be drawn. Existing personal narratives written by survivors of TBI and their caregivers were analysed. Data triangulation with clinician-authored literature was performed. Constant comparative analysis of the data was then performed through an involving substantive and theoretical coding. RESULTS: Five primary themes emerged: Ambiguous Losses, Identity Reformations, Tenuous Stability, Non Omnes Moriar and The New Us. From these, two grounded theories were developed: Relational Coring and Relational Recycling. CONCLUSIONS: These theories will allow researchers and practitioners to grasp the impact of TBI on the coupled relationship, familiarize themselves with the process by which relational experiences following TBI interact and understand the ways in which couples respond to these interacting experiences to work toward relational healing.

Assessment of sexuality following traumatic brain injury: validation of the Brain Injury Questionnaire of Sexuality.

BACKGROUND: The importance of effectively identifying and managing sexuality issues following acquired brain injury is being increasingly recognized within clinical and research domains. However, a tool specifically developed to measure sexuality following brain injury is yet to be validated. OBJECTIVES: In this study, the reliability and validity of the Brain Injury Questionnaire of Sexuality (BIQS) was evaluated. METHOD: Eight hundred and sixty-five people who had sustained traumatic brain injury participated in this study. All participants completed the BIQS, and a subsample also completed the Derogatis Interview for Sexual Functioning-Self-Report version (DISF-SR). RESULTS: Exploratory factor analysis supported a 3-subscale structure of the BIQS, which aligns with contemporary conceptual models of sexuality in chronic disease. All subscales of the BIQS demonstrated very good internal consistency. Convergent and divergent validity of all BIQS subscales was also demonstrated. CONCLUSIONS: Results from the study support the reliability and validity of the BIQS, which shows promise as a measurement tool for future traumatic brain injury sexuality research. Further validation work including evaluation for potential clinical applications is encouraged.

Embracing a new path to emotional recovery: adopting resilience theory in post-TBI psychotherapy.

In this commentary, clinical researchers examine the potential benefits of adopting Resilience Theory in the practice of psychotherapy after brain injury. This commentary presents the development of the paradigmatic shift that has given rise to the resilience movement. Additionally, the primary tenets of resilience theory are explored and the utility of the theory in practice is explained. Finally, an argument for the match between the hallmarks of resilient populations and the post-TBI needs related to emotional recovery is presented.

Neurobehavioural symptoms 1 year after traumatic brain injury: a preliminary study of the relationship between race/ethnicity and symptoms.

OBJECTIVE: To investigate whether White, African American and Hispanic individuals with a traumatic brain injury (TBI) express differences in neurobehavioural symptoms at 1 year post-injury after adjusting for demographic and injury characteristics. DESIGN: Retrospective study. PARTICIPANTS: One thousand, three hundred and thirty-nine individuals from the TBI Model Systems National Database with primarily moderate-to-severe TBI (978 White, 288 African American and 73 Hispanic) hospitalized between 1996 and 2001. MAIN OUTCOME MEASURES: Neurobehavioural Functioning Inventory (NFI) at 1 year post-injury. RESULTS: There were significant differences in NFI scores among the races/ethnicities for the depression, somatic, memory/attention, communication and motor subscales, after adjusting for demographic and injury characteristics; there were not significant differences in the aggression sub-scale. Hispanics had higher levels of symptom reporting than African Americans and Whites, while differences between African Americans and Whites were not significant. CONCLUSIONS: Hispanics scored significantly higher than Whites and African Americans on the sub-scales of the NFI, indicating more problems in these areas. Future research should focus on identifying factors that may contribute to the difference between the groups and treatment interventions should be implemented accordingly.

Marriage after brain injury: review, analysis, and research recommendations.

This critical review of the literature examines marriage after traumatic brain injury. Studies reporting information on marital stability rates and studies examining the quality of marriages through the assessment of at least 1 relational domain have been included for review. Available findings are presented along with information on methodological limitations and knowledge gaps. A rationale for the adoption of a marriage and family therapy framework to clarify remaining inconsistencies is presented. Furthermore, specific marriage and family therapy relational models and corresponding measurement instruments are outlined. Finally, suggestions for future research and potential implications for brain injury rehabilitation outcomes are discussed.

Efficacy of a brief acute neurobehavioural intervention following traumatic brain injury: a preliminary investigation.

PRIMARY OBJECTIVE: To evaluate the effectiveness of a brief acute neurobehavioural intervention, the First Steps Acute Neurobehavioural and Cognitive Intervention (FANCI), with persons who have traumatic brain injury (TBI). RESEARCH DESIGN: Prospective, controlled, repeated measures design. METHODS AND PROCEDURES: Seventy-two patients in acute TBI rehabilitation participated either as FANCI subjects or as control participants who watched videos to control for time and attention. Outcome measures included the Neurobehavioural Rating Scale-Revised (NRS-R), Functional Independence Measure (FIM™), a FANCI Learning Assessment (LA) and the Satisfaction with Life Scale (SWLS). MAIN OUTCOMES AND RESULTS: In comparison with controls, FANCI participants had significantly greater neurobehavioural (cognitive, emotional and behavioural) as well as FIM motor improvements. Significantly greater learning occurred and persisted over time for FANCI subjects as compared to controls. Pre-treatment cognitive and neurobehavioural status, length of coma and number of sessions completed were moderating variables for functional and cognitive outcomes. CONCLUSIONS: Persons with TBI can benefit from comprehensive, manualized neurobehavioural interventions, over and above standard rehabilitation care, even during the acute phase of recovery.