Publications by authors named "Jennie Ponsford"

286 Publications

Cognitive behavioural therapy versus health education for sleep disturbance and fatigue after acquired brain injury: a pilot randomised trial.

Ann Phys Rehabil Med 2021 Jul 23:101560. Epub 2021 Jul 23.

Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, VIC, Australia; Monash Epworth Rehabilitation Research Centre, Melbourne, VIC, Australia.

Background: Sleep disturbance and fatigue are highly prevalent after acquired brain injury (ABI) and are associated with poor functional outcomes. Cognitive behavioural therapy (CBT) is a promising treatment for sleep and fatigue problems after ABI, although comparison with an active control is needed to establish efficacy.

Objectives: We compared CBT for sleep disturbance and fatigue (CBT-SF) with a health education (HE) intervention to control for non-specific therapy effects.

Methods: In a parallel-group, pilot randomised controlled trial, 51 individuals with traumatic brain injury (n=22) and stroke (n=29) and clinically significant sleep and/or fatigue problems were randomised 2:1 to 8 weeks of a CBT-SF (n=34) or HE intervention (n=17), both adapted for cognitive impairments. Participants were assessed at baseline, post-treatment, and 2 and 4 months post-treatment. The primary outcome was the Pittsburgh Sleep Quality Index; secondary outcomes included measures of fatigue, sleepiness, mood, quality of life, activity levels, self-efficacy and actigraphy sleep measures.

Results: The CBT-SF led to significantly greater improvements in sleep quality as compared with HE, during treatment and at 2 months [95% confidence interval (CI) -24.83; -7.71], as well as significant reductions in fatigue maintained at all time points, which were not evident with HE (95% CI -1.86; 0.23). HE delayed improvement in sleep quality at 4 months post-treatment and in depression (95% CI -1.37; -0.09) at 2 months post-treatment. CBT-SF led to significant gains in self-efficacy (95% CI 0.15; 0.53) and mental health (95% CI 1.82; 65.06).

Conclusions: CBT-SF can be an effective treatment option for sleep disturbance and fatigue after ABI, over and above HE. HE may provide delayed benefit for sleep, possibly by improving mood.

Trial Registration: Australia New Zealand Clinical Trials Registry: ACTRN12617000879369 (registered 15/06/2017) and ACTRN12617000878370 (registered 15/06/2017).
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http://dx.doi.org/10.1016/j.rehab.2021.101560DOI Listing
July 2021

Individualized goal attainment scaling during a trial of positive behaviour support in adults with acquired brain injury.

Neuropsychol Rehabil 2021 Jul 13:1-19. Epub 2021 Jul 13.

Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia.

Background: Challenging behaviours after acquired brain injury (ABI) cause distress and reduce community participation. Evidence-based and effective interventions are needed. Positive Behaviour Support (PBS) interventions, such as PBS + PLUS, are person-driven and context-sensitive approaches which aim to improve quality of life and enhance behavioural self-regulation. This study aimed to expand the empirical outcomes of a recent waitlist-controlled trial of PBS + PLUS by examining individualized goal attainment.

Method: Participants were 44 adults with severe ABI sustained on average nine years previously (Range = 0.6-26) from the combined trial cohort who completed the intervention. Using Goal Attainment Scaling, trial therapists developed and reviewed goals collaboratively with the person with ABI and their natural supports.

Results: The 182 goals in the sample focussed on psychological wellbeing, interpersonal relationships, routines and self-care. By the end of 12-month intervention, 84.6% of goals were achieved and 53.3% exceeded their expected outcome.

Conclusions: These findings indicate high levels of personally meaningful outcomes in a broad range of life-domains can be obtained for participants with severe ABI using PBS + PLUS. Whilst these results should be considered in combination with the findings of the waitlist-controlled trial, they contribute to the growing literature regarding benefits of PBS in enhancing quality of life post-ABI.

Trial Registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12616001704482.
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http://dx.doi.org/10.1080/09602011.2021.1947325DOI Listing
July 2021

"I've never been positive … I am now": Participant perspectives of a Positive Behaviour Support intervention (PBS + PLUS) for community-living individuals with ABI and their close others.

Neuropsychol Rehabil 2021 Jul 8:1-18. Epub 2021 Jul 8.

Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia.

Challenging behaviours are common following moderate to severe acquired brain injury (ABI). These behaviours cause relationship and community participation difficulties and are a significant source of stress for many individuals with ABI and their close others (COs). A Positive Behaviour Support intervention, PBS + PLUS, was implemented to assist individuals with ABI to collaboratively build meaningful lives and self-regulate their behaviour. This study explored the perspectives of individuals with ABI and COs (family members, friends, and carers) who had completed an individualized 12-month PBS + PLUS intervention. Fifty-two individuals participated in semi-structured interviews, and a thematic analysis of interview transcripts identified the interrelated themes of Openness to Change, Embeddedness, Clinician Connection, and Preparedness for the Future. Participant perceptions of, and engagement with, PBS + PLUS were influenced by an attitude of openness to new ideas and by the intervention itself. Achieving contextual relevance allowed the intervention to become embedded in participants' lives, and the client-clinician relationship was central to participants' positive experiences. While most participants felt better equipped to cope with the future, some experienced difficulties transitioning to post-intervention life. These results suggest PBS + PLUS may assist individuals with ABI to lead meaningful lives and more confidently overcome behavioural challenges, while encouraging supportive and empowered COs.
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http://dx.doi.org/10.1080/09602011.2021.1947326DOI Listing
July 2021

Home-based light therapy for fatigue following acquired brain injury: a pilot randomized controlled trial.

BMC Neurol 2021 Jul 5;21(1):262. Epub 2021 Jul 5.

Monash Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia.

Background And Objectives: Fatigue and sleep disturbance are debilitating problems following brain injury and there are no established treatments. Building on demonstrated efficacy of blue light delivered via a lightbox in reducing fatigue and daytime sleepiness after TBI, this study evaluated the efficacy of a novel in-home light intervention in alleviating fatigue, sleep disturbance, daytime sleepiness and depressive symptoms, and in improving psychomotor vigilance and participation in daily productive activity, following injury METHODS: The impact of exposure to a dynamic light intervention (Treatment) was compared to usual lighting (Control) in a randomized within-subject, crossover trial. Outcomes were fatigue (primary outcome), daytime sleepiness, sleep disturbance, insomnia symptoms, psychomotor vigilance, mood and activity levels. Participants (N = 24, M ± SD = 44.3 ± 11.4) had mild-severe TBI or stroke > 3 months previously, and self-reported fatigue (Fatigue Severity Scale ≥ 4). Following 2-week baseline, participants completed each condition for 2 months in counter-balanced order, with 1-month follow-up. Treatment comprised daytime blue-enriched white light (CCT > 5000 K) and blue-depleted light (< 3000 K) 3 h prior to sleep.

Results: Random-effects mixed-model analysis showed no significantly greater change in fatigue on the Brief Fatigue Inventory during Treatment, but a medium effect size of improvement (p = .33, d = -0.42). There were significantly greater decreases in sleep disturbance (p = .004), insomnia symptoms (p = .036), reaction time (p = .004) and improvements in productive activity (p = .005) at end of Treatment relative to Control, with large effect sizes (d > 0.80). Changes in other outcomes were non-significant.

Conclusions: This pilot study provides preliminary support for in-home dynamic light therapy to address sleep-related symptoms in acquired brain injury.

Trial Registration: This trial was registered with the Australian and New Zealand Clinical Trials Registry on 13 June 2017, www.anzctr.org.au , ACTRN12617000866303.
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http://dx.doi.org/10.1186/s12883-021-02292-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8256500PMC
July 2021

Survey on the experiences, attitudes, and training needs of Australian healthcare professionals related to sexuality and service delivery in individuals with acquired brain injury.

Neuropsychol Rehabil 2021 May 28:1-21. Epub 2021 May 28.

Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia.

Following acquired brain injury (ABI), sexuality, self-esteem and practices are often negatively impacted. Whilst sexuality is recognized as an essential part of a person's life regardless of medical condition, it is poorly understood in the ABI rehabilitation context. This study examined current assessment and treatment practices for sexual health and wellbeing in ABI rehabilitation, including perceived barriers and facilitators to discussing sexuality with individuals after ABI. We also assessed the need for further education and training in this area. Two hundred and thirty-nine Australian healthcare professionals predominantly working with both traumatic brain injury (TBI) and stroke populations completed an online survey comprising thirty-four questions. The 12-item sexuality attitudes and beliefs survey (SABS) was included as an additional objective outcome measure. Findings suggest that healthcare professionals infrequently raise sexuality with individuals with ABI. Inadequate education and training, not knowing whose role it is and when to raise the topic, and the view that individuals with ABI will ask for the information were all identified as key barriers contributing to poor sexuality management after ABI. More education and training opportunities with greater access to resources are needed to facilitate the incorporation of sexuality into routine practice across the continuum of ABI care.
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http://dx.doi.org/10.1080/09602011.2021.1934486DOI Listing
May 2021

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

J Int Neuropsychol Soc 2021 May 17:1-9. Epub 2021 May 17.

Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Victoria, Australia.

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.
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http://dx.doi.org/10.1017/S1355617721000588DOI Listing
May 2021

Cognitive and vocational rehabilitation after mild-to-moderate traumatic brain injury: A randomised controlled trial.

Ann Phys Rehabil Med 2021 Jul 22;64(5):101538. Epub 2021 Jul 22.

Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway; Department of Psychology, University of Oslo, Oslo, Norway.

Background: Returning to work is often a primary rehabilitation goal after traumatic brain injury (TBI). However, the evidence base for treatment options regarding return to work (RTW) and stable work maintenance remains scarce.

Objective: This study aimed to examine the effect of a combined cognitive and vocational intervention on work-related outcomes after mild-to-moderate TBI.

Methods: In this study, we compared 6 months of a combined compensatory cognitive training and supported employment (CCT-SE) intervention with 6 months of treatment as usual (TAU) in a randomised controlled trial to examine the effect on time to RTW, work percentage, hours worked per week and work stability. Eligible patients were those with mild-to-moderate TBI who were employed ≥50% at the time of injury, 18 to 60 years old and sick-listed ≥50% at 8 to 12 weeks after injury due to post-concussion symptoms, assessed by the Rivermead Post Concussion Symptoms Questionnaire. Both treatments were provided at the outpatient TBI department at Oslo University Hospital, and follow-ups were conducted at 3, 6 and 12 months after inclusion.

Results: We included 116 individuals, 60 randomised to CCT-SE and 56 to TAU. The groups did not differ in characteristics at the 12-month follow-up. Overall, a high proportion had returned to work at 12 months (CCT-SE, 90%; TAU, 84%, P=0.40), and all except 3 were stably employed after the RTW. However, a significantly higher proportion of participants in the CCT-SE than TAU group had returned to stable employment at 3 months (81% vs. 60%, P=0.02).

Conclusion: These results suggest that the CCT-SE intervention might help patients with mild-to-moderate TBI who are still sick-listed 8 to 12 weeks after injury in an earlier return to stable employment. However, the results should be replicated and a cost-benefit analysis performed before concluding.
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http://dx.doi.org/10.1016/j.rehab.2021.101538DOI Listing
July 2021

Managing agitation during early recovery in adults with traumatic brain injury: An international survey.

Ann Phys Rehabil Med 2021 Jul 15;64(5):101532. Epub 2021 Jul 15.

Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia; Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia; Rehabilitation and Mental Health Division, Epworth Healthcare, Melbourne, Australia.

Background: Managing agitation is a significant challenge in the early stages of recovery after traumatic brain injury (TBI), and research investigating current practice during this period is lacking.

Objectives: This study examined how clinicians worldwide conceptualise, measure and manage agitation during early TBI recovery.

Methods: A cross-sectional anonymous online survey was distributed via email, newsletters, conferences and social media to clinicians involved in early TBI care worldwide. Respondents were 331 clinicians (66% female) from 34 countries worldwide who worked in inpatient and outpatient settings in disciplines including medicine, nursing and allied health. Participants had an average of 13 years' clinical experience working specifically with an adult TBI population.

Results: Agitated behaviour was commonly defined as aggression and restlessness. Three quarters of clinicians reported that their services measure agitation, and clinicians in North America more frequently use standardised assessment tools. Common non-pharmacological approaches used across all regions surveyed included providing familiarising information (85%) and environmental cues (82%), managing patients in single rooms (81%) and reducing noise levels (80%). Most clinicians (90%) reported pharmacology use, particularly atypical antipsychotic agents. Clinicians' mean rating of confidence in managing agitation was 7 out of 10 (10 being excellent) and was higher for services that provided staff with written guidelines for agitation management. Only half of clinicians reported sufficient training for managing agitation and 52% were satisfied with current agitation management practices.

Conclusions: Despite high rates of agitation measurement and management, many clinicians reported dissatisfaction with current agitation management and insufficient training. This study supports the development of international guidelines and training to ensure consistent and effective agitation management in early TBI care.
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http://dx.doi.org/10.1016/j.rehab.2021.101532DOI Listing
July 2021

Does cognitive decline occur decades after moderate to severe traumatic brain injury? A prospective controlled study.

Neuropsychol Rehabil 2021 Apr 15:1-20. Epub 2021 Apr 15.

Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia.

This prospective controlled study examined long-term trajectories of neuropsychological performance in individuals with traumatic brain injury (TBI) compared to healthy controls, and the impact of IQ, age at injury, time since injury, and injury severity on change over time. Fifty-three individuals with moderate to severe TBI (60.37% male; = 59.77 yrs, SD= 14.03), and 26 controls (46.15% male; = 63.96 yrs, SD= 14.42) were studied prospectively ( = 12.72 yrs between assessments). Participants completed measures of premorbid IQ (Weschler Test of Adult Reading), processing speed (Digit Symbol Coding Test), working memory (Digit Span Backwards), memory (Rey Auditory Verbal Learning Test) and executive function (Trail Making Test Part B; Hayling Errors), at a mean of 10.62 yrs (Initial) and 23.91 yrs (Follow-Up) post injury. Individuals with TBI did not show a significantly greater decline in neuropsychological performance over time compared with demographically similar controls. There was no association between change over time with IQ, time since injury or injury severity. Being older at injury had a greater adverse impact on executive function at follow-up. In this small sample, a single moderate to severe TBI was not associated with ongoing cognitive decline up to three decades post injury. Changes in cognitive function were similar between the groups and likely reflect healthy aging.
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http://dx.doi.org/10.1080/09602011.2021.1914674DOI Listing
April 2021

Investigating feasibility and preliminary efficacy of a simulator-based driving intervention for people with acquired brain injury: A randomised controlled pilot study.

Clin Rehabil 2021 Apr 2:2692155211002455. Epub 2021 Apr 2.

School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia.

Objective: To investigate the feasibility and preliminary efficacy of a driving simulator intervention on driving outcomes following acquired brain injury.

Design: Pilot randomised controlled trial.

Setting: Occupational therapy driver assessment and rehabilitation service.

Subjects: Individuals post-acquired brain injury aiming to return to driving.

Intervention: Eight sessions of simulated driver training over four weeks, in addition to usual care. Control: Usual care only.

Main Measures: Feasibility outcomes: Participant recruitment and retention; data completeness; therapy attendance and fidelity; adverse events. Performance outcomes: on-road driving performance; Simulator Sickness Questionnaire; Brain Injury Driving Self-Awareness Measure and Driving Comfort Scale - Daytime, assessed at baseline and five weeks post-randomisation.

Results: Out of 523 individuals screened, 22 (4%) were recruited and randomised, with 20 completing their allocated group ( = 12 Simulator,  = 8 Usual Care). For those who completed training, session attendance was 100% with simulator sickness rated, on average, as mild. Six individuals (50%) in the Simulator group failed the on-road assessment, versus two (25%) in the Usual Care group ( = 0.373). On average, the Simulator group reported a positive change in confidence ratings ( = 5.77, SD = 13.96) compared to the Usual Care group, who reported a negative change ( = -6.97, SD = 8.47),  = 0.034. The Simulator group ( = 0.67, SD = 3.34) demonstrated no significant change in self-awareness relative to the Usual Care group ( = -0.83, SD = 1.83,  = 0.325).

Conclusions: With adjustments to inclusion criteria and recruitment strategies, it may be feasible to deliver the intervention and conduct a larger trial. There is potential benefit of simulator training for improving driver confidence after acquired brain injury.
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http://dx.doi.org/10.1177/02692155211002455DOI Listing
April 2021

The bidirectional relationship between sleep and physical activity following traumatic brain injury.

J Sleep Res 2021 Mar 15:e13334. Epub 2021 Mar 15.

Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Vic., Australia.

Sleep and physical activity are both modifiable behavioural factors that are associated with better health and are potentially related. Following traumatic brain injury, damage to the brain caused by an external force, sleep disturbances are common. Exploring bidirectional relationships between sleep and physical activity might provide insight into whether increasing physical activity could decrease these sleep disturbances. The current study, therefore, examined inter- and intra-individual temporal associations between sleep and daytime physical activity in 64 people with traumatic brain injury reporting sleep problems or fatigue (47 males; mean age, 40 years). Sleep and physical activity were measured using actigraphy with corroborating sleep diaries over 14 consecutive days. Multilevel models were used to examine inter- and intra-individual associations between physical activity and sleep. Inter-individual variations showed that earlier bedtimes, earlier wake-up times and lower sleep efficiency were associated with more physical activity. Intra-individual temporal variations showed no significant association of daytime physical activity with sleep duration or continuity. However, shorter sleep time and less wake after sleep onset than usual were associated with more time spent in light-intensity activity the next day. Therefore, sleep may have more of an influence on physical activity than physical activity has on sleep in people with traumatic brain injury. In conclusion, the results do not confirm a potential beneficial effect of physical activity on sleep but suggest that improving sleep quality might be relevant to support of a physically active lifestyle in people with traumatic brain injury. Further research is necessary to confirm these results.
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http://dx.doi.org/10.1111/jsr.13334DOI Listing
March 2021

Poorer sleep quality predicts melatonin response in TBI patients: findings from a randomized controlled trial.

J Clin Sleep Med 2021 Mar 11. Epub 2021 Mar 11.

Monash-Epworth Rehabilitation Research Centre, Epworth HealthCare, Richmond, VIC, Australia.

Study Objectives: A recent clinical trial demonstrated that melatonin treatment was effective in improving self-perceived sleep quality in patients with TBI; however, it remains unclear which patients benefited from melatonin treatment. To that end, findings from the clinical trial were re-examined to identify possible predictors of treatment response.

Methods: Hierarchical multiple regression was utilized to identify patient characteristics, TBI injury characteristics, and self-report measures assessing sleep, fatigue, mood, and anxiety symptomatology that may uniquely explain a change in self-reported sleep quality scores (follow-up minus baseline score) as assessed by the Pittsburgh Sleep Quality Index(PSQI).

Results: After controlling for patient demographic and TBI injury-related variables, baseline self-report measures of sleep, fatigue, mood, and anxiety explained an additional 32% of the variance in change in PSQI scores. However, only baseline PSQI score made a unique and statistically significant contribution (β = -.56, p = .006). After controlling for patient and TBI characteristics, baseline PSQI scores further explained 27% of the variance in change in PSQI scores, R squared change = .27, F change (1, 27) = 11.79, p = .002). The standardized beta for baseline PSQI score revealed a statistically significant negative relationship with change in PSQI score (β = -.54, p = .002) revealing that higher PSQI score at baseline was associated with better sleep outcomes.

Conclusions: In a sample comprising predominately severe TBI and comorbid insomnia, participants who report poorer sleep quality have the most to gain from melatonin treatment irrespective of time since injury, demographics, fatigue, daytimes sleepiness, mood, and anxiety symptomology.

Clinical Trial Registration: The manuscript reports on a clinical trial which was prospectively registered with the Australian New Zealand Clinical Trials Registry on the 13th of July, 2011. Identifier: ACTRN12611000734965 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=343083&showOriginal=true&isReview=true.
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http://dx.doi.org/10.5664/jcsm.9234DOI Listing
March 2021

Evaluating telehealth delivery of a compensatory memory rehabilitation programme following stroke: A single-case experimental design.

Neuropsychol Rehabil 2021 Mar 8:1-25. Epub 2021 Mar 8.

Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia.

Rehabilitation of memory remains an unmet need for many stroke survivors. Telehealth methods may provide a solution, however evidence supporting the efficacy of remotely-delivered therapy is needed. A non-concurrent multiple baseline design was used with randomized onset of intervention across five individuals with chronic stroke-related memory complaints. A six-week compensatory memory skills programme was delivered individually via internet videoconferencing. Target behaviours of frequencies of self-reported lapses of everyday and prospective memory were measured weekly across baseline, intervention, and follow-up phases. A secondary outcome of functional goal attainment was measured once per phase, with participants setting two personal rehabilitation goals. Data were analysed visually and statistically. Improvements in memory functioning were statistically significant on at least one measure of target behaviour for four out of five participants at intervention or follow-up. Visual evidence of level change indicated at least modest improvements for all participants by follow-up. All participants attained at least one functional goal by follow-up. High rates of treatment adherence and participant satisfaction were observed. Technological issues were minimal and did not impact content delivery or engagement. These results provide preliminary support for the efficacy of a telehealth-delivered rehabilitation programme in improving memory function and achieving memory-related goals for stroke survivors.
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http://dx.doi.org/10.1080/09602011.2020.1843500DOI Listing
March 2021

Effectiveness of pharmacotherapy for depression after traumatic brain injury in adults: an umbrella review protocol.

JBI Evid Synth 2021 Jan 29. Epub 2021 Jan 29.

Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, VIC, Australia Department of Psychiatry, University of Melbourne, Melbourne, VIC, Australia Department of Forensic Medicine, Monash University, Southbank, VIC, Australia Professorial Psychiatry Unit Albert Road Clinic, Department of Psychiatry, University of Melbourne, Melbourne, VIC, Australia.

Objective: The objective of this review is to synthesize systematic reviews of the effectiveness of pharmacotherapy vs any other comparator for the management of post-traumatic brain injury depression in adults.

Introduction: Depression following a traumatic brain injury can have a considerable impact on the life of the individual, their family members, and the health care system. There have been several recent systematic reviews and meta-analyses on pharmacologic treatment for depression post-traumatic brain injury. These reviews differ in conduct, quality, and reporting, and have discordant results and conclusions. Therefore, an umbrella review can provide prescribers with a summary of the evidence.

Inclusion Criteria: This review will consider systematic reviews of studies of adults 16 years or older who have sustained a traumatic brain injury of any severity at any time in the past, who are receiving pharmacotherapy for depression of any severity in any health care setting. Studies that include the following outcomes will be considered: change in symptoms of depression and occurrence of harms.

Methods: MEDLINE, Embase, CINAHL, PsycINFO, Cochrane Database of Systematic Reviews, Epistemonikos, and PROSPERO will be searched, as well as Google Scholar, ResearchGate, TRIP Medical Database, and hand searching journals. There will be no restriction on publication date. Only systematic reviews published in English will be considered. Screening of articles, assessment of methodological quality, and data extraction will be performed independently by two reviewers. A Grading of Recommendations, Assessment, Development and Evaluation Summary of Findings will be presented. Data will be summarized in narrative form with supporting tables.

Systematic Review Registration Number: PROSPERO CRD42020184915.
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http://dx.doi.org/10.11124/JBIES-20-00363DOI Listing
January 2021

Case Report: F-MK6240 Tau Positron Emission Tomography Pattern Resembling Chronic Traumatic Encephalopathy in a Retired Australian Rules Football Player.

Front Neurol 2020 22;11:598980. Epub 2020 Dec 22.

Department of Molecular Imaging & Therapy, Austin Health, Heidelberg, VIC, Australia.

It remains unclear if tau imaging may assist diagnosis of chronic traumatic encephalopathy (CTE). Flortaucipir PET has shown superior frontal with medial temporal tau binding consistent with the provisional neuropathological criteria for mid-stage CTE in group-level analyses of retired symptomatic NFL players and in one individual with pathologically confirmed CTE. F-MK6240 is a new PET ligand that has high affinity for tau. We present the case of a 63-year-old cognitively impaired, former Australian rules football player with distinct superior frontal and medial temporal F-MK6240 binding and show it to be significantly different to the pattern seen in prodromal Alzheimer's disease (AD). The participant was recruited for a study of amyloid-β and tau several decades after traumatic brain injury. He had multiple concussions during his football career but no cognitive complaints at retirement. A thalamic stroke in his mid 50s left stable mild cognitive deficits but family members reported further short-term memory, behavioral, and personality decline preceding the study. Imaging showed extensive small vessel disease on MRI, a moderate burden of amyloid-β plaques, and F-MK6240 binding in bilateral superior frontal and medial temporal cortices. Voxel-wise analysis demonstrated that the frontally predominant pattern of the participant was significantly different to the posterior temporo-parietal predominant pattern of prodromal AD. Although lacking neuropathological examination to distinguish CTE from a variant of AD, the clear demonstration of a CTE-like tau pattern in a single at-risk individual suggests further research on the potential of F-MK6240 PET for identifying CTE is warranted.
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http://dx.doi.org/10.3389/fneur.2020.598980DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7783156PMC
December 2020

Comparing Performance Across In-person and Videoconference-Based Administrations of Common Neuropsychological Measures in Community-Based Survivors of Stroke.

J Int Neuropsychol Soc 2020 Dec 9:1-14. Epub 2020 Dec 9.

School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia.

Objective: Neuropsychological assessment via videoconference could assist in bridging service access gaps due to geographical, mobility, or infection control barriers. We aimed to compare performances on neuropsychological measures across in-person and videoconference-based administrations in community-based survivors of stroke.

Method: Participants were recruited through a stroke-specific database and community advertising. Stroke survivors were eligible if they had no upcoming neuropsychological assessment, concurrent neurological and/or major psychiatric diagnoses, and/or sensory, motor, or language impairment that would preclude standardised assessment. Thirteen neuropsychological measures were administered in-person and via videoconference in a randomised crossover design (2-week interval). Videoconference calls were established between two laptop computers, facilitated by Zoom. Repeated-measures t tests, intraclass correlation coefficients (ICCs), and Bland-Altman plots were used to compare performance across conditions.

Results: Forty-eight participants (26 men; Mage = 64.6, SD = 10.1; Mtime since stroke = 5.2 years, SD = 4.0) completed both sessions on average 15.8 (SD = 9.7) days apart. For most measures, the participants did not perform systematically better in a particular condition, indicating agreement between administration methods. However, on the Hopkins Verbal Learning Test - Revised, participants performed poorer in the videoconference condition (Total Recall Mdifference = -2.11). ICC estimates ranged from .40 to .96 across measures.

Conclusions: This study provides preliminary evidence that in-person and videoconference assessment result in comparable scores for most neuropsychological tests evaluated in mildly impaired community-based survivors of stroke. This preliminary evidence supports teleneuropsychological assessment to address service gaps in stroke rehabilitation; however, further research is needed in more diverse stroke samples.
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http://dx.doi.org/10.1017/S1355617720001174DOI Listing
December 2020

Outcomes 1 and 2 Years After Moderate to Severe Traumatic Brain Injury: An International Comparative Study.

Arch Phys Med Rehabil 2021 03 22;102(3):371-377. Epub 2020 Oct 22.

Department of Physical Medicine & Rehabilitation, The Ohio State University, Columbus, Ohio.

Objective: This study compared traumatic brain injury (TBI) outcomes from 2 cohorts: the National Institute on Disability, Independent Living, and Rehabilitation Research Traumatic Brain Injury Model Systems (TBIMS) in the United States and Longitudinal Head Injury Outcome Study conducted in Victoria, Australia, by the Monash Epworth Rehabilitation Research Centre (MERRC).

Design: Cohort study with 1- and 2-year follow-up.

Setting: Acute trauma care and inpatient rehabilitation with follow-up.

Participants: Patients (N=1056) with moderate-severe TBI admitted in 2000-2012 to inpatient rehabilitation after motor vehicle-related collisions, who completed follow-up, were matched using 1:2 matching algorithm based on age at injury, days of posttraumatic amnesia, and years education, resulting in groups of 352 (MERRC) and 704 patients (TBIMS).

Intervention: The cohorts had received acute trauma care and inpatient rehabilitation for a median 38 (MERRC) or 33 days (TBIMS). The MERRC group also had routine access to community-based support and rehabilitation for return to work or school, attendant care, and home help as justified, funded by an accident compensation system, whereas the TBIMS cohort had variable access to these services.

Main Outcome Measures: Outcomes were assessed 1 and 2 years post injury in terms of employment, living situation, marital status, and Glasgow Outcome Scale-Extended (GOS-E) scores.

Results: At 2 years post injury, MERRC participants were more likely to be competitively employed. At both 1 and 2 years post injury, MERRC participants were more likely to be married and living independently. On GOS-E, the TBIMS group had higher percentages of patients in Lower Severe Disability/Vegetative State and Upper Good Recovery than MERRC participants, whereas the MERRC cohort had higher percentages of Lower Moderate Disability than TBIMS.

Conclusions: Findings may suggest that routine provision of community-based supports could confer benefits for long-term TBI outcomes. Further studies documenting rehabilitation services are needed to explore this.
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http://dx.doi.org/10.1016/j.apmr.2020.09.387DOI Listing
March 2021

Effectiveness of non-pharmacological interventions for managing agitation during post-traumatic amnesia following traumatic brain injury: a systematic review protocol.

JBI Evid Synth 2021 02;19(2):499-512

Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Vic, Australia.

Objective: To synthesize current evidence on the effects and harms of non-pharmacological interventions for managing agitation during post-traumatic amnesia in adults who have sustained a traumatic brain injury.

Introduction: Agitation is one of the most disruptive and clinically significant sequelae observed during post-traumatic amnesia. Patients who experience agitation during this period demonstrate reduced engagement in rehabilitation and poorer long-term functional outcomes. Agitation also poses a risk to staff and patient safety. Research for the effects of pharmacological intervention for managing agitation during this period is inconclusive. Thus, synthesis of the research for non-pharmacological interventions for reducing agitation during post-traumatic amnesia is essential for improving long-term outcomes for survivors of traumatic brain injury.

Inclusion Criteria: Studies will be considered if they include participants aged 16 years and older who exhibit agitated behaviors during post-traumatic amnesia after sustaining a traumatic brain injury (irrespective of severity or mechanism). Studies will be considered if they evaluate any non-pharmacological intervention for reducing agitation, with all types of comparators accepted. Primary outcomes of interest include a change in agitation severity and any adverse effects.

Methods: Key information sources include MEDLINE Ovid SP interface, PubMed, CINAHL, Excerpta Medica Database, PsycINFO, and Cochrane CENTRAL. Studies published in English will be included, irrespective of publication year. Two independent reviewers will be involved in study selection and data extraction. Eligible studies will be critically appraised for methodological quality. Studies will be pooled with statistical meta-analysis where possible; otherwise findings will be reported in narrative form.

Systematic Review Registration Number: PROSPERO CRD42020186802.
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http://dx.doi.org/10.11124/JBIES-20-00216DOI Listing
February 2021

Assessment and Management of Patients in the Acute Stages of Recovery after Traumatic Brain Injury in Adults: A Worldwide Survey.

J Neurotrauma 2021 Apr 14;38(8):1060-1067. Epub 2020 Dec 14.

Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Victoria, Australia.

Most individuals with traumatic brain injury (TBI) experience a period of confusion after emergence from coma, termed post-traumatic amnesia, post-traumatic confusional state, or delirium. Recent guidelines suggest the importance of assessment and consistent management during this phase, but current practice worldwide remains unknown. This survey aimed to elucidate current international practice in assessment and treatment of patients in the acute stages of recovery after TBI. The web-based survey was distributed to clinicians working with patients with acute TBI. There were 400 participants (68.8% females), from 41 countries, mostly neuropsychologists, rehabilitation physicians, and occupational therapists (OTs), with an average 12.8 years of experience. Of those working with adults ( = 376, 94%), most described this acute period as post-traumatic amnesia and used its duration to indicate injury severity. More than 85% used a tool to assess patients; in order of frequency, the Glasgow Coma Scale (GCS), Westmead PTA Scale (WPTAS), Galveston Orientation and Amnesia Test, Rancho Los Amigos Scale, and O-Log. Meeting criteria on the assessment tool or clinical judgment determined emergence from this phase, indicated by recovery of orientation, day-to-day memories, and ability to follow commands or participate in rehabilitation. Most patients had physiotherapy, OT, speech therapy, and environmental changes, with a third of participants indicating sedating medication was prescribed during this phase. Findings suggest that, consistent with guidelines, PTA is a widely recognized and measured TBI recovery phase, used to determine injury severity and readiness for therapy.
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http://dx.doi.org/10.1089/neu.2020.7299DOI Listing
April 2021

Depression prevalence using the HADS-D compared to SCID major depression classification: An individual participant data meta-analysis.

J Psychosom Res 2020 12 23;139:110256. Epub 2020 Sep 23.

Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands; Faculty of Psychology, Open University of the Netherlands, Heerlen, The Netherlands; Department of Health Services Research, CAPHRI School for Public Health and Primary, Maastricht University, Maastricht, The Netherlands. Electronic address:

Objectives: Validated diagnostic interviews are required to classify depression status and estimate prevalence of disorder, but screening tools are often used instead. We used individual participant data meta-analysis to compare prevalence based on standard Hospital Anxiety and Depression Scale - depression subscale (HADS-D) cutoffs of ≥8 and ≥11 versus Structured Clinical Interview for DSM (SCID) major depression and determined if an alternative HADS-D cutoff could more accurately estimate prevalence.

Methods: We searched Medline, Medline In-Process & Other Non-Indexed Citations via Ovid, PsycINFO, and Web of Science (inception-July 11, 2016) for studies comparing HADS-D scores to SCID major depression status. Pooled prevalence and pooled differences in prevalence for HADS-D cutoffs versus SCID major depression were estimated.

Results: 6005 participants (689 SCID major depression cases) from 41 primary studies were included. Pooled prevalence was 24.5% (95% Confidence Interval (CI): 20.5%, 29.0%) for HADS-D ≥8, 10.7% (95% CI: 8.3%, 13.8%) for HADS-D ≥11, and 11.6% (95% CI: 9.2%, 14.6%) for SCID major depression. HADS-D ≥11 was closest to SCID major depression prevalence, but the 95% prediction interval for the difference that could be expected for HADS-D ≥11 versus SCID in a new study was -21.1% to 19.5%.

Conclusions: HADS-D ≥8 substantially overestimates depression prevalence. Of all possible cutoff thresholds, HADS-D ≥11 was closest to the SCID, but there was substantial heterogeneity in the difference between HADS-D ≥11 and SCID-based estimates. HADS-D should not be used as a substitute for a validated diagnostic interview.
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http://dx.doi.org/10.1016/j.jpsychores.2020.110256DOI Listing
December 2020

Efficacy and Harms of Pharmacological Interventions for Anxiety after Traumatic Brain Injury: Systematic Review.

J Neurotrauma 2021 Mar 23;38(5):519-528. Epub 2020 Nov 23.

Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia.

After a traumatic brain injury (TBI), many persons experience significant and debilitating problems with anxiety. The aim of this systematic review was to critically evaluate the evidence regarding efficacy of pharmacological interventions for anxiety after TBI. We reviewed studies published in English before July 2020 and included original research on pharmacological interventions for anxiety after TBI in adults ≥16 years of age. MEDLINE, PubMed, CINAHL, EMBASE, PsycINFO, and CENTRAL databases were searched, with additional searching of key journals, clinical trials registries, and international drug regulators. The primary outcomes of interest were reduction in symptoms of anxiety and occurrence of harms. The secondary outcomes of interest were changes in depression, cognition, quality of life, and participation. Data were summarized in a narrative synthesis, and evidence quality was assessed using the Cochrane Risk of Bias tool. Only a single non-peer-reviewed, randomized controlled trial of 19 male military service members with mild TBI met inclusion criteria. This study found no significant effect of citalopram on anxiety symptoms over a 12-week intervention. The trial was stopped early because of poor recruitment, and much of the study detail was not included in the report. The methodological quality of the study was difficult to assess because of the lack of detail. No recommendations could be drawn from this review. There is a critical need for adequately powered and controlled studies of pharmacological interventions for anxiety after TBI across all severities that examine side-effect profiles and consider issues of comorbidity and effects of long-term pharmacotherapy.
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http://dx.doi.org/10.1089/neu.2020.7277DOI Listing
March 2021

Prognostic Role of Demographic, Injury and Claim Factors in Disabling Pain and Mental Health Conditions 12 Months after Compensable Injury.

Int J Environ Res Public Health 2020 10 7;17(19). Epub 2020 Oct 7.

Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Wellington Rd, 3800 Clayton VIC, Australia.

Identifying who might develop disabling pain or poor mental health after injury is a high priority so that healthcare providers can provide targeted preventive interventions. This retrospective cohort study aimed to identify predictors of disabling pain or probable mental health conditions at 12 months post-injury. Participants were recruited 12-months after admission to a major trauma service for a compensable transport or workplace injury ( = 157). Injury, compensation claim, health services and medication information were obtained from the Victorian Orthopaedic Trauma Outcome Registry, Victorian State Trauma Registry and Compensation Research Database. Participants completed questionnaires about pain, and mental health (anxiety, depression, posttraumatic stress disorder) at 12 months post-injury. One third had disabling pain, one third had at least one probable mental health condition and more than one in five had both disabling pain and a mental health condition at 12 months post-injury. Multivariable logistic regression found mental health treatment 3-6 months post-injury, persistent work disability and opioid use at 6-12 months predicted disabling pain at 12 months post-injury. The presence of opioid use at 3-6 months, work disability and psychotropic medications at 6-12 months predicted a mental health condition at 12 months post-injury. These factors could be used to identify at risk of developing disabling pain who could benefit from timely interventions to better manage both pain and mental health post-injury. Implications for healthcare and compensation system are discussed.
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http://dx.doi.org/10.3390/ijerph17197320DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7579145PMC
October 2020

Comparing the Westmead Posttraumatic Amnesia Scale, Galveston Orientation and Amnesia Test, and Confusion Assessment Protocol as Measures of Acute Recovery Following Traumatic Brain Injury.

J Head Trauma Rehabil 2021 May-Jun 01;36(3):156-163

Turner Institute for Brain and Mental Health, and School of Psychological Sciences, Monash University, Clayton, Victoria, Australia (Drs Spiteri, Ponsford, and McKay); Epworth Healthcare, Richmond, Victoria, Australia (Drs Spiteri, Ponsford, and McKay); and Epworth Healthcare, Victoria, Australia (Drs Jones and McKay).

Background: The duration of the acute period of recovery following traumatic brain injury (TBI) remains a widely used criterion for injury severity and clinical management. Consensus regarding its most appropriate definition and assessment method has yet to be established.

Objective: The present study compared the trajectory of recovery using 3 measures: the Westmead Post-Traumatic Amnesia Scale (WPTAS), the Galveston Orientation and Amnesia Test (GOAT), and the Confusion Assessment Protocol (CAP). Patterns of symptom recovery using the CAP were explored.

Participants: Eighty-two participants with moderate to severe TBI in posttraumatic amnesia (PTA) on admission to an inpatient rehabilitation hospital.

Design: Prospective longitudinal study.

Outcome Measures: Length of PTA (days), agreement between measures (%, κ coefficient), and pattern of symptom recovery.

Results: Participants emerged from PTA earliest on the CAP followed the GOAT, and last on the WPTAS. There was good agreement between the CAP and the GOAT as to PTA status, but both tests had poor agreement with the WPTAS. Of patients considered out of PTA on the CAP, the majority exhibited signs of amnesia on the WPTAS and one-third had clinical levels of agitation.

Conclusion: The WPTAS identifies a later stage of PTA recovery that requires specialized management due to ongoing amnesia and agitation. The CAP and the GOAT are less sensitive to this extended period of PTA.
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http://dx.doi.org/10.1097/HTR.0000000000000607DOI Listing
September 2020

The Use of Atypical Antipsychotics for Managing Agitation After Traumatic Brain Injury.

J Head Trauma Rehabil 2021 May-Jun 01;36(3):149-155

Turner Institute and School of Psychological Sciences, Monash University, Melbourne, Australia (Drs McKay, Trevena-Peters, and Ponsford); Monash-Epworth Rehabilitation Research Centre (Drs McKay, Trevena-Peters, and Ponsford) and Department of Psychology (Dr McKay), Epworth HealthCare, Melbourne, Australia; and National Trauma Research Institute, Melbourne Australia (Dr Ponsford).

Objective: This study examined the use of antipsychotics for managing agitation during posttraumatic amnesia (PTA) after traumatic brain injury (TBI) and its relationship with agitated behavior.

Design: Observational prospective study with correlational design.

Setting: Inpatient rehabilitation hospital for TBI.

Participants: A total of 125 consecutive admissions who were in PTA and had moderate-severe TBI.

Measures: Antipsychotic use was compared with agitation levels as measured by the total scores on the Agitated Behavior Scale (ABS).

Results: Atypical antipsychotics were used in one-third of participants to manage agitation. Antipsychotic use was more common in participants with high levels of global agitation; however, there were many on antipsychotics who had mild or even no agitation according to the ABS. Uncontrolled observational data found no reduction in agitation after antipsychotic commencement or dose increase.

Conclusions: Antipsychotics are commonly used to manage agitation after TBI despite limited evidence of efficacy. Agitation should be formally monitored in PTA to ensure antipsychotics are used to manage more severe agitation and for evaluating treatment response. Research is needed to understand why prescribers are using antipsychotics when agitation is mild or below clinical thresholds.
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http://dx.doi.org/10.1097/HTR.0000000000000614DOI Listing
September 2020

The sibling relationship after acquired brain injury (ABI): perspectives of siblings with ABI and uninjured siblings.

Brain Inj 2020 09 31;34(11):1504-1512. Epub 2020 Aug 31.

Monash-Epworth Rehabilitation Research Centre, Monash University , Melbourne, Australia.

Primary Objective This study explored the sibling relationship across the lifespan after acquired brain injury (ABI). Research Design A qualitative approach was used to explore the perspectives of siblings with ABI and uninjured siblings. Methods and Procedures Semi-structured interviews with 19 siblings with ABI and 20 uninjured siblings (aged 6-61 years) were analyzed using reflexive thematic analysis.  Main Outcomes and Results Four themes were identified: Living with ABI; Being normal siblings; Being part of a family; Experiencing social stigma of ABI. ABI was a traumatic event which differentiated siblings but increased understanding helped accommodate its impact. This impact was experienced within perceptions of typical sibling relationships as involving closeness and conflict. The family context shaped relationships, with parents mediating across the lifespan, while siblings' partners and children contributed to adult sibling relationships. Finally, social stigma led to distance but also protectiveness between siblings. Conclusions The sibling relationship was experienced as a continually evolving source of closeness and conflict within the family context. ABI enhanced preexisting dynamics and created new dynamics, shaped by social attitudes toward ABI. Increased understanding of ABI supported closer relationships, highlighting a need for psychoeducational interventions across the lifespan.
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http://dx.doi.org/10.1080/02699052.2020.1809708DOI Listing
September 2020

Relevance of the Fear-Avoidance Model for Chronic Disability after Traumatic Brain Injury.

J Neurotrauma 2020 12 22;37(24):2639-2646. Epub 2020 Sep 22.

Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia.

Previous studies convincingly suggest that the biopsychosocial fear-avoidance model (FAM) may be of added value in understanding chronic disability after traumatic brain injury (TBI). In this model, persistent symptoms occur as a result of catastrophizing and fear-avoidance regarding initial symptoms, leading to depression, reduced mental activity, and greater disability in daily functioning. This study examined the FAM in a large English-speaking TBI sample. A cross-sectional study was conducted in 117 individuals with complicated mild, moderate, or severe TBI at 1-5 years post-injury. Participants completed questionnaires assessing personal, injury-related, and psychological characteristics. Reliability, correlational, and regression analyses were performed. Main outcome measures of chronic disability were depression, disuse (e.g., fewer mental activities), and functional disability. The results revealed that all correlations suggested by the FAM were significant. Catastrophizing thoughts were positively associated with TBI-related symptoms and fear-avoidance thoughts. Main outcome measures were positively associated with fear-avoidance thoughts and TBI-related symptoms. Further, variables in the FAM were of additive value to personal, injury-related, and psychological variables in understanding chronic disability after TBI. The separate regression analyses for depression, fewer mental activities, and disability revealed "fear-avoidance thoughts" as the only consistent variable. In conclusion, this study shows the association of the FAM with chronic disability after TBI, which has implications for assessment and future management of the FAM in TBI in English-speaking countries. Longitudinal studies are warranted to further investigate and refine the model.
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http://dx.doi.org/10.1089/neu.2020.7135DOI Listing
December 2020

Toward a global and reproducible science for brain imaging in neurotrauma: the ENIGMA adult moderate/severe traumatic brain injury working group.

Brain Imaging Behav 2021 Apr;15(2):526-554

Department of Brain Sciences, Imperial College London, London, UK.

The global burden of mortality and morbidity caused by traumatic brain injury (TBI) is significant, and the heterogeneity of TBI patients and the relatively small sample sizes of most current neuroimaging studies is a major challenge for scientific advances and clinical translation. The ENIGMA (Enhancing NeuroImaging Genetics through Meta-Analysis) Adult moderate/severe TBI (AMS-TBI) working group aims to be a driving force for new discoveries in AMS-TBI by providing researchers world-wide with an effective framework and platform for large-scale cross-border collaboration and data sharing. Based on the principles of transparency, rigor, reproducibility and collaboration, we will facilitate the development and dissemination of multiscale and big data analysis pipelines for harmonized analyses in AMS-TBI using structural and functional neuroimaging in combination with non-imaging biomarkers, genetics, as well as clinical and behavioral measures. Ultimately, we will offer investigators an unprecedented opportunity to test important hypotheses about recovery and morbidity in AMS-TBI by taking advantage of our robust methods for large-scale neuroimaging data analysis. In this consensus statement we outline the working group's short-term, intermediate, and long-term goals.
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http://dx.doi.org/10.1007/s11682-020-00313-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8032647PMC
April 2021

Understanding the Multidimensional Nature of Sexuality After Traumatic Brain Injury.

Arch Phys Med Rehabil 2020 12 1;101(12):2080-2086. Epub 2020 Aug 1.

Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria; Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia. Electronic address:

Objective: To investigate the association of sexuality with sociodemographic (age, sex, education), medical (injury severity, time since injury), physical (fatigue, pain, independence), neuropsychological (memory, attention, executive function), psychological (depression, anxiety, self-esteem), and social participation factors after traumatic brain injury (TBI).

Design: Survey. Individuals with TBI completed measures at a mean average of 2.78 years post injury (range, 1-10.3y).

Setting: All participants were community based at the time of data collection.

Participants: Eighty-four individuals with TBI consecutively recruited after discharge from rehabilitation and 88 age-, sex-, and education-matched controls with TBI recruited from the general community.

Interventions: Not applicable.

Main Outcome Measure: Brain Injury Questionnaire of Sexuality.

Results: Individuals with TBI performed significantly worse on sexuality, mood, and self-esteem measures than the control group without TBI, supporting previous findings. Research findings highlighted a range of significant correlations between sociodemographic, physical, neuropsychological, psychological, and social participation factors and sexuality outcomes after TBI. In the multiple regression model, older age, greater depression, and lower self-esteem were significant predictors of poorer sexuality post injury. Further analyses indicated that depression mediated the independent relationships between lower social participation and greater fatigue with a decline in sexuality after TBI.

Conclusions: These findings support sexuality changes after TBI as a multidimensional construct, highlighting depression as a key mechanism through which other factors may affect sexual functioning. Further research is needed to target assessment and intervention services for sexuality problems after TBI.
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http://dx.doi.org/10.1016/j.apmr.2020.06.028DOI Listing
December 2020

Factors Affecting Participation in Physical Therapy During Posttraumatic Amnesia.

Arch Phys Med Rehabil 2021 03 31;102(3):378-385. Epub 2020 Jul 31.

Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria; Monash-Epworth Rehabilitation Research Centre, Epworth Hospital, Richmond, Victoria.

Objectives: To examine the effect of agitation, cognitive impairment, fatigue, and pain on physical therapy participation and outcomes during posttraumatic amnesia (PTA) after traumatic brain injury (TBI).

Design: Prospective longitudinal study.

Setting: Inpatient rehabilitation hospital.

Participants: Participants (N=77) with moderate-to-severe TBI who were deemed to be experiencing PTA using the Westmead Post-Traumatic Amnesia Scale.

Interventions: Not applicable.

Main Outcome Measures: The Pittsburgh Rehabilitation Participation Scale and time in therapy (min) were recorded twice daily after routine physical therapy sessions during PTA. The FIM-motor (select items related to physical therapy) score rated on admission and after emergence from PTA was used to calculate FIM-motor change.

Results: Agitation was associated with lower participation in therapy. The presence of agitation and pain both predicted lower FIM-motor change at emergence from PTA. Higher levels of cognitive impairment and fatigue were also associated with lower participation and less time in therapy.

Conclusions: The presence of agitation, fatigue, pain, and cognitive impairment impede rehabilitation success during PTA. This study strengthens the case for implementing environmental and behavioral recommendations, such as conducting therapy earlier in the day within a familiar space (ie, on the ward) and tailoring session duration to patient needs. This is with the aim of minimizing fatigue, agitation, and pain, while promoting cognitive recovery and arousal during PTA to maximize physical gains. Further research is warranted to examine the factors associated with rehabilitation success across other therapeutic disciplines.
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http://dx.doi.org/10.1016/j.apmr.2020.06.024DOI Listing
March 2021

Use of olanzapine to treat agitation in traumatic brain injury: study protocol for a randomised controlled trial.

Trials 2020 Jul 20;21(1):662. Epub 2020 Jul 20.

Monash Epworth Rehabilitation Research Centre, 185-187 Hoddle Street, Richmond, Victoria, 3121, Australia.

Background: Agitation is common in the early stages of recovery from traumatic brain injury (TBI), when patients are in post-traumatic amnesia (PTA). Agitation is associated with risk of harm to patients and caregivers. Recent guidelines recommend that agitation during PTA is managed using environmental modifications. Agitation is also frequently treated pharmacologically, with the use of atypical antipsychotics such as olanzapine among the most common. This is despite a lack of well-designed studies to support the use of antipsychotics within this context. This study will be a double-blind, placebo-controlled randomised controlled trial. We will examine the efficacy, safety, cost-effectiveness and outcomes associated with the use of olanzapine for reducing agitation in patients in PTA following TBI over and above recommended environmental management.

Methods: Fifty-eight TBI rehabilitation inpatients who are in PTA and are agitated will receive olanzapine or placebo for the duration of PTA. All participants will additionally receive optimal environmental management for agitation. Measures of agitation, PTA and health will be undertaken at baseline. Treatment administration will begin at a dose of 5 mg daily and may be escalated to a maximum dose of 20 mg per day. Throughout the treatment period, agitation and PTA will be measured daily, and adverse events monitored weekly. Efficacy will be assessed by treatment group comparison of average Agitated Behaviour Scale scores during PTA. Participants will cease treatment upon emergence from PTA. Agitation levels will continue to be monitored for a further 2 weeks, post-treatment measures of health will be undertaken and cognitive and functional status will be assessed. Level of agitation and functional health will be assessed at hospital discharge. At 3 months post-discharge, functional outcomes and health service utilisation will be measured.

Discussion: This trial will provide crucial evidence to inform the management of agitation in patients in PTA following TBI. It will provide guidance as to whether olanzapine reduces agitation over and above recommended environmental management or conversely whether it increases or prolongs agitation and PTA, increases length of inpatient hospitalisation and impacts longer term cognitive and functional outcomes. It will also speak to the safety and cost-effectiveness of olanzapine use in this population.

Trial Registration: ANZCTR ACTRN12619000284167 . Registered on 25 February 2019.
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http://dx.doi.org/10.1186/s13063-020-04553-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7370410PMC
July 2020
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