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Objective: To investigate the factor structure of the Agitated Behavior Scale (ABS) in patients with traumatic brain injury (TBI) in posttraumatic amnesia (PTA). Setting: Inpatient TBI rehabilitation ward in Victoria, Australia. Participants: A total of 364 patients aged 16 to 92 years meeting diagnostic criteria for TBI and PTA admitted between September 2013 and October 2020. Design: Retrospective cohort study utilizing electronic medical record data. Main Measures: The ABS and the Westmead Post-Traumatic Amnesia Scale (WPTAS). Results: Exploratory factor analysis uncovered 2 moderately correlated underlying factors (0.52), labeled Restlessness and Aggression/Lability. Two items failed to demonstrate sufficiently large loadings on either factor. Both factors demonstrated adequate reliability (Cronbach α = 0.87 and 0.81 for Restlessness and Aggression/Lability, respectively). Linear regression indicated that higher WPTAS scores were associated with lower levels of Restlessness (β = −.14, P <.001), supporting construct validity. Conversely, WPTAS scores were not significantly associated with Aggression/Lability (β = −.12, P =.08). Subgroup analysis indicated that a history of mood disorder was associated with greater severity of Aggression/Lability (P =.02). Confirmatory factor analysis indicated superior fit of the identified 2-factor solution when compared with previously explored 1-, 2-, 3-, and 4-factor structures. Conclusion: This study suggests that the latent structure of the ABS is best explained by a single construct of agitation with 2 discrete facets reflecting Restlessness and Aggression/Lability. These subscales may be used in clinical practice to evaluate the severity of different aspects of agitated behavior, inform treatment decisions, and judge the efficacy of interventions over time. Further research is required to explain low factor loadings demonstrated by 2 items. [ABSTRACT FROM AUTHOR]

Introduction: Posttraumatic amnesia (PTA) is a common occurrence following moderate to severe traumatic brain injury (TBI) and emergence from coma. It is characterized by confusion, disorientation, retrograde and anterograde amnesia, poor attention and frequently, agitation. Clinicians and family need guidelines to support management practices during this phase. Methods: An international team of researchers and clinicians (known as INCOG) met to update the INCOG guidelines for assessment and management of PTA. Previous recommendations and audit criteria were updated on the basis of review of the literature from 2014. Results: Six management recommendations were made: 1 based on level A evidence, 2 on level B, and 3 on level C evidence. Since the first version of INCOG (2014), 3 recommendations were added: the remainder were modified. INCOG 2022 recommends that individuals should be assessed daily for PTA, using a validated tool (Westmead PTA Scale), until PTA resolution. To date, no cognitive or pharmacological treatments are known to reduce PTA duration. Agitation and confusion may be minimized by a variety of environmental adaptations including maintaining a quiet, safe, and consistent environment. The use of neuroleptic medications and benzodiazepines for agitation should be minimized and their impact on agitation and cognition monitored using standardized tools. Physical therapy and standardized activities of daily living training using procedural and errorless learning principles can be effective, but delivery should be tailored to concurrent levels of cognition, agitation, and fatigue. Conclusions: Stronger recommendations regarding assessment of PTA duration and effectiveness of activities of daily living training have been made. Evidence regarding optimal pharmacological and nonpharmacological management of confusion and agitation during PTA remains limited, with further research needed. These guidelines aim to enhance evidence-based care and maximize consistency of PTA management. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background and Purpose: Physical therapy is important in the management of traumatic brain injury (TBI) and associated multitrauma. Providing therapy during the posttraumatic amnesia (PTA) phase is challenging, given that hallmark features including confusion, amnesia, agitation, and fatigue may impede the person's ability to engage in and benefit from rehabilitation. To date, there is little empirical evidence to guide the provision of therapy during PTA. This observational study aimed to explore the frequency, duration, location, and engagement of physical therapy provision during PTA and the impact of cognition, agitation, and fatigue. Summary of Key Points: The majority of patients were found to meaningfully engage and participate in physical therapy for the majority of sessions. Only a small proportion were unable to participate in physical therapy. Patient refusal and fatigue were identified as the most prominent barriers to rehabilitation. Despite fatigue and agitation reaching clinical levels, therapy could still successfully proceed on most occasions. Recommendations for Clinical Practice: Physical therapy is feasible during the acute recovery stages after TBI. Current results support the notion that therapy should commence early to minimize secondary complications and promote the recovery of mobility. A patient-centered therapeutic model that tailors the therapeutic approach to meet the individual's current physical and fluctuating cognitive capabilities may be most suited for this population. Clinicians working with people after TBI need experience in understanding and managing the cognitive limitations and associated symptoms of PTA to optimize the provision of therapy. These findings could inform guidelines for the management of patients in PTA. Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A368). [ABSTRACT FROM AUTHOR]

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 (%, x 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 onethird 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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). Prospective longitudinal study. Inpatient rehabilitation hospital. Participants (N=77) with moderate-to-severe TBI who were deemed to be experiencing PTA using the Westmead Post-Traumatic Amnesia Scale. Not applicable. 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. 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. 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. [ABSTRACT FROM AUTHOR]

Background: Given the high frequency and significance of anxiety and depression following traumatic brain injury (TBI), there is a need to evaluate the efficacy of psychological interventions and to understand factors influencing response to such interventions. The present study investigated factors associated with positive response to cognitive behavioral therapy adapted for cognitive impairments (CBT-ABI) for individuals with anxiety and depression following TBI, including demographic and injury-related factors, pretreatment levels of anxiety and depression, working alliance, and change expectancy as predictors. Methods: Participants were 45 individuals enrolled in an active treatment condition within a randomized controlled trial, examining the efficacy of a 9-session CBT-ABI program for anxiety and depression following TBI. These participants completed all CBT sessions. Results: Mixed-effects regressions controlling for baseline anxiety and depression indicated that for anxiety, older age at injury, as well as higher level of baseline anxiety, was associated with greater symptom reduction. For depression, longer time since injury and higher expectancy for change, as well as higher baseline level of depression, were significantly associated with a greater reduction in depression symptoms. Conclusions: This study paves the way for more detailed studies of the therapeutic processes involved in alleviating anxiety and depression following TBI. [ABSTRACT FROM AUTHOR]

Abstract Objective To evaluate the cost-effectiveness of structured activities of daily living (ADL) retraining during posttraumatic amnesia (PTA) plus treatment as usual (TAU) vs TAU alone for inpatient rehabilitation following severe traumatic brain injury (TBI). Design Trial-based economic evaluation from a health-system perspective. Setting Inpatient rehabilitation center. Participants Participants (N=104) admitted to rehabilitation and in PTA for >7 days following severe TBI. Interventions Structured ADL retraining during PTA plus TAU vs TAU alone. Structured ADL retraining was manualized to minimize the risk of agitation and maximize functional improvement, following principles of errorless and procedural learning and targeting individualized therapy goals. TAU included physiotherapy and/or speech therapy during PTA plus ADL retraining after PTA emergence. Main Outcome Measures FIM total scores at baseline, PTA emergence, hospital discharge, or final follow-up (2mo postdischarge) where FIM total scores were calculated as the sum of 5 FIM motor self-care items and a FIM meal-preparation item. Results Structured ADL retraining during PTA significantly increased functional independence at PTA emergence (mean difference: 4.90, SE: 1.4, 95% confidence interval [CI]: 1.5, 8.3) and hospital discharge (mean difference: 5.22, SE: 1.4, 95% CI: 1.8, 8.7). Even in our most pessimistic scenario, structured ADL retraining was cost-saving as compared to TAU (mean: -$7762; 95% CI: -$8105, -$7419). Together, these results imply that structured ADL retraining dominates (less costly but no less effective) TAU when effectiveness is evaluated at PTA emergence and hospital discharge. Conclusions Structured ADL retraining during PTA yields net cost-savings to the health system and offers a cost-effective means of increasing functional independence at PTA emergence and hospital discharge. [ABSTRACT FROM AUTHOR]

Background: Patients in posttraumatic amnesia (PTA) may receive limited rehabilitation due to the risk of overstimulation and agitation. This assumption has not been tested. Objective: To examine the relationship between agitated behavior and participation in therapy for retraining of activities of daily living (ADL) while in PTA. Setting: Inpatient rehabilitation center. Participants: A total of 104 participants with severe traumatic brain injury, admitted to rehabilitation, in PTA of more than 7 days. Intervention: ADL retraining during PTA followed errorless and procedural learning principles. Design: Group comparison and regression modeling of patient agitation data from a randomized controlled trial comparing ADL retraining in PTA (treatment) versus no ADL retraining in PTA (treatment as usual, TAU). Outcome Measures: Agitation using the Agitated Behavior Scale. Therapy participation measured in minutes and missed sessions. Results: There were no group differences in agitated behavior (average scores, peak scores, or number of clinically agitated days) between the treatment and TAU groups. For treated patients, there was no significant relationship between agitation and therapy participation (therapy minutes or missed ADL treatment sessions). Conclusions: This study demonstrated that agitation is not increased by delivery of structured ADL retraining during PTA and agitation did not limit therapy participation. This supports the consideration of active therapy during PTA. [ABSTRACT FROM AUTHOR]

Objectives: (1) To examine the relations between performance on cognitive tests and on-road driving assessment in a sample of persons with traumatic brain injury (TBI). (2) To compare cognitive predictors of the on-road assessment with demographic and injury-related predictors. Participants: Ninety-nine people with mild-severe TBI who completed an on-road driving assessment in an Australian rehabilitation setting. Design: Retrospective case series. Main Measures: Wechsler Test of Adult Reading or National Adult Reading Test--Revised; 4 subtests from the Wechsler Adult Intelligence Scale-III; Rey Auditory Verbal Leaning Test; Rey Complex Figure Test; Trail Making Test; demographic factors (age, sex, years licensed); and injury-related factors (duration of posttraumatic amnesia; time postinjury). Results: Participants who failed the driving assessment did worse on measures of attention, visual memory, and executive processing; however, cognitive tests were weak correlates (rvalues <0.3) and poor predictors of the driving assessment. Posttraumatic amnesia duration mediated by time postinjury was the strongest predictor of the driving assessment--that is, participants with more severe TBIs had later driving assessments and were more likely to fail. Conclusion: Cognitive tests are not reliable predictors of the on-road driving assessment outcome. Traumatic brain injury severity may be a better predictor of on-road driving; however, further research is needed to identify the best predictors of driving behavior after TBI. [ABSTRACT FROM AUTHOR]

Objective To assess the efficacy of activities of daily living (ADL) retraining during posttraumatic amnesia (PTA) compared with ADL retraining commencing after emergence from PTA. Design Randomized controlled trial. Setting Inpatient rehabilitation center. Participants Participants with severe TBI (N=104), admitted to rehabilitation and remaining in PTA for >7 days, were randomized to receive either treatment as usual (TAU) with daily ADL retraining (treatment), or TAU alone (physiotherapy and/or necessary speech therapy) during PTA. Interventions ADL retraining was manualized, followed errorless and procedural learning principles, and included individualized goals. Both groups received occupational therapy as usual after PTA. Main Outcome Measures Primary outcome was the FIM completed at admission, PTA emergence, discharge, and 2-month follow-up. Secondary outcomes included length of rehabilitation inpatient stay, PTA duration, Agitated Behavior Scale scores, and Community Integration Questionnaire (CIQ) scores at follow-up. Groups did not significantly differ in baseline characteristics. Results On the primary outcome, FIM total change, random effects regression revealed a significant interaction of group and time ( P <.01). The treatment group had greater improvement in FIM scores from baseline to PTA emergence, which was maintained at discharge, but not at follow-up. Twenty-seven percent more of the treatment group reliably changed on FIM scores at PTA emergence. Group differences in length of stay, PTA duration, agitation, and CIQ scores were not significant; however, TAU trended toward longer length of stay and PTA duration. Conclusions Individuals in PTA can benefit from skill retraining. [ABSTRACT FROM AUTHOR]

Objective To evaluate the efficacy of adapted cognitive behavioral therapy (CBT) for sleep disturbance and fatigue in individuals with traumatic brain injury (TBI). Design Parallel 2-group randomized controlled trial. Setting Outpatient therapy. Participants Adults (N=24) with history of TBI and clinically significant sleep and/or fatigue complaints were randomly allocated to an 8-session adapted CBT intervention or a treatment as usual (TAU) condition. Interventions Cognitive behavior therapy. Main Outcome Measures The primary outcome was the Pittsburgh Sleep Quality Index (PSQI) posttreatment and at 2-month follow-up. Secondary measures included the Insomnia Severity Index, Fatigue Severity Scale, Brief Fatigue Inventory (BFI), Epworth Sleepiness Scale, and Hospital Anxiety and Depression Scale. Results At follow-up, CBT recipients reported better sleep quality than those receiving TAU (PSQI mean difference, 4.85; 95% confidence interval [CI], 2.56–7.14). Daily fatigue levels were significantly reduced in the CBT group (BFI difference, 1.54; 95% CI, 0.66–2.42). Secondary improvements were significant for depression. Large within-group effect sizes were evident across measures (Hedges g =1.14–1.93), with maintenance of gains 2 months after therapy cessation. Conclusions Adapted CBT produced greater and sustained improvements in sleep, daily fatigue levels, and depression compared with TAU. These pilot findings suggest that CBT is a promising treatment for sleep disturbance and fatigue after TBI. [ABSTRACT FROM AUTHOR]