Search

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., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc.)

Objective: To identify factors associated with treatment response to cognitive behavioral therapy for sleep disturbance and fatigue (CBT-SF) after acquired brain injury (ABI)., Setting: Community dwelling., Participants: Thirty participants with a traumatic brain injury or stroke randomized to receive CBT-SF in a parent randomized controlled trial., Design: Participants took part in a parallel-groups, parent randomized controlled trial with blinded outcome assessment, comparing an 8-week CBT-SF program with an attentionally equivalent health education control. They were assessed at baseline, post-treatment, 2 months post-treatment, and 4 months post-treatment. The study was completed either face-to-face or via telehealth (videoconferencing). Following this trial, a secondary analysis of variables associated with treatment response to CBT-SF was conducted, including: demographic variables; injury-related variables; neuropsychological characteristics; pretreatment sleep disturbance, fatigue, depression, anxiety and pain; and mode of treatment delivery (face-to-face or telehealth)., Main Measures: Pittsburgh Sleep Quality Index (PSQI) and Fatigue Severity Scale (FSS)., Results: Greater treatment response to CBT-SF at 4-month follow-up was associated with higher baseline sleep and fatigue symptoms. Reductions in fatigue on the FSS were also related to injury mechanism, where those with a traumatic brain injury had a more rapid and short-lasting improvement in fatigue, compared with those with stroke, who had a delayed but longer-term reduction in fatigue. Mode of treatment delivery did not significantly impact CBT-SF outcomes., Conclusion: Our findings highlight potential differences between fatigue trajectories in traumatic brain injury and stroke, and also provide preliminary support for the equivalence of face-to-face and telehealth delivery of CBT-SF in individuals with ABI., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

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 led to 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)., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Purpose: To identify predictors of treatment response to cognitive behavior therapy (CBT) for sleep disturbance following acquired brain injury (ABI)., Methods: Classification and regression tree (CART) analysis was conducted on individual patient data from two pilot randomized controlled trials (RCTs): one in traumatic brain injury (TBI), the other in stroke. The combined sample comprised 32 participants; 15 receiving CBT and 17 allocated to treatment as usual (TAU). The outcome was reliable improvement on the Pittsburgh Sleep Quality Index (PSQI)., Results: Study group was a statistically significant predictor of outcome, with CBT participants more likely to achieve reliable improvements than TAU (OR = 4.88, p = 0.042). Study group (CBT vs. TAU) exhibited an area under the ROC curve (AUROC) of 69%. In separate CART analyzes, verbal memory (CVLT-II >45.5), age (<47.5) and baseline depression (HADS-D > 6) predicted positive outcomes in CBT recipients. Each of these variables added a small (∼5%) but not statistically significant amount to AUROC over study group., Conclusions: In this ABI sample, better memory, younger age, and higher baseline depression were associated with positive treatment response to CBT although individually these variables were not better than group alone in predicting outcomes. The present findings generate hypotheses for further investigation in future studies. Implications for rehabilitation Cognitive behavior therapy improves sleep quality over treatment as usual in persons with acquired brain injury. Individuals who are younger in age with better memory and co-morbid symptoms of depression are more likely to respond to the treatment. These findings are based on a small sample and can be considered hypothesis generating for future clinical studies.

Background: This study prospectively examined the relationship between preinjury, injury-related, and postinjury factors and posttraumatic stress disorder (PTSD) following moderate to severe traumatic brain injury (TBI)., Method: Two hundred and three participants were recruited during inpatient admission following moderate to severe TBI. Participants completed an initial assessment soon after injury and were reassessed at 3, 6, and 12 months, 2, 3, 4, and 5 years postinjury. The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders-fourth edition was used to diagnose pre- and postinjury PTSD and other psychiatric disorders. The Glasgow Outcome Scale-Extended (GOSE) and the Quality of Life Inventory (QOLI) were used to evaluate functional and psychosocial outcome from 6 months postinjury., Results: The frequency of PTSD ranged between 0.5 and 9.4% during the 5-year period, increasing throughout the first 12 months and declining thereafter. After controlling for other predictors, shorter posttraumatic amnesia duration (odds ratio = 0.96, 95% CI = 0.92-1.00), other concurrent psychiatric disorder (odds ratio = 14.22, 95% CI = 2.68-75.38), and lower GOSE (odds ratio = 0.38, 95% CI = 0.20-0.72) and QOLI scores (odds ratio = 0.97, 95% CI = 0.95-0.97) were associated with greater odds of having injury-related PTSD., Discussion: The results of this study indicate that while shorter posttraumatic amnesia duration is associated with PTSD, greater TBI severity does not prevent PTSD from evolving. Patients with PTSD experienced high rates of psychiatric comorbidity and poorer functional and quality of life outcomes after TBI., Conclusion: There is a need to direct clinical attention to early identification and treatment of PTSD following TBI to improve outcomes., (© 2015 Wiley Periodicals, Inc.)

Objective: To examine self-awareness and injury-related, emotional and demographic factors across acute/subacute (3-12 months), medium-term (24-60 months), and long-term (120-240 months) time periods after traumatic brain injury (TBI), because unawareness of injury-related changes can affect engagement in rehabilitation and functional outcomes., Participants: A total of 168 individuals with mild to severe TBI and 105 of their close others., Main Outcomes Measures: Awareness Questionnaire (AQ) and Hospital Anxiety and Depression Scale., Design: Cross-sectional study., Results: There were no significant differences in awareness as a function of time postinjury, except for the AQ motor/sensory domain wherein individuals with TBI at longer time periods displayed increased awareness of deficits than those at earlier time periods. Greater patient-other AQ discrepancy scores (interpreted as lower patient awareness) were associated with longer posttraumatic amnesia duration in the individual with TBI and also with increased self-reported depressive symptoms in the close others. Conversely, smaller AQ discrepancy scores (interpreted as better awareness) were associated with increased self-reported depressive symptoms by the individuals with TBI., Conclusion: This study highlights the limitations of using discrepancy scores to measure awareness, as ratings of injury-related changes are influenced by the mood of the individual with TBI and the close other, as well as by injury severity.

This study examined the relationship between the nature of feedback provided by close-others and self-awareness in individuals with traumatic brain injury (TBI). Using a cross-sectional design, 69 individuals with mild-to-severe TBI and their close-others completed the Awareness Questionnaire, Hospital Anxiety and Depression Scale, Trail Making Test-Part B and Feedback about Cognitive Difficulties Questionnaire, between 3 months and 20 years post-injury. Results showed cognitive and/or behavioural issues post-injury were identified in 97% of individuals with TBI and over 80% of these were provided with feedback by close-others at least sometimes after making errors. Close-others reported two main reasons for not providing feedback about problems: (1) not wanting to hurt the feelings of the injured individual and (2) pointing out errors would be detrimental to the injured individual's rehabilitation. Whilst nearly 60% of the individuals with TBI were reported to detect an error once they received feedback, they showed low levels of acceptance/acknowledgement in response to feedback. Analyses including injury-related and emotional variables failed to identify any mediated or moderated relations between frequency of feedback and self-awareness. The high rates of feedback by close-others but low acceptance/acknowledgement of that feedback by individuals with TBI suggests that clinicians may need to work in partnership with close-others to facilitate supportive relationships for effective delivery of feedback.

Primary Objective: Family caregivers play an important role in managing challenging behaviours after TBI. The aims of this study were to understand how family caregivers of individuals with TBI perceive challenging behaviours and their impact on the TBI individual's community integration and family functioning., Research Design: A qualitative research design was employed to capture the lived experience of family caregivers of individuals with TBI., Methods and Procedures: Face-to-face interviews were conducted on six female family caregivers of individuals with severe TBI (sustained an average of 17 years earlier) and long-standing challenging behaviours., Main Outcomes and Results: The results revealed that family caregivers adopted a broader definition of challenging behaviour than that used by professionals and these behaviours impacted on the community integration of the individual with TBI, most notably leading to poor social relationships. Challenging behaviours were viewed as a key source of distress and burden for family caregivers and they used many different strategies to manage the behaviours., Conclusion: Greater understanding of challenging behaviours from the perspectives of family caregivers may help provide more effective support and interventions to improve quality-of-life for individuals with challenging behaviours after TBI and their families.

Objective: To examine self-awareness over the first year following traumatic brain injury (TBI) and the association of demographic, biological, cognitive, psychological and social-environmental factors with change in awareness., Research Design: Using a longitudinal design the progression of awareness and association of demographic and biopsychosocial factors with its trajectory were analysed using random effects regression., Methods and Procedures: Sixty individuals with mainly moderate-to-severe TBI completed assessments at 3, 6 and/or 12 months post-injury. Measures of awareness (Self-Awareness of Deficits Interview; SADI), demographic (age at time of injury and gender), injury severity (post-traumatic amnesia duration), cognitive (Trails Making Test-Part B), psychological (Hospital Anxiety and Depression Scale) and social-environmental (return to pre-injury activities) factors were administered., Main Outcomes and Results: Awareness improved over the first year post-injury. Analysis of SADI sub-scales revealed that females had greater awareness in terms of setting more realistic goals early in recovery compared to males. Models including demographic, biological, cognitive, psychological and social-environmental factors did not contribute significantly to prediction of awareness on the SADI above the influence of time., Conclusions: Time post-injury had the strongest influence on the development of awareness. This understanding may be important in determining the optimal timing of rehabilitative intervention.

The aim of the study was to describe the development and predictors of psychological adjustment during community-based traumatic brain injury (TBI) rehabilitation. Forty-two adolescent and adult individuals with TBI (mean age 32 years, 88% male, median post-traumatic amnesia 11 days) participated in a single-group, longitudinal design study. The main measures used were the Reactions to Impairment and Disability Inventory, Adjustment subscale; Sydney Psychosocial Reintegration Scale; Hospital Anxiety and Depression Scale; and Self-awareness of Deficits Interview. At rehabilitation start, individuals differed significantly from each other with respect to their level of psychological adjustment. Individual trajectories of psychological adjustment were highly variable. However, for the sample as a whole, psychological adjustment did not change during the course of rehabilitation (multilevel regression models; p > .05). Good psychological adjustment was related to low levels of emotional distress and a small discrepancy between current and aspired functional status. Poor functional status had a more minor impact on psychological adjustment in individuals with poor self-awareness than in individuals with high levels of self-awareness. The results confirm parts of theoretical models of psychological adjustment to acquired brain injury, especially the importance of goal refinement. However, the results need to be treated cautiously, given the limited sample size.

Background: CBT is a potentially effective treatment for anxiety disorders following TBI; however, empirical evidence has mainly come from clients with mild TBI. This paper describes a CBT-based anxiety treatment programme adapted for clients with more severe injuries. Two case studies are provided to illustrate the implementation of the programme, as a step toward larger scale testing of the programme's feasibility., Methods and Procedures: A manualised adapted CBT treatment manual was used to deliver CBT in a standardised manner to two clients, one with severe and one with moderate TBI. Outcome was evaluated using a single-subject design with repeated measures of anxiety, mood and coping style at pre- and post-CBT., Results: The two clients demonstrated positive treatment response on either a measure of anxiety or a continuous measure of distress. Although neither demonstrated a clinically significant change according to the primary outcome measure (Hospital Anxiety and Depression Scale), they showed significant change in at least one corroborated measure of anxiety., Conclusions: This study suggests the potential utility of the adapted CBT programme for clients with moderate-severe TBI. Limitations of the single case studies were discussed, while noting how they would be addressed in a follow-up randomised controlled trial.

A brief preparatory programme, based on the principles of motivational interviewing (MI), was developed as a way of engaging clients with traumatic brain injury (TBI) and preparing them for a cognitive behaviour therapy (CBT) programme for anxiety. The MI + CBT programme was delivered to a male client in his early 40s with severe TBI at four months post-injury, using a single-subject design with repeated measures pre- and post-treatment. The client received three sessions of manualised MI, followed by nine sessions of CBT. The MI sessions focused on helping the client to develop more realistic goals and supporting his self-efficacy about his ability to cope with anxiety. Specific strategies were used to accommodate the client's cognitive limitations, such as the use of personally meaningful metaphors and role plays. Re-assessments were conducted at the end of MI, CBT and nine weeks post-treatment, using a semi-structured clinical interview and self-report measures of anxiety, mood and change expectancy. The client showed significant improvement in anxiety following treatment and a significant reduction in subjective units of distress (SUDS) between the MI and CBT phases. The results suggest the potential utility of MI in people with TBI, and the need to evaluate treatment protocols in a controlled trial.

Although cognitive-behavioural therapy (CBT) is the treatment of choice for anxiety, its delivery needs to be adapted for individuals with traumatic brain injury (TBI). It also requires clients' active engagement for maximum benefit. This study was a pilot randomised controlled trial involving an anxiety treatment programme adapted for people with TBI, based on CBT and motivational interviewing (MI). Twenty-seven participants with moderate/severe TBI (aged 21-73 years, 78% males) recruited from a brain injury rehabilitation hospital were randomly allocated to receive MI + CBT (n = 9), non-directive counselling (NDC) + CBT (n = 10) and treatment-as-usual (TAU) (n = 8). CBT and MI were manualised and delivered in 12 weekly individual sessions. Primary outcome was self-reported anxiety symptoms assessed at baseline, at the end of NDC/MI and immediately following CBT. Assessment was conducted by assessors blinded to group assignment. Intention-to-treat analyses showed that the two active treatment groups demonstrated significantly greater anxiety reduction than TAU. Participants receiving MI showed greater response to CBT, in terms of reduction in anxiety, stress and non-productive coping, compared to participants who received NDC. The results provided preliminary support for the adapted CBT programme, and the potential utility of MI as treatment prelude. Longer follow-up data are required to evaluate the maintenance of treatment effects.

Levels of expressed emotion (EE) within the family, particularly criticism and emotional over-involvement, are associated with a patient's psychological outcome in a range of psychiatric and medical conditions. This study aimed to examine the relationship between levels of family EE and anxiety and depression in patients who have sustained a traumatic brain injury (TBI). A further aim was to examine whether family members' levels of psychological distress and attributions of patient symptom controllability, were related to their levels of patient-directed EE. Participants were 43 patients who had sustained a complicated mild to severe TBI three months to five years previously, and their nominated family members. Results indicated that family members' criticism and emotional over-involvement were associated with patients' levels of anxiety and depression. Moreover, family members' levels of anxiety and depression were associated with their levels of patient-directed criticism and emotional over-involvement, whilst their attributions of patient symptom control were not. These findings suggest that levels of EE within the family are associated with psychological adjustment following TBI. Consequently, interventions targeting EE in family members may help to reduce psychiatric difficulties following TBI.

Purpose: In a pilot randomized controlled trial, we investigated the effectiveness of a 12-weekly anxiety treatment programme adapted for individuals with moderate-severe TBI, based on cognitive behaviour therapy (CBT) and Motivational Interviewing (MI). The current study explored the variables associated with treatment response and group differences in change expectancy and working alliance., Methods: Twenty-seven participants recruited from a brain injury rehabilitation hospital were randomly assigned to MI + CBT, non-directive counselling (NDC) + CBT and treatment-as-usual and assessors were blinded to treatment conditions. Correlation and multiple regression were used to examine the association between reduction in anxiety ratings and a number of clinical, injury and cognitive variables. Random effects regression was used to examine group difference in changes in working alliance and expectancy., Results: There was a trend suggesting that greater injury severity may be predictive of poorer response to CBT and injury severity was significantly related to memory functioning. Participants receiving MI pre-treatment showed a greater increase in change expectancy at the end of CBT and at follow-up, but not at the end of MI., Conclusions: There is a need to further investigate the effectiveness of treatment for individuals with different injury severity and to explore the relationship between change expectancy and treatment outcome.

Background: Despite evidence of the efficacy of activities of daily living (ADL) retraining during post-traumatic amnesia (PTA) following traumatic brain injury (TBI), utilisation of this intervention in practice is unclear. Utilising an implementation science framework, the Consolidated Framework for Implementation Research, this study explored efforts to translate ADL retraining during PTA into the clinical practice of occupational therapists (OTs) working in TBI rehabilitation settings across Australia. Methods: Participants were 44 OTs who attended a day-long training workshop that included knowledge and skill-based content regarding ADL retraining during PTA. Baseline and post-training ratings were completed including evaluation of workshop utility, and skill and knowledge-based competencies relevant to the intervention. Approximately 2 years later, nine trained OTs and two administrators were interviewed to explore the results of implementing the intervention. Results: Overall, the training workshop was rated as being helpful and OT ratings of confidence (P < 0.001) and competencies (P < 0.001) significantly improved from baseline to post-workshop. At follow-up, thematic analysis of interviews identified themes related to implementing the intervention as it pertains to patients in PTA, OTs delivering the intervention and the organisational context. Various facilitators and barriers to translation were identified. Participants indicated a positive view of the clinical use of the intervention and development of their knowledge and skills, with the intervention benefiting those in PTA. Despite this, factors such as time, resourcing, team training, and rehabilitation-setting processes posed significant barriers. Conclusion: Multiple barriers were identified in implementation of ADL retraining during PTA and require consideration to facilitate translation and promote best practice. Despite evidence supporting skills retraining during post-traumatic amnesia (PTA) following traumatic brain injury (TBI), utilisation of this intervention in clinical practice in Australia is unclear. Following training in the intervention, occupational therapists reported improved confidence and competencies, and 2 years later, a key facilitator of implementing the intervention into clinical practice was the benefit to the patients. Despite this, barriers such as time and resourcing require consideration to facilitate best-practice rehabilitation for individuals in PTA. This article belongs to the Collection Clinical Implementation to Optimise Outcomes. [ABSTRACT FROM AUTHOR]

During the early recovery period after traumatic brain injury (TBI), referred to as post-traumatic amnesia (PTA), approximately 44% of individuals may exhibit agitated behaviours. Agitation can impede recovery and poses a significant management challenge for healthcare services. As families provide significant support for their injured relatives during this time, this study aimed to explore the family's experience during PTA to better understand their role in agitation management. There were 20 qualitative semi-structured interviews conducted with 24 family members of patients exhibiting agitation during early TBI recovery (75% female, aged 30–71 years), predominantly parents (n = 12), spouses (n = 7) and children (n = 3). The interviews explored the family's experience of supporting their relative exhibiting agitation during PTA. The interviews were analyzed using reflexive thematic analysis, which revealed three key themes: family contributions to patient care, expectations of the health care service and supporting families to support patients. This study emphasized the significant role of families in managing agitation during early TBI recovery and highlighted that families who are well-informed and well-supported have the potential to minimize their relative's agitation during PTA, which may reduce the burden on healthcare staff and promote patient recovery. [ABSTRACT FROM AUTHOR]

Agitated behaviours pose a significant challenge during early recovery following traumatic brain injury (TBI). This study aimed to gain a deeper understanding of how clinicians worldwide manage post-TBI agitation. Understanding the factors that influence how clinicians manage agitation can help inform the use of consistent and effective management strategies for reducing agitation in TBI care. Using a qualitative design, semi-structured interviews were conducted with 33 clinicians (58% female, aged 23–71 years) from 16 countries who had experience working with agitated patients. The interviews explored the approaches used to manage agitation during early TBI recovery. Interviews were analysed using thematic analysis. The central theme of the interviews was the effective management of agitation, consisting of three sub-themes: managing the safety of staff and patients, reducing triggers for agitation, and implementing behavioural principles for managing agitation. Two overarching themes influenced the effective management of agitation: clinician-related factors and systemic factors. This study highlighted key approaches for effective agitation management during early TBI recovery, as described by clinicians working with these patients worldwide. There were similarities in the strategies described, although there were many challenges that impeded the consistent implementation of such strategies in TBI care settings. Effective management of agitation during early traumatic brain injury (TBI) recovery continues to pose a significant challenge for clinicians worldwide. Healthcare services may improve the management of agitation by involving the patient's family in care delivery and implementing low-cost less-restrictive non-pharmacological interventions to reduce reliance on pharmacological interventions. Proactively addressing and removing potential sources of agitation (patient-related and environmental) may help reduce the risk of agitation occurring. The use of simple behaviour management strategies may be effective for reducing agitation, but strategies need to be implemented consistently and the approach should be flexible and tailored to the patient. Clinicians should develop an understanding of a patient's premorbid behaviours and interests to best inform the management approach. Management of agitation may be improved by increasing clinicians' agency in responding to agitated behaviours, through the provision of information and resources, ongoing training and skill development, supervision and support. [ABSTRACT FROM AUTHOR]

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

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

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]

Background: Up to 25% of concussed individuals experience persistent post-concussion symptoms (PPCSs) which may interfere with the return to pre-injury activities and cause significant stress. Given that multiple etiological factors are thought to contribute to PPCSs, an interdisciplinary approach is recommended. This pilot study aims to primarily investigate the feasibility of a novel interdisciplinary treatment for PPCSs. Given this intervention is novel, uncertainty exists in terms of potential recruitment and retention rates, adverse events, and treatment adherence and fidelity. These factors will be explored to inform the feasibility of a phase-2 randomised controlled trial. Preliminary efficacy of this intervention will also be explored. Methods: Fifteen individuals with mild traumatic brain injury and PPCSs will receive up to 12 weeks of interdisciplinary treatments including psychology, physiotherapy, and medical interventions. Primary feasibility outcomes including data on recruitment and retention rates and treatment adherence will be explored descriptively. The cognitive therapy rating scale will be used to assess treatment fidelity. A single-case series with multiple baseline design will be used to explore preliminary efficacy. Participants will be randomly assigned to baseline phases of 2, 4, or 6 weeks. Regarding patient-centred secondary outcomes, the Rivermead Post-Concussion Symptoms Questionnaire will be assessed three times a week during baseline and treatment phases. Secondary outcomes also include measures of mood, sleep and fatigue, physical functioning, return to activity, and health-related quality of life. Patient-centred outcomes will be assessed at baseline, pretreatment, post-treatment, and one- and three-month follow-up. Thematic analysis of participant experiences will be explored through qualitative interviews. Discussion: Results from this trial will inform the feasibility and preliminary efficacy of this interdisciplinary concussion intervention and whether proceeding to a future definitive phase-2 randomised controlled trial is worthwhile. Understanding the end-user perspective of the treatment will also enable modifications to the treatment protocol for future trials to best suit the needs of individuals with PPCSs after mTBI. Outcomes from this trial can be directly translated into community rehabilitation programmes. Trial registration: ANZCTR, ACTRN12620001111965. Registered 27 October 2020, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379118 [ABSTRACT FROM AUTHOR]

Background: In psychological research, control conditions in the form of "treatment as usual" provide support for intervention efficacy, but do not allow the attribution of positive outcomes to the unique components of the treatment itself. Attentionally and structurally equivalent active control conditions, such as health education (HE), have been implemented in recent trials of cognitive behavioural therapy (CBT). However, descriptions and evaluations of these control conditions are limited. The aims of this paper were to (i) provide a detailed description and rationale for a novel HE active control condition and (ii) to evaluate the face validity, treatment integrity and feasibility of HE. Method: We developed a HE active control similar in structure and duration to a CBT intervention for reducing sleep disturbance and fatigue (CBT-SF) in a pilot randomised controlled trial (n = 51). Face validity was measured using post-treatment participant satisfaction and helpfulness ratings for fatigue and sleep symptoms, treatment fidelity was measured with integrity monitoring ratings from an independent expert and feasibility was measured with completion and attrition rates. HE and CBT-SF groups were compared using Wilcoxon rank-sum tests and chi-square tests of independence. Results: There were no significant differences in participant ratings of overall satisfaction between HE (n = 17) and CBT (n = 34) or in how helpful each intervention was for fatigue symptoms. Participants rated helpfulness for sleep symptoms higher in the CBT-SF group compared to HE. Integrity monitoring ratings were not significantly different for overall treatment delivery and therapist competency, but HE had greater module adherence than CBT-SF. There were no significant differences in completion or attrition rates between groups. Conclusion: Our findings suggest that the HE control had adequate face validity, was delivered with fidelity and was feasible and suitable for use as a comparator for CBT-SF. In providing a real-world example of practical and theoretical issues we considered when designing this control condition, we aim to provide a framework and guidance for future investigators. Trial registration: ACTRN12617000879369 (registered 15/06/2017) and ACTRN12617000878370 (registered 15/06/2017). [ABSTRACT FROM AUTHOR]

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. [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]

Depression and anxiety are common following acquired brain injury (ABI) and can be effectively treated using cognitive behaviour therapy (CBT) that has been adapted to compensate for cognitive difficulties (CBT-ABI). Training clinicians to deliver CBT-ABI is a crucial step in effective translation into clinical practice. This study evaluated the outcome of didactic and skill-based training on competencies in delivering CBT-ABI. Participants were 39 registered psychologists who attended a day-long workshop on using CBT-ABI to treat anxiety and depression after ABI, which included knowledge and skill-based content. Fourteen participants completed three additional supervision sessions reviewing audio recordings of their use of CBT-ABI with clients. Training outcomes were measured using surveys rating the usefulness of the various workshop components, a checklist of competencies in CBT-ABI on which participants rated themselves pre-workshop and post-workshop and post-supervision, and the Cognitive Therapy Scale (CTS), used by supervisors and a blinded expert to evaluate supervisees' skills. Participant-rated competencies in CBT-ABI significantly improved following workshop training, with no further change after supervision. CTS ratings of the supervisor, but not the blinded expert, showed significant improvement after short-term supervision. At 16-month follow-up, self-rated competency gains were maintained, and therapist confidence and competence were no longer major barriers to using CBT-ABI in the workplace. These findings suggest targeted training is important for clinical translation of this evidence-based intervention. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Agitation is common during the post-traumatic amnesia (PTA) period after traumatic brain injury (TBI), although our knowledge of what causes or predicts agitation is limited. The current study aimed to examine the association of agitation in PTA with the concurrent impairments in orientation and memory while controlling for covariates of agitation. Participants were 125 patients in PTA following moderate to extremely severe TBI recruited from an inpatient brain injury rehabilitation service who were assessed throughout PTA on the Agitated Behavior Scale (ABS) and the Westmead PTA Scale (WPTAS). Agitation was observed in 42.4% of participants (ABS score > 21), with disinhibited behaviours (e.g., distractibility and impulsivity) most common. Multilevel modelling found daily ABS scores to be associated with daily scores on the WPTAS but in a non-linear pattern. Analysis of covariates found that shorter time post-admission, younger age, presence of infection and higher antipsychotic doses were associated with higher ABS scores. These results support a relationship between agitation and the concurrent cognitive impairment during PTA. While a causal link cannot yet be inferred, management strategies that can potentially interfere with cognition (e.g., sedating medications, environmental changes) should be used cautiously in case they exacerbate agitation. [ABSTRACT FROM AUTHOR]

Despite clinical guidelines recommending an interdisciplinary approach to persisting post-concussion symptom (PPCS) management, evaluations of interdisciplinary interventions remain scant. This pilot study aimed to explore the feasibility and preliminary efficacy of an interdisciplinary intervention for PPCSs. A single-case experimental design with randomisation to multiple baselines (2, 4, or 6 weeks) was repeated across 15 participants (53% female) with mild traumatic brain injury (mean age 38.3 years, SD 15.7). The 12-week treatment incorporated psychology, physiotherapy, and medical interventions. Feasibility outcomes included recruitment and retention rates, adverse events, treatment adherence and fidelity. Patient-centred secondary outcomes included the Rivermead Post-Concussion Symptoms Questionnaire (RPQ), assessed 3 times per week during the baseline and treatment phases, and at the 1- and 3-month follow-ups. Other secondary outcomes included measures of mood, sleep and fatigue, physical functioning, health-related quality of life, illness perceptions, and goal attainment. Changes in PPCSs were evaluated using systematic visual analysis and Tau- U. Clinically significant changes in secondary outcomes were explored descriptively. 16/26 individuals assessed for eligibility were enroled (61% recruitment rate); 15 completed the post-treatment follow-ups, and 13 completed the 1- and 3-month follow-up assessments (81% retention rate). High treatment adherence and competence in delivering treatments was observed. Moderate-large effect sizes for reducing PPCSs were observed in 12/15 cases, with 7/15 reaching statistical significance. Improvements were maintained at the 1- and 3-month follow-ups and were accompanied by reductions in fatigue, sleep difficulties, and mood symptoms, and changes in illness perceptions. All participants had clinically significant improvements in at least 1 outcome, with 81% of individual therapy goals achieved. This pilot study provided preliminary support for a subsequent randomised controlled trial (RCT), with satisfactory recruitment, retention, treatment compliance, and treatment fidelity. Improvement was evident on participant outcomes including symptom reduction and goal attainment, suggesting that progressing to a phase-II RCT is worthwhile. Findings highlight the potential benefit of individualized interdisciplinary treatments. [ABSTRACT FROM AUTHOR]

Primary objective:Increasing physical activity (PA) among people with severe traumatic brain injury (TBI) represents an important long-term rehabilitation goal. To design effective interventions to promote PA, the factors associated with PA engagement post-TBI need to be understood. Research design:A qualitative study design was employed to investigate the factors influencing PA engagement in people with severe TBI living in the community. Methods and Procedures:Face-to-face interviews were conducted with eight people with severe TBI three to five years post-injury. A constant comparative method of data collection and analysis was adopted. Main outcomes and results:Interviews were analysed using thematic analysis. Three themes were identified: continuance of self and PA (perception of self, stage of life, and PA normality), beliefs about PA (knowledge of PA and associated benefits), and purpose of PA engagement (reasons for being physically active). Lifelong PA habits and current life priorities impacted on PA engagement post-TBI and influenced whether TBI-associated impairments were considered as a barrier to PA. Conclusion:Among this group of people, PA engagement post-TBI was influenced by perceptions of lifelong PA habits and current life priorities. Interventions to increase PA need to address these perceptions and adapt PA to account for life priorities within the context of TBI-associated impairments. [ABSTRACT FROM AUTHOR]

After moderate to severe traumatic brain injury (TBI), sleep disturbance commonly emerges during the confused post-traumatic amnesia (PTA) recovery stage. However, the evaluation of early sleep disturbance during PTA, its recovery trajectory, and influencing factors is limited. This study aimed to evaluate sleep outcomes in patients experiencing PTA using ambulatory gold-standard polysomnography (PSG) overnight and salivary endogenous melatonin (a hormone that influences the sleep-wake cycle) assessment at two time-points. The relationships between PSG-derived sleep-wake parameters and PTA symptoms (i.e., agitation and cognitive disturbance) were also evaluated. In a patient subset, PSG was repeated after PTA had resolved to assess the trajectory of sleep disturbance. Participants with PTA were recruited from Epworth HealthCare's inpatient TBI Rehabilitation Unit. Trained nurses administered overnight PSG at the patient bedside using the Compumedics Somté portable PSG device (Compumedics, Ltd., Australia). Two weeks after PTA had resolved, PSG was repeated. On a separate evening, two saliva specimens were collected (at 24:00 and 06:00) for melatonin testing. Results of routine daily hospital measures (i.e., Agitated Behavior Scale and Westmead PTA Scale) were also collected. Twenty-nine patients were monitored with PSG (mean: 41.6 days post-TBI; standard deviation [SD]: 28.3). Patients' mean sleep duration was reduced (5.6 h, SD: 1.2), and was fragmented with frequent awakenings (mean: 27.7, SD: 15.0). Deep, slow-wave restorative sleep was reduced, or completely absent (37.9% of patients). The use of PSG did not appear to exacerbate patient agitation or cognitive disturbance. Mean melatonin levels at both time-points were commonly outside of normal reference ranges. After PTA resolved, patients (n = 11) displayed significantly longer mean sleep time (5.3 h [PTA]; 6.5 h [out of PTA], difference between means: 1.2, p = 0.005). However, disturbances to other sleep-wake parameters (e.g., increased awakenings, wake time, and sleep latency) persisted after PTA resolved. This is the first study to evaluate sleep disturbance in a cohort of patients as they progressed through the early TBI recovery phases. There is a clear need for tailored assessment of sleep disturbance during PTA, which currently does not form part of routine hospital assessment, to suggest new treatment paradigms, enhance patient recovery, and reduce its long-term impacts. [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]

Family expressed emotion (EE) is a strong predictor of outcome in a range of psychiatric and medical conditions. This study aimed to examine the relationship between family EE-criticism, patient perceived criticism and criticism sensitivity and psychiatric disorders following moderate to severe traumatic brain injury (TBI). Participants were 60 patients with TBI and their family members. Patients were assessed for psychiatric disorders using the Structured Clinical Interview for DSM-IV (SCID-I) and completed the Perceived Criticism Measure (PCM) to determine levels of perceived criticism and criticism sensitivity. Family members completed the Family Questionnaire (FQ) to assess patient directed EE-criticism. Patients were reassessed approximately 12-months post-baseline. After controlling for diagnostic status at baseline, high criticism sensitivity at baseline was associated with greater probability of psychiatric diagnosis at follow-up (odds ratio=3.99, 95% CI=1.15–13.71). Family EE-criticism and perceived criticism were not predictive of patient diagnostic status at follow-up, but patients with high EE-family members were more likely to have a concurrent psychiatric diagnosis at baseline. Findings suggest that sensitivity to interpersonal criticism may have a role in the development and course of psychiatric disorders following TBI. [ABSTRACT FROM AUTHOR]

Increasing evidence indicates that post-traumatic stress disorder (PTSD) may develop following traumatic brain injury (TBI), despite most patients having no conscious memory of their accident. This prospective study examined the frequency, timing of onset, symptom profile, and trajectory of PTSD and its psychiatric comorbidities during the first 4 years following moderate-to-severe TBI. Participants were 85 individuals (78.8% male) with moderate or severe TBI recruited following admission to acute rehabilitation between 2005 and 2010. Using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Disorders (SCID-I), participants were evaluated for pre- and post-injury PTSD soon after injury and reassessed at 6 months, 12 months, 2 years, 3 years, and 4 years post-injury. Over the first 4 years post-injury, 17.6% developed injury-related PTSD, none of whom had PTSD prior to injury. PTSD onset peaked between 6 and 12 months post-injury. The majority of PTSD cases (66.7%) had a delayed-onset, which for a third was preceded by subsyndromal symptoms in the first 6 months post-injury. PTSD frequency increased over the first year post-injury, remained stable during the second year, and gradually declined thereafter. The majority of subjects with PTSD experienced a chronic symptom course and all developed one or more than one comorbid psychiatric disorder, with mood, other anxiety, and substance-use disorders being the most common. Despite event-related amnesia, post-traumatic stress symptoms, including vivid re-experiencing phenomena, may develop following moderate-to-severe TBI. Onset is typically delayed and symptoms may persist for several years post-injury. [ABSTRACT FROM AUTHOR]

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

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 (n = 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. [ABSTRACT FROM AUTHOR]

• A range of interventions are used worldwide to manage agitation after head injury. • Non-pharmacological strategies are favoured, although medication use remains high. • Clinicians with training and guidelines are more confident in managing agitation. • Only half of clinicians were satisfied with agitation management in their services. • Findings support the development of formal guidelines for managing agitation after head injury. 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. This study examined how clinicians worldwide conceptualise, measure and manage agitation during early TBI recovery. 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. 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. 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. [ABSTRACT FROM AUTHOR]