Regional brain volume prior to treatment is linked to outcome after cognitive rehabilitation in traumatic brain injury.

Cognitive rehabilitation is useful for many after traumatic brain injury (TBI), but we lack critical knowledge about which patients benefit the most from different approaches. Advanced neuroimaging techniques have provided important insight into brain pathology and systems plasticity after TBI, and have potential to inform new practices in cognitive rehabilitation. In this study, we aimed to identify candidate structural brain measures with relevance for rehabilitation of cognitive control (executive) function after TBI. Twenty-eight patients (9 female, mean age 40.5 (SD = 13.04) years) with TBI (>21 months since injury) that participated in a randomized controlled cognitive rehabilitation trial (NCT02692352) were included in the analyses. Regional brain volume was extracted from T1-weighted MRI scans before treatment using tensor-based morphometry. Both positive and negative associations between treatment outcome (everyday cognitive control function) and regional brain volume were observed. The most robust associations between regional brain volume and improvement in function were observed in midline fronto-parietal regions, including the anterior and posterior cingulate cortices. The study provides proof of concept and valuable insight for planning future studies focusing on neuroimaging in cognitive rehabilitation after TBI.

A cross-sectional study exploring overlap in post-stroke fatigue caseness using three fatigue instruments: Fatigue Severity Scale, Fatigue Questionnaire and the Lynch's Clinical Interview.

OBJECTIVE: Post stroke fatigue (PSF) is a frequent symptom affecting 25-73% of stroke survivors. The variability in estimates of prevalence found across studies reflects differences in fatigue measures and use of different cut-offs for defining clinically significant fatigue. The main aim of this study is to explore the frequency and overlap in caseness of fatigue using three different fatigue measures in a sample of patients at 3 months post stroke. Furthermore, we wanted to explore the instrument's associations with demographic and clinical characteristics. METHODS: The sample consists of 93 patients with new onset stroke. This cross-sectional study includes three measurements of fatigue, The Fatigue Severity Scale (FSS), The Chalder Fatigue Questionnaire (FQ) and the Lynch Interview. Medical, physical, psychological data and estimates of pre-stroke fatigue were collected 3 months post stroke. RESULTS: The FQ using the bimodal scoring yielded about 2.5 more fatigue cases (n = 57) than the FSS with a cut-off mean score of 5 (n = 22). The Lynch interview identified 48 patients as fatigue cases. Conducting multivariate analyses, the three instruments were differently associated with predictor variables such as prestroke fatigue, reduced balance and burden of symptoms reported post stroke. CONCLUSION: The use of different instruments leads to a large variability in identifying fatigue cases in a sample of stroke patients. Scientifically and clinically a clarification and consensus on how to measure fatigue is warranted. Without correct identification of PSF-cases, knowledge about the causes of fatigue and development of tailored and interdisciplinary interventions are further delayed.

The feasibility and acceptability of goal management training of executive functions in children with spina bifida and acquired brain injury.

Executive dysfunction causes significant real-life disability for children with spina bifida (SB) and acquired brain injury (ABI), and efficient interventions are needed. Goal Management Training (GMT) is a cognitive rehabilitation intervention for improving executive function (EF) that has received empirical support in studies of adults with SB and ABI. The purpose of this study was to determine the feasibility and acceptability of a newly developed pediatric GMT protocol (pGMT). Thirteen children (7 boys, 10-16 years) with SB (n = 4), traumatic brain injury (n = 8), and encephalitis (n = 1) were included, based upon the presence of EF problems as described by parents. The participants received 21 h of pGMT, using inpatient intervention periods, followed by 4 h of pGMT outpatient guidance over 8 weeks. Notably, pGMT was found to be both feasible and acceptable, with satisfactory compliance for the children, parents and teachers, in addition to being considered acceptable by all participants. Furthermore, a reliable change in daily life EF was reported by the parents for 2 children. And, some children obtained scores below clinical cut-off on a measure of parent reported real-life EF after intervention. Hence, findings suggest that a randomized controlled trial of pGMT, with a larger sample size, should be conducted.

Emotional Regulation Following Acquired Brain Injury: Associations With Executive Functioning in Daily Life and Symptoms of Anxiety and Depression.

Objective: To examine whether a questionnaire measuring emotional regulation after acquired brain injury adds clinical information beyond what can be obtained with a comprehensive executive function questionnaire and an anxiety and depression measure. Method: Seventy adult persons (age 19-66 years, Mage = 43, SDage = 13) with acquired brain injury in the chronic phase and executive function complaints. All were recruited to participate in a randomized controlled trial (NCT02692352) evaluating the effects of cognitive rehabilitation. Traumatic brain injury was the dominant cause of injury (64%), and mean time since injury was 8 years. Emotional regulation was assessed with the Brain Injury Trust Regulation of Emotions Questionnaire (BREQ). Executive function was assessed with the Behavior Rating Inventory of Executive Function Adult Version (BRIEF-A). The Hopkins Symptom Checklist 25 (HCSL-25) was employed to measure anxiety and depression symptoms. Results: Overall, significant correlations were found between reports of emotional regulation (BREQ) and executive function in daily life (BRIEF-A). Furthermore, our analyses revealed a significant relationship between self-reported scores of emotional regulation (BREQ) and symptoms of anxiety and depression (HSCL-25). Conclusion: The significant associations between the BREQ and most of the other clinical measures indicate that, for patients with acquired brain injury, the BREQ does not add substantial information beyond what can be assessed with the BRIEF-A and the HSCL-25.

How do family members of individuals with spinal cord and acquired brain injuries make sense of their experiences: A qualitative study of meaning making processes.

This study explores the processes that promote coping with abruptive life changes, often experienced as life before and after injury. The consept of meaning making, was used as theoretical framework for analysisthr. Family members of individuals with spinal cord and acquired brain injury participated in two focus groups three to twenty years post-injury. Data was analysed using thematic analyses. Two main themes were identified: drawing upon different coping strategies and balancing family needs against personal autonomy. Making sense of an altered situation was by keeping a positive outlook, making comparisons to worst cases, engagement in activities and making room for own needs. Thus, the study illistrates that life can continue in a good manner after adversities, but requires flexibility and adjustments.

Trajectories of fatigue among stroke patients from the acute phase to 18 months post-injury: A latent class analysis.

INTRODUCTION: Post-stroke fatigue (PSF) is a common symptom affecting 23-75% of stroke survivors. It is associated with increased risk of institutionalization and death, and it is of many patients considered among the worst symptoms to cope with after stroke. Longitudinal studies focusing on trajectories of fatigue may contribute to understanding patients' experience of fatigue over time and its associated factors, yet only a few have been conducted to date. OBJECTIVES: To explore whether subgroups of stroke survivors with distinct trajectories of fatigue in the first 18 months post stroke could be identified and whether these subgroups differ regarding sociodemographic, medical and/or symptom-related characteristics. MATERIALS AND METHODS: 115 patients with first-ever stroke admitted to Oslo University Hospital or Buskerud Hospital were recruited and data was collected prospectively during the acute phase and at 6, 12 and 18 months post stroke. Data on fatigue (both pre- and post-stroke), sociodemographic, medical and symptom-related characteristics were collected through structured interviews, standardized questionnaires and from the patients' medical records. Growth mixture modeling (GMM) was used to identify latent classes, i.e., subgroups of patients, based on their Fatigue Severity Scales (FSS) scores at the four time points. Differences in sociodemographic, medical, and symptom-related characteristics between the latent classes were evaluated using univariate and multivariable ordinal regression analyses. RESULTS AND THEIR SIGNIFICANCE: Using GMM, three latent classes of fatigue trajectories over 18 months were identified, characterized by differing levels of fatigue: low, moderate and high. The mean FSS score for each class remained relatively stable across all four time points. In the univariate analyses, age <75, pre-stroke fatigue, multiple comorbidities, current depression, disturbed sleep and some ADL impairment were associated with higher fatigue trajectories. In the multivariable analyses, pre-stroke fatigue (OR 4.92, 95% CI 1.84-13.2), multiple comorbidities (OR 4,52,95% CI 1.85-11.1) and not working (OR 4.61, 95% CI 1.36-15,7) were the strongest predictor of higher fatigue trajectories The findings of this study may be helpful for clinicians in identifying patients at risk of developing chronic fatigue after stroke.

Trajectory of 10-Year Neurocognitive Functioning After Moderate-Severe Traumatic Brain Injury: Early Associations and Clinical Application.

OBJECTIVE: This study aimed to explore the 10-year trajectories of neurocognitive domains after moderate-severe traumatic brain injury (TBI), to identify factors related to long-term neurocognitive functioning, and to investigate whether performance remained stable or changed over time. METHOD: Seventy-nine patients with moderate-severe TBI between the ages of 16 and 55 years were assessed at 3 months, 1, 5, and 10 years postinjury using neuropsychological tests and functional outcomes. Three hierarchical linear models were used to investigate the relationships of domain-specific neurocognitive trajectories (Memory, Executive function, and Reasoning) with injury severity, demographics, functional outcome at 3 months (Glasgow Outcome Scale-Extended) and emotional distress at 1 year (Symptom Checklist 90-Revised). RESULTS: Education, injury severity measures, functional outcome, and emotional distress were significantly associated with both Memory and Executive function. Education and emotional distress were related to Reasoning. The interaction effects between time and these predictors in predicting neurocognitive trajectories were nonsignificant. Among patients with data at 1 and 10 year follow-ups (n = 47), 94-96% exhibited stable scores on Executive function and Reasoning tasks, and 83% demonstrated stable scores on Memory tasks. Significant memory decline was presented in 11% of patients. CONCLUSIONS: The findings highlight the differential contribution of variables in their relationships with long-term neurocognitive functioning after moderate-severe TBI. Injury severity was important for Memory outcomes, whereas emotional distress influenced all neurocognitive domains. Reasoning (intellectual) abilities were relatively robust after TBI. While the majority of patients appeared to be cognitively stable beyond the first year, a small subset demonstrated a significant memory decline over time.

Persons injured in the 2011 terror attacks in Norway - Relationship between post-traumatic stress symptoms, emotional distress, fatigue, sleep, and pain outcomes, and medical and psychosocial factors.

Purpose: The main aim was to assess long-term post-traumatic stress symptoms, emotional distress, fatigue, sleep disturbances and pain in individuals hospitalized with physical injuries after two terror attacks in Oslo in 2011, approximately three years after the events. A secondary aim was to explore the relationship between these outcomes and medical and psychosocial factors.Materials and methods: Thirty of 43 potential persons participated. Injury characteristics were collected from medical charts. Level of post-traumatic stress, emotional distress, fatigue, sleep disturbances and pain was assessed and the association with injury severity, resilience, optimism, neuroticism and extroversion, and perceived access to social support was explored.Results: Nine of 30 met criteria for full or partial PTSD, and 14 of 30 displayed clinical levels of emotional distress. Fifteen reported moderate to severe fatigue, and 16 said sleep disturbances affected their daily life. Twelve indicated that pain affected daily activities and work ability, and 15 that pain affected their quality of life. I Resilience, optimism, neuroticism, and perceived social support, were associated with outcomes, but injury severity was not. When controlling for pain, many of the psychosocial variables failed to reach significance.Conclusions: Injury severity was not associated with outcomes. On the other hand, psychosocial factors were, but seemed to be influenced by pain.Implications for rehabilitationPersons who have obtained physical injuries under extreme psychological conditions such as terror, are at high risk of poor long-term outcomes, and will often be in need of comprehensive interdisciplinary rehabilitation services.Psychological outcomes are not associated with severity of physical injury, but premorbid and current psychological variables such as resilience, optimism, personality, and access to social support are highly associated with long-term outcome.Longstanding pain seems to diminish or weaken the role of protective psychological factors and should be addressed in the rehabilitation context.

Polio and post-polio syndrome in non-Western immigrants: A new challenge for the healthcare system in Norway.

OBJECTIVE: To explore the health situation and identify specific health challenges in non-Western immigrants with polio in Norway, by comparing their status with Western immigrants with polio and native Norwegians with polio. DESIGN: A questionnaire covering demographics, polio history, life satisfaction, medical, psychological and social conditions was answered by 1,408 persons with polio, among them 34 immigrants from non-Western countries and 32 immigrants from Western countries. RESULTS: The non-Western immigrant polio group had a mean age of 46 years, were highly educated, reported high frequency of mental health problems and only one-third was working. Mean age for contracting polio was 2.8 years. Only 30% was hospitalized in the acute phase and 80% reported severe leg weakness. Use of a powered wheelchair was reported by 72%. Post-polio symptoms had started at a mean age of 31 years. The non-Western immigrant group reported more fatigue, pain and loneliness, and a high proportion reported insufficient assistance from the public health system. CONCLUSION: The group of non-Western immigrants with polio in Norway reported more health and social problems than the group of Western immigrants with polio or the native Norwegian group with polio, even though they were younger and more highly educated. Their complex psychological and social situation requires active intervention from the health system, and health professionals need extra skills to deal most effectively with their situation.

Use It or Lose It? A 5-Year Follow-up Study of Goal Management Training in Patients with Acquired Brain Injury.

OBJECTIVES: To determine the perceived 5-year outcome of Goal Management Training (GMT) for individuals with chronic acquired brain injury and executive dysfunction, when compared to a nonspecific psychoeducational intervention (Brain Health Workshop, BHW). METHODS: Of the 67 subjects in the initial randomized controlled trial [Tornås et al. (2016). Journal of the International Neuropsychological Society, 1-17], 50 (GMT, n = 21; BHW, n = 29) subjects returned written consent and questionnaires (54% male, age 45.8 ± 10.9 years). The 5-year follow-up consisted of two questionnaires, including the Behavior Rating Inventory of Executive Function for daily life executive function (EF) and Quality of Life after Brain Injury to assess health-related quality of life (HRQoL). Changes related to daily life EF and HRQoL were assessed pre-treatment, post-treatment, 6-month follow-up, and 5-year follow-up. Data were analyzed using a 2 × 4 mixed-design ANOVA. RESULTS: The findings indicate that GMT is efficacious in improving EF and HRQoL 6-month post-treatment. However, these changes failed to remain significant at 5-year follow-up. CONCLUSIONS: Data from 50 participants receiving either GMT or BHW suggested that the significant GMT-related improvements on perceived EF and HRQoL observed at 6-month follow-up were no longer present at 5-year follow-up. These findings indicate a need to promote maintenance of interventions post-treatment.

Chronic pain among the hospitalized patients after the 22 July 2011 terror attacks in Oslo and at Utøya Island.

BACKGROUND: On 22 July 2011, 48 people were hospitalized due to physical injuries from gun shots or explosion, following 2 terror attacks in the Oslo area, Norway. In this study, we have investigated the occurrence of chronic pain, the severity and consequences of chronic pain in these patients, 3 to 4 years after the incidents. METHODS: Totally 43 eligible terror trauma patients were invited to participate in the study, 30 patients were included. They underwent a consultation with a psychologist and a physician; containing psychological assessment, neuropsychological screening, a standardized clinical interview, medical examination, and a pain protocol. RESULTS: In 18 (60%) the injury was severe, as defined by New Injury Severity Score > 15. Twenty-four patients (80%) reported injury-related chronic pain after the trauma, in 22 with consequences on daily life. Analgesics were used by 20 patients, including 5 in need of opioids. Ten patients had unmet needs of further specialist pain care. In 12 patients, the average pain score last week was above three on a 0-10 Numeric Rating Scale. In these patients, clinical signs of neuropathic pain were evident in 10, as tested by the Douleur Neuropathique score. There were significant correlations (P < 0.05) between severity of chronic pain and presence of post-traumatic stress symptoms, reduced quality of life, reduced psychosocial and physical function; but no correlation with pre-injury patient characteristics or the degree of physical injury. CONCLUSION: Chronic pain was frequent and significant, irrespective of injury severity, in these patients who obtained their physical injuries under extreme psychological conditions.

Clinical characteristics and physical functioning in persons hospitalized following the Norwegian terror attacks in July 2011: A follow up study.

OBJECTIVE: To describe the clinical characteristics and physical functioning in persons hospitalized after 2 terror attacks in Norway in 2011. DESIGN: Cross-sectional study with retrospective acute medical data. SUBJECTS: Surviving persons hospitalized with physical injuries. METHODS: Medical and psychological assessments 3-4 years after injury, with data on injury type and severity collected from medical records. RESULTS: A total of 30 out of 43 potential subjects participated (19 women, 11 men; age range 17-71 years (median 23 years)). Eighteen participants had suffered a severe injury, with New Injury Severity Scale (NISS) scores > 15. All body parts were affected. The number of surgical procedures ranged from 0 to 22 (median 3), and days in intensive care ranged from 0 to 59 (median 2.5), of which 16 had more than 24 h intensive care. Three to 4 years later, a majority of the participants had a broad spectrum of somatic and psychological problems and reduced physical functioning. Two-thirds of the participants reported their physical health to be unsatisfactory, and continuous need for healthcare and unmet needs were identified for all except 4 of the participants. CONCLUSION: Persons hospitalized following a terror attack experience a broad spectrum of somatic and psychological problems and need long-term physical and psychological follow-up. This study indicates specific needs for rehabilitation after injuries acquired under psychological traumatic circumstances.

Moderators, mediators and nonspecific predictors of outcome after cognitive rehabilitation of executive functions in a randomised controlled trial.

Moderators, mediators and nonspecific predictors of treatment after cognitive rehabilitation of executive functions in a randomised controlled trial Objective: To explore moderators, mediators and nonspecific predictors of executive functioning after cognitive rehabilitation in a randomised controlled trial, comparing Goal Management Training (GMT) with an active psycho-educative control-intervention, in patients with chronic acquired brain injury. METHODS: Seventy patients with executive dysfunction were randomly allocated to GMT (n = 33) or control (n = 37). Outcome measures were established by factor-analysis and included cognitive executive complaints, emotional dysregulation and psychological distress. RESULTS: Higher age and IQ emerged as nonspecific predictors. Verbal memory and planning ability at baseline moderated cognitive executive complaints, while planning ability at six-month follow-up mediated all three outcome measures. Inhibitory cognitive control emerged as a unique GMT specific mediator. A general pattern regardless of intervention was identified; higher levels of self-reported cognitive-and executive-symptoms of emotional dysregulation and psychological distress at six-month follow-up mediated less improvement across outcome factors. CONCLUSIONS: The majority of treatment effects were nonspecific to intervention, probably underscoring the variables' general contribution to outcome of cognitive rehabilitation interventions. Interventions targeting specific cognitive domains, such as attention or working memory, need to take into account the patients' overall cognitive and emotional self-perceived functioning. Future studies should investigate the identified predictors further, and also consider other predictor candidates.

Description of a multifaceted intervention programme for fatigue after acquired brain injury: a pilot study.

The purpose of this pilot study was to describe and explore a group-based multifaceted intervention for patients with fatigue after acquired brain injury (ABI). We hypothesised that post-intervention changes would result in reduced fatigue, in addition to improved emotional health, sleep and attentional control. Eight subjects with traumatic brain injury (n = 3) and cerebrovascular insults (n = 5) were included. Inclusion was based upon the presence of fatigue complaints. The participants received 36 hours of intervention. Changes related to fatigue, emotional health and sleep was assessed with self-rating measures. Additionally, a neuropsychological test (Conners' Continuous Performance Test II) was included as a measure of attentional control. All subjects were assessed at baseline, post-intervention, and at 3 and 9 months follow-up. Findings indicated reduced fatigue levels (post-intervention and 3 months follow-up), anxiety (9 months follow-up), and daytime sleepiness (3 and 9 months follow-up). Pilot results suggest that multifaceted group-based interventions may have the potential to alleviate symptoms of fatigue, anxiety and sleepiness after ABI. At an individual level, a low load of psychological distress, insomnia symptoms, dysexecutive symptoms, in addition to a strong sense of self-efficacy, may be central in order to reduce levels of fatigue.

"It gets better. It can´t be worse than what we have been through." Family accounts of the minimally conscious state.

OBJECTIVES: The aim of this qualitative study was to explore family life when a family member is in a chronic minimally conscious state (MCS). Experiences with the health care system were also explored. METHODS: As part of a larger qualitative study of family life after a family member suffers severe physical injury, we conducted a focus group interview with five family members of three patients in a chronic MCS. The participants included three mothers, one father, and one sibling. The length of time since the brain injuries was four, four, and ten years. A thematic analysis was conducted. RESULTS: Three main themes emerged. Each family reflected on the challenges of maintaining family unity. They also revealed how they had dealt with the ambiguity and severity of the situation, including the communication with the health care system. Finally, they described their journeys back toward a normal, everyday family life. CONCLUSIONS: The findings demonstrate challenges faced by family members but also their capacity to withstand and overcome adversity. Clinicians are reminded to maintain a long-term perspective and understand the importance of helping families adjust, maintain hope for a better future, and mitigate their psychological pain.

Associations between self and informant ratings of executive functioning and driver behaviour following acquired brain injury.

OBJECTIVES: To investigate self and informant ratings of everyday executive functions and their correlation with driving behaviour after acquired brain injury. METHODS: A 1-year follow-up study of 24 adults with stroke and 10 adults with traumatic brain injury deemed fit to drive after a multidisciplinary driving assessment. Baseline measures included neuropsychological tests and self and informant reports of everyday executive function (Behavior Rating of Executive Function; BRIEF-A). Follow-up measurements were the Swedish Driver Behaviour Questionnaire (DBQ) and Sunnaas Driving Pattern Questionnaire (SDPQ). RESULTS: Patients' ratings on the BRIEF-A were significantly associated with the DBQ at follow-up, whereas informants' ratings were not. Neither patients' nor informants' reports were associated with accident involvement or the use of compensatory driving strategies. No significant associations were found between level of awareness and driving parameters. CONCLUSION: Patients' reports of everyday executive functioning were more strongly associated with driving behaviour than were informants' reports. Future studies are warranted to explore how informant and patient reports can contribute to distinguishing safe from unsafe drivers among patient groups with impaired awareness of deficits.

Exploring narratives of resilience among seven males living with spinal cord injury: a qualitative study.

BACKGROUND: It is a challenge for both individuals and families when an illness or traumatic injury results in a severe spinal cord injury. The on-going physical impairments experienced by persons with spinal cord injury play themselves out over time. Few qualitative studies have explored how health, resilience and wellbeing interplay across time among persons living with the consequences of severe physical injuries. Thus, the aim of this study was to obtain a deeper understanding of how individuals with spinal cord injury reflect upon the efforts, strategies and agency they perform to sustain long term resilience and wellbeing. METHODS: In this exploratory qualitative study, we conducted a thematic analysis of in-depth interviews with seven men who had lived with spinal cord injury for 2-32 years and who previously had undergone medical rehabilitation. RESULTS: The efforts revealed by the participants in normalising life with a spinal cord injury required continued flexibility, persistency and solution-focused adjustment, interpreted as processes documenting resilience. The participants were marshalling personal resources to handle challenges over time. They explained that they succeeded in maintaining health and wellbeing by manoeuvring between different strategies such as being self-protective and flexible as well as staying active and maintaining a positive attitude. Further, support from relational resources were of utmost importance emotionally, socially and when in need of practical assistance. When harnessing relational resources when needed, the participants underlined that balancing dependence and autonomy to remain a part of ordinary life was essential in staying emotionally stable. CONCLUSIONS: The findings of the present study show similarities to those of previous studies with regard to the participants' attribution of their resilience and wellbeing to their innate personal abilities and strong connection to their family and friends. In addition, the current participants provide enlightening nuances and depth that expand our understanding of the construct of resilience by highlighting the importance of continuously exerting agency, willpower and strength through rational cognitive strategies to adjust and adapt to chronic and new challenges.

Exploring associations between self-regulatory mechanisms and neuropsychological functioning and driver behaviour after brain injury.

The objective of this prospective one-year follow-up study was to explore the associations between self-regulatory mechanisms and neuropsychological tests as well as baseline and follow-up ratings of driver behaviour. The participants were a cohort of subjects with stroke and traumatic brain injury (TBI) who were found fit to drive after a multi-disciplinary driver assessment (baseline). Baseline measures included neuropsychological tests and ratings of self-regulatory mechanisms, i.e., executive functions (Behavior Rating Inventory of Executive Function-Adult Version; BRIEF-A) and impulsive personality traits (UPPS Impulsive Behavior Scale). The participants rated pre-injury driving behaviour on the Driver Behaviour Qestionnaire (DBQ) retrospectively at baseline and after one year of post-injury driving (follow-up). Better performance on neuropsychological tests was significantly associated with more post-injury DBQ Violations. The BRIEF-A main indexes were significantly associated with baseline and follow-up ratings of DBQ Mistakes and follow-up DBQ Inattention. UPPS (lack of) Perseverance was significantly associated with baseline DBQ Inattention, whereas UPPS Urgency was significantly associated with baseline DBQ Inexperience and post-injury DBQ Mistakes. There were no significant changes in DBQ ratings from baseline (pre-injury) to follow-up (post-injury). It was concluded that neuropsychological functioning and self-regulatory mechanisms are related to driver behaviour. Some aspects of driver behaviour do not necessarily change after brain injury, reflecting the influence of premorbid driving behaviour or impaired awareness of deficits on post-injury driving behaviour. Further evidence is required to predict the role of self-regulatory mechanisms on driver behaviour and crashes or near misses.

Combined cognitive and vocational interventions after mild to moderate traumatic brain injury: study protocol for a randomized controlled trial.

BACKGROUND: A considerable proportion of patients with mild to moderate traumatic brain injury (TBI) experience long-lasting somatic, cognitive, and emotional symptoms that may hamper their capacity to return to work (RTW). Although several studies have described medical, psychological, and work-related factors that predict RTW after TBI, well-controlled intervention studies regarding RTW are scarce. Furthermore, there has traditionally been weak collaboration among health-related rehabilitation services, the labor and welfare sector, and workplaces. METHODS/DESIGN: This study protocol describes an innovative randomized controlled trial in which we will explore the effect of combining manualized cognitive rehabilitation (Compensatory Cognitive Training [CCT]) and supported employment (SE) on RTW and related outcomes for patients with mild to moderate TBI in real-life competitive work settings. The study will be carried out in the southeastern region of Norway and thereby be performed within the Norwegian welfare system. Patients aged 18-60 years with mild to moderate TBI who are employed in a minimum 50% position at the time of injury and sick-listed 50% or more for postconcussive symptoms 2 months postinjury will be included in the study. A comprehensive assessment of neurocognitive function, self-reported symptoms, emotional distress, coping style, and quality of life will be performed at baseline, immediately after CCT (3 months after inclusion), following the end of SE (6 months after inclusion), and 12 months following study inclusion. The primary outcome measures are the proportion of participants who have returned to work at 12-month follow-up and length of time until RTW, in addition to work stability as well as work productivity over the first year following the intervention. Secondary outcomes include changes in self-reported symptoms, emotional and cognitive function, and quality of life. Additionally, a qualitative RTW process evaluation focused on organizational challenges at the workplace will be performed. DISCUSSION: The proposed study will combine cognitive and vocational rehabilitation and explore the efficacy of increased cross-sectoral collaboration between specialized health care services and the labor and welfare system. If the intervention proves effective, the project will describe the cost-effectiveness and utility of the program and thereby provide important information for policy makers. In addition, knowledge about the RTW process for persons with TBI and their workplaces will be provided. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03092713 . Registered on 10 March 2017.