Measurement Properties of the Dutch Multifactor Fatigue Scale in Early and Late Rehabilitation of Acquired Brain Injury in Denmark.

Fatigue is a major issue in neurorehabilitation without a gold standard for assessment. The purpose of this study was to evaluate measurement properties of the five subscales of the self-report questionnaire the Dutch Multifactor Fatigue Scale (DMFS) among Danish adults with acquired brain injury. A multicenter study was conducted (N = 149, 92.6% with stroke), including a stroke unit and three community-based rehabilitation centers. Unidimensionality and measurement invariance across rehabilitation settings were tested using confirmatory factor analysis. External validity with Depression Anxiety Stress Scales (DASS-21) and the EQ-5D-5L was investigated using correlational analysis. Results were mixed. Unidimensionality and partial invariance were supported for the Impact of Fatigue, Mental Fatigue, and Signs and Direct Consequences of Fatigue, range: RMSEA = 0.07-0.08, CFI = 0.94-0.99, ω = 0.78-0.90. Coping with Fatigue provided poor model fit, RMSEA = 0.15, CFI = 0.81, ω = 0.46, and Physical Fatigue exhibited local dependence. Correlations among the DMFS, DASS-21, and EQ-5D-5L were in expected directions but in larger magnitudes compared to previous research. In conclusion, three subscales of the DMFS are recommended for assessing fatigue in early and late rehabilitation, and these may facilitate the targeting of interventions across transitions in neurorehabilitation. Subscales were strongly interrelated, and the factor solution needs evaluation.

Social cognition and emotion regulation: a multifaceted treatment (T-ScEmo) for patients with traumatic brain injury.

BACKGROUND: Many patients with moderate to severe traumatic brain injury have deficits in social cognition. Social cognition refers to the ability to perceive, interpret, and act upon social information. Few studies have investigated the effectiveness of treatment for impairments of social cognition in patients with traumatic brain injury. Moreover, these studies have targeted only a single aspect of the problem. They all reported improvements, but evidence for transfer of learned skills to daily life was scarce. We evaluated a multifaceted treatment protocol for poor social cognition and emotion regulation impairments (called T-ScEmo) in patients with traumatic brain injury and found evidence for transfer to participation and quality of life. PURPOSE: In the current paper, we describe the theoretical underpinning, the design, and the content of our treatment of social cognition and emotion regulation (T-ScEmo). THEORY INTO PRACTICE: The multifaceted treatment that we describe is aimed at improving social cognition, regulation of social behavior and participation in everyday life. Some of the methods taught were already evidence-based and derived from existing studies. They were combined, modified, or extended with newly developed material. PROTOCOL DESIGN: T-ScEmo consists of 20 one-hour individual sessions and incorporates three modules: (1) emotion perception, (2) perspective taking and theory of mind, and (3) regulation of social behavior. It includes goal-setting, psycho-education, function training, compensatory strategy training, self-monitoring, role-play with participation of a significant other, and homework assignments. RECOMMENDATIONS: It is strongly recommended to offer all three modules, as they build upon each other. However, therapists can vary the time spent per module, in line with the patients' individual needs and goals. In future, development of e-learning modules and virtual reality sessions might shorten the treatment.

Effectiveness of a Treatment for Impairments in Social Cognition and Emotion Regulation (T-ScEmo) After Traumatic Brain Injury: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the effects of a multifaceted Treatment for Social cognition and Emotion regulation (T-ScEmo) in patients with a traumatic brain injury. PARTICIPANTS: Sixty-one patients with moderate to severe traumatic brain injury randomly assigned to an experimental T-ScEmo intervention or a Cogniplus control condition. INTERVENTIONS: T-ScEmo is a compensatory strategy training for impairments in emotion recognition, theory of mind, and social behavioral skills. Cogniplus is a computerized cognitive function training. Both interventions were given in 16 to 20 weekly 1-hour sessions. MAIN MEASURES: Social cognition tests and questionnaires for social behavior (self- and proxy-rated) administered at baseline, immediately posttreatment, and at 3 to 5 months of follow-up. RESULTS: Compared with the Cogniplus group, the T-ScEmo group improved significantly on facial affect recognition, theory of mind, proxy-rated empathic behavior, societal participation, and treatment goal attainment, which lasted up to 5 months after treatment. At follow-up, the T-ScEmo group also reported higher quality of life and their life partners rated relationship quality to be higher than the Cogniplus group. CONCLUSION: This study shows that impairments in social cognition can be effectively dealt with by using a comprehensive treatment protocol, leading to improvements in everyday life social functioning.

Cognitive Behavioral Intervention Compared to Telephone Counseling Early after Mild Traumatic Brain Injury: A Randomized Trial.

Many patients do not return to work (RTW) after mild traumatic brain injury (mTBI) because of persistent complaints that are often resistant to therapy in the chronic phase. Recent studies suggest that psychological interventions should be implemented early post-injury to prevent patients from developing chronic complaints. This study is a randomized, controlled trial that examines the effectiveness of a newly developed cognitive behavioral therapy (CBT) intervention (CBTi) compared to telephonic counseling (TC) in at-risk mTBI patients (patients with high reports of early complaints). Patients underwent either five sessions of CBT treatment or five phone conversations starting 4-6 weeks post-trauma. The main outcome measure was RTW 6 and 12 months post-trauma. Secondary measures comprised functional outcome at 6 and 12 months, and depression, anxiety, and reported post-traumatic complaints at 3, 6, and 12 months post-injury. After excluding dropouts, CBTi consisted of 39 patients and TC of 45 patients. No significant differences were found with regard to RTW, with 65% of CBTi patients and 67% of TC patients reporting a RTW at previous level. However, TC patients reported fewer complaints at 3 (8 vs. 6; p = 0.010) and 12 months post-injury (9 vs. 5; p = 0.006), and more patients in the TC group showed a full recovery 12 months post-injury compared to the CBTi group (62% vs. 39%). The results of this study suggest that early follow-up of at-risk patients can have a positive influence on patients' well-being, and that a low-intensive, low-cost telephonic intervention might be more effective than a CBT intervention at improving outcome in at-risk patients.

Description of an early cognitive behavioral intervention (UPFRONT-intervention) following mild traumatic brain injury to prevent persistent complaints and facilitate return to work.

PURPOSE: Many patients with mild traumatic brain injury do not fully return to work owing to persistent posttraumatic complaints. Research suggests that preventing chronic complaints might be prevented by giving cognitive behavioral therapy early after injury. Therefore, a new cognitive behavioral intervention (UPFRONT-intervention) was developed to not only prevent chronic complaints but to also establish a more successful return to work. The intervention is currently being evaluated in a multicenter randomized controlled trial design (trial number ISRCTN86191894) in mild traumatic brain injury patients who are at-risk of negative outcomes (patients with high numbers of early complaints). Two case examples are presented to demonstrate the application of the intervention. RATIONALE: Psychological factors, like cognitive appraisal and coping, play an important role in the persistence of posttraumatic complaints. Some patients are less able to adapt and thus to cope with the injury and its initial consequences than others. Dealing with the injury in a passive, avoidant way, focusing on negative feelings, will hamper recovery and is therefore a valuable target for an intervention. Theory into practice: The UPFRONT intervention is a short cognitive behavioral therapy intervention for patients that are at-risk of developing persistent posttraumatic complaints. Patients will undergo five sessions of cognitive behavioral therapy within 4-10 weeks after trauma. The intervention aims to enhance patients' feeling of competency of dealing with the consequences of mild traumatic brain injury by providing psycho-education, identifying and challenging unrealistic illness perceptions and improving coping style (decreasing maladaptive coping and enhancing adaptive coping).

To Fear Is to Gain? The Role of Fear Recognition in Risky Decision Making in TBI Patients and Healthy Controls.

Fear is an important emotional reaction that guides decision making in situations of ambiguity or uncertainty. Both recognition of facial expressions of fear and decision making ability can be impaired after traumatic brain injury (TBI), in particular when the frontal lobe is damaged. So far, it has not been investigated how recognition of fear influences risk behavior in healthy subjects and TBI patients. The ability to recognize fear is thought to be related to the ability to experience fear and to use it as a warning signal to guide decision making. We hypothesized that a better ability to recognize fear would be related to a better regulation of risk behavior, with healthy controls outperforming TBI patients. To investigate this, 59 healthy subjects and 49 TBI patients were assessed with a test for emotion recognition (Facial Expression of Emotion: Stimuli and Tests) and a gambling task (Iowa Gambling Task (IGT)). The results showed that, regardless of post traumatic amnesia duration or the presence of frontal lesions, patients were more impaired than healthy controls on both fear recognition and decision making. In both groups, a significant relationship was found between better fear recognition, the development of an advantageous strategy across the IGT and less risk behavior in the last blocks of the IGT. Educational level moderated this relationship in the final block of the IGT. This study has important clinical implications, indicating that impaired decision making and risk behavior after TBI can be preceded by deficits in the processing of fear.

Dutch multifactor fatigue scale: a new scale to measure the different aspects of fatigue after acquired brain injury.

OBJECTIVES: To develop the Dutch Multifactor Fatigue Scale (DMFS), a new scale to assess the nature and impact of fatigue and coping with fatigue in the chronic phase after acquired brain injury (ABI) and to analyze the psychometric properties of this scale in a mixed group of patients with ABI. DESIGN: Cross-sectional survey study. SETTING: Academic rehabilitation center. PARTICIPANTS: A mixed sample of patients with ABI (N=134). For the development of the DMFS: community-dwelling adults with stroke (n=9) and traumatic brain injury (n=5). For analyses of the psychometric properties of the DMFS: community-dwelling adults with ischemic stroke (n=55), hemorrhagic stroke (n=22), traumatic brain injury (n=35), or other ABIs (n=22), all at least 6 months after brain injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: DMFS, Hospital Anxiety and Depression Scale, Checklist Individual Strength, and Dutch Personality Questionnaire. RESULTS: Exploratory and confirmatory factor analyses on data of 134 patients showed that the final DMFS consisted of 5 factors (explaining 55% of the variance): Impact of fatigue, Mental fatigue, Signs and Direct consequences of fatigue, Physical fatigue, and Coping with fatigue. All subscales of the DMFS showed sufficient to good reliability, good convergent validity with an existing fatigue scale, and good divergent validity with measures of mood and self-esteem. CONCLUSIONS: The DMFS is believed to improve the diagnostic process of fatigue in the chronic phase after ABI. As it measures several factors of fatigue after brain injury, therapeutic indications can be targeted to patients' needs.

Performance of healthy subjects on an ecologically valid test for social cognition: the short, Dutch Version of The Awareness of Social Inference Test (TASIT).

The present paper addresses the psychometric quality of the shortened Dutch version of The Awareness of Social Inference Test (TASIT), a social cognition task comprising dynamic social interactions. Because the original TASIT required a rather long administration time, two shortened parallel forms were developed. Results showed that TASIT-short was feasible and that the two alternate forms were reasonably comparable in a group of neurologically healthy individuals (N = 98). Also, the results confirmed the ecological validity of TASIT-short in this healthy group. The test appeared sensitive to brain injury as it differentiated between the healthy subjects and a group of patients with acquired brain injury (N = 16). On the basis of the present study we conclude that TASIT-short has added value to the assessment of social cognition in patients with acquired brain injury.

Deficits in facial emotion recognition indicate behavioral changes and impaired self-awareness after moderate to severe traumatic brain injury.

Traumatic brain injury (TBI) is a leading cause of disability, specifically among younger adults. Behavioral changes are common after moderate to severe TBI and have adverse consequences for social and vocational functioning. It is hypothesized that deficits in social cognition, including facial affect recognition, might underlie these behavioral changes. Measurement of behavioral deficits is complicated, because the rating scales used rely on subjective judgement, often lack specificity and many patients provide unrealistically positive reports of their functioning due to impaired self-awareness. Accordingly, it is important to find performance based tests that allow objective and early identification of these problems. In the present study 51 moderate to severe TBI patients in the sub-acute and chronic stage were assessed with a test for emotion recognition (FEEST) and a questionnaire for behavioral problems (DEX) with a self and proxy rated version. Patients performed worse on the total score and on the negative emotion subscores of the FEEST than a matched group of 31 healthy controls. Patients also exhibited significantly more behavioral problems on both the DEX self and proxy rated version, but proxy ratings revealed more severe problems. No significant correlation was found between FEEST scores and DEX self ratings. However, impaired emotion recognition in the patients, and in particular of Sadness and Anger, was significantly correlated with behavioral problems as rated by proxies and with impaired self-awareness. This is the first study to find these associations, strengthening the proposed recognition of social signals as a condition for adequate social functioning. Hence, deficits in emotion recognition can be conceived as markers for behavioral problems and lack of insight in TBI patients. This finding is also of clinical importance since, unlike behavioral problems, emotion recognition can be objectively measured early after injury, allowing for early detection and treatment of these problems.

Speed of information processing after unilateral stroke.

Speed of information processing in the subacute stage after stroke was studied in 88 first ever, unilateral, ischemic stroke patients. The patient group included 42 right and 46 left hemisphere patients. Seventy-one control subjects were also examined. Four reaction time tasks with different levels of complexity were used: two visuomotor, and two semantic categorisation tasks. The results showed that stroke causes a decrease in decision making speed, but that the effect is different for right and left hemisphere patients. The right hemisphere group were slower than the control group on all reaction time tasks, and slower than the left hemisphere patients on the visuomotor tasks. The left hemisphere patients were slower than the healthy controls, only on the most complex tasks, the categorisation tasks.

Subjective changes in emotion, cognition and behaviour after stroke: factors affecting the perception of patients and partners.

The presence and severity of changes in emotion and cognition experienced by left- and right-sided stroke patients and observed by their partners were compared at 3 months poststroke. The results showed that, regardless of the side of stroke, several changes were reported by half of the stroke patients and their partners. It appeared that while left hemisphere stroke patients agreed with their partners on the number and severity of most changes, partners of right hemisphere patients reported more frequent and more severe changes than the patients themselves. The level of observability of the altered behaviour, distress of the partner, distress of left-sided stroke patients and hemispatial neglect of right-sided stroke patients emerged as factors related to disagreement between stroke patient and partner.