Kacey Little Maestas

Sexual functioning 1 year after traumatic brain injury: Findings from a prospective traumatic brain injury model systems collaborative study

OBJECTIVE To investigate the incidence and types of sexual difficulties in men and women with traumatic brain injury (TBI) 1 year after injury, as well as their comfort level in discussing problems with health care professionals. DESIGN Prospective cohort study. SETTING Community. PARTICIPANTS Persons with TBI (N=223; 165 men and 58 women) who had been treated at 1 of 6 participating TBI Model Systems inpatient rehabilitation units and were living in the community. INTERVENTIONS None. MAIN OUTCOME MEASURES Derogatis Interview for Sexual Functioning-self-report (DISF-SR); Global Sexual Satisfaction Index (GSSI); structured interview regarding changes in sexual functioning; and comfort level discussing sexuality with health care professionals. RESULTS Women with TBI scored significantly below the normative sample for all subscales of the DISF-SR, including sexual cognition/fantasy, arousal, sexual behavior/experience, and orgasm. Men scored significantly below the normative sample on all scales except arousal. Women reported greater dysfunction than men for sexual cognition/fantasy and arousal. Twenty-nine percent of participants reported dissatisfaction with sexual functioning on the GSSI, with a greater percentage of men reporting dissatisfaction. Sixty-eight percent of participants indicated that they would spontaneously raise issues of sexual difficulties with health care professionals, while the remainder would either bring it up only if directly asked or would not discuss it at all. CONCLUSIONS Sexual difficulties were present in a substantial portion of community-dwelling people with TBI at 1 year after injury. Educational interventions to increase awareness among people with TBI and rehabilitation professionals are warranted, as well as interventions to improve sexual functioning.

Relationship of caregiver and family functioning to participation outcomes after postacute rehabilitation for traumatic brain injury: a multicenter investigation.

OBJECTIVE To investigate the contribution of caregiver emotional functioning and family functioning to participation outcomes after postacute rehabilitation for traumatic brain injury (TBI). DESIGN Prospective cohort study. SETTING Three postacute comprehensive-integrated postacute rehabilitation programs associated with National Institute on Disability and Rehabilitation Research-funded TBI Model Systems Centers. PARTICIPANTS Persons with medically documented TBI (N=136; 57% with severe TBI, 12% moderate, 31% mild), primarily men and 69% white. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Community Integration Questionnaire and Craig Handicap Assessment and Reporting Technique (CHART). RESULTS After accounting for age, education, sex, and race/ethnicity, there was a significant interaction between caregiver emotional functioning and time since injury for CHART Occupation and Social Integration Scale scores. Better emotional functioning in caregivers was associated with greater occupation and social integration outcomes for persons who entered the postacute rehabilitation program within 6 months of injury, but not for those >6 months postinjury. There was no relationship of family functioning to participation outcomes, and no interaction between family functioning and time since injury. CONCLUSIONS Caregiver distress should be accounted for in studies investigating the effectiveness of postacute rehabilitation after TBI. Screening of caregivers early during postacute rehabilitation can target those who need assistance to improve their support of the person with TBI.

Predictors of sexual functioning and satisfaction 1 year following traumatic brain injury: A TBI model systems multicenter study

Objective:To investigate predictors of sexual functioning 1 year following traumatic brain injury (TBI). Design:Prospective cohort study. Setting:Community. Participants:A total of 255 persons with TBI (187 males; 68 females) who had been treated at 1 of 6 TBI Model Systems inpatient rehabilitation units and were living in the community. Main Measures:Derogatis Interview for Sexual Functioning-Self-Report (DISF-SR); Global Satisfaction With Sexual Functioning (Global Sexual Satisfaction Index); Participation Assessment With Recombined Tools-Objective; Patient Health Questionnaire-9. Results:Older age, female gender, and more severe injury were associated with greater sexual dysfunction 1 year following injury. As age increased from 24 to 49 years, the odds of sexual impairment increased more than 3-fold (95% confidence interval: 1.82-5.88). Females had a 2.5 increase in odds of sexual impairment compared with males (95% confidence interval: 1.23–5.26). Greater social participation was predictive of better sexual functioning. Dissatisfaction with sexual functioning was predicted by older age and depression. Conclusions and Implications:Older persons and females appear to be at greater risk for sexual dysfunction after TBI and may benefit from specialized assessment and treatment services. Relationships were identified between social participation and sexual function and between depression and sexual satisfaction that may serve as clinical indicators for further assessment and intervention. Further research is needed to elucidate these relationships and identify effective clinical approaches.

Changes in sexual functioning from 6 to 12 months following traumatic brain injury: A prospective tbi model system multicenter study

Objective:To investigate longitudinal changes in sexual functioning during the first year following moderate to severe traumatic brain injury (TBI). Design:Prospective cohort study. Setting:Community. Participants:182 persons (53 women and 129 men) with moderate to severe TBI who were admitted to 1 of 6 participating TBI Model System centers and followed in the community at 6 and 12 months after injury. Main Measures:Derogatis Interview for Sexual Functioning—Self-Report (DISF-SR); Global Sexual Satisfaction Index (GSSI). Results:Mean T-scores on the DISF-SR Arousal subscale demonstrated marginal improvement over time, with a 2.59-point increase (P = .05) from 6 to 12 months after injury. There were no significant differences over this 6-month period on the remaining DISF-SR subscales, including sexual cognition/fantasy, sexual behavior/experience, and orgasm. There was no significant change in satisfaction with sexual functioning on the GSSI from 6 months (72% satisfied) to 12 months (71% satisfied). Conclusions and Implications:Sexual function and satisfaction appears to be stable in those with moderate to severe TBI from 6 to 12 months after injury, with the exception of minimal improvement in arousal. These findings, to our knowledge, reflect the first evidence regarding prospective changes in sexual functioning in this population. Future research can go far to assist clinicians in treatment planning and managing patient expectations of recovery of sexual functioning after TBI.

Preinjury coping, emotional functioning, and quality of life following uncomplicated and complicated mild traumatic brain injury

Objective:To identify preinjury coping profiles among adults with uncomplicated mild traumatic brain injury (mTBI) and complicated mTBI and to determine whether preinjury coping profiles contribute to the prediction of emotional functioning and quality of life (QOL) 3 months post-mTBI. Participants:One hundred eighty-seven persons with medically documented mTBI (uncomplicated mTBI, n = 89; complicated mTBI, n = 98) were recruited from the emergency center of a level I trauma center and followed in community 3 months post-mTBI. Measures:The Ways of Coping Questionnaire was administered within 2 weeks of injury. Cluster analysis was used to group participants on basis of their preinjury use of problem-focused and avoidant coping strategies. The Brief Symptom Inventory and the 36-item Short-Form Health Survey were administered 3 months postinjury. Results:Cluster analysis distinguished 3 distinct preinjury coping profiles that were differentially associated with outcomes. Participants who used avoidant coping showed the worse emotional functioning and QOL outcomes, although this cluster also reported high usage of problem-focused strategies. Preinjury coping profiles explained a significant proportion of the variance in depression, anxiety, and mental health QOL at 3 months postinjury beyond that accounted for by demographic characteristics and mTBI severity. Conclusions:Cluster analysis holds practical value in illustrating the pattern of coping strategies used by person with uncomplicated and complicated mTBI. It appears worthwhile to address coping in future trials of interventions that are aimed at improving emotional functioning after mTBI.

Rehabilitation of Attention and Executive Function Impairments

Disturbances of executive functions, including the executive control of attention, are recognized as among the most common, persistent, and debilitating consequences of traumatic brain injury (TBI) [1–6]. This chapter focuses on the application of empirically supported strategies for managing impairments of higher level attention and executive functions following TBI. We recognize that the clinical neuropsychology and cognitive rehabilitation literatures have typically considered attention and executive functions in relative isolation. However, there is considerable overlap and interdependence in the structure and function of higher-level aspects of attention and executive functions. Throughout the chapter, we use the term “attention-executive functions” to refer to executive functions (e.g., anticipating consequences, planning and organizing, initiating and sustaining activities) as well as skills associated with the executive control of attention (also referred to as supervisory, complex, or higher-level attention). Skills associated with executive control of attention include the ability to sustain attention in the face of distractions (selective attention), switch focus or mental sets (alternating attention), or manipulate and control information held online (working memory). The processes involving attention-executive functions are distributed throughout the frontal regions and connect with other frontal, posterior, and subcortical areas to exert executive (i.e., top-down) control over lower level, more modular, or automatic functions [7, 8]. The frontal lobes and interconnecting circuits are particularly vulnerable to focal and diffuse damage in TBI, which accounts for the frequency of deficits involving attention-executive functions in this population. Given the overlap in the structure and function of attention-executive processes, interventions targeting these processes are also intimately related.

Sexuality After Traumatic Brain Injury

How can a traumatic brain injury affect sexual functioning? Decreased desire: Many people may have less interest in sex. Increased desire: Some people have increased interest in sex after TBI and may want to have sex more often than usual. Others may have difficulty controlling their sexual behavior; they may make inappropriate sexual advances or comments. Decreased arousal: Many people have difficulty becoming sexually aroused after TBI.Menmayhave difficulty getting or keeping an erection. Women may have decreased vaginal lubrication. Difficulty or inability to reach orgasm/climax: Both men and women may have difficulty reaching orgasm or climax. They may not feel physically satisfied after sexual activity. Reproductive changes: Women may experience irregular menstrual cycles or periods; they may also have trouble getting pregnant. In some cases, periods may not occur for weeks or months after injury. However, a woman can still get pregnant even if her period has not returned. Men may have decreased sperm production.

Accuracy of Self-reported Length of Coma and Posttraumatic Amnesia in Persons With Medically Verified Traumatic Brain Injury

OBJECTIVE To determine the accuracy of self-reported length of coma and posttraumatic amnesia (PTA) in persons with medically verified traumatic brain injury (TBI) and to investigate factors that affect self-report of length of coma and PTA duration. DESIGN Prospective cohort study. SETTING Specialized rehabilitation center with inpatient and outpatient programs. PARTICIPANTS Persons (N=242) with medically verified TBI who were identified from a registry of persons who had previously participated in TBI-related research. INTERVENTION Not applicable. MAIN OUTCOME MEASURES Self-reported length of coma and self-reported PTA duration. RESULTS Review of medical records revealed that the mean medically documented length of coma and PTA duration was 6.9±12 and 19.2±22 days, respectively, and the mean self-reported length of coma and PTA duration was 16.7±22 and 106±194 days, respectively. The average discrepancy between self-report and medical record for length of coma and PTA duration was 8.2±21 and 64±176 days, respectively. Multivariable regression models revealed that time since injury, performance on cognitive tests, and medical record values were associated with self-reported values for both length of coma and PTA duration. CONCLUSIONS In this investigation, persons with medically verified TBI showed poor accuracy in their self-report of length of coma and PTA duration. Discrepancies were large enough to affect injury severity classification. Caution should be exercised when considering self-report of length of coma and PTA duration.

Clinician versus Veteran ratings on the Mayo-Portland Participation Index in veterans with a history of mild traumatic brain injury.

Background:The Department of Veterans Affairs is encouraging administration of the Mayo-Portland Adaptability Inventory–4 Participation Index (M2PI) to identify long-term psychosocial outcomes of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans with a history of traumatic brain injury (TBI). Objective:To evaluate clinician and Veteran interrater reliability and how response validity influences M2PI item ratings. Participants:A total of 122 OEF/OIF/OND Veterans who reported a history consistent with mild TBI during deployment and were referred for neuropsychological evaluation following Comprehensive TBI Evaluation. Design:Interrater reliability study. Main Measures:M2PI; Minnesota Multiphasic Personality Inventory–2 Symptom Validity Scale (FBS). Results:Veterans reported greater perceived restrictions than clinicians across all M2PI items and total score. Interrater correlations ranged from rs = 0.27 (residence) to rs = 0.58 (money management) across items, with a total score correlation of rs = 0.60. When response bias was indicated, both Veterans and clinicians reported greater participation restrictions than those reported by Veterans without evidenced response bias. Conclusion:Low interrater correlation is consistent with previous findings. As ratings of clinicians and Veterans should not be interpreted as equivalent, documenting the raters identity is important for interpretation. Using objective indicators of functional outcome may assist clinician raters, particularly when self-report may be biased.