Posts Tagged TBI

[Abstract] Upper limb rehabilitation with movement-sound coupling after brain lesions


Recent studies showed that auditory feedback, sound and music can improve upper limb motor-recovery after stroke or Traumatic Brain Injury. However, the specific influence of different sound features and musical parameters has never been explored in this context. This study designed and tested different patterns of movement-sound coupling (sonification) that could stimulate arm movement during rehabilitation.

Material and method

Five sonification patterns were developed through a participative design process. These included two basic sound parameters, two musical extracts and environmental sounds. Upper limb movement was recorded using three Inertial Measurements Units placed on each upper limb. Movement analysis, sound-movement coupling and sound synthesis were performed using Max/MSP software (Ircam). The experimental protocol included three steps. (1) An interview to evaluate the sound universe of individuals (French Psychomusical Appraisal) and Evaluation of Amusia (Montreal Battery). (2) Sonification of two tasks: functional gestures and elbow extension, compared with the same tasks without sound. The two sides were examined, the less affected first. The IMU data were used to quantify the kinematics of arm movement. (3) A semi-directive interview to provide detail on the participant’s subjective experience.


At this stage, data has been obtained for 9 patients (stroke and TBI) and 7 healthy subjects. The subjective responses were positive, most of patients judged the sonification as interesting and stimulating. Most participants had a preference for environmental sound coupling. The observation of kinematic data showed large inter-individual differences and variable effects of sonification on movement amplitude, smoothness and velocity that varied between sides.


This study has established a novel sonification protocol which may be used to enhance and vary motor rehabilitation tasks. However, further analyses are needed, particularly on symmetry, before concluding on a quantitative effect of sonification. In addition, we need to examine the relationships between quantitative data and participants’ subjective experience.


via Upper limb rehabilitation with movement-sound coupling after brain lesions – ScienceDirect


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[ARTICLE] Psychological Resilience Is Associated With Participation Outcomes Following Mild to Severe Traumatic Brain Injury – Full Text

Traumatic brain injury (TBI) causes physical and cognitive-behavioral impairments that reduce participation in employment, leisure, and social relationships. Demographic and injury-related factors account for a small proportion of variance in participation post-injury. Personal factors such as resilience may also impact outcomes. This study aimed to examine the association of resilience alongside demographic, injury-related, cognitive, emotional, and family factors with participation following TBI. It was hypothesized that resilience would make an independent contribution to participation outcomes after TBI. Participants included 245 individuals with mild-severe TBI [Mage = 44.41, SDage = 16.09; post traumatic amnesia (PTA) duration M 24.95 days, SD 45.99] who completed the Participation Assessment with Recombined Tools-Objective (PART-O), TBI Quality of Life Resilience scale, Family Assessment Device General Functioning Scale, Rey Auditory Verbal Learning Test, National Adult Reading Test, and Hospital Anxiety and Depression Scale an average 4.63 years post-injury (SD3.02, R 0.5–13). Multiple regression analyses were used to examine predictors of PART-O scores as the participation measure. Variables in the model accounted for a significant 38% of the variability in participation outcomes, F(13, 211) = 9.93, p < 0.05, R2 = 0.38, adjusted R2 = 0.34. Resilience was a significant predictor of higher participation, along with shorter PTA duration, more years since injury, higher education and IQ, and younger age. Mediation analyses revealed depression mediated the relationship between resilience and participation. As greater resilience may protect against depression and enhance participation this may be a focus of intervention.


Following traumatic brain injury (TBI), participation in employment, education, leisure, and relationships is often significantly reduced, leaving individuals substantially less integrated in their communities (14). As a result, many individuals spend increased time at home, straining family and other relationships (5). Given that TBI occurs commonly during young adulthood (6), participation deficits coincide with a critical period of development in which individuals are completing education, establishing a vocation, leaving home, and forming important lifelong relationships. Failure to attain these goals may profoundly impact their sense of self, mental health and general well-being. Reduced participation often extends beyond the acute recovery period and continues to be associated with poorer quality of life up to two decades after injury (7). Arguably participation in these life roles, including employment, education, leisure and relationships, represents one of the most important and objective indicators of injury outcomes.

Numerous variables have been associated with participation outcomes post-TBI, including injury-related and demographic variables as well as post-injury environmental and personal factors. Injury severity, cognitive difficulties, and limb injuries with related pain and impact on mood, affect an individual’s ability to engage socially and often present significant barriers to education and employment (816). Injury severity is a particularly well-researched predictor of participation outcomes, with duration of post traumatic amnesia (PTA) having the most robust association (1721). With respect to demographic factors, younger age, higher premorbid education level, higher premorbid IQ, and being employed prior to injury have all been associated with better participation outcomes (102229). Notably, older age at injury has been found to predict both worse participation overall as well as progressively worsening participation over time (10). Although gender does not appear to be directly associated with participation (30), it may have an indirect association, for example through mood and pre-injury education (14). Post-injury psychological functioning, particularly depression and anxiety, are also important predictors of participation outcomes (10123133). The impact of family functioning on participation is thought to be both direct, and through association with emotional well-being (3435).

Due to this broad range of factors influencing outcome, research has moved toward a multivariate approach to prediction of participation outcomes following TBI (24363738). These models contribute to a more comprehensive understanding of participation outcomes; however, the average amount of variance accounted for by predictive models is around 30% (21). This suggests there are additional predictive factors yet to be identified. One such factor that has increasingly gained scholarly recognition, due its positive association with quality of life and well-being outcomes among different clinical populations, is resilience.

Resilience has been conceptualized as a process of adaptation to adversity or the ability to bounce back after trauma or adversity. Resilience arguably influences the extent to which a person is able to resume important life roles after an injury. Resilience may impact participation outcomes directly through facilitating or promoting return to normal life or the development and achievement of new life goals (39), and indirectly through its effects on improved well-being, quality of life and psychological adjustment. Participating in employment, education, leisure, and relationships represent fundamental areas of participation. Resilience has been positively associated with physical and emotional well-being in individuals with cancer (40), Parkinson’s disease (41), diabetes (42), chronic spinal cord injury (43), multiple sclerosis, spina bifida, stroke, and posttraumatic stress disorder (4445). There has been less resilience research in TBI, with only one study to date examining the association between resilience and participation. Notably, it has been suggested that the study of resilience after TBI poses a distinct challenge, in that the skills characteristically associated with resilience are typically impaired after TBI (4547). For example, resilience requires emotional stability, a positive outlook, good problem-solving skills and social perception (47); however, TBI is commonly associated with impaired executive functioning (4849), irritability and aggression (5051), depression (3345), and difficulties with social perception (52).

The little research that has focused on resilience after TBI has been largely limited to patients with mild TBI, in whom no studies have examined impact on participation. In this group, greater resilience has been associated with less reporting of post-concussional and post-traumatic stress symptoms (5355), reduced fatigue, insomnia, stress, and depressive symptoms, as well as better quality of life (56). One study found that greater pre-injury resilience was significantly associated with greater post-concussion symptom severity 1 month post-injury (57), perhaps reflecting insufficient time for participants to “bounce back” (44), or overrating of pre-injury resilience levels, a phenomenon known as the “Good Old Days”(58).

Only three studies have examined resilience in individuals with moderate to severe TBI, of which one examined an association with participation. Marwitz et al. (39), conducted a large (n = 195) longitudinal study and found that resilience was significantly associated with participation over the first 12 months post-injury (39). Other studies have associated higher resilience in individuals with moderate to severe TBI with fewer depressive and anxiety symptoms, better emotional adjustment, use of task oriented coping and greater social support (4445). However, one of these studies used a sample of individuals who were actively seeking help with adjusting to changes post-injury, possibly biasing the sample toward those experiencing greater adjustment problems (45).

The aim of the present study was to examine the relative association of resilience, as well as demographic, injury-related, cognitive, emotional, and family factors with participation (productivity, social relations and leisure) following mild to severe TBI. To the best of our knowledge, this is the first study to examine the association between resilience and participation outcomes more than 12 months after mild to severe TBI. This critically extends previous research by examining the impact of resilience across the spectrum of TBI severity, from mild to severe, and how this association influences outcomes beyond the acute post-injury period. It was hypothesized that resilience would make an independent contribution to participation after TBI, in a model that would include demographic variables (gender, age, pre-morbid IQ, education, pre-injury employment), injury variables (injury severity, cognitive functioning, limb injury, time since injury) and post-injury personal and environmental factors (depression, anxiety, family support).[…]


Continue —> Frontiers | Psychological Resilience Is Associated With Participation Outcomes Following Mild to Severe Traumatic Brain Injury | Neurology

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[Abstract] Monitoring the injured brain



Traumatic brain injury can be defined as the most complex disease in the most complex organ. When an acute brain injury occurs, several pathophysiological cascades are triggered, leading to further exacerbation of the primary damage. A number of events potentially occurring after TBI can compromise the availability or utilization of energy substrates in the brain, ultimately leading to brain energy crisis. The frequent occurrence of secondary insults in the acute phase after TBI, such as intracranial hypertension, hypotension, hypoxia, hypercapnia, hyperthermia, seizures, can then increase cerebral damage, and adversely affect outcome. Neuromonitoring techniques provide clinicians and researchers with a mean to detect and reverse those processes that lead to this energy crisis, especially ischemic processes, and have become a critical component of modern neurocritical care. Which is the best way to monitoring the brain after an acute injury has been a matter of debate for decades. This review will discuss how monitoring the injured brain can reduce secondary brain damage and ameliorate outcome after acute brain injury.


Journal of Neurosurgical Sciences 2018 Apr 18 – Minerva Medica – Journals

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[BLOG POST] Why do people act differently towards a person after their TBI?

Why do people act differently towards a person after their TBI?

Why do people act differently towards a person after a TBI? Many times, it’s because they can’t handle the truth!

By Bill Herrin

After a traumatic brain injury, acceptance is one of the first steps toward recovery…even if recovery is a long way off. When you evaluate your own personal situation and work to be content within your life’s new parameters – that is basically acceptance. Although TBI can make a huge change in a survivor’s behavior, patience, temper, attitudes, etc. – it also can cause a huge change in the people around us – and in how they act toward us. The fact is that people may not be able to handle the truth because the truth they’re facing is that you’ve changed. You’re still the same person that they know and love, but it’s the adapting part that is awkward for them (which, in turn, makes it awkward for you, too). Brain injury not only affects the TBI survivor, but it affects everyone in their life. This is one of the parts of TBI that can bring misunderstandings, judgment, and often, isolation…the truth is hard to handle for family and friends. Why? Because they don’t want to upset you, or possibly just don’t know what to say. Often, it’s no more complicated than that.

Workarounds, ideas, and other solutions

The following excerpts are from Lash & Associates tip card titled “Coping with Survival After Brain Injury.”

Brain injury has an odd way of attacking your self-esteem and self-confidence. Maybe you used to consider yourself brilliant, attractive,
handsome, beautiful and just wonderful. Brain injury has a way of landing right on your self-confidence center. Your worth as a person – both before and after your brain injury – is about more than how well you can do this or that. Don’t think of yourself as less of a person since your brain injury because of all the things you can’t do. Look at the love and warmth that you can share. Others may value you for the contents of your soul.*

With that said, how you think about your situation and approach to life could improve – despite how others may acttoward you? Here are a few more great bits of advice from the tip card titled “Coping with Survival After Brain Injury.” You’ll find that acceptance takes the focus off complaining, of fault-finding of others, and will make you see things in a more meaningful and positive light.*

For example, You can moan, groan, complain, be angry, and spend your time asking WHY did this happen to me? You can be angry at whoever and however, it happened. Be angry on a daily basis. Drink and do drugs to escape…OR you can acknowledge and accept that it happened. You certainly don’t have to like it or be happy about it, but acknowledge that it happened and move forward. Do the best you can with whatever you can. Work on getting to your “New Normal” which isn’t going to be the same as your “Old Normal.”*

If you ask yourself, whether you are religious or not, “Why did God do this to me?” – maybe instead, take the approach of asking yourself, “I was saved for some reason, what is it?”*

You may figure that you have enough of your own problems to deal with and avoid helping others – OR you could work to prevent brain injuries. Tell people your story in the hopes that they won’t have to walk down this road.*

If you let your anger and sadness spill throughout your life, and you take it out on those around you-you could (instead) be sad, but acknowledge that you aren’t the same as you used to be. Meet new people who may understand some of your challenges.*


Do you see the sharp contrast in thinking and the approach here? One approach is wallowing in self-pity, and the other changes the focus to living life to the utmost, loving people despite how they may act, and hopefully inspiring others that are also survivors. When you feel angry or sad that your “terrible family or friends” are not loyal, or may not come to visit you enough – look at the other side of the coin – maybe your partner / husband / wife / parents / kids / siblings / other friends stand by you, thank them sincerely and deeply for their loyalty, love and commitment. They didn’t ask for this any more than you did!*

*(Reference: From the Lash & Associates tip card titled “Coping with Survival After Brain Injury,” by John W. Richards, MBA, MSW, Survivor.)


Coping becomes Hoping

When it comes to family and friends’ emotional reactions to your TBI, there are some things to keep in mind. When an individual has a brain injury, most families go through the entire range of emotions. There is fear, anger, hope, despair, and even joy at times. These emotions are often seen as negative (fear, despair, anger) or positive (joy and hope). Each emotion affects how a family member acts and responds to others. Try to use your emotions effectively rather than allowing them to control or overwhelm you.**

You may have felt like you were on a roller coaster of emotions soon after the brain injury occurred. Every day there were unfamiliar terms, complicated medical information and difficult questions that often could not be answered. Your emotions may change over time but they continue to be powerful feelings. Every member of your family may feel a wide range of emotions. Some may be similar to yours; others may be different. All emotions need to be respected. It’s important to let everyone in your family know that it’s okay to feel angry, afraid, sad, helpless, and overwhelmed. It’s what you do with these emotions that matter.**

One of the hardest things to realize when you’ve been through huge life changes after TBI is that negative emotions, anger, sadness, and fear can be negative and destructive. But without them, you would lose valuable energy and perspective. They can help you not only survive, but thrive in the aftermath of a brain injury to you, or a member of your family. Imagine that! The takeaway from negative fear, sadness, anger, etc., is that it motivates you to improve your attitudes – and the result will be an overall improvement of your outlook on life, despite any setbacks.**


Handling Emotions When People Act Differently After a TBI

In closing, here is a small, but important checklist that could offer some “life hacks” to get on the right track, and away from feeling bad 
about your situation…this is only a small list, and there could certainly be more added – but in the interest of time, these are good to start off with.

Tips for handling your emotions…

✓ Stay in the moment.

Rather than wishing for the moment to pass, ask yourself what exactly this moment is about.**

✓ Allow emotions to subside or quiet.

Instead of trying to hold onto an emotion, be aware when it lessens. Notice the emotion that replaces it. Why this emotion now? What triggered it? How can it help you?**

✓ Review and reflect.

Keep a journal of your different emotions and experiences. It is often easier to understand your feelings after some time has passed. Reading your journal days, weeks, months or even years later gives you a different outlook. This can help you understand what you were feeling and why. Review and reflection can help you use your emotions effectively or change them.**

✓ Find someone you trust.

If you are feeling overwhelmed by an emotion, share it with someone you trust. Ask for the person’s views and ideas. By sharing the emotion, you will find it more manageable and less overwhelming.**

✓ Consider the opposite emotion.

Sometimes an emotion can block you from taking action or it may prevent you from getting action from someone else. When this happens, try choosing the opposite emotion and ask yourself what you’d do if you felt that way instead. For example, if you are feeling angry but need to make a request, ask yourself, “How would I say this if I were feeling warmly towards this person?”**

**Excerpted from “Emotions – Hope after brain injury”, by Ann V. Deaton, Ph.D.


Final Thoughts

The takeaway (hopefully) is that working on acceptance of your new life, and then working through your feelings (about yourself and others’ actions toward you) will bring positive change to everyone involved. Life is precious, and sometimes people just need time to sort things out – either as a TBI survivor or as the friend or loved one of a TBI survivor. Make the most of each day. Progress comes in different forms, different levels, and sometimes it’s elusive – but hope springs eternal. Choose hope.

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[BLOG POST] Miscommunication …Straight From the Horse’s Mouth

By Bill Herrin

Communication is the lifeline of any relationship!


Work to take frustration out of communication

When a TBI happens, the survivor is the primary person left with the biggest life changes of all. However, family and friends are also impacted in a huge way. For survivors of a TBI, finding ways to communicate about worries, frustrations, physical issues and emotions – as well as conveying all of these things to loved ones is not only tiring – sometimes it just doesn’t come out in a way that’s easy to understand. That’s miscommunication. Your grasp of your life after TBI is going to depend on several key factors: acceptance, progression, facing denial, and finding the inner strength to move on with your “new normal.”

That’s an easy thing to tell someone, but living it out is a challenge that every person will handle differently – as varied as each brain injury (and its effects) can be. Your mental and emotional connections to others are going to be different. Responses to how you communicate can be different as well…all leading to miscommunication on both ends of any conversation. That can lead to frustration, anger, hurt feelings, and a host of other things. We’re going to take a look at how to soften the blow of harsh words, misunderstandings, missed points, and overall miscommunications.

Saying how you feel

One of the key things to consider as a survivor of TBI is this: No matter how you feel, try to consider how the people all around you are feeling as well. They may be feeling bad for you, or they may be feeling time constraints from caregiving, or possibly just feeling overwhelmed or concerned that you’ve changed since your TBI. Communication of thoughts between the two of you (or between you and all of them) is critical to your successful recuperation, to your emotions, and your relationships. This also goes for your family and friends – they should strive to understand that you are affected by their attitude and communication with you. It’s always a two-way street, and it even was before TBI came into the picture – but, now it’s even more critically important. Miscommunication can create even more stress.

They’ve noticed change

Empathy makes things better for everyone involved

Friends come and go, many last a lifetime, but family is forever. Keep in mind, family members can be your best advocate – or your worst critic. The point is this: it’s best to surround yourself (to the best of your ability) with people who understand how you’ve changed and they embrace the change. Empathy is one of the strongest healers – having an understanding of what someone else is experiencing, and “putting yourself in their shoes” can make the worst situation more bearable for everyone involved. This goes for the survivor, family, friends, and co-workers, etc. Seeing how everyone deals with the your TBI can bring a team together, instead of having miscommunication and strife. Strife is going to happen, because nobody is perfect, but remember that we need each other!

Trying to read people

When we talk with each other, half of our expression comes from….well…our expressions. Our facial expressions and body language say a lot, and can be subtle or direct. Survivors of TBI may lose their ability to take expressions or body language into account, or even misread what it being intended. This is also miscommunication. For family and friends, a natural rapport and emotional (as well as physical) healing will usually improve with time. Remembering that is key to maintaining a friendship with the TBI survivor in your life. They’re working toward their new normal, and their frustrations are going to be running high as well. Work toward better communication together!

Expression and tone of voice

Try not to get discouraged

Voice, diction, and clarity of speech can often be affected after a TBI. As a survivor of TBI, strive to work on your speech patterns – with a clinician if possible, or with a caregiver or friend…and even on your own if possible. Enunciation is only going to improve with practice – kind of like playing a musical instrument. Practice, practice, practice! You’ll never get further without having the will to improve. It’s that simple – nobody can make you want to improve, but they can encourage you to do it. One of the bigger parts of miscommunication, beside changed behaviors and expressions is the simple fact that clarity of speech makes a huge difference. Some may never be able to achieve their previous language skills, but communicating what you feel, need, think, want, etc., as clearly as possible is going to be the reward for all your hard work.

Changes in relationships

Whether a TBI survivor is married, single, a child or teen, man, woman, or anything else – relationships are the fuel that keep most people pushing ahead. Since relationships require effort from all parties involved, be aware that brain injury is going to “throw a wrench” into the mix. Many people want to solve problems – they’re “fixers,” full of suggestions and comments, and sometimes criticism. This can bring a lot of tension into a relationship. If you can work to remember one thing about relationships, it’s this: True friends love you for who you are, and they’ll meet you wherever you’re at. Despite being different after TBI doesn’t mean you’re a completely different person, but it does mean that parts of your personality, likes, dislikes, and other things have changed. If someone points out to you that you’re not the same person any longer, consider telling them this: “Think of me as a house. I’ve made some new additions, I’ve changed some things around, I’ve gotten rid of some things, and maybe I don’t seem quite the same. But I’m still the same house…just a remodeled one, now.” Maybe that simple analogy will explain that you’re always going to be you, but changes do happen!

The bottom line

Frustration can make your day seem long

This particular blog is purposely not referencing clinical books, studies, findings, or scientific facts. The goal here is to help families and TBI survivors see themselves in a different light, as a team – as co-conspirators in a battle against TBI, that they both are fighting together. A TBI survivor needs you. You need and love them. Don’t let miscommunications become a wedge between you, because they’ve changed. Overlooking an outburst of frustration of a TBI survivor could make the rest of their day much better. For a survivor of TBI, letting go of a snide comment about them by a loved one who is frustrated or tired, could mean the difference in their day. Communicate with each other as clearly as you can, and always work toward better communication. It’s the key to progress. I hope that you can find contentment in life if you’ve experienced a TBI. I also hope that you will find it as a caregiver, family member, or friend of a TBI survivor. The words of a very well-known college basketball coach come to mind – Coach Jim Valvano, from North Carolina State University was battling terminal cancer, and in one of his last speeches to his adoring public he said “Don’t give up. Don’t ever give up.” Those are words to live by.

via Miscommunication …Straight From the Horse’s Mouth – Brain Injury Blog With Free TBI Information

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[BLOG POST] Misinterpretations, Reactions, and Anger after TBI (Traumatic Brain Injury)

You Did That on Purpose!  –  Misinterpretations and Anger after Brain Injury

By Dawn Neumann, Ph.D., FACRM

Imagine that you are waiting in line at the store and someone cuts in front of you.

A) Do you think the person cut in front of you on purpose or was trying to be mean?

B) Or do you think maybe he or she did not see you and it was an innocent mistake or there was some kind of emergency?

How you interpret this situation will affect how angry you will feel and how you will react to the situation. If you chose option A, it is likely you will be more irritated and angry than if you chose option B.

Irritability and anger are common side effects of traumatic brain injury (TBI). How we interpret others’ actions can lead us to feel irritated and angry toward those involved. Recent research suggests that one reason irritation and anger are more severe and common after TBI may be due to misinterpreting others’ harmless actions.


It is not always so obvious why people behave the way they do. So, it is normal to try to figure out the reasons behind others’ actions: What do they really want? Why did they do what they did?  If we think someone did something to us on purpose, of course, we are going to get mad, and possibly even react.  But for the most part, people without a brain injury

usually give others’ the benefit of the doubt and assume that others’ actions are not intentionally mean.  For example, many people will assume the person who cut in front of you on line did not see you and it was an innocent mistake. As a result, it does not irritate or anger them that much.  In contrast, it appears that more people with a brain injury assume others’ actions are intentionally mean.  More people with a brain injury are likely to choose option A and feel more irritated or angrier.


What is the potential impact of this type of thinking?

  • Socially inappropriate and/or violent behaviors towards others.  Someone who thinks this way and gets angry is more likely to respond aggressively (yelling, pushing), especially after a brain injury when it is hard to stop the impulsive desire to do something about it. This behavior would not sit well with others.
  • Legal troubles, criminal charges, and/or incarceration. This type of thinking could lead to violent and illegal behaviors.
  • Strained relationships and stress among family and friends. Because family members do not see the
    situation the way you do (They see Option B versus A), angry and aggressive responses to innocent situations are often unexpected, embarrassing, stressful, and scary.  Family members and friends often say it is like having to walk on

    eggshells around the person with the brain injury.

  • Social isolation. Strained and stressed relationships can often push family and friends away.
  • Decreased community participation. Because anger and aggression are not usually accepted or socially appropriate, people with these challenges may have a hard time being an active member of their community. This can also affect your work-related goals. Misinterpretations of your boss’s actions or that of your co-workers or a customer are going to make it a lot harder for you to get a job or keep a job.


Why are People with a Brain Injury More Likely to Think this Way?

First, it is important to note that not everyone with a brain injury thinks this way. People with higher level thinking difficulties, problems interpreting social cues, and those with anxiety are more prone than others to assume others’ actions are intentional or mean. Because these are common problems after brain injury, it makes them more likely to misinterpret others’ behaviors.


Some advice:

  • Give people the benefit of the doubt. Most likely you do not have enough information to know for sure why someone did something. This means you cannot assume your interpretation is true. Remember that most of the time people are probably not even aware of how their actions affected you or they did not intend to cause you harm or lead to an unpleasant outcome for you.
  • Think about alternatives. Come up with a few innocent reasons to explain the other person’s behavior.
  • Perspective taking. Try to think of the situation from the other person’s perspective. If you were in their shoes, what might have prompted you to do what they did? Try to empathize with their situation. If it is hard to imagine, role play and pretend you are the other person.
  • Don’t jump to conclusions. If you are not sure why someone did something, consider asking them why (in a nice way) instead of making assumptions.
  • Consider counseling. Psychologists and Neuropsychologists specialize in helping you see and think about things differently.


Dawn Neumann, Ph.D., FACRM
Associate Professor and Research Director PM&R, Indiana University School of Medicine and Rehabilitation Hospital of Indiana Director, IU InterFACE Center at RHI (A Human Observation Lab)

via Misinterpretations, Reactions, and Anger after TBI (Traumatic Brain Injury)

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[WEB SITE] Taking music therapy into the mainstream – ACNR

Taking music therapy into the mainstream

Posted in on 3rd Jun 2018

Conference details: March 15th, 2018, London, UK.
Report by: Daniel Thomas, Joint Managing Director at Chroma.
Conflict of interest statement: None declared.
Published online: 3/6/18

Every 90 seconds, someone in the UK is admitted to hospital with an Acquired Brain Injury.

With over one million people in the UK currently living with the effects of a brain injury the estimated bill to the UK is £15 billion. The devastating impact radiates across families causing distress, relationship strain, financial hardship and an uncertain future. The injury has a huge physical and psychological payload.

Neurologic Music Therapy (NMT) offers an effective rehabilitation treatment that is backed by a wealth of clinical evidence and has been shown to have a profound influence on the brain. However, raising awareness of the benefits of arts therapies, including NMT, can be extremely difficult.

Chroma’s recent ABI conference entitled ‘Arts Therapies and Brain Injury: Optimising Outcomes Across Assessment, Treatment and Care’ brought together some of the leading international authorities and influencers in the arts therapies field. They delivered the latest research and scientific evidence on how arts therapies are improving outcomes for patients recovering from acquired brain injuries.

Chris Bryant, MP, and chair of the All Party Parliamentary Group on Acquired Brain Injury opened the conference by highlighting the growing problem of brain injuries and the wider impact it has on society.

Caroline Klage, Head of the Child Brain Injury Team at leading niche London law firm, Bolt Burdon Kemp, who sponsored the conference, welcomed the delegates.

She said: “As a firm, Bolt Burdon Kemp is keen to support NMT and raise awareness of its benefits. We are driven by the desire to ensure our clients receive the best quality input at the earliest point possible, with a view of enabling them to flourish and thrive post brain injury. NMT definitely has a role to play in that.”

Dr Jeanette Tamplin, of the University of Melbourne, provided an introduction to the evolving field of the creative arts therapies, specifically Neurologic Music Therapy. Dr Tamplin is pioneering the use of Virtual Reality to improve the participation and engagement of rehab patients on music therapy protocols.

“Music can bypass damaged areas, providing a scaffold to do the part of the work the brain is not doing in coordinating movement. But there is also the basic ‘use it or lose it principle’. When you exercise something, it gets stronger and the more you exercise, the better it becomes.”

The inspiring responses seen in some cases still needs to be backed up by more clinical research and Dr Tamplin added: “I want people to understand that we are an evidence-based profession and there are functional outcomes from music therapy.

“There are amazing benefits for quality of life and participating in life as well as being able to walk a bit better. Music makes us feel better and we use it in ways to help us through life but I’d like people to understand the research and evidence behind what we are doing.”

Sarah Johnson, a Neurologic Music Therapist and NMT pioneer from Colorado State University, presented a session on demonstrating the efficacy of NMT. She outlined the ‘Transformational Design Model’ a system that uses a clinical reasoning process to link assessments, goals, and learning through music.

Using case studies, video examples and clinical data, Sarah O’Doherty and Rebecca O’Connor, from the National Rehabilitation Hospital in Ireland, illustrated an innovative approach to assessing and treating children with acquired brain injuries. The approach involves a systematic observation and recording of the development of the child by a neuropsychologist during a music therapy treatment.

Practical hands-on workshops on applications in neuro-rehabilitation and articulating art therapy allowed delegates to experience, engage with and understand an arts therapy process from a client’s/patient’s point of view.

Dr Wendy Magee, a professor in the Music Therapy Department, at Temple University, Philadelphia, US showcased the MATADOC assessment for patients with prolonged disorders of consciousness (PDOC) that she and her colleagues pioneered.

According to Dr Magee, music is the auxiliary engine that has the power to reboot the brain following a catastrophic head injury, tumour or stroke. Dr Magee said: “A human being is born with the capacity to express emotions such as distress, anger and pleasure through musical parameters such as volume, dynamic range, pitch and melodic contour. So, in working with people who have lost the ability to communicate we can see that music is an innate way to communicate feelings.

“There is strong neurological evidence that music activates many different areas across the brain. The motor system is very sensitive to picking up cues from the auditory system so when we hear music, particularly pulse or rhythm, it kicks straight into the motor system going around the brain.”

Summing up the conference, Daniel Thomas, managing director of Chroma, who organised the event, said: “As a neurologic music therapist and parent, I am deeply aware of the need for arts therapies to be provided in line with the rehabilitation code at the earliest possible point in someone’s recovery.

“As a profession, we regularly punch above our weight and this conference has demonstrated our ability to make a significant difference to the lives of people with brain injuries, their families and the professional teams around them.

“It has also given a glimpse into the future developments of arts therapies and shown how it can be an absolutely essential rehabilitation treatment in mainstream health services.”

via Taking music therapy into the mainstream | ACNR | Online Neurology Journal

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[Poster] Repetitive Transcranial Magnetic Stimulation (rTMS) application in cognitive deficits after Traumatic Brain Injury (TBI)/concussion

Objective: The objective of this study is to review current literature for the efficacy of Repetitive Transcranial Magnetic Stimulation (rTMS) treatment for cognitive deficits after Traumatic Brain Injury (TBI)/concussion.

Background: TBI is a major public health problem and can cause substantial disability. TBI can lead to Post Concussive Syndrome (PCS) which consists of neuro-motor, cognitive, behavioral/affective, and emotional symptoms. Cognitive deficits can significantly impact functionality. The outcome of neuropsychopharmacological treatment is limited, with risk for side effects. TMS is a form of non-invasive neuromodulation which is FDA-approved for treatment-resistant depression. However, there is limited understanding about its application in addressing cognitive deficits after TBI. We therefore sought to examine current research pertaining to the application of TMS in post-TBI cognitive deficits.

Methods: We searched the PubMed research database with the specific terms “TMS in cognitive deficits after TBI”, “rTMS” and “post concussive syndrome.” We assessed clinical trials where cognition was measured either as a primary or secondary variable. Case studies/reports were excluded.

Results: One non-controlled, pilot study was found that assessed cognition after TMS as a secondary variable in TBI. The aim of the study was to assess safety, tolerability and efficacy of repetitive TMS for treatment of PCS after mild TBI (mTBI). Patients who had sustained mTBI over three months prior and had a PCS Symptom Scale score of over 21 were selected. Repetitive TMS (rTMS) was used as the intervention with 20 sessions of rTMS using a figure-8 coil attached to MagPro stimulator. Cognitive symptoms were assessed using subjective self-report scales and objective tests for attention and speed of processing domains. Neuropsychological tests that were used include Trails A & B, Ruff’s 2 & 7 Automatic speed test, Stroop test, Language test for phonemic, and category fluency, Rey AVLT test. The study showed a reduction in overall severity of PCS symptoms but no significant changes on the cognitive symptoms questionnaire or on the majority of neuropsychological test scores.

Conclusion: Despite the limitation in this study with the lack of a control group, there appears to be a good signal for the clinical application of TMS for post-concussive syndrome after TBI/concussion. A more robust, large well-controlled study may be very reasonable approach in the future to evaluate efficacy of rTMS.


1. Koski L1, Kolivakis T, Yu C, Chen JK, Delaney S, Ptito A. Noninvasive brain stimulation for persistent postconcussion symptoms in mild traumatic brain injury. J Neurotrauma. 2015 Jan 1;32(1):38-44.

2. Bashir S1, Vernet M, Yoo WK, Mizrahi I, Theoret H, Pascual-Leone A. Changes in cortical plasticity after mild traumatic brain injury. Restor Neurol Neurosci. 2012;30(4):277-82.

3. Demirtas-Tatlidede A1, Vahabzadeh-Hagh AM, Bernabeu M, Tormos JM, Pascual-Leone A.Noninvasive brain stimulation in traumatic brain injury. J Head Trauma Rehabil. 2012 Jul-Aug;27(4):274-92.

4. Neville IS, Hayashi CY, El Hajj SA, Zaninotto AL, Sabino JP, Sousa LM Jr, Nagumo MM, Brunoni AR, Shieh BD, Amorim RL, Teixeira MJ, Paiva WS. Repetitive Transcranial Magnetic Stimulation (rTMS) for the cognitive rehabilitation of traumatic brain injury (TBI) victims: study protocol for a randomized controlled trial. Trials. 2015 Oct 5;16:440.

via Repetitive Transcranial Magnetic Stimulation (rTMS) application in cognitive deficits after Traumatic Brain Injury (TBI)/concussion – Brain Stimulation: Basic, Translational, and Clinical Research in Neuromodulation

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[PERSPECTIVE ARTICLE] Virtual Reality for Traumatic Brain Injury – Full Text

In this perspective, we discuss the potential of virtual reality (VR) in the assessment and rehabilitation of traumatic brain injury, a silent epidemic of extremely high burden and no pharmacological therapy available. VR, endorsed by the mobile and gaming industries, is now available in more usable and cheaper tools allowing its therapeutic engagement both at the bedside and during the daily life at chronic stages after injury with terrific potential for a longitudinal disease modifying effect.


The World Health Organization estimates that traumatic brain injury (TBI) is and will remain the most important cause of neurodisability in the coming years (1). The search for neuroprotective therapies for severe TBI has been extensive but unfruitful over the last few decades, testified by more than 30 failed clinical trials, and we still have no specific neuroprotective therapy, that is, effective in clinical TBI. The burden of mortality and residual disability calls for new approaches to promote recovery of function of TBI patients in the acute and chronic phase (23).

Classically described as a sudden event with short-term consequences, TBI induces dynamic pathological cascades that may persist for months or years after injury with a major impact on outcome (45). Among dynamic mechanisms, the neuroinflammatory response and the accumulation of aberrant proteins may have a critical role in establishing a neuropathological link between acute mechanical injury and late neurodegeneration (67). The close association between post-TBI neurological changes, persistent neuroinflammation, and late neuropathology highlights the fact that the window of opportunity for therapeutic intervention may be much wider than previously thought and that long-term treatment encompassing the acute and chronic phase should be tested to effectively interfere with this complex condition.

Importantly, next to the harmful processes, TBI also induces a neuro-restorative response that includes angiogenesis, neurogenesis, and brain plasticity (89). These spontaneous regenerative mechanisms are short-lived and too weak to counteract damage progression but they could point the way to new therapeutic options if appropriately boosted and amplified. Physical and cognitive exercise increase repair and brain plasticity after injury in experimental models and patients (1011). Rehabilitative programs to provide inputs/stimuli to specific sensory or motor neural circuits, could in principle start very early on, and be finely tuned over time to account for the type and degree of injury and the level of motor and cognitive disability.

Virtual Reality (VR) for Rehabilitation after TBI

Cognitive and physical rehabilitation programs are fundamental instruments to improve the clinical outcome of TBI patients optimizing the activities, function, performance, productivity, participation, and quality of life (12). They are based on restitutional, compensatory, and adaptive strategies and vary in relation to the patient potential and disability degree (212).

Traumatic brain injury encompasses heterogeneous etiology, as well as structural and molecular patterns of injury dictating different prognostic features and potential responses to rehabilitative therapy. Experimental studies indicate that depending on the degree of cognitive and sensorimotor impairment exercise may improve outcome with different window of opportunity, however, evidence supporting the optimal timing, type, and intensity of rehabilitative interventions in patients are scarce (1213). For example, rehabilitation is often delayed in patients with severe TBI until their discharge from the intensive care unit, or adopted in the most severe cases with only minimal goals aimed at limiting spasticity (14). Importantly, cognitive rehabilitation in the sub-acute stage of TBI is rarely considered. For these reasons, the use of innovative techniques is advocated to assess the TBI-related deficits and to develop and evaluate new rehabilitative interventions (12).

An emerging technology, VR, represents a new tool for this purpose and might provide TBI care teams with new neuro-restorative strategies readily available at the bedside. Since the late 1980s, this term has been used to describe a 3D synthetic environment created by computer graphics, where the user has the feeling of being inside (15). VR can be described as “an advanced form of human-computer interface that allows the user to interact with and become immersed in a computer-generated environment in a naturalistic fashion” (16). For its flexibility, sense of presence (i.e., the feeling of “being there”) and emotional engagement, VR has been tested in motor and cognitive rehabilitation, with good results. In stroke patients, the number of VR programs is rapidly increasing with compelling data showing an improvement in recovery of motor function and daily living activities (17).

Data on the effects of cognitive function and quality of life are more limited. As underlined by two recent systematic reviews (1819), VR allows a level of engagement and cognitive involvement, higher than the one provided by memory and imagination, but is more controlled and can be more easily measured than that offered by direct “real” experience. Its multisensory stimulation means VR can be considered an enriched environment that can offer functional and ecological real-world demands (e.g., finding objects, assembling things, and buying stuff) that may improve brain plasticity and regenerative processes (2022).

There are several examples in the literature where VR has been successfully used both as assessment instrument and as therapeutic intervention. As assessment tool, VR has been used to detect visual-vestibular deficits in adults after concussion and mild TBI (2324). Wright WG et al., developed a Virtual Environment TBI Screen that allows subjects to explore a digitalized setting (i.e., outdoor Greek temple with columns, different kind of floor materials, etc.) performing postural tasks while the system collects data to detect visual-vestibular deficits. Besnard et al. (25) created a virtual kitchen to assess daily-life activity and evaluate executive dysfunctions in subjects with severe TBI. Robitaille et al. (26) developed a VR avatar interaction platform to assess residual executive functions in subjects with mild TBI. The platform can capture real-time subject’s movements translating them in to a virtual body, that is, therefore placed in a simulated environment (i.e., a village). The user is then allowed to explore the simulate surroundings which comprise different navigational obstacles to overcome. Similar approaches have been used by other authors, whereas simplified settings (i.e., 3D virtual corridor that the subject can explored with a joystick) have been proved useful to assess subclinical cognitive abnormalities in asymptomatic subjects that suffered a concussion (27).

As therapeutic instrument, Dahdah et al. (28) demonstrated that immersive VR intervention can be used as an effective neuro-rehabilitative tool to enhance executive functions and information processing in the sub-acute period, providing evidence of positive effects of a virtual Stroop task over traditional non-VR-based protocol. VR as therapeutic instrument has also been used for attention training in severe TBI with positive results in the early recovery stages (29) with a specific “augmented” task in which virtual and haptic feedbacks were used in a target-reaching exercise to enhance sustained attention. Finally, virtual protocols generated upon commercial available game solutions have been effective in addressing and treating balance deficits (30).

All these works suggest that VR could be useful as assessment instrument and in the rehabilitation of TBI, nonetheless a delineated pattern seems to emerge. VR assessment protocols appear to be primarily implemented for mild TBI, which induce subtle residual deficits hard to detect with traditional instruments (23). Conversely, VR treatment protocols for cognitive rehabilitation are used transversely from mild to severe conditions, although effectiveness of these kinds of interventions needs to be further explored (31).[…]


Continue —>  Frontiers | Virtual Reality for Traumatic Brain Injury | Neurology

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[Abstract] Predicting Long-Term Global Outcome after Traumatic Brain Injury: Development of a Practical Prognostic Tool Using the Traumatic Brain Injury Model Systems National Database

For patients surviving serious traumatic brain injury (TBI), families and other stakeholders often desire information on long-term functional prognosis, but accurate and easy-to-use clinical tools are lacking. We aimed to build utilitarian decision trees from commonly collected clinical variables to predict Glasgow Outcome Scale (GOS) functional levels at 1, 2, and 5 years after moderate-to-severe closed TBI. Flexible classification tree statistical modeling was used on prospectively collected data from the TBI-Model Systems (TBIMS) inception cohort study. Enrollments occurred at 17 designated, or previously designated, TBIMS inpatient rehabilitation facilities. Analysis included all participants with nonpenetrating TBI injured between January 1997 and January 2017. Sample sizes were 10,125 (year-1), 8,821 (year-2), and 6,165 (year-5) after cross-sectional exclusions (death, vegetative state, insufficient post-injury time, and unavailable outcome). In our final models, post-traumatic amnesia (PTA) duration consistently dominated branching hierarchy and was the lone injury characteristic significantly contributing to GOS predictability. Lower-order variables that added predictability were age, pre-morbid education, productivity, and occupational category. Generally, patient outcomes improved with shorter PTA, younger age, greater pre-morbid productivity, and higher pre-morbid vocational or educational achievement. Across all prognostic groups, the best and worst good recovery rates were 65.7% and 10.9%, respectively, and the best and worst severe disability rates were 3.9% and 64.1%. Predictability in test data sets ranged from C-statistic of 0.691 (year-1; confidence interval [CI], 0.675, 0.711) to 0.731 (year-2; CI, 0.724, 0.738). In conclusion, we developed a clinically useful tool to provide prognostic information on long-term functional outcomes for adult survivors of moderate and severe closed TBI. Predictive accuracy for GOS level was demonstrated in an independent test sample. Length of PTA, a clinical marker of injury severity, was by far the most critical outcome determinant.


via Predicting Long-Term Global Outcome after Traumatic Brain Injury: Development of a Practical Prognostic Tool Using the Traumatic Brain Injury Model Systems National Database | Journal of Neurotrauma

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