Symposium 20: Building bridges in behavioral treatment for traumatic brain injury

The Centers for Medicare and Medicaid Services (CMS) recently recognized TBI as a chronic health condition requiring evidence-based approaches to long-term management. Behavioral factors and interventions play a key role in TBI management, but are discrete, siloed, and lack integration across diverse contexts.
The current symposium will demonstrate behavioral health approaches after TBI across varying contexts, intervention modalities, and personal characteristics of TBI survivors. In line with this year’s theme– “Context Matters: Bridging Perspectives in Behavioral Medicine” – we will showcase how interdisciplinary collaboration and engagement of persons with lived TBI experience can be leveraged to bridge across these contexts and behavioral health approaches and strive toward an integrative behavioral treatment paradigm. The symposium will highlight specific considerations in working with professionals with different backgrounds, goals, and expertise (e.g., industry partners, medical providers, attorneys, state offices) and with persons with lived experience of TBI, and whether and when intervention considerations should be specific and tailored to TBI, when more condition-agnostic approaches may be effective and practical, and how such considerations could apply more broadly to other chronic condition populations.
Jonathan Greenberg will present results of a feasibility randomized controlled trial testing a novel live-video mind-body program to prevent persistent concussion symptoms among young adults with anxiety. Sarah Bannon will present quantitative findings from TBI survivors surrounding their use of a Brain Injury Identification Card, a low intensity intervention developed by a law office to promote self-advocacy and communication about brain injury symptoms. Shannon Juengst will present her collaborative Community-Based Participatory Research (CBPR) project to adapt the evidence-based and condition agnostic Problem-Solving Training (PST) by engaging professionals in educational and experiential design, mobile app development in industry, psychologists, counselors, and other clinicians, and a Community Advisory Board made of persons with lived TBI experience, lived experience of other disability, and diverse community partners. Candice Osborne will then provide an integration of these findings, discuss implications for TBI treatment and behavioral health more broadly, and discuss future research.

PRESENTATION 1: A Feasibility Randomized Controlled Trial of the Toolkit for Optimal Recovery after Concussion: A Live Video Program to Prevent Persistent Concussion Symptoms in Young Adults with Anxiety

Objectives: To assess the feasibility of the Toolkit for Optimal Recovery after Concussion (TOR-C), the first mind-body program aiming to prevent persistent concussion symptoms among young adults with anxiety, and an active control (Health Enhancement after Concussion; HE-C). We also tested preliminary improvements in outcome measures and putative mechanistic targets.
Design: Single-blind, 2-arm, randomized controlled trial.
Setting: Academic medical center in the US Northeast.
Participants: Fifty young adults (ages 18-35) with a recent concussion (3-10 weeks prior) and anxiety (≥5 on the GAD7 questionnaire).
Interventions: Both interventions consisted of four 45-minute 1:1 sessions with a clinician over Zoom. TOR-C (n=25) taught mind-body, cognitive-behavioral, and return-to-activity skills. HE-C (n=25) taught health education (e.g., sleep, nutrition) without skills.
Main Outcome Measures: Primary: feasibility outcomes (e.g., recruitment, credibility, expectancy, acceptability, safety, feasibility of assessments, fidelity, satisfaction, TOR-C homework adherence) with a-priori-set benchmarks. Secondary: intervention outcomes were concussion symptoms (PCSS), physical function (WHODAS), anxiety (GAD7/HAD-A), depression (HADS-D) and pain (NRS). TOR-C mechanistic targets were pain catastrophizing (PCS), mindfulness (CAMS-R), fear avoidance (FAB-TBI), limiting behavior and all-or-nothing behavior (BRIQ).
Results: Both interventions met all feasibility benchmarks and were associated with significant improvements in outcomes (concussion symptoms, physical function, anxiety, depression and pain; d=0.44-1.21) and TOR-C mechanistic targets (pain catastrophizing, mindfulness, fear-avoidance, and limiting behavior; Cohen’s d=0.41-1.24). Improvements in all-or-nothing behavior were only significant in TOR-C (d=0.52). Improvements in all mechanistic targets except all-or-nothing behavior following TOR-C were significantly associated with improvements in at least one outcome.
Conclusion: Findings provide strong support for the feasibility of TOR-C and HE-C, and preliminary evidence for improvements in mechanistic targets and outcomes. Findings inform a future fully-powered RCT testing efficacy of TOR-C vs. HE-C.

PRESENTATION 2: Brain Injury Identification Cards: Evaluating the preliminary acceptability and user experience of a novel tool to improve community advocacy and decrease discrimination following brain injury exposure
Purpose/ Objective: Brain injuries are common health concerns with lifelong consequences that often include changes in identity, long-term disability, relationships, and reduced participation in daily activities. Changes in policy and other community- and society-level interventions are cited by experts as a critical path to reducing the impact of brain injury on impacted individuals, though such approaches have been limited in scope. Recently, qualitative investigations of user impressions of one initiative involving wallet-sized Brain Injury Identification Cards demonstrated potential wide-spread benefits on user safety, self-advocacy, and wellbeing. The primary purpose of the present study was to conduct a quantitative study assessing user acceptability, user experiences, and self-reported functioning on important intervention outcomes to inform subsequent efficacy-focused intervention trials.
Research method/ Design: In this cross-sectional survey study, we recruited individuals (N=100) that obtained Brain Injury Identification Cards and administered online self-report questionnaires assessing perceived discrimination, quality of life, and attitudes towards Brain Injury Identification Card use. We characterized survey results using descriptive statistics.
Results: We recruited participants from 32 U.S. states who had a variety of experiences of brain injury and varied in their current employment and other demographic characteristics. The majority (n=76; 76.8%) described regularly using the cards and most (n=71; 71.7%) found the cards easy or very easy to obtain. Most participants described using the cards for multiple purposes to increase advocacy with family and friends, law enforcement, healthcare providers, in their workplace, and strangers in public settings such as airports, train stations, and during travel. Participants expressed strong satisfaction on the credibility and expectancy (CEQ) items (mean scores (7.24-7.48). Further, short qualitative responses suggested that participants felt that having the Brain Injury Identification Cards meaningfully improved their lives in a number of important domains—particularly increasing self-advocacy and decreasing discrimination.
Conclusions/ Implications: Our findings lend preliminary support to the benefits of the use of Brain Injury Identification Cards on reducing perceived discrimination and promoting quality of life. Future studies assessing user experiences before and after receipt of Brain Injury Identification Cards are needed to assess intervention effects.

PRESENTATION 3: Adapting Problem-Solving Training (PST) to an online format (ePST) through Interdisciplinary collaboration and a Community-Based Participatory Research Approach
Shannon Juengst will present her collaborative Community-Based Participatory Research (CBPR) project to adapt the evidence-based and condition agnostic Problem-Solving Training (PST) to a self-directed online electronic PST (ePST). Problem-Solving Training (PST) is an evidence-based problem-solving intervention that can be applied over time and across different chronic conditions, including persons with TBI. We and others have shown that PST can reduce distress among individuals with acquired disabilities and their care partners, and metacognitive strategy training interventions, like PST, consistently have the strongest evidence base for cognitive rehabilitation in individuals with brain injury. However, access to cognitive rehabilitation and mental health services in the community for individuals with TBI is limited. Persons with TBI experience barriers to care from having limited transportation options, often having no healthcare coverage, and a shortage of specialized providers who understand TBI. While PST is already delivered remotely via telephone or video conference, it still requires somewhat intensive time from a trained coach, making PST unattainable for many persons with TBI without the financial resources or access to trained PST coaches. The emergence of electronic and mobile health (eHealth/mHealth) technology creates new opportunities for efficient, effective, and proactive intervention, promoting user-engagement and providing access to behavioral health that circumvents these barriers.
In her ongoing DoD-funded project, Dr. Juengst engages professionals in educational and experiential design, mobile app development in industry, psychologists, counselors, and other clinicians, and a Community Advisory Board made of persons with lived TBI experience, lived experience of other disability, and diverse community partners to adapt traditionally coach-delivered PST to ePST, to provide a more accessible and scalable intervention to address current barriers. She will describe the project and processes to bridge perspectives, engage in shared decision-making, and promote inclusion and engagement at every stage of the process. Qualitative data informing development of personas to guide intervention adaptation and from usability testing, as well as case examples of participants in the prospective feasibility study will be presented.

DISCUSSION
At the conclusion of the three talks, Dr. Osborne will briefly provide an integration of the findings across all three studies presented, comment on whether and when intervention considerations should be specific and tailored to TBI, when more condition-agnostic approaches may be more effective and practical, and how the work we have done could apply more broadly to other chronic condition populations. Psychologists, medical doctors, and other professions with expertise in behavioral medicine, as well as experts in technology, education, and other fields, and persons with lived experience expertise, are essential to advancing care for TBI in novel contexts. Awareness of the effect of TBI exposure on other health conditions can help “bridge the gaps” to more comprehensive, widespread care. Additionally, TBI serves as an exemplar condition to develop condition-agnostic behavioral health approaches that are responsive to the needs of diverse individuals. Consequences of TBI include a broad range of sequelae, including physical, sensory, cognitive, emotional, and social challenges. Dr. Osborne will discuss how findings from each of the projects presented could generalize to other populations and how the novel approaches taken could be employed in other populations and other contexts to maximize health and well-being outcomes.

Co-Presenter - Sarah Bannon PhD  Student
Mount Sinai Hospital

Co-Presenter - Shannon Juengst PhD  Student
TIRR Memorial Hermann

Discussant - Candice Osborne PhD, MPH, OTR  Student
Craig Hospital

The Centers for Medicare and Medicaid Services (CMS) recently recognized TBI as a chronic health condition requiring evidence-based approaches to long-term management. Behavioral factors and interventions play a key role in TBI management, but are discrete, siloed, and lack integration across diverse contexts.
The current symposium will demonstrate behavioral health approaches after TBI across varying contexts, intervention modalities, and personal characteristics of TBI survivors. In line with this year’s theme– “Context Matters: Bridging Perspectives in Behavioral Medicine” – we will showcase how interdisciplinary collaboration and engagement of persons with lived TBI experience can be leveraged to bridge across these contexts and behavioral health approaches and strive toward an integrative behavioral treatment paradigm. The symposium will highlight specific considerations in working with professionals with different backgrounds, goals, and expertise (e.g., industry partners, medical providers, attorneys, state offices) and with persons with lived experience of TBI, and whether and when intervention considerations should be specific and tailored to TBI, when more condition-agnostic approaches may be effective and practical, and how such considerations could apply more broadly to other chronic condition populations.
Jonathan Greenberg will present results of a feasibility randomized controlled trial testing a novel live-video mind-body program to prevent persistent concussion symptoms among young adults with anxiety. Sarah Bannon will present quantitative findings from TBI survivors surrounding their use of a Brain Injury Identification Card, a low intensity intervention developed by a law office to promote self-advocacy and communication about brain injury symptoms. Shannon Juengst will present her collaborative Community-Based Participatory Research (CBPR) project to adapt the evidence-based and condition agnostic Problem-Solving Training (PST) by engaging professionals in educational and experiential design, mobile app development in industry, psychologists, counselors, and other clinicians, and a Community Advisory Board made of persons with lived TBI experience, lived experience of other disability, and diverse community partners. Candice Osborne will then provide an integration of these findings, discuss implications for TBI treatment and behavioral health more broadly, and discuss future research.

PRESENTATION 1: A Feasibility Randomized Controlled Trial of the Toolkit for Optimal Recovery after Concussion: A Live Video Program to Prevent Persistent Concussion Symptoms in Young Adults with Anxiety

Objectives: To assess the feasibility of the Toolkit for Optimal Recovery after Concussion (TOR-C), the first mind-body program aiming to prevent persistent concussion symptoms among young adults with anxiety, and an active control (Health Enhancement after Concussion; HE-C). We also tested preliminary improvements in outcome measures and putative mechanistic targets.
Design: Single-blind, 2-arm, randomized controlled trial.
Setting: Academic medical center in the US Northeast.
Participants: Fifty young adults (ages 18-35) with a recent concussion (3-10 weeks prior) and anxiety (≥5 on the GAD7 questionnaire).
Interventions: Both interventions consisted of four 45-minute 1:1 sessions with a clinician over Zoom. TOR-C (n=25) taught mind-body, cognitive-behavioral, and return-to-activity skills. HE-C (n=25) taught health education (e.g., sleep, nutrition) without skills.
Main Outcome Measures: Primary: feasibility outcomes (e.g., recruitment, credibility, expectancy, acceptability, safety, feasibility of assessments, fidelity, satisfaction, TOR-C homework adherence) with a-priori-set benchmarks. Secondary: intervention outcomes were concussion symptoms (PCSS), physical function (WHODAS), anxiety (GAD7/HAD-A), depression (HADS-D) and pain (NRS). TOR-C mechanistic targets were pain catastrophizing (PCS), mindfulness (CAMS-R), fear avoidance (FAB-TBI), limiting behavior and all-or-nothing behavior (BRIQ).
Results: Both interventions met all feasibility benchmarks and were associated with significant improvements in outcomes (concussion symptoms, physical function, anxiety, depression and pain; d=0.44-1.21) and TOR-C mechanistic targets (pain catastrophizing, mindfulness, fear-avoidance, and limiting behavior; Cohen’s d=0.41-1.24). Improvements in all-or-nothing behavior were only significant in TOR-C (d=0.52). Improvements in all mechanistic targets except all-or-nothing behavior following TOR-C were significantly associated with improvements in at least one outcome.
Conclusion: Findings provide strong support for the feasibility of TOR-C and HE-C, and preliminary evidence for improvements in mechanistic targets and outcomes. Findings inform a future fully-powered RCT testing efficacy of TOR-C vs. HE-C.

PRESENTATION 2: Brain Injury Identification Cards: Evaluating the preliminary acceptability and user experience of a novel tool to improve community advocacy and decrease discrimination following brain injury exposure
Purpose/ Objective: Brain injuries are common health concerns with lifelong consequences that often include changes in identity, long-term disability, relationships, and reduced participation in daily activities. Changes in policy and other community- and society-level interventions are cited by experts as a critical path to reducing the impact of brain injury on impacted individuals, though such approaches have been limited in scope. Recently, qualitative investigations of user impressions of one initiative involving wallet-sized Brain Injury Identification Cards demonstrated potential wide-spread benefits on user safety, self-advocacy, and wellbeing. The primary purpose of the present study was to conduct a quantitative study assessing user acceptability, user experiences, and self-reported functioning on important intervention outcomes to inform subsequent efficacy-focused intervention trials.
Research method/ Design: In this cross-sectional survey study, we recruited individuals (N=100) that obtained Brain Injury Identification Cards and administered online self-report questionnaires assessing perceived discrimination, quality of life, and attitudes towards Brain Injury Identification Card use. We characterized survey results using descriptive statistics.
Results: We recruited participants from 32 U.S. states who had a variety of experiences of brain injury and varied in their current employment and other demographic characteristics. The majority (n=76; 76.8%) described regularly using the cards and most (n=71; 71.7%) found the cards easy or very easy to obtain. Most participants described using the cards for multiple purposes to increase advocacy with family and friends, law enforcement, healthcare providers, in their workplace, and strangers in public settings such as airports, train stations, and during travel. Participants expressed strong satisfaction on the credibility and expectancy (CEQ) items (mean scores (7.24-7.48). Further, short qualitative responses suggested that participants felt that having the Brain Injury Identification Cards meaningfully improved their lives in a number of important domains—particularly increasing self-advocacy and decreasing discrimination.
Conclusions/ Implications: Our findings lend preliminary support to the benefits of the use of Brain Injury Identification Cards on reducing perceived discrimination and promoting quality of life. Future studies assessing user experiences before and after receipt of Brain Injury Identification Cards are needed to assess intervention effects.

PRESENTATION 3: Adapting Problem-Solving Training (PST) to an online format (ePST) through Interdisciplinary collaboration and a Community-Based Participatory Research Approach
Shannon Juengst will present her collaborative Community-Based Participatory Research (CBPR) project to adapt the evidence-based and condition agnostic Problem-Solving Training (PST) to a self-directed online electronic PST (ePST). Problem-Solving Training (PST) is an evidence-based problem-solving intervention that can be applied over time and across different chronic conditions, including persons with TBI. We and others have shown that PST can reduce distress among individuals with acquired disabilities and their care partners, and metacognitive strategy training interventions, like PST, consistently have the strongest evidence base for cognitive rehabilitation in individuals with brain injury. However, access to cognitive rehabilitation and mental health services in the community for individuals with TBI is limited. Persons with TBI experience barriers to care from having limited transportation options, often having no healthcare coverage, and a shortage of specialized providers who understand TBI. While PST is already delivered remotely via telephone or video conference, it still requires somewhat intensive time from a trained coach, making PST unattainable for many persons with TBI without the financial resources or access to trained PST coaches. The emergence of electronic and mobile health (eHealth/mHealth) technology creates new opportunities for efficient, effective, and proactive intervention, promoting user-engagement and providing access to behavioral health that circumvents these barriers.
In her ongoing DoD-funded project, Dr. Juengst engages professionals in educational and experiential design, mobile app development in industry, psychologists, counselors, and other clinicians, and a Community Advisory Board made of persons with lived TBI experience, lived experience of other disability, and diverse community partners to adapt traditionally coach-delivered PST to ePST, to provide a more accessible and scalable intervention to address current barriers. She will describe the project and processes to bridge perspectives, engage in shared decision-making, and promote inclusion and engagement at every stage of the process. Qualitative data informing development of personas to guide intervention adaptation and from usability testing, as well as case examples of participants in the prospective feasibility study will be presented.

DISCUSSION
At the conclusion of the three talks, Dr. Osborne will briefly provide an integration of the findings across all three studies presented, comment on whether and when intervention considerations should be specific and tailored to TBI, when more condition-agnostic approaches may be more effective and practical, and how the work we have done could apply more broadly to other chronic condition populations. Psychologists, medical doctors, and other professions with expertise in behavioral medicine, as well as experts in technology, education, and other fields, and persons with lived experience expertise, are essential to advancing care for TBI in novel contexts. Awareness of the effect of TBI exposure on other health conditions can help “bridge the gaps” to more comprehensive, widespread care. Additionally, TBI serves as an exemplar condition to develop condition-agnostic behavioral health approaches that are responsive to the needs of diverse individuals. Consequences of TBI include a broad range of sequelae, including physical, sensory, cognitive, emotional, and social challenges. Dr. Osborne will discuss how findings from each of the projects presented could generalize to other populations and how the novel approaches taken could be employed in other populations and other contexts to maximize health and well-being outcomes.

Co-Presenter - Sarah Bannon, PhD, PhD,
Mount Sinai Hospital

Co-Presenter - Shannon Juengst, PhD,
TIRR Memorial Hermann

Discussant - Candice Osborne, PhD, MPH, OTR, PhD, MPH, OTR,
Craig Hospital