Neurorehabilitation Of Patients Research Articles

Secondary Suicide Prevention as Neuro-Rehabilitation

Neuro-rehabilitation and suicide prevention used to be linked together mostly as preventing suicidality in neuro-rehabilitation patients after, e.g., brain injury. However, we propose that the recent changes in neuro-rehabilitation, on the one hand, and in the suicide conceptualization, on the other, suggest the possibility of using some of the principles of neuro-rehabilitation in suicide prevention. The changes in neuro-rehabilitation include the integration of cognitive processes in motor processes [1, 2] and stressing the bottom-up in contrast to top-down procedures suggested by cognitive behavioral therapy. The changes in suicide conceptualization include the view of suicide as a distorted goal-directed action. The secondary suicide prevention procedure linked equally to neuro-rehabilitation as to psychotherapy is a consequent conceptualization of this process as a joint goal-directed action and project, using the video self-confrontation as an action experiencing procedure including mentalizing [3] and the video-self-confrontation with the integration of alternative action and action steps to revise the target actions and project [4]. Finally, a reminder in the form of a postal nudge to follow the joint life-enhancing project rounds up the secondary suicide preventive procedure. The development of professional and scientific disciplines, as well as treatment and health services is driven by their contribution to the target aims, but it also is a social process with its own institutions and professional identities that sometimes hinder a cross disciplinary fertilization. We would like to suggest that we should consider enriching the secondary suicide prevention by neuro-rehabilitation. This cross-fertilization becomes meaningful when we acknowledge the changes in each discipline. Thus, we briefly outline some of the changes in neuro-rehabilitation, in the suicide conceptualization, and in secondary suicide prevention before summarizing the secondary suicide prevention procedure encompassing some of the neuro-rehabilitation views.

Functional Neurorehabilitation using the Hybrid Assistive Limb (HAL): A First Experience in the United States

Introduction: The Hybrid Assistive Limb (HAL, Cyberdyne, Japan) facilitates voluntary, user-driven ambulation through a neurologically-controlled system based on bioelectrical signals derived from the user. This allows for the repeated execution of physiologically faithful gait patterns, crucial to recovery in cases of neurologic motor deficit. In this series, we present the first three patients in the United States to undergo HAL neurorehabilitation training. Patient and methods: A case series of three patients participating in a single-center prospective, interventional pilot study, suffering neurologic motor deficits secondary to spinal cord infarct following a pulmonary embolism (patient 1), multiple sclerosis (patient 2) and the surgical resection of a petroclival meningioma (patient 3). The patients underwent 60 sessions of body weight-supported treadmill training in the HAL over the course of 12 weeks. Measures of functional ambulation (10 Minute Walk Test, 10MWT) were performed out of the HAL before and after each session and at the 12 week and 6 month follow-up. Timed Up & Go (TUG) test was performed each week. Treadmill data (time, distance) while in HAL was recorded at each session. Measures of endurance (6 Minute Walk Test, 6MWT), risk of fall (TUG), balance impairment (Berg Balance Scale) and improvements in walking performance (Walking Index for Spinal Cord Injury II, WISCI II) were measured at baseline, after 12 weeks and at 6 months follow-up. Results: Patients 2 and 3 completed 60 visits, patient 1 completed 56 visits. All patients achieved markedly increased treadmill paces, improved functional scores, increased distance in the 6MWT and decreased TUG times at 6-month follow-up. In the 10MWT, all patients achieved a clinically significant decrease in time and steps and showed improvements in the required assistance level to perform the test. Patients 1 and 3 showed improvement on the Berg Balance Scale. Patient 2 had no change between baseline and 6-month follow-up. Only minor adverse effects were reported, including skin abrasions and irritation secondary to chaffing of the HAL unit and EMG electrodes. Conclusion: These data show that HAL training is both feasible and effective in the neurorehabilitation of patients suffering neurologic motor deficits secondary to trauma and/or pathological/neurodegenerative processes after they have undergone normal rehab. A greater number of patients are required to meaningfully assess the differences in improvement from baseline, based upon underlying pathologies.

BRAIN-COMPUTER INTERFACE: FUNDAMENTAL AND CLINICAL ASPECTS OF DEVELOPMENT AND IMPLICATION OF THE TECHNOLOGY

The article discusses the results of the III International Scientific and Practical Conference "Brain-Computer Interface: Science and Practice. Samara - 2017 ". The review covers the scientific studies dealing with fundamental and applied aspects of brain research and development of brain-computer interfaces (BCI) presented at the conference by leading domestic and foreign scientists. Clinical application of BCI is discussed in terms of neurorehabilitation of patients with motor and speech disorders, as well as the possibility of its use in diagnosis and correction of psychiatric diseases and disorders.

Online detection of amplitude modulation of motor-related EEG desynchronization using a lock-in amplifier: Comparison with a fast Fourier transform, a continuous wavelet transform, and an autoregressive algorithm

BackgroundNeurofeedback of event-related desynchronization (ERD) in electroencephalograms (EEG) of the sensorimotor cortex (SM1) using a brain–computer interface (BCI) paradigm is a powerful tool to promote motor recovery from post-stroke hemiplegia. However, the feedback delay attenuates the degree of motor learning and neural plasticity. New methodThe present study aimed to shorten the delay time to estimate amplitude modulation of the motor-imagery-related alpha and beta SM1-ERD using a lock-in amplifier (LIA) algorithm. The delay time was evaluated by calculating the value of the maximal correlation coefficient (MCC) between the time-series trace of ERDs extracted by the online LIA algorithm and those identified by an offline algorithm with the Hilbert transform (HT). ResultsThe MCC and delay values used to estimate the ERDs calculated by the LIA were 0.89±0.032 and 200±9.49ms, respectively. Comparison with Existing Method(s)The delay time and MCC values were significantly improved compared with those calculated by the conventional fast Fourier transformation (FFT), continuous Wavelet transformation (CWT), and autoregressive (AR) algorithms. Moreover, the coefficients of variance of the delay time and MCC values across trials were significantly lower in the LIA compared with the FFT, CWT, and AR algorithms. ConclusionsThese results indicate that the LIA improved the detection delay, accuracy, and stability for estimating amplitude modulation of motor-related SM1-ERD. This would be beneficial for BCI paradigms to facilitate neurorehabilitation in patients with motor deficits.

P222 Diagnostic and therapeutic possibilities of transcranial magnetic stimulation in patients after traumatic brain injury

Objectives Recovery of both mental and motor functions is one of the key problems of neurorehabilitation of patients with traumatic brain injury (TBI), accompanied by posttraumatic unconsciousness state (PUS). The purpose of pilot study is to clarify the diagnostic and therapeutic potential of TMS in patients after TBI with impaired motor activity and consciousness. Methods Observation groups: (1) 15 patients after TBI at the age of 17–56, in which the diagnostic TMS (cortical motor areas (M1) bilaterally, CVII bilaterally, registration of MEPs from musculus abductor pollicis brevis) was performed; (2) 9 patients after TBI at the age of 16–44 with a prolonged (from 60 to 220 days) unconscious state in which the rhythmic TMS was performed; (3) Control group: 5 healthy men aged 22–28. Diagnostic TMS evaluated cortical, radicular latency and amplitude of MEPs,time of central motor conduction. In the second and third groups changes of neurological status, indicators of the memory and attention, and N100, N200 and P300 components of auditory ERP hour before and hour after stimulation were estimated. Results Diagnostic TMS in patients with positive or ambiguous clinical dynamics showed initial difference of conductivity of tracts in comparison with normal data by 20–30% or 30–40%, respectively, with progressive improvement as motor and cognitive functions recovered. In patients with negative clinical dynamics TMS values had significantly larger deviation of cortical latency and amplitudes of MEPs (over 45%), and also the time of central motor conduction. Statistical analysis of acquired data revealed the greatest prognostic significance for determining the level of the amplitudes of MEPs with undeniable importance for the indicators of cortical latency and the time of central motor conduction. Therapeutic TMS of the sagittal premotor cortex areas in groups 2 and 3 concurred with improvement of any attention and normalization of amplitude and latency of all ERP components, as well as indicators of their spatial synchronism, especially for P300. Conclusions The obtained data clarifies diagnostic parameters of TMS and proposes the availability of using rTMS for therapeutic purposes in patients with PUS. Supported by RFFI N16-29-08304 .

Harmony as a convergence attractor that minimizes the energy expenditure and variability in physiological gait and the loss of harmony in cerebellar ataxia

BackgroundThe harmony of the human gait was recently found to be related to the golden ratio value (ϕ). The ratio between the duration of the stance and that of the swing phases of a gait cycle was in fact found to be close to ϕ, which implies that, because of the fractal property of autosimilarity of that number, the gait ratios stride/stance, stance/swing, swing/double support, were not significantly different from one another. We studied a group of patients with cerebellar ataxia to investigate how the differences between their gait ratios and the golden ratio are related to efficiency and stability of their gait, assessed by energy expenditure and stride-to-stride variability, respectively. MethodsThe gait of 28 patients who were affected by degenerative cerebellar ataxia and of 28 healthy controls was studied using a stereophotogrammetric system. The above mentioned gait ratios, the energy expenditure estimated using the pelvis reconstructed method and the gait variability in terms of the stride length were computed, and their relationships were analyzed. Matching procedures have also been used to avoid multicollinearity biases. FindingsThe gait ratio values of the patients were farther from the controls (and hence from ϕ), even in speed matched conditions (P=0.011, Cohen's D=0.76), but not when the variability and energy expenditure were matched between the two groups (Cohen's D=0.49). In patients with cerebellar ataxia, the farther the stance-swing ratio was from ϕ, the larger the total mechanical work (R2adj=0.64). Further, a significant positive correlation was observed between the difference of the gait ratio from the golden ratio and the severity of the disease (R=0.421, P=0.026). InterpretationHarmony of gait appears to be a benchmark of physiological gait leading to physiological energy recovery and gait reliability. Neurorehabilitation of patients with ataxia might benefit from the restoration of harmony of their locomotor patterns.

FEATURES OF SENSORIMOTOR DISTURBANCES IN DIFFERENT PERIODS AFTER ISCHEMIC STROKE

The aim of the study was to investigate the clinical and neurophysiological features of sensorimotor disturbances in patients at different time periods after ischemic stroke. Methods. The study involved 133 patients with ischemic stroke in the right and left cerebral hemispheres in the late recovery (58) and residual (75) periods. There were 35 controls. Were performed transcranial magnetic stimulation, evoked abdominal reflexes and somatosensory evoked potentials. Results. It was shown that functional recovery processes are continuing with varying degrees of severity in patients and in a year after stroke. Conclusions. Persistence and severity of sensorimotor disturbances, as well as compensatory opportunities, defined afferent component of poststroke deficit, which implies an additional impact in this area to expand the possibilities of neurorehabilitation in patients after stroke.

Neurorehabilitation in Patients with Congenital Heart Disease

Background: Progress in cardiovascular surgery and intensive care of children with congenital heart disease could reduce mortality considerably. Survival rate after surgery for complex congenital heart disease today is averaged out at ~95%. Therefore, disabling complications of other organs become more important, particularly neurologic complications. This can be seen in the increasing number of children getting neurological rehabilitation.

Role of bromocriptine in multi-spectral manifestations of traumatic brain injury

PurposeDespite the prevalence and cost of traumatic brain injury related disabilities, there is paucity in the literature on modern approaches to pharmacotherapy. Medications may promote recovery by enhancing some neurological functions without impacting others. Herein we discussed the role of bromocriptine in neurorehabilitation for patients with traumatic brain injury. MethodsA cohort comprising of 36 selective nonsurgical cases of traumatic brain injury in minimally conscious state were enrolled in the study. After hemodynamic stability, bromocriptine was given at paediatric dose of 3.75 mg/d and adult dose of 7.5 mg/d. It was administered through a naso-gastric (NG) feeding tube in the patients with minimally conscious state, then changed to oral route after proper swallowing and good gag reflex were ensured in the patient. The drug was slowly reduced over three weeks after neurological improvement in the patients. Positive result was determined by improved GCS score of 2 and motor power by at least 1 British Medical Council (BMC) motor score. Improvement of deficits was evaluated in terms of fluency of speech for aphasia, task switching, digit span double tasking and trail-making test for cognition and attention, and functional independence measure score for motor functioning and self-independence. ResultsAccelerated arousal was seen in 47.0% of cases (8/17) in 4–40 days. In 41.2% of cases (7/17), Glasgow outcome score (GOS) was improved to 4/5 in 90 days. Improvement in hemiparesis by at least 1 BMC score was seen in 55.6% of cases (5/9) in 40 days. Aphasia was improved in 80% of cases (4/5) in 7–30 days. Moderate improvement in cognitive impairment was seen in 66.7% of cases (2/3) in 14–20 days. Improvement in memory was observed in 50% of cases (1/2) in over 30 days. No cases were withdrawn from the study because of adverse reactions of the drug. There was no mortality in the study group. ConclusionBromocriptine improves neurological sequelae of traumatic brain injury as well as the overall outcome in the patients. If medication is given to promote recovery and treat its associated disabilities, clinicians should thoroughly outline the goals and closely monitor adverse effects.

P164 Modulation of semantic speech-gesture matching performance by tDCS

Introduction Co-verbal gestures are an important part of human communication. Brain imaging studies suggest a different contribution of the left frontal lobe for processing metaphoric (gesture refers to abstract sentence content) in contrast to iconic (gesture refers to concrete sentence content) co-verbal gestures. However, to our knowledge, so far the functional relevance of the left frontal lobe in metaphoric compared to iconic co-verbal gesture processing has not been demonstrated. Objectives We investigated the functional relevance of the left frontal lobe for processing metaphoric co-verbal gestures using transcranial direct current stimulation (tDCS). Consequently, we hypothesized a polarization dependent effect of left frontal tDCS on reaction times and ratings of healthy subjects in a semantic speech-gesture matching task. Materials & methods Using a complex multi-session design, we applied anodal, cathodal and sham tDCS stimulation to left and right frontal (F3/F4) and parietal (CP3/CP4) areas. During stimulation, subjects were presented with videos of an actor speaking concrete/abstract sentences accompanied by related/unrelated iconic or metaphoric gestures. After each video clip, subjects rated how well gestures matched sentence content. Results We found electrode localization (frontal, frontoparietal, parietal) and polarization (anode/cathode) dependent changes in reaction times and ratings for metaphoric vs. iconic co-verbal gestures (stimulation x gesture type interaction; SxG). Post-hoc tests revealed a specific polarization effect for frontoparietal stimulation sites, as anodal stimulation of the left frontal lobe (left frontal anode, right parietal cathode; LFA–RPC) decreased reaction times and relatedness ratings compared to cathodal (LFC–RPA) stimulation for metaphoric conditions, but not for iconic conditions (frontoparietal SxG). Conclusion Using tDCS, we demonstrated the functional relevance of the left frontal lobe for processing metaphoric co-verbal gestures. Thus, tDCS may constitute a promising approach to neurorehabilitation of patients with metaphoric gesture processing deficits, such as patients with schizophrenia.

Functional neuroimaging of the brain structures associated with language in healthy individuals and patients with post-stroke aphasia

The introduction of non-invasive functional neuroimaging techniques such as functional magnetic resonance imaging (fMRI), in the practice of scientific and clinical research can increase our knowledge about the organization of cognitive processes, including language, in normal and reorganization of these cognitive functions in post-stroke aphasia. The article discusses the results of fMRI studies of functional organization of the cortex of a healthy adult's brain in the processing of various voice information as well as the main types of speech reorganization after post-stroke aphasia in different stroke periods. The concepts of 'effective' and 'ineffective' brain plasticity in post-stroke aphasia were considered. It was concluded that there was an urgent need for further comprehensive studies, including neuropsychological testing and several complementary methods of functional neuroimaging, to develop a phased treatment plan and neurorehabilitation of patients with post-stroke aphasia.

Role of the music therapy in neurorehabilitation of patients with disorders of consciousness – looking for rules of evidence based practice

Neurological early and long-term rehabilitation plays a crucial role in the therapy of patients with disorders of consciousness (DOC) such as unresponsive wakefulness syndrome or minimally conscious state. Neuroscience tries to explain the effect of music therapy on all levels of the nervous system = activity in patients with DOC, but full understanding is still incomplete. This paper attempts to answer how current clinical outcomes may reflect the influence of various factors including music's capacity. Based on their interdisciplinary perspective and previous experiences, the authors try to investigate the extent to which current occupations have been explored. The authors analyzed the literature data concerning the results of the studies published until the first half of 2016, to sum up the current state of research. Research in the main databases: PubMed, PEDro, Health Source: Nursing/Academic Edition was made using specified keywords and inclusion and exclusion criteria. Next, the authors sorted them all out into a coherent view of the current state. Music listening may constitute a part of an enriched environment setting. However, due to weak evidence, the therapeutic value of music-based interventions in patients with DOC is uneven or limited. The role of music therapy is thus complementary. Standardized clinical settings, protocols, and behavioral measures should be developed to increase its clinical validity, reliability, sensitivity, and objectivity. There is a reasonable hypothesis that music may produce a high level of diagnostic and therapeutic outcomes as stimuli usually reflecting strong personal meaning in patients with DOC.

Psychometric testing of the modified Care Dependency Scale (Neuro-CDS).

Effective measures of nursing care dependency in neurorehabilitation are warranted to plan nursing interventions to help patients avoid increasing dependency. The Care Dependency Scale (CDS) is a theory-based, comprehensive tool to evaluate functional disability. This study aimed to modify the CDS for neurological and neurorehabilitation patients (Neuro-CDS) and to test its psychometric properties in adult neurorehabilitation inpatients. Exploratory factor analysis (EFA) was performed using a Maximum Likelihood robust (MLR) estimator. The Barthel Index (BI) was used to evaluate concurrent validity. Stability was measured using the Intra-class Correlation Coefficient (ICC). The sample included 124 patients (mean age = 69.7 years, 54% male). The EFA revealed a two-factor structure with good fit indexes, Factor 1 (Physical care dependence) loaded by 11 items and Factor 2 (Psycho-social care dependence) loaded by 4 items. The correlation between factors was 0.61. Correlations between Factor 1 and the BI and between Factor 2 and the BI were r = 0.843 and r = 0.677, respectively (p < 0.001). The Cronbach's alpha coefficients were 0.99 and 0.88 (Factor 1 and 2). The ICC was 0.98. The Neuro-CDS is multidimensional, valid, reliable, straightforward, and able to measure care dependence in neurorehabilitation patients as a basis for individualized and holistic care.

Increasing self-directed training in neurorehabilitation patients through competition.

This proof-of-concept study aimed to test whether competition could be a useful tool to increase intensity and amount of self-directed training in neurorehabilitation. Stroke patients undergoing inpatient neurorehabilitation (n=93) conducted self-directed endurance training on a (wheelchair-compatible) bicycle trainer under three experimental conditions: a "Competition" condition and two noncompetition control conditions (repeated randomized within-subject design). Training performance and perceived exertion were recorded and statistically analyzed. Three motivational effects of competition were found. First, competition led to an increase in self-directed training. Patients exercised significantly more intensively under competition than in the two noncompetition control conditions. Second, (winning a) competition had a positive influence on performance in the subsequent training session. Third, training performance was particularly high during rematch competitions; that is to say, during second encounter competitions against an opponent that the patient had just beaten. No systematic effect of competition upon perceived exertion (controlled for training performance) was found. Together, our results demonstrate that competition is a potent motivational tool to increase self-directed training in neurorehabilitation.

Brain-machine Interface in Robot-assisted Neurorehabilitation for Patients with Stroke and Upper Extremity Weakness – the Therapeutic Turning Point

Correspondence to Jung Hwan Kim National Rehabilitation Center Rehabilitation Hospital & Research Institute, 58 Samgaksanro, Gangbuk-gu, Seoul 01022, Korea. Tel: +82-2-901-1801 E-mail: view1492@gmail.com Jung Hwan Kim Brain-machine Interface in Robotassisted Neurorehabilitation for Patients with Stroke and Upper Extremity Weakness – the Therapeutic Turning Point Brain & NeuroRehabilitation 02

Neurorehabilitation in schizophrenia

Neurorehabilitation in patients with Schizophrenia is a set of activities capable of maximizing recovery capabilities through the development of it in their family, work and social sphere, and minimize the effects that arise from the chronicity and the natural course of this disease. This process emphasizes all the cognitvas both individual capacities as motor through an approach to vocational, residential, recreational, social and educational support, tailored to the unique demands of the patient, in every situation and custom mode. For this, working through concepts such as social cognition and insight, interdisciplinary way, so to set goals and accomplish them with a specific planning. Schizophrenia is a chronic disease that occurs in 1 to 2% of the world population, and causes social marginalization and stigmatization in patients who have it. Be treated, then, since the integration of multidimensional therapeutic resources. In this paper descriptively explains the techniques and activities developed individually for each professional and interdisciplinary area of building situational and individual patient diagnosis, potential and limitations as well as the specific treatment that may lead to improved cognitive and motor skills of the patient, and from it an improvement in their social inclusion and quality of life.

Injury severity at presentation is not associated with long-term vocational outcome in British Military brain injury

IntroductionInjury Severity Score (ISS) and GCS can be retrospective markers of injury severity, but if used by clinicians to decide on the treatment of acutely brain-injured casualties at the point...

Robotic neurorehabilitation in patients with chronic stroke: psychological well-being beyond motor improvement.

Although gait abnormality is one of the most disabling events following stroke, cognitive, and psychological impairments can be devastating. The Lokomat is a robotic that has been used widely for gait rehabilitation in several movement disorders, especially in the acute and subacute phases. The aim of this study was to evaluate the effectiveness of gait robotic rehabilitation in patients affected by chronic stroke. Psychological impact was also taken into consideration. Thirty patients (13 women and 17 men) affected by chronic stroke entered the study. All participants underwent neurological examination with respect to ambulation, Ashworth, Functional Independence Measure, and Tinetti scales to assess their physical status, and Hamilton Rating Scale for Depression, Psychological General Well-being Index, and Coping Orientation to Problem Experienced to evaluate the Lokomat-related psychological impact before and after either a conventional treatment or the robotic training. During each rehabilitation period (separated by a no-treatment period), patients underwent a total of 40 1 h training sessions (i.e. five times a week for 8 weeks). After the conventional treatment, the patients did not achieve a significant improvement in the functional status, except balance (P<0.001) and walking ability (P<0.01), as per the Tinetti scale. Indeed, after the robotic rehabilitation, significant improvements were detected in almost all the motor and psychological scales that we investigated, particularly for Psychological General Well-being Index and Coping Orientation to Problem Experienced. Manual and robotic-assisted body weight-supported treadmill training optimizes the sensory inputs relevant to step training, repeated practice, as well as neuroplasticity. Several controlled trials have shown a superior effect of Lokomat treatment in stroke patients' walking ability and velocity in particular. Therefore, our preliminary results proved that active robotic training not only facilitates gait and physical function but also the psychological status, even in patients affected by chronic stroke.

Noninvasive Spinal Cord Stimulation: Technical Aspects and Therapeutic Applications.

Electrical and magnetic trans-spinal stimulation can be used to increase the motor output of multiple spinal segments and modulate cortico-spinal excitability. The application of direct current through the scalp as well as repetitive transcranial magnetic stimulation are known to influence brain excitability, and hence can also modulate other central nervous system structures, including spinal cord. This study aimed to evaluate the effects and the therapeutic usefulness of these noninvasive neuromodulatory techniques in healthy subjects and in the neurorehabilitation of patients with spinal cord disorders, as well as to discuss the possible mechanisms of action. A comprehensive review that summarizes previous studies using noninvasive spinal cord stimulation is lacking. PubMed (MEDLINE) and EMBASE were systematically searched to identify the most relevant published studies. We performed here an extensive review in this field. By decreasing the spinal reflex excitability, electrical and magnetic trans-spinal stimulation could be helpful in normalizing reflex hyperexcitability and treating hypertonia in subjects with lesions to upper motor neurons. Transcutaneous spinal direct current stimulation, based on applying direct current through the skin, influences the ascending and descending spinal pathways as well as spinal reflex excitability, and there is increasing evidence that it also can induce prolonged functional neuroplastic changes. When delivered repetitively, magnetic stimulation could also modulate spinal cord functions; however, at present only a few studies have documented spastic-reducing effects induced by repetitive spinal magnetic stimulation. Moreover, paired peripheral and transcranial stimulation can be used to target the spinal cord and may have potential for neuromodulation in spinal cord-injured subjects. Noninvasive electrical and magnetic spinal stimulation may provide reliable means to characterize important neurophysiologic and pathophysiologic aspects of spinal cord function. Moreover, transcutaneous direct current stimulation and repetitive magnetic stimulation may hold therapeutic promise in patients with spinal cord disorders, although future well-controlled studies are needed to corroborate and extend the preliminary findings.

Invalid symptom reporting and performance: What are we missing?

In the evaluation of neurorehabilitation patients involved in compensation or litigation, it is often assumed that poor performance or exaggerated symptoms reflects an intentional attempt to game the system. The purpose of this article is to review multiple issues that can contribute to invalid symptom reporting and performance. Multiple factors relevant to normal behavior, including observations from social psychology and behavioral economics, are important in the context of invalid symptom reporting and performance. These factors, which include pre-injury traits and beliefs (e.g., beliefs about prognosis and symptoms after TBI), factors at the time of initial treatment (e.g., expectations of recovery, nocebo effects, stereotype threat), and thoughts and feelings during evaluations (e.g., anger, resentment, injustice), may be important explanations. To best serve our patients, further research is needed to illuminate these relative effects on performance compared to "not trying."