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Factors Related to the Quality and Stability of Partner Relationships After Traumatic Brain Injury: A Systematic Literature Review

  • Brenda van den Broek
    Correspondence
    Corresponding author Brenda van den Broek, MA, Multidisciplinary Specialist Centre for Brain Injury and Neuropsychiatry, GGZ Oost Brabant, Kluisstraat 2, 5427 EM Boekel, the Netherlands.
    Affiliations
    Multidisciplinary Specialist Centre for Brain Injury and Neuropsychiatry, GGZ Oost Brabant, Boekel, the Netherlands

    School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, the Netherlands

    Limburg Brain Injury Centre, Maastricht, the Netherlands
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  • Sophie Rijnen
    Affiliations
    Multidisciplinary Specialist Centre for Brain Injury and Neuropsychiatry, GGZ Oost Brabant, Boekel, the Netherlands

    Limburg Brain Injury Centre, Maastricht, the Netherlands
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  • Annemarie Stiekema
    Affiliations
    School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, the Netherlands

    Limburg Brain Injury Centre, Maastricht, the Netherlands
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  • Caroline van Heugten
    Affiliations
    School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, the Netherlands

    Limburg Brain Injury Centre, Maastricht, the Netherlands

    Department of Neuropsychology and Psychopharmacology, Maastricht University, Maastricht, the Netherlands
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  • Boudewijn Bus
    Affiliations
    Multidisciplinary Specialist Centre for Brain Injury and Neuropsychiatry, GGZ Oost Brabant, Boekel, the Netherlands

    Limburg Brain Injury Centre, Maastricht, the Netherlands
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Open AccessPublished:April 05, 2022DOI:https://doi.org/10.1016/j.apmr.2022.02.021

      Abstract

      Objective

      The latest literature review on partner relationships after traumatic brain injury (TBI), conducted a decade ago, discussed solely quantitative work and noted significant knowledge gaps. The current review updates and expands on this work by providing an overview of the current state of knowledge on factors related to relationship quality and stability after TBI.

      Data Sources

      Cumulative Index to Nursing and Allied Health, Embase, MEDLINE, Psychology and Behavioral Sciences Collection, APA PsycINFO, and PubMed were searched on April 23, 2020, for literature on factors associated with (1) relationship quality; and (2) relationship stability after TBI.

      Study Selection

      English quantitative and qualitative studies investigating factors associated with relationship quality and/or stability after TBI were included. Two reviewers independently assessed eligibility. If consensus was not reached, a third reviewer's conclusion was decisive. Forty-three studies were included.

      Data Extraction

      Information regarding study objectives and characteristics, participant demographics, independent and dependent variables, and main findings was extracted. Study quality was rated using the JBI Checklist for Analytical Cross-Sectional Studies and/or the CASP Checklist for Qualitative Research. Both were performed by the lead reviewer and checked by the second reviewer.

      Data Synthesis

      Thirty-eight factors related to relationship quality and/or stability were identified, covering injury characteristics (eg, severity), body functions (eg, personality changes), activities (eg, communication), participation (eg, social dependence), environment (eg, children), and personal factors (eg, coping strategies).

      Conclusions

      Relationship quality and stability after TBI are related to a multitude of factors, including newly identified factors such as personality changes and dependence. Future research may wish to quantitatively investigate factors thus far only identified in qualitative research, explore possible positive effects of TBI on relationships, study the experiences of same-sex couples, and include the perspectives of both partners with and without the injury.

      List of abbreviations:

      ABI (acquired brain injury), ICF (International Classification of Functioning, Disability, and Health), TBI (traumatic brain injury)

      Keywords

      Traumatic brain injury (TBI) has been dubbed the silent epidemic and causes more death and disability than any other traumatic insult.
      • Dewan MC
      • Rattani A
      • Gupta S
      • et al.
      Estimating the global incidence of traumatic brain injury.
      It is estimated that worldwide 69 million individuals sustain a TBI each year
      • Dewan MC
      • Rattani A
      • Gupta S
      • et al.
      Estimating the global incidence of traumatic brain injury.
      and that around 12% of adults have a history of TBI.
      • Frost RB
      • Farrer TJ
      • Primosch M
      • Hedges DW.
      Prevalence of traumatic brain injury in the general adult population: a meta-analysis.
      People with a TBI often face a multitude of physical,
      • Kraus J
      • Schaffer K
      • Ayers K
      • Stenehjem J
      • Shen H
      • Afifi AA.
      Physical complaints, medical service use, and social and employment changes following mild traumatic brain injury: a 6-month longitudinal study.
      cognitive,
      • Draper K
      • Ponsford J.
      Cognitive functioning ten years following traumatic brain injury and rehabilitation.
      ,
      • Schretlen DJ
      • Shapiro AM.
      A quantitative review of the effects of traumatic brain injury on cognitive functioning.
      emotional,
      • Jorge R
      • Robinson RG.
      Mood disorders following traumatic brain injury.
      ,
      • Lavoie S
      • Sechrist S
      • Quach N
      • et al.
      Depression in men and women one year following traumatic brain injury (TBI): a TBI Model Systems study.
      and behavioral
      • Rao V
      • Rosenberg P
      • Bertrand M
      • et al.
      Aggression after traumatic brain injury: prevalence and correlates.
      problems as a consequence of their injury that tend to be persistent, especially after moderate or severe TBI.
      • Draper K
      • Ponsford J.
      Cognitive functioning ten years following traumatic brain injury and rehabilitation.
      ,
      • Wagner AK
      • Hammond FM
      • Sasser HC
      • Wiercisiewski D
      • Norton HJ.
      Use of injury severity variables in determining disability and community integration after traumatic brain injury.
      These sequelae can be profoundly disabling and can strongly alter the extent to which an individual can participate in social,
      • Dumont C
      • Gervais M
      • Fougeyrollas P
      • Bertrand R.
      Toward an explanatory model of social participation for adults with traumatic brain injury.
      ,
      • Goverover Y
      • Genova H
      • Smith A
      • Chiaravalloti N
      • Lengenfelder J.
      Changes in activity participation following traumatic brain injury.
      household,
      • Goverover Y
      • Genova H
      • Smith A
      • Chiaravalloti N
      • Lengenfelder J.
      Changes in activity participation following traumatic brain injury.
      and recreational
      • Goverover Y
      • Genova H
      • Smith A
      • Chiaravalloti N
      • Lengenfelder J.
      Changes in activity participation following traumatic brain injury.
      • Bier N
      • Dutil E
      • Couture M.
      Factors affecting leisure participation after a traumatic brain injury: an exploratory study.
      • Wise EK
      • Mathews-Dalton C
      • Dikmen S
      • et al.
      Impact of traumatic brain injury on participation in leisure activities.
      activities.
      The consequences of TBI are not only burdensome for individuals with an injury themselves but can also greatly affect (their relationship with) their partners. As a result of TBI and its sequelae, responsibilities are often shifted and roles within the relationship can change.
      • Godwin E
      • Chappell B
      • Kreutzer J.
      Relationships after TBI: a grounded research study.
      ,
      • Wedcliffe T
      • Ross E.
      The psychological effects of traumatic brain injury on the quality of life of a group of spouses/partners.
      When the personality of an individual with a TBI is changed by the injury, their partner can feel like they are suddenly living with a stranger who they do not recognize as their partner and who they cannot rely on for support,
      • Bodley-Scott SEM
      • Riley GA.
      How partners experience personality change after traumatic brain injury–its impact on their emotions and their relationship.
      ,
      • Wood RL.
      Waking up next to a stranger.
      thus experiencing a so-called ambiguous loss.
      • Kreutzer JS
      • Mills A
      • Marwitz JH.
      Ambiguous loss and emotional recovery after traumatic brain injury.
      ,
      • Landau J
      • Hissett J.
      Mild traumatic brain injury: impact on identity and ambiguous loss in the family.
      Visser-Meily et al
      • Visser-Meily A
      • Post M
      • Gorter JW
      • Berlekom SB
      • Van Den Bos T
      • Lindeman E.
      Rehabilitation of stroke patients needs a family-centred approach.
      describe how partners of individuals with a TBI can become patients themselves as a consequence of the responsibilities they have in their role as both family member and caregiver. This notion is supported by studies showing that many of these partners have symptoms of anxiety and depression.
      • Ennis N
      • Rosenbloom BN
      • Canzian S
      • Topolovec-Vranic J.
      Depression and anxiety in parent versus spouse caregivers of adult patients with traumatic brain injury: a systematic review.
      ,
      • Kieffer-Kristensen R
      • Teasdale TW.
      Parental stress and marital relationships among patients with brain injury and their spouses.
      Moreover, previous work has indicated decreased relationship quality
      • Kieffer-Kristensen R
      • Teasdale TW.
      Parental stress and marital relationships among patients with brain injury and their spouses.
      ,
      • Burridge AC
      • Huw Williams W
      • Yates PJ
      • Harris A
      • Ward C
      Spousal relationship satisfaction following acquired brain injury: the role of insight and socio-emotional skill.
      and relationship stability (ie, increased separation rates) for couples after TBI.
      • Hoofien D
      • Gilboa A
      • Vakil E
      • Donovick PJ.
      Traumatic brain injury (TBI) 10-20 years later: a comprehensive outcome study of psychiatric symptomatology, cognitive abilities and psychosocial functioning.
      ,
      • Norup A
      • Kruse M
      • Soendergaard PL
      • Rasmussen KW
      Biering-Sørensen F. Socioeconomic consequences of traumatic brain injury: a Danish nationwide register-based study.
      At the same time, having a partner can be of major importance for individuals with a TBI. After the injury, they frequently rely on partners for informal care and to take on tasks they are no longer able to perform.
      • Godwin EE
      • Kreutzer JS
      • Arango-Lasprilla JC
      • Lehan TJ.
      Marriage after brain injury: review, analysis, and research recommendations.
      ,
      • Riley GA.
      The partner's experience of traumatic brain injury and its recovery.
      In addition, individuals who sustain a TBI are at risk of losing friendships
      • Douglas J.
      Loss of friendship following traumatic brain injury: a model grounded in the experience of adults with severe injury.
      ,
      • Flynn MA
      • Mutlu B
      • Duff MC
      • Turkstra LS.
      Friendship quality, friendship quantity, and social participation in adults with traumatic brain injury.
      and their preinjury jobs.
      • Shames J
      • Treger I
      • Ring H
      • Giaquinto S.
      Return to work following traumatic brain injury: trends and challenges.
      ,
      • van Velzen JM
      • van Bennekom CA
      • Edelaar MJ
      • Sluiter JK
      • Frings-Dresen MH.
      How many people return to work after acquired brain injury?: a systematic review.
      Consequently, their social networks often shrink to the point where they mainly consist of family members rather than also including friends.
      • Douglas J.
      Loss of friendship following traumatic brain injury: a model grounded in the experience of adults with severe injury.
      ,
      • Kinsella G
      • Ford B
      • Moran C.
      Survival of social relationships following head injury.
      ,
      • Lefebvre H
      • Cloutier G
      • Josée Levert M.
      Perspectives of survivors of traumatic brain injury and their caregivers on long-term social integration.
      The importance of a partner for individuals with a TBI is further supported by studies showing that being in a romantic relationship and receiving emotional support contribute strongly to a high quality of life after TBI.
      • Jacobsson L
      • Lexell J.
      Life satisfaction 6-15 years after a traumatic brain injury.
      ,
      • Proctor CJ
      • Best LA.
      Social and psychological influences on satisfaction with life after brain injury.
      Given the difficulties faced by partners and the significance of a partner for individuals with a TBI, it is important to understand which factors are related to the quality and stability of partner relationships after one of the partners has sustained such an injury. A decade ago, Godwin et al
      • Godwin EE
      • Kreutzer JS
      • Arango-Lasprilla JC
      • Lehan TJ.
      Marriage after brain injury: review, analysis, and research recommendations.
      reviewed the literature on marriage after TBI. Their findings suggest that age, sex, cause of injury, and injury severity were related to relationship stability and that relationship quality was related to a multitude of factors, which include age, injury severity, psychosocial adjustment, and coping skills. They also pointed out significant knowledge gaps, focusing mainly on the lack of studies in which the perspective of both the partner with and the partner without the injury is considered. Since then, various relevant studies have been conducted, further investigating factors that influence partner relationships after TBI.
      • Forslund MV
      • Arango-Lasprilla JC
      • Roe C
      • Perrin PB
      • Andelic N.
      Multilevel modeling of partnered relationship trajectories and relationship stability at 1, 2, and 5 years after traumatic brain injury in Norway.
      • Kreutzer JS
      • Sima AP
      • Marwitz JH
      • Lukow Ii HR.
      Marital instability after brain injury: an exploratory analysis.
      • Williams C
      • Wood RL.
      The impact of alexithymia on relationship quality and satisfaction following traumatic brain injury.
      In addition, qualitative studies
      • Bodley-Scott SEM
      • Riley GA.
      How partners experience personality change after traumatic brain injury–its impact on their emotions and their relationship.
      ,
      • Hammond FM
      • Davis CS
      • Whiteside OY
      • Philbrick P
      • Hirsch MA.
      Marital adjustment and stability following traumatic brain injury: a pilot qualitative analysis of spouse perspectives.
      ,
      • Layman DE
      • Dijkers MP
      • Ashman TA.
      Exploring the impact of traumatic brain injury on the older couple: 'yes, but how much of it is age, I can't tell you ...'.
      can provide additional insights to the quantitative work reviewed by Godwin et al
      • Godwin EE
      • Kreutzer JS
      • Arango-Lasprilla JC
      • Lehan TJ.
      Marriage after brain injury: review, analysis, and research recommendations.
      by presenting in-depth accounts of couples’ experiences after TBI. An updated and expanded review is thus needed. The present systematic literature review aimed to provide an overview of the current state of knowledge on factors associated with relationship quality and relationship stability for couples after TBI, thereby considering both quantitative and qualitative work. Insight into these factors can provide a valuable basis for programs intended to support couples after TBI.

      Methods

      The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines
      • Moher D
      • Shamseer L
      • Clarke M
      • et al.
      Preferred Reporting Items for Systematic Review and Meta-Analysis protocols (PRISMA-P) 2015 statement.
      were followed while conducting and reporting this review. The review protocol was registered at the PROSPERO international database of prospectively registered systematic reviews in health and social care (registration no.: CRD42020193061).

      Eligibility criteria

      English scientific publications of any type on studies investigating factors associated with relationship quality and/or relationship stability after TBI were eligible for inclusion in this review. Both quantitative and qualitative studies were considered suitable for inclusion; previous literature reviews and meta-analyses were excluded. If the participants in a study had acquired brain injury (ABI) of varying nature (eg, traumatic, stroke), the publication was only considered eligible if the large majority of participants (>75%) had a TBI.
      Studies on relationship quality were eligible for inclusion if (aspects of) the quality of adult partner relationships after one of the partners has sustained a TBI was specifically studied in relation to 1 or more other variable(s). Relationship adjustment and sexual satisfaction were seen as aspects of relationship quality, and studies focusing on these concepts were therefore selected. Studies that focused on family adjustment and/or functioning or caregiver burden were not selected because these concepts were not considered to specifically pertain to the quality of partner relationships. Studies on relationship stability were eligible for inclusion if the stability of adult partner relationships after one of the partners has sustained a TBI is specifically studied in relation to 1 or more other variable(s).

      Search

      We performed 2 searches: 1 for factors associated with relationship quality after TBI and 1 for factors associated with relationship stability after TBI. Multiple databases (Cumulative Index to Nursing and Allied Health, Embase, MEDLINE, Psychology and Behavioral Sciences Collection, APA PsycINFO, PubMed) were searched. In addition, we used the Gray Matters tool

      CADTH. Grey matters: a practical tool for searching health-related grey literature. Available at: https://www.cadth.ca/resources/finding-evidence. Accessed April 23, 2020.

      to detect potentially relevant studies described in gray literature. The searches were performed on April 23, 2020. We used the following search terms and Boolean operators to identify studies investigating factors associated with relationship quality: (TBI OR ABI OR brain injury OR head injury) AND (partner* OR couple* OR marriage OR marital OR spous* OR family) AND (quality OR satisfaction OR intimacy OR affection OR adjustment OR sexual*). We used the following search terms and Boolean operators to identify studies investigating factors associated with relationship stability: (TBI OR ABI OR brain injury OR head injury) AND (partner* OR couple* OR marriage OR marital OR spous* OR family) AND (stability OR instability OR divorce OR separation OR breakup OR breakdown).

      Study selection

      First, duplicates were removed from the search results. Journal articles were favored over conference abstracts on the same study. Next, 2 reviewers (B.v.d.B., S.R.) independently assessed eligibility of all records based on title and abstract. In case of doubt, the record was selected to be reviewed in the next step of selection. In the next step, the full texts of the potentially eligible records were read to check if they were indeed eligible for inclusion. This was again done by 2 reviewers independently (B.v.d.B., S.R.). If the 2 reviewers did not agree on whether a publication should be included in the review and were unable to reach consensus after discussion, a third reviewer (A.S.) read the full text and decided whether it should be included.

      Data extraction

      From the included studies, we extracted information regarding the study objectives and characteristics, participant demographics, independent and dependent variables used, and main findings. Data were extracted by the lead reviewer (B.v.d.B.) and checked by the second reviewer (S.R.). Where necessary, the collected information was adjusted or supplemented based on the check by the second reviewer.

      Quality assessment

      The quality of the included publications was assessed using the JBI Checklist for Analytical Cross Sectional Studies

      Joanna Briggs Institute. JBI checklist for analytical cross sectional studies. Available at: https://joannabriggsorg/sites/default/files/2020-08/Checklist_for_Analytical_Cross_Sectional_Studiespdf. Accessed June 14, 2022.

      and/or the CASP Checklist for Qualitative Research,

      Critical Appraisal Skills Programme. CASP checklist qualitative research. Available at: https://casp-uknet/wp-content/uploads/2018/03/CASP-Qualitative-Checklist-2018_fillable_formpdf. Accessed June 14, 2022.

      depending on the type of study assessed. The JBI Checklist for Analytical Cross-Sectional Studies consists of 8 items scored Yes, No, Unclear, or Not Applicable. Following the approach of Lam
      • Lam NC
      • Yeung H
      • Li W
      • et al.
      Cognitive impairment in irriatble bowel syndrome (IBS): a systematic review.
      and Poudel and colleagues
      • Poudel P
      • Griffiths R
      • Wong VW
      • et al.
      Oral health knowledge, attitudes and care practicies of people with diabeters: a systematic review.
      , we rated the quality of cross-sectional studies as high (7-8 of the items rated as Yes), moderate (4-6 items Yes), or low (<4 items Yes). The CASP Checklist for Qualitative Research consists of 9 items scored Yes, Cannot Tell, or No. Following the approach of Smeets et al,
      • Smeets M
      • Van Roy S
      • Aertgeerts B
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      Improving care for hearth failure patients in primary care, GPs’ perceptions: a qualitative evidence synthesis.
      we rated the quality of qualitative studies as high (8-9 items Yes), moderate (7 items Yes), or low (<7 items Yes). The quality rating was performed by the lead reviewer (B.v.d.B.) and checked by the second reviewer (S.R.). If assigned scores differed between the 2 reviewers, these cases were discussed until consensus was reached.

      Results

      Study selection

      Figure 1 provides a Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of the study selection process. Our final selection included 35 publications on factors associated with relationship quality and 15 publications on factors associated with relationship stability after TBI. A total of 43 unique publications were included (several publications pertained to both relationship quality and stability). Supplemental tables S1 and S2 provide an overview of the included publications on relationship quality and stability, respectively.
      Fig 1
      Fig 1Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of study selection.

      Characteristics of included studies

      Of the included publications on relationship quality, 25 reported on quantitative studies and 13 reported on qualitative studies. Multiple included publications contained both a quantitative and a qualitative component. These studies were published between 1989 and 2020. Of the included publications on relationship stability, which were published between 1996 and 2020, a total of 11 reported on quantitative studies and 6 reported on qualitative studies. Again, several publications reported on both quantitative and qualitative analyses.
      In the quantitative studies, participants were interviewed (n=16), completed questionnaires (n=25), and/or completed tests (n=2). Sample size ranged from 4 partners without an injury to 986 partners with a TBI (mean n=154), and the large majority of participants with a TBI was male. In the included qualitative studies, participants were interviewed (individually or in focus groups, n=11) or narratives were analyzed (n=2). Sample sizes ranged from 4 partners without an injury to 40 partners with a TBI, partners without an injury, or clinicians (mean n=20). The majority of participants with a TBI was male.
      Participants in the quantitative studies were mostly partners with a TBI (n=15) or both partners with and without injury (n=13). Few of these studies focused solely on partners without an injury (n=5). The qualitative studies did often focus on the perspective of partners without an injury (n=6). Over half of the qualitative studies (n=7) included both partners with and without an injury, and none focused on the perspective of the partner with a TBI.

      Quality of included studies

      Table 1 provides an overview of the quality ratings of the 33 quantitative cross-sectional studies included in this review. Three studies were rated as low, 24 as moderate, and 6 as high quality. An aspect that was lacking in the majority of studies was the identification (n=24) and appropriate management (n=29) of confounding factors. Table 2 provides the quality ratings of the 13 qualitative studies included in the review. Three studies were rated as low, 3 as moderate, and 7 as high quality. Most problems occurred regarding the consideration of ethical issues (n=5) and the relationships between researcher and participants (n=7).
      Table 1Quality rating of quantitative cross-sectional studies included in the literature review
      VariableAloni et al
      • Aloni A
      • Keren O
      • Cohen M
      • Rosentul N
      • Romm M
      • Groswasser Z.
      Incidence of sexual dysfunction in TBI patients during the early post-traumatic in-patient rehabilitation phase.
      Aloni & Katz et al
      • Aloni R
      • Katz S.
      Sexual difficulties after traumatic brain injury and ways to deal with it.
      Arango-Lasprilla et al
      • Arango-Lasprilla JC
      • Ketchum JM
      • Dezfulian T
      • et al.
      Predictors of marital stability 2 years following traumatic brain injury.
      Argüello
      • Argüello JL.
      After the “silent epidemic”: marital satisfaction in long term spousal caregivers of individuals with severe traumatic brain injury [dissertation].
      Bivona et al
      • Bivona U
      • Antonucci G
      • Contrada M
      • et al.
      A biopsychosocial analysis of sexuality in adult males and their partners after severe traumatic brain injury.
      Bivona et al
      • Bivona U
      • Rizza F
      • Antonucci G
      • Formisano R.
      Effect of traumatic brain injury on sexuality.
      Blais & Boisvert
      • Blais MC
      • Boisvert JM.
      Psychological adjustment and marital satisfaction following head injury. Which critical personal characteristics should both partners develop?.
      Burridge et al
      • Burridge AC
      • Huw Williams W
      • Yates PJ
      • Harris A
      • Ward C
      Spousal relationship satisfaction following acquired brain injury: the role of insight and socio-emotional skill.
      Forslund et al
      • Forslund MV
      • Arango-Lasprilla JC
      • Roe C
      • Perrin PB
      • Andelic N.
      Multilevel modeling of partnered relationship trajectories and relationship stability at 1, 2, and 5 years after traumatic brain injury in Norway.
      Gosling
      • Gosling J.
      Couple relationships and emotional well-being after severe traumatic brain injury [dissertation].
      Gosling & Oddy
      • Gosling J
      • Oddy M.
      Rearranged marriages: marital relationships after head injury.
      Hess & Perrone-McGovern
      • Hess RA
      • Perrone-McGovern KM.
      Quality of life for individuals with traumatic brain injury: the influence of attachment security and partner support.
      Jacobsson et al
      • Jacobsson LJ
      • Westerberg M
      • Söderberg S
      • Lexell J.
      Functioning and disability 6-15 years after traumatic brain injuries in northern Sweden.
      Kreuter et al
      • Kreuter M
      • Dahllöf AG
      • Gudjonsson G
      • Sullivan M
      • Siösteen A.
      Sexual adjustment and its predictors after traumatic brain injury.
      Kreutzer et al
      • Kreutzer JS
      • Marwitz JH
      • Hsu N
      • Williams K
      • Riddick A.
      Marital stability after brain injury: an investigation and analysis.
      Kreutzer et al
      • Kreutzer JS
      • Sima AP
      • Marwitz JH
      • Lukow Ii HR.
      Marital instability after brain injury: an exploratory analysis.
      Moore et al
      • Moore AD
      • Stambrook M
      • Peters LC
      • Lubusko A.
      Family coping and marital adjustment after traumatic brain injury.
      Moreno et al
      • Moreno JA
      • Olivera SL
      • Valdivia ER
      • et al.
      Sexual quality-of-life, sexual satisfaction and relationship satisfaction in partnered individuals with traumatic brain injury.
      Moreno et al
      • Moreno JA
      • Arango-Lasprilla JC
      • McKerral M.
      The relationship between postconcussion symptoms and sexual quality of life in individuals with traumatic brain injury.
      O'Carroll et al
      • O'Carroll RE
      • Woodrow J
      • Maroun F.
      Psychosexual and psychosocial sequelae of closed head injury.
      Parmer
      • Parmer N.
      Brain injury and romance: an examination of the impact of frontal lobe brain damage on marital and relationship satisfaction [dissertation].
      Peters et al
      • Peters LC
      • Stambrook M
      • Moore AD
      • Esses L.
      Psychosocial sequelae of closed head injury: effects on the marital relationship.
      Peters et al
      • Peters LC
      • Stambrook M
      • Moore AD
      • Zubek E
      • Dubo H
      • Blumenschein S.
      Differential effects of spinal cord injury and head injury on marital adjustment.
      Ponsford et al
      • Ponsford JL
      • Downing MG
      • Stolwyk R.
      Factors associated with sexuality following traumatic brain injury.
      Sabhesan & Natarajan
      • Sabhesan S
      • Natarajan M.
      Sexual behavior after head injury in Indian men and women.
      Sander et al
      • Sander AM
      • Maestas KL
      • Pappadis MR
      • Hammond FM
      • Hanks RA.
      Multicenter study of sexual functioning in spouses/partners of persons with traumatic brain injury.
      Stevens et al
      • Stevens LF
      • Lapis Y
      • Tang X
      • et al.
      Relationship stability after traumatic brain injury among veterans and service members: a VA TBI Model Systems study.
      Strizzi et al
      • Strizzi J
      • Olabarrieta-Landa L
      • Olivera SL
      • et al.
      Sexual function in men with traumatic brain injury.
      Vanderploeg
      • Vanderploeg RD
      • Curtiss G
      • Duchnick JJ
      • Luis CA.
      Demographic, medical, and psychiatric factors in work and marital status after mild head injury.
      Wedcliffe & Ross
      • Wedcliffe T
      • Ross E.
      The psychological effects of traumatic brain injury on the quality of life of a group of spouses/partners.
      Williams & Wood
      • Williams C
      • Wood RL.
      The impact of alexithymia on relationship quality and satisfaction following traumatic brain injury.
      Wood et al
      • Wood RL
      • Liossi C
      • Wood L.
      The impact of head injury neurobehavioural sequelae on personal relationships: preliminary findings.
      Wood & Yurdakul
      • Wood RL
      • Yurdakul LK.
      Change in relationship status following traumatic brain injury.
      Quality/stability/bothQQSQQQQQSBQQSQSSQQQQBQQQQQSQSQQBS
      Were the criteria for inclusion in the sample clearly defined?++?++++++++++++++++++++
      Were the study participants and the setting described in detail?+++++++++++++++++++++++++++
      Was the exposure measured in a valid and reliable way?+++++?+++++++++++++++++++++++++
      Were objective, standard criteria used for measurement of the condition?+++++?++++++++++++++++++?+++
      Were confounding factors identified?+++++++++
      Were strategies to deal with confounding factors stated?//+//////+///////////////+/+//
      Were the outcomes measured in a valid and reliable way?+?++++++++++++++++++++++++++++++
      Was appropriate statistical analysis used?+?++++++++++++++++++++++++/++
      QualityModerateLowModerateModerateModerateLowModerateHighModerateModerateHighModerateModerateModerateModerateModerateModerateModerateHighModerateLowModerateModerateModerateModerateModerateModerateHighHighModerateHighModerateModerate
      NOTE. JBI Checklist for Analytical Cross-Sectional Studies.
      Abbreviations: −, no; +, yes; ?, unclear; /, not Applicable; B, both; S, stability; Q, quality.
      Table 2Quality rating of qualitative studies included in the literature review
      VariableBodley-Scott & Riley
      • Bodley-Scott SEM
      • Riley GA.
      How partners experience personality change after traumatic brain injury–its impact on their emotions and their relationship.
      Chwalisz & Stark-Wroblewski
      • Chwalisz K
      • Stark-Wroblewski K.
      The subjective experiences of spouse caregivers of persons with brain injuries: a qualitative analysis.
      Gill et al
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.
      Godwin et al
      • Godwin E
      • Chappell B
      • Kreutzer J.
      Relationships after TBI: a grounded research study.
      Gosling
      • Gosling J.
      Couple relationships and emotional well-being after severe traumatic brain injury [dissertation].
      Gosling & Oddy
      • Gosling J
      • Oddy M.
      Rearranged marriages: marital relationships after head injury.
      Hammond et al
      • Hammond FM
      • Davis CS
      • Whiteside OY
      • Philbrick P
      • Hirsch MA.
      Marital adjustment and stability following traumatic brain injury: a pilot qualitative analysis of spouse perspectives.
      Layman et al
      • Layman DE
      • Dijkers MP
      • Ashman TA.
      Exploring the impact of traumatic brain injury on the older couple: 'yes, but how much of it is age, I can't tell you ...'.
      Logan
      • Logan JT.
      The phenomenon of caregiver resilience among spouses of combatants with traumatic brain injuries [disseratation].
      O'Keeffe et al
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.
      Parmer
      • Parmer N.
      Brain injury and romance: an examination of the impact of frontal lobe brain damage on marital and relationship satisfaction [dissertation].
      Robins
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      Villa & Riley
      • Villa D
      • Riley GA.
      Partners’ experiences of relationship continuity in acquired brain injury.
      Quality/stability/bothQQQQBQBBQBBQB
      Was there a clear statement of the aims of the research?+++++++++++++
      Is a qualitative method appropriate?+++++++++++++
      Was the research design appropriate to address the aims of the research?+++++++++++++
      Was the recruitment strategy appropriate to the aims of the research?+++?+++++++++
      Was the data collected in a way that addressed the research issue?++++?+++++++
      Has the relationship between researcher and participants been considered?++++++
      Have ethical issues been taken into consideration?++++++++
      Was the data analysis sufficiently rigorous?+++++++++++
      Is there a clear statement of findings?+++++++++++++
      QualityHighModerateModerateLowHighLowHighModerateHighHighLowHighHigh
      NOTE. CASP Checklist for Qualitative Research.
      Abbreviations: −, no; +, yes; ?, cannot tell; B, both; Q, quality.
      Supplemental Table S1Included publications on factors associated with relationship quality after TBI
      Authors & yearType of publicationObjectivesStudy design & methodologyParticipant demographicsIndependent & dependent variables/measuresMain findings
      Aloni & Katz, 2003
      • Aloni R
      • Katz S.
      Sexual difficulties after traumatic brain injury and ways to deal with it.
      BookInvestigate sexuality and intimacy dysfunction at the early rehabilitation phase of individuals with a TBI.- Quantitative cross-sectional study.

      - Participants were interviewed using a psychosexual questionnaire.
      46 males with a TBI (mean age: 27) in early phase of recovery and 14 of their partners.- Independent: time since injury (phase of hospitalization vs. 6 months later).

      - Dependent: Psychosexual questionnaire.
      Note that measures of sexuality are described both as independent and as dependent variables in this review. Sexual functioning (as a body function) and sexual relationship (as an activity) are described as factors found to be associated with relationship quality. Concepts such as sexual satisfaction and intimacy are described as measures of relationship quality.
      Between the phase of hospitalization and six months after, relationships and sexual functioning deteriorated.
      Aloni et al., 1999
      Aloni et al. (1999) and Aloni & Katz (2003) seem to base themselves (partly) on the same data but have a different focus in their analyses and therefore present different results. As such, both publications were included in our review.
      • Aloni A
      • Keren O
      • Cohen M
      • Rosentul N
      • Romm M
      • Groswasser Z.
      Incidence of sexual dysfunction in TBI patients during the early post-traumatic in-patient rehabilitation phase.
      Journal articleFind whether sexuality and intimacy dysfunction are already present at the early rehabilitation phase of individuals with a TBI.- Quantitative cross-sectional study.

      - Participants were interviewed using a psychosexual questionnaire.
      44 males with a TBI (mean age: 27) in early recovery.- Independent: age, Glasgow Coma Scale, independence in ADL, orthopedic problems, incontinence, paralysis, communication disorder, overt behavioral disorder, depression, cognitive disorder.

      - Dependent: Psychosexual questionnaire.
      - Individuals with sexual dysfunction were more severely injured than individuals without sexual dysfunction.

      - Prevalence of the behavioral problems was higher among those who did not complain about desire changes.
      Argüello, 2013
      • Argüello JL.
      After the “silent epidemic”: marital satisfaction in long term spousal caregivers of individuals with severe traumatic brain injury [dissertation].
      Dissertation- Provide a description of spouses who have remained married 10 years post TBI or longer.

      - Examine correlates of marital satisfaction.

      - Examine stressor types among spouses with a partner who has sustained a TBI.
      - Quantitative cross-sectional study.

      - Participants completed questionnaires.
      21 spouses (6 male, mean age: 55.20) of individuals with a severe TBI. Time since injury: at least 10 years.- Independent: age, age at time of injury, length of marriage

      - Dependent: Short Form 12 Item Health Survey, Brief COPE scale, Dyadic Adjustment Scale, stressors.
      - Higher levels of marital satisfaction were associated with longer marriages, higher age (of the partner without injury) at time of injury, and longer duration of the marriage at time of injury.

      - Relationship satisfaction was positively associated with emotion-focused coping strategies.
      Bivona et al., 2016
      • Bivona U
      • Antonucci G
      • Contrada M
      • et al.
      A biopsychosocial analysis of sexuality in adult males and their partners after severe traumatic brain injury.
      Journal article- Investigate changes in sexual function in males and their partners following severe TBI.

      - Explore the relationship between sociodemographic, emotional/behavioral, and sexual function variables.
      - Quantitative cross-sectional study.

      - Participants were interviewed and completed questionnaires.
      - 20 males with a severe TBI (mean age: 42.1) and their partners. Mean time since injury: 2.49 years.

      - 20 healthy controls and their partners.
      - Independent: age, educational level, relationship length, time since injury, Awareness Questionnaire, Neuropsychiatric Inventory, Hamilton Rating Scale for Depression, State-Trait Anxiety Inventory

      - Dependent: Sexuality Evaluation Schedule Assessment Monitoring
      - Higher levels of depression correlated with lower harmony between partners.

      - Higher age and a longer relationship were associated with less feelings towards the partner and a decreased ability to make decisions as a couple.

      - A low frequency of sexual intercourse correlated positively with injured partner evaluation of partner level of involvement.

      - Over time, feelings toward one's partner and general couple harmony worsen
      Bivona et al., 2010
      • Bivona U
      • Rizza F
      • Antonucci G
      • Formisano R.
      Effect of traumatic brain injury on sexuality.
      Conference abstractIdentify the role of a severe TBI in referring to sexual disorders and their possible impact on the couple relationship.- Quantitative cross-sectional study.

      - Participants completed questionnaires and tests.
      ?- Independent: Hamilton Depression Rating Scale, State-Trait Anxiety Inventory, Neuropsychiatric Inventory, Wisconsin Card Sorting Test, Community International Questionnaire

      - Dependent: Sexrelation Evaluation Schedule Assessment Monitoring
      Dissatisfying relationships were associated with mood and behavioral disorders.
      Blais & Boisvert, 2007
      • Blais MC
      • Boisvert JM.
      Psychological adjustment and marital satisfaction following head injury. Which critical personal characteristics should both partners develop?.
      Journal articleVerify relationships between personal characteristics of individuals with a TBI and their spouses and their level of psychological and marital adjustment.- Quantitative cross-sectional study.

      - Participants completed questionnaires.
      - 70 individuals with a mild-severe TBI (49 male, average age: 47.7) & their partners. Mean time since injury: 3.11 years.

      - 70 control couples.

      - Independent: Interpersonal Communication Skills Inventory, Ways of Coping Questionnaire, Social Problem-Solving Inventory-Revised

      - Dependent: Hospital Anxiety and Depression Scale, General Well-Being Schedule, Marital Adjustment Test, Kansas Marital Satisfaction Scale
      - The use of effective problem-solving strategies, combined with a positive perception of one's own communication skills and infrequent use of avoidance strategies by the partner without the injury are related to a high level of marital satisfaction in the partner with the injury.
      Bodley-Scott & Riley, 2015
      • Bodley-Scott SEM
      • Riley GA.
      How partners experience personality change after traumatic brain injury–its impact on their emotions and their relationship.
      Journal articleExplore how partners experience social, emotional and behavioral changes in individuals with a TBI, with a focus on their emotional impact and the effect on the couple relationship.Qualitative interview study.5 female partners (average age: 37.4 years) of individuals with a moderate-severe TBI. Mean time since injury: 3.25 years.N/AParticipants described that their love for their partner has been undermined by role changes, personality changes, aggression, reductions in shared enjoyment, and the lack of love, care, and empathy expressed by their partners.
      Burridge et al., 2007
      • Burridge AC
      • Huw Williams W
      • Yates PJ
      • Harris A
      • Ward C
      Spousal relationship satisfaction following acquired brain injury: the role of insight and socio-emotional skill.
      Journal articleExamine the role of insight and socio-emotional skills in relationship satisfaction following ABI.- Quantitative cross-sectional study.

      - Participants completed questionnaires.
      - 20 couples in which one of the partners had sustained an ABI (14 of these cases were TBIs). Partner with injury mean age: 53.35, mean time since injury: 3.3 years.

      - 20 control couples in which one of the partners had chronic pain.

      - 20 healthy control couples.
      - Independent: Cognitive Failures Questionnaire for Others, European Brain Injury Questionnaire, Socio-Emotional Questionnaire.

      - Dependent: Relationship Questionnaire.
      Low relationship satisfaction in partners of individuals with an ABI was associated with poorer functioning in and insight into overall socio-emotional skill and specifically empathic skill.
      Chwalisz & Stark-Wroblewski, 1996
      • Chwalisz K
      • Stark-Wroblewski K.
      The subjective experiences of spouse caregivers of persons with brain injuries: a qualitative analysis.
      Journal articleExamine the subjective experiences of spouse caregivers after TBI.Qualitative essay analysis study.27 spouses (26 female, mean age: 46.4) of individuals with a TBI.N/A- Participants mentioned loss of affection, sexual difficulties and conflicts in relation to problems in the marital relationship.
      Gill, et al., 2011
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.
      Journal articleExplore the experience of intimacy from the viewpoint of individuals with a TBI and their intimate partners.Qualitative interview study.18 individuals with a TBI (12 male, mean age: 38.5) and their partners. Mean time since injury: 4.78 years.N/A- Participants mentioned the following factors helped their relationships remain strong: unconditional commitment to staying and working, good communication, a strong preinjury relationship, being grateful for survival, spending time together, social support, spirituality, previous experience with overcoming hardship, coping skills.

      - Participants mentioned the following barriers to intimacy: physical, cognitive and emotional changes, emotional reactions to changes, personality changes, sexual strains and incompatibilities, role changes, conflicts, communication difficulties, balance/role strain, family issues, sense of isolation.
      Godwin, Chappell & Kreutzer, 2014
      • Godwin E
      • Chappell B
      • Kreutzer J.
      Relationships after TBI: a grounded research study.
      Journal article- Develop a framework for conceptualizing and assessing couples after TBI.

      - Establish the practices of successful couples that have subsisted TBI.
      Qualitative narrative analysis study.40 individuals with a TBI, partners without an injury, or clinicians who wrote narratives.N/A- Participants described that the loss of their old self, the loss of security in the relationship, the loss of connectivity, the loss of plans, goals, hopes and dreams for the future, identity changes, role changes, unpredictable behavior and emotions, commitment instability and connective instability negatively impacted their relationship.

      - Positive effects on the relationships were described of a retained sense of couplehood/love, commitment to each other, and glimpses of the old self of the partner with the injury.
      Gosling, 1996
      Gosling (1996) and Gosling & Oddy (1999) seem to base themselves (partly) on the same data but have a different focus in their analyses and therefore present different results. As such, both publications were included in our review.
      • Gosling J.
      Couple relationships and emotional well-being after severe traumatic brain injury [dissertation].
      DissertationExplore couple relationships after TBI.- Mixed method (quantitative cross-sectional study & qualitative interview study).

      - Participants completed questionnaires & were interviewed.
      18 males with a severe TBI (mean age: 42.06) and their spouses (mean age: 39.17). Mean time since injury: 4.14 years.- Independent: relationship length, General Health Questionnaire 12, Injury-related symptom checklist

      - Dependent: Golombok and Rust Inventory of Marital State, Relationship Change Questions
      - Partners without injury mentioned role change as a reason for lack of sexual interaction.

      - Higher perception of coercive sexual behavior of the partner with the injury was associated with lower levels of sexual satisfaction of the partner without injury.

      - The less welcome the sexual advances of the partner with the injury were, the more their partners avoided having sex with them

      - Partners without injury mentioned loss of an equal partner and companion, loss of intimacy and closeness and loss of emotional support as undermining factors of the quality of their post-injury relationship.
      Gosling & Oddy, 1999
      • Gosling J
      • Oddy M.
      Rearranged marriages: marital relationships after head injury.
      Journal articleExplore the quality of marital and sexual relationships following TBI from the point of view of the partner without injury.- Mixed method (quantitative cross-sectional study & qualitative interview study).

      - Participants completed questionnaires & were interviewed.
      18 males with a TBI- (mean age 42.1) and their partners (mean age:39.2). Mean time since injury: 4.1 years.- Independent: General Health Questionnaire, 75 item checklist used by the head injury service, Relationship Change Questionnaire

      - Dependent: Golombok and Rust Inventory of Marital State
      - If a personal injury claim was being pursued, the women rated their current marital relationship more favorably.

      - The main reasons mentioned by participants for deterioration of the sexual relationship were role change, a description of the sexual relationship as boring, flat or feeling wrong, and the loss of a sharing relationship of equals and the resultant companionship.
      Hammond et al., 2011
      • Hammond FM
      • Davis CS
      • Whiteside OY
      • Philbrick P
      • Hirsch MA.
      Marital adjustment and stability following traumatic brain injury: a pilot qualitative analysis of spouse perspectives.
      Journal articleExamine how a spouse who has experienced TBI affects the marital relationship.Qualitative focus group study.5 male & 5 female spouses of individuals with a mild-severe TBI. Ages between 40 and 75. Time since injury between 4 and 12 years.N/A- Wives reported the following to have negatively impacted their relationship: broken trust because of personality changes, emotional detachment shown by their husbands, resentment for the added responsibilities.

      - Both wives and husbands mentioned the importance of communication for the relationship.

      - Both wives and husbands mentioned that their partners’ lack of understanding or ability to control their financial situation caused stress in the relationship.
      Hess & Perrone-McGovern, 2016
      • Hess RA
      • Perrone-McGovern KM.
      Quality of life for individuals with traumatic brain injury: the influence of attachment security and partner support.
      Journal article- Elucidate significant variables that contribute to relationship functioning following TBI.

      - Investigate relational variables that contribute to quality of life following TBI.
      - Quantitative cross-sectional study.

      - Participants completed questionnaires.
      122 individuals with a TBI (49 male). Age: 57% was 25 years or younger, 21% between 26 and 40, and 22% 41 years or older.- Independent: age, gender, length of relationship, time since injury

      - Dependent: Experience in Close Relationship-Revised scale, Berlin Social Support Scale, Kansas Marital Satisfaction Scale, Short-Form Health Survey 36
      - Relationships satisfaction was positively related to emotional support & instrumental support.

      - Attachment security was positively related to emotional support & instrumental support.

      - There was a negative relation between age & relationship satisfaction.
      Kreuter et al., 1998
      • Kreuter M
      • Dahllöf AG
      • Gudjonsson G
      • Sullivan M
      • Siösteen A.
      Sexual adjustment and its predictors after traumatic brain injury.
      Journal articleInvestigate the impact of TBI on sexual ability, activity and satisfaction and relate the findings to neurological status, functioning and well-being.- Quantitative cross-sectional study.

      - Participants completed questionnaires.
      92 individuals with a TBI (65 male, median age: 40 years). Median time since injury: 9 years.- Independent: Sickness Impact Profile, Functional Independence Measure, Functional Assessment Measure, Glasgow Outcome Scale, Hospital Anxiety and Depression scale, quality of life

      - Dependent: Sexual Adjustment Questionnaire, Sexual Interest and Satisfaction Scale
      - For the participants in a partner relationship, occurrence of sexual intercourse, ability to experience orgasm and satisfaction with the overall relationship were strong determinants of sexual adjustment
      Layman, Dijkers & Ashman, 2005
      • Layman DE
      • Dijkers MP
      • Ashman TA.
      Exploring the impact of traumatic brain injury on the older couple: 'yes, but how much of it is age, I can't tell you ...'.
      Journal articleExplore the partner relationships of older couples faced with TBI.Qualitative interview study.- 8 individuals with a TBI (3 male, mean age: 71.1 years) and their partners. Mean time since injury: 6.9 years.

      - 5 comparison participants
      N/A- Some of the participating women with a TBI described their relationships as having improved as a result of their increased dependence on their partners.

      - Some of the participating men with TBI described that role changes and limitations in communication had reduced relationship quality.
      Logan, 2015
      • Logan JT.
      The phenomenon of caregiver resilience among spouses of combatants with traumatic brain injuries [disseratation].
      DissertationExamine the experiences of caregiving spouses of combatants with TBI who maintained their resilience.Qualitative interview study.5 female partners (between 18 and 49 years old) of combatants with mild-severe TBIN/A- Unpredictability and the loss of an intimate connection with their partner were mentioned as having a negative effect on marital satisfaction.

      - Participants mentioned that personal growth and self-discovery induced by the injury had a strengthening effect on their marriage.
      Moore et al., 1991
      • Moore AD
      • Stambrook M
      • Peters LC
      • Lubusko A.
      Family coping and marital adjustment after traumatic brain injury.
      Journal articleInvestigate coping strategies used by families of male TBI patients in a marital or common-law living arrangement and the relationship of these strategies to marital adjustment.- Quantitative cross-sectional study.

      - Participants completed questionnaires.
      - 46 males with a mild-severe TBI (mean age: 46.3) and their partners. Mean time since injury: 41.6 months.- Independent: Family Crisis Oriented Personal Evaluation Scales (low use of coping strategies vs. medium use of coping strategies vs. high use of coping strategies).

      - Dependent: Dyadic Adjustment Scale, Personal Assessment of Intimacy in Relationships.
      - Spouses in the high-use of coping strategies group reported greater dyadic adjustment than spouses in the low-use of coping strategies group, while spouses in the low-use of coping strategies group reported greater sexual intimacy than spouses in the medium-use of coping strategies group.
      Moreno, Arango-Lasprilla & McKerral, 2015
      • Moreno JA
      • Arango-Lasprilla JC
      • McKerral M.
      The relationship between postconcussion symptoms and sexual quality of life in individuals with traumatic brain injury.
      Journal article- Compare sexual quality of life in individuals with a TBI and healthy controls.

      - Explore the relationship between sexual quality of life and postconcussion Symptoms.
      - Quantitative cross-sectional study.

      - Participants completed questionnaires.
      - 41 individuals with a mild-severe TBI (18 male, mean age: 38). Mean time post-injury: 2.6 years.

      - 41 healthy controls
      - Independent: Post-concussion Symptom Scale, time since injury, Glasgow Coma Scale, post-traumatic amnesia, loss of consciousness.

      - Dependent: Sexual Quality of Life Questionnaire.
      - Lower sexual quality of life in individuals with a TBI was associated with more postconcussion symptoms, in particular affective postconcussion symptoms.
      Moreno et al., 2014
      • Moreno JA
      • Olivera SL
      • Valdivia ER
      • et al.
      Sexual quality-of-life, sexual satisfaction and relationship satisfaction in partnered individuals with traumatic brain injury.
      Conference abstract- Compare sexual quality-of-life, as well as sexual and relationship satisfaction, in individuals with TBI to healthy controls.- Quantitative cross-sectional study.

      - Participants completed questionnaires.
      - 28 individuals with a mild-severe TBI (19 male, mean age: 38.43). Mean time since injury: 21.3 months.

      - 27 healthy controls
      - Independent: Glasgow Coma Scale, time since injury, relationship length.

      - Independent: Sexual Quality of Life Questionnaire, Index of Sexual Satisfaction, Relationship

      Assessment Scale.
      - Injury severity, time since injury, and relationship length did not correlate with sexual quality of life, sexual satisfaction, or relationship satisfaction.
      O'Carroll, Woodrow & Maroun, 1991
      • O'Carroll RE
      • Woodrow J
      • Maroun F.
      Psychosexual and psychosocial sequelae of closed head injury.
      Journal article- Investigate psychosexual dysfunction, anxiety, and depression amongst individuals with a TBI and their partners.

      - Investigate whether the degree of psychosexual and psychosocial dysfunction is related to injury severity, time elapsed since the injury, anxiety and depression.
      - Quantitative cross-sectional study.

      - Participants completed questionnaires.
      36 individuals with a mild-severe TBI (30 male, mean age: 35.63) and 17 partners. Mean time since injury: 4.06 years.- Independent: General Health Questionnaire, Hospital Anxiety and Depression Scale, age, time since injury, injury severity

      - Dependent: Golombok Rust Inventory of Sexual Satisfaction
      - As time progressed from the date of the injury, males with a TBI became more sexually dissatisfied and sexual non-communication became more of a problem for the female partners.

      - Psychosexual dysfunction was related to psychiatric symptomatology in both partners with and without injury.

      - There was a relation between advancing age and psychosexual dysfunction in partners with an injury.
      O'Keeffe et al., 2020
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.
      Journal articleExplore the impact of TBI on couple relationships, from the perspective of both partners with and without the injury.Qualitative interview study.5 males with a moderate-severe TBI (between 35 and 64 years old) & 6 female partners. Mean time since injury: 6.3 years.N/A- Both partners with and without injury mentioned personality changes, altered emotional reactions/lack of emotional communication, aggression/conflicts, and loss of fun and enjoyment as negatively affecting the relationship.

      - Lack of sexual interest of the partner with the injury, negative self-image of the partner with the injury, role conflicts, unpredictable behaviors and negative feelings were mentioned as contributors to a lack of intimacy and reduced sexual expression.

      - Time was mentioned as an important factor in eventual adjustment.

      - Engaging with professionals who helped them understand the impact of TBI on behaviors, commitment to the relationship, and effective coping mechanisms were mentioned by partners with and without injury as having a positive effect on the relationship.
      Parmer, 2008
      • Parmer N.
      Brain injury and romance: an examination of the impact of frontal lobe brain damage on marital and relationship satisfaction [dissertation].
      DissertationExplore the effects of frontal lobe brain damage on marital/relationship satisfaction- Mixed method (- quantitative cross-sectional study & qualitative interview study).

      - Participants completed questionnaires & were interviewed.
      4 partners (2 male, between 30 and 55 years old) of individuals with a mild-severe TBI. Time post injury between 2 & 12 years.The Marital Satisfaction Inventory-Revised was used to group participants in a less dissatisfied and more dissatisfied group.- Compared to the more dissatisfied group, partners in the less dissatisfied group reported less changes in and less difficulty in dealing with their spouse's emotional instability.

      - Compared to the more dissatisfied group, partners in the less dissatisfied group reported less shifts in affective communication and conflict style, and reported fewer role changes within their relationship.

      - Compared to the more dissatisfied group, partners in the less dissatisfied group expressed less problems with emotional connectedness and emotional return.
      Peters et al., 1990
      • Peters LC
      • Stambrook M
      • Moore AD
      • Esses L.
      Psychosocial sequelae of closed head injury: effects on the marital relationship.
      Journal article- Examine the effect of injury severity on the number of marital-related problems wives of individuals with TBI experience.

      - Explore which other factors are associated with the impact of TBI on marriage.
      - Quantitative cross-sectional study.

      - Participants completed questionnaires and were interviewed.
      55 males with a mild-moderate TBI (mean age: 48.1) and their partners. Time since injury varied between a few month to 8 years.- Independent: injury severity, physical restrictions or limitations of the partner with the injury, Relatives Form of Katz Adjustment Scale, Eysenck Adult Personality Questionnaire.

      - Dependent: Dyadic Adjustment Scale, Personal Assessment of Intimacy in Relationships.
      - Wives of individuals with a severe TBI perceive more marital dysfunction in the areas of dyadic consensus, affectional expression, and overall marital adjustment as compared to wives of individuals with a mild-moderate TBI.

      - The following factors contributed to marital maladjustment: injury severity, psychosocial maladjustment of the partner with the injury, restrictiveness in day-today physical functioning of the partner with the injury, financial strain.
      Peters et al., 1992
      • Peters LC
      • Stambrook M
      • Moore AD
      • Zubek E
      • Dubo H
      • Blumenschein S.
      Differential effects of spinal cord injury and head injury on marital adjustment.
      Journal articleAssess the impact of spinal cord injury on the intact marriage and compare this impact with that of a group of individuals with moderate- severe TBI.- Quantitative cross-sectional study.

      - Participants completed questionnaires and were interviewed.
      - 48 males with a moderate-severe TBI and their partners. Time since injury varied between 1 and 10 years.

      - 24 males with spinal cord injury and their partners.
      - Independent: injury severity.

      - Dependent: Dyadic Adjustment Scale, Katz Adjustment Scale.
      When compared to wives of individuals with a moderate TBI, wives of individuals with a severe TBI reported less expressed affection, lower satisfaction and feelings of cohesiveness, and lower overall marital adjustment within their marriage.
      Ponsford, Downing & Stolwyk, 2013
      • Ponsford JL
      • Downing MG
      • Stolwyk R.
      Factors associated with sexuality following traumatic brain injury.
      Journal articleDetermine the association between sexuality following TBI and demographic, injury-related, and postinjury variables.- Quantitative cross-sectional study.

      - Participants completed questionnaires.
      986 individuals with a mild-severe TBI (676 male, mean age: 40.07). 1-20 years post injury.- Independent: age, gender, post-traumatic amnesia, time since injury, antidepressant use, Hospital Anxiety and Depression Scale, Rosenberg Self-Esteem Scale, Independence in ADL.

      - Dependent: Brain Injury Questionnaire of Sexuality.
      - Higher relationship quality was associated with younger age and a lower depression score.
      Robins, 2012
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      DissertationExplore how the experience of TBI affects intimate relationships, feelings of intimacy, and one's self-identity as a sexual or intimate partner from the perspectives of both partners with and without injury.Qualitative interview study13 individuals with a TBI (9 male, mean age: 37.61) and their partners. Mean time since injury: 5.69 years.N/A- Partners with the injury named the following factors as barriers to intimacy: physical, intellectual & emotional changes, guilt, feeling like they let their partners down, feeling like their did not pull their weight with responsibilities, feeling infantilized by their partner, their partners being skeptical to resume sexual relations, unsupportive families, resignation of their partner seeking others’ companionship, stereotypes, feeling alienated from their partner's life.

      - Partners without injury named the following factors as barriers to intimacy: personality changes, cognitive & emotional changes, change in their partners’ sexual abilities & styles, role conflicts, communication difficulties, stress, fragility of the relationship, feeling vulnerable about their own capabilities, worrying about whether their partners are equipped to engage in sexual relations, unsupportive families, unmet needs & increased responsibilities, decreased social interactions, aging with TBI.

      - Partners with the injury named the following factors as supporting intimacy: good communication, having a strong commitment to each other before the injury, spirituality, feeling grateful to be alive, support, understanding, love & acceptance from their partner, having children together, physical and cognitive improvements, acceptance of changes, counseling.

      - Partners without injury named the following factors as supporting intimacy: good communication, having a strong commitment to each other before the injury, spirituality, feeling accepted and loved by their partner, receiving reassurance of their partner's love, support from their families, having a professional health-care background, spending time together.
      Sabhesan & Natarajan, 1989
      • Sabhesan S
      • Natarajan M.
      Sexual behavior after head injury in Indian men and women.
      Journal articleInvestigate disorders in sexual functioning after TBI in the illiterate rural population in India.- Quantitative cross-sectional study.

      - Participants were interviewed.
      34 individuals with a TBI (mean age: 31.8) & their partners.- Independent: age, sex, education, cause of injury, injury severity, personality dimensions, psychiatric disturbances, marital harmony.- Dependent: sexual dysfunctionParticipants who were male, suffered from psychiatric disturbances and reported lower marital harmony were more likely to display sexual dysfunctions.
      Sander et al., 2016
      • Sander AM
      • Maestas KL
      • Pappadis MR
      • Hammond FM
      • Hanks RA.
      Multicenter study of sexual functioning in spouses/partners of persons with traumatic brain injury.
      Journal articleInvestigate sexual functioning and its predictors in partners of persons TBI.- Quantitative cross-sectional study.

      - Participants completed questionnaires and were interviewed.
      70 partners (10 male, mean age: 43.3) of individuals with a mild-severe TBI.- Independent: age and sex of partners, Functional Independence Measure,

      Participation Assessment with Recombined Tools- Objective, Derogatis Interview for Sexual Functioning Self-Report of partners with injury.

      - Dependent: Derogatis Interview for Sexual Functioning Self-Report of partners without injury.
      - Partners perceived the following factors to contribute to decreased sexual functioning: stress, fatigue in themselves or their partner with TBI, behavior changes in the partner with TBI, decreased interest on the part of their partner, feeling like a caregiver rather than a sexual partner, sad or depressed mood in themselves or their partner with TBI, concentration difficulties in the partner with TBI, movement difficulties in the partner with TBI, and difficulty communicating with their partner.

      - Worse sexual functioning in spouses/partners was associated with older age and with worse sexual functioning in persons with TBI.
      Strizzi et al., 2017
      • Strizzi J
      • Olabarrieta-Landa L
      • Olivera SL
      • et al.
      Sexual function in men with traumatic brain injury.
      Journal article- Investigate aspects of sexuality functioning in males with a TBI.

      - Investigate the relationship between the age and injury severity characteristics of individuals with a TBI, and their sexual functioning.
      - Quantitative cross-sectional study.

      - Participants completed questionnaires.
      71 males with a moderate-severe TBI (mean age: 34.35). Mean time since injury: 21.87 months.

      - 71 healthy controls
      - Independent: age, time since injury, Glasgow Coma Scale.

      - Dependent: Sexual Desire Inventory, Index of Sexual Satisfaction, Sexual Quality of Life Questionnaire.
      - TBI severity was related to sexual quality of life.
      Villa & Riley, 2017
      • Villa D
      • Riley GA.
      Partners’ experiences of relationship continuity in acquired brain injury.
      Journal articleExplore whether the conceptual framework of relationship continuity may also be applicable to understanding the experience of spousal carers in acquired brain injuryQualitative interview study5 partners (1 male, mean age: 55.6) of individuals with an ABI (4 of them sustained a TBI, one sustained a stroke). Mean time post injury: 3.4 years.N/A- Participants mentioned the following factors as having a negative effect on their relationship: role change, reduced sense of working together to meet challenges, and lack of warmth, affection and empathy provided by the partner with the injury.

      - Continued affection and consideration provided by the partner with the injury were perceived to have a positive effect on the relationship.
      Wedcliffe & Ross, 2001
      • Wedcliffe T
      • Ross E.
      The psychological effects of traumatic brain injury on the quality of life of a group of spouses/partners.
      Journal articleExplore the psychosocial impact of TBI on the quality of life of partners.- Quantitative cross-sectional study.

      - Participants completed questionnaires.
      14 partners (2 male, age 20-85) of individuals with a TBI. Time since injury between 5 months and 10 years.N/A- Partners mentioned the following changes as having the most impact on their relationships: loss of sexual relationship, communication changes, personality changes (blunted emotion & increased aggression), role change, and physical separation.
      Williams & Wood, 2013
      • Williams C
      • Wood RL.
      The impact of alexithymia on relationship quality and satisfaction following traumatic brain injury.
      Journal article- Explore relationship quality & satisfaction following TBI.

      - Explore the impact of acquired alexithymia on relationship quality & satisfaction following TBI.
      - Quantitative cross-sectional study.

      - Participants completed questionnaires and were interviewed.
      47 individuals with a moderate-severe TBI (37 male) & their partners. Mean age: 44.91 years. Mean time post injury: 2.71 years.- Independent: post-traumatic amnesia, Glasgow Coma Scale, time since injury, length of relationship, presence of children, number of children, 20-Item Toronto Alexithymia Scale.

      - Dependent: Index of Marital Satisfaction, Dyadic Adjustment Scale.
      - There was a positive relation between relationship length & relationship adjustment.

      - The number of relationship problems increased with time since injury.

      - Couples with children had higher levels of dyadic consensus.

      - Alexithymia was associated with lower partner ratings of overall relationship quality, adjustment, consensus and cohesion.
      Wood, Liossi & Wood, 2005
      • Wood RL
      • Liossi C
      • Wood L.
      The impact of head injury neurobehavioural sequelae on personal relationships: preliminary findings.
      Journal articleExplore which neurobehavioral legacies of TBI have the greatest impact on personal relationships and increase the risk of relationship breakdown.- Quantitative cross-sectional study.

      - Participants completed questionnaires.
      48 (ex-)partners of individuals with a severe TBI (35 of injured individuals were male, mean age: 40.5). Mean time post-injury: 5.75 years.A 12-item measure representing neurobehavioral characteristics potentially impacting the relationship.- On a scale from 0 to 10, partners rated the following neurobehavioral legacies as having put above mid-point strain on the relationship: aggression, memory problems, attention problems, fatigue, mood swings, and quick temper.

      - On a scale from 0 to 10, ex-partners rated the following neurobehavioral legacies as having put above mid-point strain on the relationship: aggression, reduced motivation for leisure activities, memory problems, attention problems, fatigue, mood swings, obsessiveness, problems with organization and planning, quick temper, reduced libido, and social isolation.
      low asterisk Note that measures of sexuality are described both as independent and as dependent variables in this review. Sexual functioning (as a body function) and sexual relationship (as an activity) are described as factors found to be associated with relationship quality. Concepts such as sexual satisfaction and intimacy are described as measures of relationship quality.
      low asterisklow asterisk Aloni et al. (1999) and Aloni & Katz (2003) seem to base themselves (partly) on the same data but have a different focus in their analyses and therefore present different results. As such, both publications were included in our review.
      low asterisklow asterisklow asterisk Gosling (1996) and Gosling & Oddy (1999) seem to base themselves (partly) on the same data but have a different focus in their analyses and therefore present different results. As such, both publications were included in our review.
      Supplemental Table S2Included publications on factors associated with relationship stability after TBI
      AuthorsType of publicationObjectivesStudy design & methodologyParticipants demographicsIndependent & dependent variablesMain findings
      Arango-Lasprilla et al., 2008
      • Arango-Lasprilla JC
      • Ketchum JM
      • Dezfulian T
      • et al.
      Predictors of marital stability 2 years following traumatic brain injury.
      Journal article- Determine the predictors of marital stability over 2 years post TBI.

      - Examine moderating effects of ethnicity.
      - Quantitative cross-sectional study.

      - Data were extracted from a database.
      977 individuals with a moderate-severe TBI (782 male, mean age: 46.8).- Independent: ethnicity, gender, age, employment at admission, years of education, income, cause of injury, Glasgow Coma Scale, post-traumatic amnesia, length of stay in acute care, length of rehabilitation, Disability Rating Scale.

      - Dependent: Marital status (stably married or unstably married).
      - Younger age, being male, suffering a TBI as a result of a violent injury, and having sustained a moderate (vs severe) injury were associated with greater marital instability.

      - Within minorities, an increased disability upon admission was associated with a higher likelihood of being stably married.
      Forslund et al., 2014
      • Forslund MV
      • Arango-Lasprilla JC
      • Roe C
      • Perrin PB
      • Andelic N.
      Multilevel modeling of partnered relationship trajectories and relationship stability at 1, 2, and 5 years after traumatic brain injury in Norway.
      Journal articleExamine predictors of probability trajectories of being in a partnered relationship over the first 5 years post TBI.- Quantitative cross-sectional study.

      - Data were extracted from medical records and participants were interviewed.
      105 individuals with a moderate-severe TBI (82 male, mean age at admission: 30.9). Seen at 1, 2 and 5 years post injury.- Independent: sex, age at injury, relationship status at injury, guardianship of dependent children, education, employment status at injury, occupation, Glasgow Coma Scale, cause of injury, post-traumatic amnesia, length of stay.

      - Dependent: relationship status at 1, 2 & 5 years post-injury.
      - Individuals without dependent children had much lower probabilities of being stably partnered.

      - Those with lower education had lower probabilities of being stably partnered.

      - Individuals with blue collar/manual (as opposed to white collar/nonphysical) occupations at injury had higher probabilities of being stably partnered.
      Gosling, 1996
      • Gosling J.
      Couple relationships and emotional well-being after severe traumatic brain injury [dissertation].
      DissertationExplore changes in couple relationships after TBI.- Mixed method (quantitative cross-sectional study & qualitative interview study).

      - Participants completed questionnaires & were interviewed.
      18 males with a severe TBI (mean age: 42.06) and their partners (mean age: 39.17). Mean time since injury: 4.14 years.- Independent: length of relationship, General Health Questionnaire 12, Injury-related symptom checklist

      - Dependent: Golombok and Rust Inventory of Marital State, Relationship Change Questions.
      Participants mentioned the following reasons for staying together: commitment, companionship, financial considerations.
      Hammond et al., 2011
      • Hammond FM
      • Davis CS
      • Whiteside OY
      • Philbrick P
      • Hirsch MA.
      Marital adjustment and stability following traumatic brain injury: a pilot qualitative analysis of spouse perspectives.
      Journal articleExamine how a spouse who has experienced TBI affects the marital relationship.Qualitative focus group study.5 male & 5 female spouses of individuals with a mild-severe TBI. Ages between 40 and 75. Time since injury between 4 and 12 years.N/A- Wives seemed motivated to remain married because they hoped that their husbands would one day revert back to the men they once knew.

      - Husbands, seemed motivated to remain married because of the love they felt for their wives.
      Jacobsson et al., 2009
      • Jacobsson LJ
      • Westerberg M
      • Söderberg S
      • Lexell J.
      Functioning and disability 6-15 years after traumatic brain injuries in northern Sweden.
      Journal articleTo assess long-term functioning and disability after TBI.- Quantitative cross-sectional study.

      - Data were extracted from a database and participants were interviewed.
      88 individuals with a mild-severe TBI (76 male, mean age: 44). 6-15 years post injury.- Independent: Glasgow Coma Scale.

      - Dependent: marital status (single vs married/cohabitant).
      - Changes in marital status were not significantly associated with injury severity.
      Kreutzer, et al., 2007
      • Kreutzer JS
      • Marwitz JH
      • Hsu N
      • Williams K
      • Riddick A.
      Marital stability after brain injury: an investigation and analysis.
      Journal article- Examine rates of separation after TBI.

      - Identify factors relating to risk of marital breakdown following TBI.
      - Quantitative cross-sectional study.

      - Participants completed questionnaires.
      120 individuals with a mild-severe TBI (82 male, mean age: 41. Mean time post injury:4 years.- Independent: gender, ethnicity, education, employment post injury, cause of injury, Glasgow Coma Scale, unconsciousness, post-traumatic amnesia, relationship length, age, time post injury.

      - Dependent: marital status (remained married vs separated).
      - Those who were older, had been married longer before their injury, were victims of non-violent injuries, and were less severely injured were more likely to remain married.
      Kreutzer et al., 2016
      • Kreutzer JS
      • Mills A
      • Marwitz JH.
      Ambiguous loss and emotional recovery after traumatic brain injury.
      Journal article- Characterize marital stability after TBI.

      - Identify predictors of marital stability after TBI.
      - Quantitative cross-sectional study.

      - Participants completed questionnaires and were interviewed.
      42 individuals with a mild-severe TBI (30 male) and their partners. Mean age: 49.8. Mean time post injury: 1.2 years.- Independent: sex, injury severity, number of children, relationship duration (pre- and post-injury), Revised Dyadic Adjustment Scale.

      - Dependent: Marital Status Inventory.
      - No demographic or injury variable had a significant relationship with stability for either partners with or without injury.

      - Shorter relationships were at greater risk of being unstable but only when assessed from the point of view of the partner with the injury.

      - Lower relationship quality was associated with a less stable relationship.
      Layman, Dijkers & Ashman, 2005
      • Layman DE
      • Dijkers MP
      • Ashman TA.
      Exploring the impact of traumatic brain injury on the older couple: 'yes, but how much of it is age, I can't tell you ...'.
      Journal articleQualitatively explore the partner relationships of older couples faced with traumatic brain injury.Qualitative interview study.- 8 individuals with a mild-severe TBI (mean age: 71) and their partners (mean age: 69). Mean time post injury: 6.9 years.

      - 6 controls.
      N/AParticipants mentioned the following reasons for staying together: dependence on partner, having learned previously that leaving one relation does not guarantee that the next will be better, feeling that surviving difficulties together had fortified the relationship, increased awareness of mortality, acceptance of imperfections, financial and social repercussions of separation, a principled stance against separation, feelings of love.
      O'Keeffe et al., 2020
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.
      Journal articleExplore the impact of TBI on couple relationships, from the perspective of both partners with and without injury in the relationship.Qualitative interview study.5 males with a moderate-severe TBI (between 35 and 64 years old) and 6 female partners. Mean time since injury: 6.3 years.N/APartners described staying in the relationship out of respect for who their injured partner used to be, for the sake of their children, on the grounds of positive aspects of the relationships, and because of their hopes for the future.
      Parmer, 2008
      • Parmer N.
      Brain injury and romance: an examination of the impact of frontal lobe brain damage on marital and relationship satisfaction [dissertation].
      DissertationInvestigate the impact of frontal lobe brain damage on relationships.- Mixed method (quantitative cross-sectional study & qualitative interview study).

      - Participants completed questionnaires and were interviewed.
      4 partners of individuals with a TBI (2 male, 2 female, 30-55 years old). Time post injury between 2 & 12 years.N/APartners mentioned the following reasons for staying together: having a sense of duty and loyalty, feeling a strong connection to the partner with the injury, and wanting to keep the family together for the children.
      Stevens et al., 2017
      • Stevens LF
      • Lapis Y
      • Tang X
      • et al.
      Relationship stability after traumatic brain injury among veterans and service members: a VA TBI Model Systems study.
      Journal articleExplore relationship stability and predictors of change in relationship status 2 years following TBI/polytrauma.- Quantitative cross-sectional study.

      - Data were extracted from medical records and participants were interviewed.
      357 service members who had suffered a TBI.- Independent: age at injury, education level, injury severity, cause of injury, injury during deployment, FIM cognitive score at discharge, FIM motor score at discharge, mental health utilization prior, problematic substance use.

      - Dependent: Relationships status change (unchanged vs positive change vs negative change).
      - Younger age at injury, lower education level, and history of 1-year-pre-injury mental health utilization were associated with relationship breakdown.

      - Being injured during deployment (vs stateside) was associated with positive relationship status change (ie, acquiring new relationships).
      Vanderploeg et al., 2003
      • Vanderploeg RD
      • Curtiss G
      • Duchnick JJ
      • Luis CA.
      Demographic, medical, and psychiatric factors in work and marital status after mild head injury.
      Journal articleExplore factors associated with long-term outcomes of work and marital status in individuals who experienced a mild TBI.- Quantitative cross-sectional study.

      - Data were extracted from medical charts, and participants were interviewed and completed neurologic examinations.
      - 626 veterans who had sustained a mild TBI (mean age: 37.35). Mean time since injury: 8 years.

      - 3896 controls.
      - Independent: age, level of education, race, General Technical Test, region of residence, concurrent or past medical problems, early life psychiatric difficulties, work status.

      - Dependent: marital status.
      - Older age, majority ethnicity (white), the absence of preexisting externalizing psychiatric difficulties, and current full-time employment were associated with higher rates of marriage. In addition, interactions between the predictors were found.
      Villa & Riley, 2017
      • Villa D
      • Riley GA.
      Partners’ experiences of relationship continuity in acquired brain injury.
      Journal articleExplore whether the conceptual framework of relationship continuity may also be applicable to understanding the experience of spousal carers in acquired brain injury.Qualitative interview study.5 partners (1 male, mean age: 55.6) of individuals with an ABI (4 of them sustained a TBI, one sustained a stroke). Mean time post injury: 3.4 years.N/A- Partners mentioned loyalty, love, and dependence as reasons for staying in the relationship.
      Wood, Liossi & Wood, 2005
      • Wood RL
      • Liossi C
      • Wood L.
      The impact of head injury neurobehavioural sequelae on personal relationships: preliminary findings.
      Journal articleExplore which neurobehavioral legacies of TBI have the greatest impact on personal relationships and increase the risk of relationship breakdown.- Quantitative cross-sectional study.

      - Participants completed questionnaires.
      48 (ex-)partners of individuals with a severe TBI (35 of the injured individuals were male, mean age: 40.5). Mean time post injury: 5.75 years.- Independent: extent to which different neurobehavioral characteristics adversely affected relationships.

      - Dependent: relationship status (still together vs separated).
      - Mood swings were perceived to have placed more strain on the relationships of separated couples than of couples who were still together.
      Wood & Yurdakul, 1997
      • Wood RL
      • Yurdakul LK.
      Change in relationship status following traumatic brain injury.
      Journal article- Record how frequently relationships break down in the years following TBI.

      - Determine predictors of relationship breakdown.
      - Quantitative cross-sectional study.

      - Data were extracted from archive files and participants were interviewed or completed a questionnaire.
      131 individuals with a mild-severe TBI (97 male, 22-84 years old). Mean time post injury: 5.42 years.- Independent: age, sex, presence of children under 15, post-traumatic amnesia, relationship length, time since injury.

      - Dependent: relationship status change.
      - The risk of relationship breakdown was increased when functional deficits or altered behavior required admission to a rehabilitation unit.

      - Couples who had been together longer before their injury were more likely to remain together.

      - The likelihood of separation increased with time from the injury, with the watershed for breakdown being around 5-6 years post-injury.

      Factors associated with relationship quality after TBI

      The factors identified to be associated with relationship quality after TBI will be described and presented (fig 2) according to the domains of the International Classification of Functioning, Disability, and Health (ICF) model.

      World Health Organization. Towards a common language for functioning and health: ICF. Available at: https://wwwwhoint/docs/default-source/classification/icf/icfbeginnersguidepdf?sfvrsn=eead63d3_4. Accessed June 14, 2022.

      Fig 2
      Fig 2Factors associated with relationship quality after TBI. Note. Here the ICF model is used to classify the factors affecting the functioning of couples, rather than individuals. The amount of time passed since the injury is displayed as a circle encompassing all domains represented in the model since this factor has the potential to influence almost all other incorporated factors.

      Health condition

      In 4 cross-sectional studies of moderate (n=3) to high (n=1) quality, more severe injuries were associated with lower relationship quality as indicated by marital maladjustment experienced by the partner without the injury,
      • Peters LC
      • Stambrook M
      • Moore AD
      • Esses L.
      Psychosocial sequelae of closed head injury: effects on the marital relationship.
      ,
      • Peters LC
      • Stambrook M
      • Moore AD
      • Zubek E
      • Dubo H
      • Blumenschein S.
      Differential effects of spinal cord injury and head injury on marital adjustment.
      less satisfaction and feelings of cohesiveness of the partner without the injury,
      • Peters LC
      • Stambrook M
      • Moore AD
      • Zubek E
      • Dubo H
      • Blumenschein S.
      Differential effects of spinal cord injury and head injury on marital adjustment.
      and more sexual problems experienced by the partner with the TBI.
      • Aloni A
      • Keren O
      • Cohen M
      • Rosentul N
      • Romm M
      • Groswasser Z.
      Incidence of sexual dysfunction in TBI patients during the early post-traumatic in-patient rehabilitation phase.
      ,
      • Strizzi J
      • Olabarrieta-Landa L
      • Olivera SL
      • et al.
      Sexual function in men with traumatic brain injury.
      Two other cross-sectional studies of moderate (n=1) to high (n=1) quality found no relation between injury severity and relationship quality as reported by the partner with
      • Ponsford JL
      • Downing MG
      • Stolwyk R.
      Factors associated with sexuality following traumatic brain injury.
      or the partner without the injury.
      • Williams C
      • Wood RL.
      The impact of alexithymia on relationship quality and satisfaction following traumatic brain injury.
      In addition, included cross-sectional studies of low (n=1), moderate (n=2), and high (n=1) quality found that, as time progressed from the moment of the injury, the number of relationship problems experienced by the partner without the injury increased,
      • Williams C
      • Wood RL.
      The impact of alexithymia on relationship quality and satisfaction following traumatic brain injury.
      feelings between partners and couple harmony worsened,
      • Bivona U
      • Antonucci G
      • Contrada M
      • et al.
      A biopsychosocial analysis of sexuality in adult males and their partners after severe traumatic brain injury.
      and sexual problems experienced by both partners became more prominent.
      • Aloni R
      • Katz S.
      Sexual difficulties after traumatic brain injury and ways to deal with it.
      ,
      • O'Carroll RE
      • Woodrow J
      • Maroun F.
      Psychosexual and psychosocial sequelae of closed head injury.
      Some partners with and without injury in the high-quality qualitative study by O'Keeffe et al,
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.
      however, referred to time as a factor contributing to relationship adjustment, and 2 cross-sectional studies of moderate quality found no relationship between time since injury and relationship quality as reported by partners with a TBI.
      • Aloni A
      • Keren O
      • Cohen M
      • Rosentul N
      • Romm M
      • Groswasser Z.
      Incidence of sexual dysfunction in TBI patients during the early post-traumatic in-patient rehabilitation phase.
      ,
      • Hess RA
      • Perrone-McGovern KM.
      Quality of life for individuals with traumatic brain injury: the influence of attachment security and partner support.

      Body functions and structure

      In cross-sectional studies of moderate (n=2) to high (n=1) quality, physical problems such as fatigue, movement difficulties, and insecurity about physical changes were linked by both partners with and without injury to sexual problems in the relationship
      • Sander AM
      • Maestas KL
      • Pappadis MR
      • Hammond FM
      • Hanks RA.
      Multicenter study of sexual functioning in spouses/partners of persons with traumatic brain injury.
      ,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      and by partners without the injury to marital maladjustment.
      • Peters LC
      • Stambrook M
      • Moore AD
      • Esses L.
      Psychosocial sequelae of closed head injury: effects on the marital relationship.
      In a qualitative study of moderate quality, physical problems were also described as limiting the injured partner's ability to be flirtatious and playful.
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.
      In qualitative and cross-sectional studies of moderate (n=3) to high (n= 1) quality, cognitive problems were found to affect relationships.
      • Sander AM
      • Maestas KL
      • Pappadis MR
      • Hammond FM
      • Hanks RA.
      Multicenter study of sexual functioning in spouses/partners of persons with traumatic brain injury.
      ,
      • Wood RL
      • Liossi C
      • Wood L.
      The impact of head injury neurobehavioural sequelae on personal relationships: preliminary findings.
      ,
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.
      ,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      Most notably, difficulties alternating attention were identified by partners with the injury as barriers to spontaneous moments of intimacy.
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.
      ,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      Furthermore, personality changes after the injury were identified as having a strong negative effect on couples in 6 qualitative studies of low (n=1), moderate (n=1), and high (n=4) quality
      • Godwin E
      • Chappell B
      • Kreutzer J.
      Relationships after TBI: a grounded research study.
      ,
      • Bodley-Scott SEM
      • Riley GA.
      How partners experience personality change after traumatic brain injury–its impact on their emotions and their relationship.
      ,
      • Hammond FM
      • Davis CS
      • Whiteside OY
      • Philbrick P
      • Hirsch MA.
      Marital adjustment and stability following traumatic brain injury: a pilot qualitative analysis of spouse perspectives.
      ,
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.
      ,
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.
      ,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      and a cross-sectional study of moderate quality.
      • Wedcliffe T
      • Ross E.
      The psychological effects of traumatic brain injury on the quality of life of a group of spouses/partners.
      Partners without injury frequently report that their injured partner has fundamentally changed and feels like a stranger. As a result, they can find it difficult to love
      • Bodley-Scott SEM
      • Riley GA.
      How partners experience personality change after traumatic brain injury–its impact on their emotions and their relationship.
      and trust
      • Hammond FM
      • Davis CS
      • Whiteside OY
      • Philbrick P
      • Hirsch MA.
      Marital adjustment and stability following traumatic brain injury: a pilot qualitative analysis of spouse perspectives.
      this “new” person. Regarding socioemotional skills, 3 high-quality qualitative studies
      • Bodley-Scott SEM
      • Riley GA.
      How partners experience personality change after traumatic brain injury–its impact on their emotions and their relationship.
      ,
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.
      ,
      • Villa D
      • Riley GA.
      Partners’ experiences of relationship continuity in acquired brain injury.
      and 1 high-quality cross-sectional study
      • Burridge AC
      • Huw Williams W
      • Yates PJ
      • Harris A
      • Ward C
      Spousal relationship satisfaction following acquired brain injury: the role of insight and socio-emotional skill.
      reported that partners without injury experience negative effects on their relationship when their injured partners have difficulty recognizing and responding empathically to their emotions.
      • Bodley-Scott SEM
      • Riley GA.
      How partners experience personality change after traumatic brain injury–its impact on their emotions and their relationship.
      ,
      • Burridge AC
      • Huw Williams W
      • Yates PJ
      • Harris A
      • Ward C
      Spousal relationship satisfaction following acquired brain injury: the role of insight and socio-emotional skill.
      ,
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.
      ,
      • Villa D
      • Riley GA.
      Partners’ experiences of relationship continuity in acquired brain injury.
      In high-quality cross-sectional and qualitative studies, both partners with and without injury report that relationships also suffer when the partners with the injury find it difficult to recognize and express their own emotions.
      • Williams C
      • Wood RL.
      The impact of alexithymia on relationship quality and satisfaction following traumatic brain injury.
      ,
      • Hammond FM
      • Davis CS
      • Whiteside OY
      • Philbrick P
      • Hirsch MA.
      Marital adjustment and stability following traumatic brain injury: a pilot qualitative analysis of spouse perspectives.
      ,
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.
      Additionally, in a cross-sectional study of moderate quality, better communication skills were associated with higher levels of marital satisfaction of the partner without the injury.
      • Blais MC
      • Boisvert JM.
      Psychological adjustment and marital satisfaction following head injury. Which critical personal characteristics should both partners develop?.
      In cross-sectional studies of low (n=1) to moderate (n=1) quality, behavioral problems were associated with dissatisfying relationships
      • Bivona U
      • Rizza F
      • Antonucci G
      • Formisano R.
      Effect of traumatic brain injury on sexuality.
      and sexual problems as reported by the partner without the injury.
      • Sander AM
      • Maestas KL
      • Pappadis MR
      • Hammond FM
      • Hanks RA.
      Multicenter study of sexual functioning in spouses/partners of persons with traumatic brain injury.
      More specifically, cross-sectional and qualitative studies of low (n=1), moderate (n=2), and high (n=2) quality reported negative effects of aggression
      • Wedcliffe T
      • Ross E.
      The psychological effects of traumatic brain injury on the quality of life of a group of spouses/partners.
      ,
      • Bodley-Scott SEM
      • Riley GA.
      How partners experience personality change after traumatic brain injury–its impact on their emotions and their relationship.
      ,
      • Wood RL
      • Liossi C
      • Wood L.
      The impact of head injury neurobehavioural sequelae on personal relationships: preliminary findings.
      ,
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.
      and unpredictable behavior.
      • Godwin E
      • Chappell B
      • Kreutzer J.
      Relationships after TBI: a grounded research study.
      ,
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.
      In addition, 5 moderate-quality cross-sectional studies found that psychiatric problems affect partner relationships by affecting couple harmony as experienced by the partner without the injury,
      • Bivona U
      • Antonucci G
      • Contrada M
      • et al.
      A biopsychosocial analysis of sexuality in adult males and their partners after severe traumatic brain injury.
      relationship quality as experienced by the partner with the TBI,
      • Ponsford JL
      • Downing MG
      • Stolwyk R.
      Factors associated with sexuality following traumatic brain injury.
      and sexual satisfaction of both partners.
      • O'Carroll RE
      • Woodrow J
      • Maroun F.
      Psychosexual and psychosocial sequelae of closed head injury.
      ,
      • Ponsford JL
      • Downing MG
      • Stolwyk R.
      Factors associated with sexuality following traumatic brain injury.
      ,
      • Sabhesan S
      • Natarajan M.
      Sexual behavior after head injury in Indian men and women.
      ,
      • Sander AM
      • Maestas KL
      • Pappadis MR
      • Hammond FM
      • Hanks RA.
      Multicenter study of sexual functioning in spouses/partners of persons with traumatic brain injury.
      These effects were mainly found for depression. Along these lines, mood problems experienced by either the partner with or without the injury were in cross-sectional studies of low (n=1), moderate (n=2), and high (n=1) quality reported to be associated with dissatisfactory relationships,
      • Bivona U
      • Rizza F
      • Antonucci G
      • Formisano R.
      Effect of traumatic brain injury on sexuality.
      ,
      • Wood RL
      • Liossi C
      • Wood L.
      The impact of head injury neurobehavioural sequelae on personal relationships: preliminary findings.
      a low sexual quality of life of the partner with the injury,
      • Moreno JA
      • Arango-Lasprilla JC
      • McKerral M.
      The relationship between postconcussion symptoms and sexual quality of life in individuals with traumatic brain injury.
      and low sexual satisfaction of the partner without injury.
      • Sander AM
      • Maestas KL
      • Pappadis MR
      • Hammond FM
      • Hanks RA.
      Multicenter study of sexual functioning in spouses/partners of persons with traumatic brain injury.
      Finally, a total of 9 qualitative and cross-sectional studies of moderate (n=7) to high (n=2) quality found that sexual functioning affects the quality of partner relationships as reported by both partners.
      • Wedcliffe T
      • Ross E.
      The psychological effects of traumatic brain injury on the quality of life of a group of spouses/partners.
      ,
      • Gosling J.
      Couple relationships and emotional well-being after severe traumatic brain injury [dissertation].
      ,
      • Kreuter M
      • Dahllöf AG
      • Gudjonsson G
      • Sullivan M
      • Siösteen A.
      Sexual adjustment and its predictors after traumatic brain injury.
      ,
      • Sander AM
      • Maestas KL
      • Pappadis MR
      • Hammond FM
      • Hanks RA.
      Multicenter study of sexual functioning in spouses/partners of persons with traumatic brain injury.
      ,
      • Wood RL
      • Liossi C
      • Wood L.
      The impact of head injury neurobehavioural sequelae on personal relationships: preliminary findings.
      ,
      • Chwalisz K
      • Stark-Wroblewski K.
      The subjective experiences of spouse caregivers of persons with brain injuries: a qualitative analysis.
      ,
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.
      ,
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.
      ,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      Negative effects were reported for a lack of sexual drive or interest,
      • Wedcliffe T
      • Ross E.
      The psychological effects of traumatic brain injury on the quality of life of a group of spouses/partners.
      ,
      • Sander AM
      • Maestas KL
      • Pappadis MR
      • Hammond FM
      • Hanks RA.
      Multicenter study of sexual functioning in spouses/partners of persons with traumatic brain injury.
      ,
      • Wood RL
      • Liossi C
      • Wood L.
      The impact of head injury neurobehavioural sequelae on personal relationships: preliminary findings.
      ,
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.
      ,
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.
      ,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      coercive sexual behaviors,
      • Gosling J.
      Couple relationships and emotional well-being after severe traumatic brain injury [dissertation].
      arousal problems,
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.
      and an inability to experience orgasm.
      • Kreuter M
      • Dahllöf AG
      • Gudjonsson G
      • Sullivan M
      • Siösteen A.
      Sexual adjustment and its predictors after traumatic brain injury.

      Activities and participation

      Two cross-sectional studies of moderate quality reported negative effects on relationship quality experienced by partners with and without injury of a decrease or lack of occurrence of sexual intercourse.
      • Wedcliffe T
      • Ross E.
      The psychological effects of traumatic brain injury on the quality of life of a group of spouses/partners.
      ,
      • Kreuter M
      • Dahllöf AG
      • Gudjonsson G
      • Sullivan M
      • Siösteen A.
      Sexual adjustment and its predictors after traumatic brain injury.
      In low- (n=1), moderate- (n=1), and high-quality (n=1) qualitative studies, negative effects were also reported of the sexual relationships feeling “wrong”
      • Gosling J
      • Oddy M.
      Rearranged marriages: marital relationships after head injury.
      or vastly changed.
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.
      ,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      In cross-sectional and qualitative studies of moderate (n=4) to high (n=2) quality, communication problems were reported by both partners with and without injury to reduce relationship quality
      • Wedcliffe T
      • Ross E.
      The psychological effects of traumatic brain injury on the quality of life of a group of spouses/partners.
      ,
      • Hammond FM
      • Davis CS
      • Whiteside OY
      • Philbrick P
      • Hirsch MA.
      Marital adjustment and stability following traumatic brain injury: a pilot qualitative analysis of spouse perspectives.
      ,
      • Layman DE
      • Dijkers MP
      • Ashman TA.
      Exploring the impact of traumatic brain injury on the older couple: 'yes, but how much of it is age, I can't tell you ...'.
      ,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      and to form a barrier to intimacy.
      • Sander AM
      • Maestas KL
      • Pappadis MR
      • Hammond FM
      • Hanks RA.
      Multicenter study of sexual functioning in spouses/partners of persons with traumatic brain injury.
      ,
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.
      ,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      Good communication was actively mentioned by partners with and without injury in qualitative studies of moderate (n=1) to high (n=1) quality as critical to keeping the relationship strong.
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.
      ,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      Furthermore, societal and family role changes were reported to affect relationships. Regarding societal role changes, 6 qualitative studies of low (n=1), moderate (n=2), and high (n=3) quality reported that injured partners who were breadwinners before the injury can frequently no longer fulfil this role after the injury.
      • Hammond FM
      • Davis CS
      • Whiteside OY
      • Philbrick P
      • Hirsch MA.
      Marital adjustment and stability following traumatic brain injury: a pilot qualitative analysis of spouse perspectives.
      ,
      • Layman DE
      • Dijkers MP
      • Ashman TA.
      Exploring the impact of traumatic brain injury on the older couple: 'yes, but how much of it is age, I can't tell you ...'.
      ,
      • Gosling J.
      Couple relationships and emotional well-being after severe traumatic brain injury [dissertation].
      ,
      • Gosling J
      • Oddy M.
      Rearranged marriages: marital relationships after head injury.
      ,
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.
      ,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      Consequently, partners with the injury reported feeling guilt and shame,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      and partners without the injury reported feeling resentment for having to take on this role.
      • Hammond FM
      • Davis CS
      • Whiteside OY
      • Philbrick P
      • Hirsch MA.
      Marital adjustment and stability following traumatic brain injury: a pilot qualitative analysis of spouse perspectives.
      Regarding family role change, 9 qualitative studies of low (n=2), moderate (n=3), and high (n=4) quality reported that partners without the injury can feel like they have become more of a caregiver or a parent than a lover to their injured partner.
      • Bodley-Scott SEM
      • Riley GA.
      How partners experience personality change after traumatic brain injury–its impact on their emotions and their relationship.
      ,
      • Layman DE
      • Dijkers MP
      • Ashman TA.
      Exploring the impact of traumatic brain injury on the older couple: 'yes, but how much of it is age, I can't tell you ...'.
      ,
      • Gosling J.
      Couple relationships and emotional well-being after severe traumatic brain injury [dissertation].
      ,
      • Gosling J
      • Oddy M.
      Rearranged marriages: marital relationships after head injury.
      ,
      • Parmer N.
      Brain injury and romance: an examination of the impact of frontal lobe brain damage on marital and relationship satisfaction [dissertation].
      ,
      • Sander AM
      • Maestas KL
      • Pappadis MR
      • Hammond FM
      • Hanks RA.
      Multicenter study of sexual functioning in spouses/partners of persons with traumatic brain injury.
      ,
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.
      ,
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.
      ,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      In many cases, this caregiving role was experienced as incompatible with the role of romantic
      • Bodley-Scott SEM
      • Riley GA.
      How partners experience personality change after traumatic brain injury–its impact on their emotions and their relationship.
      ,
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.
      ,
      • Villa D
      • Riley GA.
      Partners’ experiences of relationship continuity in acquired brain injury.
      or sexual
      • Gosling J
      • Oddy M.
      Rearranged marriages: marital relationships after head injury.
      ,
      • Kreutzer JS
      • Marwitz JH
      • Hsu N
      • Williams K
      • Riddick A.
      Marital stability after brain injury: an investigation and analysis.
      ,
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.
      ,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      partner. In addition, decision-making
      • Layman DE
      • Dijkers MP
      • Ashman TA.
      Exploring the impact of traumatic brain injury on the older couple: 'yes, but how much of it is age, I can't tell you ...'.
      ,
      • Gosling J.
      Couple relationships and emotional well-being after severe traumatic brain injury [dissertation].
      and financial
      • Godwin E
      • Chappell B
      • Kreutzer J.
      Relationships after TBI: a grounded research study.
      ,
      • Hammond FM
      • Davis CS
      • Whiteside OY
      • Philbrick P
      • Hirsch MA.
      Marital adjustment and stability following traumatic brain injury: a pilot qualitative analysis of spouse perspectives.
      ,
      • Layman DE
      • Dijkers MP
      • Ashman TA.
      Exploring the impact of traumatic brain injury on the older couple: 'yes, but how much of it is age, I can't tell you ...'.
      responsibilities were reported in qualitative studies of low (n=1), moderate (n=1), and high (n=2) quality to often shift from the partner with the injury to the partner without the injury, triggering feelings of resentment in partners without the injury.
      • Godwin E
      • Chappell B
      • Kreutzer J.
      Relationships after TBI: a grounded research study.
      ,
      • Hammond FM
      • Davis CS
      • Whiteside OY
      • Philbrick P
      • Hirsch MA.
      Marital adjustment and stability following traumatic brain injury: a pilot qualitative analysis of spouse perspectives.
      Lastly, in 4 qualitative studies of moderate (n=1) to high (n=3) quality and a cross-sectional study of moderate quality, being able to spend time and share enjoyment together was important for maintaining a strong relationship as reported by both partners with and without injury.
      • Bodley-Scott SEM
      • Riley GA.
      How partners experience personality change after traumatic brain injury–its impact on their emotions and their relationship.
      ,
      • Wood RL
      • Liossi C
      • Wood L.
      The impact of head injury neurobehavioural sequelae on personal relationships: preliminary findings.
      ,
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.
      ,
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.
      ,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].

      Environmental factors

      Three qualitative studies of moderate (n=1) to high (n=2) quality highlighted the importance of support provided by family members,
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.
      ,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      other members of a couple's social network,
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.
      ,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      and professionals.
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.
      ,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      The support of family members is described as invaluable because it helps decrease stress, fatigue, and anxiety in couples, which has a positive effect on their relationship.
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.
      ,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      The support of professionals is mainly reported to help partners without the injury understand the consequences of TBI better, which also benefits the relationship.
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.
      ,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      In both a cross-sectional study of high quality and qualitative studies of moderate (n=1) to high (n=1) quality, having children together contributed to relationship quality by keeping both partners committed to the relationship for the welfare of their children.
      • Williams C
      • Wood RL.
      The impact of alexithymia on relationship quality and satisfaction following traumatic brain injury.
      ,
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.
      ,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].

      Personal factors

      In 5 moderate quality cross-sectional studies, older age was associated with lower levels of relationship quality experienced by both partners with and without injury.
      • Bivona U
      • Antonucci G
      • Contrada M
      • et al.
      A biopsychosocial analysis of sexuality in adult males and their partners after severe traumatic brain injury.
      ,
      • Hess RA
      • Perrone-McGovern KM.
      Quality of life for individuals with traumatic brain injury: the influence of attachment security and partner support.
      ,
      • O'Carroll RE
      • Woodrow J
      • Maroun F.
      Psychosexual and psychosocial sequelae of closed head injury.
      ,
      • Ponsford JL
      • Downing MG
      • Stolwyk R.
      Factors associated with sexuality following traumatic brain injury.
      ,
      • Sander AM
      • Maestas KL
      • Pappadis MR
      • Hammond FM
      • Hanks RA.
      Multicenter study of sexual functioning in spouses/partners of persons with traumatic brain injury.
      One cross-sectional study of moderate quality reported an opposite effect,
      • Argüello JL.
      After the “silent epidemic”: marital satisfaction in long term spousal caregivers of individuals with severe traumatic brain injury [dissertation].
      and 2 cross-sectional studies of moderate (n=1) to high (n=1) quality found no association between age and relationship quality.
      • Strizzi J
      • Olabarrieta-Landa L
      • Olivera SL
      • et al.
      Sexual function in men with traumatic brain injury.
      ,
      • Sabhesan S
      • Natarajan M.
      Sexual behavior after head injury in Indian men and women.
      Regarding relationship length, cross-sectional studies of moderate (n=1) to high (n=1) quality suggested longer relationships are associated with higher relationship quality reported by the partner without the injury
      • Williams C
      • Wood RL.
      The impact of alexithymia on relationship quality and satisfaction following traumatic brain injury.
      ,
      • Argüello JL.
      After the “silent epidemic”: marital satisfaction in long term spousal caregivers of individuals with severe traumatic brain injury [dissertation].
      78po 1 cross-sectional study of moderate quality suggested an association with lower relationship quality reported by the partner with the TBI,
      • Bivona U
      • Antonucci G
      • Contrada M
      • et al.
      A biopsychosocial analysis of sexuality in adult males and their partners after severe traumatic brain injury.
      and 2 cross-sectional studies of moderate quality found no association between relationship length and relationship quality as reported by the partner with the injury.
      • Hess RA
      • Perrone-McGovern KM.
      Quality of life for individuals with traumatic brain injury: the influence of attachment security and partner support.
      ,
      • Moreno JA
      • Olivera SL
      • Valdivia ER
      • et al.
      Sexual quality-of-life, sexual satisfaction and relationship satisfaction in partnered individuals with traumatic brain injury.
      Both partners with and without injury did mention in qualitative studies of moderate (n=1) to high (n=1) quality that a strong preinjury relationship formed a solid foundation helping them to keep their relationship strong.
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.
      ,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      In addition, 4 qualitative and cross-sectional studies of low (n=1) and high (n=3) quality revealed that partners with and without injury felt that loving and feeling loved were critical for a satisfactory relationship while facing the changes caused by the injury.
      • Godwin E
      • Chappell B
      • Kreutzer J.
      Relationships after TBI: a grounded research study.
      ,
      • Bodley-Scott SEM
      • Riley GA.
      How partners experience personality change after traumatic brain injury–its impact on their emotions and their relationship.
      ,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      ,
      • Villa D
      • Riley GA.
      Partners’ experiences of relationship continuity in acquired brain injury.
      Similarly, commitment to the relationship was described by couples in low- (n=1), moderate- (n=1), and high-quality (n=2) qualitative studies as a lifeline holding them together when times were hard.
      • Godwin E
      • Chappell B
      • Kreutzer J.
      Relationships after TBI: a grounded research study.
      ,
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.
      ,
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.
      ,
      • Robins N.
      Exploring intimacy after traumatic brain injury (TBI) for TBI survivors and their partners [dissertation].
      Finally, in qualitative studies of moderate (n=1) to high (n=1) quality
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.
      ,
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.
      and in 2 cross-sectional studies of moderate quality,
      • Argüello JL.
      After the “silent epidemic”: marital satisfaction in long term spousal caregivers of individuals with severe traumatic brain injury [dissertation].
      ,
      • Moore AD
      • Stambrook M
      • Peters LC
      • Lubusko A.
      Family coping and marital adjustment after traumatic brain injury.
      the use of effective coping strategies by both partners was associated with relationship quality. Coping strategies that were beneficial for relationship quality included emotion focused coping strategies,
      • Argüello JL.
      After the “silent epidemic”: marital satisfaction in long term spousal caregivers of individuals with severe traumatic brain injury [dissertation].
      positive appraisal,
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.
      and humor.
      • Gill CJ
      • Sander AM
      • Robins N
      • Mazzei DK
      • Struchen MA.
      Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.

      Factors associated with relationship stability after TBI

      Figure 3 provides an overview of the factors associated with relationship stability after TBI, again displayed using the format of the ICF-model.

      World Health Organization. Towards a common language for functioning and health: ICF. Available at: https://wwwwhoint/docs/default-source/classification/icf/icfbeginnersguidepdf?sfvrsn=eead63d3_4. Accessed June 14, 2022.

      Fig 3
      Fig 3Factors associated with relationship stability after TBI. Note. Here the ICF model is used to classify the factors affecting the functioning of couples, rather than individuals. The amount of time passed since the injury is displayed as a circle encompassing all domains represented in the model since this factor has the potential to influence almost all other incorporated factors.

      Health condition

      One cross-sectional study of moderate quality indicated that the likelihood of relationship breakdown increases with time post injury,
      • Wood RL
      • Yurdakul LK.
      Change in relationship status following traumatic brain injury.
      while another cross-sectional study of moderate quality found no association between time post injury and incidence of separation.
      • Kreutzer JS
      • Marwitz JH
      • Hsu N
      • Williams K
      • Riddick A.
      Marital stability after brain injury: an investigation and analysis.
      Four cross-sectional studies of moderate quality found no relationship between injury severity and separation rates,
      • Kreutzer JS
      • Sima AP
      • Marwitz JH
      • Lukow Ii HR.
      Marital instability after brain injury: an exploratory analysis.
      ,
      • Jacobsson LJ
      • Westerberg M
      • Söderberg S
      • Lexell J.
      Functioning and disability 6-15 years after traumatic brain injuries in northern Sweden.
      ,
      • Stevens LF
      • Lapis Y
      • Tang X
      • et al.
      Relationship stability after traumatic brain injury among veterans and service members: a VA TBI Model Systems study.
      ,
      • Wood RL
      • Yurdakul LK.
      Change in relationship status following traumatic brain injury.
      1 moderate-quality cross-sectional study found that more severely injured individuals were more likely to separate,
      • Kreutzer JS
      • Marwitz JH
      • Hsu N
      • Williams K
      • Riddick A.
      Marital stability after brain injury: an investigation and analysis.
      and yet another cross-sectional study of moderate quality found that those with moderate injuries were more likely to separate than those with severe injuries.
      • Arango-Lasprilla JC
      • Ketchum JM
      • Dezfulian T
      • et al.
      Predictors of marital stability 2 years following traumatic brain injury.
      Two cross-sectional studies of moderate quality reported that survivors of violent injuries are more likely to separate than survivors of nonviolent injuries.
      • Arango-Lasprilla JC
      • Ketchum JM
      • Dezfulian T
      • et al.
      Predictors of marital stability 2 years following traumatic brain injury.
      ,
      • Kreutzer JS
      • Marwitz JH
      • Hsu N
      • Williams K
      • Riddick A.
      Marital stability after brain injury: an investigation and analysis.
      This finding was, however, not replicated by the moderate-quality cross-sectional study of Stevens et al.
      • Stevens LF
      • Lapis Y
      • Tang X
      • et al.
      Relationship stability after traumatic brain injury among veterans and service members: a VA TBI Model Systems study.

      Body functions and structures

      The results of the cross-sectional study of moderate quality by Wood and Yurkadal
      • Wood RL
      • Yurdakul LK.
      Change in relationship status following traumatic brain injury.
      indicated that the risk of relationship breakdown increases when behavioral problems and functional deficits resulting from the injury are severe enough to require admission to a rehabilitation unit. Two other cross-sectional studies of moderate (n=1) to high (n=1) quality, however, did not find a relation between motor or cognitive functioning and relationship stability.
      • Stevens LF
      • Lapis Y
      • Tang X
      • et al.
      Relationship stability after traumatic brain injury among veterans and service members: a VA TBI Model Systems study.
      ,
      • Vanderploeg RD
      • Curtiss G
      • Duchnick JJ
      • Luis CA.
      Demographic, medical, and psychiatric factors in work and marital status after mild head injury.
      In their moderate quality cross-sectional study, Wood et al
      • Wood RL
      • Liossi C
      • Wood L.
      The impact of head injury neurobehavioural sequelae on personal relationships: preliminary findings.
      found that partners without injury who had separated from their injured partners rated mood swings to have placed more pressure on their relationship than did partners without injury that were still together with their injured partner.

      Activities and participation

      Functional dependence was reported by both partners with and without injury in qualitative studies of moderate (n=1) to high (n=1) quality as something that prevented separation.
      • Layman DE
      • Dijkers MP
      • Ashman TA.
      Exploring the impact of traumatic brain injury on the older couple: 'yes, but how much of it is age, I can't tell you ...'.
      ,
      • Villa D
      • Riley GA.
      Partners’ experiences of relationship continuity in acquired brain injury.
      Similarly, financial dependence, frequently caused by loss of employment of the partner with the injury, was reported in qualitative studies of moderate (n=1) to high (n=1) quality as a factor preventing separation.
      • Layman DE
      • Dijkers MP
      • Ashman TA.
      Exploring the impact of traumatic brain injury on the older couple: 'yes, but how much of it is age, I can't tell you ...'.
      ,
      • Gosling J.
      Couple relationships and emotional well-being after severe traumatic brain injury [dissertation].
      Finally, in a qualitative study of moderate quality, partners with a TBI mentioned preserving the relationship because they were socially dependent on their partners as their social circles had narrowed since the injury, and they relied on their partners for the coordination of social events.
      • Layman DE
      • Dijkers MP
      • Ashman TA.
      Exploring the impact of traumatic brain injury on the older couple: 'yes, but how much of it is age, I can't tell you ...'.

      Environmental factors

      In cross-sectional and qualitative studies of low (n=1), moderate (n=1), and high (n=1) quality, having children together contributed to relationship stability. Generally, couples who have children are less likely to separate, and partners report staying together for the sake of their children.
      • Forslund MV
      • Arango-Lasprilla JC
      • Roe C
      • Perrin PB
      • Andelic N.
      Multilevel modeling of partnered relationship trajectories and relationship stability at 1, 2, and 5 years after traumatic brain injury in Norway.
      ,
      • Parmer N.
      Brain injury and romance: an examination of the impact of frontal lobe brain damage on marital and relationship satisfaction [dissertation].
      ,
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.
      Kreutzer et al,
      • Kreutzer JS
      • Sima AP
      • Marwitz JH
      • Lukow Ii HR.
      Marital instability after brain injury: an exploratory analysis.
      however, found no association between the presence of children and relationship stability in their cross-sectional study of moderate quality.

      Personal factors

      Four cross-sectional studies of moderate (n=3) to high (n=1) quality
      • Arango-Lasprilla JC
      • Ketchum JM
      • Dezfulian T
      • et al.
      Predictors of marital stability 2 years following traumatic brain injury.
      ,
      • Kreutzer JS
      • Marwitz JH
      • Hsu N
      • Williams K
      • Riddick A.
      Marital stability after brain injury: an investigation and analysis.
      ,
      • Stevens LF
      • Lapis Y
      • Tang X
      • et al.
      Relationship stability after traumatic brain injury among veterans and service members: a VA TBI Model Systems study.
      ,
      • Vanderploeg RD
      • Curtiss G
      • Duchnick JJ
      • Luis CA.
      Demographic, medical, and psychiatric factors in work and marital status after mild head injury.
      found that separation after TBI was less likely at a higher age, but 1 moderate-quality cross-sectional study did not find such an association.
      • Forslund MV
      • Arango-Lasprilla JC
      • Roe C
      • Perrin PB
      • Andelic N.
      Multilevel modeling of partnered relationship trajectories and relationship stability at 1, 2, and 5 years after traumatic brain injury in Norway.
      One cross-sectional study of moderate quality found that men with TBI were less likely to remain stably married than women with TBI,
      • Arango-Lasprilla JC
      • Ketchum JM
      • Dezfulian T
      • et al.
      Predictors of marital stability 2 years following traumatic brain injury.
      but 3 other cross-sectional studies of moderate quality found no effect of sex.
      • Forslund MV
      • Arango-Lasprilla JC
      • Roe C
      • Perrin PB
      • Andelic N.
      Multilevel modeling of partnered relationship trajectories and relationship stability at 1, 2, and 5 years after traumatic brain injury in Norway.
      ,
      • Kreutzer JS
      • Sima AP
      • Marwitz JH
      • Lukow Ii HR.
      Marital instability after brain injury: an exploratory analysis.
      ,
      • Kreutzer JS
      • Marwitz JH
      • Hsu N
      • Williams K
      • Riddick A.
      Marital stability after brain injury: an investigation and analysis.
      Regarding ethnicity, 1 cross-sectional study of high quality reported that white persons were more likely to be stably married,
      • Vanderploeg RD
      • Curtiss G
      • Duchnick JJ
      • Luis CA.
      Demographic, medical, and psychiatric factors in work and marital status after mild head injury.
      another cross-sectional study of moderate quality reported no relation between ethnicity and separation rates,
      • Kreutzer JS
      • Marwitz JH
      • Hsu N
      • Williams K
      • Riddick A.
      Marital stability after brain injury: an investigation and analysis.
      and yet another cross-sectional study of moderate quality reported moderating effects of ethnicity on the association between disability and relationship stability.
      • Arango-Lasprilla JC
      • Ketchum JM
      • Dezfulian T
      • et al.
      Predictors of marital stability 2 years following traumatic brain injury.
      Two moderate-quality cross-sectional studies reported that more highly educated individuals were more likely to be stably partnered,
      • Forslund MV
      • Arango-Lasprilla JC
      • Roe C
      • Perrin PB
      • Andelic N.
      Multilevel modeling of partnered relationship trajectories and relationship stability at 1, 2, and 5 years after traumatic brain injury in Norway.
      ,
      • Stevens LF
      • Lapis Y
      • Tang X
      • et al.
      Relationship stability after traumatic brain injury among veterans and service members: a VA TBI Model Systems study.
      while 2 other cross-sectional studies of moderate quality found no association between relationship stability and level of education.
      • Arango-Lasprilla JC
      • Ketchum JM
      • Dezfulian T
      • et al.
      Predictors of marital stability 2 years following traumatic brain injury.
      ,
      • Kreutzer JS
      • Marwitz JH
      • Hsu N
      • Williams K
      • Riddick A.
      Marital stability after brain injury: an investigation and analysis.
      Two cross-sectional studies of moderate (n=1) to high (n=1) quality reported that working full time (vs not working full time) and having a blue collar occupation (vs a white collar occupation) is associated with a higher level of relationship stability.
      • Forslund MV
      • Arango-Lasprilla JC
      • Roe C
      • Perrin PB
      • Andelic N.
      Multilevel modeling of partnered relationship trajectories and relationship stability at 1, 2, and 5 years after traumatic brain injury in Norway.
      ,
      • Vanderploeg RD
      • Curtiss G
      • Duchnick JJ
      • Luis CA.
      Demographic, medical, and psychiatric factors in work and marital status after mild head injury.
      Two other moderate-quality cross-sectional studies found no relation between occupation and relationship stability.
      • Arango-Lasprilla JC
      • Ketchum JM
      • Dezfulian T
      • et al.
      Predictors of marital stability 2 years following traumatic brain injury.
      ,
      • Kreutzer JS
      • Marwitz JH
      • Hsu N
      • Williams K
      • Riddick A.
      Marital stability after brain injury: an investigation and analysis.
      Furthermore, cross-sectional studies of moderate (n=4) to high (n=1) quality found that those with preinjury mental health problems were more likely to separate
      • Stevens LF
      • Lapis Y
      • Tang X
      • et al.
      Relationship stability after traumatic brain injury among veterans and service members: a VA TBI Model Systems study.
      ,
      • Vanderploeg RD
      • Curtiss G
      • Duchnick JJ
      • Luis CA.
      Demographic, medical, and psychiatric factors in work and marital status after mild head injury.
      and that those with longer preinjury relationships were less likely to separate.
      • Kreutzer JS
      • Sima AP
      • Marwitz JH
      • Lukow Ii HR.
      Marital instability after brain injury: an exploratory analysis.
      ,
      • Kreutzer JS
      • Marwitz JH
      • Hsu N
      • Williams K
      • Riddick A.
      Marital stability after brain injury: an investigation and analysis.
      ,
      • Wood RL
      • Yurdakul LK.
      Change in relationship status following traumatic brain injury.
      In qualitative studies of low (n=1) and high (n=2) quality, commitment to the relationship, sometimes phrased as loyalty, a sense of duty, or devotion, was an important factor preventing separation.
      • Gosling J.
      Couple relationships and emotional well-being after severe traumatic brain injury [dissertation].
      ,
      • Parmer N.
      Brain injury and romance: an examination of the impact of frontal lobe brain damage on marital and relationship satisfaction [dissertation].
      ,
      • Villa D
      • Riley GA.
      Partners’ experiences of relationship continuity in acquired brain injury.
      Additionally, feelings of love, respect, and acceptance were associated with relationship stability in qualitative studies of low (n=1), moderate (n=1), and high (n=3) quality. Feelings of love between partners helped couples weather the difficulties caused by TBI and prevented partners from initiating separation even when times were hard.
      • Hammond FM
      • Davis CS
      • Whiteside OY
      • Philbrick P
      • Hirsch MA.
      Marital adjustment and stability following traumatic brain injury: a pilot qualitative analysis of spouse perspectives.
      ,
      • Layman DE
      • Dijkers MP
      • Ashman TA.
      Exploring the impact of traumatic brain injury on the older couple: 'yes, but how much of it is age, I can't tell you ...'.
      ,
      • Parmer N.
      Brain injury and romance: an examination of the impact of frontal lobe brain damage on marital and relationship satisfaction [dissertation].
      ,
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.
      ,
      • Villa D
      • Riley GA.
      Partners’ experiences of relationship continuity in acquired brain injury.
      Similarly, feelings of respect for the injured partner
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.
      and mutual acceptance of imperfections
      • Layman DE
      • Dijkers MP
      • Ashman TA.
      Exploring the impact of traumatic brain injury on the older couple: 'yes, but how much of it is age, I can't tell you ...'.
      contributed to relationship stability. Finally, 2 high-quality qualitative studies reported that some of the partners without the injury persisted with their relationship because they hoped that their partners would improve with time.
      • Hammond FM
      • Davis CS
      • Whiteside OY
      • Philbrick P
      • Hirsch MA.
      Marital adjustment and stability following traumatic brain injury: a pilot qualitative analysis of spouse perspectives.
      ,
      • O'Keeffe F
      • Dunne J
      • Nolan M
      • Cogley C
      • Davenport J.
      The things that people can't see” the impact of TBI on relationships: an interpretative phenomenological analysis.

      Discussion