Social Skills Treatment for People With Severe, Chronic Acquired Brain Injuries: A Multicenter Trial

Frontal and Temporal Structural Connectivity Is Associated with Social Communication Impairment Following Traumatic Brain Injury

OBJECTIVES

Although it has been well documented that traumatic brain injury (TBI) can result in communication impairment, little work to date has examined the relationship between social communication skills and structural brain integrity in patients with TBI. The aim of the current study was to investigate the association between self- and other-perceived communication problems and white matter integrity in patients with mild to severe TBI.

METHODS

Forty-four individuals (TBI=24) and people with whom they frequently communicate, as well as demographically matched normal healthy comparisons (NC) and their frequent communication partners, were administered, respectively, the La-Trobe Communication Questionnaire Self form (LCQ-SELF) and Other form (LCQ-OTHER). In addition, diffusion tensor imaging data were collected, and fractional anisotropy (FA) measures were extracted for each lobe in both hemispheres.

RESULTS

Within the TBI group, but not within the NC group, participants who were perceived by their close others as having more communication problems had lower FA in the left frontal and temporal lobes (p<.01), but not in other brain regions.

CONCLUSIONS

Frontotemporal white matter microstructural integrity is associated with social communication abilities in adults with TBI. This finding contributes to our understanding of the mechanisms leading to communication impairment following TBI and can inform the development of new neuromodulation therapies as well as diagnostic tools. (JINS, 2016, 22, 705-716).

Effectiveness of Interventions to Improve Occupational Performance for People With Psychosocial, Behavioral, and Emotional Impairments After Brain Injury: A Systematic Review

OBJECTIVE

This systematic review evaluates the effectiveness of interventions to improve occupational performance for people with psychosocial, behavioral, or emotional impairments after traumatic brain injury (TBI).

METHOD

Medline, PsycINFO, CINAHL, OTseeker, and the Cochrane Database of Systematic Reviews were searched. Of the 1,512 articles initially identified, 35 met the inclusion criteria.

RESULTS

Six types of interventions were identified: (1) education, (2) peer mentoring, (3) goal-directed therapy, (4) physical activity, (5) skills training, and (6) cognitive-behavioral therapy (CBT). Strong evidence from well-conducted research supports the use of CBT in individual and group settings. Moderate evidence supports goal-directed interventions, aquatic exercise, and functional skills training. Limited evidence supports peer mentoring, aerobic exercise, educational interventions, and various skills training.

CONCLUSION

An increasing body of evidence supports specific interventions to improve occupational performance and participation for people with psychosocial, behavioral, or emotional impairments after TBI.

Return to Learn: A review of cognitive rest versus rehabilitation after sports concussion

BACKGROUND

Cognitive rest is the recommendation for all patients with acute sports concussion.

OBJECTIVE/METHODS

A comprehensive literature search was conducted for the research question "What is the optimal cognitive load for patients with a sports concussion?"

RESULTS

Seven studies met the inclusion criteria. The optimal cognitive load for patients after sports concussion is yet to be determined.

CONCLUSIONS

Additional controlled trials of cognitive rehabilitation are needed to establish best clinical practice. The authors suggest memory training, cognitive behavioral therapy, and environmental interventions as areas of future research for sports concussion injuries.

Cognitive Impairment and Rehabilitation Strategies After Traumatic Brain Injury

Traumatic brain injury (TBI) is among the significant causes of morbidity and mortality in the present world. Around 1.6 million persons sustain TBI, whereas 200,000 die annually in India, thus highlighting the rising need for appropriate cognitive rehabilitation strategies. This literature review assesses the current knowledge of various cognitive rehabilitation training strategies. The entire spectrum of TBI severity; mild to severe, is associated with cognitive deficits of varying degree. Cognitive insufficiency is more prevalent and longer lasting in TBI persons than in the general population. A multidisciplinary approach with neuropsychiatric evaluation is warranted. Attention process training and tasks for attention deficits, compensatory strategies and errorless learning training for memory deficits, pragmatic language skills and social behavior guidance for cognitive-communication disorder, meta-cognitive strategy, and problem-solving training for executive disorder are the mainstay of therapy for cognitive deficits in persons with TBI. Cognitive impairments following TBI are common and vary widely. Different cognitive rehabilitation techniques and combinations in addition to pharmacotherapy are helpful in addressing various cognitive deficits.

Effectiveness of Interventions to Address Visual and Visual–Perceptual Impairments to Improve Occupational Performance in Adults With Traumatic Brain Injury: A Systematic Review

OBJECTIVE. Visual and visual–perceptual impairments occur frequently with traumatic brain injury (TBI) and influence occupational performance. This systematic review examined the effectiveness of interventions within the scope of occupational therapy to improve occupational performance for adults with visual and visual–perceptual impairments as a result of TBI.

METHOD. Medline, PsycINFO, CINAHL, OTseeker, and the Cochrane Database of Systematic Reviews were searched, and 66 full text articles were reviewed. Sixteen articles were included in the review.

RESULTS. Strong evidence supports the use of scanning, limited evidence supports the use of adaptive strategies, and mixed evidence supports the use of cognitive interventions to improve occupational performance for adults with TBI. Evidence related to vision therapy varies on the basis of the specific intervention implemented.

CONCLUSION. Although the strength of the research varied, implications are discussed for practice, education, and research.

Effectiveness of Occupation- and Activity-Based Interventions to Improve Everyday Activities and Social Participation for People With Traumatic Brain Injury: A Systematic Review

This systematic review presents research on the effectiveness of occupation- and activity-based interventions to improve everyday activities and areas of occupation and social participation for people with traumatic brain injury (TBI). Nineteen studies identified through a comprehensive database search were reviewed and synthesized into five themes: (1) multidisciplinary and interdisciplinary treatment approaches, (2) community-based rehabilitation programs, (3) treatment approaches using client-centered goals and relevant contexts, (4) social skills training and peer mentoring interventions, and (5) community mobility interventions. Evidence supports the use of multidisciplinary and interdisciplinary approaches across a variety of settings, with no single treatment approach or setting clearly superior to another. The specific contributions of occupational therapy practitioners and the nature of occupational therapy interventions have not been well studied, making it difficult to determine the extent to which occupation- and activity-based interventions provided by occupational therapy practitioners improve occupational performance and social participation after TBI.

Non pharmacological treatments for psychological and behavioural disorders following traumatic brain injury (TBI). A systematic literature review and expert opinion leading to recommendations

INTRODUCTION

The non pharmacological approach is an important issue in the treatment of psychological and behavioural disorders in traumatic brain injury (TBI) patients. It remains nevertheless insufficiently known and defined. The objective of this work was to develop precise recommendations for caregivers and relatives.

METHOD

The elaboration of these guidelines followed the procedure validated by the French health authority for good practice recommendations, close to the Prisma statement, involving a systematic, critical review of the literature and the expert opinions of the French Society of Physical Medicine and Rehabilitation (SOFMER) group.

RESULTS

458 articles were identified, among which 98 were selected for their relevance to the theme of the research. None of the studies reached the highest level of evidence. Fifteen controlled studies reached a relatively high level of evidence (level 2); other studies were case series or expert opinions, and other articles again were reviews of the literature and theoretical points of view. The holistic approach structured into programmes, cognitive-behavioural therapy, and family and systemic therapy, despite the low levels of proof, are recommended in first intention at all stages in the evolution of TBI. Relational and adaptive approaches, rehabilitation and vocational approaches, and psychoanalytical therapies may be useful, provided that therapists are familiar with and trained in traumatic brain injury.

CONCLUSION

Despite the small number of publications and a low level of proof, a number of recommendations for the non-pharmacological approach to psychological and behavioural disorders in TBI is proposed by the consensus conference of experts. Scientific research in this domain is needed to confirm and complete these first recommendations.

Resilience Following Traumatic Brain Injury: A Traumatic Brain Injury Model Systems Study

OBJECTIVE

To examine resilience at 3 months after traumatic brain injury (TBI).

DESIGN

Cross-sectional analysis of an ongoing observational cohort.

SETTING

Five inpatient rehabilitation centers, with 3-month follow-up conducted primarily by telephone.

PARTICIPANTS

Persons with TBI (N=160) enrolled in the resilience module of the TBI Model System study with 3-month follow-up completed.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Connor-Davidson Resilience Scale.

RESULTS

Resilience scores were lower than those of the general population. A multivariable regression model, adjusting for other predictors, showed that higher education, absence of preinjury substance abuse, and less anxiety at follow-up were significantly related to greater resilience.

CONCLUSIONS

Analysis suggests that lack of resilience may be an issue for some individuals after moderate to severe TBI. Identifying persons most likely at risk for low resilience may be useful in planning clinical interventions.

Non-pharmacological interventions for depression in adults and children with traumatic brain injury

BACKGROUND

Following traumatic brain injury (TBI) there is an increased prevalence of depression compared to the general population. It is unknown whether non-pharmacological interventions for depression are effective for people with TBI.

OBJECTIVES

To investigate the effectiveness of non-pharmacological interventions for depression in adults and children with TBI at reducing the diagnosis and severity of symptoms of depression.

SEARCH METHODS

We ran the most recent search on 11 February 2015. We searched the Cochrane Injuries Group Specialised Register, The Cochrane Library, MEDLINE (OvidSP), Embase (OvidSP), three other databases and clinical trials registers. Relevant conference proceedings and journals were handsearched, as were the reference lists of identified studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of non-pharmacological interventions for depression in adults and children who had a TBI.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials from the search results, then assessed risk of bias and extracted data from the included trials. The authors contacted trial investigators to obtain missing information. We rated the overall quality of the evidence of the primary outcomes using the GRADE approach.

MAIN RESULTS

Six studies met the inclusion criteria, with a total of 334 adult participants. We identified no studies that included children as participants. All studies were affected by high risk of bias due to a lack of blinding of participants and personnel; five studies were affected by high risk of bias for lack of blinding of outcome assessors. There was high or unclear risk of biases affecting some studies across all the Cochrane risk of bias measures.Three studies compared a psychological intervention (either cognitive behaviour therapy or mindfulness-based cognitive therapy) with a control intervention. Data regarding depression symptom outcome measures were combined in a meta-analysis, but did not find an effect in favour of treatment (SMD -0.14; 95% CI -0.47 to 0.19; Z = 0.83; P = 0.41). The other comparisons comprised of single studies of depression symptoms and compared; cognitive behaviour therapy versus supportive psychotherapy (SMD -0.09; 95% CI -0.65 to 0.48; Z = 0.30; P = 0.77); repetitive transcranial magnetic stimulation plus tricyclic antidepressant (rTMS + TCA) versus tricyclic antidepressant alone (SMD -0.84; 95% CI -1.36 to -0.32; Z = 3;19, P = 0.001); and a supervised exercise program versus exercise as usual (SMD -0.43; 95% CI -0.88 to 0.03; Z = 1.84; P = 0.07). There was very-low quality evidence, small effect sizes and wide variability of results, suggesting that no comparisons showed a reliable effect for any intervention.Only one study mentioned minor, transient adverse events from repetitive transcranial magnetic stimulation.

AUTHORS' CONCLUSIONS

The review did not find compelling evidence in favour of any intervention. Future studies should focus on participants with a diagnosed TBI and include only participants who have a diagnosis of depression, or who record scores above a clinical cutoff on a depression measure. There is a need for additional RCTs that include a comparison between an intervention and a control that replicates the effect of the attention given to participants during an active treatment.

Elizabeth Usher Memorial Lecture: Placing therapy in the context of the self and social connection

BACKGROUND

The concept of self influences the choice of goals and helps to make sense of lives. Essentially, self-concept is a dynamic internal representation of the individual. This representation shapes behaviour and how information about oneself is processed. The self-story is developed and validated through social interactions and shaped continuously through life experiences.

METHOD

The focus of this paper is the client's perspective of self and how one can actively use that perspective to plan therapy, particularly in the case of individuals with acquired brain injury (ABI). The paper draws upon the results of a number of research projects constructed around two primary aims: (1) to represent the perspectives of clients and their close others and (2) to maximize social connection through the delivery of effective communication intervention.

RESULT

A model of self, derived from in-depth qualitative exploration of the experiences of people with ABI, is presented as a framework to guide collaborative therapy. The model depicts the multidimensional and cyclical nature of self- conceptualization supported by factors that facilitate social connection.

CONCLUSION

Communication is crucial to maintaining social ties and communication breakdown is a significant predictor of participation. A new intervention that effectively improves coping with communication breakdown is presented.

Training Adults with Brain Injury How to Help-seek when Lost: A Pilot Study

There is no research on the assessment or treatment of help-seeking behaviours for individuals with traumatic brain injury (TBI). This paper describes the development of a protocol, NICE (Noticing you have a problem, Identifying the information you need for help, Compensatory strategies, Evaluating progress) to train help-seeking for adults with TBI when lost. Theoretical and treatment components from three empirically validated interventions that target social problem-solving and communication skills were adapted to develop NICE: the Group Interactive Structured Treatment for Social Competence (GIST), the Problem Solving Group Protocol (PSG) and Interpersonal Recall (IPR). Preliminary pilot data evaluating the efficacy are presented for three adult persons with TBI. All three participants improved on the Executive Function Route Finding Task (EFRT) and help-seeking behaviours when wayfinding. Help-seeking is a constitutive factor in the wayfinding process capable of improvement. Preliminary evidence supports further investigation of this group intervention.

INCOG recommendations for management of cognition following traumatic brain injury, part IV: cognitive communication

INTRODUCTION

Cognitive-communication disorders are common in individuals with traumatic brain injury (TBI) and can have a major impact on long-term outcome. Guidelines for evidence-informed rehabilitation are needed, thus an international group of researchers and clinicians (known as INCOG) convened to develop recommendations for assessment and intervention.

METHODS

An expert panel met to select appropriate recommendations for assessment and treatment of cognitive-communication disorders based on available literature. To promote implementation, the team developed decision algorithms incorporating the recommendations, based on inclusion and exclusion criteria of published trials, and then prioritized recommendations for implementation and developed audit criteria to evaluate adherence to best practice recommendations.

RESULTS

Rehabilitation of individuals with cognitive-communication disorders should consider premorbid communication status; be individualized to the person's needs, goals, and skills; provide training in use of assistive technology where appropriate; include training of communication partners; and occur in context to minimize the need for generalization. Evidence supports treatment of social communication problems in a group format.

CONCLUSION

There is strong evidence for person-centered treatment of cognitive-communication disorders and use of instructional strategies such as errorless learning, metacognitive strategy training, and group treatment. Future studies should include tests of alternative service delivery models and development of participation-level outcome measures.

Videogame-based group therapy to improve self-awareness and social skills after traumatic brain injury

Background

This study determines the feasibility of different approaches to integrative videogame-based group therapy for improving self-awareness, social skills, and behaviors among traumatic brain injury (TBI) victims and retrieves participant feedback.

Methods

Forty-two adult TBI survivors were included in a longitudinal study with a pre- and post-assessments. The experimental intervention involved weekly one-hour sessions conducted over six months. Participants were assessed using the Self-Awareness Deficits Interview (SADI), Patient Competency Rating Scale (PCRS), the Social Skills Scale (SSS), the Frontal Systems Behavior Scale (FrSBe), the System Usability Scale (SUS). Pearson's chi-squared test (χ²) was applied to determine the percentage of participants who had changed their clinical classification in these tests. Feedback of the intervention was collected through the Intrinsic Motivation Inventory (IMI).

Results

SADI results showed an improvement in participant perceptions of deficits (χ² = 5.25, p < 0.05), of their implications (χ² = 4.71, p < 0.05), and of long-term planning (χ² = 7.86, p < 0.01). PCRS results confirm these findings (χ² = 5.79, p < 0.05). SSS results were also positive with respect to social skills outcomes (χ² = 17.52, p < 0.01), and FrSBe results showed behavioral improvements (χ² = 34.12, p < 0.01). Participants deemed the system accessible (80.43 ± 8.01 out of 100) and regarded the intervention as interesting and useful (5.74 ± 0.69 out of 7).

Conclusions

Integrative videogame-based group therapy can improve self-awareness, social skills, and behaviors among individuals with chronic TBI, and the approach is considered effective and motivating.

Improving Communication-specific Coping after Traumatic Brain Injury: Evaluation of a New Treatment using Single-case Experimental Design

Background and aims: Impaired communication is a well-documented and enduring consequence of traumatic brain injury (TBI). As a result of this impairment, people with TBI frequently experience communication breakdown and associated stress. Typically, we use communication-specific coping strategies in situations characterised by communication breakdown. Productive strategies enhance message transfer; non-productive strategies do little to resolve problems and frequently result in negative social interaction. This research aimed to evaluate the effectiveness of a new treatment, Communication-specific Coping Intervention (CommCope-I), which specifically targets coping in the context of communication breakdown.

Method: Single-case experimental design (A–B–A with follow-up using multiple probes) across two participants was used. Participants were Samantha, a 30-year-old woman who had sustained severe TBI 8 years previously, and Thomas, a 34-year-old man who had sustained severe TBI when he was 29 years old. CommCope-I is a 6-week programme which targets personally relevant productive coping strategies identified collaboratively with the client. Productive coping scripts are developed and practised through a series of graded scenarios that are evaluated with the aid of video recording.

Results: Percentage of non-overlapping corrected data (PNCD) was used to analyse the results. PNCD involves a data-correction procedure to remove baseline trend from the data series prior to calculating the change produced as a result of intervention. A large treatment effect was demonstrated in both participants (PNCD: end of treatment Samantha = 100%, Thomas = 100%, 3-month follow-up Samantha = 100%, Thomas = 100%). These results are consistent with highly effective treatment.

Conclusions: This study provides sound phase-1 evidence for the effectiveness of CommCope-I.

Long-term social integration and community support

TBI often results in reduced social participation. This decrease in social participation is independent of injury severity and time since injury. Thus, it is one of the many stable hallmarks of TBI. Changes in social participation have been related to many factors, including emotional dysregulation and disturbance and executive dysfunction. While there are evidenced-based treatments available to improve mood and executive functioning, none of the research has examined the impact of the various treatments on social participation or social integration. Therefore, while it is reasonable to expect that individuals who are feeling better about themselves and who improve their approach to day-to-day function will also experience increased social contact, there is no evidence to support this claim. This chapter reviews the literature on post-TBI social integration and its relationship to depression and executive dysfunction. In addition the intervention research in this area is briefly examined.

Randomized controlled trials in adult traumatic brain injury: a review of compliance to CONSORT statement

OBJECTIVE

To describe the extent to which adherence to Consolidated Standards of Reporting Trials (CONSORT) statement in randomized controlled trials (RCTs) in adult traumatic brain injury (TBI) has improved over time.

DATA SOURCES

MEDLINE, PsycINFO, and CINAHL databases were searched from inception to September 2013.

STUDY SELECTION

Primary report of RCTs in adult TBI. The quality of reporting on CONSORT checklist items was examined and compared over time. Study selection was conducted by 2 researchers independently. Any disagreements were solved by discussion.

DATA EXTRACTION

Two reviewers independently conducted data extraction based on a set of structured data extraction forms. Data regarding the publication years, size, locations, participation centers, intervention types, intervention groups, and CONSORT checklist items were extracted from the including trials.

DATA SYNTHESIS

Of 105 trials reviewed, 38.1%, 5.7%, and 32.4% investigated drugs, surgical procedures, and rehabilitations as the intervention of interest, respectively. Among reports published between the 2 periods 2002 and 2010 (n=51) and 2011 and September 2013 (n=16), the median sample sizes were 99 and 118; 39.2% and 37.5% of all reports detailed implementation of the randomization process; 60.8% and 43.8% provided information on the method of allocation concealment; 56.9% and 31.3% stated how blinding was achieved; 15.7% and 43.8% reported information regarding trial registration; and only 2.0% and 6.3% stated where the full trial protocol could be accessed, all respectively.

CONCLUSIONS

Reporting of several important methodological aspects of RCTs conducted in adult TBI populations improved over the years; however, the quality of reporting remains below an acceptable level. The small sample sizes suggest that many RCTs are likely underpowered. Further improvement is recommended in designing and reporting RCTs.

Sociosexual and communication deficits after traumatic injury to the developing murine brain

Despite the life-long implications of social and communication dysfunction after pediatric traumatic brain injury, there is a poor understanding of these deficits in terms of their developmental trajectory and underlying mechanisms. In a well-characterized murine model of pediatric brain injury, we recently demonstrated that pronounced deficits in social interactions emerge across maturation to adulthood after injury at postnatal day (p) 21, approximating a toddler-aged child. Extending these findings, we here hypothesized that these social deficits are dependent upon brain maturation at the time of injury, and coincide with abnormal sociosexual behaviors and communication. Age-dependent vulnerability of the developing brain to social deficits was addressed by comparing behavioral and neuroanatomical outcomes in mice injured at either a pediatric age (p21) or during adolescence (p35). Sociosexual behaviors including social investigation and mounting were evaluated in a resident-intruder paradigm at adulthood. These outcomes were complemented by assays of urine scent marking and ultrasonic vocalizations as indices of social communication. We provide evidence of sociosexual deficits after brain injury at p21, which manifest as reduced mounting behavior and scent marking towards an unfamiliar female at adulthood. In contrast, with the exception of the loss of social recognition in a three-chamber social approach task, mice that received TBI at adolescence were remarkably resilient to social deficits at adulthood. Increased emission of ultrasonic vocalizations (USVs) as well as preferential emission of high frequency USVs after injury was dependent upon both the stimulus and prior social experience. Contrary to the hypothesis that changes in white matter volume may underlie social dysfunction, injury at both p21 and p35 resulted in a similar degree of atrophy of the corpus callosum by adulthood. However, loss of hippocampal tissue was greater after p21 compared to p35 injury, suggesting that a longer period of lesion progression or differences in the kinetics of secondary pathogenesis after p21 injury may contribute to observed behavioral differences. Together, these findings indicate vulnerability of the developing brain to social dysfunction, and suggest that a younger age-at-insult results in poorer social and sociosexual outcomes.

The current practices of speech-language pathologists in providing information to clients with traumatic brain injury

The provision of information about cognitive-communication disorders (CCDs) following traumatic brain injury (TBI) is important given the impact these communication impairments can have on the rehabilitation of people with TBI. This study describes the results of an online survey which investigated the current practices of 74 Australian speech-language pathologists (SLPs) working with adults with TBI. Thirty-seven SLPs outlined their practices in information provision. SLPs reported they provide information to adults with TBI about CCDs, the impact of CCDs on participation in life activities, and rehabilitation from CCDs. In addition, SLPs identified barriers and facilitators to information provision. Barriers identified included time, impairments resulting from TBI, and personal characteristics of the client. Facilitators included family functioning and support and the multidisciplinary team. Findings of this research indicate a need for some changes in the format and content of information that SLPs provide to adults with TBI, to ensure they can achieve fundamental levels of health literacy and better health outcomes.

Social Cognition Interventions in Neuro-Rehabilitation: An Overview

This article provides an overview of interventions developed and trialled in the embryonic field of social cognition neuro-rehabilitation. Interventions are categories under the headings of explicit skills training, embodied/relational interventions, and relational approaches. The assessment and treatment of social neuropsychological impairments have received comparably less attention and development than other domains of cognition. These include difficulties in representing the intentions and perspectives of others (mentalising), recognising emotions, inferring nuanced social communications such as sarcasm and deceit, accessing social knowledge, and emotion-based decision-making. Founded on distributed neuroanatomical substrates, impairments of these functions have been found to be present and enduring across major sub-groups of acquired brain injury (for review see [1]). The theoretical richness of the social neuroscience revolution has not been matched by the translation of concepts and findings into rehabilitation practice. This article will review the embryonic field of social cognition rehabilitation, categorised into three intervention clusters: a) explicit skills training, b) embodied and affective interventions and c) relational approaches.

Emotional and behavioral dyscontrol after traumatic brain injury

Emotional and behavioral dyscontrol are relatively common neuropsychiatric sequelae of traumatic brain injury and present substantial challenges to recovery and community participation. Among the most problematic and functionally disruptive of these types of behaviors are pathologic laughing and crying, affective lability, irritability, disinhibition, and aggression. Managing these problems effectively requires an understanding of their phenomenology, epidemiology, and clinical evaluation. This article reviews these issues and provides clinicians with brief and practical suggestions for the management of emotional and behavioral dyscontrol.

Addiction and empathy: a preliminary analysis

Addicted patients show impaired social functioning. Chronic drug consumption may lead to impairments in decoding empathic cues. The aim of the study is to explore empathy abilities in addicted patients and the hypothesis of a differential impairment between affective and cognitive empathy. 62 addicted patients and 40 healthy volunteers were evaluated using the empathy quotient (EQ) and its subscales cognitive empathy (factor 1), emotional empathy (factor 2), social skills (factor 3). Patients scored statistically significantly lower than controls in EQ total score, in particular in factor 2. No difference was found in factor 1 and in factor 3. Consistent with previous findings, our study suggests specific impairment in emotional empathy combined with preserved cognitive empathy. These findings show important clinical implication in the development of specific rehabilitative programmes for the empowerment of empathy abilities and interpersonal skills that constitute important components in the prevention of relapse.

Sensitivity of the evaluation of social interaction measures among people with and without neurologic or psychiatric disorders

OBJECTIVE

To determine whether the Evaluation of Social Interaction (ESI) is sensitive enough to differentiate between people without identified diagnoses and those with neurologic or psychiatric disorders in terms of their observed quality of social interaction.

METHOD

Participants were age 16-69 and were without identified diagnoses (n = 304) or had neurologic (n = 77) or psychiatric (n = 104) disorders. They were evaluated using the ESI.

RESULTS

Nonparametric Kruskal-Wallis tests and post hoc Mann-Whitney U tests revealed that the group without identified diagnoses had significantly better quality of social interaction than did either group with disabilities (Us = 3,172 and 3,189, respectively; p ≤ .001).

CONCLUSION

The ESI is sensitive with regard to detecting differences in quality of social interaction among groups expected to differ, suggesting that it is valid for use when the desired purpose is to identify people with diminished quality of social interaction.

Rehabilitation of executive function and social cognition impairments after brain injury

PURPOSE OF REVIEW

Brain injury is a major cause of long-term disability. Executive and social cognition sequelae are associated with poor outcome. This review examines recent evidence on the efficacy of rehabilitation in these areas.

RECENT FINDINGS

Accumulating evidence shows that interventions that work with patients on developing insight and strategies to offset executive impairments can produce significant benefits. Training of specific capacities, such as working memory, holds some promise, but more needs to be known about effect generalization. Evidence on social cognition rehabilitation following brain injury is sparse. Although there are some encouraging early results, more information on the clinical significance of change for everyday function is required.

SUMMARY

Rehabilitation in these areas is inherently difficult but vital if outcomes are to improve. Significant gains have been reported, and further work applying appropriate methods is urgently required.

In-person versus telehealth assessment of discourse ability in adults with traumatic brain injury

OBJECTIVES

To compare in-person versus telehealth (TH) assessment of discourse ability in adults with chronic traumatic brain injury (TBI).

DESIGN

Repeated-measures design with random order of conditions.

PARTICIPANTS

Twenty adults with moderate-to-severe TBI.

METHOD

Participants completed conversation, picture description, story-generation, and procedural description tasks. Sessions were video-recorded and transcribed.

MEASURES

Measures of productivity and quality of discourse.

RESULTS

Significant differences between conditions were not detected in this sample, and feedback from participants was positive.

CONCLUSIONS

These preliminary results support the use of TH for the assessment of discourse ability in adults with TBI, at least for individuals with sufficient cognitive skills to follow TH procedures.

Randomized controlled trials in adult traumatic brain injury

BACKGROUND

To optimize strategies for achieving the effectiveness of interdisciplinary interventions, this study conducted a comprehensive literature review of all Randomized Controlled Trials (RCT) in adults with traumatic brain injury (TBI) over the past 30 years.

METHOD

Three major databases including Medline, PsycINFO and CINAHL were searched, yielding 1176 peer reviewed publications. One hundred RCTs were included, encompassing 55 pharmacologic and non-pharmacologic acute phase trials and 45 rehabilitation and pharmacologic post-acute trials.

RESULTS

The majority of acute phase pharmacologic or non-pharmacologic trials (40/55) showed either no effect or adverse effect on TBI outcomes. Several trials involving early nutritional therapy or pre-hospital rapid intubation demonstrated significant treatment effects. The effect of decompressive craniectomy, therapeutic hypothermia and osmotic therapy remained controversial. The majority of post-acute phase trials (36/45), consisting of cognitive rehabilitation, physical rehabilitation and pharmacotherapy, produced various beneficial treatment effects.

CONCLUSION

The data indicate that several active interventions during the acute phase of TBI are likely to be more effective than pharmacotherapy, whereas a comprehensive rehabilitation approach is preferred in post-acute phase TBI management. Great progress has been made in understanding the heterogeneous injury mechanisms as well as the complexity of medical management and rehabilitation following the recovery course of TBI.

Impairments in social cognition following severe traumatic brain injury

Severe traumatic brain injury (TBI) leads to physical, neuropsychological, and emotional deficits that interfere with the individual’s capacity to return to his or her former lifestyle. This review focuses on social cognition, that is, the capacity to attend to, recognize and interpret interpersonal cues that guide social behavior. Social cognition entails ‘‘hot’’ processes, that is, emotion perception and emotional empathy and ‘‘cold’’ processes, that is, the ability to infer the beliefs, feelings, and intentions of others (theory of mind: ToM) to see their point of view (cognitive empathy) and what they mean when communicating (pragmatic inference). This review critically examines research attesting to deficits in each of these domains and also examines evidence for theorized mechanisms including specific neural networks, the role of simulation, and non-social cognition. Current research is hampered by small, heterogeneous samples and the inherent complexity of TBI pathology. Nevertheless, there is evidence that facets of social cognition are impaired in this population. New assessment tools to measure social cognition following TBI are required that predict everyday social functioning. In addition, research into remediation needs to be guided by the growing empirical base for understanding social cognition that may yet reveal how deficits dissociate following TBI.

Effect of psychological interventions on depressive symptoms in long-term rehabilitation after an acquired brain injury: a systematic review and meta-analysis

OBJECTIVE

To summarize empirical studies on the effectiveness of psychological interventions in long-term rehabilitation after an acquired brain injury (ABI) in reducing depressive symptoms.

DATA SOURCES

A systematic literature search was conducted on MEDLINE, PsycINFO, Embase, and CINAHL to identify articles published between January 1990 and October 2011. Search terms included the 3 concepts (1) "brain injur*" or "stroke," (2) "psychotherap*" or "therapy" or "intervention" or "rehabilitation," and (3) "depress*."

STUDY SELECTION

Studies evaluating psychological interventions in patients after ABI were included. Time since injury was on average more than 1 year. Trials reported data on validated depression questionnaires before and after the psychological intervention.

DATA EXTRACTION

Two independent reviewers extracted information from the sample, the intervention, and the outcome of the included studies and calculated effect sizes (ESs) from depression questionnaires. Thirteen studies were included in a pre-post analysis. Seven studies were eligible for a meta-analysis of ESs in active interventions and control conditions.

DATA SYNTHESIS

Pre-post ESs were significant in 4 of 13 studies. The overall ES of .69 (95% confidence interval [CI], .29-1.09) suggests a medium effectiveness of psychological interventions on depressive symptoms compared with control conditions. Moderator analysis of the number of sessions and adequate randomization procedure did not show significant ES differences between strata. Studies with adequate randomization did not, however, suggest the effectiveness of psychological interventions on depressive symptoms after ABI.

CONCLUSIONS

Psychological interventions are a promising treatment option for depressive symptoms in long-term rehabilitation after ABI. Since only a few adequately randomized controlled trials (RCTs) exist, more RCTs are required to confirm this initial finding.

Bringing Single-case Methodology into the Clinic to Enhance Evidence-based Practices

There are many challenges in incorporating an evidence-based approach into clinical practice and a large literature exists on various barriers and facilitators. Within this context, we have developed a framework to advocate an empirical approach to therapeutic interventions, using our Model to Assess Treatment Effect (MATE). The MATE is designed to characterise how an intervention is delivered to an individual patient/client. It is organised hierarchically into seven levels, from low levels of capacity to demonstrate treatment effect (e.g., Level 1: treatment commenced without pre-intervention assessment) to high levels where cause–effect relationships can be established between the intervention and the behaviour being treated (e.g., Level 6: implementation of a well-designed single-case experimental design). Consequently, the MATE captures all levels of clinical intervention and can be applied readily to an individual patient, as well as an entire clinical setting. In this paper, we present a decision tree in the form of a detailed flow-chart which assists the clinician to classify treatment delivery on the MATE. We believe that the MATE has the capacity not only to document current clinical practice, but also to provide a model whereby future treatments can be planned and implemented with greater scientific rigour and hence accountability in relation to treatment outcomes.

A randomised controlled trial evaluating a brief intervention for deficits in recognising emotional prosody following severe ABI

Many adults with acquired brain injuries, including traumatic brain injuries (TBI) have impaired emotion perception. Impaired perception of emotion in voice can occur independently to facial expression and represents a specific target for remediation. No research to date has addressed this. The current study used a randomised controlled trial to examine the efficacy of a short treatment (three x two-hour sessions) for improving the ability to recognise emotional prosody for people with acquired brain injury, mostly TBI. Ten participants were allocated to treatment and 10 to waitlist. All participants remained involved for the duration of the study in the groups to which they were allocated. There were no significant treatment effects for group, but analyses of individual performances indicated that six of the treated participants made demonstrable improvements on objective measures of prosody recognition. The reasons why some participants showed improvements while others did not, was not obvious. Improvements on objective lab-based measures did not generalise to relative reports of improvements in everyday communicative ability. Nor was there clear evidence of long-term effects. In conclusion, treatment of emotional prosody was effective in the short-term for half of the participants. Further research is required to determine what conditions are required to optimise generalisability and longer-term gains.

Strategies to Improve Research Outcomes in the Field of Acquired Brain Injury: The Kevin Bacon Effect, Networking and Other Stories

This paper describes the added value that arises from capitalising on academic and social networks for researchers and people with acquired brain injury. First, it is proposed that brain injury researchers are connected within six degrees of separation. As a model, ‘The Oracle of Bacon’ demonstrates how any actor can be linked through his or her film roles to the actor Kevin Bacon within six steps. This concept is extrapolated to the existing networks of brain injury researchers. Capitalising on these networks can lead to potent and ground-breaking discoveries. The Clinical Centre of Research Excellence (CCRE) in Aphasia Rehabilitation provides an example of the benefits of networking and collaboration in the quest to improve the lives of people with aphasia. The CCRE uses multiple theoretical perspectives in studies evaluating the assessment and treatment of aphasia. It is utilising capacity building, knowledge translation and a community of practice to inform and expand research capacity. Networks can also be used to improve the communication of people with brain injury within their everyday environment. A recent study is described where communication partners were trained to improve the interactions of people with traumatic brain injury, which led to improvements in social networks and improved engagement in life activities. Finally, it is suggested that with the advances in e-communication, there is a great deal of scope for the use of social networking technologies in the assessment and treatment of people with acquired brain injury.

Treatment of post-traumatic cognitive impairments

OPINION STATEMENT

• Cognitive impairment is a common consequence of traumatic brain injury (TBI) and a substantial source of disability. Across all levels of TBI severity, attention, processing speed, episodic memory, and executive function are most commonly affected.• The differential diagnosis for post-traumatic cognitive impairments is broad, and includes emotional, behavioral, and physical problems as well as substance use disorders, medical conditions, prescribed and self-administered medications, and symptom elaboration. Thorough neuropsychiatric assessment for such problems is a prerequisite to treatments specifically targeting cognitive impairments.• First-line treatments for post-traumatic cognitive impairments are nonpharmacologic, including education, realistic expectation setting, environmental and lifestyle modifications, and cognitive rehabilitation.• Pharmacotherapies for post-traumatic cognitive impairments include uncompetitive N-methyl-D-aspartate receptor (NMDA) antagonists, medications that directly or indirectly augment cerebral catecholaminergic or acetylcholinergic function, or agents with combinations of these properties.• In the immediate post-injury period, treatment with uncompetitive NMDA receptor antagonists reduces duration of unconsciousness. The mechanism for this effect may involve attenuation of neurotrauma-induced glutamate-mediated excitotoxicity and/or stabilization of glutamate signaling in the injured brain.• During the subacute or late post-injury periods, medications that augment cerebral acetylcholinergic function may improve declarative memory. Among responders to this treatment, secondary benefits on attention, processing speed, and executive function impairments as well as neuropsychiatric disturbances may be observed. During these post-injury periods, medications that augment cerebral catecholaminergic function may improve hypoarousal, processing speed, attention, and/or executive function as well as comorbid depression or apathy.• When medications are used, a "start-low, go-slow, but go" approach is encouraged, coupled with frequent reassessment of benefits and side effects as well as monitoring for drug-drug interactions. Titration to either beneficial effect or medication intolerance should be completed before discontinuing a treatment or augmenting partial responses with additional medications.

An exploration of participant experience of a communication training program for people with traumatic brain injury and their communication partners

PURPOSE

To investigate the experiences of participants who attended communication training programs for people with traumatic brain injury (TBI) and their everyday communication partners (CP) as part of a non-randomised controlled trial.

METHOD

The participants were people with TBI and their CP, who were family members or carers of the people with TBI. Twenty-six participants (13 participants with TBI and 13 CP) completed the JOINT program, which involved participants with TBI and CP attending the program together. Fourteen participants with TBI completed the TBI SOLO training program, which did not involve the participation of a CP. Semi-structured videotaped interviews were completed by all participants at the end of the training. Using a six-step generic analysis procedure, data were categorised into topics and then subtopics to identify conceptually discrete units.

RESULTS

Participants described improvements in communication skills, the impact of improved communication skills, valuable components of the programs and components that needed changes.

CONCLUSION

The accounts of participants provided additional evidence for the effectiveness of the training programs, assisted with identifying helpful components of the training and demonstrated the usefulness of a qualitative research methodology as part of evaluating the outcomes of the clinical trial.

Beyond utterances: distributed cognition as a framework for studying discourse in adults with acquired brain injury

Considerable effort has been directed at understanding the nature of the communicative deficits observed in individuals with acquired brain injuries. Yet several theoretical, methodological, and clinical challenges remain. In this article, we examine distributed cognition as a framework for understanding interaction among communication partners, interaction of communication and cognition, and interaction with the environments and contexts of everyday language use. We review the basic principles of distributed cognition and the implications for applying this approach to the study of discourse in individuals with cognitive-communication disorders. We also review a range of protocols and findings from our research that highlight how the distributed cognition approach might offer a deeper understanding of communicative mechanisms and deficits in individuals with cognitive communication impairments. The advantages and implications of distributed cognition as a framework for studying discourse in adults with acquired brain injury are discussed.

Assessing Social Skills in People With Very Severe Traumatic Brain Injury: Validity of the Social Performance Survey Schedule (SPSS)

The current study was designed to determine whether the Social Performance Survey Schedule (SPSS; Lowe & Cautela, 1978) is a useful measure of social skills in people with traumatic brain injuries (TBI). Forty-nine adults with TBI were compared on the SPSS to 190 adults without injuries. The validity of the SPSS was also investigated in relation to another measure of social performance, the first scale of the Katz Adjustment Scale (KAS-R1; Katz & Lyerly, 1963) and a broad measure of social function (the SPRS; Tate, Hodgkinson, Veerabangsa, & Maggiotto, 1999). Individuals with TBI had significantly lower scores on the positive scale of the SPSS than nonbrain-injured individuals. They did not have lower scores on the SPSS negative scale relative to the normative sample. Significant correlations with the KAS-R1 and SPRS provided evidence for the construct and criterion validity of SPSS within this population. In conclusion, this study suggests that where an appropriate normative sample is used, the positive subscale of the SPSS is a sound measure for detecting the extent and nature of deficits in prosocial behaviour seen in TBI, but raises the question as to how we define negative behaviours in the 21st century on scales such as the SPSS.

Training Communication Partners of People With Traumatic Brain Injury: Reporting the Protocol for a Clinical Trial

This article reports on the design of a three-arm, nonrandomised controlled trial of interventions targeting social communication skills following traumatic brain injury (TBI) in adult participants. People with severe TBI were allocated to one of the three groups: the TBI group, where only the person with TBI was trained, the JOINT group where both the everyday communication partner (ECP) and the person with TBI were trained together, and a delayed treatment control condition. The trial is comparing whether including everyday communication partners in the training process provide additional benefit when compared to training the person with TBI alone; and additionally, whether training the person with TBI alone is more effective than no training. A range of primary and secondary outcome measures will be used to evaluate outcomes. Publishing the protocol prior to the results of the trial being available has several important benefits (Godlee, 2001). The original hypotheses and intentions of the research are made explicit to ensure that the process of conducting this clinical trial is transparent to readers, and so that comments may be made before results are finalised. It provides the opportunity to outline a detailed description of this intervention and methodology, or to acknowledge changes to methodology, which may assist with eventual clinical application of the intervention. This article also informs the research community of the work that is underway to promote opportunities for collaboration and reduce unnecessary duplication of research. The protocol for this trial has previously been registered on Current Controlled Trials (http://www.controlled-trials.com/ISRCTN57815281).

A Multidisciplinary Social Communication and Coping Skills Group Intervention for Adults with Acquired Brain Injury (ABI): A Pilot Feasibility Study in an Inpatient Setting

There is evidence that individuals with an acquired brain injury (ABI) are at increased risk of developing psychological problems and that they commonly experience difficulties in social communication, associated with poorer long-term outcomes. Although several relevant group interventions have been evaluated, there has been limited exploration of the feasibility of an ABI inpatient intervention. This nonrandomised pilot study tested the feasibility of an inpatient multidisciplinary social communication and coping skills group intervention within 1-year post traumatic/nontraumatic ABI. Seven participants completed a 4-week group program (3 × 1 hour sessions per week) facilitated by a speech pathologist and clinical psychologist and were assessed pre/post intervention and at 3 months with the La Trobe Communication Questionnaire, Correct Information Unit analysis, Hospital Anxiety and Depression Scale, Mini International Neuropsychiatric Interview, Coping Self-Efficacy scale and World Health Organization Quality of Life assessment. Most participants improved between baseline and 3 months post intervention in terms of greater informativeness and efficiency of connected speech and reduced anxiety and they provided positive feedback about the group program. Despite the challenges and limitations of this pilot study, the findings are encouraging and support both the value and feasibility of developing such a program into routine inpatient rehabilitation services.

Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008

OBJECTIVE

To update our clinical recommendations for cognitive rehabilitation of people with traumatic brain injury (TBI) and stroke, based on a systematic review of the literature from 2003 through 2008.

DATA SOURCES

PubMed and Infotrieve literature searches were conducted using the terms attention, awareness, cognitive, communication, executive, language, memory, perception, problem solving, and/or reasoning combined with each of the following terms: rehabilitation, remediation, and training for articles published between 2003 and 2008. The task force initially identified citations for 198 published articles.

STUDY SELECTION

One hundred forty-one articles were selected for inclusion after our initial screening. Twenty-nine studies were excluded after further detailed review. Excluded articles included 4 descriptive studies without data, 6 nontreatment studies, 7 experimental manipulations, 6 reviews, 1 single case study not related to TBI or stroke, 2 articles where the intervention was provided to caretakers, 1 article redacted by the journal, and 2 reanalyses of prior publications. We fully reviewed and evaluated 112 studies.

DATA EXTRACTION

Articles were assigned to 1 of 6 categories reflecting the primary area of intervention: attention; vision and visuospatial functioning; language and communication skills; memory; executive functioning, problem solving and awareness; and comprehensive-holistic cognitive rehabilitation. Articles were abstracted and levels of evidence determined using specific criteria.

DATA SYNTHESIS

Of the 112 studies, 14 were rated as class I, 5 as class Ia, 11 as class II, and 82 as class III. Evidence within each area of intervention was synthesized and recommendations for Practice Standards, Practice Guidelines, and Practice Options were made.

CONCLUSIONS

There is substantial evidence to support interventions for attention, memory, social communication skills, executive function, and for comprehensive-holistic neuropsychologic rehabilitation after TBI. Evidence supports visuospatial rehabilitation after right hemisphere stroke, and interventions for aphasia and apraxia after left hemisphere stroke. Together with our prior reviews, we have evaluated a total of 370 interventions, including 65 class I or Ia studies. There is now sufficient information to support evidence-based protocols and implement empirically-supported treatments for cognitive disability after TBI and stroke.