Evaluation of the short-term executive plus intervention for executive dysfunction after traumatic brain injury: a randomized controlled trial with minimization

Cognitive Training for Post-Acute Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Objective: To quantitatively aggregate effects of cognitive training (CT) on cognitive and functional outcome measures in patients with traumatic brain injury (TBI) more than 12-months post-injury.

Design: We systematically searched six databases for non-randomized and randomized controlled trials of CT in TBI patients at least 12-months post-injury reporting cognitive and/or functional outcomes.

Main Measures: Efficacy was measured as standardized mean difference (Hedges’ g) of post-training change. We investigated heterogeneity across studies using subgroup analyses and meta-regressions.

Results: Fourteen studies encompassing 575 patients were included. The effect of CT on overall cognition was small and statistically significant (g = 0.22, 95%CI 0.05 to 0.38; p = 0.01), with low heterogeneity (I² = 11.71%) and no evidence of publication bias. A moderate effect size was found for overall functional outcomes (g = 0.32, 95%CI 0.08 to 0.57, p = 0.01) with low heterogeneity (I² = 14.27%) and possible publication bias. Statistically significant effects were also found only for executive function (g = 0.20, 95%CI 0.02 to 0.39, p = 0.03) and verbal memory (g = 0.32, 95%CI 0.14 to 0.50, p < 0.01).

Conclusion: Despite limited studies in this field, this meta-analysis indicates that CT is modestly effective in improving cognitive and functional outcomes in patients with post-acute TBI and should therefore play a more significant role in TBI rehabilitation.

Goal Management Training Combined With External Cuing as a Means to Improve Emotional Regulation, Psychological Functioning, and Quality of Life in Patients With Acquired Brain Injury: A Randomized Controlled Trial

OBJECTIVE

To investigate whether goal management training (GMT) expanded to include external cuing and an emotional regulation module is associated with improved emotional regulation, psychological functioning, and quality of life (QOL) after chronic acquired brain injury (ABI).

DESIGN

Randomized controlled trial with blinded outcome assessment at baseline, posttraining, and 6-month follow-up.

SETTING

Outpatient.

PARTICIPANTS

Persons with ABI and executive dysfunction (N=70; 64% traumatic brain injury; 52% men; mean age ± SD, 43±13y; mean time since injury ± SD, 8.1±9.4y).

INTERVENTION

Eight sessions of GMT in groups, including a new module addressing emotional regulation, and external cuing. A psychoeducative control condition (Brain Health Workshop) was matched on amount of training, therapist contact, and homework.

MAIN OUTCOME MEASURES

Emotional regulation was assessed with the Brain Injury Rehabilitation Trust Regulation of Emotions Questionnaire, the Emotional Control subscale and the Emotion Regulation factor (Behavior Rating Inventory of Executive Function-Adult Version), and the Positive and Negative Affect subscales from the Dysexecutive Questionnaire. Secondary outcome measures included psychological distress (Hopkins Symptom Checklist-25) and QOL (Quality of Life After Brain Injury Scale).

RESULTS

Findings indicated beneficial effects of GMT on emotional regulation skills in everyday life and in QOL 6 months posttreatment. No intervention effects on measures of psychological distress were registered.

CONCLUSIONS

GMT is a promising intervention for improving emotional regulation after ABI, even in the chronic phase. More research using objective measures of emotional regulation is needed to investigate the efficacy of this type of training.

Treatment of persistent post-concussive symptoms after mild traumatic brain injury: a systematic review of cognitive rehabilitation and behavioral health interventions in military service members and veterans

Increased prevalence of traumatic brain injury (TBI) has been associated with service members and veterans who completed combat deployments in support of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Management of persistent post-concussive symptoms (PCS) has been a challenge to healthcare providers throughout the Military and Veterans Healthcare Systems, as well as civilian healthcare providers, due in part to the chronic nature of symptoms, co-occurrence of behavioral health disorders such as depression, Posttraumatic Stress Disorder (PTSD), and substance use disorders, and fear of a potential stigma associated with psychiatric diagnoses and behavioral health treatment(s). This systematic review examined non-pharmacologic behavioral health interventions and cognitive rehabilitation interventions for PCS in military service members and veterans with a history of mild TBI (mTBI). Six electronic databases were searched with specific term limitations, identifying 121 citations. Ultimately, 19 articles met criteria for inclusion in this systematic review. Studies were broadly categorized into four subtypes: psychoeducational interventions, cognitive rehabilitation, psychotherapeutic approaches, and integrated behavioral health interventions for PCS and PTSD. The review provides an update of the empirical evidence for these four types of interventions for PCS in active duty service members and veterans. Recommendations for future research are discussed, including the need to expand and improve the limited evidence basis on how to manage persistent post-concussive symptoms in this population.

Rehabilitation of Executive Functions in Patients with Chronic Acquired Brain Injury with Goal Management Training, External Cuing, and Emotional Regulation: A Randomized Controlled Trial

Executive dysfunction is a common consequence of acquired brain injury (ABI), causing significant disability in daily life. This randomized controlled trial investigated the efficacy of Goal Management Training (GMT) in improving executive functioning in patients with chronic ABI. Seventy patients with a verified ABI and executive dysfunction were randomly allocated to GMT (n=33) or a psycho-educative active control condition, Brain Health Workshop (BHW) (n=37). In addition, all participants received external cueing by text messages. Neuropsychological tests and self-reported questionnaires of executive functioning were administered pre-intervention, immediately after intervention, and at 6 months follow-up. Assessors were blinded to group allocation. Questionnaire measures indicated significant improvement of everyday executive functioning in the GMT group, with effects lasting at least 6 months post-treatment. Both groups improved on the majority of the applied neuropsychological tests. However, improved performance on tests demanding executive attention was most prominent in the GMT group. The results indicate that GMT combined with external cueing is an effective metacognitive strategy training method, ameliorating executive dysfunction in daily life for patients with chronic ABI. The strongest effects were seen on self-report measures of executive functions 6 months post-treatment, suggesting that strategies learned in GMT were applied and consolidated in everyday life after the end of training. Furthermore, these findings show that executive dysfunction can be improved years after the ABI.

Effectiveness of Interventions to Address Cognitive Impairments and Improve Occupational Performance After Traumatic Brain Injury: A Systematic Review

OBJECTIVE. To determine the effectiveness of interventions addressing cognitive impairments to improve occupational performance for people with traumatic brain injury.

METHOD. A total of 37 studies met inclusion criteria: 9 Level I systematic reviews, 14 Level I studies, 5 Level II studies, and 9 Level III studies.

RESULTS. Strong evidence supports use of direct attention training, dual-task training, and strategy training to optimize executive functioning, encoding, and use of memory compensations, including assistive technology. However, in most studies, occupational performance was a secondary outcome, if it was evaluated at all.

CONCLUSION. Although evidence supports many intervention approaches used by occupational therapy practitioners to address cognitive impairments of adults with traumatic brain injury, more studies are needed in which occupational performance is the primary outcome of cognitive intervention.

Factor structure and item level psychometrics of the Social Problem Solving Inventory-Revised: Short Form in traumatic brain injury

Social problem-solving deficits characterise individuals with traumatic brain injury (TBI), and poor social problem solving interferes with daily functioning and productive lifestyles. Therefore, it is of vital importance to use the appropriate instrument to identify deficits in social problem solving for individuals with TBI. This study investigates factor structure and item-level psychometrics of the Social Problem Solving Inventory-Revised: Short Form (SPSI-R:S), for adults with moderate and severe TBI. Secondary analysis of 90 adults with moderate and severe TBI who completed the SPSI-R:S was performed. An exploratory factor analysis (EFA), principal components analysis (PCA) and Rasch analysis examined the factor structure and item-level psychometrics of the SPSI-R:S. The EFA showed three dominant factors, with positively worded items represented as the most definite factor. The other two factors are negative problem-solving orientation and skills; and negative problem-solving emotion. Rasch analyses confirmed the three factors are each unidimensional constructs. It was concluded that the total score interpretability of the SPSI-R:S may be challenging due to the multidimensional structure of the total measure. Instead, we propose using three separate SPSI-R:S subscores to measure social problem solving for the TBI population.

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.

Screening for traumatic brain injury: findings and public health implications

OBJECTIVE

To provide an overview of a series of projects that used a structured self-report screening tool in diverse settings and samples to screen for lifetime history of traumatic brain injury (TBI).

SETTING

Diverse community settings.

PARTICIPANTS

Homeless persons (n = 111), individuals with HIV seeking vocational rehabilitation (n = 173), youth in the juvenile justice system (n = 271), public schoolchildren (n = 174), substance users (n = 845), intercollegiate athletes (n = 90), and other community-based samples (n = 396).

DESIGN

Cross-sectional.

MAIN MEASURE

Brain Injury Screening Questionnaire.

RESULTS

Screening using the Brain Injury Screening Questionnaire finds that 27% to 54% of those in high-risk populations report a history of TBI with chronic symptoms. Associations between TBI and social, academic, or other problems are evident in several studies. In non-high-risk community samples, 9% to 12% of individuals report TBI with chronic symptoms.

CONCLUSION

Systematic TBI screening can be implemented efficiently and inexpensively in a variety of settings. Lifetime TBI history data gathered using a structured self-report instrument can augment existing estimates of the prevalence of TBI, both as an acute event and as a chronic condition. Identification of individuals with TBI can facilitate primary prevention efforts, such as reducing risk for reinjury in high-risk groups, and provide access to appropriate interventions that can reduce the personal and societal costs of TBI (tertiary prevention).

Delivering group treatment via videoconference to individuals with traumatic brain injury: a feasibility study

The objective was to assess the feasibility of delivering a group treatment to improve emotional regulation via videoconferencing to individuals with traumatic brain injury (TBI). A pre-post feasibility study was undertaken. Seven individuals with TBI were recruited at a brain injury research centre in an urban medical centre. The main measures were therapist assessment of session-by-session progress and feasibility, Difficulties in Emotion Regulation Scale (DERS), Brain Injury Rehabilitation Trust Regulation of Emotions Questionnaire (BREQ), Satisfaction with Therapy and Therapist Scale (STTS), and exit interview. Attendance across sessions and participants was over 90%. Adequate skill acquisition and ease of use of the technology were demonstrated. Self-reported satisfaction with treatment was high. Participants noted several benefits in terms of the treatment delivery modality. There was no change is self-reported emotional dysregulation. This is the first study to report the use of videoconferencing for the delivery of group treatment to individuals with TBI. The exceptional compliance and self-reported satisfaction suggest that this treatment delivery option could be a viable alternative for increasing access to healthcare in this population. The findings of the study supported the development of a large clinical trial to assess treatment effectiveness.