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

Classification of Rehabilitation Participation in Elderly In-patients with Mild Cognitive Impairments Utilizing Physiological Responses

This study investigated the possibility of utilising physiological responses and machine learning techniques to determine the degree of participation of in-patients with mild cognitive impairment at rehabilitation institutions. Physiological signals related to autonomic functions, cardio-activity, sweat gland activation, and skin surface temperature were obtained, and machine learning classifiers were used to classify rehabilitation participation levels as higher or lower participation when participants were required to perform a VR-based rehabilitative task. Classifiers such as a decision tree or support vector machine can effectively determine two different levels of participation suggesting the proposed approach can help therapists assess an important aspect of client satisfaction.

Brain-computer interfaces in neurologic rehabilitation practice

The brain-computer interfaces (BCIs) for neurologic rehabilitation are based on the assumption that by retraining the brain to specific activities, an ultimate improvement of function can be expected. In this chapter, we review the present status, key determinants, and future directions of the clinical use of BCI in neurorehabilitation. The recent advancements in noninvasive BCIs as a therapeutic tool to promote functional motor recovery by inducing neuroplasticity are described, focusing on stroke as it represents the major cause of long-term motor disability. The relevance of recent findings on BCI use in spinal cord injury beyond the control of neuroprosthetic devices to restore motor function is briefly discussed. In a dedicated section, we examine the potential role of BCI technology in the domain of cognitive function recovery by instantiating BCIs in the long history of neurofeedback and some emerging BCI paradigms to address cognitive rehabilitation are highlighted. Despite the knowledge acquired over the last decade and the growing number of studies providing evidence for clinical efficacy of BCI in motor rehabilitation, an exhaustive deployment of this technology in clinical practice is still on its way. The pipeline to translate BCI to clinical practice in neurorehabilitation is the subject of this chapter.

Multidisciplinary rehabilitation of a post-stroke pediatric patient considering the ICF perspective

PURPOSE

There is a general lack of evidence on the efficacy of rehabilitation training methods after childhood stroke. The aim of the current paper is to provide an example of a multidisciplinary assessment and intensive patient-centered rehabilitation program that was devised following the Clinical Guidelines for Childhood Stroke Diagnosis, Management and Rehabilitation, based on the International Classification of Functioning, Disability and Health.

METHOD

The case of a 13-year-old teenager with physical, linguistic, cognitive and emotional impairments after acute ischemic stroke (AIS) in left middle cerebral artery territories is presented and his neurorehabilitation program is described.

RESULTS

After an intensive and comprehensive rehabilitation period, the patient showed significant improvement involving language abilities, cognitive flexibility, logical reasoning and motor independence. A 6-month post-stroke follow-up evaluation showed further gains in spontaneous language, improved motivation and collaboration, reduction of impulsiveness and better general motor stability.

CONCLUSION

This case highlights how an intensive, patient-centered, interdisciplinary rehabilitation approach can lead to good improvement across different domains, maximizing the spontaneous recovery in children and adolescents after AIS.

Treatment of spatial neglect in clinical practice: A nationwide survey

OBJECTIVES

Clinical research has documented a range of evidence-based treatment approaches for spatial neglect (SN), but there is a lack of research on the implementation of treatment into clinical practice. The purpose of this study is to describe the current clinical practice of SN treatment across healthcare sectors including involved professions, methods, timing and sources of evidence.

MATERIAL AND METHODS

This is the second part of a nationwide, anonymous, open Internet survey that was conducted among healthcare professionals in Denmark on assessment and treatment of SN.

RESULTS

A total of 525 healthcare professionals participated in the survey of which 411 (78.3%) reported that SN treatment was provided at their workplace. Occupational and physiotherapist were most often involved in the treatment, most commonly characterized by training of activities of daily living (ADL), sensoric stimulation and cueing. Less frequently reported were evidence-based methods such as prism adaptation and visual scanning. The overall intensity of the SN treatment varied considerably across sectors and might consequently be inadequate. A minority of the participants consulted clinical research evidence in their choice of SN treatment approaches.

CONCLUSIONS

There is a profound lack of dissemination and translation of clinical research into current clinical practice, which unarguably leads to an underuse of evidence-based treatment approaches in SN rehabilitation. The results call for international multidisciplinary clinical guidelines for the treatment of SN at different stages of rehabilitation and the tailoring of treatment approaches to the individual patient.

Virtual Reality for Pediatric Traumatic Brain Injury Rehabilitation: A Systematic Review

Objective. Pediatric traumatic brain injury (TBI) is associated with physical and psychobehavioral impairment in children. Effective rehabilitation programs postinjury are critical for children with TBI. Virtual reality (VR) has been increasingly adopted for brain injury rehabilitation. However, scientific synthesis is lacking in evaluating its effectiveness in pediatric TBI rehabilitation. This article aimed to conduct a systematic review on the effectiveness of VR-based pediatric TBI rehabilitation. Methods. A systematic literature search was conducted in PubMed, PsycInfo, SCOPUS, CENTRAL, BioMed Central, CiNAHL, and Web of Science through November 2015. Personal libraries and relevant references supplemented the search. Two authors independently reviewed the abstracts and/or full text of 5824 articles. Data extraction and qualitative synthesis was conducted along with quantitative assessment of research quality by 2 authors. Results. A positive impact was found for VR-based interventions on children's physical rehabilitation post-TBI. The quality of research evidence was moderate, which largely suffered from small samples, lack of immersive VR experience, and lack of focus on socioemotional outcomes post-TBI. Conclusions. The present review identified positive effects of VR interventions for pediatric TBI rehabilitation especially in physical outcomes. Future research should include larger samples and broader post-TBI outcomes in children using VR-based interventions.

Metacognitive knowledge and functional outcomes in adults with acquired brain injury: A meta-analysis

Pronounced difficulties in functional outcomes often follow acquired brain injury (ABI), and may be due, in part, to deficits in metacognitive knowledge (being unaware of one's cognitive strengths and limitations). A meta-analytic review of the literature investigating the relationship between metacognitive knowledge and functional outcomes in ABI is timely, particularly given the presence of apparently inconsistent findings. Twenty-two articles revealed two distinct methods of measuring metacognitive knowledge: (1) absolute (the degree of inaccurate self-appraisal regardless of whether the error tends towards under- or over-confident estimations) and (2) relative (the degree and the direction of the inaccuracy) discrepancy. Separate meta-analyses were conducted for absolute and relative discrepancy studies to assess the relationship between metacognitive knowledge and functional outcomes (affect-related quality of life, family and community integration, and work outcomes). The pattern of results found suggested that better metacognitive knowledge is related to better overall functional outcomes, but the relationship may differ depending on the outcome domain. These findings generally support the importance of focusing on metacognitive knowledge to improve outcomes following ABI. Nonetheless, the relatively small effect sizes observed suggest that other predictors of functional outcome should be investigated, including other subdomains of metacognition.

Both Individual and Group-Based Neuropsychological Interventions of Dyslexia Improve Processing Speed in Young Adults: A Randomized Controlled Study

Effectiveness of individual and group-based neuropsychological interventions on cognitive aspects of dyslexia in young adults was evaluated. Dyslexic adults were randomly assigned into individual intervention (n = 40), group intervention (n = 40), or wait-list control group (n = 40). The interventions focused on cognitive strategy learning, supporting self-esteem, and using psychoeducation. Cognitive performance and symptoms were assessed via psychometric testing and self-report questionnaires at baseline, after the intervention/wait-list control time at 5 months and at 10 months. And, 15 months post intervention long-term status was checked via mailed inquiry. Wait-list control group also received an intervention after the 5-month control period. No significant effects were found in primary self-report outcome measures. Both interventions had a positive effect on a measure of processing speed and attention and the effect remained after the 5-month follow-up period. In self-reported cognitive symptoms, a positive trend was evident in self-reported reading habits. Furthermore, minor self-evaluated benefits reaching up to 15 months post intervention were found. There were no significant differences between the results of individual and group intervention as both interventions improved cognitive performance. The results indicate that a structured neuropsychological intervention could be effective in ameliorating dyslexia-related cognitive symptoms in young adults.

Participation Following Inpatient Rehabilitation for Traumatic Disorders of Consciousness: A TBI Model Systems Study

Severe traumatic brain injury (TBI) may result in a disorder of consciousness (DoC) and lead to substantial long-term disability. While level of independence with activities of daily living, especially for persons who recover consciousness during inpatient rehabilitation, generally improves over time, the degree of change in participation remains unknown. We determined level of participation among persons with TBI between 2005 and 2017 who were admitted to inpatient rehabilitation unable to follow commands and subsequently enrolled in the TBI Model Systems National Database. Participation on the Participation Assessment with Recombined Tools-Objective (PART-O) Productivity, Social Relations, and Out and About subscales was evaluated at 1-5 years post-injury. We used a mixed-effects model to longitudinally compare participation between persons who did and did not regain command-following during inpatient rehabilitation. We further explored the level of participation associated with increasing levels of functional independence (FIM). The analysis included 333 persons (229 recovered command-following during rehabilitation, mean age = 35.46 years, 74.9% male). Participation across groups, at all follow-up time points, on all PART-O subscales, was remarkably low (mean range = 0.021-1.91, maximum possible score = 5). Performance was highest on the Social Relations subscale and lowest on the Productivity subscale. Longitudinal analyses revealed no difference in level of participation or change in participation across time for persons who regained command-following during rehabilitation compared to those who did not. While productivity increased over time, social participation did not and participation outside the home increased more for younger than for older persons. Across all three PART-O subscales, FIM Motor scores positively predicted participation. FIM Cognitive scores positively predicted level of participation on the Productivity and Social Relations subscales. Exploratory analyses revealed that even persons who achieved independence on the FIM Motor and Cognitive subscales had low levels of participation across domains and follow-up years. In summary, persons with severe TBI who were admitted to inpatient rehabilitation unable to follow commands were found to be unlikely to participate in productive tasks, social endeavors, or activities outside of the home up to 5 years post-injury, even if functional independence was recovered.

Activity Performance, Participation, and Quality of Life Among Adults in the Chronic Stage After Acquired Brain Injury-The Feasibility of an Occupation-Based Telerehabilitation Intervention

Objective: Acquired brain injury (ABI) is a leading cause of long-term disability. This calls for effective and accessible interventions to support participation in the community over time. One promising avenue to answer this need is telerehabilitation. Prior to conducting a larger trial, the main objective of this pilot study is to explore the feasibility, acceptability, and preliminary efficacy of a metacognitive occupation-based intervention in a telerehabilitation format with adults and older adults in the chronic phase after ABI.

Methods: Five community dwelling participants (ages 65–72), 6–10 months post-ABI, with scores 2–4 on the modified Rankin scale and without dementia, completed the teleintervention. The intervention included ~10 weekly videoconferencing sessions administered by an occupational therapist using the Cognitive Orientation to Daily Occupational Performance approach. Each participant defined five functional goals and three were trained and two were not trained during the intervention. Evaluations were conducted at pre, post, and 3-month follow-up. The primary outcome measures included activity performance (The Canadian Occupational Performance Measure; COPM), participation (the Mayo-Portland Adaptability Inventory-4 Participation Index; MPAI-4-P), and quality of life (QoL) (stroke impact scale; SIS). Other measures included a feedback interview, satisfaction questionnaire, field notes, and a treatment fidelity checklist.

Results: The teleintervention was found to be feasible and the participants expressed a high degree of satisfaction with the intervention and the technology use. A Wilcoxon Signed-Ranks test indicated statistically significant improvements post intervention in COPM performance (z = −2.023, p = 0.043) and satisfaction (z = −2.023, p = 0.043) ratings. Additionally, clinically significant improvements (≥2 points) in both performance and satisfaction with performance were found for each participant in at least three of their five defined functional goals. Trends toward significant improvement were found in MPAI-4-P ratings post intervention (z = −1.826, p = 0.068). Furthermore, clinically significant improvements (≥15 points) post intervention were found for each participant in some subscales of the SIS. Results were partially maintained at 3-month follow-up.

Conclusions: This pilot study demonstrated the feasibility of a metacognitive occupation-based telerehabilitation intervention and its potential benefits in activity performance, participation, and QoL for older adults coping with long-term disability following ABI.

Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03048708.

Traumatic brain injury in homeless and marginally housed individuals: a systematic review and meta-analysis

BACKGROUND

Homelessness is a global public health concern, and traumatic brain injury (TBI) could represent an underappreciated factor in the health trajectories of homeless and marginally housed individuals. We aimed to evaluate the lifetime prevalence of TBI in this population, and to summarise findings on TBI incidence and the association between TBI and health-related or functioning-related outcomes.

METHODS

For this systematic review and meta-analysis, we searched without date restrictions for original research studies in English that reported data on the prevalence or incidence of TBI, or the association between TBI and one or more health-related or function-related outcome measures. Studies were included if they had a group or clearly identifiable subgroup of individuals who were homeless, marginally housed, or seeking services for homeless people. With use of random-effects models, we calculated pooled estimates of the lifetime prevalence of any severity of TBI and the lifetime prevalence of moderate or severe TBI. We used meta-regression and subgroup analysis to evaluate potential moderators of prevalence estimates and the leave-one-out method for sensitivity analyses. We then summarised findings from all studies that evaluated TBI incidence and the association between TBI and health-related or functioning-related outcomes. All statistical analyses were done using R version 3.5.1. The study is registered with PROSPERO, number CRD42019119678.

FINDINGS

Of 463 potentially eligible studies identified by the search, 38 studies were included in the systematic review and 22 studies were included in the meta-analysis. The lifetime prevalence of any severity of TBI in homeless and marginally housed individuals (18 studies, n=9702 individuals) was 53·1% (95% CI 46·4-59·7; I²=97%) and the lifetime prevalence of moderate or severe TBI (nine studies, n=5787) was 22·5% (13·5-35·0; I²=99%). The method used to ascertain TBI history, the age of the sample, and the sample size significantly moderated estimated lifetime prevalence of any severity of TBI. TBI was consistently associated with poorer self-reported physical and mental health, higher suicidality and suicide risk, memory concerns, and increased health service use and criminal justice system involvement.

INTERPRETATION

The lifetime prevalence of TBI is high among homeless and marginally housed individuals, and a history of TBI is associated with poorer health and general functioning. Health-care providers and public health officials should have an increased awareness of the burden of TBI in this population. Prospective and longitudinal studies are needed to better understand how the health of this population is affected by TBI.

FUNDING

Canadian Institutes of Health Research.

What is known about the cost-effectiveness of neuropsychological interventions for individuals with acquired brain injury? A scoping review

The aim of this scoping review was to examine the literature related to economic evaluations of neuropsychological rehabilitation in individuals with acquired brain injury (ABI). PsychINFO, Medline, EMBASE, Cochrane and CINHAL databases were searched in accordance with formal scoping review methodology. Studies were included if published between 1995 and 2019 with a study population of adults aged 18 years or more with any ABI aetiology and there was reported data on resource use, costs or comparative economic analyses as part of an outcome study for rehabilitation interventions. Case studies and trial protocols were excluded. Of 3575 records screened, 30 articles were identified as meeting the inclusion criteria. The majority of studies documented cost savings from provision of various models of multidisciplinary inpatient or outpatient rehabilitation. However, these benefits were estimated without a control group. Eight studies included a cost-effectiveness analysis, and in three, the intervention was reported to be cost-effective compared to the control, one of which saved $9,654 per treated patient. Overall, few eligible studies were identified. Those that included a cost-effectiveness analysis yielded mixed evidence for interventions to be considered cost-effective for ABI. Recommendations for how to incorporate cost-effectiveness analyses into intervention studies are discussed.

Evidence based practice and knowledge translation: A survey of Australian occupational therapy practice with clients experiencing neurocognitive impairments

INTRODUCTION

The clinical practice patterns and use of research evidence by Australian occupational therapists working with clients experiencing neurocognitive impairments has not been surveyed for nearly 10 years. This survey aimed to evaluate the current status of occupational therapy practice and evidence use and provide recommendations for ongoing evidence translation.

METHODS

An online survey of occupational therapists working in Australia was conducted over four months targeting registered clinicians working with adults experiencing neurocognitive impairments.

RESULTS

191 occupational therapists from a wide range of clinical practice areas, with a significant level of experience completed the survey. Functional retraining (n = 180, 94%), compensatory training (n = 173, 91%) and task/environmental modifications (n = 161, 84%) were the most commonly reported intervention techniques, while more targeted interventions such as context-sensitive training (n = 54, 28%), positive behaviour supports (n = 42, 22%) and metacognitive strategy training (n = 37, 19%) were used less frequently. Half the respondents were aware of current research evidence and suggested a wide range of strategies supporting evidence translation. Traditional barriers of limited time, access and skills to interpret research were also reported.

CONCLUSION

Consistent with earlier surveys most occupational therapists continue to use a functional/compensatory approach to cognitive rehabilitation, with an increasing number of therapists using specialist cognitive interventions. The current challenge for occupational therapists is embedding specialist techniques into occupation-based intervention. Knowledge translation and implementation strategies will be a critical component to achieving this.

The application of Strategy-based Training to Enhance Memory (STEM) in multiple sclerosis: A pilot RCT

New learning and memory (NLM) impairments are common in multiple sclerosis (MS), negatively impacting daily life. Few studies seek to remediate these deficits to improve everyday functioning. Self-generation, spaced learning and retrieval practice have been shown to improve NLM in healthy persons and have been incorporated into an 8-session treatment protocol, Strategy-based Training to Enhance Memory (STEM). STEM teaches participants about each of the techniques, how to apply them in daily life and provides practice. Participants are taught to restructure a memory-demanding situation to optimize self-generation, spaced learning and retrieval practice. This pilot double-blind, placebo-controlled, randomized clinical trial (RCT) tested the efficacy of STEM in 20 learning-impaired participants with clinically definite MS (9 treatment, 11 control). Significant treatment effects were noted on self-report measures of daily functioning (primary outcome). Objective neuropsychological testing approached significance, showing a medium-large effect on verbal NLM. Results suggest that STEM may improve everyday functioning in individuals with MS. A full-scale RCT is warranted to validate findings in a larger sample so that findings may be generalized to the broader MS community.

Cognitive rehabilitation for attention deficits following stroke

BACKGROUND

Many survivors of stroke report attentional impairments, such as diminished concentration and distractibility. However, the effectiveness of cognitive rehabilitation for improving these impairments is uncertain.This is an update of the Cochrane Review first published in 2000 and previously updated in 2013.

OBJECTIVES

To determine whether people receiving cognitive rehabilitation for attention problems 1. show better outcomes in their attentional functions than those given no treatment or treatment as usual, and 2. have a better functional recovery, in terms of independence in activities of daily living, mood, and quality of life, than those given no treatment or treatment as usual.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PsycBITE, REHABDATA and ongoing trials registers up to February 2019. We screened reference lists and tracked citations using Scopus.

SELECTION CRITERIA

We included controlled clinical trials (CCTs) and randomised controlled trials (RCTs) of cognitive rehabilitation for impairments of attention for people with stroke. We did not consider listening to music, meditation, yoga, or mindfulness to be a form of cognitive rehabilitation. We only considered trials that selected people with demonstrable or self-reported attentional deficits. The primary outcomes were measures of global attentional functions, and secondary outcomes were measures of attentional domains (i.e. alertness, selective attention, sustained attention, divided attention), functional abilities, mood, and quality of life.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data, and assessed the risk of bias. We used the GRADE approach to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included no new trials in this update. The results are unchanged from the previous review and are based on the data of six RCTs with 223 participants. All six RCTs compared cognitive rehabilitation with a usual care control. Meta-analyses demonstrated no convincing effect of cognitive rehabilitation on subjective measures of attention either immediately after treatment (standardised mean difference (SMD) 0.53, 95% confidence interval (CI) -0.03 to 1.08; P = 0.06; 2 studies, 53 participants; very low-quality evidence) or at follow-up (SMD 0.16, 95% CI -0.23 to 0.56; P = 0.41; 2 studies, 99 participants; very low-quality evidence). People receiving cognitive rehabilitation (when compared with control) showed that measures of divided attention recorded immediately after treatment may improve (SMD 0.67, 95% CI 0.35 to 0.98; P < 0.0001; 4 studies, 165 participants; low-quality evidence), but it is uncertain that these effects persisted (SMD 0.36, 95% CI -0.04 to 0.76; P = 0.08; 2 studies, 99 participants; very low-quality evidence). There was no evidence for immediate or persistent effects of cognitive rehabilitation on alertness, selective attention, and sustained attention. There was no convincing evidence for immediate or long-term effects of cognitive rehabilitation for attentional problems on functional abilities, mood, and quality of life after stroke.

AUTHORS' CONCLUSIONS

The effectiveness of cognitive rehabilitation for attention deficits following stroke remains unconfirmed. The results suggest there may be an immediate effect after treatment on attentional abilities, but future studies need to assess what helps this effect persist and generalise to attentional skills in daily life. Trials also need to have higher methodological quality and better reporting.

Modification of everyday activities and its association with self-awareness in cognitively diverse older adults

Cognitive impairment (CI) in older adults is frequently accompanied by difficulty performing complex everyday activities (e.g., managing finances). However, it is unclear if and how older adults with CI modify their activities (i.e., Do individuals continue, monitor, seek help with, change their approach to, or stop different activities?). In the current study, we examined if older adults with CI are concerned about their ability to carry out complex activities, if and how they modify activities based on their concern, and the factors associated with activity modification. We hypothesized that older adults with CI will more frequently be concerned about, and modify, everyday activities than cognitively healthy (HE) older adults, and that higher awareness of memory loss in the CI group would relate to more frequent modification. The sample included 81 older adults (51 HEs; mean age 70.02 (7.34) and 30 CI; mean age 75.97 (8.12)). Compared to HEs, the CI group reported having more concern about, F(3,77) = 5.50, p = 0.02, and modifying a greater number of activities, F(3,77) = 5.02, p = 0.03. Medication management (30%) and completing taxes (33.3%) were among the most frequently modified activities for the CI and HE groups, respectively. In the CI group, higher memory awareness was associated with more concern (r = .53, p = .005) and activity modification (r = 0.55, p = .003). Findings provide novel information about how cognitively diverse older adults navigate complex activities in daily life. We propose a preliminary theoretical model by which self-awareness may influence navigation of everyday activities in the context of CI.

[Formula: see text] Addressing the neurodevelopmental needs of children and adolescents with congenital heart disease: A review of the existing intervention literature

Congenital heart disease (CHD) is among the most prevalent birth defects in the United States. Given that children with CHD are at risk for differences with development, learning, and psychosocial functioning, effective intervention becomes a central tenant of recommendations following neuropsychological consultation and evaluation. The primary focus of this review is to summarize available interventions for children and adolescents with CHD. The existing CHD literature has concentrated on early developmental services, psychopharmacological treatment, and need for academic supports. The literature is limited with regard to intervention studies that target cognitive deficits and psychosocial difficulties. To address this discrepancy, efficacious interventions that have been used to mitigate these concerns within other medical groups are also discussed in an effort to provide options for alternative recommendations and services. The current paper is intended to facilitate comprehensive care for cardiac patients by providing clinicians with a review of the available intervention literature, as well as potential interventions that may serve as supplemental strategies in the interim.

Positive outcome of visuospatial deficit rehabilitation in children with epilepsy using computer-based FORAMENRehab program

Children with epilepsy often show deficits in attention and visuospatial functions. Still, very few systematically controlled evidence-based pediatric neurorehabilitation methods exist. The aim was to assess the effectiveness of a computer-based rehabilitation program for visuospatial deficit remediation in children with epilepsy. Fifty-eight children aged 8-12 years participated: 17 children with epilepsy diagnosis in intervention group, 22 patients in waiting-list control group, and 19 healthy age equivalent controls. The intervention group received guided visuospatial functions rehabilitation with FORAMENRehab software twice a week for a 5-week period. Baseline assessments were carried out before and immediately after the intervention period, and as follow-up 1.31 years later. Intervention group showed positive immediate rehabilitation effect in 3 out of 4 visuospatial components: visual organization, visual attention, and visuospatial perception. A long-term rehabilitation effect in the study group was observed in all 4 of the trained components. Also, a positive generalized effect was confirmed by the parents' and children's qualitative feedback with some of the improved skills transferring to children's everyday life. One hundred percent compliance further confirmed the children's motivation to participate and the effectiveness of FORAMENRehab for pediatric neurorehabilitation.

Use It or Lose It? A 5-Year Follow-up Study of Goal Management Training in Patients with Acquired Brain Injury

OBJECTIVES

To determine the perceived 5-year outcome of Goal Management Training (GMT) for individuals with chronic acquired brain injury and executive dysfunction, when compared to a nonspecific psychoeducational intervention (Brain Health Workshop, BHW).

METHODS

Of the 67 subjects in the initial randomized controlled trial [Tornås et al. (2016). Journal of the International Neuropsychological Society, 1-17], 50 (GMT, n = 21; BHW, n = 29) subjects returned written consent and questionnaires (54% male, age 45.8 ± 10.9 years). The 5-year follow-up consisted of two questionnaires, including the Behavior Rating Inventory of Executive Function for daily life executive function (EF) and Quality of Life after Brain Injury to assess health-related quality of life (HRQoL). Changes related to daily life EF and HRQoL were assessed pre-treatment, post-treatment, 6-month follow-up, and 5-year follow-up. Data were analyzed using a 2 × 4 mixed-design ANOVA.

RESULTS

The findings indicate that GMT is efficacious in improving EF and HRQoL 6-month post-treatment. However, these changes failed to remain significant at 5-year follow-up.

CONCLUSIONS

Data from 50 participants receiving either GMT or BHW suggested that the significant GMT-related improvements on perceived EF and HRQoL observed at 6-month follow-up were no longer present at 5-year follow-up. These findings indicate a need to promote maintenance of interventions post-treatment.

Cognitive Training Targeting Planning Dysfunction in Adults with Prader-Willi Syndrome: Brief Report of a Study Protocol

Background: Prader-Willi syndrome (PWS) is a neurodevelopmental genetic disorder involving executive deficits notably with planning. The main objective of the study is to assess the effectiveness of cognitive training on daily life planning difficulties in PWS patients. Methods/design: The study is a double-blind randomized controlled trial which will compare the effectiveness of a metacognitive strategy intervention designed to improve planning difficulties for PWS patients to usual occupational therapy. Sixty adults will be included over 20 months. The main outcome measure will be the performance on the Modified Six Elements Test from the BADS; secondary outcome measures will be computerized executive tasks and questionnaires. Daily life planning difficulties will be identified and transformed into measurable goals using Goal Attainment Scaling. Discussion: The project will provide knowledge on the difficulties experienced by PWS patients, in relation to their executive functioning in order to implement effective intervention for planning in daily life.

Characteristics of traumatic brain injury during Operation Enduring Freedom–Afghanistan: a retrospective case series

Traumatic brain injury (TBI) is a significant cause of morbidity and mortality, especially among members of the armed services. Injuries sustained in the battlefield are subject to different mechanisms than those sustained in civilian life, particularly blast and high-velocity injury. Due to the unique nature of these injuries and the challenges associated with battlefield medicine, surgical interventions play a key role in acute management of TBI. However, the burden of chronic disease posed by TBI is poorly understood and difficult to investigate, especially in the military setting. The authors report the case logs of a United States Navy neurosurgeon, detailing the acute management and outcomes of 156 patients sustaining TBI between November 2010 and May 2011 during the war in Afghanistan. By demographics, more than half of the patients treated were local nationals. By mechanism of injury, blunt trauma (40.4%) and explosive injury (37.2%) were the most common contributors to TBI. Decompressive craniectomies (24.0%) and clot evacuations (14.7%) were the procedures most commonly performed. Nearly one-quarter of patients were transferred to receive further care, yet only 3 patients were referred for rehabilitative services. Furthermore, the data suggest that patients sustaining comorbid injuries in addition to TBI may be predisposed to worse outcomes. Improvements in documentation of military patients may improve knowledge of TBI and further identify potential variables or treatments that may affect prognosis. The increased survivability from TBI also highlights the need for additional research expenditure in the field of neurorehabilitation specifically.

Evidence-based systematic review of cognitive rehabilitation, emotional, and family treatment studies for children with acquired brain injury literature: From 2006 to 2017

This paper updates guidelines for effective treatments of children with specific types of acquired brain injury (ABI) published in 2007 with more recent evidence. A systematic search was conducted for articles published from 2006 to 2017. Full manuscripts describing treatments of children (post-birth to 18) with acquired brain injury were included if study was published in peer-reviewed journals and written in English. Two independent reviewers and a third, if conflicts existed, evaluated the methodological quality of studies with an Individual Study Review Form and a Joanna Briggs Institute (JBI) Critical Appraisal Checklist. Strength of study characteristics was used in development of practice guidelines. Fifty-six peer-reviewed articles, including 27 Class I studies, were included in the final analysis. Established guidelines for writing practice recommendations were used and 22 practice recommendations were written with details of potential treatment limitations. There was strong evidence for family/caregiver-focused interventions, as well as direct interventions to improve attention, memory, executive functioning, and emotional/behavioural functioning. A majority of the practice standards and guidelines provided evidence for the use of technology in delivery of interventions, representing an important trend in the field.

Is a structured work task application for the assessment of work performance in a constructed environment, useful for patients with attention deficits?

BACKGROUND

The purpose of our study was to develop a Structured Work Task application for the Assessment of Work Performance for patients with attention deficits.

MATERIAL AND METHODS

We developed a computer-based registration task titled the Attention-demanding Registration Task. It had a structured administrative procedure with additional scoring regarding time and accuracy, also linked to the original scoring of the Assessment of Work Performance. We evaluated the Attention-demanding Registration Task for content validity. Furthermore, we investigated it concerning sensitivity and specificity in patients with attention deficits due to acquired brain injury (n = 65) against a comparison group of healthy people (n = 47).

RESULTS

Our investigation on content validity using the Assessment of Work Characteristics confirmed that the Attention-demanding Registration Task sets high demands on process skills, especially on energy, temporal organization, and adaptation. The Attention-demanding Registration Task showed high sensitivity and specificity in differing between patients with attention deficits and a healthy working group; nine out of ten participants were placed in the correct group.

CONCLUSIONS

To assess work performance, the use of a Structured Work Task application, the Attention-demanding Registration Task, linked with the Assessment of Work Performance, proved to be sensitive to attention deficits.Implications for rehabilitationA Structured Work Task application for the Assessment of Work Performance was developed for use in people with attention deficits and showing a high degree of sensitivity and specificity.Linking performance time and accuracy to the Assessment of Work Performance scoring and providing a guide for linking task performance to the Assessment of Work Performance skills in addition to the usual observations performed, may increase scoring accuracy.Reference data for a comparison group of healthy subjects are provided.The use of the Attention demanding Registration Task, while using the Assessment of Work Performance within clinical practice ensures a more accurate description of process skills in performance.

A Latent Content Analysis of Barriers and Supports to Healthcare: Perspectives From Caregivers of Service Members and Veterans With Military-Related Traumatic Brain Injury

OBJECTIVE

To identify barriers and supports that caregivers of individuals with military-related traumatic brain injury (TBI) encounter when navigating the military healthcare system; this information will be used as the foundation of a new patient-reported outcome measure.

SETTING

Community.

PARTICIPANTS

Forty-five caregivers of service members and veterans (SMV) who sustained a medically documented mild, moderate, severe, or penetrating TBI.

DESIGN

Latent content analysis.

MAIN MEASURES

Nine focus group discussions of barriers and supports to navigating the military healthcare system and community resources.

RESULTS

Latent content analysis indicated that caregivers discussed barriers (66%) and supports (34%) to obtaining care within the military healthcare system and the community. Caregivers most frequently discussed SMVs' interactions with healthcare, their own interactions with healthcare, family care, and community organizations.

CONCLUSIONS

Caregivers confront numerous challenges while pursuing healthcare services. Although much of the discussion focused on barriers and perceived unmet needs within the military healthcare system, caregivers also recognized supports within the military healthcare system and general community. Increased attention to accessibility and quality of services, as well as reducing financial burden, can lead to improved health-related quality of life for caregivers and their SMVs.

A retrospective study on the acceptability, feasibility, and effectiveness of LoveYourBrain Yoga for people with traumatic brain injury and caregivers

PURPOSE

To conduct a mixed methods, pre-post, retrospective study on the feasibility, acceptability, and effectiveness of the LoveYourBrain Yoga program.

MATERIALS AND METHODS

People were eligible if they were a traumatic brain injury survivor or caregiver, age 15-70, ambulatory, and capable of gentle exercise and group discussion. We analyzed attendance, satisfaction, and mean differences in scores on Quality of Life After Brain Injury Overall scale (QOLIBRI-OS) and four TBI-QOL/Neuro-QOL scales. Content analysis explored perceptions of benefits and areas of improvement.

RESULTS

1563 people (82.0%) participated ≥1 class in 156 programs across 18 states and 3 Canadian provinces. Mean satisfaction was 9.3 out of 10 (SD 1.0). Mixed effects linear regression found significant improvements in QOLIBRI-OS (B 9.70, 95% CI: 8.51, 10.90), Resilience (B 1.30, 95% CI: 0.60, 2.06), Positive Affect and Well-being (B 1.49, 95% CI: 1.14, 1.84), and Cognition (B 1.48, 95% CI: 0.78, 2.18) among traumatic brain injury survivors (n = 705). No improvement was found in Emotional and Behavioral Dysregulation, however, content analysis revealed better ability to regulate anxiety, anger, stress, and impulsivity. Caregivers perceived improvements in physical and psychological health.

CONCLUSIONS

LoveYourBrain Yoga is feasible and acceptable and may be an effective mode of community-based rehabilitation.IMPLICATIONS FOR REHABILITATIONPeople with traumatic brain injury and their caregivers often experience poor quality of life and difficulty accessing community-based rehabilitation services.Yoga is a holistic, mind-body therapy with many benefits to quality of life, yet is largely inaccessible to people affected by traumatic brain injury in community settings.Participants in LoveYourBrain Yoga, a six-session, community-based yoga with psychoeducation program in 18 states and 3 Canadian provinces, experienced significant improvements in quality of life, resilience, cognition, and positive affect.LoveYourBrain Yoga is feasible and acceptable when implemented on a large scale and may be an effective mode of, or adjunct to, community-based rehabilitation.

Usability Analysis of a System for Cognitive Rehabilitation, "Gradior", in a Spanish Region

Objective: The main aim of our research is to assess the use, satisfaction, and pedagogy of software for neuropsychological rehabilitation by computer, called "Gradior™," to obtain relevant information on the impact of information and communications technology on people with severe and prolonged mental illness. Methods: To evaluate the usability and satisfaction standards, the questionnaire "Usability survey on the use of the cognitive rehabilitation and assessment program by computer" was completed by 83 patients of the Rodríguez Chamorro Hospital. Results: The results of the study show that Gradior has 81.2% acceptance and 83.7% general assessment. This indicates that those who responded to the survey consider that the Gradior program improves cognitive functions and abilities in patients with severe and prolonged mental illness and therefore their quality of life. Conclusion: This research is oriented toward professionals of the Health Area and Systems Engineers, who develop software for neuropsychological rehabilitation with neurocognitive deficit. The purpose is to make the learning process more effective among the people who use it and to improve usability for specific groups. We hope that the reading of the work contributes to the activities, techniques and materials planned are in accordance with the needs of the population affected with cognitive disorders.

Randomised controlled clinical trial of a structured cognitive rehabilitation in patients with attention deficit following mild traumatic brain injury: study protocol

OBJECTIVES

To measure the clinical, structural and functional changes of an individualised structured cognitive rehabilitation in mild traumatic brain injury (mTBI) population.

SETTING

A single centre study, Malaysia.

PARTICIPANTS

Adults aged between 18 and 60 years with mTBI as a result of road traffic accident, with no previous history of head trauma, minimum of 9 years education and abnormal cognition at 3 months will be included. The exclusion criteria include pre-existing chronic illness or neurological/psychiatric condition, long-term medication that affects cognitive/psychological status, clinical evidence of substance intoxication at the time of injury and major polytrauma. Based on multiple estimated calculations, the minimum intended sample size is 50 participants (Cohen's d effect size=0.35; alpha level of 0.05; 85% power to detect statistical significance; 40% attrition rate).

INTERVENTIONS

Intervention group will receive individualised structured cognitive rehabilitation. Control group will receive the best patient-centred care for attention disorders. Therapy frequency for both groups will be 1 hour per week for 12 weeks.

OUTCOME MEASURES

Primary: Neuropsychological Assessment Battery-Screening Module (S-NAB) scores. Secondary: Diffusion Tensor Imaging (DTI) parameters and Goal Attainment Scaling score (GAS).

RESULTS

Results will include descriptive statistics of population demographics, CogniPlus cognitive program and metacognitive strategies. The effect of intervention will be the effect size of S-NAB scores and mean GAS T scores. DTI parameters will be compared between groups via repeated measure analysis. Correlation analysis of outcome measures will be calculated using Pearson's correlation coefficient.

CONCLUSION

This is a complex clinical intervention with multiple outcome measures to provide a comprehensive evidence-based treatment model.

ETHICS AND DISSEMINATION

The study protocol was approved by the Medical Research Ethics Committee UMMC (MREC ID NO: 2016928-4293). The findings of the trial will be disseminated through peer-reviewed journals and scientific conferences.

TRIAL REGISTRATION NUMBER

NCT03237676.

Intensive and standard group-based treatment for persons with social communication difficulties after an acquired brain injury: study protocol for a randomised controlled trial

INTRODUCTION

Social communication difficulties (SCDs) occur frequently after an acquired brain injury (ABI) and have disabling consequences, but effective interventions are scant. Group Interactive Structured Treatment (GIST) is a holistic group treatment targeting SCD that has received empirical support.

OBJECTIVE

To determine the efficacy of two GIST protocols, standard GIST and a newly developed intensive GIST, comparing standard GIST results to a wait-list control group (WL), as well as to intensive GIST received by participants following WL. The within subject results for WL and intensive GIST will also be examined.

METHODS AND ANALYSIS

Sixty adults (18-75 years) with SCD after ABI will be recruited for this randomised controlled trial. Standard GIST (n=30) will be delivered via outpatient sessions for 2.5 hours once per week for 12 weeks, plus one initial orientation session. Participants will be assessed at preintervention and postintervention and at 3-month and 6-month follow-ups (T1-T4). Intensive GIST (n=30) participants will be admitted to an inpatient rehabilitation unit for 4 weeks (two times 3 days/week, two times 4 days/week) and receive full-day sessions each week. Those participants will complete four assessments (T1-T4) in 12-week intervals as part of WL, assessments preintensive and postintensive GIST and at 3-month and 6-month follow-ups (T4-T7). The primary outcome measure is the La Trobe Questionnaire (self-report). Secondary outcome measures include the Profile of Pragmatic Impairment in Communication, a test of emotion recognition, the Goal Attainment Scale and questionnaires addressing social, emotional and cognitive functions, self-efficacy and quality of life.

ETHICS AND DISSEMINATION

Results will be communicated through international, peer-reviewed and popular science journals and presentations at scientific conferences. The study is approved by the Regional Committees for Medical and Health Research Ethics Norway (2017/1360). The trial will be conducted in accordance with the Declaration of Helsinki and reported in accordance with the Consolidated Standards of Reporting Trials 2010 statement and Standard Protocol Items: Recommendations for Interventional Trials recommendations.

TRIAL REGISTRATION NUMBER

NCT03636399.

Cognitive and Functional Outcomes following Inpatient Rehabilitation in Patients with Acquired Brain Injury: A Prospective Follow-up Study

OBJECTIVES

To study the effects of cognitive retraining and inpatient rehabilitation to study the effects of cognitive retraining and inpatient rehabilitation in patients with acquired brain injury (ABI).

DESIGN AND SETTING

This was a prospective follow-up study in a neurological rehabilitation department of quaternary research hospital.

PATIENTS AND METHODS

Thirty patients with ABI, mean age 36.43 years (standard deviation [SD] 12.6, range 18-60), mean duration of illness 77.87 days (SD 91.78, range 21-300 days) with cognitive, physical, and motor-sensory deficits underwent inpatient rehabilitation for minimum of 14 sessions over a period of 3 weeks. Nineteen patients (63%) reported in the follow-up of minimum 3 months after discharge. Type of ABI, cognitive status (using Montreal Cognitive assessment scale [MoCA] and cognitive Functional Independence Measure [Cog FIM]^®), and functional status (motor FIM^®) were noted at admission, discharge, and follow-up and scores were compared.

RESULTS

Patients received inpatient rehabilitation addressing cognitive and functional impairments. Baseline MoCA, motor FIM, and Cog FIM scores were 15.27 (SD = 7.2, range 3-30), 31.57 (SD = 15.6, range 12-63), and 23.47 (SD = 9.7, range 5-35), respectively. All the parameters improved significantly at the time of discharge (MoCA = 19.6 ± 7.4 range 3-30, motor FIM^® = 61.33 ± 18.7 range 12-89, Cog FIM^® =27.23 ± 8.10 range 9-35). Patients were discharged with home-based programs. Nineteen patients reported in follow-up and observed to have maintained cognition on MoCA (18.8 ± 6.8 range 6-27), significantly improved (P < 0.01) on Cog FIM^® (28.0 ± 7.7 range 14-35) and motor FIM^® =72.89 ± 16.2 range 40-96) as compare to discharge scores.

CONCLUSIONS

Cognitive and functional outcomes improve significantly with dedicated and specialized inpatient rehabilitation in ABI patients, which is sustainable over a period.

Setting and achieving individualized social communication goals for people with acquired brain injury (ABI) within a group treatment

BACKGROUND

Cognitive-communication disorders are common following an acquired brain injury (ABI). Remediation should involve individualized goal-setting, yet few reports describe the effectiveness of setting communication goals in a group setting.

AIMS

To describe a process for setting and achieving goals for people with ABI.

METHODS & PROCEDURES

A total of 21 participants with ABI participated in a group treatment (triads and dyads) over 6 weeks (20 h in total). Specific social communication goals were set using goal attainment scaling (GAS) with the participant and their communication partner. Goals targeted strategy use that accounted for existing cognitive abilities. The participant and their communication partner evaluated the goals post-treatment and 6-8 weeks later. Data were analysed using Friedman's test to identify the achievement of GAS goals.

OUTCOMES & RESULTS

A total of 20 participants recalled goals independently post-treatment. Significant improvement post-treatment on GAS goals was rated by both the participant (p < 0.001) and their communication partner (p < 0.001). This improvement was maintained at follow-up. No significant differences in ratings were found between participants and their communication partners at either time point.

CONCLUSIONS & IMPLICATIONS

Individualized social communication goals can be set and achieved for people with ABI in group treatment, even when participants are several years post-injury. GAS offers a method for structuring and quantifying goal progress. Involving communication partners and cognitive strategies were effective in improving communication.

Lived experiences of chronic cognitive and mood symptoms among community-dwelling adults following stroke: a mixed-methods analysis

Objectives: Few studies have explored the lived experiences of chronic cognitive and mood symptoms following stroke using a racially/ethnically diverse sample. Therefore, we aimed to explore the perceptions of chronic post-stroke cognition and mood symptoms and goals among a racially/ethnically diverse sample of community-dwelling adults aging with stroke. Method: This qualitative study using mixed-methods analysis included semi-structured interviews regarding perceived post-stroke cognitive and mood symptoms among community-dwelling stroke survivors at least one-year post stroke. Transcripts were subjected to thematic content analysis, and differences in theme usage patterns by age, gender, race/ethnicity, and post-acute rehabilitation setting were assessed using an inferential clustering technique. Results: The majority of participants (93%) reported cognition-related themes, including language and communication, memory, thinking abilities, comprehension, visual-spatial processing, and cognitive assessments and training. Nearly half of participants mentioned mood-related themes, including depression, aggression and anger, mood fluctuations, anxiety, and psychological services and medication. Nearly half reported an unmet need for cognition or mood-related treatment. Inferential clustering analysis revealed that older participants reported a different pattern of cognitive and mood symptoms than those aged younger than 65 (p = 0.02). Older adults were more likely to describe post-stroke language/communication changes, while younger adults described post-stroke mood changes. Conclusion: Stroke survivors experienced cognitive and mood-related symptoms beyond one-year post stroke, which has implications for long-term assessment and management. Incorporation of continued symptom monitoring into existing community-based services is needed to address chronic cognitive and mood symptoms affecting the quality of life of persons with stroke.

The effectiveness of cognitive rehabilitation program on auditory perception and verbal intelligibility of deaf children

Linguistic information and cognitive rehabilitation has more related with auditory perception and verbal intelligibility. The aim of the present study was to assessment of the effectiveness of cognitive rehabilitation program on the auditory perception and verbal intelligibility of deaf children. This study was a quasi-experimental study with pre-test, post-test and control group design. Participants were 24 deaf children from Ava rehabilitation center of mother child in Isfahan city, Iran. Participants were selected by convenient sampling method. They were randomly divided into experimental and control groups, each group consisted of 12 children. The experimental group participated in the cognitive rehabilitation training program in 10 sessions for 45 min, while control group did not participate this program. The instruments of present research were Categories of Auditory Performance (CAP) and Speech Intelligibility Rating (SIR). The data were analyzed using multivariate analysis of covariance (MANCOVA) in 24th version of SPSS. The results of MANCOVA showed that cognitive rehabilitation program had significant effect on the auditory perception and verbal intelligibility in the experimental group at post intervention stage (P < 0/0001). There was a positive and significant increase in auditory perception and verbal intelligibility of experimental group. Our findings showed that Cognitive rehabilitation program training led to promote of auditory perception and verbal intelligibility of deaf children.

Cognitive rehabilitation for cancer-related cognitive dysfunction: a systematic review

PURPOSE

Individuals with non-central nervous system (CNS) cancers can experience cancer-related cognitive dysfunction (CRCD), negatively impacting daily functioning and quality of life. This systematic review examined cognitive rehabilitation programs aimed at improving cognitive function.

METHODS

PsychInfo and PubMed were searched in February 2019. Eligible studies evaluated a cognitive rehabilitation program for adults with non-CNS cancers and included at least one objective cognitive measure. Across studies, we assessed methodological quality using relevant criteria based on published intervention-related review guidelines and examined findings from performance-based and self-reported outcome measures.

RESULTS

19 studies met inclusion criteria, totalling 1124 participants altogether. These studies included randomized controlled trials (n = 12), partial, quasi or non-randomized controlled trials (n = 3) and single-arm pilot studies (n = 4). All studies found improvements on at least one cognitive measure (performance-based or self-reported). By cognitive domain, objective improvements in memory were most commonly reported, followed by executive functions and processing speed. In terms of methodological quality, studies generally provided clear descriptions of participants and interventions. However, limitations included lack of standardized terminology for interventions, discrepancies in outcome measures, and incomplete statistical reporting.

CONCLUSIONS

The available evidence supports clinical implementation of cognitive rehabilitation to improve CRCD, with further work in program development, dissemination, and feasibility recommended. We provide specific recommendations to facilitate future research and integration in this field.

Long-Term Effect of Cognitive Rehabilitation Regardless of Prerehabilitation Cognitive Status for Veterans with TBI

Persisting difficulties in executive functioning (EF) are common after traumatic brain injury (TBI). Cognitive rehabilitation can be effective, but the impact of pretreatment neurocognitive functioning on long term effects of rehabilitation is unknown. Because this information can impact treatment planning, we examined the relationship between prerehabilitation neurocognitive status and long-term effects of EF training. Archival data were drawn from a trial of Goal-Oriented Attentional Self-Regulation group-format EF training for Veterans with TBI [mild-severe; 11 years postinjury; 96% male, 32% nonwhite, 14.21 years education (SD 1.72), 41.13 years old (SD 11.39)]. Using prerehabilitation neurocognitive performance, participants were clustered into cognitive difficulty (CD) and cognitively normal (CN) groups. Six-plus months after EF rehabilitation training, participants completed a structured telephone interview and/or in-person cognitive/functional/emotional assessment using standardized measures of cognitive, daily, and emotional functioning frequently employed in TBI research. At 6+ months post-EF training compared to prerehabilitation, CD and CN improved in multiple cognitive (Overall Attention/EF: F(1,18) = 26.17, partial η² = .59; Total Memory: F(1,18) = 6.82, partial η² = .28) and functional domains (Goal Processing Scale [GPS] total score: F(1,15) = 6.71, partial η² = .31). CD improved more than CN on Learning and Memory functional domain [F(1,15) = 6.10, partial η² = .29]. Results of our small archival analysis raise the possibility that Veterans with chronic TBI may demonstrate long-term effects of EF training.

Validity and reliability of the Neuropsychological Assessment Battery - Screening Module (S-NAB) in a subset of Malaysian population with mild traumatic brain injury (mTBI)

This study assessed the validity (construct validity) and reliability (internal consistency) of the Neuropsychological Assessment Battery Screening Module (S-NAB) in detecting mild cognitive deficit/alteration in multicultural, multilingual, and multiethnic mild traumatic brain injury (mTBI) population of Malaysia. S-NAB and Montreal Cognitive Assessment (MoCA) data from 114 patients with mTBI (93 males; 21 females) aged 18 to 60 years old were obtained at University Malaya Medical Center, Malaysia. The mean age was 28.17 ± 8.57 years and mean education years was 12.40 ± 2.01. Convergent validity was assessed between S-NAB domain scores and MoCA total scores by using Pearson's correlation and internal consistency was assessed using Cronbach's alpha. Acceptable internal consistency (α ≥ .70) was found for Attention, Language, and Memory domains but weak internal consistencies (α < .50) were found for Spatial and Executive Function domains. There were positive but weak correlations between S-NAB and MoCA. These findings provide some support for the application of S-NAB in assessing mild cognitive deficits of mTBI population in a Malaysian setting.

Long-term effects of executive function training among veterans with chronic TBI

Objective: To investigate long-term effects of GOALS executive function training in Veterans with chronic TBI. In a recently completed study Veterans with chronic TBI showed improvement immediately post-GOALS but not control training on measures of executive function, functional task performance, and emotion regulation. We now examine the long-term maintenance of post-GOALS training changes in the same sample. Setting: San Francisco VA Health Care System (SFVAHCS), and VA Northern California Health-Care System (VANCHS) in Martinez. Participants and Design: 24 Veterans with chronic TBI were assessed at baseline, post-GOALS training, and long-term follow-up 6+ months following completion of training with a structured telephone interview, neuropsychological and complex functional performance measures, and self-report measures of daily and emotional functioning. Results: Participants reported an increased likelihood of involvement in competitive employment/volunteering at follow-up (61%) compared to baseline (26%; χ2 = 5.66, p < .01, ѱ = .35). Repeated measures MANOVAS indicated improvement on attention/executive function (F = 13.85, p < .01, partial η2 = .42), complex functional task performance (GPS Total: F = 9.12, p < .01, partial η2 = .38) and daily functioning (MPAI Total: F = 3.23, p < .05, partial η2 = .21), and reduction in overall mood disturbance (POMS Total: F = 3.42, p < .05, partial η2 = .22) at follow-up relative to baseline. Discussion: Training in attention regulation applied to participant-defined goals is associated with meaningful long-term improvement in cognitive skills, emotion regulation, and daily functioning in Veterans with chronic TBI.

Isolated and early-onset cerebral fat embolism syndrome in a multiply injured patient: a rare case

Background

Fat embolism syndrome (FES) is a rare complication that can occur between 12 and 72 h after the initial insult. Isolated cerebral FES without pulmonary symptoms is rarer. Early fracture fixation might prevent FES. We report a case of multiple-fracture with FES despite definite fixation three hours post-injury.

Case presentation

A 54-year-old man presented with multiple fractures: left femoral shaft (AO B2), left distal radius (AO C3), left comminuted patella, right comminuted 1st metatarsal base and left 2nd-4th metatarsal neck. Because he was stable, we gave him early total care and definite fixation, which required seven hours and yielded no complications. After he recovered from anesthesia, however, his eyes deviated right, his right upper arm was paralyzed, his consciousness level was poor, and his Glasgow Coma Scale score was E3VeM4. Chest X-rays showed clear lung fields, and brain computed tomography showed no intracranial hemorrhage. He did, however, have tachycardia, anemia, and thrombocytopenia. Brain magnetic resonance images showed a hyperintensive starfield pattern on diffuse weighted images, which suggested cerebral FES. After supportive care, his consciousness cleared on postoperative day 17, and he recovered full right upper arm muscle power after four months; however, he had a significant cognitive deficit. One-year post-injury, after regular rehabilitation therapy, he was able to independently perform his activities of daily living but still had a residual mild cognitive deficit.

Conclusion

Early fixation can attenuate but not eliminate the incidence of FES. Early assessment and rehabilitation therapy might be required for patients with cerebral FES and cognitive deficits; however, such deficits are difficult to predict and need long-term follow-ups.

Treating Patients with Frontal Neurocognitive Deficits After SAH and Stroke

Five frontal systems circuits connect with the basal ganglia and other structures to control and regulate thinking and behavior. Subarachnoid hemorrhage and stroke following anterior circulation aneurysms typically disrupt these circuits, sometimes markedly affecting a patient's function. This article reviews the primary pathways and associated brain functions. The principles of cognitively and behaviorally rehabilitating these functions are also discussed by creating external structure and building on what the brain is still capable of doing.

Paediatric goal management training in patients with acquired brain injury: study protocol for a randomised controlled trial

INTRODUCTION

Compromised integrity of the brain due to paediatric acquired brain injury (pABI) has been associated with cognitive impairment, particularly executive dysfunction, in addition to somatic and emotional symptoms and reduced everyday function. Goal Management Training (GMT) is a cognitive rehabilitation intervention for improving executive function (EF) that has received empirical support in studies of adults with ABI. The purpose of the present study is to determine the efficacy of a recently developed paediatric version of GMT (pGMT) for children and adolescents with ABI and reported executive dysfunction.

METHODS AND ANALYSIS

This study protocol describes a parallel randomised controlled trial including allocation concealment and assessor blinding. Eighty survivors after pABI, aged 10-17 years at the time of intervention, will be recruited. Participants will be randomly allocated to either pGMT (n=40) or a psychoeducative control intervention (n=40; paediatric Brain Health Workshop). Both interventions consist of seven group sessions for participants and parents, followed by external cueing and telephone counselling. The study also includes involvement of teachers. Assessments will be performed at baseline, immediately postintervention and at 6 months' follow-up. Primary outcome measure will be changes in daily life EF as reported by parents (The Behavior Rating Inventory of Executive Function). Secondary outcomes include other assessments of EF (neuropsychological tests and questionnaires). Furthermore, we aim to assess generalisation effects of pGMT on other cognitive functions, as well as emotional, behavioural, adaptive and family function, academic performance, fatigue and quality of life.

ETHICS AND DISSEMINATION

Results from this study will be disseminated to relevant research, clinical, health service and patient communities through publications in peer-reviewed and popular science journals, in addition to presentations at scientific conferences. The study will be conducted in accordance with the Helsinki declaration and the Ethical Research Involving Children (ChildWatch International and Unicef). In accordance to Good Clinical Practice our study includes safety and quality monitoring guarantees in compliance with research ethics and safety. The trial will be reported in accordance with the Consolidated Standards of Reporting Trials 2010 statement and Standard Protocol Items for Reporting in Trials recommendations, in addition to being registered at ClinicalTrials.gov. The study has been approved by the Regional Committees for Medical and Health Research Ethics Norway (2017/772).

TRIAL REGISTRATION NUMBER

NCT03215342.

Reporting on novel complex intervention development for adults with social communication impairments after acquired brain injury

PURPOSE

Interventions are often poorly described in published controlled trials, with relatively little information regarding intervention development, content and fidelity. This makes it difficult to conduct replication studies, interpret and compare findings across studies and for therapists to deliver the intervention in clinical practice. Complete reporting of interventions (including fidelity) is now recommended for treatment studies, and this standardized approach is achieved using the Template for Intervention Description and Replication (TIDieR). The aim of this article is to describe the multi-phase process of developing a novel intervention for adults with acquired brain injury (ABI) and report on the findings from involving practicing therapists in this process.

METHODS

Phase 1 involved a review of relevant literature and specifying the intervention as a prototype intervention manual. Phase 2 comprised a focus group with eight practicing therapists exploring their experiences and perceptions of the intervention, potential active components, and essential elements; it also included a review of the prototype manual. Data from the focus group discussion was transcribed and analyzed thematically. Phase 3 investigated actual fidelity of the intervention undertaken, achieved by observers viewing videoed sessions and appraising against the fidelity checklist, which was then analyzed using Cohen's kappa.

RESULTS

Project-based intervention was defined as having six essential elements: a project or tangible end product focus; group-based intervention; individualized communication-based goals; communication partner involvement; acknowledgement and support of participants' cognitive ability; and consideration and plan to address impaired awareness. Analysis of focus group data revealed four themes of essential elements; group context; therapeutic skills; and manual core components and informed the development of a fidelity checklist with 13 essential and 6 desirable criteria. Fidelity assessed using percent agreement was acceptable for almost all rater pairs; where significant, Kappa coefficients had values ranging from poor to excellent (k = 0.34-1.0) depending on rater pair and session.

DISCUSSION

The TIDieR framework provided a clear systematic approach for the complete description and reporting of a complex communication intervention for people with ABI. This article comprehensively described the development and manualisation of intervention in collaboration with practicing therapists which can be used for future testing. In addition, the process undertaken has the potential to inform rehabilitation researchers in other fields on the development of complex interventions.Implications for rehabilitationThe results of this study detail the steps needed to describe an intervention, from the identification of the essential elements through to the creation of a manual and checklist to show fidelity. The process provides a starting point for other rehabilitation researchers developing complex interventions.This article provides a clear and comprehensive description of a novel intervention containing six essential elements for people with acquired brain injury presenting with communication impairments.Project-based intervention is one intervention, which intends to help improve communication skills and quality of life in people with acquired brain injury.This study highlights the important role practicing therapists can play in the creation of an intervention manual and fidelity checklist and in ensuring that sufficient detail is provided to help therapists implement the intervention into clinical practice.

Clinical and cost effectiveness of memory rehabilitation following traumatic brain injury: a pragmatic cluster randomized controlled trial

OBJECTIVE

To evaluate the clinical and cost effectiveness of a group-based memory rehabilitation programme for people with traumatic brain injury.

DESIGN

Multicentre, pragmatic, observer-blinded, randomized controlled trial in England.

SETTING

Community.

PARTICIPANTS

People with memory problems following traumatic brain injury, aged 18-69 years, able to travel to group sessions, communicate in English, and give consent.

INTERVENTIONS

A total of 10 weekly group sessions of manualized memory rehabilitation plus usual care (intervention) vs. usual care alone (control).

MAIN MEASURES

The primary outcome was the patient-reported Everyday Memory Questionnaire (EMQ-p) at six months post randomization. Secondary outcomes were assessed at 6 and 12 months post randomization.

RESULTS

We randomized 328 participants. There were no clinically important differences in the primary outcome between arms at six-month follow-up (mean EMQ-p score: 38.8 (SD 26.1) in intervention and 44.1 (SD 24.6) in control arms, adjusted difference in means: -2.1, 95% confidence interval (CI): -6.7 to 2.5, p = 0.37) or 12-month follow-up. Objectively assessed memory ability favoured the memory rehabilitation arm at the 6-month, but not at the 12-month outcome. There were no between-arm differences in mood, experience of brain injury, or relative/friend assessment of patient's everyday memory outcomes, but goal attainment scores favoured the memory rehabilitation arm at both outcome time points. Health economic analyses suggested that the intervention was unlikely to be cost effective. No safety concerns were raised.

CONCLUSION

This memory rehabilitation programme did not lead to reduced forgetting in daily life for a heterogeneous sample of people with traumatic brain injury. Further research will need to examine who benefits most from such interventions.

Randomized Controlled Trials of Rehabilitation Services in the Post-acute Phase of Moderate and Severe Traumatic Brain Injury - A Systematic Review

Background and aims: There is a gap in knowledge regarding effective rehabilitation service delivery in the post-acute phase after traumatic brain injury (TBI). Recently, Gutenbrunner et al. proposed a classification system for health-related rehabilitation services (International Classification System for Service Organization in Health-related Rehabilitation, ICSO-R) that could be useful for contrasting and comparing rehabilitation services. The ICSO-R describes the dimensions of Provision (i.e., context of delivered services), Funding (i.e., sources of income and refunding), and Delivery (i.e., mode, structure and intensity) at the meso-level of services.

We aim to:

-Provide an overview of randomized, controlled trials (RCTs) with rehabilitation service relevance provided to patients with moderate and severe TBI in the post-acute phase using the ICSO-R as a framework; and

-Evaluate the extent to which the provision, funding and delivery dimensions of rehabilitation services were addressed and differed between the intervention arms in these studies.

Materials and methods: A systematic literature search was performed in OVID MEDLINE, EMBASE, CINHAL, PsychINFO, and CENTRAL, including multidisciplinary rehabilitation interventions with RCT designs and service relevance targeting moderate and severe TBI in the post-acute phase.

Results: 23 studies with 4,644 TBI patients were included. More than two-thirds of the studies were conducted in a hospital-based rehabilitation setting. The contrast in Context between the intervention arms often co-varied with Resources. The funding of the services was explicitly described in only one study. Aspects of the Delivery dimension were described in all of the studies, and the Mode of Production, Intensity, Aspects of Time and Peer Support were contrasted in the intervention arms in several of the studies. A wide variety of outcome measures were applied often covering Body function, as well as the Activities and Participation domains of the International Classification of Functioning, Disability, and Health (ICF).

Conclusion: Aspects of service organization and resources as well as delivery may clearly influence outcome of rehabilitation. Presently, lack of uniformity of data and collection methods, the heterogeneity of structures and processes of rehabilitation services, and a lack of common outcome measurements make comparisons between the studies difficult. Standardized descriptions of services by ICSO-R, offer the possibility to improve comparability in the future and thus enhance the relevance of rehabilitation studies.