Efficacy of Activities of Daily Living Retraining During Posttraumatic Amnesia: A Randomized Controlled Trial

Occupation-based interventions to improve occupational performance and participation in the hospital setting: a systematic review

PURPOSE

To critically review the evidence for occupation-based interventions in improving occupational performance and participation outcomes in the hospital setting.

METHODS

Five databases were searched from 2000-2022. Peer-reviewed studies of any design investigating the impact of occupation-based interventions in the hospital setting were included. Methodological quality was assessed using the appropriate tool for each study design. Following data extraction, a narrative synthesis was conducted.

RESULTS

Thirty-three studies comprising of 26 experimental, five non-experimental, and two mixed methods studies were included (n = 1646 participants). Results indicate good evidence to support occupation-based interventions to improve occupational performance and participation outcomes in inpatient rehabilitation; it is unclear whether they are more effective than any control/alternative intervention. Research in the acute and mental health hospital settings were scarcer. Understanding the benefits of occupation-based interventions was enhanced through qualitative results including improving independence and confidence to discharge home, increasing motivation for therapy, connecting with others, and peer-based learning.

CONCLUSIONS

Heterogeneity and methodological weaknesses across existing studies limits the conclusions that can be drawn on the impact of occupation-based interventions in the hospital setting. More rigorous research should be conducted with better reporting of intervention design and the use of robust measures of occupational performance.Implications For RehabilitationThe use of occupation-based interventions should be considered to improve occupational performance and participation outcomes in the hospital setting.There is good evidence to support the impact of occupation-based interventions on improving occupational performance and participation outcomes in the inpatient rehabilitation setting; evidence in the acute and mental health settings is scarcer.Occupation-based interventions are valued by both patients and clinicians for their impact on patient outcomes and the patient experience.

Implementation of activities of daily living retraining for individuals in post-traumatic amnesia

Background Despite evidence of the efficacy of activities of daily living (ADL) retraining during post-traumatic amnesia (PTA) following traumatic brain injury (TBI), utilisation of this intervention in practice is unclear. Utilising an implementation science framework, the Consolidated Framework for Implementation Research, this study explored efforts to translate ADL retraining during PTA into the clinical practice of occupational therapists (OTs) working in TBI rehabilitation settings across Australia. Methods Participants were 44 OTs who attended a day-long training workshop that included knowledge and skill-based content regarding ADL retraining during PTA. Baseline and post-training ratings were completed including evaluation of workshop utility, and skill and knowledge-based competencies relevant to the intervention. Approximately 2 years later, nine trained OTs and two administrators were interviewed to explore the results of implementing the intervention. Results Overall, the training workshop was rated as being helpful and OT ratings of confidence (P  P   Conclusion Multiple barriers were identified in implementation of ADL retraining during PTA and require consideration to facilitate translation and promote best practice.

Post-traumatic amnesia: a scoping review & content analysis of behavioral disturbances

OBJECTIVE

The aim of this scoping review was to identify behavioral disturbances exhibited by patients in post-traumatic amnesia (PTA). While behavioral disturbances are common in PTA, research into their presentation and standardized measures for their assessment are limited.

DESIGN

The study protocol was registered with PROSPERO (CRD42021268275). A scoping review of databases was performed according to pre-determined criteria on 29 July 2021 and updated on 13 July 2022. A conventional content analysis was used to examine and categorize behavioral disturbances.

RESULTS

Thirty papers met the inclusion criteria, of which 27 reported observations and/or scores obtained on behavioral scales, and 3 on clinician interviews and surveys. None focused exclusively on children. Agitation was the most frequently assessed behavior, and Agitated Behavior Scale was the most used instrument. Content analysis, however, bore eight broad behavioral categories: disinhibition, agitation, aggression, lability, lethargy/low mood, perceptual disturbances/psychotic symptoms, personality change and sleep disturbances.

CONCLUSION

Our study revealed that while standardized assessments of behavior of patients in PTA are often limited to agitation, clinical descriptions include a range of behavioral disturbances. Our study highlights a significant gap in the systematic assessment of a wide range of behavioral disturbances observed in PTA.

Managing agitation during early recovery following traumatic brain injury: qualitative interviews with clinicians

PURPOSE

Agitated behaviours pose a significant challenge during early recovery following traumatic brain injury (TBI). This study aimed to gain a deeper understanding of how clinicians worldwide manage post-TBI agitation. Understanding the factors that influence how clinicians manage agitation can help inform the use of consistent and effective management strategies for reducing agitation in TBI care.

METHODS

Using a qualitative design, semi-structured interviews were conducted with 33 clinicians (58% female, aged 23-71 years) from 16 countries who had experience working with agitated patients. The interviews explored the approaches used to manage agitation during early TBI recovery.

RESULTS

Interviews were analysed using thematic analysis. The central theme of the interviews was the effective management of agitation, consisting of three sub-themes: managing the safety of staff and patients, reducing triggers for agitation, and implementing behavioural principles for managing agitation. Two overarching themes influenced the effective management of agitation: clinician-related factors and systemic factors.

CONCLUSIONS

This study highlighted key approaches for effective agitation management during early TBI recovery, as described by clinicians working with these patients worldwide. There were similarities in the strategies described, although there were many challenges that impeded the consistent implementation of such strategies in TBI care settings.

IMPLICATIONS FOR REHABILITATIONEffective management of agitation during early traumatic brain injury (TBI) recovery continues to pose a significant challenge for clinicians worldwide.Healthcare services may improve the management of agitation by involving the patient's family in care delivery and implementing low-cost less-restrictive non-pharmacological interventions to reduce reliance on pharmacological interventions.Proactively addressing and removing potential sources of agitation (patient-related and environmental) may help reduce the risk of agitation occurring.The use of simple behaviour management strategies may be effective for reducing agitation, but strategies need to be implemented consistently and the approach should be flexible and tailored to the patient.Clinicians should develop an understanding of a patient's premorbid behaviours and interests to best inform the management approach.Management of agitation may be improved by increasing clinicians' agency in responding to agitated behaviours, through the provision of information and resources, ongoing training and skill development, supervision and support.

Occupational Therapy Practice Guidelines for Adults With Traumatic Brain Injury

IMPORTANCE

Occupational therapy practitioners are uniquely qualified to address the occupational needs of people with traumatic brain injury (TBI) and their caregivers to maximize participation, health, and well-being.

OBJECTIVE

These Practice Guidelines are informed by systematic reviews of the effectiveness of interventions that address impairments and skills to improve the occupational performance of people with TBI, as well as interventions for caregivers of people with TBI. The purpose of these guidelines is to summarize the current evidence available to assist clinicians' clinical decision-making in providing interventions for people with TBI and their caregivers.

METHOD

We reviewed six systematic reviews and synthesized the results into clinical recommendations to be used in occupational therapy clinical practice.

RESULTS

Sixty-two articles served as the basis for the clinical recommendations.

CONCLUSIONS AND RECOMMENDATIONS

Strong to moderate evidence supports multimodal sensory stimulation, unimodal auditory stimulation, physical activity, virtual reality, cognitive interventions, vision therapy, goal-focused interventions, individual and group training and education, and caregiver supports. Occupational therapy practitioners should incorporate these interventions into individual and group sessions to maximize recovery and promote occupational participation. Additional interventions are also available, based on emerging evidence and expert opinion, including prevention approaches, complexity of injury, and the use of occupation-based performance assessments. What This Article Adds: These Practice Guidelines provide a summary of evidence in clinical recommendations tables supporting occupational therapy interventions that address impairments resulting from and skills to improve occupational performance after TBI. The guidelines also include case study examples and evidence graphics for practitioners to use to support clinical reasoning when selecting interventions that address the goals of the person with TBI and their caregiver's needs.

The role of the Neuropsychologist across the stages of recovery from acquired brain injury: a summary from the pediatric rehabilitation Neuropsychology collaborative

Neuropsychologists working in a pediatric neurorehabilitation setting provide care for children and adolescents with acquired brain injuries (ABI) and play a vital role on the interdisciplinary treatment team. This role draws on influences from the field of clinical neuropsychology and its pediatric subspecialty, as well as rehabilitation psychology. This combination of specialties is uniquely suited for working with ABI across the continuum of recovery. ABI recovery often involves a changing picture that spans across stages of recovery (e.g., disorders of consciousness, confusional state, acute cognitive impairment), where each stage presents with distinctive characteristics that warrant a specific evidence-based approach. Assessment and intervention are used reciprocally to inform diagnostics, treatment, and academic planning, and to support patient and family adjustment. Neuropsychologists work with the interdisciplinary teams to collect and integrate data related to brain injury recovery and use this data for treatment planning and clinical decision making. These approaches must often be adapted and adjusted in real time as patients recover, demanding a dynamic expertise that is currently not supported through formal training curriculum or practice guidelines. This paper outlines the roles and responsibilities of pediatric rehabilitation neuropsychologists across the stages of ABI recovery with the goal of increasing awareness in order to continue to develop and formalize this role.

Assessments of Functional Cognition Used with Patients following Traumatic Brain Injury in Acute Care: A Survey of Australian Occupational Therapists

This study aimed to describe how occupational therapists working in acute care settings in Australia assess cognitive function in patients with TBI, the influences on assessment choice, and clinician perceptions of performance-based assessment. An online survey was completed by 81 occupational therapists. The most common method of cognitive assessment was reported as non-standardized observation of functional tasks (94.7%), followed by carer-report / self-report (93%). Despite their being positive perceptions of performance-based assessment there was limited use in practice. Assessment use was impacted by practical and organizational constraints including access to assessment resources, time and the built environment in acute care.

Cross-cultural adaptation, translation, and validation of a Spanish version of the Westmead Post-traumatic Amnesia Scale for use following a traumatic brain injury

Health professionals need linguistically and culturally correct tools with proven validity to effectively assess people in their native language. This study aimed to translate and validate the Westmead Post-traumatic Amnesia Scale (WPTAS) into a Spanish version to measure the progression and duration of post-traumatic amnesia (PTA) in Spanish-speaking populations. Seven native Spanish and English translators, 11 therapists and 15 people with a traumatic brain injury (TBI) and nine people with non-traumatic acquired brain injury participated in the forward-backward translation method to adapt the WPTAS. Participants with a TBI in PTA (n = 20), out of PTA (n = 21), and controls without cognitive impairment (n = 21) participated in the validation test phase by completing the WPTAS, Selective Reminding Test, Short Portable Metal Status Questionnaire, Digit Span, and Agitated Behaviour Scale. The translated version of the WPTAS produced consistent responses and appropriate errors (2%) among all pre-test participants. Results from the validation phase showed that participants in PTA scored significantly lower in all tests (p < .05) when compared with those out of PTA and controls. The Spanish version of the WPTAS created and tested in this study is culturally and linguistically appropriate as well as valid for use with Spanish speakers.

Cognitive Interventions With Occupational Performance as a Primary Outcome for Adults With TBI (June 2013-October 2020)

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on cognitive interventions to improve occupational performance for adults with traumatic brain injury.

Cognitive Interventions to Improve a Specific Cognitive Impairment for Adults With TBI (June 2013-October 2020)

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on cognitive interventions to improve a specific cognitive impairment for adults with TBI.

Effectiveness of Non-Pharmacological Interventions for Agitation during Post-Traumatic Amnesia following Traumatic Brain Injury: A Systematic Review

Agitation is common in the early recovery period following traumatic brain injury (TBI), known as post-traumatic amnesia (PTA). Non-pharmacological interventions are frequently used to manage agitation, yet their efficacy is largely unknown. This systematic review aims to synthesize current evidence on the effectiveness of non-pharmacological interventions for agitation during PTA in adults with TBI. Key databases searched included MEDLINE Ovid SP interface, PubMed, CINAHL, Excerpta Medica Database, PsycINFO and CENTRAL, with additional online reviewing of key journals and clinical trial registries to identify published or unpublished studies up to May 2020. Eligible studies included participants aged 16 years and older, showing agitated behaviours during PTA. Any non-pharmacological interventions for reducing agitation were considered, with any comparator accepted. Eligible studies were critically appraised for methodological quality using Joanna Briggs Institute Critical Appraisal Instruments and findings were reported in narrative form. Twelve studies were included in the review: two randomized cross-over trials, three quasi-experimental studies, four cases series and three case reports. Non-pharmacological interventions were music therapy, behavioural strategies and environmental modifications, physical restraints and electroconvulsive therapy. Key methodological concerns included absence of a control group, a lack of formalised agitation measurement and inconsistent concomitant use of pharmacology. Interventions involving music therapy had the highest level of evidence, although study quality was generally low to moderate. Further research is needed to evaluate non-pharmacological interventions for reducing agitation during PTA after TBI.Systematic review registration number: PROSPERO (CRD42020186802), registered May 2020.

Effectiveness of Non-Pharmacological Interventions for Agitation during Post-Traumatic Amnesia following Traumatic Brain Injury: A Systematic Review

Agitation is common in the early recovery period following traumatic brain injury (TBI), known as post-traumatic amnesia (PTA). Non-pharmacological interventions are frequently used to manage agitation, yet their efficacy is largely unknown. This systematic review aims to synthesize current evidence on the effectiveness of non-pharmacological interventions for agitation during PTA in adults with TBI. Key databases searched included MEDLINE Ovid SP interface, PubMed, CINAHL, Excerpta Medica Database, PsycINFO and CENTRAL, with additional online reviewing of key journals and clinical trial registries to identify published or unpublished studies up to May 2020. Eligible studies included participants aged 16 years and older, showing agitated behaviours during PTA. Any non-pharmacological interventions for reducing agitation were considered, with any comparator accepted. Eligible studies were critically appraised for methodological quality using Joanna Briggs Institute Critical Appraisal Instruments and findings were reported in narrative form. Twelve studies were included in the review: two randomized cross-over trials, three quasi-experimental studies, four cases series and three case reports. Non-pharmacological interventions were music therapy, behavioural strategies and environmental modifications, physical restraints and electroconvulsive therapy. Key methodological concerns included absence of a control group, a lack of formalised agitation measurement and inconsistent concomitant use of pharmacology. Interventions involving music therapy had the highest level of evidence, although study quality was generally low to moderate. Further research is needed to evaluate non-pharmacological interventions for reducing agitation during PTA after TBI.

Systematic review registration number: PROSPERO (CRD42020186802), registered May 2020.

Occupational Therapy and the IMPACT Act: Part 2. A Systematic Review of Evidence for Functional Status, Medication Reconciliation, and Skin Integrity Interventions

IMPORTANCE

Interventions that promote function, medication reconciliation, and skin integrity assist occupational therapy practitioners in demonstrating professional value, improving quality, and reducing health care costs.

OBJECTIVE

In this systematic review, we focus on three outcome areas of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014: functional status, medication reconciliation, and skin integrity.

DATA SOURCES

We conducted a search of the literature published between 2009 and 2019 in CINAHL, Cochrane, MEDLINE, PsycINFO, OTseeker, and Scopus. We also hand searched the systematic reviews and meta-analyses in our search results for articles that met our inclusion criteria. Study Selection and Data Collection: This study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

FINDINGS

We found 47 articles that address the three outcome areas. Regarding functional status, low strength of evidence is available for cognition and functional mobility interventions to support functional performance, moderate strength of evidence supports interventions for vision, and moderate evidence supports task-oriented and individualized interventions to promote activities of daily living (ADL) outcomes among people with neurological conditions. Strong strength of evidence supports individualized occupational therapy interventions focusing on medication adherence. Low strength of evidence was found for occupational therapy interventions to reduce pressure ulcers and promote skin integrity. Conclusion and Relevance: The evidence supports occupational therapy interventions to improve functional status in ADLs and medication management. Additional research is needed that examines the outcomes of occupational therapy interventions for other areas of function and skin integrity. What This Article Adds: We found evidence to support occupational therapy interventions that align with value-based measures in the three outcome areas of interest. The effectiveness of these interventions highlights the viability of occupational therapy as an essential profession and the worth of occupational therapy to the public, potential clients, and payers.

Change in Activity Performance Mediates the Relationship between Occupational Therapy Utilization and Discharge Disposition among Adults with Traumatic Brain Injuries

A retrospective cross-sectional study was conducted on 435 adults with TBI who received occupational therapy services in an acute care trauma center hospital. Outcome measures were (1) occupational therapy utilization based on billed minutes of occupational therapy evaluation and treatment (low vs. high); (2) Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" to assess activities of daily living level of assistance; and (3) Discharge disposition (community vs. institution). Community discharge included home and supported living facilities. Institutional discharge involved long term care, rehabilitation facility, short term hospital, and skilled nursing facility. Results indicated that change in ADL performance, between admission and discharge, partially mediated the relationship between occupational therapy utilization and community discharge (OR= 0.80, p = .003). High occupational therapy utilization (vs. low) was associated with greater change in ADL performance (β = 0.39, p < .001). Greater change in ADL performance was associated with lower odds of community discharge (OR= 0.96, p <.001). Independent of change in ADL performance, higher occupational therapy utilization was associated with significantly lower odds for community discharge (OR = 0.57, p = 0.023). In conclusion, patients who received more occupational therapy were less likely to be community discharged, as mediated by change in ADL performance. This result can provide direction for future research exploring acute care occupational therapy utilization and discharge disposition.

Assessing Sleep Architecture With Polysomnography During Posttraumatic Amnesia After Traumatic Brain Injury: A Pilot Study

BACKGROUND

Early-onset sleep disturbance is common following moderate to severe traumatic brain injury (TBI) and often emerges while patients are in posttraumatic amnesia (PTA). However, sleep disruptions during this subacute recovery phase are not well-defined, and research often utilizes indirect measures (actigraphy) that quantify sleep based on activity. This study aims to examine sleep macro-architecture and sleep quality directly with ambulatory polysomnography (PSG) and measure endogenous salivary melatonin levels for patients experiencing PTA following moderate to severe TBI.

METHOD

Participants were recruited from an inpatient TBI rehabilitation unit. Nighttime PSG was administered at the patient's bedside. Two saliva specimens were collected for melatonin testing on a separate evening (24:00 and 06:00 hours) using melatonin hormone profile test kits.

RESULTS

Of 27 patients in whom PSG was recorded, the minimum required monitoring time occurred in n =17 (adherence: 63%) at a median of 37.0 days (quartile 1 [Q1] to quartile 3 [Q3]: 21.5-50.5) postinjury. Median non-rapid eye movement (NREM) and REM sleep proportions were similar to normal estimates. Slow-wave sleep was reduced and absent in 35.3% of patients. Sleep periods appeared fragmented, and median sleep efficiency was reduced (63.4%; Q1-Q3: 55.1-69.2). Median melatonin levels at both timepoints were outside the normal range of values specified for this test (from Australian Clinical Labs).

CONCLUSION

This study reports that ambulatory PSG and salivary melatonin assessment are feasible for patients experiencing PTA and offers new insight into the extent of sleep disturbance. Further research is necessary to understand associations between PTA and sleep disturbance.

Assessment and Management of Patients in the Acute Stages of Recovery after Traumatic Brain Injury in Adults: A Worldwide Survey

Most individuals with traumatic brain injury (TBI) experience a period of confusion after emergence from coma, termed post-traumatic amnesia, post-traumatic confusional state, or delirium. Recent guidelines suggest the importance of assessment and consistent management during this phase, but current practice worldwide remains unknown. This survey aimed to elucidate current international practice in assessment and treatment of patients in the acute stages of recovery after TBI. The web-based survey was distributed to clinicians working with patients with acute TBI. There were 400 participants (68.8% females), from 41 countries, mostly neuropsychologists, rehabilitation physicians, and occupational therapists (OTs), with an average 12.8 years of experience. Of those working with adults (n = 376, 94%), most described this acute period as post-traumatic amnesia and used its duration to indicate injury severity. More than 85% used a tool to assess patients; in order of frequency, the Glasgow Coma Scale (GCS), Westmead PTA Scale (WPTAS), Galveston Orientation and Amnesia Test, Rancho Los Amigos Scale, and O-Log. Meeting criteria on the assessment tool or clinical judgment determined emergence from this phase, indicated by recovery of orientation, day-to-day memories, and ability to follow commands or participate in rehabilitation. Most patients had physiotherapy, OT, speech therapy, and environmental changes, with a third of participants indicating sedating medication was prescribed during this phase. Findings suggest that, consistent with guidelines, PTA is a widely recognized and measured TBI recovery phase, used to determine injury severity and readiness for therapy.

Improving communication with patients in post-traumatic amnesia: development and impact of a clinical protocol

OBJECTIVE

To assess the impact of staff training focused on improved treatment and communication with patients in post-traumatic amnesia (PTA) or other disorders of explicit (declarative) memory. A major aim was to minimize questions demanding recall from explicit memory, e.g., orientation quizzing, and personal/medical history questions, which may produce unreliable information and exacerbate patient frustration and anxiety.

METHODS

Mixed-methods design. Inpatients with impairments of explicit memory were observed before (n = 4) and after (n = 4) training, with staff interactions recorded verbatim. Records were coded for types of questions and patient responses. Clinicians who worked before and after training were surveyed regarding perceived changes in practice, team functioning, and patient behavior.

RESULTS

Explicit memory questions decreased significantly, as did irrelevant or "don't know" responses from patients, with large nonparametric effect sizes noted. The frequency of questions not relying on explicit memory remained stable. Most clinicians reported positive effects on their own and others' practice with memory impaired patients, and one-quarter noted less patient frustration or agitation.

CONCLUSIONS

Although questioning patients is a natural part of medical care, targeted staff training can result in positive changes in communication practice and should be considered for facilities treating patients in PTA.

Kitchen-related tasks used in occupational therapy during rehabilitation of adults with acquired brain injury: A systematic review

Introduction

Kitchen-related tasks are widely used in occupational therapy for adults with acquired brain injury. This study aimed to investigate the effectiveness of kitchen-related, task-based occupational therapy interventions for improving clinical and functional outcomes in the rehabilitation of adults with acquired brain injury.

Method

A systematic review of the literature was conducted with narrative synthesis (PROSPERO registration CRD42019141898), by searching relevant electronic databases (BNI, CINAHL Plus, MEDLINE, DORIS, OT Seeker etc.), registries of ongoing studies (ISRCTN, PROSPERO, etc.), and grey literature (OpenGrey, etc.). English-language studies that evaluated kitchen-related tasks in the rehabilitation of adults with acquired brain injury were included and independently appraised for their methodological quality by two reviewers.

Results

Seventeen primary studies met the eligibility criteria. Studies were heterogeneous in methods, methodological quality, setting, sample size, purpose, and design of kitchen-related tasks. Fifteen studies evaluated kitchen-related, task-based treatments for improving function, and two studies examined kitchen-related task assessments for safety and task performance. This provides very limited evidence for the effectiveness of kitchen-related, task-based interventions compared to interventions not based on kitchen-related tasks.

Conclusion

While kitchen-related, task-based occupational therapy interventions in acquired brain injury rehabilitation are common practice, there is currently limited research evidence to support this. Further studies are warranted to strengthen the evidence base.

Comparing the Westmead Posttraumatic Amnesia Scale, Galveston Orientation and Amnesia Test, and Confusion Assessment Protocol as Measures of Acute Recovery Following Traumatic Brain Injury

BACKGROUND

The duration of the acute period of recovery following traumatic brain injury (TBI) remains a widely used criterion for injury severity and clinical management. Consensus regarding its most appropriate definition and assessment method has yet to be established.

OBJECTIVE

The present study compared the trajectory of recovery using 3 measures: the Westmead Post-Traumatic Amnesia Scale (WPTAS), the Galveston Orientation and Amnesia Test (GOAT), and the Confusion Assessment Protocol (CAP). Patterns of symptom recovery using the CAP were explored.

PARTICIPANTS

Eighty-two participants with moderate to severe TBI in posttraumatic amnesia (PTA) on admission to an inpatient rehabilitation hospital.

DESIGN

Prospective longitudinal study.

OUTCOME MEASURES

Length of PTA (days), agreement between measures (%, κ coefficient), and pattern of symptom recovery.

RESULTS

Participants emerged from PTA earliest on the CAP followed the GOAT, and last on the WPTAS. There was good agreement between the CAP and the GOAT as to PTA status, but both tests had poor agreement with the WPTAS. Of patients considered out of PTA on the CAP, the majority exhibited signs of amnesia on the WPTAS and one-third had clinical levels of agitation.

CONCLUSION

The WPTAS identifies a later stage of PTA recovery that requires specialized management due to ongoing amnesia and agitation. The CAP and the GOAT are less sensitive to this extended period of PTA.

Post-traumatic Confusional State: A Case Definition and Diagnostic Criteria

In response to the need to better define the natural history of emerging consciousness after traumatic brain injury and to better describe the characteristics of the condition commonly labeled posttraumatic amnesia, a case definition and diagnostic criteria for the posttraumatic confusional state (PTCS) were developed. This project was completed by the Confusion Workgroup of the American Congress of Rehabilitation Medicine Brain Injury Interdisciplinary Special Interest group. The case definition was informed by an exhaustive literature review and expert opinion of workgroup members from multiple disciplines. The workgroup reviewed 2466 abstracts and extracted evidence from 44 articles. Consensus was reached through teleconferences, face-to-face meetings, and 3 rounds of modified Delphi voting. The case definition provides detailed description of PTCS (1) core neurobehavioral features, (2) associated neurobehavioral features, (3) functional implications, (4) exclusion criteria, (5) lower boundary, and (6) criteria for emergence. Core neurobehavioral features include disturbances of attention, orientation, and memory as well as excessive fluctuation. Associated neurobehavioral features include emotional and behavioral disturbances, sleep-wake cycle disturbance, delusions, perceptual disturbances, and confabulation. The lower boundary distinguishes PTCS from the minimally conscious state, while upper boundary is marked by significant improvement in the 4 core and 5 associated features. Key research goals are establishment of cutoffs on assessment instruments and determination of levels of behavioral function that distinguish persons in PTCS from those who have emerged to the period of continued recovery.

Minimum Competency Recommendations for Programs That Provide Rehabilitation Services for Persons With Disorders of Consciousness: A Position Statement of the American Congress of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research Traumatic Brain Injury Model Systems

Persons who have disorders of consciousness (DoC) require care from multidisciplinary teams with specialized training and expertise in management of the complex needs of this clinical population. The recent promulgation of practice guidelines for patients with prolonged DoC by the American Academy of Neurology, American Congress of Rehabilitation Medicine (ACRM), and National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) represents a major advance in the development of care standards in this area of brain injury rehabilitation. Implementation of these practice guidelines requires explication of the minimum competencies of clinical programs providing services to persons who have DoC. The Brain Injury Interdisciplinary Special Interest Group of the ACRM, in collaboration with the Disorders of Consciousness Special Interest Group of the NIDILRR-Traumatic Brain Injury Model Systems convened a multidisciplinary panel of experts to address this need through the present position statement. Content area-specific workgroups reviewed relevant peer-reviewed literature and drafted recommendations which were then evaluated by the expert panel using a modified Delphi voting process. The process yielded 21 recommendations on the structure and process of essential services required for effective DoC-focused rehabilitation, organized into 4 categories: diagnostic and prognostic assessment (4 recommendations), treatment (11 recommendations), transitioning care/long-term care needs (5 recommendations), and management of ethical issues (1 recommendation). With few exceptions, these recommendations focus on infrastructure requirements and operating procedures for the provision of DoC-focused neurorehabilitation services across subacute and postacute settings.

Cognition, Cognitive Rehabilitation, and Occupational Performance

The American Occupational Therapy Association (AOTA) asserts that occupational therapists and occupational therapy assistants, through the use of occupations and activities, facilitate clients’ cognitive functioning to enhance occupational performance, self-efficacy, participation, and perceived quality of life. Cognitive processes are integral to effective performance across the broad range of daily occupations such as work, educational pursuits, home management, and play and leisure. Cognition plays an integral role in human development and in the ability to learn, retain, and use new information to enable occupational performance across the lifespan.

This statement defines the role of occupational therapy in evaluating and addressing cognitive functioning to help clients maintain and improve occupational performance. The intended primary audience is practitioners1 within the profession of occupational therapy. The statement also may be used to inform recipients of occupational therapy services, practitioners in other disciplines, and the wider community regarding occupational therapy theory and methods and to articulate the expertise of occupational therapy practitioners in addressing cognition and challenges in adapting to cognitive dysfunction.

Psychological Intervention in Traumatic Brain Injury Patients

Objective

To provide a brief and comprehensive summary of recent research regarding psychological interventions for patients surviving a traumatic brain injury.

Methods

A bibliographical search was performed in PubMed, Cochrane Library, PsycNET, Scopus, ResearchGate, and Google Scholar online databases. Analysis included distribution by year of publication, age stage of participants (paediatric, adult), location of the research team, study design, type of intervention, and main outcome variables.

Results

The initial search eliciting 1541 citations was reduced to 62 relevant papers. Most publications had adult samples (88.7%). The United States outstands as the country with more research (58.1%); Latin America countries provided no results. Cognitive behavioural therapy (CBT) was the most widely used approach for treatment of (sub)clinical mental disturbances (41.9%). Neuropsychological interventions were scarce (4.8%). Outcome measures included psychiatric disorders (e.g., posttraumatic stress disorder (PTSD), depression, and anxiety) (37.1%), postconcussive symptoms (16.1%), cognitive and functional deficits (48.1%), and social and psychological dimensions (62.9%).

Conclusions

CBT outstands as the preferred therapeutic approach for treating behavioural and emotional disturbances. Also, other related therapies such as dialectical behaviour, mindfulness, and acceptance and commitment therapies have been proposed, and probably in the years to come, more literature regarding their effectiveness will be available. On the other hand, evidence showed that interventions from the field of neuropsychology are minimal if compared with its contribution to assessment. Future research should be aimed at performing studies on more diverse populations (e.g., nonmilitary communities and paediatric and Latin American populations) and at controlling designs to examine the therapeutic efficacy of psychotherapeutic and neurocognitive rehabilitation interventions and compare amelioration by injury severity, age of patients, and clinical profile, in the hopes of creating better guidelines for practitioners.

Neurocognitive Rehabilitation: Skills or Strategies?

The author describes personal and professional milestones in becoming an occupational therapist and his early experience in the first behavior disorder program for neurologically based aggression in the world. A real clinical example is used to bring these early lessons into vivid focus. New evidence underlines occupational therapists' unique role in skill-habit training in clients with severe neurological impairment. For clients with milder impairments, irrespective of diagnosis, strategy training may maximize community independence and reduce hospital recidivism. The concept of functional cognition is described as an important development for the profession. Even in an environment of rapid innovation, occupational therapists need to recognize that it is the commonplace activities that have meaning for the individual that really matter. This is both the art and science of occupational therapy, and it will never be superseded by technological innovation because true creativity and genuine empathy cannot be mechanized.

The interrelationship of functional skills in individuals living in the community, following moderate to severe traumatic brain injury

OBJECTIVE

The Adaptive Behaviour and Community Competency Scale was used to investigate the interrelationship of 22 basic and instrumental activities of daily living (ADL/IADL) in individuals with moderate to severe traumatic brain injury (TBI). The relationship of self-awareness to task performance was also investigated.

RESEARCH DESIGN

Prospective descriptive study.

METHOD

The profiles of 100 community dwelling individuals were used to compare the degree to which independence in each ADL/IADL was associated with independence in every other ADL/IADL. The interrelationship of these skills was further explored in a factor analysis, and comparisons made between the degree of self-awareness of those who could and could not complete IADL independently.

RESULTS

We found evidence of a hierarchy of skills: individuals who were independent in IADL were more able to perform ADL, than vice versa. Factor analysis supported a two-factor solution distinguishing ADL and IADL. Self-awareness was more strongly associated with IADL than with ADL independence.

CONCLUSIONS

A subset of individuals with moderate to severe TBI are able to perform a range of IADL. This group appears to have higher levels of self-awareness than those who are limited to performing only ADL skills. Implications for the applications of functional retraining interventions are discussed.