A review of awareness interventions in brain injury rehabilitation

Engaging carers in neuropsychological rehabilitation for brain cancer survivors: The "I'm aware: Patients And Carers Together" (ImPACT) program

BACKGROUND

Cognitive impairment is a common late effect in child and adult brain cancer survivors (BCS). Still, there is a dearth of research aimed at therapeutic interventions and no standard treatment options for most BCS.

OBJECTIVE

To describe 1) a novel neuropsychological rehabilitation program for BCS - the "I'm aware: Patients And Carers Together" (ImPACT) program, and 2) two studies that aim to assess the feasibility of the ImPACT program in child and adult BCS, respectively. The program adapts the holistic neuropsychological approach pioneered by Leonard Diller and Yehuda Ben-Yishay to an outpatient setting.

METHODS

Two feasibility studies are described: 1) A single-armed study with 15 child BCS (10-17 years) (ImPACT Child); and 2) a randomized waitlist-controlled trial with 26 adult BCS (>17 years) (ImPACT Adult). In both studies, patients will undergo an 8-week program together with a cohabiting carer. Primary outcomes (i.e., cognitive and neurobehavioral symptoms), and secondary outcomes (i.e., behavioral and psychological symptoms, e.g., quality of life, fatigue) will be assessed at four time points: pre-, mid-, and post intervention, and 8 weeks follow-up. Adult waitlist controls will be assessed at equivalent time points and will be included in the intervention group after all study assessments. Semi-structured interviews will be conducted at follow-up.

EXPECTED OUTCOMES

Results will provide feasibility data in support of future larger scale trials.

DISCUSSION

The findings could potentially improve the management of cognitive impairment in BCS and transform available services. The program can be delivered in-person or remotely and harnesses existing resources in patients' lives.

Components of self-awareness affecting caregiver burden: a long-term follow-up study

OBJECTIVE

Studies utilizing the discrepancy model of the Mayo-Portland Adaptability Inventory-4 (MPAI-4) have commonly used the cognitive and physical domains to estimate self-awareness. This study included other aspects of self-awareness such as awareness of one's social and emotional status and daily functioning to explore their effects on caregiver burden for ABI survivors.

METHODS

We studied 64 patient-caregiver pairs up to 29 years post-discharge from a holistic, milieu-oriented outpatient neurorehabilitation program. Discrepancy scores between ABI survivors' and caregivers' reports on the MPAI-4 subscales (i.e. Abilities, Adjustment, and Participation) and Total Score were used to determine self-awareness. Caregiver burden was measured using the Zarit Burden Interview (ZBI).

RESULTS

Exploratory linear regression analyses revealed that caregiver burden derived from the ZBI was predicted by the discrepancy scores generated from the Abilities (p < 0.0001), Adjustment (p < 0.01), Participation subscales (p = 0.01), and Total Score (p < 0.001), respectively. Among the exploratory models generated, the Total Score model had the highest predictive value (R2 = .33) for caregiver burden.

CONCLUSIONS

Measures of self-awareness should be comprehensive by considering diverse components of self-awareness. Increasing ABI survivors' self-awareness in different domains has the potential to effectively alleviate caregiver burden.

The perspectives of participants with traumatic brain injury on prospective memory rehabilitation incorporating compensatory and metacognitive skills training

OBJECTIVE

Patient feedback is rarely gathered systematically in cognitive rehabilitation research. This study examined the perceptions and experiences of people with traumatic brain injury (TBI) who participated in a trial of a 6-session educational program for the rehabilitation of prospective memory (PM) impairment.

METHODS

A mixed methods design was used with 47 participants with TBI who completed a compensatory strategy training program (COMP) or COMP plus metacognitive strategy training program (COMP-MST) delivered by an occupational therapist. Data were collected via a participant survey, extracts from progress notes, and audiotaped discussions about learnings from the program during the final session.

RESULTS

Participants from both programs were highly satisfied and perceived improvements in everyday PM performance post-intervention. Elements that were highly valued include setting individualised client-centred goals, repetitive training of strategy use, establishing habits and routines, and receiving experiential, verbal, and written feedback.Changes including more therapy sessions were recommended.

CONCLUSIONS

Both the COMP and COMP-MST programs were perceived as effective by participants with TBI in improving their PM performance in everyday life using compensatory strategies such as assistive technology.

PRACTICE IMPLICATIONS

Routine collection of patient feedback on cognitive rehabilitation can provide valuable information to support person-centred implementation of clinical practice guidelines.

A Biopsychosocial Framework for Apathy Following Moderate to Severe Traumatic Brain Injury: A Systematic Review and Meta-analysis

Apathy, the deficit of goal-directed behaviour, is well recognised as one of the most debilitating syndromes after moderate-to-severe traumatic brain injury (TBI). However, mechanisms underlying apathy, or at least factors associated with apathy, are sporadically reported. Based on a biopsychosocial framework, this systematic review and meta-analysis synthesised evidence regarding neurobiological, socio-environmental and individual factors associated with apathy. Our searches identified 21 studies satisfying inclusion and exclusion criteria. Results showed that the majority of work has focused on cognitive dysfunction, TBI-related factors, demographic variables and psychological correlates of apathy, while evidence for neural substrates and socio-cultural and premorbid aspects is scant. Overall, the current literature suggests that TBI-related and patient demographic factors did not contribute to apathy after TBI, whereas complex neurocognitive alterations, socio-environmental and cultural factors as well as patients' self-related factors may be important components. The evidence points to the multifaceted interplay of certain biopsychosocial contributors to apathy and suggests future investigations of more complex behavioural traits, cultural elements and pre-injury levels to better characterise the aetiology of this detrimental impairment after TBI.

Value-consistent rehabilitation is associated with long-term psychological flexibility and quality of life after traumatic brain injury

Meaningful steps have been taken toward using holistic approaches in outpatient rehabilitation for traumatic brain injury (TBI) (i.e., treating the whole individual); however, research and practice continue to disproportionately focus on adapting to physical and cognitive changes. Research suggests treatment focusing on individual values may be important for psychological adjustment after TBI. The current study sought to explore individual values across multiple life domains in those with TBI as well as what values outpatient rehabilitation was helpful for, and to examine discrepancies between these factors (i.e., value-consistent rehabilitation) in relation to important long-term treatment outcomes. 215 adults with a history of TBI who had participated in outpatient rehabilitation completed online surveys assessing how consistent outpatient rehabilitation was with individual values, psychological flexibility, and quality of life. The life domains with the greatest discrepancies between individual importance and rehabilitation helpfulness were spirituality, intimate relations, and family relations. Greater value-consistent rehabilitation was associated with higher levels of psychological flexibility and quality of life beyond demographics and injury characteristics. Our findings provide further support in favour of holistic, client-centred approaches that are facilitated by neurological rehabilitation programs.

Clinician reports of self-awareness after traumatic brain injury: a retrospective chart review

BACKGROUND

Impaired self-awareness (i.e., a lack of insight) is experienced by most individuals who have sustained a moderate to severe traumatic brain injury (TBI). During the early recovery period post-injury, these individuals may not be able to recognize their abilities and limitations, hence, negatively impacting their daily life and function. Although there are assessments and interventions to improve self-awareness after TBI, little is known about how clinicians assess and address this impairment in an inpatient rehabilitation setting.

OBJECTIVE

To examine how clinicians assess, report, and provide interventions for impaired self-awareness after TBI.

METHODS

A retrospective chart review was conducted on interdisciplinary rehabilitation clinician entries for individuals with TBI (n = 67) who received inpatient rehabilitation within a five-year period (2014-2019). A reflexive thematic analysis was used to identify themes pertaining to self-awareness.

RESULTS

Three themes were generated to explore clinician responses to their clients' impaired self-awareness: 1) 'recalling and understanding' described clinician observations of client behaviors and expressions of self-awareness, 2) 'applying and analyzing' identified clinicians providing relevant tasks and advice to clients, and 3) 'evaluating and creating' described clinicians actively interacting with clients by providing feedback, guided prompts, and a follow-up plan.

CONCLUSION

Clinicians produced varied responses to clients' impaired self-awareness after TBI. Findings may help to develop research priorities and integrated knowledge translation initiatives to increase evidence-based practice for impaired self-awareness after TBI.

A Neuropsychological Rehabilitation Framework to Address Cognitive and Neurobehavioral Impairments After Strokes to the Anterior Communicating Artery

Patients with strokes to the Anterior Communicating Artery (ACoA) pose an important challenge to rehabilitation teams due to a particular mix of cognitive and behavioral impairments (anosognosia, anterograde amnesia, prospective memory problems, and executive dysfunction). These deficits often compromise engagement with rehabilitation, learning and generalization. The goal of this article is to describe the long-term presentation of a patient with an ACoA stroke (Mrs. B, a 60-year-old electric engineer) as well as her rehabilitation needs and the many challenges experienced by the rehabilitation team when attempting to facilitate functional, vocational and psychosocial recovery. Based on this case, and the existing literature, a neuropsychological rehabilitation framework to understand and address the specific problems and needs of this population is proposed. This framework demands rehabilitation teams to consider: the slow pattern of recovery of this population, the interaction between cognitive and behavioral impairments, the relevance of physical and social environments, the value of personal projects and the need to include psychological and relational interventions.

Unravelling the complex interactions between self-awareness, cognitive change, and mood at 6-months post-stroke using the Y-shaped model

We investigated the relationships between cognitive change following stroke, awareness of cognitive impairments, and mood to further understanding of change processes influencing psychological outcomes post-stroke in line with the "Y-shaped" process model. Patients (n = 143; M_age = 73 years, SD = 13.73; 74 males) were assessed at 3-weeks (T1) and 6-months (T2) post-stroke and had completed the Oxford Cognitive Screen (T1 and T2), the Cognitive Failures Questionnaire (CFQ; T2), and the Hospital Anxiety and Depression Scale (HADS; T2). An ANCOVA controlling for disability relating to activities of daily living (ADL) revealed that awareness of cognitive impairment was significantly lower in participants with moderate-severe cognitive impairment. Regression analysis indicated that greater awareness of cognitive impairment and reduced independence in ADL were associated with greater emotional distress at T2. Cognitive improvement was associated with lower emotional distressat T2. Contrary to the awareness hypothesis, moderation analyses suggest that this effect was largest for those most cognitively impaired at T1. Findings emphasize the importance of monitoring stroke patients' capacity to be self-aware when assessing and formulating long-term post-stroke distress and have potential implications for improving long-term emotional status in those most cognitively impaired post-stroke, e.g., through psychoeducation, cognitive rehabilitation, and emotional support.

"They just say how stupid I was for being conned". Cyberscams and acquired brain injury: A qualitative exploration of the lived experience of survivors and close others

Individuals with acquired brain injury (ABI) may be vulnerable to cyberscams due to their cognitive and psychosocial impairments. However, the lived experiences of cyberscam survivors with ABI and their close others is not understood, and no effective intervention has been identified. This qualitative study aimed to explore the perspectives of cyberscam survivors with ABI (n = 7) and their close others (n = 6). Semi-structured interviews explored the scam experience, impacts, vulnerabilities and interventions. Reflexive thematic analysis of interview transcripts identified seven themes: "who is at the helm?: vulnerabilities," "the lure: scammer tactics," "scammers aboard: scam experience," "the discovery," "sinking in: impacts," "responding to the mayday: responses from others," and "lifesavers: suggestions for intervention." The journey towards scam victimisation was complex, and complicated by the ABI. Cyberscams contributed to substantial financial disadvantage, loss of trust and shame. ABI related impairments and social isolation reportedly increased scam vulnerability and interfered with intervention attempts by family and professionals. Confusion, denial and disbelief created further barriers to discovery. The practical and emotional impacts on both cyberscam survivors with ABI and their family members, and a lack of effective intervention, highlight the need for increased education and awareness in order to improve online safety for those with ABI.

Returning to work after acquired brain injury: A mixed method case study

BACKGROUND: Vocation is a meaningful area of rehabilitation after Acquired Brain Injury (ABI). There is a discrepancy between the number of individuals with an ABI who feel able to work and those who are employed in Ireland. Research suggests that Vocational Rehabilitation (VR) programs enhance Return to Work (RTW) outcomes after ABI, however existing literature is limited. OBJECTIVE: This study explores the experience of engaging in VR post ABI, and its impact upon work self-efficacy. METHODS: A mixed methods case study design was selected to represent the individuality of ABI presentations. Participants completed a qualitative interview at VR follow up (N = 2) and the Work Self-Efficacy Inventory at pre/post VR. RESULTS: Four overarching themes emerged including Stigma, Adjustment, Support and Readiness. RTW challenges included fatigue, accepting support, adjusting to work and stigma. RTW benefits included routine, pride in work, skills development, and empowerment. Wilcoxon signed rank indicated that work self-efficacy scores mildly improved post VR. CONCLUSIONS: This research may inform VR Programs and offers pragmatic clinical implications based on the data. Future research should consider the role that readiness plays in facilitating RTW. Limitations include sample size, a lack of longitudinal data and control group.

"I Couldn't Be Better": Assessing Self-Awareness With the Mayo-Portland Adaptability Inventory-4 Following TBI

INTRODUCTION/OBJECTIVE

To describe level of awareness, as assessed by the Mayo-Portland Adaptability Inventory-4 (MPAI-4), across physical, cognitive, functional, and emotional domains in individuals with mild, moderate, and severe traumatic brain injury (TBI) participating in a residential rehabilitation program. In addition, this study aimed to examine the relationship between time since injury and awareness. A novel way the MPAI-4 can be used to measure self-awareness is also presented.

METHOD

Retrospective analysis of existing data. The MPAI-4 was completed by the patient on admission, as well as by provider consensus within 2 weeks of admission. Level of awareness was determined by discrepancy scores, computed as MPAI-4 provider consensus score minus self-report MPAI-4 score, for the total score and for each index score: Ability, Adjustment, and Participation.

PARTICIPANTS

A total of 101 military veterans and active duty service members admitted to a Veterans Affairs community reintegration rehabilitation program.

RESULTS

Discrepancies between patient and provider reports of functioning were found among all severities of TBI across the MPAI-4 total score and index domains measuring Ability, Adjustment, and Participation. Interestingly, those with mild TBI endorsed greater impairments than their providers, while those with moderate and severe TBI reported less impairment on the MPAI-4 than providers. The effect of time varied across domains, and those who were more than 1 year postinjury displayed greater self-awareness.

CONCLUSION

This study highlights the importance of measuring awareness of functional ability over time and across TBI severity and introduces a novel method for doing so, using the MPAI-4 for comparison between staff and patient reports.

An exploration of goal-setting practices in Queensland rehabilitation services

BACKGROUND

Goals are vital in rehabilitation; however, how goal-setting occurs varies widely in clinical practice. This study aims to review goal-setting practices across the rehabilitation continuum within varied case mix services in Queensland, Australia.

METHOD

A descriptive multisite qualitative case study with medical record audits and interviews of adult rehabilitation clients was used to evaluate four propositions across three inpatient and two community rehabilitation services. The propositions evaluated the process in which goal-setting occurs, action planning and review of goals, as well as the type, specificity and client-centeredness of goals set.

RESULTS

Goals (n = 1120) were often poorly defined, focussed on short term physical functioning and were predominantly set by individual disciplines with the client rather than using an interdisciplinary approach. Clients were not consistently given action plans to pursue goals (n = 59, 18%) and the review of goal progress (n = 60, 18%) was limited. Few clients reported receiving copies of their rehabilitation goals (n = 16, 25%).

CONCLUSION

Goal-setting in rehabilitation should be specific, meaningful and include the client in action planning, feedback and review. However, goal-setting in rehabilitation is often multidisciplinary and unstructured.Implications for rehabilitationBest-practice rehabilitation team goal-negotiation and goal-setting should include a common goal focus and incorporate components of staff and client action planning, coping planning, feedback and review.Rehabilitation clients prefer shared-decision making approaches to setting meaningful and personalised goals, however, require time and support to engage in the goal-setting and negotiation process.Rehabilitation clinicians need training and support to improve their goal negotiation and goal writing skills to create specific, understandable and meaningful goals with rehabilitation clients.

Anosognosia in Mild Cognitive Impairment: Lack of Awareness of Memory Difficulties Characterizes Prodromal Alzheimer's Disease

While anosognosia is often present in Alzheimer's disease, the degree of awareness of cognitive difficulties in the earlier stages, such as Mild Cognitive Impairment (MCI), is less clear. Using a questionnaire and Feeling-of-Knowing tasks, the aims of this study were (1) to test the hypothesis that anosognosia is present specifically in prodromal AD stage in patients that, owing to a more severe AD neuropathology, will rapidly progress to overt dementia and (2) to assess the neural bases of self-awareness for memory functioning. A group of 44 patients with amnestic MCI and a group of 29 healthy older participants (CTRL) performed two Feeling-of-Knowing tasks (episodic and semantic FOK) and responded to the Functional Memory Scale (MARS), also completed by one of their relatives. They underwent FDG-PET and structural MRI. The participants were followed clinically for 4 years. At the end of follow-up, 23 patients with MCI developed Alzheimer's disease (converters) and 21 patients still presented symptoms of MCI without progression (non-converters). The analyses focused on the data from inclusion stratified according to clinical status 4 years later (converters, non-converters, CTRL). On the episodic FOK task, converters patients overestimated their ability to later recognize unrecalled words and they showed prediction accuracy (Hamann coefficient) at the level of chance. No difficulty was observed in any group with the semantic FOK task. On the MARS, converters patients had a higher anosognosia score than non-converters patients and CTRL, which did not differ from each other. Correlations between self-awareness scores and neuroimaging data using small volume correction analyses in a priori regions of interest in converters indicated that inaccurate episodic FOK judgments was related to changes in brain areas that might support interpretation of retrieved content for judging the likelihood of recognition. For the MARS, the association between anosognosia and decreased gray matter density of the left inferior prefrontal cortex in converters might indicate poor inhibition over outdated personal knowledge. In amnestic MCI, anosognosia could be an early sign of neurodegeneration in brain areas that would support control mechanisms over memory representations.

Occupation Based Telerehabilitation Intervention for Adolescents with Myelomeningocele: A Pilot Study

AIMS

This pilot study examined the impact of an occupation based intervention using a telerehabilitation format with adolescents with myelomeningocele (MMC).

METHODS

We conducted a nonrandomized pilot study including four adolescents ages 14-18 with MMC. The intervention program included 10-12 sessions of the Cognitive Orientation to daily Occupational Performance remotely delivered via videoconferencing. Outcome measures included the Canadian Occupational Performance Measure (COPM), Wee-Functional Independence Measure;(Wee-FIM), and the Pediatric Quality of Life Inventory (PedsQL). Assessments were administered at baseline, post intervention and at three-month follow-up.

RESULTS

Following intervention, participants rated their performance as having improved 2 points on the COPM for 8 out of 12 trained goals and on 2 out of 8 untrained goals. At 3-month follow-up improvement was reported on 9 out of 12 trained goals and 3 out of 8 untrained goals All participants made clinically significant improvements on the Wee-FIM total score following intervention and improvements were maintained at 3-month follow-up. The intervention effect on the PedsQL was inconclusive. Feedback interviews suggested that participants experience high satisfaction from the results and implementation of the intervention.

CONCLUSIONS

Our results demonstrate potential efficacy of occupation based teleintervention for adolescents with MMC.

Accepting what we do not know: A need to improve professional understanding of brain Injury in the UK

Acquired brain injury (ABI) can lead to life-long changes and disability. The complex and extensive nature of behavioural, cognitive, executive, physical and psychological difficulties mean ABI survivors and their families may come into contact with a range of health and social care services as part of their long-term care. This study aimed to understand the ABI knowledge base of professionals across a range of organisations within the UK, and to identify areas for improvement. This was achieved through a mixed methods approach using a mixed methods questionnaire (117 participants) and qualitative semi-structured interviews about service experiences (31 participants) of professionals and service users (families and individuals with ABI). Participants included UK health and social care professionals, ABI specialists, ABI survivors and family members. Data were collected from February 2017 to April 2018. The results of the study identified a lack of knowledge and understanding of ABI among health and social care professionals in the UK, from those involved in acute care through to long-term community services. Poor knowledge was associated with a lack of understanding of "hidden" disabilities associated with ABI, a lack of empathy and a lack of knowledge regarding specific safeguarding. Health and social care professionals across a range of services could benefit in ABI-specific training to improve their knowledge and improve the service currently being provided to individuals with ABI and their families.

Experiential Neurorehabilitation: A Neurological Therapy Based on the Enactive Paradigm

With the arrival of the cognitive paradigm during the latter half of the last century, the theoretical and scientific bases of neurorehabilitation have been linked to the knowledge developed in cognitive neuropsychology and cognitive neuroscience. Although the knowledge generated by these disciplines has made relevant contributions to neurological therapy, their theoretical premises may create limitations in therapeutic processes. The present manuscript has two main objectives: first, to explicitly set forth the theoretical bases of cognitive neurorehabilitation and critically analyze the repercussions that these premises have produced in clinical practice; and second, to propose the enactive paradigm to reinterpret perspectives on people with brain damage and their therapy (assessment and treatment). This analysis will show that (1) neurorehabilitation as a therapy underutilizes body-originated resources that aid in recovery from neurological sequelae (embrained therapy); (2) the therapeutic process is based exclusively on subpersonal explanation models (subpersonal therapy); and (3), neurorehabilitation does not take subjectivity of each person in their own recovery processes into account (anti-subjective therapy). Subsequently, and in order to attenuate or resolve the conception of embrained, subpersonal and anti-subjective therapy, I argue in support of incorporating the enactive paradigm in rehabilitation of neurological damage. It is proposed here under a new term, "experiential neurorehabilitation." This proposal approaches neurological disease and its sequelae as alterations in dynamic interaction between the body structure and the environment in which the meaning of the experience is also altered. Therefore, when a person is not able to walk, remember the past, communicate a thought, or maintain efficient self-care, their impairments are not only a product of an alteration in a specific cerebral area or within information processing; rather, the sequelae of their condition stem from alterations in the whole living system and its dynamics with the environment. The objective of experiential neurorehabilitation is the recovery of the singular and concrete experience of the person, composed of physical and subjective life attributes.

Cognitive predictors of self-awareness in patients with acquired brain injury along neuropsychological rehabilitation

Previous research has identified a critical role of executive function and memory in self-awareness, a metacognitive capacity often impaired in acquired brain injury. Through this observational study, we aimed to explore the effect of cognitive rehabilitation on the predictive value of these variables, as also whether any of them can predict the level of self-awareness once the cognitive rehabilitation is completed. 69 patients underwent a neuropsychological assessment, including self-awareness, at admission to and discharge from a cognitive rehabilitation process. Regression analysis was performed at these two moments and a third one was conducted to evaluate whether any of the variables at admission predicted the level of self-awareness at discharge. Verbal fluency was found to be the best predictor of self-awareness, both at admission and discharge. In addition, inhibition and cognitive flexibility, as well as episodic memory, appeared as significant predictors of post-rehabilitation self-awareness. Finally, verbal fluency was revealed as the unique pre-rehabilitation predictor of subsequent level of self-awareness following rehabilitation. While post-acute self-awareness is predicted by non-specific executive measures, the cognitive improvement putatively induced by neuropsychological rehabilitation reveals the contribution of more specific executive and memory functions. Importantly, pre-rehabilitation verbal fluency scores predicted the level of self-awareness after cognitive rehabilitation.

The Relation Between Empathy and Insight in Psychiatric Disorders: Phenomenological, Etiological, and Neuro-Functional Mechanisms

Lack of insight, i.e., unawareness of one's mental illness, is frequently encountered in psychiatric conditions. Insight is the capacity to recognize (psychical insight) and accept one's mental illness (emotional insight). Insight growth necessitates developing an objective perspective on one's subjective pathological experiences. Therefore, insight has been posited to require undamaged self-reflexion and cognitive perspective-taking capacities. These enable patients to look objectively at themselves from the imagined perspective of someone else. Preserved theory-of-mind performances have been reported to positively impact insight in psychosis. However, some patients with schizophrenia or obsessive-compulsive disorders, although recognizing their mental disease, are still not convinced of this and do not accept it. Hence, perspective-taking explains psychical insight (recognition) but not emotional insight (acceptance). Here, we propose a new conceptual model. We hypothesize that insight growth relies upon the association of intact self-reflexion and empathic capacities. Empathy (feeling into someone else) integrates heterocentered visuo-spatial perspective (feeling into), embodiment, affective (feeling into) and cognitive processes, leading to internally experience the other's thought. We posit that this subjective experience enables to better understand the other's thought about oneself and to affectively adhere to this. We propose that the process of objectification, resulting from empathic heterocentered, embodiment, and cognitive processes, generates an objective viewpoint on oneself. It enables to recognize one's mental illness and positively impacts psychical insight. The process of subjectification, resulting from empathic affective processes, enables to accept one's illness and positively impacts emotional insight. That is, affectively experiencing the thought of another person about oneself reinforces the adhesion of the emotional system to the objective recognition of the disease. Applying our model to different psychiatric disorders, we predict that the negative effect of impaired self-reflexion and empathic capacities on insight is a transnosographic state and that endophenotypical differences modulate this common state, determining a psychiatric disease as specific.

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.

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.

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.

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.

Participants' perspectives of feasibility of a novel group treatment for people with cognitive communication difficulties following acquired brain injury

Purpose: To determine whether treatment was acceptable to participants and perceived as beneficial by exploring the experiences of people with cognitive communication difficulties following acquired brain injury who participated in a novel, group, communication, project-based treatment. The purpose of the treatment was to improve participants' communication skills and quality of life, by focussing group activity towards the production of a project and by incorporating individualised communication goals into group sessions.Methods: Twenty-one people with acquired brain injury recruited from community settings participated in project-based treatment, which comprised one individual and nine group sessions (of 2-3 people) over six weeks. Structured interviews were conducted post-treatment as part of a broader assessment battery. Interviews were transcribed verbatim and analysed using content analysis to identify codes, categories, and themes.Results: Themes identified from the analysis centred around the treatment experience (general experience; group experience; project experience; working on goals) and benefit of treatment (communicative benefit; other benefits; emotional effects; meeting others; something to do). These themes were consistent with the treatment being perceived as acceptable and having initial efficacy for the participant group.Conclusion: The qualitative data presented here provide positive feasibility findings (acceptability and initial efficacy) of project-based treatment for people with acquired brain injury. The results highlight the value of incorporating participants' views in assessing feasibility in developing novel interventions.Implications for rehabilitationInviting people (with cognitive communication difficulties following acquired brain injury) to feedback on their treatment experience provides valuable information that can confirm treatment choice and content or inform adjustments to future treatment.Group treatment with a meaningful and motivating focus, and individualised communication goals, seem to promote positive change in communication, emotional state, cognition, self-awareness, and social interaction.This study highlights the value of individuals' perspectives in evaluating feasibility of a novel intervention.

Predictors of working alliance in cognitive behaviour therapy adapted for traumatic brain injury

Cognitive Behaviour Therapy (CBT) has the strongest preliminary support for treatment of depression and anxiety following traumatic brain injury (TBI). TBI associated cognitive impairments may pose an obstacle to development of a strong working alliance, on which therapeutic gains depend. The current study examined the association of demographic (i.e., gender, age at study entry, years of education and premorbid IQ) and injury-related (i.e., years since injury, post-trauma amnesia duration, memory and executive functioning test performance) variables with alliance in CBT adapted for TBI (CBT-ABI). The audio-recordings of 177 CBT-ABI sessions from 31 participants were assessed with an observer version of the Working Alliance Inventory at nine time-points. Multi-level mixed model regressions showed that participants and therapists maintained a relatively strong alliance across all sessions. Pre-intervention symptom severity was considered as a confounder variable and was found to have no statistically significant influence on the models. None of the demographic variables were significantly associated with alliance scores. More years since injury was associated with a stronger alliance. These findings demonstrate that TBI associated cognitive impairments do not necessarily pose an obstacle to development and maintenance of a strong working alliance, which is more likely to develop with more time post-brain injury.

The role of cognitive rehabilitation in limbic encephalitis: A case report

RATIONALE

Limbic encephalitis is a parenchymal inflammation caused by viral, bacterial, or other microbial and postinfectious agents, which is usually expressed by multifocal neurological signs and cognitive impairment.

PATIENT CONCERNS

A 50-year-old female was admitted in postacute phase, at our rehabilitative Center, to undertake neuro-motor treatment for a period of 4 months.

DIAGNOSES

The patient was affected by limbic encephalitis. Clinical presentation revealed attention, memory and executive dysfunctions, as well as behavioral changes, emotional dysregulation and reduction of self-awareness.

INTERVENTIONS

The patients received an intensive cognitive and motor rehabilitation training.

OUTCOMES

Neuropsychological assessment and magnetic resonance imaging were performed before and after rehabilitative training to evaluate the cognitive and cerebral changes induced by treatment. The patient showed an improvement in cognitive performances and behavioral aspects.

LESSONS

The reducing cognitive deficits, especially memory deficits, could improve quality of life by using available cognitive resources.

Value of schizophrenia treatment I: The patient journey

BACKGROUND

The aim of the European Brain Council project "The Value of Treatment" was to provide evidence-based, cost-effective policy recommendations for a patient-centered and sustainable coordinated care model for brain disorders. The first part of schizophrenia study examined the needs and gaps in the patients' care pathway.

METHODS

Descriptive analysis was based on an inventory of needs and treatment opportunities, using focus group sessions, expert interviews, users' input, and literature review. Three patient pathways were selected: indicated prevention, duration of untreated psychosis, and relapse prevention.

RESULTS

The analysis identified several critical barriers to optimal treatment. Available health care services often miss or delay detection of symptoms and diagnosis in at-risk individuals. There is a lack of illness awareness among patients, families, and the public; scarcity of information, training and education among primary care providers; stigmatizing beliefs. Early symptom recognition and timely intervention result in better outcome and prognosis; effective management leads to a functional recovery. In the current model of care, there is insufficient cooperation between health and social care providers, patients and families, inadequate utilization of pharmacological and psychosocial interventions, lacking patient monitoring, and low implementation of integrated community care.

CONCLUSIONS

Early detection and early intervention programs, timely intervention, and relapse prevention are essential for effective management of schizophrenia. It requires a paradigm shift from symptom control, achieving and maintaining remission, to the emphasis on recovery. Since the current services are not able to accomplish this goal, changes in mental health policies are needed.

Repressive Coping Does Not Contribute to Anosognosia in First-Diagnosis Patients With Alzheimer Disease

Anosognosia is common in patients with Alzheimer disease (AD) even in early stages. Although neural correlates and the impact of cognitive dysfunctions have been described, possible psychodynamic processes such as a repressive coping style as described in other illnesses, have not been examined. Our study aimed to examine possible psychological influence factors on illness perception embracing a repressive coping style and cognitive functions in AD patients in the diagnostic process. Fifty-four subjects with mild AD diagnosed in our memory clinic were enrolled. Anosognosia was evaluated using a patient-caregiver discrepancy rating. All patients underwent comprehensive neuropsychological testing. In addition, characteristics of a repressive coping style were assessed. In total, 79.6% of our patients showed a lack of awareness at least to some degree. 33.3% of the patients were classified as repressors. Repressors and nonrepressors did not differ in cognition, or the unawareness score. Multivariate regression analysis showed that repressive coping style did not significantly contribute to anosognosia, but that verbal memory and naming ability had a strong influence. Although our data indicate that a high proportion of patients with mild AD show characteristics of repressive coping, this possible defense mechanism had no influence on the awareness of illness-related deficits measured by caregiver patient discrepancy.

Measuring Adolescent Self-Awareness and Accuracy Using a Performance-Based Assessment and Parental Report

Aim

The aim of this study was to assess awareness of performance and performance accuracy for a task that requires executive functions (EF), among healthy adolescents and to compare their performance to their parent’s ratings.

Method

Participants: 109 healthy adolescents (mean age 15.2 ± 1.86 years) completed the Weekly Calendar Planning Activity (WCPA). The discrepancy between self-estimated and actual performance was used to measure the level of awareness. The participants were divided into high and low accuracy groups according to the WCPA accuracy median score. The participants were also divided into high and low awareness groups. A comparison was conducted between groups using WCPA performance and parent ratings on the Behavior Rating Inventory of Executive Function (BRIEF).

Results

Higher awareness was associated with better EF performance. Participants with high accuracy scores were more likely to show high awareness of performance as compared to participants with low accuracy scores. The high accuracy group had better parental ratings of EF, higher efficiency, followed more rules, and were more aware of their WCPA performance.

Conclusion

Our results highlight the important contribution that self-awareness of performance may have on the individual’s function. Assessing the level of awareness and providing metacognitive training techniques for those adolescents who are less aware, could support their performance.

The Neuropsychology of Traumatic Brain Injury: Looking Back, Peering Ahead

The past 50 years have been a period of exciting progress in neuropsychological research on traumatic brain injury (TBI). Neuropsychologists and neuropsychological testing have played a critical role in these advances. This study looks back at three major scientific advances in research on TBI that have been critical in pushing the field forward over the past several decades: The advent of modern neuroimaging; the recognition of the importance of non-injury factors in determining recovery from TBI; and the growth of cognitive rehabilitation. Thanks to these advances, we now have a better understanding of the pathophysiology of TBI and how recovery from the injury is also shaped by pre-injury, comorbid, and contextual factors, and we also have increasing evidence that active interventions, including cognitive rehabilitation, can help to promote better outcomes. The study also peers ahead to discern two important directions that seem destined to influence research on TBI over the next 50 years: the development of large, multi-site observational studies and randomized controlled trials, bolstered by international research consortia and the adoption of common data elements; and attempts to translate research into health care and health policy by the application of rigorous methods drawn from implementation science. Future research shaped by these trends should provide critical evidence regarding the outcomes of TBI and its treatment, and should help to disseminate and implement the knowledge gained from research to the betterment of the quality of life of persons with TBI. (JINS, 2017, 23, 806-817).

Rehabilitation of emergent awareness of errors post traumatic brain injury: A pilot intervention

Impaired awareness of errors is common following traumatic brain injury (TBI) and can be a barrier to successful rehabilitation. The objective of this study was to develop and evaluate a computer-based intervention programme aimed at improving error awareness in individuals with TBI. A further aim was to explore its effects on metacognitive awareness and variability of performance. Participants were 11 individuals with TBI and impaired error awareness who performed a sustained attention task twice-weekly for four weeks. The intervention consisted of audio-visual feedback-on-errors during the sustained attention task. Six participants received audio-visual feedback-on-error, five did not receive feedback. Emergent and metacognitive awareness were measured pre- and post-intervention. Between-groups comparisons of emergent awareness from pre- to post-intervention showed that audio-visual feedback-on-error improved emergent awareness compared to no feedback-on-error. Some changes in metacognitive awareness of executive behaviours as a result of feedback were observed. Audio-visual feedback-on-error improved emergent awareness in individuals with TBI following a four-week/eight-session intervention. This improvement was not observed in the no-feedback group. This pilot intervention is not a stand-alone treatment but it has potential to be usefully incorporated into cognitive or clinical rehabilitation programmes to improve emergent awareness.

The Overt Behaviour Scale-Self-Report (OBS-SR) for acquired brain injury: exploratory analysis of reliability and validity

The objectives were to test the properties, via a psychometric study, of the Overt Behaviour Scale-Self-Report (OBS-SR), a version of the OBS-Adult Scale developed to provide a client perspective on challenging behaviours after acquired brain injury. Study sample 1 consisted of 37 patients with primary brain tumour (PBT) and a family-member informant. Sample 2 consisted of 34 clients with other acquired brain injury (mixed brain injury, MBI) and a service-provider informant. Participants completed the OBS-SR (at two time points), and the Awareness Questionnaire (AQ) and Mayo Portland Adaptability Inventory-III (MPAI-III) once; informants completed the OBS-Adult and AQ once only. PBT-informant dyads displayed "good" levels of agreement (ICC_2,k = .74; OBS-SR global index). Although MBI-informant dyads displayed no agreement (ICC_2,k = .22; OBS-SR global index), the sub-group (17/29) rated by clinicians as having moderate to good levels of awareness displayed "fair" agreement (ICC_2,k = .58; OBS-SR global index). Convergent/divergent validity was demonstrated by significant correlations between OBS-SR subscales and MPAI-III subscales with behavioural content (coefficients in the range .36 -.61). Scores had good reliability across one week (ICC_2,k = .69). The OBS-SR took approximately 15 minutes to complete. It was concluded that the OBS-SR demonstrated acceptable reliability and validity, providing a useful resource in understanding clients' perspectives about their behaviour.

Long-Term Use and Perceived Benefits of Goal-Oriented Attentional Self-Regulation Training in Chronic Brain Injury

Primary Objective. To investigate the long-term use and perceived benefit(s) of strategies included in Goal-Oriented Attentional Self-Regulation (GOALS) training (Novakovic-Agopian et al., 2011) by individuals with acquired brain injury (ABI) and chronic executive dysfunction. Research Design. Longitudinal follow-up of training. Methods and Procedures. Sixteen participants with chronic ABI participated in structured telephone interviews 20 months (range 11 to 31 months) following completion of GOALS training. Participants responded to questions regarding the range of strategies they continued to utilize, perceived benefit(s) of strategy use, situations in which strategy use was found helpful, and functional changes attributed to training. Results. Nearly all participants (94%) reported continued use of at least one trained strategy in their daily lives, with 75% of participants also reporting improved functioning resulting from training. However, there was considerable variability with respect to the specific strategies individuals found helpful as well as the perceived impact of training on overall functioning. Conclusions. GOALS training shows promising long-term benefits for individuals in the chronic phase of brain injury. Identifying individual- and injury-level factors that account for variability in continued strategy use and the perceived long-term benefits of training will help with ongoing intervention development.

The efficacy of prospective memory rehabilitation plus metacognitive skills training for adults with traumatic brain injury: study protocol for a randomized controlled trial

BACKGROUND

Impairment of prospective memory (PM) is common following traumatic brain injury (TBI) and negatively impacts on independent living. Compensatory approaches to PM rehabilitation have been found to minimize the impact of PM impairment in adults with TBI; however, poor self-awareness after TBI poses a major barrier to the generalization of compensatory strategies in daily life. Metacognitive skills training (MST) is a cognitive rehabilitation approach that aims to facilitate the development of self-awareness in adults with TBI. This paper describes the protocol of a study that aims to evaluate the efficacy of a MST approach to compensatory PM rehabilitation for improving everyday PM performance and psychosocial outcomes after TBI.

METHODS/DESIGN

This randomized controlled trial has three treatment groups: compensatory training plus metacognitive skills training (COMP-MST), compensatory training only (COMP), and waitlist control. Participants in the COMP-MST and COMP groups will complete a 6-week intervention consisting of six 2-h weekly training sessions. Each 1.5-h session will involve compensatory strategy training and 0.5 h will incorporate either MST (COMP-MST group) or filler activity as an active control (COMP group). Participants in the waitlist group receive care as usual for 6 weeks, followed by the COMP-MST intervention. Based on the sample size estimate, 90 participants with moderate to severe TBI will be randomized into the three groups using a stratified sampling approach. The primary outcomes include measures of PM performance in everyday life and level of psychosocial reintegration. Secondary outcomes include measures of PM function on psychometric testing, strategy use, self-awareness, and level of support needs following TBI. Blinded assessments will be conducted pre and post intervention, and at 3-month and 6-month follow-ups.

DISCUSSION

This study seeks to determine the efficacy of COMP-MST for improving and maintaining everyday PM performance and level of psychosocial integration in adults with moderate to severe TBI. The findings will advance theoretical understanding of the role of self-awareness in compensatory PM rehabilitation and skills generalization. COMP-MST has the potential to reduce the cost of rehabilitation and lifestyle support following TBI because the intervention could enhance generalization success and lifelong application of PM compensatory strategies.

TRIAL REGISTRATION

New Zealand Clinical Trials Registry, ACTRN12615000996561 . Registered on 23 September 2015; retrospectively registered 2 months after commencement.

Investigating the relationship between reduced self-awareness of falls risk, rehabilitation engagement and falls in older adults

The present study aimed to investigate whether self-awareness of falls risk is associated with rehabilitation engagement, motivation for rehabilitation, and number of falls after hospital discharge. The sample comprised 91 older adults (M_age=77.97, SD=8.04) undergoing inpatient rehabilitation. The Self-Awareness of Falls Risk Measure (SAFRM) was used to measure different aspects of self-awareness. The treating physiotherapist and occupational therapist rated the patient's engagement in rehabilitation and the patient reported his/her motivation for treatment. Falls information was collected from the patient and significant other once a month for three months following hospital discharge. Significant correlations were found between physiotherapist-rated engagement and intellectual (r_s=-0.22, p<0.05) and anticipatory awareness (r_s=-0.24, p<0.05). Occupational therapist-rated engagement and patient-reported motivation for rehabilitation was correlated with emergent awareness (r_s=-0.38 and -0.31, p<0.05, respectively) and overall self-awareness (r_s=-0.31 and -0.26, p<0.05, respectively). Regression analyses indicated that overall self-awareness provided a unique contribution to occupational therapist-rated engagement when controlling for age, gender, cognition and functional ability. Falls were reported by 29.9% of participants, however, self-awareness did not differ significantly between fallers and non-fallers. The findings suggest that self-awareness of falls risk is associated with rehabilitation engagement and motivation. Therefore, improving patient self-awareness of falls risk may increase engagement in therapy leading to better patient outcomes.

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

OBJECTIVE

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

DESIGN

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

SETTING

Outpatient.

PARTICIPANTS

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

INTERVENTION

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Feasibility of online self-administered cognitive training in moderate-severe brain injury

PURPOSE

Cognitive environmental enrichment (C-EE) offers promise for offsetting neural decline that is observed in chronic moderate-severe traumatic brain injury (TBI). Brain games are a delivery modality for C-EE that can be self-administered over the Internet without therapist oversight. To date, only one study has examined the feasibility of self-administered brain games in TBI, and the study focused predominantly on mild TBI. Therefore, the primary purpose of the current study was to examine the feasibility of self-administered brain games in moderate-severe TBI. A secondary and related purpose was to examine the feasibility of remote monitoring of any C-EE-induced adverse symptoms with a self-administered evaluation tool.

METHOD

Ten patients with moderate-severe TBI were asked to complete 12 weeks (60 min/day, five days/week) of online brain games with bi-weekly self-evaluation, intended to measure any adverse consequences of cognitive training (e.g., fatigue, eye strain).

RESULTS

There was modest weekly adherence (42.6% ± 4.4%, averaged across patients and weeks) and 70% patient retention; of the seven retained patients, six completed the self-evaluation questionnaire at least once/week for each week of the study.

CONCLUSIONS

Even patients with moderate-severe TBI can complete a demanding, online C-EE intervention and a self-administered symptom evaluation tool with limited therapist oversight, though at daily rate closer to 30 than 60 min per day. Further self-administered C-EE research is underway in our lab, with more extensive environmental support. Implications for Rehabilitation Online brain games (which may serve as a rehabilitation paradigm that can help offset the neurodegeneration observed in chronic TBI) can be feasibly self-administered by moderate-to-severe TBI patients. Brain games are a promising therapy modality, as they can be accessed by all moderate-to-severe TBI patients irrespective of geographic location, clinic and/or therapist availability, or impairments that limit mobility and access to rehabilitation services. Future efficacy trials that examine the effect of brain games for offsetting neurodegeneration in moderate-to-severe TBI patients are warranted.

Facilitating Transfer of Skills and Strategies in Occupational Therapy Practice: Practical Application of Transfer Principles

In Occupational Therapy (OT) practice, practitioners assume that the skills and strategies taught to clients during rehabilitation will transfer to performance and participation in everyday life. Despite transfer serving as a practice foundation, outcome studies conclude that this assumption of transfer is not occurring and it often results in decreased efficacy of rehabilitation. This paper investigated key aspects of transfer and found concepts in the psychology literature that can support transfer of skills and strategies in OT. Six key principles proposed from educational psychology can serve as a guide for practitioners to better train for transfer. In this paper, we discuss the six principles and apply concepts from psychology. Each principle is supported with examples of how they may be incorporated OT practice. If occupational therapists understand these principles and implement them in treatment, the efficacy of treatment may improve for many populations.

Self-awareness and traumatic brain injury outcome

PRIMARY OBJECTIVE

Impaired self-awareness following a traumatic brain injury (TBI) can reduce the effectiveness of rehabilitation, resulting in poorer outcomes. However, little is understood about how the multi-dimensional aspects of self-awareness may differentially change with recovery and impact outcome. Thus, this study examined four self-awareness variables represented in the Dynamic Comprehensive Model of Awareness: metacognitive awareness, anticipatory awareness, error-monitoring and self-regulation.

RESEARCH DESIGN

This study evaluated change of the self-awareness measures with recovery from TBI and whether the self-awareness measures predicted community re-integration at follow-up.

METHODS AND PROCEDURES

Participants were 90 individuals with moderate-to-severe TBI who were tested acutely following injury and 90 age-matched controls. Forty-nine of the TBI participants and 49 controls were re-tested after 6 months.

MAIN OUTCOME AND RESULTS

Results revealed that the TBI group's error-monitoring performance was significantly poorer than controls at both baseline and follow-up. Regression analyses revealed that the self-awareness variables at follow-up were predictive of community re-integration, with error-monitoring being a unique predictor.

CONCLUSIONS

The results highlight the importance of error-monitoring and suggest that interventions targeted at improving error-monitoring may be particularly beneficial. Understanding the multi-dimensional nature of self-awareness will further improve rehabilitation efforts and understanding of the theoretical basis of self-awareness.

Maintenance of treatment effects of an occupation-based intervention with video feedback for adults with TBI

BACKGROUND

Video feedback interventions have been found to improve self-awareness and occupational performance to a greater extent than other feedback interventions after traumatic brain injury (TBI). However, it is unclear whether the effects of video feedback are maintained over time.

OBJECTIVE

To evaluate the maintenance of gains in self-awareness achieved with a video feedback intervention in people with TBI.

METHODS

There were 32 participants with TBI and impaired self-awareness who had completed a randomized controlled trial with three feedback conditions (video plus verbal, verbal and experiential). Eight to ten weeks after the final feedback intervention session, a follow-up assessment was conducted. The primary outcome was maintenance of gains in online awareness measured by the number of errors made during a meal preparation task. Group outcomes were compared using an unstructured linear mixed regression model.

RESULTS

The video plus verbal feedback group continued to demonstrate significantly greater gains in online awareness compared to the verbal feedback group (mean difference 20.6, 95% CI 8.8 to 32.3) and the experiential feedback group (mean difference 14.4, 95% CI 3.1 to 25.6). There was no significant impact of the interventions on participants' emotional status at the 8 to 10 week follow-up.

CONCLUSIONS

A combination of video plus verbal feedback is an effective technique for achieving maintained gains in self-awareness in people with TBI.