Efficacy of rehabilitation for functional skills more than 10 years after extremely severe brain injury

A neurobehavioral therapy approach to the rehabilitation and support of persons with brain injury: Practice-based evidence from a UK charitable rehabilitation provider

Background

The treatment and rehabilitation for people with acquired brain injury is continually evolving, with increasing recognition of the importance of approaches that adopt a multi-disciplinary biopsychosocial perspective focused on improving adjustment, social participation, and wellbeing. However, there is significant variability as to how such approaches are delivered, across the various stages of recovery, rehabilitation settings, and within different healthcare systems.

Objective

This paper had three aims. The first was to describe the neurobehavioral therapy (NBT) approach to brain injury rehabilitation adopted in our charitable organization. The second aim was to report how the NBT approach evolved in response to changes in referral patterns, and patient needs within a broader, longer-term clinical pathway. The third aim was to assess the effectiveness of the NBT approach by analyzing outcome data.

Methods

Retrospective analyses of standardized outcome data were completed to investigate the effectiveness of our approach. Case vignettes are provided to illustrate the key components of the approach.

Results

Outcome data suggested that the approach is effective in delivering positive outcomes for patients. Furthermore, the data show differences in presentation between three clinical streams (restoration, compensation, and scaffolding) within the NBT approach.

Conclusions

This paper describes the adaption of the ‘traditional' neurobehavioral approach to brain injury rehabilitation into a model of delivery that can benefit a more diverse range of people living with the heterogenous and long-term consequences of brain injury.

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.

Application of an Intensive Rehabilitation Program After Very Late Recovery of Consciousness: A Single-Case Neurorehabilitation and Neuroimaging Study

Late recovery of consciousness in vegetative state is considered as an exceptional outcome and has been reported prevalently in patients who suffered a traumatic brain injury. In these patients, the benefits of prolonging the rehabilitation, aimed at the recovery of autonomy in basic everyday activities, has been demonstrated. Here, we describe the application of an intensive multi-professional rehabilitation program carried out on a young female patient, with exceptionally late recovery of consciousness, specifically, after 7 years of vegetative state due to severe brain hemorrhage. Neuropsychological and functional assessment was conducted before and after the end of the rehabilitation program. In addition, functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI)-based probabilistic tractography were performed. Two follow-up neuropsychological and functional assessments were also conducted 6 and 29 months after the conclusion of the program. Functional results showed an improvement, maintained over time, in walking with assistance, cognitive efficiency, visual acuity and visual field, dysarthria, and execution of activities of daily living. Moreover, functional and structural magnetic resonance imaging (MRI) data documented the existence of preserved neural networks involved in sensory, motor, and linguistic tasks, which in all likelihood support the recovery process. This report suggests the possibility of undertaking an intensive rehabilitation program in patients who remain for long periods in altered states of consciousness, in spite of early negative prognosis.

Efficacy of a Micro-Prompting Technology in Reducing Support Needed by People With Severe Acquired Brain Injury in Activities of Daily Living: A Randomized Control Trial

OBJECTIVE

To evaluate the effectiveness of an automated interactive prompting technology in supporting the morning routine of persons with acquired brain injury. The morning routine included maintaining personal hygiene and dressing.

SETTING

An inpatient neurorehabilitation hospital.

PARTICIPANTS

Persons with acquired brain injury who required prompting when following their morning routine (n = 24), but were not limited by physical disability or dysphasia, took part in the study. Participants (67% with traumatic brain injury) had impairment on indices of memory and executive function.

DESIGN

A randomized control trial evaluated the effect of an automated interactive micro-prompting device on the number of prompts by trained staff required for successful completion of the morning routine.

MAIN MEASURES

Study-specific checklists assessed sequence performance, errors, and verbal prompts required over baseline, rehabilitation as usual, intervention, and return to baseline conditions.

RESULTS

The intervention significantly reduced the support required to complete the task compared with usual rehabilitation.

CONCLUSIONS

Micro-prompting technology is an effective assistive technology for cognition, which reduces support needs in people with significant cognitive impairments.

Revisiting the neurofunctional approach: conceptualizing the core components for the rehabilitation of everyday living skills

BACKGROUND

Introduced in the 1980s, the neurofunctional approach (NFA) is one of the few interventions designed primarily for clients with severe deficits following traumatic brain injury (TBI). Specifically the NFA was intended for those individuals who were limited in their ability to solve novel problems or generalize skills from one setting to another and whose lack of insight limited their engagement in the rehabilitative process. DESCRIPTION OF THE APPROACH: The NFA is a client-centred, goal-driven approach that incorporates the principles of skill learning and promotes the development of routines and competencies in practical activities required for everyday living. Programmes based on the NFA are developed specifically to meet each client's unique needs, using a range of evidence-based interventions. RECENT EVIDENCE: Recently the NFA has been found to be more effective than cognitive-retraining for some individuals with moderate-to-severe TBI who have deficits in activities of daily living. This paper aims to define the core features of the NFA, outline the theoretical basis on which it is founded and consider implications of the findings for rehabilitation after TBI in general. The NFA is highly relevant for clients living in the community who require a case manager to direct an integrated, rehabilitation programme or provide structured input for the long-term maintenance of skills.

Application of the Multicontextual Approach in Promoting Learning and Transfer of Strategy Use in an Individual with TBI and Executive Dysfunction

The multicontext approach addresses strategy use and self-monitoring skills within activities and contexts that are systematically varied to facilitate transfer of learning. This article illustrates the application of the multicontext approach by presenting a case study of an adult who is 5 years post-traumatic brain injury with executive dysfunction and limited awareness. A single case study design with repeated pre-post measures was used. Methods to monitor strategy generation and specific awareness within intervention are described. Findings suggest improved functional performance and generalization of use of an external strategy despite absence of changes in general self-awareness of deficits. This case describes the multicontext intervention process and provides clinical suggestions for working with individuals with serious deficits in awareness and executive dysfunction following traumatic brain injury.

The needs experienced by individuals and their loved ones following a traumatic brain injury

Traumatic brain injury (TBI) is an important public health concern that presents real challenges for health care systems throughout the world. Through an international partnership between Canadian and French researchers, a vast qualitative study aimed to explore the needs of individuals with TBIs and their loved ones throughout the continuum of care and services. The study was first conducted in 3 regions of Quebec (Canada) and subsequently replicated in 3 regions of France. Overall, the data were collected from focus groups with 150 participants: individuals with TBIs, their loved ones, and health care professionals. Despite regional differences, the results demonstrate participants' very similar perceptions regarding the needs such as information, support, and a collaborative relationship with health care professionals experienced by individuals with TBIs and their loved ones. These needs change throughout the stages of care. The fulfillment of these needs play a determining role throughout the adaptation process of individuals with TBIs and their loved ones. Health care professionals must adopt a personalized approach to respond to needs related to the evolution of information, support, and relationships.

Integrating Interventions after Traumatic Brain Injury: A Synergistic Approach to Neurorehabilitation

Deficits in attention, processing speed and executive functioning are among the most commonly reported and functionally limiting cognitive impairments among individuals with TBI. Changes in mood can exacerbate cognitive deficits and reduce life quality. Contemporary hierarchical models of cognitive functioning suggest that attention/arousal processes underlie and support higher-order functions. Building on decades of clinical research, a synergistic, integrative approach to neurorehabilitation is described, which combines bottom-up and top-town cognitive interventions in addition to psychotherapeutic interventions for mood. This approach is intended to address directly impairments in both foundational (i.e., attention) and higher-order (i.e., executive functions) processes. Executive dysfunction is addressed in a top-down fashion through the application of a series of problem-solving and emotional regulation modules that teach and integrate strategies that can be generalised across situations with practice. Attention, arousal and information processing are necessary prerequisites of successful higher-order thinking, attention skills, and are addressed in a bottom-up fashion through intensive individualised attention and processing training tasks. Combining top-down and bottom-up approaches within a comprehensive day-treatment programme can effect a synergistic improvement of overall functioning.

Invited commentary and correspondence

I would like to thank both the commentators for taking the time to review my recent article ‘Facilitating independence in personal activities of daily living after a severe traumatic brain injury’ Vol 17(9): 474–482, and take this opportunity to address some of the questions and points raised by Helen Harrington.

Facilitating independence in personal activities of daily living after a severe traumatic brain injury

Aims

This study examined the effectiveness of two components of a treatment programme typically used by occupational therapists (OTs) in personal activities of daily living (PADL) rehabilitation.

Methods

A multiple baseline probe design across PADL tasks was used, one which is particularly suited to the examination of the effects of complex interventions on skill performance. The subjects were two male adults with severe brain injuries and cognitive impairments who were in the acute stages of recovery. The OT treatment program consisted of a combination of errorless learning and strategy training approaches. The impact of the program was measured by the number of steps completed independently in each of these tasks, the level and type of assistance required, and by administering the UK Functional Independence Measure and the Assessment of Motor and Process Skills.

Findings

Errorless learning and strategy training, as used within an OT programme, was demonstrated to be effective in reducing the amount of assistance both participants required to complete the targeted PADL tasks. Further, there was evidence of generalization of training effects among trained and untrained activities.

Conclusions

Selecting and combining treatment techniques based on detailed assessment of functional performance is an area of high clinical importance but with limited research; the current study stands as an attempt towards that direction.

Cognitive versus functional approaches to rehabilitation after traumatic brain injury: commentary on a randomized controlled trial

I describe the findings of one of the largest randomized controlled trials (RCTs) of rehabilitation after traumatic brain injury (TBI) ever conducted, examine the theoretical relationship between cognitive and functional rehabilitation after TBI, and describe the historical preference for cognitive (top-down) rather than functional (bottom-up) interventions. I also contrast the goals and principles of cognitive rehabilitation and of the neurofunctional approach of Giles and Clark-Wilson (1993; Giles, 2005)--a bottom-up approach. Findings of the RCT provide empirical support for both functional and cognitive interventions following acute TBI. In addition, they provide evidence that each type of intervention offers significant advantages for a specific subpopulation. The clinical implications of these findings for occupational therapy practitioners are discussed.