Error self-regulation following traumatic brain injury: A single case study evaluation of metacognitive skills training and behavioural practice interventions

Reduced awareness of cognitive deficits in idiopathic normal pressure hydrocephalus and its change following lumbar puncture

OBJECTIVE

Awareness of cognitive deficits is related to executive functions and may, therefore, be sensitive to the effects of lumbar puncture (LP) in idiopathic normal pressure hydrocephalus (iNPH). Although a reduction in awareness of cognitive deficits (RACD) has been previously described in iNPH, there is a lack of systematic, psychometrically validated reports. In this study, we investigated RACD and its LP-related changes in iNPH patients and compared them with those in clinical and healthy control groups.

METHODS

RACD was assessed before and after lumbar puncture (LP) in 24 patients (14 iNPH, 10 other age-associated cognitive syndromes; AACS) and compared with 23 healthy controls (HC), employing two RACD measures alongside cognitive examination. Local metacognition was measured using a visual percentile-based rating system and operationalized as the t-scaled distance between the participants' task-specific performance estimations and their objective test performance (ΔTSPE). Global metacognition, targeting broader estimates of cognitive functioning (ECF), was quantified by subtracting self- from informant-obtained sum scores on a questionnaire evaluating participants' dysexecutive problems (DEX-DS). Within-group and between-group differences in ΔTSPE and DEX-DS scores were compared non-parametrically, focusing on post-LP changes.

RESULTS

Averaged ΔTSPE was higher in the patient groups and mirrored the groups' lower objective test performance, while averaged DEX-DS showed no group difference. Following LP, group comparisons revealed iNPH-specific decrease in both RACD measures.

CONCLUSION

Our study revealed LP-related RACD changes in iNPH patients compared to those in AACS and HC participants. The results suggest a mitigation of impaired metacognitive abilities in iNPH, possibly resulting from LP-induced improvements in (local) metacognitive performance, facilitating ECF adjustment alongside a metacognitively stimulating testing procedure.

Errorful learning improves recognition memory for new vocabulary for people living with memory and dysexecutive impairment following brain injury

A widely accepted view is that errorless learning is essential for supporting new learning in people with anterograde amnesia, but findings are mixed for those with a broader range of memory impairments. People at a chronic stage of recovery from brain injury (BI) with impaired memory and executive function (N = 26) were compared with adults in a comparison group without any known risks to brain function (N = 25). Learning techniques were compared using a "Generate-and-correct" and "Read-only" condition when learning novel word pairs. At test, both groups scored above chance and showed benefits of Generate-and-correct (errorful learning). Poor learners in the BI group were classified from "flat" learning slopes extracted from an independent word-pair learning task. Critically, poor learners showed no benefit, but also no decrement to learning, using the Generate-and-correct method. No group was harmed by errorful learning; all, except the poorest learners, benefitted from errorful learning. This study indicates, that in some rehabilitation settings, encouraging clients to guess the meaning of unfamiliar material (e.g., from cards, magazines, newspapers) and then correct their errors, could have benefits for recognition memory. Determining when and how errorful learning benefits learning is a key aim for future research.

Training to deal with distractions and conflicting situations in activities of daily living after traumatic brain injury (TBI): Preliminary evidence from a single-case experimental design study

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03958487.

Assessment of executive function impairments in adults with acquired brain injury across single-case experimental design: A scoping review of primary outcomes

The use of single-case experimental design (SCED) to evaluate cognitive remediation is growing. SCEDs require rigorous methodology and appropriate choice of primary outcomes. To review primary outcomes that assess executive function impairments in patients with acquired brain injury (ABI). A scoping review was conducted using the Arksey and O'Malley framework and the PRISMA extension for scoping review (PRISMA-ScR). Five databases were searched resulting in the inclusion of twenty-one studies. Primary outcomes were extracted and classified according to the type of measure, ecological setting and sources of possible bias. A wide variety of primary outcomes were identified; the majority of which evaluated behavioural performance during a real-life activity or in a real-life simulated setting. The most frequent bias observed across outcomes was the coaching effect. The findings of this scoping review highlight the importance of selecting appropriate outcomes for repeated measures in SCED studies. Direct observation of the target behaviour is a potential gold standard for assessing the effectiveness of a cognitive intervention.

Online awareness: a concept analysis and review of assessment approaches for adults with neurological conditions

PURPOSE

Self-awareness is a multifaceted phenomenon that comprises two main concepts: general awareness and online awareness. The latter is an emerging concept that requires further consensus on its definition. The aim of this paper is to define the key components of online awareness and identify approaches for measuring this concept for adults with neurological conditions.

MATERIALS AND METHODS

Concept analysis using Rodgers' evolutionary method was used to systematically review and summarise relevant literature. Papers were included if they provided a definition of online awareness or method for assessing online awareness for an adult neurological population.

RESULTS

Fifty-six papers were included in this review, with 21 online awareness assessment approaches identified. Online awareness was described to occur within the context of task performance, with the definition framework comprising four main aspects: 1/appraisal; 2/anticipation and prediction; 3/monitoring; and 4/self-evaluation. Self-regulation is a related concept that is considered to sit outside the conceptual boundaries of online awareness.

CONCLUSIONS

The findings of this analysis highlight the complexity of online awareness and its importance in rehabilitation. Psychometrically robust measures of online awareness that are inclusive of the essential elements of this concept are needed to advance practice in this area.

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.

Revisiting the dynamic comprehensive model of self-awareness: a scoping review and thematic analysis of its impact 20 years later

This study aimed to (1) describe the scope of research related to the Dynamic Comprehensive Model of Awareness (DCMA) (Toglia & Kirk, 2000); (2) identify themes and support for key model postulates; and (3) suggest future research directions related to this model. Using PRISMA scoping guidelines, 366 articles were reviewed, and 54 articles met our inclusion criteria. Selected studies were clustered into three themes: (1) the relationship between general and online self-awareness (50%); (2) interventions based on the model (41%); and (3) factors contributing to self-awareness (9%). Most studies were conducted with participants with acquired brain injury (BI) and traumatic BI (68%), most used a cross-sectional design (50%), and most intervention studies utilized a single-subject design (18%), followed by an experimental design (9%). This review provides evidence for the wide application of the DCMA across varying ages and populations. The need for a multidimensional assessment approach is recognized; however, stronger evidence that supports a uniform assessment of online self-awareness is needed. The intervention studies frequently described the importance of direct experience in developing self-awareness; however, few studies compared how intervention methods to influence general versus online self-awareness, or how cognitive capacity, self-efficacy, psychological factors, and context, influence the development of self-awareness.

Improving self-awareness of prospective memory function after TBI using experiential feedback on a board game activity: An observational study

This study investigated whether experiential and video feedback on performance of prospective memory (PM) tasks embedded within a board game activity improved self-awareness of PM function in adults with moderate-severe traumatic brain injury. An observational pre-post study design with 26 participants from a larger trial of a 6-session PM rehabilitation programme. Sessions 3 and 4 included a board game activity with embedded time-, event-, and activity-based PM tasks. Verbal feedback was provided by therapists during the game and video feedback afterwards. Self-ratings of performance were used to divide the sample into under-estimators (n = 7), accurate estimators (n = 9) and over-estimators (n = 10) of actual PM performance. The discrepancy between self- and therapist ratings of PM performance was measured before and after the game, and following video feedback, and compared between timepoints using non-parametric statistics. Post-task self-evaluations were more accurate than pre-task self-evaluations for the under- and over-estimator groups. Under-estimators showed significant improvement in accuracy of ratings for activity-based PM. Over-estimators showed improvement for event-based PM. Further improvements after video feedback were not significant. The board game activity provided a vehicle for experiential feedback and a means of engaging both those with impaired self-awareness and heightened self-awareness of PM in cognitive rehabilitation.

A Systematic Review on Serious Games in Attention Rehabilitation and Their Effects

Attention is a basic and main mental task and can play an important role in the functioning of other brain abilities such as intelligence, memory, learning, and perception, and its deficit occurs in 80% of patients with traumatic brain injury. The use of game-based tools for rehabilitation is rapidly expanding. Cognitive rehabilitation via video games is an emerging hot topic in cognitive science. Serious games serve a specific purpose in addition to entertainment. They can be more engaging than exercises since they replace reward and motivation systems with real-world motivations as a complement for rehabilitation activities. This study was aimed at identifying and categorizing serious computer games used for attention rehabilitation and evaluating their effects. Six electronic databases (Scopus, PubMed, ISI, Embase, IEEE, and Cochrane) were searched in August 2021. The search strategy consisted of three main concepts of “serious game”, “cognitive deficits”, and “cognitive rehabilitation”. The inclusion criteria were (1) journal articles, (2) English language, (3) being published in the last 10 years, (4) human participants, and (5) game-based intervention. In the 30 included studies, 22 unique games were utilized for attention rehabilitation. Lumosity (20%), Brain Age (Dr. Kawashima's Brain Training) (10%), and MoHRS (6.66%) were the most common games among the studies. There were (57%) casual, (23%) action, (10%) simulation, and (10%) multiple genres. Of the 47 tools used in the studies, 5 utilized cross-modal oddball attention tasks, 4 utilized game performance, 3 utilized the paced auditory serial additional test (PASAT), and the rest employed other tools. A total of 73 outcome measures were related to attention, 42 measures did not have significant results, 30 were significantly improved, 1 was significantly deteriorated, and 4 articles did not have any specific measures for attention evaluation. Thus, the results revealed the positive effect of serious games on attention. However, issues such as absence of scientific teams, the variety of the disorders that cause defects, the variety of criteria, differences in measurements, lack of long-term follow-up, insufficient RCT studies, and small sample sizes should be considered when designing, developing, and using game-based systems to prevent bias.

Metacognitive Treatment in Acquired Brain Injury and Its Applicability to Aphasia: A Systematic Review

Purpose

The purpose of this systematic review is to identify the utility of metacognitive therapeutic intervention for persons with acquired brain injury (ABI), with a focus on persons with aphasia.

Methods

A search of six databases resulted in two hundred and sixty-six unique manuscripts relating to the explicit use of metacognitive treatment for people with ABI. Two independent reviewers rated abstracts for inclusion or exclusion of the study given predetermined criteria. Twenty-nine articles, five of which included people with aphasia, were selected for inclusion in this systematic review. SCED+ and PEDro+ rating scales were used to rate the methodological quality of each study.

Results

Methodological quality of the 29 studies that met inclusion criteria ranged from weak to high quality studies. Three -hundred and sixty-nine individuals with ABI took part in the 29 studies. Varying treatment methods were employed. Outcome measures were inconsistent. Metacognitive treatment has been applied to people with aphasia with positive results, but efficacy of the treatment cannot yet be determined.

Conclusions

Metacognitive therapeutic intervention tends to be effective for persons with acquired brain injury (ABI) despite variability between intervention designs and treatment outcomes across studies. Due to so few studies with participants with aphasia, we were unable to draw conclusions regarding the efficacy of metacognitive treatment for people with aphasia. Further research on the efficacy of metacognitive treatment for this population is warranted.

Conceptualization of self-awareness in adults with acquired brain injury: A qualitative systematic review

Self-awareness is an important consideration in cognitive rehabilitation for clinicians working with individuals following acquired brain injury (ABI), with impaired self-awareness linked to poor outcomes. To appropriately target assessment and intervention for self-awareness, its theoretical foundation and definition must be considered. The aim was to identify the definitions, theoretical models and conceptual frameworks of self-awareness in adults with ABI, and how self-awareness is conceptualized within those models. A qualitative systematic review was completed using search terms related to descriptions of models/frameworks, ABI and self-awareness. Data were analysed by narrative synthesis. Thirty-five papers were included in the review. Within these, 13 models, 12 conceptual frameworks and 2 theories were described. The main themes and subthemes conceptualized in the synthesis were: Clinical presentation of self-awareness (classifications and dimensions of self-awareness), development of self-awareness (knowledge, feedback mechanisms, temporal aspects, self-evaluation, enablers, barriers), understanding (dys)function (cognitive processing mechanisms, neurological foundations, causal factors), and practice guidance (assessment and intervention). This review identified an extensive theoretical basis to support conceptualization of self-awareness following ABI, underpinned by a distinction between intellectual awareness, on-line awareness, and psychological denial. Clinical application of an evaluation process that includes these elements would be beneficial to inform the rehabilitation process.

Evaluation of an occupation-based metacognitive intervention targeting awareness, executive function and goal-related outcomes after traumatic brain injury using single-case experimental design methodology

Self-awareness is commonly impaired after traumatic brain injury and impacts on rehabilitation engagement and community re-integration outcomes. Interventions which incorporate metacognitive strategy instruction have the potential to improve rehabilitation engagement and outcomes. This study aimed to determine whether an occupation-based intervention incorporating metacognitive strategy instruction resulted in goal achievement and improved online awareness and executive function performance during goal-related tasks. A single-case experimental design using a multiple-baseline design across behaviours was used with two participants with severe traumatic brain injury to evaluate the effectiveness of the 6-week intervention. Repeated measures of goal-related performance, percentage of self-corrected errors and executive function were made via independent analysis of video footage and documentation logs. Data analysis involved 2SD bandwidth analysis and overlap data, reliable change index and evaluation of goal achievement across phases. There were improvements in self-corrected errors for one participant, which were maintained. Significant reductions in anxiety (RCI = ±5.98) were evident for both participants, with a significant reduction in stress (RCI = ±7.05) for one participant following the intervention. The occupation-based intervention incorporating metacognitive strategy instruction led to improvements compared to baseline performance in some targeted goals, online awareness and executive function performance during goal-related tasks and reduced stress and anxiety.

Developing an evidence-based reading intervention for early brain injury rehabilitation

Introduction:

Providing evidence-based services in areas with emerging or low-level evidence is a challenge for many clinicians. The aim of the current study was to apply a newly designed novel methodology to develop and describe a new intervention for cognitive-communication reading comprehension deficits in early acquired brain injury rehabilitation.

Methods:

An emergent multi-phase mixed methods design allowed phases of different research activity to build an evidence base of quantitative and qualitative data. A pragmatic clinical framework was developed to combine these traditional research findings with principles from knowledge translation and implementation science, evidence-based practice and intervention development models, clinical contextual practice guidelines and the Medical Research Council’s guidelines for developing and evaluating complex interventions, to create an evidence-based contextually driven clinical intervention.

Results:

The resulting reading comprehension intervention and service delivery model is presented and involves a multiple-strategy intervention across increasing level of reading comprehension complexity. In areas where traditional methodologies provide low-level evidence, this method provides an alternate way to conduct evidence-based clinical research.

Strategy-based reading comprehension therapy during early acquired brain injury rehabilitation: preliminary results

Introduction: An evidence-based intervention and service delivery model for early acquired brain injury reading comprehension rehabilitation (involving multiple-strategy, hierarchical reading) was investigated with 3 clients <3 m post onset as part of their brain injury rehabilitation program.Materials and methods: A multiple-baseline single case experimental design was used for each participant, with data analysed using Tau-U. Assessments of reading comprehension (impairment and activity level) were performed pre/post intervention, and at follow-up (3-6 months post-treatment). Participants' perceptions of the intervention and service delivery model were captured via semi-structured interviews.Results: All participants demonstrated improved reading comprehension post-intervention on all formal measures. At follow-up, reading comprehension was grossly maintained by 2 participants. The single case experimental design results (Tau-U) showed moderate-large intervention effect sizes for factual and inferential reading comprehension, two participants had significant (p = 0.01) changes. Participants reported overall positive experiences with the intervention.Conclusion: The intervention and service delivery model were successfully implemented in clinical practice, and preliminary results show the intervention has clinical promise with an early acquired brain injury population.IMPLICATIONS FOR REHABILITATIONCognitive communication reading comprehension deficits occur following acquired brain injury and impact participation during rehabilitation and in the community.An evidence-based intervention for the early rehabilitation of cognitive communication reading comprehension deficits following acquired brain injury has been developed and trialled in clinical practice with adults <3 months post-acquired brain injury, via a series of single-case experimental designs.Improvements in reading comprehension skill and activity/participation occurred for all participants post-intervention; statistically significant changes occurred for 2 of 3 clients.Early rehabilitation of cognitive communication reading comprehension deficits can be successfully implemented as a component of a multidisciplinary rehabilitation program.

Hospital psychosocial interventions for patients with brain functional impairment: A retrospective cohort study

Psychosocial interventions could improve health and care outcomes, however, little is known about their use for patients with complex needs in the acute hospital care setting. This study aimed to evaluate factors associated with psychosocial intervention use when treating patients with brain functional impairment during their hospital care. The all-inclusive New South Wales (NSW) Admitted Patient Data were employed to identify patients with neurodevelopment disorders, brain degenerative disorders, or traumatic brain injuries admitted to NSW public hospitals for acute care from July 2001 to June 2014. We considered receipt of psychosocial interventions as the primary outcome, and used mixed effect logistic models to quantify factors in relation to outcome. Of important note, psychosocial intervention use was more common in principal hospitals, and amongst those receiving intensive care or having comorbid mental disorders in the study populations. Approximate 70.8% of patients with traumatic brain injuries did not receive psychosocial interventions, despite attempts to target those in need and an overall increasing trend in adoption. Continuing efforts are warranted to improve service delivery and uptake.

Everyday Multitasking Abilities in Older HIV+ Adults: Neurobehavioral Correlates and the Mediating Role of Metacognition

Objective

The prevalence of older adults living with HIV is rising, as is their risk for everyday functioning problems associated with neurocognitive dysfunction. Multitasking, the ability to maintain and carry out subgoals in support of a larger goal, is a multidimensional skill ubiquitous during most real-life tasks and associated with prefrontal networks that are vulnerable in HIV. Understanding factors associated with multitasking will improve characterization of HIV-associated neurocognitive disorders. Metacognition is also associated with frontal systems, is impaired among individuals with HIV, and may contribute to multitasking.

Method

Ninety-nine older (≥50 years) adults with HIV completed: the Everyday Multitasking Test (MT), a performance-based measure during which participants concurrently attempt four everyday tasks (e.g., medication management) within a time limit; a comprehensive neuropsychological battery; measures of metacognition regarding their MT performance (e.g., metacognitive knowledge and online awareness).

Results

Better global neuropsychological performance (i.e., average T-score across all domains) was associated with better Everyday MT total scores (rho = 0.34; p < .001), as was global metacognition (rho = 0.37, p < .01). Bootstrapping mediation analysis revealed global metacognition was a significant partial mediator between neurocognition and Everyday MT (b = 0.09, 95% confidence interval [CI] = 0.01, 0.25). Specifically, metacognitive knowledge (but not online awareness) drove this mediation (b = 0.13, 95% CI = 0.03, 0.27).

Conclusions

Consistent with findings among younger persons with HIV, neuropsychological performance is strongly associated with a complex, laboratory-based test of everyday multitasking, and metacognition of task performance was a pathway through which successful multitasking occurred. Interventions aimed at modifying metacognition to improve daily functioning may be warranted among older adults with HIV.

Effectiveness and feasibility of Socratic feedback to increase awareness of deficits in patients with acquired brain injury: Four single-case experimental design (SCED) studies

OBJECTIVE

To investigate the effectiveness and feasibility of a Socratic feedback programme to improve awareness of deficits in patients with acquired brain injury (ABI).

SETTING

Rehabilitation centre.

PARTICIPANTS

Four patients with ABI with awareness problems.

DESIGN

A series of single-case experimental design studies with random intervention starting points (A-B + maintenance design).

MAIN MEASURES

Rate of trainer-feedback and self-control behaviour on everyday tasks, patient competency rating scale (PCRS), self-regulating skills interview (SRSI), hospital anxiety and depression scale.

RESULTS

All patients needed less trainer feedback, the change was significant in 3 out of 4. One patient increased in overt self-corrective behaviour. SRSI performance increased in all patients (medium to strong effect size), and PCRS performance increased in two patients (medium and strong effect size). Mood and anxiety levels were elevated in one patient at the beginning of the training and decreased to normal levels at the end of the training. The feasibility of the programme was scored 9 out of 10.

CONCLUSIONS

The Socratic feedback method is a promising intervention for improving awareness of deficits in patients with ABI. Controlled studies with larger populations are needed to draw more solid conclusions about the effect of this method.

Do People With Severe Traumatic Brain Injury Benefit From Making Errors? A Randomized Controlled Trial of Error-Based and Errorless Learning

Background. Errorless learning (ELL) and error-based learning (EBL) are commonly used approaches to rehabilitation for people with traumatic brain injury (TBI). However, it is unknown whether making errors is beneficial in the learning process to promote skills generalization after severe TBI. Objective. To compare the efficacy of ELL and EBL for improving skills generalization, self-awareness, behavioral competency, and psychosocial functioning after severe TBI. Method. A total of 54 adults (79% male; mean age = 38.0 years, SD = 13.4) with severe TBI were randomly allocated to ELL or EBL and received 8 × 1.5-hour therapy sessions that involved meal preparation and other goal-directed activities. The primary outcome was total errors on the Cooking Task (near-transfer). Secondary outcome measures included the Zoo Map Test (far-transfer), Awareness Questionnaire, Patient Competency Rating Scale, Sydney Psychosocial Reintegration Scale, and Care and Needs Scale. Results. Controlling for baseline performance and years of education, participants in the EBL group made significantly fewer errors at postintervention (mean = 36.25; 95% CI = 32.5-40.0) than ELL participants (mean = 42.57; 95% CI = 38.8-46.3). EBL participants also demonstrated greater self-awareness and behavioral competency at postintervention than ELL participants ( P < .05). There were no significant differences on other secondary outcomes ( P > .05), or at the 6-month follow-up assessment. Conclusion. EBL was found to be more effective than ELL for enhancing skills generalization on a task related to training and improving self-awareness and behavioral competency.

Evaluation of a computer-based prompting intervention to improve essay writing in undergraduates with cognitive impairment after acquired brain injury

This study evaluated a computer-based prompting intervention for improving expository essay writing after acquired brain injury (ABI). Four undergraduate participants aged 18-21 with mild-moderate ABI and impaired fluid cognition at least 6 months post-injury reported difficulty with the writing process after injury. The study employed a non-concurrent multiple probe across participants, in a single-case design. Outcome measures included essay quality scores and number of revisions to writing counted then coded by type using a revision taxonomy. An inter-scorer agreement procedure was completed for quality scores for 50% of essays, with data indicating that agreement exceeded a goal of 85%. Visual analysis of results showed increased essay quality for all participants in intervention phase compared with baseline, maintained 1 week after. Statistical analyses showed statistically significant results for two of the four participants. The authors discuss external cuing for self-monitoring and tapping of existing writing knowledge as possible explanations for improvement. The study provides preliminary evidence that computer-based prompting has potential to improve writing quality for undergraduates with ABI.

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 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.

Treating reading comprehension deficits in sub-acute brain injury rehabilitation: Identifying clinical practice and management

There is limited evidence for cognitive-communication reading comprehension (CCRC) interventions for adults following acquired brain injury (ABI), particularly during sub-acute rehabilitation. The purpose of this study was to investigate the clinical practice of speech-language pathologists (SLPs) with CCRC deficits during sub-acute ABI rehabilitation and compare it to the best available evidence. An electronic survey was used to gather information from clinicians across Australia regarding clinical practice in the areas of assessment, intervention, treatment hierarchies and service delivery; survey questions were developed from an extensive review of the literature and expert clinician opinion. Survey findings were then compared with the literature in the form of a systematic review. Surveyed clinicians provided multiple interventions for CCRC rehabilitation, including impairment based (94.7%), activity based (94.7%) and reading strategy interventions (100.0%). Five strategies were used by >94% of SLPs (highlighting, identifying main points/wh- questioning, re-reading, summarising, reducing visual load). When compared with the literature, strong similarities were found for strategy-based interventions and individual service delivery, with broad similarities for functional and impairment-based interventions, and impairment based treatment hierarchies. Strong differences in assessment were identified. Strategy use reported in clinical practice (100.0% SLPs) was higher than in the literature. Further investigation into the effectiveness of specific reading strategies for people with ABI is warranted.

Abbreviated Goal Management Training Shows Preliminary Evidence as a Neurorehabilitation Tool for HIV-associated Neurocognitive Disorders among Substance Users

OBJECTIVE

Substance use disorders are highly comorbid with and contribute to the increased prevalence of neurocognitive dysfunction observed in HIV infection. Despite their adverse impact on everyday functioning, there are currently no compensatory-based neurorehabilitation interventions validated for use among HIV+ substance users (HIV/SUD). This study examined the effectiveness of goal management training (GMT) alone or GMT as part of a metacognitive training among HIV/SUD individuals with executive dysfunction.

METHODS

Ninety HIV/SUD individuals were randomized to a single 15-min session: (1) GMT (n = 30); (2) GMT plus metacognitive training (neurocognitive awareness; GMT + Meta; n = 30); or (3) active control (n = 30). Following a brief neurocognitive battery and study condition, participants performed a complex laboratory-based function task, Everyday Multitasking Test (Everyday MT), during which metacognition (awareness) was evaluated.

RESULTS

There was an increasing, but non-significant tendency for better Everyday MT performances across study conditions (Control ≤ GMT ≤ GMT + Meta; ps < .08). Post hoc analyses showed that GMT and GMT + Meta groups demonstrated small benefits (d = .20-.27) compared to the control arm but did not differ from one another (ds < .10). When GMT groups were combined, there were significant medium effect size benefits in Everyday MT performance and metacognitive task appraisals as compared to the control condition. Among participants who underwent GMT, benefits were most prominent in persons with poorer pre-training dual-tasking ability, depression, and methamphetamine use disorders (ds = .35-1.04).

CONCLUSIONS

A brief compensatory strategy has benefits for everyday multitasking and metacognition among HIV+ substance users with executive dysfunction. Future work exploring more intensive trainings, potentially complimentary to other restorative approaches and/or pharmacological treatments, is warranted.

Self-predictions of prospective memory in HIV-associated neurocognitive disorders: evidence of a metamemory deficit

HIV-associated neurocognitive disorders (HAND) are associated with deficits in prospective memory (PM; "remembering to remember"), conferring risk of daily functioning declines. However, self-perceptions of PM functioning are not reliably associated with PM performance in HIV, suggesting a possible deficit in awareness of PM abilities (meta-PM). Our study examined meta-PM in HAND and its correlates using self-predictions of laboratory-based PM performance. Performance-based PM abilities, self-reported prediction of PM performance, and PM complaints in everyday life were assessed in 49 individuals with HAND, 93 HIV+ without HAND (HIV+ noHAND), and 121 seronegative adults (HIV-). After controlling for group-level differences, HAND was associated with a greater number of PM symptoms in everyday life and worse PM performance when compared with both HIV+ noHAND and HIV- samples. Although HAND individuals reported somewhat lower predictions regarding their laboratory PM performance relative to the other study groups, they nevertheless exhibited significantly greater inaccurate overconfidence in time-based PM abilities. Within the HAND group, overconfidence in time-based meta-PM was associated with executive dysfunction and antiretroviral (ARV) nonadherence. HAND individuals evidenced a moderate deficit in awareness of PM functioning characterized by overconfidence in time-based PM abilities. Overconfidence in PM may result in absence of compensatory strategy use, and lead to increased errors in daily functioning (e.g., ARV nonadherence).

Training to Optimize Learning after Traumatic Brain Injury

One of the major foci of rehabilitation after traumatic brain injury is the design and implementation of interventions to train individuals to learn new knowledge and skills or new ways to access and execute previously acquired knowledge and skills. To optimize these interventions, rehabilitation professionals require a clear understanding of how traumatic brain injury impacts learning, and how specific approaches may enhance learning after traumatic brain injury. This brief conceptual review provides an overview of learning, the impact of traumatic brain injury on explicit and implicit learning, and the current state of the science examining selected training approaches designed to advance learning after traumatic brain injury. Potential directions for future scientific inquiry are discussed throughout the review.

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.

Videogame-based group therapy to improve self-awareness and social skills after traumatic brain injury

Background

This study determines the feasibility of different approaches to integrative videogame-based group therapy for improving self-awareness, social skills, and behaviors among traumatic brain injury (TBI) victims and retrieves participant feedback.

Methods

Forty-two adult TBI survivors were included in a longitudinal study with a pre- and post-assessments. The experimental intervention involved weekly one-hour sessions conducted over six months. Participants were assessed using the Self-Awareness Deficits Interview (SADI), Patient Competency Rating Scale (PCRS), the Social Skills Scale (SSS), the Frontal Systems Behavior Scale (FrSBe), the System Usability Scale (SUS). Pearson's chi-squared test (χ²) was applied to determine the percentage of participants who had changed their clinical classification in these tests. Feedback of the intervention was collected through the Intrinsic Motivation Inventory (IMI).

Results

SADI results showed an improvement in participant perceptions of deficits (χ² = 5.25, p < 0.05), of their implications (χ² = 4.71, p < 0.05), and of long-term planning (χ² = 7.86, p < 0.01). PCRS results confirm these findings (χ² = 5.79, p < 0.05). SSS results were also positive with respect to social skills outcomes (χ² = 17.52, p < 0.01), and FrSBe results showed behavioral improvements (χ² = 34.12, p < 0.01). Participants deemed the system accessible (80.43 ± 8.01 out of 100) and regarded the intervention as interesting and useful (5.74 ± 0.69 out of 7).

Conclusions

Integrative videogame-based group therapy can improve self-awareness, social skills, and behaviors among individuals with chronic TBI, and the approach is considered effective and motivating.

An occupation-based video feedback intervention for improving self-awareness: Protocol and rationale

Background.

Impaired self-awareness can limit rehabilitation outcomes for people with traumatic brain injury (TBI). Video feedback on occupational performance has been found to improve self-awareness after TBI when delivered according to specific principles.

Purpose.

The purpose of this article is to describe an occupation-based video feedback intervention found to be effective in a randomized controlled trial to assist with translation into clinical practice.

Key Issues.

The intervention uses therapist-mediated video feedback on clients’ occupational performance, aiming to facilitate self-reflection on performance and improve self-awareness. This paper describes the theoretical background, intervention principles, and protocol of the intervention.

Implications.

Therapists can use video feedback intervention, incorporating the principles in this article, to improve people’s intellectual awareness and ability to recognize and correct errors during task performance after TBI without a negative impact on emotional status.

Development of Self-Awareness After Severe Traumatic Brain Injury Through Participation in Occupation-Based Rehabilitation: Mixed-Methods Analysis of a Case Series

OBJECTIVE. We examined participation in goal planning and development of self-awareness for people with impaired self-awareness after traumatic brain injury.

METHOD. We performed a mixed-methods study of 8 participants recently discharged from inpatient rehabilitation. Self-awareness was measured using discrepancy between self and significant other ratings on the Mayo–Portland Adaptability Index (MPAI–4) at four time points. We calculated effect size to evaluate the change in MPAI–4 discrepancy over time.

RESULTS. Seven participants identified their own goals. We found a large reduction in mean MPAI–4 discrepancy (M = 8.57, SD = 6.59, N = 7, d = 1.08) in the first 6 wk and a further small reduction (M = 5.33, SD = 9.09, N = 6, d = 0.45) in the second 6 wk of intervention. Case data indicated that 7 participants demonstrated some growth in self-awareness.

CONCLUSION. Engagement in occupation-based, goal-directed rehabilitation appeared to foster awareness of injury-related changes to varying extents.

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.

Comparison of error-based and errorless learning for people with severe traumatic brain injury: study protocol for a randomized control trial

BACKGROUND

Poor skills generalization poses a major barrier to successful outcomes of rehabilitation after traumatic brain injury (TBI). Error-based learning (EBL) is a relatively new intervention approach that aims to promote skills generalization by teaching people internal self-regulation skills, or how to anticipate, monitor and correct their own errors. This paper describes the protocol of a study that aims to compare the efficacy of EBL and errorless learning (ELL) for improving error self-regulation, behavioral competency, awareness of deficits and long-term outcomes after TBI.

METHODS/DESIGN

This randomized, controlled trial (RCT) has two arms (EBL and ELL); each arm entails 8 × 2 h training sessions conducted within the participants' homes. The first four sessions involve a meal preparation activity, and the final four sessions incorporate a multitasking errand activity. Based on a sample size estimate, 135 participants with severe TBI will be randomized into either the EBL or ELL condition. The primary outcome measure assesses error self-regulation skills on a task related to but distinct from training. Secondary outcomes include measures of self-monitoring and self-regulation, behavioral competency, awareness of deficits, role participation and supportive care needs. Assessments will be conducted at pre-intervention, post-intervention, and at 6-months post-intervention.

DISCUSSION

This study seeks to determine the efficacy and long-term impact of EBL for training internal self-regulation strategies following severe TBI. In doing so, the study will advance theoretical understanding of the role of errors in task learning and skills generalization. EBL has the potential to reduce the length and costs of rehabilitation and lifestyle support because the techniques could enhance generalization success and lifelong application of strategies after TBI.

TRIAL REGISTRATION

ACTRN12613000585729.

Goal Management Training for rehabilitation of executive functions: a systematic review of effectiveness in patients with acquired brain injury

PURPOSE

To determine if Goal Management Training (GMT) is effective for the rehabilitation of executive functions following brain injury when administered alone or in combination with other interventions.

METHOD

Systematic review, with quality appraisal specific to executive functions research and calculation of effect sizes.

RESULTS

Twelve studies were included. Four studies were "Proof-of-principle" studies, testing the potential effectiveness of GMT and eight were rehabilitation studies. Effectiveness was greater when GMT was combined with other interventions. The most effective interventions appeared to be those combing GMT with: Problem Solving Therapy; personal goal setting; external cueing or prompting apply GMT to the current task; personal homework to increase patients' commitment and training intensity; ecological and daily life training activities rather than paper-and-pencil, office-type tasks. Level of support for GMT was higher for studies measuring outcome in terms of increases in participation in everyday activities rather than on measures of executive impairment.

CONCLUSION

Comprehensive rehabilitation programs incorporating GMT, but integrating other approaches, are effective in executive function rehabilitation following brain injury in adults. There is insufficient evidence to support use of GMT as a stand-alone intervention.

Video Feedback on Functional Task Performance Improves Self-awareness After Traumatic Brain Injury

Background. Feedback is used in rehabilitation to improve self-awareness in people with traumatic brain injury (TBI), but there have been no comparisons of the different methods of providing feedback. Objective. To compare the effect of different methods of feedback on impaired self-awareness after TBI. Method. This was a randomized, assessor-blinded trial with concealed allocation. A total of 54 participants with TBI and impaired self-awareness (85% male) were recruited from inpatient and community rehabilitation settings. Participants performed a meal preparation task on 4 occasions and were randomly assigned to 1 of 3 feedback intervention groups: video plus verbal feedback, verbal feedback, or experiential feedback. The primary outcome was improvement in online awareness measured by the number of errors made during task completion. Secondary outcomes included level of intellectual awareness, self-perception of rehabilitation, and emotional status. Results. Receiving video plus verbal feedback reduced the number of errors more than verbal feedback alone (mean difference = 19.7 errors; 95% confidence interval [CI] = 9.2-30.1) and experiential feedback alone (mean difference = 12.4 errors; 95% CI = 1.8-23.0). Conclusion. The results suggest that the video plus verbal feedback approach used in this study was effective in improving self-awareness in people with TBI. The results also provide evidence that improvement in self-awareness was not accompanied by deterioration in emotional status.

Feedback interventions for improving self-awareness after brain injury: a protocol for a pragmatic randomised controlled trial

BACKGROUND

Occupational therapists working in brain injury rehabilitation use functional tasks as a means of providing feedback to improve self-awareness of people who have a brain injury and ultimately improve their occupational performance.

PURPOSE

To compare the effectiveness of video, verbal and experiential feedback for improving self-awareness in people with traumatic brain injury.

METHODS

A randomised controlled trial will be conducted to compare the efficacy of video and verbal feedback during occupational therapy. Fifty-four participants with traumatic brain injury will be randomly allocated into three intervention groups: (i) video plus verbal feedback, (ii) verbal feedback and (iii) experiential feedback (control condition). Participants will receive the allocated intervention based on performance of a meal preparation task. The intervention sessions will occur four times during a two-week period. Blinded assessment will occur at baseline, post-intervention, and two months follow up. The primary outcome will be a measure of on-line self-awareness (number of self-corrected and therapist corrected errors). Secondary outcomes to be assessed include levels of intellectual self-awareness, emotional distress, and acceptance of disability. Data will be analysed using an intention to treat approach. Linear mixed effects models will be used to investigate the intervention effects.

FINDINGS AND IMPLICATIONS

Results will contribute to evidence-based guidelines to support therapists to choose the most effective form of feedback for people with decreased self-awareness after traumatic brain injury.

Performance monitoring and cognitive control in individuals with mild traumatic brain injury

Literature suggests that individuals with mild traumatic brain injury (mTBI) show subtle abnormalities in the cognitive control process of performance monitoring. The neural bases of performance monitoring can be measured using the error-related negaitivity (ERN) and post-error positivity (Pe) components of the scalp-recorded event-related potential (ERP). Thirty-six individuals with mTBI and 46 demographically similar controls completed a modified color-naming Stroop task while ERPs were recorded. Separate repeated-measures analyses of variance were used to examine the behavioral (response times [RT] and error rates) and ERP (ERN and Pe amplitudes) indices of performance monitoring. Both groups showed slower RTs and increased error rates on incongruent trials relative to congruent trials. Likewise, both groups showed more negative ERN and more positive Pe amplitude to error trials relative to correct trials. Notably, there were no significant main effects or interactions of group for behavioral and ERP measures. Subgroup and correlational analyses with post-concussive symptoms and indices of injury severity were also not significant. Findings suggest comparable performance to non-injured individuals in some aspects of cognitive control in this sample. Neuropsychological implications and comparison with other cognitive control component processes in individuals with TBI are provided.