Simulation-based executive cognitive assessment and rehabilitation after traumatic frontal lobe injury: A case report

Purpose.?To investigate whether identifying specific deficits after brain injury can lead to a more focused and potentially effective cognitive rehabilitation technology.

Method.?Cognitive simulation assessment was undertaken in a 47-year-old man with trauma-related prefrontal damage and persisting occupational and cognitive-behavioral difficulties at 15 months post brain injury.

Results.?Results revealed significant difficulties in measured levels of activity, initiative, information utilization, response flexibility, and effective decision-making strategies which accorded well with his real-life complaints despite normal neuropsychological test scores. This profile of findings was then used to design a two-stage intervention program. The first stage focused on participant education and awareness about his simulation-based problem solving difficulties. In the second stage specific goals were formulated to improve problem solving impairments that were then the target of weekly training sessions using pertinent decision-making and problem-solving vignettes. A parallel version of the cognitive simulation assessment was undertaken post-cognitive training (3 months after initial assessment) and revealed significant improvements in targeted executive cognitive-behavioral areas.

Conclusion.?Results of this cognitive rehabilitation probe supported the feasibility and validity of undertaking a cognitive simulation approach to identify residual executive function deficits after traumatic brain injury, even with a normal neuropsychological test profile. Further studies are needed to establish the reliability, generalizability and maintenance of such gains.     

Prediction of long-term occupational performance outcomes for adults after moderate to severe traumatic brain injury

Purpose. To examine predictors of long-term occupational performance outcomes for adults after moderate to severe traumatic brain injury (TBI).

Method. This study involved analysis of data from a retrospective cohort of adults (N = 306) with moderate to severe TBI discharged from a Pennsylvania rehabilitation treatment facility. Extensive pre-injury sociodemographic, injury-severity, post-injury personal (cognitive, physical, affective), post-injury environmental (social, institutional, physical), and post-injury occupational performance (participation in self-care, productivity, leisure activities) data were gathered from hospital records and using in-person interviews. Interviews occurred at a mean time of 14 (range, 7-24) years post-injury. Hierarchical multiple regression analysis was used to investigate determinants of long-term occupational performance outcomes.

Results. Pre-injury behavioural problems, male gender, post-injury cognitive and physical deficits, and lack of access to transportation were significant independent predictors of worse occupational performance outcomes.

Conclusions. The study supports the use of a comprehensive model for long-term outcomes after TBI where pre-injury characteristics and post-injury cognitive and physical characteristics account for the greatest proportion of explained variance.     

Long-term outcomes after moderate to severe traumatic brain injury

Objective: This research examined the long-term outcomes of rehabilitation patients with moderate to severe traumatic brain injury (TBI).

Design: Retrospective cohort study.

Setting and subjects: We examined consecutive records of persons with moderate to severe traumatic brain injury who were discharged from a large rehabilitation hospital in Pennsylvania from 1973 to 1989. We interviewed consenting participants (n = 306) up to 24 years post-injury.

Main outcome measures: Self-rated health, activity limitations, employment, living arrangements, marital status, Community Integration Questionnaire, and use of rehabilitation services.

Results: Participants were most limited in activities such as managing money and shopping. Twenty-nine per cent of our participants were working full time. There were significant relationships between activity limitations and residual cognitive impairment at follow-up. Self-rated health was correlated with most instrumental activities of daily living.

Conclusion: Our findings document health and function in a large post acute TBI population and implications for rehabilitation are discussed.     

Investigation of factors related to employment outcome following traumatic brain injury: a critical review and conceptual model

Purpose: The purpose of this article is to critically review the literature to examine factors that are most consistently related to employment outcome following traumatic brain injury (TBI), with a particular focus on metacognitive skills. It also aims to develop a conceptual model of factors related to employment outcome.

Method: The first stage of the review considered 85 studies published between 1980 and December 2003 which investigated factors associated with employment outcome following TBI. English-language studies were identified through searches of Medline and PsycINFO, as well as manual searches of journals and reference lists. The studies were evaluated and rated by two independent raters (Kappa = 0.835) according to the quality of their methodology based upon nine criteria. Fifty studies met the criteria for inclusion in the second stage of the review, which examined the relationship between a broad range of variables and employment outcome.

Results: The factors most consistently associated with employment outcome included pre-injury occupational status, functional status at discharge, global cognitive functioning, perceptual ability, executive functioning, involvement in vocational rehabilitation services and emotional status.

Conclusions: A conceptual model is presented which emphasises the importance of metacognitive, emotional and social environment factors for improving employment outcome.     

Reliability and validity of The Awareness of Social Inference Test (TASIT): a clinical test of social perception

Purpose. The Awareness of Social Inference Test (TASIT) is an audiovisual tool designed for the clinical assessment of social perception with alternate forms for re-testing. Part 1 assesses emotion recognition, Parts 2 and 3 assess the ability to interpret conversational remarks meant literally (i.e., sincere remarks and lies) or non-literally (i.e., sarcasm) as well as the ability to make judgments about the thoughts, intentions and feelings of speakers. This paper aims to examine TASIT's reliability and validity.

Method. Some 32 adults with severe, chronic brain injuries were administered Form A twice, one week apart. 38 adults with brain injuries were readministered alternate forms over a period of 5 - 26 weeks. Construct validity was examined in subsets of a sample of 116 adults with brain injuries by relating TASIT performance to standard tests of neuropsychological function and specific social perception measures.

Results. Test-retest reliability ranged from 0.74 - 0.88. Alternate forms reliability ranged from 0.62 - 0.83. TASIT performance was associated with face perception, information processing speed and working memory. Socially relevant new learning and executive tasks were significantly associated with TASIT performance whereas non-social tasks showed little association. Social perception tasks such as Ekman photos and theory of mind stories were also associated.

Conclusions. TASIT has adequate psychometric properties as a clinical test of social perception. It is not overly prone to practice effects and is reliable for repeat administrations. Performance on TASIT is affected by information processing speed, working memory, new learning and executive functioning, but the uniquely social material that comprises the stimuli for TASIT will provide useful insights into the particular difficulties people with clinical conditions experience when interpreting complex social phenomena.     

The work of rehabilitation

Purpose. To describe three years of activity of a rehabilitation unit and to make comparisons between clients who receive different levels of active rehabilitation.

Method. A retrospective study set in an inpatient rehabilitation facility located in Dunedin, New Zealand, examining 874 inpatient admissions over three financial years (2000 - 2002). Outcome measures include Functional Independence Scores (FIM) at admission and discharge, length of stay, weekly gains in FIM scores, and changes in FIM sub-scores.

Results. Assessment and rehabilitation patients made significant FIM gains in comparison to assessment only and social relief (respite care) patients. Assessment and rehabilitation patients showed greater gains in the Physical dimensions of the FIM in comparison to the Cognitive although this is probably a function of different scaling. Floor and ceiling effects were not present in the FIM.

Conclusions. The interdisciplinary rehabilitation program brings about real functional and cognitive gains in a range of patients as measured with the FIM. This adds to the considerable body of research which documents FIM gains and further provides evidence that physical and cognitive gains differ.     

The QE Health Scale (QEHS): assessment of the clinical reliability and validity of a spiritually based holistic health measure

Purpose. To assess the clinical reliability and validity of a holistic health measure, the QE Health Scale (QEHS), for use with people with physical disabilities.

Method. A test-retest design saw the QEHS administered and compared with established measures of health at admission and discharge from three-week inpatient rehabilitation programmes. Data was analysed by factor and correlation analysis. Clinician-reported credibility and usefulness of the theoretical basis of the QEHS, the QEHS itself, and Patient Profiles derived from the QEHS were also used to evaluate clinical validity.

Results. The QEHS was judged to possess satisfactory reliability and validity.

Conclusion. The QEHS is a clinically reliable, valid, credible and useful holistic health instrument to facilitate client-centred therapeutic interventions, inform decision-making and evaluate outcomes for people with physical disabilities.     

Reading to stroke unit patients: perceived impact and potential of an innovative arts based therapy

Objective. This study investigated the delivery of an arts based intervention to stroke patients and sought users' and professionals' views of any perceived benefits.

Setting. The study was undertaken on the stroke rehabilitation ward of a London teaching hospital.

Design. Semi-structured interviews were carried out with 21 patients, 3 health care professionals and 5 reading service personnel. Observation sessions were carried out weekly for the 10-month duration of the project. Data were analysed using the Framework method.

Intervention. The reading service, run by Interact, a registered charity, aims to entertain, stimulate and engage patients. Readers are professional actors trained to work specifically with stroke patients. Interact provide a selection of reading materials or alternatively patients provide their own material.

Results. Participants' accounts suggested that the service met its aim of providing entertainment and stimulation. Additionally, there was some evidence that taking part in the reading service was associated with participants' emotional well being, the processes of adjusting to hospitalisation and to their engagement in rehabilitation therapies. Hospital staff acknowledged the service benefited patients with regard to spiritual, emotional/psychological needs. However they maintained that the service, as entertainment rather than therapy, was of minor importance.

Conclusion. This arts based intervention was welcomed by patients and seemed to address some needs not met in the current configuration of care. These findings suggest that interventions such as the reading service point to ways in which it is possible to enhance the rehabilitation environment and perhaps facilitate better outcomes for stroke patients.     

The system for medical rehabilitation in Croatia

Purpose. To describe the framework for medical rehabilitation in Croatia and to discuss its influence on the practice of the specialty.

Methods. Collection, analysis and interpretation of data pertaining to the need for medical rehabilitation in the country and to its elements of structure, process and outcome of care.

Results. The practice of medical rehabilitation in Croatia has evolved without strategic planning on the national level and therefore without a designed system. This lack in the present framework causes shortcomings in all three elements of rehabilitation care and impedes the advancement of the specialty.

Conclusion. Medical rehabilitation in Croatia needs a national strategic plan for a three-level system that incorporates inpatient, outpatient and community-based rehabilitation.     

Fitting back in: adolescents returning to school after severe acquired brain injury

Purpose. To explore the experiences of Australian adolescents with severe acquired brain injury (ABI) and their families as the adolescent returned to school. In particular, to understand the influence of services and support on the school return.

Method. In-depth interviews conducted over a two-year period with families who had an adolescent with a recent severe ABI (mean age 15 years, 11 months) analysed using a grounded theory approach.

Results. Two critical phases for adolescents returning to school post ABI were identified: organizing the school return and being back at school.Experience in these phases was influenced by length of school absence, extent of noticeable and hidden problems and school response to the students' return post injury. The central concept characterizing experience was the challenge of fitting back in. Some adolescents fitted back in adequately and continued school participation. Those that did not fit in tried again by revisiting the organizing phase, re-evaluated their school experience and either continued or left school.

Conclusions. Adolescents with ABI faced the challenge of fitting back in when they returned to school. This was either facilitated or hindered by the extent and quality of organization, communication and support from parents, schoolteachers and the rehabilitation team.     

Perceptions of persons with multiple sclerosis on cognitive changes and their impact on daily life

Purpose. Cognitive changes occur in over 50% of persons diagnosed with multiple sclerosis (MS). Although previous research has provided information of the nature and severity of cognitive changes among persons with MS, it has offered relatively limited insight on the impact of these changes on levels of functioning and disability. The purpose of this study was to explore the impact of cognitive changes on the lives of four individuals with MS with different life roles (worker, parent, retired older adult).

Method. Qualitative methodologies were used in the study and included multiple open-ended interviews with the study participants and the completion of Cognitive Experience Forms in between interviews. In addition, the Perceived Deficits Questionnaire and a demographics form were administered. Thematic analysis was used to analyse the study data.

Results. Participants described the types of cognitive changes they are experiencing and how these changes affect their ability to participate and engage in desired activities and maintain their primary roles. Participants also talked about how cognitive changes affect their quality of life.

Conclusions. This study points to the complexity of cognitive changes and highlight the importance of addressing these changes in rehabilitation.     

Rehabilitation approaches in fibromyalgia

Purpose. This paper provides an overview of the evidence for the principal approaches taken to the rehabilitation of patients with fibromyalgia (FM): exercise, psychologically-based approaches, multimodal approaches, self-management approaches, and complementary and alternative therapies.

Method. A review of current published evidence.

Results. Owing to factors such as methodological shortcomings of existing studies, and the lack of evidence on individual modalities, it is difficult to draw definitive conclusions as to which is the most appropriate rehabilitation approach in FM. However, there is growing evidence for the role of exercise training, and clear indications that if appropriately prescribed, this can be undertaken without adverse effects. Similarly, psychologically-based interventions such as cognitive-behavioural therapy have received some support from the literature. Evidence for other interventions is more equivocal.

Conclusions. It appears that a combination of interventions, in a multimodal approach (e.g., exercises combined with education and psychologically-based interventions) is the most promising means of managing patients with FM.     

Pain perception during the rehabilitation phase following traumatic hip fracture in the elderly is an important prognostic factor and treatment tool

Purpose. To evaluate the role of pain perception on admission to geriatric rehabilitation on the functional recovery after rehabilitation treatment in elderly patients with hip fracture and on the length of stay.

Method. One hundred and sixty-five community dwelling elderly 65-year-old and over (mean age of 78 years), following recent operated traumatic hip fracture without clinical evidence for another acute medical or surgical condition were assessed regarding age, sex, chronic medical conditions, pre-fracture functional status, type of fracture and of operation, pain perception, and cognitive status. Pain was measured using the Visual Analogue Score (VAS). Functional status was measured using the Functional Independence Measurement (FIM). Activities of Daily Living (ADL) were assessed using the Katz index.

Results. The average VAS score on admission was 7.38 ± 1.20 and on discharge 3.67 ± 1.18. Pain on admission inversely correlated to family support, function prior to fracture and cognitive status on admission, and correlated positively with depressed mood. With every increase of one point in VAS on admission above 4 points, the FIM on discharge decreased by 8.77 and the length of stay increased by 4.76 days.

Conclusions. Pain intensity may add a valuable dimension for the prognostic evaluation of the patients with hip fractures. Inadequate early patient assessment and associated treatment impact on the patients' functional outcome, prolonged duration of rehabilitation treatment, and therefore, in addition to socio-economic effect, increase the cost to the local health care setting.     

Rehabilitation medicine in countries of Central/Eastern Europe

Purpose. To describe attributes of rehabilitation medicine common to the five countries of Central Eastern Europe (CEE) and their implications for future challenges.

Methods. Critical collection and study of pertinent data on evolvement and present state of rehabilitation medicine in CEE countries by a coordinated team of rehabilitation experts from each of the relevant countries.

Results. CEE countries are similar in their need for rehabilitation medicine, its evolvement, present state and current practice. Settings largely emerged without strategic planning on the national level and lagged behind those in Central and Western Europe both in time and content.

Conclusion. The framework that evolved in all except Slovenia is not appropriate to needs. In order to meet future challenges all five CEE countries need the incorporation of inpatient, outpatient and community-based rehabilitation into one system.     

Physiotherapy in Afghanistan: an analysis of current challenges

Introduction. Afghanistan has high levels of disability due to prolonged conflict. An important part of the reconstruction process in Afghanistan is strengthening health service capacity and, within this, rehabilitation services.

Aims: To identify training needs of, and key issues affecting, Afghan physiotherapists.

Methods. 20 interviews and clinical accompaniment of 15 physiotherapists/physiotherapy assistants (APA) carried out in the second quarter of 2003. Analysis was using a grounded theory approach.

Results. Five themes emerged: (1) Low professional profile of physiotherapy; (2) Difficult working conditions; (3) Difficulty identifying personal training needs; (4) Difficulty with clinical reasoning at undergraduate level; (5) Variable levels of clinical competence.

Discussion. Many of the challenges facing Afghan physiotherapists are not unique to Afghanistan but are exacerbated by a lack of government recognition of the profession. War has isolated Afghan physiotherapists from completed professional links and consequently the undergraduate curriculum had not matched developments in other comparable countries. This has contributed to the difficulties therapists' experience with current clinical reasoning and accessing new practice developments. Culture also influences attitudes towards training and has restricted female travel and access to education.

Conclusions. Core training needs include disability sensitization, reflective practice and clinical reasoning. The physiotherapy curriculum needs updating and links with ongoing research need to be established to keep abreast of new developments.     

Theory development and a science of rehabilitation

Purpose. This article considers the role of theory and theory building in science and specifically in rehabilitation. It is argued that rehabilitation has tended to value theory testing over theory building and some evidence is presented for this.

Method. Some general questions concerning the role of theory in scientific progress are discussed including: What is a theory? What is the role of theory in science? What makes a good scientific theory? How does theoretical change occur in science? Where relevant these questions are discussed in terms of examples from clinical rehabilitation research.

Results. Two important issues arising from the preceding discussion are then considered. First is the question of whether a general or unifying theory of rehabilitation is a desirable goal. The second concerns how we might begin to develop a coherent programme of theory building in rehabilitation.

Conclusion. More time spent on rehabilitation theory building may enhance the fruits of empirical theory testing.     

The cognitive competence of speakers with acquired dysarthria: judgements by doctors and speech and language therapists

Background. Studies have shown that listeners make negative attributions towards people with communication impairments. This appears to be the case for healthcare professionals as well as non-professional listeners.

Aims. This study extends this line of research to speakers with acquired dysarthria. These clients often complain that listeners treat them differently after the onset of their speech impairment. The study examines judgements of the cognitive status of speakers with acquired dysarthria made by health care professionals.

Methods and procedures. Doctors, speech and language therapists and speech and language therapy students viewed videos of speakers with acquired dysarthria and of controls matched for age and gender who had acquired neurological deficits that did not affect their speech. Listeners judged whether speakers could carry out a number of everyday tasks. All the tasks were known to be within the speakers' competence.

Outcomes and results. Doctors were significantly less confident of the competence of speakers with dysarthria than of the controls. No difference was found for speech and language therapists or speech and language therapy students.

Conclusions Although caution is required in generalizing these results to other speakers, the results lend some support to the complaints of clients with acquired dysarthria that their speech leads others, in this case doctors, to misjudge their cognitive competence.     

Reduced community integration in persons following traumatic brain injury, as measured on the Community Integration Measure: an exploratory analysis

Purpose. To explore the community integration of individuals who had suffered a Traumatic Brain Injury (TBI) and compare this to members of the general public.

Method. An independent groups design explored differences in three groups' levels of community integration. These groups consisted of ten survivors of TBI, ten male and ten female controls and were measured using The Community Integration Measure (CIM). All participants were resident in Northern Ireland (NI). The brain injured participants were drawn from a Belfast-based social skills programme.

Results. Mann-Whitney U tests showed a statistically significant difference between female controls and brain-injured individuals (U = 26.50, N₁ = 10, N₂ = 10, p = 0.037, one-tailed).

Conclusion. Females were more integrated into their communities than males, who were, in turn, more integrated than brain injured individuals. It would appear that brain injury survivors are doubly disadvantaged. Their gender (mainly male), and the injury itself, conspire to reduce their integration within the wider community.     

Skin problems in lower limb amputees: a systematic review

Purpose. Skin problems of the stump in lower limb amputees are relative common in daily rehabilitation practice, possibly impeding prosthetic use. This impediment may have great impact in daily life. Our objective was to review literature systematically concerning incidence and prevalence of skin disorders of the stump in lower limb amputees.

Method. A literature search was performed in several medical databases (MEDLINE, CINAHL, EMBASE, RECAL) using database specific search strategies. Reference lists in the identified publications were used as threads for retrieving more publications missed in the searches. Only clinical studies and patient surveys were eligible for further assessment.

Results. 545 publications were initially found. After selection, 28 publications were assessed for research methodology. Only one publication fulfilled the selection criteria. The prevalence of skin problems in a series of 45 lower leg amputees of 65 years and older was 16%.

Conclusions. Prevalence and incidence of skin problems of the stump in lower limb amputees are mainly unknown.