A pilot study for rehabilitation of central executive deficits after traumatic brain injury

Primary objective: An impairment of the central executive system (CES) of working memory (WM) is a common consequence of traumatic brain injury (TBI), and may also explain deficits in divided attention, long-term memory and executive functions. Here we investigated the efficacy of a rehabilitative program (working memory training: WMT) targeting the CES in improving WM and other cognitive functions dependent on this system.

Methods and procedures: Nine TBI patients with severe WM deficits underwent the WMT (experimental training). The WMT was preceded by a general stimulation training (GST; control training). Patients' cognitive performance was evaluated at the admission, after the GST and at the end of the WMT.

Main outcomes and results: Whereas the GST had no effect on patients' performance, after the WMT patients improved in all the cognitive functions dependent on the CES, but not in those functions not thought to tap this system. Importantly, a beneficial WMT effect was found on patients' everyday life functioning.

Conclusions: The results support the efficacy of the WMT in recovering CES impairments.     

Neuropsychological profile of persons with anoxic brain injury: differences regarding physiopathological mechanism

Primary objective: To determine the neuropsychological profile of persons with anoxic brain injury.

Methods and procedures: A retrospective study on a population of persons with anoxic brain injury admitted to a Brain Injury Unit (Institut Guttmann, Spain) from 1995-2003. The sample was divided according to physiopathological mechanisms in two sub-groups: ischemic anoxia (21 cases) and hypoxemic anoxia (11 cases). Functions assessed included orientation, attention, language, visuo-perceptive and visuo-constructive processing and verbal memory.

Results: Neuropsychological assessment showed diffuse cognitive impairment in all assessed functions. Episodes of ischemic anoxia caused more severe verbal memory and learning problems than episodes of hypoxemic anoxia.

Conclusions: This study shows that memory problems are the most prominent and relevant impairment, although all other cognitive functions are also impaired, affecting both memory itself and general behaviour. Statistical analysis also provides preliminary evidence on the different profile of memory impairment whether cerebral anoxia had hypoxic or ischemic origin.     

Beneficial effect from a cognitive training programme on children with acquired brain injuries demonstrated in a controlled study

Primary objective: To test the effectiveness of a cognitive training programme in children and adolescents with attention and memory deficits after acquired brain injury (ABI).

Research design: Randomized controlled study.

Participants: Thirty-eight children with ABI, 9-16 years of age.

Methods and procedures: The treatment group trained with the cognitive programme for 30 minutes per day interactively with a teacher or parent for a period of 17 weeks. Children in the control group had a freely chosen interactive activity 30 minutes daily for 17 weeks. Pre- and post-training assessments were made using a neuropsychological test battery.

Main outcome and results: Significant improvements in the majority of neuropsychological tests of sustained and selective attention as well as in memory performance were shown in the treatment group as compared to controls.

Conclusions: The immediate effect of the training programme improved complex attention and memory functions, indicating that this method may be a valuable treatment option for improving cognitive efficiency in children after ABI. On the basis of these results, the next step will be to evaluate long-term effects and further ecological validity.     

Central executive system impairment in traumatic brain injury

Primary objective: This study investigated whether cognitive impairment after traumatic brain injury (TBI) can be considered a consequence of (1) a speed processing deficit or (2) an impairment of the Central Executive System (CES) of working memory.

Methods and procedures: Thirty-seven TBI patients underwent a standardized battery of neuropsychological tests evaluating speed processing, sustained attention, short-term memory, working memory, divided attention, executive functions and long-term memory.

Main outcomes and results: Patients showed severe deficits in working memory, divided attention, executive functions and long-term memory. Divided attention, long-term memory and executive functions deficits significantly correlated with working memory, but not with speed processing deficits. Moreover, multiple regression analyses showed that a CES impairment and not a speed processing deficit predicted divided attention, executive functions and long-term memory deficits. The severity and the site of brain lesions did not predict the level of CES or speed processing impairment.

Conclusions: The cognitive impairment following TBI seem to be caused by an impairment of the Central Executive System, rather than a speed processing deficit.     

Stroke rehabilitation in a patient with cerebellar cognitive affective syndrome

Objective: It has become evident that the cerebellum plays a role in cognitive function, and Schmahmann et al. have introduced the term “Cerebellar cognitive affective syndrome (CCAS).” In the present paper we report a patient with cerebellar hemorrhage who developed CCAS.

Design: A case study.

Methods: The patient was a 61-year-old right-handed man who was admitted to our hospital because of sudden headache, dizziness and vomiting. The patient showed ataxia of the trunk and the extremities, but no paralysis and disturbance of sensation. He was disoriented in time and showed recent memory disturbance, disturbance of attention, impairment of executive functions and reduced volition, and due to these symptoms, his daily living was also severely impaired.

Results: With the aim of returning home, the patient received exercise therapy and cognitive rehabilitation, while home modification was performed, and living at home under the supervision of his family became possible. Cognitive function improved, while memory and attention disturbance, impairment of executive function remained.

Conslusion: Cognitive dysfunction in patients with cerebellar damage is assumed to develop from disturbance of the cerebrocerebellar circuit, and that rehabilitation of these patients must include assessment of not only the motor function, but also of detailed assessment of cerebral function.     

An Internet training intervention for people with traumatic brain injury: barriers and outcomes

Primary objective: To test whether people with cognitive-linguistic impairments following traumatic brain injury could learn to use the Internet using specialized training materials.

Research design: Pre-post test design.

Methods and procedures: Seven participants were each matched with a volunteer tutor. Basic Internet skills were taught over six lessons using a tutor's manual and a student manual. Instructions used simple text and graphics based on Microsoft Internet Explorer 5.5. Students underwent Internet skills assessments and interviews pre- and post-training. Tutors completed a post-training questionnaire.

Main outcomes and results: Six of seven participants reached moderate-to-high degrees of independence. Literacy impairment was an expected training barrier; however, cognitive impairments affecting concentration, memory and motivation were more significant.

Conclusions: Findings suggest that people with cognitive-linguistic impairments can learn Internet skills using specialized training materials. Participants and their carers also reported positive outcomes beyond the acquisition of Internet skills.     

The effects of cognitive teletherapy on reported everyday memory behaviours of persons with chronic traumatic brain injury

Primary objective: The purpose of this study was to evaluate the effects of an errorless training approach, Spaced Retrieval (SR) training delivered over the telephone, on the reported everyday memory problems of adults with chronic traumatic brain injury (TBI).

Research design: The study was a randomized controlled clinical trial.

Methods: Thirty-eight participants received either SR training or didactic strategy instruction (SI). Participants in both groups identified three memory-related goals and were paired to receive the same total telephone contact time. The main outcome measures were frequency of reported memory problems and perceived quality of life.

Results: Participants in the SR group reported significantly more treatment goal mastery/strategy use than those in the SI group, immediately and at 1-month post-training. Caregivers reported similarly significant between-groups differences in everyday use of treatment behaviours at 1 month. Both groups reported some generalized strategy use to other non-targeted behaviours and decreased frequency of reported memory problems, but there were no significant between-groups differences in participant or caregiver reports of generalized strategy use or reported memory problems at either time-point. There was no change in perceived quality of life in either group.

Conclusions: SR treatment delivered by phone produced significantly more treatment goal mastery/strategy use and maintenance than SI; however, both treatments improved reported everyday memory functioning for persons with TBI, without significant group differences on measures of generalized strategy use or perceived quality of life.     

Gender and traumatic brain injury: do the sexes fare differently?

Objective: To examine the relationship between gender and cognitive recovery 1 year following traumatic brain injury (TBI).

Methods: Patients with blunt TBI were identified from the TBI Model Systems of Care National Database, multi-centre cohort study. The included patients (n = 325) were 16-45 years at injury, admitted to an acute care facility within 24 hours, received inpatient rehabilitation, had documented admission Glasgow Coma Scale (GCS) scores, completed neuropsychological follow-up 1 year post-injury and did not report pre-morbid learning problems. Multivariate analyses of variance examined the unadjusted association between gender and six cognitive domains examining attention/working memory, verbal memory, language, visual analytic skills, problem-solving and motor functioning. Analyses of covariance models were constructed to determine if confounding factors biased the observed associations.

Results: Females performed significantly better than males on tests of attention/working memory and language. Males outperformed females in visual analytic skills. Gender remained significantly associated with performance in these areas when controlling for confounding variables.

Conclusions: These results suggest a better cognitive recovery of females than males following TBI. However, future studies need to include non-TBI patients to control for possible pre-injury gender-related differences, as well as to conduct extended follow-ups to determine the stability of the observed differences.     

Clinician influences on use of portable electronic memory devices in traumatic brain injury rehabilitation

Primary objective: To explore the relationship between a group of clinicians' own experience, training and confidence with portable electronic memory devices and their use of the same in traumatic brain injury (TBI) rehabilitation.

Research design: Survey study.

Methods and procedures: Eighty-one TBI clinicians from various disciplines and work settings completed a survey distributed in person or by mail.

Main outcomes and results: Twenty-nine respondents (36%) reported using portable electronic memory devices with patients with TBI. Using regression analysis, respondent device training and confidence teaching patients device use were statistically associated with respondents' use of such devices in TBI rehabilitation.

Conclusions: Portable electronic memory device use with persons following TBI may be under-utilized. The importance of ongoing clinician training and of maximizing clinician confidence utilizing these devices in TBI rehabilitation is emphasized. The representativeness of the respondent sample is discussed. Specific training strategies and continued research needs are presented.     

The relationship between clients' cognitive functioning and the therapeutic working alliance in post-acute brain injury rehabilitation

Objective: To examine the impact of brain-injured patients' cognitive abilities on their working alliance (WA) with their therapist in post-acute rehabilitation.

Design: Cognitive tests were administered to brain-injured individuals at the beginning of post-acute, holistic brain-injury rehabilitation. Clients as well as their primary therapists rated their mutual WA at four time points throughout a 14-week rehabilitation programme. Subjects consisted of 86 clients as well as their primary therapists. Clients had suffered a traumatic brain injury (n = 27), a cerebrovascular accident (n = 49) or another neurological insult (n = 10).

Measures: (1) Neuropsychological tests of attention, memory and higher cognitive functions; (2) the Working Alliance Inventory, client and therapist short form.

Results: Overall, the relationships between cognitive tests and WA ratings were weak. The tests of attention, memory and higher cortical functions were differentially related to clients' and therapists' view of their mutual WA at the different stages of their collaborative work.

Discussion and conclusion: Clients' cognitive profile affects clients' and therapists' view of their WA in different ways. The weakness of the correlations between cognitive tests and WA ratings may indicate that a good WA is achievable also with clients with severe cognitive difficulties.     

Social communication skills in persons with post-acute traumatic brain injury: three perspectives

Objective: To describe social communication skills problems identified by individuals with traumatic brain injury (TBI) compared to significant other (SO) and clinician ratings; and associations between these skills and participation outcome measures.

Design: Cohort study.

Methods: Sixty individuals with TBI ≥ 1 year post-injury were administered measures of social communication, societal participation, social integration and life satisfaction. Clinicians and SOs rated the social communication skills of the subjects.

Results: Subjects were able to identify social communication skills problems, associated with lower ratings of community integration and satisfaction with life. Males reported higher scores in social communication and social integration than females. SOs and clinicians identified more social skills problems than subjects.

Conclusions: Persons with TBI experience social communication skills deficits, associated with decreased societal participation and life satisfaction. Further research is needed to determine efficacy of social communication skills treatment and association with improved participation and satisfaction with life.     

Two case studies in the application of errorless learning techniques in memory impaired patients with additional executive deficits

Primary objective: The purpose of the present study was to examine in what extent errorless learning can be applied to amnesic patients with additional executive dysfunction.

Research design: Two case studies were used in which two patients with severe closed head-injury were compared according to their different neuropsychological profiles.

Methods and procedures: Patients were taught complex semantic information about their therapists and cognitive procedures needed to programme an electronic organizer.

Main outcomes and results: Both semantic and procedural results suggest that the errorless method can be very helpful for teaching complex new knowledge to amnesic patients with mild executive impairment, whereas the presence of a dysexecutive syndrome may hamper the success of this form of memory rehabilitation.

Conclusions: The present study puts forward that executive deficits should be taken into account when neuropsychologists are planning to use errorless techniques.     

The relationship between working memory, processing speed, verbal comprehension and FAS performance following traumatic brain injury

Primary objective: To investigate the relationship of working memory, processing speed and verbal comprehension with FAS performance in individuals who had sustained a traumatic brain injury (TBI).

Methods and procedure: Sixty-three patients with a TBI were grouped according to the presence of impaired verbal fluency performance and then compared on a number of cognitive and demographic variables.

Results: Following a TBI, working memory and processing speed had the greatest influence on verbal fluency performance. For those individuals who have not sustained a TBI, education, verbal intelligence, working memory and speed of information processing were related to FAS performance.

Conclusions: The findings of the study indicate that FAS performance was related to verbal intelligence, working memory ability, attention and speed of information processing. The results further suggest that different variables are related to FAS performance following a TBI as compared with control group performances.     

Direct clinician-delivered versus indirect family-supported rehabilitation of children with traumatic brain injury: a randomized controlled trial

Primary objectives: To explore the relative effectiveness of clinician-delivered vs family-supported interventions for children with chronic impairment after TBI.

Research design: Randomized controlled clinical trial.

Methods and procedures: Children aged 5-12 years in the chronic phase of their recovery were randomly assigned to the clinician-delivered or to the family-supported intervention group; both samples received intensive services for 1 year; physical outcome was measured by the SARAH scales, cognitive outcome by the WISC-III.

Main outcomes and results: Parents in the family-supported intervention sample efficiently acquired the skills needed to deliver physical and cognitive interventions within the context of everyday routines of the child's life at home; family education level was not a factor. Although both groups demonstrated improvements, only the children in the family-supported intervention group demonstrated statistically significant — and clinically important — improvements on both outcome measures.

Conclusions: This RCT provides compelling evidence for organizing cognitive and physical interventions and supports for children with TBI around the everyday routines of their lives, with intensive supports for their families.     

Clinical progression and outcome of dysphagia following paediatric traumatic brain injury: a prospective study

Objectives: To provide a preliminary clinical profile of the resolution and outcomes of oral-motor impairment and swallowing function in a group of paediatric dysphagia patients post-traumatic brain injury (TBI). To document the level of cognitive impairment parallel to the return to oral intake, and to investigate the correlation between the resolution of impaired swallow function versus the resolution of oral-motor impairment and cognitive impairment.

Participants: Thirteen children admitted to an acute care setting for TBI.

Main outcome measures: A series of oral-motor (Verbal Motor Production Assessment for Children, Frenchay Dysarthria Assessment, Schedule for Oral Motor Assessment) and swallowing (Paramatta Hospital's Assessment for Dysphagia) assessments, an outcome measure for swallowing (Royal Brisbane Hospital's Outcome Measure for Swallowing), and a cognitive rating scale (Rancho Level of Cognitive Functioning Scale).

Results: Across the patient group, oral-motor deficits resolved to normal status between 3 and 11 weeks post-referral (and at an average of 12 weeks post-injury) and swallowing function and resolution to normal diet status were achieved by 3-11 weeks post-referral (and at an average of 12 weeks post-injury). The resolution of dysphagia and the resolution of oral-motor impairment and cognitive impairment were all highly correlated.

Conclusion: The provision of a preliminary profile of oral-motor functioning and dysphagia resolution, and data on the linear relationship between swallowing impairment and cognition, will provide baseline information on the course of rehabilitation of dysphagia in the paediatric population post-TBI. Such data will contribute to more informed service provision and rehabilitation planning for paediatric patients post-TBI.     

Development and evaluation of a pictorial-based analogical problem-solving programme for people with traumatic brain injury

Background: People with traumatic brain injury (TBI) must often deal with cognitive problems, including social problem-solving. The study reported herein evaluated the effectiveness of a newly developed pictorial-based analogical problem-solving skills training programme. It is hypothesized that the programme can help people with TBI to learn better problem-solving skills through systematic, theoretically driven learning strategies.

Method: Based on the instrumental enrichment model and the hierarchy of daily problem-solving as suggested by Holloran and Bressler, analogical problem-solving training software was developed. Thirty subjects with TBI then attended a 20-session interactive analogical problem-solving skills training programme. Another 20 subjects with TBI and of similar demographics formed the control group. The outcome measures included session-based quizzes on analogical problem-solving, the Category Test of the Halstead Reitan Test Battery (HRTB) and the Lawton IADL Scale.

Findings: The analogical problem-solving training strategies were found to be effective in improving problem-solving skills. The subjects generally demonstrated a selective improvement in their functional and overall problem-solving skills, but not in their basic problem-solving skills. The subjects in the control group showed stable problem-solving skills over a 4-week interval (no statistically significant changes). The findings indicated the therapeutic significance of the training programme.

Conclusions: The results of the study suggested that innovative cognitive rehabilitation programmes can be customized to match the needs of clients with TBI. The applicability and implications of the interactive pictorial-based analogical problem-solving skill-training programme that was used in the study and possibilities for future study in this research area are also discussed.     

Memory function after resolution of post-traumatic amnesia

Primary objectives: The aims of this pilot study were (1) to examine neuropsychological, particularly memory functions immediately after post-traumatic amnesia (PTA) resolution according to the Galveston Orientation and Amnesia Test (GOAT), and (2) to provide a preliminary exploration of pattern of performance on GOAT items across PTA duration.

Methods and procedures: Thirty-seven head injured patients were administered the Recognition Memory Tests on the day that PTA resolved. Formal neuropsychological assessment was conducted on average 10 days after PTA resolution.

Main outcomes and results: All the patients in the series showed memory impairment which varied in severity but was typically characterized as global and severe. Deficits in executive and speed and attention functions were common. GOAT items relating to orientation were typically passed, while items concerning anterograde and retrograde recall were most commonly failed across all stages of PTA duration.

Conclusions: These findings suggest that reliance on memory performance as a measure of PTA is not ideal and highlight the need for further research of this issue.     

Factors triggering relatives' judgements of personality change after traumatic brain injury

Objective: This study assesses neuropsychological and psychosocial determinants of judgements of personality change (PC) after traumatic brain injury (TBI).

Design: Cross-sectional data from 87 participants with TBI analysed using hierarchical binary regression.

Methods: Interview of participants assessed, injury severity (post-traumatic amnesia), degree of cognitive impairment (IQ and memory), presence of orbitofrontal and/or medial temporal damage (olfaction) and emotional reactions (anger, depression and anxiety questionnaires). Separate interview of relatives assessed their own response to the injury (emotional reactions and critical comments from the Expressed Emotion index) and their judgements of participants' behavioural change.

Results: As expected, memory loss and impaired olfaction predicted relatives' PC judgements. However, the most striking and novel result was that social-emotional factors (participants' and relatives' reactions) predicted PC judgements best.

Conclusions: This study emphasizes the need (a) for future studies measuring social behaviours (e.g. impulsivity and emotional perception) (b) to explore the differing determinants of relatives' and participants' PC judgements and (c) to develop and to tailor clinical responses to the various psychosocial determinants of PC.     

Cerebral anoxia and disability

Objectives: To describe the sequelae of cerebral anoxia following out-of-hospital cardiac arrest, to study the functional outcome and to seek a link between the acute stage and the disability.

Method: A retrospective study was performed. The initial findings and the neurological and neuropsychological status are recorded of 12 patients admitted to the rehabilitation unit for after-effects of cerebral anoxia following out-of-hospital cardiac arrest.

Results: After clinical and neuropsychological assessment, all patients displayed cognitive impairment. Two groups of patients appeared: seven patients were severely disabled with a dysexecutive and behavioural frontal lobe syndrome and memory deficit; five out of the seven also presented an extra-pyramidal syndrome; the other five patients presented behavioural dysfunction related to frontal lobe disorder but were independent in daily life activities. No correlation was found between the acute stage data and the outcome.

Conclusion: Neurological and neuropsychological impairment after cerebral anoxia may be severe but seems difficult to predict. A dysexecutive syndrome was noted in all 12 patients.