Clinician expectations for portable electronic devices as cognitive-behavioural orthoses in traumatic brain injury rehabilitation

Objective : To ascertain experiences and expectations of clinicians as to uses of portable electronic devices such as hand-held computers as cognitive-behavioural orthoses in TBI rehabilitation.

Design : Survey study.

Procedures : A survey developed and piloted with the input of clinician focus groups was completed by 81 TBI clinicians from a variety of disciplines and work settings.

Results : About half of the respondents reported prior exposure to clients with TBI who had used portable electronic aids. Of 10 key cognitive/behavioural areas, respondents saw most potential for devices in the areas of learning/memory, planning/organization and initiation; less potential was seen for social/interpersonal or behavioural difficulties. However, many respondents also identified learning and memory abilities as essential client characteristics for successful use of portable electronics. Cost was identified as a significant barrier to use of portable devices in rehabilitation. Respondents expressed low confidence overall in their ability to guide clients in use of devices; those who reported personal use were significantly more confident than those who did not.

Conclusion : Clinicians believe that new electronic devices have potential for treatment of some cognitive impairments, but clinical experimentation may be limited by costs of technology and low clinician confidence.     

Portable electronic devices as memory and organizational aids after traumatic brain injury: a consumer survey study

OBJECTIVE: To ascertain consumer experiences and attitudes regarding the use of portable electronic devices as memory and organizational aids after traumatic brain injury (TBI). DESIGN: Survey study. SETTING: Post-acute TBI rehabilitation programs, research registries. PARTICIPANTS: Eighty persons with moderate to severe TBI interviewed a median of 3.7 years postinjury. OUTCOME MEASURE: Survey administered in structured interview format, analyzed both quantitatively and qualitatively. RESULTS: Two thirds of participants reported regular use of computers, but fewer than one third had experience with hand-held computers or similar devices. Interest in using portable devices for everyday memory and organizational tasks was higher than the expressed need for improvement in participants' current strategies. Respondents expressed reliable preferences for key device features, including simplicity of use, technical support, and long-lasting battery power. Preferred functions included keeping track of money spent, remembering things to do, and remembering what other people say. CONCLUSION: Portable electronic devices are acceptable or desirable by consumers with moderate to severe TBI for use as compensatory aids.     

Psychostimulant use in the rehabilitation of individuals with traumatic brain injury

BACKGROUND: Psychostimulants are used commonly in the rehabilitation of individuals with traumatic brain injury (TBI), despite the dearth of well-controlled studies of their effects. The available literature suggests that these drugs predominantly affect the speed of cognitive processing and certain observational ratings of mood and behavior. Effects on sustained attention, distractibility, and memory are less clear. OBJECTIVE: This article reviews the controlled research literature on the use of these drugs in TBI and presents preliminary data from the authors' laboratory that extends these findings. Some of the common research pitfalls that have limited progress in research on these drugs are discussed.     

Donepezil mediated memory improvement in traumatic brain injury during post acute rehabilitation

Memory dysfunction is a recognized and difficult to treat complication of traumatic brain injury (TBI). Since medial-temporal lobe injury is a frequent contributor to memory dysfunction in TBI, it is likely that an acetylcholine deficit contributes to memory dysfunction in this population. Recently, Donepezil, an acetylcholine-esterase inhibitor which has demonstrated a high selectivity for neural Ach-esterase (with minimal side effects), was approved for use in dementia in Alzheimer s patients. Due to its promising results in Alzheimer s patients, and reports in the literature describing the use of physostigmine (an anti cholinesterase with significant cardiovascular and autonomic side effects) to treat memory deficits in closed head injury, we decided to begin a trial of Donepezil in two patients with TBI who were experiencing long term static memory dysfunction refractory to conventional treatment. Both patients were admitted to our facility for physical and cognitive rehabilitation, and were started on a trial of Donepezil. Modified memory tests and subjective observations by both family and staff pointed to an improvement in memory within three weeks of starting Donepezil. Should these initial results be supported in larger trials, Donepezil may prove to be a valuable tool for the treatment of memory dysfunction in TBI.     

Outcome of memory rehabilitation in traumatic brain injury assessed by neuropsychological tests and questionnaires

OBJECTIVES: To evaluate the effectiveness of a memory rehabilitation program. To compare different outcome measures. PARTICIPANTS: Twelve patients with severe traumatic brain injury. SETTING: Outpatient rehabilitation service. MAIN OUTCOME MEASURES: Rey-Osterrieth Complex Figure Test (REY), California Verbal Learning Test (CVLT), Rivermead Behavioural Memory Test (RBMT), and the Memory Failures in Everyday Memory Questionnaire (MFE). STATISTICAL ANALYSIS: Exact nonparametric procedures. RESULTS: All patients achieved meaningful functional gains. Modest improvements were found in some of the scales of the CVLT but not in the REY, RBMT, or MFE. CONCLUSION: Functional gains did not correlate with improvement in memory processes. Measurement of changes in independence in activities of daily living mediated by compensatory aids and educational intervention plans with relatives are proposed.     

Everyday memory following traumatic brain injury

Residual memory deficits may represent a problem to the everyday functioning of a large number of people, including those who have sustained traumatic brain injury (TBI). The present exploratory study sought to investigate the interrelationships between subjective memory reports, performance on traditional memory tests, and performance on tests of prospective memory. These interrelationships were contrasted between a group of 24 adults who had sustained TBI and a group of 24 matched control subjects. Prospective memory was hypothesized to be indicative of everyday memory functioning. The results provided preliminary evidence that prospective memory tests are sensitive to TBIrelated neurological impairment and, in comparison to traditional tests, may be better indicators of functional memory capacity. This pattern was particularly true for control subjects, possibly because TBI subjects had difficulties in evaluating their memory functioning.     

Neuropsychological rehabilitation of mild traumatic brain injury

A significant minority of patients who have sustained a mild traumatic brain injury (MTBI) may exhibit persistent disability. There have been few attempts to describe and evaluate the effectiveness of neurorehabilitation for these patients. We conducted a retrospective analysis of the results of a neuropsychological rehabilitation programme for 20 patients with MTBI. Based upon the ability to resume productive functioning after treatment, 10 patients were determined to exhibit a good outcome and 10 patients were considered to exhibit a poor outcome. Patients with good outcome exhibited significant pre-post-treatment improvements on both neuropsychological measures of cognitive functioning and self-reported post-concussive symptoms. Patients with poor outcome demonstrated little improvement in either area, and in some cases showed a decline in functioning. The results are consistent with the view that there may be significant variability in recovery and response to treatment after MTBI. There is a continued need to identify which patients may benefit from neurorehabilitation, develop specially tailored interventions, and conduct controlled, prospective studies in this area.     

Canadian healthcare perspective in traumatic brain injury rehabilitation

Brain injury rehabilitation is based on principles of universal access to healthcare in a publicly funded system and is available to all residents in Canada. However, a variability of resources exists because of the vastness of the country and differences in provincial funding. Rehabilitation is typically provided by an interprofessional team and is client centered, goal directed, evidence based, and aimed at improving quality of life for survivors of brain injury. Work is being done exploring different models of care including community treatment and the use of rehabilitation therapists. Patient education is an ongoing priority. Data collection is considered mandatory in many centers for program evaluation and quality improvement. There is a clear need for coordinated standards of care across the country.     

Recovery and rehabilitation following traumatic brain injury

Although most patients are discharged following traumatic brain injury TBI with good recovery , recent reports indicate that many have persistent neuropsychological deficits. The purposes of this study were to 1 determine if functional, neuropsychological and social outcome at 3 and 6 months in patients hospitalized following TBI could be ascertained via telephone follow up, and 2 assess use of rehabilitation services in this population. Patients were identified through acute hospital admissions. A trained nurse practitioner abstracted data from acute charts. Using the Functional Independence Measure FIM , Neurobehavioral Rating Scale NRS , Telephone Interview for Cognitive Status TICS , and a social questionnaire she obtained follow up information at 3 and 6 months post injury. Of 74 patients initially identified, 51 and 48 were available at 3 and 6 months, respectively. Most experienced mild to moderate TBI. Physical disability was minimal at follow up as indicated by the FIM. Approximately half of the patients were rated cognitively impaired on the TICS at 3 months and over one third remained impaired at 6 months. At 6 months 60.5% remained unemployed. Only eight of the 67 discharged survivors received any rehabilitation services. A brief telephone follow up appears to be a cost effective way to ascertain functional and neuropsychological outcome in TBI survivors. Since few of these patients received rehabilitation, a telephone follow up may identify those who would potentially benefit from additional rehabilitation services.     

Cultural variations in the understanding of traumatic brain injury and brain injury rehabilitation

Little is known about how people from different cultures experience and understand traumatic brain injury (TBI) and the process of brain injury rehabilitation. The Brain Injury Rehabilitation Unit (BIRU) undertook a qualitative project to research cultural variations in the understanding of TBI and the rehabilitation process, interviewing 39 people with TBI and family members from Italian, Lebanese and Vietnamese backgrounds. The focus was on the reporting of sequelae of the TBI; valued qualities of service providers; barriers to effective communication; the role of the families in the rehabilitation process; and the experience of social stigma. Findings suggest there is a universal experience of TBI that transcends individual cultures. Study participants valued attentiveness, friendliness and guidance from rehabilitation staff. Family support was not always available to the person with TBI due to family conflict. Generally, people with TBI and family members valued the assistance of health interpreters facilitating their communication with rehabilitation staff. People with TBI from all three cultures experienced problems of stigma and social isolation. The findings have a number of implications for how brain injury rehabilitation staff can approach service provision to people from diverse cultural backgrounds.     

Prospective memory rehabilitation for adults with traumatic brain injury: a compensatory training programme

PRIMARY OBJECTIVE: To describe a prospective memory rehabilitation programme based on a compensatory training approach and report the results of three case studies. RESEARCH DESIGN: Programme evaluation using pre- and post-intervention assessments and telephone follow-up. METHODS AND PROCEDURES: Three participants with traumatic brain injury completed 8 weeks of training with 1-2 hour individual sessions. Assessments were formal prospective memory assessment, self-report and measures of diary use. EXPERIMENTAL INTERVENTIONS: Intervention aimed to identify potential barriers, establish self-awareness of memory deficits, introduce a customized compensatory tool, a cueing system and organizational strategies. A significant other was involved in training to assist generalization. MAIN OUTCOMES AND RESULTS: All three participants improved on formal prospective memory assessment and demonstrated successful diary use after the programme. Self-report of prospective memory failure fluctuated and may reflect increased self-awareness. CONCLUSION: A compensatory approach may be useful in improving prospective memory performance following TBI.     

Team development and memory training in traumatic brain injury rehabilitation: Two birds with one stone

The need for developing team cooperation procedures when treating patients with traumatic brain injury (TBI) is stated. One approach in promoting team cooperation is to combine team development with a specific training programme. A memory training programme used in a subacute TBI rehabilitation unit is described. A combination of a team development procedure and memory training programme was performed in the unit. A questionnaire to assess team members' attitudes to team cooperation was administered before and after team development, and memory training procedures were implemented. The post-training questionnaire administration indicated a more positive perception among team members of how the team functioned. The efficacy of memory training showed variable results. The programme described may illustrate the advantages of combining a specific treatment programme with efforts to promote team development.     

Use of a portable voice organizer to remember therapy goals in traumatic brain injury rehabilitation: a within-subjects trial

OBJECTIVE: To test the efficacy of a portable voice organizer in helping people with traumatic brain injury (TBI) to recall therapy goals and plans discussed with their clinical case managers. DESIGN: Prospective within-subjects trial, in which individualized therapy goals were randomly assigned to intervention or no intervention. SETTING: Comprehensive postacute TBI rehabilitation program. PARTICIPANTS: Ten people with moderate to severe TBI enrolled from 3 months to 18 years after injury. OUTCOME MEASURE: Memory for therapy goals. Clinicians generated statements describing six current therapy goals, half of which were randomly assigned to be recorded on a voice organizer during the next case management session. Participants selected three times per day to listen to the recorded goals, prompted by an alarm. One-week recall was tested using both free- and cued-recall formats. RESULTS: Recorded goals were recalled better than unrecorded goals and appeared to be associated with better awareness or follow-through with therapy objectives. CONCLUSION: Portable electronic devices have the potential to assist with treatment areas beyond tasks involving prospective memory.     

Executive and compensatory memory retraining in traumatic brain injury

A controlled treatment outcome study was conducted comparing the efficacy of memory remediation treatment with no treatment on traumatic brain-injury patients. The memory remediation treatment consisted of both compensatory and executive training skills and was delivered 6 hours weekly over a 2 1/2-week period. Six subjects in the treatment group and 6 subjects in the control group were matched on WAIS-R FSIQ scores, pre-test memory scores and age. Pre-and post-test measures were obtained for both groups on a paragraph memory task. A significant difference was demonstrated between the treatment and control post-test memory scores. The experimental group significantly improved memory scores beyond that of the control group, suggesting that memory remediation is effective for head-injury patients with memory deficits. Discussion of findings and suggestions for further investigation are presented.     

Executive memory dysfunctions following mild traumatic brain injury

OBJECTIVES: To explore the contribution of executive dysfunctions to mnemonic problems in adults with mild traumatic brain injury (MTBI). DESIGN: Prospective quasiexperimental between-groups design. PARTICIPANTS: Ninety-nine persons with MTBI were compared to 90 control group participants matched for gender, age, and education. SETTING: Two Canadian brain injury rehabilitation programs. MAIN OUTCOME MEASURE: California Verbal Learning Test. RESULTS: Participants with MTBI showed a significant deficit in free recall on the California Verbal Learning Test but performed similarly to the comparison group on the recognition task. Furthermore, the participants with MTBI were less likely to use semantic clustering as a memorizing strategy and made more intrusion errors and false-positive errors on the recognition task. CONCLUSIONS: While the scores for the participants with MTBI are only slightly lower than the norm, they demonstrate that MTBI has a negative effect on mnemonic performance. The results are explained in terms of a deficit in registration/retrieval processes rather than a malfunction of the storage processes. This supports the initial hypothesis that executive dysfunctions are detrimental to the quality of mnemonic functions in patients with MTBI.     

Participation as an outcome of traumatic brain injury rehabilitation

OBJECTIVES: Participation in meaningful life situations is an important aspect of functioning after traumatic brain injury (TBI). However, to date, few studies have included measures of social participation or community integration as outcome measures after TBI rehabilitation. This paper is a selective review of the literature that examines the effects of TBI rehabilitation on measures of participation or community integration. It also addresses the related questions of clinically significant improvements in community integration, variability in patterns of community functioning, and the relationship of participation and quality of life after TBI. DESIGN: Literature review. CONCLUSIONS: A small number of studies suggest that postacute TBI rehabilitation can produce improvements in participation and community integration. However, a considerable amount of variability in rehabilitation outcomes may be apparent. Analysis of clinically significant changes in individual's functioning suggests that rehabilitation may exert its benefits not only by facilitating improvements, but also by preventing declines in community functioning. Subjective well-being and quality of life have generally been ignored as TBI rehabilitation outcomes. There is considerable evidence that participation and subjective well-being represent distinct and dissociable outcomes after TBI, which may reflect the importance of patients' preferences and values in evaluating the effectiveness of rehabilitation.     

The effects of Donepezil on traumatic brain injury acute rehabilitation outcomes

Primary objective: To evaluate the effects of administering Donepezil during inpatient rehabilitation for individuals with TBI.

Research design: Retrospective, age and injury severity matched, mixed between-within subjects analysis.

Methods and procedures: Thirty-six patients with moderate-to-severe TBI admitted to acute rehabilitation within 90 days of injury. Main outcome measures included FIM cognitive total scores and rehabilitation lengths of stay.

Intervention: Initiation of Donepezil administration beginning at 5 mg daily. Dose titration and continuation based on perceived clinical response.

Main outcomes and results: No differences in cognitive improvement were observed between the Donepezil treatment group and the matched control group. Sub-set analyses suggested that administration of Donepezil early in the rehabilitation stay was significantly related to higher rates of cognitive improvement.

Conclusions: Preliminary evidence suggests that Donepezil administration early in the rehabilitation stay may have advantageous treatment effects. A prospective, randomized, placebo-controlled clinical trial with standard timing, dosage and treatment duration is recommended to further evaluate treatment efficacy.