Treatment to improve self-awareness in persons with acquired brain injury

Aim: To examine the effects of an awareness training protocol embedded within the practice of instrumental activities of daily living (IADLs) in participants with acquired brain injury on levels of self-awareness and functional performance.

Methods: This study used a randomized control trial design: 10 participants with moderate-to-severe brain injury received six sessions of the self-awareness training while they performed IADLs (experimental group) and 10 participants performed the same IADLs but received conventional therapeutic practice (control group). In the experimental group, participants were asked to predict their performance before each task performance and to estimate their performance level after the performance.

Outcome measures: Pre- and post-intervention outcome measures taken from the two groups were compared. Instruments were standardized measures of 'general' self-awareness with collateral reports by informants (e.g. Awareness Questionnaire); 'task-specific' self-awareness (e.g. Assessment of Awareness of Disability) and Self-Regulation Skills Inventory (SRSI). Performance on IADLs was assessed using the Assessment of Motor and Process Skills (AMPS).

Results: Compared to the control group, the intervention significantly improved IADL performances and self-regulation. No significant treatment effect was observed for task-specific self-awareness, general self-awareness or community integration.

Conclusions: The self-awareness intervention significantly but selectively improved self-awareness during IADL task performance as well as functional performance. The need for a larger study with more treatment sessions is discussed.     

Who benefits? Outcome following a coping skills group intervention for traumatically brain injured individuals

Primary objective: To investigate the variables associated with positive psychological outcome following a group intervention for 33 individuals with traumatic brain injury.

Research design: Evaluation study which used multiple regression analysis to examine the variables associated with change in psychological adjustment following a 10-session cognitive behaviour therapy-based group.

Methods and procedures: The predictor variables were age at injury, time since injury, injury severity, self-awareness, pre-morbid intellectual function, memory function, executive function and level of depression and anxiety prior to intervention.

Main outcomes and results: The predictor variables contributed a significant proportion of the variance in percentage change in depression. The major finding was that better outcomes following intervention were associated with greater self-awareness of injury-related deficits.

Conclusions: The present study identified a number of variables that were associated with improvement in depression following psychological intervention and may assist future treatment resources to be directed most effectively.     

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.     

Dizziness after traumatic brain injury: results from an interview study

Background: Dizziness is a commonly reported sequel to traumatic brain injury (TBI).

Objective: To better define the nature of the symptomatology and the impact that dizziness has on the TBI survivor.

Setting: A community brain injury rehabilitation programme and a community access programme for TBI survivors.

Method: Focus groups with TBI survivors and individual interviews with TBI survivors and some of their carers.

Results: The data confirmed that dizziness is difficult for TBI survivors to define and describe and it consists of multiple symptoms. Dizziness also appears to be associated with significant functional difficulties. Additionally, many of the participants of this study reported falling. Carers reported a number of observable signs of dizziness and indicated that they believed they were able to tell when the person they cared for was dizzy.

Conclusion: The results provide information which will help in the development of more appropriate outcome measurement tools for dizziness after a TBI.     

Feedback of brain-imaging findings: effect on impaired awareness and mood in acquired brain injury

Primary objective: To investigate the utility of feedback of brain-imaging findings as an intervention for improving impaired awareness, depression and anxiety levels.

Research design and methods: A prospective within-subjects repeated measures design was used with an intervention sample of 17 adults with acquired brain injury. Baseline and post-intervention measures included self-report and questionnaire-based self-awareness instruments and self-report questionnaires for depression and anxiety. Participants also completed a range of neuropsychological tests.

Intervention: The intervention consisted of a session where a Consultant Neurologist explained the findings of brain scans in terms of pathological findings and possible neurobehavioural outcome.

Results: Scores on measures of unawareness and two of three mood measures decreased significantly following the intervention. This improvement was maintained at 2-week follow-up.

Conclusion: Individuals with an acquired brain injury may benefit from a feedback procedure where the findings of brain scans are presented.     

Long-term outcome in severe traumatic brain injury is significantly influenced by brainstem involvement

Primary objective: To study the 1-year-outcome of 32 survivors of severe traumatic brain injury with respect to the impact of brainstem injury.

Research design: Retrospective clinical study performed in a university hospital.

Methods and procedures: Thirty-two 1-year-survivors (15 with brainstem injury present) of severe traumatic brain injury were investigated for neurological function, activities of daily living, need for care and professional ability.

Main outcomes and results: Visual impairment, spasticity, co-ordination deficits and organic psychosis were more frequent in the group harbouring brainstem lesions. Professional ability was worse among these patients.

Conclusion: Brainstem involvement in survivors of severe traumatic brain injury conveys a negative impact on long-term outcome.     

Awareness of activity limitations, goal setting and rehabilitation outcome in patients with brain injuries

Primary objective: To examine the relationship between self-awareness, goal setting ability (i.e. ability to set realistic goals) and performance/outcome in a cognitive task and for rehabilitation.

Research design: Regression analyses were conducted to compare the predictive power of self-awareness and demographic/neuropsychological variables on goal setting ability and performance/outcome.

Methods and procedures: Self-awareness of 63 patients with brain injuries was measured by direct clinicians' rating and the difference between patient and staff ratings in a questionnaire.

Results: The awareness measures predicted 32% of the variance for goal setting ability in the rehabilitation context but only 4% of the goal setting variance in the cognitive task. Similarly, self-awareness predicted 33% of the variance for rehabilitation outcome but only 5% of the performance in the cognitive task.

Conclusions: Self-awareness seems to be related to goal setting ability and outcome in a long-term rehabilitation process but less in short-term experimental tasks.     

Functional outcome following Botulinum toxin A injection to reduce spastic equinus in adults with traumatic brain injury

Primary objective: The aim of this study was to assess the effect of Botulinum toxin A in the management of spastic equinus resulting from traumatic brain injury.

Research design: A before-after intervention design was used without controls.

Methods and procedures: Subjects were seven patients suffering from traumatic brain injury of average duration 14 (4-38) months as a result of motor vehicle trauma, who had spastic equinus interfering with gait.

Experimental intervention: The patients were treated with injections of Botulinum toxin A into the spastic calf muscles: gastrocnemius, soleus and tibialis posterior. Assessments were made pre-injection and at 2 weeks and 3 months post-injection.

Main outcome and results: At the end of the 3-month period, all patients showed a significant improvement in gait velocity, cadence and stride length. Conclusions: The findings suggest that Botulinum toxin A may be useful in the management of spastic equinus following traumatic brain injury.     

TEACH-M: A pilot study evaluating an instructional sequence for persons with impaired memory and executive functions

Primary objective: The purpose of this pilot study was to evaluate an instructional package that facilitates learning and retention of multi-step procedures for persons with severe memory and executive function impairments resulting from traumatic brain injury.

Research design: The study used a multiple baseline across participants design.

Methods and procedures: Four participants, two males and two females, ranging in age from 36-58 years, were taught a 7-step e-mail task. The instructional package (TEACH-M) was the experimental intervention and the number of correct e-mail steps learned was the dependent variable.

Main outcomes and results: Treatment effects were replicated across the four participants and maintained at 30 days post-treatment. Generalization and social validity data further supported the treatment programme.

Conclusions: The results suggest that individuals with severe cognitive impairments are capable of learning new skills. Directions for future research include application of the instructional package to other multi-step procedures.     

The influence of neuropsychological rehabilitation on symptomatology and quality of life following brain injury: a controlled long-term follow-up

Primary objective: To establish whether, following acquired brain injury, intensive post-acute neuropsychological rehabilitation could have long-term beneficial effects.

Methods and procedures: A group of 37 adults who had suffered cerebrovascular accidents or traumatic brain injuries and who had undergone a rehabilitation programme were followed up 12-22 years post-injury, together with a non-rehabilitated control group of 13 adults, matched for brain-injury and demographics characteristics. Both groups completed a set of questionnaires concerning broad aspects of psychological well-being. Significant others completed similar questionnaires.

Main outcomes and results: The rehabilitation group showed significantly lower levels of brain injury symptoms and higher levels of competency at follow-up. They also rated internal locus of control and general self-efficacy as significantly higher than the control group. Anxiety and depression levels were significantly lower and quality of life significantly higher in the rehabilitation group for both the subjects themselves and for their significant others.

Conclusions: Within methodological limitations this study suggests that post-acute neuropsychological rehabilitation can have long-term beneficial effects.     

Return to work following moderate-to-severe traumatic brain injury

Primary objective: To investigate the role of cognitive functioning, fatigue, mood and behaviour in return to work (RTW) following moderate-to-severe traumatic brain injury.

Design and methods: Between-groups comparisons were conducted with 20 participants who had RTW and 13 who had not. Participants were well matched for age, pre-morbid intellectual functioning, years of education, injury severity and time since injury.

Outcomes and results: The unemployed group reported significantly higher levels of fatigue and depression and significantly more problems on self-report questionnaires. A significantly higher proportion of this group was seeking compensation. No significant differences were obtained on neuropsychological measures of cognitive functioning.

Conclusions: Mood, fatigue and behavioural problems may impede a person's ability to RTW. Subjective measures may be more superior to objective measures in predicting RTW. The litigation process may affect people's motivation to RTW.     

The relationship between naming difficulty and FAS performance following traumatic brain injury

Primary objective: To investigate the relationship between naming difficulty (ND) and FAS performance in traumatic brain injury (TBI).

Methods and procedure: Sixty-three patients with a TBI were divided into two groups based on the presence of a ND and were compared with a control group on FAS performance.

Results: Whilst the group with a TBI performed more poorly than the control group on the FAS task, there was no difference between those participants who featured a ND and those who did not. The TBIs produced fewer words than the control group in the first time slice of the task, but there was no difference between the group with a ND and the non-ND group on this measure.

Conclusion: The results indicate that the effect of word finding deficits is not the principal cause of the diminution of phonemic verbal fluency performance in TBI, which is probably more likely due to compromise in speed of information processing associated with the injury.     

Recognition of emotion from facial expression following traumatic brain injury

Primary Objective: To assess three domains of emotion recognition in people with traumatic brain injury (TBI).

Research design: A between group comparison.

Procedures: Twenty-four participants with severe TBI and 15 matched participants without brain damage were asked to label and match facial expressions with and without context. The participants with TBI were also interviewed regarding changes in subjective experience of emotion.

Main outcomes and results: Participants with TBI were found to be significantly impaired on expression labelling and matching, but experienced some improvement when provided with context. Negative emotions were particularly affected. Affective semantic knowledge and face perception appeared to be relatively intact in this group. The majority of participants with TBI reported some change in the post-injury experience of everyday emotion, although the pattern of changes differed greatly between individuals. Reduced subjective experience, especially of sadness and fear, was associated with poor emotion matching but not emotion labelling.     

Do men and women differ in their course following traumatic brain injury? A preliminary prospective investigation of early outcome

Primary objective: To examine the effect of a patient's sex on measures of outcome in a matched sample of patients admitted for acute traumatic brain injury (TBI).

Research design: A prospective multi-centred group comparison study based in metropolitan Sydney, Australia.

Methods and procedures: Data was collected on 25 women admitted for treatment following non-penetrating TBI. Forty-five men were then matched with regards to age and injury severity. All subjects met the study criteria of having a moderate-to-severe TBI and aged 50 years old or younger. Exclusion criteria included history of previous head injury, psychiatric disturbance and significant alcohol and/or substance abuse. Data included injury details and physiological and psychometric measures of outcome.

Main outcomes and results: Women demonstrated better outcomes as indicated by their Glasgow Outcome Scale scores (adjusted for initial injury severity and age at injury odds ratio [OR] 4.2, 95% CI 1.4-12.7) and having shorter Length of Stay (adjusted OR 9.03, 95% CI 3.13-26.08).

Conclusions: Understanding the presence of sex differences in outcome following TBI is an emerging area of research. This study indicated that, after matching for initial injury severity and age at injury, women with severe TBI demonstrate a better early outcome than men.     

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.     

The role of serum testosterone and TBI in the in-patient rehabilitation setting

Objectives: To explore the relationship between serum testosterone levels, age, length of stay, admission, discharge and changes in functional capacity over time among patients with traumatic brain injury treated in a rehabilitation hospital.

Design: This study used a nonrandomized chart review of 54 males, consecutively admitted to a brain injury rehabilitation hospital.

Methods: The charts of 54 males consecutively admitted to a brain injury rehabilitation unit between the periods of December 2004 and May 2005 were included in this study. Individuals were included in this study if they were 18 years of age or older, had suffered a traumatic brain injury, undergone admission and discharge, functional independence measure (FIM) testing and had received a serum testosterone level check within one to seven days from admission.

Main outcome and results: The main outcome measure of this study was the FIM changes over time, as compared with admission testosterone levels. Low serum testosterone levels on admission to the in-patient rehabilitation unit were associated with longer lengths of stay, lower average admission FIM scores, less improvement in FIM scores, and a lower FIM efficiency. Although not statistically significant, individuals presenting to our unit with low testosterone levels, on average, stayed 26 days longer than did those with normal levels. Age and the presence of multi-trauma did not appear to be factors associated with serum testosterone levels. Changes in discharge cognitive FIM scores between the two groups approached statistical significance (p = 0.06).

Conclusion: This pilot study suggests that testosterone levels may be important in the recovery of patients with traumatic brain injury, treated at an in-patient rehabilitation hospital.     

Increased inattentional blindness in severe traumatic brain injury: evidence for reduced distractibility?

Primary objective: To examine the role of selective attention and visual perception in medicating inattentional blindness in a severe traumatic brain injured sample.

Research design: Cross-sectional design with age and education matched control sample.

Methods and procedures: Twenty participants with severe traumatic brain injury (n = 10) and matched controls (n = 10) completed a series of tests of focused attention (Stroop test), divided attention (Trail Making Test), visual perception (Visual Object and Space Perception Battery) and two tasks of inattentional blindness.

Main outcomes and results: The group with severe TBI were significantly slower on the Stroop test and TMT and displayed significantly elevated Stroop interference and TMT ratio scores. On the inattentional blindness tasks, fewer TBI participants identified a distracting stimulus.

Conclusion: The results indicate severe TBI is associated with deficits to focused and divided attention with the finding of a potentially more debilitating impairment arising from reduced distractibility following severe TBI.