Comparison of individual, group and combined intevention formats in a randomized controlled trial for facilitating goal attainment and improving psychosocial function following acquired brain injury

Psychosocial interventions for suicidal and self-injurious-related behaviors among adolescents: a systematic review and meta-analysis of Chinese practices

Background

Suicidal and self-injurious-related behaviors (SSIRBs) are a serious public health challenge in China. However, a comprehensive systematic review of psychosocial interventions for SSIRBs among Chinese adolescents has not been performed. To fill this gap, this systematic review and meta-analysis aimed to examine psychosocial interventions for SSIRBs among Chinese adolescents.

Methods

Eight international (PubMed, EMBASE, Cochrane Library, ScienceDirect, Clinical Trial, CINAHL, PsycINFO, and Web of Science) and four Chinese (Wanfang, SinoMed, CEPS, and CNKI) databases were searched from inception to 31 January 2023. Data extraction and quality assessment were independently conducted by two groups of researchers. Qualitative synthesis and meta-analysis were both used.

Results

The initial search yielded 16,872 titles. Of the 649 full texts reviewed, 19 intervention articles focusing on SSIRBs met the inclusion criteria. Thirteen out of the 19 included studies involved cognitive-behavioral therapy (CBT). Seven non-suicidal self-injury (NSSI) studies assessing self-injurious behaviors were included (six short-term studies and three long-term studies). Compared with long-term interventions [-1.30 (95% CI: -1.84, -0.76)], short-term psychosocial interventions had a higher standardized mean difference (SMD) value [1.86 (95% CI: -2.72, -0.99)]. Meta-regression showed an inverse relationship between the treatment response and sample size (slope = 0.068, Z = 2.914, p = 0.004) and proportion of females (slope = 1.096, Z = 5.848, p < 0.001). Subgroup analyses showed that compared with the "less than 1 month" group [-0.494 (-0.783, -0.205)], in the "immediate postintervention" group, the pooled estimate was significantly lower [-2.800 (-4.050, -1.550), p < 0.001].

Conclusion

Our review systematically summarized the key characteristics and effectiveness of existing psychosocial interventions for SSIRBs among Chinese adolescents. Short-term psychosocial interventions for NSSI were significantly effective in reducing self-injurious behavior scores, especially in the immediate postintervention period. More favorable treatment responses could be observed in both male and small samples.

Combined Cognitive and Psychological Interventions Improve Meaningful Outcomes after Acquired Brain Injury: A Systematic Review and Meta-Analysis

Interventions addressing cognitive and emotional difficulties after acquired brain injury (ABI) often focus on specific impairments in cognition or mood. These interventions can be effective at addressing their specific target, but do not routinely translate to improved activity and participation outcomes. Approaches that combine cognitive and psychological rehabilitation are increasingly popular; however, to date, there have been no systematic evaluations of their efficacy. We conducted a systematic review of five databases, searching for randomised controlled trials of adults with diagnoses of non-progressive ABI at least 1-month post injury, in receipt of interventions that combined cognitive and psychological components compared to any control. Screening and data extraction were evaluated by two independent reviewers using a standardised protocol. Effect sizes were calculated using Hedge's g and estimated using a random-effects model. Risk of bias was assessed using the PEDro-P rating system, and quality of evidence evaluated using the grading of recommendation, assessment, development and evaluation (GRADE) approach. Thirteen studies were included in the meta-analysis (n = 684). There was an overall small-to-medium effect (g = 0.42) for combined interventions compared with controls, with gains maintained at 6-month follow-up. Improvements were observed at the level of impairment, activity, participation and quality of life. GRADE ratings and analyses investigating sensitivity, heterogeneity and publication bias indicated that these effects were robust. No a priori variables moderated these effects. Overall, this review provides strong evidence that combined cognitive and psychological interventions create meaningful change in the lives of people with ABI.

Perceived service adequacy and unmet need after discharge from brain injury rehabilitation

PURPOSE

The present study aimed to quantify the perceived needs and adequacy of realised access to post-acute services in a sample of people with acquired brain injury in the first 6-months after discharge from inpatient rehabilitation. A secondary focus was the influence of access to funding and specialist transitional rehabilitation on unmet needs.

MATERIALS AND METHODS

Participants were 51 adults with a median age of 50 (IQR 35-57) recruited from an inpatient rehabilitation unit in an Australian tertiary hospital. The sample was those who had an acquired brain injury, including 23 who sustained a traumatic injury and 28 who sustained a non-traumatic injury. Measures were collected via telephone at 3- and 6-months, in a prospective observational cohort design using the Needs and Provisions Complexity Scale. A series of logistic regression models were used to determine the effects of participation in a transitional rehabilitation program and funding pathway on adequacy and unmet needs.

RESULTS

Unmet needs for rehabilitation were most commonly reported (60%), followed by unmet needs in relation to health care (40%), social care (35%), personal care (32%) and environment-related (14%). Participants who attended transitional rehabilitation were more likely to indicate unmet health care needs (OR = 6.40, 95% CI = 1.40-29.24, p = 0.02).

CONCLUSIONS

The study highlights the need to look beyond functional impairment when conceptualising appropriate access. Additionally, the present research highlighted the need for greater work into an expectation of services.IMPLICATIONS FOR REHABILITATIONThe majority of people with an acquired brain injury report unmet needs at 6 months post discharge.Present findings support the utility of patient reported measures when considering treatment evaluation with people with ABI, where assessing the personal appraisal of individuals needs may prove to be a key indicator to facilitate optimal service access.There are specific services that needed and not provided including psychological, speech pathology, family carer needs and vocational rehabilitation, and therefore are a key target for ensuring appropriate support is provided.

Landed property as collateral to access credit for housing development in Ghana: The case of Northern Region of Ghana

Property in the commons, or the Washington Consensus, as it is known in other circles, posits that landed property and access to formal credit are directly related. Whether landed property improves access to formal credit or not has been at the centre of the debate, with varying practical evidence, especially for the Global South. Another related dimension of the debate concerns the implications of family-help-mortgage arrangements using intra-family transfer of land as collateral to support a member's mortgage by placing a charge on the collective property. This paper investigates the use of landed property as collateral to access formal credit from financial institutions for housing development in the Tamale Metropolitan Area (TMA) in the Northern Region of Ghana. The primary research question is: does formal documentation of landed property as collateral help in accessing formal credit for housing development in TMA? The study involves the use of in-depth interviews to investigate the opinions of estate developers, credit officers of universal banks, and land title holders on the relative importance of landed property and access to credit for housing development. The data are analysed by means of thematic content analysis. The findings indicate that even though landed property may contribute to the decision to grant formal credit, it is not a turn-key solution easily accepted in the final lending decision. This study adds to the body of knowledge primarily by evaluating the effects of reforms to increase credit access with landed property as collateral in Ghana, investigating the implications of family-help mortgage arrangements, including the use of intra-family assets as collateral in obtaining loans for investment at the micro-level in Ghana. The paper concludes that while formal documentation of land rights matters in the broad scheme of estate financing, it is not sufficient to bring about more immediate access to credit, especially for those who lack regular or reliable systems of income that could be critical in ensuring the payback of loans contracted using landed property as collateral for housing development.

Normalising interdisciplinary role-based goal setting in inpatient brain injury rehabilitation: reflections and recommendations of clinicians

PURPOSE

Person-centred goal setting with people with brain injury, by interdisciplinary teams has benefits including improved communication between patients, families and clinicians, person-centred care, and improved engagement in rehabilitation. Exploring the experiences of team members who have adopted interdisciplinary, person-centred goal setting may assist in understanding what is needed to implement this complex, core component of rehabilitation practice. This study explored experiences of clinicians working in an extended inpatient brain injury rehabilitation unit about implementing a role-based goal planning approach within an interdisciplinary team.

MATERIALS AND METHODS

Semi-structured interviews with 13 clinicians working at the rehabilitation unit explored their experiences about the cognitive participation and collective actions required to carry out the practice, with data analysed using inductive content analysis guided by Normalisation Process Theory.

RESULTS

Three primary themes were identified: putting the person at the centre, accepting the mind-shift to participation focused goals and working collaboratively.

CONCLUSIONS

This study has elucidated some key processes that occurred and were necessary to carry out goal setting. A mind-shift towards holistic, participation-focussed goal setting was described as "unlearning" discipline-specific goal setting. Development and ownership by the team, acceptance of team members and willingness to share, and structured processes and resources were necessary.IMPLICATIONS FOR REHABILITATIONNormalising interdisciplinary role-based goal setting in multi-professional teams requires a mind-shift away from traditional, discipline-specific goal setting.Implementation of interdisciplinary, collaborative team goal setting within health service settings requires collective actions including collaborative working by team members, structured processes including organised time for collaborative team and family meetings, practical resources and training to support processes.Clinicians perceived the goal setting approach to put the person at the centre resulting in a deep understanding of the person, shared understanding, and motivation for rehabilitation.

American Speech-Language-Hearing Association Clinical Practice Guideline: Cognitive Rehabilitation for the Management of Cognitive Dysfunction Associated With Acquired Brain Injury

BACKGROUND

Cognitive-communication impairments following acquired brain injury (ABI) can have devastating effects on a person's ability to participate in community, social, vocational, and academic preinjury roles and responsibilities. Guidelines for evidence-based practices are needed to assist speech-language pathologists (SLPs) and other rehabilitation specialists in the delivery of cognitive rehabilitation for the adult population.

PURPOSE

The American Speech-Language-Hearing Association, in conjunction with a multidisciplinary panel of subject matter experts, developed this guideline to identify best practice recommendations for the delivery of cognitive rehabilitation to adults with cognitive dysfunction associated with ABI.

METHOD

A multidisciplinary panel identified 19 critical questions to be addressed in the guideline. Literature published between 1980 and 2020 was identified based on a set of a priori inclusion/exclusion criteria, and main findings were pooled and organized into summary of findings tables. Following the principles of the Grading of Recommendations Assessment, Development and Evaluation Evidence to Decision Framework, the panel drafted recommendations, when appropriate, based on the findings, overall quality of the evidence, balance of benefits and harms, patient preferences, resource implications, and the feasibility and acceptability of cognitive rehabilitation.

RECOMMENDATIONS

This guideline includes one overarching evidence-based recommendation that addresses the management of cognitive dysfunction following ABI and 11 subsequent recommendations focusing on cognitive rehabilitation treatment approaches, methods, and manner of delivery. In addition, this guideline includes an overarching consensus-based recommendation and seven additional consensus recommendations highlighting the role of the SLP in the screening, assessment, and treatment of adults with cognitive dysfunction associated with ABI. Future research considerations are also discussed.

Community-Based Interventions After Acquired Brain Injury-A Systematic Review of Intervention Types and Their Effectiveness

OBJECTIVES

Comprehensive review of existing types and effectiveness of community-based interventions delivered to adults (mean age 18-65 years) with long-lasting (≥6 months) difficulties following acquired brain injury (ABI).

DESIGN

Systematic review of controlled intervention studies published until February 2021.

MAIN MEASURES

Systematic searches in databases (MEDLINE, PsycINFO, Database of Abstracts of Reviews of Effects [Cochrane Library], and Cochrane Central Register of Controlled Trials [Cochrane Library]) and inclusion of English peer-reviewed full-text articles; randomized or controlled community-based intervention studies; sample size of 20 or more participants; and 3 or more intervention sessions. Two reviewers independently extracted data for the synthesis and assessed the methodological quality. Data extraction included study characteristics, demographics of participants, content and dose of intervention, outcome measures, and findings.

RESULT

The search returned 7386 publications, of which 49 eligible studies were included, revealing a diverse range of community-based interventions and a myriad of outcome measures applied for assessing functional capacities, participation, and quality of life in the chronic phase of ABI. Intervention types encompassed 14 holistic, 23 physical, and 12 specific interventions. A large heterogeneity regarding intervention frequency and intensity was found. Meta-analyses performed on the holistic, physical, and specific interventions did not indicate any significant pooled effects but showed highly variable effects between individuals, both in persons with traumatic and nontraumatic brain injuries.

CONCLUSIONS

Because of lack of pooled effects within types of community-based interventions, specific evidence-based recommendations within holistic, physical, and specific interventions designed to mitigate long-lasting ABI problems cannot be made. This review highlights the need for future studies to address methodological issues concerning larger sample size, lack of clear description interventions and comparator, missing reports of effects in change scores, need for consistent use of recommended outcome measures, and investigating the wide variety in intervention responsiveness among participants with ABI. Systematic review registration: PROSPERO (CRD42019124949).

Participation based intervention with acquired brain injury: Systematic review and meta-analysis

BACKGROUND

Continued long-term rehabilitation programs with acquired brain injury are important for their participation in meaningful daily activities.

OBJECTIVE

This paper investigated the participation-based interventions on outcomes in patients with acquired brain injury.

METHODS

A systematic review and meta-analysis search for randomized control trials published between 1998 and 2019 using PubMed, CINAHL, and MEDLINE was performed. Nine studies were selected and analyzed for systematic review. Five studies analyzed the effectiveness of participation-based intervention using meta-analysis and assessed the level of evidence of qualitative studies.

RESULTS

A total of 843 publications were searched. Nine studies met the inclusion criteria and were of high quality. The effective score for improving participation following participation-based interventions in persons with acquired brain injury was 0.32 and significant in this study (p < 0.05).

CONCLUSIONS

The findings of this systematic review and meta-analysis suggest that, in persons with acquired brain injury, participation-based interventions are essential for community living.

Cognitive strategy training for adults with neurological conditions: a systematic review and meta-analysis exploring effect on occupational performance

Introduction

The objective of this systematic review was to synthesise the evidence for cognitive strategy training to determine its effectiveness to improve performance of activities of daily living in an adult neurological population.

Method

Medline, CINAHL, EMBASE, PSYCInfo, PsycBITE and Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews were searched until August 2019. Studies examining the effect of cognitive strategy training on functional performance were included. Population criteria included adults with non-progressive neurological conditions. External and internal validity of included studies was systematically evaluated using an appropriate methodological quality assessment for each study design. A content analysis was conducted of the methodologies used.

Findings

Forty-one studies met the inclusion criteria and were appraised for content, 16 randomised or quasi-randomised trials were meta-analysed. Trial quality was generally ‘good’, Physiotherapy Evidence Database scale scores ranged from 3 to 8 (out of 10). For activity performance outcomes post-intervention, there was a significant benefit of cognitive strategy training over usual care (standardised mean difference 0.79, 95% confidence interval 0.49–1.09; P < 0.00001).

Conclusion

More high-quality research is needed to strengthen the evidence base for cognitive strategy interventions to improve activity performance outcomes for adults with non-progressive neurological conditions.

Systematic review registration

PROSPERO CRD42016033728

The effect of access to a designated interdisciplinary post-acute rehabilitation service on participant outcomes after brain injury

OBJECTIVE

This study aimed to determine the influence of participation in a designated acquired brain injury (ABI) transitional rehabilitation service (ABI TRS) on outcome, in the context of a historical comparison group (HIST). Design: A cohort study, with retrospective comparison. Participants: 187 persons with ABI. Measures: The Depression, Anxiety and Stress Scale (DASS-21), Mayo-Portland Adaptability Index (MPAI-4) and Sydney Psychosocial and Reintegration Scale (SPRS) were completed at discharge and 3 months after discharge. Participation in the ABI TRS involved interdisciplinary rehabilitation, 2-4 times per week, for 3 months after hospital discharge. Results: There was evidence that at 3 months, participants with ABI TRS showed stabilized psychological wellbeing, and improvements in MPAI-4 ability and participation scores; in addition to improvements in SPRS occupational activity and living skills scores. Conclusion: A designated ABI TRS may improve the transition from hospital to home, and could form an important part of the brain injury rehabilitation continuum, between the inpatient and community setting.

A Neuropsychological Rehabilitation Program for Cognitive Impairment in Psychiatric and Neurological Conditions: A Review That Supports Its Efficacy

Neuropsychological rehabilitation has been the focus of much scientific research over the past decades due to its efficacy in different pathologies. Advances in the neuropsychology field have led to improvements and changes in neuropsychological interventions, which in turn have given rise to different approaches and rehabilitation programs. REHACOP is an integrative neuropsychological rehabilitation program designed by specialist neuropsychologists. With an integrated bottom-up and top-down approach, REHACOP includes neurocognition, social cognition, and daily living tasks hierarchically organized on an increasing level of difficulty. Task arrangement is addressed to maximize improvements and transfer effects into participant's daily living. To date, REHACOP has been implemented on different clinical samples such as patients with schizophrenia, multiple sclerosis (MS), and Parkinson's disease (PD). This manuscript presents the efficacy data of REHACOP across these three populations and discusses it in the context of the available literature. Overall, the magnitude of improvements obtained by means of REHACOP ranged from medium to high across samples. These changes were not restricted to specific neurocognitive domains since participants attending the REHACOP program also showed changes in social cognition and daily functioning variables by means of both direct and transfer effects. Results regarding REHACOP's efficacy in psychiatric and neurological conditions have contributed to expanding the existing evidence about the use of structured neuropsychological rehabilitation. In addition, the results obtained after its implementation highlighted the need and importance of designing and implementing integrative neuropsychological rehabilitation programs that are focused not only on cognition per se but also on participants' performance in daily living.

Setting and achieving individualized social communication goals for people with acquired brain injury (ABI) within a group treatment

BACKGROUND

Cognitive-communication disorders are common following an acquired brain injury (ABI). Remediation should involve individualized goal-setting, yet few reports describe the effectiveness of setting communication goals in a group setting.

AIMS

To describe a process for setting and achieving goals for people with ABI.

METHODS & PROCEDURES

A total of 21 participants with ABI participated in a group treatment (triads and dyads) over 6 weeks (20 h in total). Specific social communication goals were set using goal attainment scaling (GAS) with the participant and their communication partner. Goals targeted strategy use that accounted for existing cognitive abilities. The participant and their communication partner evaluated the goals post-treatment and 6-8 weeks later. Data were analysed using Friedman's test to identify the achievement of GAS goals.

OUTCOMES & RESULTS

A total of 20 participants recalled goals independently post-treatment. Significant improvement post-treatment on GAS goals was rated by both the participant (p < 0.001) and their communication partner (p < 0.001). This improvement was maintained at follow-up. No significant differences in ratings were found between participants and their communication partners at either time point.

CONCLUSIONS & IMPLICATIONS

Individualized social communication goals can be set and achieved for people with ABI in group treatment, even when participants are several years post-injury. GAS offers a method for structuring and quantifying goal progress. Involving communication partners and cognitive strategies were effective in improving communication.

Reporting on novel complex intervention development for adults with social communication impairments after acquired brain injury

PURPOSE

Interventions are often poorly described in published controlled trials, with relatively little information regarding intervention development, content and fidelity. This makes it difficult to conduct replication studies, interpret and compare findings across studies and for therapists to deliver the intervention in clinical practice. Complete reporting of interventions (including fidelity) is now recommended for treatment studies, and this standardized approach is achieved using the Template for Intervention Description and Replication (TIDieR). The aim of this article is to describe the multi-phase process of developing a novel intervention for adults with acquired brain injury (ABI) and report on the findings from involving practicing therapists in this process.

METHODS

Phase 1 involved a review of relevant literature and specifying the intervention as a prototype intervention manual. Phase 2 comprised a focus group with eight practicing therapists exploring their experiences and perceptions of the intervention, potential active components, and essential elements; it also included a review of the prototype manual. Data from the focus group discussion was transcribed and analyzed thematically. Phase 3 investigated actual fidelity of the intervention undertaken, achieved by observers viewing videoed sessions and appraising against the fidelity checklist, which was then analyzed using Cohen's kappa.

RESULTS

Project-based intervention was defined as having six essential elements: a project or tangible end product focus; group-based intervention; individualized communication-based goals; communication partner involvement; acknowledgement and support of participants' cognitive ability; and consideration and plan to address impaired awareness. Analysis of focus group data revealed four themes of essential elements; group context; therapeutic skills; and manual core components and informed the development of a fidelity checklist with 13 essential and 6 desirable criteria. Fidelity assessed using percent agreement was acceptable for almost all rater pairs; where significant, Kappa coefficients had values ranging from poor to excellent (k = 0.34-1.0) depending on rater pair and session.

DISCUSSION

The TIDieR framework provided a clear systematic approach for the complete description and reporting of a complex communication intervention for people with ABI. This article comprehensively described the development and manualisation of intervention in collaboration with practicing therapists which can be used for future testing. In addition, the process undertaken has the potential to inform rehabilitation researchers in other fields on the development of complex interventions.Implications for rehabilitationThe results of this study detail the steps needed to describe an intervention, from the identification of the essential elements through to the creation of a manual and checklist to show fidelity. The process provides a starting point for other rehabilitation researchers developing complex interventions.This article provides a clear and comprehensive description of a novel intervention containing six essential elements for people with acquired brain injury presenting with communication impairments.Project-based intervention is one intervention, which intends to help improve communication skills and quality of life in people with acquired brain injury.This study highlights the important role practicing therapists can play in the creation of an intervention manual and fidelity checklist and in ensuring that sufficient detail is provided to help therapists implement the intervention into clinical practice.

Cognitive oriented strategy training augmented rehabilitation (COSTAR) for ischemic stroke: a pilot exploratory randomized controlled study

Purpose: To investigate the effect of adding cognitive strategy training to task-specific training (TST), called Cognitive Oriented Strategy Training Augmented Rehabilitation (COSTAR), compared with TST on activity and participation for chronic stroke survivors in an outpatient occupational therapy settingMaterials and methods: We conducted an exploratory, single-blind, randomized controlled trial. Participants were randomized to TST or COSTAR protocol. Our primary outcomes measured activity and participation after stroke: the Stroke Impact Scale (SIS), Canadian Occupational Performance Measure (COPM), and Performance Quality Rating Scale (PQRS).Results: Forty-four participants were randomized. The COSTAR group had an attrition rate of 50% and an average of 9.8 of 12 sessions were completed; the TST group had an attrition rate of 25% and an average of 10.7 sessions were completed. Generally both groups improved on the majority of primary and secondary outcomes. There is little evidence to support a beneficial effect of COSTAR over TST for improvement of primary measures of activity performance or secondary measures.Conclusion: Negligible findings may be attributed to an inadvertent treatment group equivalency. Further, the research design did not allow for adequate measurement of the effect of each intervention on participants' ability to generalize learned skills.Implications for rehabilitationStroke rehabilitation is largely based upon the principles of task-specific training, which is associated with improvements in upper extremity motor performance; however, TST requires a heavy dosage and lacks generalization to untrained activities.Cognitive strategy use has been associated with improved generalization of treatment to untrained activities and novel contexts however, it is often not used in TST protocols.The results of this preliminary study found no clear advantage between task-specific training and strategy-adapted task-specific training on trained and untrained activities when both interventions targeted activity performance.Task-specific training, if focused at the activity performance level rather than the impairment reduction level, may have a stronger effect on improving in individual's ability to participate in everyday life activities even without the use of cognitive-strategies.Incorporating cognitive strategy-use into TST would likely produce the greatest effect on generalization and transfer of the treatment effects to other activities and contexts rather than solely on activity performance of trained activities.

Goal statements in brain injury rehabilitation: A cohort study of client-centredness and relationship with goal outcome

Background:

Currently, there is increasing recognition of the need to use a client-centred approach to goal setting in rehabilitation. However, there is limited research to guide practice with community-dwelling clients with acquired brain injury. An understanding of the characteristics of client-centred goals and the extent to which client-centeredness influences goal outcomes is required.

Objective:

To examine the relationships between the client-centredness of goals and their characteristics, content, recall and outcomes of client-centred goals in brain injury rehabilitation.

Methods:

A prospective cohort design study was employed. Participants were 45 clients with brain injury receiving outpatient rehabilitation, who completed measures of client-centredness after goal setting. Each goal was classified according to whether it was specific, measurable, non-jargonistic, and participation-focussed, included a timeframe and was recalled by participants.

Results:

Participants set 223 goals with 20 clinicians from multiple disciplines. Levels of client-centredness did not differ according to the characteristics, content and recall of goals, with the exception of goal specificity (p< 0.01). Client-centredness was significantly and positively correlated with goal outcomes (p< 0.05).

Conclusions:

The use of client-centred goals is recommended for improved rehabilitation outcomes. Applying goal documentation criteria does not necessarily mean that goals will be client-centred, and highly specific goal statements may not reflect what is important and meaningful to clients.

The nature of occupational gaps and relationship with mood, psychosocial functioning and self-discrepancy after severe traumatic brain injury

Purpose: To examine the nature of occupational gaps and desired re-engagement following severe traumatic brain injury (TBI), and the relationship to mood, self-discrepancy, and psychosocial functioning.Materials and methods: Fifty-nine adults with severe TBI (73% male, M age = 36.50, SD = 12.54) were administered measures of past, current, and desired occupations (Occupational Gaps Questionnaire), mood (Depression Stress and Anxiety Scale - 21), and self-discrepancy (Head Injury Semantic Differential Scale - version 3). Psychosocial functioning was rated by relatives on the Sydney Psychosocial Reintegration Questionnaire.Results: Participants reported that they engaged in significantly fewer occupations than prior to their injury (p < 0.001). Further, they participated in fewer occupations than they desired (p < 0.001). Desired re-engagement was identified for 18 of the 30 occupations (e.g., working, sports, managing personal finances, and supporting others). A higher number of these re-engagement gaps was significantly related to greater anxiety (r = 0.30, p < 0.05) and lower psychosocial functioning (r = -0.29, p < 0.05). A mediation analysis revealed that re-engagement gaps were indirectly related to self-discrepancy through an association with anxiety.Conclusions: Occupational gaps are commonly experienced after severe traumatic brain injury. Lack of engagement in desired occupations is associated with greater anxiety and poorer psychosocial functioning. Anxiety regarding these gaps may contribute to negative comparisons between one's pre-injury and post-injury self. Identification of occupational gaps and their psychological impact may guide the focus of client-centred rehabilitation approaches.Implications for RehabilitationGaps between current activity engagement (i.e., post injury) and desired activity engagement are commonly experienced after severe traumatic brain injury.Greater desired re-engagement gaps (i.e., when individuals report they are not completing activities that they would like to do) are associated with greater anxiety and poorer psychosocial functioning.Individuals who are unable to re-engage in desired activities are more likely to experience anxiety, which in turn may contribute to negative self-discrepancy.It may be beneficial to explore the personal meaning of changes in occupation after traumatic brain injury.

The effect and importance of physical activity on behavioural and psychological symptoms in people with dementia: A systematic mixed studies review

Background

People with dementia may benefit from the effect of physical activity on behavioural and psychological symptoms of dementia. Qualitative synthesis of the importance of physical activity might complement and help clarify quantitative findings on this topic. The purpose of this systematic mixed studies review was to evaluate findings from both quantitative and qualitative methods about the effect and importance of physical activity on behavioural and psychological symptoms of dementia in people with dementia.

Methods

The systematic literature search was conducted in EMBASE, CINAHL, PubMed, PEDro and PsycINFO. Inclusion criteria were: people with a light to moderate degree of dementia, interventions including physical activity and outcomes focusing on behavioural and psychological symptoms of dementia or quality of life. To assess the methodological quality of the studies, the AMSTAR and GRADE checklists were applied for the quantitative studies and the CASP qualitative checklist for the qualitative studies.

Results

A small reduction in depression level and improved mood were seen in some quantitative studies of multi-component physical activity interventions, including walking. Due to high heterogeneity in the quantitative studies, a single summary of the effect of physical activity on behavioural and psychological symptoms of dementia should be interpreted with some caution. Across the qualitative studies, the common themes about the importance of physical activity were its ‘socially rewarding’ nature, the ‘benefits of walking outdoors’ and its contribution to ‘maintaining self-hood’.

Conclusion

For people with dementia, there was a small, quantitative effect of multi-component physical activity including walking, on depression level and mood. People with dementia reported the importance of walking outdoors, experiencing the social rewards of physical activity in groups, as well as physical activity were a means toward maintaining self-hood.

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

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

Treatment of persistent post-concussion syndrome due to mild traumatic brain injury: current status and future directions

Persistent post-concussion syndrome caused by mild traumatic brain injury has become a major cause of morbidity and poor quality of life. Unlike the acute care of concussion, there is no consensus for treatment of chronic symptoms. Moreover, most of the pharmacologic and non-pharmacologic treatments have failed to demonstrate significant efficacy on both the clinical symptoms as well as the pathophysiologic cascade responsible for the permanent brain injury. This article reviews the pathophysiology of PCS, the diagnostic tools and criteria, the current available treatments including pharmacotherapy and different cognitive rehabilitation programs, and promising new treatment directions. A most promising new direction is the use of hyperbaric oxygen therapy, which targets the basic pathological processes responsible for post-concussion symptoms; it is discussed here in depth.

Effectiveness of Interventions to Improve Occupational Performance for People With Psychosocial, Behavioral, and Emotional Impairments After Brain Injury: A Systematic Review

OBJECTIVE

This systematic review evaluates the effectiveness of interventions to improve occupational performance for people with psychosocial, behavioral, or emotional impairments after traumatic brain injury (TBI).

METHOD

Medline, PsycINFO, CINAHL, OTseeker, and the Cochrane Database of Systematic Reviews were searched. Of the 1,512 articles initially identified, 35 met the inclusion criteria.

RESULTS

Six types of interventions were identified: (1) education, (2) peer mentoring, (3) goal-directed therapy, (4) physical activity, (5) skills training, and (6) cognitive-behavioral therapy (CBT). Strong evidence from well-conducted research supports the use of CBT in individual and group settings. Moderate evidence supports goal-directed interventions, aquatic exercise, and functional skills training. Limited evidence supports peer mentoring, aerobic exercise, educational interventions, and various skills training.

CONCLUSION

An increasing body of evidence supports specific interventions to improve occupational performance and participation for people with psychosocial, behavioral, or emotional impairments after TBI.

Effectiveness of Occupation- and Activity-Based Interventions to Improve Everyday Activities and Social Participation for People With Traumatic Brain Injury: A Systematic Review

This systematic review presents research on the effectiveness of occupation- and activity-based interventions to improve everyday activities and areas of occupation and social participation for people with traumatic brain injury (TBI). Nineteen studies identified through a comprehensive database search were reviewed and synthesized into five themes: (1) multidisciplinary and interdisciplinary treatment approaches, (2) community-based rehabilitation programs, (3) treatment approaches using client-centered goals and relevant contexts, (4) social skills training and peer mentoring interventions, and (5) community mobility interventions. Evidence supports the use of multidisciplinary and interdisciplinary approaches across a variety of settings, with no single treatment approach or setting clearly superior to another. The specific contributions of occupational therapy practitioners and the nature of occupational therapy interventions have not been well studied, making it difficult to determine the extent to which occupation- and activity-based interventions provided by occupational therapy practitioners improve occupational performance and social participation after TBI.

Multi-disciplinary rehabilitation for acquired brain injury in adults of working age

BACKGROUND

Evidence from systematic reviews demonstrates that multi-disciplinary rehabilitation is effective in the stroke population, in which older adults predominate. However, the evidence base for the effectiveness of rehabilitation following acquired brain injury (ABI) in younger adults has not been established, perhaps because this scenario presents different methodological challenges in research.

OBJECTIVES

To assess the effects of multi-disciplinary rehabilitation following ABI in adults 16 to 65 years of age.

SEARCH METHODS

We ran the most recent search on 14 September 2015. We searched the Cochrane Injuries Group Specialised Register, The Cochrane Library, Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic+Embase (OvidSP), Web of Science (ISI WOS) databases, clinical trials registers, and we screened reference lists.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing multi-disciplinary rehabilitation versus routinely available local services or lower levels of intervention; or trials comparing an intervention in different settings, of different intensities or of different timing of onset. Controlled clinical trials were included, provided they met pre-defined methodological criteria.

DATA COLLECTION AND ANALYSIS

Three review authors independently selected trials and rated their methodological quality. A fourth review author would have arbitrated if consensus could not be reached by discussion, but in fact, this did not occur. As in previous versions of this review, we used the method described by Van Tulder 1997 to rate the quality of trials and to perform a 'best evidence' synthesis by attributing levels of evidence on the basis of methodological quality. Risk of bias assessments were performed in parallel using standard Cochrane methodology. However, the Van Tulder system provided a more discriminative evaluation of rehabilitation trials, so we have continued to use it for our primary synthesis of evidence. We subdivided trials in terms of severity of brain injury, setting and type and timing of rehabilitation offered.

MAIN RESULTS

We identified a total of 19 studies involving 3480 people. Twelve studies were of good methodological quality and seven were of lower quality, according to the van Tulder scoring system. Within the subgroup of predominantly mild brain injury, 'strong evidence' suggested that most individuals made a good recovery when appropriate information was provided, without the need for additional specific interventions. For moderate to severe injury, 'strong evidence' showed benefit from formal intervention, and 'limited evidence' indicated that commencing rehabilitation early after injury results in better outcomes. For participants with moderate to severe ABI already in rehabilitation, 'strong evidence' revealed that more intensive programmes are associated with earlier functional gains, and 'moderate evidence' suggested that continued outpatient therapy could help to sustain gains made in early post-acute rehabilitation. The context of multi-disciplinary rehabilitation appears to influence outcomes. 'Strong evidence' supports the use of a milieu-oriented model for patients with severe brain injury, in which comprehensive cognitive rehabilitation takes place in a therapeutic environment and involves a peer group of patients. 'Limited evidence' shows that specialist in-patient rehabilitation and specialist multi-disciplinary community rehabilitation may provide additional functional gains, but studies serve to highlight the particular practical and ethical restraints imposed on randomisation of severely affected individuals for whom no realistic alternatives to specialist intervention are available.

AUTHORS' CONCLUSIONS

Problems following ABI vary. Consequently, different interventions and combinations of interventions are required to meet the needs of patients with different problems. Patients who present acutely to hospital with mild brain injury benefit from follow-up and appropriate information and advice. Those with moderate to severe brain injury benefit from routine follow-up so their needs for rehabilitation can be assessed. Intensive intervention appears to lead to earlier gains, and earlier intervention whilst still in emergency and acute care has been supported by limited evidence. The balance between intensity and cost-effectiveness has yet to be determined. Patients discharged from in-patient rehabilitation benefit from access to out-patient or community-based services appropriate to their needs. Group-based rehabilitation in a therapeutic milieu (where patients undergo neuropsychological rehabilitation in a therapeutic environment with a peer group of individuals facing similar challenges) represents an effective approach for patients requiring neuropsychological rehabilitation following severe brain injury. Not all questions in rehabilitation can be addressed by randomised controlled trials or other experimental approaches. For example, trial-based literature does not tell us which treatments work best for which patients over the long term, and which models of service represent value for money in the context of life-long care. In the future, such questions will need to be considered alongside practice-based evidence gathered from large systematic longitudinal cohort studies conducted in the context of routine clinical practice.

To Err is Human; to Self-Regulate After Brain Injury, Divine

Traumatic brain injury (TBI) can reduce people's ability to monitor their own actions and identify and correct errors on everyday tasks. This usually occurs because of damage to neural pathways that support ‘metacognition’ or the higher-order capacity to reflect upon and regulate one's own behaviour. This paper initially reviews the neuro-cognitive mechanisms underlying error self-regulation. An overview of assessment approaches is provided which emphasises how approaches to measuring error self-regulation following TBI have been extended from the laboratory to people's real life environments. Over the last few decades, the evidence base supporting the efficacy of error-based learning or metacognitive approaches in rehabilitation has advanced considerably. An overview of the theory underpinning rehabilitation approaches and evidence supporting the efficacy of error-based learning is provided. Finally, the paper briefly describes the protocol for a randomised controlled trial that aims to determine whether people with severe TBI benefit from making errors when they learn new complex tasks.

Training to Optimize Learning after Traumatic Brain Injury

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

Maintenance of treatment effects of an occupation-based intervention with video feedback for adults with TBI

BACKGROUND

Video feedback interventions have been found to improve self-awareness and occupational performance to a greater extent than other feedback interventions after traumatic brain injury (TBI). However, it is unclear whether the effects of video feedback are maintained over time.

OBJECTIVE

To evaluate the maintenance of gains in self-awareness achieved with a video feedback intervention in people with TBI.

METHODS

There were 32 participants with TBI and impaired self-awareness who had completed a randomized controlled trial with three feedback conditions (video plus verbal, verbal and experiential). Eight to ten weeks after the final feedback intervention session, a follow-up assessment was conducted. The primary outcome was maintenance of gains in online awareness measured by the number of errors made during a meal preparation task. Group outcomes were compared using an unstructured linear mixed regression model.

RESULTS

The video plus verbal feedback group continued to demonstrate significantly greater gains in online awareness compared to the verbal feedback group (mean difference 20.6, 95% CI 8.8 to 32.3) and the experiential feedback group (mean difference 14.4, 95% CI 3.1 to 25.6). There was no significant impact of the interventions on participants' emotional status at the 8 to 10 week follow-up.

CONCLUSIONS

A combination of video plus verbal feedback is an effective technique for achieving maintained gains in self-awareness in people with TBI.

INCOG recommendations for management of cognition following traumatic brain injury, part IV: cognitive communication

INTRODUCTION

Cognitive-communication disorders are common in individuals with traumatic brain injury (TBI) and can have a major impact on long-term outcome. Guidelines for evidence-informed rehabilitation are needed, thus an international group of researchers and clinicians (known as INCOG) convened to develop recommendations for assessment and intervention.

METHODS

An expert panel met to select appropriate recommendations for assessment and treatment of cognitive-communication disorders based on available literature. To promote implementation, the team developed decision algorithms incorporating the recommendations, based on inclusion and exclusion criteria of published trials, and then prioritized recommendations for implementation and developed audit criteria to evaluate adherence to best practice recommendations.

RESULTS

Rehabilitation of individuals with cognitive-communication disorders should consider premorbid communication status; be individualized to the person's needs, goals, and skills; provide training in use of assistive technology where appropriate; include training of communication partners; and occur in context to minimize the need for generalization. Evidence supports treatment of social communication problems in a group format.

CONCLUSION

There is strong evidence for person-centered treatment of cognitive-communication disorders and use of instructional strategies such as errorless learning, metacognitive strategy training, and group treatment. Future studies should include tests of alternative service delivery models and development of participation-level outcome measures.

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

Background

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

Methods

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

Results

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

Conclusions

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

Evaluation of brief interventions for managing depression and anxiety symptoms during early discharge period after stroke: a pilot randomized controlled trial

BACKGROUND

Prevalence estimates for depression and anxiety in individuals post-stroke are approximately 33 and 29%, yet there are few effective preventive interventions. Interventions which commence pre-discharge and continue during the early post-discharge period may support individuals during the critical transition to home adjustment period. This study aimed to evaluate the efficacy of a self-management intervention and a coping skills intervention, compared to usual care, on anxiety and depression post-stroke.

METHODS

A pilot, three-arm randomized trial involving 33 stroke patients (coping skills: n = 11, self-management: n = 12, usual care: n = 10) recruited from an Australian stroke unit. Both interventions were eight 1-hour weekly sessions, with the first two pre-discharge and the remainder at home; targeted both anxiety and depression; and tailored content to individuals. Primary outcome was severity of depressive and anxiety symptoms (measured using Montgomery andÅsberg Depression Rating Scale and Hospital Anxiety and Depression Scale). Secondary measures were: self-efficacy, stroke knowledge, basic and extended activities of daily living, and quality of life. Outcome measures were administered at baseline, one week post-intervention, and at a three month follow-up by a blinded assessor.

RESULTS

Thirty (91%) participants completed the trial. Immediately post-intervention there was a small improvement in stroke knowledge and a small increase in depression symptoms (on one of the two measures of depression symptoms) in the coping skills group compared to usual care. These differences did not remain significant at the 3-month follow-up, nor were there any other significant differences.

CONCLUSION

Neither a coping skills nor self-management intervention reduced anxiety nor depression symptoms early post-stroke more than usual care. Lack of statistical power may have contributed to the non-significant findings in this pilot study.

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

Background.

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

Purpose.

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

Key Issues.

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

Implications.

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

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

BACKGROUND

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

METHODS/DESIGN

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

DISCUSSION

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

TRIAL REGISTRATION

ACTRN12613000585729.

[Interindividual variability in recovery after traumatic brain injury: effect of cognitive reserve]

BACKGROUND AND OBJECTIVE

The aim of this study was to examine the effect of cognitive reserve in recovery after a moderate or severe traumatic brain injury (TBI). Different authors proposed that this construct might account for the mismatch between TBI severity, its clinical expression, and subsequent recovery.

PATIENTS AND METHOD

Eighty-four patients who sustained moderate-to-severe TBI participated in the study. Participants were divided into a high cognitive reserve group (n=46) or low cognitive reserve group (n=38) based on premorbid educational and occupational attainment. Patient's functional status was examined with the Patient Competency Rating Scale (PCRS).

RESULTS

There were no significant differences between groups in demographic and injury variables (sex, age, severity of injury, post-traumatic amnesia duration, and time since injury). The analysis revealed statistically significant differences between the 2 groups on the PCRS: The high cognitive reserve group scored better than the low cognitive reserve group.

CONCLUSIONS

The results of this study suggest that cognitive reserve may mediate recovery after a moderate or severe TBI. Educational and occupational attainments provide a cognitive provision that would be associated with better functional status after injury.

Acceptance and Commitment Therapy (ACT) for Psychological Adjustment after Traumatic Brain Injury: Reporting the Protocol for a Randomised Controlled Trial

Following a severe traumatic brain injury (TBI) there is a complex presentation of psychological symptoms which may impact on recovery. Validated treatments addressing these symptoms for this group of people are limited. This article reports on the protocol for a single-centre, two-armed, Phase II Randomised Control Trial (RCT) to address the adjustment process following a severe TBI. Participants will be recruited from Liverpool Brain Injury Rehabilitation Unit and randomly allocated to one of two groups, Acceptance and Commitment Therapy (ACT) or an active control (Befriending). The active treatment group utilises the six core processes of ACT with the intention of increasing participation and psychological flexibility and reducing psychological distress. A number of primary and secondary outcome measures, administered at assessment, post-treatment and 1-month follow-up, will be used to assess clinical outcomes. The publication of the protocol before the trial results are available addresses fidelity criterion (intervention design) for RCTs. This ensures transparency in the RCT and that it meets the guidelines according to the CONSORT statement. The protocol has also been registered on the Australian New Zealand Clinical Trials Registry ACTRN12610000851066.

Do traditional executive measures tell us anything about daily-life functioning after traumatic brain injury in Spanish-speaking individuals?

PRIMARY OBJECTIVE

To examine the relationship between traditional executive function measures and everyday competence in Spanish-speaking individuals with moderate-to-severe traumatic brain injury (TBI).

METHODS AND PROCEDURES

Thirty-two TBI patients (24 men, eight women) with an age range of 17-59 years (mean age = 30.73 years; SD = 13.34) were administered a battery of performance-based executive function measures. Such measures included the Trail Making Test part B, Wisconsin Card Sorting Test, Stroop Colour Word Interference Test, Controlled Oral Word Association Test and Letter-Number Sequencing. Behavioural manifestations of executive deficits were assessed by the Behaviour Rating Inventory of Executive Function-Adult version (BRIEF-A). Patient's everyday functioning was examined with the Patient Competency Rating Scale (PCRS).

MAIN OUTCOMES AND RESULTS

Traditional performance-based executive measures correlated significantly, although moderately, with the PCRS; this relationship was more significant in the Controlled Oral Word Association Test and Trail Making Test part B. A significant correlation was obtained between the BRIEF-A clinical scales and patient's everyday competence as measured by the PCRS.

CONCLUSIONS

The current findings suggest that traditional performance-based executive measures reveal some degree of ecological validity or real-world relevance, providing relevant information for predicting everyday competence after moderate-to-severe TBI.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

FINDINGS AND IMPLICATIONS

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

Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008

OBJECTIVE

To update our clinical recommendations for cognitive rehabilitation of people with traumatic brain injury (TBI) and stroke, based on a systematic review of the literature from 2003 through 2008.

DATA SOURCES

PubMed and Infotrieve literature searches were conducted using the terms attention, awareness, cognitive, communication, executive, language, memory, perception, problem solving, and/or reasoning combined with each of the following terms: rehabilitation, remediation, and training for articles published between 2003 and 2008. The task force initially identified citations for 198 published articles.

STUDY SELECTION

One hundred forty-one articles were selected for inclusion after our initial screening. Twenty-nine studies were excluded after further detailed review. Excluded articles included 4 descriptive studies without data, 6 nontreatment studies, 7 experimental manipulations, 6 reviews, 1 single case study not related to TBI or stroke, 2 articles where the intervention was provided to caretakers, 1 article redacted by the journal, and 2 reanalyses of prior publications. We fully reviewed and evaluated 112 studies.

DATA EXTRACTION

Articles were assigned to 1 of 6 categories reflecting the primary area of intervention: attention; vision and visuospatial functioning; language and communication skills; memory; executive functioning, problem solving and awareness; and comprehensive-holistic cognitive rehabilitation. Articles were abstracted and levels of evidence determined using specific criteria.

DATA SYNTHESIS

Of the 112 studies, 14 were rated as class I, 5 as class Ia, 11 as class II, and 82 as class III. Evidence within each area of intervention was synthesized and recommendations for Practice Standards, Practice Guidelines, and Practice Options were made.

CONCLUSIONS

There is substantial evidence to support interventions for attention, memory, social communication skills, executive function, and for comprehensive-holistic neuropsychologic rehabilitation after TBI. Evidence supports visuospatial rehabilitation after right hemisphere stroke, and interventions for aphasia and apraxia after left hemisphere stroke. Together with our prior reviews, we have evaluated a total of 370 interventions, including 65 class I or Ia studies. There is now sufficient information to support evidence-based protocols and implement empirically-supported treatments for cognitive disability after TBI and stroke.

Sample size calculation in physical medicine and rehabilitation: a systematic review of reporting, characteristics, and results in randomized controlled trials

OBJECTIVE

To assess systematically the reporting of sample size calculation in randomized controlled trials (RCTs) in 5 leading journals in the field of physical medicine and rehabilitation (PM&R).

DATA SOURCES

The data source was full reports of RCTs in 5 leading PM&R journals (Journal of Rehabilitation Medicine, Archives of Physical Medicine and Rehabilitation, American Journal of Physical Medicine and Rehabilitation, Clinical Rehabilitation, and Disability and Rehabilitation) between January and December of 1998 and 2008. Articles were identified in Medline.

STUDY SELECTION

A total of 111 articles met our inclusion criteria, which include RCTs of human studies in the 5 selected journals.

DATA EXTRACTION

Sample size calculation reporting and trial characteristics were collected for each trial by independent investigators.

DATA SYNTHESIS

In 2008, 57.3% of articles reported sample size calculation as compared with only 3.4% in 1998. The parameters that were commonly used were a power of 80% and alpha of 5%. Articles often failed to report effect size or effect estimates for sample size calculation. Studies reporting sample size calculation were more likely to describe the main outcome and to have a sample size greater than 50 subjects. The study outcome (positive vs negative) was not associated with the likelihood of sample size reporting. Trial characteristics of the 2 periods (1998 vs 2008) were similar except that in 1998 there were more negative studies compared with 2008.

CONCLUSIONS

Although sample size calculation reporting has improved dramatically in 10 years and is comparable with other fields in medicine, it is still not adequate given current publication guidelines.