A consecutive series of adults with brain injury treated with a washing and dressing retraining program

Implementation of activities of daily living retraining for individuals in post-traumatic amnesia

Background Despite evidence of the efficacy of activities of daily living (ADL) retraining during post-traumatic amnesia (PTA) following traumatic brain injury (TBI), utilisation of this intervention in practice is unclear. Utilising an implementation science framework, the Consolidated Framework for Implementation Research, this study explored efforts to translate ADL retraining during PTA into the clinical practice of occupational therapists (OTs) working in TBI rehabilitation settings across Australia. Methods Participants were 44 OTs who attended a day-long training workshop that included knowledge and skill-based content regarding ADL retraining during PTA. Baseline and post-training ratings were completed including evaluation of workshop utility, and skill and knowledge-based competencies relevant to the intervention. Approximately 2 years later, nine trained OTs and two administrators were interviewed to explore the results of implementing the intervention. Results Overall, the training workshop was rated as being helpful and OT ratings of confidence (P  P   Conclusion Multiple barriers were identified in implementation of ADL retraining during PTA and require consideration to facilitate translation and promote best practice.

The interrelationship of functional skills in individuals living in the community, following moderate to severe traumatic brain injury

OBJECTIVE

The Adaptive Behaviour and Community Competency Scale was used to investigate the interrelationship of 22 basic and instrumental activities of daily living (ADL/IADL) in individuals with moderate to severe traumatic brain injury (TBI). The relationship of self-awareness to task performance was also investigated.

RESEARCH DESIGN

Prospective descriptive study.

METHOD

The profiles of 100 community dwelling individuals were used to compare the degree to which independence in each ADL/IADL was associated with independence in every other ADL/IADL. The interrelationship of these skills was further explored in a factor analysis, and comparisons made between the degree of self-awareness of those who could and could not complete IADL independently.

RESULTS

We found evidence of a hierarchy of skills: individuals who were independent in IADL were more able to perform ADL, than vice versa. Factor analysis supported a two-factor solution distinguishing ADL and IADL. Self-awareness was more strongly associated with IADL than with ADL independence.

CONCLUSIONS

A subset of individuals with moderate to severe TBI are able to perform a range of IADL. This group appears to have higher levels of self-awareness than those who are limited to performing only ADL skills. Implications for the applications of functional retraining interventions are discussed.

Effectiveness of Interventions to Address Cognitive Impairments and Improve Occupational Performance After Traumatic Brain Injury: A Systematic Review

OBJECTIVE. To determine the effectiveness of interventions addressing cognitive impairments to improve occupational performance for people with traumatic brain injury.

METHOD. A total of 37 studies met inclusion criteria: 9 Level I systematic reviews, 14 Level I studies, 5 Level II studies, and 9 Level III studies.

RESULTS. Strong evidence supports use of direct attention training, dual-task training, and strategy training to optimize executive functioning, encoding, and use of memory compensations, including assistive technology. However, in most studies, occupational performance was a secondary outcome, if it was evaluated at all.

CONCLUSION. Although evidence supports many intervention approaches used by occupational therapy practitioners to address cognitive impairments of adults with traumatic brain injury, more studies are needed in which occupational performance is the primary outcome of cognitive intervention.

Revisiting the neurofunctional approach: conceptualizing the core components for the rehabilitation of everyday living skills

BACKGROUND

Introduced in the 1980s, the neurofunctional approach (NFA) is one of the few interventions designed primarily for clients with severe deficits following traumatic brain injury (TBI). Specifically the NFA was intended for those individuals who were limited in their ability to solve novel problems or generalize skills from one setting to another and whose lack of insight limited their engagement in the rehabilitative process. DESCRIPTION OF THE APPROACH: The NFA is a client-centred, goal-driven approach that incorporates the principles of skill learning and promotes the development of routines and competencies in practical activities required for everyday living. Programmes based on the NFA are developed specifically to meet each client's unique needs, using a range of evidence-based interventions. RECENT EVIDENCE: Recently the NFA has been found to be more effective than cognitive-retraining for some individuals with moderate-to-severe TBI who have deficits in activities of daily living. This paper aims to define the core features of the NFA, outline the theoretical basis on which it is founded and consider implications of the findings for rehabilitation after TBI in general. The NFA is highly relevant for clients living in the community who require a case manager to direct an integrated, rehabilitation programme or provide structured input for the long-term maintenance of skills.

Beyond Dressing and Driving: Using Occupation to Facilitate Community Integration in Neurorehabilitation

During the process of community integration, individuals with acquired brain injury may experience difficulties in all areas of occupational performance including self-care, home management, community access, leisure, social activities and vocational pursuits. Community based rehabilitation services provide opportunities to minimise such difficulties by working with clients as they engage in meaningful real-life context-based occupations. The therapeutic use of occupation is at the core of occupational therapy practice. We reflect on the nature and principles of occupation and highlight particular benefits for facilitating community integration after brain injury. This is illustrated using the example of executive dysfunction. Several challenges for the occupational therapy profession arise from the shift in focus from hospital to community based rehabilitation, and the need for further research on community integration after brain injury from an occupational perspective is recognised.

Application of cognitive rehabilitation theory to the development of smart prompting technologies

Older adults with cognitive impairments often have difficulty performing instrumental activities of daily living (IADLs). Prompting technologies have gained popularity over the last decade and have the potential to assist these individuals with IADLs in order to live independently. Although prompting techniques are routinely used by caregivers and health care providers to aid individuals with cognitive impairment in maintaining their independence with everyday activities, there is no clear consensus or gold standard regarding prompt content, method of instruction, timing of delivery, or interface of prompt delivery in the gerontology or technology literatures. In this paper, we demonstrate how cognitive rehabilitation principles can inform and advance the development of more effective assistive prompting technologies that could be employed in smart environments. We first describe cognitive rehabilitation theory (CRT) and show how it provides a useful theoretical foundation for guiding the development of assistive technologies for IADL completion. We then use the CRT framework to critically review existing smart prompting technologies to answer questions that will be integral to advancing development of effective smart prompting technologies. Finally, we raise questions for future exploration as well as challenges and suggestions for future directions in this area of research.

Invited commentary and correspondence

I would like to thank both the commentators for taking the time to review my recent article ‘Facilitating independence in personal activities of daily living after a severe traumatic brain injury’ Vol 17(9): 474–482, and take this opportunity to address some of the questions and points raised by Helen Harrington.

Facilitating independence in personal activities of daily living after a severe traumatic brain injury

Aims

This study examined the effectiveness of two components of a treatment programme typically used by occupational therapists (OTs) in personal activities of daily living (PADL) rehabilitation.

Methods

A multiple baseline probe design across PADL tasks was used, one which is particularly suited to the examination of the effects of complex interventions on skill performance. The subjects were two male adults with severe brain injuries and cognitive impairments who were in the acute stages of recovery. The OT treatment program consisted of a combination of errorless learning and strategy training approaches. The impact of the program was measured by the number of steps completed independently in each of these tasks, the level and type of assistance required, and by administering the UK Functional Independence Measure and the Assessment of Motor and Process Skills.

Findings

Errorless learning and strategy training, as used within an OT programme, was demonstrated to be effective in reducing the amount of assistance both participants required to complete the targeted PADL tasks. Further, there was evidence of generalization of training effects among trained and untrained activities.

Conclusions

Selecting and combining treatment techniques based on detailed assessment of functional performance is an area of high clinical importance but with limited research; the current study stands as an attempt towards that direction.

Cognitive versus functional approaches to rehabilitation after traumatic brain injury: commentary on a randomized controlled trial

I describe the findings of one of the largest randomized controlled trials (RCTs) of rehabilitation after traumatic brain injury (TBI) ever conducted, examine the theoretical relationship between cognitive and functional rehabilitation after TBI, and describe the historical preference for cognitive (top-down) rather than functional (bottom-up) interventions. I also contrast the goals and principles of cognitive rehabilitation and of the neurofunctional approach of Giles and Clark-Wilson (1993; Giles, 2005)--a bottom-up approach. Findings of the RCT provide empirical support for both functional and cognitive interventions following acute TBI. In addition, they provide evidence that each type of intervention offers significant advantages for a specific subpopulation. The clinical implications of these findings for occupational therapy practitioners are discussed.

Community reintegration following acquired brain injury

OBJECTIVE

To evaluate the interventions and strategies used to enable transition from acute care or post-acute rehabilitation to the community following brain injury.

METHODS AND MAIN OUTCOMES

A systematic review of the literature from 1980-2005 was conducted focusing on ABI rehabilitation. Five major aspects of community reintegration, including: independence and social integration, caregiver burden, satisfaction with quality of life, productivity and return to driving were considered.

RESULTS

With the exception of one, the majority of interventions are supported by only limited evidence, denoting an absence of randomized controlled trials (RCTs) in the literature. Of 38 studies evaluated for this review, only one RCT was found. That RCT provided moderate evidence that behavioural management, coupled with caregiver education, did not help to improve caregiver burden.

CONCLUSIONS

Further research, using an interventional approach, is required to advance the evidence base of reintegration into the community following brain injury.

Efficacy of rehabilitation for functional skills more than 10 years after extremely severe brain injury

PURPOSE

To determine whether gains in personal independence can be achieved in individuals 10 or more years after very severe acquired brain injury.

METHOD

Four individuals in a continuing (slow stream) rehabilitation centre were assessed by an occupational therapist (OT) and programmes were designed to help the individual enhance personal independence. Support staff were trained to implement these programmes under the guidance of the OT. Methods described by Giles, Ridley, Dill, and Frye (1997) were used. Pre- and post-training measures were taken as well as follow up measures to assess the durability of such changes.

RESULTS

The results demonstrate that it is possible to achieve clinically significant improvements in personal independence many years after very severe acquired brain injury.

CONCLUSIONS

The findings of this study suggest that personally and clinically significant goals can be achieved 10 or more years after brain injury and there should be continuing effort to improve the circumstances of individuals with acquired brain injury. Such gains can be achieved through consistent application of such programmes by support workers working under the supervision of an occupational therapist.

Twenty-month effectiveness of a non-aversive, long-term, low-cost programme for persons with persisting neurobehavioural disability

PRIMARY OBJECTIVE

To examine the effectiveness of a programme developed for persons with persisting neurobehavioural/ neuropsychiatric disorders.

RESEARCH DESIGN

Descriptive study of a programme that has a philosophy of normalization, respect, non-confrontation, positive engagement, support and functional and behavioural skill development.

METHODS AND PROCEDURES

Participants were the 40 clients admitted during the initial 20 months of operation. Prior to admission clients had recurrent placement failures secondary to behavioural disregulation and typically were housed at County or State Hospitals. An expanded version of the Overt Aggression Scale Modified for Neurorehabilitation was used to provide detailed descriptions of assaults.

MAIN OUTCOMES AND RESULTS

Over the 20-month period, 49 incidents of client-to-client aggression occurred representing a rate of 0.11 incidents per client month. Thirty-five of 40 clients remained at the end of 20 months, with only three discharges due to behaviour.

CONCLUSIONS

A long-term, stable living environment has been provided for individuals who had been intractable management problems elsewhere.

Therapeutic strategies used by occupational therapists in self-care training: a qualitative study

Self-care training is one of the most frequently used interventions in rehabilitation. However, there is a need for clear descriptions of what occupational therapists do during self-care training with clients. The aim of this qualitative study was to describe what characterizes the therapeutic strategies used by occupational therapists during self-care training. Twelve occupational therapists working with clients who had had a stroke (n = 6) or spinal cord injury (n = 6) were interviewed and asked to tell a therapeutic story focusing on the self-care training process of one client. Data were transcribed and analysed using the Empirical, Phenomenological, Psychological (EPP) method, a qualitative method that aims to describe the essence, structure and character of the studied phenomenon (that is, therapeutic strategies). The characteristics of eight intervention strategies, used by all participants during self-care training, were identified. Findings showed that the occupational therapists' strategies focused primarily on how to create a relationship built on trust with their clients, how to find the right way to motivate clients, how to support the setting of goals, and how to provide enabling occupational experience and adjust training to the needs of the client, rather than focusing on teaching clients how to use technical and compensatory strategies. The general aim for using the strategies was to support the clients in taking control of their lives again. One conclusion from this study is that occupational therapists could, through understanding the individual's unique situation, vary their strategies and adapt themselves, like a chameleon, to meeting clients' experiences and needs during self-care training. However, the therapeutic outcome of using these strategies needs to be verified in future studies focusing on clients' experiences from self-care training.

The use of artificial intelligence in the design of an intelligent cognitive orthosis for people with dementia

Dementia often reduces a person's ability to perform activities of daily living because he or she becomes confused and cannot remember the sequence of steps to perform. The current solution is to have a caregiver continually supervise and assist the person using verbal reminders or cues. This loss of privacy and increased dependency may cause the affected person to become embarrassed and agitated. We propose that this situation might be improved by using a computerized device that monitors progress and provides the reminders needed. The COACH is a first prototype of such a device. It uses artificial intelligence to observe a user, learn from his or her actions, and issue prerecorded cues of varying detail. The device was developed using a personal computer and a video camera that unobtrusively tracked the user. Preliminary testing with subjects who simulated confused behavior as they washed their hands showed that the device was performing its functions with an efficacy of approximately 95%. More extensive clinical testing and evaluation has begun, and the results will be reported in future publications.

A conceptual model for treatment of externalizing behaviour in acquired brain injury

This paper describes a conceptual model for treatment of the externalizing behavioural sequelae to an acquired brain injury and discusses relevant research. Use of the model by practitioners should lead to sophisticated and minimally intrusive intervention. In the model, there are two different categories of approaches. The first category is remedial approaches. These interventions are typically used in the post-acute environment for teaching adaptive skills to replace aberrant behaviour patterns. Skills provided with such training allow the individual to self-manage difficult everyday situations effectively, without external control by others. The second category is moderating approaches, which can be used in the acute phase of ABI recovery for management of severe behavioural episodes that may be associated with conditions present at this time, such as agitation and confusion. Moderating approaches can also be used as a prelude to remedial approaches in the post-acute environment when problem behaviours occur at a high frequency or intensity and render the use of remedial approaches difficult.