C.M. van Heugten

EFNS guidelines on cognitive rehabilitation: report of an EFNS task force

In 1999, a Task Force was set up under the auspices of the European Federation of Neurological Societies with the aim to evaluate the existing evidence for the clinical effectiveness of cognitive rehabilitation. This review led to the development of a set of guidelines to be used in the management of adult patients with cognitive disorders due to acquired focal neurological damage.

Cognitive interventions in healthy older adults and people with mild cognitive impairment: a systematic review.

Given that the research area of cognitive intervention studies in the aging population is growing rapidly, it is important to review and gauge more recent intervention studies, in order to determine the evidence for the effectiveness of cognitive interventions. The purpose of the present review was to update the recent systematic reviews of Papp et al. (2009) and Martin et al. (2011), to evaluate the effectiveness of cognitive interventions in healthy older adults and people with MCI, by taking into account the methodological quality of the interventions studies. A systematic review of randomized controlled trials (RCT) and clinical studies published between August 2007 and February 2012 in Pubmed and PsychINFO was performed. The quality of the included RCTs was assessed according to the CONSORT criteria for RCTs. A total of thirty-five studies were included; twenty-seven RTCs and eight clinical studies. The content of the intervention studies differed widely, as did the methodological quality of the included RCTs, but was considerably low with an average of 44% of the Consort items included. The results show evidence that cognitive training can be effective in improving various aspects of objective cognitive functioning; memory performance, executive functioning, processing speed, attention, fluid intelligence, and subjective cognitive performance. However, the issue whether the effects of cognitive interventions generalize to improvement in everyday life activities is still unresolved and needs to be addressed more explicitly in future research.

Life after survival: Long-term daily functioning and quality of life after an out-of-hospital cardiac arrest

BACKGROUND Information about long-term consequences of cardiac arrest is sparse. Because the survival rate is expected to increase, better knowledge of long-term functioning and quality of survival is essential. OBJECTIVES To determine the level of functioning of out-of-hospital cardiac arrest survivors 1-6 years later, and to evaluate the predictive value of medical variables on long-term functioning. METHODS A retrospective cohort study including 63 survivors of an out-of-hospital cardiac arrest, admitted to a Dutch University hospital between 2001 and 2006. Participants received a questionnaire by post. Primary outcome measures were: participation in society (Community Integration Questionnaire) and quality of life (SF-36). Secondary outcome measures were: physical, cognitive and emotional impairment, daily functioning and caregiver strain. Statistical analyses included multiple regression analyses. RESULTS On average 3 years post-cardiac arrest, 74% of the patients experienced a low participation level in society compared with the general population. Over 50% reported severe fatigue, 38% feelings of anxiety and/or depression and 24% a decreased quality of life. Caregivers reported stress related responses, feelings of anxiety and lower quality of life. Seventeen percent of the caregivers reported high caregiver strain, which was associated with the patients level of functioning. Gender, age, percutaneous coronary intervention (PCI) and therapeutic hypothermia contributed to outcome on at least one domain of long-term functioning. CONCLUSIONS After surviving an out-of-hospital cardiac arrest, many patients and partners encounter extensive impairments in their level of functioning and quality of life. Gender, age, PCI and therapeutic hypothermia are associated with differences in long-term functioning of patients.

Determinants of quality of life in survivors of cardiac arrest

OBJECTIVE To study factors related to quality of life after a hypoxic period due to cardiac arrest. DESIGN Retrospective cohort study. SUBJECTS Eighty-eight survivors of out-of-hospital cardiac arrest, admitted to a Dutch academic hospital between 2001 and 2006. METHODS Patients received a set of questionnaires at home. The main outcome measures were physical and mental quality of life (Medical Outcomes Study 36-item Short Form Health Survey; SF-36). Potential determinants were cognitive complaints, emotional problems depression/anxiety), post-traumatic stress, fatigue, daily functioning and participation in society. Multiple linear regression analyses were performed with physical and mental quality of life as dependent variables. RESULTS Sixty-three (72%) patients responded. Mean time since cardiac arrest was 36 months (standard deviation (SD) 19). Backward regression analyses showed that physical quality of life was significantly (p < 0.001, adjusted R2 = 0.531) related to cognitive complaints (beta = -0.378), instrumental daily life activities (beta = 0.262), post-traumatic stress (beta = -0.246) and fatigue (beta = -0.226). Mental quality of life was significantly (p < 0.001, adjusted R2 = 0.664) explained by anxiety/depression (beta = -0.609), fatigue (beta = -0.177) and cognitive complaints (beta = -0.175). CONCLUSION Quality of life is related to cognitive complaints, fatigue, anxiety/depression, post-traumatic stress and difficulties in daily activities in survivors of out-of-hospital cardiac arrest. Rehabilitation programmes for this group should specifically address these topics.

OCCURRENCE AND MEASUREMENT OF TRANSFER IN COGNITIVE REHABILITATION: A CRITICAL REVIEW

OBJECTIVE To investigate the occurrence of transfer of cognitive strategy training for persons with acquired brain injury, and to investigate the way in which transfer is measured. METHODS Electronic searches in PubMed, PsychINFO, EMBASE and CINAHL using combinations of search terms in the following categories: type of brain injury, transfer, type of disorder, type of intervention. A total of 39 papers was included in the review. The following aspects were judged: study design and participant characteristics, intervention characteristics and type of outcome measures used. RESULTS Transfer outcome measures could be classified into 3 groups: non-trained items, standardized daily tasks and daily life. Most studies reported at least one type of transfer; however, the methodological quality of the studies was low. Cognitive strategy training in the evaluated studies focused on 7 domains of functioning: information processing, problem solving/executive functioning, memory/attention, language, neglect, apraxia and daily activities. CONCLUSION Transfer of training effects of cognitive strategy training has been evaluated in a relatively small number of studies. Outcome measures used in these studies could be classified into 3 groups. Most studies reported the occurrence of transfer of training effects, although some serious remarks can be made concerning the methodological quality of the studies.

Outcome of strategy training in stroke patients with apraxia: a phase II study

Objective: Evaluation of a therapy programme for stroke patients with apraxia. The programme is based on teaching patients strategies to compensate for the presence of apraxia. This programme was designed for assessment and treatment by occupational therapists. Design: The outcome was studied in a pre–post test design. Measurements were conducted at baseline and 12 weeks later. Subjects: Thirty-three stroke patients with apraxia were treated at occupational therapy departments in general hospitals, rehabilitation centres and nursing homes. Main outcome measures: The following measurements were conducted: an apraxia test, a motor functioning test, observation of activities of daily living (ADL), Barthel Index, and an ADL questionnaire for the therapist and the patient. Results: The patients showed large improvements in ADL functioning on all measures and small improvements on the apraxia test and the motor functioning test. The effect sizes for the disabilities, ranging from 0.92 to 1.06, were large compared to the effect sizes for apraxia (0.34) and motor functioning (0.19). The significant effect of treatment is also seen when individual improvement and subjective improvement are considered. Measured with the Barthel Index for instance, 71% of the patients improved. Conclusions: These results suggest that the programme seems to be successful in teaching patients compensatory strategies that enable them to function more independently, despite the lasting presence of apraxia.

Comprehensive rehabilitation programmes in the chronic phase after severe brain injury: a systematic review.

OBJECTIVE The aim of this study was to perform a systematic review of the effectiveness of comprehensive rehabilitation programmes for adults in the chronic phase after severe acquired brain injury. METHODS PubMed, PsychINFO and PsychLit were searched for articles published between 1990 and 2008 and a quality assessment was performed. The comprehensive programmes were subdivided into neurobehavioral interventions, residential community reintegration and day-treatment programmes. The extracted data included study characteristics, patient characteristics and intervention characteristics. RESULTS Thirteen studies met pre-established criteria. Two studies were randomized controlled trials, 5 were controlled comparative studies and 6 were uncontrolled longitudinal cohort studies. Overall, their methodological quality was limited. The investigated programmes led to substantial improvement in daily life functioning and community integration of severe chronic brain injury patients, with lasting effects at follow-up. Day-treatment programmes had the highest level of evidence. CONCLUSION Comprehensive rehabilitation programmes appear to be effective in terms of a reduction in psychosocial problems, a higher level of community integration and an increase in employment. Although this is the first review to differentiate between specific programmes, clear-cut clinical recommendations cannot yet be set out due to limited methodological quality and poor description of patient and intervention characteristics. Specific recommendations for future studies are given.

Rehabilitation of stroke patients with apraxia: the role of additional cognitive and motor impairments.

Purpose : The present study investigated which additional cognitive and motor impairments were present in stroke patients with apraxia and which of these factors influenced the effects of treatment. Method : A group of 33 patients with apraxia were treated according to the guidelines of a therapy programme based on teaching patients strategies to compensate for the presence of apraxia. Patients were treated at occupational therapy departments in general hospitals, rehabilitation centres and nursing homes. The outcome of the strategy training was studied in a pre-post test design; measurements were conducted at baseline and after 12 weeks of therapy. The pretreatment scores of the patients with apraxia were compared to normscores and scores of a control group of patients without apraxia ( n = 36) to investigate which impairments are present. The following variables were analysed in order to determine which factors influence outcome: additional neuropsychological deficits (comprehension of language, cognitive impairments due to dementia, neglect and short term memory), level of motor functioning, severity of apraxia and performance on activities of daily living (ADL), and some relevant patient characteristics (gender, age, type of stroke, time since stroke, and location of treatment). Results : The results showed that the presence of apraxia is associated with the presence of additional cognitive and motor impairments. The successful outcome of strategy training was not negatively influenced by cognitive comorbidity. The outcome seemed to be more prominent in patients who were more severely impaired at the start of rehabilitation in terms of the degree of motor impairments, the severity of apraxia and the initial ADL dependence. The ADL observations, however, displayed a ceiling effect, which was taken into account in discussing the results. Demographic variables, especially age, did not predict the outcome of treatment. Conclusions : We suggest that the effect of this training is stronger in more severely disabled patients. However, neither the presence of additional cognitive impairments nor the severity of motor problems nor old age should be an indication for refraining from treating apraxia.

The adaptation process following acute onset disability: an interactive two-dimensional approach applied to acquired brain injury

Objective: To describe a new model of the adaptation process following acquired brain injury, based on the patient’s goals, the patient’s abilities and the emotional response to the changes and the possible discrepancy between goals and achievements. Background: The process of adaptation after acquired brain injury is characterized by a continuous interaction of two processes: achieving maximal restoration of function and adjusting to the alterations and losses that occur in the various domains of functioning. Consequently, adaptation requires a balanced mix of restoration-oriented coping and loss-oriented coping. The commonly used framework to explain adaptation and coping, ‘The Theory of Stress and Coping’ of Lazarus and Folkman, does not capture this interactive duality. Relevant theories: This model additionally considers theories concerned with self-regulation of behaviour, self-awareness and self-efficacy, and with the setting and achievement of goals. The two-dimensional model: Our model proposes the simultaneous and continuous interaction of two pathways; goal pursuit (short term and long term) or revision as a result of success and failure in reducing distance between current state and expected future state and an affective response that is generated by the experienced goal-performance discrepancies. This affective response, in turn, influences the goals set. This two-dimensional representation covers the processes mentioned above: restoration of function and consideration of long-term limitations. We propose that adaptation centres on readjustment of long-term goals to new achievable but desired and important goals, and that this adjustment underlies re-establishing emotional stability. We discuss how the proposed model is related to actual rehabilitation practice.

A prospective study to evaluate a new residential community reintegration programme for severe chronic brain injury: the Brain Integration Programme.

Purpose: To assess the effectiveness of a residential community reintegration programme for participants with chronic sequelae of severe acquired brain injury that hamper community functioning. Design: Prospective cohort study. Subjects: Twenty-four participants with acquired brain injury (traumatic n= 18; stroke n= 3, tumour n= 2, encephalitis n= 1). Participants had impaired illness awareness, alcohol and drug problems and/or behavioural problems. Intervention: A skills-oriented programme with modules related to independent living, work, social and emotional well-being. Methods: The Community Integration Questionnaire, CES-Depression, EuroQOL, Employability Rating Scale, living situation and work status were scored at the start (T0), end of treatment (T1) and 1-year follow-up (T2). Results: Significant effects on the majority of outcome measures were present at T1. Employability significantly improved at T2 and living independently rose from 42% to over 70%. Participants working increased from 38% to 58% and the hours of work per week increased from 8 to 15. Conclusion: The Brain Integration Programme led to a sustained reduction in experienced problems and improved community integration. It is concluded that even participants with complex problems due to severe brain injury who got stuck in life could improve their social participation and emotional well-being through a residential community reintegration programme.