Catherine Wiseman-Hakes

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 persons 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.

Knowledge translation in ABI rehabilitation: A model for consolidating and applying the evidence for cognitive-communication interventions.

Primary objectives: (1) To propose a model for consolidating and disseminating existing evidence relevant to cognitive-communication interventions after ABI. (2) To present the Cognitive-Communication Intervention Review Framework (CCIRF). (3) To outline future considerations for applying evidence to clinical practice. Research design: Employment of a model for knowledge translation. Methods and procedures: Application of evidence requires synthesis and dissemination of information in an accessible format for end users. A literature search identified 20 systematic reviews (1997–2007) with a complex array of 72 practice recommendations relevant to cognitive-communication interventions. The CCIRF was used to synthesize the evidence within 11 intervention categories. Reviews were analysed according to: organization, population, intervention, comparison and outcome, with a focus on communication outcomes. Main outcomes and results: Consolidated evidence revealed support for interventions relating to: social communication, behavioural regulation, verbal formulation, attention, external memory aids, executive functions and communication partner training. Research gaps were noted in the areas of comprehension (auditory/reading), written expression and vocational communication interventions. Similar recommendations emerge across reviews. Conclusions: Implementation of the growing body of evidence for cognitive-communication interventions is challenged by variability in study populations, interventions, and research focus on communication. The CCIRF provides a means of promoting consistency in knowledge translation and application.

INCOG Recommendations for management of cognition following traumatic brain injury. Part II: Attention and information processing speed

Introduction:Traumatic brain injury, due to its diffuse nature and high frequency of injury to frontotemporal and midbrain reticular activating systems, may cause disruption in many aspects of attention: arousal, selective attention, speed of information processing, and strategic control of attention, including sustained attention, shifting and dividing of attention, and working memory. An international team of researchers and clinicians (known as INCOG) convened to develop recommendations for the management of attentional problems. Methods:The experts selected recommendations from published guidelines and then reviewed literature to ensure that recommendations were current. Decision algorithms incorporating the recommendations based on inclusion and exclusion criteria of published trials were developed. The team then prioritized recommendations for implementation and developed audit criteria to evaluate adherence to these best practices. Results:The recommendations and discussion highlight that metacognitive strategy training focused on functional everyday activities is appropriate. Appropriate use of dual task training, environmental modifications, and cognitive behavioral therapy is also discussed. There is insufficient evidence to support mindfulness meditation and practice on de-contextualized computer-based tasks for attention. Administration of the medication methylphenidate should be considered to improve information-processing speed. Conclusion:The INCOG recommendations for rehabilitation of attention provide up-to-date guidance for clinicians treating people with traumatic brain injury.

Evaluating the impact of treatment for sleep/wake disorders on recovery of cognition and communication in adults with chronic TBI

Abstract Objective: To longitudinally examine objective and self-reported outcomes for recovery of cognition, communication, mood and participation in adults with traumatic brain injury (TBI) and co-morbid post-traumatic sleep/wake disorders. Design: Prospective, longitudinal, single blind outcome study. Setting: Community-based. Participants: Ten adults with moderate–severe TBI and two adults with mild TBI and persistent symptoms aged 18–58 years. Six males and six females, who were 1–22 years post-injury and presented with self-reported sleep/wake disturbances with onset post-injury. Interventions: Individualized treatments for sleep/wake disorders that included sleep hygiene recommendations, pharmacological interventions and/or treatments for sleep apnea with follow-up. Main outcome measures: Insomnia Severity Index, Beck Depression and Anxiety Inventories, Latrobe Communication Questionnaire, Speed and Capacity of Language Processing, Test of Everyday Attention, Repeatable Battery for the Assessment of Neuropsychological Status, Daily Cognitive-Communication and Sleep Profile. Results: Group analysis revealed positive trends in change for each measure and across sub-tests of all measures. Statistically significant changes were noted in insomnia severity, p = 0.0003; depression severity, p = 0.03; language, p = 0.01; speed of language processing, p = 0.007. Conclusions: These results add to a small but growing body of evidence that sleep/wake disorders associated with TBI exacerbate trauma-related cognitive, communication and mood impairments. Treatment for sleep/wake disorders may optimize recovery and outcomes.

Rest-activity cycle disturbances in the acute phase of moderate to severe traumatic brain injury

Background. Sleep-wake disturbances are among the most persistent sequelae after traumatic brain injury (TBI) and probably arise during the hospital stay following TBI. These disturbances are characterized by difficulties sleeping at night and staying awake during the day. Objective. The aim of the present study was to document rest-activity cycle consolidation in acute moderate/severe TBI using actigraphy and to assess its association with injury severity and outcome. Methods. In all, 16 hospitalized patients (27.1 ± 11.3 years) with moderate/severe TBI wore actigraphs for 10 days, starting in the intensive care unit (ICU) when continuous sedation was discontinued and patients had reached medical stability. Activity counts were summed for daytime (7:00-21:59 hours) and nighttime periods (22:00-6:59 hours). The ratio of daytime period activity to total 24-hour activity was used to quantify rest-activity cycle consolidation. An analysis of variance was carried out to characterize the evolution of the daytime activity ratio over the recording period. Results. Rest-activity cycle was consolidated only 46.6% of all days; however, a significant linear trend of improvement was observed over time. Greater TBI severity and longer ICU and hospital lengths of stay were associated with poorer rest-activity cycle consolidation and evolution. Patients with more rapid return to consolidated rest-activity cycle were more likely to have cleared posttraumatic amnesia and have lower disability at hospital discharge. Conclusions. Patients with acute moderate/severe TBI had an altered rest-activity cycle, probably reflecting severe fragmentation of sleep and wake episodes, which globally improved over time. A faster return to rest-activity cycle consolidation may predict enhanced brain recovery.

Quality of guidelines for cognitive rehabilitation following traumatic brain injury.

Introduction:Cognitive rehabilitation following traumatic brain injury can aid in optimizing function, independence, and quality of life by addressing impairments in attention, executive function, cognitive communication, and memory. This study aimed to identify and evaluate the methodological quality of clinical practice guidelines for cognitive rehabilitation following traumatic brain injury. Methods:Systematic searching of databases and Web sites was undertaken between January and March 2012 to identify freely available, English language clinical practice guidelines from 2002 onward. Eligible guidelines were evaluated using the validated Appraisal of Guidelines for Research and Evaluation II instrument. Results:The 11 guidelines that met inclusion criteria were independently rated by 4 raters. Results of quality appraisal indicated that guidelines generally employed systematic search and appraisal methods and produced unambiguous, clearly identifiable recommendations. Conversely, only 1 guideline incorporated implementation and audit information, and there was poor reporting of processes for formulating, reviewing, and ensuring currency of recommendations and incorporating patient preferences. Intraclass correlation coefficients for agreement between raters showed high agreement (intraclass correlation coefficient > 0.80) for all guidelines except for 1 (moderate agreement; intraclass correlation coefficient = 0.76). Conclusion:Future guidelines should address identified limitations by providing implementation information and audit criteria, along with better reporting of guideline development processes and stakeholder engagement.

Impact of post-traumatic hypersomnia on functional recovery of cognition and communication

Primary objective: To assess aspects of cognition and communication, in response to the treatment of post-traumatic hypersomnia and mood disturbance. Research design: A single case study; pre–post intervention. Methods and procedures: The participant was a male with severe TBI and cognitive-communication impairments, who subsequently developed sleep and mood disturbance and excessive daytime sleepiness. The Daily Cognitive-Communication and Sleep Profile (D-CCASP), Clinical Interview, Epworth and Stanford Sleepiness Scales and polysomnography assessed sleep and wakefulness. Cognitive-communication was also assessed by the D-CCASP. His sleep, wake and mood difficulties were pharmacologically managed. Main outcomes and results: Baseline polysomnography indicated abnormal sleep. There was a clear positive relationship between quality of sleep, language processing, attention and memory, seen across the phases of the medication intervention (p < 0.01). Conclusions: A comprehensive pharmacological management programme addressing the multi-factorial underlying aetiology was successful in improving sleep, arousal and mood. The D-CCASP was found to be clinically and statistically sensitive to reported changes in cognitive-communication function in relation to improvements in sleep and daytime arousal. These findings suggest that management of sleep/wake disturbances and mood post-traumatic brain injury can potentially facilitate improvements in cognitive-communication function which may, in turn, facilitate participation in rehabilitation and community integration.

Two case study evaluations of an arts-based social skills intervention for adolescents with childhood brain disorder.

Objective: Arts-based programmes have been shown to be useful for individuals with disturbances in cognitive and behavioural functioning. The current case studies examined the feasibility and effectiveness of a theatre skills training programme to facilitate social skills and participation for adolescents with childhood brain disorder. Methods: A case study approach was used with two adolescent participants. Focus groups were conducted immediately post-intervention, while a battery of quantitative measures were administered pre- and post-treatment, as well as 8 months post-treatment. Results: Perceived and documented improvements in social skills and participation were observed from pre- to post-intervention and at follow-up. Conclusion: Results support the use of an arts-based intervention for youth with brain injuries to facilitate social skills and participation. Findings also highlight the need for more sensitive measures of these skills for youth with childhood brain disorder, who may have impaired awareness of their abilities and/or impairments in memory and language comprehension.

Arts-based social skills interventions for adolescents with acquired brain injuries: Five case reports

Abstract Objective: Previous research has demonstrated the value of arts-based programs for adolescents with childhood brain disorder to facilitate social skills and participation. The current study extends this work by examining the feasibility and effectiveness of an arts-based intervention for youth with acquired brain injuries (ABI). Methods: A case study approach was used with four adolescent participants and one case control. A battery of quantitative measures were administered four and one week pre-intervention, one week post-intervention, as well six to eight month post-intervention. Results: Improvements in pragmatic communication skills and social and participation goals were observed across intervention participants. Similar improvements were not seen with the case control participant. Conclusion: Results support the use of an arts-based intervention for youth with ABI to facilitate social skills and participation. Findings also highlight the need for more sensitive measures of these skills for these youth. Suggested guidelines for program implementation are provided.

Sleep in the Acute Phase of Severe Traumatic Brain Injury: A Snapshot of Polysomnography.

Background and Objectives. The onset of pervasive sleep-wake disturbances associated with traumatic brain injury (TBI) is poorly understood. This study aimed to (a) determine the feasibility of using polysomnography in patients in the acute, hospitalized stage of severe TBI and (b) explore sleep quality and sleep architecture during this stage of recovery, compared to patients with other traumatic injuries. Methods. A cross-sectional case-control design was used. We examined the sleep of 7 patients with severe TBI (17-47 years; 20.3 ± 15.0 days postinjury) and 6 patients with orthopedic and/or spinal cord injuries (OSCI; 19-58 years; 16.9 ± 4.9 days postinjury). One night of ambulatory polysomnography was performed at bedside. Results. Compared to OSCI patients, TBI patients showed a significantly longer duration of nocturnal sleep and earlier nighttime sleep onset. Sleep efficiency was low and comparable in both groups. All sleep stages were observed in both groups with normal proportions according to age. Conclusion. Patients in the acute stage of severe TBI exhibit increased sleep duration and earlier sleep onset, suggesting that the injured brain enhances sleep need and/or decreases the ability to maintain wakefulness. As poor sleep efficiency could compromise brain recovery, further studies should investigate whether strategies known to optimize sleep in healthy individuals are efficacious in acute TBI. While there are several inherent challenges, polysomnography is a useful means of examining sleep in the early stage of recovery in patients with severe TBI.