Joseph F. Rath

Group treatment of problem‐solving deficits in outpatients with traumatic brain injury: A randomised outcome study

Sixty higher‐level outpatients with traumatic brain injury (TBI), all at least 1 year post‐injury, were randomly assigned to either conventional group neuropsychological rehabilitation or an innovative group treatment focused on the treatment of problem‐solving deficits. Incorporating strategies for addressing underlying emotional self‐regulation and logical thinking/reasoning deficits, the innovative treatment is unique in its attention to both motivational, attitudinal, and affective processes and problem‐solving skills in persons with TBI. Participants in the innovative group improved in problem solving as assessed using a variety of measures, including (1) executive function, (2) problem‐solving self‐appraisal, (3) self‐appraised emotional self‐regulation and clear thinking, and (4) objective observer ratings of roleplayed scenarios. These improvements were maintained at follow‐up. Baseline performance on timed attention tasks was related to improvement; individuals who processed the most slowly benefited the most. These participants did not show improvements on timed attention tasks, but did improve on problem‐solving measures. Such findings are consistent with successful compensatory strategy use—the person may still have deficits and symptoms, but now has effective strategies for reducing their impact on daily functioning.

Mild Traumatic Brain Injury: Longitudinal Regional Brain Volume Changes

PURPOSE To investigate longitudinal changes in global and regional brain volume in patients 1 year after mild traumatic brain injury (MTBI) and to correlate such changes with clinical and neurocognitive metrics. MATERIALS AND METHODS This institutional review board-approved study was HIPAA compliant. Twenty-eight patients with MTBI (with 19 followed up at 1 year) with posttraumatic symptoms after injury and 22 matched control subjects (with 12 followed up at 1 year) were enrolled. Automated segmentation of brain regions to compute regional gray matter (GM) and white matter (WM) volumes was performed by using three-dimensional T1-weighted 3.0-T magnetic resonance imaging, and results were correlated with clinical metrics. Pearson and Spearman rank correlation coefficients were computed between longitudinal brain volume and neurocognitive scores, as well as clinical metrics, over the course of the follow-up period. RESULTS One year after MTBI, there was measurable global brain atrophy, larger than that in control subjects. The anterior cingulate WM bilaterally and the left cingulate gyrus isthmus WM, as well as the right precuneal GM, showed significant decreases in regional volume in patients with MTBI over the 1st year after injury (corrected P < .05); this was confirmed by means of cross-sectional comparison with data in control subjects (corrected P < .05). Left and right rostral anterior cingulum WM volume loss correlated with changes in neurocognitive measures of memory (r = 0.65, P = .005) and attention (r = 0.60, P = .01). At 1-year follow-up, WM volume in the left cingulate gyrus isthmus correlated with clinical scores of anxiety (Spearman rank correlation r = -0.68, P = .007) and postconcussive symptoms (Spearman rank correlation r = -0.65, P = .01). CONCLUSION These observations demonstrate structural changes to the brain 1 year after injury after a single concussive episode. Regional brain atrophy is not exclusive to moderate and severe traumatic brain injury but may be seen after mild injury. In particular, the anterior part of the cingulum and the cingulate gyrus isthmus, as well as the precuneal GM, may be distinctively vulnerable 1 year after MTBI.

Heart rate variability biofeedback, executive functioning and chronic brain injury

Primary objective: To determine if individuals with brain injury can modify heart rate variability (HRV) through biofeedback and, if so, enhance its pattern to improve emotional regulation and problem-solving ability. Design: A quasi-experimental design with repeated measures was employed. Thirteen individuals aged 23–63 years with severe brain injury (13–40 years post-onset) participating in a community-based programme were enrolled. Main outcomes: Response-to-treatment was measured with HRV indices, Behavior Rating Inventory of Executive Function (BRIEF-A-Informant) and attention/problem-solving tests. Results: At post-treatment, HRV indices (Low Frequency/High Frequency [LF/HF] and coherence ratio) increased significantly. Increased LF/HF values during the second-half of a 10-minute session were associated with higher attention scores. Participants who scored better (by scoring lower) in informant ratings at pre-treatment had highest HRV scores at post-treatment. Accordingly, at post-treatment, families’ ratings of participants’ emotional control correlated with HRV indices; staffs’ ratings of participants’ working memory correlated with participants’ HRV indices. Self-ratings of the BRIEF-A Task Monitoring scale at post-treatment correlated with family ratings at pre-treatment and post-treatment. Conclusions: Results demonstrate an association between regulation of emotions/cognition and HRV training. Individuals with severe, chronic brain injury can modify HRV through biofeedback. Future research should evaluate the efficacy of this approach for modifying behavioural problems.

Clinical applications of problem-solving research in neuropsychological rehabilitation: addressing the subjective experience of cognitive deficits in outpatients with acquired brain injury.

OBJECTIVE The goal of this paper is to illustrate how the lessons learned in over 20 years of randomized clinical trials have advanced cognitive rehabilitation beyond traditional approaches to problem solving by more explicitly integrating subjective self-appraisal factors in routine clinical practice. RESULTS The concept of problem orientation, as proposed by cognitive-behavioral psychologists, provides a much-needed framework for conceptualizing interventions to address the impact of subjective experience on cognitive functioning, within the context of cognitive remediation. By explicitly focusing on the beliefs, assumptions, and expectations that individuals with acquired brain injury have about their own cognitive functioning, the concept of problem orientation allows rehabilitation psychologists to add an element to interventions, not systematically addressed in standard approaches to cognitive remediation. Targeting objective deficits in cognitive remediation is necessary, but not sufficient: For optimal benefit, remedial interventions must address objective cognitive deficits and the patients subjective experience of such deficits in tandem. CONCLUSION Contemporary evidence-based treatment recommendations now typically include incorporating interventions to address motivational, attitudinal, and affective factors in cognitive remediation. Further research is needed to directly compare the effectiveness of cognitive rehabilitative interventions that systematically address subjective factors with those that do not.

Measurement of problem-solving deficits in adults with acquired brain damage.

Objective: To compare the relative utility of conventional neuropsychological and social problem-solving approaches to measuring functional problem solving deficits in individuals with acquired brain damage (ABD). Design: In Study I, scores for individuals with ABD were compared to scores for control and normative samples. In Study II, pre- and posttest scores were compared for individuals with ABD who completed a program of outpatient cognitive rehabilitation. Participants: In Study I, individuals with ABD were compared to healthy controls. In Study II, pre- and posttreatment assessments were obtained for 34 individuals with ABD. Main Outcome Measures: Two approaches were used, conventional neuropsychological (WAIS-R/II Comprehension subtest and Wisconsin Card Sorting Test) and social problem solving (Problem Solving Inventory and Rusk Problem Solving Role Play Test). Results: In Study I, the ABD group demonstrated significant deficits on both social problem solving measures; however, neither conventional neuropsychological measure detected significant deficits in the ABD group, relative to control and normative groups. In Study II, significant treatment gains were demonstrated on both social problem-solving measures, however neither conventional neuropsychological measure was sensitive to improvements in functional problem-solving ability. Conclusions: In higher-level cognitive rehabilitation settings, the evaluation of functional problem-solving deficits in individuals with ABD can be facilitated by augmenting neuropsychological test data with results from social problem-solving measures.

Positive psychology in rehabilitation medicine: A brief report

BACKGROUND The field of positive psychology has grown exponentially within the last decade. To date, however, there have been few empirical initiatives to clarify the constructs within positive psychology as they relate to rehabilitation medicine. Character strengths, and in particular resilience, following neurological trauma are clinically observable within rehabilitation settings, and greater knowledge of the way in which these factors relate to treatment variables may allow for enhanced treatment conceptualization and planning. OBJECTIVE The goal of this study was to explore the relationships between positive psychology constructs (character strengths, resilience, and positive mood) and rehabilitation-related variables (perceptions of functional ability post-injury and beliefs about treatment) within a baseline data set, a six-month follow-up data set, and longitudinally across time points. METHODS Pearson correlations and supplementary multiple regression analyses were conducted within and across these time points from a starting sample of thirty-nine individuals with acquired brain injury (ABI) in an outpatient rehabilitation program. RESULTS Positive psychology constructs were related to rehabilitation-related variables within the baseline data set, within the follow-up data set, and longitudinally between baseline positive psychology variables and follow-up rehabilitation-related data. CONCLUSIONS These preliminary findings support relationships between character strengths, resilience, and positive mood states with perceptions of functional ability and expectations of treatment, respectively, which are primary factors in treatment success and quality of life outcomes in rehabilitation medicine settings. The results suggest the need for more research in this area, with an ultimate goal of incorporating positive psychology constructs into rehabilitation conceptualization and treatment planning.

Group Treatment in Acquired Brain Injury Rehabilitation

The current article describes critical issues in adapting traditional group-treatment methods for working with individuals with reduced cognitive capacity secondary to acquired brain injury. Using the classification system based on functional ability developed at the NYU Rusk Institute of Rehabilitation Medicine (RIRM), we delineate the cognitive and interpersonal capabilities that differentiate group-participation capacity. An overview of the RIRM interventional process, including strategies of change (cognitive remediation versus psychosocial groups), is provided. Empirical support for the RIRM method of group assignment and treatment outcomes for our model is also referenced.

Anxiety as a primary predictor of functional impairment after acquired brain injury: a brief report.

OBJECTIVE Cognitive and emotional symptoms are primary causes of long-term functional impairment after acquired brain injury (ABI). Although the occurrence of post-ABI emotional difficulties is well-documented, most investigators have focused on the impact of depression on functioning after ABI, with few examining the role of anxiety. Knowledge of the latters impact is essential for optimal treatment planning in neurorehabilitation settings. The purpose of the present study is therefore to examine the predictive relationships between cognition, anxiety, and functional impairment in an ABI sample. METHOD Multiple regression analyses were conducted with a sample of 54 outpatients with ABI. Predictors selected from an archival data set included standardized neuropsychological measures and Beck Anxiety Inventory scores. Dependent variables were caregiver ratings of functional impairments in the Affective/Behavioral, Cognitive, and Physical/Dependency domains. RESULTS Anxiety predicted a significant proportion of the variance in caregiver-assessed real-life affective/behavioral and cognitive functioning. In contrast, objective neuropsychological test scores did not contribute to the variance in functional impairment. Neither anxiety nor neuropsychological test scores significantly predicted impairment in everyday physical/dependency function. CONCLUSION These findings support the role of anxiety in influencing functional outcome post-ABI and suggest the necessity of addressing symptoms of anxiety as an essential component of treatment in outpatient neurorehabilitation.

Gay Men Living with Chronic Illness or Disability

Abstract This paper examines the experiences of gay men living with disabilities or chronic illness from a social constructivist perspective. Emphasizing the sociocultural aspects of disability, such an approach recognizes that the questions asked and the answers given about disability are embedded in sociohistorical contexts, and that language both shapes and reveals underlying assumptions and behaviors related to disability. Using Kamenys (1971) concept of sociological minority, it is proposed that gay men and persons with disabilities constitute minority groups with experiences in common with those of other recognized minority groups. Implications for mental health practitioners providing services to gay men with disabilities are addressed.

Heart Rate Variability Biofeedback, Self-Regulation, and Severe Brain Injury

This article describes a study using heart rate variability (HRV) biofeedback to treat emotional dysregulation in 13 individuals with severe chronic brain injury. Measures included HRV indices, tests of attention and problem solving, and informant reports of behavioral regulation. Results demonstrated that individuals with severe brain injury were able to learn HRV biofeedback and increase coherence between the parasympathetic and sympathetic nervous systems. Individuals who attained the greatest coherence were rated as being able to best regulate their emotions and behavior.