Joshua Cantor

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.

Traumatic Brain Injury Rehabilitation: State of the Science

Gordon WA, Zafonte R, Cicerone K, Cantor J, Brown M, Lombard L, Goldsmith R, Chandna T: Traumatic brain injury rehabilitation: State of the science. Am J Phys Med Rehabil 2006;85:343–382.

The reliability and validity of the SF-36 health survey questionnaire for use with individuals with traumatic brain injury

In order to examine the reliability and validity of the SF-36 for use with individuals with TBI, the SF-36 and three measures of health-related problems in persons with TBI (BDI-II, TIRR Symptom Checklist, Health Problems List) were administered to 271 individuals without a disability, 98 individuals with mild TBI, and 228 individuals with moderate-severe TBI. Internal consistency (reliability) was demonstrated for all SF-36 scales. Significant correlations were found between the SF-36 scales and the other measures, with stronger correlations emerging in the TBI groups. The TBI groups obtained significantly lower SF-36 scores than the comparison group, and the mild TBI group scored lower than the moderate-severe group. For the most part, the differences between the TBI groups disappeared when BDI-II scores were controlled for. These findings suggest that the SF-36 is a reliable and valid measure for use with persons with TBI.

Peer support in the community: Initial findings of a mentoring program for individuals with traumatic brain injury and their families

Objectives:To evaluate the impact of a community-based peer support program for individuals and their family members following traumatic brain injury (TBI). Settings:Community-based sample of family members and individuals with traumatic brain injury. Participants:Twenty individuals who had participated in the peer support program (11 individuals with TBI and 9 family members). Main Outcome Measures:Quantitative and qualitative approaches were used: a retrospective structured interview assessing self-reported impacts of peer support on empowerment, quality of life, mood, skills and knowledge, and social supports; an in-depth qualitative interview with a subgroup of family members focused on the specific benefits/limitations of the peer support program. Results:Participants in the peer support program reported positive impacts of peer support on increasing their knowledge of TBI, enhancing their overall quality of life, improving their general outlook, and enhancing their ability to cope with depression post TBI. The peer support program was reported to have had a minimal impact on enhancing social support from families, friends, and the community, with varying impacts noted on levels of happiness, coping with anger and anxiety, communication with professionals, and control over ones life. Qualitative analysis suggests the merits of this type of community-based support and areas of improvement for the peer support program itself. Conclusions:Preliminary data suggest that peer support is a promising approach to enhancing coping for both individuals and their family members after TBI.

A Randomized Controlled Trial of Sertraline for the Treatment of Depression in Persons With Traumatic Brain Injury

OBJECTIVE To examine the efficacy of sertraline in the treatment of depression after traumatic brain injury (TBI). DESIGN Double-blind, randomized controlled trial. SETTING Research center at a major urban medical center. PARTICIPANTS Subjects were a referred and volunteer sample of 52 participants with TBI, a diagnosis of major depression disorder (MDD), and a score on the Hamilton Rating Scale for Depression (HAM-D) of 18 or greater. The majority of the sample was male (58%), had less than 14 years of education (73%), had incomes below

The Role of Self-discrepancy Theory in Understanding Post–traumatic Brain Injury Affective Disorders: A Pilot Study

20,000 (82%), and were from minority backgrounds (75%). Approximately one third of the sample had mild brain injuries, and two thirds had moderate to severe brain injuries. The mean age was 47+/-11, and the mean time since injury was 17+/-14 years. One participant withdrew from the study because of side effects. INTERVENTION Daily oral sertraline in doses starting at 25mg and increasing to therapeutic levels (up to 200mg) or placebo for 10 weeks. MAIN OUTCOME MEASURES The HAM-D, the Beck Anxiety Inventory, and the Life-3 quality of life (QOL). RESULTS No statistically significant differences were found at baseline between drug and placebo groups on baseline measures of depression (24.8+/-7.3 vs 27.7+/-7.0), anxiety (16.4+/-12.3 vs 24.0+/-14.9), or QOL (2.96+/-1.0 vs 2.9+/-0.9). The income level of those receiving placebo was significantly lower than those participants receiving medication. Analyses of covariance revealed significant changes from preintervention to posttreatment for all 3 outcome measures (P<.001) but no group effects. Random-effects modeling did not find any significant difference in patterns of scores of the outcome measures between the placebo and medication groups. CONCLUSIONS Both groups showed improvements in mood, anxiety, and QOL, with 59% of the experimental group and 32% of the placebo group responding to the treatment, defined as a reduction of a persons HAM-D score by 50%.

Objective measurement of fatigue following traumatic brain injury.

This pilot study examined the utility of self-discrepancy theory (SDT) in explaining post–traumatic brain injury (TBI) depression and anxiety. The SDT model was expanded to include the discrepancy between the postinjury self and the preinjury self. Study participants were 21 individuals with mild to severe TBI residing in the community, who completed the Selves Interview, the Selves Adjective Checklist, the Beck Depression Inventory–II and the Beck Anxiety Inventory. Strong correlations were found between affective distress and self-discrepancies, as measured by the checklist. Scores on the interview were not related to affective distress. The findings suggest that further research is merited to examine the utility of the SDT in addressing issues of post-TBI depression and anxiety.

Insomnia, fatigue, and sleepiness in the first 2 years after traumatic brain injury: an NIDRR TBI Model System Module study

ObjectivesTo quantify posttraumatic brain injury (post-TBI) mental fatigue objectively by documenting changes in performance on neuropsychological tests as a result of sustained mental effort and to examine the relationship between objectively measured mental fatigue and self-reported situational and day-to-day fatigue. ParticipantsThe study included 202 community-dwelling individuals with mild-severe TBI and 73 noninjured controls. MeasuresMeasures included Cambridge Neuropsychological Test Automated Battery, Global Fatigue Index, and situational fatigue rating. MethodSubjects were administered a 30-minute computerized neuropsychological test battery 3 times. The second and third administrations of the battery were separated by approximately 2 hours of interviews and administration of self-report measures. ResultsThe neuropsychological test scores were factor analyzed, yielding 3 subscales: speed, accuracy, and executive function. Situational fatigue and day-to-day fatigue were significantly higher in individual with TBI group than in individuals without TBI and were associated with speed subscale scores. Individuals with TBI evidenced a significant decline in performance on the accuracy subscale score. These declines in performance related to sustained mental effort were not associated with subjective fatigue in the TBI group. While practice effects on the speed and accuracy scores were observed in non–brain-injured individuals, they were not evidenced in individuals with TBI. ConclusionsFindings were largely consistent with previous literature and indicated that while subjective fatigue is associated with poor performance in individuals with TBI, it is not associated with objective decline in performance of mental tasks.

Treatment of Post-tbi Executive Dysfunction: Application of Theory to Clinical Practice

Objective:To determine the prevalence of insomnia and posttraumatic brain injury (TBI) fatigue (PTBIF) in individuals with moderate to severe TBI, to explore the relationship between PTBIF and insomnia and their association with outcomes. Design:Cross-sectional study. Setting:Five National Institute of Disability and Rehabilitation Research TBI Model Systems. Participants:Three hundred thirty-four individuals with TBI who completed 1-year (n = 213) or 2-year (n = 121) follow-up interviews between 2008 and 2012. Main Outcome Results:Insomnia occurred in 11% to 24% and PTBIF in 33% to 44% of the individuals. Insomnia and fatigue were both related to sleep disturbance, sleep hygiene, satisfaction with life, anxiety, and depression. PTBIF was associated with greater disability and sleepiness. Insomnia without fatigue was rare (2%-3%) but PTBIF without insomnia occurred in 21% to 23% of the individuals. Comorbidity occurred in 9% to 22% of the individuals. Conclusions:Although PTBIF and insomnia are closely related and both associated with poorer quality of life, they are affected independently by a variety of factors, especially psychopathology and sleep quality. A majority of individuals with PTBIF do not have insomnia; and PTBIF appears to be related to disability severity and daytime sleepiness, where insomnia is not. Demographic and injury variables are not strong predictors of insomnia or PTBIF.

The relationship between employment-related self-efficacy and quality of life following traumatic brain injury.

The authors propose a theory-based model for the treatment of post–traumatic brain injury executive dysfunction that integrates (1) theories of cerebral function and organization, (2) cognitive-behavioral theory of problem solving, and (3) learning theory. The model delineates appropriate targets of and methods for the treatment of executive dysfunction. A practical application of the theoretical model is described in the form of a comprehensive day treatment program, Executive Plus. A test of the model is also discussed, focused on the comparison of Executive Plus and a standard day treatment program along parameters dictated by the model.