McKay Moore Sohlberg

Evaluation of Attention Process Training and Brain Injury Education in Persons with Acquired Brain Injury

Fourteen patients with stable acquired brain injuries exhibiting attention and working memory deficits were given 10 weeks of attention process training (APT) and 10 weeks of brain injury education in a cross-over design. Structured interviews and neuropsychological tests were used prior to rehabilitation and after both treatments to determine the influence of the interventions on tasks of daily life and performance on attentional networks involving vigilance, orienting, and executive function. The overall results showed that most patients made improvements. Some of these gains were due to practice from repetitive administration of the tests. In addition, the type of intervention also influenced the results. The brain injury education seemed to be most effective in improving self-reports of psychosocial function. APT influenced self-reports of cognitive function and had a stronger influence on performance of executive attention tasks than was found with the brain injury education therapy. Vigilance and orienting networks showed little specific improvement due to therapy. However, vigilance level influenced the improvement with therapy on some tests of executive attention. We consider the implications of these results for future studies of the locus of attentional improvement and for the design of improved interventions.

Intervention for executive functions after traumatic brain injury: A systematic review, meta-analysis and clinical recommendations

A systematic review of studies that focused on the executive functions of problem solving, planning, organising and multitasking by adults with traumatic brain injury (TBI) was performed through 2004. Qualitative and quantitative methods were used to evaluate the 15 studies that met inclusion criteria. Demographic variables, design and intervention features, and impairment and activity/participation outcomes (ICF) (World Health Organization, 2001) were documented. Five randomised control treatment (RCT) studies used step-by-step, metacognitive strategy instruction (MSI) and outcomes were evaluated in a meta-analysis. Effect sizes (ESs) from immediate impairment outcomes after MSI and “control” intervention were similar to each other, and both were significantly larger than chance. ESs from immediate activity/participation outcomes after MSI were significantly larger than the ESs from control intervention, and both were significantly larger than chance. These results, along with positive outcomes from the other group, single-subject design and single case studies, provided sufficient evidence to make the clinical recommendation that MSI should be used with young to middle-aged adults with TBI, when improvement in everyday, functional problems is the goal (Level A) (American Academy of Neurology, 2004). Although maintenance effects were generally positive, there was insufficient data quantitatively to evaluate this. Furthermore, there was insufficient evidence to make clinical recommendations for children or older adults. Intervention that trained verbal reasoning and multi-tasking was promising, although the evidence is insufficient to make clinical recommendations at this time. Additional research needs were highlighted.

Behavioural interventions for children and adults with behaviour disorders after TBI: A systematic review of the evidence

Objective: To systematically review the evidence for the effectiveness of behavioural interventions for children and adults with behaviour disorders after TBI. Design: Using a variety of search procedures, 65 studies were identified. This literature was reviewed using a set of questions about participants, interventions, outcomes and research methods. Participants: The 65 studies included 172 experimental participants, including children and adults. Interventions: A number of specific intervention procedures were used, falling into three general categories: traditional contingency management, positive behaviour interventions and supports and combined. Results: All of the studies reported improvements in behavioural functioning. Conclusions: Behavioural intervention, not otherwise specified, can be considered a treatment guideline for children and adults with behaviour disorders after TBI. Both traditional contingency management procedures and positive behaviour support procedures can be said to be evidence-based treatment options. However, a variety of methodological concerns block stronger conclusions.

Evidence-based practice guidelines for instructing individuals with neurogenic memory impairments: What have we learned in the past 20 years?

This article examines the instructional research literature pertinent to teaching procedures or information to individuals with acquired memory impairments due to brain injury or related conditions. The purpose is to evaluate the available evidence in order to generate practice guidelines for clinicians working in the field of cognitive rehabilitation. A systematic review of the instructional literature from 1986 to 2006 revealed 51 studies meeting search criteria. Studies were analysed and coded within the following four key domains: Population Sample, Intervention, Study Design, and Treatment Outcomes. Coding included 17 characteristics of the population sample; seven intervention parameters; five study design features; and five treatment outcome parameters. Interventions that were evaluated included systematic instructional techniques such as method of vanishing cues and errorless learning. The majority of the studies reported positive outcomes in favour of systematic instruction. However, issues related to the design and execution of effective instruction lack clarity and require further study. The interaction between the target learning objective and the individual learner profile is not well understood. The evidence review concludes with clinical recommendations based on the instructional literature and a call to clinicians to incorporate these methods into their practice to maximise patient outcomes.

PC-RE: a method for personal and contextual requirements engineering with some experience

A method for requirements analysis is proposed that accounts for individual and personal goals, and the effect of time and context on personal requirements. First a framework to analyse the issues inherent in requirements that change over time and location is proposed. The implications of the framework on system architecture are considered as three implementation pathways: functional specifications, development of customisable features and automatic adaptation by the system. These pathways imply the need to analyse system architecture requirements. A scenario-based analysis method is described for specifying requirements goals and their potential change. The method addresses goal setting for measurement and monitoring, and conflict resolution when requirements at different layers (group, individual) and from different sources (personal, advice from an external authority) conflict. The method links requirements analysis to design by modelling alternative solution pathways. Different implementation pathways have cost–benefit implications for stakeholders, so cost–benefit analysis techniques are proposed to assess trade-offs between goals and implementation strategies. The use of the framework is illustrated with two case studies in assistive technology domains: e-mail and a personalised navigation system. The first case study illustrates personal requirements to help cognitively disabled users communicate via e-mail, while the second addresses personal and mobile requirements to help disabled users make journeys on their own, assisted by a mobile PDA guide. In both case studies the experience from requirements analysis to implementation, requirements monitoring, and requirements evolution is reported.

Improving Attention and Managing Attentional Problems

Abstract: Research and clinical experience in the field of brain injury rehabilitation have focused quite extensively on the need and potential to retrain attentional skills that are commonly affected by acquired brain injury. Four approaches to managing attention impairments that have emerged from this literature include attention process training, training use of strategies and environmental support, training use of external aids, and the provision of psychosocial support. Most often, several of these will be used in combination. For example, a therapy regimen might include attention process training emphasizing specific components of attention (e.g., sustained attention), in conjunction with training in pacing techniques, and psychosocial support, where the client keeps behavioral logs and discusses insights gained from tracking attention successes and attention lapses. Although there are as yet little data with regard to the effectiveness of these approaches in adults with developmental disorders of attention, there is a growing literature suggesting they may be effective in children and adolescents with ADHD. Further investigation of the application of such techniques in adults with a wide variety of attention disorders, including developmental disorders, would be valuable.

Contemporary approaches to the management of executive control dysfunction

This article reviews a conceptual framework of frontal lobe functions based on the premise that there is a hierarchy of interrelated independent functions, each of which contains a feedback control system. This model provides a framework to assist clinicians in selecting appropriate interventions. Treatment options for managing executive control dysfunction are reviewed and related to the theoretical model.

A comparison of four prompt modes for route finding for community travellers with severe cognitive impairments.

Primary objective: Navigational skills are fundamental to community travel and, hence, personal independence and are often disrupted in people with cognitive impairments. Navigation devices are being developed that can support community navigation by delivering directional information. Selecting an effective mode to provide route-prompts is a critical design issue. This study evaluated the differential effects on pedestrian route finding using different modes of prompting delivered via a handheld electronic device for travellers with severe cognitive impairments. Research design: A within-subject comparison study was used to evaluate potential differences in route navigation performance when travellers received directions using four different prompt modes: (1) aerial map image, (2) point of view map image, (3) text based instructions/no image and (4) audio direction/no image. Methods and procedures: Twenty travellers with severe cognitive impairments due to acquired brain injury walked four equivalent routes using four different prompting modes delivered via a wrist-worn navigation device. Navigation scores were computed that captured accuracy and confidence during navigation. Main outcome: Results of the repeated measures Analysis of Variance suggested that participants performed best when given prompts via speech-based audio directions. The majority of the participants also preferred this prompting mode. Findings are interpreted in the context of cognitive resource allocation theory.

Personal and contextual requirements engineering

A framework for requirements analysis is proposed that accounts for individual and personal goals and the effect of time and context on personal requirements. The implications of the framework on system architecture are considered as three implementation pathways: functional specifications, development of customisable features and automatic adaptation by the system. These pathways imply the need to analyse system architecture requirements. Different implementation pathways have cost-benefit implications for stakeholders, so cost-benefit analysis techniques are proposed to assess tradeoffs between goals and implementation strategies. The use of the framework is illustrated with two case studies in assistive technology domains: e-mail and a personalised navigation system.

A pilot study exploring electronic (or e-mail) mail in users with acquired cognitive-linguistic impairments

This paper reports the results of an exploratory study into the usability of a simplified e-mail interface for eight individuals with acquired cognitive-linguistic impairments. Participatory Action Research, a qualitative research method, was used to capture the range of performance variables and to emphasize a user-centred approach to the research process. The participants were asked to read and reply to e-mails across four writing prompt conditions. An analysis of errors and participant preferences for the prototype e-mail system was conducted. Errors fell into two general categories: (1) computer usability (e.g. conceptual understanding of mouse/cursor operation) and (2) message composition (e.g. generating ideas for a message). Participant preferences for the writing prompt conditions varied considerably. All participants endorsed the use of customized e-mail interfaces as a means of connecting with friends and family, thereby reducing social isolation. Implications for interface design, rehabilitation and future research into assistive technology are discussed.