Teresa Ashman

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.

Participation Objective, Participation Subjective: A Measure of Participation Combining Outsider and Insider Perspectives

BackgroundParticipation now replaces community integration or handicap as concepts reflecting the social and interpersonal aspects of disability. If rehabilitation is to adequately measure participation, new measures of participation are needed. To represent the voice of the consumer, such measures should reflect not just “objective,” normative aspects, but also subjective ones, tapping the consumers view of participation. ObjectivesTo describe the development of and preliminary metrological information on a new measure of participation, Participation Objective, Participation Subjective (POPS). MethodsA total of 454 community-living individuals with traumatic brain injury (TBI) completed the POPS, as well as measures of quality of life (Life 3), depressive mood (BDI), and TBI symptoms (BISQ). The POPS requires reporting of the share of household activities performed, or the frequency or hours of nonhousehold activities. For each, the subject indicates whether he or she wants to perform more, the same, or less of the activity, and the importance of the activity to well-being. Five subscales and a total scale are calculated, for an objective component (PO), and a subjective component (PS) that reflects importance-weighted satisfaction with activity level. ResultsIndividuals with mild TBI scored minimally higher than those with moderate-severe TBI on PO subscores, but desired more change on the PS. Test-retest reliability for the PO and the PS and the subscales was from weak (intraclass correlation coefficient 0.28) to adequate (0.89), with PS components having better reliability. The PS component scores had the expected correlations with TBI symptoms, depressed mood, and life satisfaction, among both those with mild injury and those with moderate-severe injury. Injury severity and time since onset were not related to PO or PS scores. ConclusionsThe POPS shows promise as a measure of participation. It fills a void in that it reflects both insider and outsider perspectives on participation after TBI.

Construct Validity of the Posttraumatic Stress Disorder Checklist in Cancer Survivors: Analyses Based on Two Samples.

The measurement of posttraumatic stress disorder (PTSD) is critically important for the identification and treatment of this disorder. The PTSD Checklist (PCL; F. W. Weathers and J. Ford, 1996) is a self-report measure that is increasingly used. In this study, the authors investigated the factorial validity of the PCL with data from 236 cancer survivors who received a bone marrow or stem cell transplantation. The authors examined the fit of these data with the clinical model of 3 symptom clusters for PTSD, as proposed in the Diagnostic and Statistical Manual of Mental Disorders, and alternative models tested in prior research. By using confirmatory factor analysis the authors found that a 4-first-order-factor model of PTSD provided the best fit. The relations of PTSD symptoms with sociodemographic and medical variables were also explored.

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

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%.

A study of the efficacy of a comprehensive memory enhancement program in healthy elderly persons

OBJECTIVES This study examines the relative contribution of employment-related and general self-efficacy to perceptions of quality of life (QoL) for individuals with traumatic brain injury. DESIGN Correlational. SETTING Community-based research and training center. PARTICIPANTS 427 individuals with self-reported TBI under the age of 65 were included in analysis. MAIN OUTCOME MEASURE Employment-related self-efficacy, general self-efficacy, perceived quality of life (PQoL), unmet important needs (UIN). RESULTS Significant correlations were found between income, injury severity, age at injury, and employment and the QoL variables. In addition, employment-related and general self-efficacy correlated positively with both PQoL and UIN. Employment-related and general self-efficacy accounted for 16% of the variance in PQoL and 9.5% of the variance in UIN, over and above other variables traditionally associated with QoL. CONCLUSIONS These findings highlight the importance of including subjective appraisals of employment, such as perceived self-efficacy at the workplace, in assessing QoL and successful return to work following TBI.

Screening for substance abuse in individuals with traumatic brain injury

Well educated, high functioning older adults (ages 60-90) were given a comprehensive memory enhancement training program to determine the effectiveness of the program in increasing cognitive performance and positively influencing self-assessments of memory efficacy. The 68 subjects who participated in the memory enhancement training were compared to 74 subjects who were enrolled in a video control group. Between subject differences were analyzed prior to the interventions and at three time points following the interventions (immediately post, 3 months and 6 months). Only one cognitive measure, assessing verbal memory, revealed a significant difference between the groups, with participants in the memory enhancement group showing less decline from baseline than the video control group immediately following the intervention but with no difference between groups at 6 months post-intervention. Several self-report measures showed that the memory enhancement training subjects experienced improved memory functioning and decreased memory concerns relative to the video control group. The self-reported effects of the training were sustained over the 6-month follow-up period.

Does gender influence cognitive outcome after traumatic brain injury

Primary objective: To determine the utility of the CAGE, the Brief Michigan Alcohol Screening Test (BMAST) and the Substance Abuse Subtle Screening Inventory (SASSI-3) with individuals with traumatic brain injury (TBI), two studies were conducted examining the accuracy, sensitivity and specificity of these instruments. Research design: Data from self-report instruments were compared to a clinical interview, Structured Clinical Interview for DSM-IV (SCID), to determine the accuracy, sensitivity and specificity. Methods and procedures: Two studies were conducted. In study I, 100 individuals with TBI were screened for alcohol abuse using the CAGE and the resulting classifications were compared with those derived from the SCID. In study II, 223 individuals were screened for alcohol abuse and drug abuse using the BMAST and SASSI-3 and the results of these screenings were compared with diagnoses obtained by the SCID. Main outcomes and results: The specificity of the self-report instruments was moderately high, ranging between 81–83%. The specificity of the CAGE for alcohol abuse both pre- and post-TBI was high, 96% and 86%, respectively. The sensitivity of the self-report instruments was most variable, ranging from 32–95%, with the SASSI face valid drug scale and the CAGE alcohol post-TBI indicating the most sensitivity, 95 and 91%, respectively. Conclusions: The findings suggest that the CAGE may be useful in screening for alcohol abuse and the face valid drug sub-scale of the SASSI-3 may be useful in screening for drug abuse in individuals with TBI.

Co-Morbidity of Substance Abuse and Traumatic Brain Injury

The aim of this study was to determine whether males and females differ in post-acute cognitive outcome following traumatic brain injury (TBI). Performances of 83 men and 75 women with mild to severe TBI were compared on measures of cognitive functions typically impacted by TBI (i.e., processing speed, executive functioning, and memory). Participants completed selected subtests of the Cambridge Neuropsychological Test Automated Battery (CANTAB). Among the participants with mild TBI, women scored significantly higher than men on a test of visual memory. There were no other significant gender differences in cognitive outcomes. These findings overall suggest that cognitive outcome after TBI does not differ according to gender, with the possible exception of memory functioning. Further research is needed to replicate this finding and determine which moderating variables may impact on the relationship between gender and cognitive outcome after TBI.

Exploring the impact of traumatic brain injury on the older couple: ‘Yes, but how much of it is age, I can’t tell you …’

While there has been considerable research on the patterns of pre- and post-substance use among individuals with traumatic brain injury (TBI), little is known about the incidence of co-morbidity between TBI and substance abuse (SA) in individuals whose primary disorder is SA. In the current study, the prevalence of co-occurring TBI in individuals seeking treatment for SA was examined. A total of 845 individuals seeking treatment for SA in New York State were screened via the Brain Injury Screening Questionnaire for the presence of a co-morbid TBI. Results indicate that more than 50% of the sample had results that were positive for a TBI. On average, individuals reported a mean of 6 ± 8 blows to the head, with the number ranging from 0 to 57 and the average age of the first TBI being 14.5 years. Results indicate a high level of co-morbidity between TBI and SA and the need for routine screening for TBI in this population.