Tessa Hart

It's more than a black box; it's a Russian doll: defining rehabilitation treatments.

Whyte J, Hart T: It’s more than a black box; it’s a Russian doll: Defining rehabilitation treatments. Am J Phys Med Rehabil 2003;82:639–652.Research on treatment efficacy and effectiveness requires that the treatments of interest be objectively defined. Such definitions are relatively straightforward for pharmacologic and surgical treatments, in which the active ingredients can be specified in terms of chemical structure or anatomic result. Definitions of treatment are more difficult for the many experience-based interventions employed in rehabilitation. This has led to the criticism that much clinical rehabilitation research has characterized the treatments of interest as a “black box,” allowing little insight into the active ingredients contained therein. Moreover, rehabilitation care may involve the simultaneous application of multiple different treatments, raising the question of whether to define the individual components or the service delivery system. In this article, we consider how the levels of analysis considered in rehabilitation (disease, impairment, activity, and participation) and the role of theory shape the definition of treatment, and we address the need to develop protocol-based treatments and tools to objectively verify their contents. Rigorous definition of rehabilitation treatments, supported by theory, will facilitate needed efficacy research, will allow replication of that research, and will ultimately foster dissemination of effective treatments into clinical practice.

Treatment for Depression after Traumatic Brain Injury: A Systematic Review

The aim of this systematic review was to critically evaluate the evidence on interventions for depression following traumatic brain injury (TBI) and provide recommendations for clinical practice and future research. We reviewed pharmacological, other biological, psychotherapeutic, and rehabilitation interventions for depression following TBI from the following data sources: PubMed, CINAHL, PsycINFO, ProQuest, Web of Science, and Google Scholar. We included studies written in English published since 1980 investigating depression and depressive symptomatology in adults with TBI; 658 articles were identified. After reviewing the abstracts, 57 articles met the inclusion criteria. In addition to studies describing interventions designed to treat depression, we included intervention studies in which depressive symptoms were reported as a secondary outcome. At the end of a full review in which two independent reviewers extracted data, 26 articles met the final criteria that included reporting data on participants with TBI, and using validated depression diagnostic or severity measures pre- and post-treatment. Three external reviewers also examined the study methods and evidence tables, adding 1 article, for a total of 27 studies. Evidence was classified based on American Academy of Neurology criteria. The largest pharmacological study enrolled 54 patients, and none of the psychotherapeutic/rehabilitation interventions prospectively targeted depression. This systematic review documents that there is a paucity of randomized controlled trials for depression following TBI. Serotonergic antidepressants and cognitive behavioral interventions appear to have the best preliminary evidence for treating depression following TBI. More research is needed to provide evidence-based treatment recommendations for depression following TBI.

Journal of Head Trauma Rehabilitation: Preface

T BRAIN INJURY can often be associated with long-lasting symptoms and effects on function in a wide variety of areas. Expertise in the assessment and management of chronic physical, cognitive, and behavioral complaints is limited in many geographic areas, especially in rural America. Even in urban and suburban areas, the ability to fund treatment and education may be limited over the long course of recovery from and living with a chronic disorder. However, alternatives to face-to-face visits and therapy may be found through the blossoming of communication technologies. Few are without access to good reliable telephone services these days and, increasingly, Internet access is available through cable and wireless services. Audio and visual contact is possible with individuals and groups through various means. Facebook, Wikis, and Twitter, all new and innovative means of communication, are potentially available to extend the reach of the healthcare provider. Reaching out electronically to provide treatment and education to patients and caregivers is the focus of this issue of The Journal of Head Trauma Rehabilitation. Dr Bombardier and colleagues report on the results of a telephone-based counseling intervention aimed at educating and improving problem-solving skills of persons with moderate to severe traumatic brain injury with a range of depressive symptoms. Dr Wade and her group present their findings on using Web-based education and therapy to improve outcomes among children, adolescents, and their families. Finally, focusing on caregiver support and education, Dr Sander and her fellow investigators describe the use of videoconferencing technology to provide access to those living at a distance from the brain injury rehabilitation site. Many pilot research and clinical uses of Web-based communication technology can be found, particularly in the military (eg, www.afterdeployment.org) and veterans healthcare worlds. Little is currently known about how and who accesses these resources, how effective they are in terms of education and outcome, or how these electronic resources compare with more traditional avenues of education and treatment. Experience gained in other fields of healthcare will need to be evaluated in light of the special cognitive challenges our patients bring to the process, for both education and therapy. Definitions and measures of “dosing” for interventions delivered by telecommunication methods will require further explication. With respect to currently available funding, only face-to-face education and treatment are generally covered by insurers and healthcare intermediaries, funded by government. As these techniques are researched and further developed, the means of financing electronically mediated interventions will need to be resolved. We could not present these papers without stretching our own avenues of education and dissemination as well. We will be presenting a Webinar on this JHTR Telerehabilitation issue at 3 PM ET on August 6, 2009. Registration for the Webinar, part of the Mitch Rosenthal Memorial Lecture series, will be available in the bookstore of the Brain Injury Association of America in early July. The path is www.biausa.org. Click on Bookstore, and then click on Strauss and Rosenthal Lecture Series to register. More information can be obtained by contacting Marianna Abashian at mabashian@biausa.org.

Naturalistic action impairment in closed head injury.

The authors sought to determine whether errors of action committed by patients with closed head injury (CHI) would conform to predictions derived from frontal lobe theories. In Study 1, 30 CHI patients and 18 normal controls performed routine activities, such as wrapping a present, under conditions of graded complexity. CHI patients committed more errors even on the simplest condition; but, except for a higher proportion of omitted actions, their error profile was very similar to that of controls. Study 2 involved a subset of patients whose performance in Study 1 was within normal limits. When these high functioning patients were asked to perform the routine tasks under still more taxing conditions, they, too, committed errors in excess of the control group. Accounts based on frontal mechanisms have a difficult time explaining the overall pattern of findings. An alternative based on limited-capacity resources is suggested.

Effects of methylphenidate on attentional function after traumatic brain injury. A randomized, placebo-controlled trial.

Attention deficits after traumatic brain injury (TBI) are common and disabling. Many pharmacologic agents have been used to ameliorate attention deficits, and considerable interest has focused on methylphenidate (MP) because of its documented efficacy in attention deficit disorder. However, clinical studies of MP in subjects with TBI have yielded mixed results. We examined the effects of MP on attentional function in individuals with TBI referred specifically for attentional assessment and treatment. Subjects were studied in a double-blind, placebo-controlled, repeated crossover design, using five different tasks designed to measure various facets of attentional function. MP produced a significant improvement in the speed of mental processing. Orienting to distractions, most aspects of sustained attention, and measures of motor speed were unaffected. These results suggest that MP may be a useful treatment in TBI but is primarily useful for symptoms that can be attributed to slowed mental processing.

Naturalistic action production following right hemisphere stroke

An unselected group of right hemisphere, semi-acute stroke patients (n = 30) was run on a laboratory test of naturalistic action production and was found to commit errors of action at a higher rate than what was previously reported for recovering head injury patients [Schwartz et al., Naturalistic action impairment in closed head injury. Neuropsychology, 1997, 8, 59-72]. There were strong similarities in how these two patient groups responded to variations in task demands and in the pattern of errors they produced. Hemispatial biases were evident in the errors of right hemisphere patients with neglect but not those without neglect; and neglect patients also many errors that were unrelated to the spatial layout. We argue that a non-specific resource limitation--which might translate as reduced arousal or effort--is central to the breakdown of naturalistic action production after brain damage, and right hemisphere patients are especially vulnerable to this resource limitation and its behavioral consequences.

Use of a portable voice organizer to remember therapy goals in traumatic brain injury rehabilitation: a within-subjects trial.

Objective:To test the efficacy of a portable voice organizer in helping people with traumatic brain injury (TBI) to recall therapy goals and plans discussed with their clinical case managers. Design:Prospective within-subjects trial, in which individualized therapy goals were randomly assigned to intervention or no intervention. Setting:Comprehensive postacute TBI rehabilitation program. Participants:Ten people with moderate to severe TBI enrolled from 3 months to 18 years after injury. Outcome measure:Memory for therapy goals. Clinicians generated statements describing six current therapy goals, half of which were randomly assigned to be recorded on a voice organizer during the next case management session. Participants selected three times per day to listen to the recorded goals, prompted by an alarm. One-week recall was tested using both free- and cued-recall formats. Results:Recorded goals were recalled better than unrecorded goals and appeared to be associated with better awareness or follow-through with therapy objectives. Conclusion:Portable electronic devices have the potential to assist with treatment areas beyond tasks involving prospective memory.

Impact of Age on Long-Term Recovery From Traumatic Brain Injury

OBJECTIVE To determine whether older persons are at increased risk for progressive functional decline after traumatic brain injury (TBI). DESIGN Longitudinal cohort study. SETTING Traumatic Brain Injury Model Systems (TBIMS) rehabilitation centers. PARTICIPANTS Subjects enrolled in the TBIMS national dataset. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Disability Rating Scale (DRS), FIM instrument cognitive items, and the Glasgow Outcome Scale-Extended. RESULTS Participants were separated into 3 age tertiles: youngest (16-26y), intermediate (27-39y), and oldest (> or =40y). DRS scores were comparable across age groups at admission to a rehabilitation center. The oldest group was slightly more disabled at discharge from rehabilitation despite having less severe acute injury severity than the younger groups. Although DRS scores for the 2 younger groups improved significantly from year 1 to year 5, the greatest magnitude of improvement in disability was seen among the youngest group. In addition, after dividing patients into groups according to whether their DRS scores improved (13%), declined (10%), or remained stable (77%) over time, the likelihood of decline was found to be greater for the 2 older groups than for the youngest group. A multiple regression model showed that age has a significant negative influence on DRS score 5 years post-TBI after accounting for the effects of covariates. CONCLUSIONS This study supported our primary hypothesis that older patients show greater decline over the first 5 years after TBI than younger patients. In addition, the greatest amount of improvement in disability was observed among the youngest group of survivors. These results suggest that TBI survivors, especially older patients, may be candidates for neuroprotective therapies after TBI.

Executive function and self-awareness of "real-world" behavior and attention deficits following traumatic brain injury

ObjectiveTo investigate the relationship between executive function and awareness of real-world behavioral and attentional dysfunction in persons with moderate and severe traumatic brain injury (TBI) and uninjured controls. DesignObservational 2-group study. ParticipantsThirty-six persons with moderate to severe TBI and residual cognitive deficits, recruited from therapy programs and the community, and 30 uninjured control participants of similar age, education, gender, and race. MeasuresEight clinical measures of executive function were combined in a composite score, the Executive Composite (EC). Awareness of behavioral and attentional lapses in everyday life was estimated using Self and Significant Other (SO) ratings on the Dysexecutive (DEX) Questionnaire and the Cognitive Failures Questionnaire (CFQ). ResultsParticipants with TBI scored significantly worse on the EC than control participants and exhibited impaired self-awareness (ISA) compared to controls. Control participants agreed closely with their SOs on both the DEX and CFQ scales, whereas the SOs of TBI participants reported significantly greater degrees of difficulty on both scales than was endorsed by participants with TBI. Low-EC scorers within the TBI group had significantly worse ISA than controls, lending support to the hypothesis that executive function is related to ISA in chronic, moderate to severe TBI. Executive function and discrepancy scores demonstrated a modest but statistically significant association across the sample. ConclusionAlthough executive function was associated with ISA in this sample, further research is needed to determine whether executive function deficits contribute in a causal fashion to ISA, and which of the cognitive operations within executive function are responsible for supporting self-awareness.

Major and Minor Depression After Traumatic Brain Injury

OBJECTIVE To examine minor as well as major depression at 1 year posttraumatic brain injury (TBI), with particular attention to the contribution of depression severity to levels of societal participation. DESIGN Observational prospective study with a 2-wave longitudinal component. SETTING Inpatient rehabilitation centers, with 1-year follow up conducted primarily by telephone. PARTICIPANTS Persons with TBI (N=1570) enrolled in the TBI Model System database and followed up at 1-year postinjury. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES FIM, Patient Health Questionnaire-9, Participation Assessment with Recombined Tools-Objective, Glasgow Outcome Scale-Extended, and the Satisfaction With Life Scale. RESULTS Twenty-two percent of the sample reported minor depression, and 26% reported major depression at 1-year post-TBI. Both levels of depression were associated with sex (women), age (younger), preinjury mental health treatment and substance abuse, and cause of injury (intentional). There was a monotonic dose-response relationship between severity of depression and all 1-year outcomes studied, including level of cognitive and physical disability, global outcome, and satisfaction with life. With other predictors controlled, depression severity remained significantly associated with the level of societal participation at 1-year post-TBI. CONCLUSIONS Minor depression may be as common as major depression after TBI and should be taken seriously for its association to negative outcomes related to participation and quality of life. Findings suggest that, as in other populations, minor and major depression are not separate entities, but exist on a continuum. Further research should determine whether people with TBI traverse between the 2 diagnoses as in other patient groups.