Theodore Tsaousides

Cognitive rehabilitation following traumatic brain injury: Assessment to treatment

Cognitive rehabilitation refers to a set of interventions that aim to improve a persons ability to perform cognitive tasks by retraining previously learned skills and teaching compensatory strategies. Cognitive rehabilitation begins with a thorough neuropsychological assessment to identify cognitive strengths and weaknesses and the degree of change in cognitive ability following a brain injury. The conclusions of the assessment are used to formulate appropriate treatment plans. Common interventions for improvements in attention, memory, and executive function, as well as the nature of comprehensive programs, which combine treatment modalities, are reviewed. Cognitive rehabilitation is effective for mild-to-severe injuries and beneficial at any time post-injury. Sufficient evidence exists supporting the efficacy and effectiveness of cognitive rehabilitation, which has become the treatment of choice for cognitive impairments and leads to improvements in cognitive and psychosocial functioning.

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

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.

Suicidal ideation following traumatic brain injury: Prevalence rates and correlates in adults living in the community

Objective:To explore the rates of suicidal ideation (SI) in a sample of community-dwelling adults with traumatic brain injury (TBI) and to assess the relationship between SI and demographic and injury characteristics, pre- and postinjury psychiatric history, and psychosocial functioning. Participants:Data were collected from a cohort study focused on health, psychosocial functioning, and community integration post-TBI (N = 356). Participants were individuals with mild to severe TBI living in the community. Measures:The Beck Depression Inventory II (BDI-II) was used to assess SI. Psychiatric functioning was assessed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) Axis I disorders (SCID-I), and psychosocial functioning was assessed using the Life-3, the Flanagan Scale of Unmet Needs, and the Bigelow Quality of Life Questionnaire. Results:There were no differences in SI endorsement based on gender, age, race, income, education, injury severity, or length of time since injury. Those who met current criteria for a psychiatric diagnosis of depression, anxiety, or posttraumatic stress disorder reported SI more frequently. Those with SI reported significantly lower psychosocial functioning. Conclusion:Individuals with TBI from all demographic groups and with injuries of varying severity are at risk for SI and thus for emotional distress and suicidal behavior. Screening for SI is indicated in all individuals with TBI, particularly those with a history of premorbid substance misuse and concurrent mood and anxiety disorders. The importance of interventions to maximize social support and reduce social isolation is discussed.

Development of a theory-driven rehabilitation treatment taxonomy: conceptual issues.

Many rehabilitation treatment interventions, unlike pharmacologic treatments, are not operationally defined, and the labels given to such treatments do not specify the active ingredients that produce the intended treatment effects. This, in turn, limits the ability to study and disseminate treatments, to communicate about them clearly, or to train new clinicians to administer them appropriately. We sought to begin the development of a system of classification of rehabilitation treatments and services that is based on their active ingredients. To do this, we reviewed a range of published descriptions of rehabilitation treatments and treatments that were familiar to the authors from their clinical and research experience. These treatment examples were used to develop preliminary rules for defining discrete treatments, identifying the area of function they directly treat, and identifying their active ingredients. These preliminary rules were then tested against additional treatment examples, and problems in their application were used to revise the rules in an iterative fashion. The following concepts, which emerged from this process, are defined and discussed in relation with the development of a rehabilitation treatment taxonomy: rehabilitation treatment taxonomy; treatment and enablement theory; recipient (of treatment); essential, active, and inactive ingredients; mechanism of action; targets and aims of treatment; session; progression; dosing parameters; and social and physical environment. It is hoped that articulation of the conceptual issues encountered during this project will be useful to others attempting to promote theory-based discussion of rehabilitation effects and that multidisciplinary discussion and research will further refine these rules and definitions to advance rehabilitation treatment classification.

Toward a theory-driven classification of rehabilitation treatments.

Rehabilitation is in need of an organized system or taxonomy for classifying treatments to aid in research, practice, training, and interdisciplinary communication. In this article, we describe a work-in-progress effort to create a rehabilitation treatment taxonomy (RTT) for classifying rehabilitation interventions by the underlying treatment theories that explain their effects. In the RTT, treatments are grouped together according to their targets, or measurable aspects of functioning they are intended to change; ingredients, or measurable clinician decisions and behaviors responsible for effecting changes; and the hypothesized mechanisms of action by which ingredients are transformed into changes in the target. Four treatment groupings are proposed: structural tissue properties, organ functions, skilled performances, and cognitive/affective representations, which are similar in the types of targets addressed, ingredients used, and mechanisms of action that account for change. The typical ingredients and examples of clinical treatments associated with each of these groupings are explored, and the challenges of further subdivision are discussed. Although a Linnaean hierarchical tree structure was envisioned at the outset of work on the RTT, further development may necessitate a model with less rigid boundaries between classification groups, and/or a matrix-like structure for organizing active ingredients along selected continua, to allow for both qualitative and quantitative variations of importance to treatment effects.

Familiarity and prevalence of Facebook use for social networking among individuals with traumatic brain injury.

Objective: To examine use of Facebook among individuals with traumatic brain injury (TBI) and to identify barriers preventing Facebook use. Method: An online survey was developed assessing frequency and barriers to use of Facebook. The survey was distributed electronically to individuals with TBI through four state brain injury associations. Ninety-six individuals with TBI completed the survey (60% female, age range: 23–70). Results: The relative majority of respondents (60%) reported using Facebook on a regular basis. Among those who reported not using Facebook, the most commonly reported barriers were security concerns and cognitive deficits. Approximately half of non-users indicated interest in learning to use the site, with 70% reporting that they would use it more if they were more knowledgeable about it. Both users and non-users indicated that they would be interested in receiving training to learn how to use Facebook better. Conclusions: Social networking sites are increasingly important in creating and maintaining social networks. A significant number of survey respondents expressed interest in further training on Facebook use. Increased use of social networking may have important implications for social integration among individuals with TBI.

Comparison of cognitive behavioral therapy and supportive psychotherapy for the treatment of depression following traumatic brain injury: a randomized controlled trial.

Objective:To determine the efficacy of 2 different interventions (cognitive behavioral therapy [CBT] and supportive psychotherapy [SPT]) to treat post-traumatic brain injury (TBI) depression. Participants:A sample of 77 community-dwelling individuals with a TBI, and a diagnosis of depression. Participants were randomized into treatment conditions either CBT or SPT and received up to 16 sessions of individual psychotherapy. Measures:Participants completed the Structured Clinical Interview for DSM-IV and self-report measures of depression (Beck Depression Inventory-Second Edition), anxiety (State-Trait Anxiety Inventory), perceived social support (Interpersonal Support Evaluation List), stressful life events (Life Experiences Survey), and quality of life (QOL) before beginning and immediately following treatment. Results:No significant differences were found at baseline between CBT and SPT groups on demographic factors (sex, age, education, race, and time since injury) or baseline measures of depression, anxiety, participation, perceived social support, stressful life events, or QOL. Analyses of variance revealed significant time effects for the Beck Depression Inventory-Second Edition, State-Trait Anxiety Inventory, and QOL outcome measures but no group effects. Intention-to-treat mixed effects analyses did not find any significant difference in patterns of scores of the outcome measures between the CBT and SPT intervention groups. Conclusions:Both forms of psychotherapy were efficacious in improving diagnoses of depression and anxiety and reducing depressive symptoms. These findings suggest that in this sample of individuals with TBI, CBT was not more effective in treating depression than SPT, though further research is needed with larger sample sizes to identify different components of these interventions that may be effective with different TBI populations. ClinicalTrials.gov Identifier: NCT00211835

Objective and subjective assessment of long-term community integration in minority groups following traumatic brain injury.

Previous studies that used objective measures of community integration found that in the first year after injury, minority groups with traumatic brain injury (TBI) exhibit lower levels of community integration than White participants. The objective of this study was to determine if this discrepancy persists beyond one year post injury, and if assessing subjective components of community integration helps understand these differences. Participants were 360 community dwelling adults with TBI including 29% from minority backgrounds. Mean time post injury was 8.66 years (SD = 9.94). Main outcome measure utilized was the Participation Objective Participation Subjective (POPS). Multiple regression indicated that minority status predicted levels of transportation use (p < 0.01), with white participants reporting less use, after controlling for demographic and injury variables. When looking at subjective indicators, minority status predicted levels of dissatisfaction with community, civic, life and leisure participation (p < 0.01), and total levels of participation (p < 0.0125), with White participants reporting significantly less dissatisfaction. Findings indicate that differences between minorities and white participants in objective aspects of community integration after one year post-injury are only evident in levels of transportation use. However, when looking at subjective indicators differences between groups are present in other areas. These findings underscore the importance of considering the consumers subjective experience when providing services to minorities in a rehabilitation setting.

Delivering group treatment via videoconference to individuals with traumatic brain injury: a feasibility study.

The objective was to assess the feasibility of delivering a group treatment to improve emotional regulation via videoconferencing to individuals with traumatic brain injury (TBI). A pre–post feasibility study was undertaken. Seven individuals with TBI were recruited at a brain injury research centre in an urban medical centre. The main measures were therapist assessment of session-by-session progress and feasibility, Difficulties in Emotion Regulation Scale (DERS), Brain Injury Rehabilitation Trust Regulation of Emotions Questionnaire (BREQ), Satisfaction with Therapy and Therapist Scale (STTS), and exit interview. Attendance across sessions and participants was over 90%. Adequate skill acquisition and ease of use of the technology were demonstrated. Self-reported satisfaction with treatment was high. Participants noted several benefits in terms of the treatment delivery modality. There was no change is self-reported emotional dysregulation. This is the first study to report the use of videoconferencing for the delivery of group treatment to individuals with TBI. The exceptional compliance and self-reported satisfaction suggest that this treatment delivery option could be a viable alternative for increasing access to healthcare in this population. The findings of the study supported the development of a large clinical trial to assess treatment effectiveness.

Rehabilitation Treatment Taxonomy: Implications and Continuations

In relation to the conceptual framework for a rehabilitation treatment taxonomy (RTT), which has been proposed in other articles in this supplement, this article discusses a number of issues relevant to its further development, including creating distinctions within the major target classes; the nature and quantity of allowable targets of treatment; and bracketing as a way of specifying (1) the skill or knowledge taught; (2) the nature of compensation afforded by changes in the environment, assistive technology, and orthotics/prosthetics; and (3) the ingredients in homework a clinician assigns. Clarification is provided regarding the role of the International Classification of Functioning, Disability and Health, focusing a taxonomy on ingredients versus other observable aspects of treatment, and regarding our lack of knowledge and its impact on taxonomy development. Finally, this article discusses the immediate implications of the work to date and presents the need for rehabilitation stakeholders of all disciplines to be involved in further RTT development.