Thomas F. Bergquist

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.

Focused versus unstructured intervention for attention deficits after traumatic brain injury

Objective:To examine the effectiveness of focused versus unstructured cognitive remediation to address attention deficits following traumatic brain injury (TOO. Based on previous reports on postacute TBI subjects, it was hypothesized that focused intervention would yield superior results. Design:Intervention study with pre- and posttreatment data collection. Setting:Acute rehabilitation hospital. Patients:Sixty-one consecutive patients with severe TBI referred for cognitive remediation were randomly assigned to focused or unstructured remediation of attention deficits. From this sample, 22 pairs were selected, matched for age, education, time postonset of injury, and number of remediation sessions. Interventions:Structured, hierarchical interventions were presented to the focused group. The unstructured group participated in nonsequential, nonhierarchical activities. The average number of sessions was 20. Main Outcome Measures:Digit Span, Mental Control, Simple and Choice Reaction Time, Functional Independence Measure, selected neuropsychological tests. Results:No significant group differences were detected in attentional skills, functional skills, or general cognitive abilities. Conclusions:Progress in attentional skills during acute rehabilitation after TBI is similar with focused and unstructured cognitive remediation

Relationship Between Stress, Coping, and Postconcussion Symptoms in a Healthy Adult Population

Study 1 examined the association between intensity of postconcussive symptoms (PCS), impact of daily stress, and level of perceived stress over the past month in a group of healthy young adults. There was a significant relationship between intensity of PCS and impact of daily stress, as well as level of perceived stress over the past month, independent of the frequency of stressful events experienced. Study 2 assessed the stability of the relationship between PCS and stress. Subjects rated intensity of PCS, impact of daily stress, and level of perceived stress on two separate occasions approximately 1 month apart. The Perceived Stress Scale demonstrated high test-retest reliability. Significant relationships were again found between intensity of PCS and level of perceived stress at both time points, independent of the frequency of stressful events. These results suggest that persistent symptoms in some individuals with postconcussive syndrome may be due, at least in part, to individual differences in the perceived stress of incurring a mild traumatic brain injury.

Awareness and goal setting with the traumatically brain injured

One of the most disabling effects of traumatic brain injury is limited awareness of cognitive, emotional and interpersonal functioning. For this reason it is often difficult for a traumatically brain-injured person to form realistic goals and appreciate the need for rehabilitation. A goal-setting process is outlined in which therapists play a supportive but nondirective role and goals are developed which incorporate information in self-awareness. The aim of this approach is to create goals which are realistic and increase the likelihood of maintenance following treatment. Specific strategies to incorporate patient awareness during goal setting are discussed.

The effect of internet-based cognitive rehabilitation in persons with memory impairments after severe traumatic brain injury

Primary objective: The current study examined whether cognitive rehabilitation delivered over the Internet was associated with improvements in functioning. Research design: A total of 14 individuals with medically documented traumatic brain injury completed this study. Participants completed 30 sessions of an active calendar acquisition intervention and 30 sessions of a control diary intervention in a cross-over study design for a total of 60 online sessions. All sessions were completed using an instant messaging system via the Internet. Measures of cognitive functioning, ratings of memory and mood and frequency of use of common memory and cognitive compensation techniques were gathered from participants and family members. Main outcomes and results: There were no significant differences between the active and control conditions on the primary outcome measure of memory functioning. However, significant improvements in use of compensatory strategies as well as family reports of improved memory and mood were observed following completion of all sessions. Individuals with less use of compensatory strategies at baseline were significantly less likely to complete the study. Conclusions: These results suggest that the Internet may be an effective delivering mechanism for compensatory cognitive rehabilitation, particularly among individuals who are already utilizing some basic compensatory strategies.

Telehealth for persons with severe functional disabilities and their caregivers: facilitating self-care management in the home setting.

Persons with severe functional disabilities are the highest users of health care services. Caring for the needs of this population represents a significant percentage of our national health care costs. A growing body of research has demonstrated the efficacy of self-management strategies and caregiver engagement for effective long-term care for individuals with chronic medical conditions. Economic forces over the past decade have led to new challenges and resulted in major changes in health care delivery resulting in shortened length of inpatient stays and greater limits on the length of outpatient treatment. Telehealth is an innovative method for health care delivery and a means of meeting this new challenge. This article highlights the findings of 3 pilot studies on the use of telecommunications technologies in promoting self-care management and enhancing health care outcomes in persons with severe disabilities and their family caregivers. The importance of matching technology to the needs of this population, lessons learned from these investigations, and future directions for research are addressed.

Preinjury Predictors of Life Satisfaction at 1 Year After Traumatic Brain Injury

OBJECTIVE To investigate the predictive value of preinjury factors for satisfaction with life (SWL) at 1-year posttraumatic brain injury (TBI). DESIGN Secondary analysis of prospective, longitudinal registry using data collected during inpatient rehabilitation and at 1-year post-TBI. SETTING Fifteen specialized brain injury units providing acute rehabilitation care as part of the Traumatic Brain Injury Model Systems (TBIMS) program. PARTICIPANTS Community-dwelling persons (N=444) with moderate to severe TBI aged 16 to 64 years enrolled in the TBIMS program between October 2007 and October 2008 with 1-year follow-up data. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Satisfaction With Life Scale (SWLS). RESULTS Hierarchical stepwise linear regression revealed that injury-related and demographic variables did not contribute significantly to the explained variance in SWLS scores. In contrast, the preinjury functioning (education, productivity/employment) and preinjury condition (psychiatric and substance use problems, severe sensory dysfunction, learning problems, prior TBI) blocks each contributed significantly to the explained variance in SWLS scores. Preinjury functioning accounted for 2.9% of the variance and preinjury conditions for 3.8%. CONCLUSIONS Although their contributions are small, preinjury functioning and preinjury conditions are important to consider in the prediction of SWL post-TBI. Educational level and history of psychiatric and other premorbid difficulties are particularly important for clinicians to consider when implementing or developing interventions for persons with moderate to severe TBI.

Satisfaction ratings after receiving internet-based cognitive rehabilitation in persons with memory impairments after severe acquired brain injury

OBJECTIVE This study looked at patient satisfaction with an Internet-based cognitive rehabilitation program, which has been previously shown to be associated with functional improvements. MATERIALS AND METHODS Fourteen individuals with documented traumatic brain injury and memory impairments completed this study. Participants completed 60 sessions of Internet-based cognitive rehabilitation: 30 sessions of an active calendar intervention and 30 sessions of a control diary intervention. A four-question satisfaction questionnaire (responses were generated using a seven-point Likert scale) was completed after 30 sessions and again after 60 sessions. RESULTS No significant differences in satisfaction were found between time of assessment and treatment condition. In addition, a higher level of calendar use prior to beginning the study was associated with greater satisfaction at study completion. CONCLUSION These results suggest that persons with traumatic brain injury are not only willing to use the Internet to receive cognitive rehabilitation treatment, but are generally highly satisfied with the treatment. Further, individuals with some baseline compensatory strategies may be particularly well suited to this method of treatment.

Internet-based cognitive rehabilitation in individuals with acquired brain injury: A pilot feasibility study

Primary objective: The goal of the current study was to assess the feasibility of an Internet-based cognitive rehabilitation program for individuals with acquired brain injuries and memory impairment. Methods: Participants were 10 individuals with a history of an acquired brain injury and documented memory impairment. All participants received training in how to use a secure IM system. They were then scheduled to log into the system weekly to participate in online cognitive rehabilitation therapy sessions over the Internet. Treatment focused on training to use a calendar system aimed at improving accuracy and efficiency in home and work tasks. Participants underwent assessment of cognitive function, psychological status, level of functioning and use of compensation techniques both pre- and post-treatment. Results: All participants were able to learn to use the IM system. Only two of the 10 participants missed any planned sessions, despite severe memory impairments. Conclusions: Individuals with a history of an acquired brain injury with concomitant memory impairment appear to be able to learn how to successfully use an Internet-based cognitive rehabilitation program. Future research will assess whether participation in this Internet based cognitive rehabilitation program results in improved daily functioning.

Resilience Following Traumatic Brain Injury: A Traumatic Brain Injury Model Systems Study

OBJECTIVE To examine resilience at 3 months after traumatic brain injury (TBI). DESIGN Cross-sectional analysis of an ongoing observational cohort. SETTING Five inpatient rehabilitation centers, with 3-month follow-up conducted primarily by telephone. PARTICIPANTS Persons with TBI (N=160) enrolled in the resilience module of the TBI Model System study with 3-month follow-up completed. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Connor-Davidson Resilience Scale. RESULTS Resilience scores were lower than those of the general population. A multivariable regression model, adjusting for other predictors, showed that higher education, absence of preinjury substance abuse, and less anxiety at follow-up were significantly related to greater resilience. CONCLUSIONS Analysis suggests that lack of resilience may be an issue for some individuals after moderate to severe TBI. Identifying persons most likely at risk for low resilience may be useful in planning clinical interventions.