Efficacy of Cognitive and Behavioral Interventions after ABI Kari Begnaud Master of Occupational Therapy Student LSU Health Shreveport Objectives • • • • • • • • • Background Purpose of Review Study Objective Search Strategies Summary of Study Procedures Methodology Outcomes Implications for OT Practice Implications for Future Research Background Acquired Brain Injury Causes Falls MVA Blow to Head Assault Other ginacarson.com Glasgow Coma Scale Glasgow Coma Score braininjuryhawaii.com Severity of Brain Injury Mild Brain Injury Moderate Brain Injury Severe Brain Injury •Score 13-15 •Unconscious ≤ 30 minutes •No PTA >24 hours •Score 9-12 •Unconscious 30 minutes – 24 hours •PTA 30 minutes – 24 hours •Score ≤ 8 •Unconscious/ PTA > 24 hours Purpose of Review Cost to Society and Client • • • • Financial Emotional Behavioral Cognitive Small window of opportunity brainline.org Types of Rehabilitation Cognitive Rehabilitation Behavioral Rehabilitation • Improves quality of life • Retrains the brain in organization • Patient education • Compensatory strategies • Adaptive devices • Retrain individuals with disruptive tendencies • Socially appropriate behavior • System of rewards & consequences Study Objective The objective of this review is to investigate the efficacy of cognitive rehabilitation and behavioral rehabilitation for individuals who have an acquired brain injury resulting in attention, memory, and behavioral deficits. Search Strategies Search Terms • Brain Injury • Cognitive Rehabilitation • Behavioral Rehabilitation • Occupational Therapy Databases • CINAHL • Google Scholar • PubMed Summary of Study Procedures Types of Studies • Prospective Randomized Controlled Trial (2) • One-group Pre-Post Study (2) • One-group Pre-Post Study/ Group Qualitative Study with Triangulation of Data (2) • Qualitative Inquiry • Case-Control Study with Pre-Existing Groups • Case-Control Study/ Group Qualitative Study with Triangulation of Data • Single-subject study Participants • Acquired Brain Injuries • Age o 6.7 to 66 years • Gender o Predominately male • Time since injury o 77 days to 34 years • Sample Size o 1 to 120 participants Study Criteria Inclusion • • • • • • • • ABI (10) Cognitive deficits (7) Behavioral outbursts (3) Family members/ caregivers willing to participate (2) Severity of Injury Good awareness of deficit & completed cognitive rehab program (1) Children 6-18 Adults 18-66 • • • • Exclusion Aphasia (2) History of substance abuse (2) Previous injuries (10) Deficits prior to ABI (10) Cognitive Rehabilitation Interventions • Functional Training in vs. Cognitive Education (Salazar et al., 2000) • Attention Process Training (Boman et al., 2004) • Categorization Program (CP) (Constantinidou et al., 2008) • Personal Digital Assistants (PDAs) (Gentry et al., 2008) • Amsterdam Memory and Attention Training for Children (AMAT-C) (van’t Hooft et al., 2003; Sjo et al., 2010) • Insight of deficits and its impact on use of compensatory strategies (Dirette, 2002) o Qualitative study Behavioral Rehabilitation Interventions • Token Economy (Mottram & Berger-Gross, 2004) o Response costs o Mystery motivators • Intensive positive supports (Gardner et al., 2003) o Teenagers • Operant conditioning-based behavioral intervention (Slifer et al., 1995) o 8 year old female o PTA Outcome Measurements • Cognitive o o o o o Interview process Canadian Occupational Performance Measure (COPM) Craig Handicap Assessment and Rating Technique-Revised (CHART) Visual & Auditory Reaction Time Tests Wechsler Intelligence Scale for Children III • Behavioral o Behavior Assessment System for Children Student Observation System (BASC-SOS) o Observations • Qualitative o Interview o Questionnaires Methodology • Control Group (3) • Randomized Groups (2) • Small Sample Sizes (7) o < 10 participants • Inter-rater reliability (2) • Inclusion/Exclusion Criteria o No Mention o Vague • Large variability of intervention length Limitations • Variability of sample sizes o 1-120 • Variability in time since injury o 77 days – 34 years • Lack of consistency • Length of intervention o Only 1 study looked at long-term effects Results Cognitive Outcomes: Setting Functional training in hospital setting vs. cognitive education in the home = no difference hickokcenter.org Cognitive Outcomes: APT Attention process training (APT) 3 month follow up improvements in: Attention Selective Attention Alternating Attention www.lapublishing.com/apt1-attention-process-training/ Cognitive Outcomes: CP Categorization Program (CP) Improvements in : o Ability to categorize familiar objects o Implement logical rules to categorize objects o Implement learned skills to categorize new objects Cognitive Outcomes: PDA Personal Digital Assistants (PDAs) o Pre & Post COPM o Pre & Post Satisfaction Cognitive Outcomes: AMAT-C • Amsterdam Memory and Attention Training for Children (AMAT-C) Greatest improvements in Sustained Attention Tests of Attention, Tempo, Visuo-Constructive, Learning and Memory, and Executive Functions www.pearson.com Cognitive Outcomes: Insight Insight of deficits and its impact on use of compensatory strategies qef.org.uk Behavioral Outcomes • Token Economy • Intensive positive supports • Operant conditioning-based behavioral intervention Discussion • Cognitive rehabilitation is effective • Behavioral intervention programs that use a reward system are effective Future Implications Implications for OT Practice • Understand phenomenological experience of ABI • Generalization of skills • Awareness and understanding of cause of deficit Implications for Future Research • In-depth qualitative exploration of phenomenological experience • Increased control/comparison groups • Stricter inclusion/exclusion criteria • Increased sample sizes • Consistency with interventions studied Questions References Boman, L., Lindsted, M., Hemmingsson, H., & Barfai, A. (2004). Cognitive training in home environment. Brain Injury, 18(10), 985-995. Centre for Neuro Skills. (2011). Overview of traumatic brain injury. Retrieved from http://www.neuroskills.com/tbi/injury.shtml Centers for Disease Control and Prevention. (2011, Octo 6). Traumatic brain injury. Retrieved from http://www.cdc.gov/traumaticbraininjury/ Constantinidou, F., Thomas, R.D., & Robinson, L. (2008). Benefits of categorization training in patients with traumatic brain injury during post-acute rehabilitation: Additional evidence from a randomized controlled trial. Journal of Head Trauma and Rehabilitation, 23(5), 312-328. Dirette, D. (2002). The development of awareness and the use of compensatory strategies for cognitive deficits. Brain Injury, 16(10), 861-871. Gardner, R.M., Bird, F.L., Maguire, H., Carriero, R., & Abenaim, N. (2003). Intensive positive behavior supports for adolescents with acquired brain injury; long-term outcomes in community settings. Journal of Head Trauma Rehabilitation, 18(1), 52-74. Gentry, T., Wallace, J., Kvarfordt, C., & Lynch, K.B. (2008). Personal digital assistants as cognitive aids for individuals with severe traumatic brain injury: A community-based trial. Brain Injury, 22(1), 19-24. References cont. Mottram, L., & Berger-Gross, P. (2004). An intervention to reduce disruptive behaviours in children with brain injury. Pediatric Rehabilitation, 7(2), 133-143. Salazar, A.M., Warden, D.L., Schwab, K., Spector, J., Braverman, S., & et al. (2000). Cognitive rehabilitation for traumatic brain injury, a randomized trial. Journal of American Medical Assoication, 283(23), 3075-3081. Sjo, N.M., Spellerberg, S., Weidner, S., Kihlgren, M. (2010). Training of attention and memory deficits in children with acquired brain injury. Acta Paediatrica, 99, 230-236. Slifer, K.J., Cataldo, M.D., & Kurtz, P.F. (1995). Behavioural training during acute brain trauma rehabilitation: an empirical case study. Brain Injury, 9(6), 585 – 593. The Brain Injury Recovery Network. (2003). The brain injury recovery network. Retrieved from http://tbirecovery.org/Overview.html van't Hooft, I., Andersson, K., Sejersen, T., Bartfai, A., & von Wendt, L. (2003). Attention and memory training in children with acquired brain injuries. Acta Paediatrica, 92, 935940.