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
ginacarson.com
Causes
FallsMVABlow to HeadAssaultOther
Glasgow Coma Scale
braininjuryhawaii.com
Glasgow Coma Score
Severity of Brain Injury
Mild Brain Injury
• Score 13-15
• Unconscious ≤ 30 minutes
• No PTA >24 hours
Moderate Brain Injury
• Score 9-12 • Unconscio
us 30 minutes – 24 hours
• PTA 30 minutes – 24 hours
Severe Brain Injury
• Score ≤ 8• Unconscio
us/ 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
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.
Study Objective
Search Terms Databases
• Brain Injury• Cognitive
Rehabilitation• Behavioral
Rehabilitation• Occupational
Therapy
• CINAHL• Google Scholar• PubMed
Search Strategies
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
• Ageo 6.7 to 66 years
• Gendero Predominately male
• Time since injuryo 77 days to 34 years
• Sample Sizeo 1 to 120 participants
Inclusion Exclusion• 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
• Aphasia (2)• History of
substance abuse (2)
• Previous injuries (10)
• Deficits prior to ABI (10)
Study Criteria
Cognitive Rehabilitation Interventions
• 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
• Functional Training in vs. Cognitive Education (Salazar et al., 2000)
• Attention Process Training (Boman et al., 2004)
• Categorization Program (CP) (Constantinidou et al., 2008)
Behavioral Rehabilitation Interventions
• Token Economy (Mottram & Berger-Gross, 2004)o Response costso Mystery motivators
• Intensive positive supports (Gardner et al., 2003)o Teenagers
• Operant conditioning-based behavioral intervention (Slifer et al., 1995)o 8 year old femaleo PTA
Outcome Measurements
• Cognitiveo Interview processo Canadian Occupational Performance Measure (COPM) o Craig Handicap Assessment and Rating Technique-Revised
(CHART)o Visual & Auditory Reaction Time Testso Wechsler Intelligence Scale for Children III
• Behavioral o Behavior Assessment System for Children Student Observation
System (BASC-SOS)o Observations
• Qualitativeo Interviewo Questionnaires
• Control Group (3)• Randomized Groups (2)• Small Sample Sizes (7)
o < 10 participants
• Inter-rater reliability (2)• Inclusion/Exclusion Criteria
o No Mentiono Vague
• Large variability of intervention length
Methodology
Limitations• Variability of sample sizes
o 1-120
• Variability in time since injuryo 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: CPCategorization 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: PDAPersonal 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 AttentionTests 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
ReferencesBoman, 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, 935-940.