Impaired self-awareness following acquired brain injury

Impaired self-awareness of everyday task ability following acquired brain injury (ABI) presents a serious obstacle to progress in rehabilitation. However, there is a lack of consensus about the optimal method of determining awareness level, how best to increase awareness, and even with regard to the very nature of impaired awareness. Awareness level is usually ascertained by comparing self/third party ratings of task performance. A behavioural measure of task performance would circumvent some of the concerns regarding the validity of methods relying solely on verbal report. Three main research questions were identified: 1. Is it possible to measure self-awareness of activity limitation and impairment? 2. Is it possible to increase self-awareness of activity limitation and impairment? 3. What is the nature of impaired awareness of activity limitation and impairment? To address these questions, the research programme had four phases: In phase 1, a cross-sectional design was used, incorporating behavioural observation and quantitative questionnaires, to develop a task battery that could be used as a behavioural measure of self-awareness. The resultant task battery consisted of six everyday tasks. In phase 2, a group comparison design was used to establish the sensitivity of the task battery to impaired self-awareness. Questionnaires were administered to obtain a quantitative measure of awareness - including social skills - in the acquired brain injury (ABI) participants. Eighteen ABI participants, identified as having impaired self-awareness, were compared with three comparison groups. The task battery was found to be sensitive to impaired awareness of everyday task ability. In phase 3, a single-case, experimental design methodology was attempted in two ABI participants to determine the effectiveness of interventions designed to increase awareness. Four ABI participants were followed up longitudinally, as natural history case studies, to ascertain changes in awareness over time, and critical incidents contributing to change. The intervention programmes were not found to be effective. Phase 4 included two qualitative studies to explore the nature of impaired awareness. In study 1, interview scripts from thirty-six clinicians were analysed thematically. In study 2, interview data from phase 3 were re-examined to explore 'objects' of awareness and factors contributing to fluctuations in awareness. Both phase 4 studies indicated that manifestations of impaired self-awareness were very varied in terms of 'objects' of awareness, severity of the awareness impairment, and the number of factors contributing. Impaired self-awareness is complex in nature, necessitating repeated measures, of verbal report and behaviour within variolls functional domains, to determine awareness level. Detailed examination of further single cases could help identify profiles of impaired self-awareness for which specific interventions and explanatory models could be developed. It is argued that intervention to address impaired selfawareness within the social skills domain should be prioritised

Occupational performance and information processing in adults with agitation following traumatic brain injury

Agitation following traumatic brain injury (TBI) is characterised by a heightened state of activity with disorganised information processing that interferes with learning and achieving functional goals. This thesis outlines a series of studies across four research phases, investigating how occupational performance of adults with TBI is affected by agitated behaviour and information processing difficulties. Clinicians report the presence of agitation interferes with engagement in therapy and achievement of rehabilitation goals. Research Phase One used a retrospective chart review of 80 adults with severe TBI to identify a high incidence of agitated behaviour during inpatient TBI rehabilitation. Agitated behaviour was associated with lengthier rehabilitation admission, prolonged duration of post-traumatic amnesia (PTA), and poor cognitive functioning at discharge. The association between agitation and poor cognition persisted for at least two years after discharge, highlighting the significant impact of agitated behaviour on people’s ability to relearn cognitive skills for daily function. These initial research findings directed subsequent research phases, in which an information processing model was adopted to examine application of cognitive strategies during occupational performance. An emerging occupational therapy assessment, The Perceive, Recall, Plan and Perform (PRPP) System of Task Analysis, was selected as the primary method for evaluating how application of cognitive strategies during occupational performance is affected in agitated patients. Clinical utility of this measure was established in a case study of an adult demonstrating severely agitated behaviour during inpatient TBI rehabilitation, followed by examination of instrument reliability and validity with ten experienced occupational therapists and five adults with agitated behaviour following brain injury. The PRPP System of Task Analysis emerged as a valid and reliable method for determining strategy application deficits during occupational performance of adults with agitated behaviour, in acute stages of TBI rehabilitation. Consistent patterns of processing deficits were related to the Perceive and Recall Quadrants of the PRPP System. The assessment tool forms part of a dynamic, interactive assessment and intervention system. The PRPP System of Intervention was evaluated in the final research phase, using an experimental single case design with replication across eight adults. The effectiveness of PRPP Intervention was examined in comparison to conventional occupational therapy in an ABAB design. Efficacy of the PRPP Intervention was demonstrated, with patients applying significantly more information processing strategies to occupational performance tasks during PRPP Intervention than during conventional occupational therapy sessions. Agitated behaviour concurrently reduced over the period of the study. Relationships between information processing and agitated behaviour are hypothesised

Occupational performance and information processing in adults with agitation following traumatic brain injury

Agitation following traumatic brain injury (TBI) is characterised by a heightened state of activity with disorganised information processing that interferes with learning and achieving functional goals. This thesis outlines a series of studies across four research phases, investigating how occupational performance of adults with TBI is affected by agitated behaviour and information processing difficulties. Clinicians report the presence of agitation interferes with engagement in therapy and achievement of rehabilitation goals. Research Phase One used a retrospective chart review of 80 adults with severe TBI to identify a high incidence of agitated behaviour during inpatient TBI rehabilitation. Agitated behaviour was associated with lengthier rehabilitation admission, prolonged duration of post-traumatic amnesia (PTA), and poor cognitive functioning at discharge. The association between agitation and poor cognition persisted for at least two years after discharge, highlighting the significant impact of agitated behaviour on people’s ability to relearn cognitive skills for daily function. These initial research findings directed subsequent research phases, in which an information processing model was adopted to examine application of cognitive strategies during occupational performance. An emerging occupational therapy assessment, The Perceive, Recall, Plan and Perform (PRPP) System of Task Analysis, was selected as the primary method for evaluating how application of cognitive strategies during occupational performance is affected in agitated patients. Clinical utility of this measure was established in a case study of an adult demonstrating severely agitated behaviour during inpatient TBI rehabilitation, followed by examination of instrument reliability and validity with ten experienced occupational therapists and five adults with agitated behaviour following brain injury. The PRPP System of Task Analysis emerged as a valid and reliable method for determining strategy application deficits during occupational performance of adults with agitated behaviour, in acute stages of TBI rehabilitation. Consistent patterns of processing deficits were related to the Perceive and Recall Quadrants of the PRPP System. The assessment tool forms part of a dynamic, interactive assessment and intervention system. The PRPP System of Intervention was evaluated in the final research phase, using an experimental single case design with replication across eight adults. The effectiveness of PRPP Intervention was examined in comparison to conventional occupational therapy in an ABAB design. Efficacy of the PRPP Intervention was demonstrated, with patients applying significantly more information processing strategies to occupational performance tasks during PRPP Intervention than during conventional occupational therapy sessions. Agitated behaviour concurrently reduced over the period of the study. Relationships between information processing and agitated behaviour are hypothesised

The Impact Of Neurological Fatigue On Linguistic Choices After TBI

Traumatic brain injury (TBI) is one of the leading causes of death or long-term disability in the United States. Individuals with these injuries must adapt to significant changes in neurological functioning, and oftentimes attention, memory, and processing difficulties mean that these individuals feel overwhelmed by the onslaught of information provided by the outside world, leading to mental fatigue. Mental fatigue, a common consequence of a TBI, may influence an individual’s ability to participate effectively in previous everyday work and social activities. Thus, it is not surprising that many individuals with TBI report significant fatigue. Research in the area of fatigue post injury has indicated that there is a relationship between fatigue and physical, cognitive, emotional, and social factors. Individuals with linguistic difficulties due to TBI related fatigue may experience difficulty with functional language, and understanding these deficits is critical for speech-language pathologists, who must understand the implications of fatigue on a client’s ability to communicate effectively. Systemic functional linguistics (SFL) is a theory of language use that focuses heavily on linguistic choices as influenced by social context. This research used principles from SFL to investigate the language use of one individual after a moderate-severe TBI. The individual’s interactions were analyzed to examine changes in her ability to successfully negotiate interactions that are secondary to the effects of fatigue. Overall findings indicated significant differences in the participant’s use of modality and appraisal between non-fatigued and fatigued samples. Differences include increases in the participant’s use of inclination and potential in modal auxiliaries, which demonstrate the participant’s aspirational tone during non-fatigued language samples, as well as increases in negative appraisal during fatigued samples, demonstrating negative emotional involvement in these exchanges. These differences are discussed in light of assessment and self-reported survey results and implications for treatment are outlined

Rehabilitation of executive function deficits following acquired brain injury: a randomised controlled trial using Goal Management Training and Implementation Intentions to improve prospective memory

Introduction: Deficits in executive function (e.g. planning, problem-solving, prospective memory) following brain injury are associated with significant negative social and occupational outcomes. Prospective memory (PM) is particularly susceptible to the effects of brain injury, as it relies on controlled attentional resources to establish and recall intentions. Implementation intentions (II) have been shown to improve performance on prospective memory tasks across a variety of durations, by circumventing controlled attention and establishing strong cue-action associations using imagery and declarative statements. Aims: To determine the efficacy of a theory-based training intervention for prospective memory deficits following acquired brain injury. Methods: A single-blind, randomised trial was used to assess the efficacy of implementation intentions as compared to a control intervention for individuals with acquired brain injury. A within-between repeated measures designs was used. Participants were assessed using an ecologically valid measure of executive function. Results: No significant differences in interaction effects were found according to treatment allocation. Use of baseline performance, estimated premorbid intelligence, depression, fluid intelligence and processing speed as covariates did not result in significant changes to the effectiveness of interventions. Discussion: The lack of treatment effect may be attributable to several factors, including the interaction of severity of impairments, length of training, and complexity of the outcome measure. The appropriateness of group designs when assessing neuropsychological rehabilitation is also discussed

A FUNCTIONAL ASSESSMENT OF EXECUTIVE FUNCTIONING: THE HAMBURGER TURNING TASK

The number of neuropsychological tests and functional assessments that claim to have a relationship between the patient's testing performance and behavior in real-world settings is limited. Additionally, there is a growing concern among testing professionals that most, if not all, psychological tests and standardized assessments introduce environments and stimuli that people never encounter and tasks that often do not emulate life situations or vocational requirements. In order to address the current issues surrounding the ecological validity of psychometric tests, this pilot study introduced a hands-on assessment using a simulated real-world vocational task. Twenty-three subjects between the ages of 18-26, with varying cognitive disabilities, completed a vocational simulation task, the Hamburger Turning Task (HTT), and the results were compared to their scores on a battery of commonly used neuropsychological tests (Wisconsin Card Sorting Test, Finger Tapping test, Controlled Oral Word Association Test, Trailmaking Test, Stroop Color-Word test) that purport to measure aspects of executive functioning analogous to those measured by the HTT. A Pearson-product correlation was run to compare the relationship between the scores from the HTT and the psychometric tests, as well as the relationship between both psychometric tests and HTT scores and daily behavioral observations of executive functioning related performance over a 7 week period. The results of the study found a significant correlation between the HTT and behavioral data, leading us to believe that the HTT can be used to evaluate real-world aspects of executive functioning. It was also found that there was a high level of interrater reliability on the scoring of the HTT, allowing future researchers to use this as a standardized tool

PROBLEM SOLVING OF TYPICALLY DEVELOPING CHILDREN ON AN ADAPTATION OF THE TWENTY QUESTIONS TASK

This cross sectional study examined problem solving by typically developing children on the Rapid Assessment of Problem Solving test (RAPS). The RAPS, a modification of Mosher and Hornsby’s 20Q task, requires the examinee to solve three problems. Each problem involves asking yes/no questions to identify a target picture from a 32-picture array with as few questions as possible. Participants were 73 young (ages 7-9), 79 early adolescent (ages 10-13) and 77 adolescent (ages 14-17) children residing in Kentucky. Children were seen in the summer months and administered the RAPS on a single occasion, with 22 of the children being testing twice. All children passed screening tasks and completed RAPS testing without difficulty. Test-retest stability for the RAPS was adequate for clinical purposes and no learning effects were seen on the test. Results were examined to identify group differences in components of executive functioning (planning, strategy selection, strategy execution, and strategy shifting) that impact problem solving efficiency. To determine how children went about solving problems, questions were classified by type and in terms of when they were asked in the sequence of questions leading to solving of a problem. Results revealed that the young group differed from the early adolescent and adolescent groups on several objective measures: number of questions to problem solve, use of constraint questions, problem solving efficiency, mean integration planning score, and overall RAPS efficiency. The young group also differed from the two older groups in terms of the types of questions asked and when certain types of questions were asked in solving a problem. Young children were more prone to guess on early questions whereas older children asked effective constraint questions. Many of the differences suggest young and older children and young and older adults differ in their ability to integrate information needed to solve RAPS problems effectively. Findings of this study suggest there are age-related differences in solving fixed-alternative 20Q problems and provide a normative data base for using the RAPS to assess problem solving of both normal and disabled children in the age range studied

Discourse Communication in Individuals with and without Traumatic Brain Injury

Traumatic brain injury (TBI) is a global health epidemic that has detrimental consequences for individuals who sustain the brain injury, their families, and society. As a result of TBI, many individuals experience significant cognitive-communicative impairments, including difficulties with structuring and eliciting discourse. The purpose of this study was to gain a better understanding of these language difficulties and their possible clinical implications by comparing discourse communication samples from adults with TBI to those from adults without TBI. Audio recordings of 18 adults, consisting of narratives on different genres of discourse communication (e.g., conversational, procedural, personal narrative, and fictional narrative), were used for the purposes of this project. The discourse samples of 4 individuals with TBI were compared with the discourse samples of 14 individuals without TBI on the basis of several discourse communication measures including: (1) story length, (2) frequency of discourse errors, (3) elements, (4) story organization, (5) information content, and (6) information relevance. Overall, the differences observed between the TBI and non-TBI individuals on the discourse communication tasks reflect the typical communication impairments experienced by those living with TBI. Compared to the discourse samples of participants without TBI, the individuals with TBI produced more linguistic dysfluencies and discourse errors which indicated impairments related to pragmatic skill, information transfer and relevance, linking the events in a story, and effectively structuring discourse communication. The participants without TBI showed strengths in the quality and completeness of their spoken narratives. Ultimately, the differences observed among participants from each group provide important insight into what types of speech-language therapy might be appropriate and effective for these individuals

An investigation into the ecological validity of virtual reality measures of planning and prospective memory in adults with acquired brain injury and Clinical research portfolio

Background: Improving the ecological validity of the assessment of executive functioning after brain injury has been an important focus of research in recent years. This study investigates the ecological validity of the “JAAM test”, a novel office-based virtual-reality task, in assessing real-life difficulties post-brain injury in the domains of planning and prospective memory. The comparative ecological validity of two traditional “desktop” tests for these domains and the convergent validity between the measures are also explored. Methods: Forty adults with an acquired brain injury completed the JAAM test, the Tower Test (a test of planning) and the Cambridge Prospective Memory Test (CAMPROMPT). Self and informant versions of questionnaires (the Dysexecutive Questionnaire; DEX) and the Prospective and Retrospective Memory Questionnaire (PRMQ) designed to measure real-life difficulties in these cognitive domains were also completed. Results: Significant correlations were observed between JAAM planning scores and the DEX (r = -.49), as well as between the Tower Test and the DEX (r = -.39). The difference between the strength of these correlations was not significant. Neither the JAAM prospective memory score nor CAMPROMPT scores correlated significantly with the PRMQ. Significant correlations were found between the JAAM and Tower Test (r = .33) and CAMPROMPT (rho = .59). Discussion: Results suggest the JAAM possesses at least similar ecological validity to traditional assessments of planning and prospective memory, and it also has convergent validity with these measures. Implications and limitations of the current study are discussed and recommendations for future research proposed

“I started to feel again.” : an individually guided dance rehabilitation intervention may enhance mood, abstract reasoning, and quality of life in traumatic brain injury : a pilot study

Tutkimuksen tarkoitus: Traumaattinen aivovamma on merkittävä kansanterveysongelma, jolla on pitkäaikaisia kognitiivisia, emotionaalisia ja fyysisiä seurauksia. Aivovammakuntoutukseen tarvitaan uusia, vaikuttavia, multimodaalisia ja monialaisia kuntoutuskäytäntöjä. Tanssi on multimodaalista ja aktivoi useita aivoalueita yhtä aikaa ja saattaa siten myös kuntouttaa monimutkaisia toimintoja. Tanssi myös yhdistää liikunnan ja musiikin, joilla kummallakin on positiivisia vaikutuksia sekä terveisiin että neuropatologisiin kohderyhmiin. Tutkimushankkeen tavoite oli kehittää monialainen tanssikuntoutusmenetelmä ja arvioida sen käytettävyyttä ja vaikuttavuutta vakavan aivovamman kroonisessa vaiheessa. Tässä tutkimuksessa tarkastellaan intervention vaikutuksia kognitioon, masentuneeseen mielialaan ja terveyteen liittyvään elämänlaatuun sekä arvioidaan menetelmän käytettävyyttä. Menetelmät: Tutkimukseen osallistui 11 vakavan traumaattisen aivovamman saanutta 19 – 45 -vuotiasta henkilöä, joista neljä oli naisia ja seitsemän miehiä. Tutkimuksen alkaessa vammautumisesta oli kulunut keskimäärin 7,6 vuotta. Tutkimuksessa käytettiin crossover-asetelmaa, jossa osallistujat satunnaistettiin kahteen ryhmään. Interventio kesti kolme kuukautta, sisälsi kaksi viikottaista tanssituntia ja sen toteuttivat yhdessä tanssinopettaja ja fysioterapeutti. Neuropsykologiset tutkimukset tehtiin tutkimuksen alussa (t0) ja kahdesti sen jälkeen kolmen kuukauden välein (t3 ja t6). Suoriutumista yleisen kognition, otsalohkotoimintojen, abstraktin päättelyn, visuospatiaalisen päättelyn ja työmuistin tehtävissä sekä itsearvioitua mielialaa, terveyteen liittyvää elämänlaatua ja toiminnanohjausta ennen interventiota ja sen jälkeen tutkittiin parittaisilla t-testeillä. Ryhmien eroavaisuuksia tutkittiin toistettujen mittausten varianssianalyyseillä. Tulokset: Abstrakti päättelykyky, terveyteen liittyvä elämänlaatu sekä merkittävimmin mieliala paranivat intervention aikana. Laadulliset löydökset kertoivat myös mielialan kohentumisesta. Eräs osallistujista kertoi saaneensa yhteyden tunteisiinsa ensimmäistä kertaa vammautumisen jälkeen ja useat muut osallistujat kuvasivat positiivisia tuntemuksia ja kokemuksia intervention aikana. Johtopäätökset: Tanssikuntoutus näyttää vaikuttavan positiivisesti mielialaan, abstraktiin päättelykykyyn sekä elämänlaatuun vakavan aivovamman kroonisessa vaiheessa. Tulokset ovat alustavia ja tarvitaan lisää tutkimuksia suuremmilla otoksilla vahvistamaan löydökset.Objective: Traumatic brain injury (TBI) is a major public health issue leading to long-term cognitive, emotional, and physical impairments. New, effective, multimodal and multidisciplinary rehabilitation practices are needed. Dance is a multimodal activity that engages several brain regions simultaneously and, therefore, might be ideal for enhancing complex functions. Dance also combines physical exercise and the use of music, both of which positively affect healthy and neuropathological populations. The aim of the research project was to develop a multidisciplinary dance rehabilitation method and to evaluate its feasibility and effectiveness in chronic severe TBI. The current study investigates the intervention’s effects on cognition, depressive mood, and health-related quality of life. The feasibility of the intervention is also discussed. Methods: The current study had 11 participants with severe TBI; four women and seven men, 19 – 45 years old, with an average time of 7.6 years from the acquisition of the injury. A two-group crossover design with random allocation was used. The intervention (three months, two weekly sessions) was carried out together by a dance instructor and a physiotherapist. Neuropsychological assessments were conducted at the beginning of the study (t0), and twice after that every three months (t3 and t6). Performance before and after the intervention in general cognition, frontal lobe functions, abstract reasoning, visuo-spatial reasoning, working memory, mood, health-related quality of life, and executive functions were compared with paired sample t-tests. Time and group interactions were studied by repeated measures analyses of variance. Results: Abstract reasoning, health-related quality of life, and most saliently, mood improved significantly during the intervention. Qualitative findings also indicated enhanced mood. One of the participants described being reconnected to emotions for the first time a after the acquisition of the TBI and several other participants expressed positive feelings and experiences during the intervention. Conclusions: The current study suggests that dance rehabilitation may improve mood, abstract reasoning, and quality of life in the chronic state of severe TBI. These results are tentative and more research with larger samples is needed to verify the findings