Videogame-based group therapy to improve self-awareness and social skills after traumatic brain injury

[EN] Background: This study determines the feasibility of different approaches to integrative videogame-based group therapy for improving self-awareness, social skills, and behaviors among traumatic brain injury (TBI) victims and retrieves participant feedback. Methods: Forty-two adult TBI survivors were included in a longitudinal study with a pre- and post-assessments. The experimental intervention involved weekly one-hour sessions conducted over six months. Participants were assessed using the Self-Awareness Deficits Interview (SADI), Patient Competency Rating Scale (PCRS), the Social Skills Scale (SSS), the Frontal Systems Behavior Scale (FrSBe), the System Usability Scale (SUS). Pearson's chi-squared test (χ 2 ) was applied to determine the percentage of participants who had changed their clinical classification in these tests. Feedback of the intervention was collected through the Intrinsic Motivation Inventory (IMI). Results: SADI results showed an improvement in participant perceptions of deficits (χ 2 = 5.25, p < 0.05), of their implications (χ 2 = 4.71, p < 0.05), and of long-term planning (χ 2 = 7.86, p < 0.01). PCRS results confirm these findings (χ 2 = 5.79, p < 0.05). SSS results were also positive with respect to social skills outcomes (χ 2 = 17.52, p < 0.01), and FrSBe results showed behavioral improvements (χ 2 = 34.12, p < 0.01). Participants deemed the system accessible (80.43 ± 8.01 out of 100) and regarded the intervention as interesting and useful (5.74 ± 0.69 out of 7). Conclusions: Integrative videogame-based group therapy can improve self-awareness, social skills, and behaviors among individuals with chronic TBI, and the approach is considered effective and motivating.This study was funded in part by Ministerio de Economia y Competitividad of Spain (Project TEREHA, IDI-20110844; and NeuroVR, TIN2013-44741-R), by Ministerio de Educacion y Ciencia of Spain (Projects Consolider-C, SEJ2006-14301/PSIC; and "CIBER of Physiopathology of Obesity and Nutrition, an initiative of ISCIII"), and by the Excellence Research Program PROMETEO (Generalitat Valenciana. Conselleria de Educacion, 2008-157).Llorens Rodríguez, R.; Noé Sebastián, E.; Ferri, J.; Alcañiz Raya, ML. (2015). Videogame-based group therapy to improve self-awareness and social skills after traumatic brain injury. Journal of NeuroEngineering and Rehabilitation. 12(37):1-9. https://doi.org/10.1186/s12984-015-0029-1S191237Sherer M, Bergloff P, Levin E, High Jr WM, Oden KE, Nick TG. Impaired awareness and employment outcome after traumatic brain injury. J Head Trauma Rehabil. 1998;13(5):52–61.Sherer M, Hart T, Nick TG. Measurement of impaired self-awareness after traumatic brain injury: a comparison of the patient competency rating scale and the awareness questionnaire. Brain Inj. 2003;17(1):25–37.Simmond M, Fleming J. Occupational therapy assessment of self-awareness following traumatic brain injury: a literature review. Br J Occup Ther. 2003;66:447–53.Bogod NM, Mateer CA, MacDonald SWS. Self-awareness after traumatic brain injury: a comparison of measures and their relationship to executive functions. J Int Neuropsychol Soc. 2003;9(03):450–8.Stuss DT, Levine B. Adult clinical neuropsychology: lessons from studies of the frontal lobes. Annu Rev Psychol. 2002;53:401–33.Ham TE, Bonnelle V, Hellyer P, Jilka S, Robertson IH, Leech R, et al. The neural basis of impaired self-awareness after traumatic brain injury. Brain. 2014;137(Pt 2):586–97.Prigatano GP, Schacter DL. Awareness of Deficit After Brain Injury: Clinical and Theoretical Issues. New York: Oxford University Press; 1991.Katz N, Fleming J, Keren N, Lightbody S, Hartman-Maeir A. Unawareness and/or denial of disability: implications for occupational therapy intervention. Can J Occup Ther. 2002;69(5):281–92.Fleming JM, Strong J, Ashton R. Self-awareness of deficits in adults with traumatic brain injury: how best to measure? Brain Inj. 1996;10(1):1–15.Goverover Y, Johnston MV, Toglia J, Deluca J. Treatment to improve self-awareness in persons with acquired brain injury. Brain Inj. 2007;21(9):913–23.Bach LJ, David AS. Self-awareness after acquired and traumatic brain injury. Neuropsychol Rehabil. 2006;16(4):397–414.Prigatano GP. Behavioral Limitations TBI patients tend to underestimate: a replication and extension to patients with lateralized cerebral dysfunction. Clin Neuropsychol. 1996;10(2):191–201.Sherer M, Boake C, Levin E, Silver BV, Ringholz G, High WM. Characteristics of impaired awareness after traumatic brain injury. J Int Neuropsychol Soc. 1998;4(04):380–7.Sveen U, Mongs M, Roe C, Sandvik L, Bautz-Holter E. Self-rated competency in activities predicts functioning and participation one year after traumatic brain injury. Clin Rehabil. 2008;22(1):45–55.Crosson B, Barco PP, Velozo CA, Bolesta MM, Cooper PV, Werts D, et al. Awareness and compensation in postacute head injury rehabilitation. J Head Trauma Rehabil. 1989;4(3):46–54.Toglia J, Kirk U. Understanding awareness deficits following brain injury. NeuroRehabilitation. 2000;15(1):57–70.Schrijnemaekers AC, Smeets SM, Ponds RW, van Heugten CM, Rasquin S. Treatment of unawareness of deficits in patients with acquired brain injury: a systematic review. J Head Trauma Rehabil. 2014;29(5):E9–30.Tate R, Kennedy M, Ponsford J, Douglas J, Velikonja D, Bayley M, et al. INCOG recommendations for management of cognition following traumatic brain injury, part III: executive function and self-awareness. J Head Trauma Rehabil. 2014;29(4):338–52.Chittum WR, Johnson K, Chittum JM, Guercio JM, McMorrow MJ. Road to awareness: an individualized training package for increasing knowledge and comprehension of personal deficits in persons with acquired brain injury. Brain Inj. 1996;10(10):763–76.Zhou J, Chittum R, Johnson K, Poppen R, Guercio J, McMorrow MJ. The utilization of a game format to increase knowledge of residuals among people with acquired brain injury. J Head Trauma Rehabil. 1996;11(1):51–61.Ownsworth TL, McFarland K, Mc Young R. Self-awareness and psychosocial functioning following acquired brain injury: an evaluation of a group support programme. Neuropsychol Rehabil. 2000;10(5):465–84.Lundqvist A, Linnros H, Orlenius H, Samuelsson K. Improved self-awareness and coping strategies for patients with acquired brain injury–a group therapy programme. Brain Inj. 2010;24(6):823–32.Schmidt J, Lannin N, Fleming J, Ownsworth T. Feedback interventions for impaired self-awareness following brain injury: a systematic review. J Rehabil Med. 2011;43(8):673–80.Schmidt J, Fleming J, Ownsworth T, Lannin NA. Video feedback on functional task performance improves self-awareness after traumatic brain injury: a randomized controlled trial. Neurorehabil Neural Repair. 2013;27(4):316–24.McGraw-Hunter M, Faw GD, Davis PK. The use of video self-modelling and feedback to teach cooking skills to individuals with traumatic brain injury: a pilot study. Brain Inj. 2006;20(10):1061–8.Ownsworth T, Quinn H, Fleming J, Kendall M, Shum D. Error self-regulation following traumatic brain injury: a single case study evaluation of metacognitive skills training and behavioural practice interventions. Neuropsychol Rehabil. 2010;20(1):59–80.Lucas SE, Fleming JM. Interventions for improving self-awareness following acquired brain injury. Aust Occup Ther J. 2005;52(2):160–70.Malec JF, Brown AW, Leibson CL, Flaada JT, Mandrekar JN, Diehl NN, et al. The mayo classification system for traumatic brain injury severity. J Neurotrauma. 2007;24(9):1417–24.Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189–98.Nakase-Thompson R, Manning E, Sherer M, Yablon SA, Gontkovsky SL, Vickery C. Brief assessment of severe language impairments: initial validation of the Mississippi aphasia screening test. Brain Inj. 2005;19(9):685–91.Prigatano GP, Fordyce DJ. Neuropsychological rehabilitation after brain injury. Baltimore: The Johns Hopkins University Press; 1986.Gismero E. EHS, Escala de habilidades sociales. TEA: Madrid; 2000.Reid-Arndt SA, Nehl C, Hinkebein J. The Frontal Systems Behaviour Scale (FrSBe) as a predictor of community integration following a traumatic brain injury. Brain Inj. 2007;21(13–14):1361–9.Brooke J. SUS: A quick and dirty usability scale. In Usability evaluation in industry. PW Jordan, et al. Editors. Taylor and Francis; 1996Plant RW, Ryan RM. Intrinsic motivation and the effects of self-consciousness, self-awareness, and ego-involvement: An investigation of internally controlling styles. J Pers. 1985;53(3):435–49.Cheng SK, Man DW. Management of impaired self-awareness in persons with traumatic brain injury. Brain Inj. 2006;20(6):621–8.Ownsworth T, Fleming J, Shum D, Kuipers P, Strong J. Comparison of individual, group and combined intervention formats in a randomized controlled trial for facilitating goal attainment and improving psychosocial function following acquired brain injury. J Rehabil Med. 2008;40(2):81–8.Ownsworth T, Fleming J, Desbois J, Strong J, Kuipers P. A metacognitive contextual intervention to enhance error awareness and functional outcome following traumatic brain injury: a single-case experimental design. J Int Neuropsychol Soc. 2006;12(1):54–63.Fleming JM, Lucas SE, Lightbody S. Using occupation to facilitate self-awareness in people who have acquired brain injury: a pilot study. Can J Occup Ther. 2006;73(1):44–55.McDonald S, Tate R, Togher L, Bornhofen C, Long E, Gertler P, et al. Social skills treatment for people with severe, chronic acquired brain injuries: a multicenter trial. Arch Phys Med Rehabil. 2008;89(9):1648–59.Schefft BK, Malec JF, Lehr BK, Kanfer FH. The role of self-regulation therapy with the brain-injured client. In: Maurish ME, Moses JA, editors. Clinical neuropsychology: theoretical foundations for practitioners. Mahwah, NJ: Erlbaum; 1997. p. 237–82.Pollens RD, McBratnie BP, Burton PL. Beyond cognition: executive functions in closed head injury. Cogn Rehabil. 1988;6(5):26–32.Carbery H, Burd B. Social aspects of cognitive retraining in an outpatient group setting for head trauma patients. Cogn Rehabil. 1983;1:5–7.Bennett TL, Raymond MJ. Emotional consequences and psychotherapy for individuals with mild brain injury. Appl Neuropsychol. 1997;4(1):55–61.Delmonico RL, Hanley-Peterson P, Englander J. Group psychotherapy for persons with traumatic brain injury: management of frustration and substance abuse. J Head Trauma Rehabil. 1998;13(6):10–22.Alexy WD, Foster M, Baker A. Audio-visual feedback: an exercise in self-awareness for the head injured patient. Cogn Rehabil. 1983;1(6):8–10.Ranseen JD, Bohaska LA, Schmitt FA. An investigation of anosognosia following traumatic head injury. Int J Clin Neuropsychol. 1990;12(1):29–36.Sasse N, Gibbons H, Wilson L, Martinez-Olivera R, Schmidt H, Hasselhorn M, et al. Self-awareness and health-related quality of life after traumatic brain injury. J Head Trauma Rehabil. 2013;28(6):464–72.Malec JF, Testa JA, Rush BK, Brown AW, Moessner AM. Self-assessment of impairment, impaired self-awareness, and depression after traumatic brain injury. J Head Trauma Rehabil. 2007;22(3):156–66.Fleming JM, Ownsworth T. A review of awareness interventions in brain injury rehabilitation. Neuropsychol Rehabil. 2006;16(4):474–500