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• Unconscio

us ≤ 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 opportunitybrainline.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• 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

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 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: APTAttention 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.