Effects of intensive neuropsychological rehabilitation for acquired brain injury

The objective of the study was to examine the effects of a comprehensive neuropsychological rehabilitation programme (Intensive NeuroRehabilitation, INR) on the emotional and behavioural consequences of acquired brain injury (ABI). The participants were 75 adult patients suffering from ABI (33 traumatic brain injury, 14 stroke, 10 tumour, 6 hypoxia, 12 other), all of whom were admitted to the INR treatment programme. The main outcome measures were: general psychological well-being (Symptom-Checklist-90), depression and anxiety (Beck Depression Inventory-II, Hospital Anxiety and Depression Scale, State Trait Anxiety Inventory), and quality of life (Quality of Life in Brain Injury). The study was a non-blinded, waiting-list controlled trial. During the waiting-list period no or minimal care was provided. Multivariate analysis of the main outcome measures showed large effect sizes for psychological well-being (partial η²?=?.191, p?η²?=?.168, p?η²?=?.182, p?η²?=?.130, p?=?.001). Changes on neuropsychological tests did not differ between the groups. It was concluded that the INR programme improved general psychological well-being, depressive symptoms, anxiety, and quality of life. The programme does not affect cognitive functioning.     

Music evoked autobiographical memory after severe acquired brain injury: Preliminary findings from a case series

Music evoked autobiographical memories (MEAMs) have been characterised in the healthy population, but not, to date, in patients with acquired brain injury (ABI). Our aim was to investigate music compared with verbal evoked autobiographical memories. Five patients with severe ABI and matched controls completed the experimental music (MEAM) task (a written questionnaire) while listening to 50 “Number 1 Songs of the Year” (from 1960 to 2010). Patients also completed the Autobiographical Memory Interview (AMI) and a standard neuropsychological assessment. With the exception of Case 5, who reported no MEAMs and no autobiographical incidents on the AMI and who also had impaired pitch perception, the range of frequency and type of MEAMs in patients was broadly in keeping with their matched controls. The relative preservation of MEAMs in four cases was particularly noteworthy given their impaired verbal and/or visual anterograde memory, and in three cases, autobiographical memory impairment. The majority of MEAMs in both cases and matched controls were of a person/people or a period of life. In three patients music was more efficient at evoking autobiographical memories than the AMI verbal prompts. This is the first study of MEAMs after ABI. The findings suggest that music is an effective stimulus for eliciting autobiographical memories, and may be beneficial in the rehabilitation of autobiographical amnesia, but only in patients without a fundamental deficit in autobiographical recall memory and intact pitch perception.     

Google Calendar: A new memory aid to compensate for prospective memory deficits following acquired brain injury

Prospective memory impairment is common following acquired brain injury (ABI) and intervention has proved challenging. The current treatment of choice involves using external memory aids as a method of compensation, with those incorporating active reminders proving most successful. In this paper we report findings of an investigation into the effectiveness of a novel external memory aid, Google Calendar. This aid incorporates active reminders and overcomes some of the limitations associated with existing aids. Twelve participants with ABI took part in the study incorporating a randomised control crossover within-subjects design, consisting of a 5-week baseline phase, followed by two 5-week intervention phases where either Google Calendar or a standard diary were used. Participants identified activities to target during the study and a family member monitored their success. Google Calendar was more effective than the diary in enhancing prospective memory performance. It also proved more popular, on account of its active reminders which helped trigger the retrieval of intentions, whilst reducing the need for monitoring. While further research is required to substantiate these initial findings, it is recommended that clinicians familiarise themselves with using Google Calendar, as it appears to offer additional potential in the management of prospective memory deficits following ABI.     

Technological memory aid use by people with acquired brain injury

Evans, Wilson, Needham, and Brentnall (2003 Evans, J. J., Wilson, B. A., Needham, P., &; Brentnall, S. (2003). Who makes good use of memory aids? Results of a survey of people with acquired brain injury. Journal of the International Neuropsychological Society, 9(6), 925–935. doi: 10.1017/S1355617703960127[Crossref], [PubMed], [Web of Science ®] , [Google Scholar]) investigated memory aid use by people with acquired brain injury (ABI) and found little use of technological memory aids. The present study aims to investigate use of technological and other memory aids and strategies 10 years on, and investigate what predicts use. People with ABI and self-reported memory impairments (n?=?81) completed a survey containing a memory aid checklist, demographic questions and memory questionnaires. Chi-square analysis showed that 10 of 18 memory aids and strategies were used by significantly more people in the current sample than in Evans et al. (2003 Evans, J. J., Wilson, B. A., Needham, P., &; Brentnall, S. (2003). Who makes good use of memory aids? Results of a survey of people with acquired brain injury. Journal of the International Neuropsychological Society, 9(6), 925–935. doi: 10.1017/S1355617703960127[Crossref], [PubMed], [Web of Science ®] , [Google Scholar]). The most commonly used strategies were leaving things in noticeable places (86%) and mental retracing of steps (77%). The most commonly used memory aids were asking someone to remind you (78%), diaries (77%), lists (78%), and calendars (79%) and the most common technologies used were mobile phone reminders (38%) and alarms/timers (38%). Younger people who used more technology prior to their injury and who use more non-technological memory aids currently were more likely to use technology. Younger people who used more memory aids and strategies prior to their injury and who rated their memory as poorer were more likely to use all types of memory aids and strategies.     

Effectiveness of an electronic cognitive aid in patients with acquired brain injury: A multicentre randomised parallel-group study

The objective of the study was to examine the effectiveness of a customised personal digital assistant (PDA) as a cognitive aid for people with acquired brain injury, using a randomised parallel-group study. The participants were 34 patients with acquired brain injury in a cognitive rehabilitation setting. The experimental group used a customised PDA, while the control group received care-as-usual (paper-and-pencil aids). Measurements were conducted at baseline (T0), after 8 hours of training (T1), after 16 hours of training (T2), and at 5-month follow-up (T3). The main outcome was the attainment of individualised goals. Both groups showed a significant increase in goal attainment (GAS) (p?<?.001). There were no significant differences between the groups at T1 or T2 on any of the other outcome measures. It was concluded that the customised PDA was as effective as paper-and-pencil aids, and may therefore serve as a useful alternative when choosing the optimal rehabilitation strategy for a patient.     

A randomised controlled crossover trial evaluating Television Assisted Prompting (TAP) for adults with acquired brain injury

Assistive technologies for cognition (ATC) provide an effective means to compensate for prospective memory failures among adults with acquired brain injury (ABI; de Joode, van Heugten, Verhey, & van Boxtel, 2010 de Joode, E., van Heugten, C., Verhey, F. and van Boxtel, M. 2010. Efficacy and usability of assistive technology for patients with cognitive deficits: A systematic review. Clinical Rehabilitation, 24: 701–714. doi:10.1177/0269215510367551[Crossref], [PubMed], [Web of Science ®] , [Google Scholar]; Sohlberg et al., 2007 Sohlberg, M. M., Kennedy, M., Avery, J., Coelho, C., Turkstra, L., Ylvisaker, M. and Yorkston, K. 2007. Evidence-based practice for the use of external aids as a memory compensation technique. Journal of Medical Speech-Language Pathology, 15(1): 15–51.  [Google Scholar]). This study evaluated a novel ATC device, the Television Assisted Prompting (TAP) system, which provides audiovisual reminders at scheduled prospective times on a person's home television. A randomised, controlled crossover design evaluated task completion for two preferred, two non-preferred, and two structured experimental tasks among 23 adults with ABI between two conditions: TAP prompting or typical (TYP) practice, without TAP reminders. Main outcomes showed a significant advantage of prospective memory prompting (72% completion) over no prompting (43% completion) and higher task completion with TAP prompting for researcher-assigned experimental tasks (81%) compared to self-selected preferred (68%) or non-preferred (68%) tasks. Results are discussed in the context of ATC efficacy to support prospective memory prompting following ABI, with contributions and future directions for continued investigation of customisation of prompts to maximise task completion.     

Outcomes of a community-based treatment programme for people with acquired brain injury in the chronic phase: a pilot study

The objective of the study was to evaluate the outcomes of Brainz, a low intensity community-based treatment programme for people with acquired brain injury (ABI). Participants were 62 people with sustained ABI (5.2 years post-injury, SD?=?4.5) and 35 family caregivers. Participants attended two to five cognitive and physical group modules and received two hours of individual home treatment every two weeks. Primary outcomes for people with ABI were participation, perceived difficulties in daily life and need of care, level of goal attainment, and self-esteem. Primary family caregiver outcome was perceived burden of care. Attrition rate of people with ABI was 24% (n?=?15), and of family caregivers was 31% (n?=?11). People with ABI were more satisfied with the level of their participation after completing Brainz (p?<?.01), but showed no change in participation frequency or in restrictions (both ps?>?.01). They perceived fewer difficulties in daily life and less need of care (both ps?<?.01). Also, in two cognitive modules people improved on their goal achievement (p?<?.01). However, their self-esteem was reduced (p?<?.01). Caregiver burden was reduced (p?<?.01). This study has provided preliminary evidence of the effectiveness of a combined group-based clinical and individual home-based treatment programme, but more research is needed, preferably in larger controlled studies.     

Effect of type of cue,type of response,time delay and two different ongoing tasks on prospective memory functioning after acquired brain injury

Failures of prospective memory (PM) are one of the most frequent, and least studied, sequelae of brain injury. PM, also referred to as memory for intentions, is the ability to remember to carry out a future task. Successful completion of a PM task requires the ability to monitor time, keep the action to be performed periodically in awareness, remember the task to be performed, and initiate the action. Although PM has been shown to be a common difficulty after brain injury, it remains unknown which aspects of performance are impaired. In this study, the performance of 25 individuals with brain injury and that of 25 healthy participants were measured separately on the following variables: time until completion of the task, difficulty of the ongoing task being performed while waiting, whether the task to be performed is an action or is verbal, and whether the cue to perform the task is the passing of a particular amount of time (e.g., 10 minutes) or is an external cue (e.g., an alarm sounding). Individuals with brain injury demonstrated impairment compared to healthy adults on virtually all variables. PM performance was also compared to a battery of standard neuropsychological measures of attention, memory, and executive functions, and to self-report measures of PM functioning, in order to determine the underlying cognitive deficits responsible for poor PM performance, if any. PM performance was correlated with measures of executive functioning but not to self-report measures of PM functioning. Implications are discussed in terms of cognitive rehabilitation recommendations.     

Management of spasticity and dystonia in children with acquired brain injury with rehabilitation and botulinum toxin A

Objective: To investigate the effect of a combination of botulinum toxin A (BTX-A) and rehabilitation on spasticity, pain and motor functioning in children with acquired brain injury (ABI).

Methods: All children and adolescents with ABI, aged 2–20 years, consecutively treated in the department over a 22-month period, were prospectively followed-up and clinically assessed pre- and post-treatment. They had spasticity and/or dystonia leading to impairment in activities of daily living, orthopaedic deformations and/or pain. Injections were performed using electro-stimulation. Doses of BTX-A (Botox®) were administered using recent recommendations.

Results: Twenty-five children (mean age 6.3 years) participated in the study (51 injection sessions). All patients received BTX-A injections, followed with physical and/or occupational therapy. Significant improvement was achieved for spasticity reduction (p < 0.0001), command on antagonist muscles (p = 0.03 for the tibialis anterior) and goniometry assessment (p < 0.05). Pain relief was achieved in patients in a minimally responsive state. Functional goals were achieved, such as improving transfers or gait, grasping and releasing abilities, with significant transfer in activities of daily living (p < 0.0001).

Conclusion: A combination of BTX-A injection with rehabilitation is an interesting option for treatment of muscle tone disorders in children with ABI.     

Wii-habilitation as balance therapy for children with acquired brain injury

Purpose: To evaluate the effectiveness of the Nintendo Wii compared to traditional balance therapy in improving balance, motivation, and functional ability in children undergoing acute rehabilitation after brain injury.

Methods: A non-concurrent, randomized multiple baseline single-subject research design was used with three participants. Data were analyzed by visual inspection of trend lines.

Results: Daily Wii balance training was equally motivating to traditional balance therapy for two participants and more motivating for one participant. While improvements in dynamic balance were observed, the results for static balance remain inconclusive. All participants demonstrated improvements in functional ability.

Conclusion: Wii balance therapy is a safe, feasible, and motivating intervention for children undergoing acute rehabilitation after an acquired brain injury. Further research to examine the effectiveness of Wii balance therapy in this population is warranted.     

Effects of a behaviour management technique for nursing staff on behavioural problems after acquired brain injury

The ABC method is a behaviour management technique for use by nurses. ABC refers to the identification of Antecedent events, target Behaviours, and Consequent events. In this longitudinal intervention study with double baseline measurements we evaluated the effectiveness of the ABC method in patients with behavioural problems after acquired brain injury. Fifty-six patients participated in this study. Outcome was measured in terms of overall neuropsychiatric problem behaviour, aggression, apathy and emotional burden experienced by nurses. A process evaluation was performed to investigate usability and acceptability of the method and identify factors that influenced effectiveness. Friedman’s ANOVA showed a small significant reduction over time in overall neuropsychiatric problem behaviour and aggression. The reduction was most prominent between the first baseline measurement and the post-implementation and follow-up measurements, not between the second baseline measurement and the post-implementation or follow-up measurements. This first group study on the effects of the ABC method could not prove this technique is effective for patients with behavioural problems after acquired brain injury. Nurses indicated that the ABC method was not fully implemented in their daily routines. This may have influenced results and makes it yet premature to draw firm conclusions on the effects of the ABC method.     

Comparing memory and meta-memory abilities between children with acquired brain injury and healthy peers

This study compared visual memory and meta-memory abilities of children with ABI to that of healthy peers. Participants included 16 children (aged 13.55 ± 3.29 years) with moderate or severe ABI and 16 healthy children (aged 12.44 ± 3.24 years) with typical development. Children completed the Contextual Memory Test for Children (CMT-CH). The study group showed significantly lower immediate and delayed recall abilities. While the controls used the context for better memorizing, most of the children with ABI used rehearsals. In both groups better delayed recall correlated with the use of a more efficient strategy. Meta-memory should be an integral part of the assessment for children with ABI. Therapists should enhance child's self-awareness to his/her abilities and encourage the use of strategies (e.g. context) for memorizing in daily life.     

Prospective memory intervention using visual imagery in individuals with brain injury

Prospective memory deficits are common after brain injury and can create impediments to independent living. Most approaches to management of such deficits are compensatory, such as the use of notebooks or electronic devices. While these can be effective, a restorative approach, in theory, could lead to greater generalisation of treatment. In the current study a metacognitive technique, using visual imagery, was employed under conditions of rote repetition and spaced retrieval. Treatment was provided in an AB-BA crossover design with A as the active treatment and B as a no-treatment attention control to 20 individuals with brain injury. A group of 20 healthy participants served to control for effects of re-testing. Individuals with brain injury demonstrated improvement on the main outcome measure of prospective memory, the Memory for Intentions Screening Test, only after the active treatment condition. In addition, some generalisation of treatment was measured in daily life. Moreover, treatment gains were maintained for one year after treatment was completed.     

The use of a smartwatch as a prompting device for people with acquired brain injury: a single case experimental design study

Prompting-based memory compensation is a potential application for smartwatches. This study investigated the usability and efficacy of a Moto360 smartwatch as a memory aid. Four community dwelling adults with memory difficulties following acquired brain injury (ABI) were included in an A-B-A single case experimental design study. Performance of everyday memory tasks was tested over six weeks with the smartwatch and software provided during weeks three and four. Participants were asked to use their usual memory aids and strategies during the control phases (weeks 1–2, 5–6). Three participants successfully used the smartwatch throughout the intervention weeks and gave positive usability ratings. A fourth participant experienced a seizure and subsequently left the study before the intervention phase. Three participants showed improved memory performance when using the smartwatch. Nonoverlap of all pairs (NAP) analysis showed a non-significant small increase in memory performance between baseline and intervention phases (mean NAP?=?0.1, p?=?.84). There was a larger, significant decline between the intervention and return to baseline (mean NAP?=?0.58, p?<?.01). The use of an off-the-shelf smartwatch device and software was feasible for people with ABI in the community. It was effective compared to practice as usual, although this was only apparent on withdrawal of the device.     

Factor analysis of the everyday memory questionnaire in persons with traumatic brain injury

Objectives: To investigate the factor structure of the Everyday Memory Questionnaire (EMQ) in persons with traumatic brain injury (TBI). Method: This was a secondary analysis of baseline data from two clinical trials targeting memory impairment after TBI. Participants were 169 persons with complicated mild, moderate, or severe TBI at an average of 41 months post-injury. They completed the EMQ via clinical interview. Exploratory factor analysis was conducted using a three-factor principal axis factoring estimation method with a polychoric correlation matrix and oblique rotation. Results: The three factors accounted for 49.2% of the variance, with moderate correlations observed among the factors. The three factors appeared to represent general everyday memory (prospective and episodic), conversational memory, and spatial or action memory. The three factors added significantly to the variance in age-corrected objective learning test scores predicted by injury severity, education, and sex. Conclusions: The three factors of the EMQ are consistent with the heterogeneity of memory impairments observed after TBI. The factor scores may be used to target treatments for impaired memory and to evaluate their effectiveness.     

Blissfully unaware: Anosognosia and anosodiaphoria after acquired brain injury

Historically, anosognosia referred to under-report of striking symptoms of acquired brain injury (e.g., hemiplegia) with debilitating functional consequences and was linked with anosodiaphoria, an emotional reaction of indifference. It was later extended to include under-report of all manner of symptoms of acquired brain injury by the patient compared to clinicians, family members, or functional performance. Anosognosia is related to time since onset of brain injury but not consistently to demographic variables, lesion location (except that it is more common after unilateral right than left hemispheric injury), or specific neuropsychological test scores. This review considers all manifestations of anosognosia as a unitary phenomenon with differing clinical characteristics dictated by variability in linked cognitive impairments. It is concluded that anosognosia has three chief contributing factors: (1) procedural: measurement differences across studies in terms of symptom selection and the designation of a “gold standard” of patient symptomatology; (2) psychological: a tendency towards positive self-evaluation and the avoidance of adverse information, that also occurs in neurologically intact individuals; and (3) neuropathological: an increased likelihood of error recognition failure from disconnections that disrupt feedback between injured brain regions governing specific behaviours (symptoms) and anterior cingulate/insular cortex. Anosodiaphoria is considered as an associated symptom, resulting from the same psychological and neuropathological factors.     

Neurobehavioural treatment for obsessive-compulsive disorder in an adult with traumatic brain injury

Although obsessive-compulsive disorder has been reported as one of many anxiety-related sequelae of brain injury, few empirical data of its responsiveness to psychological intervention are available. In this study, a single participant changing criterion experimental design was used to evaluate a neurobehavioural intervention for compulsive behaviour of an adult with severe traumatic brain injury. The participant, a man aged 24 years, had sustained frontal-temporal lobe brain trauma 12 months earlier, and presented with compulsive counting and voiding of bladder. The neurobehavioural intervention consisted of regular in-home consultations, self-regulation procedures including self-recording of compulsive behaviour, stress-coping strategies, errorless remediation, social reinforcement, and gradual fading of intervention. Baseline showed counting occurred on average 80% of daily hourly intervals, and voiding 12 times per day. Intervention produced elimination of compulsive counting, acceptable voiding at 8 times per day, and reports of the participant's satisfaction with intervention methods and outcomes. At 6 months follow-up, counting remained at zero levels, and voiding had decreased further to 7 times per day.     

Description of a multifaceted intervention programme for fatigue after acquired brain injury: a pilot study

The purpose of this pilot study was to describe and explore a group-based multifaceted intervention for patients with fatigue after acquired brain injury (ABI). We hypothesised that post-intervention changes would result in reduced fatigue, in addition to improved emotional health, sleep and attentional control. Eight subjects with traumatic brain injury (n?=?3) and cerebrovascular insults (n?=?5) were included. Inclusion was based upon the presence of fatigue complaints. The participants received 36 hours of intervention. Changes related to fatigue, emotional health and sleep was assessed with self-rating measures. Additionally, a neuropsychological test (Conners’ Continuous Performance Test II) was included as a measure of attentional control. All subjects were assessed at baseline, post-intervention, and at 3 and 9 months follow-up. Findings indicated reduced fatigue levels (post-intervention and 3 months follow-up), anxiety (9 months follow-up), and daytime sleepiness (3 and 9 months follow-up). Pilot results suggest that multifaceted group-based interventions may have the potential to alleviate symptoms of fatigue, anxiety and sleepiness after ABI. At an individual level, a low load of psychological distress, insomnia symptoms, dysexecutive symptoms, in addition to a strong sense of self-efficacy, may be central in order to reduce levels of fatigue.