Efficacy of Cognitive
and Behavioral
Interventions
after ABI
Kari Begnaud
Master of Occupational Therapy Student
LSU Health Shreveport
Objectives
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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
Causes
Falls
MVA
Blow to Head
Assault
Other
ginacarson.com
Glasgow Coma Scale
Glasgow Coma Score
braininjuryhawaii.com
Severity of Brain Injury
Mild Brain
Injury
Moderate
Brain Injury
Severe Brain
Injury
•Score 13-15
•Unconscious
≤ 30 minutes
•No PTA >24
hours
•Score 9-12
•Unconscious
30 minutes –
24 hours
•PTA
30 minutes –
24 hours
•Score ≤ 8
•Unconscious/
PTA > 24
hours
Purpose of Review
Cost to Society and Client
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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
Study Objective
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.
Search Strategies
Search Terms
• Brain Injury
• Cognitive
Rehabilitation
• Behavioral
Rehabilitation
• Occupational Therapy
Databases
• CINAHL
• Google Scholar
• PubMed
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
Study Criteria
Inclusion
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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
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Exclusion
Aphasia (2)
History of substance
abuse (2)
Previous injuries (10)
Deficits prior to ABI
(10)
Cognitive Rehabilitation
Interventions
• Functional Training in
vs. Cognitive Education
(Salazar et al., 2000)
• Attention Process
Training (Boman et al., 2004)
• Categorization
Program (CP) (Constantinidou et
al., 2008)
• 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
Behavioral Rehabilitation
Interventions
• Token Economy (Mottram & Berger-Gross, 2004)
o Response costs
o Mystery motivators
• Intensive positive supports (Gardner et al., 2003)
o Teenagers
• Operant conditioning-based behavioral
intervention (Slifer et al., 1995)
o 8 year old female
o PTA
Outcome Measurements
• Cognitive
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Interview process
Canadian Occupational Performance Measure (COPM)
Craig Handicap Assessment and Rating Technique-Revised (CHART)
Visual & Auditory Reaction Time Tests
Wechsler Intelligence Scale for Children III
• Behavioral
o Behavior Assessment System for Children Student Observation System
(BASC-SOS)
o Observations
• Qualitative
o Interview
o Questionnaires
Methodology
• Control Group (3)
• Randomized Groups (2)
• Small Sample Sizes (7)
o < 10 participants
• Inter-rater reliability (2)
• Inclusion/Exclusion Criteria
o No Mention
o Vague
• Large variability of intervention length
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: 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: CP
Categorization 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: PDA
Personal 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 Attention
Tests 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
References
Boman, 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, 935940.