Implementation of activities of daily living retraining for individuals in post-traumatic amnesia.

Background Despite evidence of the efficacy of activities of daily living (ADL) retraining during post-traumatic amnesia (PTA) following traumatic brain injury (TBI), utilisation of this intervention in practice is unclear. Utilising an implementation science framework, the Consolidated Framework for Implementation Research, this study explored efforts to translate ADL retraining during PTA into the clinical practice of occupational therapists (OTs) working in TBI rehabilitation settings across Australia. Methods Participants were 44 OTs who attended a day-long training workshop that included knowledge and skill-based content regarding ADL retraining during PTA. Baseline and post-training ratings were completed including evaluation of workshop utility, and skill and knowledge-based competencies relevant to the intervention. Approximately 2 years later, nine trained OTs and two administrators were interviewed to explore the results of implementing the intervention. Results Overall, the training workshop was rated as being helpful and OT ratings of confidence (P P Conclusion Multiple barriers were identified in implementation of ADL retraining during PTA and require consideration to facilitate translation and promote best practice.

INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part I: Posttraumatic Amnesia.

INTRODUCTION: Posttraumatic amnesia (PTA) is a common occurrence following moderate to severe traumatic brain injury (TBI) and emergence from coma. It is characterized by confusion, disorientation, retrograde and anterograde amnesia, poor attention and frequently, agitation. Clinicians and family need guidelines to support management practices during this phase. METHODS: An international team of researchers and clinicians (known as INCOG) met to update the INCOG guidelines for assessment and management of PTA. Previous recommendations and audit criteria were updated on the basis of review of the literature from 2014. RESULTS: Six management recommendations were made: 1 based on level A evidence, 2 on level B, and 3 on level C evidence. Since the first version of INCOG (2014), 3 recommendations were added: the remainder were modified. INCOG 2022 recommends that individuals should be assessed daily for PTA, using a validated tool (Westmead PTA Scale), until PTA resolution. To date, no cognitive or pharmacological treatments are known to reduce PTA duration. Agitation and confusion may be minimized by a variety of environmental adaptations including maintaining a quiet, safe, and consistent environment. The use of neuroleptic medications and benzodiazepines for agitation should be minimized and their impact on agitation and cognition monitored using standardized tools. Physical therapy and standardized activities of daily living training using procedural and errorless learning principles can be effective, but delivery should be tailored to concurrent levels of cognition, agitation, and fatigue. CONCLUSIONS: Stronger recommendations regarding assessment of PTA duration and effectiveness of activities of daily living training have been made. Evidence regarding optimal pharmacological and nonpharmacological management of confusion and agitation during PTA remains limited, with further research needed. These guidelines aim to enhance evidence-based care and maximize consistency of PTA management.

The Use of Atypical Antipsychotics for Managing Agitation After Traumatic Brain Injury.

OBJECTIVE: This study examined the use of antipsychotics for managing agitation during posttraumatic amnesia (PTA) after traumatic brain injury (TBI) and its relationship with agitated behavior. DESIGN: Observational prospective study with correlational design. SETTING: Inpatient rehabilitation hospital for TBI. PARTICIPANTS: A total of 125 consecutive admissions who were in PTA and had moderate-severe TBI. MEASURES: Antipsychotic use was compared with agitation levels as measured by the total scores on the Agitated Behavior Scale (ABS). RESULTS: Atypical antipsychotics were used in one-third of participants to manage agitation. Antipsychotic use was more common in participants with high levels of global agitation; however, there were many on antipsychotics who had mild or even no agitation according to the ABS. Uncontrolled observational data found no reduction in agitation after antipsychotic commencement or dose increase. CONCLUSIONS: Antipsychotics are commonly used to manage agitation after TBI despite limited evidence of efficacy. Agitation should be formally monitored in PTA to ensure antipsychotics are used to manage more severe agitation and for evaluating treatment response. Research is needed to understand why prescribers are using antipsychotics when agitation is mild or below clinical thresholds.

The relationship between agitation and impairments of orientation and memory during the PTA period after traumatic brain injury.

Agitation is common during the post-traumatic amnesia (PTA) period after traumatic brain injury (TBI), although our knowledge of what causes or predicts agitation is limited. The current study aimed to examine the association of agitation in PTA with the concurrent impairments in orientation and memory while controlling for covariates of agitation. Participants were 125 patients in PTA following moderate to extremely severe TBI recruited from an inpatient brain injury rehabilitation service who were assessed throughout PTA on the Agitated Behavior Scale (ABS) and the Westmead PTA Scale (WPTAS). Agitation was observed in 42.4% of participants (ABS score > 21), with disinhibited behaviours (e.g., distractibility and impulsivity) most common. Multilevel modelling found daily ABS scores to be associated with daily scores on the WPTAS but in a non-linear pattern. Analysis of covariates found that shorter time post-admission, younger age, presence of infection and higher antipsychotic doses were associated with higher ABS scores. These results support a relationship between agitation and the concurrent cognitive impairment during PTA. While a causal link cannot yet be inferred, management strategies that can potentially interfere with cognition (e.g., sedating medications, environmental changes) should be used cautiously in case they exacerbate agitation.

Economic Evaluation of Activities of Daily Living Retraining During Posttraumatic Amnesia for Inpatient Rehabilitation Following Severe Traumatic Brain Injury.

OBJECTIVE: To evaluate the cost-effectiveness of structured activities of daily living (ADL) retraining during posttraumatic amnesia (PTA) plus treatment as usual (TAU) vs TAU alone for inpatient rehabilitation following severe traumatic brain injury (TBI). DESIGN: Trial-based economic evaluation from a health-system perspective. SETTING: Inpatient rehabilitation center. PARTICIPANTS: Participants (N=104) admitted to rehabilitation and in PTA for >7 days following severe TBI. INTERVENTIONS: Structured ADL retraining during PTA plus TAU vs TAU alone. Structured ADL retraining was manualized to minimize the risk of agitation and maximize functional improvement, following principles of errorless and procedural learning and targeting individualized therapy goals. TAU included physiotherapy and/or speech therapy during PTA plus ADL retraining after PTA emergence. MAIN OUTCOME MEASURES: FIM total scores at baseline, PTA emergence, hospital discharge, or final follow-up (2mo postdischarge) where FIM total scores were calculated as the sum of 5 FIM motor self-care items and a FIM meal-preparation item. RESULTS: Structured ADL retraining during PTA significantly increased functional independence at PTA emergence (mean difference: 4.90, SE: 1.4, 95% confidence interval [CI]: 1.5, 8.3) and hospital discharge (mean difference: 5.22, SE: 1.4, 95% CI: 1.8, 8.7). Even in our most pessimistic scenario, structured ADL retraining was cost-saving as compared to TAU (mean: -$7762; 95% CI: -$8105, -$7419). Together, these results imply that structured ADL retraining dominates (less costly but no less effective) TAU when effectiveness is evaluated at PTA emergence and hospital discharge. CONCLUSIONS: Structured ADL retraining during PTA yields net cost-savings to the health system and offers a cost-effective means of increasing functional independence at PTA emergence and hospital discharge.

Activities of daily living retraining and goal attainment during posttraumatic amnesia.

It is uncertain whether therapy delivered during posttraumatic amnesia (PTA) following traumatic brain injury can be effective due to risk of agitation and poor learning capacity. This study used goal attainment scaling (GAS) to assess gains in activities of daily living (ADL) retraining during PTA. Occupational therapists' perspectives on goal setting and therapy delivery were also explored qualitatively. Forty-nine rehabilitation inpatients were provided with manualised ADL retraining following errorless and procedural learning principles during PTA. From 104 GAS goals, 90% were achieved at PTA emergence. GAS T-scores changed significantly (p < .001) from baseline (M = 26.94, SD = 4.90) to post-intervention (M = 61.44, SD = 11.45). Mean post-intervention T-scores correlated significantly (p < .001) with change in Functional Independence Measure scores. The four therapists reported that GAS was unfamiliar and time-consuming initially, although it aided goal-directed therapy and measurement of patient performance. Application of manualised skill retraining using errorless and procedural learning techniques was described as novel and challenging, but providing valuable structure. The intervention reportedly promoted therapeutic alliance, skill-building and meaningful time-use without elevating agitation, but fatigue impeded therapy. Overall, GAS captured positive individual change following ADL retraining during PTA and therapists indicated that the intervention and use of GAS was generally beneficial and feasible within clinical practice.

Agitated Behavior and Activities of Daily Living Retraining During Posttraumatic Amnesia.

BACKGROUND: Patients in posttraumatic amnesia (PTA) may receive limited rehabilitation due to the risk of overstimulation and agitation. This assumption has not been tested. OBJECTIVE: To examine the relationship between agitated behavior and participation in therapy for retraining of activities of daily living (ADL) while in PTA. SETTING: Inpatient rehabilitation center. PARTICIPANTS: A total of 104 participants with severe traumatic brain injury, admitted to rehabilitation, in PTA of more than 7 days. INTERVENTION: ADL retraining during PTA followed errorless and procedural learning principles. DESIGN: Group comparison and regression modeling of patient agitation data from a randomized controlled trial comparing ADL retraining in PTA (treatment) versus no ADL retraining in PTA (treatment as usual, TAU). OUTCOME MEASURES: Agitation using the Agitated Behavior Scale. Therapy participation measured in minutes and missed sessions. RESULTS: There were no group differences in agitated behavior (average scores, peak scores, or number of clinically agitated days) between the treatment and TAU groups. For treated patients, there was no significant relationship between agitation and therapy participation (therapy minutes or missed ADL treatment sessions). CONCLUSIONS: This study demonstrated that agitation is not increased by delivery of structured ADL retraining during PTA and agitation did not limit therapy participation. This supports the consideration of active therapy during PTA.

Efficacy of Activities of Daily Living Retraining During Posttraumatic Amnesia: A Randomized Controlled Trial.

OBJECTIVE: To assess the efficacy of activities of daily living (ADL) retraining during posttraumatic amnesia (PTA) compared with ADL retraining commencing after emergence from PTA. DESIGN: Randomized controlled trial. SETTING: Inpatient rehabilitation center. PARTICIPANTS: Participants with severe TBI (N=104), admitted to rehabilitation and remaining in PTA for >7 days, were randomized to receive either treatment as usual (TAU) with daily ADL retraining (treatment), or TAU alone (physiotherapy and/or necessary speech therapy) during PTA. INTERVENTIONS: ADL retraining was manualized, followed errorless and procedural learning principles, and included individualized goals. Both groups received occupational therapy as usual after PTA. MAIN OUTCOME MEASURES: Primary outcome was the FIM completed at admission, PTA emergence, discharge, and 2-month follow-up. Secondary outcomes included length of rehabilitation inpatient stay, PTA duration, Agitated Behavior Scale scores, and Community Integration Questionnaire (CIQ) scores at follow-up. Groups did not significantly differ in baseline characteristics. RESULTS: On the primary outcome, FIM total change, random effects regression revealed a significant interaction of group and time (P<.01). The treatment group had greater improvement in FIM scores from baseline to PTA emergence, which was maintained at discharge, but not at follow-up. Twenty-seven percent more of the treatment group reliably changed on FIM scores at PTA emergence. Group differences in length of stay, PTA duration, agitation, and CIQ scores were not significant; however, TAU trended toward longer length of stay and PTA duration. CONCLUSIONS: Individuals in PTA can benefit from skill retraining.