Evidence-Based Cognitive Rehabilitation: Systematic Review of the Literature From 2009 Through 2014.

OBJECTIVES: To conduct an updated, systematic review of the clinical literature, classify studies based on the strength of research design, and derive consensual, evidence-based clinical recommendations for cognitive rehabilitation of people with traumatic brain injury (TBI) or stroke. DATA SOURCES: Online PubMed and print journal searches identified citations for 250 articles published from 2009 through 2014. STUDY SELECTION: Selected for inclusion were 186 articles after initial screening. Fifty articles were initially excluded (24 focusing on patients without neurologic diagnoses, pediatric patients, or other patients with neurologic diagnoses, 10 noncognitive interventions, 13 descriptive protocols or studies, 3 nontreatment studies). Fifteen articles were excluded after complete review (1 other neurologic diagnosis, 2 nontreatment studies, 1 qualitative study, 4 descriptive articles, 7 secondary analyses). 121 studies were fully reviewed. DATA EXTRACTION: Articles were reviewed by the Cognitive Rehabilitation Task Force (CRTF) members according to specific criteria for study design and quality, and classified as providing class I, class II, or class III evidence. Articles were assigned to 1 of 6 possible categories (based on interventions for attention, vision and neglect, language and communication skills, memory, executive function, or comprehensive-integrated interventions). DATA SYNTHESIS: Of 121 studies, 41 were rated as class I, 3 as class Ia, 14 as class II, and 63 as class III. Recommendations were derived by CRTF consensus from the relative strengths of the evidence, based on the decision rules applied in prior reviews. CONCLUSIONS: CRTF has now evaluated 491 articles (109 class I or Ia, 68 class II, and 314 class III) and makes 29 recommendations for evidence-based practice of cognitive rehabilitation (9 Practice Standards, 9 Practice Guidelines, 11 Practice Options). Evidence supports Practice Standards for (1) attention deficits after TBI or stroke; (2) visual scanning for neglect after right-hemisphere stroke; (3) compensatory strategies for mild memory deficits; (4) language deficits after left-hemisphere stroke; (5) social-communication deficits after TBI; (6) metacognitive strategy training for deficits in executive functioning; and (7) comprehensive-holistic neuropsychological rehabilitation to reduce cognitive and functional disability after TBI or stroke.

Cognitive-motor interference during functional mobility after stroke: state of the science and implications for future research.

Cognitive-motor interference (CMI) is evident when simultaneous performance of a cognitive task and a motor task results in deterioration in performance in one or both of the tasks, relative to performance of each task separately. The purpose of this review is to present a framework for categorizing patterns of CMI and to examine the specific patterns of CMI evident in published studies comparing single-task and dual-task performance of cognitive and motor tasks during gait and balance activities after stroke. We also examine the literature for associations between patterns of CMI and a history of falls, as well as evidence for the effects of rehabilitation on CMI after stroke. Overall, this review suggests that during gait activities with an added cognitive task, people with stroke are likely to demonstrate significant decrements in motor performance only (cognitive-related motor interference), or decrements in both motor and cognitive performance (mutual interference). In contrast, patterns of CMI were variable among studies examining balance activities. Comparing people poststroke with and without a history of falls, patterns and magnitude of CMI were similar for fallers and nonfallers. Longitudinal studies suggest that conventional rehabilitation has minimal effects on CMI during gait or balance activities. However, early-phase pilot studies suggest that dual-task interventions may reduce CMI during gait performance in community-dwelling stroke survivors. It is our hope that this innovative and critical examination of the existing literature will highlight the limitations in current experimental designs and inform improvements in the design and reporting of dual-task studies in stroke.

Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008.

OBJECTIVE: To update our clinical recommendations for cognitive rehabilitation of people with traumatic brain injury (TBI) and stroke, based on a systematic review of the literature from 2003 through 2008. DATA SOURCES: PubMed and Infotrieve literature searches were conducted using the terms attention, awareness, cognitive, communication, executive, language, memory, perception, problem solving, and/or reasoning combined with each of the following terms: rehabilitation, remediation, and training for articles published between 2003 and 2008. The task force initially identified citations for 198 published articles. STUDY SELECTION: One hundred forty-one articles were selected for inclusion after our initial screening. Twenty-nine studies were excluded after further detailed review. Excluded articles included 4 descriptive studies without data, 6 nontreatment studies, 7 experimental manipulations, 6 reviews, 1 single case study not related to TBI or stroke, 2 articles where the intervention was provided to caretakers, 1 article redacted by the journal, and 2 reanalyses of prior publications. We fully reviewed and evaluated 112 studies. DATA EXTRACTION: Articles were assigned to 1 of 6 categories reflecting the primary area of intervention: attention; vision and visuospatial functioning; language and communication skills; memory; executive functioning, problem solving and awareness; and comprehensive-holistic cognitive rehabilitation. Articles were abstracted and levels of evidence determined using specific criteria. DATA SYNTHESIS: Of the 112 studies, 14 were rated as class I, 5 as class Ia, 11 as class II, and 82 as class III. Evidence within each area of intervention was synthesized and recommendations for Practice Standards, Practice Guidelines, and Practice Options were made. CONCLUSIONS: There is substantial evidence to support interventions for attention, memory, social communication skills, executive function, and for comprehensive-holistic neuropsychologic rehabilitation after TBI. Evidence supports visuospatial rehabilitation after right hemisphere stroke, and interventions for aphasia and apraxia after left hemisphere stroke. Together with our prior reviews, we have evaluated a total of 370 interventions, including 65 class I or Ia studies. There is now sufficient information to support evidence-based protocols and implement empirically-supported treatments for cognitive disability after TBI and stroke.

Enhancing quality of life for survivors of stroke through phenomenology.

Kaufman argued for the need to implement a phenomenological approach to explore the boundaries of authority and responsibility associated with modern Western medicine. Twenty-two years later, survivors of stroke and their families continue to experience a poor quality of life (QOL) due to unmet health care expectations. Therefore, the need to establish a phenomenological approach to examine the issues impacting the QOL of survivors of stroke is as important as ever. This article will examine 3 issues germane to the QOL of survivors of stroke that can be addressed through phenomenological methodology: (1) comprehensive-holistic treatment; (2) active, problem-based coping strategies; and (3) education for the general public and health care personnel. Existential responses from survivors of stroke and recent findings from narrative-based research will help to highlight these important issues.

Mentoring programme for adolescent survivors of acquired brain injury.

PRIMARY OBJECTIVE: To report the findings of a mentor-adolescent relationship between two survivors of acquired brain injury (ABI). RESEARCH DESIGN: Case study report. METHODS AND PROCEDURES: The adolescent, a survivor of Eastern Equine Encephalitis, was paired with an adult mentor, a survivor of a TBI. Baseline scores on the Youth Quality of Life (YQOL), Wisconsin Quality of Life Index (WQLI) and the Mayo-Portland Adaptability Index-4 (MPAI-4) were recorded. EXPERIMENTAL INTERVENTIONS: The mentor provided support to the adolescent during the 10-week relationship conducted as a community-based programme for adults with acquired brain injury. In addition, both participants attended group activities that address the long-term needs of survivors of ABI. Post-programme scores were recorded on the YQOL, WQLI, MPAI-4 and a retrospective questionnaire. MAIN OUTCOMES AND RESULTS: The adolescent demonstrated improved quality of life on the YQOL and improved ability, adjustment and participation on the MPAI-4. The mentor demonstrated improved quality of life on the WQLI and improved adjustment and participation on the MPAI-4. Both participants indicated satisfaction with the programme on the retrospective questionnaire. CONCLUSIONS: The mentor programme provided enhanced quality of life and psycho-social support to both participants. The authors do caution, however, that these findings are preliminary and examination of the efficacy of such programming is ongoing.

Oral histories: bridging misconceptions and reality in brain injury recovery.

PURPOSE: The purpose of this investigation is to show that listening to oral histories (OH) told by survivors of acquired brain injury (ABI) can influence the attitudes and beliefs held by practicing Speech-Language Pathologists, and graduate and undergraduate students studying communication sciences and disorders. METHOD: Eighty-seven subjects participated in this investigation. Subjects consisted of 27 certified Speech-Language Pathologists (SLPs), 21 graduate students (GS) and 39 undergraduate students (UG) enrolled in a Communication Sciences and Disorders program. Participants responded to a 10-item questionnaire before and after exposure to OH. The questionnaires assessed amount of exposure to adults with ABI, and attitudes and beliefs about the ABI recovery process. RESULTS: Findings indicate that exposure to OH resulted in a significant change in attitudes and beliefs among the participants. UG demonstrated significant changes in all questionnaire items. GS were most influenced on items related to the role of speech therapy in the rehabilitation of speech, language, and cognitive deficits. SLPs were influenced on issues related to social and vocational attainment following ABI. CONCLUSIONS: Oral histories detailing the life-changing effects of ABI and arduous journey to overcome deficits associated with ABI may have an impact in better understanding these issues.

A systematic review of education programmes to prevent concussion in rugby union.

BACKGROUND: There is a high incidence of concussion sustained by athletes participating in rugby union, many of which go unreported. A lack of sufficient knowledge about concussion injuries may explain athletes' failure to report. Several rugby union-playing countries have developed injury education and prevention programmes to address this issue. OBJECTIVE: The aim of the current review was to systematically assess the content and level of evidence on concussion education/prevention programmes in rugby union and to make recommendations for the quality, strength, and consistency of this evidence. METHODS: We searched PubMed, PsycInfo, MEDLINE, SPORTDiscuss, Webofscience, and conducted a manual search for articles. RESULTS: Ten articles were included for review. Of these, six focused on the BokSmart injury prevention programme in South Africa, two focused on the RugbySmart injury prevention programme in New Zealand, one was an analysis of prevention programmes, and one was a systematic review of rugby injury prevention strategies. CONCLUSIONS: Despite the initiative to develop concussion education and prevention programmes, there is little evidence to support the effectiveness of such programmes. There is evidence to support education of coaches and referees. In addition, there is scant evidence to suggest that education and rule changes may have the benefit of changing athlete behaviours resulting in a reduction in catastrophic injury.

Concussion history and reporting rates in elite Irish rugby union players.

OBJECTIVES: To determine the self-reported, seasonal rates of concussion and the reporting practices among Irish rugby union players. DESIGN: Descriptive epidemiology study. SETTING: The study was conducted at the training grounds of four professional Irish rugby union clubs. PARTICIPANTS: One hundred seventy-two players (24.97 ± 4.11 years of age, 13.49 ± 5.79 years playing experience) gave consent to participate. MAIN OUTCOME MEASURES: Number of concussions reported during the 2010-2011 season, reasons for not reporting, and positions of concussed players. RESULTS: Forty-five percent of players reported at least one concussion during the 2010-2011 season, but only 46.6% of these presented to medical staff. The reasons for not reporting their concussions included, not thinking the injury was serious enough, and not wanting to be removed from the game. The relative proportion of concussions was higher for backs than forwards; however, the severity of injury was greater for forwards. Scrum-halves (12.0%) and flankers (10.9%) accounted for the majority of concussions reported. CONCLUSIONS: The self-reported rate of concussion in elite rugby union players in Ireland is higher than reported in other countries or other sports. Many concussions remain unreported and, therefore, unmanaged. However, recent changes in concussion management guidelines by the International Rugby Board may impact future reporting practices of players.

The use of narratives to identify characteristics leading to a productive life following acquired brain injury.

PURPOSE: To determine the factors leading to successful recovery and productive lifestyles after acquired brain injury (ABI). METHOD: Qualitative investigation examined semistructured interviews of 31 survivors of ABI. Thematic analysis followed a phenomenological approach and revealed 4 major themes and 28 subthemes in the interviews. Four participants stood out as exemplars of the themes embodied by all the participants in this investigation. Quotes from each are used to highlight the prevailing themes. RESULTS: The following 4 major themes emerged from the interviews: development of social support networks, grief and coping strategies, acceptance of the injury and redefinition of self, and empowerment. CONCLUSIONS: The issues raised in these interviews may serve to inspire other survivors and provide them with hope and motivation as they progress through the recovery process. Suggestions on how clinicians can help to facilitate this process are discussed.

Expressive electronic journal writing: freedom of communication for survivors of acquired brain injury.

In addition to the impaired ability to effectively communicate, adults with acquired brain injury (ABI) also experience high incidences of depression, social isolation, and decreased quality of life. Expressive writing programs have been shown to be effective in alleviating these concomitant impairments in other populations including incarcerated inmates (Lane, Writing as a road to self-discovery, F & W, Cincinnati 1993). In addition, computer applications such as email have been suggested as an effective means of improving communication and social isolation in adults with brain injury (Sohlberg et al. [2003]. Brain Injury, 17(7), 609-629). This investigation examines the effects of on-line expressive journal writing on the communication, emotional status, social integration and quality of life of individuals with brain injury.

Meeting the long-term needs of adults with acquired brain injury through community-based programming.

PRIMARY OBJECTIVE: To determine the effectiveness of a community-based programme for meeting the long-term needs of survivors of acquired brain injury (ABI). METHODS AND PROCEDURES: Qualitative and quantitative methods were employed. Surveys were administered to practicing clinicians to validate the needs found in the literature that should be provided by such programmes. Surveys administered to participants in the programme assessed how effective they perceived it to be in meeting those needs. Focus group discussion provided support to the survey findings. MAIN OUTCOMES AND RESULTS: Survey responses indicate differences among members, caregivers and student interns participating in the programme on issues of emotional support, social support, recreation and transportation. Focus group participants agree that emotional, social and cognitive needs are the most important needs of the members. Overall, these member needs were found to be met by the programme. The needs that participants found to remain unmet include social support for caregivers, transportation issues and community education. CONCLUSIONS: This community-based, posts-rehabilitation programme for survivors of ABI appears to effectively meet many long-term needs. Investigations that examine the role of similar programming to meet caregiver needs, educate the public and provide transportation for participants are required.