Inpatient trial of a tablet app for communicating brain injury rehabilitation goals.

PURPOSE: We examine the use of a custom iPad application, the Rehab Portal, to provide clients in an inpatient brain injury rehabilitation service with access to short videos where clinicians-or the clients themselves-discuss their current rehabilitation goals. MATERIALS AND METHODS: We developed an initial version of the Rehab Portal app based on our previous co-design with service users, their families, and clinicians. This was examined in a field trial with a series of six clients over the course of their stays in inpatient rehabilitation, collecting quantitative data on clinician and client engagement with the Rehab Portal, alongside a thematic analysis of qualitative interviews with clients and clinicians at the point of discharge. RESULTS: Engagement with the platform was high for two clients while it was limited with four more. In our thematic analysis we discuss how introduction of the Rehab Portal disrupted practice, changing how things are done, causing deviation from usual routines, adding burden, and threatening professional integrity. At the same time, where it worked well it led to a repositioning of goal planning away from being clinician directed and towards an ongoing, dynamic collaboration between clinicians, clients and their families. Finally, in some cases we identified a reverting to the status quo, with client demotivation having an unexpected impact on clinician behaviour leading to the process being abandoned. CONCLUSIONS: The current findings do not provide wholesale support for this approach, yet we continue to feel that approaches that support clinician-client communication using asynchronous video may offer considerable future value and are worthy of further investigation.IMPLICATIONS FOR REHABILITATIONThe use of a novel technique to communicate rehabilitation goals via video disrupted practice, changed how things are done, caused deviation from usual routines, added burden, and threatened professional integrity for clinicians.Where it worked well it led to a repositioning of goal planning away from being clinician-directed and towards an ongoing, dynamic collaboration between clinicians, clients and their families.Approaches that support clinician-client communication using asynchronous video may offer considerable future value and are worthy of further investigation.

Stroke survivors' expectations and post-intervention perceptions of mindfulness training: A qualitative study.

Depression and anxiety are common sequelae of stroke, occurring in at least one-third of patients. This study evaluated the acceptability and feasibility of providing mindfulness training (MT) to stroke survivors with the aim of reducing depression and anxiety. Following a six-week one-on-one MT course, 17 participants were interviewed. The median age of participants was 71, and 10 participants were male. This paper focuses on participants' expectations of the MT and their views about its impact on their everyday lives. Conventional content analysis was used for coding and analysis. A single theme, Seizing rehabilitation opportunities, was captured in relation to expectations of MT, and four themes provided information relating to participants' perceived impact of the course: Calming the mind, Reduced reactivity, Remedying physical symptoms, and Not quite there yet.Most participants knew little about mindfulness before the MT and did not have specific goals in mind when volunteering to take part. The findings suggest that most participants considered MT beneficial through reducing stress and giving them additional skills to cope with their everyday lives. A tailored mindfulness intervention may be a useful adjunct to other rehabilitation therapies for stroke survivors.

Design considerations for a multiple sclerosis fatigue mobile app MS Energize: A pragmatic iterative approach using usability testing and resonance checks.

Multiple sclerosis (MS) is a chronic neurological condition affecting around 2.2 million people worldwide. The illness includes a range of symptoms, with fatigue considered to be one of the most disabling. This paper describes how a pragmatic and iterative approach, supported by usability and resonance testing, was used to build a minimum viable product of MS Energize-or MS Energise in UK English regions. MS Energise is a mobile application focused on self-management of fatigue for people with MS. The iterative approach included various stages of testing, during which user feedback including comments about interface, navigation and content, was sought to inform incremental app development and continual improvement. Usability testing was conducted with 11 people with longstanding multiple sclerosis in New Zealand and the United Kingdom, and focused on particular sections of the app as well as the accessibility of the app to users with MS. Two participants contributed to further resonance testing post-release to ensure the app was perceived as relevant and useful to the user. The usability testing and resonance testing phases suggested that user experience of MS Energise was mostly positive. Participants provided a number of suggestions for improvements to aspects of content and design; some of which we implemented during our app development process. Findings will also contribute to future planning and design iteration to enhance the user experience. The next step is further improvement of MS Energise prior to a trial of its clinical and cost effectiveness.

Effect of a behavioral-educational sleep intervention for first-time mothers and their infants: pilot of a controlled trial.

STUDY OBJECTIVES: This study tested the acceptability and efficacy of a perinatally delivered behavioral-educational sleep intervention. METHODS: Participants were 40 primiparous women assigned in late pregnancy to either an intervention (n = 20) or control (n = 20) group. The sleep intervention group (SIG) received prenatal anticipatory education and guidance regarding their own and their infant's sleep during the first 3 months postpartum. This was reinforced during phone calls within the first 6 weeks postpartum. The control group (CG) received brief sleep hygiene information at a prenatal session, followed by 2 phone calls during the same period. Mother-infant pairs wore actigraphs for 48 hours at 6 and 12 weeks postpartum, and mothers kept sleep diaries. Questionnaires completed in late pregnancy and 6 and 12 weeks postpartum related to sleep, newborn care, and mood. The main outcome measures included maternal sleep quantity, efficiency, and self-reported quality and infant sleep duration and consolidation. RESULTS: Mothers reported high acceptability of the study processes. Sleep duration and quality increased for mothers and infants across time in both groups, with a significantly greater increase in nocturnal sleep duration for mothers in the SIG. CONCLUSIONS: Prenatal sleep guidance and postnatal follow-up seems to enhance nocturnal sleep of mothers, change their perceptions of their own sleep, and increase confidence in managing their infant's sleep. Follow-up at later intervals and replication with larger, more diverse samples may reveal further differences.

Attitudes of rural communities towards the use of technology for health purposes in New Zealand: a focus group study.

OBJECTIVES: Examine attitudes to using online health and wellness services, and determine what barriers may exist to this in two rural communities in New Zealand. DESIGN: A thematic analysis informed by a social constructivist paradigm explored the attitudes of youth and adults to give voice to these communities. Eighteen focus groups-nine in each region-were held for an hour each, with between three and nine participants in each group. SETTING: Two rural areas at the Northern and Southern ends of New Zealand were chosen. In each area, we partnered with a local health centre providing primary care services. Three localities were identified within each region where we conducted the data collection. PARTICIPANTS: Participants were youth aged 12-15 years, aged 16-20 years and adults over 21 years. Overall, 74 females and 40 males were recruited. Recruitment occurred through schools, community organisations or personal contacts of the facilitators, who were youth workers in their respective communities. Ethnicity of the participants was representative of each area, with a higher percentage of Maori participants in Northland. RESULTS: Eight themes were identified which described participants' attitudes to technology use in healthcare. Themes covered accessibility, cost, independence, anonymity and awareness issues: technology makes health information easily accessible; access to technology can be limited in rural communities; technology can reduce the cost of healthcare but it is too expensive for some; technology increases independence and autonomy of people's own health; independent healthcare decisions come with risks; anonymity encourages people to seek help online; technology can help raise awareness and provide peer-support for people with health issues; technology impacts on social relationships. CONCLUSIONS: Participants-particularly youth-were generally positive about the role of technology in healthcare delivery, and interested in ways technology could improve autonomy and access to health and wellness services.

MS Energize: Field trial of an app for self-management of fatigue for people with multiple sclerosis.

Multiple sclerosis (MS) is a lifelong neurological condition affecting around 2.2 million people worldwide. There are a wide range of symptoms, with fatigue reported as one of the most troublesome. MS Energize-or MS Energise in UK English regions-is an iPhone app focused on self-management of fatigue for people with MS. Based on cognitive-behavioral therapy principles, the app covers MS fatigue, how to use energy effectively, how behavior, thoughts and emotions interact and impact on MS fatigue, as well as the potential effects of bodily and environmental factors. MS Energize provides education, interactive tasks, and supports application of the principles into a user's day-to-day life. We field tested the usability and perceived usefulness of MS Energize with 11 people with longstanding multiple sclerosis in New Zealand and the United Kingdom. Participants used the app over a period of five to six weeks after which they rated the usability of the app and participated in an in-depth qualitative interview. We developed four main themes through our thematic analysis. 1. Validation of participants' own experiences of living with MS fatigue. 2. The personal cost in engaging with such an intervention. 3. Reframing experiences and adding to knowledge. 4. That the app was generally a good idea. Field testers' feedback also identified usability issues that could be addressed. In particular, the amount of text-based content in the app contributed to the app itself being fatiguing. This field-testing process has highlighted the value of the app while also guiding our roadmap for further developments to enhance usability and usefulness. The next step is further refinement of components of MS Energize in preparation for a trial of its clinical and cost effectiveness.

Sex differences in response to emotion recognition training after traumatic brain injury.

OBJECTIVE: To examine sex differences in the effectiveness of a Stories intervention for teaching affect recognition in people with a traumatic brain injury (TBI). SETTING: Post-acute rehabilitation facilities. PARTICIPANTS: 203 participants (53 women and 150 men) with moderate to severe TBI were screened. 71 were eligible and randomized to one of three treatment conditions: two affect recognition conditions and an active control (cognition). This paper examines sex differences between the Stories intervention (n = 23, 5 women and 18 men) and the cognitive treatment control (n = 24, 8 women and 16 men). DESIGN: Randomized controlled trial with immediate, 3- and 6-month follow-up post-tests. Interventions were 9 hours of computer-based training with a therapist. MEASURES: Facial Affect Recognition (DANVA2-AF); Emotional Inference from Stories Test (EIST). RESULTS: A significant treatment effect was observed for the Stories intervention for women, who demonstrated and maintained improved facial affect recognition. In contrast, males in our sample did not benefit from the Stories intervention. CONCLUSION: This positive finding for the Stories intervention for females contrasts with our conclusions in a previous paper, where an analysis collapsed across sex did not reveal an overall effectiveness of the Stories intervention. This intervention warrants further research and development.

Efficacy of memory aids after traumatic brain injury: A single case series.

BACKGROUND: Individuals living with traumatic brain injury commonly have difficulties with prospective memory-the ability to remember a planned action at the intended time. Traditionally a memory notebook has been recommended as a compensatory memory aid. Electronic devices have the advantage of providing a cue at the appropriate time to remind participants to refer to the memory aid and complete tasks. Research suggests these have potential benefit in neurorehabilitation. OBJECTIVE: This study aimed to investigate the efficacy of a memory notebook and specifically a smartphone as a compensatory memory aid. METHODS: A single case series design was used to assess seven participants. A no-intervention baseline was followed by training and intervention with either the smartphone alone, or a memory notebook and later the smartphone. Memory was assessed with weekly assigned memory tasks. RESULTS: Participants using a smartphone showed improvements in their ability to complete assigned memory tasks accurately and within the assigned time periods. Use of a smartphone provided additional benefits over and above those already seen for those who received a memory notebook first. CONCLUSIONS: Smartphones have the potential to be a useful and cost effective tool in neurorehabilitation practice.

Systematic behavioural observation of executive performance after brain injury.

OBJECTIVE: To develop an ecologically valid measure of executive functioning (i.e. Planning and Organization, Executive Memory, Initiation, Cognitive Shifting, Impulsivity, Sustained and Directed Attention, Error Detection, Error Correction and Time Management) during a functional chocolate brownie cooking task. METHODS: In Study 1, the inter-rater reliability of a novel behavioural observation assessment method was assessed with 10 people with traumatic brain injury (TBI). In Study 2, 27 people with TBI and 16 healthy controls completed the functional task along with other measures of executive functioning to assess validity. RESULTS: Intraclass correlation coefficients for six of the nine aspects of executive functioning ranged from .54 to 1.00. Percentage agreements for the remaining aspects ranged from 70% to 90%. Significant and non-significant, moderate, correlations were found between the functional cooking task and standard neuropsychological measures. The healthy control group performed better than the TBI group in six areas (d = 0.56 to 1.23). CONCLUSIONS: In this initial trial of a novel assessment method, adequate inter-rater reliability was found. The measure was associated with standard neuropsychological measures, and our healthy control group performed better than the TBI group. The measure appears to be an ecologically valid measure of executive functioning.

Mobile Technology Use by People Experiencing Multiple Sclerosis Fatigue: Survey Methodology.

BACKGROUND: Fatigue is one of the most commonly reported symptoms of multiple sclerosis (MS). It has a profound impact on all spheres of life, for people with MS and their relatives. It is one of the key precipitants of early retirement. Individual, group, and Internet cognitive behavioral therapy-based approaches to supporting people with MS to manage their fatigue have been shown to be effective. OBJECTIVE: The aim of this project was to (1) survey the types of mobile devices and level of Internet access people with MS use or would consider using for a health intervention and (2) characterize the levels of fatigue severity and their impact experienced by the people in our sample to provide an estimate of fatigue severity of people with MS in New Zealand. The ultimate goal of this work was to support the future development of a mobile intervention for the management of fatigue for people with MS. METHODS: Survey methodology using an online questionnaire was used to assess people with MS. A total of 51 people with MS participated. The average age was 48.5 years, and the large majority of the sample (77%) was female. RESULTS: Participants reported significant levels of fatigue as measured with the summary score of the Neurological Fatigue Index (mean 31.4 [SD 5.3]). Most (84%) respondents scored on average more than 3 on the fatigue severity questions, reflecting significant fatigue. Mobile phone usage was high with 86% of respondents reporting having a mobile phone; apps were used by 75% of respondents. Most participants (92%) accessed the Internet from home. CONCLUSIONS: New Zealand respondents with MS experienced high levels of both fatigue severity and fatigue impact. The majority of participants have a mobile device and access to the Internet. These findings, along with limited access to face-to-face cognitive behavioral therapy-based interventions, create an opportunity to develop a mobile technology platform for delivering a cognitive behavioral therapy-based intervention to decrease the severity and impact of fatigue in people with MS.

Film clips and narrative text as subjective emotion elicitation techniques.

Film clips and narrative text are useful techniques in eliciting emotion in a laboratory setting but have not been examined side-by-side using the same methodology. This study examined the self-identification of emotions elicited by film clip and narrative text stimuli to confirm that selected stimuli appropriately target the intended emotions. Seventy participants viewed 30 film clips, and 40 additional participants read 30 narrative texts. Participants identified the emotion experienced (happy, sad, angry, fearful, neutral-six stimuli each). Eighty-five percent of participants self-identified the target emotion for at least two stimuli for all emotion categories of film clips, except angry (only one) and for all categories of narrative text, except fearful (only one). The most effective angry text was correctly identified 74% of the time. Film clips were more effective in eliciting all target emotions in participants for eliciting the correct emotion (angry), intensity rating (happy, sad), or both (fearful).

Solvent neurotoxicity in vehicle collision repair workers in New Zealand.

OBJECTIVES: To assess whether solvent use and workplace practices in the vehicle collision repair industry are associated with symptoms of neurotoxicity in spray painters and panel beaters (auto body repair workers). METHODS: Neurobehavioural symptoms were assessed using a cross-sectional study design in 370 vehicle collision repair and 211 reference workers using the EUROQUEST questionnaire. Full-shift airborne solvent levels were measured in a subset (n=92) of collision repair workers. RESULTS: Solvent exposures were higher in spray painters than in panel beaters, but levels were below current international exposure standards. Collision repair workers were more likely to report symptoms of neurotoxicity than reference workers with ORs of 2.0, 2.4 and 6.4 (all p<0.05) for reporting ≥5, ≥10 and ≥15 symptoms respectively. This trend was generally strongest for panel beaters (ORs of 2.1, 3.3 and 8.2 for ≥5, ≥10 and ≥15 symptoms respectively). Associations with specific symptom domains showed increased risks for neurological (OR 4.2), psychosomatic (OR 3.2), mood (OR 2.1), memory (OR 2.9) and memory and concentration symptoms combined (OR 2.4; all p<0.05). Workers who had worked for 10-19 years or 20+ years in the collision repair industry reported consistently more symptoms than those who had only worked less than 10 years even after adjusting for age. However, those who worked more than 20 years generally reported fewer symptoms than those who worked 10-19 years, suggesting a possible healthy worker survivor bias. CONCLUSIONS: Despite low airborne solvent exposures, vehicle collision repair spray painters and panel beaters continue to be at risk of symptoms of neurotoxicity.

Exploration of a new tool for assessing emotional inferencing after traumatic brain injury.

OBJECTIVE: To explore validity of an assessment tool under development-the Emotional Inferencing from Stories Test (EIST). This measure is being designed to assess the ability of people with traumatic brain injury (TBI) to make inferences about the emotional state of others solely from contextual cues. METHODS AND PROCEDURES: Study 1: 25 stories were presented to 40 healthy young adults. From this data, two versions of the EIST (EIST-1; EIST-2) were created. Study 2: Each version was administered to a group of participants with moderate-to-severe TBI-EIST 1 group: 77 participants; EIST-2 group: 126 participants. Participants also completed a facial affect recognition (DANVA2-AF) test. Participants with facial affect recognition impairment returned 2 weeks later and were re-administered both tests. MAIN OUTCOMES: Participants with TBI scored significantly lower than the healthy group mean for EIST-1, F(1,114) = 68.49, p < 0.001, and EIST-2, F(1,163) = 177.39, p < 0.001. EIST scores in the EIST-2 group were significantly lower than the EIST-1 group, t = 4.47, p < 0.001. DANVA2-AF scores significantly correlated with EIST scores, EIST-1: r = 0.50, p < 0.001; EIST-2: r = 0.31, p < 0.001. Test-re-test reliability scores for the EIST were adequate. CONCLUSIONS: Both versions of the EIST were found to be sensitive to deficits in emotional inferencing. After further development, the EIST may provide clinicians valuable information for intervention planning.

A randomized controlled trial of emotion recognition training after traumatic brain injury.

OBJECTIVE: To examine the effectiveness of 2 affect recognition interventions (Faces and Stories) in people with a traumatic brain injury. SETTING: Postacute rehabilitation facilities. PARTICIPANTS: A total of 203 participants with moderate to severe traumatic brain injury were screened; 71 were eligible and randomized to the Faces (n = 24), Stories (n = 23), and Control interventions (n = 24). Participants were an average of 39.8 years of age and 10.3 years postinjury; 74% of participants were male. DESIGN: Randomized controlled trial with immediate, 3-month, and 6-month follow-up posttests. Interventions were 9 hours of computer-based training with a therapist. MEASURES: Diagnostic Assessment of Nonverbal Accuracy 2-Adult Faces; Emotional Inference From Stories Test; Empathy (Interpersonal Reactivity Index); and Irritability and Aggression (Neuropsychiatric Inventory). RESULTS: The Faces Intervention did significantly better than the Control Intervention on the Diagnostic Assessment of Nonverbal Accuracy 2-Adult Faces (P = .031) posttreatment; no time effect or group interaction was observed. No other significant differences were noted for the Faces Intervention. No significant differences were observed between the Stories and the Control Interventions; however, a significant time effect was found for the Emotional Inference From Stories Test. CONCLUSION: The Faces Intervention effectively improved facial affect recognition in participants with chronic post-traumatic brain injury, and changes were maintained for 6 months. Future work should focus on generalizing this skill to functional behaviors.

Open and abundant data is the future of rehabilitation and research.

Development of our current research practices has been driven by a number of assumptions and from operating within practical constraints. Technological change is beginning to remove many of these limits, although our research and practice has so far only gradually and partially evolved in response. The U.S. federal government is now mandating open data repositories for research that it funds. Policy changes regarding open data repositories and an increasing abundance of data arising from both research and practice provide the opportunity to revisit some assumptions. With abundant sources of data that may increasingly be collected automatically during rehabilitation, it seems fundamentally flawed that the resolution of the primary quantitative analysis approaches widely understood in our field is so limited by the need to contain the risk of false positives. Identification of more sophisticated approaches to our data, which may well already exist in the statistical literature, is a high priority.

Facial affect recognition difficulties in traumatic brain injury rehabilitation services.

PRIMARY OBJECTIVE: The occurrence of facial affect recognition difficulties in a sample of people accessing traumatic brain injury (TBI) rehabilitation services was examined. It was hypothesized that between 13-39% of participants would demonstrate clinically significant impairment in facial affect recognition. RESEARCH DESIGN: Cross-sectional sample of eligible participants who were current clients of eight brain injury services were invited to participate. METHODS AND PROCEDURES: Forty-five participants with mild-to-severe TBI were assessed for facial affect recognition difficulties using the facial affect discrimination, naming, selection and matching sub-tests of the Florida Affect Battery. MAIN OUTCOMES AND RESULTS: Fifty-one per cent of participants had at least moderate difficulties with facial affect recognition. CONCLUSIONS: The current sample was not a random selection from the population of people with TBI, so the results do not establish a formal estimate of prevalence. Nonetheless, the data indicate that when assessing typical clients with severe brain injuries presenting to neurorehabilitation services, there is likely to be a high frequency of occurrence of facial affect recognition difficulties. Rehabilitation outcomes may be improved by screening for and treating facial affect recognition difficulties following TBI. Further examination and development of treatment options is warranted.

The relationship between facial affect recognition and cognitive functioning after traumatic brain injury.

PRIMARY OBJECTIVE: There is considerable evidence suggesting facial affect recognition and cognitive functions are impaired in many people with moderate-to-severe traumatic brain injury (TBI). However, little is known about the relationship between these two domains in the TBI population. RESEARCH DESIGN: This study investigated the relationship between facial affect recognition and cognitive functioning in 75 adults with moderate-to-severe TBI. METHODS AND PROCEDURES: Participants were administered three facial affect recognition tests and a computerized cognitive test battery that assessed seven cognitive domains. MAIN OUTCOMES AND RESULTS: Deficits in facial affect recognition were significantly correlated with impairments in non-verbal memory, working memory, speed of processing, verbal memory and verbal delayed memory. No significant relationship was found between executive dysfunction and facial affect recognition impairments. Non-verbal memory, working memory and speed of processing significantly predicted overall facial affect recognition performance. CONCLUSIONS: It is concluded that impairment in several cognitive processes may contribute to facial affect recognition deficits in TBI, in particular non-verbal memory, working memory and speed of processing. Furthermore, executive functioning may not be a critical factor in facial affect recognition, but would most likely be important in deciding what to do once facial affect is perceived.

Affect recognition, empathy, and dysosmia after traumatic brain injury.

OBJECTIVE: To investigate if olfaction is associated with affect recognition and empathy deficits after traumatic brain injury (TBI). Prior research has shown that TBI often leads to loss of smell. We hypothesized a relationship with emotion perception, because the neural substrates of the olfactory system overlap with the ventral circuitry of the orbital frontal cortex, which play a critical role in affective responses, such as empathy. DESIGN: Comparative study investigating differences between participants with TBI who had impaired olfaction (dysosmia) with those with normal olfaction (normosmia). SETTING: Postacute rehabilitation facilities in the United States, Canada, and New Zealand. PARTICIPANTS: Participants (N=106) in the current study were a convenience sample of adults with moderate to severe TBI who were tested for olfactory function as part of a larger, related study on affect recognition. On average, participants were 11.5 years postinjury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Olfaction (Brief Smell Identification Test), facial affect recognition (Diagnostic Assessment of Nonverbal Affect 2-Adult Faces [DANVA2-AF]), vocal affect recognition (Diagnostic Assessment of Nonverbal Affect 2-Adult Paralanguage [DANVA2-AP]), emotional inference (Emotional Inference from Stories Test [EIST]), and empathy (Interpersonal Reactivity Index [IRI]). RESULTS: Fifty-six percent of participants were dysosmic and only 36% of these participants were aware of their deficit. Participants with dysosmia performed significantly poorer on the DANVA2-AF (P=.003), DANVA2-AP (P=.007), EIST (P=.016), and IRI (P=.013). Medium effect sizes were found for all measures. Dysosmia had a sensitivity value of 86.4% for detecting facial affect recognition impairments and 67.8% for vocal affect recognition impairments. CONCLUSIONS: This study shows that olfactory deficits may be indicative of affect recognition impairments and reduced empathy. Early knowledge of affect recognition and empathy deficits would be valuable so that treatment could be implemented predischarge.

Meta-analysis of facial affect recognition difficulties after traumatic brain injury.

OBJECTIVE: Difficulties in communication and social relationships present a formidable challenge for many people after traumatic brain injury (TBI). These difficulties are likely to be partially attributable to problems with emotion perception. Mounting evidence shows facial affect recognition to be particularly difficult after TBI. However, no attempt has been made to systematically estimate the magnitude of this problem or the frequency with which it occurs. METHOD: A meta-analysis is presented examining the magnitude of facial affect recognition difficulties after TBI. From this, the frequency of these impairments in the TBI population is estimated. Effect sizes were calculated from 13 studies that compared adults with moderate to severe TBI to matched healthy controls on static measures of facial affect recognition. RESULTS: The studies collectively presented data from 296 adults with TBI and 296 matched controls. The overall weighted mean effect size for the 13 studies was -1.11, indicating people with TBI on average perform about 1.1 SD below healthy peers on measures of facial affect recognition. Based on estimation of the TBI population standard deviation and modeling of likely distribution shape, it is estimated that between 13% and 39% of people with moderate to severe TBI may have significant difficulties with facial affect recognition, depending on the cut-off criterion used. CONCLUSION: This is clearly an area that warrants attention, particularly examining techniques for the rehabilitation of these deficits.

Assessing executive performance during cognitive rehabilitation.

Executive functioning influences a host of other cognitive processes and people who attend neuropsychological services are more likely to display executive dysfunction than any other cognitive deficit (Stuss & Levine, 2002). Impairment in executive functioning disrupts a person's ability to effectively employ their intact areas of functioning, and undermines effective self-management of other areas of dysfunction, hampering attempts to employ compensatory strategies. Therefore, assessment of a person's executive functioning is a high priority as part of a comprehensive neurorehabilitation plan. Guided by the International Classification of Functioning, Disability, and Health model (ICF model; Peterson, 2005), we suggest that an important development in the field is moving to formal assessment of executive performance in functional contexts, in addition to more traditional assessment of executive impairment. We outline a number of existing studies in this area, review current measures that can provide clinicians with useful information on these issues, and discuss how this research could be further advanced.