Cognitive Interventions With Occupational Performance as a Primary Outcome for Adults With TBI (June 2013-October 2020).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on cognitive interventions to improve occupational performance for adults with traumatic brain injury.

Cognitive Interventions to Improve a Specific Cognitive Impairment for Adults With TBI (June 2013-October 2020).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on cognitive interventions to improve a specific cognitive impairment for adults with TBI.

A Framework for Addressing Clients' Functional Cognitive Deficits After COVID-19.

Occupational therapy's focus on functional cognition offers a distinct approach to the assessment of and intervention for occupational performance deficits that may follow coronavirus disease 2019 (COVID-19). Although the majority of people survive COVID-19, many people experience persistent functional cognitive sequelae severe enough to interfere with occupational performance. After COVID-19, people may be categorized as either (1) those who experience severe or critical illness requiring hospitalization or (2) those with mild to moderate presentations of the virus without hospitalization. A third group of those who do not have ongoing signs of active infection but who experience new, lasting, or deteriorating symptoms has begun to emerge and may represent a distinct COVID-19 long-haul syndrome. By following the Occupational Therapy Practice Framework and using established processes for occupational therapy assessment and treatment of functional cognition, occupational therapy practitioners can tailor assessments and interventions to meet clients' needs.

The construct validity of a new screening measure of functional cognitive ability: The menu task.

This study evaluated the construct validity of the Menu Task (MT): a new performance-based screening measure of functional cognition. We enrolled 114 community dwelling adults (55 years or older) in the study: all participants completed the MT and four other neuropsychological screening measures. Construct validity was evaluated using a three-step hierarchical regression model with the MT as the dependent variable. Demographic control variables were entered at step 1, followed by the Brief Interview of Mental Status (BIMS), and the Trail Making Test A (TMT A) at step 2, and finally TMT B and the Montreal Cognitive Assessment (MoCA) at step 3. It was hypothesised that measures sensitive to executive functioning (TMT B and MoCA) would significantly explain MT performance after controlling for demographic variables and adding measures of cognitive function to the model, providing additional evidence for construct validity of the MT. All three steps of the model were statistically significant (p < 0.01). Inclusion of measures sensitive to executive function in step 3 explained 30% of variability in MT score (adjusted R2 = 0.30). Our findings provide further empirical support for the construct validity of the MT, and offer implications for the use of the MT in acute and post-acute care settings.

Making Functional Cognition a Professional Priority.

Functional cognition is a critical domain of concern for occupational therapy practice. As the health care system moves to assessing value through achievement of quality outcomes, the field of occupational therapy must address the inclusion of functional cognition in evaluation and treatment. Evidence indicates that impaired cognition contributes to risk of hospital readmission and poor overall health outcomes across diagnostic groups. Moreover, expenditure on occupational therapy services that address functional cognition has been shown to lower hospital readmission rates. To improve client outcomes, occupational therapists must consistently screen for and, when appropriate, evaluate and treat functional cognition impairments and consider functional cognition in the discharge planning process. Occupational therapy professionals must make a proactive, coordinated effort to establish the profession's role in evaluating and treating clients' limitations in functional cognition as a means to achieving improved quality care and client outcomes.

The interrelationship of functional skills in individuals living in the community, following moderate to severe traumatic brain injury.

OBJECTIVE: The Adaptive Behaviour and Community Competency Scale was used to investigate the interrelationship of 22 basic and instrumental activities of daily living (ADL/IADL) in individuals with moderate to severe traumatic brain injury (TBI). The relationship of self-awareness to task performance was also investigated. RESEARCH DESIGN: Prospective descriptive study. METHOD: The profiles of 100 community dwelling individuals were used to compare the degree to which independence in each ADL/IADL was associated with independence in every other ADL/IADL. The interrelationship of these skills was further explored in a factor analysis, and comparisons made between the degree of self-awareness of those who could and could not complete IADL independently. RESULTS: We found evidence of a hierarchy of skills: individuals who were independent in IADL were more able to perform ADL, than vice versa. Factor analysis supported a two-factor solution distinguishing ADL and IADL. Self-awareness was more strongly associated with IADL than with ADL independence. CONCLUSIONS: A subset of individuals with moderate to severe TBI are able to perform a range of IADL. This group appears to have higher levels of self-awareness than those who are limited to performing only ADL skills. Implications for the applications of functional retraining interventions are discussed.

Reliability and Validity of a Functional Cognition Screening Tool to Identify the Need for Occupational Therapy.

IMPORTANCE: The Centers for Medicare & Medicaid Services (CMS) has identified the need to assess functional cognition as part of the postacute care planning process. OBJECTIVE: We examined the reliability, validity, and clinical utility of the Menu Task (MT) as a screening measure of functional cognition to assess the need for occupational therapy services. DESIGN: Cross-sectional study testing a convenience sample of community-dwelling older adults (n = 130) and adults hospitalized for elective orthopedic surgery (n = 60). The MT and four neuropsychological screening tests-the Brief Interview of Mental Status, the Montreal Cognitive Assessment, Trail Making Tests A and B, and an instrumental activities of daily living (IADL) scale-were administered. SETTING: Community-dwelling participants were tested at the University of Wisconsin occupational therapy program and in community settings. Hospitalized participants were tested at the University of Missouri Orthopedic Institute. PARTICIPANTS: We recruited healthy community-dwelling adults in Madison, WI (community sample; n = 130) and patients hospitalized for elective orthopedic surgery in Columbia, MO (hospital sample; n = 60). Inclusion criteria were age 55 yr or older, living in the community, and willingness to be tested in English; for the hospital sample, participants had to be referred for elective orthopedic surgery requiring a hospital stay and be independent in activities of daily living before being admitted for surgery. RESULTS: We found significant differences between groups classified as impaired or not impaired on the basis of MT scores. Participants classified as impaired on the MT performed significantly less well than those classified as not impaired on the neurocognitive and IADL measures. CONCLUSION: The reliability and validity of the MT were supported. WHAT THIS ARTICLE ADDS: The American Occupational Therapy Association and the occupational therapy experts advising CMS have stressed the importance of a brief performance-based screening tool to identify people who need more comprehensive occupational therapy evaluation. The implementation of a functional cognition screening tool as part of the required CMS assessment protocol should greatly increase the number of patients referred for occupational therapy evaluation and treatment. The MT has the capacity to address the gap in the proposed CMS assessment of Medicare recipients across postacute care settings.

Neurocognitive Rehabilitation: Skills or Strategies?

The author describes personal and professional milestones in becoming an occupational therapist and his early experience in the first behavior disorder program for neurologically based aggression in the world. A real clinical example is used to bring these early lessons into vivid focus. New evidence underlines occupational therapists' unique role in skill-habit training in clients with severe neurological impairment. For clients with milder impairments, irrespective of diagnosis, strategy training may maximize community independence and reduce hospital recidivism. The concept of functional cognition is described as an important development for the profession. Even in an environment of rapid innovation, occupational therapists need to recognize that it is the commonplace activities that have meaning for the individual that really matter. This is both the art and science of occupational therapy, and it will never be superseded by technological innovation because true creativity and genuine empathy cannot be mechanized.

Screening for Functional Cognition in Postacute Care and the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014.

Occupational therapists have a long history of assessing functional cognition, defined as the ability to use and integrate thinking and performance skills to accomplish complex everyday activities. In response to passage of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 (Pub. L. 113-185), the American Occupational Therapy Association has been advocating that the Centers for Medicare and Medicaid Services consider functional cognition for inclusion in routine patient assessment in postacute care settings, with important implications for occupational therapy. These efforts have the potential to increase referrals to occupational therapy, emphasize the importance of addressing functional cognition in occupational therapy practice, and support the value of occupational therapy in achieving optimal postacute care outcomes.

Factors influencing community case management and care hours for clients with traumatic brain injury living in the UK.

OBJECTIVE: To investigate the relationship between deficits associated with traumatic brain injury (TBI) and case management (CM) and care/support (CS) in two UK community samples. RESEARCH DESIGN: Prospective descriptive study. METHOD: Case managers across the UK and from a single UK CM service contributed client profiles to two data sets (Groups 1 and 2, respectively). Data were entered on demographics, injury severity, functional skills, functional-cognition (including executive functions), behaviour and CM and CS hours. Relationships were explored between areas of disability and service provision. RESULTS: Clients in Group 2 were more severely injured, longer post-injury and had less family support than clients in Group 1. There were few significant differences between Groups 1 and 2 on measures of Functionalskill, Functional-cognition and Behaviour disorder. Deficits in Functionalskills were associated with CS, but not CM. Deficits in measures of executive functions (impulsivity, predictability, response to direction) were related to CM, but not to CS. Insight was related to both CM and CS. Variables related to behaviour disorder were related to CM, but were less often correlated to CS. CONCLUSIONS: The need for community support is related not only to Functionalskills (CS), but also to behaviour disorder, self-regulatory skills and impaired insight (CM).

Performance-based testing in mild stroke: identification of unmet opportunity for occupational therapy.

Age at first stroke is decreasing, and most strokes are mild to moderate in severity. Executive function (EF) deficits are increasingly recognized in the stroke population, but occupational therapists have not altered their evaluation methods to fully accommodate changing patient needs. We present a hierarchical performance-based testing (PBT) pathway using data to illustrate how PBT could identify patients with mild stroke-related EF deficits in need of occupational therapy intervention. Data suggest that a substantial number of patients with EF deficits after mild stroke could benefit from occupational therapy services.

Revisiting the neurofunctional approach: conceptualizing the core components for the rehabilitation of everyday living skills.

BACKGROUND: Introduced in the 1980s, the neurofunctional approach (NFA) is one of the few interventions designed primarily for clients with severe deficits following traumatic brain injury (TBI). Specifically the NFA was intended for those individuals who were limited in their ability to solve novel problems or generalize skills from one setting to another and whose lack of insight limited their engagement in the rehabilitative process. DESCRIPTION OF THE APPROACH: The NFA is a client-centred, goal-driven approach that incorporates the principles of skill learning and promotes the development of routines and competencies in practical activities required for everyday living. Programmes based on the NFA are developed specifically to meet each client's unique needs, using a range of evidence-based interventions. RECENT EVIDENCE: Recently the NFA has been found to be more effective than cognitive-retraining for some individuals with moderate-to-severe TBI who have deficits in activities of daily living. This paper aims to define the core features of the NFA, outline the theoretical basis on which it is founded and consider implications of the findings for rehabilitation after TBI in general. The NFA is highly relevant for clients living in the community who require a case manager to direct an integrated, rehabilitation programme or provide structured input for the long-term maintenance of skills.

Online awareness is associated with superior performance on assessments of functional cognition.

Background: Intact awareness facilitates an individual's adoption of strategies to support community living skills. However, most studies have not examined awareness during ongoing complex task performance. Objective: To examine whether community-dwelling adult's Accuracy and Strategy use on the Weekly Calendar Planning Activity 17-item version (WCPA-17), Total Cues on the Performance Assessment of Self-care Skills Checkbook Balancing and Shopping Task (PCST), and scores on the self-report Alzheimer's Disease Cooperative Study - Activities of Daily Living Scale (ADCS-ADL) differ between groups who do and do not demonstrate awareness of performance difficulties on the WCPA-17. Methods: Using data collected as part of a larger study we performed a cross-sectional analysis of 274 community-dwelling adults aged 55 to 93 years. Two methods classified participants into groups aware or unaware of their performance. Independent sample t-tests examined group differences on four dependent variables: Accuracy and Strategy use on the WCPA-17, PCST Total Cues, and score on the ADCS-ADL. Results: Using one classification method, aware individuals showed superior Accuracy (p < 0.001), used more Strategies (p = 0.002), needed fewer PCST Total Cues (p < 0.001), and reported greater independence on the ADCS-ADL (p < 0.004), similar trends were observed with the other method in Accuracy (p < 0.001) and PCST Total Cues (p < 0.001) but Strategy use and ADCS-ADL differences failed to reach significance after Bonferroni correction. Conclusion: Groups categorized as aware performed better on all measures. Intact awareness is critical to performance on complex everyday activities and can be evaluated with functional cognition assessments.

Staff-reported antecedents to aggression in a post-acute brain injury treatment programme: what are they and what implications do they have for treatment?

Research in psychiatric settings has found that staff attribute the majority of in-patient aggression to immediate environmental stressors. We sought to determine if staff working with persons with brain injury-related severe and chronic impairment make similar causal attributions. If immediate environmental stressors precipitate the majority of aggressive incidents in this client group, it is possible an increased focus on the management of factors that initiate client aggression may be helpful. The research was conducted in a low-demand treatment programme for individuals with chronic cognitive impairment due to acquired brain injury. Over a six-week period, 63 staff and a research assistant reported on 508 aggressive incidents. Staff views as to the causes of client aggression were elicited within 72 hours of observing an aggressive incident. Staff descriptions of causes were categorised using qualitative methods and analysed both qualitatively and quantitatively. Aggression towards staff was predominantly preceded by (a) actions that interrupted or redirected a client behaviour, (b) an activity demand, or (c) a physical intrusion. The majority of aggressive incidents appeared hostile/angry in nature and were not considered by staff to be pre-meditated. Common treatment approaches can be usefully augmented by a renewed focus on interventions aimed at reducing antecedents that provoke aggression. Possible approaches for achieving this are considered.

Loss-of-Set and Strategy Application on the Menu Task: An Exploratory Study.

Background. The Menu Task (MT) is an occupational therapy screening measure designed to identify people in need of functional cognitive (FC) assessment. Purpose. To explore whether test-taker strategy selection on the MT is clinically informative. Methods. Using a cross-sectional design we administered assessments of FC including the MT and the After MT interview, cognitive screening measures, and self-report instrumental activities of daily living assessment to a convenience sample of 55 community-dwelling adults. After MT interviews responses were qualitatively characterized as (a) loss of set (e.g., not recognizing that food preferences are irrelevant to task performance), (b) calorie counting, or (c) planning. Findings. Loss of set was associated with poorer performance on most study measures, calorie counting was associated with superior performance on most study measures, and no differences were observed relating to planning. Implications. Determining the test-takers approach to the MT adds information to that provided by the MT itself.

Methodological Issues in Advancing the Status of Functional Cognitive Assessment.

Many individuals in acute hospital and post-acute care settings experience changes in their capacity to perform complex activities of daily living associated with deficits in functional cognition. Occupational therapists regularly assess and treat these occupational performance deficits. The construct of functional cognition offers oportunities for occupational therapists to define an approach to cognition that is both distinct from that of other disciplines and that supports evidence-based interventions. This article provides a rationale for performance-based assessment of functional cognition and an overview of the methodological issues associated with the development and implementation of reliable and valid screening and comprehensive asseements of functional.

Can service members with mild traumatic brain injury learn to develop implementation intentions for self-identified goals?

PURPOSE: Goal achievement relies heavily on executive functions, which may be compromised following mild traumatic brain injury (mTBI). Implementation intentions (II) have been found to help people act in accordance with their goals. II are written statements that describe a behavior that a person plans to enact when they encounter some form of anticipated trigger or stimulus. We evaluated the feasibility of teaching participants with mTBI to develop II for self-identified goals within the context of cognitive rehabilitation. METHODS: Soldiers with mTBI were recruited from a traumatic brain injury clinic. During the intervention, participants were assigned to develop an II for one of three self-identified goals every day. Descriptive methods were used to examine implementability and acceptability of the II training protocol as well as the extent to which participants learned to develop II for their own goals. RESULTS: The II training protocol was found to be highly implementable and acceptable to participants. Overall, participants (n = 16) were able to develop II related to their self-identified goals, which primarily focused on managing cognitive problems. For the most part, participants developed II that involved event- rather than time- or somatic/feeling-based triggers. CONCLUSION AND IMPLICATIONS: Participants with mTBI were able to learn to develop II for their self-identified goals. Further study is needed to determine whether adding II to cognitive rehabilitation advances patient goal achievement.IMPLICATIONS FOR REHABILITATIONIt is feasible to incorporate training in implementation intentions (predetermined "if/when-then" plans that are intended to link specific situational triggers with actions) in metacognitive strategy instruction for patients with mild traumatic brain injury.Participants with mild traumatic brain injury in this study demonstrated that they were able to develop implementation intentions for multiple self-identified rehabilitation goals, which holds promise for also teaching patients with mild cognitive impairment from other conditions.Learning to develop implementation intentions may help patients with mild traumatic brain injury initiate a range of other cognitive strategies in their everyday lives.Implementation intentions have the potential to help patients enact goal behaviors associated with their rehabilitation goals, making cognitive rehabilitation more "customizable" and relevant to clients' specific needs.

Cognitive versus functional approaches to rehabilitation after traumatic brain injury: commentary on a randomized controlled trial.

I describe the findings of one of the largest randomized controlled trials (RCTs) of rehabilitation after traumatic brain injury (TBI) ever conducted, examine the theoretical relationship between cognitive and functional rehabilitation after TBI, and describe the historical preference for cognitive (top-down) rather than functional (bottom-up) interventions. I also contrast the goals and principles of cognitive rehabilitation and of the neurofunctional approach of Giles and Clark-Wilson (1993; Giles, 2005)--a bottom-up approach. Findings of the RCT provide empirical support for both functional and cognitive interventions following acute TBI. In addition, they provide evidence that each type of intervention offers significant advantages for a specific subpopulation. The clinical implications of these findings for occupational therapy practitioners are discussed.

Comparison of constraint-induced movement therapy and bilateral treatment of equal intensity in people with chronic upper-extremity dysfunction after cerebrovascular accident.

OBJECTIVE: We compared the effectiveness of constraint-induced movement therapy (CIMT) with bilateral treatment of equal intensity for chronic upper-extremity (UE) dysfunction caused by cerebrovascular accident (CVA). DESIGN: We conducted a 2-group, randomized intervention trial with stratification by severity of UE dysfunction. Twelve community-dwelling adults were provided with 6 hr of occupational therapy for 10 days plus additional home practice. Six participants wore a mitt on the unimpaired UE, and 6 participants were intrusively and repetitively cued to use both UEs. The Wolf Motor Function Test (WMFT) and the Canadian Occupational Performance Measure (COPM) were administered before and after treatment and at 6-mo follow-up. RESULTS: Significant improvements were found in WMFT and COPM scores across time in both groups. No significant between-group differences were found on the WMFT. CONCLUSION: High-intensity occupational therapy using a CIMT or a bilateral approach can improve UE function in people with chronic UE dysfunction after CVA. Treatment intensity rather than restraint may be the critical therapeutic factor.