Training In Compensatory Strategies Research Articles

Efficacy of cognitive training on cognition, symptoms and functioning: Impact of motivation and attendance

While cognitive remediation therapy (CRT) and compensatory strategy training both have large literature bases supporting their efficacy on both proximal and distal outcomes, the research base on stand-alone cognitive training (CT) is smaller and less consistent, with little information about factors associated with better outcomes. In this study, we examined the efficacy of CT on training task, cognitive, symptom, and functional ability measures as well as the impact of motivational interviewing (MI), motivation level, and session attendance on treatment outcomes. Adults with psychotic spectrum disorders (n = 114) were randomized to MI or a sham control interview (CI), followed by 4 months of computerized CT. In whole sample analyses, participants improved on training tasks, cognitive performance, and psychiatric symptoms, but self-reported cognition, self-reported depression, and functional ability did not change. Compared to CI, MI was associated with greater reductions in self-reported depressive symptoms. Motivation level and session attendance did not significantly influence outcomes. Findings support the efficacy of CT on several key outcomes, and its simplicity may be advantageous in uptake in community clinics with limited staffing. The lack of functional gains underscores the need to incorporate treatment ingredients that promote generalization and real-world implementation of learned skills. We also speculate that engagement during course of training may be a better predictor of training success than baseline task-specific motivation.

3 Exploring the Relationship Between Cognition, Adherence, and Engagement in Compensatory Strategy Training in Mild Cognitive Impairment

Objective:Compensatory strategy training has been identified as a useful mechanism to improve everyday cognitive function among older adults with Mild Cognitive Impairment (MCI). Despite this, few studies have looked at cognitive factors that support adherence and engagement in these programs, which are key to maximizing benefit. The present study aimed to evaluate the relationship between cognition, adherence, and engagement during a group-based compensatory strategy training for people with MCI. We hypothesized individuals with better memory and executive function performance would show better adherence and higher engagement scores in cognitive training classes.Participants and Methods:Twenty-five participants enrolled in Emory University's Charles and Harriet Schaffer Cognitive Empowerment Program (CEP) completed an 11-week compensatory strategy training group (CEP-CT). CEP-CT is adapted from Ecologically Oriented Neurorehabilitation to be suitable for people with MCI. Participants enrolled were on average 74.3 years old (SD= 5.4), 52% Male, primarily Caucasian (80%; 16% African American), and college educated (M= 16.5 years; SD= 2.7). All participants received clinical diagnoses of MCI prior to enrollment in the program. Participants completed multiple cognitive measures, including Montreal Cognitive Assessment (MoCA), Hopkins Verbal Learning Test (HVLT), Trail Making Test A & B (TMT), Number Span Forward (NSF) and verbal fluency (S-words and Animals). For all group sessions, class attendance (present vs. not present) was recorded for each participant and their care partner, and engagement ratings for participants were recorded by the facilitator on a 1 to 5 scale (higher scores indicate better engagement). Outcomes include adherence to cognitive training (percentage of sessions attended; M= 82% class attendance, SD= 18%) as well as the average engagement ratings across 11 weeks (M= 3.25, SD= .40).Results:Bivariate Pearson correlations revealed that individuals who attended more classes also demonstrated better engagement in class, r= .44, p= .03. Class attendance was significantly related to performance on measures of memory and executive function (HVLT: r= -.42, p= .04; TMT-B: r= .69, p= .04), such that participants who performed worse on these measures attended more CEP-CT classes. Average engagement ratings were unrelated to cognitive performance.Conclusions:Results did not support initial hypotheses, and instead indicate individuals with poorer performance on measures of memory and executive function had better adherence to CEP-CT classes, as measured by attendance. These results may indicate individuals experiencing cognitive difficulties are more likely to attend cognitive training classes. Subjective engagement ratings were unrelated to cognition; however, individuals who attended more sessions were more engaged in cognitive training classes. Future areas of research include objective measurement of class engagement as well as the incorporation of nuanced adherence metrics to further elucidate the relationship between these factors and cognition in MCI.

The perspectives of participants with traumatic brain injury on prospective memory rehabilitation incorporating compensatory and metacognitive skills training

ObjectivePatient feedback is rarely gathered systematically in cognitive rehabilitation research. This study examined the perceptions and experiences of people with traumatic brain injury (TBI) who participated in a trial of a 6-session educational program for the rehabilitation of prospective memory (PM) impairment. MethodsA mixed methods design was used with 47 participants with TBI who completed a compensatory strategy training program (COMP) or COMP plus metacognitive strategy training program (COMP-MST) delivered by an occupational therapist. Data were collected via a participant survey, extracts from progress notes, and audiotaped discussions about learnings from the program during the final session. ResultsParticipants from both programs were highly satisfied and perceived improvements in everyday PM performance post-intervention. Elements that were highly valued include setting individualised client-centred goals, repetitive training of strategy use, establishing habits and routines, and receiving experiential, verbal, and written feedback.Changes including more therapy sessions were recommended. ConclusionsBoth the COMP and COMP-MST programs were perceived as effective by participants with TBI in improving their PM performance in everyday life using compensatory strategies such as assistive technology. Practice implicationsRoutine collection of patient feedback on cognitive rehabilitation can provide valuable information to support person-centred implementation of clinical practice guidelines.

A randomised controlled trial evaluating two cognitive rehabilitation approaches for cancer survivors with perceived cognitive impairment

PurposeUp to 70% of survivors report cognitive symptoms after chemotherapy. We compared two cognitive rehabilitation programs to a control group in cancer survivors.MethodsStudy population were adult cancer survivors with cognitive symptoms 6–60 months after adjuvant chemotherapy. Participants randomised to: Attention Process Training (APT), Compensatory Strategy Training (CST), or control group. Active interventions comprised 6–week, 2–h/week small group sessions. Assessments: pre- and post-intervention, 6- and 12-months later. Primary outcome was change in cognitive symptoms (FACT-COG-PCI subscale) between baseline and post-intervention. Secondary endpoints included objective neuropsychological performance, Functional Impact Assessment (FIA), patient-reported outcome measures, and associations. Analyses were on an intention-to-treat basis. Analysis of covariance mixed models were used for continuous outcomes.ResultsSixty-five participants were randomised (APT n = 21; CST n = 24; controls n = 20): 94% breast cancer, median age 54. Median time since chemotherapy 20.7 months. FACT-COG-PCI, clinical neuropsychological T-scores, and FIA improved in all groups over time, but no significant differences between arms. On mean neuropsychological T-scores 19/65 (29%) were impaired at baseline; post-intervention impairment controls 31.3%, CST 16.7%, APT 20.0%. On FIA at baseline, nine were impaired; this decreased to three post-intervention (one/group). FACT-COG-PCI was weakly associated with neuropsychological tests (rho = 0.24, p = 0.051) at baseline, and had no association with FIA. Neuropsychological total mean T-score was moderately positively associated with FIA (rho = 0.37, p = 0.003).ConclusionThere were no significant differences between intervention groups and controls using linear mixed models adjusted for baseline scores.Implications for Cancer SurvivorsCognitive symptoms and neuropsychological test scores improve over time.

Efficacy of Prospective Memory Rehabilitation Plus Metacognitive Skills Training for Adults With Traumatic Brain Injury: A Randomized Controlled Trial

Background Prospective memory (PM) failure can limit independence and productivity following traumatic brain injury (TBI). Compensatory strategy use may ameliorate the effect of PM impairment on daily life but requires sufficient self-awareness. Metacognitive skills training (MST) can facilitate self-awareness and strategy use and may improve the efficacy of PM rehabilitation. Objective To evaluate the effectiveness of compensatory strategy training (COMP) with an MST component (COMP-MST) for reducing everyday PM failure and improving psychosocial integration in adults with moderate–severe TBI, compared to COMP alone and a control condition. Secondary aims were to evaluate the effect of training on psychometric PM test scores, strategy use, self-awareness, and level of care. Methods Assessor and participant-blinded randomized controlled trial with 52 participants (77% male, mean age = 39.0. SD = 13.6) allocated to 3 groups: COMP-MST, COMP, and waitlist control. Interventions were delivered over 6 weekly sessions. Measures were collected pre- and post-intervention and 3-month follow-up. Data were analyzed using unstructured linear mixed-effects modeling for repeated measures and planned contrasts between time-points for each group. Results The models showed no significant differences between the groups on primary or secondary outcome measures. Significant pre–post intervention improvements were found for significant other’s ratings of everyday PM failure for both intervention groups but not the control group, with medium to large effect sizes. Clinically relevant improvements on primary outcomes were found for participants across all 3 groups. Conclusions This study found no significant benefits of combining MST with COMP for improving everyday PM and psychosocial integration. Clinical Trial Registration: Australian and New Zealand Clinical Trials Registry https://www.anzctr.org.au/ ACTRN12615000996561

The development of a cognitive rehabilitation and psycho-social group programme for teenage and young adult survivors of brain tumours: A feasibility study.

Treatment for childhood and adolescent brain tumours is often intensive, with significant neurocognitive and psycho-social late effects (Zeltzer et al., 2009). This feasibility Study aimed to inform the development of a cognitive rehabilitation and psycho-social group intervention for Teenage and Young Adult (TYA) survivors of brain tumours. A group-based intervention incorporated ideas from the current evidence base, including psychoeducation and compensatory strategy training, with a focus on real-life goals and improving quality of life. Participants (N = 19, 13-24 years) were recruited from the University College London Hospital TYA Oncology Service. Participants had received treatment for a malignant brain tumour and had completed their treatment at least 1 year prior to participation. Four group-based, whole-day interventions ran every 3 months throughout a year. Feasibility criteria were established to answer questions about acceptability of the intervention and recruitment. Qualitative and quantitative feedback from all four groups demonstrated acceptability and suitability of the intervention with regards to the content, structure and delivery. Recruitment presented more of a challenge with 35% fewer referrals than expected. Feedback suggests that the intervention is suitable and acceptable, whilst limitations include numbers of referrals and referral pathways. Future directions are discussed.

Clinical Practice Patterns of Speech-Language Pathologists Delivering Dysphagia Services to Persons with COPD: Analysis of Survey Outcomes.

Swallowing impairments co-occur with chronic obstructive pulmonary disease (COPD) leading to aspiration, disease exacerbations, and malnutrition. This pilot survey study aimed to identify current clinical practice patterns for swallowing evaluation and treatment in persons with COPD. A 35-question Qualtrics survey was deployed to medical speech-language pathology (SLP) social media sites and professional boards; flyers were distributed at a professional conference. Forty-eight SLPs completed the study. SLPs routinely include a clinical swallow examination (96%), videofluoroscopic swallowing study (79%), adjunctive respiratory measures (respiratory rate [83%], and pulse oximetry [67%], respiratory-swallow pattern [77%]) but less frequently include fiberoptic endoscopic evaluation of swallowing (23%). Self-reported advanced clinical experience and expert respiratory analysis skills were associated with adjunctive respiratory measure (respiratory rate, pulse oximetry) inclusion during assessment. Compensatory strategy training (77%) is a preferred treatment for dysphagia in COPD; however, respiratory-swallow pattern training and expiratory muscle strength training are increasing in use. SLPs self-report a comprehensive, individualized patient-centered care approach with inclusion of adjunctive respiratory-focused methods in dysphagia evaluation and treatment practice in persons with COPD. Advances in the identification of the integral role of respiratory function in swallowing integrity may be translating to clinical practice methods for dysphagia management in persons with COPD.

Social cognition and emotion regulation: a multifaceted treatment (T-ScEmo) for patients with traumatic brain injury

Background: Many patients with moderate to severe traumatic brain injury have deficits in social cognition. Social cognition refers to the ability to perceive, interpret, and act upon social information. Few studies have investigated the effectiveness of treatment for impairments of social cognition in patients with traumatic brain injury. Moreover, these studies have targeted only a single aspect of the problem. They all reported improvements, but evidence for transfer of learned skills to daily life was scarce. We evaluated a multifaceted treatment protocol for poor social cognition and emotion regulation impairments (called T-ScEmo) in patients with traumatic brain injury and found evidence for transfer to participation and quality of life. Purpose: In the current paper, we describe the theoretical underpinning, the design, and the content of our treatment of social cognition and emotion regulation (T-ScEmo). Theory into practice: The multifaceted treatment that we describe is aimed at improving social cognition, regulation of social behavior and participation in everyday life. Some of the methods taught were already evidence-based and derived from existing studies. They were combined, modified, or extended with newly developed material. Protocol design: T-ScEmo consists of 20 one-hour individual sessions and incorporates three modules: (1) emotion perception, (2) perspective taking and theory of mind, and (3) regulation of social behavior. It includes goal-setting, psycho-education, function training, compensatory strategy training, self-monitoring, role-play with participation of a significant other, and homework assignments. Recommendations: It is strongly recommended to offer all three modules, as they build upon each other. However, therapists can vary the time spent per module, in line with the patients’ individual needs and goals. In future, development of e-learning modules and virtual reality sessions might shorten the treatment.

The efficacy of prospective memory rehabilitation plus metacognitive skills training for adults with traumatic brain injury: study protocol for a randomized controlled trial

BackgroundImpairment of prospective memory (PM) is common following traumatic brain injury (TBI) and negatively impacts on independent living. Compensatory approaches to PM rehabilitation have been found to minimize the impact of PM impairment in adults with TBI; however, poor self-awareness after TBI poses a major barrier to the generalization of compensatory strategies in daily life. Metacognitive skills training (MST) is a cognitive rehabilitation approach that aims to facilitate the development of self-awareness in adults with TBI. This paper describes the protocol of a study that aims to evaluate the efficacy of a MST approach to compensatory PM rehabilitation for improving everyday PM performance and psychosocial outcomes after TBI.Methods/designThis randomized controlled trial has three treatment groups: compensatory training plus metacognitive skills training (COMP-MST), compensatory training only (COMP), and waitlist control. Participants in the COMP-MST and COMP groups will complete a 6-week intervention consisting of six 2-h weekly training sessions. Each 1.5-h session will involve compensatory strategy training and 0.5 h will incorporate either MST (COMP-MST group) or filler activity as an active control (COMP group). Participants in the waitlist group receive care as usual for 6 weeks, followed by the COMP-MST intervention. Based on the sample size estimate, 90 participants with moderate to severe TBI will be randomized into the three groups using a stratified sampling approach. The primary outcomes include measures of PM performance in everyday life and level of psychosocial reintegration. Secondary outcomes include measures of PM function on psychometric testing, strategy use, self-awareness, and level of support needs following TBI. Blinded assessments will be conducted pre and post intervention, and at 3-month and 6-month follow-ups.DiscussionThis study seeks to determine the efficacy of COMP-MST for improving and maintaining everyday PM performance and level of psychosocial integration in adults with moderate to severe TBI. The findings will advance theoretical understanding of the role of self-awareness in compensatory PM rehabilitation and skills generalization. COMP-MST has the potential to reduce the cost of rehabilitation and lifestyle support following TBI because the intervention could enhance generalization success and lifelong application of PM compensatory strategies.Trial registrationNew Zealand Clinical Trials Registry, ACTRN12615000996561. Registered on 23 September 2015; retrospectively registered 2 months after commencement.

Non-pharmacological interventions for cognitive impairment due to systemic cancer treatment.

It is estimated that up to 75% of cancer survivors may experience cognitive impairment as a result of cancer treatment and given the increasing size of the cancer survivor population, the number of affected people is set to rise considerably in coming years. There is a need, therefore, to identify effective, non-pharmacological interventions for maintaining cognitive function or ameliorating cognitive impairment among people with a previous cancer diagnosis. To evaluate the cognitive effects, non-cognitive effects, duration and safety of non-pharmacological interventions among cancer patients targeted at maintaining cognitive function or ameliorating cognitive impairment as a result of cancer or receipt of systemic cancer treatment (i.e. chemotherapy or hormonal therapies in isolation or combination with other treatments). We searched the Cochrane Centre Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PUBMED, Cumulative Index of Nursing and Allied Health Literature (CINAHL) and PsycINFO databases. We also searched registries of ongoing trials and grey literature including theses, dissertations and conference proceedings. Searches were conducted for articles published from 1980 to 29 September 2015. Randomised controlled trials (RCTs) of non-pharmacological interventions to improve cognitive impairment or to maintain cognitive functioning among survivors of adult-onset cancers who have completed systemic cancer therapy (in isolation or combination with other treatments) were eligible. Studies among individuals continuing to receive hormonal therapy were included. We excluded interventions targeted at cancer survivors with central nervous system (CNS) tumours or metastases, non-melanoma skin cancer or those who had received cranial radiation or, were from nursing or care home settings. Language restrictions were not applied. Author pairs independently screened, selected, extracted data and rated the risk of bias of studies. We were unable to conduct planned meta-analyses due to heterogeneity in the type of interventions and outcomes, with the exception of compensatory strategy training interventions for which we pooled data for mental and physical well-being outcomes. We report a narrative synthesis of intervention effectiveness for other outcomes. Five RCTs describing six interventions (comprising a total of 235 participants) met the eligibility criteria for the review. Two trials of computer-assisted cognitive training interventions (n = 100), two of compensatory strategy training interventions (n = 95), one of meditation (n = 47) and one of physical activity intervention (n = 19) were identified. Each study focused on breast cancer survivors. All five studies were rated as having a high risk of bias. Data for our primary outcome of interest, cognitive function were not amenable to being pooled statistically. Cognitive training demonstrated beneficial effects on objectively assessed cognitive function (including processing speed, executive functions, cognitive flexibility, language, delayed- and immediate- memory), subjectively reported cognitive function and mental well-being. Compensatory strategy training demonstrated improvements on objectively assessed delayed-, immediate- and verbal-memory, self-reported cognitive function and spiritual quality of life (QoL). The meta-analyses of two RCTs (95 participants) did not show a beneficial effect from compensatory strategy training on physical well-being immediately (standardised mean difference (SMD) 0.12, 95% confidence interval (CI) -0.59 to 0.83; I(2)= 67%) or two months post-intervention (SMD - 0.21, 95% CI -0.89 to 0.47; I(2) = 63%) or on mental well-being two months post-intervention (SMD -0.38, 95% CI -1.10 to 0.34; I(2) = 67%). Lower mental well-being immediately post-intervention appeared to be observed in patients who received compensatory strategy training compared to wait-list controls (SMD -0.57, 95% CI -0.98 to -0.16; I(2) = 0%). We assessed the assembled studies using GRADE for physical and mental health outcomes and this evidence was rated to be low quality and, therefore findings should be interpreted with caution. Evidence for physical activity and meditation interventions on cognitive outcomes is unclear. Overall, the, albeit low-quality evidence may be interpreted to suggest that non-pharmacological interventions may have the potential to reduce the risk of, or ameliorate, cognitive impairment following systemic cancer treatment. Larger, multi-site studies including an appropriate, active attentional control group, as well as consideration of functional outcomes (e.g. activities of daily living) are required in order to come to firmer conclusions about the benefits or otherwise of this intervention approach. There is also a need to conduct research into cognitive impairment among cancer patient groups other than women with breast cancer.

Training in Compensatory Strategies Enhances Rapport in Interactions Involving People with Möbius Syndrome.

In the exploratory study reported here, we tested the efficacy of an intervention designed to train teenagers with Möbius syndrome (MS) to increase the use of alternative communication strategies (e.g., gestures) to compensate for their lack of facial expressivity. Specifically, we expected the intervention to increase the level of rapport experienced in social interactions by our participants. In addition, we aimed to identify the mechanisms responsible for any such increase in rapport. In the study, five teenagers with MS interacted with three naïve participants without MS before the intervention, and with three different naïve participants without MS after the intervention. Rapport was assessed by self-report and by behavioral coders who rated videos of the interactions. Individual non-verbal behavior was assessed via behavioral coders, whereas verbal behavior was automatically extracted from the sound files. Alignment was assessed using cross recurrence quantification analysis and mixed-effects models. The results showed that observer-coded rapport was greater after the intervention, whereas self-reported rapport did not change significantly. Observer-coded gesture and expressivity increased in participants with and without MS, whereas overall linguistic alignment decreased. Fidgeting and repetitiveness of verbal behavior also decreased in both groups. In sum, the intervention may impact non-verbal and verbal behavior in participants with and without MS, increasing rapport as well as overall gesturing, while decreasing alignment.

The rehabilitation of face recognition impairments: a critical review and future directions.

While much research has investigated the neural and cognitive characteristics of face recognition impairments (prosopagnosia), much less work has examined their rehabilitation. In this paper, we present a critical analysis of the studies that have attempted to improve face-processing skills in acquired and developmental prosopagnosia, and place them in the context of the wider neurorehabilitation literature. First, we examine whether neuroplasticity within the typical face-processing system varies across the lifespan, in order to examine whether timing of intervention may be crucial. Second, we examine reports of interventions in acquired prosopagnosia, where training in compensatory strategies has had some success. Third, we examine reports of interventions in developmental prosopagnosia, where compensatory training in children and remedial training in adults have both been successful. However, the gains are somewhat limited—compensatory strategies have resulted in labored recognition techniques and limited generalization to untrained faces, and remedial techniques require longer periods of training and result in limited maintenance of gains. Critically, intervention suitability and outcome in both forms of the condition likely depends on a complex interaction of factors, including prosopagnosia severity, the precise functional locus of the impairment, and individual differences such as age. Finally, we discuss future directions in the rehabilitation of prosopagnosia, and the possibility of boosting the effects of cognitive training programmes by simultaneous administration of oxytocin or non-invasive brain stimulation. We conclude that future work using more systematic methods and larger participant groups is clearly required, and in the case of developmental prosopagnosia, there is an urgent need to develop early detection and remediation tools for children, in order to optimize intervention outcome.

The relationship of neuropsychological variables to driving status following holistic neurorehabilitation.

Objective: The main objectives of the present study were to evaluate the cognitive and driving outcomes of a holistic neurorehabilitation program and to examine the relationship between the neuropsychological variables of attention, speed of information processing, and visuospatial functioning and driving outcomes.Methods: One hundred and twenty-eight individuals with heterogeneous neurological etiologies who participated in a holistic neurorehabilitation program. Holistic neurorehabilitation consisted of therapies focusing on physical, cognitive, language, emotional, and interpersonal functioning, including training in compensatory strategies. Neuropsychological testing was administered at admission and prior to starting driving or program discharge. Subtests of processing speed, working memory, and perceptual reasoning from the Wechsler Adult Intelligence Scale-III and Trail Making Test were included.Results: At the time of discharge, 54% of the individuals returned to driving. Statistical analyses revealed that at the time of discharge: the sample as a group made significant improvements on cognitive measures included in the study; the driving and non-driving groups differed significantly on aspects of processing speed, attention, abstract reasoning, working memory, and visuospatial functions. Further, at the time of admission, the driving group performed significantly better than the non-driving group on several neuropsychological measures.Conclusion: Cognitive functions of attention, working memory, visual-motor coordination, motor and mental speed, and visual scanning significantly contribute to predicting driving status of individuals after neurorehabilitation. Holistic neurorehabilitation facilitates recovery and helps individuals to gain functional independence after brain injury.

Are There Gender Differences in Cognitive Function, Chronic Stress, and Neurobehavioral Symptoms After Mild-to-Moderate Traumatic Brain Injury?

Research is inconclusive on whether gender differences exist in cognitive function in persons who sustain a mild-to-moderate traumatic brain injury (TBI). Furthermore, it is also unclear whether there is a relationship between chronic stress and cognitive function in these persons. The purpose of this integrative review is to determine whether gender differences exist in cognitive function, neurobehavioral symptoms, and chronic stress levels after a mild-to-moderate TBI. Participants (n = 72) were recruited from eight outpatient rehabilitation centers. Participants completed the demographic questions, the Immediate Postconcussion Assessment Cognitive Testing neurocognitive test battery, the Perceived Stress Scale-14, and the Neurobehavioral Functioning Inventory (NFI). Gender differences were present on verbal memory composite scores (p = .033), with women performing worse than men. There were no other between-gender differences on cognitive tasks, neurobehavioral symptoms, or chronic stress. Higher chronic stress levels result in a decrease in verbal memory (p = .015) and motor processing speed (p = .006) and slower reaction time (p = .007) for women. As male NFI cognition scores increased, motor processing speed scores decreased (p = .012) and reaction time got slower (p = .019), whereas women exhibited decreased verbal memory (p = .017) and slower reaction time (p = .034). As NFI motor symptoms increased, men exhibited decreased verbal memory (p = .005), visual memory (p = .002), and motor processing speed (p = .002) and slower reaction time (p = .002). Overall, this study only found gender differences on verbal memory composite scores, whereas the remaining cognitive tasks, neurobehavioral symptoms, and chronic stress did not indicate gender differences. Correlations between chronic stress, neurobehavioral symptoms, and cognitive function differed in both men and women with TBI. Persons in the chronic phase of recovery from a TBI may benefit from training in compensatory strategies for verbal memory deficits and stress management.

Time Pressure Management as a Compensatory Strategy Training after Closed Head Injury

Following severe closed head injury, deficits in speed of information processing are common. As a result, many head-injured patients experience a feeling of “information overload” in daily tasks that once were relatively easy. Many remedial programmes have been designed that treat different aspects of attention (often including mental speed requirements) by repetitive exercises. In the present study, a different approach to slow information processing has been taken, namely Time Pressure Management (TPM). TPM consists of a set of alternative cognitive strategies that allow head-injured patients in real-life tasks to compensate for their mental slowness. In a randomised pre-training vs. post-training vs. follow-up group study, the effectiveness of TPM training was compared with concentration training in which verbal instruction was the key element. The results indicate that specific TPM strategies are learned by the experimental subjects but that both treatments improve task performance significantly for an information intake task. TPM, however, produces greater gains than concentration training and also appears to generalise to other measures of speed and memory function.

Executive function disorders: rehabilitation challenges and strategies.

Individuals with frontal lobe impairments often demonstrate a variety of disorders of executive function that pose significant challenges to rehabilitation. Impairments in initiation, sequencing, impulse control, attention, prospective memory, and self-awareness frequently manifest in disorganized and maladaptive behaviors that severely impact many aspects of adaptive functioning. A greater awareness of the nature of these deficits, improved tools for evaluation, and an increased interest in rehabilitation have led to the development of both specific strategies and general schemas for treating and managing executive function deficits. Studies supporting the use of environmental manipulations, compensatory strategy training, and techniques to improve underlying skills, including attention and prospective memory, are described. An overarching strategy for working with individuals with impaired executive functions is proposed, based on the individual's level of awareness and context dependency. Rehabilitation is conceptualized as a set of activities, which assist the individual in moving from a more dependent, externally supported state to a more independent, internally supported and self-regulated state through the systematic shift in external to internal regulation of behavior. Successful movement along this continuum is variable across cases, but the literature suggests that significant gains in function and behavior are possible.

Cognitive rehabilitation: advancing the stature of occupational therapy.

As occupational therapists, we can advance our stature in cognitive rehabilitation by first narrowing our scope of practice to become the team experts in compensatory strategy training, the domain of cognitive rehabilitation most consistent with our history and expertise. Supported and aided by our professional association, we must also intensify our contribution to this developing field through research and individual and professional involvement in transdisciplinary organizations. Increased involvement and leadership from occupational therapy promise to improve the prospect that cognitive rehabilitation services will improve day-to-day performance for survivors of brain injury.