Brain Injury Professional: Cognitive Rehabilitation Updates and Current State of the Field. by Brain Injury Professional

BRAIN INJURY professional vol. 17 issue 4

Cognitive Rehabilitation: Updates and Current State of the Field

Highlight the quality services that you provide for people with acquired brain injury. You have quality practices in place to ensure optimal outcomes. Accreditation is the next step in growing your organization by demonstrating your person-centred focus, and your commitment to continuous quality improvement. CARF is a leading independent, nonprofit accreditor of health and human services that accredits more than 1,200 brain injury programs in the United States, Europe, the Middle East, New Zealand, and Canada. Our accreditation covers the continuum of services offered to individuals with ABI in a variety of treatment settings. About CARF: • Accredits programs internationally • Reviews business and clinical practices • Guides person-centred, evidence-based practices • Establishes quality performance improvement systems • Hosts training and education on standards Benefits of CARF accreditation: • Service excellence • Business improvement • Funding access • Competitive differentiation • Risk management • Positive visibility • Accountability • Peer networking

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vol. 17 issue 4

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Editor in Chief Message Guest Editor’s Message Technology Article Expert Interview

features

Evidence-based Cognitive Rehabilitation for Traumatic Brain Injury and Stroke: Latest Update from the ACRM Cognitive Rehabilitation Task Force

Keith Cicerone, PhD, ABPP-Cn, FACRM

Contextualized Treatment: An Active Ingredient in Acute TBI Rehabilitation?

Cynthia Beaulieu, PhD • Jennifer Bogner, PhD

The Changing Landscape of Holistic Brain Injury Rehabilitation

Lance E. Trexler, PhD, HSPP, FACRM

Cognitive Rehabilitation for Emotion Recognition Deficits after Brain Injury

Dawn Neumann, PhD • Barbra Zupan, PhD • Barry Willer, PhD

featurets

Training Professionals in Delivering Evidence-based Cognitive Rehabilitation

Amy Shapiro-Rosenbaum, Ph.D. FACRM

Medical Interventions – Opportunities for Optimizing and Augmenting Cognitive Rehabilitation

Anthony J.-W. Chen, MD

Current State of Pediatric Cognitive Rehabilitation

Drew Nagele, PsyD, CBIST, FACRM

Brain Injury Professional is a membership benefit of the North American Brain Injury Society and the International Brain Injury Association

NORTH AMERICAN BRAIN INJURY SOCIETY CHAIRMAN Mariusz Ziejewski, PhD VICE CHAIR Debra Braunling-McMorrow, PhD IMMEDIATE PAST CHAIR Ronald C. Savage, EdD TREASURER Bruce H. Stern, Esq. FAMILY LIAISON Skye MacQueen EXECUTIVE DIRECTOR/ADMINISTRATION Margaret J. Roberts EXECUTIVE DIRECTOR/OPERATIONS J. Charles Haynes, JD MARKETING MANAGER Megan Bell-Johnston GRAPHIC DESIGNER Kristin Odom BRAIN INJURY PROFESSIONAL PUBLISHER J. Charles Haynes, JD CO-EDITOR IN CHIEF Beth Slomine, PhD - USA CO-EDITOR IN CHIEF Nathan Zasler, MD - USA ASSOCIATE EDITOR Juan Arango-Lasprilla, PhD – Spain TECHNOLOGY EDITOR Stephen K. Trapp, PhD - USA EDITOR EMERITUS Debra Braunling-McMorrow, PhD - USA EDITOR EMERITUS Ronald C. Savage, EdD - USA DESIGN AND LAYOUT Kristin Odom ADVERTISING SALES Megan Bell-Johnston EDITORIAL ADVISORY BOARD Nada Andelic, MD - Norway Philippe Azouvi, MD, PhD - France Mark Bayley, MD - Canada Lucia Braga, PhD - Brazil Ross Bullock, MD, PhD - USA Fofi Constantinidou, PhD, CCC-SLP, CBIS - USA Gordana Devecerski, MD, PhD - Serbia Sung Ho Jang, MD - Republic of Korea Cindy Ivanhoe, MD - USA Inga Koerte, MD, PhD - USA Brad Kurowski, MD, MS - USA Jianan Li, MD, PhD - China Christine MacDonell, FACRM - USA Calixto Machado, MD, PhD - Cuba Barbara O’Connell, OTR, MBA - Ireland Lisandro Olmos, MD - Argentina Caroline Schnakers, PhD - USA Lynne Turner-Stokes, MD - England Olli Tenovuo, MD, PhD - Finland Asha Vas, PhD, OTR - USA Walter Videtta, MD – Argentina Thomas Watanabe, MD – USA Alan Weintraub, MD - USA Sabahat Wasti, MD - Abu Dhabi, UAE Gavin Williams, PhD, FACP - Australia Hal Wortzel, MD - USA Mariusz Ziejewski, PhD - USA EDITORIAL INQUIRIES Managing Editor Brain Injury Professional PO Box 131401, Houston, TX 77219-1401 Tel 713.526.6900 Email: mbell@hdipub.com Website: www.nabis.org ADVERTISING INQUIRIES Megan Bell-Johnston Brain Injury Professional HDI Publishers PO Box 131401, Houston, TX 77219-1401 Tel 713.526.6900 Email: mbell@internationalbrain.org NATIONAL OFFICE North American Brain Injury Society PO Box 1804, Alexandria, VA 22313 Tel 703.960.6500 / Fax 703.960.6603 Website: www.nabis.org ISSN 2375-5210 Brain Injury Professional is a quarterly publication published jointly by the North American Brain Injury Society and HDI Publishers. © 2020 NABIS/HDI Publishers. All rights reserved. No part of this publication may be reproduced in whole or in part in any way without the written permission from the publisher. For reprint requests, please contact, Managing Editor, Brain Injury Professional, PO Box 131401, Houston, TX 77219-1400, Tel 713.526.6900, Fax 713.526.7787, e-mail mbell@hdipub.com.

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from the

editor in chief

It is a privilege to serve as Editor-in-Chief for this issue of Brain Injury Professional that provides an overview and update on the existing body of evidence evaluating treatment efficacy and exploring active ingredients of cognitive rehabilitation for individuals with acquired brain injury (ABI). For the last three decades, there has been a growing body of literature exploring evidence-based cognitive interventions for individuals with ABI, primarily traumatic brain injury (TBI) and stroke. The Cognitive Rehabilitation Task Force of the American Congress of Rehabilitation Medicine Brain Injury Special Interest Group (ACRM BI-ISIG), championed by Dr. Keith Cicerone, has taken the lead by periodically reviewing and summarizing this mounting literature and providing standards, guidelines, and options for the field. Beth S. Slomine, PhD, ABPP

Our current guest editor, Dr. Yelena Goldin, is steeped in the topic of cognitive rehabilitation for individuals with ABI. She currently serves as the co-chair of the ACRM BI-ISIG Cognitive Rehabilitation Task Force, and was a lead author in the most recent updated systematic review of evidence-based cognitive rehabilitation in TBI and stroke which was published in Archives of Physical Medicine and Rehabilitation in 2019. Dr. Goldin ’s commitment to the field of brain injury rehabilitation is evident from her leadership roles within the world of brain injury, her strong research publication track record, and her commitment to training the next generation of neuropsychologists. I am so pleased that Dr. Goldin has taken the time and effort to organize this fantastic issue in which she has brought together highly regarded experts in in the field of brain injury and cognitive rehabilitation interventions for individuals with ABI. Dr. Keith Cicerone's feature article, entitled “Evidence-based Cognitive Rehabilitation for Traumatic Brain Injury and Stroke: Latest Update from the ACRM Cognitive Rehabilitation Task Force“ describes selected results and recommendations based on the cumulative evidence on efficacy of cognitive rehabilitation interventions which were detailed in the 2019 systematic review. The issue includes many other excellent articles, each packed with relevant information for brain injury professionals from a range of disciplines. A few highlights include Drs. Beaulieu and Bogner’s discussion of active ingredients in acute TBI rehabilitation research, Dr. Trexler’s report on the changing landscape of holistic brain injury rehabilitation, Dr. Bogdanova’s article on role of technology in cognitive rehabilitation during the COVID-19 pandemic, Drs. Neumann, Zupan, and Willer’s summary of cognitive rehabilitation for emotional recognition deficits after brain injury, and an expert interview with Dr. Corrigan about how cognitive rehabilitation can be used to help individuals to more effectively live with brain injury as a chronic condition. Finally, mark your calendars now for the 2021 Virtual World Congress on Brain Injury! This multidisciplinary event will offer a broad and varied program spanning cutting-edge research to practical and applied techniques for improving outcome for persons with brain injury. The conference is a joint initiative the International Brain Injury Association (IBIA), ABI Ireland, the International Paediatric Brain Injury Society (IPBIS), The North American Brain Injury Society (NABIS), PINK Concussions, and the IBIA Special Interest Groups. Additionally, be on the lookout for upcoming IBIA, NABIS, and IPBIS webinars. For more information, go to https:// www.internationalbrain.org/meetings-and-events/ibia-webinar-series

Editor Bio Beth S. Slomine, PhD, ABPP, is co-director of the Center for Brain Injury Recovery and director of neuropsychology training and neuropsychological rehabilitation services at Kennedy Krieger Institute. She is a Professor of Psychiatry & Behavioral Sciences and Physical Medicine & Rehabilitation at Johns Hopkins University School of Medicine. She is a licensed psychologist, board certified clinical neuropsychologist, and board certified subspecialist in pediatric neuropsychology. Research interests include developing neurobehavioral assessment tools and understanding factors influencing outcome following pediatric neurological injury. Dr. Slomine has authored >70 peer-reviewed manuscripts, numerous book chapters, and co-edited a textbook entitled Cognitive Rehabilitation for Pediatric Neurological Conditions.

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from the

Yelena Goldin, PhD, ABPP-CN

guest editor

Acquired brain injury (ABI) leads to persistent debilitating neurocognitive and functional impairments that limit activity, productivity, and social participation in a significant proportion of individuals. This is one of the leading causes of disability in the United States and worldwide. Since emerging over forty years ago, cognitive rehabilitation has aimed to provide targeted interventions to address ABI-related deficits and improve individuals’ functioning and quality of life. As a relatively young field, ongoing research efforts have focused on evaluating treatment efficacy, and on expanding our understanding of the specific mechanisms of action and active ingredients of cognitive rehabilitation interventions. The substantial growth of the literature base in this area by the 1990’s allowed for the emergence of evidence-based systematic reviews to evaluate the existent evidence and develop specific treatment guidelines. The largest known effort, which was conducted by the Cognitive Rehabilitation Task Force of the American Congress of Rehabilitation Medicine Brain Injury Special Interest Group and led by Dr. Keith Cicerone, has become known as “the Cicerone reviews”. The first of these evidence-based reviews and clinical practice guidelines covered all the available literature through 1997. They have been routinely updated every 5 years. The latest update, which was recently published in Archives of Physical Medicine and Rehabilitation, is highlighted in this issue’s feature article by Dr. Cicerone. Two important things that become notable from more than two decades of this work are that with each update 1) emerging literature tends to strengthen previous recommendations and leads to new/additional recommendations, and 2) the quality of the studies continue to improve over time, which may be a function of the ongoing growth of the field, being subjected to scrutiny of the evidence-based reviews, or both. Throughout its growth, the field of cognitive rehabilitation continues to see shifts in terms of treatment approaches, delivery, modality, and targets. While some of this has been fueled directly by the advancement of research and resultant knowledge in this and associated fields, a lot of the influence comes from factors related to policy, reimbursement, and other situational and environmental factors. These are often intertwined. The articles in issue aim to address the most relevant intra- and extra-field factors that impact cognitive rehabilitation in order to provide a comprehensive view of the current state of the field and offer a glimpse into the future. There have been striking changes in the overall landscape of cognitive rehabilitation, leading to changes in the delivery (including modality, dosage, and intensity) of cognitive rehabilitation services. The impact of these changes on individual and societal outcomes is not yet clear. What may be considered to be in contrast to this, is the significant progress in the understanding of the long-term effects of brain injury and in the shift of the narrative of traumatic brain injury to view it as a chronic medical condition – all of which is expected to expand access to much-needed rehabilitation services across all stages of injury. Recent years have also seen advancements in critical areas or components of cognitive rehabilitation that were previously overlooked or understudied (e.g. alexithymia, adjunctive medical treatments, pediatric rehabilitation) that are explored in this issue. Technological advancements, which can help bridge accessibility gaps in cognitive rehabilitation, have been increasingly incorporated in treatment delivery, with increasingly more evidence emerging in this domain. This has been especially relevant in the current global COVID-19 pandemic environment. Finally, and perhaps most critical, practice frequently tends to lag research by more than a decade, which impedes timely application of the best available treatment options. Current and prospective efforts in translation and implementation of the growing evidence-based knowledge in cognitive rehabilitation are discussed.

Editor Bio Dr. Goldin is a board-certified senior neuropsychologist at the JFK-Johnson Rehabilitation Institute, Clinical Assistant Professor of Physical Medicine and Rehabilitation at Rutgers-Robert Wood Johnson Medical School, Project Director of the JFK-Johnson TBI Model Systems, and Training Director of the JFK-Johnson neuropsychology residency program. She is the co-chair of the ACRM BI-ISIG Cognitive Rehabilitation Task Force, where she is currently leading the next update to the evidence-based systematic review on cognitive rehabilitation in TBI and stroke, as well as the co-chair of the Girls and Women’s with ABI Task Force. She earned several awards for her work in brain injury rehabilitation.

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Evidence-based Cognitive Rehabilitation for Traumatic Brain Injury and Stroke: Latest Update from the ACRM Cognitive Rehabilitation Task Force Keith Cicerone, PhD, ABPP-Cn, FACRM

Evidence-based medicine strives to incorporate the best available scientific knowledge to inform and guide clinical practice. Toward that end, the Cognitive Rehabilitation Task Force (CRTF) of the American Congress of Rehabilitation Medicine, Brain Injury Special Interest Group, has published four systematic reviews of cognitive rehabilitation after TBI or stroke. 1 - 4 Our intent has been to summarize the existing literature in order to provide evidence-based recommendations for the clinical practice of cognitive rehabilitation. We have consistently attempted to base our recommendations on the best available scientific evidence, to be applied in conjunction with clinical judgment and patients’ preferences and values. Our methods for the development of evidence-based recommendations are described in more detail in our initial publication.1 Briefly, articles were reviewed and classified as providing Class I, Class II, or Class III evidence. Well-designed, prospective, RCTs were considered class I evidence. Class II studies consisted of prospective, nonrandomized cohort studies; retrospective, nonrandomized case-control studies; or multiplebaseline studies that permitted a direct comparison of treatment conditions. Clinical series without concurrent controls, or singlesubject designs with adequate quantification and analysis were considered class III evidence. The levels of evidence for specific areas of intervention were synthesized to develop recommendations for clinical practice. Practice Standards are based upon at least one class I study and substantial evidence of effectiveness to support a recommendation that the treatment be specifically considered for people with acquired neurocognitive impairments and disability after TBI or stroke. Practice Guidelines are based upon evidence of probable effectiveness to support consideration of the intervention. Practice Options are based upon evidence of possible effectiveness and no indication of harm to support consideration of the intervention in clinical practice. The level of evidence required to determine Practice Standards, Practice Guidelines, or Practice Options was based on the decision rules applied in our initial review. All recommendations were reviewed for consensus by the CRTF through face-to-face discussion.

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To date, the CRTF has now evaluated 491 papers on cognitive rehabilitation interventions for individuals with TBI and stroke (109 Class I, 68 Class II, and 314 Class III) and has made 29 recommendations for evidence-based practice of cognitive rehabilitation (9 Practice Standards, 9 Practice Guidelines and 11 Practice Options). Evidence supports Practice Standards for attention deficits after TBI or stroke; visual scanning for neglect after right hemisphere stroke; compensatory strategies for mild memory deficits; targeted cognitive interventions (language formulation, reading comprehension training) for language deficits after left hemisphere stroke; specialized focused approaches (e.g. metaphor interpretation training) for social communication deficits after TBI; metacognitive strategy training for deficits in executive functioning; and comprehensive-holistic neuropsychological rehabilitation to reduce cognitive and functional disability after TBI or stroke. We have conducted an additional review of a subsample of 53 papers investigating cognitive interventions after TBI using extended methodological rating criteria to evaluate internal validity, external validity, and statistical analyses. 5 The results from this rigorous reanalysis support our original recommendations for the effectiveness of evidence-based interventions for attention, communication skills, executive functioning, and comprehensiveholistic rehabilitation after TBI. This paper will describe selected results and recommendations based upon the cumulative evidence regarding effectiveness of cognitive rehabilitation after TBI or stroke. The reader is encouraged to read the original reviews for more detailed discussion of specific studies and interventions.

Rehabilitation of Attention We reviewed 29 studies (12 Class I, 6 Class II and 21 Class III) addressing the remediation of attention. The most thoroughly investigated intervention is Attention Process Training (APT), which is based on direct training designated for specific attentional processes.

The most recent iteration of APT (APT-3) incorporates formal interventions for metacognitive strategy training. There is substantial evidence that APT can improve performance on training tasks and direct measures of global attention. Training with APT is also associated with a reduction of self-reported attentional lapses in everyday functioning. There is evidence of possible benefits from APT-3, which incorporates direct attention training and metacognitive strategy training, on functional tasks such as reading comprehension. It is thought that improvements in allocation of attention and self-monitoring may underlie improvements in reading comprehension, although there is limited evidence for transfer of attention training to functional cognition. Metacognitive strategy training has been shown to benefit the self-management of attentional difficulties in everyday functioning, such as increased use of strategies and fewer subjective complaints through Time Pressure Management. The CRTF recommends that treatment of attention deficits should incorporate both direct attention training and metacognitive strategy training to increase task performance and promote generalization to daily functioning after TBI (Practice Standard) after both TBI and stroke during the post-acute stages of recovery.

Rehabilitation of Memory Deficits

Improvements in working memory are evident after training on specific, “modular” components of working memory, whether this is achieved through the use of either computer-based or therapist-administered interventions. The evidence also suggests improvement on patient-reported outcomes of everyday activities after working memory training. Based on recent evidence, we recommend that direct attention training for specific “modular” impairments in Working Memory, including the use of computerbased interventions, be considered to enhance both cognitive and functional outcomes during post-acute rehabilitation for acquired brain injury (Practice Guideline). The CRTF continues to emphasize the importance of therapist involvement and intervention to promote awareness and generalization (e.g., metacognitive strategy training) over the stand-alone use of computer-based tasks. There continues to be insufficient evidence to indicate differential benefits of direct attention training compared with standard (inpatient) brain injury rehabilitation on functional outcomes during acute recovery from TBI or stroke, although this training may improve specific aspects of attention and there is no indication that the incorporation of direct attention training during acute rehabilitation has negative or adverse effects.

In its earlier reviews, the CRTF focused its recommendations on particular techniques as a Practice Option for improving more severe memory impairment, such as the use of errorless learning techniques and externally-directed assistive devices for patients with moderate to severe memory impairments. Current literature suggests increased emphasis on use of assistive technology and remote treatment delivery using the Internet, but no new evidence to support changing prior recommendations.

Rehabilitation of Visuospatial Functioning

We reviewed 81 studies (27 Class I, 16 Class II and 38Class III studies in the area of visual functioning, with many of these studies addressing the remediation of visual neglect after right hemisphere stroke. Rehabilitation of neglect through practice in visual scanning after right hemisphere stroke has demonstrated substantial evidence of effectiveness and consistent support for recommendation as a Practice Standard. More recent research has focused on enhancements of scanning procedures and on alternative procedures (left hand stimulation or limb activation with mirror therapy) in conjunction with visual scanning training for left neglect. Several studies addressed the application of visuospatial interventions to functional limitations but were unable to document generalization of neglect rehabilitation to functional activities. The CRTF does not recommend the use of computer-based training to extend visual fields.

The CRTF has reviewed 90 studies (17 Class I, 14 Class II, and 59 Class III) addressing remediation of memory. The CRTF has consistently recommended a Practice Standard of compensatory memory strategy training for mild memory impairments after TBI, including the use of internalized strategies and external compensations. Current evidence supports the use of visual imagery, association techniques, and the use of assistive technology for the treatment of prospective remembering difficulties in persons with mild memory impairment (Practice Standard). Memory strategy training is also recommended for the improvement of recall in the performance of everyday tasks in people with mild memory impairments after TBI (Practice Standard). Current evidence supports the use of groupbased memory strategy training for the purpose of improving PM and recall in the performance of everyday tasks after TBI, and extends this recommendation to the treatment of people with mild to moderate memory impairments after stroke (Practice Option). There is consistent evidence suggesting that internal strategies are more effective for participants with less severe memory impairments and greater cognitive reserve.

Rehabilitation of Communication and Pragmatic Language Functioning The CRTF has reviewed 140 studies in the areas of cognitivelinguistic functioning after stroke and social communication after TBI (20 Class I, 12 Class II, and 98 Class III studies). Cognitive-linguistic interventions are recommended during both acute and postacute rehabilitation for language deficits after left-hemisphere stroke (Practice Standard). Treatment intensity is a critical consideration for increasing effectiveness. The CRTF has recommended cognitive interventions for specific language impairments such as reading comprehension and language formulation after left hemisphere stroke or TBI (Practice Guideline). Several studies emphasize the need to match reading comprehension strategies to patient-specific needs and abilities as a more clinically effective approach. The CRTF has consistently recommended, as a Practice Standard, specific interventions for functional communication deficits, including pragmatic conversational skills following TBI. Specific intervention to improve the recognition of emotions from facial expressions may be effectively incorporated as component of the Practice Standard for treating functional communication deficits after TBI. However, the CRTF notes that this effect may be specific to this training and may not generalize to training emotional perception based on prosodic or semantic-contextual cues, nor to empathy or neuropsychiatric behaviors. There is consistent evidence to support the recommendation (Practice Option) for group-based interventions for the remediation of language deficits after left hemisphere stroke and for socialcommunication deficits after TBI.

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Rehabilitation of Executive Functioning The CRTF has reviewed 82 studies of interventions for executive functioning (24 Class I, 7 Class II, and 51 Class III). The central aspect of most of these interventions is the facilitation of metacognitive knowledge (awareness) and metacognitive self-regulation (e.g., goal setting, planning, initiation, execution, self-monitoring, and error management). Many of these interventions addressed multiple aspects of executive dysfunction within an integrated treatment approach. The CRTF has previously recommended Metacognitive Strategy Training (self-monitoring and self-regulation) (MST) as a Practice Standard for treating deficits in executive functioning after TBI, including impairments of emotional self-regulation, and as a component of interventions for deficits in attention, neglect, and memory. The most current evidence suggests that the incorporation of formal protocols for Problem Solving Training and Goal Management Training, and their application to everyday situations and functional activities, should be considered as components of MST during post-acute rehabilitation after TBI. Deficits in emotional regulation may play a critical role in patients’ ability to apply a strategy for the planning and regulation of complex tasks and may require specific interventions. Treatment for difficulties in emotional regulation has been incorporated into some multi-faceted interventions for executive dysfunction. Emerging Class I evidence supports the incorporation of MST into occupation-based treatment for practical goals and functional skills to promote both acquisition and transfer of functional skills during post-acute rehabilitation after TBI and stroke. There is a notable emergence of research on the effectiveness of the Cognitive Orientation to Occupational Performance (CO-OP), an approach integrating functional skills training and metacognitive strategy training. This procedure includes client-centered goal setting, particularly in relation to performance of functional activities, and the use of a global metacognitive strategy of Goal-Plan-Do-Review. The remediation of specific cognitive components or impairments is avoided in favor of interventions directly at the level of relevant client-centered functional activities. A combination of functional skills training at the activity level, and incorporation of metacognitive strategies is related to improved performance on trained tasks, and greater transfer of training to untrained tasks. These studies suggest that the effects of intervention on untrained functional tasks requires the incorporation of deliberate efforts to promote transfer and generalization, including the use of a general metacognitive strategy for planning, implementing and self-monitoring performance of functional activities. There is specific evidence that explicit (verbal-and-video) performance feedback should be considered to facilitate the positive effects of metacognitive strategy training (Practice Guideline). There is consistent evidence that group-based interventions may be considered for remediation of executive and problem-solving deficits after TBI. (Practice Option). For patients with severe cognitive (executive) deficits, including limitations of emergent awareness and use of compensatory strategies, the use of direct, skill-specific training including errorless learning may be considered to promote performance of specifically trained functional tasks, with no expectation of transfer to untrained activities. While the direct evidence for this intervention is limited to participants with chronic stroke, the CRTF considered that there is a sound clinical rationale and indirect evidence for applying this recommendation to the treatment of people with severe cognitive impairments after TBI (Practice Option).

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Participants with relatively mild cognitive impairments appear to benefit from metacognitive strategy training and explicit instructions to generalize across situations, while participants with more severe impairments are more likely to respond to errorless learning and specific skill training on functional tasks.

There is preliminary evidence suggesting that MST as a component of training on functional activities may increase the effectiveness of acute rehabilitation for patients with cognitive impairment after stroke (Practice Option).

Comprehensive Rehabilitation Programs The CRTF reviewed 69 studies (9 Class I, 13 Class II and 47 Class III) of comprehensive-holistic rehabilitation. Modular approaches to cognitive remediation are typically aimed at a single cognitive impairment; patients with multiple impairments may receive a mix of modular treatments that target several cognitive impairments. Comprehensive-holistic programs typically target specific cognitive impairments but also provide individual and group therapies that address self-awareness of the impact of cognitive deficits, interpersonal and emotional functioning, and psychological coping through an organized and integrated therapeutic environment. There is strong, consistent evidence that post-acute, comprehensiveholistic neuropsychological rehabilitation should be provided to reduce functional, cognitive, and psychosocial disability after TBI (Practice Standard). Whereas the earlier research focused on individuals with TBI, the recent results support extending the recommendation to individuals with both traumatic and nontraumatic brain injuries, regardless of severity or time post injury. Comprehensive neuropsychological programs should integrate individualized interventions to address cognitive and interpersonal functioning after acquired brain injury. Such interventions should be goal directed and emphasize individualized client-centered goal setting to promote enhanced residential independence and occupational functioning (Practice Option). Group interventions may be considered as part of comprehensive-holistic neuropsychological rehabilitation to address the functional application of specific interventions and improve psychological well-being (Practice Option). While not a formal recommendation, the CRTF recognizes the evidence that the presence of Postconcussive Syndrome (PCS) and co-morbid psychiatric symptomatology should not preclude participation in cognitive rehabilitation that includes psychoeducational and cognitive strategy training after mild to moderate TBI. Multi-modal, computer-assisted cognitive retraining with the active involvement and direction of a rehabilitation therapist is recommended as a component of neurorehabilitation for the remediation of attention, memory, and executive function deficits following stroke or TBI. (Practice Guideline). Computer-assisted cognitive retraining programs should stimulate the cognitive domains of interest, adapt task difficulty to the patient’s level of performance, and provide feedback and objective performance data (Practice Guideline).

It is notable that the RehaCom package incorporates components that have contributed to the efficacy of other rehabilitation techniques, including: repeated stimulation, intensity of training, adjusting task difficulty to the patient’s performance, feedback, therapist involvement, and simulated functional tasks.

Conclusions In our initial review, we concluded that “cognitive rehabilitation should always be directed toward improving everyday functioning and should include active attempts to promote generalization or directly apply compensatory strategies to functional contexts.” In our latest review, this position holds steady with a continuously developing evidence base. Several principles operate across varied interventions to promote acquisition, such as adjusting task difficulty to the patient’s performance and providing explicit performance feedback. In general, participants with relatively mild cognitive impairments appear to benefit from metacognitive strategy training and explicit instructions to generalize across situations, while participants with more severe impairments are more likely to respond to errorless learning and specific skill training on functional tasks. Several interventions, such as Attention Process Training, Goal Management Training, Cognitive Orientation to Occupational Performance, and RehaCom, are standardized and manualized to promote practical application. The CRTF has also produced a manual (currently under revision) and associated workshops to facilitate the application of evidence-based recommendations in clinical practice. 6 In clinical practice, it is the responsibility of the clinician to make overt the targets of the intervention and to make sure that any evidence-based intervention is relevant to the person’s everyday functioning.

References 1. Cicerone, KD, Dahlberg C, Kalmar K, Langenbahn DM, Malec JF, Bergquist TF et al: Evidence-Based Cognitive Rehabilitation: Recommendations for Clinical Practice. Arch Phys Med Rehab 2000, 81: 1596-615. 2. Cicerone, KD, Dahlberg C, Malec JF, Langenbahn DM, Felicetti T, Kneipp S, et al: Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature 1998 through 2002. Arch Phys Med Rehabil 2005; 86: 1681-92. 3. Cicerone KD, Langenbahn DM, Braden C, Malec JF, Kalmar K et al: Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature from 2003 through 2008. Arch Phys Med and Rehabil 2011; 92: 519-30. 4. Cicerone KD, Goldin Y, Ganci K, Rosenbaum A, Wethe JV, Langenbahn DM, Malec JF, Bergquist TG, Kingsley K, Nagele D, Trexler L, Fraas M, Bogdanova Y, Harley JP. Evidence-based cognitive rehabilitation: Systematic review of the literature from 2009 through 2014. Arch Phys Med Rehabil 2019; 100:1515-1533.c 5. Cicerone KD, Azulay J, Trott C. Methodological quality of research on cognitive rehabilitation after traumatic brain injury. Arch Phys Med Rehabil 2009; 90: S52-9. 6. Haskins EC, Cicerone KD, Dams-O’Connor K, Eberle R, Cicerone K, Langenbahn D, Shapiro-Rosembaum A, Trexler L. Cognitive Rehabilitation Manual: Translating Evidence-Based Recommendations into Practice. Reston, VA: American Congress of Rehabilitation Medicine. 2012.

Author Bio Keith D. Cicerone, PhD, ABPP-CN is a Board Certified clinical neuropsychologist. He was Clinical Director of Neuropsychology and Cognitive Rehabilitation at JFK-Johnson Rehabilitation Institute, New Jersey, from 1986 to 2019. He is the principal author of four systematic reviews of Evidence-Based Cognitive Rehabilitation after TBI and Stroke, conducted through the Cognitive Rehabilitation Task Force of the American Congress of Rehabilitation Medicine. The first reviews are among the top 10 most frequently cited papers in physical medicine and rehabilitation from 1984 through 2013. The most recent review, published in 2019, is among the most frequently cited rehabilitation papers published since 2017.

A Nationally Recognized Leader in Brain Injury Care and Research The Center for Brain Injury Recovery at Kennedy Krieger Institute is a leading research institution offering comprehensive brain injury care, from concussion to severe brain injury, including inpatient and outpatient services, and telehealth consultations and care. To learn more or make an appointment at our Baltimore area locations, visit KennedyKrieger.org/BrainInjuryCenter or call 443-923-9400.

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Contextualized Treatment: An Active Ingredient in Acute TBI Rehabilitation? Cynthia Beaulieu, PhD • Jennifer Bogner, PhD

We know that acute inpatient rehabilitation is necessary for optimizing recovery from brain injury, but if asked, “Why is inpatient rehabilitation needed?” could you answer without hesitation? This question is not asking for the evidence-based interventions shown to be efficacious for select deficits, impairments, or medical problems. The question is asking for the science-based evidence supporting the process of multi-disciplinary rehabilitation, the team-based approach utilized during inpatient rehabilitation. Could you identify any active ingredient that makes rehabilitation a necessity following injury? The truth is, it’s complicated. Inpatient rehabilitation is a dynamic process, which means it is a process that shifts day-to-day and across the recovery trajectory following injury. Patient, injury, treatment, and providers are intertwined in the process, and all of these factors influence the goal of rehabilitation—recovery from injury. The purpose of research on the rehabilitation process is to understand how these intertwining factors influence recovery. Scientific investigation into rehabilitation seeks to identify and understand what ingredients within the complex and holistic rehabilitation process promote the best recovery. Gaining this knowledge is more than a heuristic exercise. It is necessary in order to establish the return on investment of rehabilitation (i.e., is it worth the money), to ensure cost-effective care delivery (i.e., is it a prudent use of money), and to meet a need (i.e., recovery from injury). Discovering how acute inpatient rehabilitation impacts recovery and produces desired outcomes following TBI is the goal behind research about rehabilitation; that is, answering the question of whether the whole is greater than the sum of its parts.

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Identifying the Active Ingredients in Acute TBI Rehabilitation Research Multidisciplinary inpatient rehabilitation involves multiple medical specialties, therapeutic activities and interventions. Studying each of these variants individually is not feasible, however it is possible to study the larger approach used in rehabilitation from a bird’s eye view. Two such approaches are contextualized and decontextualized treatment.1 Contextualized treatment is a holistic approach that utilizes real-life functional activity (e.g., dressing, taking medications, walking to a car).2 Contextualized treatments have face validity to observers, and are familiar to the person undergoing treatment. They are by definition patient-specific and individualized; thereby, more difficult to standardize and to systematically studying outside of small groups or single-subject designs.3-4 Decontextualized treatments, on the other hand, are impairmentspecific and target component skills to reduce impairment (e.g., therapeutic exercise, range of motion, list-learning tasks). These treatments are usually only seen in clinic settings, are rarely familiar to the person undergoing treatment or to observers, and are generally not associated with daily life. They lend themselves more easily to standardization and thus they are more extensively studied. However, decontextualized treatments also have limited generalizability to real-life.1 In addition to contextualized and decontextualized categories of treatment, a third classification is necessary to consider when classifying treatments designed to attenuate disability.

classifications are relevant to all three disciplines. contextualized treatment time (piece of the pie) and not on total time (whole pie)—the amo

delivered therapy consisted of contextualized treatment over the course of the inpatient sta TABLE 1. Examples of treatment classifications by therapy disciplines.

measures included motor and cognition from the Functional Independence MeasureTM (FIM OT

Decontextualized

SLP

participation fromtothe Participation Assessment with Recombined Tools-Objective (PART Perform arm exercises improve Practice sit-to-stand on a raised Recite a list of daily therapies. range of motion for arm

mat in the therapy gym.

satisfaction from the Satisfaction with Life Scale (SWLS)9; and depression symptoms from extension. Quasi-Contextualized

Contextualized

Questionnaire-910.

Verbalize the steps to safely dress.

Verbalize safe steps to stand from a seated position on the toilet.

FIGURE 1. Percentage of Contextualized Therapy Time. Dressing.

Sit and stand from the toilet.

Verbalize a strategy to improve independent attendance to therapies. Self-manage daily activities calendar.

This third category, quasi-contextualized treatment, simulates real life Evidence activity (e.g.,for compensatory strategy Rehabilitation training, virtual Treatment Approaches The Contextualized reality, hypothetical problem solving).5 The critical component of quasi-contextualized treatment is the patient’s ability to relate 2 task they are engaging in with their everyday theBogner relevance et of al.the utilized propensity score methodology on treatment data classified as contextualized, defunction and goals. This puts the onus on the therapist to ensure contextualized, make the dataset manageable, classification of treatment was explicit explanation ofand the quasi-contextualized. relationship between the To selected activity and the patient’s real-world goal. Without the patient’s restricted to the treatments delivered by OT, PT, and SLP. The proportion of time patients spent in therapy ability to associate the task to their real-world activity, the therapy task becomesindecontextualized. TABLE 1 lists exampleswere of thedelivered three sessions which contextualized treatments during the acute inpatient stay was examined at treatment classifications across the three disciplines of occupational three (OT), points in time: at discharge from acute inpatient therapy physical therapy (PT), and speech-language pathologyhospitalization, at 3 months post discharge, and at 9 (SLP). The three classifications are relevant to all three disciplines.

The Evidence for Contextualized Rehabilitation Treatment Approaches

FIGURE 1. Percentage of Contextualized Therapy Time.

Furthermore, better outcomes associated with the contextualized 2 were greater seen regardless of the severity of impairment al.approach indicated proportions of time spent inascontextualiz assessed upon admission to inpatient rehabilitation.

Bogner et al. utilized propensity score on treatment Themethodology findings from Bogner et data classified as contextualized, de-contextualized, and quasicontextualized. To make the datasetassociated manageable,with classification betterofoutcomes. Specifically, participants with larger proportions of conte While these findings imply better functional outcomes, particularly treatment was restricted to the treatments delivered by OT, PT, and better community participation, over year were found to be participating more in their community at 3the and 9 following monthsinpatient after discharge w SLP. The proportion of time patients spent in therapy sessions in rehabilitation when a greater proportion therapy time is devoted which contextualized treatments were delivered during the acute participants lower proportions of contextualized treatment. the effect to contextualized treatment, the corollary isWhile not necessarily true. sizes wer inpatient stay was examined at three points in time:with at discharge That is, we cannot say that decontextualized treatment results from acute inpatient hospitalization, at 3 months post discharge, findingsDecontextualized of better outcomes function-based int in poorer outcomes. treatmentwith has its place, and at 9 months post discharge. were consistent with previous research particularly in reducing impairments. However, 11-12 the findings outcomes were maintained wellsuggest into the first yearthe following injury. treatment Furthermore, better recommending use of contextualized over Figure 1 visually depicts the unit of measurement. The analysis decontextualized treatment if therapy goals are achievable with was on proportion of contextualized treatment time (piece of with the contextualized approach were seen regardless of the severity of impairment as ass either treatment approach. the pie) and not on total time (whole pie)—the amount of time the delivered therapy consisted of to contextualized inpatient treatment rehabilitation. Why would contextualized treatment be an active ingredient in over the course of the inpatient stay. The outcome measures acute inpatient rehabilitation? It could be that function-based included motor and cognition from the Functional Independence TM TM 6 activities engage patients in therapy sessions since the activity Measure (FIM ) ; community participation from the Participation 7-8 is familiar and overtly meaningfulparticularly to their goals. better Both effort ; life Assessment with Recombined Tools-Objective (PART-O) While these findings imply better functional outcomes, community parti and meaningful engagement are considered integral to the satisfaction from the Satisfaction with Life Scale (SWLS)9; and 13-14 10 rehabilitation process. yearHealth following inpatient when a greater proportion therapy time is devoted to . rehabilitation depression symptoms from the Patient Questionnaire-9 2

treatment, corollary The findings from Bogner et al.2 indicated greaterthe proportions of is time spent in contextualized treatments were associated with better outcomes. Specifically, participants with larger proportions of contextualized treatment were found to be participating more in their community at 3 and 9 months after discharge when compared to participants with lower proportions of contextualized treatment. While the effect sizes were small, the results were consistent with previous research findings of better outcomes with function-based interventions and the outcomes were maintained well into the first year following injury.11-12

not necessarily That is, we cannot saylatent thatordecontextualized It could also betrue. that holistic approaches tap into dormant abilities masked by visible and observable impairments. The experiential basis of functional activities may allow patients the opportunity for behavioral expression of these dormant abilities automatically.15 Equally plausible is function-based activities may tap into procedural or implicit processes, which may remain intact following injury and thus can be harnessed by providers and persons with TBI to enhance performance.16 Identifying “why” contextualized treatments impact outcomes will require ongoing investigation.

BRAIN INJURY professional 13

Contextualized treatment requires increased treatment planning time on the front end due to the need to tailor it to the individual, which requires intricate knowledge of the patient and their life prior to injury.

The Challenge to Rehabilitation Professionals Increasing time spent in contextualized treatment may seem reasonable and doable in theory, but the reality is quite different. Shifting rehabilitation culture to incorporate new evidencebased practices in any setting can be daunting. Challenges to implementation come from many different angles, including professional, administrative, and environmental. Contextualized treatment requires increased treatment planning time on the front end due to the need to tailor it to the individual, which requires intricate knowledge of the patient and their life prior to injury. This knowledge is not necessarily available at admission, requiring added time to a provider’s evaluation and treatment planning time for research and data collection from family and friends. Only then could the information be available to design a contextualized treatment plan. Shortened lengths of stay, increased productivity expectations, professional or attitudinal resistance to change, and burdensome documentation systems are also contributing barriers to shifting the inpatient rehabilitation environment to incorporate more contextualized treatments. Resolving these challenges and overcoming the barriers will require collaboration between clinicians and business leaders within the rehabilitation industry. References 1.Institute of Medicine. (2011). Cognitive rehabilitation therapy for traumatic brain injury: evaluating the evidence. Washington, D.C.: National Academies Press. 2. Bogner, J., Dijkers, M., Hade, E. M., Beaulieu, C., Montgomery, E., Giuffrida, C., Timpson, M., Peng, J., Gilchrist, K., Lash, A., Hammond, F. M., Horn, S. D., Corrigan, J. D. (2019). Contextualized treatment in traumatic brain injury rehabilitation: effects on outcomes during the first year after discharge. Arch Phys Med Rehabil, 100(10), 1810-1817. 3. Feeney, T. J. & Ylvisaker, M. (2003). Context-sensitive behavioral supports for young children with TBI: short-term effects and long-term outcomes. J Head Trauma Rehabil, 18, 33-51. 4. Hayden, M. E., Moreault, A. M., LeBlanc, J., Plenger, P.M. (2000). Reducing level of handicap in traumatic brain injury: an environmentally based model of treatment. J Head Trauma Rehabil, 15, 1000-21. 5. Brain Injury Association of America web site. Guidelines for the rehabilitation and chronic disease management of persons with moderate to severe traumatic brain injury: Cognitive Issues Panel. http://www. biausa.org/TBIGuidelines/tbi-rehabilitation-guidelines. Accessed 2015. 6. Granger, C. V., Hamilton, B. B., Linacre, J. M., Heinemann, A.W., Wright, B.D. (1993). Performance profiles of the functional independence measure. Am J Phys Med Rehabil, 1993, 72, 84-89. 7. Whiteneck, G. G., Dijkers, M. P., Heinemann, A. W., Bogner, J. A., Bushnik, T., Cicerone, K. D., Corrigan, J. D., Hart, T., Malec, J. F., Millis, S. R. (2011). Development of the participation assessment with recombined toolsobjective for use after traumatic brain injury. Arch Phys Med Rehabil, 92, 542-552. 8. Bogner, J. A., Whiteneck, G. G., Corrigan, J. D., Lai, J. S., Dijkers, M. P., Heinemann, A. W. (2011). Comparison of scoring methods for the participation assessment with recombined tools-objective. Arch Phys Med Rehabil, 92 ,552-563. 9. Diener, E., Emmons, R. A., Larsen, R. J., Griffin, S. (1985). The satisfaction with life scale. J Pers Assess, 49, 71-75. 10. Kroenke, K., Spitzer, R. L., Williams, J. B. (2001). The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med, 16, 606-613. 11. Bode, R. K., Heinemann, A. W., Semik, P., Mallinson, T. (2004). Relative importance of rehabilitation therapy characteristics on functional outcomes for persons with stroke. Stroke, 35, 2537-2542. 12. Horn, S. D., Corrigan, J. D., Beaulieu, C. L., Bogner, J., Barrett, R. S., Giuffrida, C. G., Ryser, D, K., Cooper, K., Carroll, D. M., Deutscher, D. (2015). Traumatic brain injury patient, injury, therapy, and ancillary treatments associated with outcomes at discharge and 9 months postdischarge. Arch Phys Med Rehabil, 96(8)(suppl 3), S304-S329.

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13. Mateer, C. A. (1999). Executive function disorders: rehabilitation challenges and strategies. Semin Clin Neuropsychiatry, 4, 50-9. 14. Maclean, N. & Pound, P. (2000). A critical review of the concept of patient motivation in the literature on physical rehabilitation. Soc Sci Med, 50, 495-506. 15. Nudo, R. J. (2013). Recovery after brain injury: mechanisms and principles. Front Hum Neurosci, 7, 887. doi: 10.3389/fnhum.2013.00887. Accessed March 12, 2020. 16. Ewert, J., Levin, H. S., Watson, M. G., Kalisky, Z. (1989). Procedural memory during posttraumatic amnesia in survivors of severe closed head injury: implications for rehabilitation. Arch Neurology, 46, 911-916.

Author Bios Dr. Bogdanova is an Assistant Professor of Psychiatry at Boston University School of Medicine and a Principal Investigator at the VA Boston HCS. She holds a PhD in Behavioral Neurosciences and a PhD in Clinical Neuropsychology. Dr. Bogdanova is a Principal Investigator on the federally-funded clinical trials of cognitive rehabilitation and neuromodulation in TBI. Her program of research focuses on development and evaluation of multimodal neurorehabilitation interventions for TBI. She currently leads the Virtual Care and LED TBI Home Treatment Programs at the VA Physical Medicine & Rehabilitation Service. She serves on Cognitive Rehabilitation and AP Technology Task Force (ACRM). Jennifer Bogner, PhD, ABPP, FACRM is a Professor and Vice-Chair of Research and Academic Affairs in the Department of Physical Medicine and Rehabilitation, Bert C. Wiley, MD Endowed Chair in Physical Medicine and Rehabilitation, Director of the Division of Rehabilitation Psychology, Project Director for the Ohio Regional TBI Model Systems, and Co-Project Director of the SCI Model Systems. She serves as Associate Editor for the Journal of Head Trauma Rehabilitation and previously served as Secretary on the Board of Governors and as Chair for the Brain Injury Interdisciplinary Special Interest Group of ACRM. She earned several prestigious career awards.

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events 2021 July 11 – 14: Neurotrauma 2021, July 11 – 14, Virtual event. For more information, visit www.neurotrauma.org 23: NABIS Legal and Medical Conference on Brain Injury, July 23, 2021, Virtual Event. For more information, visit www.internationalbrain.org 28 – 30: 2021 Virtual World Congress on Brain Injury, July 28 – 30, 2021, Virtual Event. For more information, visit www.internationalbrain.org. September 16: EBIS Conference, September 16, Brussels, Belgium. For more information, please visit ebissociety.org. 26 – 29, ACRM 98th Conference, September 26 – 29, Virtual. For more information, visit www.acrm.org.

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The Changing Landscape of Holistic Brain Injury Rehabilitation Lance E. Trexler, PhD, HSPP, FACRM

In the Beginning The need for specialized rehabilitation strategies for those with acquired brain injury became particularly apparent in the United States in the 1980’s. Traditional rehabilitation paradigms did not address the cognitive and neurobehavioral impairments associated with acquired brain injury, or their psychological consequences. Holistic brain injury rehabilitation programs included group and individual psychotherapy, cognitive rehabilitation, family education and therapy, all in context of a therapeutic milieu that was typically structured as a day treatment program.1 Ben-Yishay2 described four stages of holistic rehabilitation, including 1) awareness and understanding of one’s own impairments and commitment to rehabilitation goals, 2) becoming malleable to treatment, 3) learning new metacognitive strategies to compensate for the impairments and integrating them into real world environments, and 4) acceptance and finding a new meaning in life. Many of these programs also included physical, occupational, and speech therapies as appropriate. The holistic model was structured as a day treatment program, four to five days a week, typically lasting for six to nine months with follow-up thereafter as needed. The most recent evidence-based review demonstrated that holistic neuropsychologically-oriented rehabilitation programs resulted in significant improvements in societal participation, vocational outcome, short and long term functional skills, and psychosocial adaptation.3 The findings also suggested that these programs also reduced societal cost and reduced caregiver burden. Based on the strength of the evidence, holistic neuropsychological rehabilitation programs were determined to be a practice standard for people with traumatic brain injury.

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However, even by 2000, reviews of the evidence demonstrated that comprehensive-holistic programs resulted in significant reductions in the level of disability, and these programs were therefore considered to a Practice Guideline .4

And then Catastrophe Despite the fact that brain injury professionals created new programs and provided abundant scientific evidence of their positive impact in twenty years, “managed” care decimated holistic brain injury rehabilitation beginning in the early 1990’s and very few programs now remain throughout the United States. The charges for holistic programs were typically structured as a daily or weekly rate, and in some programs, a total charge for a six or nine-month program. The insurance companies began to require individual charges for each discipline-specific service and limit the total number of sessions per discipline. However, many holistic programs included services for which either no CPT code existed or was very poorly reimbursed, like family education and family therapy without the patient present, group therapy, community-based therapeutic experiences that involved travel time and expense, vocational trials, and team conferences to plan and revise rehabilitation goals and strategies. These changes also included restrictions on how many total therapy services could be provided in a day. As a consequence, these changes served to deconstruct programs that were specifically designed to meet the needs of people with acquired brain damage and their families with a “holistic” approach that addressed the inter-related cognitive, neurobehavioral, and psychological challenges that negatively affected independent living, return to work or school, and psychosocial adjustment.

Recovery and Plasticity As noted by Cicerone in 2012, it had been recognized that brain plasticity served recovery of function, even many years after injury, and that “plasticity is a lifelong characteristic of our lifelong existence, and thus brain reorganization is possible even many years after brain damage occurs”.5 It indeed seems quite the paradox, that while at the same time we were discovering the neurophysiological basis for a potential lifelong recovery, we at the same time were limited from providing an evidence-based holistic program that resulted in a number of significant benefits to people with brain damage, their families, and society. The field of neurorehabilitation is fortunately recovering. We have learned through research and clinical experience in holistic neuropsychological rehabilitation a variety of important and meaningful lessons. We learned that a neuropsychologically-informed approach to the impairments of awareness and other neurobehavioral disorders as well as the psychological struggles that follow brain injury could be and have to be treated to improve long-term psychosocial and vocational outcome. We learned that families also need education and therapy. And, we learned that we have to integrate and coordinate treatment and work as a team. Fortunately, we have been able to sustain and advance some elements of what was achieved in the research and development of holistic programs. And now, while 40 years ago, a neuropsychologist was not to be found in the vast majority of neurorehabilitation programs, their presence in some capacity is fortunately more common, although their engagement maybe less intense than was the case in the original holistic programs. Further, some holistic programs persist, but with less intensity and duration. Neuropsychologists are still part of many rehabilitation programs, sometimes providing individual and group treatment, and in some, providing consultation at a programmatic level. Additionally, while the training of neuropsychologists 40 years ago seldom included rehabilitation experiences, review of the currently available Fellowships listed in the Association of Postdoctoral Programs in Clinical Neuropsychology revealed that 35 percent of pediatric and 43 percent of adult neuropsychology fellowships included rehabilitation or intervention, not including psychotherapy, as either a strong or moderate emphasis of training. Research and clinical practice on specific elements of the holistic model have fortunately continued to evolve. Significant advances in the scientific evidence on the effectiveness of cognitive rehabilitation have been made, as reflected in all four of the Cicerone reviews and practice recommendations provided for rehabilitation of attention, memory, visuospatial, communication and social cognition, and executive functions in addition to the recommendations for comprehensive-holistic neuropsychological programs.3,4,6,7 Moreover, in 2012, the first edition of a manual that provided the rehabilitation strategies and clinical methods used in the studies supporting the evidence was published to promote evidence-based practice.8,9 Research in group therapy for people with acquired brain injury and their families has provided substantial evidence for the effectiveness of this ingredient in holistic neurorehabilitation programs. Backhaus and colleagues have developed the Brain Injury Coping Skills (BICS) group, which is a manualized 16-session psychoeducational and cognitive-behavioral intervention for the survivor and family.10-12

Their research has demonstrated significant improvements in perceived self-efficacy to manage the emotional and behavioral consequences of brain injury, emotional functioning as well as better maintenance of treatment gains as compared to a non-structured peer support group. While holistic programs were found to significantly improve return to work through helping the participant utilize and generalize rehabilitation strategies in the community and work trials, neurorehabilitation programs cannot typically include vocational trials secondary to reimbursement barriers. In response, Trexler and colleagues studied a model referred to as Resource Facilitation to improve return to work and school.13-15 Resource Facilitation was defined as: • •

•

Providing brain injury specific education and promoting awareness of resources to individuals with brain injury, their families, other providers and the community; Proactively helping the individual identify, obtain, and navigate needed instrumental, brain injury-specific, community and vocational supports and services specific to the person’s brain trauma and their specific goals; and Ensuring collaboration, integration and coordination between providers and community-based resources.

These studies demonstrated significantly better vocational outcomes for people with acquired brain injuries for both cohorts that were recruited relatively soon after injury, but also for those who were on average almost ten years post-injury. Resource Facilitation was also found to significantly reduce level of disability and decrease both perceived need for services and actual service utilization. We have learned how to provide some of the elements or ingredients of holistic rehabilitation in new ways, and with good results.

And Now the Future The perspective on brain injury rehabilitation is changing however in a significant way. Prior to the 1990’s, people with especially traumatic brain injury (TBI) may have received rehabilitation services for years after injury. By 2020, if people with traumatic brain injury get rehabilitation services, it is often for a few months and certainly less than a year. While it has long been recognized that some with acquired brain injury will have chronic disability, initiatives to look at TBI as a public health concern and viewed as a chronic condition rather than as a “injury” from which one presumably recovers have only recently emerged (Corrigan & Hammond, 2013).16 They noted that the recovery from especially moderate to severe TBI is very dynamic, and that over time, people fluctuate significantly in their level of disability associated with a variety of TBI-associated risks, such as dementia, psychiatric struggles, seizures, and many others. Managing TBI as a chronic condition will require new long-term strategies for clinical surveillance and protocols for early, preventative intervention for a condition before it worsens, depression for example. Condition management models often include self-management strategies, but in the case of TBI, they will need to include methods to accommodate for particularly the cognitive impairments attendant TBI. While there are clear models for managing other chronic conditions, like diabetes or congestive heart failure, a model of managing TBI as a chronic condition does not exist.

BRAIN INJURY professional 17

The National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) TBI Model Systems program recently determined through a strategic planning process that developing a disease model specific for managing TBI as a chronic condition was a significant priority (personal communication, Flora Hammond, M.D., Traumatic Brain Injury Model Systems Executive Committee Chair, July 30, 2020). This reconceptualization of TBI as a chronic condition provides a significant number of new opportunities for research and clinical practice of neurorehabilitation. And, basic science has already taught us that neuroplasticity is a lifelong capacity. Both of these perspectives give new promise to brain injury rehabilitation. References 1. Trexler, LE. Empirical support for neuropsychological rehabilitation. In: A.-L. Christensen and B. P. Uzzell (Eds), International Handbook of Neuropsychological Rehabilitation. New York, Kluwer Academic/Plenum Publishers, 2000. 2. Ben-Yishay Y. Postacute neuropsychological rehabilitation: A holistic perspective. In: A.-L. Christensen and B. P. Uzzell (Eds), International Handbook of Neuropsychological Rehabilitation. New York, Kluwer Academic/ Plenum Publishers, 2000. 3. Cicerone KD, Goldin Y, Ganci K, Rosenbaum A, Wethe JV, Langenbahn DM, et al. (2019). Evidence-Based Cognitive Rehabilitation: Systematic Review of the Literature From 2009 Through 2014. Archives of Physical Medicine & Rehabilitation, 100, 1515-1533. https://doi.org/10.1016/j.apmr.2019.02.011, 10.1016/j. apmr.2019.02.011 4. Cicerone KD, Dahlberg C, Kalmar K, Langenbahn DM, Malec JF, Bergquist TF, et al. (2000). Evidencebased cognitive rehabilitation: recommendations for clinical practice. Archives of Physical Medicine & Rehabilitation, 81, 1596-615. https://doi.org/10.1053/apmr.2000.19240 5. Cicerone KD. (2012). Facts, theories, values: shaping the course of neurorehabilitation. The 60th John Stanley Coulter memorial lecture. Archives of Physical Medicine & Rehabilitation, 93, 188-91. https://doi. org/10.1016/j.apmr.2011.12.003, 10.1016/j.apmr.2011.12.003 6. Cicerone KD, Dahlberg C, Malec JF, Langenbahn DM, Felicetti T, Kneipp S, et al. (2005). Evidence-based cognitive rehabilitation: updated review of the literature from 1998 through 2002. Archives of Physical Medicine & Rehabilitation, 86, 1681-92. https://doi.org/10.1016/j.apmr.2005.03.024 7. Cicerone KD, Langenbahn DM, Braden C, Malec JF, Kalmar K, Fraas M, et al. (2011). Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008. Archives of Physical Medicine & Rehabilitation, 92, 519-30. https://doi.org/10.1016/j.apmr.2010.11.015, 10.1016/j. apmr.2010.11.015

8. Trexler LE (Ed). Cognitive Rehabilitation Manual: Translating Evidence-Based Recommendations into Practice. Reston, Virginia: ACRM Publishing, 2012. 9. Trexler LE (2015). The American Congress of Rehabilitation Medicine Cognitive Rehabilitation Manual: History and development. Brain Injury Professional, 11 (4), 24-25. 10. Backhaus SL, Ibarra SL, Klyce D, Trexler LE & Malec JF. (2010). Brain injury coping skills group: a preventative intervention for patients with brain injury and their caregivers. Archives of Physical Medicine & Rehabilitation, 91, 840-8. https://doi.org/10.1016/j.apmr.2010.03.015, 10.1016/j.apmr.2010.03.015 11. Backhaus SL, Ibarra SL. Brain Injury Coping Skills: A support and education program for adults with brain injury and their caregivers. Youngsville, North Carolina: Lash and Associates Publishing, Inc., 2012. 12. Backhaus SL, Ibarra SL, Parrott DR & Malec JF. (2016). Comparison of a Cognitive-Behavioral Coping Skills Group to a Peer Support Group in a Brain Injury Population. Archives of Physical Medicine & Rehabilitation, 97, 281-91. https://doi.org/10.1016/j.apmr.2015.10.097, 10.1016/j.apmr.2015.10.097 13. Trexler LE and Parrott DR. (2018). Models of Brain Injury Vocational Rehabilitation: The Evidence for Resource Facilitation from Efficacy to Effectiveness. Journal of Vocational Rehabilitation, 49(2), 195-203. 14. Trexler LE, Parrott DR, & Malec JF. (2016). Replication of a Prospective Randomized Controlled Trial of Resource Facilitation to Improve Return to Work and School After Brain Injury. Archives of Physical Medicine & Rehabilitation, 97, 204-10. https://doi.org/10.1016/j.apmr.2015.09.016, 10.1016/j.apmr.2015.09.016 15. Trexler LE, Trexler LC, Malec JF, Klyce D & Parrott DR. (2010). Prospective randomized controlled trial of resource facilitation on community participation and vocational outcome following brain injury. Journal of Head Trauma Rehabilitation, 25, 440-6. https://doi.org/10.1097/HTR.0b013e3181d41139, 10.1097/ HTR.0b013e3181d41139 16. Corrigan JD & Hammond FM. (2013). Traumatic brain injury as a chronic health condition. Archives of Physical Medicine & Rehabilitation, 94, 1199-201. https://doi.org/10.1016/j.apmr.2013.01.023, 10.1016/j. apmr.2013.01.023

Author Bio Lance Trexler, PhD, FACRM is the Executive Director of Brain Injury Rehabilitation Research and Program Development at Rehabilitation Hospital of Indiana, Adjunct Clinical Assistant Professor of PM&R at Indiana University School of Medicine, Adjunct Assistant Professor of Speech and Hearing Sciences at Indiana University, and Adjunct Assistant Professor of Psychological Sciences at Purdue University. He is Fellow of ACRM 2013, and received the ACRM Distinguished Member and Lifetime Achievement awards. A clinician in rehabilitation neuropsychology since 1979, he authored over fifty peer-reviewed articles and book chapters and remains committed to developing, implementing and disseminating rehabilitation and social interventions for acquired brain injury.

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Technology in Brain Injury Neurorehabilitation: Access to Care in COVID-19 Role of Technology in Cognitive Neurorehabilitation During Pandemic Yelena Bogdanova, PhD

Rapidly evolving worldwide, the public health emergency of coronavirus disease (COVID-19) is quickly changing traditional health care approach and delivery methods. The restrictive measures implemented nationwide in an effort to control the spread of the pandemic present significant barriers and impose additional challenges for vulnerable patient populations, limiting their access to health care.1 Individuals with brain injury (BI) are among those most vulnerable to the ongoing outbreak and its effects on physical and mental health. Individuals with BI are more likely to be disproportionally affected by the COVID-19 pandemic, as people with cognitive impairments may be at higher risk of being infected due to difficulties in understanding and/or complying with preventive measures (social distancing, wearing personal protective equipment) and public health recommendations when provided in inaccessible form (through an opaque mask).2 Providing timely, continuous care is critical for patients with BI as it helps to avoid delays in clinical care and prevent negative effects of missed or interrupted neurorehabilitation efforts. In this unprecedented time, health care providers are pressed to embrace the rapid change and to adapt and implement new methods of health care delivery. Technology can offer useful tools enabling practitioners to provide clinical care and decrease the risk of exposure of vulnerable patient populations during the ongoing COVID-19 public health emergency. Providing continuous clinical care and treatment monitoring to the patients practicing social distancing, observing quarantine restrictions, or patients residing in rural locations is now possible utilizing various communication tools and portable home-based treatment modalities. Technology supports and enhances rehabilitation efforts, streamlines treatment delivery and promotes participation.

Telehealth Communication Technology supports telehealth services during the ongoing public health crisis. Technology enables and facilitates remote access to clinical services, which may also increase participation for medically and cognitively vulnerable patients or those who do not have easy access to rehabilitation centers and specialists.

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Communication technology and remote access can also help preserve the patient-clinician relationship while a face-to-face visit is not feasible.1 Telehealth enables provision of virtual services (synchronous, asynchronous, or remote monitoring) for evaluations and routine care, and supports delivery and continuous monitoring of long-term rehabilitation programs. There are multiple technology home-based rehabilitation tools such as smartphones, tablets, computers, virtual assistants, and assistive devices, which can provide access to health information, health services, and even social connections for those in isolation. The extraordinarily high demand for remote healthcare access, driven by the ongoing COVID-19 pandemic, prompted the unprecedented surge in telehealth services. Based on the current trajectory of the pandemic, the need for social distancing (for both patients and providers) is likely to continue and the demand for virtual care is likely to grow. The many benefits of telehealth, such as treatment accessibility, opportunity to provide interdisciplinary rehabilitation, continuous care and timely (early or chronic) treatment, as well as reduced cost and reduced travel burden (for the patient and their caregiver) provide additional incentive for the development of telehealth-specific rehabilitation protocols and home-based rehabilitation programs. There are some situations in which telehealth visits may not be feasible or possible due to various factors, such as: limited access to technology/devices (smartphone, computer, or tablet) required for a telehealth visit or limited or no connectivity; patient’s discomfort disclosing personally sensitive information in virtual care sessions and other privacy concerns; personal level of comfort and capacity using technology (especially relevant for patients with BI); as well as family approval and cultural acceptance of virtual healthcare. Home-based neurorehabilitation programs with telephone-based treatment monitoring and support can provide a viable solution in these situations.

Virtual Care and Home-Based Treatments Telehealth or virtual visits, home-based treatment programs, and other web-based rehabilitation paradigms are being deployed in multiple medical centers across the US, either as a standalone rehabilitation treatment or as part of the interdisciplinary rehabilitation effort.

Innovative rehabilitation programs and methods of treatment delivery, such as home-based neuromodulation treatment for cognitive impairments and computer-based cognitive interventions have become an important part of virtual care for persons with BI. LED TBI Virtual Care Program The LED TBI Home Treatment Program is part of the interdisciplinary rehabilitation program at the Physical Medicine & Rehabilitation Service (PMRS) at Boston VA Healthcare System and Boston University School of Medicine.3 The LED TBI Home Treatment Program is the first program in the US that provides advanced neuromodulation treatment using light-emitting diodes (LED) for patients with chronic TBI. LED therapy is a non-invasive, non-pharmacological treatment that promotes healing of injured brain cells and improves cellular function.4,5 LED therapy improves attention and concentration, improves sleep, and reduces PTSD symptoms in patients with TBI.6,7 The LED Program provides 12-Week LED Home Treatment with telehealth support. The LED TBI Clinic services include clinical evaluation, individualized treatment plan, LED treatment, and follow up visits. To ensure the quality of home treatment and to further reduce the burden of travel, the LED Clinic provides telehealth support and followup visits.8 The LED TBI clinic was converted to completely virtual (contactless) care following the COVID-19 pandemic restrictions, and has continued to provide virtual treatment services for the last five months. Patients who completed the treatment program reported improved cognitive and neurobehavioral symptoms, and opted to continue the longterm home treatment program and virtual care appointments after the COVID restrictions are lifted. The LED TBI Clinic team is now providing virtual training for the VA PMRS providers in other states across the US.

Computer-based Cognitive Interventions Computer-based cognitive interventions have shown great potential for improving treatment access for individuals with BI by addressing the barriers and restrictions imposed by disability-related limitations, geographical and social barriers, and time constraints.

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Computer-based cognitive interventions can improve traditional rehabilitation of cognitive functions by enhancing the treatment consistency and delivery and providing continuous adaptive adjustment of task difficulty based on a patient’s performance.9,10 The ACRM BI-ISIG Cognitive Rehabilitation Task Force has set forth guidelines for the use of computer-based interventions, such as direct-attention training for specific working memory impairments (Practice Guideline) in postacute rehabilitation of individuals with acquired BI.10 The Task Force presented new evidence on multimodal computerized training of attention, memory, and executive functions, demonstrating the effectiveness of this type of computerized intervention (Practice Guideline) for individuals with acquired BI. The guidelines emphasize that this type of computerized interventions is most effective when managed by a rehabilitation specialist and when the treatment adheres to the principles of neuroplasticity (including adaptive task difficulty adjustment and immediate objective feedback on task performance).

Resources & Support for Healthcare Providers The COVID-19 pandemic significantly impacts healthcare providers who often work in a stressful environment of rapidly changing demands. Technology and IT support have become essential for providing and monitoring treatment and assuring the continuous quality of patient care. Many academic institutions and larger hospitals in the US and other countries have utilized various telehealth platforms and are already offering virtual visits with rehabilitation professionals and other health specialists. There are multiple telehealth-specific workshops and trainings offered through professional organizations and academic institutions nationwide. However, rehabilitation professionals in the private practice and smaller organizations may need additional support. To accommodate the patients’ needs in the COVID-19 pandemic, rehabilitation providers have come up with innovative ways to deliver rehabilitation services for the individuals with BI and their caregivers. Systematic research of innovative interventions and methods of treatment delivery evaluating most optimal and lasting rehabilitation outcomes is needed to inform clinical recommendations and guidelines for persons with BI and other neurologically impaired populations. Acknowledgements: This work was supported by the VHA Center for Compassionate Care Innovation (Clinical Lead: Yelena Bogdanova) and the VA Boston HCS Psychology Research and Physical Medicine and Rehabilitation Services. References 1. Centers for Disease Control and Prevention. 2020. Coronavirus Disease 2019 (COVID-19). [online] Available at: <https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html> [Accessed 15 August 2020]. 2. Jesus TS, Kamalakannan S, Bhattacharjya S, Bogdanova Y, Arango-Lasprilla J, Bentley J, Gibson BE, Papadimitriou C, Refugee Empowerment Task Force, International Networking Group of the American Congress of Rehabilitation Medicine. (2020). People with disabilities and other forms of vulnerability to the COVID-19 pandemic: Study protocol for a scoping review and thematic analysis. Archives of Rehabilitation Research & Clinical Translation. [Epub, ahead of print] 3. VHA, Center for Compassionate Care Innovation (2020, June 15). LED treatment improves cognitive function for mTBI patients. https://www.va.gov/healthpartnerships/updates/cci/06152020.asp [Accessed 15 August 2020]. 4. Hamblin, MR. (2018). Photobiomodulation for traumatic brain injury and stroke. J Neuroscience Research, 96, 731-743. https://doi.org/10.1002/jnr.24190 5. Naeser, MA, Martin, PI, Ho, MD, Krengel, MH, Bogdanova, Y, Knight, JA, Yee, MK, Zafonte, R, Frazier, JA, Hamblin, MR, Koo, BB (2016). Transcranial, Red/near-infrared light-emitting diode (LED) therapy for chronic, traumatic brain injury. Photomedicine and Laser Surgery, 34(12), 610-626. https://doi.org/10.1089/ pho.2015.4037 6. Bogdanova, Y., Ho, V.T., Martin, P.I., Ho, M.D., Yee, M.K., Hamblin, M.R., Naeser, M.A (2017). Transcranial LED Treatment for Cognitive Dysfunction and Sleep in Chronic TBI: Randomized Controlled Pilot Trial. Abstract. Archives of Physical Medicine & Rehabilitation, 98(10), e122 -123. https://doi.org/10.1016/j. apmr.2017.08.398

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7. Martin PI, Ho MD, Bogdanova Y, Krengel M, Knight J, Hamblin M, Koo B, Naeser MA (2018). LED therapy improves functional connectivity and cognition in professional football player with chronic TBI: case study. Abstract. Archives of Physical Medicine & Rehabilitation, 99 (10), e104 - e105. https://doi.org/10.1016/j. apmr.2019.02.011 8. Bogdanova, Y., Gilbert, K., Baird, L., Naeser, M.A. (2019). LED Home Treatment Program for Chronic TBI and PTSD: Clinical Program Evaluation. Abstract. Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 12, e187-188. https://doi.org/10.1016/j.apmr.2019.10.077 9. Bogdanova, Y., Yee, M.K., Ho, V.T., & Cicerone, K.D. (2016). Computerized cognitive rehabilitation of attention and executive function in acquired brain injury: A systematic review. Journal of Head Trauma Rehabilitation. 31(6), 419-433. https://doi.org/10.1097/HTR.0000000000000203 10. Cicerone KD, Goldin Y, Ganci K, Rosenbaum A, Wethe JV, Langenbahn DM, Malec JF, Bergquist TF, Kingsley K, Nagele D, Trexler L, Fraas M, Bogdanova Y, Harley JP (2019). Evidence-Based Cognitive Rehabilitation: Systematic Review of the Literature From 2009 Through 2014. Archives of Physical Medicine and Rehabilitation, 100(8), 1515-1533. https://doi.org/10.1016/j.apmr.2019.02.011

Author Bio Dr. Bogdanova is an Assistant Professor of Psychiatry at Boston University School of Medicine and a Principal Investigator at the VA Boston HCS. She holds a PhD in Behavioral Neurosciences and a PhD in Clinical Neuropsychology. Dr. Bogdanova is a Principal Investigator on the federally-funded clinical trials of cognitive rehabilitation and neuromodulation in TBI. Her program of research focuses on development and evaluation of multimodal neurorehabilitation interventions for TBI. She currently leads the Virtual Care and LED TBI Home Treatment Programs at the VA Physical Medicine & Rehabilitation Service. She serves on Cognitive Rehabilitation and AP Technology Task Force (ACRM).

July 28 - 30, 2021 A Global Conference and Meeting of Minds for Adult and Pediatric Brain Injury Professionals

Abstract Portal Now Open! Abstracts due: April 23, 2021 Share your work with brain injury professionals around the globe! The organizers welcome the submission of original research and clinical findings on a broad range of brain injury topics. All submissions will be peer-reviewed, and accepted abstracts will be published and indexed in IBIA’s official journal, Brain Injury. This multidisciplinary event will offer a broad and varied program spanning cutting-edge research to practical and applied techniques for improving outcomes for persons with brain injury. The conference is a joint initiative of the International Brain Injury Association, ABI Ireland, the International Paediatric Brain Injury Society, the North American Brain Injury Society, PINK Concussions, and the IBIA Special Interest Groups.

Visit internationalbrain.org to submit your abstract and for more conference details as they are announced. Conference dates: July 28 - 30, 2021 BIP filler ad 2021 virtual congress.indd 1

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Cognitive Rehabilitation for Emotion Recognition Deficits after Brain Injury Dawn Neumann, PhD • Barbra Zupan, PhD Barry Willer, PhD

Communication of emotion is integral to human interactions but people don’t often convey their feelings to others through words. Instead, people are expected to recognize others’ feelings through facial expressions, tone of voice, and other nonverbal cues. 1,2 One’s ability to recognize emotion in others is an important compass for guiding social behaviors3 because it facilitates better understanding of others and strengthens interpersonal connections.

Facial Emotion Recognition Deficits after TBI Research shows a high prevalence of emotion recognition deficits in people who have had a moderate to severe traumatic brain injury (TBI).4,5 These deficits are likely due to a disruption in optimal functioning of the brain regions and networks typically engaged in processing emotional information.6,7 Recognizing emotion via facial affect is particularly difficult, impacting 39%4 of the TBI population. Studies suggest that men and women with TBI are equally impaired at recognizing emotions from faces 8 and that negatively valenced emotions are more challenging to identify than positively valenced ones.5 This means someone with a TBI is likely to misinterpret or fail to recognize their loved ones’ sad or anxious emotions. As such, impaired emotion recognition may have serious implications for psychosocial outcomes for people with TBI and their family members. It is widely known that individuals with TBI and their family members often report poorer relationship quality, fewer social interactions, and increased isolation after their injury.9-11 A growing body of evidence supports an association between emotion recognition abilities and social behavior and outcomes after TBI .12-15

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It is possible that the inability to recognize how a family member or friend is feeling hinders appropriate responses to emotional situations, including empathic ones. Notably, up to 70% of individuals with TBI have low empathy16-18, and poor emotion recognition may be partly to blame. Indeed, one study found that when participants with TBI accurately identified emotions portrayed by actors in a video clip, they had an empathic response 71% of the time. In other words, if they perceived the actor as sad, they also felt sad.19 In contrast, when participants did not recognize the emotion, empathic responses only occurred about a third of the time. Social functioning is also reported to be associated with facial emotion recognition following TBI. This has been indicated in studies that have shown an increase in inappropriate behavior, poorer interpersonal communication, and less successful social integration in participants with TBI who had trouble recognizing facial affect14,15,12,13,20,21 A literature review published in 2019 identified that 60% of studies in this area reported a significant association between emotion perception and social functioning after TBI.15 While the author of the literature review acknowledged that there are likely several factors contributing to poor social and behavioral outcomes after TBI, he also stated that it was clear that impaired affect recognition is an important relevant factor that should be addressed when trying to improve social outcomes for individuals with TBI.12,22-25

Evidence-based Treatment for Facial Affect Recognition Deficits

A couple of studies offer strong evidence to indicate that impaired facial affect recognition after TBI can be remediated with treatment.26

A recent systematic review of evidence-based cognitive rehabilitation designated the FAR intervention a Practice Standard for treating facial affect recognition deficits in people with acquired neurocognitive impairments and disability.27 The FAR intervention should be perceived as an important foundation from which more advanced social skills could be trained. Notably, researchers in the Netherlands did exactly that. They added modules to the existing FAR intervention aimed at teaching empathy and related social skills and included caregivers in several of the treatment sessions. Findings from their RCT indicated significant improvements in emotion recognition in participants with TBI, and importantly, caregivers reported significantly more empathic behaviors and perceived improvement in relationship quality.28 FAR Intervention: The 9-session treatment was a computer-based program led by a clinical research assistant over two to three weeks. In the study, sessions lasted 60 to 90 minutes and focused on teaching three core skills: 1. Attention to relevant facial features; 2. Emotion replication and experience; and 3. Conceptual associative knowledge. The FAR intervention uses a software program to present 40 pictures of emotional faces29 via computer, over the course of the intervention. The faces vary in intensity (obvious/subtle), gender, and ethnicity.

Findings indicated significant improvements in emotion recognition in participants with TBI, and importantly, caregivers reported significantly more empathic behaviors and perceived improvement in relationship quality.

The first study to provide Level 1 evidence came from a randomized controlled trial (RCT), which compared a facial affect recognition intervention (FAR) to an active control intervention (Control) training basic cognitive skills. This multisite study conducted in the USA, Canada and New Zealand, examined outcomes a week after treatment ended and then also three and six months later. Twenty-four participants were randomized to the FAR intervention (described below) and 24 to the Control intervention. Participants were an average of 10.3 years post-injury. Both interventions were computer-based programs delivered individually by a clinical research assistant over nine sessions.26 Study results indicated that participants who received the FAR intervention significantly improved at recognizing emotions in facial expressions, and that their outcomes at posttest exceeded those participants who received the pure cognitive skills training. Moreover, participants retained the improvement in their facial affect recognition skills for six months after the treatment ended.

Participants are trained to look at and interpret important features (e.g., scrunched eyebrows; wide open eyes) and to select which emotion best describes how the person is feeling from a list of four options (happy, angry, sad, and fearful). Visual cues, which gradually diminish over time, are provided to help the participant learn to attend to the relevant features. Incorrect responses are met with “pop-up messages” that describe the characteristics of the facial features of emotional face, and the correct emotion (e.g., wide eyes and fear). In addition to recognizing facial expressions, each lesson includes exercises that require participants to replicate and experience the emotion just identified by recalling personal events that elicited that same feeling. Participants are guided through a process to help them generate the emotions (e.g., mimicking of facial expressions and generation of physiological feelings). This exercise is to help the person gain insight into the “feeling” behind the emotion, which is believed to facilitate emotion recognition. Additional exercises in the program require the person to compare visual features across different faces in order to identify similarities and differences in emotional expressions. Each lesson concludes with an in-depth discussion of their personal emotional events to tie all the lessons together and build important associative knowledge. During this discussion, participants are asked questions about their emotions and the emotions of others also involved in the situation they identified. These questions center around how the emotions were expressed and what they felt like, why they felt those emotions, and how emotions influenced their behaviors in the context of that situation. More information about the intervention can be found at the following link http://links.lww.com/JHTR/A103. The software and treatment manual can be obtained by contacting the primary author.

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Clinical Implementation Despite increasing acknowledgement of the prevalence and significance of emotion recognition deficits after TBI, it appears that the evaluation and treatment of these problems has not been an adopted into standard clinical practice.30 It is not completely clear why social cognition skills have fallen through the rehabilitation cracks. Some realistic and challenging reasons might include time constraints, uncertainty regarding whose responsibility it is, lack of knowledge about or access to assessments and interventions, and/or lack of self-efficacy.(ref) However, we must acknowledge that to discharge people with TBI back into the community without addressing this important skill as part of their rehabilitation program, is doing them and their families a disservice. Together, we must work to identify and overcome the implementation barriers. References 1. Nowicki S, Duke MP. Individual differences in the nonverbal communication of affect: The Diagnostic Analysis of Nonverbal Accuracy Scale. Journal of Nonverbal Behavior. 1994;18(1):9-35. 2. Watts A, and Douglas, JM Interpreting facial expression and communication competence following severe traumatic brain injury. Aphasiology. 2006;20(8):707-722. 3. Fusar-Poli P, Placentino A, Carletti F, et al. Functional atlas of emotional faces processing: a voxel-based meta-analysis of 105 functional magnetic resonance imaging studies. Journal of Psychiatry & Neuroscience: JPN. 2009;34(6):418. 4. Babbage DR, Yim J, Zupan B, Neumann D, Tomita MR, Willer B. Meta-analysis of facial affect recognition difficulties after traumatic brain injury. Neuropsychology. 2011;25(3):277. 5. Zupan B, Babbage D, Neumann D, Willer B. Recognition of facial and vocal affect following traumatic brain injury. Brain injury. 2014;28(8):1087-1095. 6. Neumann D, Keiski MA, McDonald BC, Wang Y. Neuroimaging and facial affect processing: implications for traumatic brain injury. Brain Imaging and Behavior. 2014;8(3):460-473. 7. Neumann D, McDonald BC, West J, Keiski MA, Wang Y. Neurobiological mechanisms associated with facial affect recognition deficits after traumatic brain injury. Brain imaging and behavior. 2016;10(2):569-580. 8. Zupan B, Babbage D, Neumann D, Willer B. Sex differences in emotion recognition and emotional inferencing following severe traumatic brain injury. Brain Impairment. 2017;18(1):36-48.

28. Westerhof-Evers HJ, Visser-Keizer AC, Fasotti L, et al. Effectiveness of a Treatment for Impairments in Social Cognition and Emotion Regulation (T-ScEmo) After Traumatic Brain Injury: A Randomized Controlled Trial. The Journal of head trauma rehabilitation. 2017;32(5):296-307. 29. Gur RC, Sara R, Hagendoorn M, et al. A method for obtaining 3-dimensional facial expressions and its standardization for use in neurocognitive studies Journal of Neuroscience Methods. 2002;115(2):137-143. 30. Kelly M, McDonald S, Frith MH. A survey of clinicians working in brain injury rehabilitation: Are social cognition impairments on the radar? The Journal of head trauma rehabilitation. 2017;32(4):E55-E65.

9. Temkin NR, Corrigan JD, Dikmen SS, Machamer J. Social functioning after traumatic brain injury. The Journal of head trauma rehabilitation. 2009;24(6):460. 10. Struchen MA, Pappadis MR, Sander AM, Burrows CS, Myszka KA. Examining the contribution of social communication abilities and affective/behavioral functioning to social integration outcomes for adults with traumatic brain injury. The Journal of head trauma rehabilitation. 2011;26(1):30-42.

Author Bios

11. Lezak MD, O'Brien KP. Longitudinal study of emotional, social, and physical changes after traumatic brain injury. Journal of Learning Disabilities. 1988;21(8):456.

Dawn Neumann, PhD, FACRM is an Associate Professor at Indiana University School of Medicine in the Department of Physical Medicine and Rehabilitation, and the Research Director at the Rehabilitation Hospital of Indiana. She has a PhD in Rehabilitation Science from SUNY Buffalo and her MA in Psychology from Rutgers. Her research advances the understanding and treatment of social cognition and emotion dysregulation deficits after traumatic brain injury. She serves on the Journal of Head Trauma Rehabilitation editorial review board, and has received several recognitions, including the ACRM Deborah Wilkerson Award, ACRM Mitchell Rosenthal Award, and the Joshua Cantor Scholar Award.

12. Knox La, Douglas J. Long-term ability to interpret facial expression after traumatic brain injuryand its relation to social integration. Brain and Cognition. 2009;69:442-449. 13. May M, Milders M, Downey B, et al. Social behavior and impairments in social cognition following traumatic brain injury. Journal of the International Neuropsychological Society. 2017;23(5):400-411. 14. Spikman JM, Milders MV, Visser-Keizer AC, Westerhof-Evers HJ, Herben-Dekker M, van der Naalt J. Deficits in facial emotion recognition indicate behavioral changes and impaired self-awareness after moderate to severe traumatic brain injury. PloS one. 2013;8(6):e65581. 15. Milders M. Relationship between social cognition and social behaviour following traumatic brain injury. Brain injury. 2019;33(1):62-68. 16. De Sousa A, McDonald S, Rushby J, Li S, Dimoska A, James C. Why don't you feel how I feel? Insight into the absence of empathy after severe Traumatic Brain Injury. Neuropsychologia. 2010;48(12):3585-3595. 17. Williams C, Wood RL. Alexithymia and emotional empathy following traumatic brain injury. Journal of Clinical and Experimental Neuropsychology. 2010;32(3):259-267. 18. Wood RLL, Williams C. Inability to empathize following traumatic brain injury. Journal of the International Neuropsychological Society. 2008;14(02):289-296. 19. Neumann D, Zupan B. Empathic responses to affective film clips following brain injury and the association with emotion recognition accuracy. Archives of physical medicine and rehabilitation. 2019;100(3):458-463. 20. Milders M, Ietswaart M, Crawford JR, Currie D. Social behavior following traumatic brain injury and its association with emotion recognition, understanding of intentions, and cognitive flexibility. Journal of the International Neuropsychological Society. 2008;14(02):318-326. 21. Struchen MA, Pappadis MR, Mazzei DK, Clark AN, Davis LC, Sander AM. Perceptions of communication abilities for persons with traumatic brain injury: Validity of the La Trobe Communication Questionnaire. Brain Injury. 2008;22(12):940-951. 22. Radice-Neumann D, Zupan B, Babbage DR, Willer B. Overview of impaired facial affect recognition in persons with traumatic brain injury. Brain Inj. 2007;21(8):807-816. 23. Cooper CL, Phillips LH, Johnston M, Radlak B, Hamilton S, McLeod MJ. Links between emotion perception and social participation restriction following stroke. Brain Injury. 2013(0):1-5. 24. Ryan NP, Anderson V, Godfrey C, et al. Social communication mediates the relationship between emotion perception and externalizing behaviors in young adult survivors of pediatric traumatic brain injury (TBI). International Journal of Developmental Neuroscience. 2013;31(8):811-819. 25. Shamay-Tsoory SG, Tomer R, Berger BD, Aharon-Peretz J. Characterization of empathy deficits following prefrontal brain damage: the role of the right ventromedial prefrontal cortex. J Cogn Neurosci. 2003;15(3):324-337. 26. Neumann D, Babbage DR, Zupan B, Willer B. A randomized controlled trial of emotion recognition training after traumatic brain injury. The Journal of Head Trauma Rehabilitation. 2015;30(3):E12-23. 27. Cicerone KD, Goldin Y, Ganci K, et al. Evidence-Based Cognitive Rehabilitation: Systematic Review of the Literature From 2009 Through 2014. Archives of Physical Medicine and Rehabilitation. 2019.

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Barbra Zupan is an Associate Professor and Head of Course of Speech Pathology at CQ University in Rockhampton, Queensland Australia. She received her PhD in Speech Pathology at the State University of New York at Buffalo. Her research focuses on perception and integration of facial and vocal cues of emotion, and the impact of traumatic brain injury on these processes. Her research also investigated other aspects of social cognition, including emotional inferencing and empathy. She contributed to the development of facial affect recognition and emotional inferencing treatment programs as well as the development of an assessment tool for emotional inferencing. Barry Willer received his PhD in Psychology from York University, Toronto, Canada and has been faculty at the University at Buffalo since 1976. He is a professor in the Department of Psychiatry, with a long history of research in TBI. He was director of the initial Research and Training Center on Community Integration and spearheaded the development of the Model Systems database for TBI. He was lead author of the Community Integration Questionnaire. He published widely on the psychological and social consequences of severe brain injury. He has been actively involved in research on mild traumatic brain injury and concussion.

Training Professionals in Delivering Evidence-based Cognitive Rehabilitation Amy Shapiro-Rosenbaum, Ph.D. FACRM Many systematic reviews support the effectiveness of cognitive rehabilitation interventions for adults and children with acquired brain injuries. Over the twenty years since the first published review, the field of Cognitive Rehabilitation has gained increased acceptance as being a key component of brain injury rehabilitation. A solid research base set the stage for the development of evidence-based practice recommendations, yet, there remains a lack of standardization in how these guidelines are applied in clinical settings. The creation of the “Cognitive Rehabilitation Manual: Translating Evidence-Based Recommendations into Practice” and associated American Congress of Rehabilitation Medicine (ACRM) live training program represented a landmark effort to provide professional training in evidence-based practice and develop a standard cognitive rehabilitation service delivery model for individuals with brain injury. While an important first step towards systematizing clinical practice, it is now necessary to explore how implementation science concepts and models can be employed to further bridge the gap between research and its practical application in real world settings. Currently, global implementation efforts are being incorporated into the development of an updated cognitive rehabilitation training program, to identify factors that facilitate implementation of knowledge into practice, as well as barriers to implementation at both the individual and organizational level. A highly integrated approach to professional education and training requires ongoing research to guide knowledge translation efforts and establishing best training methods to ensure the effective delivery of evidence-based cognitive rehabilitation across the world.

Author Bio Amy Rosenbaum, Ph.D., FACRM is Director of the inpatient Traumatic Brain Injury Rehabilitation Program at Park Terrace Care Center. She received her BA in Psychology from the State University of New York at Albany in 1996 and her Doctorate in Clinical Psychology from Hofstra University in 2001. She has specialized in acquired brain injury rehabilitation for 20 years, focusing on evidence-based clinical practice to maximize functional outcomes in those with complex medical and rehabilitation care needs. She has been involved in numerous educational, research and guideline development projects for cognitive rehabilitation and clinical management of individuals with disorders of consciousness.

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Medical Interventions – Opportunities for Optimizing and Augmenting Cognitive Rehabilitation Anthony J.-W. Chen, MD

Medical interventions may address multiple, intersecting influences on learning, plasticity, and functional cognition after injury to the brain. In this tanged ball, interventions can target and modify factors that optimize vs. compromise rehabilitation processes. Interventions may target brain networks that must be regulated for optimal learning and adaptation. Pharmacotherapy through dopaminergic, adrenergic, serotonergic and/or cholinergic systems may help address neuromodulator dysregulation, modifying behavioral functions such as alertness, attention, and information processing. Targeting aspects of brain state involved in emotions (e.g. the biology of severe depression) can change an individual’s trajectory. Injectables and electrical modulation add to medication options for depression. Other interventions may target post-traumatic stress, addressing influences such as avoidance, hyperarousal, and disrupted sleep. The discovery and treatment of medical conditions may make seemingly intractable problems tractable. For example, dense behavioral dysregulation, inattention and forgetfulness may improve with treatment of sleep conditions (e.g. recurrent hypoxia from apnea). Complementing this, sleepwake physiology vital for learning can inform optimization of rhythms using light therapy, melatonin, and other timed pharmacotherapies. Neurologic changes causing migraines and seizures can impede or even seemingly erase rehabilitation gains. Migraines may be targeted by medications, electrical nerve stimulation, and modification of molecular cascades.

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Treating seizure disorders through medications and direct modulation of neural circuitry can dramatically improve progress. Frontiers include feedback-supported learning using neurophysiologic metrics, electrical modulation of neural network dynamics, and injections of small molecules, exosomes, growth factors or stem cells to augment experience-based learning. Cognitive rehabilitation will benefit from an evergrowing toolbox of medical interventions.

Author Bio Anthony J.-W. Chen, MD is a rehabilitation neurologistneuroscientist who has worked to develop a ‘continuum of care’ in support of Veterans in their journey from injury to wellness, with contributions through direct clinical care, innovations in interdisciplinary care, development of rehabilitation interventions, and neuroscience investigation. Dr. Chen completed degrees in Neuroscience from Harvard, MD from Harvard Medical School-M.I.T., internship at Harvard Beth Israel-Deaconess, Neurology at University of California San Francisco, fellowship in cognitive neuroscience, patientoriented research, and rehabilitation neurology at UCSF/ Berkeley and VA San Francisco/Northern California. Dr. Chen is on faculty with VA Northern California, affiliated with UCSF/ Berkeley.

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Current State of Pediatric Cognitive Rehabilitation Drew Nagele, PsyD, CBIST, FACRM

However, the expertise to integrate cognitive rehabilitation strategies into the student’s everyday life experience is not uniformly available throughout US schools. There are a number of Return to School brain injury consulting programs throughout the country, that utilize various training/ consultation models to infuse strategies and techniques that are demonstrated to work into the student’s learning program. Such programs include BrainSTEPS (Pennsylvania)4, COKids (Colorado)5, CBIRT Teams (Oregon) 6, Project BRAIN (Tennessee)7, and Columbus City Schools Traumatic Brain Injury Project & School Based Concussion Management Program (Ohio)8. Some of these brain injury consulting programs are currently the subject of a CDC funded RCT to establish evidence of the benefit to students with TBI. Advocacy is needed to increase awareness that cognitive rehabilitation works, and that training is needed for teachers and healthcare providers. Improved collaboration between medical rehabilitation providers and educators would ensure that students’ specific learning needs are identified as early as possible, and to provide cognitive rehabilitation strategies and learning supports as soon as the student returns to school, as well as throughout key points in transition to adult roles. References 1 .Laatsch, L., Harrington, D., Hotz, G., Marcantuono, J., Mozzoni, M., Walsh, V., Hersey, K.P., An evidence-based review of cognitive and behavioral rehabilitation treatment studies in children with acquired brain injury. (2007), Journal of Head Trauma Rehabilitation, 22(4), pp. 248-256

The body of evidence-based research supporting the use of cognitive rehabilitation in children with brain injury continues to grow. Systematic review of this literature from 1980 to 2006 1 found only 28 studies that included actual interventions, the majority of which were Class III/IV studies, from which the authors were able to put forth only 2 treatment recommendations and 1 treatment option. In stark contrast, a recent systematic review of pediatric cognitive rehabilitation interventions published between 2006 and 2017 2 found 56 studies, including 27 Class 1 studies. This review produced 22 practice recommendations, including interventions to improve attention, memory, executive functioning and emotional/ behavioral functioning. A number of the interventions were family/caregiver focused and many provided evidence for the use of technology in delivering interventions. One of the major issues for children to actually receive these interventions that are demonstrated to work is how training is provided on cognitive rehabilitation and how these services are made available to children. 3 Typically, cognitive rehabilitation has been the purview of neuropsychologists, rehabilitation psychologists, speech-language pathologists, and occupational/physical therapists in the medical/rehab system. However, decreasing lengths of hospital stays and lack of access to outpatient services can dramatically limit a child’s access to cognitive rehabilitation. In school systems, cognitive rehabilitation strategies can be built into the student’s learning support program, either through direct instruction by teachers and special educators as well by ancillary school therapy services (speech therapy, occupational therapy, and school psychology).

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2. Laatsch, L., Dodd, J., Brown, T., Ciccia, A., Connor, F., Davis, K., Doherty, M., Mark Linden, M, Locascio, G., Lundine, J., Murphy, S., Nagele, D., Niemeier, J., m, Adam Politis, A., Rodeo, C., Slomine, B., Smetanar, R., and Yaegers, L. Evidence-based systematic review of cognitive rehabilitation, emotional, and family treatment studies for children with acquired brain injury literature: From 2006 to 2017. (2019). Neuropsychological Rehabilitation. https://doi.org/10.1080/09602011.2019.1678490 3. Nagele, D. Advocacy in Service Delivery, in Cognitive Rehabilitation for Pediatric Neurological Disorders. Editors Gianna Locascio and Beth Slomine, Cambridge University Press, London, 2018. 4. Brain Injury Association of Pennsylvania, Pennsylvania Department of Health, Pennsylvania Department of Education. BrainSTEPS. www.brainsteps.net Accessed on September 1, 2020. 5. Colorado Department of Education, Colorado Brain Injury Program. Colorado Kids Brain Injury Resource Network. http://cokidswithbraininjury.com Accessed on September 1, 2020. 6. University of Oregon, The Center for Brain Injury Research and Training (CBIRT) – www.cbirt.org. Accessed on September 1, 2020. 7. Tennessee Disability Coalition and TN Departments of Health and Education, Division of Special Populations. Project BRAIN. http://tndisability.org/brain. Accessed September 1, 2020. 8. Columbus City Schools & Disability Rights Ohio. Columbus City Schools Traumatic Brain Injury Project & School Based Concussion Management Program. https://www.ccsoh.us/Page/1218 Accessed on September 1, 2020.

Author Bio Dr. Drew Nagele is a NeuroRehabilitation Psychologist with a 35 year career in creating and running brain injury rehabilitation programs for children, adolescents, and adults with acquired brain injury. He serves on the Board of Governors of BIAA's Academy for Certification of Brain Injury Specialists (ACBIS) which is developing an advanced practice certification in NeuroRehabilitation. As Clinical Professor at the Philadelphia College of Osteopathic Medicine he teaches Neuropsychology, Neuropathology, and Cognitive Rehabilitation. He Co-Chairs the National Collaborative on Children’s Brain Injury and the ACRM Pediatric and Adolescent Task Force, and is a Fellow of the American Congress of Rehabilitation Medicine.

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Restore Neurobehavioral Center is a residential, post acute healthcare organization dedicated exclusively to serving adults with acquired brain injury who also present with moderate to severe behavioral problems. Services range from intensive inpatient neuro-rehabilitation and transitional community re-entry services to long term supported living services. Restore Neurobehavioral Center, located in a suburb north of Atlanta, is the site of our inpatient post acute neuro-rehabilitation program as well as one of our supported living sites. We operate two other community living sites, Restore-Lilburn (GA) and Restore-Ragland (AL).

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BIP

expert interview

An interview with John D. Corrigan, PhD, about how Cognitive Rehabilitation fits with brain injury as a chronic health condition. Dr. Corrigan is a Professor in the Department of Physical Medicine and Rehabilitation at Ohio State University and Editor-in-Chief of the Journal of Head Trauma Rehabilitation. He is Director of the Ohio Valley Center for Brain Injury Prevention and Rehabilitation and has been the PI and co-PI of the Ohio Regional Traumatic Brain Injury Model System since 1997. He also directs the Ohio Brain Injury Program, which is the designated lead agency in the state of Ohio for policy and planning related to living with brain injury. Dr. Corrigan is a member of the Board of Directors of the Brain Injury Association of America and has previously served national organizations, including CARF, the Injury Control Center at CDC, the Veterans Administration and the U.S. Department of Defense, Defense Health Board.

Why did we start thinking about brain injury as a chronic health condition? Most traumatic brain injuries (TBI) are mild and cause temporary neurological impairments. While some mild TBIs, and many severe injuries, cause permanent changes, the clinical precept in the past was that residual impairments due to TBI are static once an initial recovery phase has plateaued. This assumption––that the effects of TBI do not change over the remainder of a person’s life––has been drawn into question by several independent bodies of research. The emerging picture is that for more severe injuries, as well as some less severe, the long-term course of TBI is better characterized as dynamic, not static. A broad group of stakeholders in the brain injury field met at the Galveston Brain Injury Conferences and arrived at the following consensus statement: “Injury to the brain can evolve into a lifelong health condition termed chronic brain injury. Chronic brain injury impairs the brain and other organ systems and may persist or progress over an individual’s life span. Chronic brain injury must be identified and proactively managed as a lifelong condition to improve health, independent function and participation in society.” We have been working since to conduct the research and develop the clinical protocols that will turn this recognition into real advancements for people living with brain injury. What is a “disease management" model? As noted in the aforementioned Galveston Brain Injury Conferences consensus statement, as a chronic condition living with brain injury needs to be approached proactively. This is common in other chronic health conditions like diabetes and heart disease—the individual, family and healthcare professionals all have roles intended to optimize a person’s health. Chronic disease management entails: • • • •

on-going surveillance and screening for early detection and intervention of new health conditions that might emerge; prevention efforts targeting high incidence and/or high-risk complications; person and caregiver engagement in self-management skills to improve health and well-being; access to specialized medical and rehabilitation services to keep health and functioning optimal.

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I am pleased to add that a grant award recently announced by the National Institute on Disability Independent Living and Rehabilitation Research will provide resources to develop a “Chronic Disease Management” model specific for living with brain injury. Flora Hammond from Indiana University will be leading that effort and I will be serving as the Co-PI. We will be engaging all the resources of the civilian and VA TBI Model Systems in the development of the “BeHealthy” model. How does Cognitive Rehabilitation (CR) fit into a disease management model”? CR is both a direct intervention to improve function and a “gateway” to multiple other ways to improve health. Many years of research support the specific ways in which CR can improve function after brain injury. But we sometimes ignore that the improvements accomplished via CR allow a person to more effectively take advantage of other services and supports. That is what I mean by being a “gateway”. Compensatory skills I’ve learned for maximizing my attention will improve my ability to participate in education or treatment for an addiction, if that was something I needed. Being better organized will allow me to be more consistent with goals I have set for exercising or better nutrition. Compensatory strategies for memory will allow me to be more effective in my selfmanagement of any medical conditions I may have. Thus, in addition to the direct positive effect on functional independence, CR also has a very important role in maximizing other aspects of life, including a disease management approach. Another important aspect of a disease management model is that services should be available throughout one’s lifetime. This includes therapies like Physical, Occupational and Speech therapies, and it definitely includes CR. While the initial phase of recovery right after the injury is really important, we need to also recognize that services should be available over the years following injury. There is a tendency for skill levels we attain to diminish over time, either because we don’t use the skill enough, we develop some other condition that affects our abilities, or we simply experience aging-related changes. There are numerous studies supporting the effectiveness of CR long after the initial injury. We need to be able to access CR professionals periodically throughout life in order to keep our cognitive skills at their optimum levels.

What do you think is the biggest barrier to making CR available across a person’s lifespan? Unfortunately, currently there are multiple barriers to being able to access CR services across the lifespan. First and foremost is that healthcare professionals have not embraced chronic disease management approaches for brain injury and thus don’t recognize the importance of sustaining skills and abilities over one’s lifetime. If a professional does recognize the need for CR, a second barrier is the lack of, or limited, health insurance coverage. CR needs to be a standard part of the therapies covered by insurance, and that coverage should be adequate to allow any therapies to be accessed to re-optimize abilities. A big step forward for those with the most severe disabilities would be to include CR among allowable services in Medicaid-funded Home and Community Based Service Waivers.

A big step forward for those with the most severe disabilities would be to include CR among allowable services in Medicaidfunded Home and Community Based Service Waivers.

Finally, we need to make sure we have a workforce of trained professionals who know how to do evidence-based CR. Speech Pathologists, Occupational Therapists and Psychologists all include practitioners with the needed competency, but instruction in CR needs to become more integrated into training programs so that a larger number of professionals, geographically dispersed, are available to people with brain injuries. Along these lines, I am optimistic about what I am seeing in training programs for Occupational Therapists. Any final thoughts? Thank you for the opportunity to share a few ideas. I see the field of brain injury rehabilitation making some important changes in how we think about brain injury. Most encouraging, I see significant increases in the attention given to living one’s life with a brain injury. This awareness and attention in both research and services will result in much better lives for persons living with the effects of brain injury and their families.

About the Interviewer Dr. Yelena Goldin is a board-certified senior neuropsychologist at the JFKJohnson Rehabilitation Institute, Clinical Assistant Professor of Physical Medicine and Rehabilitation at Rutgers-Robert Wood Johnson Medical School, Project Director of the JFK-Johnson TBI Model Systems, and Training Director of the JFK-Johnson neuropsychology residency program. She is the co-chair of the ACRM BI-ISIG Cognitive Rehabilitation Task Force, where she is currently leading the next update to the evidence-based systematic review on cognitive rehabilitation in TBI and stroke, as well as the co-chair of the Girls and Women’s with ABI Task Force. She earned several awards for her work in brain injury rehabilitation.

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Interactive issues of Brain Injury Professional are available for viewing on the BIP website.

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Madison Schwartz, Stanford Law, Randall H. Scarlett, Randall A. Scarlett, Ronnie Pang, Olga Rios, Mary Anne Scarlett, and Brendan D. Nay.

SCARLETT LAW GROUP Scarlett Law Group is a premier California personal injury law firm that in two decades has become one of the state’s go-to practices for large-scale personal injury and wrongful death cases, particularly those involving traumatic brain injuries. With his experienced team of attorneys and support staff, founder Randall Scarlett has built a highly selective plaintiffs’ firm that is dedicated to improving the quality of life of its injured clients. “I live to assist people who have sustained traumatic brain injury or other catastrophic harms,” Scarlett says. “There is simply no greater calling than being able to work in a field where you can help people obtain the treatment they so desperately need.” To that end, Scarlett and his firm strive to achieve maximum recovery for their clients, while also providing them with the best medical experts available. “As a firm, we ensure that our clients receive both

the litigation support they need and the cutting-edge medical treatments that can help them regain independence,” Scarlett notes. Scarlett’s record-setting verdicts for clients with traumatic brain injuries include $10.6 million for a 31-year-old man, $49 million for a 23-year-old man, $26 million for a 7-year-old, and $22.8 million for a 52-year-old woman. In addition, his firm regularly obtains eight-figure verdicts for clients who have endured spinal cord injuries, automobile accidents, big rig trucking accidents, birth injuries, and wrongful death. Most recently, Scarlett secured an $18.6 million consolidated case jury verdict in February 2014 on behalf of the family of a woman who died as a result of the negligence of a trucking company and the dangerous condition of a roadway in Monterey, Calif. The jury awarded $9.4 million to Scarlett’s clients, which ranks as

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one of the highest wrongful death verdicts rendered in recent years in the Monterey County Superior Court. “Having successfully tried and resolved cases for decades, we’re prepared and willing to take cases to trial when offers of settlement are inadequate, and I think that’s ultimately what sets us apart from many other personal injury law firms,” observes Scarlett, who is a Diplomate of the American Board of Professional Liability Attorneys. In 2015, Mr. Scarlett obtained a $13 million jury verdict for the family of a one year old baby who suffered permanent injuries when a North Carolina Hospital failed to diagnose and properly treat bacterial meningitis that left the child with severe neurological damage. Then, just a month later, Scarlett secured an $11 million settlement for a 28-year-old Iraq War veteran who was struck by a vehicle in a crosswalk, rendering her brain damaged.

Brain Injury Professional: Cognitive Rehabilitation Updates and Current State of the Field.

Articles inside

Expert Interview

Current State of Pediatric Cognitive Rehabilitation

Cognitive Rehabilitation for Emotion Recognition Deficits after

Technology Article

Evidence-based Cognitive Rehabilitation for Traumatic Brain Injury and Stroke: Latest Update from the ACRM Cognitive Rehabilitation Task Force

Editor in Chief Message

The Changing Landscape of Holistic Brain Injury Rehabilitation

Medical Interventions – Opportunities for Optimizing and Augmenting Cognitive Rehabilitation

Training Professionals in Delivering Evidence-based Cognitive Rehabilitation

Guest Editor’s Message