Education and Skills Training Interventions for Adults With Traumatic Brain Injury (TBI) (Dates of Review: 2013

Abstract

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association’s Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on education and skills training interventions that address psychosocial, behavioral, and emotional skills for people with traumatic brain injury (TBI).

Full Systematic Review Question

This systematic review addressed the question “What is the evidence for effectiveness of interventions that address psychosocial, behavioral, and/or emotional skills to improve social participation and other everyday activities and occupations for persons with TBI?”

Current Theme Reported

The main theme of the studies including in this systematic review brief is education and skills training interventions for adults with traumatic brain injury.

Clinical Scenario

Traumatic brain injury (TBI) is a leading cause of death and disability that affects about 2.5 million Americans each year. Although the symptoms and severity of TBI vary among individuals, psychosocial, behavioral, and emotional changes are common and significantly impact successful and satisfying community participation. The increased prevalence of psychological problems in people with TBI, including depression, anxiety, suicidal ideation, substance abuse, sleep disorders, and posttraumatic stress disorder, highlight the need for appropriate and empirically based interventions. Psychological issues are commonly cited among those unmet rehabilitation needs (Mahoney et al., 2021), and these directly fall within occupational therapy’s scope of practice. Individual and group-based educational interventions, including direct teaching, coaching, and counseling approaches, are used with people post TBI to develop skills and strategies to improve home and community participation. Occupational therapy practitioners have knowledge, skills, and training in assessing and treating psychological impairments to improve occupational performance following TBI, making their role in the rehabilitation process vital across the continuum of recovery.

Summary of Key Findings

Seven articles were included in the review related to education and skills training interventions. These seven articles were further divided into three categories, depending on method of delivery (Table 1). The levels of evidence used in this review are from Oxford Centre for Evidence-Based Medicine (2009).

Table 1.

Evidence Table for Education and Skills Training Interventions for Adults With Traumatic Brain Injury

Author/Level of Evidence	Intervention	Statistically Significant Improvement Resulting From Intervention
Individualized Education Intervention Three Level 1B studies examined occupational therapy practitioners’ use of one-on-one instructional training programs to improve or teach compensatory strategies for TBI-related symptoms. Strong strength of evidence supports this type of intervention. The studies indicate effectiveness for mild, moderate, and severe injuries to improve quality of life, psychosocial functioning, and social relationships.
Hart et al. (2017) Level 1B—RCT Setting Outpatient clinic Country USA	Population Moderate to severe TBI, minimum 6 mo post TBI. N = 90 Intervention AST, psychoeducational group supplemented with 1:1 treatment with weekly assignments. Intervention included education about anger, self-monitoring, identifying feelings, reading anger signals, communication, active listening, self-assessment, and problem solving. Delivery Method Individual Dose 8 sessions, 1×/week for 60–90 min per session.	Intervention group reported significantly improved trait anger (i.e., personality dimension of anger) compared with the control group at program follow-up.
Vuletic et al. (2016) Level 1B— Setting Telephone/home based Country USA	Population Mild TBI. Active military service members or National Guard/reserve enrollment within past 24 mo. N = 356 Intervention Brochures mailed out related to common issues experienced with mTBI like sleep issues, cognitive problems, pain, etc. Participants underwent a telephone-based problem-solving intervention. Participants talked to master-level trained counselors on a problem of their choosing. Delivery Method Individual Dose Biweekly phone calls for 6 mo.	Intervention group reported significantly improved sleep-quality associated with PTSD symptoms, depression, and mental health at program completion. Intervention group also reported fewer unproductive days at program completion.
Westerhof-Evers et al. (2017) Level 1B—RCT Setting Research Laboratory Country Netherlands	Population Moderate-severe TBI, significant other/proxy to fill out questionnaires. N = 59 Intervention Treatment of Social Cognition and Emotional Regulation (T-ScEmo) compensatory strategy training; directed at maintaining and improving social relationships. Homework assignments for generalization. Delivery Method Individual Dose Total treatment consisting of max 20 individual sessions offered 1–2×/week by a therapist.	Intervention participants reported significantly less perceived burden, improved quality of life, better resumption of roles, and improved goal attainment compared with control group subjects at program completion.
Group Intervention Related to Coping/Stress Management Three articles related to group-based interventions specific to coping and/or stress management were included in this research brief. Group interventions “use distinct knowledge of the dynamics of a group and social interaction and leadership techniques to facilitate learning and skill acquisition across the lifespan” (American Occupational Therapy Association [AOTA], 2020, p.62). One Level 1B RCT, one Level 2B, and one Level 3B study examined occupational therapy practitioners’ provision of group educational interventions to address anger management, social participation, and psychosocial well-being for adults with TBI. Moderate strength of evidence supports this type of intervention.
Harrison-Felix et al. (2018) Level 1B—RCT Setting Community and VA rehabilitation centers Country USA	Population TBI >6 mo, overnight supervision to independent level of functioning. N = 179 Intervention GIST, an interactive structured treatment program combining psychoeducational curriculum with an interactive group format, emphasizing group feedback and social learning. Topics include self-assessment, goal setting, starting conversations, conversation strategies, feedback, assertiveness, social problem solving, positive self-talk, social boundaries, and conflict resolution. Included a community outing with the therapists to practice goals. An alternative intervention was the GIST curriculum presented in a classroom lecture format with groups of 6–8 students. Delivery Method Group. Dose 13 weekly group interactive sessions for 1.5 hr	Both types of intervention (GIST group and GIST lecture format) resulted in significantly improved reported psychological distress immediately posttreatment and at 3 mo posttreatment for the lecture format only. No significant difference between intervention conditions was found.
Aboulafia-Brakha et al. (2016) Level 2B Setting Outpatient Clinic Country Switzerland	Population Acquired brain injury. N = 26 Intervention Anger management program comprised 4 modules: A. Identification of emotions / self-awareness (setting intervention goals, discussing possible psychosocial consequences); B. Managing emotions in emergency situations (relaxation techniques, behavioral interruption); C. Cognitive restructuring; and D. Prevention strategies (identifying vulnerable situations, promoting pleasant activities). Delivery Method Group. Dose 8-wk program followed by a 4-wk intervention of education. Groups comprised max of 3 participants/group with 60-min sessions 1×/week.	Intervention resulted in significant reported improvement in the areas of aggression, anger, venting, rumination, and self-appraisal at program completion.
McCarron et al. (2019) Level 3B Setting Outpatient clinic (VA) Country USA	Population Moderate, severe, or multiple mild traumatic brain injury. Experiencing depression, anxiety, or PTSD symptoms and chronic social dysfunction. N = 10 Intervention Participants met for a weekly workbook group with a licensed SLP, neuropsychologist, and a neuropsychology postdoctoral fellow. The workbook contained 22 topics focused on social competence. Delivery Method Group. Dose 1× a week for 90 min for a year.	Intervention group reported significantly improved ability to view other’s perspectives, quality of life (social and emotional), social functioning, and depressive symptoms at program completion.
Group Instruction Combined with Interdisciplinary Rehabilitation One Level 3B study examined interdisciplinary individual and group rehabilitation to improve occupational performance, satisfaction with role performance, and symptoms associated with posttraumatic stress disorder and depression. Low strength of evidence supports this type of intervention.
Speicher et al. (2014) Level 3B Setting VA Residential Treatment Center Country USA	Population Veterans with PTSD and history of traumatic brain injury. N = 26 Intervention Residential treatment program that included CPT groups and individual sessions and adjunctive interventions included individualized occupational therapy 1×/week and speech therapy 2–3×/week. Focus on identifying maladaptive beliefs, encouraging patients to complete related worksheets designed to increase self-awareness of thoughts and feelings, and challenging problematic thinking and beliefs, and providing opportunities to successfully engage in activities that challenge maladaptive behaviors in a safe environment. Delivery Method Combined group and individual. Dose In total, veterans attended approximately 15 groups/wk for 60 min over 8-wk period.	Intervention participants reported improved occupational performance and satisfaction, PTSD symptoms, and depressive symptoms at program completion.

Note. AST = anger self-management training; CPT = cognitive processing therapy; GIST = group interactive structured treatment; mTBI = mild traumatic brain injury; PTSD = posttraumatic stress disorder; RCTs = randomized controlled trials; SLP = speech language pathologist; TBI = traumatic brain injury.

Bottom Line for Occupational Therapy Practice

Occupational therapy practitioners provide individual and group interventions to facilitate skill development in various capacities to support successful and satisfying community participation. The findings of this review indicate strong evidence to support instruction-based rehabilitation when interventions are performed individually with the client. Such one-to-one treatment is conducive to tailoring programs to the unique and varying needs of the individual. Referenced by Maas (2016, p.3) as “the most complex disease in the most complex organ,” the great heterogeneity among severity and symptoms across the population of survivors could potentially limit the effectiveness of any intervention approach or protocol that targets the “average” individual with brain injury.

Support for group-based instructional and skill training had moderate strength of evidence in this review. Although less individualized to the specific needs of the client, group therapy may provide an enhanced level of social support and feedback that may be effective for addressing issues common to members of the group, including anger, social behaviors, or the experience of psychological symptoms. The evidence regarding interdisciplinary rehabilitation is low in this review, based on the findings of a single study, but supportive of occupational therapy. Statistically significant outcomes from the Speicher et al.’s (2014) study include occupational performance and life satisfaction, areas characteristic of occupational therapy intervention. Common across both individual and group educational approaches is the finding that change occurs over time. Providing the intervention over multiple sessions, with homework or practice activities between sessions can facilitate improvements in both psychological functioning as well as social and community participation.

Footnotes

*

Indicates articles included in the systematic review brief.

References

Aboulafia-Brakha

Allain

, & Ptak

(2016). Emotion regulation after traumatic brain injury: Distinct patterns of sympathetic activity during anger expression and recognition. Journal of Head Trauma Rehabilitation , 31 , E21–E31. https://doi.org/10.1097/HTR.0000000000000171

American Occupational Therapy Association (AOTA). (2020). Occupational therapy practice framework: Domain and process (4th ed.). Author. Retrieved October 22, 2021, from https://search.ebscohost.com/login.aspx?direct=true&scope=site&db=nlebk&db=nlabk&AN=2678393 .

Harrison-Felix

Newman

J. K.

Hawley

Morey

Ketchum

J. M.

Walker

W. C.

, . . . Howe

(2018). Social competence treatment after traumatic brain injury: A multicenter, randomized controlled trial of interactive group treatment versus noninteractive treatment. Archives of Physical Medicine and Rehabilitation , 99 , 2131–2142. https://doi.org/10.1016/j.apmr.2018.05.030

Hart

Brockway

J. A.

Maiuro

R. D.

Vaccaro

Fann

J. R.

Mellick

, . . . Temkin

(2017). Anger self-management training for chronic moderate to severe traumatic brain injury: Results of a randomized controlled trial. Journal of Head Trauma Rehabilitation , 32 , 319–331. https://doi.org/10.1097/HTR.0000000000000316

Maas

(2016). Traumatic brain injury: Changing concepts and approaches. Chinese Journal of Traumatology , 19 , 3–6. https://doi.org/10.1016/j.cjtee.2016.01.001

Mahoney

E. J.

Silva

M. A.

Reljic

Dams-O’Connor

Hammond

F. M.

Monden

K. R.

, . . . Nakase-Richardson

(2021). Rehabilitation needs at 5 years post-traumatic brain injury: a VA TBI model systems study. Journal of Head Trauma Rehabilitation , 36 , 175–185. https://doi.org/10.1097/HTR.0000000000000629

McCarron

K. K.

Dasgupta

M. K.

Campbell

C. A.

Hull

A. E.

Namazi

Adams

A. H.

, . . . Schwartz

B. L.

(2019). Social rehabilitation for military veterans with traumatic brain injury, psychological trauma, and chronic neuropsychiatric symptoms: Intervention development and initial outcomes. Psychiatric Rehabilitation Journal , 42 , 296–304. https://doi.org/10.1037/prj0000361

Oxford Centre for Evidence-Based Medicine. (2009). Levels of evidence (March 2009). https://www.cebm.ox.ac.uk/resources/levels-of- evidence/oxford-centre-for-evidence-based-medicine-levels-of- evidence-march-2009

Speicher

S. M.

Walter

K. H.

, & Chard

K. M.

(2014). Interdisciplinary residential treatment of posttraumatic stress disorder and traumatic brain injury: Effects on symptom severity and occupational performance and satisfaction. American Journal of Occupational Therapy , 68 , 412–421. https://doi.org/10.5014/ajot.2014.011304

10.

Vuletic

Bell

K. R.

Jain

Bush

Temkin

Fann

J. R.

, . . . Gahm

G. A.

; CONTACT Investigators. (2016). Telephone problem-solving treatment improves sleep quality in service members with combat-related mild traumatic brain injury: Results from a randomized clinical trial. Journal of Head Trauma Rehabilitation , 31 , 147–157. https://doi.org/10.1097/HTR.0000000000000221

11.

Westerhof-Evers

H. J.

Visser-Keizer

A. C.

Fasotti

Schönherr

M. C.

Vink

van der Naalt

, & Spikman