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 cognitive interventions to improve occupational performance for adults with traumatic brain injury.
Full Systematic Review Question
This systematic review addressed the question “What is the evidence for the effectiveness of cognitive processing, activity, and occupation-based interventions to improve participation for people with TBI and cognitive impairments?”
Current Theme Reported
The main theme of the studies included in this systematic review brief is cognitive intervention for which occupational performance was a primary outcome.
Clinical Scenario
Occupational performance deficits associated with cognitive impairment are common following traumatic brain injury (TBI; Dikmen et al., 2009; Temkin et al., 2009) and frequently prompts referral to occupational therapy services. Severity of occupational performance deficits following TBI is associated with both time since injury and injury severity (Novack et al., 2009). Across the range of mild to severe TBI, the most frequently occurring cognitive impairments are in information processing speed, memory, and executive functions (Sigurdardottir et al., 2015). Depending on the severity of occupational performance deficits, occupational therapy practitioners use a variety of approaches that attempt to help adults with TBI improve their functioning including strategy or task-training approaches (Dawson et al., 2013; Trevena-Peters et al., 2018). In this Systematic Review Brief, we summarize the evidence in support of both strategy and task-training approaches. In general, strategy training involves the use of new ways to recognize and work around impaired cognitive skills, and task/ habit training involves the repetitive practice of specific activities of daily living until mastery is achieved (Dawson et al., 2013; Trevena-Peters et al., 2018).
Summary of Findings
Ten articles were included in the review for which occupational performance of adults with TBI was a primary outcome (Table 1). Evidence was found that strategy-based training approaches and task/habit-training approaches can address cognitive impairments to improve occupational performance. The levels of evidence used in this review are from Oxford Centre for Evidence-Based Medicine (2009).
Evidence Table for Cognitive Interventions With Occupational Performance as a Primary Outcome
Note. ADL = activities of daily living; CogSMART = Cognitive Symptom Management and Rehabilitation Therapy; CO-OP = Cognitive orientation to [daily] occupational performance; EBL = error-based learning; ELL = errorless learning; EO = education-only; mTBI = traumatic brain injury; PDA = personal digital assistant; PST = problem-solving treatment; PTA = posttraumatic amnesia; TBI = traumatic brain injury.
Bottom Line for Occupational Therapy Practice
This systematic review provides evidence in support of both strategy and task/habit-training approaches to help adults with TBI to improve cognition and occupational performance. Individuals exposed to strategy training demonstrated reductions in self-reported postconcussion symptoms and, in some cases, improved self-awareness. Reported outcomes of strategy-based interventions varied but included improvements in prospective memory and some measures of general participation, including return to work, and self- selected occupational performance problems. The use of technology in the context of strategy training appeared to enhance sleep outcomes, achievement of functional goals, and reduction in memory failures. Of note, many of the participants in studies involving strategy training had mild TBI. In task/habit training for people with severe TBI, error-based learning appeared to result in greater self-awareness and behavioral competence than errorless learning. However, for individuals with severe impairments of memory occurring during posttraumatic amnesia, a specialized habit-based errorless learning intervention was superior to treatment as usual in improving functional performance. Prompting technologies appear to hold promise for augmenting task/habit training. People with severe TBI who were exposed to an automated prompting system had greater success learning a morning routine than those who received usual care. The potential for prompting-based intervention was demonstrated when participants had greater success performing a cooking task in a technology-enhanced kitchen that provided automatic prompts than when a user-controlled prompting system was used. These findings underscore the importance of adopting cognitive intervention approaches that are aligned with patients’ severity of injury and outcome goals.
Footnotes
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Indicates articles included in the systematic review brief.