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


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Objective: The Adaptive Behaviour and Community Competency Scale was used to investigate the interrelationship of 22 basic and instrumental activities of daily living (ADL/IADL) in individuals with moderate to severe traumatic brain injury (TBI). The relationship of self-awareness to task performance was also investigated. Research design: Prospective descriptive study. Method: The profiles of 100 community dwelling individuals were used to compare the degree to which independence in each ADL/IADL was associated with independence in every other ADL/IADL. The interrelationship of these skills was further explored in a factor analysis, and comparisons made between the degree of self-awareness of those who could and could not complete IADL independently. Results: We found evidence of a hierarchy of skills: individuals who were independent in IADL were more able to perform ADL, than vice versa. Factor analysis supported a two-factor solution distinguishing ADL and IADL. Self-awareness was more strongly associated with IADL than with ADL independence. Conclusions: A subset of individuals with moderate to severe TBI are able to perform a range of IADL. This group appears to have higher levels of self-awareness than those who are limited to performing only ADL skills. Implications for the applications of functional retraining interventions are discussed.
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Brain Injury
ISSN: 0269-9052 (Print) 1362-301X (Online) Journal homepage:
The interrelationship of functional skills in
individuals living in the community, following
moderate to severe traumatic brain injury
Gordon Muir Giles, Jo Clark-Wilson, Doreen M. Tasker, Ross Baxter, Mark
Holloway & Stephanie Seymour
To cite this article: Gordon Muir Giles, Jo Clark-Wilson, Doreen M. Tasker, Ross Baxter, Mark
Holloway & Stephanie Seymour (2018): The interrelationship of functional skills in individuals
living in the community, following moderate to severe traumatic brain injury, Brain Injury, DOI:
To link to this article:
© 2018 The Author(s). Published by Taylor &
Published online: 14 Nov 2018.
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The interrelationship of functional skills in individuals living in the community,
following moderate to severe traumatic brain injury
Gordon Muir Giles
, Jo Clark-Wilson
, Doreen M. Tasker
, Ross Baxter
, Mark Holloway
, and Stephanie Seymour
Department of Occupational Therapy, Samuel Merritt University, Oakland, CA, California, USA;
Crestwood Treatment Center 2171 Mowry Avenue,
Fremont, CA, California, USA;
Head First, Grove Mills, Hawkhurst, UK;
School of Sociology & Social Policy, University of Nottingham, UK
Objective: The Adaptive Behaviour and Community Competency Scale was used to investigate the
interrelationship of 22 basic and instrumental activities of daily living (ADL/IADL) in individuals with
moderate to severe traumatic brain injury (TBI). The relationship of self-awareness to task performance
was also investigated.
Research design: Prospective descriptive study.
Method: The profiles of 100 community dwelling individuals were used to compare the degree to which
independence in each ADL/IADL was associated with independence in every other ADL/IADL. The
interrelationship of these skills was further explored in a factor analysis, and comparisons made between
the degree of self-awareness of those who could and could not complete IADL independently.
Results: We found evidence of a hierarchy of skills: individuals who were independent in IADL were more
able to perform ADL, than vice versa.
Factor analysis supported a two-factor solution distinguishing ADL and IADL. Self-awareness was
more strongly associated with IADL than with ADL independence.
Conclusions: A subset of individuals with moderate to severe TBI are able to perform a range of IADL.
This group appears to have higher levels of self-awareness than those who are limited to performing
only ADL skills. Implications for the applications of functional retraining interventions are discussed.
Received 13 August 2017
Revised 24 May 2018
Accepted 19 October 2018
Traumatic brain injury; brain
injury; activities of daily
living; self-awareness;
executive function
In the USA, functional skills are typically divided into activ-
ities of daily living (ADL) and instrumental activities of daily
living (IADL). ADL include, but are not limited to, the rou-
tine self-care activities of eating, bathing, dressing, toileting,
and transferring (13). IADL include a range of activities
related to independent functioning, such as meal preparation,
shopping, community mobility skills (4,5), and other activities
that involve managing social interaction or environmental
variability. IADL are more varied, and typically performed
in a greater range of settings than are ADL (6,7).
Moderate to severe traumatic brain injury (TBI) is a major
cause of long-term ADL and IADL disability (8,9). Indeed, direct
assessment of ADL and IADL appear to be the best predictor of an
individuals need for support or ability to function independently
in the community (6,7). The frequency with which individuals can
perform ADL versus IADL would suggest the latter are more
difficult to accomplish. For instance, in a 35 year follow-up
study, Dikmen and colleagues (10) estimated that approximately
10% of persons in their severe TBI sample required long-term
assistance or were dependent on others for help with ADL tasks.
By contrast, 60% had difficulty or required support with IADL
tasks. Powell et al. (11) identified similar rates of ADL and IADL
dependence. However, observing the frequency with which defi-
cits occur is insufficient for a full understanding of what makes
some tasks more difficult than others. There is evidence that ADL/
IADL skills are hierarchically organized in older individuals across
diagnostic categories (12), but to our knowledge this finding has
not been replicated amongst people following moderate to severe
TBI. There is evidence that executive functioning is the best pre-
dictor of functional performance in older adults living in the
community (13) and predicts progress during acute TBI rehabili-
tation (14). Lack of insight is generally associated with poorer
functional recovery and worse rehabilitation and employment
outcomes (1517). It has been proposed that adequate IADL
performance post TBI depends on both the individualscognitive
status and their self-awareness (18,19). In a prior publication we
reported that lack of insight was associated with increased need for
case management and care-support for individuals living in the
community following TBI (20). To our knowledge, there have
been no studies that have examined how insight relates directly
to ADL versus IADL performance after TBI (18). An enhanced
understanding of the way in which ADL/IADL skills interrelate
could provide a rationale for choosing the order in which func-
tional independence skills are addressed in rehabilitation.
The current study was designed to test the following
(1) A hierarchical relationship exists between IADL and
ADL skills in individuals following moderate to
severe TBI. Independent performance of IADL skills
is more strongly associated with independent perfor-
mance of ADL skills, than the other way around
(2) An exploratory factor analysis of ADL and IADL
independence would support a two-factor solution:
CONTACT Gordon Muir Giles, PhD OTR/L, FAOTA, Crestwood Treatment Center, 2171 Mowry Avenue, Fremont, CA, USA.
© 2018 The Author(s). Published by Taylor & Francis.
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a procedural/motoric factor, and a planning, pro-
blem-solving and decision-making factor
(3) Individuals who are unable to perform IADL would
be more impaired in self-awareness than those who
are able to perform IADL.
Data were collected as part of a larger study and the current report
is a secondary analysis. A detailed description of the data-collec-
tion procedures is reported elsewhere (20). There were 141 client
vided by UK brain injury case managers from different case
management companies. Case managers were knowledgeable
about the clients whose profiles they contributed. In the prior
paper, we found that the two samples were comparable in the
frequency with which clients could accomplish ADL/IADL tasks,
suggesting that the relative frequencies of independence in these
skills did not occur by chance. There were no differences in the
distribution of the ADL and IADL items between data sets, so the
sampleswerecombinedtoproduceasingledataset(20). The
Mayo system was used to classify injury severity and only those
were included (21), yielding a total of 100 profiles. Samuel Merritt
University Institutional Review Board approved the study.
Study population
Client profiles were included if clients were living in the com-
munity (i.e., not in residential or other institutional care), over
the age of 12 years at the time of injury, and had sustained a TBI
(e.g., vehicular, falls, assaults, sporting injuries), hypoxia, anoxia,
or anesthetic accident, or a limited range of vascular events (e.g.,
subarachnoid hemorrhage). Clients were excluded if they had
sustained a stroke, or brain injury associated with a cardiac
event, as these diagnostic groups were considered to have differ-
ent patterns of cognitive and functional outcomes from those
seen in TBI (22). Individuals were not excluded on the grounds
of substance abuse or psychiatric impairment.
Adaptive Behaviour and Community Competency Scale
The Adaptive Behaviour and Community Competency Scale
(ABCCS) was designed specifically to be sensitive to the types
of problems experienced by clients with TBI living in the com-
munity in the post-acute period (20,23). The ABCCS uses ordi-
nal scales linked to concrete behavioral descriptions or a
specification of the need for prompting or physical assistance,
in line with the World Health Organization level of impairment
and ability. The ABCCS has excellent interrater and testretest
reliability when used with a UK TBI community population
(23,24). Each item relating to ADL/IADL was dichotomized
into independent or not independent. Independence in an activ-
ity was defined as safe, habitual task performance without the
need for physical or verbal prompting, assistance or supervision.
A definition of each of the 22 ADL/IADL items used in the
ABCCS is given in Appendix A. The ABCCS also includes a 4-
point Insight scale measuring the clients global self-awareness,
based on the descriptive theory of Crosson et al. (25)(Table 1
provides the ABCCS Insight scale).
Data analysis
SPSS version 19 (26) was used to examine client demographics.
The frequency with which independence was achieved in
each of the 22 ABCCS ADL/IADL items was calculated, and
the items ordered in terms of most (item 1) to least (item 22)
frequently completed independently.
The rates of independence versus dependence and Fisher
Exact Probability Test with Bonferroni correction were calcu-
lated using a 2 × 2 contingency table as a guide for each bi-
directional ADL/IADL skill pair (27)(for further explanation
of how data for Table 3 were calculated see Appendix B).
An exploratory factor analysis was conducted to determine
whether the 22 ADL and IADL items truly represent two differ-
ent types of activity. Since the data are binary, the exploratory
factor analysis was conducted on a tetrachoric correlation matrix
for the 22 functional skills using minimum residual observed
least squares and varimax rotation. Foxs (2014) polycor package
in R was used to calculate the tetrachoric correlation matrix (28).
Having ordered the 22 ADL and IADL in terms of the
frequency with which clients were independent in these skills,
the midpoint activity was identified (i.e. Health Maintenance).
Items above Health Maintenance in Table 3 were considered
mostly ADL and those below it were considered mostly IADL.
MannWhitney Utest SPSS version 19 (26) was used to analyze
whether severity of injury was associated with independence in
items above or below this midpoint Health Maintenance (i.e., the
ADL versus IADL items). A similar procedure was used to
determine if there were differences between the lack of aware-
ness of clients who could perform activities above or below the
Health Maintenance item. The z distribution was used to calcu-
late the effect size from the MannWhitney Uresults (29).
Client characteristics
Client demographics, severity of injury and indicators of severity
of outcome are provided in Table 2. Data were available for 84
individuals regarding their employment status pre- and post-
injury (see Table 2). Post-injury only 3 clients were in competitive
Table 1. ABCCS Insightscale.
(Please select the statement that best applies. If the client is unable to
respond or communicate, please do not record anything)
3 Recognizes the effects of impairments on daily functioning, foresees
potential problems and implements compensatory strategies
2 Describes physical, cognitive, and emotional impairments, if asked,
but does not understand the implications of impairments
1 Acknowledges physical impairments, if asked, but not other
0 Does not acknowledge any impairment
employment and only 10 clients were in education, with a further
12 clients in voluntary or sheltered work settings. Most clients (74)
were living at home alone or with family post-injury with the
remainder(26)intheirownhomewithsupport(seeTable 2): all
clients were receiving case management.
Independence rates
Table 3 provides the 462 independent, pairwise comparisons for
each ADL or IADL skill with every other ADL or IADL skill,
ordered from most-to-least commonly achieved. In examining
the table, the reader should first read acrossthe top of the table to
locate the predictor ADL or IADL skill of interest (labeled 122),
below which is given the number of people in the sample who
are independent in that predictor skill. Looking at each cell by
row, the first number indicates the absolute number of people
who are independent in the predictor skill who are also inde-
pendent in the associated skill (identified by the name at the side
of the table row). The second number in each cell is the percen-
tage of people who are independent in the predictor skill (who
are also independent in the associated skill). Visual inspection of
Table 3 reveals that the number of people achieving indepen-
dence in the list of reordered items gradually reduces in each
column, with only some minor exceptions (i.e. the hierarchy is
not perfect). Those individuals who achieve independence in the
lower items in the table (e.g. items 19, 20, 21, 22; items that are
typically considered IADL) are far more likely to be independent
in items higher in the table (e.g. 1, 2, 3, 4; items that are typically
considered ADL) than vice versa. If, for example, the reader
examines column 19 Laundry/Housework, 13/100 people are
independent in the IADL Laundry/Housework and almost all
are also independent in most of the items above the midpoint
Health Maintenance in the table (84100%, i.e. in the ADLs
items Telephone Use, Continence, Outdoor and Indoor Mobility,
Oral Care, Showering, Dressing and Nail Care).If,however,the
reader examines column 8, 49/100 people are rated as indepen-
dent in Dressing, but only 13/100 (26%) are independent in the
IADL of Laundry/Housework.Appendix B (Tables 5 and 6)
illustrate the creation of the 2 × 2 table.
Exploratory factor analysis
An exploratory factor analysis was conducted to determine
whether the 22 ADL and IADL represent two underlying types
of skills. First, a tetrachoric correlation matrix was computed
(available on request from the first author). Almost all of the
tetrachoric correlations for each pair of ADL and IADL skills
were significant at the 95 percent confidence level. Using 0.40 as
the cut-off value for factor loadings, it was determined that
eleven ADL and IADL skills loaded on both factors, seven
ADL and IADL skills loaded only on factor 1, and four ADL
and IADL skills loaded only on factor 2. In the cases where a
functional skill loaded on both factors, the factor with the higher
factor loading for each ADL or IADL skill was chosen as the final
factor. In Table 4, boxes have been drawn around the final ADL
and IADL skills included in each factor which we labeled: (1)
procedural/motoric, and (2) planning, problem-solving, and deci-
A comparison was made between clients who were inde-
pendent in Health Management and/or independent in one
or more of the items below Health Management in Table 3
(IADL-independent group) and clients who were dependent
for Health Management and all tasks below it in Table 3
(IADL-dependent group). This grouping resulted in an
IADL-independent group of 58 clients and an IADL-depen-
dent group of 42 clients. MannWhitney analysis of
Glasgow Coma Scale (GCS), coma duration or post trau-
matic amnesia (PTA) indicated that the IADL-independent
and IADL-dependent groups did not differ significantly in
any of the TBI severity measures. Thus for PTA, the IADL-
dependent group (n= 31) had a mean rank of 38.0 while
the IADL-independent group (n=40)hadameanrankof
34.5 with the resultant MannWhitney U= 558.0, p= 0.36.
For the GCS, the IADL-dependent group (n=36)hada
mean rank of 41.0 and the IADL-independent group (n=
51) had a mean rank of 46.2 with the resultant Mann
Whitney U= 808.5, p= 0.13. For duration of coma, the
IADL-dependent group (n= 28) had a mean rank of 38.5,
and the IADL-independent group (n= 39) had a mean rank
of 30.8 with a resultant MannWhitney Uthat approached,
but did not reach, significance = 420.5, p=0.06.
The MannWhitney Utest was used to compare the same
IADL-dependent and IADL-independent grouping on the 4-
point ABCCS Insight scale (see Table 1). The IADL-dependent
group had an average score of 1.94 on Insight and the IADL-
independent group an average score of 2.21. The IADL-depen-
dent group (n= 42) had a mean rank of 31.0 while the IADL-
independent group (n= 58) had a mean rank of 40.0, with the
Table 2. Sample demographic and clinical characteristics.
N= 100
Variable Mean SD
Age 34.99 ± 12.2
Age when injured 25.92 ± 11.21
Years post-injury 9.09 ± 5.26
Gender N(%)
Male 66 (66)
Female 34 (34)
GCS Score N=87
38 74 (85%)
912 9 (10%)
1315 4 (5%)
Coma duration N=67
1 hour 2 (3%)
124 hours 3 (4%)
27 days 18 (27%)
>7 days 44 (66%)
Duration of PTA N=71
17 days 3 (4%)
14 weeks 17 (24%)
>4 weeks 51 (72%)
Post-injury living situation N= 100
Living alone 23 (23%)
With family 51 (51%)
With care-support 26 (26%)
Work and educational status N(%)
Competitive employment 56 (61)
In educational setting 28 (30)
Missing 8 (9)
Competitive employment 3 (3)
Volunteer work 17 (17)
Sheltered work 2 (2)
In educational setting
Not working or in education
10 (10)
68 (68)
resultant MannWhitney U=772,p= 0.001. Effect size calcula-
tion indicates an eta squared of 0.10 indicating that 10% of the
variability in self-awareness as measured by the ABCCS variable
Insight can be attributed to the IADL-independent and IADL-
dependent groups.
Hypothesis 1, that a hierarchical relationship exists between IADL
and ADL skills in individuals following moderate to severe TBI
was supported. Hypothesis 2, that an exploratory factor analysis of
the 22 ADL and IADL skills would support a two-factor solution
which we labeled procedural/motoric vs planning, problem-solving,
and decision-making was partially supported. The two-factor solu-
tion found that 7 of the 22 skill items (mostly ADL) loaded
predominantly on factor one (procedural/motoric), and four
items (predominantly complex IADL) loaded mostly on factor 2
(planning, problem-solving, and decision-making). The other
skills loaded on both factors. Hypothesis 3, that clients rated as
dependent on IADL items are more impaired in self-awareness
Table 3. The co-occurrence of functional skill independence in 100 community dwelling individuals with moderate to severe TBI.
Functional skills
1. Telephone use 34/100 25/96 22/100 19/95 17/100 17/100 14/100 13/100 13/100 12/100 08/100
2. Continence 34/100 24/92 22/100 20/100 17/100 17/100 14/100 13/100 13/100 11/91 08/100
3. Eating 33/97 22/48 20/90 18/90 17/100 17/100 14/100 12/92 12/92 11/91 07/88
4. Outdoor mobility 30/88 21/80 21/95 18/90 16/94 16/94 13/92 13/100 13/100 10/83 08/100
5. Indoor mobility 28/82 18/69 20/90 18/90 15/88 13/76 10/76 13/100 12/92 08/100 08/100
6. Oral care 30/88* 22/84 22/100* 16/80* 16/94 16/94 13/92 13/100 13/100 10/83 07/88
7. Showering 29/85* 19/73 19/86 16/80 16/94* 14/82 12/85 13/100 12/92 09/75 07/88
8. Dressing 26/76 18/69 18/82 16/80 17/100* 15/88 12/85 13/100* 10/76 09/75 07/88
9. Nail care 25/73* 16/61 18/82* 15/75* 15/88* 14/82 11/78 13/100* 12/92 07/58 07/88
10. Street crossing 23/67* 17/65 21/95* 17/85* 13/76 13/76 12/85 11/84 10/76 09/75 06/75
11. Med management 19/56 14/53 14/64 13/65 13/76 10/58 10/71 12/92* 08/61 08/66 07/88
12. Health Maintenance 18/69* 14/64 12/60 13/76 11/64 12/85* 12/92* 10/76 09/75 07/88
13. Shopping 18/53* 10/45 09/45 09/53 11/64 10/71 09/69 08/61 10/83* 04/50
14. Route finding 14/41 10/38 13/65* 07/41 08/47 09/64 06/46 10/76* 06/50 03/37
15. Driving 12/35 09/34 13/59* 07/41 06/35 06/42 05/38 05/38 05/41 02/25
16. Room tidy 13/38 09/34 07/31 07/35 06/35 05/36* 11/84 04/30 05/41 06/75
17. Meal preparation 11/32 11/42 08/36 06/30 06/35 10/71* 06/46 06/46 05/41 03/37
18. Community skills 12/35* 10/36 09/41 06/30 05/29 10/58* 05/38 07/53 05/41 01/13
19. Laundry/Housework 12/35* 09/34 06/27 05/25 11/64* 06/35 05/36 06/46 05/41 07/88*
20. Public transport 10/29 08/30 10/45* 05/25* 04/23 06/35 07/50 06/46 04/33 03/37
21. Finances 09/26 10/38* 06/27 05/25 05/29 05/29 05/36 05/38 04/30 03/37
22. House maintenance 07/20 04/15 03/14 02/10 06/35 03/17 01/07 07/53* 03/23 03/33
Bonferroni Corrected * p0.00022 = 0.05/231.
Note: The Fisher exact test of statistical significance is affected by both the rate of independence and the rate of dependence in a particular pair of ADL and IADL
skills though only the rate of independence is included in Table 2. At the top and the bottom of the hierarchy the number of persons who may or may not be able
to perform a particular ADL and IADL skill is small (e.g., only 16 clients are incontinent in the sample). This combined with the number of tests conducted and the
resulting magnitude of the Bonferroni Corrected *p0.00022 = 0.05/231 resulted in many of the Fisher exact tests being non-significant where visual inspects
suggests the presence of a relationship between the skills.
Table 3. The co-occurrence of functional skill independence in 100 community dwelling individuals with moderate to severe TBI with Bonferroni corrected
Functional skills
1. Telephone use 77/93* 73/91 69/100* 63/97 58/98* 50/96 47/95 44/100* 38/97 34/97
2. Continence 77/92* 74/92* 66/96 64/98* 59/100* 52/100* 49/100* 44/100* 39/100* 35/100
3. Eating 73/87 74/89* 64/93 63/97* 52/88 48/92 44/89 40/91 36/92 34/97
4. Outdoor mobility 69/82* 66/79 64/80 61/94* 50/84 45/86 45/91* 42/95* 37/95* 32/91
5. Indoor mobility 63/75 64/77* 63/79* 61/88* 49/83* 45/86* 41/84* 40/91 35/90* 30/86
6. Oral care 58/69* 59/71* 52/65 50/72 49/75* 49/94* 46/93* 43/98* 36/92* 29/83
7. Showering 50/59 52/62* 48/60 45/65 45/69* 49/83* 43/88* 38/86* 31/79* 27/77
8. Dressing 47/56 49/59* 44/55 45/65* 41/63 46/78* 43/82* 40/91* 33/85* 27/77*
9. Nail care 44/52* 44/53* 40/50 42/60* 40/61* 43/73* 38/73* 40/81* 32/82* 24/68
10. Street crossing 38/45 39/46* 36/45 37/53* 35/54* 36/61* 31/60* 33/67* 32/73* 25/71*
11. Med management 34/36 35/42 34/42 32/46 30/46 29/49 27/52 27/55* 24/54 25/64*
12. Health maintenance 34/36 34/40 33/41 30/43 28/43 30/51* 29/56* 26/53 25/57* 23/59* 19/54
13. Shopping 25/30 24/28 22/27 21/30 18/28 22/37 19/36 18/36 16/36 17/43 14/40
14. Route finding 22/26 22/26 20/25 21/30 20/31 22/37* 19/36 18/36 18/41* 21/54* 14/40
15. Driving 19/22 20/24 18/22 18/28 18/27 16/31 16/32 16/32 15/34 17/33* 13/37
16. Room tidy 17/20 17/20 17/21 16/23 15/23 16/27 16/31* 17/34* 15/34* 13/33 13/37
17. Meal preparation 17/20 17/20 17/21 16/23 13/20 16/27 14/27 15/30 14/32 13/33 10/28
18. Community skills 14/16 14/17 14/17 13/19 10/15 13/22 12/23 12/24 11/25 12/31 10/28
19. Laundry/Housework 13/15 13/16 12/15 13/19 13/20 13/22 13/25 13/26* 13/29* 11/28 12/34*
20. Public transport 13/15 13/16 12/15 13/19 12/18 13/22 12/23 10/20 12/27 10/26 08/23
21. Finances 12/14 11/13 11/14 10/14 08/12 10/17 09/17 09/18 07/16 09/23 08/23
22. House maintenance 08/09 08/09 07/08 08/12 08/12 07/11 07/14 07/16 07/15 06/20 07/20
Bonferroni corrected *p0.00022 = 0.05/231. (continued).
than those clients who are able to perform IADL was supported.
Severity of injury did not differentiate between those who were or
were not independent in IADL.
We interpret the data as suggesting that the key distinction
between the ADL and IADL functions is not complexityper se,
but rather the necessity for planning, in-the-moment problem-
solving, and decision-making. Many ADL can be accomplished
in a highly routine manner where one step follows another in an
invariant sequence. During IADL tasks the client needs to use
executive functions to adapt responses to novelty and changing
environmental demands. Although IADL tasks can become
easier with practice, because of the need for novel problem-
solving, they do not become fully automatic (30,31).
Individuals, who lack insight and are poor at recognizing that
they might experience difficulty with task performance, are
unlikely to use compensatory strategies. The data presented in
Table 3 allow the clinician a method to identify inconsistencies
in a clients pattern of skills, which need to be explained with
reference to the clients particular circumstances or addressed in
a more systematic way. Clients with impaired executive func-
tioning may be unable to generate ways to work around their
cognitive or physical impairments and may need others to do
this for them. For example, one of our early reports (32)
described a 23-year-old male with a very severe injury who
received 12 months of intensive in-patient rehabilitation. At
25-month post-injury, he could manage his personal finances,
but could not bathe or dress due to a combination of physical
skills (lower extremity hypertonicity, and contractures) and
executive function deficits. The application of a structured bath-
ing and dressing retraining program resulted in independence
after only 11 days of treatment (32). Conversely, based on our
findings, we hypothesize that, if after sufficient training, a client
is unable to manage the problem-solving required for indepen-
dence in an IADL task, it is unlikely that the client will be able to
learn to perform tasks that have greater problem-solving
demands (20). What seems to be required is to reduce the on-
the-spot decision-making requirements so the task becomes
invariant. At the core of decisions about rehabilitation is the
recognition that some activities require novel problem-solving
and some do not. For ADL, the therapists role is to perform a
task analysis and construct a procedure the client can carry out
successfully (32,33). Learning can then take place via the repeti-
tive enactment of behavior chains using errorless learning pro-
cedures (30,3235). This is not possible for IADL that require a
response to novelty and changing task and environmental
demands. Independence in such tasks may be more achievable
client has the ability to make use of this type of intervention (20).
Clearly these ideas are conjectural and based on a combi-
nation of our data and clinical experience. Further work is
required to establish their general validity. At present we can
simply say that, within this sample of 100 community dwell-
ing individuals with moderate to severe TBI, independence in
ADL and IADL skills was hierarchically organized, albeit
imperfectly. The conceptual distinction between ADL and
IADL skills is supported by the data and corresponds to
observations of the everyday performance of individuals
with moderate to severe TBI. Level of awareness was asso-
ciated with IADL independence.
The study sample consisted of clients who had sustained a
moderate to severe TBI who were receiving case management,
and may not be representative of the wider population of indi-
viduals with moderate to severe TBI. We were not able to explore
the effects of age, gender, or ethnicity of participants, although
there is little evidence that these variables are significant pre-
dictors of outcome in the post-acute period (36). Despite an
overall sample size of 100, for some 2 × 2 comparisons, sample
sizes were small. Results are entirely dependent on the specific
definition of independence used in the ABCCS definitions of the
22 ADL/IADL items. For example, shopping independence on
the ABCCS requires that a client is able to shop for items that
typically require planning and problem-solving (e.g., major
appliances, furniture: see Appendix A). Additionally, there are
many factors that may affect an individualsengagementin
ADL/IADL that are not addressed here. Mood and motivational
factors, as well as personal choice, may all affect activity engage-
ment. Our data did not include details of the clientsprevious
rehabilitation services, and whether, for instance, the current
results might have been achieved because of a selective focus
on teaching ADL, rather than IADL skills. The current results
will need to be validated in a prospective study with a larger
sample size.
We would like to thank the following organizations and individuals for
their contributions to data collection: Anglia Case Management, Ben
Holden, Brain Injury Case Management, Bush and Co, Care For Life,
Case Management Services, Coochi, Debbie Eaton Case Management
Limited, Family Focused Case Management Limited, Head First,
Medico Rehab Limited, Independent Case Management, Independent
Case Management Services, Jacky Parker and Associates, Maggie
Sargent and Associates, N-Able, The Rehabilitation Partnership, RT
Disability and West Country Case Management.
Table 4. Exploratory factor analysis loadings for functional skills.
Functional skill Factor 1 Factor 2
Indoor mobility 0.94 0.06
Laundry/housework 0.87 0.39
Nail care 0.85 0.39
Outdoor mobility 0.84 0.21
House maintenance 0.84 0.08
Continence 0.82 0.56
Dress 0.77 0.43
Shower 0.76 0.43
Room tidy 0.73 0.39
Oral care 0.70 0.58
Phone use 0.68 0.65
Med management 0.65 0.39
Street crossing 0.64 0.59
Eating 0.48 0.46
Public transport 0.55 0.58
Health maintenance 0.53 0.66
Route finding 0.51 0.62
Driving 0.42 0.45
Meal preparation 0.34 0.76
Community skills 0.23 0.90
Finances 0.11 0.76
Shopping 0.03 0.79
Note. In this table, a loading threshold of 0.40 is used. Grey cells signify that the
loading is above the 0.40 threshold
Disclosure statement
Jo Clark-Wilson, Stephanie Seymour, Ross Tasker, and Mark Holloway
are managing partner, employees, or contractors with Head First, a case
management company in Kent, UK. There are no other declarations of
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Appendix A. ABCCS definitions of independence
ABCCs Scale
independent Definition of independence
Phone use 84 Makes and receives calls with land-line telephone independently
Continence 83 Is fully continent of bowel and bladder or manages own incontinence independently
Eating and drinking safely 80 Eats and drinks safely and independently
Outdoor mobility 72 Walks or uses wheel chair sufficiently well to travel in the local community independently
Indoor mobility 67 Walks indoors safely and independently (with or without an assistive device)
Oral care 59 Initiates and completes oral hygiene independently
Bathing/Shower 52 Initiates and completes bathing/showering independently
Dressing 49 Completely dresses self independently and changes clothes regularly
Nail care 44 Initiates and performs nail care independently
Street crossing 39 Is believed to be at no more than normal risk when street crossing
Medication management 35 Receives no routinely prescribed medication or manages own medication and can obtain prescriptions and have
prescriptions filled without help or reminders
Health management 34 Manages own minor ailments (e.g., colds) independently and knows when to seek medical assistance
Shopping 27 Makes major purchases requiring planning (e.g., buys own shoes, furniture etc.)
Route finding 22 Travels to novel destinations in the local community independently
Driving 20 Drives a car and is believed to be at no more than normal risk
Room tidying 17 Keeps household clean and tidy without reminders
Meal preparation 17 Plans and prepares complex meals (multistep multi-item) can use the stove top (hob) and oven safely and
Community tasks 14 Completes multiple novel community tasks each day (e.g., tasks are not purely routine, but involve different
places, people, shops, etc.)
Laundry/housework 13 Completes own laundry/ housework independently (includes washing dishes, household cleaning, and taking out
the trash/rubbish)
Public transport 13 Usesa public transport (e.g., railway, bus, taxis) on unfamiliar journeys independently
Finances 12 Handles own finances (uses banking facilities, pays own bills, etc.) independently
Household maintenance 8 Able to perform household maintenance activities independently (e.g., gardening, simple household repairs,
decorating, etc.)
Appendix B.
Appendix B (Tables 5 and 6)provideexamplesofhowTable 3 was
developed using 2 × 2 tables. The independence rate is the number
of clients who are independent in skill A and independent in skill B
divided by the total number of clients who are independent in skill
independent in skill B who are also independent in skill A. In
Table 5,thefirst2×2tableLaundry/Housework is the predictor
skill and Street Crossing is the associated skill and the Fishersexact
probability test pvalue with the Bonferroni correction is non-sig-
nificant. In Table 6,the2×2tableRoom Tidying is the predictor
skill and Dressing is the associated skill and the Fishersexactprob-
ability test pvalue with the Bonferroni correction is significant.
Visual inspection of the frequency with which clients are indepen-
dent however suggests that individuals who are independent in doing
Laundry/Housework arelikelytobeindependentinStreet crossing
and individuals who are independent in Room tidying are likely to be
independent in Dressing.
Fishers exact probability test (two-tailed) was calculated with
Bonferroni correction for each 2 × 2 contingency table. In understanding
the Fishers exact probability test, it should be recognized that the test is
influenced by differential rates of both independence and dependence
between the predictor and the associated variable. The pvalues of the
tests are also provided in Table 3.
Table 5. Two-by-two contingency table for the functional skills of laundry/housework and street crossing.
Associated skill: street crossing
Condition present: independence
(Can cross the street)
Condition absent: dependence
(Cannot cross the street) TOTAL
Predictor skill:
(Can do laundry/housework)
11 2 13
(Cannot do laundry/housework)
28 59 87
Total 39 61 100
Table 6. Two-by-two contingency table for room tidying and dressing.
Associated skill:
Condition present:
(Can Dress)
Condition absent: Dependence
(Cannot dress) TOTAL
Predictor skill:
Room tidying
(Can tidy room)
17* 0 17
(Cannot tidy room)
32 51 83
Total 49 51 100
Bonferroni Corrected * p0.00022 = 0.05/231
... To assess other aspects of recovery after TBI, in addition to the Glasgow Outcome Scale Extended (GOS-E) and the Disability Rating Scale (DRS), which are already widely applied [16], some studies [17,18] analyzed the routine performance of these patients using the Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) scale. Describing ADL and IADL is relevant to document the different levels of independence and deficits in carrying out daily activities according to severity, especially in the first few months after TBI [19][20][21][22][23]. Hammond et al. showed that more than half of the 110 individuals with disorders of consciousness (i.e., coma, vegetative state, minimally conscious state) due to moderate and severe TBI achieved ADL independence one year after injury, with progressive improvements over a 10-year follow-up [22]. ...
... The institutional ethics committee (Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo, Brazil) approved the study and waived the need for patient informed consent. This study was carried out following the recommendations of the Declaration of Helsinki II [23]. ...
Full-text available
Objective: The presence of focal lesion (FL) after a severe traumatic brain injury is an important factor in determining morbidity and mortality. Despite this relevance, few studies show the pattern of recovery of patients with severe traumatic brain injury (TBI) with FL within one year. The objective of this study was to identify the pattern of recovery, independence to perform activities of daily living (ADL), and factors associated with mortality and unfavorable outcome at six and twelve months after severe TBI with FL. Methodology: This is a prospective cohort, with data collected at admission, hospital discharge, three, six, and twelve months after TBI. Results: The study included 131 adults with a mean age of 34.08 years. At twelve months, 39% of the participants died, 80% were functionally independent by the Glasgow Outcome Scale Extended, 79% by the Disability Rating Scale, 79% were independent for performing ADLs by the Katz Index, and 53.9% by the Lawton Scale. Report of alcohol intake, sedation time, length of stay in intensive care (ICU LOS), Glasgow Coma Scale, trauma severity indices, hyperglycemia, blood glucose, and infection were associated with death. At six and twelve months, tachypnea, age, ICU LOS, trauma severity indices, respiratory rate, multiple radiographic injuries, and cardiac rate were associated with dependence. Conclusions: Patients have satisfactory functional recovery up to twelve months after trauma, with an accentuated improvement in the first three months. Clinical and sociodemographic variables were associated with post-trauma outcomes. Almost all victims of severe TBI with focal lesions evolved to death or independence.
... Unawareness of motor deficits was documented in 28% of individuals with a history of cerebrovascular accident, whereas unawareness of cognitive deficits was documented in 72% of those with cerebrovascular accident (Gillen, 2009). Decreased insight into memory, executive function, and attention deficits have been shown to translate into poor judgment and safety (Skidmore et al., 2018), dysfunctional interpersonal relationships (Bivona et al., 2014;Chesnel et al., 2018), the inability to set realistic goals (Fleming et al., 1996;McPherson et al., 2009;Robertson & Schmitter-Edgecombe, 2015), poor compliance and participation in rehabilitation (Geytenbeek et al., 2017), and inadequate performance in instrumental activities of daily living (Giles et al., 2019). Research has shown that lack of self-awareness is also a common problem in individuals who suffer a moderate to severe traumatic brain injury (Robertson & Schmitter-Edgecombe, 2015;Sherer et al., 2003). ...
... Impaired awareness has been identified as a major factor in determining outcomes for traumatic brain injury survivors . If an individual has poor selfawareness of the difficulties they can potentially experience with task performance, he or she is unlikely to use compensatory strategies that would improve the success and safety of the task that is being performed (Giles et al., 2019). ...
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Background: The development of assessments that measure functional skills is a priority in the profession. Anticipatory awareness (i.e., the ability to anticipate the difficulties that might be experienced in daily life situations) is a critical skill in occupational performance. There is a lack of assessments measuring anticipatory awareness. The Occupational Therapy Anticipatory Awareness Test (OTAAT) is a performance-based assessment tool developed for individuals with neurological conditions. This study aimed to determine the tool’s content validity. Methods: We recruited five experts to review whether the test items are essential for assessment and calculated the Content Validity Ratio (CVR). Open-ended questions allowed opportunity to provide feedback for tool revision. Results: Ten of the 14 items of the OTAAT were preserved. Eight out of the 14 items were rated as essential for measurement. Two of the 10 items were identified as useful but not essential. Following discussion, review of supporting literature, and analysis of qualitative feedback, the two emergent awareness items were kept. Four items were removed (strategy implementation and awareness of strategy use subdomains), as these were deemed not essential. Conclusion: This study determined preliminary content validity of the OTAAT. Future research should focus on establishing construct validity and test reliability.
... Previous studies have identified cognitive process related to SA, especially executive functions (Bivona et al., 2019;Ciurli et al., 2010;Hart et al., 2005;Morton & Barker, 2010) and declarative memory (Noé et al., 2005;Zimmermann et al., 2017). Also, the relation between SA and functional independence has been described (Giles et al., 2019;Kelley et al., 2014;Ownsworth & Clare, 2006). Finally, some studies have even found associations between executive functions and declarative memory, and independence at instrumental ADL (Overdorp et al., 2016;Perna et al., 2012). ...
... In contrast, patients with declarative memory deficits and low SA would benefit more from directly intervening on their mnemonic difficulties, rather than aiming to increase their level of SA. According to our data, and considering declarative memory as a prerequisite for SA (Morris & Mograbi, 2013), rehabilitation-induced declarative memory enhancement would have a positive impact on SA that would be reflected in better functional independence (Giles et al., 2019;Kelley et al., 2014;Ownsworth & Clare, 2006; see also Villalobos et al., 2020a for a systematic review). ...
Full-text available
Objective: Impaired self-awareness (SA) is a common symptom after suffering acquired brain injury (ABI) which interferes with patient's rehabilitation and their functional independence. SA is associated with executive function and declarative memory, two cognitive functions that are related to participants' daily living functionality. Through this observational study, we aim to explore whether SA may play a moderator role in the relation between these two cognitive processes and functional independence. Method: A sample of 69 participants with ABI completed a neuropsychological assessment focused on executive function and declarative memory which also included a measure of SA and functional independence. Two separated linear models were performed including functional independence, SA, and two neuropsychological factors (declarative memory and executive function) derived from a previous principal component analysis. Results: Moderation analysis show a significant interaction between SA and executive function, reflecting an association between lower executive functioning and poorer functional outcome, only in participants with low levels of SA. Notwithstanding, declarative memory do not show a significant interaction with SA, even though higher declarative memory scores were associated with better functional independence. Conclusions: SA seems to play a moderator effect between executive function, but not declarative memory, and functional independence. Accordingly, participants with executive deficits and low levels of SA might benefit from receiving specific SA interventions in the first instance, which would in turn positively impact on their functional independence.
... Brain injuries are typically classified as mild, moderate, and severe based on the Glasgow Coma Scale (GCS; Teasdale & Jennett, 1974), while the consequences of such injury can range from shortterm loss of consciousness to coma or even death as a result of a traumatic event (Faul & Coronado, 2015). Several studies have confirmed that TBI can cause the impairment of cognitive, motor, emotional, and behavioural functions, subsequently affecting long-term independence and participation in many areas of daily life (Beadle, Ownsworth, Fleming & Shum, 2016;Douglas, 2020;Giles et al. 2019;Klepo, Sangster Jokić & Tršinski, 2020;Milders, 2019;Rapport, Hanks & Bryer, 2006;Tršinski, Tadinac, Bakran & Klepo, 2019;Watkin, Phillips & Radford, 2020). ...
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Family involvement is recognised as an important part of the rehabilitation process for individuals suffering from brain injuries. However, in an attempt to prevent the spread of COVID-19, healthcare institutions were obligated to implement visitor restrictions. The aim of this study was to understand the experiences of family members with respect to communication based on video calls with their close relatives who were suffering from brain injuries and undergoing inpatient rehabilitation during the pandemic. We included a purposive sample of 11 participants/family members who communicated consistently with their loved ones via video conferencing as part of the occupational therapy intervention. Qualitative data was collected using a semi-structured interview. Two independent researchers performed a thematic analysis based on the data inquiry method and highlightedthree main themes: (1) coping with a traumatic brain injury of a family member, (2) video conferencing experiences with a family member during rehabilitation, and (3) family resilience factors. Our study highlighted that there were changes in the daily lives of the family, as well as that family members had a strong emotional response due to the traumatic event and the inability to stay with the affected individuals in the hospital. Interactions via video conferencing proved to be significant for the participants since it provided them with an insight into the health condition of their family members, enabled their involvement in the rehabilitation process, and allowed them to monitor the recovery process. The above-mentioned factors also contributed to the resilience of participants. Our findings indicate the benefits of virtual communication and involving family members in the rehabilitation process, especially in situations where hospital visitation is impossible. Keywords: brain injury, inpatient rehabilitation, family resilience, COVID-19, video conferencing
... Individuals post ABI who often struggle with impairments to their executive skills are identified as more able to perform regular and unvarying activities of daily living than instrumental activities of daily living that require "online" thinking, idea generation, problem solving, decision making and planning (Giles et al., 2019). The concept of the support an individual requires is therefore considerably broader than in standard care services and is sometimes referred to as "scaffolding" around an individual; supporting that person to act rather than acting on their behalf (Vygotsky, 1978). ...
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Context: The Acquired Brain Injury (ABI) literature highlights various factors that can prevent successful community rehabilitation and hinder good long-term outcomes. Brain injury case management is a service model with the potential to overcome these barriers within rehabilitation and longer-term care and support, but there is minimal research surrounding the effectiveness of case management in ABI. Objectives: This study aims to gain a better understanding of outcomes in brain injury case management and what facilitates good outcomes when working with clients. Methods: Using a mixed qualitative approach using both conventional content analysis and thematic analysis, 28 Brain Injury Case Managers completed an online qualitative questionnaire about what constitutes a good outcome in brain injury case management. Of these, five took part in a follow-up interview. Findings: The analysis identified four themes related to brain injury case management outcomes; 1) A client-centred approach to outcome, 2) the role of the Brain Injury Case Manager, 3) Monitoring outcome in case management, and 4) Issues of funding. Limitations: Response rate to the survey and interviews was low due to recruiting during the COVID-19 pandemic. The study only included Brain Injury case mangers and future studies should consider including clients and family members perspectives. Outcome and brain injury case management Implications: This study identified that brain injury case management is a holistic approach to rehabilitation and case coordination that requires further attention. Appropriate holistic measures of quality of life and outcome need to be developed to support the evidence-base for case management.
... [71][72][73] In moderate-to-severe injuries, global cognitive decline can be observed, including impaired verbal learning and metacognition, which may be attributable to the vulnerability of the ventral frontal and medial temporal lobes during closed TBI. 74,75 Therefore, potential cognitive effects of medical cannabis are especially a concern for patients who have compromised cognitive functioning related to TBI history. ...
There is not a single pharmacological agent with demonstrated therapeutic efficacy for traumatic brain injury (TBI). With recent legalization efforts and the growing popularity of medical cannabis, patients with TBI will inevitably consider medical cannabis as a treatment option. Preclinical TBI research suggests cannabinoids have neuroprotective and psychotherapeutic properties. In contrast, recreational cannabis use has consistently shown to have detrimental effects. Our review identified a paucity of high-quality studies examining the beneficial and adverse effects of medical cannabis on traumatic brain injury, with only a single Phase III randomized control trial. However, observational studies demonstrate that TBI patients are using medical and recreational cannabis to treat their symptoms, highlighting inconsistencies between public policy, perception of potential efficacy, and the dearth of empirical evidence. We conclude that randomized controlled trials and prospective studies with appropriate control groups are necessary to fully understand the efficacy and potential adverse effects of medical cannabis for TBI.
... Because executive function is projected in the prefrontal cortex, which is sensitive to aging-related brain atrophy and traumatic brain injury (TBI), it would be interesting to know if the present findings can be applied to prevent or reverse the decline in prefrontal cortex functional activity and the ability of daily living of TBI patients (41). It is tempting to speculate that playing mahjong could stimulate activity and restore some of the lost functions of prefrontal cortex and thus improve the executive function and instrumental activities of daily living in TBI patients because improved social interactions are important for restoring executive function and instrumental activities of daily living in subjects with TBI (42). ...
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Background: Mild cognitive impairment (MCI) is common among elderly people. So far, effective treatment that can stabilize or reverse the cognitive decline associated with MCI is lacking. Recent studies suggest that playing mahjong may improve attention and memory in elderly people. However, its effect on executive function remains unknown.Methods: 56 elderly people (74.3 ± 4.3 years of age) with MCI from the First Social Welfare the First Nursing Home of Nanchong were randomized into mahjong and control groups (N = 28, each group). Subjects in the mahjong group played mahjong three times a week for 12 weeks, while people in the control group assumed normal daily activity. Executive function was evaluated using the Montreal Cognitive Assessment—Beijing (MoCA-B), the Shape Trail Test (STT), and the Functional Activities Questionnaire (FAQ) before the study and then at 6 and 12 weeks after mahjong administration.Results: There were no baseline differences in MoCA-B, STT, and FAQ scoring between the two groups. The MoCA-B, STT, and FAQ scores, however, improved significantly in the mahjong group but not in the control group after the 12-week mahjong administration. Significant correlations were also found between STT and FAQ scores.Conclusions: Playing Mahjong for 12 weeks improved the executive function of elderly people with MCI. Because Mahjong is a simple, low-cost entertainment activity, it could be widely applied to slow down or reverse the progression of cognitive decline in people with MCI, including those with traumatic brain injury.
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Kenevirin tıpta yeri
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We aimed to (1) apply cluster analysis techniques to mixed-type data (numerical and categorical) from baseline neuropsychological standard and widely used assessments of patients with acquired brain injury (ABI) (2) apply state-of-the-art cluster validity indexes (CVI) to assess their internal validity (3) study their external validity considering relevant aspects of ABI rehabilitation such as functional independence measure (FIM) in activities of daily life assessment (4) characterize the identified profiles by using demographic and clinically relevant variables and (5) extend the external validation of the obtained clusters to all cognitive rehabilitation tasks executed by the participants in a web-based cognitive rehabilitation platform (GNPT). We analyzed 1,107 patients with ABI, 58.1% traumatic brain injury (TBI), 21.8% stroke and 20.1% other ABIs (e.g., brain tumors, anoxia, infections) that have undergone inpatient GNPT cognitive rehabilitation from September 2008 to January 2021. We applied the k-prototypes algorithm from the clustMixType R package. We optimized seven CVIs and applied bootstrap resampling to assess clusters stability (fpc R package). Clusters' post hoc comparisons were performed using the Wilcoxon ranked test, paired t- test or Chi-square test when appropriate. We identified a three-clusters optimal solution, with strong stability (>0.85) and structure (e.g., Silhouette > 0.60, Gamma > 0.83), characterized by distinctive level of performance in all neuropsychological tests, demographics, FIM, response to GNPT tasks and tests normative data (e.g., the 3 min cut-off in Trail Making Test-B). Cluster 1 was characterized by severe cognitive impairment ( N = 254, 22.9%) the mean age was 47 years, 68.5% patients with TBI and 22% with stroke. Cluster 2 was characterized by mild cognitive impairment ( N = 376, 33.9%) mean age 54 years, 53.5% patients with stroke and 27% other ABI. Cluster 3, moderate cognitive impairment ( N = 477, 43.2%) mean age 33 years, 83% patients with TBI and 14% other ABI. Post hoc analysis on cognitive FIM supported a significant higher performance of Cluster 2 vs. Cluster 3 ( p < 0.001), Cluster 2 vs. Cluster 1 ( p < 0.001) and Cluster 3 vs. Cluster 1 ( p < 0.001). All patients executed 286,798 GNPT tasks, with performance significantly higher in Cluster 2 and 3 vs. Cluster 1 ( p < 0.001).
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Background: Inpatient rehabilitation with patients who have sustained an acquired brain injury (ABI), including traumatic brain injury (TBI), focuses on improving performance in activities of daily living (ADLs). Although not studied to date in patients with ABI/TBI, Task Analysis (TA) integrates assessment and the prompting/cueing levels required to complete various tasks, with the goal to achieve effective skill acquisition and rehabilitation planning. TA has demonstrated efficacy in teaching life skills in individuals with developmental disabilities and in this study is applied to teaching ADL skills in ABI/TBI rehabilitation. Primary objective: To validate the use of TA in measuring progress in teaching ADLs by comparing it with three common ADL measures: Functional Independence Measure, Barthel Index and Klein-Bell. Methods: Twenty-four inpatients were administered the Functional Independence Measure (FIM), Barthel Index (BI) and the Klein-Bell ADL Scale (KB) TA within 72 hours of admission, at 4 weeks and within 72 hours of discharge, for showering and dressing tasks. A repeated measures ANOVA compared scores across the four measures, at three time points, for both tasks. Conclusion: Concurrent validity of TA in measuring improvements in the ADL tasks was established. Improvements were associated with reductions in supervision and disability levels. TA was shown to be an effective evaluation and teaching strategy during rehabilitation, with demonstrated reductions in disability and supervision levels.
Background: Patients in posttraumatic amnesia (PTA) may receive limited rehabilitation due to the risk of overstimulation and agitation. This assumption has not been tested. Objective: To examine the relationship between agitated behavior and participation in therapy for retraining of activities of daily living (ADL) while in PTA. Setting: Inpatient rehabilitation center. Participants: A total of 104 participants with severe traumatic brain injury, admitted to rehabilitation, in PTA of more than 7 days. Intervention: ADL retraining during PTA followed errorless and procedural learning principles. Design: Group comparison and regression modeling of patient agitation data from a randomized controlled trial comparing ADL retraining in PTA (treatment) versus no ADL retraining in PTA (treatment as usual, TAU). Outcome measures: Agitation using the Agitated Behavior Scale. Therapy participation measured in minutes and missed sessions. Results: There were no group differences in agitated behavior (average scores, peak scores, or number of clinically agitated days) between the treatment and TAU groups. For treated patients, there was no significant relationship between agitation and therapy participation (therapy minutes or missed ADL treatment sessions). Conclusions: This study demonstrated that agitation is not increased by delivery of structured ADL retraining during PTA and agitation did not limit therapy participation. This supports the consideration of active therapy during PTA.
Objective: To assess the efficacy of Activities of Daily Living (ADL) retraining during posttraumatic amnesia (PTA), compared with ADL retraining commencing after emergence from PTA. Design: Randomised controlled trial. Setting: Inpatient rehabilitation centre. Participants: 104 participants with severe TBI, admitted to rehabilitation and remaining in PTA for > 7 days, were randomised to receive either treatment as usual (TAU) with daily ADL retraining (Treatment), or TAU alone (physiotherapy, necessary speech therapy), during PTA. Intervention: ADL retraining was manualised, followed errorless and procedural learning principles, and included individualised goals. Both groups received occupational therapy as usual following PTA. Outcome measures: Primary outcome was the Functional Independence Measure (FIM) completed at admission, PTA emergence, discharge, and 2-month follow-up. Secondary outcomes included length of rehabilitation inpatient stay, PTA duration, Agitated Behavior Scale scores, and Community Integration Questionnaire (CIQ) scores at follow-up. Groups did not significantly differ in baseline characteristics. Results: On the primary outcome, FIM total change, random effects regression revealed a significant interaction of group and time (p<0.01). The treatment group had greater improvement in FIM scores from baseline to PTA emergence, maintained at discharge, although not at follow-up. Twenty-seven percent more of the treatment group reliably changed on FIM scores at PTA emergence. Group differences in length of stay, PTA duration, agitation, and CIQ scores were not significant; however, TAU trended toward longer length of stay and PTA duration. Conclusion: Individuals in PTA can benefit from skill retraining.
Objective: To investigate the relationship between deficits associated with traumatic brain injury (TBI) and case management (CM) and care/support (CS) in two UK community samples. Research design: Prospective descriptive study. Method: Case managers across the UK and from a single UK CM service contributed client profiles to two data sets (Groups 1 and 2, respectively). Data were entered on demographics, injury severity, functional skills, functional-cognition (including executive functions), behaviour and CM and CS hours. Relationships were explored between areas of disability and service provision. Results: Clients in Group 2 were more severely injured, longer post-injury and had less family support than clients in Group 1. There were few significant differences between Groups 1 and 2 on measures of Functionalskill, Functional-cognition and Behaviour disorder. Deficits in Functionalskills were associated with CS, but not CM. Deficits in measures of executive functions (impulsivity, predictability, response to direction) were related to CM, but not to CS. Insight was related to both CM and CS. Variables related to behaviour disorder were related to CM, but were less often correlated to CS. Conclusions: The need for community support is related not only to Functionalskills (CS), but also to behaviour disorder, self-regulatory skills and impaired insight (CM).
The third edition of the Framework, available online at, reflects internal and external changes to occupational therapy practice, emerging concepts, and advances in the field.