1. Re-entering the community after traumatic brain injury: Effective interventions for the military Sarah Tucker, OTS

2. Objectives  Ascertain incidence rates of military members with TBI, along with its related costs  Investigate the effectiveness of cognitive interventions to improve community integration among returning military members  Identify areas for future research

3. Incidence rates From 2000 through 2011, a total of 235,046 service members were diagnosed with a TBI Vast majority were classified as mild

4. Percentage of U.S. Military Service Members Diagnosed with a TBI, by TBI Severity, 2000-2011 Penetrating 1.6% Severe 1.0%

5. Estimated cost of TBI  Inpatient rehabilitation: $1.9 million  Outpatient rehabilitation: $377,000 to $907,000  Unemployment: $13 million  Reduced wages: $1.2 million

6. The Role of Occupational Therapy OT and service member Establish/Restore Modify Prevent

7. Research Method  Searched databases including Academic Search Premier (EBSCO), CINAHL, MEDLINE, the Military and Government Collection, PsycARTICLES, PscyINFO.  Searched in American Journal of Occupational Therapy, British Journal of Occupational Therapy, and Canadian Journal of Occupational Therapy  Search terms included “mild traumatic brain injury”, “errorless learning”, “attention and TBI” “problem solving and TBI,” “cognitive interventions”

8. Cognitive Interventions

9. Attention  No standard definition of attention  Similar measures have been used to study varying forms of attention

10. Attention Evidence is mixed regarding the usefulness of drills and structured practice to improve attention (Rees, Marshall, Hartridge, Mackie, & Weiser, 2007; Helmick, 2010) Difficult to separate practice effects for any type of intervention or spontaneous recovery from treatment effects

11. Attention Process Training (APT)  Developed by Sohlberg and Mateer  Drill training focused on sustained, selective, alternating, and divided attention increasing in complexity over time  Current version is computer-based (APT-3)

12. Attention Process Training (APT)  Overall, studies showed modest gains at best, and these gains were not generalized outside the program (Zickefoose et al., 2013; Sohlberg et al., 2000; Park, Proulx & Towers, 1999).  Currently, there is not enough evidence to demonstrate APT’s effect is statistically significant outside of practice effects

13. Learning  One of the most studied methods to improve learning is errorless learning (EL)  Found to be most effective when used to improve memory impairment among those with severe ABI (Clare & Jones, 2008)

14. Errorless Learning & Opportunities for Occupational Therapy

15. Metacognitive functions  Self-awareness, problem-solving, goal setting

16. Self-awareness  Cheng & Mann (2006) found that both an Awareness Intervention Program and conventional rehab were equally effective

17. Goal Management Training (GMT)  Early studies did not focus on real-world tasks (Levine et al., 2000)  More recent studies have found GMT effective in managing patient selected goals and financial management  A recent systematic review cites GMT as effective in combination with problem-solving, external cues, and practice outside of therapy for generalization

18. Future research and practice  APT-3  Mild TBI  GMT and problem-solving  Align future studies with returning soldiers’ concerns  Identify the needs of veterans with TBI as they age

19. References American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62,625–683. Campbell, L., Wilson, F. C., McCann, J., Kernahan, G. & Rogers, R. G. (2007). Single case experimental design study of carer facilitated errorless learning in a patient with severe memory impairment following TBI. NeuroRehabilitation, 22, 325-333. The CDC, NIH, DoD, and VA Leadership Panel. Report to Congress on Traumatic Brain Injury in the United States: Understanding the Public Health Problem among Current and Former Military Personnel. Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), the Department of Defense (DoD), and the Department of Veterans Affairs (VA). 2013. Cheng, S. K. W. & Man, D. W. K. (2006). Management of impaired self-awareness in persons with traumatic brain injury. Brain Injury, 20(6), 621-628. Cicerone, K., Levin, H., Malec, J., Stuss, D., & Whyte, J. (2006), Cognitive rehabilitation interventions for executive function: Moving from bench to bedside in patients with traumatic brain injury. Journal of Cognitive Neuroscience, 18(7), 1212-1222. Clare, L. & Jones, R. S. (2008). Errorless learning in the rehabilitation of memory impairment: A critical review. Neuropsychology Review, 18, 1-23. doi: 10.1007/s11065-008-9051-4 Grant, M., Ponsford, J., & Bennett, P. C. (2012). The application of Goal Management Training to aspects of financial management in individuals with traumatic brain injury. Neuropsychological Rehabilitation, 22(6), 852-873. Helmick, K. (2010). Cognitive rehabilitation for military personnel with mild traumatic brain injury and chronic post-concussional disorder: Results of April 2009 consensus conference. NeuroRehabilitation, 26, 239-255.

20. References Kim, H. & Colantonio, A. (2010). Effectiveness of rehabilitation in enhancing community integration after acute traumatic brain injury: A systematic review. The American Journal of Occupational Therapy, 64(5), 709- 719. Lash & Associates Publishing/Training Inc. (2009). Attention Process Training. Retrieved from http://www.lapublishing.com/apt-attention-process-training/ http://www.lapublishing.com/apt-attention-process-training/ Levine, B., Robertsion, I. H., Clare, L., Carter, G., Hong, J., Wilson, B. A.,... & Stuss, D. T. (2000). Rehabilitation of executive functioning: An experimental clinical validation of Goal Management Training. Journal of the International Neuropsychological Society, 6, 299-312. Lloyd, J., Riley, G. A., & Powell, T. E. (2009). Errorless learning of novel routes through a virtual town in people with acquired brain injury. Neuropsychological Rehabilitation, 19(1), 98-109. Marshall, R.C., Karow, C. M., Morelli, C.A., Iden, K.K., Dixon, J., & Cranfill T. B. (2004). Effects of interactive strategy modelling training on problem-solving by persons with traumatic brain injury. Aphasiology, 18, 659-673. doi:10.1080/02687030444000237 McPherson, K. M., Kayes, N., & Weatherall, M. (2009). A pilot study of self-regulation informed goal setting in people with traumatic brain injury. Clinical Rehabilitation, 23, 296-309. Pacini-Krasny, A., Chevignard, M., & Evans, J. (2014). Goal Management Training for rehabilitation of executive functions: a systematic review of effectiveness in patients with acquired brain injury. Disability and Rehabiliation, 36(2), 105-116. doi: 10.3109/09638288.2013.777807.

21. References Plach, H. L., & Sells, C. H. (2013). Occupational performance needs of young veterans. American Journal of Occupational Therapy, 67, 73–81. http://dx.doi.org/10.5014/ajot.2013.003871http://dx.doi.org/10.5014/ajot.2013.003871 Rees, L., Marshall, S., Hartridge, C., Mackie, D., & Weiser, M. (2007). Cognitive interventions post acquired brain injury. Brain Injury, 21(2), 161-200. Sohlberg, M. M., McLaughlin, K. A., Pavese1, A., Heidrich, A., & Posner, M. I. (2000). Evaluation of Attention Process Training and brain injury education in persons with acquired brain injury. Thickpenny-Davis, K. L., & Barker-Collo, S. L. (2007). Evaluation of a structured group format memory rehabilitation program following brain injury. Journal of Head Trauma Rehabilitation, 22, 303-313. Zickefoose, S., Hux, K., Brown, J., & Wolf K. (2013). Let the games begin: A preliminary study using Attention Process Training-3 and Lumosity ™ brain games to remediate attention deficits following traumatic brain injury. Brain Injury, (27)6, 707-716. doi: 10.3109/02699052.2013.775484