New York University School of Medicine
Rehabilitation Medicine
Sixty higher-level outpatients with traumatic brain injury (TBI), all at least 1 year post-injury, were randomly assigned to either conventional group neuropsychological rehabilitation or an innovative group treatment focused on the... more
Sixty higher-level outpatients with traumatic brain injury (TBI), all at least 1 year post-injury, were randomly assigned to either conventional group neuropsychological rehabilitation or an innovative group treatment focused on the treatment of problem-solving deficits. Incorporating strategies for addressing underlying emotional self-regulation and logical thinking/reasoning deficits, the innovative treatment is unique in its attention to both motivational, attitudinal, and affective processes and problem-solving skills in persons with TBI. Participants in the innovative group improved in problem solving as assessed using a variety of measures, including (1) executive function, (2) problem-solving self-appraisal, (3) self-appraised emotional self-regulation and clear thinking, and (4) objective observer ratings of roleplayed scenarios. These improvements were maintained at follow-up. Baseline performance on timed attention tasks was related to improvement; individuals who processed the most slowly benefited the most. These participants did not show improvements on timed attention tasks, but did improve on problem-solving measures. Such findings are consistent with successful compensatory strategy use-the person may still have deficits and symptoms, but now has effective strategies for reducing their impact on daily functioning.
To enhance understanding of the role that social problem solving (SPS) plays in community integration following traumatic brain injury (TBI). Study Design: Regression analysis. Participants: Forty-five adults with TBI participating in... more
To enhance understanding of the role that social problem solving (SPS) plays in community integration following traumatic brain injury (TBI). Study Design: Regression analysis. Participants: Forty-five adults with TBI participating in higher level outpatient cognitive rehabilitation and 15 uninjured adults. Main Outcome Measures: Measures of community integration, problem-solving ability, and SPS self-appraisal and performance. Results: Individuals with TBI demonstrated poorer problem-solving as measured by both neuropsychological and SPS methods; however, the largest effect size was observed for SPS self-appraisal. Only SPS self-appraisal predicted a significant proportion of the variance in community integration. Conclusions: It is important to assess brain-injured persons' confidence in their ability to cope with problems. A focus on objective test scores alone may lead to underdetection of disabling problem-solving deficits.
Three inter-related studies examine the construct of problem solving as it relates to the assessment of deficits in higher level outpatients with traumatic brain injury (TBI). Sixty-one persons with TBI and 58 uninjured participants... more
Three inter-related studies examine the construct of problem solving as it relates to the assessment of deficits in higher level outpatients with traumatic brain injury (TBI). Sixty-one persons with TBI and 58 uninjured participants completed measures of problem solving and conceptually related constructs, which included neuropsychological tests, self-report inventories, and roleplayed scenarios. In Study I, TBI and control groups performed with no significant differences on measures of memory, reasoning, and executive function, but medium to large between-group differences were found on timed attention tasks. The largest between-group differences were found on psychosocial and problem-solving self-report inventories. In Study II, significant-other (SO) ratings of patient functioning were consistent with patient self-report, and for both self-report and SO ratings of patient problem solving, there was a theoretically meaningful pattern of correlations with timed attention tasks. In Study III, a combination of self-report inventories that accurately distinguished between participants with and without TBI, even when cognitive tests scores were in the normal range, was determined. The findings reflect intrinsic differences in measurement approaches to the construct of problem solving and suggest the importance of using a multidimensional approach to assessment.
Objective: To compare the relative utility of conventional neuropsychological and social problem-solving approaches to measuring functional problem solving deficits in individuals with acquired brain damage (ABD). Design: In Study I,... more
Objective: To compare the relative utility of conventional neuropsychological and social problem-solving approaches to measuring functional problem solving deficits in individuals with acquired brain damage (ABD). Design: In Study I, scores for individuals with ABD were compared to scores for control and normative samples. In Study II, pre- and posttest scores were compared for individuals with ABD who completed a program of outpatient cognitive rehabilitation. Participants: In Study I, individuals with
ABD were compared to healthy controls. In Study II, pre- and posttreatment assessments were obtained for 34 individuals with ABD. Main Outcome Measures: Two approaches were used, conventional neuropsychological
(WAIS-R/II Comprehension subtest and Wisconsin Card Sorting Test) and social problem solving (Problem Solving Inventory and Rusk Problem Solving Role Play Test). Results: In Study I, the ABD group demonstrated significant deficits on both social problem solving measures; however, neither
conventional neuropsychological measure detected significant deficits in the ABD group, relative to control
and normative groups. In Study II, significant treatment gains were demonstrated on both social problem-solving measures, however neither conventional neuropsychological measure was sensitive to improvements in functional problem-solving ability. Conclusions: In higher-level cognitive rehabilitation
settings, the evaluation of functional problem-solving deficits in individuals with ABD can be facilitated by
augmenting neuropsychological test data with results from social problem-solving measures.
ABD were compared to healthy controls. In Study II, pre- and posttreatment assessments were obtained for 34 individuals with ABD. Main Outcome Measures: Two approaches were used, conventional neuropsychological
(WAIS-R/II Comprehension subtest and Wisconsin Card Sorting Test) and social problem solving (Problem Solving Inventory and Rusk Problem Solving Role Play Test). Results: In Study I, the ABD group demonstrated significant deficits on both social problem solving measures; however, neither
conventional neuropsychological measure detected significant deficits in the ABD group, relative to control
and normative groups. In Study II, significant treatment gains were demonstrated on both social problem-solving measures, however neither conventional neuropsychological measure was sensitive to improvements in functional problem-solving ability. Conclusions: In higher-level cognitive rehabilitation
settings, the evaluation of functional problem-solving deficits in individuals with ABD can be facilitated by
augmenting neuropsychological test data with results from social problem-solving measures.
The current article describes critical issues in adapting traditional group-treatment methods for working with individuals with reduced cognitive capacity secondary to acquired brain injury. Using the classification system based on... more
The current article describes critical issues in adapting traditional group-treatment methods for working with individuals with reduced cognitive capacity secondary to acquired brain injury. Using the classification system based on functional ability developed at the NYU Rusk Institute of Rehabilitation Medicine (RIRM), we delineate the cognitive and interpersonal capabilities that differentiate group-participation capacity.
Abstract Rehabilitation psychology depends upon a broad theoretical base incorporating frameworks, theories, models, and methodologies from many different areas of psychology, as well as from other professions invested in the health and... more
Abstract Rehabilitation psychology depends upon a broad theoretical base incorporating frameworks, theories, models, and methodologies from many different areas of psychology, as well as from other professions invested in the health and rehabilitation of persons living with disabilities and chronic health conditions.
Objective: To introduce an approach to remediating problemsolving deficits in outpatients with moderate-to-severe cognitive impairments due to acquired brain damage. Design: Randomized clinical trial (RCT). Setting: Outpatient... more
Objective: To introduce an approach to remediating problemsolving deficits in outpatients with moderate-to-severe cognitive impairments due to acquired brain damage. Design: Randomized clinical trial (RCT). Setting: Outpatient hospital-based rehabilitation facility. Participants: 46 outpatients with mild-to-moderate cognitive impairments completed group treatment. 120 outpatients with moderate-tosevere impairments are being recruited for individual treatment. Interventions: After training in emotional self-regulation strategies, participants are taught a step-by-step template to assess problem situations in a structured, systematic manner. A unique element is the introduction of "clear-thinking questions" designed to teach participants to compensate for deficits in reasoning skills by "thinking their way through" problematic situations. Main Outcome Measures: Executive-function tests, problem-solving self-appraisal, self-reported clear-thinking skills, and objective observer ratings of role-played scenarios. Results: In the completed group-treatment RCT, participants improved on clear thinking and related measures. Illustrative case examples of methods and initial outcomes for individual treatment study will be provided. Conclusions: Based on a previously supported group treatment for mild-to-moderate impairments following acquired brain damage, our methods, currently being evaluated in an RCT funded by the National Institutes of Health, have the potential to improve outcomes for those with moderate-to-severe impairments.
Objective: The goal of this paper is to illustrate how the lessons learned in over 20 years of randomized clinical trials have advanced cognitive rehabilitation beyond traditional approaches to problem solving by more explicitly... more
Objective: The goal of this paper is to illustrate how the lessons learned in over 20 years of randomized clinical trials have advanced cognitive rehabilitation beyond traditional approaches to problem solving by more explicitly integrating subjective self-appraisal factors in routine clinical practice. Results: The concept of problem orientation, as proposed by cognitive-behavioral psychologists, provides a much-needed framework for conceptualizing interventions to address the impact of subjective experience on cognitive functioning, within the context of cognitive remediation. By explicitly focusing on the beliefs, assumptions, and expectations that individuals with acquired brain injury have about their own cognitive functioning, the concept of problem orientation allows rehabilitation psychologists to add an element to interventions, not systematically addressed in standard approaches to cognitive remediation. Targeting objective deficits in cognitive remediation is necessary, but not sufficient: For optimal benefit, remedial interventions must address objective cognitive deficits and the patient's subjective experience of such deficits in tandem. Conclusion: Contemporary evidence-based treatment recommendations now typically include incorporating interventions to address motivational, attitudinal, and affective factors in cognitive remediation. Further research is needed to directly compare the effectiveness of cognitive rehabilitative interventions that systematically address subjective factors with those that do not.
As one of the oldest psychology specialties active in interdisciplinary medical centers and health and public policy, rehabilitation psychology focuses on the optimal adjustment of individuals with disabilities, their families, and... more
As one of the oldest psychology specialties active in interdisciplinary medical centers and health and public policy, rehabilitation psychology focuses on the optimal adjustment of individuals with disabilities, their families, and
primary support systems. The wide array of circumstances confronting individuals with disabilities demands a
broad skill set and flexibility in the rehabilitation psychologist’s approach. Throughout its 50-year history, the field has been shaped and informed by theory and research drawn from other academic and practice areas of
psychology including social, clinical, and counseling psychology, rehabilitation counseling, behavioral
neuroscience, and neuropsychology. This rich heritage contributes to the specialty’s resilience and potential to
address current challenges facing American health care, including the aging of the baby boom generation and the
unprecedented numbers of wounded veterans returning to society with injuries that may require life-long services.
primary support systems. The wide array of circumstances confronting individuals with disabilities demands a
broad skill set and flexibility in the rehabilitation psychologist’s approach. Throughout its 50-year history, the field has been shaped and informed by theory and research drawn from other academic and practice areas of
psychology including social, clinical, and counseling psychology, rehabilitation counseling, behavioral
neuroscience, and neuropsychology. This rich heritage contributes to the specialty’s resilience and potential to
address current challenges facing American health care, including the aging of the baby boom generation and the
unprecedented numbers of wounded veterans returning to society with injuries that may require life-long services.
Objective: Cognitive and emotional symptoms are primary causes of long-term functional impairment after acquired brain injury (ABI). Although the occurrence of post-ABI emotional difficulties is well-documented, most investigators have... more
Objective: Cognitive and emotional symptoms are primary causes of long-term functional impairment after acquired brain injury (ABI). Although the occurrence of post-ABI emotional difficulties is well-documented, most investigators have focused on the impact of depression on functioning after ABI,
with few examining the role of anxiety. Knowledge of the latter’s impact is essential for optimal treatment planning in neurorehabilitation settings. The purpose of the present study is therefore to examine the predictive relationships between cognition, anxiety, and functional impairment in an ABI
sample. Method: Multiple regression analyses were conducted with a sample of 54 outpatients with ABI. Predictors selected from an archival data set included standardized neuropsychological measures and Beck Anxiety Inventory scores. Dependent variables were caregiver ratings of functional impairments in the Affective/Behavioral, Cognitive, and Physical/Dependency domains. Results: Anxiety predicted a
significant proportion of the variance in caregiver-assessed real-life affective/behavioral and cognitive functioning. In contrast, objective neuropsychological test scores did not contribute to the variance in functional impairment. Neither anxiety nor neuropsychological test scores significantly predicted impairment in everyday physical/dependency function. Conclusion: These findings support the role of anxiety in influencing functional outcome post-ABI and suggest the necessity of addressing symptoms of anxiety as an essential component of treatment in outpatient neurorehabilitation.
with few examining the role of anxiety. Knowledge of the latter’s impact is essential for optimal treatment planning in neurorehabilitation settings. The purpose of the present study is therefore to examine the predictive relationships between cognition, anxiety, and functional impairment in an ABI
sample. Method: Multiple regression analyses were conducted with a sample of 54 outpatients with ABI. Predictors selected from an archival data set included standardized neuropsychological measures and Beck Anxiety Inventory scores. Dependent variables were caregiver ratings of functional impairments in the Affective/Behavioral, Cognitive, and Physical/Dependency domains. Results: Anxiety predicted a
significant proportion of the variance in caregiver-assessed real-life affective/behavioral and cognitive functioning. In contrast, objective neuropsychological test scores did not contribute to the variance in functional impairment. Neither anxiety nor neuropsychological test scores significantly predicted impairment in everyday physical/dependency function. Conclusion: These findings support the role of anxiety in influencing functional outcome post-ABI and suggest the necessity of addressing symptoms of anxiety as an essential component of treatment in outpatient neurorehabilitation.
BACKGROUND: The field of positive psychology has grown exponentially within the last decade. To date, however, there have been few empirical initiatives to clarify the constructs within positive psychology as they relate to... more
BACKGROUND: The field of positive psychology has grown exponentially within the last decade. To date, however, there
have been few empirical initiatives to clarify the constructs within positive psychology as they relate to rehabilitation medicine.
Character strengths, and in particular resilience, following neurological trauma are clinically observable within rehabilitation
settings, and greater knowledge of the way in which these factors relate to treatment variables may allow for enhanced treatment
conceptualization and planning.
OBJECTIVE: The goal of this studywas to explore the relationships between positive psychology constructs (character strengths,
resilience, and positive mood) and rehabilitation-related variables (perceptions of functional ability post-injury and beliefs about
treatment) within a baseline data set, a six-month follow-up data set, and longitudinally across time points.
METHODS: Pearson correlations and supplementary multiple regression analyses were conducted within and across these time
points from a starting sample of thirty-nine individuals with acquired brain injury (ABI) in an outpatient rehabilitation program.
RESULTS: Positive psychology constructs were related to rehabilitation-related variables within the baseline data set, within the
follow-up data set, and longitudinally between baseline positive psychology variables and follow-up rehabilitation-related data.
CONCLUSIONS: These preliminary findings support relationships between character strengths, resilience, and positive mood
states with perceptions of functional ability and expectations of treatment, respectively, which are primary factors in treatment
success and quality of life outcomes in rehabilitation medicine settings. The results suggest the need for more research in this
area, with an ultimate goal of incorporating positive psychology constructs into rehabilitation conceptualization and treatment
planning.
have been few empirical initiatives to clarify the constructs within positive psychology as they relate to rehabilitation medicine.
Character strengths, and in particular resilience, following neurological trauma are clinically observable within rehabilitation
settings, and greater knowledge of the way in which these factors relate to treatment variables may allow for enhanced treatment
conceptualization and planning.
OBJECTIVE: The goal of this studywas to explore the relationships between positive psychology constructs (character strengths,
resilience, and positive mood) and rehabilitation-related variables (perceptions of functional ability post-injury and beliefs about
treatment) within a baseline data set, a six-month follow-up data set, and longitudinally across time points.
METHODS: Pearson correlations and supplementary multiple regression analyses were conducted within and across these time
points from a starting sample of thirty-nine individuals with acquired brain injury (ABI) in an outpatient rehabilitation program.
RESULTS: Positive psychology constructs were related to rehabilitation-related variables within the baseline data set, within the
follow-up data set, and longitudinally between baseline positive psychology variables and follow-up rehabilitation-related data.
CONCLUSIONS: These preliminary findings support relationships between character strengths, resilience, and positive mood
states with perceptions of functional ability and expectations of treatment, respectively, which are primary factors in treatment
success and quality of life outcomes in rehabilitation medicine settings. The results suggest the need for more research in this
area, with an ultimate goal of incorporating positive psychology constructs into rehabilitation conceptualization and treatment
planning.
In the 1930s, Babcock began a longitudinal study of syphilitic patients, a project that was less notable for its outcomes (many of which were not subsequently replicated) than for its methodology. Classic neurological studies from the... more
In the 1930s, Babcock began a longitudinal study of syphilitic patients, a project that was less notable for its outcomes (many of which were not subsequently replicated) than for its methodology. Classic neurological studies from the time of Paul Broca and Karl Wernicke were centered around clinical case observation. In a departure from this classic tradition, Babcock adopted the methods of scientific psychology to study the cognitive effects of neurological disease. Her research methods were well-characterized and repeatable, she utilized standardized psychometric measures, and she incorporated normal control comparison groups in her research. Anticipating later batteries of neuropsychological tests, Babcock attempted to quantify deficits in discrete mental abilities and used an ''efficiency index'' to summarize the overall functioning of her patients. Babcock based her efficiency index on the idea that intellectual function varies over time. More specifically, people may exhibit a higher level of intellectual function while healthy and in the prime of life, than they do after suffering neurological or psychiatric disorders. Babcock believed that mental disorders do not affect tests of prior knowledge acquisition (e.g., vocabulary). She further identified a number of tests that she thought were sensitive to mental disorders, including tests familiar to contemporary neuropsychologists (e.g., reverse digit span and various reasoning tasks). Babcock quantified mental efficiency by contrasting performance on these two kinds of tests, a forerunner of the hold-don't hold test comparison (▶ Hold-Don't Hold Tests). Babcock's contemporary influence is also evident in her story memory format. In this format, a story is initially presented and recall is tested. The story is presented a second time followed by 10 min of interpolated activity and a final recall test. This format has been adopted in some contemporary memory batteries and has the advantage of allowing the neuropsychologist to test both immediate and delayed recall, as well as learning with repetition. Although the original Babcock Story is rarely used today, some current memory batteries incorporate its format (▶ Wechsler Memory Scale). In this and other respects, Babcock's work continues to influence clinical and scientific neuropsychology.
Disclosure: None disclosed.
Primary objective: To determine if individuals with brain injury can modify heart rate variability (HRV) through biofeedback and, if so, enhance its pattern to improve emotional regulation and problem-solving ability. Design: A... more
Primary objective: To determine if individuals with brain injury can modify heart rate variability (HRV) through biofeedback and, if so, enhance its pattern to improve emotional regulation and problem-solving ability. Design: A quasi-experimental design with repeated measures was employed. Thirteen individuals aged 23-63 years with severe brain injury (13-40 years post-onset) participating in a community-based programme were enrolled. Main outcomes: Response-to-treatment was measured with HRV indices, Behavior Rating Inventory of Executive Function (BRIEF-A-Informant) and attention/problem-solving tests. Results: At post-treatment, HRV indices (Low Frequency/High Frequency [LF/HF] and coherence ratio) increased significantly. Increased LF/HF values during the second-half of a 10-minute session were associated with higher attention scores. Participants who scored better (by scoring lower) in informant ratings at pre-treatment had highest HRV scores at post-treatment. Accordingly, at post-treatment, families' ratings of participants' emotional control correlated with HRV indices; staffs' ratings of participants' working memory correlated with participants' HRV indices. Self-ratings of the BRIEF-A Task Monitoring scale at post-treatment correlated with family ratings at pre-treatment and post-treatment. Conclusions: Results demonstrate an association between regulation of emotions/cognition and HRV training. Individuals with severe, chronic brain injury can modify HRV through biofeedback. Future research should evaluate the efficacy of this approach for modifying behavioural problems.
This article describes a study using heart rate variability (HRV) biofeedback to treat emotional dysregulation in 13 individuals with severe chronic brain injury. Measures included HRV indices, tests of attention and problem solving, and... more
This article describes a study using heart rate variability (HRV) biofeedback to treat emotional dysregulation in 13 individuals with severe chronic brain injury. Measures included HRV indices, tests of attention and problem solving, and informant reports of behavioral regulation. Results demonstrated that individuals with severe brain injury were able to learn HRV biofeedback and increase coherence between the parasympathetic and sympathetic nervous systems. Individuals who attained the greatest coherence were rated as being able to best regulate their emotions and behavior.
- by Joseph F Rath and +3
- •
- Biofeedback
Objective: To introduce an approach to remediating problemsolving deficits in outpatients with moderate-to-severe cognitive impairments due to acquired brain damage. Design: Randomized clinical trial (RCT). Setting: Outpatient... more
Objective: To introduce an approach to remediating problemsolving deficits in outpatients with moderate-to-severe cognitive impairments due to acquired brain damage. Design: Randomized clinical trial (RCT). Setting: Outpatient hospital-based rehabilitation facility. Participants: 46 outpatients with mild-to-moderate cognitive impairments completed group treatment. 120 outpatients with moderate-tosevere impairments are being recruited for individual treatment. Interventions: After training in emotional self-regulation strategies, participants are taught a step-by-step template to assess problem situations in a structured, systematic manner. A unique element is the introduction of "clear-thinking questions" designed to teach participants to compensate for deficits in reasoning skills by "thinking their way through" problematic situations. Main Outcome Measures: Executive-function tests, problem-solving self-appraisal, self-reported clear-thinking skills, and objective observer ratings of role-played scenarios. Results: In the completed group-treatment RCT, participants improved on clear thinking and related measures. Illustrative case examples of methods and initial outcomes for individual treatment study will be provided. Conclusions: Based on a previously supported group treatment for mild-to-moderate impairments following acquired brain damage, our methods, currently being evaluated in an RCT funded by the National Institutes of Health, have the potential to improve outcomes for those with moderate-to-severe impairments.
Objective: The goal of this paper is to illustrate how the lessons learned in over 20 years of randomized clinical trials have advanced cognitive rehabilitation beyond traditional approaches to problem solving by more explicitly... more
Objective: The goal of this paper is to illustrate how the lessons learned in over 20 years of randomized clinical trials have advanced cognitive rehabilitation beyond traditional approaches to problem solving by more explicitly integrating subjective self-appraisal factors in routine clinical practice. Results: The concept of problem orientation, as proposed by cognitive-behavioral psychologists, provides a much-needed framework for conceptualizing interventions to address the impact of subjective experience on cognitive functioning, within the context of cognitive remediation. By explicitly focusing on the beliefs, assumptions, and expectations that individuals with acquired brain injury have about their own cognitive functioning, the concept of problem orientation allows rehabilitation psychologists to add an element to interventions, not systematically addressed in standard approaches to cognitive remediation. Targeting objective deficits in cognitive remediation is necessary, but not sufficient: For optimal benefit, remedial interventions must address objective cognitive deficits and the patient's subjective experience of such deficits in tandem. Conclusion: Contemporary evidence-based treatment recommendations now typically include incorporating interventions to address motivational, attitudinal, and affective factors in cognitive remediation. Further research is needed to directly compare the effectiveness of cognitive rehabilitative interventions that systematically address subjective factors with those that do not.
The objective of this study was to investigate the efficacy of a group treatment protocol called NICE (Noticing you have a problem, Identifying the information you need for help, Compensatory strategies, Evaluating progress) to train... more
The objective of this study was to investigate the efficacy of a group treatment protocol called NICE (Noticing you have a problem, Identifying the information you need for help, Compensatory strategies, Evaluating progress) to train help-seeking when wayfinding for individuals with acquired brain injury (ABI). Seven participants completed the NICE group treatment in an outpatient rehabilitation department at a university medical centre. A single subject multiple baseline design was employed to evaluate the efficacy of the NICE group treatment. The Social Behaviour Rating Scale and the Executive Function Route-Finding Task-Revised were repeated measures used to evaluate potential changes in help-seeking and wayfinding. Secondary outcome measures included pre-and post-treatment evaluation of social problem solving and social cognition. Results revealed that all participants improved on measures of help-seeking and wayfinding. Patterns of improvement and implications for rehabilitation are discussed. This is the first experimental study to evaluate the treatment of help-seeking behaviours and discuss its application to wayfinding in adults with ABI. Preliminary evidence supports further investigation of the NICE group treatment protocol.
- by Joseph F Rath
- •
improve the health function for those with GWI. The goals of this article are to provide social workers with information about GWI, and describe how we modified an evidence based treatment, problem-solving therapy, for veterans with GWI.... more
improve the health function for those with GWI. The goals of this article are to provide social workers with information about GWI, and describe how we modified an evidence based treatment, problem-solving therapy, for veterans with GWI. This tailoring of an existing treatment may serve as a model for adapting evidence-based treatments for veterans and civilians with multiple chronic symptoms and other complex health concerns. Furthermore, the detailed description provided may facilitate dissemination of problem solving therapy among social workers and trainees.
- by Joseph F Rath and +1
- •
- Rehabilitation, Military Veterans