sign130

Brain injury rehabilitation in adults
5.5 ExECuTIVE fuNCTIoNING
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Two systematic reviews 85,100 and two additional RCTs 101,102 address the efficacy of interventions for executive
deficits in relation to executive functioning. All four studies show that treatment approaches based on
training patients in meta-cognitive strategies (eg training in problem solving, goal management and strategic
reasoning) are effective at improving performance in practical or functional settings. Such interventions do
not necessarily restore completely normal executive functioning, but nevertheless do improve functioning
in everyday contexts or on tests that reflect well the demands associated with everyday problem solving,
multitasking and goal management.
B Patients with TBI and deficits in executive functioning should be trained in meta-cognitive strategies
relating to the management of difficulties with planning, problem solving and goal management
in personally relevant functional situations.
5.6 VISuoSPATIAl fuNCTIoNING
The available evidence on visual perception related mainly to patients with stroke and almost all of the
evidence relates to the treatment of unilateral visual neglect. Evidence relating to treatment of other forms
of visuospatial deficits is limited. (SIGN 118 discusses the management of visuospatial functioning in patients
following a stroke). 5
5.7 EMoTIoNAl PRoCESSING
There is limited evidence on the treatment of emotional perception deficits in ABI. Two good quality RCTs
indicate that participants significantly improved in judging basic emotional stimuli when it was presented
in a naturalistic format (video vignettes) and in making social inferences on the basis of speaker demeanour,
but small numbers of participants limit the conclusions that can be drawn. 103,104 There is insufficient evidence
to recommend use of strategies to improve emotional processing.
5.8 CoMPREHENSIVE/HolISTIC TREATMENT PRoGRAMMES
Treatment of cognitive impairment is not usually undertaken in isolation. One approach to rehabilitation
after brain injury is comprehensive/holistic neuropsychological rehabilitation. This refers to programmes that
aim to simultaneously address cognitive, emotional and behavioural difficulties in the context of a focus on
returning to participation in meaningful activities. One systematic review concluded that there was sufficient
evidence to recommend the use of comprehensive-holistic neuropsychological rehabilitation during postacute
rehabilitation to minimise the impact of moderate or severe traumatic brain injury. 97 A limitation of
studies of such programmes is that it is not possible to identify the specific components that lead to positive
change and improvement. However, it does appear that such programmes, which have in part an explicit
focus on addressing cognitive impairment, do improve functioning after brain injury.
D In the post-acute setting interventions for cognitive deficits should be applied in the context
of a comprehensive/holistic neuropsychological rehabilitation programme. This would involve
an interdisciplinary team using a goal-focused programme which has the capacity to address
cognitive, emotional and behavioural difficulties with the aim of improving functioning in
meaningful everyday activities.
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