Comparing frameworks for Cognitive issues from Traumatic Brain Injury (TBI)

The Paper
Park, H. Y., Maitra, K., & Martinez, K. M. (2015). The Effect of Occupation‐based Cognitive Rehabilitation for Traumatic Brain Injury: A Meta‐analysis of Randomized Controlled Trials. Occupational therapy international, 22(2), 104-116.

The Problem
Cognitive issues from Traumatic Brain Injury (TBI) lead to disability for millions of people, and cognitive rehab has a ton of approaches.

The challenge for you as an OT, is that occupation-based approaches aren’t as established in research as other strategies.

So how do you choose the best framework?  

This meta-analysis compared: occupation-based treatment v.s. other forms of cognitive rehab

How The Author's Did It
Occupation-based treatment was:

  • motor imagery programmes

  • awareness intervention programmes

  • social communication skills training

  • treatment of executive dysfunctions and divided attention

  • cognitive didactic rehabilitation and intensive cognitive rehabilitation program

  • ...and interventions where outcomes were based on functional tasks

The comparison group was:

  • computerized cognitive training package

  • repetitive exercise

  • TBI education

  • individual counselling

  • ...or no treatment

Outcomes measured: 

  • Mental functions

  • Activities of Daily Living (ADLs) 

  • Quality of Life (QOL)

Do statistics make you want to crawl into a ball and watch netflix reruns?  No worries, skip to the outcome.

Meta-analyses report effect size which is the difference between the mean (average) outcome of the intervention and the control groups. In general, a positive effect size means the intervention works...and a negative one means it doesn’t.  

But the magnitude! also matters - because even if an intervention works, well... it might not work very well. Thus, the magnitude! tells us how well the intervention works.

This review used Cohen’s d to show us how many standard deviations difference there was between the groups.

The overall effect size found was 0.19 (that’s the average of the effect size on ADL, cognitive function and QOL) which was quite small.

Basically, they found that the OT based intervention was not too different than the control intervention.

Sometimes a picture can help.

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Dark blue on the left would be the control group, and light blue on the right the intervention group.  In this case the outcomes of intervention vs. control were the same 92% of the time.

The authors noted:

  • “Although the effect was small, it is significant as this is one of the first attempts that generates meta‐analytic evidence for occupation‐based cognitive rehabilitation with TBI patients.

  • The results suggested that occupation‐based cognitive rehabilitation not only improved specific cognitive functions and ADL performance but also had overarching and significant effect on values, beliefs and spirituality in the treatment groups compared with the comparison groups.

  • “We (the authors) believe that this is a very noteworthy finding encompassing the holistic domains of occupational therapy despite the small effect size”

So yes, the difference was small, but occupation-based intervention was still marginally better than computerized cognitive training package. Most importantly, this research provides a good step forward for evidence based OT.

The need to be evidence based increases each year for OTs. But the reality is that when research asks the question, “does OT work here?” the answer is often... “it’s complicated”.

The challenge for you as a modern OT, is to connect the dots between what you do know from relevant research, with the reality of your practice and the patient in front of you.

That’s both a science, and an art.

Each time you make this connection for your patients, then you take another step towards doing truly remarkable work.