Category of Submission : Research

Objective: The present study examined the effectiveness of two components of a treatment program typically used by OTs in personal activities of daily living (PADL) rehabilitation. Design: A multiple baseline probe design across PADL tasks was used which is particularly suited to the examination of the effects of complex interventions on skill performance. Subjects: Two male adults with severe brain injuries and cognitive impairments who were in the acute stages of recovery. Interventions: OT treatment program consisted of a combination of errorless learning and strategy training approaches. Main measures: The impact of the program was measured by the number of steps completed independently in each of these tasks, the level and type of assistance required, and by administering the UK FIM and the AMPS. Results: Errorless learning and strategy training as used within an OT program was demonstrated to be effective in reducing the amount of assistance both participants required to complete the targeted PADL tasks. Further, there was evidence of generalization of training effects among trained and untrained activities. Conclusions: Selecting and combining treatment techniques based on detailed assessment of functional performance is an area of high clinical importance but with limited research; the current study stands as an attempt towards that direction. This article is a version after peer-review, with revisions having been made (i.e., pre-publication version). In terms of appearance only this might not be the same as the published article. Final manuscript published as: “Kelly, F. , & Nikopoulos, C.K. (2010). Facilitating independence in personal activities of daily living after a severe traumatic brain injury; preliminary findings. International Journal of Therapy and Rehabilitation, 17(9), 474-482”. 2 Key-words: Traumatic brain injury, personal activities of daily living, rehabilitation, single-case experimental design. Traumatic Brain Injury (TBI) is common and affects a predominantly younger population at a significant rate of 275/100,000 per year in the UK (Tennant, 2005). Despite the high incidence rates, the rate of death is low at 6-10 per 100,000 (NICE, 2007). This has resulted in higher numbers of survivors living with long-term disabilities that require specialist care. In particular, the majority of individuals with a neurological injury in the acute stages (88% 95%) present with dependency in personal activities of daily living (PADL) (Grill et al, 2005). PADL refer to self care activities usually completed on a daily basis, such as bathing, dressing, grooming or toileting which are often a primary goal for neurological rehabilitation (Legg et al, 2006; Sunderland et al, 2006). Typically, promotion of functional skills towards PADL training constitutes a large percentage of the occupational therapy (OT) interventions within neurological rehabilitation. Adaptation is the approach most commonly applied within functional skills training and there are two treatment techniques frequently used by OTs; strategy training (ST) and errorless learning (EL). ST refers to a hierarchical protocol developed by Heughten et al (1998) that provides a framework for providing instructions, assistance and feedback in accordance with patients’ ability to initiate, execute and control an activity. EL is an approach whereby patients are taught to perform a new skill whilst they are prevented, as far as possible, from making mistakes (Page et al, 2006). Techniques such as backward and forward chaining are examples of this approach. Undoubtedly, there have been notable gains within TBI rehabilitation research. However, there is still a lack of transparency regarding the active ingredients within rehabilitation interventions, which has caused them to be referred to as a ‘black box’ (Whyte and Hart, 2003). Further, there has been no research specifically investigating the effectiveness of PADL rehabilitation within the acute stages of recovery for TBI patients or the efficacy of specific interventions provided by OTs (Steultjens et al, 2005). Accordingly, the present study was designed to investigate the effectiveness of combining strategy training and errorless learning approaches within an individualized OT program in the treatment of selected PADL for individuals with cognitive impairment in the acute stages of recovery post TBI. Method Experimental design A multiple baseline probe design across PADL tasks was used for each participant. This design is particularly suited to the examination of the effects of complex interventions on skill sequences in which successful performance on later steps in the sequence is impossible or unlikely before acquisition of its preceding steps (Barlow et al, 2008; Cooper et al, 2007). Participants Two male adults (Keith & Joe; pseudonyms) with severe brain injuries, who were in the acute stages of recovery, participated in the study. Keith was 47 years old and he was This article is a version after peer-review, with revisions having been made (i.e., pre-publication version). In terms of appearance only this might not be the same as the published article. Final manuscript published as: “Kelly, F. , & Nikopoulos, C.K. (2010). Facilitating independence in personal activities of daily living after a severe traumatic brain injury; preliminary findings. International Journal of Therapy and Rehabilitation, 17(9), 474-482”. 3 admitted to Accident and Emergency (A&E) following an assault with a GCS of 4-5/15. When he entered the study (18 weeks post injury), aspects of his physical condition included limited passive and active range of motion (AROM) within right shoulder, reduced co-ordination and control in all four limbs and trunk with a wide based ataxic gait and high level balance problems. Joe was 58 years old and he was admitted to A&E following a fall at home which resulted in a large left acute subdural haematoma and a smaller right frontal haematoma. His GCS was 6/15 at the scene and 8/15 on admission. At the time he entered the study (25 days post injury), he presented right hemiparesis and impaired sensation, no AROM in right upper limb with increased tone throughout, no AROM right lower limb, and impaired static and dynamic sitting balance. Further, both participants were assessed using the Westmead Post Traumatic Amnesia Scale (McCarter et al, 2007) the Apraxia Screen (Almeida et al, 2002) Assessment of Motor and Process Skills (AMPS, Fisher, 2003) and the UK Functional Independence Measure (FIM eg. Skinner and Turner-Stokes, 2006). Collectively, Keith displayed significant retrograde amnesia, poor insight and safety awareness and severely impaired ability to initiate, plan and problem solve within functional tasks. He presented with persistent levels of disorientation to place, time, and person and inability to recall any of 3 items after 1 minute delay; scoring an average of 4/12 on assessment with the Westmead Post Traumatic Amnesia (PTA) Scale (McCarter et al, 2007). However it residual memory deficits are common post TBI and he did not demonstrate any other characteristic behaviours described in PTA such as agitation, restlessness or wandering. Therefore he was deemed to have emerged from PTA based on repeated behavioural observations and indepth functional assessment however determining emergence from PTA is an area of debate (Wilson et al 1999). He required prompting to initiate and complete all PADL as well as he needed supervision with indoor mobility and functional transfers in order to maintain safety. Joe presented attentional bias to left side, poor hand positions/distal differentiation and direction of movement, impaired attention and impulsivity within tasks, omission of key task steps, perseveration of movements and difficulty imitating actions after a short delay. He also had significant expressive dysphasia, dysarthria and oromotor apraxia. He was experiencing increased physical difficulty and effort when performing fairly simple PADL and had difficulties choosing appropriate objects, logically sequencing or modifying his actions to prevent and overcome potential problems. He was unable to mobilize and received full assistance with all PADL requiring assistance of two people with bed mobility and a hoist for all functional transfers. The study was conducted in an acute neurosurgical unit within a regional neurosciences centre. Its protocol was approved by the School of Health Sciences and Social Care Research Ethics Committee at Brunel University and the Bromley Local Research Ethics Committee, whilst site specific approval was obtained from the respective Medical School Research Ethics Committee. Full written informed consent was also obtained from both participants. Outcome measures Three PADL tasks were selected for each participant. Each of these tasks was broken into smaller workable units/steps following specific suggestions and examples in the This article is a version after peer-review, with revisions having been made (i.e., pre-publication version). In terms of appearance only this might not be the same as the published article. Final manuscript published as: “Kelly, F. , & Nikopoulos, C.K. (2010). Facilitating independence in personal activities of daily living after a severe traumatic brain injury; preliminary findings. International Journal of Therapy and Rehabilitation, 17(9), 474-482”. 4 literature for conducting a task analysis (eg. Stokes et al, 2004). The impact of the OT intervention was measured by the number of steps completed independently in each task, the level and type of assistance required. Steps were performed independently if they occurred within 5 seconds (secs) after the completion of the previous step in the sequence and in the absence of any further instruction or assistance. During baseline assessment if independent performance was not achieved within either this specified time during intervention or 2 minutes (mins) of the last instructi