Effectiveness of the Bridge/Adapt Program on Functional Skill Generalization After Acquired Brain Injury

This study explored the effectiveness of the Bridge/Adapt program for generalizing increased cognition to functional skills. Three participants, identified as having significant cognitive impairments as measured by the Cognistat assessment, participated in the Bridge/Adapt program, an eight-week program that includes both remedial and compensatory components. The remedial component used was a computer-based cognitive rehabilitation program called Parrot Software. Past studies have proven computer-based cognitive rehabilitation to be effective in increasing overall cognition. The Bridge/Adapt module is the compensatory component that utilized a variety of strategies and everyday tasks to facilitate the generalization of improved cognition to functional performance. A homework component was also implemented for participants to incorporate the strategies learned in the Bridge/Adapt program to their own meaningful occupations. This study utilized a pretest posttest design using the medication box assessment to measure functional performance. Results of the medication box assessment indicated that one of the three participants demonstrated generalization of skills from improved cognition to functional performance. Future research should include reevaluating the Bridge/Adapt modules and the medication box assessment. Recommendations to improve future implementation are provided to increase likelihood of generalization. BRIDGE/ADAPT EFFECTIVENESS 1 Introduction Acquired brain injury (ABI) is any injury to the brain caused after birth – the two most common forms being cerebrovascular accidents (CVA) and traumatic brain injuries (TBI) (Brands, Köhler, Stapert, Wade, & van Heugten, 2014). Individuals with ABI often experience cognitive deficits that impair their ability to perform daily activities and negatively affect their quality of life (Cicerone et al., 2011). Participation in daily activities is influenced by client factors such as cognition, and cognitive deficits may hinder or impair participation (American Occupational Therapy Association [AOTA], 2014). Many cognitive rehabilitation interventions have proven effective in addressing these cognitive deficits including remedial approaches such as computer-based cognitive rehabilitation (CBCR) programs and compensatory approaches like problem-solving strategies (Dams-O'Connor & Gordan, 2010; Li, Alonso, Chadha, & Pulido, 2015; Li, Robertson, Ramos, & Gella, 2013). Despite acquiring or improving cognitive skills through CBCR, current evidence shows that what is learned is not generalized outside of intervention (Li et al., 2015). Gains made through CBCR are not translating into functional performance in real-world situations. It is imperative that effective interventions target skill transfer as occupational therapy is dedicated to improving individual functioning so that the highest quality of life can be attained. The Bridge/Adapt program was developed by Bergen, Repin, Bennet, and LaFrenz (2015) to be used alongside a CBCR program, combining compensatory and remedial approaches to promote generalization of learning. There is currently no research to support the effectiveness of the Bridge/Adapt program in bridging the gap between intervention and functional performance. The purpose of this study is to determine the effectiveness of the Bridge/Adapt program in facilitating generalization of improved cognitive skills to functional performance in BRIDGE/ADAPT EFFECTIVENESS 2 individuals with ABI. The results may contribute to evidence-based practice so that cognitive rehabilitation with individuals with ABI can be conducted in the most effective possible manner. Literature Review This literature review discusses cognitive rehabilitation for individuals with ABI. First, ABI and its impact on cognition and functional performance are addressed. Second, cognitive rehabilitation is examined through remedial and compensatory approaches. Included in the discussion of cognitive rehabilitation is the use of remedial CBCR and two frameworks that guide compensatory approaches. Third, skill transfer and generalization of learning to other situations and environments is discussed. Lastly, various cognitive and performance-based assessments to measure cognition are described. Acquired Brain Injury ABI refers to any non-progressive injury to the brain following birth. The two most common forms of ABI are CVA and TBI (Brands et al., 2014). CVA is currently the fourth leading cause of death in the United States. To date, more than 800,000 new CVA cases are reported every year (Centers for Disease Control and Prevention, 2014a). The two most common forms of CVA, ischemic and hemorrhagic, can lead to various physical and cognitive deficits (Kearney, 2014). In 2010, 2.5 million incidences of TBI were reported (Centers for Disease Control and Prevention, 2014b). TBI is categorized as either primary or secondary brain injuries. Primary brain injury is the immediate physical damage sustained at the time of the injury to the brain. Secondary brain injury refers to a cascade of subsequent cellular and molecular processes triggered by the initial mechanical damage to the cerebral tissues associated with the primary insult (Tran, 2014). TBI may result in long-term cognitive, emotional, and physical impairments BRIDGE/ADAPT EFFECTIVENESS 3 that negatively affect performance of activities of daily living (ADL) and instrumental activities of daily living (IADL) (AOTA, 2014; Truelle et al., 2010). Cognitive and performance deficits. Individuals with ABI may experience cognitive deficits. These deficits can include: memory impairment, attention deficit, executive dysfunction, impaired awareness (decreased awareness of one’s own strengths and weaknesses regarding cognitive abilities), and impaired behavioral and interpersonal skills (Bartfai, Markovic, Landahl, & Schult, 2014; Smeets et al., 2014). When working with individuals with ABI, a clear understanding of the relationship between cognitive deficits and functional performance is necessary for successful implementation of interventions (Bertisch et al., 2013). Using remedial and compensatory interventions to address the cognitive deficits of individuals with ABI may yield to improvements in functional performance of ADL and IADL. Neuroplasticity Neuroplasticity refers to the brain’s ability to reorganize neural pathways throughout the lifespan by changing neural structure, function, and connections between neurons as a result of learning and cognitive, behavioral, and sensory experiences (Chen, Epstein, & Stern, 2010; Duffau, 2006). To restore function after injury, neuroplasticity may involve strengthening synaptic connections to reinforce neural pathways, weakening synaptic connections to cull unnecessary synapses, creating new synaptic connections, creating new or alternate neural networks, or linking new neural networks to existing ones (Berlucchi, 2011; Chen et al., 2010). Brain injury stimulates generation and migration of neuroblasts, precursors to neurons. Neurons that survive the brain injury can re-establish some function through the generation of new synapses between neurons by developing axonal branches and dendritic spines (Berlucchi, 2011; Chen et al., 2010). Neuroplasticity is the process by which the central nervous BRIDGE/ADAPT EFFECTIVENESS 4 system restores function, and, thus, it has important implications for cognitive rehabilitation (Berlucchi, 2011). Cognitive Rehabilitation Cognitive rehabilitation is a set of interventions designed to maximize functional performance of individuals with ABI (Dams-O’Connor & Gordon, 2010). The goal of cognitive rehabilitation is to optimize cognitive functioning and improve quality of life for individuals with ABI by remediating or compensating for cognitive deficits (Cicerone et al., 2000; Tsaousides & Gordon, 2009). Cognitive rehabilitation targets deficits in a number of cognitive domains including attention, memory, learning, executive function, and visual perception. It also addresses the psychosocial aspects of ABI such as training in emotional regulation and social skills (Dams-O’Connor & Gordon, 2010). Cognitive rehabilitation uses targeted, purposeful activities with the goal of facilitating neuroplasticity to regain functional performance (Duffau, 2006). The parameters of cognitive rehabilitation, such as number of repetitions and intensity, influence neuroplasticity and functional outcomes of intervention (Kleim & Jones, 2008). A study by Kim et al. (2009), using an observational study design, provided evidence in support of cognitive rehabilitation inducing neuroplasticity by using functional magnetic resonance imaging (fMRI) to compare images of participants’ brains before and after intervention. Seventeen participants with chronic TBI, averaging 16 months post-injury, were compared with 15 control subjects. For the intervention, the participants participated in a CBCR program focused on visual and auditory attention over four weeks with three sessions per week. Participants underwent fMRI as they engaged in a visuospatial attention task. The researchers noted significant improvement in performance on the task after the CBCR, and changes in the brain’s neural network, neuroplasticity, detected by BRIDGE/ADAPT EFFECTIVENESS 5 fMRI corresponded with increased organization and activation of areas within the brain associated with attention, and indicated neuroplasticity had occurred (Kim et al., 2009). The effectiveness of cognitive rehabilitation on improving cognitive skills, such as memory retrieval and attention, for individuals with ABI is supported by robust evidence (Cicerone et al., 2000; Cicerone et al., 2005; Cicerone et al., 2011; Rohling, Faust, Beverly, & Demarkis, 2009). Cicerone et al. (2000, 2005, 2011) published three seminal literature reviews in the field spanning 20 years, from 1988 through 2008, and generated several practice standards based on the best ava