Virtual reality in the assessment of selected cognitive function after brain injury.

OBJECTIVE: To assess selected cognitive functions of persons with traumatic brain injury using a computer-simulated virtual reality environment. STUDY DESIGN: A computer-simulated virtual kitchen was used to assess the ability of 30 patients with brain injury and 30 volunteers without brain injury to process and sequence information. The overall assessment score was based on the number of correct responses and the time needed to complete daily living tasks. Identical daily living tasks were tested and scored in participants with and without brain injury. Each subject was evaluated twice within 7 to 10 days. A total of 30 tasks were categorized as follows: information processing, problem solving, logical sequencing, and speed of responding. RESULTS: Persons with brain injuries consistently demonstrated a significant decrease in the ability to process information (P = 0.04-0.01), identify logical sequencing (P = 0.04-0.01), and complete the overall assessment (P < 0.01), compared with volunteers without brain injury. The time needed to process tasks, representing speed of cognitive responding, was also significantly different between the two groups (P < 0.01). CONCLUSION: A computer-generated virtual reality environment represents a reproducible tool to assess selected cognitive functions and can be used as a supplement to traditional rehabilitation assessment in persons with acquired brain injury.

Levels of self-awareness after acute brain injury: how patients' and rehabilitation specialists' perceptions compare.

OBJECTIVE: To examine self-awareness regarding performance on 4 daily living tasks and to test theoretical predictions for a model of self-awareness in persons with acquired brain injury. DESIGN: A comparative design examining the level of self-awareness recorded by patients and actual patient performance as judged by rehabilitation clinicians. SETTING: A community-based residential center providing comprehensive rehabilitation services to persons with acquired brain injury. PARTICIPANTS: Fifty-five persons with acquired brain injury and the identified potential to return to independent function in the community. Ten subjects without brain injury provided comparison data. INTERVENTION: Information was collected by using patient self-report, clinician rating of patient performance, patient rating of non-brain-injured subjects, and clinician rating of non-brain-injured subjects. MAIN OUTCOME MEASURES: Three self-awareness criteria were examined: intellectual, emergent, and anticipatory. Self-awareness was rated for 3 tasks: dressing, meal planning, and money management. RESULTS: Statistically significant differences (p <.05) were found for all levels of self-awareness across the 3 tasks. Persons with brain injury judged their abilities higher than clinician ratings of actual performance. No statistical support was found for a hierarchy among intellectual, emergent, and anticipatory self-awareness. CONCLUSIONS: No evidence was found supporting a hierarchy among levels of self-awareness as defined and measured in the present study. New methods for operationally defining intellectual, emergent, and anticipatory self-awareness are necessary to examine the relationship between self-awareness and performance.

Competence in scientific inquiry and research.

The survival and expansion of the profession of occupational therapy depends on its ability to respond to continually changing environments. One of the most current and critical factors in this adaptation is the capacity of therapists to achieve competence in scientific inquiry and research. Competence in the role of researcher is necessary because it contributes to the development of the individual therapist, the profession, and the organization within which the therapist functions. The aim of this article is to review and elaborate on the competencies associated with the role of researcher and to propose a reconceptualization of the knowledge, skills, and attitudes that shape competence in scientific inquiry.

Development of critical paths for post-acute brain injury rehabilitation: lessons learned.

One important tool for case management is critical path analysis. This article explains four critical pathways developed by an interdisciplinary team for a post-acute brain injury rehabilitation program. The heterogeneity of the brain injury population mandates the need for systematic coordination of direct care services. Yet, variations in the neurobehavioral consequences of brain injury necessitate differing goals and treatment tracks for individual clients. The critical pathways in this setting define and describe the procedures and services to be rendered from admission to discharge to achieve optimal goals for four treatment program tracks: Return to Work, Return to School, Functional Independence, and Neurorehabilitation. The tracks reflect a hierarchy of expectations for information processing and functional performance. Critical pathways provide a tool for enhancing communication among service providers and external case managers and for determining the extent to which a client's course of treatment compares with a clinical standard considered to be ideal. This article compares the four critical pathways, provides representative case samples, and discusses lessons learned in the development and implementation process.

The effect of environmental regulations on postural control after stroke.

OBJECTIVES: The primary objective of this study was to examine the effect of environmental predictability on postural control after stroke. A reaching task for seated subjects was used as the postural perturbation. Trajectory stability (the pathway followed by the subject's body center for pressure with respect to time during the reaching task) was used as the index of postural control. It was hypothesized that trajectory stability would be greater under predictable conditions. METHOD: A specially designed electromechanical system was used to measure the trajectory stability ratios for 100 subjects, 50 with poststroke hemiplegia and 50 who had not had stroke. All subjects completed a task that required reaching to the left versus reaching to the right, under predictable versus unpredictable conditions. Postural control was measured via a trajectory instability ratio in both the anterior-posterior and medial-lateral planes. RESULTS: Although the effect of predictability on postural control was significant, it was not as hypothesized for both groups. There was greater trajectory stability under unpredictable conditions when reaching to the right as measured in both the anterior-posterior and medial-lateral planes and when reaching to the left as measured in the medial-lateral plane. CONCLUSION: These findings refute the assumption of the hierarchical, predictable-to-unpredictable-environment model for postural control evaluation and treatment. The relationship between information processing demands and postural skill is probably more complex than the simple linear association implied. Perhaps the two conditions, predictable and unpredictable, should be worked on concurrently, not sequentially.

Evaluating the hand: issues in reliability and validity.

Evaluation of hand function is a qualitative and quantitative process. This article provides a review of several quantitative tests and measures used to evaluate range of motion, edema, muscle performance, sensation, dexterity, and physical capacity. The validity and reliability of these instruments are emphasized. Some of the hand assessments reviewed are in the early developmental phase with further refinements yet to come. This article demonstrates the continued need to provide support for the validity and reliability of hand-assessment instrumentation. Regardless of the statistical support provided, however, the authors believe that hand therapy will remain an art as well as a science.

Cognitive rehabilitation: a model for occupational therapy.

A theoretical model that provides a foundation for understanding function and dysfunction in cognition and perception is needed as a prerequisite for the development of effective assessment and treatment tools to be used with the brain-injured adult. Such a model and clear definitions are absent in the occupational therapy literature on adult brain function and dysfunction. This paper represents a cognitive rehabilitation model adapted for occupational therapy from the fields of neuropsychology and cognitive psychology. Differentiation of terms, an overview of the model's theory, and evaluation principles are discussed. Cognitive rehabilitation is presented from an information processing perspective. Three other treatment approaches identified in the literature are discussed and compared with cognitive rehabilitation.