Executive Functioning in TBI from Rehabilitation to Social Reintegration:COMPASS

U.S. Dept/Vets Affairs Medical Center, San Juan DC

Investigators

Abstract

DESCRIPTION (provided by applicant): Traumatic brain injury (TBI) is a major health problem that leads to deficits in executive function a term used for the cognitive operations responsible for planning, decision making, and other aspects of goal management. Executive functions are akin to the self-regulation processes by which humans manage their own thoughts, behaviors, and emotions in order to identify, prioritize, and meet goals.1 After TBI, which often affects the frontal regions of the brain and their connections, self-regulation processes become disordered and behavior may lose its goal-directed quality.2 This, along with other cognitive, physical, and behavioral deficits that follow TBI, contributes to injured Veterans' reduced ability to return to work or school and to regain satisfactory personal lives. Our understanding of the neurological disabling impact of TBI on executive function is necessary for both the accurate diagnosis of impairment and individual-tailoring of rehabilitation processes aimed at recovery of independent function in returning service members.3 Goal-setting and goal management concepts are part of the natural language of rehabilitation. However, collaborative goal-setting between clinician/case manager and client can be difficult because of the cognitive deficits that follow TBI, and because clients with TBI have heterogeneous problems and diffuse goals that are difficult even for experienced clinicians to address. It might be argued that re-training returning Veterans with TBI how to self-manage their goals, with appropriate help and support, would essentially treat deficits in executive function. Such treatment would have multiple benefits: Practical, real-life goals would be achieved, and injured Veterans would re-learn the skills needed to manage their own goals in the future. A structured approach to goal self-management would foster greater independence and self-efficacy, help clients to gain insight into goals that are realistic for them at a given time, and help clinicians and clients to work more effectively as true collaborators. The COMPASS (Community Participation through Self-Efficacy Skills Development) program aims at developing and testing a novel patient-centered intervention framework that can be utilized as a platform for VA community re-integration comparative effectiveness research. The COMPASSgoal intervention will be developed and implemented to meet these needs. COMPASSgoal will integrate principles and best practices of goal self-management. Goal setting is a core skill in self-management training by which persons with chronic health conditions learn to improve their status and decrease symptom impact.4 One important mechanism of action of this program appears to be its positive effect on self-efficacy, or confidence in one's ability to attain goals and solve problems.5 The study goal is to gather data on the efficacy of a novel approach to psychosocial rehabilitation for Veterans with executive function impairment due to traumatic brain injury (TBI), and to explore over time, through relevant measures, Veteran responsiveness to intervention. Veterans with mild TBI will be randomized into two groups: the COMPASS (Community Participation through Self-Efficacy Skills Development) goal-management intervention group and the supported discharge group. 110 participants with residual deficits in executive function due to TBI will be recruited 3 months post-injury from the TBI program at the DC VAMC over the three-year period of the study. The operational definition of executive dysfunction/ inclusion into the study is based on both clinical diagnosis by a study physician and a standardized executive dysfunction measure, the Frontal Systems Rating Scale (FrSBe score), such that a total score or any of the 3 subscale scores < 1 SD compared to the normative score would indicate executive dysfunction sufficient to include in the study. The treatment phase for the Veterans enrolled in the intervention group will continue for two consecutive months (8 weekly sessions). Each participant in the intervention and control group will be assessed at baseline (enrollment), post-intervention, and at 3 months post-treatment follow up.