Approaches to Managing Executive Cognitive Functioning Impairment Following TBI: A Focus on Facilitating Community Participation

Abstract

The stages and settings associated with recovery following TBI are summarized in figure 1. The early stages of recovery following moderate to severe TBI generally involve a period of acute care and rehabilitation which are hospital based and include medications, surgery, and therapeutic exercises/activities directly targeted to managing identified symptoms. In the United States, there is a trend towards decreasing length of inpatient stay following TBI. According to a study by Turkstra [4], the average length of stay in inpatient TBI rehabilitation was 18 days. She noted that, compared to previous decades, patients with brain injury are "sicker when they are admitted to inpatient rehabilitation and sicker when they leave" (p. 333). Rehabilitation during the inpatient recovery period tends to be governed by the medical model, which emphasizes the patient's dependency on health care professionals who act in the interest of the patient in an effort to preserve and minimize the severity of impairments. While this approach is recognized as a necessary component of TBI treatment, it has been argued that by fostering the 'rehabilitation patient' role, the inpatient setting is poorly suited to address executive cognitive functions and facilitating the transition to important life roles. Term Definition Self-awareness The ability to accurately recognize one's abilities and limitations. It is influenced by many factors including memory, decreased sensory or perceptual abilities, impulsivity, and inability to plan for the future. Deficits include displaying very limited or no apparent appreciation with regard to the nature of difficulties or impairments and the impact of these on everyday functioning. They impact ability to acceptance of feedback from others related to limitations, affecting the ability to benefit from rehabilitation [5]. Impaired self-awareness impacts performance of social interactions, including difficulties with personal boundaries, appreciating their impact on others, managing arguments, anger management, and adjusting to unexpected changes [6]. Goal Setting The ability to determine what one wants and to foresee the future realization of those needs. Goal attainment involves estimating task difficulty and self-evaluating performance so that adjustments can be made, both of which are impacted by impaired self-awareness of deficits or abilities. Initiation The ability to start an activity. Deficits in this area include lacking spontaneity, being slow to respond, or lacking initiative. The individual may verbalize an intent to act but fail to follow through [7]. Deficits may be misinterpreted as lack of motivation or drive and can be a considerable source of frustration for both client and family. Inhibition Deficits include problems stopping-demonstrating disinhibition, impulsivity, and quick shifts in behavior and emotional tone [7]. Planning The ability to organize the steps to complete an action, weigh alternatives, develop a framework for carrying out the plan, prepare for setbacks in carrying out th...

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