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  Occupational Therapy Interventions for ADLs in Adults Post-TBI with Visual Symptoms: A Systematic Review

  Connor Jarman BS; Olivia Vander Haar BMS; Lauren Wobken BS; Stacy Smallfield DrOT, MSOT, OTR/L, BCG, FAOTA; and Molly Whitlow PhD, MPH

  PURPOSE: Traumatic brain injury (TBI) is a leading cause of death and injury in the United States. In fact, it is estimated that 1.5 million Americans experience them every year (CDC, 2022). Visual impairments may be a symptom following TBI (Richman, 2014). This affects an individual’s ability to perform activities of daily living (ADLs) such as dressing, hygiene, and functional mobility, including the reading required for these activities. The purpose of this systematic review was to synthesize the evidence and intervention options within the scope of occupational therapy for adults post-TBI experiencing visual symptoms.

  DESIGN: We conducted a systematic review of the literature from 2002 to 2022 that included adults 18 years and older post TBI, had a measurable ADL outcome, and were within the scope of occupational therapy.

  METHOD: We reviewed 163 articles and abstracts from CINAHL, Cochrane, PubMed, and Scopus databases. Eighty-seven articles were retrieved for full review and seven met inclusion criteria. U.S. Preventative Task Force levels of certainty and grade definitions were used to describe the strength of evidence.

  RESULTS: Articles were themed by intervention type: oculomotor and compensatory scanning training, and training in device use. Five articles ranging from Level I-III evidence focused on oculomotor and compensatory scanning training and provide moderate strength of evidence to improve ADL performance post-TBI. Oculomotor and compensatory scanning training dosages ranged from 20 to 90 minutes sessions 1-2 times a week, for 4 to 11 weeks. Two articles, one each of Level II and III evidence, addressed training in device use, providing low strength of evidence to improve ADL performance post-TBI. These devices may include the BrainPort Vision Pro, prisms, a dichoptic device, or a cheiroscope with 4-10 hours of training.

  CONCLUSION: Based on moderate strength of evidence, we recommend routine use of oculomotor and compensatory scanning training for individuals experiencing visual symptoms post-TBI. Device use training should be done on a case-by-case basis due to low strength of evidence. Many of the interventions in this systematic review were exercise- rather than occupation-based. Rote eye exercises without link to occupation may be considered outside the occupational therapy scope of practice, therefore integration with occupation and collaboration with an eye care professional is important.
  
  Practitioners should consider collaborating with researchers to design occupation-based interventions that can be tested with larger sample sizes to determine effective interventions to improve ADL performance in adults post-TBI experiencing visual symptoms. Professional development can ensure occupational therapists have advanced training and education in oculomotor and compensatory scanning.

  IMPACT STATEMENT: Current research supports oculomotor and compensatory scanning training for adults post-TBI experiencing visual symptoms. Future research should continue to explore occupation-based interventions for this population to maximize visual function for performance of everyday activities.

  REFERENCES:

  Centers for Disease Control and Prevention. (2022, January 6). Multiple cause of death data on CDC wonder. Centers for Disease Control and Prevention. https://wonder.cdc.gov/mcd.html

  Richman, E. (2014, March). Traumatic brain injury and visual disorders: What every ophthalmologist should know. American Academy of Ophthalmology; EyeNet Magazine. https://www.aao.org/eyenet/article/traumatic-brain-injury-visual-disorders-what-every-2

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  Effectiveness of Functional Cognition Intervention for Adults with Traumatic Brain Injuries: A Systematic Review

  Lauren McCormick, Madison Otte, Delaney Hill, Emily Leahy, Stacy Smallfield, and Molly Whitlow

  Purpose: An estimated 5.3 million Americans are living with a permanent disability due to having a traumatic brain injury (TBI) (CDC, 1999). A common deficit seen in this population includes impaired functional cognition, which is the ability to use and integrate thinking and processing skills to complete complex instrumental activities of daily living (IADLs) (Giles et al., 2017). Occupational therapy practitioners support individuals post-TBI by creating and implementing occupation-based interventions during rehabilitation to optimize functional cognition and improve individuals' ability to complete IADLs. This study aims to identify the effectiveness of interventions within the scope of occupational therapy practice to improve functional cognition in adults with post-TBI.

  Design: This systematic review included randomized controlled trials published in peer-reviewed journals between 2010 and 2022, which addressed adults with TBI, and implemented functional cognition interventions which were within the scope of occupational therapy practice.

  Method: Results from four literature databases produced 1154 articles. Duplicate articles were removed (n=19). Teams of two researchers screened the titles and abstracts of each of the remaining 1135 articles to determine eligibility for full-text review. Next, the full text of 289 articles were reviewed to determine if they met the study’s inclusion criteria; eight articles were included in the systematic review. The U.S. Preventative Services Task Force levels of certainty and grade definitions were used to describe the strength of evidence.

  Results: The eight studies included in this systematic review were categorized into two themes: simulated electronic-based interventions and metacognitive strategy training. Three articles addressed simulated electronic-based interventions, which examined the effectiveness of Cognitive Symptom Management and Rehabilitation Therapy (CogSMART) and virtual reality training (VTR). All three articles supported the use of simulated electronic-based interventions, though the strength of evidence is classified as moderate, given their methodological limitations, which included small sample sizes and differences in participant characteristics at baseline. Five articles addressed metacognitive strategy training, of which four supported its effectiveness. This evidence is classified as moderate, in light of methodological limitations, including small sample sizes and heterogeneity of the interventions.

  Conclusion: Occupational therapists have a critical role in selecting and implementing intervention strategies that will aid in rehabilitating functional cognition. Based on the findings of this review, occupational therapy practitioners should consider routinely implementing metacognitive strategy training and simulated electronic-based interventions to enhance functional cognition in adults following a TBI. Occupational therapy educational programs should address these interventions in occupational curricula. Additional research is warranted to address the heterogeneity of outcome measures and interventions.

  Center for Disease Control and Prevention. (1999). Report to Congress: Traumatic brain injury in the United States. U.S. Department of Health and Human Services. https://www.cdc.gov/traumaticbraininjury/

  Giles, G. M., Edwards, D. F., Morrison, M. T., Baum, C., & Wolf, T. J. (2017). Screening for functional cognition in postacute care and the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. The American Journal of Occupational Therapy, 71(5), 7105090010. https://doi.org/10.5014/ajot.2017.715001