Impaired self-awareness is common after traumatic brain injury (TBI). Lack of understanding of post-injury impairments can reduce individuals’ participation in rehabilitation, decrease compliance with compensatory strategies and impair the ability to set realistic goals. In this way, impaired self-awareness may reduce independence and occupational performance after TBI. Self-awareness is described as a person’s understanding of his or her own strengths and limitations, and how these impact on everyday functioning. Self-awareness is conceptualised as having two components, 1) intellectual awareness, involving self-knowledge and beliefs about one’s abilities, and 2) online awareness, involving the capacity to self-monitor and adjust one’s behaviour (e.g., self-correction of errors) during task performance.
Occupational therapists working in brain injury rehabilitation use occupation-based metacognitive interventions and provide feedback to improve individuals’ self-awareness and to ultimately improve their occupational performance. Despite the well-recognised clinical benefits and common use of interventions involving feedback, there is currently limited high level evidence on the type of feedback that is most effective to improve impaired self-awareness in people after a TBI.
The aim of this thesis is first to examine the evidence for self-awareness interventions with a feedback component in adults with brain injury. Second, the thesis aims to compare the effect of different methods of feedback, specifically video, verbal and experiential feedback, on self-awareness in people with TBI. Finally, the thesis aims to determine the maintenance of gains following the occupation-based feedback interventions.
The main components of the thesis include a systematic review with a meta-analysis and a randomised controlled trial (RCT) with assessor and participant blinding and concealed allocation. The systematic review included studies that investigated the effects of a self-awareness intervention involving a feedback component on clinical outcomes in adults with brain injury. The review aimed to determine if feedback interventions improve self-awareness and other outcomes such as occupational performance and satisfaction with performance.
The RCT included 54 participants, recruited over a period of 30 months. Participants were included in the study if they sustained a TBI, had emerged from post-traumatic amnesia (PTA), were over 16-years old, had functional English language, and demonstrated impaired self-awareness. The primary outcome variable of online awareness was measured by a blinded assessor counting the number of errors made on videotaped recordings of meal preparation during therapy sessions. Secondary outcomes were intellectual awareness, measured by the Awareness Questionnaire (AQ), emotional distress measured by the Depression, Anxiety and Stress Scales (DASS-21) and perceptions of rehabilitation measured using the Self-Perceptions of Rehabilitation Questionnaire (SPIRQ). Participants also completed a battery of neuropsychological function tests.
Participants were randomly allocated to one of three groups: video plus verbal feedback, verbal feedback, or experiential feedback condition. The participants received a feedback intervention, based on their group allocation, after each of four meal preparation sessions. Post-intervention data were collected during the last session for error count and following completion of all four of the intervention sessions for secondary variables. A follow-up assessment was conducted 8 to 10 weeks following the last intervention session and included the primary and secondary outcome measures.
The systematic review included twelve studies; two were RCTs, one was a quasi-RCT and nine employed AB designs (pre-post comparisons). The meta-analysis included the three RCTs with results indicating that feedback interventions produce modest improvements in self-awareness in people with brain injury.
The results from the RCT suggest that video plus verbal feedback led to significantly greater improvements in online and intellectual awareness in participants with a TBI compared to both verbal feedback and experiential feedback, with no changes in emotional distress. The provision of verbal feedback alone did not improve online or intellectual awareness over and above experiential feedback (i.e., participation in the occupational task with no subsequent feedback from the therapist). In addition, 8 to 10 weeks after the final intervention session, all groups in a follow-up sample (n=32) maintained the reduced number of errors made in the meal preparation task as well as the improved level of intellectual awareness, without any changes to emotional distress. Furthermore, participants in the video plus verbal feedback group demonstrated maintenance of significantly greater improvements in online and intellectual awareness as compared to the verbal feedback group and the experiential feedback group. There were no significant differences at follow-up in number of errors made or intellectual awareness in the verbal feedback group compared with the experiential feedback group.
This program of studies has contributed new and important evidence for the rehabilitation of adults after brain injury. While the systematic review suggested that feedback interventions lead to modest improvements in self-awareness after TBI, studies to date were not able to provide guidance to therapists on what type of feedback intervention would be most effective. The RCT demonstrated that video plus verbal feedback used within an occupation-based intervention approach was effective in improving self-awareness in people with TBI with no accompanying deterioration in emotional status. Although the video feedback was specifically designed to reduce the number of errors made in an occupational task (i.e., online awareness), it had broader effects on self-knowledge about personal abilities (i.e., improvement in intellectual awareness). The multi-modal combination of video plus verbal feedback involved self-observation of performance and therapist-guided reflection on errors and strategies. In addition to facilitating error monitoring, this approach may help individuals with TBI to process the meaning of their experiences and modify self-knowledge about their abilities.