Friesen et al. [11] confirmed that **good communication and positive relations** between stakeholders (employee, employer and health professional) was important during the return to work process. This good communication was seen as a measure of being transparent. Transparency with their employers about their condition then employers was aware of their functional limitations. The clients felt that they could resume their worker roles when they had the experience of working in different jobs. This means that health professionals such as occupational therapists need to focus on the other skills that clients may have as this could aid, if individuals with brain injury was transparent with the employers their clients in finding alternative employment. Watt and Penn [18] found that individuals with brain injury who had an education of Grade 12 or less and who were unskilled were significantly less likely to return to work than those with tertiary education and who had managerial or professional jobs.

### **5. Barriers to return to work for individuals with brain injury**

Barriers relating to the health system included the **poor administration procedures** relating to the access of individuals with brain injury to the hospital system or when they have to apply for a disability benefit. Poor administration systems could be linked to **poor communication** between the various departments as well as the work pressure that staff works under. Another concern is that these staff members become **emotionally depleted** because of the psychological and physical energy that they utilize in treating patients. When this occurs they become frustrated and treat patients without sympathy. McGee [19] attributes this to a concept called depersonalization which is described as a state in which the helping professional no longer has sympathy, respect or positive feelings for clients. In brain injury rehabilitation research conducted, Abreu, Seale, Podlesak and Hartley [20] mention that the best case scenario in developing quality intervention would involve adequate funding for patient stay in the hospital and ideal clinical treatment which should be provided in terms of personnel and adequate therapy for rehabilitation. Other barriers included the clients **receiving incompetent medical and rehabilitative services** from hospital staff. The high costs of medical or rehabil‐ itative services prevent client`s access to hospital services. Other barriers that prevented individuals with brain injury from returning to work included client`s not being explained the **side effects of medication,** this often caused the brain injured individual to be dizzy, and tired in the workplace therefore negatively affecting the client`s work performance. Individuals with brain injury in a study conducted by Soeker [21] indicated that they were not given thorough explanations regarding the medications that were prescribed to them. As a result they developed side effects such as stomach complications that had a long term effect on their health. Frieg and Hendry [22] identified that health care professionals should educate both the client and caregivers (family) about the use of medication. A **lack of communication about reasonably accommodating the injured worker** in the workplace negatively affected their chances of returning to work. Friesen et al [22] confirmed that good communication between all stakeholders greatly enhanced the potential of the injured worker to return to work. Finally the failure of health professionals to recognise the **patients` rights charter** caused the individ‐ ual with the brain injury to lose confidence in rehabilitation programmes. The right to have a second opinion about their medical condition closely relate to the patients' rights charter which states a number of patient rights for example the right to be treated with dignity and respect, the right to be counselled about your condition and the right to have a second opinion. [23]

### **6. Current rehabilitation approaches**

nities available. After a brain injury an individual`s work skills could become compromised resulting in them being dismissed from their work. As a result they viewed self employment or entrepreneurship activities as a measure of sustaining themselves. Individuals with brain injury often view the **support of their family** during the recovery stages after their injury to be extremely beneficial. Family assistance is often seen as essential for the clients to resume their worker roles without the assistance of their family. Rehabilitation professionals should incorporate the family of the individual with the brain injury as a form of support during the intervention process. Piece and Salter [17] states that the goals of a support group is to provide a safe accepting environment in which to express feelings; to give the participants the oppor‐ tunity to hear others express similar feelings and conflicts; to ask help and to provide an environment for problem solving. It could therefore be argued that a support group would be

Friesen et al. [11] confirmed that **good communication and positive relations** between stakeholders (employee, employer and health professional) was important during the return to work process. This good communication was seen as a measure of being transparent. Transparency with their employers about their condition then employers was aware of their functional limitations. The clients felt that they could resume their worker roles when they had the experience of working in different jobs. This means that health professionals such as occupational therapists need to focus on the other skills that clients may have as this could aid, if individuals with brain injury was transparent with the employers their clients in finding alternative employment. Watt and Penn [18] found that individuals with brain injury who had an education of Grade 12 or less and who were unskilled were significantly less likely to return to work than those with tertiary education and who had managerial or professional jobs.

**5. Barriers to return to work for individuals with brain injury**

Barriers relating to the health system included the **poor administration procedures** relating to the access of individuals with brain injury to the hospital system or when they have to apply for a disability benefit. Poor administration systems could be linked to **poor communication** between the various departments as well as the work pressure that staff works under. Another concern is that these staff members become **emotionally depleted** because of the psychological and physical energy that they utilize in treating patients. When this occurs they become frustrated and treat patients without sympathy. McGee [19] attributes this to a concept called depersonalization which is described as a state in which the helping professional no longer has sympathy, respect or positive feelings for clients. In brain injury rehabilitation research conducted, Abreu, Seale, Podlesak and Hartley [20] mention that the best case scenario in developing quality intervention would involve adequate funding for patient stay in the hospital and ideal clinical treatment which should be provided in terms of personnel and adequate therapy for rehabilitation. Other barriers included the clients **receiving incompetent medical and rehabilitative services** from hospital staff. The high costs of medical or rehabil‐ itative services prevent client`s access to hospital services. Other barriers that prevented individuals with brain injury from returning to work included client`s not being explained the **side effects of medication,** this often caused the brain injured individual to be dizzy, and tired

extremely helpful when designing a rehabilitation programme.

376 Traumatic Brain Injury

Rehabilitation in the context of occupational therapy is currently defined as 'a service that aims to enable and empower people whose occupations are restricted because of disadvantage, illness or disabling physical or social barriers, to adapt to restrictions in function. [24] In the North American health system, rehabilitation, inclusive of cognitive rehabilitation, starts immediately after the patient has been medically stabilised in the intensive care unit. Patients are then transferred to an in-patient rehabilitation facility and thereafter, they enter a transi‐ tional living programme as an out-patient. [25]

Two of the major cognitive rehabilitation approaches are the remedial approach and the adaptive approach. The remedial approach is characterised by attempts to improve memory and perceptual skills. [26] The remedial approach is also referred to as the restorative approach focussing on attempting to remediate core areas of cognitive dysfunction by means of sys‐ tematic training. Assessment procedures entail a sequence of highly structured psychometric tasks. These tasks are chosen in order to exercise the identified area of cognitive impairment and are graded by complexity, quality, speed or presentation and the cuing needed to complete the task. The therapeutic modalities include pencil exercises, computerised soft ware, table top tasks and graded occupations of daily living. [27] A popular critique of this approach is that the amount of transference of the learned skill to functional settings is minimal. [27]

The compensatory approach, which is also known as the adaptive approach, is generally geared toward the facilitation of activities of daily living. [27] This approach capitalises on the intact area of cognitive abilities and attempts to bypass the area of cognitive impairment. The emphasis of this approach is on successful participation in daily occupations rather than specific cognitive skills underlying task performance. This approach is further characterised by internal compensatory strategies such as verbal description, rehearsing and mnemonics. Whereas the external compensatory approach is characterised by memory aids such as diaries, calendars and electronic cuing devises. [27, 28] Critique of these approaches include that they offer therapeutic intervention during the early stages of recovery but they fail to meet the client's needs in the later stages of recovery. Blundon and Smits [27] state that there is no strong evidence supporting the effectiveness of either of these approaches in enhancing occupational performance. Neither approach is client centred, nor do they take the client's personally felt or expressed needs into consideration.

### **7. Return to work programmes**

### **7.1. Holistic return to work programmes**

Another programme that is used to gain employment among the brain injured population is the holistic cognitive rehabilitation programmes. It is normally described by three phases, namely, holistic remedial intervention focussing on the general strategies to aid daily living; guided occupational trials in vocational placement and support for the maintenance of employment. Ben-Yishay, Silver, Piatsetsky and Rattok [29] investigated the return to work success rates of 94 participants who participated in a head trauma programme which utilised a holistic cognitive approach. The study results revealed a 63% return to competitive work at the levels (academic, skilled and unskilled).

Sarajuuri, Kaipio, Koskinen, Niemelä, Servo and Vilkki [30] describe a comprehensive neurorehabilitation programme as an alternative to returning to work. The above programme, which could be classified as a holistic cognitive programme, consisted of a post-acute, intensive interdisciplinary six week rehabilitation programme. In this programme a treatment group was compared to a control group. The treatment group received neuropsychological rehabil‐ itation, psychotherapy, vocational intervention and follow up support. The control group received conventional care and rehabilitation. In the latter study productivity was defined as working, studying or participating in volunteer activities. The results indicated that 89% of treated patients returned to a productive pursuit in comparison to 55% of the control group. One critique of this study is that of the 19 participants, only three participants returned to part time work and one to full time work.

### **7.2. Supportive employment**

Supportive employment is defined as competitive employment in an integrated setting with ongoing support services for people with the most severe disabilities. [31] Jones, Perkins and Born [32] further described supportive employment as programmes that promote selfsufficiency and improve the quality of life of people with disabilities by motivating them to pursue work in the traditional environment at equal pay to non-disabled people. Supported employment programmes provides assistance with job coaches, transportation, assistive technology, specialized job training and tailored supervision. [33] Wehman, West, Kregal, Sharron and Kreutzer [34] conducted a study utilising the supportive employment framework in which 87 participants participated. The results indicated that only 51.3% of the participants were employed after a period of 12 months. The above authors attributed the poor return to work rates to medical/health problems, economic lay off, slow/poor quality work, poor job match and inappropriate behaviour by the participants. In a study conducted by Wehman, Sharron, Kregal, Kreutzer, Tran and Cifu [35] of the 80 participants, the monthly employment ratio increased from 13% before services to 67% after participation in the supportive employ‐ ment programme. However, only 46% of these participants maintained continual employ‐ ment. The authors attributed the poor return to work rates to psychiatric/psychological complications, social adjustments and substance abuse. Another study by Preston and Ulicny [36] showed that in a sample of 124 participants, 61% were either placed in a competitive job setting or were considered job ready at the time of program completion with half of those placed in competitive employment found employment with their former employers, even though some job modifications were required. In a more recent study Gamble and Moore [37], followed 1073 participants with TBI of which 78% received supported employment services during the vocational rehabilitation process. Of the participants, 48.6% were competitively employed by the time their cases were closed and 51.4% were not employed. Of the participants who were not employed, 7.3% were provided with additional supported employment services and 92.7% were not provided with supported employment. Of the clients who were provided with supported employment, 67.9% of these clients were placed in competitive employment.

### **7.3. Summary of return to work programmes**

offer therapeutic intervention during the early stages of recovery but they fail to meet the client's needs in the later stages of recovery. Blundon and Smits [27] state that there is no strong evidence supporting the effectiveness of either of these approaches in enhancing occupational performance. Neither approach is client centred, nor do they take the client's personally felt

Another programme that is used to gain employment among the brain injured population is the holistic cognitive rehabilitation programmes. It is normally described by three phases, namely, holistic remedial intervention focussing on the general strategies to aid daily living; guided occupational trials in vocational placement and support for the maintenance of employment. Ben-Yishay, Silver, Piatsetsky and Rattok [29] investigated the return to work success rates of 94 participants who participated in a head trauma programme which utilised a holistic cognitive approach. The study results revealed a 63% return to competitive work at

Sarajuuri, Kaipio, Koskinen, Niemelä, Servo and Vilkki [30] describe a comprehensive neurorehabilitation programme as an alternative to returning to work. The above programme, which could be classified as a holistic cognitive programme, consisted of a post-acute, intensive interdisciplinary six week rehabilitation programme. In this programme a treatment group was compared to a control group. The treatment group received neuropsychological rehabil‐ itation, psychotherapy, vocational intervention and follow up support. The control group received conventional care and rehabilitation. In the latter study productivity was defined as working, studying or participating in volunteer activities. The results indicated that 89% of treated patients returned to a productive pursuit in comparison to 55% of the control group. One critique of this study is that of the 19 participants, only three participants returned to part

Supportive employment is defined as competitive employment in an integrated setting with ongoing support services for people with the most severe disabilities. [31] Jones, Perkins and Born [32] further described supportive employment as programmes that promote selfsufficiency and improve the quality of life of people with disabilities by motivating them to pursue work in the traditional environment at equal pay to non-disabled people. Supported employment programmes provides assistance with job coaches, transportation, assistive technology, specialized job training and tailored supervision. [33] Wehman, West, Kregal, Sharron and Kreutzer [34] conducted a study utilising the supportive employment framework in which 87 participants participated. The results indicated that only 51.3% of the participants were employed after a period of 12 months. The above authors attributed the poor return to work rates to medical/health problems, economic lay off, slow/poor quality work, poor job

or expressed needs into consideration.

378 Traumatic Brain Injury

**7. Return to work programmes**

**7.1. Holistic return to work programmes**

the levels (academic, skilled and unskilled).

time work and one to full time work.

**7.2. Supportive employment**

Holzberg [33] states that the most effective treatment approaches in North America are holistic cognitive rehabilitation and supported employment services. These approaches consist of elements of the remedial and adaptive approaches but go further in assisting the client to gain or maintain employment. However, neither the holistic cognitive rehabilitation nor the supported employment services reveal highly successful return to employment rates. [29, 34] According to Sarajuuri et al. [30] employment rates for patients with traumatic brain injury have ranged from 19% to 99%, thus indicating that there is disparity pertaining to return to work rates of this population.

### **7.4. A need for the exploration of the personal perspectives of brain injured individuals**

There is a lack of research that address the personal experience of brain injured individuals when adapting to their worker role after rehabilitation. Johansson and Tham [38] indicate that one area in which there is a lack of knowledge is the meaning of work to people with brain injuries. It could be argued that it is important to take the perspectives of the individual living with the brain injury into account especially when developing rehabilitation models of intervention programmes. Similarly, there are minimal occupational therapy studies that focus on the lived experience of brain injured individuals. [38] The literature suggests that the quality of intervention programmes and services tend to be ineffective when the health professional does not take the brain injured individual's self-identified needs into consideration, hence it needs to be client centred. [39] My exploration of the literature also revealed only one study that focused on the best practice for maintaining employment. [33] The study described the best practice for gaining and employing people with brain injuries from a developed world perspective. However the study lacked information on how brain injured individuals adapt to different working environments and it lacked the incorporation of the personal perspectives of the brain injured individuals themselves.

### **8. Description of the model of occupational self efficacy**

The structure of the model is a spiral which indicates that the stages of the model are not linear (see Figure 1). The individual can fluctuate between the stages due to his or her level of Occupational Self Efficacy. In between each stage is another spiral representing the influence of the environment on the individual's performance. The environment is also presented by a spiral as the environment will affect the person's performance throughout the four stages of the model. The environment may present family members, structural barriers, workplace, work colleagues, health professionals and external organizations. Throughout the process of developing Occupational Self Efficacy, there are critical contacts. These contacts serve as points of activation which set the process into action. These contacts include the contact with the occupational therapist or health therapist that facilitates the first stage of the model. Other forms of contacts may include the person himself, family members, health care team, other brain injured individuals who had completed rehabilitation and work colleagues. It is envisaged that these critical contacts could be present throughout the four stages of the model.

**Figure 1.** A graphical description of Occupational Self Efficacy: An occupational therapy practice model to facilitate returning to work after a brain injury.

### **STAGE ONE**

**8. Description of the model of occupational self efficacy**

380 Traumatic Brain Injury

The structure of the model is a spiral which indicates that the stages of the model are not linear (see Figure 1). The individual can fluctuate between the stages due to his or her level of Occupational Self Efficacy. In between each stage is another spiral representing the influence of the environment on the individual's performance. The environment is also presented by a spiral as the environment will affect the person's performance throughout the four stages of the model. The environment may present family members, structural barriers, workplace, work colleagues, health professionals and external organizations. Throughout the process of developing Occupational Self Efficacy, there are critical contacts. These contacts serve as points of activation which set the process into action. These contacts include the contact with the occupational therapist or health therapist that facilitates the first stage of the model. Other forms of contacts may include the person himself, family members, health care team, other brain injured individuals who had completed rehabilitation and work colleagues. It is envisaged that these critical contacts could be present throughout the four stages of the model.

**Figure 1.** A graphical description of Occupational Self Efficacy: An occupational therapy practice model to facilitate

returning to work after a brain injury.

During this stage the brain injured individual would be seen as an outpatient in the rehabili‐ tation unit, a client that is receiving home based intervention in the community and or a client that has already resumed employment. Regarding the participant's cognitive status it is envisaged that he or she should be classified on level VIII of the Ranchos Los Amigos cognitive scale. The scale describes an individual that is alert and orientated, is able to recall and integrate past and recent events, and is aware of and responsive to his or her culture. [40] Based on introspection and reflection the client would be able to develop new insights into his or her ability to cope within the environment. This process will enable the client to develop inner strength and a sense of efficacy. Ultimately the client would be able to better plan his or her choices and future actions through this process. The occupational therapist facilitates the process of reflection as advocated by Gibbs [41]. This process of reflection would in turn encourage introspection.

### *Reflection is described by six steps namely:*

### **Step one: Description of the event or what happened:**

During this step the occupational therapist would request that the client give a detailed description of the event or concern that he or she may have. This concern may be related to feelings regarding the acceptance of the brain injury, barriers that he or she may be experi‐ encing relating to occupational roles and community re entry or return to work. During this step the client will be encouraged to reflect on the environment, context of the event or action, other people's roles and his or her role as well as the outcome of the event.

### **Step two: Feelings**

During this step the occupational therapist will enable the client to explore his or her thought processes. The client will explore his or her feelings regarding the actual event or stressors. They may want to know how the event or people made them feel and also how they felt about the outcome of the event.

### **Step three: Evaluation of the circumstances**

During this step the client will be requested to evaluate his or her circumstances or make a judgment about his or her experience regarding the event or phenomena of interest. The occupational therapist will enable the client to consider what was good and bad about the experience. For example if the client was reflecting about a problem in performing tasks at work, the occupational therapist would ask him to think about what is required to do the tasks. Is it the process of doing the task that is difficult, is it the tools or equipment that is difficult to manage or is it the instructions that are difficult to understand? Once the problem is thoroughly evaluated then the individual needs to determine which aspects of the processes he or she did successfully.

### **Step four: Analysis of the situation or problem**

During this step the client will be encouraged to break the problem into its component parts. The client may have to thoroughly analyze the problem as a whole. Here he will ask questions such as what went well and what did not go well. During this process the client may have to determine who would be able to assist him in rectifying the problem and also what he or she needs to do in order to rectify or minimize problems. For example the client may need to seek further training in order to improve his skills, he or she may need to adapt his tools or her or work routine.

### **Step five: Conclusion**

During this step the client reflected on his or her problem situation by exploring it from different perspectives. The client has now accumulated a lot of information which will enable them to develop insight into their problem. The occupational therapist needs to encourage the client to be as honest as possible in his or her reflection about him or herself and others regarding the issue of concern. This honest exploration of the problem should be reflected in all the stages as inaccurate information may decrease the valuable opportunities for learning.

### **Step six: Action plan**

The client will be requested to think about him or herself in the same situation or experiencing the same problem. He or she will then have to determine whether he would manage the problem or situation in the same way as before or would he or she manage the problem or situation differently. The above process could take place with the client alone or in the presence of his or her family. His or her family could assist the client in the reflection process and in goal setting if appropriate. Stage one focused on introspection and reflection, successfully working through this phase would enable the client to move to the next phase of the model.

### **STAGE TWO**

Through the process of introspection and inner strength development, the client would be able to realize his autonomy to participate more in occupational activities of choice (i.e. activities of daily living, leisure and work). During this stage the occupational therapist would continue to act in the role of a facilitator as the self reflection process would have enabled the client to develop a plan of overcoming the barriers that they experienced at that point in time. Specific areas that need remediation according to the needs of the client will be focused upon. During this stage, specific components of function may need to be enhanced. For example, clients, in collaboration with the therapist, may decide that they need continued rehabilitation in order to improve their range of motion, muscle strength, tone, co ordination and balance. They may also require continued cognitive behavioural therapy whereby the client's memory, concen‐ tration and frustration tolerance are improved. At this point, the occupational therapist will be acting in a dual role that of a facilitator and of a case manager. In the role of a case manager the occupational therapist would enable the client to contact other role players such as a speech therapist, physiotherapist or physician who may be able to assist the client. Ultimately the goal would be for the client to act as his own case manager however, initially the occupational therapist would be able to facilitate the process. During this step, the client in collaboration with the occupational therapist would utilize a transdisciplinary1 approach whereby all of the stakeholders may it be health professionals, employer or family should be aware of the client's goals. For example, if the client's goal is to return to work then the physiotherapist, occupa‐ tional therapist, family and employer should be aware of this goal. This means that even if the physiotherapist focuses on balance and the speech therapist on improving communication skills, the ultimate goal of these health professionals would be to return the client to the work place. The client through participation in meaningful occupation would realise his strengths, weaknesses and potential. Engagement in occupations of choice would also enable the client to revise their self concept and ultimately improve their self esteem. Calhoun and Acocella [42] defines the mental self portrait as comprising three dimensions namely knowledge, expecta‐ tions and evaluation of self.

**Knowledge of self** is described by what the person knows about him/herself. It is envisaged that through the participation in occupation the client revises their knowledge themselves. For example, through a simple activity such as dressing, the client would be able to get an idea of their functional limitations.

**Expectation of self** is described by the person's perceptions of what he or she could be. These expectations in turn propel the client into the future and guide his or her actions. The client, who has an expectation of returning to his or her role as a worker, would be able to visualize what actions will be required to return to work. These expectations become realistic expecta‐ tions when the client is allowed to actually engage in work tasks. Through engagement in these tasks the client would develop the insight to adjust his expectations of self.

**Evaluation of self** is described by the person's judgment about him or herself, measuring what he or she is against, his or her expectations of self or his or her standards for self. The client's perception of their satisfaction with themselves facilitates their self esteem. It is important to note that there should be balance between the client's actual self or functional ability in occupational tasks and their expectations of themselves to enable them to develop a realistic self esteem and self concept.

### **STAGE THREE**

such as what went well and what did not go well. During this process the client may have to determine who would be able to assist him in rectifying the problem and also what he or she needs to do in order to rectify or minimize problems. For example the client may need to seek further training in order to improve his skills, he or she may need to adapt his tools or her or

During this step the client reflected on his or her problem situation by exploring it from different perspectives. The client has now accumulated a lot of information which will enable them to develop insight into their problem. The occupational therapist needs to encourage the client to be as honest as possible in his or her reflection about him or herself and others regarding the issue of concern. This honest exploration of the problem should be reflected in all the stages as inaccurate information may decrease the valuable opportunities for learning.

The client will be requested to think about him or herself in the same situation or experiencing the same problem. He or she will then have to determine whether he would manage the problem or situation in the same way as before or would he or she manage the problem or situation differently. The above process could take place with the client alone or in the presence of his or her family. His or her family could assist the client in the reflection process and in goal setting if appropriate. Stage one focused on introspection and reflection, successfully working through this phase would enable the client to move to the next phase of the model.

Through the process of introspection and inner strength development, the client would be able to realize his autonomy to participate more in occupational activities of choice (i.e. activities of daily living, leisure and work). During this stage the occupational therapist would continue to act in the role of a facilitator as the self reflection process would have enabled the client to develop a plan of overcoming the barriers that they experienced at that point in time. Specific areas that need remediation according to the needs of the client will be focused upon. During this stage, specific components of function may need to be enhanced. For example, clients, in collaboration with the therapist, may decide that they need continued rehabilitation in order to improve their range of motion, muscle strength, tone, co ordination and balance. They may also require continued cognitive behavioural therapy whereby the client's memory, concen‐ tration and frustration tolerance are improved. At this point, the occupational therapist will be acting in a dual role that of a facilitator and of a case manager. In the role of a case manager the occupational therapist would enable the client to contact other role players such as a speech therapist, physiotherapist or physician who may be able to assist the client. Ultimately the goal would be for the client to act as his own case manager however, initially the occupational therapist would be able to facilitate the process. During this step, the client in collaboration with the occupational therapist would utilize a transdisciplinary1 approach whereby all of the stakeholders may it be health professionals, employer or family should be aware of the client's goals. For example, if the client's goal is to return to work then the physiotherapist, occupa‐ tional therapist, family and employer should be aware of this goal. This means that even if the

work routine.

382 Traumatic Brain Injury

**Step five: Conclusion**

**Step six: Action plan**

**STAGE TWO**

This stage is described as the creation of competence through participation in occupation. During this stage the client will focus on a specific occupational performance area (i.e. work). If the client has not resumed his worker role he or she will gradually be reintegrated into this role. In stage two the client had already participated in intervention programmes aimed at improving their functional performance. He or she now has the functional skills to resume his or her occupational roles. The occupational therapist will continue to act as a facilitator and case manager where the client will be encouraged to self reflect and problem solve the manner in which he would like to resume employment. The client will be encouraged to utilize their social relations by initiating contact with stakeholders such as the employer, colleagues, health professionals and family for the purpose of participation in their worker role and in order to improve their support systems. This stage will place emphasis on improving the client's knowledge base. The occupational therapist will encourage clients to improve their problem solving skills. The client will be encouraged to use the reflective process as a method for solving problems. The occupational therapist may want to refer the client to another occupational therapist who specializes in vocational rehabilitation, work assessment or screening or they

<sup>1</sup> A transdisciplinary model of functional rehabilitation is described as a model where health team members conduct an integrated evaluation that results in the collaboration of assessment information. [43]

could initiate this process themselves. The client will be requested to demonstrate a problem‐ atic workplace scenario. For example, a client who had worked as a sales person may indicate that he or she has a problem in coping with difficult customers. The occupational therapist will request that the client verbalizes the actual workplace problem and will then advise him or her on various coping strategies that may assist him or her. The client will be asked to analyze the reasons why he or she struggled to cope with customers. Possible reasons could be a lack of assertiveness or poor communication skills.

The client will be asked to role play a scenario where they did not cope with a difficult customer. He or she will then be requested to identify the reasons why he or she could not cope. Thereafter they will be asked what they could have done to change their interaction with the difficult customers (if role playing a conflict situation between service provider and a difficult custom‐ er). The client in collaboration with the occupational therapist will then physically and practically role play a scenario where they expresses the desired behaviour to improve their interaction with the difficult customer. Feedback will then be given to the client regarding his or her behaviour and approach. The family and or other patients who have suffered from a brain injury could give feedback if this stage is done in a group set up. The client and the occupational therapist would then be responsible for setting up a work test placement with his existing employer. The work test placement will entail that the client perform the actual duties of his occupation under supervision of the occupational therapist who will be acting as a job coach. At this stage the employer or a designated person from the workplace could be present to ensure that the work is performed according to the required standard. The client's work performance would then be monitored with a schedule. The schedule would assist the occupational therapist in observing the client's occupational (work) behaviour, components of function (i.e. physical components of function and psychological components of function), his or her work endurance and productivity. After the work test placement which may be 1-3 days in duration, the results will be discussed with the client. The client and occupational therapist would engage in the reflective process where their opinions about their performance will be explored. Any problems or aspects that did not go well and aspects that did go well will be discussed. After the discussion the client and occupational therapist may have to explore the use of assistive devices in order to make the job easier, or consider workplace accommodation strategies and adaptation to workplace routines. Furthermore the client and occupational therapist may explore his or her legal rights within the workplace, possibly in the form of their right to work in a safe environment, their right to be reasonably accommo‐ dated in the workplace and their right to access disability pension benefits, if applicable. Based on the client's perceptions of their performance and realistic expectations they may choose to seek another form of employment to accommodate their current functional capacity.

During this stage the client would develop renewed confidence and knowledge of their ability to resume their occupational role as a worker. This paves the way for stage four which is the development of the client into a capable individual.

### **STAGE FOUR**

During this stage clients would be encouraged to undergo self reflection about the previous stages and about their ability to participate in the occupational role as a worker. The client ultimately would synthesize and internalize the actions that they undertook and skills that they learnt during the previous stages. He or she would be able to conceptualize his or her ability to overcome various barriers to participation in his or her worker role. It is important to take note of the model's dynamic and spiral nature. This means that a client could revert back to a previous level based on his ability to meet the challenges of the various stages. Ultimately this stage emphasizes an individual that has fully accepted their condition and that has developed a strong occupational efficacy to overcome various barriers to the worker role.

This stage is also described by prolonged participation in the satisfactory worker role whereby the client experiences meaning and fulfilment. There may be a positive interaction between the client and the environment, which may consist of the family system, work system and health system. During this stage the client would view themselves as capable and would be able to engage in the worker role with maximum independence. The occupational therapist`s role is gradually withdrawn. This process will be a unique experience for each client.

### **9. Guidelines for the operationalization of Occupational Self Efficacy: An occupational therapy practice model to facilitate returning to work after a brain-injury**

### **9.1. To facilitate a strong personal belief**

could initiate this process themselves. The client will be requested to demonstrate a problem‐ atic workplace scenario. For example, a client who had worked as a sales person may indicate that he or she has a problem in coping with difficult customers. The occupational therapist will request that the client verbalizes the actual workplace problem and will then advise him or her on various coping strategies that may assist him or her. The client will be asked to analyze the reasons why he or she struggled to cope with customers. Possible reasons could be a lack

The client will be asked to role play a scenario where they did not cope with a difficult customer. He or she will then be requested to identify the reasons why he or she could not cope. Thereafter they will be asked what they could have done to change their interaction with the difficult customers (if role playing a conflict situation between service provider and a difficult custom‐ er). The client in collaboration with the occupational therapist will then physically and practically role play a scenario where they expresses the desired behaviour to improve their interaction with the difficult customer. Feedback will then be given to the client regarding his or her behaviour and approach. The family and or other patients who have suffered from a brain injury could give feedback if this stage is done in a group set up. The client and the occupational therapist would then be responsible for setting up a work test placement with his existing employer. The work test placement will entail that the client perform the actual duties of his occupation under supervision of the occupational therapist who will be acting as a job coach. At this stage the employer or a designated person from the workplace could be present to ensure that the work is performed according to the required standard. The client's work performance would then be monitored with a schedule. The schedule would assist the occupational therapist in observing the client's occupational (work) behaviour, components of function (i.e. physical components of function and psychological components of function), his or her work endurance and productivity. After the work test placement which may be 1-3 days in duration, the results will be discussed with the client. The client and occupational therapist would engage in the reflective process where their opinions about their performance will be explored. Any problems or aspects that did not go well and aspects that did go well will be discussed. After the discussion the client and occupational therapist may have to explore the use of assistive devices in order to make the job easier, or consider workplace accommodation strategies and adaptation to workplace routines. Furthermore the client and occupational therapist may explore his or her legal rights within the workplace, possibly in the form of their right to work in a safe environment, their right to be reasonably accommo‐ dated in the workplace and their right to access disability pension benefits, if applicable. Based on the client's perceptions of their performance and realistic expectations they may choose to

seek another form of employment to accommodate their current functional capacity.

development of the client into a capable individual.

**STAGE FOUR**

During this stage the client would develop renewed confidence and knowledge of their ability to resume their occupational role as a worker. This paves the way for stage four which is the

During this stage clients would be encouraged to undergo self reflection about the previous stages and about their ability to participate in the occupational role as a worker. The client

of assertiveness or poor communication skills.

384 Traumatic Brain Injury

The following guidelines should be implemented in order to achieve the above objective:

### **9.2. To encourage the client's use of him or her self**

The following guidelines should be implemented in order to achieve the above objective:

### **9.3. To enhance competency through occupational engagement**

The following guidelines should be implemented in order to achieve the above objective:

### **9.4. To develop a capable individual**

The following guidelines should be implemented in order to achieve the above objective:

### **10. Application of the case study**

### **10.1. Case study 1**

**•** The occupational therapist should have good communication skills, problem solving skills, negotiation skills, empathy and be transparent. He or she should be a role model to the brain

**•** In addition to the role of a facilitator the occupational therapist would act as a case manager in that he or she would have to be able to provide the participant with choices relating to

**•** Furthermore the occupational therapist, in their role in the medical team would facilitate a

The following guidelines should be implemented in order to achieve the above objective:

**•** The occupational therapist will continue to act in his or her role as a facilitator and the

**•** Client centred practice will enable the client and therapist to identify various needs that will enhance competency in occupational roles. For example, if there is a need to improve the client`s life skills such as coping skills or assertiveness skills then this will be a focus of

**•** The occupational therapist will continue to act as a case manager in that he or she would enable the client to identify and utilize resources that will enable him or her to resume their worker roles. The occupational therapist will put the client into contact with stakeholders such as the employer, relevant people in the medical sector and family members as this will

**•** Supportive employment workshops will be held with the client and his employer whereby gradual return to work will be emphasized. During this process the client and occupational therapist will identify further needs that the client may require such as the use of compen‐

**•** Work test placement with the client's previous employer will be initiated and workplace

The following guidelines should be implemented in order to achieve the above objective:

**•** Self reflection pertaining to the client`s performance in work related tasks should be

**•** Prolonged participation in the occupational role as a worker should be encouraged and positive interaction/communication between the client, environment, worker and family

**•** Transformation of the client into a capable person, who would be able to participate in the

worker role with maximum independence, is the final goal.

injured individual.

386 Traumatic Brain Injury

intervention.

emphasized

should continue

continued rehabilitation or return to work.

**9.3. To enhance competency through occupational engagement**

participant will be guided into participation in his or her worker role.

client centred approach to intervention.

form a base for long term support.

satory equipment or techniques.

**9.4. To develop a capable individual**

accommodation should be encouraged

J.K. Is a 20 year old female who suffered a moderate brain injury at the age of three, a taxi driver lost control of his vehicle and drove into JK who was walking with her mother on a pavement. She has a Grade 11 level of education which she completed at a school for children with physical and mental disabilities. JK lived with her parents and 3 siblings in a low socio economic area, both her parents were unemployed and the family was dependent on a government support grant. As JK was injured while being a pedestrian, she qualified to have compensation from the South African Road Accident Fund. This compensation was +/- R1000 (equivalent to U\$100) per month.

Results: Individual is currently employed for 8 months at a Fast Food Restaurant.

	- Ranchos Los Amigos scale VIII

–**Introspection**, Gibbs reflection cycle- Initially it was very difficult to get JK to trust the health therapist as she was protected by her parents all her life. The health therapist had to arrange intervention sessions with JK at her home as well as at the restaurant where she was going to work. It was difficult to get JK to attend the sessions on her own initially as she did not feel competent in using transport independently. The type of questions asked included: Describe the incident, 2) Practically how has the incident changed your life/ circumstances? 3) Emotionally, do you think that your ability to do tasks is different when compared to your ability to do tasks before the accident?

– JK slowly responded to the questions and really had to introspect and accept what had happened to her and focus on improving her work skills. JK decided that she would want to work in the food retain industry. She initially wanted to work in a bakery where she could bake and prepare various delicacies.

**• Stage 2** To encourage the client's therapeutic use of him or her self

– Introspection continued: During stage to JK and the health therapist focused on improving her work skills such as numeracy and comprehensive ability. Furthermore JK was walking with an "abnormal gait" as a result of the TBI. The health therapist had to assess whether JK`s abnormal gait was going to affect her ability to initiate tasks such as standing for more than 30 minutes and walk over short distances while carrying weights and trays. At this stage it was felt that no further rehabilitation was going to improve her gait and that compensatory measures had to be used by the participant. These compensatory measures included the use of memorization/visualization techniques, whereby JK had to remind herself about the pace at which she was walking, the structural barriers such as steps in the workplace, distances between restaurant tables, danger of certain equipment example stoves and fryers, distance of transportation pick up points for employees of the etc.

– During this stage the health therapist acted in the capacity of a case manager the aim was for the client to take responsibility for his or her own rehabilitation.

**• Stage 3**: To enhance competency through occupational engagement

– Focus on the occupational area of work. During this phase the health therapist and JK focused on improving JK`s work skills such as coping skills, problem solving skills, use of transport, money management, setting up a CV, basic work abilities (social presentation, communication skills, ability to work an 8 hour work shift) and in-service-training. During this stage the client (JK) was asked to reflect back onto her initial goals i.e. working in a food retail or fast food restaurant environment. The health therapist and JK identified the requirements of working in a super market and a fast food store. A job analysis was performed whereby the physical layout of the workplace, equipment used, hours worked and job tasks were explored in detail. The health therapist communicated with possible employers in the food retail industry in order to provide JK with a work experience opportunity. JK was provided with an opportunity to work for 5 hours initially in order to determine how she will cope in the new work environment. A meeting was set up with the restaurant manager, JK and her mother, and the health therapist. The type of work duties, hours of work as well as what should be done if a problem occurs. During stage two, the health therapist arranged a meeting with staff members of the restaurant in order to prepare them for the arrival of JK.

– The type of intervention used before the provision of the work experience included role plays of different problems that could occur in the work place. These roles plays helped improve the client`s life skills such as coping skills, problem solving skills and assertiveness. Her work performance was monitored with a work schedule (see Appendix 1), the work schedule could give the client a visual concrete view of how their performance was improving during the work skills training process. During this period of time, the client worked reduced hours initially, she also only worked day shifts, however as her confidence and skills improved, her work hours increased and she was allowed to work night shift duty. The client was provided with weekly supervision initially thereafter, the supervision was decreased to twice monthly.

**• Stage 4**: To develop a capable individual

– During this phase the client was requested to undergo self reflection about the previous phases (i.e. she internalised the skills that she learned). She was asked to identify how her work skills and confidence improved during the four phases. JK indicated that she was able to use transport independently, she was able to work any work shift provided and that she has mastered most of the work tasks in the fast food restaurant. She also indicated that she would follow a systematic problem solving process should she experience any difficulty at work e.g. write down the difficult problem that she experienced and explore options of solving it. The supervision process was reduced to once every three months with on- going telephonic supervision when required. At the end of one year the supervision was drasti‐ cally reduced as the client did not require constant supervision.

### **10.2. Case study 2**

– During this stage the health therapist acted in the capacity of a case manager the aim was

– Focus on the occupational area of work. During this phase the health therapist and JK focused on improving JK`s work skills such as coping skills, problem solving skills, use of transport, money management, setting up a CV, basic work abilities (social presentation, communication skills, ability to work an 8 hour work shift) and in-service-training. During this stage the client (JK) was asked to reflect back onto her initial goals i.e. working in a food retail or fast food restaurant environment. The health therapist and JK identified the requirements of working in a super market and a fast food store. A job analysis was performed whereby the physical layout of the workplace, equipment used, hours worked and job tasks were explored in detail. The health therapist communicated with possible employers in the food retail industry in order to provide JK with a work experience opportunity. JK was provided with an opportunity to work for 5 hours initially in order to determine how she will cope in the new work environment. A meeting was set up with the restaurant manager, JK and her mother, and the health therapist. The type of work duties, hours of work as well as what should be done if a problem occurs. During stage two, the health therapist arranged a meeting with staff members of the restaurant in order to prepare

– The type of intervention used before the provision of the work experience included role plays of different problems that could occur in the work place. These roles plays helped improve the client`s life skills such as coping skills, problem solving skills and assertiveness. Her work performance was monitored with a work schedule (see Appendix 1), the work schedule could give the client a visual concrete view of how their performance was improving during the work skills training process. During this period of time, the client worked reduced hours initially, she also only worked day shifts, however as her confidence and skills improved, her work hours increased and she was allowed to work night shift duty. The client was provided with weekly supervision initially thereafter, the supervision

– During this phase the client was requested to undergo self reflection about the previous phases (i.e. she internalised the skills that she learned). She was asked to identify how her work skills and confidence improved during the four phases. JK indicated that she was able to use transport independently, she was able to work any work shift provided and that she has mastered most of the work tasks in the fast food restaurant. She also indicated that she would follow a systematic problem solving process should she experience any difficulty at work e.g. write down the difficult problem that she experienced and explore options of solving it. The supervision process was reduced to once every three months with on- going telephonic supervision when required. At the end of one year the supervision was drasti‐

cally reduced as the client did not require constant supervision.

for the client to take responsibility for his or her own rehabilitation.

**• Stage 3**: To enhance competency through occupational engagement

them for the arrival of JK.

388 Traumatic Brain Injury

was decreased to twice monthly.

**• Stage 4**: To develop a capable individual

### **Application of the case study**

S.S is a 24 year old male who suffered a moderate brain injury at the age of 20, he sustained a stab wound to the head by gangsters. SS has a Grade 12 level of education and was going to study at a local University. Due to the extent of his injury, he decided to rather discontinue schooling in order to recover and find employment. After participating in physiotherapy and occupational therapy intervention, SS tried to find employment, however was unsuccessful. Due to him struggling with comprehension and numeracy skills he struggled to obtain work that required administrative skills. SS was dependent on a disability grant which is equivalent to U\$100. SS is single but has 2 dependents, he is currently living in a low socio economic area. SS has had no formal work training prior to the injury, however he reported that he was working at a fast food restaurant as a general assistant.

Results: Individual is currently employed for 8 months at a Fast Food Restaurant.

	- Ranchos Los Amigos scale VIII

–**Introspection**, Gibbs reflection cycle- During the stage of reflection and introspection, SS clearly indicated that he wanted to improve his employability skills by improving his level of education. He felt that he would not be able to resume employment in a "well paid" job without a tertiary qualification. However during the work skills assessment it was obvious that he needed intense remediation regarding his reading and writing skills. The type of questions asked included: Describe the incident, 2) Practically how has the incident changed your life/ circumstances? 3) Emotionally, do you think that your ability to do tasks is different when compared to your ability to do tasks before the accident?

– SS responded openly to the questions and it was clear that he was determined to find employment in the Open Labour Market. As SS was determined to improve his work skills, he was informed of the possibility of completing a short course in the area of entrepreneur‐ ship with the South African Department of labour. As an incentive to complete the course he was provided with a monthly stipend of U\$200 in addition to his disability grant. The initial intervention sessions took place in a hospital environment.

**• Stage 2** To encourage the client's therapeutic use of him or her self

– Introspection continued: During stage to SS was provided with the details of the short course especially the duration of the course as well as where the course was going to be offered. He was encouraged to make contact with the service provider and ask questions related to the course. This would therefore enable him to take responsibility for improving his own work skills. After engaging in tasks such as developing a CV, doing simulated administrative tasks (arranging files and post alphabetically) and doing inventory related work such as collecting stock from shelves and placing stock on shelves using a product list; he increased his confidence to engage in administrative tasks. SS successfully completed the entrepreneurship short course with the Department of labour over a period of 12 months. Some of the questions asked to the participants during this phase included: 1) How did you find the rehabilitation experience so far? 2) What in your opinion was beneficial and not relevant about the experience, 3) How do you think you could use what you were taught practically in a work experience or at home? 4) Do you think you have improved as a worker?

**• Stage 3**: To enhance competency through occupational engagement

– Focus on the occupational area of work. During this phase the health therapist and SS focused on providing SS with a work experience and integrating him into the Open labour market. A company that manufactures soft drinks indicated that they were willing to provide him with this work experience over a period of 2 months. An initial meet‐ ing was arranged with the staff members and Human Resource manager of the compa‐ ny. The purpose of the project was explained as well as there was a discussion that focused on the fears that staff had in working with individuals who was diagnosed with a brain injury. This initial discussion with staff members was fruitful in that in im‐ proved the insight of staff members regarding the strengths and limitations of individu‐ als with brain injury.

His work tasks included operating a conveyor belt as well as separating poor quality bottles from good quality bottles. He also had to keep a schedule of the amount of bottles packed into crates and had to collect raw material from the company stores. The health therapist regularly contacted the line manager in order to monitor SS`s work performance. His work performance was measured according to the company work performance chart. As he performed at the same level as his colleagues, this enhanced the confidence of SS as he could measure his own work standards to the standards required in the Open Labour Market. In terms of the work shifts, SS was only required to work night shifts.this period of time, the client worked reduced hours initially, however as his confidence and skills improved, his work hours increased and he was allowed to work night shift duty. The client was provided with weekly supervision initially thereafter, the supervision was decreased to once monthly.

**• Stage 4**: To develop a capable individual

– During this phase the client was requested to undergo self reflection about the previous phases (i.e. he internalised the skills that she learned). He was asked to identify how his work skills and confidence improved during the four phases. SS indicated that he was able to use transport independently, that he completed the training course successfully and that he can relate to work related tasks. He could use transport independently, he was able to work any work shift provided and that transport was made available at the end of their night shift. She also indicated that she would follow a systematic problem solving process should she experience any difficulty at work e.g. write down the difficult problem that she experienced and explore options of solving it. The supervision process was reduced to once every three months with on- going telephonic supervision when required. At the end of one year the supervision was drastically reduced as the client did not require constant supervision. SS was offered a 12 month contract at the soft drink company.

### **11. Conclusion**

Some of the questions asked to the participants during this phase included: 1) How did you find the rehabilitation experience so far? 2) What in your opinion was beneficial and not relevant about the experience, 3) How do you think you could use what you were taught practically in a work experience or at home? 4) Do you think you have improved as a worker?

– Focus on the occupational area of work. During this phase the health therapist and SS focused on providing SS with a work experience and integrating him into the Open labour market. A company that manufactures soft drinks indicated that they were willing to provide him with this work experience over a period of 2 months. An initial meet‐ ing was arranged with the staff members and Human Resource manager of the compa‐ ny. The purpose of the project was explained as well as there was a discussion that focused on the fears that staff had in working with individuals who was diagnosed with a brain injury. This initial discussion with staff members was fruitful in that in im‐ proved the insight of staff members regarding the strengths and limitations of individu‐

His work tasks included operating a conveyor belt as well as separating poor quality bottles from good quality bottles. He also had to keep a schedule of the amount of bottles packed into crates and had to collect raw material from the company stores. The health therapist regularly contacted the line manager in order to monitor SS`s work performance. His work performance was measured according to the company work performance chart. As he performed at the same level as his colleagues, this enhanced the confidence of SS as he could measure his own work standards to the standards required in the Open Labour Market. In terms of the work shifts, SS was only required to work night shifts.this period of time, the client worked reduced hours initially, however as his confidence and skills improved, his work hours increased and he was allowed to work night shift duty. The client was provided with weekly supervision initially thereafter, the supervision was

– During this phase the client was requested to undergo self reflection about the previous phases (i.e. he internalised the skills that she learned). He was asked to identify how his work skills and confidence improved during the four phases. SS indicated that he was able to use transport independently, that he completed the training course successfully and that he can relate to work related tasks. He could use transport independently, he was able to work any work shift provided and that transport was made available at the end of their night shift. She also indicated that she would follow a systematic problem solving process should she experience any difficulty at work e.g. write down the difficult problem that she experienced and explore options of solving it. The supervision process was reduced to once every three months with on- going telephonic supervision when required. At the end of one year the supervision was drastically reduced as the client did not require constant supervision. SS was offered a 12 month contract at the soft drink

**• Stage 3**: To enhance competency through occupational engagement

als with brain injury.

390 Traumatic Brain Injury

decreased to once monthly.

company.

**• Stage 4**: To develop a capable individual

The model of Occupational Self Efficacy could be used in both a private and public hospital or rehabilitation setting. It could also be implemented in the homes or workplaces of the clients. The model could used in conjunction with other treatment modalities such as biomedical and cognitive rehabilitation approaches. Furthermore the model focuses on using reflection and improving self efficacy beliefs through engagement in work related tasks. Inevitable the model seeks the bridge the gap from rehabilitation and returning to work. Finally the model provide a step by step process for developing occupational self efficacy and resuming the worker role of the individual with the brain injury.

### **Appendix**

#### **WORK ABILITY SCREENING TOOL**

Returning Individuals with Mild to Moderate Brain Injury Back to Work: A Systematic Client Centered Approach http://dx.doi.org/10.5772/57309 393

Ability to recognise errors

Ability to correct errors

Ability to handle criticism

supervisors in the unit

Ability to fulfil a supervisor role

Ability to follow verbal instructions

Co – operation

392 Traumatic Brain Injury

Demonstrated

Ability to listen Comprehension Interpretation

prompts of the assessor

Orientation to work area

Ability to start the task Tolerance to maintain task Ability to complete task Ability to retain task

Efficiency Ergonomics

activity

Written Illustrated

General social interaction with co- workers and

Ability to follow and execute instructions 1-3 steps Ability to follow and execute instructions 1-6 steps

Accurate execution of instructions with minimal or no

Planning of work area in relation to structuring

Practical planning of the work task in relation to steps of

**WORK COMPTENCY AND SKILLS**

**INSTRUCTION RETENTION**

**TASK PLANNING AND EXECUTION**

**TASK COMPLETION**

*Date:* Remarks

*Date* Remarks

*Date:* Remarks

*Date:* Remarks

### **Author details**

Shaheed Soeker\*

Address all correspondence to<EMAIL_ADDRESS>
Occupational Therapy Department, University of the Western Cape, South Africa

### **References**

[8] Vuadens,P. & Arnold,P & Bellmann,A. Return to work after a traumatic brain injury-Vocational Rehabilitation. Pari: Springer Paris; 2006.

Packing- assembly- inspecting Physical/ manual labour tasks

General comments (if any):

**Author details**

Shaheed Soeker\*

**References**

2001.

2010.

Hours lapsed to reach above quantity

Address all correspondence to<EMAIL_ADDRESS>
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396 Traumatic Brain Injury

**Cognitive Impairment in Traumatic Brain Injury**

## **Understanding, Assessing and Treating Prospective Memory Dysfunctions in Traumatic Brain Injury Patients**

Giovanna Mioni, Shawn M. McClintock and Franca Stablum

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/57307

### **1. Introduction**

Our capacity to shape and direct our future behaviour is of fundamental importance in the development, pursuit, and maintenance of independence and autonomy from early childhood to late adulthood. A cognitive ability required for those functions is prospective memory (PM), which is the ability to form and remember to prospectively perform the intended action [1, 2]. Researchers have extensively focused on PM impairment in patients with traumatic brain injury (TBI) [3]. However, there has been limited research into the assessment and treatment of PM impairment in TBI patients. Reliable and valid tests with normative data are necessary for health professionals working with people with PM impairments. This chapter reviews the principal findings on PM impairment in TBI patients, and the main procedures used to assess and rehabilitate PM.

### **2. Prospective Memory**

Prospective Memory (PM) refers to the cognitive ability to form and remember to perform an intended action at a specific moment in the future [1, 2]. That cognitive ability is essential for many daily activities, such as remembering to pick up something at the market after work, send a gift for a birthday, or call a friend at a specific time. Although past researchers tended to characterize PM as a unitary process, it is very complex and comprised of various compo‐ nents [4]. For example, consider the situation in which a principal asks a teacher to relay a message to a student. The teacher has committed him/herself to two memory tasks: one is to remember the content of the message, and the second is to deliver it as soon as he/she sees the

© 2014 Mioni et al.; licensee InTech. This is a paper distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

student. Remembering the content of a PM task is essential to perform the PM task, which researchers refer to as the *content* of a PM task (*retrospective component*). However, remembering only the content of the PM task will not produce successful performance. The action must also be performed at the appropriate moment in the future. This is referred to as the *prospective component* of PM tasks. Thus, a critical aspect to success on PM tasks is not only recalling the content of the intended action, but also performing the action at the appropriate moment in the future [4].

A four stages model has been proposed to explain the functioning of PM [1, 4-6]:

A fifth phase, *Evaluation of outcome* was proposed and is concerned with monitoring the output of the execution of the intended action*.* The evaluation of outcome describes the process by which a person checks if the intended action has been accurately performed [1].

According to Einstein and McDaniel's model [12], there are two types of PM targets, eventbased and time-based tasks1 , that trigger the execution of our delayed intention. In conditions that require event-based PM, a person performs an action when a specific event occurs (i.e. passing a message when a friend calls); while in situations that require time-based PM, the action has to be performed at a specific time in the future (i.e. remembering the appointment with a friend at 4:00 p.m.) [12]. Event-based PM tasks are considered to be less cognitively demanding than time-based PM tasks because they require less self-initiated retrieval and external cue(s) are available to help recall the task [13, 14].

### **2.1. Prospective memory in traumatic brain injury patients**

student. Remembering the content of a PM task is essential to perform the PM task, which researchers refer to as the *content* of a PM task (*retrospective component*). However, remembering only the content of the PM task will not produce successful performance. The action must also be performed at the appropriate moment in the future. This is referred to as the *prospective component* of PM tasks. Thus, a critical aspect to success on PM tasks is not only recalling the content of the intended action, but also performing the action at the appropriate moment in

**1.** *Intention formation* - the first phase consists on the formation of the delayed intention, which often involves forming a plan. Different degrees of motivation may influence the strength of encoding the delayed intention. In fact, the strength of an intention may reflect not only the personal importance, but also the potential benefits and costs of realizing the

**2.** *Intention retention* - the retention intervals describe the delay between the formation of and execution of the intended action. The retention interval, most of the time, is filled with an "ongoing task" [7]. Some authors found lower performance after a long relative to a short delay [8], though others failed to find an association between delay length and decline [9, 10] or improvement in performance [11]. In addition to the length of the delay interval, the cognitive load added during the delay interval (filled or un-filled intervals) may

**3.** *Intention initiation* - the point in time at which execution of the intention is (or should be) initiated. Successful performance on PM tasks, not only required to accurately encode the intended action and maintain the intended action active during the interval delay, but also to recognize the cue, retrieve the action associated with that intention, and perform the action. People may fail on their performance not only because they fail to recall the intended action when the target occurs, but also because their cognitive resources were

**4.** *Intention execution -* where and when the intended action is executed. This may be considered the final stage with the execution of the delayed intention. However, success‐ fully completing all previous phases, errors can occur and the delayed intention may not be performed. Distractions or failure to complete the task due to external circumstances may compromise performance. For example, the intention to phone a friend may fail because of interruption by the doorbell or the friend was not at home. When the delayed intention is not executed, it is necessary to re-establish the intended action and re-form

A fifth phase, *Evaluation of outcome* was proposed and is concerned with monitoring the output of the execution of the intended action*.* The evaluation of outcome describes the process by

According to Einstein and McDaniel's model [12], there are two types of PM targets, event-

that require event-based PM, a person performs an action when a specific event occurs (i.e.

, that trigger the execution of our delayed intention. In conditions

which a person checks if the intended action has been accurately performed [1].

A four stages model has been proposed to explain the functioning of PM [1, 4-6]:

the future [4].

402 Traumatic Brain Injury

delayed intention.

the plan [1].

based and time-based tasks1

influence performance [7, 9].

captured by the demands of the ongoing task.

It has been suggested that the prefrontal cortex predominantly mediates executive control mechanisms [15], which are required to successfully initiate and execute the intended action [5, 13, 14, 16]. Because of this link between executive functions and the prefrontal cortex, and because prefrontal areas are commonly damaged after a TBI, it is not surprising that individ‐ uals with TBI are often impaired on PM tasks [3]. For individuals with TBI, frequent PM failures (e.g., forgetting to repay a loan to a friend, maintain an appointment, take medication, turn off the stove) can be frustrating, embarrassing and in some cases, life threatening. These failures have the potential to limit the independence of these individuals, causing them to rely on a carer for prompting and completion of activities and instrumental activities of daily living. Moreover, these failures may affect their opportunity to return to work or start a new vocation [3, 17, 18].

Impairment of PM in TBI patients would differ according to the complexity and requirement of the tasks [7, 19]; moreover, when tested both on event- and time-based tasks, TBI patients are particularly impaired on time-based tasks consistent with the idea that those tasks require more self-initiation. Dysfunctions on time-based tasks may also be due to less strategic monitoring behaviour engaged by TBI patients [1, 4, 16].

The earliest studies that examined the effect of TBI on PM performance used self-rating scales [20] or few PM items [21, 22]. In those studies, the Prospective Memory Question‐ naire (PMQ) was tested along with attentional and memory tasks [20]. Adults with TBI and older adults performed more poorly than younger adults on short-term PM tasks, and TBI patients rated themselves more poorly than younger adults. Two PM tasks were used to assess PM performance [22]: the first task involved telling the participants about a selfreport memory questionnaire at the beginning of an assessment session and instructing them to ask for the questionnaire at the end of the session (even-based task). The second task involved asking the participants to return (by mail) an evaluation form with the date written in the top corner (time-based task). Because of the small number of items used and the correct/incorrect nature of these items, the PM scores obtained with these tasks were limited in range and thus were unreliable [23].

To assess PM more reliably and accurately, it is necessary to increase either the number of items used or the number of responses required for each item. Recent studies considered these limitations and developed more appropriated tasks to investigate the effects of TBI on eventand time-based PM performance (Table 1).

<sup>1</sup> A third prospective remembering task, called, activity-based [1]. An activity-based prospective memory task required to carry out an intended action at the end of an activity (i.e., torn off the oven when you have finished cooking).

1 Studies included here have been conducted with behavioral measures.

**TBI characteristics Type of prospective memory tasks**

WCST, COWAT and DASS

TOL, COWAT and LNST

Verbal intelligence and WCST

Digit span forward and backward, TMT, LM Visual recognition, COWAT, Stroop, WCST

Visual (Story sub-test, RAVLT) and verbal (Pictures, Faces and Routes sub-tests of RBMT) declarative memory, digit span, TMT, COWAT and WCST

TMT, COWAT and metacognitive variables

**NPS assessment2, 3 Event-based Time-based**

Response to questions and the target word

Deliver a message (unfilled and filled conditions)

Response to a cue (low and high cognitive demand)

Perform actions when the target appeared (relatedunrelated cues) (10 vs. 45 min delay)

> Complex tasks following the multiprocess model

Press a designed key on focal cue or peripheral cue

RBMT

Response to a cue (one or four cue targets)

Press a key every 5 min and monitor the time

Stop the timer after 5 min (unfilled and filled conditions)

Perform actions after the interval (relatedunrelated cues) (10 vs. 45 min delay)

Stop a timer and send the envelop

CAMPROMPT CAMPROMPT

**Time since injury (months)**

8 or less 24.58 (15.58) -

8 or less 108 -

6.6 (3.3) 1.8 (0.7)

3 to 15 9.71 (7.5)

severe 41.71 (11.79)

8 or less 25.75 (21.63)

8 or less 7

7.08 (3.89) -

11.67 (3.50) 41.28 (32.52) -

**Study1 Year Sample GCS**

12 TBI and 12 controls

13 TBI and 13 controls

14 TBI and 14 controls

16 TBI and 16 controls

7 TBI, 21 older and 19 younger controls

24 TBI and 24 controls

25 TBI and 25 controls

17 TBI and 16 controls

44 TBI but no controls

**[25]** 1999

404 Traumatic Brain Injury

**[26]** 2001

**[28]** 2003

**[11]** 2004

**[19]** 2004

**[29]** 2004

**[27]** 2005

**[7]** 2007

**[18]** 2008

2 References of neuropsychological tests are not reported because the authors referred to different versions. Please refer to the specific articles for the appropriate references.

3 Appendix A reports the full name of neuropsychological tasks employed in the studies with a brief description.

**Table 1.** Studies that used behavioural tasks to investigate PM performance on TBI patients. GCS = Glasgow Coma Scale (Scores < 8 = severe; scores 9-12 = moderate; scores 13-15 = mild); Time refers to the time post injury (months); NPS assessment refers to the neuropsychological tasks included in the studies; WCST = Wisconsin Card Sorting Test; COWAT = Controlled Oral Word Association Test; DASS = Depression, Anxiety, Stress Scale; TOL = Tower of London; LNST = Letter-Number Sequencing Test; TMT = Trial Making Test; RBMT = Rivermead Behavioural Memory Test; CAMPROMPT = Cambridge Behavioural Prospective Memory Test; MIST = Memory for Intention Screening Test.

Among the studies identified2 , only one included patients with mild TBI [24]. Most studies included have evaluated event-based PM performance, 6 examined both event- and timebasedperformance, andone only analyzedtime-basedPMperformance.When both event- and time-based tasks were included in the studies, TBI patients obtained lower performance on time-based PM tasks [11, 25-27], which substantiated that time-based tasks are more difficult to executeprobablydue to more self-initiatedretrieval impairment[12].Generally,TBIpatients showed PM dysfunctions compared to healthy controls, but the degree of impairment varied according to the characteristics of the employed tasks. By varying the cognitive demand on the ongoingtaskTBIpatientsperformedmorepoorlythancontrolsonthehigh,butnotlowdemand condition [28]. Some authors also manipulated the salience of the event cue in PM perform‐ ance [29]. The cue was either integrated (focal cue) or peripheral (no-focal cue) to the ongoing working memory task. TBI patients and controls showed no differences on the ongoing task, but PM performance was poorer in TBI patients in both focal and peripheral cue conditions. That finding suggested that even with highly salient cues, TBI patients exhibit PM failures. Moreover, both TBI and controls self-reported that greater monitoring effort was required for the peripheral, rather than for the focal-cue condition. Instead, when the cue is maintained in a focal condition, but is varied the number of distractions during the ongoing task, TBI patients performed more poorly both on one and four target conditions [7]. Finally, some authors have varied the delay between encoding and task performance (10 vs 45 min) expecting lower performance in the longer delay condition. Researchers have also manipulated the functional link (semantic inter-item associative link) between intended actions with the expectation that

<sup>2</sup> Studies were included if conducted with TBI patients and match controls. Research was conducted on Psychinfo and PubMed with key words: "Prospective Memory", "Traumatic brain injury", "Event-based" and "Time-based".

performance would improve. Patients with TBI performed significantly lower than controls; however, there were no significant effects of delay interval or functional link of the intended actions [11].

A subset of studies included executive functions tasks to determine whether impairment on PM was associated with executive dysfunctions. The available evidences were mixed regard‐ ing the relationship between PMandexecutive functions, as some studies found significant[16, 22, 28] and others no [27] association between those two constructs. For example, we found [16] that working memory significantly correlated with PM accuracy only in TBI patients, while inhibition was involved in controls. Also, working memory significantly correlated with PM performance in the low cognitive demand condition in both TBI and controls [28]. These results suggested that for the employed dual-task event-based paradigm, participants had to active‐ ly maintain in memory the requirement while undertaking the ongoing task [16, 28]. Spontane‐ ous flexibility assessed through the Controlled Oral Word Association Test (COWAT) [30] significantly correlated withevent-basedPMperformance inthehigh-demandconditioninTBI patients. TBI event-based PM performance significantly correlated with attention/speed processing tasks, which added further support to the notion of a strong relationship between attention and PM performance [29, 31]. In particular, the authors pointed out that those PM dysfunctionsmaybeduetomomentarylapsesofattentiontotaskdetails ratherthantocomplete forgettingofthetaskinstructions.Retrospectivememoryalsoaccountedforasignificantamount of variance in PM tasks of TBI patients independent of executive functions [25]. In particular, it was found that executive functions were involved both on time- and event-based PM perform‐ ance,butitparticularlyinfluencedtime-basedPMperformance,whereas retrospectivememory contributed most to event-based performance. Finally, a complex PM paradigm was adopted [19, 32] to investigate which of the four phases of PM were affected in TBI patients. Impair‐ ment of PM was found on intention formation, intention re-instantiation, and intention execution. That finding confirmed that executive functions are involved on these three phases ratherthanonlyonintentionretention.Onlyonestudyinvestigatedtheinvolvementoftemporal abilities in time-based PM performance and found that adequate temporal abilities were involved in monitoring behavior rather than PM [16].

In addition, two studies have investigated PM performance according to demographic, clinical and metacognitive variables [18, 25]. Depressive symptoms were found to adversely affect successful performance on the timing component of the time-based task [20], while anxiety symptoms adversely affected performance on event-based tasks [25]. In a more recent study, the localization of the damage (mainly frontal) significantly correlated with event-based Cambridge Test of Prospective Memory (CAMPROMPT) scores, whereas duration of post‐ traumatic amnesia (PTA) and metacognitive variables significantly correlated with both timeand event-based scores [18].

### **2.2. Virtual tasks to investigate prospective memory in TBI patients**

For adequate clinical assessment and rehabilitation programs, neuropsychologists need information about how a patient functions in routine daily activities, and laboratory-based tasks may be unable to always provide such information [33]. Chaytor and Schmitter-Edgecombe (2003) found that the relationship between neuropsychological tests and measures of outcome is often limited. Recently, it was concluded that most PM tasks lack adequate reliability [23]. As a consequence, it is often impossible to translate test scores into either goals for rehabilitation or conclusions about the level of impairment; that is, many conventional tests of memory-related abilities lack ecological validity [23, 33, 34]. To solve this important discrepancy between performance on neuropsychological tests and performance in everyday life, researchers, following the evolution of computer programs, have developed tasks that can bridge conventional neuropsychological tests with behavioral observations. Virtual tasks, in fact, can simulate the activity of everyday life in a controlled setting [33].

performance would improve. Patients with TBI performed significantly lower than controls; however, there were no significant effects of delay interval or functional link of the intended

A subset of studies included executive functions tasks to determine whether impairment on PM was associated with executive dysfunctions. The available evidences were mixed regard‐ ing the relationship between PMandexecutive functions, as some studies found significant[16, 22, 28] and others no [27] association between those two constructs. For example, we found [16] that working memory significantly correlated with PM accuracy only in TBI patients, while inhibition was involved in controls. Also, working memory significantly correlated with PM performance in the low cognitive demand condition in both TBI and controls [28]. These results suggested that for the employed dual-task event-based paradigm, participants had to active‐ ly maintain in memory the requirement while undertaking the ongoing task [16, 28]. Spontane‐ ous flexibility assessed through the Controlled Oral Word Association Test (COWAT) [30] significantly correlated withevent-basedPMperformance inthehigh-demandconditioninTBI patients. TBI event-based PM performance significantly correlated with attention/speed processing tasks, which added further support to the notion of a strong relationship between attention and PM performance [29, 31]. In particular, the authors pointed out that those PM dysfunctionsmaybeduetomomentarylapsesofattentiontotaskdetails ratherthantocomplete forgettingofthetaskinstructions.Retrospectivememoryalsoaccountedforasignificantamount of variance in PM tasks of TBI patients independent of executive functions [25]. In particular, it was found that executive functions were involved both on time- and event-based PM perform‐ ance,butitparticularlyinfluencedtime-basedPMperformance,whereas retrospectivememory contributed most to event-based performance. Finally, a complex PM paradigm was adopted [19, 32] to investigate which of the four phases of PM were affected in TBI patients. Impair‐ ment of PM was found on intention formation, intention re-instantiation, and intention execution. That finding confirmed that executive functions are involved on these three phases ratherthanonlyonintentionretention.Onlyonestudyinvestigatedtheinvolvementoftemporal abilities in time-based PM performance and found that adequate temporal abilities were

In addition, two studies have investigated PM performance according to demographic, clinical and metacognitive variables [18, 25]. Depressive symptoms were found to adversely affect successful performance on the timing component of the time-based task [20], while anxiety symptoms adversely affected performance on event-based tasks [25]. In a more recent study, the localization of the damage (mainly frontal) significantly correlated with event-based Cambridge Test of Prospective Memory (CAMPROMPT) scores, whereas duration of post‐ traumatic amnesia (PTA) and metacognitive variables significantly correlated with both time-

For adequate clinical assessment and rehabilitation programs, neuropsychologists need information about how a patient functions in routine daily activities, and laboratory-based tasks may be unable to always provide such information [33]. Chaytor and Schmitter-Edgecombe (2003) found that the relationship between neuropsychological tests and measures

involved in monitoring behavior rather than PM [16].

**2.2. Virtual tasks to investigate prospective memory in TBI patients**

and event-based scores [18].

actions [11].

406 Traumatic Brain Injury

1 References of neuropsychological tasks are not reported because the authors referred to different version of the tasks. Please refer to the specific articles for the appropriate references.

2 The study includes 3 patients with brain injury: SR suffered a severe TBI as a result of assault, TJ suffered a TBI as a result of motor vehicle accident and RW suffered cerebellar and sub-arachnoid haemorrhages. Only information on patients SR and TJ were included because TBI patients.

**Table 2.** Studies that used ecological tasks to investigate PM performance on TBI patients. GCS = Glasgow Coma Scale; NPS assessment refers to the neuropsychological tasks included in the studies; NART = National Adults Reading Test; WCST = Wisconsin Card Sorting Test; LM = Logic Memory; COWAT = Controlled Oral Word Association Test; TMT = Trial Making Test; WMS = Wechsler Memory Scale; DEX = questionnaire from the Behavioural Assessment of Dyexecutive Syndrome; HVLT = Hopkins Verbal Learning Test.

In Table 2 are revised studies that were conducted with virtual tasks. This literature is presented separately from other studies on PM because it is more representative of everyday PM performance, and focused on filling the gap between performance on laboratory tasks and PM performance in real life.

The Prospective Remembering Video Procedure (PRVP) was designed to test PM abilities in virtual street simulation [35]. The task involves remembering to carry out a set of activities while watching a videotape filmed by a person walking slowly through a shopping complex. Participants virtually visited a shopping centre, with a set of event-based activities, each of which involved an action (`buy a record') and a cue (`from the record stand'). As each cue comes into view, the associated action must be recalled. The view that was presented focused mostly on the shop-front, although the footage also included views of passengers crossing the street. Studies conducted with health students and mix-brain injury patients demonstrated that the PRVP procedure was reliable and easier to complete when the video was set in a familiar location. Moreover, it was found that the video-based task was correlated with performance on an equivalent real life memory task, and provided evidence for criterion validity [35, 36, 37]. Twenty severe TBI patients and 20 matched controls were also tested with PRVP and completed the ongoing and PM tasks while "walking" along the street. Severe TBI patients showed poorer performance and were more affected by distractions on the PM tasks compared to controls [38]. Previous findings were confirmed and extended with a Virtual Street task [37, 38, 39]. Results showed that TBI patients performed more poorly than the control group on the PM tasks, but had similar performance on the Wechsler Memory Scale (3rd Edition) Logical Memory subtest. The authors discussed this result in favor of sensitivity of the Virtual Street task to measure PM performance. These results also suggested that TBI patients may show normal performance on memory tests, particularly in a controlled and quiet setting, but when memory performance is tested in a less controlled setting with distractors and tasks that require more strategic processes (like in real life conditions), real TBI dysfunc‐ tions may emerge [39].

Interesting, following the idea to create tasks more representative to real life situations, other authors have investigated the "generation effect", which refers to the effect of people demon‐ strating better memory for self-generated material than for experimenter-generated materials [40, 41, 42]. Considering the instructions often presented in PM setting to perform the action at a specific time or when a specific cue occurs, these instructions may allow control over the tasks, but they are unable to produce the same level of motivation in participants compared to self-generated activities [42]. Some authors reasoned whether people with TBI were more likely to remember a PM task if it is self-generated as opposed to experimenter-generated [40]. TBI patients were less accurate than controls, but the source of the to-be-remembered item exerted minimal influence on PM performance in both TBI patients and controls. Additional analyses were conducted to further investigate the source of errors, and it was found that both groups were able to recognize at post-test the shopping item they had intended to buy, but TBI patients failed to activate their intention to buy the intended item at the appropriate time. Moreover, significant correlations were found between working memory, attention-set shifting and PM performance, which provided further support to the notion that higher order cognitive functions are necessary in PM [19, 40, 42].

In Table 2 are revised studies that were conducted with virtual tasks. This literature is presented separately from other studies on PM because it is more representative of everyday PM performance, and focused on filling the gap between performance on laboratory tasks and

The Prospective Remembering Video Procedure (PRVP) was designed to test PM abilities in virtual street simulation [35]. The task involves remembering to carry out a set of activities while watching a videotape filmed by a person walking slowly through a shopping complex. Participants virtually visited a shopping centre, with a set of event-based activities, each of which involved an action (`buy a record') and a cue (`from the record stand'). As each cue comes into view, the associated action must be recalled. The view that was presented focused mostly on the shop-front, although the footage also included views of passengers crossing the street. Studies conducted with health students and mix-brain injury patients demonstrated that the PRVP procedure was reliable and easier to complete when the video was set in a familiar location. Moreover, it was found that the video-based task was correlated with performance on an equivalent real life memory task, and provided evidence for criterion validity [35, 36, 37]. Twenty severe TBI patients and 20 matched controls were also tested with PRVP and completed the ongoing and PM tasks while "walking" along the street. Severe TBI patients showed poorer performance and were more affected by distractions on the PM tasks compared to controls [38]. Previous findings were confirmed and extended with a Virtual Street task [37, 38, 39]. Results showed that TBI patients performed more poorly than the control group on the PM tasks, but had similar performance on the Wechsler Memory Scale (3rd Edition) Logical Memory subtest. The authors discussed this result in favor of sensitivity of the Virtual Street task to measure PM performance. These results also suggested that TBI patients may show normal performance on memory tests, particularly in a controlled and quiet setting, but when memory performance is tested in a less controlled setting with distractors and tasks that require more strategic processes (like in real life conditions), real TBI dysfunc‐

Interesting, following the idea to create tasks more representative to real life situations, other authors have investigated the "generation effect", which refers to the effect of people demon‐ strating better memory for self-generated material than for experimenter-generated materials [40, 41, 42]. Considering the instructions often presented in PM setting to perform the action at a specific time or when a specific cue occurs, these instructions may allow control over the tasks, but they are unable to produce the same level of motivation in participants compared to self-generated activities [42]. Some authors reasoned whether people with TBI were more likely to remember a PM task if it is self-generated as opposed to experimenter-generated [40]. TBI patients were less accurate than controls, but the source of the to-be-remembered item exerted minimal influence on PM performance in both TBI patients and controls. Additional analyses were conducted to further investigate the source of errors, and it was found that both groups were able to recognize at post-test the shopping item they had intended to buy, but TBI patients failed to activate their intention to buy the intended item at the appropriate time. Moreover, significant correlations were found between working memory, attention-set

PM performance in real life.

408 Traumatic Brain Injury

tions may emerge [39].

Although they showed a high level of correspondence with real-life situations, the PRVP and the Virtual Street required participants to perform only event-based tasks. This was a limitation as PM performance should be investigated both with event- and time-based tasks. To resolve these limitations, the Virtual Week task was developed [42]. This task simulates daily life activities in a board game, where participants move around the board with the roll of a dice. Each circuit around the board represents one virtual day. Participants are required to perform 10 PM activities each virtual day (5 virtual days from Monday to Friday; additional information about the task procedures are presented in the section "Behavioral measures"). We found that people with TBI had significant difficulties executing PM tasks, which were more pronounced for time-based than event-based tasks [44]. These data suggested a relatively global PM deficit in people with TBI. Of particular interest was the finding that the magnitude of TBI impairment was consistent across regular and irregular tasks. Because the key distinction between regular and irregular tasks was that they place low and high demands on retrospective memory, respectively, these data suggested that failures of retrospective memory were not the major cause of TBI-related impairment in PM [44].

Taken together, TBI patients showed PM impairment when measured with laboratory based PM tasks. Some studies have reported that TBI patients were particularly impaired when they performed time-based tasks [11, 25-27] consistent with the view that time-based tasks are demanding and require more self-initiated processes [12]. However, other studies found a more generalized PM impairment in TBI patients [3, 44]. General agreement was observed between authors concerning the involvement of executive functions in PM performance; participants with lower executive functions would also present lower PM performance [16, 22, 25, 26, 28, 29, 31, 44]. The degree of the involvement of executive functions in PM performance varies according to the task employed and cognitive load. It is important to note that some authors have observed lower correspondence between PM performance obtained with laboratory-based tasks and real life situations [23, 33, 34, 45, 46]. Studies conducted with virtual reality tasks are trying to fill this gap, but further research is required to provide reliable and valid scores, and to develop tasks that can be used in clinical settings to screen for PM performance.

### **3. Assessment of prospective memory dysfunctions in clinical settings**

Reliable and valid PM tools with normative data are necessary for health professionals working with people with any type of neurological disorder to acquire reliable information regarding PM performance. Such psychometrically sound tools are important not only to evaluate the degree of PM impairment, but also to provide useful information to inform the appropriate rehabilitation program. This section provides the most commonly used tools to investigate PM in clinical settings.

### **3.1. Self-report questionnaires**

Self-report questionnaires are the most commonly employed tools to assess PM in real life situations. They assess PM dysfunctions by asking participants to rate their memory abilities by answering questions regarding their frequency of forgetting or remembering. They are particularly useful in clinical settings and in the rehabilitation process, because they can provide information about the patients' PM dysfunctions. However, it is very important to consider that a common problem after TBI is an inability to recognize impairments or disabil‐ ities that resulted from injury. This phenomenon has been termed "lack of insight" [22] or impaired "self-awareness" [47]. Self-report questionnaires have been recognized for their value in contributing to the understanding of patients' everyday PM dysfunctions; however, when used with TBI patients, impaired self-awareness may compromise the validity of selfreport measures. Useful information can be acquired from relatives or caregivers. Question‐ naires completed by significant others of the patients' general PM function have been found to correlate with objective PM test scores, and reliably address the patients' PM dysfunction in daily life [17, 18, 45].

The first developed questionnaires investigated general memory dysfunction in daily life with no specific distinction between retrospective or PM dysfunctions. These questionnaires included the Memory Functioning Questionnaire [48], Inventory of Everyday Memory Functioning [49], Cognitive Failure Questionnaire [50], Everyday Memory Questionnaire [51] and the Subjective Memory Questionnaire [52].

The Prospective Memory Questionnaire (PMQ) is a 52-item questionnaire that includes four PM subscales: 1) the *long-term episodic subscale* is related to memory for irregularly scheduled tasks, which require completion some hours or days after a cue to perform it (i.e. "I forgot to return books to the library by the due date"), 2) the *short-term habitual subscale* addresses memory for tasks to be completed shortly after the relevant cue that occur on regular basis (i.e. "I forgot to put a stamp on a letter before mailing it"), 3) the *internally cued subscale* addresses memory for tasks that do not have a clear external cue (i.e. "I was driving and temporarily forgot where I was going"), and 4) the *techniques to remember subscale* measures the use of strategies to aid prospective memory (i.e. "I rehearse things in my mind so I will not forget to do them") [20]. The PMQ questionnaire was administrated to 114 younger adults, 27 older adults and 15 patients with TBI [20]. Coefficient alpha was.92 for the PMQ total score, and ranged from.78 to.90 for the subscales. Factor analysis confirmed the 4-subscale structure. Testretest reliability was found to be high, *r* =.88for the PMQ total and ranged from.64 to.88 for the subscales. Overall, the results found that the ratings of TBI patients were significantly different from those of controls on one of the short-term habitual subscales of the PMQ, however, very few studies have used the PMQ with TBI patients [53].

The Comprehensive Assessment of Prospective Memory (CAPM) measure was developed to evaluate the frequency of PM failure, and to evaluate the perceived amount of concern about these memory lapses and the reasons why people are successful or unsuccessful in performing PM tasks [54]. The items include both basic and instrumental activities of everyday life and are divided into three sections. Section A analyses frequency of failure (39 items; i.e. "Forget‐ ting an appointment with your doctor or therapist", "not locking the door when leaving **3.1. Self-report questionnaires**

410 Traumatic Brain Injury

in daily life [17, 18, 45].

and the Subjective Memory Questionnaire [52].

few studies have used the PMQ with TBI patients [53].

Self-report questionnaires are the most commonly employed tools to assess PM in real life situations. They assess PM dysfunctions by asking participants to rate their memory abilities by answering questions regarding their frequency of forgetting or remembering. They are particularly useful in clinical settings and in the rehabilitation process, because they can provide information about the patients' PM dysfunctions. However, it is very important to consider that a common problem after TBI is an inability to recognize impairments or disabil‐ ities that resulted from injury. This phenomenon has been termed "lack of insight" [22] or impaired "self-awareness" [47]. Self-report questionnaires have been recognized for their value in contributing to the understanding of patients' everyday PM dysfunctions; however, when used with TBI patients, impaired self-awareness may compromise the validity of selfreport measures. Useful information can be acquired from relatives or caregivers. Question‐ naires completed by significant others of the patients' general PM function have been found to correlate with objective PM test scores, and reliably address the patients' PM dysfunction

The first developed questionnaires investigated general memory dysfunction in daily life with no specific distinction between retrospective or PM dysfunctions. These questionnaires included the Memory Functioning Questionnaire [48], Inventory of Everyday Memory Functioning [49], Cognitive Failure Questionnaire [50], Everyday Memory Questionnaire [51]

The Prospective Memory Questionnaire (PMQ) is a 52-item questionnaire that includes four PM subscales: 1) the *long-term episodic subscale* is related to memory for irregularly scheduled tasks, which require completion some hours or days after a cue to perform it (i.e. "I forgot to return books to the library by the due date"), 2) the *short-term habitual subscale* addresses memory for tasks to be completed shortly after the relevant cue that occur on regular basis (i.e. "I forgot to put a stamp on a letter before mailing it"), 3) the *internally cued subscale* addresses memory for tasks that do not have a clear external cue (i.e. "I was driving and temporarily forgot where I was going"), and 4) the *techniques to remember subscale* measures the use of strategies to aid prospective memory (i.e. "I rehearse things in my mind so I will not forget to do them") [20]. The PMQ questionnaire was administrated to 114 younger adults, 27 older adults and 15 patients with TBI [20]. Coefficient alpha was.92 for the PMQ total score, and ranged from.78 to.90 for the subscales. Factor analysis confirmed the 4-subscale structure. Testretest reliability was found to be high, *r* =.88for the PMQ total and ranged from.64 to.88 for the subscales. Overall, the results found that the ratings of TBI patients were significantly different from those of controls on one of the short-term habitual subscales of the PMQ, however, very

The Comprehensive Assessment of Prospective Memory (CAPM) measure was developed to evaluate the frequency of PM failure, and to evaluate the perceived amount of concern about these memory lapses and the reasons why people are successful or unsuccessful in performing PM tasks [54]. The items include both basic and instrumental activities of everyday life and are divided into three sections. Section A analyses frequency of failure (39 items; i.e. "Forget‐ ting an appointment with your doctor or therapist", "not locking the door when leaving home"), and is considered to be the best section to evaluate PM dysfunction and outcome after rehabilitation [55]. Section B analyses the amount of concern about these failures (39 items; the same items used in the first session), and Section C analyses the reasons associated with the success or failures of PM tasks (15 items; "I rely to other people to remind me when I have to remember to do things"). Section A was used with 33 severe TBI patients (GCS = 5.1; PTA = 6.66 days), 33 relatives and 29 healthy controls to investigate frequency of PM failure [54]. Analyses were conducted on self-rating and informant-rating, and the difference between these two indices provided a measure of self-awareness on PM dysfunction. The results showed no significant differences between the TBI and controls' self-ratings of the frequency of PM failure. However, a significant difference was found between the informant-ratings, which suggested that relatives and/or caregivers reported higher levels of PM failure. These findings are likely to be due to the commonly found self-awareness difficulties in patients with TBI [47, 54]. The section C was used to investigate how TBI patients perceived and self-rated the reasons for PM failure [56]. Relatives and caregivers were also asked to rate TBI patients' PM failures. One-hundred thirty-six participants were included in the study and divided into four groups: 38 severe TBI (GCS = 5.1, PTA = 62.6 days), 34 significant others of TBI patients, 34 controls, and 30 significant others of controls. Results showed that patients with TBI were more likely to forget planned activities; moreover, TBI patients forgot to do things when they focused on other tasks or if they considered other activities unimportant. Patients with TBI seemed also to rely more on relatives to remind them to do things. However, no significant differences were found between TBI patients and controls on reporting reason of remembering or forgetting, and indicated that TBI patients tended to overestimate their PM abilities [54, 56]. It is important to note that authors reported that some TBI patients included in the study indicated that they have difficulty understanding some questions included in section C and suggested to further investigate the internal consistency of the section C [56]. The validity of CAMP (section A) was investigated in a study conducted with 45 patients with moderate and severe TBI (age M=30.02 years; GCS = 7.08; PTA = 47.89) and their relatives [45]. Participants also performed two tests of PM, the CAMPROMPT [57] and the Memory Intentions Screening Test (MIST) [58]. Concurrent validity was investigated by the comparison of scores on the CAPM with scores on the CAMPROMPT and MIST. Results showed that self-report CAPM scores did not significantly correlate with scores on the CAMPROMPT or MIST. TBI patients reported very few PM failures on the CAPM, but demonstrated impairments on neuropsy‐ chological testing. Interestingly, results showed that the responses provided by the relatives on CAPM correlated with CAMPROMPT and MIST performance. These findings suggested that the relative version of the CAPM has some concurrent validity when compared with performance on neuropsychological assessments, and that the relative version of the CAPM is an objective and valid measure of PM failure in TBI patients [17, 45]. To our knowledge, no studies have been conducted with TBI on section B of CAMP.

Finally, the Prospective and Retrospective Memory Questionnaire (PRMQ) was developed to investigate the rate of frequency with which patients make particular types of memory errors [59]. The PRMQ consists of 16 items that are divided into 8 categories (two items in each category) that tap different aspects of memory failure: prospective short-term self-cued, prospective short-term environmentally-cued, prospective long-term self-cued, prospective long-term environmentally cued, retrospective short-term self-cued, retrospective short-term environmentally-cued, retrospective long-term self-cued, and retrospective long-term envi‐ ronmentally-cued [59]. Different forms of the PRMQ are available for patients and caregivers. In addition to the 16 items included in the patient form, caregivers are asked to respond to four additional questions. Two of the questions concern the caregivers' frustration and two ask the caregivers to rate the patients' frustration. The PRMQ has never been used with TBI patients, but was tested with 242 healthy older adults (age M = 72.74 years) and 155 patients with Alzheimer disease (AD; age M = 73.95 years). One-hundred fifty-five caregivers of AD patients (age M= 56.85) and younger participants (age M = 44.19) were also included in the study. The split half reliability of the PRMQ conducted in younger and older adults (n = 406) compared the two items within each category was found to be*.*84. Results showed that memory dys‐ function was highest for AD patients and lowest for caregivers, with younger and older adults in between. Moreover, caregivers rated PM dysfunctions of AD patients more frustrating than patients did, and PM errors were rated as significantly more frustrating than retrospective memory errors. The authors concluded that the PRMQ might be a potentially useful tool for investigating differences in frequency of prospective and retrospective memory failure in nonpatient samples, but that the questionnaire needed to be adapted to increase its sensitivity to allow for more extensive clinical use [59]. These results were extended through the testing of 87 younger adults (age M = 44.11 years) with PRMQ and with a standard laboratory procedure of PM [60]. The reliability of PRMQ was.86 (Cronbach's alpha) for the total scale,.72 for the PM scale, and.72 for the retrospective memory scale. Participants reported higher scores (higher memory failure) for the PM than retrospective memory scale. To examine whether the PRMQ scores may predict actual performance in the laboratory PM tasks, correlation analyses were conducted and showed that only the PM scale was a significant predictor for the standard laboratory PM performance. In sum, the study extended initial findings and added additional support for the validity of the PRMQ. In addition, it provided the first evidence for the utility of the PRMQ subscales in differentiating between prospective and retrospective memory task performance [59, 60].

To our knowledge, no other studies appear to have examined the relationships between PM performance and measures of self-awareness in TBI patients. This may reflect the unreliability of self-rated PM measures [47]. Despite previous studies that have provided good validity and reliability of questionnaires, the results are mixed when self-rated scores were compared with laboratory-based measures of PM performance [3, 56, 60, 61]. There are two important caveats to the questionnaires. First, it is important to consider that some authors have reported lower correspondence between the PM tasks used in the examina‐ tion condition, and PM activities in the everyday situation. Indeed, in real word situa‐ tions, people required higher levels of executive functioning to perform multiple tasks than in a controlled experimental standardized setting. Therefore, some authors have found that TBI patients showed unimpaired performance on neuropsychological PM tests, but reported impaired PM performance in real life [45, 46]. Second, it is important to consider the selfawareness dysfunction often observed in TBI patients that might compromise the validi‐ ty of TBI participants' self-report measures [22, 47].

### **3.2. Behavioral measures**