Comments on American Psychological Association’s Structure and Function of Interdisciplinary Team for Persons with Acquired Brain Injury
Submitted online July 24, 2012
Submission Format: No more than 5 comments, 1000 characters maximum per comment
The American Occupational Therapy Association (AOTA) commends APA and ASHA for aspiring to provide guiding principles for interdisciplinary teams involved in habilitative and rehabilitative services for individuals with acquired brain injury. We welcome the opportunity to comment on behalf of the 140,000 occupational therapy practitioners and students we represent.
Like ASHA, AOTA has incorporated the 2001 WHO International Classification of Functioning, Disability and Health into our policies and procedures (e.g., see Occupational Therapy Practice Framework) (American Occupational Therapy Association, 2008).
We agree that individuals with acquired brain injuries are likely to have activity/participation limitations and restrictions and these should be addressed by the interdisciplinary healthcare team. Although occupational therapy is mentioned as a potential interdisciplinary team member, we respectfully request that occupational therapy's role and contributions to the clinical care of individuals with acquired brain injuries be stated more explicitly.
Specifically, AOTA takes issue with the sentence "When cognitive, communication, emotional, and psychosocial domains are affected, the team should include at least a clinical neuropsychologist or rehabilitation psychologist, and speech-language pathologist." Occupational therapy (OT) practitioners can: (a) address cognition through functional activities, (b) help the team understand the client's emotional and psychosocial functioning, and (c) work with speech-language pathologists to increase the client's communication skills (e.g., generalization of skills, adapting assistive technology). A RCT by an occupational therapist found that self-awareness training resulted in significant improvement on instrumental activities of daily living performance and self-regulation compared to a control group (Goverover, Johnston, Toglia, & Deluca, 2007) . Additional evidence to support OT's role in addressing attention, memory, executive functioning, psychosocial/behavior functions, social skills, and coping, can be found in AOTA's Occupational Therapy Practice Guidelines for Adults with Traumatic Brain Injuries (Golisz, 2009).
All healthcare professions work to achieve the best outcomes by providing effective and efficient clinical services. AOTA requests that APA acknowledge that different approaches may be effective for different subgroups of persons with acquired brain injuries. For example, an RCT with 360 active duty personnel, randomized to either functional-experiential treatment or cognitive-didactic rehabilitation found no significant differences between groups (Vanderploeg et al., 2008) . However, subgroup analysis revealed that older participants (>30) and those with more education had better outcomes in terms of independent living at one year if they participated in the functional experiential approach, whereas younger (<30) and those with less education who participated in the cognitive group had better work related outcomes at one year follow up. Thus, functional interventions, and occupational therapy's perspective, are important to include when we strive to improve performance of daily living activities (Activity/Participation).
AOTA is pleased to see that the person-task-environment interaction is emphasized in this document. We concur and would add that many occupational therapists have developed theories and tools to measure person, environment, and occupation variables (Dunn, Brown, & McGuigan, 1994; Letts et al., 1994; Strong et al., 1999) . As an example of how the environment can be used to understand impairments and activity limitations of individuals with traumatic brain injuries, occupational therapists assessed the cognitive functions of 30 participants with traumatic brain injury using a computer-simulated virtual reality environment (Zhang et al., 2003) . The researchers concluded that a computer-generated virtual reality environment was feasible to assess selected cognitive functions and could be useful as a supplement to traditional rehabilitation assessment in persons with acquired braininjury.
AOTA requests that the section "Interdisciplinary Team Membership" specifically cite occupational therapy as well as other professions (e.g., speech-language pathology, physical therapy, etc.) as essential team members. The Centers for Medicare and Medicaid Services require a certain number of hours and days of core therapy services (e.g., OT, PT Speech) in comprehensive rehabilitation centers.
AOTA agrees with the conclusion that the purpose of the interdisciplinary team is to maximize the recovery of the person with acquired brain injury. Occupational therapy can help individuals with acquired brain injury (ABI) to achieve their goals and return to living meaningful lives. A study of 31 adults with ABI found that participation in goal-specific outpatient occupationaltherapy that focused on teaching compensatory strategies was strongly associated with achievement of self-identified goals and reduction of disability in adults with mild to moderate braininjury (Trombly, Radomski, Trexel, & Burnett-Smith, 2002).
American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed). American Journal of Occupational Therapy, 62, 625-688.
Dunn, W., Brown, C., & McGuigan, A. (1994). The Ecology of Human Performance: a framework for considering the effect of context. American Journal of Occupational Therapy, 48(7), 595-607.
Golisz, K. (2009). Occupational therapy practice guidelines for adults with traumatic brain injury. Bethesda: AOTA Press.
Goverover, Y., Johnston, M. V., Toglia, J., & Deluca, J. (2007). Treatment to improve self-awareness in persons with acquired brain injury. Brain Injury, 21(9), 913-923.
Letts, L., Law, M., Rigby, P., Cooper, B., Stewart, D., & Strong, S. (1994). Person-environment assessments in occupational therapy. American Journal of Occupational Therapy, 48(7), 608-618.
Strong, S., Rigby, P., Stewart, D., Law, M., Letts, L., & Cooper, B. (1999). Application of the Person-Environment-Occupation Model: a practical tool. Canadian Journal of Occupational Therapy, 66(3), 122-133.
Trombly, C. A., Radomski, M. V., Trexel, C., & Burnett-Smith, S. E. (2002). Occupational therapy and achievement of self-identified goals by adults with acquired brain injury: phase II. American Journal of Occupational Therapy, 56(5), 489-498.
Vanderploeg, R. D., Schwab, K., Walker, W. C., Fraser, J. A., Sigford, B. J., Date, E. S., et al. (2008). Rehabilitation of traumatic brain injury in active duty military personnel and veterans: Defense and Veterans Brain Injury Center randomized controlled trial of two rehabilitation approaches. Archives of Physical Medicine & Rehabilitation, 89(12), 2227-2238.
Zhang, L., Abreu, B. C., Seale, G. S., Masel, B., Christiansen, C. H., & Ottenbacher, K. J. (2003). A virtual reality environment for evaluation of a daily living skill in brain injury rehabilitation: reliability and validity. Archives of Physical Medicine & Rehabilitation, 84(8), 1118-1124.