Goal-oriented rehabilitation of executive functioning using video-telehealth to improve community reintegration for Veterans with chronic TBI and cognitive difficulties

About This Grant

Significance to VA: TBI is prevalent in post-9/11 Veterans (1-2). Deficits in cognitive control processes (attention, executive functions, memory) are common sequela of TBI associated with difficulties in community reintegration, educational and occupational functioning, and one of leading long-term disability causes among Veterans (3-6,10-12). As Veterans transition from military to community, many are interested in serving on the home front, with success in community, school, and work being essential to this goal. Innovation and Impact: At present, there are no validated evidence-based executive function tele- rehabilitation interventions to support community reintegration for Veterans with chronic TBI/Polytrauma. This proposal aims to increase access and availability of evidence-based, in-person administered GOALS cognitive rehabilitation training for Veterans with chronic TBI interested in improving their community integration. The adaptations include: 1) video telehealth delivery (GOALS TH) and 2) focus on Veteran-chosen community integration goals. In previous studies (21-30) Veterans with TBI/Polytrauma significantly improved post GOALS on measures of attention/executive function, functional performance, and emotional regulation. Neuroimaging results indicated training-related increase in prefrontal functional connectivity and improved white matter integrity (26,61,67). At 6+ month follow-up Veterans maintained training gains, reported improvements in daily functioning, and two times increase of return to competitive employment relative to baseline (27-28,30). Specific Aims: Aim 1: To characterize feasibility and acceptability of GOALS TH. Hypothesis: Feasibility will be demonstrated by achieving high rates of retention and adherence to training. Acceptability will be demonstrated with high participant rating on post-training acceptability questionnaire. Aim 2: To determine effects of GOALS TH training on community integration related goal attainment. Hypothesis: Veterans who participate in GOALS TH training will demonstrate greater improvement compared to control Brain Health Education (EDU TH) on individually chosen community integration goal attainments. Aim 3: To determine effects of GOALS training on neuro-cognitive performance and emotional regulation: Hypothesis: Veterans who participate in GOALS TH training will demonstrate greater improvements compared to EDU TH on measures of: a) complex attention and executive function, and b) emotional regulation. Aim 4: To determine long-term stability of GOALS TH on the Primary Outcomes in Aims 2-3. Hypothesis: Significant treatment effects associated with AIMs 2 & 3 will remain stable at 6-month follow-up. Methodology: Veterans ages18-65 with chronic mild to moderate TBI and cognitive difficulties, interested in improving their community integration, will be randomized to in either GOALS TH or a control EDU TH intervention, matched for time and intensity. Both GOALS TH and EDU TH groups will participate in pre- and post-training measurements at baseline, after training, and at 6-month follow-up. Measurements will include: neuro-cognitive tests, community integration goal attainment, daily functioning and emotional regulation. Path to Translation/Implementation This project will provide important data regarding the value and validation of telerehabilitation training in strengthening goal-directed functioning, and will help determine whether a functional approach of training attentional self-regulatory control functions via personally relevant goals is effective in improving community integration for Veterans with TBI/Polytrauma. Findings will provide information that can help guide rehabilitation training to maximize success in attaining goals related to school, work, and beyond. The intervention tools and methods implemented in this project have the potential to translate directly to services in which Veterans can engage in skill strengthening where they are (any location). If validated, we plan to disseminate GOALS TH manuals, and provide training workshops and consultation to clinicians and researchers at VA TBI Polytrauma Systems of Care and others within the VA System of Care.