Department of Neurobiology, Care Sciences and Society Division of Occupational Therapy

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Department of Neurobiology, Care Sciences and Society

Division of Occupational Therapy

Master thesis in Occupational Therapy, 30 credits

Spring term 2009

Holistic group rehabilitation

A shortcut to adaptation to the new life

after mild acquired brain injury


Lotta Nilsson


Aniko Bartfai

Monika Löfgren


Christensen, A-L. (1998). Sociological and Cultural Aspects in Postacute Neuropsychological Rehabilitation. Journal of Head Trauma Rehabilitation. Oct;13 (5):79-86 33

Christensen, A-L. (1998). Sociological and Cultural Aspects in Postacute Neuropsychological Rehabilitation. Journal of Head Trauma Rehabilitation. Oct;13 (5):79-86 33


Introduction: Patients with mild acquired brain injury (mABI) often receive the same interventions as patients with moderate and severe brain injury, which might be ineffective for patients with mABI. Research on the efficacy of occupational interventions for patients with mABI is very limited. In this study the experiences of patients in a holistic group rehabilitation programme for patients with mABI was investigated. The aim of the programme was to facilitate performance in daily life. The programme included information concerning brain injury, compensatory strategies for daily life and coping discussions.

Aim: To explore and gain understanding about what individuals with mild acquired brain injury consider are the most effective ingredients in a group rehabilitation programme and describe how the programme affects the rehabilitation process.
Methods: Interviews were conducted with 10 patients (men/women, 5/5) between 33-59 years of age, with diagnosed acquired mild brain injury. The patients were recruited by purposive sampling after completing the group rehabilitation programme. Data analysis was performed using constant comparative method.
Results: All patients perceived that the programme provided them with awareness of their difficulties in daily life which was a start for being motivated to develop and use compensatory strategies in order to function better in daily life. Holistic group rehabilitation can be considered as a shortcut to change and increased awareness by speeding up adaptation. The core category “process of change” and five sub-categories were defined; “the injury”, the group process”,” the individual”,”family” and “work”. The results are discussed within the framework of the Canadian Model of Occupational Performance (CMOP)
Conclusion: The holistic group rehabilitation programme provided an integration of knowledge, strategies and self-image leading to changes in how to cope with problems in daily life.

Keywords: brain injuries; group rehabilitation; awareness, occupational therapy


The aim of this master thesis is to qualitatively evaluate a group intervention, tailored for persons with a mild acquired brain injury (mABI). Despite the term “mild”, a mABI can result in apparently severe problems (Comper et al, 2005). Persisting emotional and cognitive symptoms after mABI can be so disabling for some patients that daily life becomes a challenge and reduces life satisfaction (Tiersky et al, 2005, Stålnacke et al, 2007). The evidence base for management of mABI is limited and relevant data of interventions are scant. Often treatment strategies intended for moderate and severe acquired brain injuries (ABI) patients are used, which might be ineffective for individuals with mABI (Ponsford, 2005, Comper, 2005, Miller & Mittenberg, 1998, Stålnacke et al, 2007).
With this starting-point, a group rehabilitation programme was developed and established 1997, with focus on the needs for patients with a mild acquired brain injury in the post acute phase (Bartfai et al, 2000). The base of the rehabilitation was gathered from holistic neuropsychological rehabilitation approaches from Ben-Yishai (2000), and Christensen (1998), addressed to the needs of patients with moderate to severe traumatic brain injury (TBI) (Prigatano, 1999). It was considered that the programme should benefit from an integrated knowledge base from both occupational therapy and psychology (Bartfai et al, 2000). A holistic approach consists of five specific interrelated activities: establishing a therapeutic milieu or community, cognitive rehabilitation or retraining, psychotherapy, the ongoing involvement and education of family members, and a protected work trial. It aims to foster awareness and acceptance of the consequences of one’s brain injury, helps to improve social skills and helps to achieve a higher level of independence and productivity (Ben-Yishai, 2000, Prigatano 1999).
The development of the rehabilitation programme in the current study was build within the model of the International Classification of Functioning, Disability and health (ICF) in mind (WHO, 2001). ICF provides an international and inter professional scientific-base for understanding and studying health. The concept of participation in the ICF is a central construct in rehabilitation and occupational therapy and for occupational therapy another value is the connection between health and occupation (Hemmingsson & Jonsson, 2005). The components of the ICF classification are illustrated in figure 1. The group rehabilitation programme integrates pedagogical components targeting body functions, body structure, activity, participation, environmental factors and personal factors. For example, the theoretical information in the programme, the discussions connected to the theoretical briefings and the body awareness training relates to body function, practical exercises connecting to the theory part relate to the activity component and homework, meetings with family relates to the participation component.

Figure 1. Interactions between the components of the international

classification of functioning, disability and health (ICF)

(WHO, 2001 p 26).
The Canadian Model of Occupational Performance (CMOP)

From an occupational therapy perspective, health is more than absence of disease. It has personal dimensions and is strongly influenced by having choice and control in everyday occupations. Occupation is a basic human need and is defined by Canadian Association of Occupational Therapists (CAOT, 2002); everything people do to occupy themselves, including looking after themselves (self-care), enjoying life (leisure), and contributing to the social and economic fabric of their community (productivity) . The primary role of occupational therapy is enabling occupation and doing it with a client-centred focus. Enabling occupation means collaborating with people to choose, organise and perform occupations which people finds useful or meaningful in a given environment. Occupational performance is the result of the dynamic relationship between persons, environment and occupation over a person’s lifespan (CAOT, 2002). The Canadian Model of Occupational Performance (CMOP) provides a framework for enabling occupation for all persons and is illustrated of a dynamic interdependence between person, environment and occupation. In the model the person is an integrated whole who incorporates spirituality, social and cultural experiences and observable occupational performance components. The environment is those contexts and situations which occur outside individuals and elicit responses from them. The environment is the context within which occupational performance takes place. Change in any aspect of the model would affect all other aspects.

Figure 2. The Canadian Model of Occupational Performance, illustrating the dynamic relationship between persons, environment, and occupation over a person’s lifespan (CAOT, 2002, p.32).
Brain injury

Acquired Brain Injury (ABI) is damage to the brain acquired after birth that can result from traumatic brain injury (i.e. accidents, falls, assaults, etc.) and non-traumatic brain injury (i.e. stroke, brain tumors, infection, poisoning, hypoxia, ischemia, metabolic disorders or substance abuse). It can affect cognitive, physical, emotional, social or independent functioning. The severity of problems varies from mild to severe (Turner-Stokes, 2008). After ABI cognitive and emotional symptoms often persists and can significantly affect an individual’s abilities to perform everyday tasks, fulfil former roles and maintain personal-social relationships (Tiersky et al, 2005), Toglia ,1998a, Prigatano, 1999). Depending on severity and location of injury this means that a brain injury can affect all aspects of life, from personal ADL to complex roles.

Cognitive disability

Cognition can be defined as the individual’s capacity to acquire and use information in order to adapt to environmental demands. (Toglia, 1998a) This definition encompasses information processing skills, learning, and generalisation. The capacity to acquire information involves information, processing skills or the ability to take in, organise, assimilate, and integrate new information with previous experience. Cognition is an ongoing product of the dynamic interaction between the individual, the task, and the environment (Toglia, 1998a). Cognitive disability may be seen in a) reduced efficiency, b) pace and c) persistence of functioning, d) decreased effectiveness in the performance of routine activities of daily living, e) failure to adapt to novel or problematic situations (Cicerone et al, 2000). Clinical studies have mainly focused on effects from moderate to severe injuries, which imply that the knowledge of the effects impairments of mild acquired brain injuries is weak.

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