REHABILITATION has been called “theory-poor.” We have few organizing principles by which to conceptualize our existing treatments and develop new ones. There may be many reasons for this, including the multiplicity of disciplines, populations, and settings that comprise the field. What we gain in the diverse viewpoints of the interdisciplinary team, we lose in cohesive treatment theory: explanations for why and how our interventions are effective (or not).1 Yet both scientists and practitioners in rehabilitation need to attend more to treatment theories; they help to make clinical assumptions explicit, to bring coherence to otherwise jumbled observations, and to bring a focus to the most important dimensions of treatment.2,3 In brain injury rehabilitation, in particular, treatment theories are critical to make sure members of the team are “on the same page,” all using concepts and strategies that cut across disciplines to effect change in the face of cognitive and behavioral challenges.
If rehabilitation is too diverse to hope for what John Whyte called a “grand unifying theory,”4 where should these crosscutting strategies come from? Learning theories provide one possible source. Alan Baddeley wrote, “a theory of rehabilitation without a model of learning is a vehicle without an engine.”5 Our patients, and often their family members, are expected to learn new facts, concepts, skills, attitudes, and habits throughout rehabilitation. What are the best ways to teach all of these things? Although there is evidence that therapists can readily learn and apply specific teaching techniques,6,7 overarching learning principles are relatively neglected in the training and practice of rehabilitation.8,9
This topical issue of the Journal of Head Trauma Rehabilitation on principles of learning is the product of the Treatment Theory Task Force, which was formed within the American Congress of Rehabilitation Medicine's Brain Injury Interdisciplinary Special Interest Group to examine and disseminate treatment theories of particular relevance to brain injury rehabilitation. The task force identified learning theories as prime targets for consideration, and this issue is the first tangible outcome of many stimulating discussions. For the issue, we sought a mix of empirical and review articles addressing learning in rehabilitation for traumatic brain injury (TBI) from various perspectives, and asked authors to emphasize both theoretical aspects of their work and its implications for brain injury rehabilitation.
Our work on the issue, and that of the manuscript authors, was challenged by the sometimes confusing concepts and terminology that permeate the field. It is not always clear even what a learning theory is, or what it tries to explain. For example, learning is sometimes explained as an outcome, that is, what is learned; other times as a process, that is, how the change in knowledge or behavior takes place.10 Either way, learning theories do not fit neatly into an established hierarchy or taxonomy that can be easily applied to rehabilitation. On the contrary, different learning theories may offer different explanatory frameworks for the same phenomena. For example, consider a patient whose performance improves on a rehabilitation task. A behavioral learning theorist might explain that the improvement followed reinforcement of performance by the therapist (eg, praise). A cognitive learning theorist might emphasize the therapist's detailed explanation of the task, noting that the patient improved because she attained a better understanding (cognitive structure). The social learning theorist might point out that the patient was working harder to meet a personally and socially relevant goal. Of course, all of these explanations could be “correct” because all of the explanatory factors cited in this example have been shown to have powerful effects on behavior change. Still other theories emphasize the neural substrates involved in various types or levels of learning (eg, implicit vs explicit). Our task as rehabilitationists is to parse the treatment components specified by promising theories of learning and test their effects on different types of tasks, in patients with different characteristics. For brain injury rehabilitation, added complexities ensue from the obvious fact that the organ of learning, the brain, has been altered and that its learning capabilities change over time relative to injury.
The articles in this issue reflect the diversity of models that can be applied to learning after TBI. In the first article, Wright and Schmitter-Edgecombe present the results of a study embedded in a familiar framework that emphasizes the temporal stages of encoding, consolidation, and retrieval of learned material. On the basis of a comparison of performance on a list-learning task between participants with TBI and age- and education-matched controls at two time points, they conclude that encoding is a primary memory deficit following TBI and suggest that treatments focusing on initial acquisition of information may be most helpful in enhancing verbal learning.
The next article, by Jason Crowther and colleagues, concerns learning in children with TBI, a population of obvious importance considering the impact of learning impairment on cognitive development and educational achievement. This longitudinal study examines several factors pertaining to verbal learning, including age, severity of TBI, and time postinjury. The theoretical construct of metamemory–the ability to evaluate one's own learning and memory ability and deploy strategies as needed–was explicitly measured by asking participants both to predict and to judge their performance. Crowther et al found that after moderate or severe TBI, children's ability to learn with repetition remains impaired for up to 2 years. Moreover, severely injured children were poorly able to predict their own learning ability, despite accurately reporting on their past performances. These results suggest that children with TBI may not spontaneously deploy learning strategies, possibly because they cannot adequately anticipate the need.
The final 3 articles deal directly with intervention strategies based on learning concepts. The article by Wood and Alderman focuses on the use of interventions derived from operant learning theory to manage challenging behaviors following TBI. The authors review a series of studies that demonstrate how various reinforcement and antecedent control methods have been used to decrease the frequency of maladaptive behaviors, such as aggression, that can limit participation in rehabilitation programs. They discuss some of the challenges of applying these types of techniques, including the need for specialized training, and suggest ways for overcoming these barriers. The article also discusses how operant approaches may be combined with one another for maximal effect, and how cognitive deficits affect the selection and evaluation of particular strategies.
Kennedy and Krause used self-regulated learning theory as the basis for developing a supported education intervention for college students with TBI. In their article, they describe how they implemented this approach with two returning college students using a dynamic coaching model. Students received direct instruction from the coaches in strategies relating to studying and learning, time management, and relating to others. Crucially, they also learned how to self-assess their performance and their use of strategies, and to adjust what they did as needed–another example of metamemory, essential in this case for the effective, independent use of strategies. This study also illustrates the use of “process” measures such as strategy use, in addition to more traditional outcome measures, to capture the results of treatment.
Finally, Vas, Chapman, and colleagues describe the results of a randomized controlled trial on a treatment program designed to remediate gist reasoning, a learning strategy that emphasizes attention to the meaning, rather than the details, in complex or lengthy information. Compared to a training program that provided TBI education, participants in a gist-reasoning group showed improvements that were retained for 6 months following treatment. These improvements were seen not only on a primary outcome closely related to the treatment, but on a real-world measure of social integration.
Many other learning concepts not tapped by this topical issue also deserve further consideration for brain injury rehabilitation. These include how to capitalize on implicit learning capability following TBI, how to incorporate advances in motor learning theory into TBI rehabilitation, how to maximize motivation and effort in the learning process, and how to structure feedback for optimal learning across tasks and patients. In the realm of outcome measurement, tasks at the impairment level (eg, list learning) are convenient to use and amenable to scoring along theoretically important dimensions, but we also need further development of learning and memory performance measures with “real world” relevance.
Certainly, much work is needed before we will know precisely how to maximize learning following TBI for each individual client at any given point after injury. In the meantime, taking a more explicit look at the theories we have, and making note of where development is needed, may lay the foundation for improving our clinical and research efforts. We hope that this issue will help to stimulate discussion and thought as to how learning concepts may be applied to help persons with TBI to gain the skills and knowledge they need to adapt to the changes in their lives. We also hope that clinical researchers considering the articles here will be challenged to develop new studies to help us fill the gaps that mark our field.
—Tessa Hart, PhD
Moss Rehabilitation Research Institute
Elkins Park, Pennsylvania
—Janet M. Powell, PhD, OTR/L
University of Washington
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