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Summary of Neuropsychological Rehabilitation and Treatment
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Week 1: Mechanisms of Recovery and TreatmentPlanning
CHAPTER 1: HISTORICAL EXAMINATIONS OF
THEORETICAL AND PRACTICAL ISSUES
BRIEF HISTORY OF THE GROWTH OF NP REHABILITATION
ANCIENT EGYPT
Earliest known description of treatment of brain injury – comes from an Egyptian document
of 2500-3000 years ago
Edwin Smith (1862) – Papyrus
The papyrus – describes the treatment of 48 cases of injury – 24 of which were brain trauma
cases
It contains the first known descriptions of:
(1) The cranial structures
(2) The meninges
(3) The external surface of the brain
(4) The cerebrospinal fluid
(5) And, the intracranial pulsations
The word brain – appears for the first time in any language
Treatment procedures demonstrate an Egyptian level of knowledge that surpasses that of
Hippocrates – who lived 1000 years later
First cases described – a man with a gaping wound in his head – penetrating the bone of the
skull – rending the brain open
Procedures described in the Smith Papyrus – were more about treatment than rehabilitation
Cases Describing Treatment
Include a case of Paul Broca’s – he was seeing an adult patient who was no longer able to
read words aloud
, (1) He was first taught to read letters – then syllables – before combining syllables into
words
(2) He failed to learn to read words of more than one syllable
- Treatment was switched to a whole word approach – and patient learnt to
recognize a number of words
WORLD WAR I
Modern rehabilitation began in WWI:
(1) More soldiers with gun wounds to the head survived – penetrating head wounds
occurred
(2) Dedicated brain injury rehab centers were created for 1st time
Kurt Goldstein
A German neurologists and psychiatrist – a pioneer in modern NP
(1) Made specific recommendations about therapy for impairments of speech, reading,
and writing
(2) Following WWI – he established the Institute into the Consequences of Brain Injuries
- There he developed a theory of brain-mind relationships
In Amsterdam – wrote his master work The Organism
Walter Poppelreuter
Another German neurologist and psychiatrist
Carried out investigations of brain-injured soldiers during WWI – documented the results of
loss and impairment of brain function
(1) Wrote his 1st book – describing his treatment of soldiers with visuospatial and
visuoperceptual disorders
(2) Discussed vocational rehabilitation
WORLD WAR II
Again – a need for specialized centers to treat individuals with gunshot wounds to the head
Most people received only physiotherapy for motor difficulties
, - Those with sig cognitive and behavioral problems – were sent to mental
institutions
Alexander Luria
The grandfather of NP
Established the Kazan Psychoanalytic Association – planned on a career in psychoanalytic
psychology
Earliest research – sought to establish objective methods for assessing Freudian ideas about
(1) abnormalities of thought and (2) the effects of fatigue on mental processes
During WWII – led a research team at army hospital looking for ways to compensate for
psych dysfunctions in brain damaged patients
He believed that psych research should be for the benefit of human kind – argued that we
should look at the person in his or her social context
Cairns
Head NP at Oxford
Realized that the sooner wounds to the head were treated – the better the prognosis
Mortality rate decreased form 50% during WWI to 5% in WWII
Oliver Zangwill
Father of British NP
Wrote an important paper on rehabilitation of people with brain damage – he discussed the
principles of re-education
Three main approaches:
(1) Compensation – reorganization of psychological function so as to minimize or
circumvent a particular disability
- Believed that compensation took place spontaneously – without explicit intention
by the patient
- But sometimes it could occur by (1) patient’s own efforts or as a (2) result of
instruction and guidance from the psychologist
, (2) Substitution – the building up of a new method of response to replace one damaged
irreparably by a cerebral lesion
- Recognized that this was a form of compensation but taken much further – e.g.,
lip reading for deaf people, braille for blind people
(3) Direct Retraining – highest form of training – some damaged functions could be
restored via training
- Direct – as opposed to substitutive training – has a real but limited part to play in
re-education
MORE RECENT TIMES
The first program to call itself Cognitive Rehabilitation program – appears to be the one
opened by Leonard Diller in NY, 1976
(1) Diller was one of the first to publish studies on unilateral neglect
Goldstein, and later Ben-Yishay, recognized that cognition, emotion, and behavior are
interlinked – hard to separate and should be addressed together in rehab programs
(1) This is the core of the holistic approach
THEORETICAL DEVELOPMENTS WITHIN NP REHABILITATION
MEANING OF REHABILITATION AND ITS PRACTICE
Rehabilitation – not synonymous with recovery – if by this we mean getting an individual
back to what he was like before the injury or illness
- Neither is it synonymous with treatment – which is something we do to people or
give to people – e.g., administer a drug or surgery
Rehabilitation
It is a two-way interactive process – whereby survivors of brain injury work together with
professional staff and others – to achieve their optimal physical, psychological, social, and
vocational well-being
The British Society of Rehabilitation Medicine and Royal College of Physicians in the UK:
(1) Define rehabilitation as “a process of active change by which one – who has become
disabled – acquires the knowledge and skills needed for optimal physical,
psychological and social function”
, (2) In terms of service provision – this entails “the use of all means to (1) minimize the
impact of disabling conditions and (2) to assist disabled people to achieve their
desired level of autonomy and participation in society”
EARLY APPROACHES TO REHABILITATION
Powel (1981)
One of the first attempts to provide a model for treatment
Listed six procedures ranging from the non-intervention strategy – letting nature take its
course – to practice – most widely used strategy – to medical, biochemical, and surgical
treatments – which can be combined with other therapeutic treatments
Gross and Schutz (1986)
Suggested five steps of NP interventions:
(1) Environmental control
(2) Stimulus-Response (S-R) conditioning
(3) Skills training
(4) Strategy substitution
(5) And, cognitive cycle
Claimed these guidelines are hierarchical:
- Patients who cannot learn – treated with environmental control techniques
- Patients who can learn but cannot generalize – treated with S-R conditioning
- Patients who can learn and generalize, but cannot self-monitor – treated with skills
training
- Patients who can generalize – benefit from strategy substitution
- Patients who can manage all of the above and are able to set their own goals – best
suited for treatment that is incorporated within the cognitive style model
Model sounds plausible – but doubtful whether therapists would be able to determine whether
or not a patient can learn or generalize
COGNITIVE FUNCTIONING
Cognitive functioning – the area where theory has been most influential in rehabilitation –
particularly, in the treatment of language and reading disorders
,A model can be thought of as a representation – that can help us (1) understand and (2)
predict related phenomena
- It was in aphasia therapy that models first made their appearance
Coltheart
Argued that in order to treat a deficit – it is necessary to fully understand its nature – and to
do this, one has to have in mind how the function is normally achieved
Without this model – one cannot determine what kinds of treatment would be appropriate
Model is limited in rehabilitation – models of language and reading allow us to understand
the nature of the deficit – or, what is wrong – they do not tell us how to put things right
People undergoing rehabilitation – rarely have isolated deficits – such as difficulty
understanding reversible sentences or passive sentences – which the models proposed by
Coltheart identify
(1) Most individuals – have additional cognitive deficits – such as slowed info processing
or poor memory, attention, or executive deficits
- Likely to have emotional, social and behavioral problems
(2) In rehabilitation – patients are more likely to require help with everyday problems –
such as using the phone – rather than solely help with the impairment identified by the
models
Theoretical models from cognitive NP – not sufficient for developing rehabilitation programs
LEARNING
A theory of rehabilitation without a model of learning – is a vehicle without an engine
In rehabilitation – difficulty distinguishing between learning and memory:
(1) Memory – at least episodic memory – is the ability to recall personally experienced
events
(2) Learning – any system or process that results in the modification of behavior by
experience
Learning theory and behavior modification – intrinsically linked and have been used in
rehabilitation – including cognitive rehabilitation
, Goodkin (1996)
First to explicitly advocate behavioral techniques with brain injured patients
The behavioral strategy operant conditioning – initially applied to motor problems
(1) Goodkin applied it to help a stroke patient with dysphasia improve language skills
Today
Behavioral approaches – widely used in rehab to (1) help reduce or (2) compensate for
cognitive deficits
Behavior therapy and behavior modification techniques – adapted and modified to help
people with memory, perceptual, language, and reading disorders
These techniques – incorporate into cognitive rehab – because they provide:
(1) Structure
(2) A way of analyzing cognitive problems
(3) A means of assessing everyday manifestations of cognitive problems
(4) And, a means of evaluating the efficacy of treatment
They also supply us with many strategies – such as shaping, chaining, modeling,
desensitization, flooding, extinction, positive reinforcement, response cost, etc. – all of which
can be adapted to suit particular rehab purposes
EMOTION
Survivors of brain injury – common emotional problems include social isolation, anxiety,
depression and others
(1) Rehab is likely to fail – if we do not deal with the emotional issues
(2) Understanding theories and models of emotion – crucial to successful rehab
Beck – Cognitive Therapy and the Emotional Disorders
Appeared in 1976
Cognitive Behavioral Therapy (CBT)
It has become one of the most important and best validated psychotherapeutic procedures
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