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Summary Neuropsychological Rehabilitation and Treatment
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Summary of 6 lectures of the course; Neuropsychological Rehabilitation and Treatment.
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Neuropsychological Rehabilitation and TreatmentWeek 1 Mechanisms of recovery and treatment planning
Rehabilitation and treatment
Treatment=
- Care given to a patient
o E.g. administration of drugs, or surgery
Rehabilitation =
- Two-way interactive process (between patient and professional)
- To achieve optimum well-being (physical, psychological, social, vocational)
Historical milestones
Ancient Egyptians (about 1600 BC)
- Description of 48 cases of treatment of (brain) injury
- First appearance of term ‘brain’ in any language
- Rather treatment than rehabilitation
- Wounds were treated with fresh meat on day 1, then with grease, honey, and lint on
following days
- No saturation of wounds with open TBIs
- Recommendation of sitting upright in some cases (to counteract elevated intracranial
pressure?)
- No trepanations mentioned for the treatment of TBI.
World War 1
- More survivors with gunshot wounds to the head opened modern rehabilitation.
- Kurt Goldstein treated soldiers at the front before sending them to therapy:
Recommendations about therapy for impairments in speech, reading, and writing.
- Walter Poppelreuter treated soldiers with visuospatial and visual perceptual disorders and
discussed vocational rehabilitation
World War 2
- Alexander Romanovich Luria (army hospital): Working on ways to compensate for
psychological dysfunctions in brain damaged patients and argued that patients should be
regarded in his or her social context!
- Oliver Zangwill (1947): Introduction of three main approaches: Compensation, substitution,
direct retraining
More recent times…
- First ‘Cognitive Rehabilitation’ programme by Leonard Diller, New York (1976)
- Acceptance of holistic approach linking cognition, emotion, and behaviour
Hierarchical stages of holistic programmes (Ben-Yishay and Prigatano, 1990)
1. Increasing awareness of what has happened
2. Increasing acceptance and understanding of what has happened
3. Providing strategies or exercises to reduce problems
4. Developing compensatory skills
5. Providing vocational counselling
Early model of neuropsychological treatment (Gross & Schutz, 1986)
1. Environmental control
2. Stimulus-Response (S-R) conditioning Hierarchical model builds up upon each other
,3. Skill training
4. Strategy substitution
5. Cognitive cycle
Who are we treating?
Groups referred to neuropsychological rehabilitation:
Adults with non-progressive brain injury
- Traumatic brain injury
- Alteration of brain function caused by external force
- Hospital admission rates of about 150 to 250 per 100,000
- Highest in young children, older adolescents, and elderly
- Various and long-lasting cognitive and behavioral impairments, depending also on severity of
trauma
- stroke
- Disease of the blood vessels supplying the brain.
- Incidence rate of 94-117 per 100,000 age-adjusted person years
- Burden is increasing due to ageing population and better survival rates.
- Various cognitive, emotional, and behavioral consequences
-
- Encephalitis
- Inflammation of the brain tissue
- Brain damage caused by infection and/or swelling
- About 6 cases per 100,000 (for all age groups)
- Various cognitive, emotional and behavioral consequences
- Anoxia
- Deprivation of oxygen resulting in brain damage.
- Main cause is cardiac arrest: 1-2 per 1000 persons per year.
- Other causes: Embolism, poisoning, drug overdose, hanging, near drowning, or as a result
from stroke/TBI
- Various symptoms commonly observed, such as cognitive problems, emotional problems
(depression, anxiety), posttraumatic stress, lowered quality of life
- epilepsy
- Recurrent, unprovoked seizure (or high prob. after single seizure)
- Multiple causes can result in seizures.
- Most common neurological disorder and comorbidity
Adults with progressive brain injury
➢ Dementia
➢ Parkinson’s disease
➢ Huntington’s disease
➢ Brain tumour
➢ Multiple sclerosis
- Progressive decline in cognitive functions
- Cognitive decline progresses gradually, in many cases resulting in severe reduction or even
loss of abilities to perform everyday life activities.
- Focus of rehabilitation may differ from non-progressive neuropsychological conditions.
Children with brain injury
,➢ Developing brain is particularly vulnerable to brain trauma (in particular skills that are not yet
developed)
➢ Severity assessment more difficult than in adults and remains often undetected
➢ Higher risk for generalized pathology, distorting normal developmental processes
➢ Next to injury parameters, individual development level, pre-injury function, and family support
are crucial predictors for outcome and functioning in adulthood
Psychiatric disorders
➢ Neuropsychological impairments commonly seen in patients with psychiatric disorders
- Mood and anxiety related disorders
- Psychotic disorders
- Substance use disorders
- Developmental disorders
➢ Attention impairments are core features of neuropsychological impairments of patients with
psychiatric disorders
➢ Various treatment approaches (that may differ from those applied to neurological patients)
- Pharmacological interventions (e.g. stimulants)
- Physical interventions (e.g. exercise programs)
- Cognitive interventions (e.g. cognitive training)
- Behavioral interventions
- Brain stimulation (e.g. TMS) and neurofeedback
Mechanisms of recovery
Substantial spontaneous recovery within first period (weeks/months) after injury
➢ Recovery with no formal rehabilitation training
➢ Assumed to be experience independent.
Possible mechanisms explaining spontaneous recovery:
1. Resolution of diaschisis
➢ Diaschisis: Temporal loss of functions in regions distant from lesion
➢ Focal diaschisis (changes in well-defined brain areas distant from lesion) vs. connectional
diaschisis (changes in connectivity between damaged and unaffected brain regions)
➢ Diaschisis assumed to be dynamic and resolve over time.
2. Functional network recovery
➢ Reorganization of intact neural circuits
➢ Shifting activity towards perilesional brain areas and homologue areas of the contralesional
hemisphere
3. Behavioral compensation
➢ Unintentional use of different neuropsychological systems in the performance of a task
➢ E.g. Rapidly switching fixation point of patients with visual field defect
Experience-dependent learning
- Skills training leading to functional and cortical progress
- Teaching patients compensatory strategies: No restoration or substitution of impaired
neuropsychological functions, but offering patients strategies to compensate for their
impairments (behavioral bypass)
- Hebbian learning (increase in synaptic strength between neurons that fire together) as a likely
mechanisms of experience-dependent learning
Powerful booster in neuropsychological rehabilitation!
Treatment planning
, ➢ Goal setting
Why setting goals?
- Goals improve performance and direct attention towards relevant activities
- Goals motivate people to achieve more than without goals: Both patient and rehabilitation
team!
Who sets goals?
- Cognitive impairments and decreased insight may make it difficult for patients with brain
injury to set and formulate goals
o Interactive process between:
▪ Patient with brain injury
▪ Rehabilitation team
▪ Family members
Core components of goal setting: Goal setting and Action Planning (G-AP)
➢ Goal negotiation
- Motivation and outcome likely increased if goal setting process is:
o Collaborative (involving the patient)
o Patient-oriented (focus on goals relevant and important to client)
➢ Goal setting
- Formulation of clear, specific, and measurable goals
o SMART: Specific, Measurable, Achievable/Challenging, Relevant, Time frame
o Long-term goals can be broken down into a set of short-term goals (may lead to higher
achievement as goals are more easily achievable)
➢ Action planning and Developing coping plans
- Who will do what and when?
- Including both rehabilitation team and patient
- Identification of challenges in implementation and developing coping plans (goals are not
remembered by patients with memory impairment)
➢ Appraisal and Feedback
- Monitoring performance in relation to goal achievement
- Regular feedback important because awareness often compromised in patients with brain
injury
- Evaluation of goal achievement:
o Overall evaluation in terms of dichotomous decision (Y/N)
o Introduction of partial achievement
o Ordinal scaled goal attainment scales
Treatment planning:
➢ Assessment
Monitoring progress: Goal attainment scaling (GAS)
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