Module 1 A.E.M. van Wordragen 2100382
MODULE 1: WHAT IS NR?
ARTICLE: WILSON (2008)
o One of the major differences between academic neuropsychologists engaging in
rehabilitation research and clinical neuropsychologists working in rehabilitation
centres is the manner in which the needs of brain-injured people are determined.
Academic neuropsychologists believe that detailed assessment informed by
theoretical models can highlight areas that require rehabilitation.
Clinical neuropsychologists are less likely to determine rehabilitation needs
through theoretically informed models and are more likely to target real-life
problems identified by patients and their families.
o McLellan’s definition or cognitive rehabilitation: ‘a process whereby people with brain
injury work together with professional staff and others to remediate or alleviate
cognitive deficits arising from a neurological insult’ (used as a guide in this article).
o Rehabilitation needs to involve personally meaningful themes, activities, settings, and
interactions.
o Because the ultimate goal of rehabilitation is to enable people with disabilities to
function as adequately as possible in their own, most appropriate, environments, real-
life issues should be at the forefront of rehabilitation programs.
Motivation is likely to be increased because working on real-life problems also
prevents generalization difficulties.
Four major changes in defining rehabilitation
1. Goal Setting to Plan Rehabilitation
o Because goal planning is simple, focuses on practical everyday problems, is tailored to
individual needs, and avoids the artificial distinction between many outcomes
measures and real-life functioning, it is used increasingly in rehabilitation.
This approach provides direction for rehabilitation, identifies priorities for
intervention, evaluates progress, break rehabilitation down into achievable
steps, promotes team working, and results in better outcomes.
o McMillan and Sparkes proposed several principles involved in the goal-planning
approach:
The patient should be engaged in setting his or her goals.
The goals set should be reasonable and client centered.
Patient’s behavior when a goal is reached should be described.
The method to be used in achieving the goals should be defined in such a
manner that anyone reading the plan would know what to do.
Goals should be specific and measurable and have definite deadline.
o The SMART acronym summarizes the main principles in goal defining: specific,
measurable, achievable, realistic, and timely.
o Failure to achieve a goal is attributed to reasons in one of four main categories:
Client or carer (client unwell)
Staff member (staff member unwell)
Internal administration failure
External administration failure
o Direct patient involvement in neurorehabilitation goal setting results in significant
improvements in reaching and maintaining those goals.
,Module 1 A.E.M. van Wordragen 2100382
2. Cognitive, Emotional, and Psychosocial Deficits are Interlinked
o Although cognitive deficits are the main focus of neuropsychological rehabilitation
(NR), there is growing awareness that the emotional and psychosocial consequences
of brain injury need to be addressed in rehabilitation programs.
Not only does emotional affect how we think and how we behave, but also
cognitive deficits can be exacerbated by emotional distress and can cause
apparent behavior problems.
Psychosocial difficulties can also result in increased emotional and behavioral
problems, and anxiety can reduce the effectiveness of intervention programs.
o The holistic approach is founded on the belief that the cognitive, psychiatric, and
functional aspects of brain injury should not be separated from emotional, feelings,
and self-esteem.
Holistic program include group and individual therapy in which patients are
encouraged to be more aware of their strengths and weaknesses, helped to
understand and accept these, given strategies to compensate for cognitive
difficulties, and offered vocational guidance and support.
Such programs appear to result in emotional distress, increased self-
esteem, and greater productivity.
3. Increasing Use of Technology in NR
o The increasing use of sophisticated technology such as PET and fMRI is enhancing
our understanding of brain damage.
o One of the major themes in rehabilitation is the adaptation of technology for the
benefit of people with cognitive impairments.
4. Rehabilitation Needs a Broad Theoretical Base
o In order to improve cognitive, social, emotional, and behavioral functioning in the
everyday life of these individuals, NR should not be constrained by a single theoretical
framework.
o Ethical and effective NR requires a synthesis and integration of several frameworks,
theories, and methodologies to achieve its aims and ensure the best clinical practice.
Cognitive Aspects of NR
o Unless the brain damage is very mild, cognitive deficits are almost invariable found in
survivors of an insult to the brain.
Problems with memory, attention, executive functioning, and speed of
information processing are the most typical difficulties faced by those who
have TBI.
Language problems are common after life hemisphere damage as a result of a
stroke. Unilateral neglect is seen frequently after right hemisphere damage.
o Tackling real-life targets and individualizing programs within a specific framework is
the way forward in cognitive rehabilitation.
Patients and families select the target behaviors they wanted to achieve.
o Considering retraining versus compensation, retraining was found effective for some
cognitive functions (such as language), whereas compensation was necessary for
others (such as memory).
, Module 1 A.E.M. van Wordragen 2100382
Emotional Aspects of NR
o Social isolation, anxiety, and depression are common in survivors of brain injury.
o Gainotti distinguishes three main factors causing emotional and psychosocial
problems after brain injury:
Those resulting from neurological factors.
Those due to psychological or psychodynamic factors.
Those due to psychosocial factors.
o At some level, patients are aware of their disabilities but are unable to accept them.
CBT is well suited for improving coping skills, helping client to manage
cognitive difficulties, and addressing more generalized anxiety and depression
in the context of a brain injury.
o However, given that PTSD seems to occur even when there is a loss of consciousness
for the event, there could be two main mediating mechanisms to suggest how trauma-
related materials may be processed to lead to PTSD symptoms:
Survivors may evoke ‘island of memory’ for their trauma, such a being trapped
in a crashed car.
Survivors may be reminded of elements of their trauma event when exposed to
similar situations that serve to produce intrusive thoughts.
o Dealing with emotional consequences of brain injury may make the difference
between a successful and an unsuccessful outcome.
o Cognitive behavioral psychotherapy and cognitive remediation appear to minish
psychological distress and improve cognitive functioning among community-living
persons with mild and moderate TBI.
Psychosocial Aspect of NR
o Psychosocial disorders are often defined as: ‘a mental illness caused or influenced by
life experiences, as well as mal-adjusted cognitive and behavioral processes’.
In brain injury rehabilitation the term is often used to refer to psychosocial
outcomes such as work, friendship, and community activities.
o The psychosocial framework consists of four levels: pathology, impairment, activity,
and participation.
o The WHO model considers three major contexts influencing behavior: personal,
physical, and social contexts.
Personal context: relevant characteristics of an individual such a expectations,
beliefs, and attitudes.
Physical context: the environment in which the individual finds himself or
herself.
Social context: the culture in which the individual functions.
o Lack of productivity (employment) decreases the opportunity for individuals with
brain injury to develop social contacts and leisure activities, which in turn contribute
to depression and low self-esteem.
o Engagement in paid and nonpaid productive activities has beneficial impact on
community integration.
o People who are given intensive rehabilitation have an improved likelihood of
returning to work.
The definition of ‘returning to work’ should be expanded to include part-time
work and other meaningful functional activities rather than simply full-time
competitive work.
