Neuropsychological Rehabilitation for People with Non-Progressive Brain Damage
Abstract and Keywords
Neuropsychological rehabilitation (NR) is concerned with the amelioration of deficits caused by insult to the brain. It adopts a goal-planning approach and addresses real-life difficulties. Neuropsychology studies how the brain affects behavior, emotion, and cognition. Rehabilitation is a process whereby people who are disabled work together with professional staff, relatives, and others to achieve optimum physical, psychological, and vocational well-being. Rehabilitation is not synonymous with recovery, nor is it treatment. It is a two-way interactive process with professional staff and others who aim to remediate or alleviate difficulties, adopting a holistic approach in which cognition, emotion, and psychosocial problems are treated together, aided by an increasing use of technological aids.
NR enables people with disabilities to achieve their optimum level of well-being, reduce problems in everyday life, and help them return to the most appropriate environments. There may also be some partial or limited recovery of function and certainly some substitution of function. Accepting that return of normal functioning is highly unlikely, rehabilitation finds ways to help people learn more efficiently, compensate for their difficulties, and, when necessary, modify the environment.
While theoretical models have proved helpful, indeed essential, in identifying cognitive strengths and weaknesses, in explaining phenomena, and in making predictions about behavior, they are insufficient, on their own, to seriously influence rehabilitation aimed at making lives more adaptable to problems encountered in everyday living. NR should focus on goals relevant to a person’s individual everyday life, it should be implemented in the environment where the person lives, and have personally meaningful themes, activities, settings, and interactions.
We know from numerous studies that NR can be clinically effective. Although rehabilitation can be expensive in the short term, there is evidence that it is cost-effective in the long term.
The British Society for Rehabilitation Medicine (BSRM) and Royal College of Physicians (RCP) in the United Kingdom define rehabilitation as “a process of active change by which a person who has become disabled acquires the knowledge and skills needed for optimal physical, psychological and social function”; in terms of service provision this entails “the use of all means to minimise the impact of disabling conditions and to assist disabled people to achieve their desired level of autonomy and participation in society” (BSRM/RCP, 2003, p. 7). This is a useful start when trying to understand neuropsychological rehabilitation (NR), but in order to delve a little deeper let us consider the meanings of neuropsychology, rehabilitation, and NR.
Neuropsychology is the study of the relationship between brain and behavior or, to put it another way, we could say it is the study of how the brain affects behavior, emotion, and cognition. Rehabilitation is a process whereby people who are disabled by injury or disease work together with professional staff, relatives, and members of the wider community to achieve their optimum physical, psychological, social, and vocational well-being. It aims to reduce the impact of disability and handicapping conditions, and, indirectly, improve the quality of life of patients.
Given these two definitions, how should we define NR? It is not synonymous with recovery, if by recovery we mean returning to one’s former self before injury or illness. Nor is it the same as treatment, as that is something done to or given to people, like drugs or surgery. Rehabilitation is, in fact, a two-way interactive process. Although similar to cognitive rehabilitation, whereby people with a brain injury work together with professional staff and others to remediate or alleviate cognitive deficits arising from a neurological insult, NR is a broader process, being concerned with the amelioration of cognitive, emotional, psychosocial, and behavioral deficits caused by an insult to the brain.
For the most part, NR concentrates on cognitive and emotional deficits following brain injury, although physical, social, and behavioral disorders are sometimes addressed. It can, therefore, be distinguished from cognitive rehabilitation in that it encompasses a wider range of deficits. It is one of many fields needing a broad theoretical base incorporating frameworks, theories, and models from many different areas. Being constrained by one theoretical model can lead to poor clinical practice, as no one model, theory, or framework is sufficient to meet the many complex needs of those requiring NR services (Wilson & Betteridge, 2019).
NR is mostly centered around a goal-planning approach in partnership with survivors of brain injury, their families, and professional staff who negotiate and select goals to be achieved. There is a widespread recognition that cognition, emotion, and psychosocial functioning are interlinked and all should be targeted in rehabilitation. This is the basis of the holistic approach. There is increasing use of technology to compensate for cognitive deficits and some of these technological aids are discussed. Evidence for effective treatment of cognitive, emotional, and psychosocial difficulties is presented, models which have been most influential in NR are described, and this article concludes with guidelines for good practice.
The main purpose of NR is to enable people with disabilities to achieve their optimum level of well-being, to reduce the impact of their problems in everyday life, and to help them return to their own most appropriate environments. It is not to teach them to score better on tests or to learn lists of words or to be faster at detecting stimuli. As far as possible NR should address the real-life difficulties experienced by people with brain injuries unless one is asking a particular question which cannot be answered in this way. The results should then be applicable to real-life problems. Thus, NR should focus on goals relevant to a patient’s own everyday life; it should be implemented in the setting where the patient lives (or generalize to that setting); it should be collaborative; it should try to reduce disability and improve real-life functioning. Ylvisaker and Feeney (2000) remind us that rehabilitation needs to involve personally meaningful themes, activities, settings, and interactions.
Further details can be found in Barker, Gibson and Robinson (2018)
Recovery from Brain Injury
Following brain injury some improvement will almost always occur. Can we call this recovery? Recovery means different things to different people. To some it means the complete reinstatement of the functions lost or impaired as a result of the brain damage (Finger, Levere, Almli, & Stein, 1988). For survivors of moderate or severe brain injury this is almost always unattainable. To others recovery means the resumption of normal life even though there may be minor neurological or psychological deficits (Jennett & Bond, 1975). This may be achievable for some traumatic brain injury (TBI) survivors. Marshall (1985) defines recovery as the diminution of impairments in behavioral or physiological functions over time. This is likely to occur for the majority of patients. Another interpretation of the term “recovery” is that of Kolb (1995), who suggests that recovery typically involves partial recovery of function together with substitution of function. This is probably the definition of recovery that most closely reflects the situation for the majority of people with brain damage. Recovery may be natural or it may be helped through rehabilitation procedures that enable improvement on natural recovery. Brain damage resulting from TBI can be due to both primary and secondary causes. Primary damage is that which occurs as a direct result of the accident or insult, such as contusions or shearing of axons. Secondary damage is due to complications arising from the initial injury, such as reduced blood pressure or infections. If secondary damage is avoided through expert medical care then the final outcome or recovery is maximized. As Miller, Pentland, and Berrol (1990), indicate, the final outcome of any patient who suffers head injury is governed by three groups of factors, namely: the pre-injury status of the brain, the total amount of damage done to the brain by the impact of the head injury (primary damage), and the cumulative effect of the secondary pathological damage to the already injured brain. Secondary damage may result in more permanent disability than primary damage even though it is, at least potentially, avoidable (Daisley, Tams, & Kischka, 2009).
Although recovery from TBI is variable, far from uniform, and may, in some individuals, continue for years (Millis et al., 2001), most survivors undergo some, and often considerable, recovery. This is likely to be fairly rapid in the early weeks and months post-injury, followed by a slower recovery that can continue for many years. A similar pattern may be seen following other kinds of non-progressive injury, including strokes, encephalitis, and hypoxia (Wilson, 2019).
A number of factors influence the extent of recovery, some of which cannot be changed once the damage has occurred: these include the age of the person at the time of insult, the severity of damage, the location of damage, the status of undamaged areas of the brain, and the pre-morbid cognitive status of the brain. Other factors such as motivation, family support systems, and the quality of rehabilitation available can be manipulated.
Three major factors which may influence recovery are age, gender, and cognitive reserve. In 1940 Kennard showed that young primates with lesions in the motor and premotor cortex exhibited sparing and partial recovery of motor function. Her findings came to be known as “the Kennard principle.” However, even Kennard herself recognized that such sparing did not always occur and that some problems became worse over time. Several studies have shown that younger children fare worse than older children (Anderson et al., 2006; Hessen, Nestvold, & Anderson, 2007). These findings suggest that younger children, particularly those below the age of 2 years, fare worse in the long term than older children. Those studies suggesting the opposite (Montour-Proulx, Braun, Daigneault, Rouleau, & Kuehn, 2004) or no difference (Mosch, Max, & Tranel, 2005) are looking at children with focal rather than diffuse lesions.
Age, then, is just one factor in the recovery process that has to be considered alongside other perhaps more important factors, such as whether the lesion is focal or diffuse, the severity of the insult, and the time since acquisition of the function under consideration. For example, someone who has just learned to read at the time of the insult is more likely to show reading deficits than someone who learned to read many years before.
What about gender? In 1987, Attella, Nattinville, and Stein suggested that female animals may be protected against the effects of brain injury at certain stages of their cycle due to the effects of estrogen and progesterone. This was confirmed by Roof and Hall (2000). Potentially important for rehabilitation (Stein, 2007), progesterone has been given to survivors of TBI with some suggestion that this leads to a better outcome (Wright et al., 2007). In addition, some studies have looked at the long-term outcome for females and males following TBI. The findings are contradictory, with, for example, Ratcliff et al. (2007) suggesting that females do better than males while other studies suggest the opposite (Farace & Alves, 2000; Ponsford et al., 2008). The latter study controlled for Glasgow Coma Scale score, age, and cause of injury. They found that females had both a lower rate of survival and a lower rate of good outcome at six months post-injury. The authors thought this might be due to the fact that more females died in the early stages. In general, they found no evidence that women did better and some evidence that they did worse than males. The debate continues, with Skolnick et al. (2014) suggesting no differences between males and females in a large randomized control trial while Cancelliere, Donavan, and Cassidy (2015) found small sex differences for some outcomes for mild TBI.
People whose brain injuries are in similar locations and of the same severity and extent may, nevertheless, have very different problems and outcomes. This led to the concept of cognitive reserve, which is the third factor to be considered in the understanding of recovery from brain injury. The principle of cognitive reserve says that people with more education and high intelligence may show less impairment than those with poor education and low intelligence. Stern (2007) suggests that individuals with high intelligence may process tasks in a more efficient way. Consequently, in cases of Alzheimer’s Disease (AD), task impairment manifests itself later in the disease in people with such cognitive reserve. Stern also reminds us that most clinicians are aware of the fact that any insult of the same severity can produce profound damage in one patient and minimal damage in another. This may also explain differences in recovery following non-progressive brain injury for, as Symonds said in an often quoted remark, “It is not only the kind of head injury that matters but the kind of head” (1937, p. 1092).
Restoration of Function
Rehabilitation is carried out in several ways, for example through attempts to restore lost functioning, or encouragement of anatomical reorganization or ways to help patients learn more efficiently, or to help them find an alternative means to achieve their goals or through modifying/restructuring the environment. The majority of British neuropsychologists working in adult brain injury rehabilitation use the last three of these (Wilson, Rous, & Sopena, 2009), with fewer attempting to restore lost functioning or working toward anatomical reorganization.
As far back as 1947, Zangwill wrote “We wish to know in particular how far the brain injured patient may be expected to compensate for his disabilities and the extent to which the injured human brain is capable of re-education” (Zangwill, 1947, p. 62). This question is as pertinent now in the 21st century as it was just after World War II. Zangwill believed that some damaged functions could, perhaps, be restored through training. He said “direct, as opposed to substitutive training has a real though limited part to play in re- education” (Zangwill, 1947, p. 66).
Is it, in fact, possible to restore lost functioning? This is a debatable point and may depend on the cognitive function being trained. Clinicians can, for example, teach problem-solving skills (Evans, 2009) and other executive deficits, but it is not clear whether this is a restoration or a compensatory approach. If the training is considered to be learning or relearning the skill of problem-solving, then this might be considered to be a restoration approach. On the other hand, if it is regarded as providing a strategy to deal with everyday problems then this might be seen as compensation. The same can be said of unilateral neglect. There are several studies which can reduce neglect (summarized in Wilson, Mole, & Manly, 2017), but whether restoration of function or compensation is the underlying explanation is disputable.
Does the cognitive function matter when trying to restore lost functioning? With regard to episodic memory, there is no good evidence that restoration of memory functioning can occur (Broman, Rose, Hotson, & Casey, 1997; Wilson, 2009), but there is plenty of evidence that compensatory strategies can help people manage everyday problems (O’Neill, Jamieson, & Goodwin, 2017). What about attention? Here there is limited evidence of restoration of function but there are typically problems with generalization (Fish, 2017). With regard to perceptual recognition difficulties, there is no strong evidence that it is possible to retrain the ability to recognize faces for people with prosopagnosia (Wilson, Robertson, & Mole, 2015) or recognize objects again for those with visual object agnosia (Wilson et al., 2017), so compensatory strategies need to be employed. Language is, perhaps the area where there is some evidence of restoration (Kolb, 1995; Raymer & Turkstra, 2017). Why should this be so?
Robertson (2002) suggests that recovery is rapid for deficits that are subserved by multiple circuits, such as unilateral neglect, and slowest for deficits that are subserved by a more limited number of circuits, such as hemianopia, because fewer alternative pathways are available to take over the functioning of the damaged pathways. This could be the reason why language functions appear to show better recovery over time than memory functions (Kolb, 1995). Consider a paper by Vargha-Khadem, Carr, et al. (1997). They describe a boy with Sturge-Weber Syndrome who was mute until the age of 9 when he had a hemispherectomy. He then went on to develop clearly articulated, well-structured, and appropriate language skills. At the age of 15 he had the language skills of an 8–10-year-old. In contrast, they report on three cases of childhood amnesia where the subjects had considerable memory deficits into adulthood (Vargha-Khadem, Gadian, et al., 1997). With regard to memory functions it seems that neither children nor adults are likely to recover from the amnesic syndrome. It would seem true, therefore, that some cognitive functions can be at least partially restored, while, for others, this is impossible.
What Are the Most Influential Models in NR?
Because of the complexity of NR and the variety of problems faced by survivors of brain injury, it is important to draw on a number of theories and models when designing rehabilitation programs to avoid the danger of poor clinical practice (Wilson & Betteridge, 2019). Some of the most influential models and theories in NR since the late 1990s have been those of cognition, emotion, behavior, and learning. Several models of cognitive functioning have proved useful in rehabilitation, including models of language, reading, memory, attention, and perception. The most influential theories would appear to be those from cognitive neuropsychology, particularly from the fields of language and reading (see, e.g., Coltheart, Bates, & Castles, 1994; Mitchum & Berndt, 1995). Although it is true that theoretical models from cognitive neuropsychology have been highly influential in understanding and explaining related phenomena (Wilson & Patterson, 1990), and developing assessment procedures, the trap waiting for them is rehabilitation irrelevance (Robertson, 1991). Because models from cognitive neuropsychology specify what to treat and not how to treat, they are insufficient on their own to guide neuropsychologists through the many intricate processes involved in the rehabilitation process.
Furthermore, people undergoing rehabilitation rarely have isolated deficits such as difficulty understanding reversible sentences or passive sentences, which the models proposed by Coltheart and others identify. Most individuals will have additional cognitive deficits such as slowed information processing or poor memory, attention or executive deficits. They are also likely to have emotional, social, and behavioral problems. Patients are more likely to require help with everyday problems, such as using the telephone, rather than help with impairments identified by models (Wilson & Betteridge, 2019).
The management and remediation of the emotional consequences of brain injury have become increasingly important over the past 25 years. Prigatano (1999) suggests that rehabilitation is likely to fail if emotional issues are not addressed. One influential model is the “Y”-shaped model (Gracey, Evans, & Malley, 2009). This model suggests that “A complex and dynamic set of biological, psychological and social factors interact to determine the consequences of acquired brain injury” (Gracey et al., 2009, p. 867). The model integrates findings from psychosocial adjustment, awareness, and well-being. It attempts to reduce the discrepancy between the old “me” and the current “me” into the “new” me. It describes consolidation of new, adaptive, and positive meanings in life, highlighting the importance of ending therapy with a sense of starting a journey, rather than having completed one (Ownsworth & Gracey, 2017). Addressing issues in identity has become increasingly important in rehabilitation. Ownsworth (2014) covers this work in depth in her excellent book Self Identity after Brain Injury.
Theories and models from learning theory and behavioral psychology have also been used in rehabilitation since the 1970s (Ince, 1976; Lincoln, 1978), and in cognitive rehabilitation (Wilson, 1991). For example, behavioral assessments are employed in many cognitive programs to: (a) identify and measure variables that control behavior, (b) select treatment, and (c) evaluate treatment. Numerous approaches from behavior therapy and behavior modification have been adopted for helping people with memory, perceptual, reading, and language disorders (Wilson, 1999). A behavioral analysis approach is usually incorporated into cognitive rehabilitation because it provides a structure, a way of analyzing cognitive problems, a means of assessing everyday manifestations of cognitive problems, and a means of evaluating the efficacy of treatment programs. It also provides many existing treatment strategies such as shaping, chaining, modeling, desensitization, flooding, extinction, positive reinforcement, response cost, and so forth, all of which can be modified or adapted to suit particular rehabilitation purposes (Wilson & Betteridge, 2019).
In 1991 Coltheart stated 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. This approach is limited because, as stated, people undergoing rehabilitation rarely have isolated deficits, such as difficulty with reversible sentences; they may have emotional, social, and behavioral problems together with additional cognitive deficits; they are more likely to require help with the everyday problems caused by the deficit rather than help with the impairment; and understanding the deficit in detail (knowing what to do or treat) does not provide information on how to treat. From this it can be concluded that theories of cognitive functioning are necessary but not sufficient in NR.
Similarly, Caramazza and Hillis (1993) argued “For a theory of remediation of cognitive deficits.” They were not concerned with the question of whether cognitive models are helpful in rehabilitation for “surely they are, it is hard to imagine that efforts at therapeutic intervention would not be facilitated by having the clearest possible idea of what needs to be rehabilitated” (p. 218). Instead they were concerned with the potential role of these models in articulating theoretically informed constraints on cognitive disorders. The belief that detailed assessment informed by theoretical cognitive models can identify “what needs to be rehabilitated” highlights, perhaps, the major difference between academic neuropsychologists engaged in cognitive rehabilitation and clinical neuropsychologists working at the “coal face.” Those engaged in the day-to-day practice of helping people with cognitive deficits care more about real-life problems rather than impairments identified by theoretically informed models. These impairments may well be caused by cognitive deficits but in most cases neuropsychologists are not trying to rehabilitate the deficit so much as reduce or overcome the associated everyday problems seen as important by the patient and the family. Wilson (2002) tried to come up with a comprehensive theory of rehabilitation encompassing cognition, emotion, behavior, new learning, recovery, and all the other factors of importance in the belief that no one theory is likely to be sufficient.
Does this mean theoretical models are not important? Of course not. Models of cognitive functioning have proved very helpful in identifying cognitive strengths and weaknesses, in explaining phenomena, and in making predictions about behavior. All are important features in designing and evaluating rehabilitation programs. They are not, however, sufficient on their own for designing NR programs. More details on the models and theories influential in NR can be found in Wilson and Betteridge (2019).
Strategies to Employ in NR: Improving Learning, Compensatory Strategies, and Adjusting the Environment
One of the common consequences of brain injury is difficulty learning new information (Wilson, 2009). Families, patients, and others frequently believe that an answer to this problem is repetition. They may say something like “it is just a question of repetition really, isn’t it?” Although widely used, however, repetition by itself is insufficient as information may go “in one ear and out the other.” As long ago as 1973 it was clear that there was no relationship between the rehearsal time (number of repetitions) and the amount learned (Craik & Watkins, 1973). Even in circumstances where repeated practice does lead to improvement there may be no generalization. A famous experiment carried out by Ericcson, Chase, and Falconer (1980) involved training a student to increase his forward digit span from the norm of seven plus or minus two (Miller, 1956). After 20 months of practice the student’s span increased from seven to a phenomenal 80 digits, that is, having heard the 80 digits once only he could repeat them back correctly, in the same order as originally presented! In order to do this, however, he had to convert them into something meaningful. He was an athlete so imagined the digits as representing running times or distances or other athletic information. As impressive as this performance was, the improvement did not generalize to other memory tasks, not even to remembering consonants; his span here at the end of the 20 months training was around six. Rote rehearsal then, or simply repeating information, is of limited value.
There are, however, methods that do help to improve learning. Three which are used regularly, at least in memory rehabilitation, are spaced retrieval (also known as expanded rehearsal), errorless learning, and vanishing cues.
Spaced retrieval (SR) or expanded rehearsal as it is also known, is a method developed from the work of Landauer and Bjork (1978). It is most often used to teach a new name, telephone number, or short address. The main principle to be followed here is distributed practice. The material to be remembered is presented and tested immediately. Most people have a normal or nearly normal immediate memory so this capitalizes on this system. The information is tested again after a very short delay (just a second or two), then after a slightly longer delay, and so forth. The retention interval is gradually increased. The little and often rule, otherwise known as distributed practice, is followed. When people are trying to learn something they learn better when the learning occasions or trials are spread over a period of time rather than crowded all together. Baddeley and Longman (1978) describe an experiment where postmen were taught to type; three groups each had 12 hours of tuition: one group spent one hour a day learning for 12 days, another group spent two hours a day for six days, and the third group spent six hours a day for two days. Those learning for one hour a day did better and forgot less.
SR has been used with people with dementia (e.g., Camp, Bird, & Cherry, 2000). While Hopper et al. (2005) looked at 15 studies and recommends SR for people with dementia. Wilson (2009) describes in more detail the research behind some of the SR studies and success with non-progressive patients. SR probably works because distributed practice is better than massed practice (Baddeley & Longman, 1978) but may work even better when combined with errorless learning.
Errorless learning (EL) is a teaching technique whereby people are prevented, as far as possible, from making mistakes while they are learning a new skill or acquiring new information. This can be carried out in a number of ways, such as providing spoken or written instructions or guiding the person through a task. The principle is to avoid mistakes being made during learning and to minimize the possibility of erroneous responses.
EL was first described by Terrace (1963) in his work with pigeons. He taught the birds to discriminate a red key from a green key, a difficult discrimination for pigeons to make. Half were taught using a method in which very few errors were made, while the other half were taught in the traditional trial-and-error method. Furthermore, the pigeons showed less emotionality when taught by errorless method than when taught by trial-and-error. This also seems true when used with survivors of brain injury.
Once Terrace’s work was published, it was adopted in the field of learning disability; Sidman and Stoddard (1967), for example, adapted this method to teach children with intellectual handicaps to discriminate between circles and ellipses. They could have taught them something more practical perhaps? (1976) taught color, size, weight, and shape using errorless learning principles, while Walsh and Lamberts (1979) used this method to teach reading skills to developmentally delayed children. For many years, then, EL has been widely used for people with developmental learning disabilities. Cullen (1976) believed that if errors were made during learning it was harder to remember what had been learned. In addition, of course, more reinforcement occurs in EL and nobody likes failing.
Behavioral psychology is one important theoretical strand behind the success of EL. The other strand comes from studies of implicit learning (learning without conscious recollection) from cognitive psychology (Graf & Schacter, 1985). From such work it is clear that people with amnesia who have very severe difficulties learning new information can learn normally or nearly normally under some circumstances. This is with implicit learning tasks such as motor tracking, mirror reading, or fragmented picture (perceptual priming) tests, where learning without conscious recollection can be demonstrated. Anomalies can sometimes be seen, however. So, on a fragmented picture task, even though there may be general improvement over time, a mistaken response, an error, may stick no matter how many times the correct answer is given. This led Baddeley and Wilson (1994) to pose the question “Do people with amnesia learn more if prevented from making mistakes while learning?” There was a small effect in favor of EL with the young and elderly control participants, while every one of the amnesic patients did better with the EL condition. The finding was so robust the experimenter changed her clinical behavior immediately and now never asks memory-impaired people to guess unless they are doing a forced choice test. The conclusions from Baddeley and Wilson (1994) were that Errorless learning (EL) was more effective than Errorful learning (EF); this advantage was greater for the people with amnesia; the amnesic people showed less forgetfulness under EL; therefore, people with amnesia should not be asked to guess.
However, results from experiments to answer a rehabilitation question need to be applicable to real-life problems. Thus, the next step was to see if EL principles could be applied to real-life difficulties. Wilson, Baddeley, Evans, and Shiel (1994) did this with four individuals. The first experiment taught object recognition to a man with amnesia and agnosia; the second taught a man with Korsakoff’s Syndrome how to program an electronic organizer; the third helped a man who had sustained a thalamic stroke to learn people’s names; and the fourth taught orientation items to a man in post-traumatic amnesia. In each case half the stimuli used were presented in an EL way and half in an EF way. All learned more when the EL method was used.
The reason EL works is probably because in order to benefit from mistakes people need to be able to remember them. Page, Wilson, Shiel, Carter, and Norris (2006) believe that EL is dependent on implicit memory and this system is not good at error elimination (episodic memory does that). Therefore, if people who depend on implicit memory functioning make an incorrect response, this response may be strengthened. It is also clear from several studies that prior errors cause more interference for those more reliant on implicit memory (Jacoby, Wahlheim, Rhodes, Daniels, & Rogers, 2010).
There has also been considerable interest in using EL for people with language deficits. The main conclusion (Lambon-Ralph, 2009 personal communication) is that there is not much difference between EL and EF learning. For those with severe deficits, however, EL is preferred. This is probably because it is kinder and less likely to lead to failure.
Vanishing cues (VC) is a method whereby prompts are provided and then gradually faded out. First reported by Glisky, Schacter, and Tulving (1986), a number of studies since have reported some success (Wilson, 2009). For example, Clare, Wilson, Breen, and Hodges (1999) used VC in combination with SR and EL to teach a man who had been diagnosed with AD six years earlier to remember the names of people at his social club. Each name was taught in the following way: first the man was shown a photograph of the person whose name he was to learn and asked how he could remember Gloria or Caroline (or whoever). For Gloria he said “Gloria with the gleaming smile.” He was then requested to copy GLORIA, then asked to copy GLORI_ and complete the final letter himself. He then had to complete the final two letters GLOR_ _ and so on. Once he completed all letters, SR was employed to ensure the name was retained. He was also requested not to guess and only recall the name if he was sure; if not sure, he could turn the photograph over to see the name printed on the back. He learned all names in this way. VC probably works because it is an EL (or at least an error-reduction) approach.
External aids, not necessarily technological, are the most effective and widely used interventions for the rehabilitation of memory impairments (O’Neill et al., 2017; Sohlberg, 2005). They can also be used to offset other cognitive impairments such as language disorders, executive problems, calculation deficits, recognition problems, and unilateral neglect.
Boake (2003) includes discussion of some of the early computer-based cognitive rehabilitation programs while a paper by Wilson, Emslie, Quirk, and Evans (2001) used a randomized control crossover design to demonstrate that it is possible to reduce the everyday problems of neurologically impaired people with memory and/or planning difficulties by using a paging system. In 1986, Glisky and Schacter taught memory-impaired people computer terminology and one of their participants was able to find employment as a computer operator.
Many studies can be found providing evidence for the effectiveness of compensatory aids. A systematic review of seven studies by Jamieson, Cullen, McGee-Lennon, Brewster, and Evans (2014) showed significant and large effects when people used external memory aids. There is evidence for a number of strategies such as television-prompting devices, Google calendar, cell phones, and smartphones (Dewar, Kopelman, Kapur, & Wilson, 2015). For a more recent (2017) update on the use of computer-assisted devices in NR see O’Neill et al. They consider several areas where assistive technology can be used not only for cognitive deficits but also for difficulties with time perception and recognition of objects, actions, emotions, and faces. Robots, too, are increasingly likely to be used in rehabilitation. Moyle (2017), for example, discusses the use of robots for people with dementia, and observes how these can be used to help care for them and reduce the feeling of social isolation.
The final technological area to mention is virtual reality (VR), as this is more and more likely to be used in rehabilitation in general and in NR in particular. VR can be both an assessment tool and a teaching technique. It refers to the use of computer hardware and software in addition to adjunct technologies to create interactive simulations and environments.
These allow opportunities to engage in settings that resemble and feel similar to real-world interactions. The ultimate goal of VR-based intervention is to make it possible for clients to become more able to participate in community life (Kizony, 2011). VR technology simulates real-world environments and situations that can be easily adapted to the needs and characteristics of various groups and can train cognitive strategies in various contexts, to facilitate their transfer to the real world. Within the virtual environment users are provided with different types of feedback modalities for their performance. These include visual and audio feedback and, less often, haptic and vestibular feedback (Weiss, Kizony, Feintuch, & Katz, 2006). Rose, Brooks, and Rizzo (2005) discuss the use of VR for the assessment and treatment of memory problems, executive deficits, visuospatial difficulties, and unilateral neglect.
The opportunity for experiential and active learning in a relevant setting encourages and motivates the user. Enhancing motivation is especially important for clients with cognitive deficits who often have low levels of motivation and compliance during the rehabilitation process. The same is true for clients with executive deficits which affect their ability to initiate performance and to set goals. Some examples of VR in NR include a virtual kitchen to assess cognitive abilities during meal preparation in people with TBI (Christiansen, Huddleston, & Ottenbacher, 2001); a virtual mall (Rand, Basha-Abu Rukan, Weiss, & Katz, 2009) to look at executive functions; a library-based task (Renison, Ponsford, Test, Richardson, & Brownfield, 2012), requiring participants to prioritize and complete multiple tasks whilst managing interruptions, and new information necessitating a shift in their approach (this task assesses seven types of executive functioning); a virtual classroom; a virtual town; and a virtual hospital (Jansari, Devlin, Agnew, & Akesson, 2014).
The ultimate goal of VR is to make it possible for patients to become more able to participate in community life.
Modifying or Restructuring the Environment.
Sometimes it is necessary to adjust the physical or verbal environment to avoid the need for cognitive functioning. This strategy is particularly useful for people with severe and widespread problems but can also be used for others with less severe problems. Smart houses, signposts, and labeling can all be employed and even the verbal environment may be altered too (Wilson, 2009). For example, someone who always asks the same question or tells the same joke may do this in response to a verbal trigger from a relative or member of staff and the repetition may be avoided if the relative or member of staff chooses a different form of words. Thus, CW (Wilson, 1999) regularly told everyone he had just woken up. If people sympathized or repeated the phrase back to him, CW became more and more agitated. The solution was to change the topic and ask him something he was comfortable with. More often, however, it will be the physical environment that needs changing. Just as people with severe physical disabilities can use environmental control systems to enable them to open and close doors, turn the pages of a book, answer the telephone, and so forth, so people with cognitive deficits can avoid the need to use their cognitive functions provided the environment is structured in a certain way. Thus, someone with severe executive deficits may be able to function in a structured environment, with no distractions and where there is no need to problem-solve, as the task at hand is clear and unambiguous. Similarly, people with severe memory problems may not be handicapped in environments where there are no demands made on memory. Thus if doors, cupboards, drawers, and storage jars are clearly labeled, if rooms are cleared of dangerous equipment, if someone reminds or accompanies the memory-impaired person when it is time to go to the dentist or to eat dinner, the person may cope reasonably well (Wilson, 2009).
Kapur, Glisky, and Wilson (2004) give other examples. Items can be left by the front door for people who forget to take belongings with them when they leave the house; a message can be left on the mirror in the hallway and a simple flow chart can be used to help people search in likely places when they cannot find a lost belonging (Moffat, 1989). Cars, cell phones, and other items may have intrinsic alarms to remind people to do things. These can be paired with voice messages to remind people why the alarm is ringing. Further discussion of this topic can be found in Wilson and Betteridge (2019). For those interested in memory rehabilitation in healthy aging, please see Anderson (2018) while Boller and Belleville (2018) address cognitive intervention in older adults with mild cognitive impairments.
Is NR Effective?
We know from numerous studies that NR is clinically effective. For example, Cicerone et al. have done several meta-analyses (Cicerone et al., 2005, 2011). They found that comprehensive holistic NR can improve community integration, functional independence, and productivity, even for patients who were injured many years previously (Cicerone et al., 2011). Van Heugten, Gregorio, and Wade (2012) looked at 95 randomized control trials from January 1980 until August 2010, with a total of 4,068 patients. They concluded that there is a large body of evidence to support the efficacy of cognitive rehabilitation.
Is NR also cost-effective? All countries are probably interested in whether results from rehabilitation justify the costs. Wood, McCrea, Wood, and Merriment (1999) argue international opinion about the clinical effectiveness and cost-effectiveness of neurorehabilitation is divided, with considerable skepticism seen among neurologists, neurosurgeons, and others, while some staff providing such rehabilitation are enthusiastic. Who is right? An American study of 145 brain-injured patients found the estimated savings in care costs following rehabilitation for people with severe brain injury was over £27,000 ($40,500) per year. The number of people requiring 24-hour care dropped from 23% to 4% after rehabilitation (Cope, Cole, Hall, & Barkan, 1991). In Denmark, Mehlbye and Larsen (1994) found that the costs of providing rehabilitation were recouped in five years.
Evans, Emslie, and Wilson (1998) reported a stroke patient who used to have one week’s respite care every three months to give her family a break. Her local health authority paid for this at a cost of £1,000 for one week’s care, that is, £4,000 per annum. Since having the pager she has never needed respite care, so over a five-year period her health authority saved £20,000.
Although rehabilitation may be expensive in the short term, there is evidence that it is cost-effective in the long term (Wilson, Winegardner, & Ashworth, 2014). The costs of not rehabilitating people with brain injuries are considerable given the fact that many are young with a relatively normal life expectancy (McMillan & Greenwood, 1993). Substantial economic benefits, as well as familial and social improvements, make it almost impossible to deny the advantages to be gained by “Comprehensive-holistic neuropsychologic rehabilitation, recommended to improve post-acute participation and quality of life after moderate or severe TBI” (Cicerone et al., 2011, p. 526).
Worthington, da Silva Ramos, and Oddy (2017) summarize work on cost-effectiveness during the 2000s and say that “evidence is emerging and there are many ways that neuropsychologists can contribute to the development of cost-effective interventions and service organisation. Meeting this challenge is likely to engage the profession for many years to come” (p. 476).
Guidelines for Good Practice
These are the core principles that staff at the Oliver Zangwill Centre for Neuropsychological Rehabilitation believe should be followed in providing rehabilitation for survivors of brain injury.
1. Provide a therapeutic milieu whereby people feel safe.
2. The goals of rehabilitation should be meaningful and functionally relevant.
3. Ensure shared understanding between staff, patients, families, and everyone involved in the rehabilitation process.
4. Apply psychological interventions to address mood and emotional issues.
5. Manage cognitive impairments through compensatory strategies and retraining skills.
6. Work closely with families and carers.
NR is concerned with the amelioration of cognitive, emotional, psychosocial, and behavioral deficits caused by an insult to the brain. Rehabilitation is a process whereby people with brain injuries work together with others to achieve their optimal physical, psychological, social, and vocational outcomes. Its main purpose is to enable those with disabilities to achieve their optimum level of well-being, to reduce the impact of their problems on everyday life, and to help them return to their own most appropriate environments. It is not to teach them to score better on tests or to learn lists of words or to be faster at detecting stimuli.
Considerable recovery can and does take place after brain injury. It is not always true that young people recover better than older ones; other factors, such as whether or not the lesion is focal or widespread and the time that has elapsed since the acquisition of the function, also play a part. There is conflicting evidence on the issue of whether females recover better than males. It would appear that people with higher intelligence or with better cognitive processing strategies may fare better than those without such cognitive reserve.
NR focuses both on restoration of function and on attempts to help people compensate for their difficulties. Cognitive, emotional, and psychosocial difficulties should all be addressed in rehabilitation. As of 2020, rehabilitation is a partnership between patients, families, and healthcare staff; it addresses personally meaningful and relevant goals; it recognizes that cognition, emotion, and behavior are interlinked; there is an increasing use of technology to help people compensate for their difficulties; a number of theories and models help address the complex problems faced by survivors of brain damage. There is substantial evidence that people who have sustained an insult to the brain benefit from rehabilitation. The article concludes with general guidelines to follow in order to ensure good rehabilitation.
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