Neuropsychology 1: Introduction to
Recovery and Rehabilitation
The changing role of clinical neuropsychology
History:
- Emergence as a profession during WW2
- A diagnostic, assessment role supervised by neurologists
- A shift towards greater independence and more involvement in rehab from 70’s onwards
- Physiotherapy , occupational therapists, speech therapists
- By far the greatest input into rehab programmes
- A practical approach without a clear scientific foundation
Today:
- Rehabilitation professionals remain the mainstay of rehabilitation services
- Still practically orientated but increasing evidence - based practise
- Many examples of collaborative work with neuropsychologists
- Continuing importance of neuropsychological assessment
- Most clinical neuropsychologists now have at least an advisory role in rehab
- Primary scientific base is cognitive neuroscience
- Need for more development of a scientific rationale for intervention
Functional recovery after brain damage:
The brain does not regenerate after damage due to stroke or head injury
Hole in the brain stays there forever, fills with fluid
But long term functional improvements do occur over months or years
Wong et al. (2001):
Large database of 319 patients with a broad range of coma duration used to construct recovery
curves for performance IQ (non verbal)
Recovery is influenced by severity but is always faster early with slower changes apparent over
many months
Different views on the extent of recovery:
Kolb & Whishaw describe cases of “no recovery” on cognitive tests after brain damage -
misleading
But where ability is measured carefully in cases with no additional complications, a degree of
recovery is always expected
, This spans at least months, and in cases where the original injury is very severe , recovery can
occur very slowly over many years
Two routes to recovery:
Long term recovery is poorly understood, but it is thought two processes contribute:
Restitution: restoration of a lost function by intact areas of the rain taking over the functions of
the damaged areas - not sure how important this is
Compensation: an adaptive change to circumvent persistent impairment
- E.g. external compensation through use of aids - more obvious to see
- Internal compensation e.g. through changes in cognitive strategy
- Very Important.
Should Rehabilitation Therapy Aim for Restitution or Compensation ?
Do we provide stimulation to attempt to restore impaired function e.g. computer games
Or do we teach strategies and provide aids to teach the person to compensate for the problems
they face in everyday life
Wilson (2004) argues that the rehabilitation should be focused on compensations to overcome
disability, not attempts to abolish underlying impairments, but this approach has been
questioned in recent years
Playing a waiting game at first, then can help.
Hard to tell if people are recovering or using compensations
Changing views on restitution:
The traditional clinical belief is that the restitution component is restricted to the early stages
and is spontaneous or natural recovery, which is largely unaffected by therapy
So therapy should come later and should focus on teaching compensations
More recent neurological evidence suggests that brain remapping is influenced by therapeutic
input
This is known as cortical reorganisation or neuroplasticity
It can happen at any time after brain injury
Taub (2002):
- Tied off small vessels in the monkey’s cortex and looked at effects
- For monkeys kept in cages - shrinking of the area of motor control
- For monkeys who made attempts at moving - no shrinking in area
- But how can you really tell if they are recovering or compensating? Is it really the return of
lost functions? Change of hand movements to wrist - so may be brain changes relayed to
learning subtle compensations
- Suggests that intensive practise should be encouraged to promote neuroplasticity
- But there is still uncertainty over how big an impact this can have on final outcome
Traditional Belief:
Early: brain is recovering spontaneously
Recovery and Rehabilitation
The changing role of clinical neuropsychology
History:
- Emergence as a profession during WW2
- A diagnostic, assessment role supervised by neurologists
- A shift towards greater independence and more involvement in rehab from 70’s onwards
- Physiotherapy , occupational therapists, speech therapists
- By far the greatest input into rehab programmes
- A practical approach without a clear scientific foundation
Today:
- Rehabilitation professionals remain the mainstay of rehabilitation services
- Still practically orientated but increasing evidence - based practise
- Many examples of collaborative work with neuropsychologists
- Continuing importance of neuropsychological assessment
- Most clinical neuropsychologists now have at least an advisory role in rehab
- Primary scientific base is cognitive neuroscience
- Need for more development of a scientific rationale for intervention
Functional recovery after brain damage:
The brain does not regenerate after damage due to stroke or head injury
Hole in the brain stays there forever, fills with fluid
But long term functional improvements do occur over months or years
Wong et al. (2001):
Large database of 319 patients with a broad range of coma duration used to construct recovery
curves for performance IQ (non verbal)
Recovery is influenced by severity but is always faster early with slower changes apparent over
many months
Different views on the extent of recovery:
Kolb & Whishaw describe cases of “no recovery” on cognitive tests after brain damage -
misleading
But where ability is measured carefully in cases with no additional complications, a degree of
recovery is always expected
, This spans at least months, and in cases where the original injury is very severe , recovery can
occur very slowly over many years
Two routes to recovery:
Long term recovery is poorly understood, but it is thought two processes contribute:
Restitution: restoration of a lost function by intact areas of the rain taking over the functions of
the damaged areas - not sure how important this is
Compensation: an adaptive change to circumvent persistent impairment
- E.g. external compensation through use of aids - more obvious to see
- Internal compensation e.g. through changes in cognitive strategy
- Very Important.
Should Rehabilitation Therapy Aim for Restitution or Compensation ?
Do we provide stimulation to attempt to restore impaired function e.g. computer games
Or do we teach strategies and provide aids to teach the person to compensate for the problems
they face in everyday life
Wilson (2004) argues that the rehabilitation should be focused on compensations to overcome
disability, not attempts to abolish underlying impairments, but this approach has been
questioned in recent years
Playing a waiting game at first, then can help.
Hard to tell if people are recovering or using compensations
Changing views on restitution:
The traditional clinical belief is that the restitution component is restricted to the early stages
and is spontaneous or natural recovery, which is largely unaffected by therapy
So therapy should come later and should focus on teaching compensations
More recent neurological evidence suggests that brain remapping is influenced by therapeutic
input
This is known as cortical reorganisation or neuroplasticity
It can happen at any time after brain injury
Taub (2002):
- Tied off small vessels in the monkey’s cortex and looked at effects
- For monkeys kept in cages - shrinking of the area of motor control
- For monkeys who made attempts at moving - no shrinking in area
- But how can you really tell if they are recovering or compensating? Is it really the return of
lost functions? Change of hand movements to wrist - so may be brain changes relayed to
learning subtle compensations
- Suggests that intensive practise should be encouraged to promote neuroplasticity
- But there is still uncertainty over how big an impact this can have on final outcome
Traditional Belief:
Early: brain is recovering spontaneously
