Neuropsychological rehabilitation & treatment – college 1 16 april
Mechanisms of recovery & treatment planning Anselm Fürmaier
Rehabilitation and treatment
- Treatment
o Care given to a patient
o E.g. administration of drugs, or surgery
- Rehabilitation
o Two way interactive process (between patient and professional)
o To achieve optimum well-being (physical, psychological, social, vocational)
Historical milestones
- Ancient Egyptians (about 1600BC)
o Description of 48 cases of treatment of (brain) injury
o First appearance of term ‘brain’ in any language
o Rather treatment than rehabilitation
o Wounds were treated with fresh meat on day 1, then with grease, honey, and lint on
following days
o No saturation of wounds with open TBIs – counteract intercranial pressure, so don’t
close the brain
o Recommendation of sitting upright in some cases (to counteract elevated intracranial
pressure?)
o No trepanations mentioned for the treatment of TBI
- WW1
o More survivors with gunshot wounds to the head opened modern rehabilitation
Large sample sizes of people with focal injuries to the brain
o Kurt Goldstein treated soldiers at the front before sending them to therapy
recommendations about therapy for impairments in speech, reading and writing
o Walter Poppelreuter treated soldiers with visuospatial and visualperceptual
disorders and discussed vocational rehabilitation
- WW2
o Alexander Romanovich Luria (army hospital) – working on ways to compensate for
psychological dysfunctions in brain damaged patients and argued that patient should
be regarded in his or her social context!
Not everything can be restored completely so look what the maximum is that
can be reached
o Oliver Zangwill (1947) – Introduction of three main approaches
Compensation
Substitution
Direct retraining
- More recent times
o First ‘Cognitive Rehabilitation’ program by Leonard Diller, NY (1976)
Young field
o Acceptance of holistic approach linking cognition, emotion, and behavior – see
everything together than reach optimal wellbeing
o Hierarchical stages of holistic programs (Ben-Yishay and Prigatano, 1990)
assessment is the start and should be done very thoroughly
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
1
, 5. Providing vocational counselling
o Early model of npsy treatment (Gross & Schutz, 1986) hierarchical model builds
upon each other
1. Environmental control – when patient cannot learn (no sounds, no distractions,
easy overloaded)
2. Stimulus-Response (S-R) conditioning – simple SR, cannot make own goals, only
simple learning
3. Skill training – able to generalize
4. Strategy substitution – can monitor own behavior
5. Cognitive cycle – patient able to everything, teach some more complex skills
Content
1. Mechanisms of recovery and treatment planning
2. Evidence based rehabilitation and treatment
a. How do we evaluate treatment?
i. Randomized controlled trials
ii. Single case studies
3. Rehabilitation of visual disorders (neglect and hemianopia)
4. Applied neuroscience rehab: neuroprosthetics, BCIs & NFB, TMS
5. Rehabilitation of cognitive disorders
o How do cognitive impairments disturb daily functioning?
o How can we treat cognitive problems and improve functioning in
daily life?
6. Rehabilitation in severe mental illness
7. Ambulant treatment and problem behavior
Exam
- Online with open questions
- Open questions on various (all) topics of the course
- Example exam questions will be provided on Nestor
- Please be aware that example exam questions DO NOT
o Give information about the difficulty of all exam questions
o Give information about the proportions of exam questions that will focus on the
readings or the lecture slides
o Give information about certain topics which might be more important than others
for the exam
- Give examples and deep-knowledge, reason and argue
- Cover each topic (7 overall questions)
Who are we treating? groups referred to npsy rehabilitation
o Adults with non-progressive brain injury most referred to npsy rehab
TBI
Alteration of brain function caused by external force
Hospital admission rates of about 150 -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
2
, 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 O2 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), post-traumatic 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
o Adults with progressive brain injury loss in abilities, loss of functioning
Dementia – Parkinson’s disease – Huntington’s disease – Brain tumor – 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 npsy conditions
Dementia worldwide why difference in rate of dementia across the world
Less old in Africa less cases
Less testing
Not the same structure in health care systems
Underestimation in south America and Africa
Case report
Sandra independently shopping again
Worried get lost when going alone
Feel more confident when contact husband while out
Mobile phone know how to receive calls but not how to make them
Therapist assessment ability to learn (what resources are still available)
Goals (to make treatment or plan) use mobile to contact husband while out
4 main aspects to address
o Sandra needed to learn how to make calls. Based on a cognitive
assessment, an action-based procedural learning approach was adopted.
o Sandra needed to remember to take the phone with her. A
compensatory strategy was adopted with visual prompts placed close to
the front door to remind her to pick up her phone.
Compensate for memory failure
o Sandra needed external help to be able to use the phone without
difficulty. A bag with a shoulder strap was selected so that Sandra could
have both hands free to use the phone.
o Sandra needed to be able to cope if she became anxious and worried
while out shopping. She practiced a relaxation exercise based on
breathing that she could use if she felt anxious.
o 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
3
, Higher risk for injury parameters, individual development level, pre-injury function, and
family support are crucial predictors for outcome and functioning in adulthood
o Psychiatric disorders
Npsy 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 npsy 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
Introduction and general issues
- Mechanisms of recovery
o Substantial spontaneous recovery within first period (weeks/months) after injury
Recovery with no formal rehabilitation training is this possible?
Not possible to have spontaneous recovery without experience
o Cannot live experience-independent
o Always learning and coping
No formal professional training
Assumed to be experience independent (experience dependent learning)
Skills training to functional and cortical progress
Teaching patients compensatory strategies – No restoration or
substitution of impaired npsy 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 npsy rehabilitation!
Possible mechanisms explaining spontaneous recovery
1. Resolution of diaschisis
a. Diaschisis Temporal loss of functions in regions distant
from lesion (other brain regions lose their function for a
period, after time start working again)
b. Focal diaschisis (changes in well-defined brain areas distant
from lesion) vs. Connectional diaschisis (changes in
connectivity between damaged and unaffected brain
regions)
c. Diaschisis assumed to be dynamic and resolve over time
2. Functional network recovery
a. Reorganization of intact neural circuits
b. Shifting activity towards perilesional brain areas (other
regions of the same hemisphere) and homologue areas of
the contralesional hemisphere (same areas of damaged one,
but of the same hemisphere take over some functions)
4
Mechanisms of recovery & treatment planning Anselm Fürmaier
Rehabilitation and treatment
- Treatment
o Care given to a patient
o E.g. administration of drugs, or surgery
- Rehabilitation
o Two way interactive process (between patient and professional)
o To achieve optimum well-being (physical, psychological, social, vocational)
Historical milestones
- Ancient Egyptians (about 1600BC)
o Description of 48 cases of treatment of (brain) injury
o First appearance of term ‘brain’ in any language
o Rather treatment than rehabilitation
o Wounds were treated with fresh meat on day 1, then with grease, honey, and lint on
following days
o No saturation of wounds with open TBIs – counteract intercranial pressure, so don’t
close the brain
o Recommendation of sitting upright in some cases (to counteract elevated intracranial
pressure?)
o No trepanations mentioned for the treatment of TBI
- WW1
o More survivors with gunshot wounds to the head opened modern rehabilitation
Large sample sizes of people with focal injuries to the brain
o Kurt Goldstein treated soldiers at the front before sending them to therapy
recommendations about therapy for impairments in speech, reading and writing
o Walter Poppelreuter treated soldiers with visuospatial and visualperceptual
disorders and discussed vocational rehabilitation
- WW2
o Alexander Romanovich Luria (army hospital) – working on ways to compensate for
psychological dysfunctions in brain damaged patients and argued that patient should
be regarded in his or her social context!
Not everything can be restored completely so look what the maximum is that
can be reached
o Oliver Zangwill (1947) – Introduction of three main approaches
Compensation
Substitution
Direct retraining
- More recent times
o First ‘Cognitive Rehabilitation’ program by Leonard Diller, NY (1976)
Young field
o Acceptance of holistic approach linking cognition, emotion, and behavior – see
everything together than reach optimal wellbeing
o Hierarchical stages of holistic programs (Ben-Yishay and Prigatano, 1990)
assessment is the start and should be done very thoroughly
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
1
, 5. Providing vocational counselling
o Early model of npsy treatment (Gross & Schutz, 1986) hierarchical model builds
upon each other
1. Environmental control – when patient cannot learn (no sounds, no distractions,
easy overloaded)
2. Stimulus-Response (S-R) conditioning – simple SR, cannot make own goals, only
simple learning
3. Skill training – able to generalize
4. Strategy substitution – can monitor own behavior
5. Cognitive cycle – patient able to everything, teach some more complex skills
Content
1. Mechanisms of recovery and treatment planning
2. Evidence based rehabilitation and treatment
a. How do we evaluate treatment?
i. Randomized controlled trials
ii. Single case studies
3. Rehabilitation of visual disorders (neglect and hemianopia)
4. Applied neuroscience rehab: neuroprosthetics, BCIs & NFB, TMS
5. Rehabilitation of cognitive disorders
o How do cognitive impairments disturb daily functioning?
o How can we treat cognitive problems and improve functioning in
daily life?
6. Rehabilitation in severe mental illness
7. Ambulant treatment and problem behavior
Exam
- Online with open questions
- Open questions on various (all) topics of the course
- Example exam questions will be provided on Nestor
- Please be aware that example exam questions DO NOT
o Give information about the difficulty of all exam questions
o Give information about the proportions of exam questions that will focus on the
readings or the lecture slides
o Give information about certain topics which might be more important than others
for the exam
- Give examples and deep-knowledge, reason and argue
- Cover each topic (7 overall questions)
Who are we treating? groups referred to npsy rehabilitation
o Adults with non-progressive brain injury most referred to npsy rehab
TBI
Alteration of brain function caused by external force
Hospital admission rates of about 150 -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
2
, 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 O2 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), post-traumatic 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
o Adults with progressive brain injury loss in abilities, loss of functioning
Dementia – Parkinson’s disease – Huntington’s disease – Brain tumor – 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 npsy conditions
Dementia worldwide why difference in rate of dementia across the world
Less old in Africa less cases
Less testing
Not the same structure in health care systems
Underestimation in south America and Africa
Case report
Sandra independently shopping again
Worried get lost when going alone
Feel more confident when contact husband while out
Mobile phone know how to receive calls but not how to make them
Therapist assessment ability to learn (what resources are still available)
Goals (to make treatment or plan) use mobile to contact husband while out
4 main aspects to address
o Sandra needed to learn how to make calls. Based on a cognitive
assessment, an action-based procedural learning approach was adopted.
o Sandra needed to remember to take the phone with her. A
compensatory strategy was adopted with visual prompts placed close to
the front door to remind her to pick up her phone.
Compensate for memory failure
o Sandra needed external help to be able to use the phone without
difficulty. A bag with a shoulder strap was selected so that Sandra could
have both hands free to use the phone.
o Sandra needed to be able to cope if she became anxious and worried
while out shopping. She practiced a relaxation exercise based on
breathing that she could use if she felt anxious.
o 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
3
, Higher risk for injury parameters, individual development level, pre-injury function, and
family support are crucial predictors for outcome and functioning in adulthood
o Psychiatric disorders
Npsy 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 npsy 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
Introduction and general issues
- Mechanisms of recovery
o Substantial spontaneous recovery within first period (weeks/months) after injury
Recovery with no formal rehabilitation training is this possible?
Not possible to have spontaneous recovery without experience
o Cannot live experience-independent
o Always learning and coping
No formal professional training
Assumed to be experience independent (experience dependent learning)
Skills training to functional and cortical progress
Teaching patients compensatory strategies – No restoration or
substitution of impaired npsy 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 npsy rehabilitation!
Possible mechanisms explaining spontaneous recovery
1. Resolution of diaschisis
a. Diaschisis Temporal loss of functions in regions distant
from lesion (other brain regions lose their function for a
period, after time start working again)
b. Focal diaschisis (changes in well-defined brain areas distant
from lesion) vs. Connectional diaschisis (changes in
connectivity between damaged and unaffected brain
regions)
c. Diaschisis assumed to be dynamic and resolve over time
2. Functional network recovery
a. Reorganization of intact neural circuits
b. Shifting activity towards perilesional brain areas (other
regions of the same hemisphere) and homologue areas of
the contralesional hemisphere (same areas of damaged one,
but of the same hemisphere take over some functions)
4
