NeuroRehabilitation

Many who provide cognitive rehabilitation therapy (CRT) are unaware of the theoretical rationale that underlies their decisions concerning therapeutic intervention. Can the survivor form goals for treatment? When should treatment end? When should the therapist retrain skills, provide remedial cognitive treatments, or simply adapt surroundings because a survivor is too handicapped to be treated at all?

This paper combines theory with the author's experience to provide therapists with a structure for clinical reasoning in their daily practice.

The discussion begins with a description of different models of recovery after brain injury. It goes on to discuss similarities, commonalities, and general principles that can be derived from all of them. It ends with suggestions for treatment that serve as useful guidelines for therapists in their practices.

Combining the clinician's clinical intuition with knowledge of the theory of CRT can greatly improve the quality of treatment the therapist provides.

Many studies have investigated the impact of pediatric Cognitive Rehabilitation Therapy (CRT) upon intellectual functioning after traumatic brain injury; however, relatively few have identified efficacious treatment in a school setting.

The purpose is to present a variety of CRT strategies that would be useful to a teacher or therapist working with students who are learning disabled or who have who have had a traumatic brain injury (TBI).

This article investigates the particular challenges in learning which result from impaired cognition, and suggests techniques for improving memory and executive functioning.

Students who are learning disabled or who have TBI face social and emotional issues that impact their learning. Special therapeutic interventions are necessary to assist with orienting to their setting, integrating with peers, and coping with distressing emotions.

Students with TBI can adapt and flourish in a school based setting provided that therapies and learned strategies are targeted to their specific needs.

There is a dearth of systematic studies of expressive writing disorder (EWD) in persons with Traumatic Brain Injury (TBI). It is unclear if TBI survivors' written expression differs significantly from that experienced by persons with learning disabilities. It is also unclear which cognitive or neuropsychological variables predict problems with expressive writing (EW) or the EWD.

This study investigated the EW skill, and the EWD in adults with mild traumatic brain injuries (TBI) relative to those with learning disabilities (LD). It also determined which of several cognitive variables predicted EW and EWD.

Principle Component Analysis (PCA) of writing samples from 28 LD participants and 28 TBI survivors revealed four components of expressive writing skills: Reading Ease, Sentence Fluency, Grammar and Spelling, and Paragraph Fluency.

There were no significant differences between the LD and TBI groups on any of the expressive writing components. Several neuropsychological variables predicted skills of written expression. The best predictors included measures of spatial perception, verbal IQ, working memory, and visual memory.

TBI survivors and persons with LD do not differ markedly in terms of expressive writing skill. Measures of spatial perception, visual memory, verbal intelligence, and working memory predict writing skill in both groups. Several therapeutic interventions are suggested that are specifically designed to improve deficits in expressive writing skills in individuals with TBI and LD.

Individuals who have had a traumatic brain injury (TBI) often have difficulty processing nonverbal communication (Ekman, 1976) The published research in this area has focused on a TBI patient's ability to recognize facial expression, vocal intonation, and postural expression (Croker, 2005; Hopkins, Dywan & Segalowitz, 2002).

This study compared the non-verbal processing skills of brain-injured patients versus non-injured controls in all three domains.

The stimuli were photographs of facial and postural expressions and audio recordings of intonational expressions.

The results indicated that persons with TBI have particular difficulty recognizing non-verbal communication resulting from vocal intonations.

The TBI patients had difficulty processing tonality, therefore, it is reasonable to suggest that clinicians, friends, and family members should emphasize the explicit verbal content of spoken language when speaking to a person with TBI.

Anosognosia is commonly reported after acquired brain injury (ABI) or stroke and often hinders an ABI survivor's ability to perceive the social consequences of their behavior and to modify it.

This study concerned the question of whether awareness discrepancy scores could predict cognitive performance with a focus on the acquired brain injured (ABI) population. It was hypothesized that lack of awareness would predict performance on cognitive tasks.

Archival data was assessed for a total of 21 patients; 10 learning disabled (LD) and 11 with a brain injury with each person having one “observer”. Data consisted of patient and observer ratings on the Acquired Deficit Awareness Management System (ADAMS) profile, a 36-item survey that measured both patient self-report and observer assessment of awareness. These data yielded two discrepancy scores: deficit with awareness (DWA) and deficit without awareness (DWoA). The discrepancy scores were used to predict IQ scores from the Wechsler Adult Intelligence Scale, academic performance on the Woodcock-Johnson Psychoeducational Battery, memory functioning on the Wechsler Memory Scale, and a measure of fine motor skill.

The DWoA measure correlated significantly with several cognitive variables and with finger tapping speed on the non-dominant hand. These correlations were not apparent in the LD group.

Measures of lack of awareness predicted cognitive performance in the ABI population. Therapeutic interventions are discussed that address lack of awareness after ABI.

Stroke is a leading cause of disability and sequelae may include physical, emotional, and cognitive impairments. The methods employed to cope with distress, both emotional and cognitive, have not been evaluated in individuals post-stroke. However, research in traumatic brain injury (TBI) suggests that executive function is positively correlated with adaptive coping and negatively correlated with maladaptive coping strategies (Krpan et al., 2007). Examination of these constructs post-stroke may assist with enriching our understanding of cognitive and emotional symptomatology and optimize rehabilitation strategies.

The present study aimed to assess the association between executive function and coping strategies in a sample of chronic stroke survivors. The researchers hypothesized that executive function would be positively correlated with adaptive coping strategies and negatively correlated with maladaptive coping strategies.

Fifteen stroke survivors were administered a battery of cognitive tests assessing executive function and also completed the Ways of Coping Questionnaire (WAYS), a self-report coping measure.

Analyses indicated that executive function deficits were related to increased avoidant coping. Contrary to expectations, executive function was not significantly related to active coping. In addition, post hoc analyses revealed that executive function was a significant predictor of avoidant coping after controlling for demographics.

Our data, in accordance with prior work in TBI, suggests that executive function and aspects of coping are associated. Rehabilitation strategies that improve executive function may also lead to utilization of adaptive coping strategies. Research has shown that aerobic exercise increases activation in the frontal lobe and improves executive function (Colcombe & Kramer, 2003; Colcombe et al., 2004). Future studies should examine whether aerobic exercise positively affects executive function and coping in stroke survivors.

Individuals with Acquired Brain Injury (ABI) could benefit from further cognitive rehabilitation, after they have returned home. However, a lack of specialist services to provide such rehabilitation often prevents this. This leads to reduced reintegration of patients, increased social disadvantages and ultimately, higher economic costs.

10 months post-stroke, a 69 year-old woman was discharged from an inpatient rehabilitation program and returned home with severe cognitive impairments. We describe a pilot project which provided an individualised, low cost rehabilitation program, supervised and trained by a neuropsychologist. Progress was monitored every 3 months in order to decide on continuation of the program, based on the achieved results and predicted costs.

Post intervention, despite severe initial impairment, cognitive and most notably daily functioning had improved. Although the financial investment was moderately high for the family, the intervention was still considered cost-effective when compared with the required costs of care in a local non-specialist care home. Moreover, the pilot experience was used to build a “local expert team” available for other individuals requiring rehabilitation.

These results encourage the development of similar local “low cost” teams in the community, to provide scientifically-grounded cognitive rehabilitation for ABI patients returning home.

Magnetic resonance imaging (MRI) has brought about advances in the fields of brain plasticity and lifespan brain change, that might be of special interest for cognitive rehabilitation research and, eventually, in clinical practice. Parallel, intensive cognitive training studies show promising results for the prospect of retraining some of the impaired functioning following acquired brain injury.

However, cognitive training research is largely performed without concurrent assessments of brain structural change and reorganization, which could have addressed possible mechanisms of training-related neuroplasticity.

Criticism of cognitive training studies is often focused on lack of ecologically valid, daily-living assessments of treatment effect, and on whether the applied cognitive measures overlap too much with the training exercises. Yet, the present paper takes another point of view, where the relevance of recent MRI research of brain plasticity to the field of cognitive rehabilitation is examined.

Arguably, treatment ought to be measured at the same level of the International Classification of Functioning, Disability and Health model, as it is targeting. In the case of cognitive training that will be the “body structure” and “body function” levels.

MRI has shown promise to detect macro- and microstructural activity-related changes in the brain following intensive training.

Measures of cognitive rehabilitation should include comprehensive holistic rehabilitation as well as interventions targeting specific cognitive functions; it is however not clear how this knowledge should be put into practice.

To describe services provided at the cognitive rehabilitation unit at Sunnaas Rehabilitation Hospital (SRH), a regional rehabilitation centre in Norway.

Cognitive rehabilitation programs offered at SRH are described. For all patients served in 2011 and 2012, epidemiological and hospitalization related data were retrieved. Results from a patient satisfaction survey are presented.

The services include individual holistic cognitive rehabilitation as well as group programs. 307 individual patients were served in 355 hospitalizations; 68.1% were male; age ranged from 18 to 78 years. The largest patient groups were stroke (46.6%) and traumatic brain injury (33.0%). Mean length of stay was 36.9 days. Median time post injury was 0.8 years (range 16 days – 14 years). More than 90% of the patients were satisfied with the services they received to a large or very large extent.

Providing cognitive rehabilitation that encompasses both a holistic approach and targets specific cognitive functions is challenging. More research is warranted to illuminate further how cognitive rehabilitation services should be designed and conducted in practice.

Previous studies have shown that cyclic nucleotide phosphodiesterase type 5 (PDE5) inhibition with the drugs sildenafil and vardenafil can enhance spatial performance and object recognition in rodent models of learning and memory.

We review recent studies on PDE5 inhibition and report novel data that specifically tests the systemic effects of both pharmacological agents in aged rats using two different spatial learning/memory paradigms.

The 14-unit T-maze was used as a test of egocentric spatial processing that requires rats to learn a series of left/right turns to avoid mild footshock. The Morris water maze is a test of allocentric spatial learning that requires the acquisition of place information to localize a hidden platform relative to distal room cues.

In both cases, acquisition (i.e., learning performance) was not improved, however after a one week drug washout period, aged animals demonstrated improved spatial memory retention compared to aged controls, ruling out simple performance effects.

These findings are discussed in relation to recent reports on the use of PDE inhibitors to treat Alzheimer's disease (AD) dementia and age-related memory impairments. While some report promising pre-clinical results, others note that PDE5 may not be an appropriate target in AD due to a lack of localization within critical brain structures where therapeutic activity is needed. Despite these limitations, PDE5 inhibition may produce beneficial effects via several mechanisms that target predisposing risk factors leading to increased incidence of memory impairment in aged individuals and influence memory consolidation mechanisms that preserve long-term retention of cognitive information.

Subjects affected by Parkinson's disease have substantially impaired static and dynamic balance, leading to diminished functional ability. Conventional and innovative exercises have been suggested, but most of them were focused on motor features of posture and gait, deserving poor attention to perceptive aspects of balance.

To evaluate the efficacy of the perceptive rehabilitation, based on perceptual surfaces, for postural balance (primary aim) and pain, depression and activity daily living.

In this pilot study, we have treated 9 patients with Parkinson's disease undergone rehabilitation aiming to restoring their correct body midline perception, according a schema treatment – no treatment – treatment.

During the rehabilitative intervention, both Tinetti balance score (p = 0.007 in both phases) and Tinetti gait score (p = 0.011 and p = 0.016, respectively), such as pain relief assessed by Visual Analogue Scale (p = 0.011, p = 0.010) were improved. Conversely in the phase of no-intervention, lasting the same amount of time, it was showed a significant reduction of Tinetti Balance score (p = 0.010) and no significant changes in terms of Tinetti Gait score and Visual Analogue Scale.

These preliminary results highlighted the importance of introducing perceptive training into the exercises proposed to patients with Parkinson's disease for reducing both their static and dynamic balance impairments.

The debilitating fatigue that patients with multiple sclerosis (MS) commonly experience during day-to-day living activities responds poorly to current therapeutic options. Direct currents (DC) delivered through the scalp (transcranial DC stimulation or tDCS) at weak intensities induce changes in motor cortical excitability that persist for almost an hour after current offset and depend on current polarity. tDCS successfully modulates cortical excitability in various clinical disorders but no information is available for MS related fatigue.

In this study we aimed to assess fatigue symptom after five consecutive sessions of anodal tDCS applied over the motor cortex in patients with MS.

We enrolled 25 patients with MS all of whom experienced fatigue. We delivered anodal and sham tDCS in random order in two separate experimental sessions at least 1 month apart. The stimulating current was delivered for 15 minutes once a day for 5 consecutive days. In each session the Fatigue Impact Scale (FIS) and the Back Depression Inventory (BDI) were administered before the treatment (baseline), immediately after treatment on day five (T1), one week (T2) and three weeks (T3) after the last tDCS session.

All patients tolerated tDCS well without adverse events. The fatigue score significantly decreased after anodal tDCS in 65% of the patients (responders). After patients received tDCS for 5 days their FIS scores improved by about 30% and the tDCS-induced benefits persisted at T2 and T3.

Our preliminary findings suggest that anodal tDCS applied over the motor cortex, could improve fatigue in most patients with MS.

Considering the extensive neural network of the oculomotor subsystems, traumatic brain injury (TBI) could affect oculomotor control and related reading dysfunction.

To evaluate comprehensively the effect of oculomotor-based vision rehabilitation (OBVR) in individuals with mTBI.

Twelve subjects with mTBI participated in a cross-over, interventional study involving oculomotor training (OMT) and sham training (ST). Each training was performed for 6 weeks, 2 sessions a week. During each training session, all three oculomotor subsystems (vergence/accommodation/version) were trained in a randomized order across sessions. All laboratory and clinical parameters were determined before and after OMT and ST. In addition, nearvision-related symptoms using the Convergence Insufficiency Symptom Survey (CISS) scale and subjective visual attention using the Visual Search and Attention Test (VSAT) were assessed.

Following the OMT, over 80% of the abnormal parameters significantly improved. Reading rate, along with the amplitudes of vergence and accommodation, improved markedly. Saccadic eye movements demonstrated enhanced rhythmicity and accuracy. The improved reading-related oculomotor behavior was reflected in reduced symptoms and increased visual attention. None of the parameters changed with ST.

OBVR had a strong positive effect on oculomotor control, reading rate, and overall reading ability. This oculomotor learning effect suggests considerable residual neuroplasticity following mTBI.

As a sequential, programmed movement of fingers, keyboard playing is a promising technique for inducing execution and a high level of coordination during finger movements. Also, keyboard playing can be physically and emotionally rewarding for adolescents in rehabilitation settings and thereby motivate continued involvement in treatment.

The purpose of this study is to evaluate the effects of keyboard playing using Musical Instrument Digital Interface (MIDI) on finger movement for adolescents with brain damage.

Eight adolescents with brain damage, ages 9 to 18 years (M = 13 years, SD = 2.78), in physical rehabilitation settings participated in this study. Measurements included MIDI keyboard playing for pressing force of the fingers and hand function tests (Grip and Pinch Power Test, Box and Block Test of Manual Dexterity [BBT], and the Jebsen Taylor Hand Function Test).

Results showed increased velocity of all fingers on the MIDI-based test, and statistical significance was found in the velocity of F2 (index finger), F3 (middle finger), and F5 (little finger) between pre- and post-training tests. Correlation analysis between the pressing force of the finger and hand function tests showed a strong positive correlation between the measure of grip power and the pressing force of F2 and F5 on the Grip and Pinch Strength Test. All fingers showed strong correlation between MIDI results and BBT. For the Jebsen Taylor Hand Function Test, only the moving light objects task at post-training yielded strong correlation with MIDI results of all fingers.

The results support using keyboard playing for hand rehabilitation, especially in the pressing force of individual finger sequential movements. Further investigation is needed to define the feasibility of the MIDI program for valid hand rehabilitation for people with brain damage.

Return to driving is a goal and milestone in the recovery process following acquired brain injury (ABI). Knowledge of whether and when a person is likely to return to driving is important to people with ABI, family members and clinicians.

To determine the rates, timing, correlates, and predictors of return to driving in the first 6 months after discharge from hospital following ABI.

Survey of 212 participants with ABI and 121 family members at discharge and 3 and 6 months later. Participants with ABI were grouped according to driving status (not driving, returned within 3 months, returned within 6 months). Groups were compared on demographics, injury severity, quality of life, functioning, psychosocial integration, depression, and carer well-being.

By 6 months post-discharge 62.3% had resumed driving. Between group differences existed on measures of injury severity, and psychosocial integration at 6 months, and carer depression and strain at discharge and 6 months. Whether and when someone returned to driving could be predicted by length of hospital stay, and level of community integration, and pain at discharge.

Educating clients about their likelihood and timing of return to driving, and supporting non-drivers and their carers may improve psychosocial outcomes.

Traumatic brain injury (TBI) is a leading cause of death in Mexico, and Mexican TBI caregivers have been shown to experience significant mental health problems and high levels of family needs.

This study investigated the associations between family needs and Mexican TBI caregiver mental health.

Ninety TBI caregivers from Guadalajara, Mexico completed measures assessing their own mental health (depression, anxiety, burden, satisfaction with life, and self-esteem) and family needs (physical health, informational, financial, social support, and household).

Family health needs were uniquely associated with all indices of caregiver mental health, and household needs were uniquely associated with caregiver depression, burden, and anxiety. Additionally, social support needs were related to caregiver satisfaction with life, informational needs to burden, and financial needs to self-esteem.

Interventions for TBI caregivers in Mexico—and likely in other global regions with high levels of familism—should include an emphasis on overall family health, the delineation of family roles regarding household responsibilities, the improvement of social support networks and the social presence of family members, and the provision of complete and relevant information regarding TBI. When these needs are more comprehensively met, caregiver mental health will likely improve.

Spasticity is a common impairment following upper motor neuron lesions such as stroke. The appropriate measurement of muscle spasticity using validated tools to evaluate the outcome of therapies is important in clinical and research settings.

To determine the concurrent criterion-related validity of the Modified Tardieu Scale (MTS) in assessing poststroke wrist flexor muscle spasticity based on its correlation with H-reflex tests.

A total of 20 adult patients poststroke underwent clinical and electrophysiological assessment of wrist flexor muscle spasticity on the affected side. The primary outcome measures were: R2−R1 of the MTS; and the H-reflex indices of H_max/M_max ratio and H_slp/M_slp ratio. The H_slp and the latency of H-reflex were also measured.

Correlations tests did not reveal significant associations between the clinical and H-reflex tests.

This study suggests that the MTS may not be a valid tool to evaluate muscle spasticity in this sample of patients after stroke.

Botulinum neurotoxin A (BoNT-A) may reduce lower limb spasticity but its role in improving walking ability remains to be established.

To investigate the efficacy of simultaneous BoNT-A injections into several targeted spastic muscles of different joints on gait speed and on functional gains in gait performance in chronic stroke and MS patients.

Twenty patients affected by stroke or multiple sclerosis were tested before, one and three months after BoNT-A administration. Gait was evaluated by the 10 Meter Walk Test; patients were stratified into functional ambulation classes accordingly. Spasticity was assessed using the modified Ashworth Scale.

At final assessment, spasticity was reduced in hip adductors and ankle plantar-flexors, gait speed improved and, 1/3rd of patients transitioned to a higher ambulation class. The pre-post difference in Level of Spasticity of the hips was a predictor for an increase in gait speed.

A meaningful improvement in walking performance can be obtained in chronic spastic patients after BoNT-A injection into several muscles, specifically the hip adductors.

Rhythmic auditory stimulation (RAS) improves gait velocity, cadence, and stride length in hemiplegic stroke patients, yet little is known about the effectiveness of RAS on standing balance.

To examine and compare the effectiveness on standing balance and gait parameter of two different types of gait trainings, gait training with RAS versus gait training without RAS, was compared in two groups of hemiplegic stroke patients over a three-week period (RAS group, n = 8; control group = 8).

Sixteen hemiplegic stroke patients were included in the study. Standing balance was measured by using Biosway^®. Stride length, gait velocity, and cadence were calculated from the number of steps and required time for a 10 m-walk.

Pre- to post-test measures showed a significant improvement in RAS group for overall stability index (p = 0.043), mediolateral index (p = 0.006), anteroposterior index (p = 0.016), gait velocity (p = 0.012), stride length (p = 0.03) and cadence (p = 0.012) over the control group.

The results of this study showed that RAS was an effective therapeutic method to improve gait velocity, stride length, cadence, and standing balance in hemiplegic stroke patients.

Constraint-Induced Movement Therapy (CIMT) is an evidence-based rehabilitation intervention for stroke. Several factors influence the motor gain from CIMT, including age and level of impairment. However, it is currently unknown to what extent cognitive status affects motor gain during CIMT.

The aim of this study was to investigate whether cognitive and emotional status affects motor improvement during two weeks of CIMT and retention of the gain at three months follow-up.

Twenty stroke patients (3–12 months post stroke) completed two weeks of CIMT. Motor performance was measured using the Wolf Motor Function Test (WMFT). Cognitive and emotional status was measured with a comprehensive neuropsychological test battery and a questionnaire on emotional status. All measures were performed at baseline, after two weeks of training, and at three months follow-up.

We found no significant correlation between cognitive or emotional measures at baseline and improvement in motor performance post training. Also, cognitive and emotional status did not correlate with motor retention at three months follow-up.

We found no evidence to support that cognitive performance in stroke patients can predict motor gain from CIMT.

Stroke is a leading cause of functional impairments. High percentage of these patients will experience some degree of cognitive affection, ranging from mild cognitive impairment to dementia.

Demonstrate the role of aerobic exercises enhancing cognitive functions and its effect on Brain Derived Neurotrophic factor (BDNF) in post-ischemic stroke patients in the territory of anterior circulation.

We included thirty Egyptian ischemic stroke patients in the territory of anterior circulation. They were divided into 2 groups; group 1 (G1) were subjected to physiotherapy program without aerobic exercises and group 2 (G2) were subjected to the same previous program followed by aerobic exercises. Both groups were subjected to pre- and post-treatment Addenbrookes's Cognitive Examination- Revised (ACER) and serum level of BDNF.

Our results showed a significant improvement in ACER score in G2 compared to G1 post-treatment (p = 0.017). BDNF serum level significantly increased in G2 post-treatment compared to pre-treatment (p = 0.001) and compared to G1 group (p = 0.0458). ACER improvement was positively correlated to increase in serum level of BDNF (r = 0.53, p = 0.044).

Aerobic exercises improve cognitive functions of ischemic stroke patients. This improvement is related to the increase in serum level of BDNF.