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DEPARTMENT OF CLINICAL PSYCHOLOGY

CENTRAL INSTITUTE OF PSYCHIATRY, RANCHI-834006

MINISTRY OF HEALTH AND FAMILY WELFARE

GOVERNMENT OF INDIA

DEPARTMENTAL SEMINAR- NEUROPSYCHOLOGICAL REHABILITATION

PRESENTER- MR. SHUVABRATA PODDAR M.PHIL 2ND YEAR MEDICAL


AND SOCIAL PSYCHOLOGY

SUPERVISED BY- MRS. DEYASHINI LAHIRI TIKKA

Rehabilitation is a process whereby people, who have been injured by injury


or illness, work together with health service staff and others to achieve their
optimum level of physical, psychological, social and vocational well-being
(McLellan, 1991). Rehabilitation aims to protect or restore personal and social
identity.

Neuropsychological rehabilitation (NR) is concerned with the amelioration of


cognitive, emotional, psychosocial, and behavioral deficits caused by an
insult to the brain. Neuropsychological rehabilitation is the process of helping
a patient to recover the functions which are impaired due to brain damage.

Although Neuropsychological rehabilitation is partly concerned with the


remediation or alleviation of emotional, behavioral and motor consequences
of brain injury, it is probably true to say that the major role of
neuropsychological rehabilitation is the treatment of cognitive deficits
resulting from damage to the brain. It extensively uses cognitive retraining to
improve the impaired functions. Neuropsychological rehabilitation includes
those psychological procedures, which are targeting the damaged functions.
In addition, counseling and other techniques may be used as ancillary
techniques for augmenting the patients recovery (Rao, 1991).

Major areas of use

Traumatic Brain Injury (TBI),

Stroke,

Tumor,

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Epilepsy,

Alzheimers disease ,

Schizophrenia,

Attention-deficit disorder,

Learning disabilities,

Cognitive changes associated with aging.

Access to neuropsychological rehabilitation must be preceded by a


neuropsychological examination focusing on the specific nature of the
difficulties experienced and their severity, extent, degree of impairment and
treatability.

BRAIN PLASTICITY:

Plasticity of the brain is the basis of neuropsychological rehabilitation.


Plasticity refers to the brains capacity to adapt to changes in the
environment. In severe brain injury, plasticity is the capacity of one part of
brain to take on the function of a part of the brain which is damaged. Since
adaptive function is the integrated function of brain, cognitive rehabilitation
considers a thorough evaluation of the individuals profile of cognitive
abilities, personality, emotional make-up, motivation, and social situation
and most importantly, his/her cognitive reserve to formulate any intervention
programme. Also, depth, size, and site of the lesion and severity of the injury
are significant considerations for recovery and restitution.

Evidence of brain plasticity lies in three functions of brain.

Regeneration,

Reorganization ,

Recovery.

Regeneration

Nerve regeneration is the reconstruction and renewal of cell structure and


function which is generally restricted to myelinated nerve fibers (Medical
Dictionary, 2008). Regeneration occurs primarily through collateral

Neuropsychological rehabilitation; Poddar, S., Lahiri, D. T.


sprouting (Liu and Chambers, 1958). In catecholaminergic fibres, during
axonal recovery, growing zones tend to invade vacant terminal spaces; and
neighboring neurons also may sprout and send fibres if possible. Collateral
sprouting occurs both from intact axons and from the collaterals of damaged
ones. Some central structures become more responsive to stimulation after
damage. However, the remaining fibers from the damaged area may produce
a greater effect on the denervated region, promoting recovery. Intelligence of
living substance is one of the most vivid examples of regeneration.

Reorganization:

Reorganization of the neural circuits is brought about by strengthening of


existing neural connection and the establishment of new connections by
collateral sprouting. In fact, behavior modification or remediation
programmes work at long term reorganization of these neural circuits
through strengthening of the stimulus response bond.

Recovery:

Recovery from brain damage due to stroke or trauma can be divided into two
stages:
The first stage is related to recovery from the acute effects of
metabolic and membrane failure. The rapid recovery from neurological
deficit after a stroke is often attributed to the recovery of function of
the cells.
In second stage recovery, nervous system damage may result into a
variety of compensatory changes. Gradual improvement in the months
after damage could reflect the learning of new cognitive behavioral
strategies rather than return of lost function. Kapur (1997) in his
studies found that observed improvement did not occur because the
patients have actually recovered lost cognitive function but because
their cognition allowed them to accomplish cognitive tasks in
alternative way.

Thus, neural reorganization along with adult neurogenesis (growth of neuron)


plays a role in recovery, particularly when the damage affects the
hippocampus, as hippocampus is the major area for new learning. Thus the
approaches to cognitive rehabilitation can be restorative (focus: weakness)
and or compensatory (focus: strength), bringing us back to organization of
intact circuitry and or development of novel circuitry.

PRINCIPLES OF NEUROPSYCHOLOGICAL REHABILITATION

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There are several principles of neuropsychological rehabilitation (Prigatano,
1993):

Clinicians must begin with the patients subjective or


phenomenological experience to reduce their frustrations and
confusion in order to engage them in rehabilitation process.

The patients symptom picture is a mixture of premorbid cognitive and


personality characteristics as well as neuropsychological changes
directly associated with brain pathology

Neurological rehabilitation focus on both the remediation of higher


cerebral disturbances and their management in interpersonal
situations

It helps patients observe their behavior and thereby teaches them


about the direct and indirect effects of brain injury. This may help
patients avoid destructive choices and better manage their
catastrophic reactions.

Failure to study the intimate interaction of cognition and personality


leads to an inadequate understanding of many issues n cognitive
sciences and neuropsychological rehabilitation.

Little is known about how to retain a brain dysfunctional patient


cognitively because the nature of higher cerebral functions is not fully
understood. General guidelines for cognitive remediation, however,
can be specified.

Psychotherapeutic interventions are often an important part of


neuropsychological rehabilitation because such individualized
programs help patients and their families deal with their personal
losses.

Working with brain dysfunctional patient produces affective reactions


in both the patients family and the rehabilitation staff. Appropriate
management of these reactions facilitates the rehabilitative and
adaptive processes.

Each neuropsychological rehabilitation program is a dynamic entity. It


is either in a state of development or decline. Ongoing scientific

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investigation helps the rehabilitation team learn from their own
success and failure and is needed to maintain a dynamic, creative,
rehabilitation effort.

Failure to identify which patients can or cant be helped by different


neuropsychological rehabilitation approaches creates a lack of
credibility for the field.

Disturbances in self awareness after brain injury are often poorly


understood and mismanaged.

Competent patient management and planning innovative rehabilitation


programme depend on understanding mechanisms of recovery and
deterioration of direct and indirect symptoms after brain injury.

The rehabilitation of patients with higher cerebral deficits requires both


scientific and phenomenological approaches. Both are necessary to
maximize recovery and adaptation to the effects brain injury.

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ASSESSMENT IN NEUROSPYCHOLOGICAL REHABILITATION

All neuropsychological rehabilitation process must begin with an adequate


neuropsychological assessment. The assessment should consist of
neurocognitive, behavioral or social deficits. The assessment should include
identification of the functions impaired, the zone groups or neural networks
impaired and the contribution each makes to the injured functional systems
to be assessed. The assessment can be categorized into (Carron, 1997):

Neuropsychological rehabilitation; Poddar, S., Lahiri, D. T.


Quantitative Model- it is centered in the lesion and the neurocognitive
deficits the patient show on standardized tests and neuropsychological
batteries. This model focuses mainly on the disorder or deficits that the
patient shows which is considered to be the direct result of a lesion in
the brain tissue.

Qualitative model is based on the principles of Luria. It is centered on


what functions are intact in a particular patient along with what are the
deficit areas. It is based on the view that neuropsychological
rehabilitation must initiate with what remains intact and not from what
has been damaged. Thus the main objective is not the patients return
to his her earlier normalcy (Leon-Carrion, 1986) but to achieve
neuropsychological coherence in the person.

There are basically two standard comprehensive batteries that are widely
used for assessment for rehabilitation: Halstead Reitan Battery (Reitan &
Davison, 1974) and Luria Nebraska Neuropsychological batteries (LNNB)
(Golden, Hammeke et al., 1980). Both procedures have standard
administration and scoring methods, providing evaluations of the various
cognitive perceptual and motor abilities. These areas included general
intelligence, abstraction and related conceptual abilities, attention,
language, memory and a variety of perceptual motor skills.

In addition to these batteries, appropriate Weschler Intelligence Scale and


its subtests depending on the need of the patient may be used. Many
researchers also use Weschler Memory Scale, Boston Diagnostic Aphasia
Scale. A single test widely used for neuropsychological rehabilitation is
Wisconsin Card Sorting Test (Heaton, Chelune etal., 1993). It is basically a
test of executive functions that assess planning, concept formation and
conceptual flexibility (berg, 1948).

Besides these standardized behavioral observations and assessments


play a vital role. Behavioral interviewing scales, checklists and direct
observation can all be used to identify and monitor the everyday
implication of neuropsychological impairment. These identify problems for
the treatment and also can evaluate the effectiveness of treatment.

These test batteries, individual tests and behavioral assessment should


fulfill the need to:

Neuropsychological rehabilitation; Poddar, S., Lahiri, D. T.


Know the cognitive abilities and deficits in order to build a map of
what is and is not cognitively possible for the patient.

Know how the problems are manifested in real life and what the
people involved consider to be important

Individualize treatment such individualizations involves the


identification of problems from the patients point of view.

TECHNIQUES OF COGNITIVE REHABILITATION:

Techniques of cognitive remediation fall into three categories

Restorative

Compensatory

Holistic

Restoration

Restoration involves regaining function by remediating the impaired


cognitive ability (for example, selective attention, spatial perception, or
memory retrieval) using systematic training. The primary technique is to
engage a person in repetitive exercises designed to ameliorate the specific
impairment. Restorative approaches take a bottom-up approach;
remediation is directed towards restoring a particular area of cognitive
functioning (such as attention) rather than towards developing strategies for
successfully performing specific work tasks.

Compensation

Compensation focuses on the disability (for example, following written


instructions, navigating the community, or remembering appointments) and
trains a person to use strategies to again accomplish these tasks. The
primary techniques include training in self-cueing and use of external
prosthetics. It aims to develop strategies for accomplishing specific
functions, including determining which specific work activities are affected by
the individuals cognitive impairment (for instance, keeping a schedule,
organizing tasks, or sustaining effort for the entire day).

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Restorative techniques would be used to focus on weaknesses, while
compensatory techniques are often driven by a persons strengths, which
serve as the basis for developing effective strategies

Holistic Approach

In contrast to retraining and compensatory approaches that focus primarily


on specific cognitive processes, holistic programmes attempt cognitive
rehabilitation in the context of the full range of problems experienced by
brain damaged individuals. The holistic approaches are predicated on several
key assumptions.

Cognitive therapies must not be isolated from other (physical, psychological)


therapies that are essential to functional rehabilitation.

Cognitive interventions must proceed in sequential fashion from lower levels


to more complex functions.

The disorganized and sometimes chaotic nature of thought processes in


brain damaged people necessitates an orderly and structured therapeutic
programme.

Because the problems of brain injured people are highly personalized,


treatment must be as individualized as possible.

Holistic programmes are multidimensional and attempt to treat cognitive,


emotional and social consequences of brain injury in an integrated manner.
Individuals participate in a variety of tasks, including simple drills and
retraining exercises, as well as learning compensatory techniques. An
important feature is to help patients gain insights into their strengths and
weaknesses in order to achieve a realistic sense of their potential for
improvement. The expectation is that, through heightened awareness and an
appreciation of the practical limitations imposed by their brain damaged,
individuals will be better motivated and equipped to restructure their lives.

Two prominent holistic programmes are developed by Ben-Yishay (1978), a


pioneer in the field, and Prigatano (1986). Ben- Yishays approach is
characterized by the creation of a therapeutic community in which the
patients, members of the therapeutic team, as well as family and significant

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others, work together to promote the rehabilitative process. Prigatano follows
a similar approach but one that attaches great importance to the
psychosocial consequences of neuropsychological disturbances. Prigatanos
programme focuses on residual function and it is guided by the philosophy
that optimal use of these functions can be achieved if the patient has
psychosocially adjusted to the injury induced changes and is coping
effectively.

Selection of the different approaches is highly individualized and most often


techniques from each method are collectively implemented to achieve the
best outcome

Cognitive rehabilitation may be done in

Individual Setting

Group setting

BRAIN REORGANISATION

Reorganization after brain injury is basically concerned with plasticity, which


appears to be one of the most important factors contributing to the speed
and level of final recovery. Immature nervous system is more plastic than
those of adults, there are basically two ways of brain reorganization:

Axonal and collateral sprouting- axons in the central nervous system


dont regenerate after total severing. However, axons that have been
sheared may resprout and collateral sprouting can occur from nearly
intact neurons. Thus, it is a way through which brain reorganizes
through the regrowth that have been only partially damaged.
Theoretically, sprouting could replace the lost function.

Denervation super sensitivity- if any area of the brain is lesioned, any


remaining neurons in that area may become hypersensitive to the
neurotransmitters that act on them. This may result in a grater
excitatory or inhibitory potential depending on the type of the neuron.

COGNITIVE REHABILITATION FOR SPECIFIC DOMAINS:

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Cognitive Rehabilitation is a widely used umbrella term encompassing a
variety of intervention strategies such as:

Cognitive Retraining

Compensatory Strategy Training

Cognitive Retraining

Retraining programmes usually involve repeated practice of specific


cognitive exercises designed to strengthen basic skills (attention, encoding)
that are essential for more complex cognitive function. This approach is
continuing to develop and one promising adaptation is a scaffolding
approach whereby training begins with basic processes and progresses to
more complex skills. This approach is clearly reflected in Sohlberg and
Mateers (1989a) process-oriented model in which component processes
that are presumed to mediate a particular cognitive skill are trained in a
hierarchical order, such that progressively more complex processes are
trained as learning occurs . Within each level of training, skills are
repetitively practiced, under the assumption that repeated practice in a
structured setting is a necessary component to strengthen and reautomatise
cognitive skills. Cognitive retraining should be embedded in real life,
everyday contexts, building on residual or already learnt cognitive routines.
Tasks may also be personalized to some degree. Regular feedback must be
given.

Compensatory Strategy Training

Compensatory approaches are based on the principle that individuals can


compensate for reduced cognitive abilities by utilizing specific techniques
that can help organize information during learning or access stored
information for retrieval purposes.

Compensatory strategies include:

Internal strategies

External strategies

Domain specific techniques

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o Internal strategies can help individuals to make the necessary effort to
solve a problem. Such techniques place considerable demands on the
individuals ability to use them appropriately but, as West (1995)
pointed out, an added benefit of this effort is increased attention to the
task at hand.

o With external strategies, the objective is to identify distinctive cues


that can be readily associated with to-be-remembered material.
External strategies make use of objects in the environment to
compensate for cognitive deficits.

o Domain specific approaches capitalize on preserved domain or systems


to train functions that are normally mediated by other impaired
system.

Types of cognitive retraining

Attention and concentration retraining

Memory retraining

Organizational skills retraining

Reasoning

Problem solving

Decision making

Executive skills.

ATTENTION RETRAINING

This type of cognitive retraining aims to improve several abilities, including


focusing attention; divided attention; maintaining attention while reducing
the effects of boredom and fatigue; and resisting distraction. It helps to
reduce time pressure and improving stimulation by making necessary
changes in the environment. Appropriate expectations regarding the
attention and self-regulation abilities of the individual should be present.
Smaller tasks, more reinforcement, and alternating tasks of varying interest
are essential components of attention retraining. Usage of job cards,
outlines, checklists, graphic organizers, colour coding, or other highlighting

Neuropsychological rehabilitation; Poddar, S., Lahiri, D. T.


procedures for assignments, repeating instructions is made. Attention
process training involves creating tasks (exercises) that engage attention
functions in a hierarchical manner, which is then, practiced using massed
(back-to-back) learning trials.

One of the techniques developed by Sohlberg and Mateer (1987, 1989)


intended to improve deficits in four areas of attention. The basic idea behind
the repetition in the targeted area is to provide repeated stimulation to the
brains attenional system; which is considered to facilitate strengthening and
repair of the neuronal system via process of restitution of function. The four
areas include:

Sustained attention- to train sustained attention or hierarchies of tasks


that require constant attention presented.

Selective attention training- incorporates distraction into tasks such as


those used for sustained attention.

Alternative attention training- it entails switching between two


attention requiring tasks.

Divided attention raining- entails simultaneous attention to two or


more tasks. This may be accomplished by first training performance on
two single sustained attention tasks.

MEMORY RETRAINING

In memory training, compensatory approach such as maintaining a daily log


or schedule to using voice-activated dictation devices is made. Strategies for
memory such as association, chunking, and the use of mnemonics that can
be trained in therapy and then generalized to functional settings are used.
Among the core processes of memory (encoding, storage, retrieval),
encoding and retrieval can be significantly impaired. However, storage is
often relatively spared.

Strategies for managing memories

Using a Dictaphone/ tape recorder to record meetings , lectures ie as


an aid to memory

Neuropsychological rehabilitation; Poddar, S., Lahiri, D. T.


Using a watch with an alarm or a paging device as a cue to look at
diary or to perform particular task .This may also increase immediate
arousal level sufficiently to overcome initiation impairments

Systematically using written or photo journals for episodic memory


deficits (memory for events)

Using notes, calendars and list as external cues and reminders. These
may also helps with initiation difficulty.

Introducing a notice board or white board in a prominent place in the


home to prompt patients about specific actions as well as daily /
weekly schedule

Using errorless learning when teaching new skills to minimize the need
to unlearn mistakes that is promptings and cueing in such a way that
no errors are made during the training process.

Developing internal memory strategies through

Repetition

Association

Chunking

Maximizing the relevance and depth of understanding of material.

Mnemonics:

Pegword method

Method of loci

Image name match method

REASONING

Reasoning retraining techniques include listing the facts or reality of a


situation; excluding irrelevant facts or details; putting the steps to solve a

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problem in a logical order, avoiding irrational thinking, such as jumping to
conclusions based on incomplete information, focusing on the negative
aspects of the situation and ignoring the positive. When the person can
connect relevant information in a logical way, they are better able to
understand or comprehend.

PROBLEM SOLVING.

Problem-solving retraining aims to help people define a problem come


up with possible solutions to it and discuss the solutions with others and
listen to their advice; review the various possible solutions from many
perspectives; and evaluate whether the problem was solved after going
through these steps. This sequence may be repeated several times until the
problem is solved. This process is referred to as "SOLVE," from the first letter
of the name of each step: Specify; Options; Listen; Vary and Evaluate. The
"SOLVE" technique is more appropriate for use with individuals at a higher
level of functioning. Providing problem solving skills involves, training to help
develop an explicit and systematic approach to solving difficulties.

DECISION-MAKING RETRAINING

Decision-making retraining is used when a person must choose among a


number of options. The goal of this retraining is to help him or her consider
the decision thoroughly before taking any action. The considerations may
range from such practical matters as money, people, rules and policies, to
personality issues.

EXECUTIVE SKILLS.

Executive skills retraining refers to teaching individuals how to monitor


themselves, control their thinking and actions, think in advance, set goals,
manage time, act in socially acceptable ways, and transfer skills to new
situations. These are higher-level cognitive skills. Charts and videotapes may
be used to monitor behavior, and a variety of questions, tasks, and games
may be used in retraining these skills.

Both restorative and compensatory strategies are used for the remediation.

Compensatory strategies are used if the patient is very acute and is


demonstrating very severe executive function disturbance, focus should be

Neuropsychological rehabilitation; Poddar, S., Lahiri, D. T.


on teaching task specific routines. They may profit from training of particular
sequences for standard highly repetitive functional activities such as
showering, taking care of ones toilet or dressing. Behavior techniques
include shaping and reinforcement.

Cognitive retraining in case of traumatic brain injury:

General Cognitive strategies:

Developing habits , routines and over learned procedures to maximize


the use of implicit and procedural memory functions

Provide structures

minimize cognitive load

Developing a tidy living and working environment where belongings


are kept at same , intuitively obvious places and can easily be found. These
help to minimize demand on memory and problem solving skills and make
maximum use of spare implicit memory.

Taking many small breaks when impairments become apparent rather


than pushing on, until force to take a break due to cognitive overload

Rearranging working environments to minimize back ground noise,


dizziness unexpected events and time pressure. This helps to reduce
restrictions arising from attentional deficits, slow speed of information
processing and cognitive inflexibility.

Graduated return to premorbid activities and minimization of non


essential activity to reduce cognitive overload and fatigue. This maximizes
the chances of successful completion of activities.

Identifying specific times or specific types of activity where fatigue,


irritability anxiety or frustration occur and facilitation of appropriate changes
in these areas.

Individuals suffering from traumatic brain injury disorders may


experience

Neuropsychological rehabilitation; Poddar, S., Lahiri, D. T.


Depression

Anxiety

Posttraumatic stress disorder

Obsessional behaviors

Additionally, behaviors such as,

Hostility

Impatience

Irritability

Argumentativeness

Anger

Difficulty in becoming interested

Lack of initiative

Irresponsibility

Aggression

Lack of control over social behavior are also prominent

Training and cognitive behavioral remediation in these areas is also


needed to make the person feel better and more productive

In case of dementia we would focus on the environmental management, i.e.


structured environment should be provided by

keeping a clock, a beeper, written direction(depending on


requirement)

Keeping demand on their ability & responsibility

Encourage decision- making

Leaving everyday possessions in handy places, in same location.

Neuropsychological rehabilitation; Poddar, S., Lahiri, D. T.


Keeping furniture in the same place

Making a list of things so that it can be ticked off

Stick to routine as far as practicable

Setting out things in order of priority

Using memo,stickers,diary, back of hand

Wrist watch with alarms

DEVELOPMENT OF NEW TECHNOLOGIES

Computer-Assisted Cognitive Rehabilitation (CACR)

Graphic advance organisers

Neuro-feedback

Virtual reality

Prosthetic aids

CONCLUSION:

In conclusion, it may be said that neuropsychological rehabilitation is an


effective mode of treatment in organic and psychiatric conditions. The
refinement of standard approaches more reasons to be optimistic but
perhaps the most encouraging development is the growing willingness to
combine the best of the various approaches. The result is the emergence of
the holistic approaches, which have been associated with positive outcomes.

Neuropsychological rehabilitation; Poddar, S., Lahiri, D. T.

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