Cognitive Rehabilitation: Fundamental Characteristics and Functional Significance

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Cognitive Rehabilitation Fundamental
Characteristics and Functional Significance

• Catherine Mateer, Ph.D., ABCN

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Fundamental Characteristics and Underlying
Assumptions

• Interventions are tailored to the individual
• Interventions are collaborative
• The focus is on functional goals/outcomes
• Interventions have multiple targets
• Implementation of external or internal
  compensations
• The development of skills/behaviors
• Effective cognitive interventions must be
  integrated with psychological interventions

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Interventions need to be matched with client
characteristics

• For clients with low insight, and high
  environmental dependency
• Environmental supports/structure
• Functional routines
• Behavioral interventions

• For clients with emerging insight and some
  self-regulation
• Process training
• Active Compensations
• Self-regulatory and meta-cognitive interventions
• Cognitive-behavioral interventions

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What have we learned?

• Timing of interventions
• Critical elements of interventions
• Interactions between individual variables and the
  level of intervention
• Generalization of interventions
• How to better conceptualize and address emotional
  correlates

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Timing of treatment

• Little support for effectiveness of process
  training in the early, acute stage
• Changes may occur but are difficult to
  distinguish from the background of spontaneous
  recovery
• Evidence of potential for change well beyond
  period of spontaneous recovery

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Critical elements in effective cognitive
interventions

• Use a wide range of activities
• Organize training hierarchically
• Facilitate generalization
• Incorporate learning principles that facilitate
  acquisition, retention, and transfer (e.g.,
  errorless learning)

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Results of Treatment Study Using Child Pay
Attention (Kerns, et al, 1999)
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Individual client profiles interact with level
of training

• Sturm et al, (1997)
• Stroke patients with good basic arousal
  benefited from broad attention training
• When basic attention is poor, training at complex
  levels alone had no affect or actually decreased
  attention

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Measuring Generalization The psychometric
approach
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Broader measurement of generalization

• Development and reliance on more ecologically
  valid measures
• Emphasis on everyday functioning
• Self-report rating scales, diary studies
• Structured observation scales (EMF, EAF)
• Involvement of family, caregivers, etc.
• Multiple perspectives on improvement

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Everyday memory failures following 2 group
interventions(Schmitter-Edgecombe, et al, 1996)

• Fewer everyday memory failures after memory
  notebook training
• No changes following supportive group therapy

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Effects of memory group training on
self-reported perceptions
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Use of new technologies to facilitate
generalization

• Virtual reality allows simulation of real
  environments yet allows manipulation of sensory
  input and task demands (Rizzo, 1999)
• Simulated classroom environments to evaluate and
  train attention
• Office environments to train multitasking and
  prospective memory
• Social environments to teach anger management

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Importance of emotional factors

• Cognitive complaints more related to subjective
  distress than to degree of injury
• or to psychometric findings

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Cog/Beh Prevention of PCS Mittenberg et al.
(1996)

• of initially symptomatic patients who
  continued to report specific symptoms 6 months
  post injury
• Control Treatment
• Headache 86 44
• Fatigue 82 47
• Memory 80 38
• Concentration 80 29
• Anxiety 58 38
• Depression 56 27
• Dizziness 50 36

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Important messages

• Normalize symptoms and provide a realistic
  explanation as to their bases
• Regulate lifestyle/environment to avoid problems
• Recognize early signs of stress and take steps to
  reduce it
• Develop compensations - reduce overall workload,
  introduce a diary

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Cognitive self-efficacy

• An individuals beliefs about
• His/her own cognitive capacity
• How much cognitive abilities have changed
• The degree to which performance on cognitive
  tasks is under personal control

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Why are self-efficacy beliefs important?

• People who judge themselves inefficacious on
  memory tasks and who believe they lack control
  over their memory show lower levels of motivation
  and poorer memory performance
• (Dixon Hultsch, 1990)

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• The belief that one has a poor memory may lead
  to increased dependence on others, avoidance of
  memory challenges, and a pattern of helplessness
  and demoralization in the face of memory
  difficulties
• Elliot Lachman, 1989

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Many intervention studies have combined approaches

• Attention training
• Memory
• compensations
• Skill training
• Feedback

• Education
• Monitoring of emotional response to
  difficulties
• Stress management
• Confidence building

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Conceptualizing the psychological piece

• Look to principles of cognitive-behavioral
  therapy (CBT)
• Based on principle that self-talk and self-belief
  influences ones behavior
• Identify and alter distorted cognitions
• Build self-regulatory skills
• Increase stress and frustration management
• Strong support for efficacy of CBT in other
  domains

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Components and goals of APT-II psychosocial
intervention

• Develop awareness of not only attentional
  failures but reasons for the failures
• Instill a sense of self-control over attentional
  successes and failures
• Assist client in managing their emotional
  response to treatment by decreasing negative
  self-statements and distorted beliefs

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Cognitive changes reported with two types of
intervention (Sohlberg et al, 2000)
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Psychosocial Changes Reported with Two Types of
Intervention
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Lessons from other kinds of recovery Constraint
Induced Movement Therapy

• Monkeys made hemiparetic through surgical
  deafferentation will permanently cease use of the
  affected arm (Taub, 1978)
• If, however, the unaffected arm is constrained,
  the animal begins to use the affected arm
• Hypothesizes learned non-use

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CIMT in humans

• Requires some residual limb function
• Constraint is not a sufficient condition
• Intensive work with the limb
• Shaping of movement
• Suggests extensive opportunity in context
  insufficient to affect change
• Lessons for cognitive intervention?
• How much of what we see is learned non-use
• Involvement in functional context is insufficient

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Evidence of change in brain activity with
rehabilitation

• Increased activity over the motor and sensory
  cortex following CIMT
• Increased activity over these same cortical
  regions simply with attention to the activity
• Changes on PET in ipsilateral and contralateral
  cortex following aphasia treatment
• Multiple published studies demonstrating
  normalization of ERP (P300) after attention
  training

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New imaging work revealing patterns of neural
recovery
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Individualized Treatment

• Dr. M. (47 yo Professor of Economics)
• Severe anterograde amnesia and adynamia secondary
  to vitamin uptake disorder
• Anxiety, guilt, false memories
• 2- Stage Intervention
• Implement pager cuing device
• Memory book
• Outcome
• Initiations, mood, behaviors

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Fundamental Characteristics and Underlying
Assumptions

• Interventions are tailored to the individual
• Interventions are collaborative
• The focus is on functional goals/outcomes
• Interventions have multiple targets
• Implementation of external or internal
  compensations
• The development of skills/behaviors
• Effective cognitive interventions must be
  integrated with psychological interventions

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Summary

• The principles underlying effective cognitive
  rehabilitation are more clearly established
• The emphasis on everyday functioning in
  assessment, intervention, and outcome is clear
• Interventions are integrative, and there is
  greater focus on and specification with respect
  to influencing emotional adjustment
• Exciting developments in neuroplasticity and in
  rehabilitative technology raise exciting new
  questions as well as answers