Neuropsychological rehabilitation

Neuropsychological rehabilitation focused on improving cognitive functions which further results in improving symptoms, functional ability which enhance overall quality of life.

1. NEUROPSYCHOLOGICAL REHABILITATION PRAGYA CLINICAL PSYCHOLOGIST 1

2. WHAT IS NEUROPSYCHOLOGICAL REHABILITATION ? Concerned with improvement of cognitive, emotional, psycho-social and behavioral deficits caused by an insult to them Consist of task designed to reinforce or re-establish previously learned pattern of behavior and to establish new compensatory mechanism 2

3. FACTORS AFFECTING Course of intervention is based upon: DIAGNOSIS OF PATIENT AGE PREMORBID FUNCTIONING EDUCATION HISTORY OF ILLNESS/ INJURY 3

4. INDICATION Applicable on several brain related conditions: Traumatic Brain injury(TBI) Tumors Brain related infections Neurodegenerative conditions Psychiatric disorder 4

5. FEATURES Team effort (patient’s awareness and motivation, family support as well as therapist expertise) Aim is to restore premorbid function and to compensate lost functions Ultimate goal is to facilitate meaningful and measurable improvement in patient’s everyday functions 5

6. NEED FOR NEUROPSYHCOLOGICAL REHABILITATION Brain is chief organ which controls functioning of different parts of body Recent advances in surgical techniques and pharmacotherapy have considerably reduced the mortality after brain damage However, morbidity after brain damage continues to be high as neurons do not regenerate like skin or bone 6

7. NEED contd … The morbidity can be observed in physical and psychological domains of functioning: Physical morbidity is easily perceived and addressed through techniques of physiotherapy (neurological rehabilitation) Psychological morbidity is more subtle 7

8. N EED contd … Psychological morbidity may arise due to impairment at basic level of functioning (memory loss) or integrated functioning (personality ) Brain damage also affects family and society apart from patient which needs to be addressed 8

9. THEORIES The role of neuronal plasticity Restitution/ substitution/ compensation Role of diastasis/unmasking 9

10. NEURONAL PLASTICITY Refers to adaptation of brain as a result of several factors that may produces changes in brain Modification of nervous system that occur in response to either internal or external environmental demands It includes short-term modulation of functions and long term structural changes 10

11. RESTITUTION, SUBSTITUTION AND COMPENSATION Three major principles of neuropsychological rehabilitation: 11

12. DIASCHISIS AND UNMASKING Sudden change of function or unmasking of latent function in a portion of brain connected to distant but damaged brain area 12

13. REGENERATION - reaction to injury If the cell body of neuron is lost or damaged, whole neuron is lost as the axon will also degenerate and there is no cell division in adult brain If the axon of neuron is lost or damaged and cell body is intact, there is chance that axon will regenerate 13

14. REGENERATION IN PNS (Parasympathetic N ervous System) After degeneration , macrophage clean up the debris Macrophage release “Mitogens” , that include Schwann cells to divide Schwann cells make “ Laminin” and macrophage make “Interleukin” which induce Schwann cells and make “ NERVE GROWTH FACTOR (NGF)” 14

15. Axons sprout and enter new Schwann cell tube and axonal growth cones successfully grow 15

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17. REGENERATION IN CNS (Central Nervous System) Astrocytes and microglia form glial scars which physically block axonal regeneration Oligodendrocytes produce NEURITE OUTGROWTH INHIBITOR (NOGO) which inhibits axonal regeneration Regeneration in CNS occurs only when some branches of presynaptic axons are damaged 17

18. CNS RECOVERY 18

19. GOALS OF NEUROPSYCHOLOGICAL REHABILITATION Primary goal is to restore functions/functional abilities of patient to premorbid level. Attempts made to improve overall cognitive function so that it will generalize to everyday functioning Secondary goal is to improve functions at least to the extent that patient become productive and to continue with family or social responsibility 19

20. GOALS contd … Tertiary goal is to provide cognitive aids which support patient in day-to-day functioning. Aim is to execute functions optimally, reduce burden on support system and to minimize residual impairment 20

21. APPROACHES BASIC FUNCTION APPROACH : Aims is to restitute deficient function or deals with environmental manipulation Expectation is improved deficient function leads to reduction of symptoms which improved behavior mediated by that function 21

22. 2. SKILL TRAINING APPROACH : Focused on the skill needed for day-to-day functioning of patient which are deficient following brain damage Approach is more direct and targeted behavior is specific and narrower No expectation about generalization of improvement 22

23. 3. HOLISTIC APPROACH : Includes both basic function approach and skills training approach 23

24. MODEL OF NEUROPSYCHOLOGICAL REHABILITATION 24

25. Pre-morbid function Patient & family member Current problem Assessment Nature of brain injury Cause, changes overtime and expected recovery Neurocognitive Emotional/psychosocial Behavioral observation, self report & interview Decide on treatment Process Evaluation Reassessment 25

26. METHODS I n brain-related injuries, initial perspective focused on acute management and intensive medical care targeting basic survival Later perspective addresses outcome of injury in terms of basic functioning and quality of life Deficient component are improved by using tasks target specific component which is being introduced at several level of difficulty 26

27. Tasks can be presented through: Computer-based tasks Paper-and-pencil tasks 27

28. COMPUTER-BASED TASKS Advantages: Uniformity of administration of tasks Commence task at level of difficulty most suitable to patient Difficulty level would be increased in real time as per patient’s performance on a trial-by-trial basis Objective record of patient’s performance 28

29. COMPUTER-BASED TASKS contd … Disadvantages: Tasks are too structured Do not permit changes depending on patient’s deficit Consuming time of program designed for every patient’s need 29

30. PAPER AND PENCIL TASKS Advantages: Inexpensive and easily obtained Improve functions at several levels Includes number of tasks for a single domain Grain sorting used to improve information processing speed and focused attention Task difficulty was increased by mixing different types of grains, based on size/shape/color 30

31. Letter cancellation in newspapers or magazine articles increased sustained attention Divided attention was improved by giving two tasks simultaneously which do not combine same stimulus modality, response or nature of processing 31

32. Improvement of memory functions include tasks which improve automatic encoding of temporal, frequency and spatial information These components provide contextual cues to recall Their improvement helps in improving memory 32

33. Frequency encoding- list with repetitions of words were read out. Frequency of repetitions had to be encoded by patient Temporal encoding- asking patient to identify words which were in beginning, middle or end of list Spatial encoding- asking patient to remember location of individual objects which were arranged on table 33

34. Studies also reveal development of EEG neuro-biofeedback training is used to modify brain waves using operation conditioning methods Neuro-feedback has been used to improve physical balance, incontinence, memory and learning improvement 34

35. PRACTICE PRINCIPLES Mateer (2005) outlined several practice principles: Tailored to the individual Collaboration between client, therapist and family/ caregiver Focused on mutually set and functionally relevant goals Evaluation of efficacy and outcome should incorporate and capture changes in functional abilities Eclectic and use multiple approach Address affective and emotional component of cognitive deficits Self-evaluative 35

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