Professional Documents
Culture Documents
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Neuropsychological
Rehabilitation
Barbara A. Wilson
Cognition and Brain Sciences Unit, Medical Research Council, Addenbrookes
Hospital, Cambridge CB2 2QQ, United Kingdom;
email: barbara.wilson@mrc-cbu.cam.ac.uk
Key Words
Abstract
Neuropsychological rehabilitation (NR) is concerned with the
amelioration of cognitive, emotional, psychosocial, and behavioral
decits caused by an insult to the brain. Major changes in NR have
occurred over the past decade or so. NR is now mostly centered
on a goal-planning approach in a partnership of survivors of brain
injury, their families, and professional staff who negotiate and select
goals to be achieved. There is widespread recognition that cognition, emotion, and psychosocial functioning are interlinked, and all
should be targeted in rehabilitation. This is the basis of the holistic
approach. Technology is increasingly used to compensate for cognitive decits, and some technological aids are discussed. Evidence for
effective treatment of cognitive, emotional, and psychosocial difculties is presented, models that have been most inuential in NR
are described, and the review concludes with guidelines for good
practice.
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Contents
INTRODUCTION: WHAT IS
NEUROPSYCHOLOGICAL
REHABILITATION? . . . . . . . . . . . .
HOW HAS
NEUROPSYCHOLOGICAL
REHABILITATION CHANGED
IN RECENT YEARS? . . . . . . . . . . .
Goal Setting to Plan
Rehabilitation . . . . . . . . . . . . . . . . .
Cognitive, Emotional, and
Psychosocial Decits are
Interlinked . . . . . . . . . . . . . . . . . . . .
Increasing Use of Technology in
Neuropsychological
Rehabilitation . . . . . . . . . . . . . . . . .
Rehabilitation Needs a Broad
Theoretical Base . . . . . . . . . . . . . .
COGNITIVE ASPECTS OF
NEUROPSYCHOLOGICAL
REHABILITATION . . . . . . . . . . . . .
EMOTIONAL ASPECTS OF
NEUROPSYCHOLOGICAL
REHABILITATION . . . . . . . . . . . . .
PSYCHOSOCIAL ASPECTS OF
NEUROPSYCHOLOGICAL
REHABILITATION . . . . . . . . . . . . .
MODELS AND THEORETICAL
APPROACHES
CONTRIBUTING TO
NEUROPSYCHOLOGICAL
REHABILITATION . . . . . . . . . . . . .
GUIDELINES FOR GOOD
PRACTICE IN
NEUROPSYCHOLOGICAL
REHABILITATION . . . . . . . . . . . . .
SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . .
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INTRODUCTION: WHAT IS
NEUROPSYCHOLOGICAL
REHABILITATION?
Most people receiving rehabilitation for the
consequences of brain injury have both cognitive and noncognitive problems. A typical patient in a rehabilitation center has
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several cognitive problems such as poor attention, poor memory, and planning and organizational difculties, together with some
emotional problems such as anxiety, depression, or in some cases, post-traumatic stress
disorder. The patient may exhibit behavior
problems such as poor self-control or anger
outbursts and may experience some subtle
motor difculties leading to reduced stamina
and unsteady gait, as well as problems connected with social skills and relationships. In
addition, the patients family members may be
unable to comprehend what has happened to
the person they once felt they knew and understood, and the patient will probably struggle with issues connected with the continuation of work or education. Tables 1 and 2
show the main patient groups seen by neuropsychologists working in rehabilitation and
the main problems these patients face.
We can dene neuropsychology as the
study of the relationship between brain
and behavior. One of the major differences
between academic neuropsychologists engaged in rehabilitation research and clinical neuropsychologists working in rehabilitation centers is the manner in which the
needs of brain-injured people are determined.
Academic neuropsychologists believe that detailed assessments informed by theoretical
models can highlight areas that require rehabilitation. Thus, testing of different components contained in a model of language
can identify a particular decit as the area
to work on in rehabilitation (Caramazza &
Table 1 Main patient groups seen by
neuropsychologists working in rehabilitation
Main groups seen for rehabilitation
Traumatic brain injury
Stroke (cerebrovascular accident; CVA)
Infections of the brain (e.g., encephalitis)
Hypoxic brain damage
Other groups sometimes seen
Progressive conditions
(e.g., Alzheimers disease, multiple sclerosis)
Cerebral tumors
Epilepsy (idiopathic)
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Table 2
A. Problems faced by
survivors of brain injury
Motor
Sensory
Cognitive
Behavioral
Social
Emotional
Pain
Fatigue, etc.
C. Typical emotional and
psycho-social problems
Anxiety
Depression
Anger
Fear
Social isolation
Grief
Poor self-esteem
Lack of condence
Memory
Attention
Communication
Planning
Organization
Reasoning
Perception
Spatial awareness
D. Typical behavior problems
Temper outbursts
Shouting
Swearing
Physical aggression
Disinhibition
Poor self control
Refusal to cooperate, etc.
NR:
neuropsychological
rehabilitation
Goal: the state (or
change in state) that
an intervention or
course of action
intends to achieve
Stroke: a brain
injury caused by a
sudden interruption
of blood ow
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HOW HAS
NEUROPSYCHOLOGICAL
REHABILITATION CHANGED
IN RECENT YEARS?
In some ways, NR today is similar to that provided to soldiers in Germany in World War I
and in Russia and the United Kingdom in
World War II. In their historical review of
NR in Germany, Poser et al. (1996) remind
us, Many of the rehabilitation procedures developed in special military hospitals during
World War I are still in use today in modern rehabilitationat least to some extent
(p. 259). The vocational rehabilitation described by Poppelreuter in 1917 (translated
by Zihl & Weiskrantz 1991) is not unlike
that provided today. In addition, Poppelreuter
(1917) argued for an interdisciplinary approach between psychology, neurology, and
psychiatry, and in a paper published in 1918,
he emphasized the importance of the patients
own insight into the effects of disabilities
and treatment. Goldstein (1942), also writing
about the First World War, stressed the importance of cognitive and personality decits
following brain injury and touched upon what
today would be called cognitive rehabilitation strategies (Prigatano 2005). In 1918,
Goldstein (quoted by Poser et al. 1996) was
concerned with decisions as to whether to try
to restore lost functioning or to compensate
for lost or impaired functions, and this debate
is still ongoing today.
During the Second World War, Luria in
the (then) Soviet Union and Zangwill in the
United Kingdom were both working with
brain-injured soldiers. One important principle, stressed by both Luria and Zangwill, was
that of functional adaptation, whereby an intact skill is used to compensate for a damaged
one. Goldstein was also committed to a similar concept. Lurias publications of 1963 and
1970 and his book with Naydin, Tsvetkova,
and Vinarskaya (Luria et al. 1969) are well
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worth reading today for the insights they offer. So too is Zangwills (1947) paper in which
he discusses, among other things, the principles of re-education and refers to three main
approaches to rehabilitation: compensation,
substitution, and direct retraining.
Despite these similarities in concepts,
there have been major changes, four of which
are addressed in this section. The rst is
goal setting to plan rehabilitation programs;
second is a growing recognition that cognitive, emotional, and psychosocial difculties
should all be addressed in rehabilitation; third
is the increasing use of technology to compensate for cognitive difculties; and fourth is a
realization that NR requires a broad theoretical base or indeed a number of theoretical
bases.
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SMART: acronym
applied to goals that
are specic,
measurable,
achievable, realistic,
and timely
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emotional distress and can cause apparent behavior problems. Psychosocial difculties can
also result in increased emotional and behavioral problems, and anxiety can reduce the effectiveness of intervention programs. There
is clearly an interaction between all these aspects of human functioning, as recognized by
those who argue for the holistic approach to
brain injury rehabilitation. This approach, pioneered by Diller (1976), Ben-Yishay (1978),
and Prigatano (1986), is founded on the belief that the cognitive, psychiatric, and functional aspects of brain injury should not be
separated from emotions, feelings, and selfesteem. Holistic programs include group and
individual therapy in which patients are (a) encouraged to be more aware of their strengths
and weaknesses, (b) helped to understand and
accept these, (c) given strategies to compensate for cognitive difculties, and (d ) offered
vocational guidance and support. Prigatano
(1994) suggests that such programs appear to
result in less emotional distress, increased selfesteem, and greater productivity. Prigatano
(1999, 2005) and Sohlberg & Mateer (2001)
describe the importance of dealing with the
cognitive, emotional, and psychosocial consequences of brain injury. Wilson et al. (2000)
present a British holistic program, based
on the principles of Ben-Yishay (1978) and
Prigatano (1986), that is followed at the Oliver
Zangwill Center for Neuropsychological Rehabilitation in Ely, Cambridgeshire. Although
these programs appear to be expensive in the
short term, they are probably cost-effective
in the long term (see Prigatano & Pliskin
2002).
Williams (2003), who is concerned with
the rehabilitation of emotional disorders following brain injury, suggests that survivors are
at particular risk of developing mood disorders. He argues that this is one of the key
areas for development in neurological services. Alderman (2003) targets behavior disorders in work with some of the most severely
disturbed brain-injured people in the United
Kingdom.
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Virtual reality
(VR): a technology
that allows a user to
interact with a
computer-simulated
environment
CBT: cognitive
behavior therapy
Traumatic brain
injury (TBI): a
sudden trauma
causing damage to
the brain (also called
head injury)
COGNITIVE ASPECTS OF
NEUROPSYCHOLOGICAL
REHABILITATION
It is worth restating that it is not easy
to separate the cognitive, emotional, and
psychosocial consequences of brain injury.
However, because many of the studies in
the literature report these three components
separately, I examine them individually. Unless the brain damage is very mild, cognitive
decits are almost invariably found in survivors of an insult to the brain. Problems with
memory, attention, executive functioning,
and speed of information processing are the
most typical difculties faced by those who
have sustained traumatic brain injury (TBI).
For survivors of stroke, language problems
are common after left hemisphere damage,
and unilateral neglect is seen frequently
after right hemisphere damage. Numerous
studies have been published on the efcacy of
cognitive rehabilitation, ranging from singlecase experimental designs to randomized
controlled trials (RCTs).
Chesnut et al. (1999) traced 2536 abstracts
from articles on rehabilitation to nd answers
to ve questions, one of which was concerned
with cognitive rehabilitation. This particular
report was based on 363 articles, of which
114 related to cognitive rehabilitation. The
authors asked specically, Does the application of compensatory rehabilitation enhance
www.annualreviews.org Neuropsychological Rehabilitation
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studies that fullled certain inclusion criteria. They looked at several cognitive domains
including attention difculties, visuo-spatial
decits, apraxia, language and communication
problems, memory decits, executive functioning, problem solving, and awareness. On
the issue of retraining versus compensation,
they found that retraining was effective for
some cognitive functions (for example, language), whereas compensation was necessary
for others (such as memory decits). Their
overall conclusion was, There is now a substantial body of evidence demonstrating that
patients with TBI or stroke benet from cognitive rehabilitation (Cicerone et al. 2005,
p. 1689). These authors also state, Future research should move beyond the simple question of whether cognitive rehabilitation is
effective, and examine the therapy factors
and patient characteristics that optimize the
clinical outcomes of cognitive rehabilitation
(p. 1681). Halligan & Wade (2005) provide a
summary of much of the work on the effectiveness of rehabilitation for cognitive decits.
EMOTIONAL ASPECTS OF
NEUROPSYCHOLOGICAL
REHABILITATION
The management and remediation of emotional consequences of brain injury have become increasingly important in recent years.
Prigatano (1999) suggests that rehabilitation
is likely to fail if clinicians do not deal with
the emotional issues. Consequently, an understanding of theories and models of emotion
is crucial to successful rehabilitation. Social
isolation, anxiety, and depression are common in survivors of brain injury. Kopelman &
Crawford (1996) found that 40% of 200 consecutive referrals to a memory clinic were suffering from clinical depression. Bowen et al.
(1998) found that 38% of survivors of TBI
experienced mood disorders. Williams et al.
(2002) found that estimates of the prevalence
of post-traumatic stress disorder (PTSD) following TBI range from 3% to 27%. In
their own study, they found that 18% of 66
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Psychosocial
functioning:
encompasses work,
leisure, and social
relationships;
overlaps with
emotional well-being
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vivid intrusive cognitions and avoidance behaviors (Sbordone & Liter 1995). However,
given that PTSD seems to occur even when
there is a loss of consciousness for the event,
there could be two main mediating mechanisms to suggest how trauma-related material
may be processed to lead to PTSD symptoms.
First, survivors may evoke islands of memory for their trauma, such as being trapped
in a crashed car, or other secondary experiences that could fuel intrusive ruminations
(McMillan 1996). Second, survivors may be
reminded of elements of their trauma event
when exposed to similar situations that serve
to produce intrusive thoughts and fuel avoidance behaviors (Brewin et al. 1996). McNeil
& Greenwood (1996) described a survivor of
TBI who was hyperaroused in, and avoidant
of, situations that were similar to the trauma
event, a road trafc accident, even though
he had no declarative memory of the event.
If an event is unexpected but has biological
signicance and, hence, emotional salience,
McNeil & Greenwood (1996) suggested, it
may lead to the event being stored (or burned
in to memory) despite disruption to areas
of the brain that store declarative memories
(see Markowitsch 1998). Such a view would
be compatible with the concept that PTSD is
caused by a conditioning of fear. The mechanism responsible is one in which traumatic experiences can be processed independently of
higher cortical functions (see Bryant 2001).
Analytic psychotherapy is also used in rehabilitation, particularly in the United States.
Prigatano is perhaps the best-known proponent of psychotherapy treatment of individuals surviving TBI. He describes his approach
(based on the milieu therapy approach of BenYishay) in Principles of Neuropsychological Rehabilitation (Prigatano 1999).
Dealing with the emotional consequences
of brain injury may make the difference between a successful and an unsuccessful outcome. CM, mentioned above, was stabbed
through the head in the right temperoparietal area with a hunting knife while traveling on a train. She was 19 at the time and
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PSYCHOSOCIAL ASPECTS OF
NEUROPSYCHOLOGICAL
REHABILITATION
Considerable overlap exists between psychosocial and emotional difculties. Indeed, one denition of a psychosocial
disorder is a mental illness caused or inuenced by life experiences, as well as maladjusted cognitive and behavioral processes
(www.healthatoz.com). In brain injury rehabilitation, however, the term is more often
used to refer to psychosocial outcomes such as
work, friendships, and community activities.
In other words, psychosocial functioning is
close to participation as dened by the International Classication of Functioning, Disability
and Health (World Health Org. 2001). Wade
(2005) says that the World Health Organization (WHO) framework was developed as
a means of describing the totality that is the
experience of illness (p. 32). The framework
consists of four levels: pathology, impairment,
activity, and participation. Thus, in the case of
a brain-injured person, the pathology might
be damage to the cerebral cortex and the resulting impairment might be a poor memory.
This, in turn, causes limitations to the persons
everyday activities; so, for example, s/he is unable to remember appointments. This problem might affect the extent of participation in
the persons social environment, causing difculties with work, the duties of parenthood, or
the ability to engage in leisure activities. The
WHO model also considers three major contexts inuencing behavior: personal, physical,
and social contexts. Wade (2005) says these
contexts might be considered to affect the
interactions between pathology and impairment, impairment and activities and activities and participation (p. 34). Personal context includes the relevant characteristics of an
individual such as expectations, beliefs, and
attitudes. Physical context refers to the environment in which the individual nds himself or herself, and social context refers to the
culture in which the individual functions. All
these factors contribute to the quality of life
WHO: World
Health Organization
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as experienced by the person with a disability. For the purposes of this review, psychosocial problems are seen as synonymous with the
WHO denition of participation.
Twenty-rst century rehabilitation programs are typically concerned with psychosocial adjustment to disability (Sopena et al.
2007, Yates 2003). Included in this category
are employment or other productive activity, social relationships, and leisure. Some
believe that the psychosocial problems associated with TBI may actually be the major challenge of rehabilitation (Morton & Wehman
1995). Survivors of brain injury face problems of social isolation and decreased leisure
activities, thus creating a renewed dependence on their family members. Karlovits &
McColl (1999) interviewed 11 survivors of severe brain injury to discover impediments to
reintegration into the community. Nine stressors were identied: orientation, transportation, living situation, loss of independence, relationships, loneliness, routine, problems with
studying, and work. Much of the focus of post
acute rehabilitation is on helping people to
return to a productive lifestyle (Petrella et al.
2005). Indeed, the success of NR programs
is often measured by such outcomes. Lack
of productivity, particularly employment, decreases the opportunity for individuals with
brain injury to develop social contacts and
leisure activities, which in turn contributes to
depression and low self-esteem. In contrast,
engagement in paid and nonpaid productive
activities, such as volunteering or homemaking, has a benecial impact on community integration (Petrella et al. 2005).
Return to work is one of the major
goals that clients in brain-injury rehabilitation programs want to achieve. A number
of studies have addressed the issue of returning to work after rehabilitation. Failure
to succeed at work is associated with poor
self-awareness, impaired executive functioning, and poor metacognition (Ownsworth &
Fleming 2005). In a multicenter study, Walker
et al. (2006) found that that those who were
employed prior to the onset of their brain
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understanding the consequences of brain injury, followed by goals connected with work
or study skills (119).
It is clear that rehabilitation for psychosocial difculties is an important part of the care
of survivors of brain injury. Physical difculties are less likely to affect the quality of life
of a brain-injured person than are the cognitive, emotional, and psychosocial sequelae,
so these should be the focus of rehabilitation
programs. In the words of Khan et al. (2003),
Cognitive and behavioral changes, difculties maintaining personal relationships and
coping with school and work are reported by
survivors as more disabling than any residual
physical decits (p. 290).
A collection of papers on biopsychosocial
approaches in neurorehabilitation edited by
Williams & Evans (2003) summarizes much
of the work tackled in this eld.
NeuroPage: a
reminding system
using radio-paging
technology
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els from a number of different areas. Constraint of rehabilitation workers to one model
could lead to poor clinical practice because
important aspects of patients lives could be
neglected.
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Principle No.
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Principle
Begin with the patients subjective or phenomenological experience.
The symptoms presented are a mixture of premorbid cognitive and personality characteristics together
with the neuropsychological changes resulting from the brain pathology.
Neuropsychological rehabilitation focuses on both the remediation of higher cerebral disturbances and
their management in interpersonal situations.
Neuropsychological rehabilitation helps patients observe their behavior to teach them about the direct
and indirect effects of brain injury.
Failure to study the interaction of cognition and personality leads to an inadequate understanding of
many issues.
Little is known about how to retrain cognitive dysfunction, but general guidelines of cognitive
remediation can be specied.
Psychotherapeutic interventions help patients (and families) deal with their personal losses.
Working with patients who have dysfunctional brains produces affective reactions in the patients family
and the rehabilitation staff. Appropriate management of these reactions facilitates adaptation.
Each neuropsychological rehabilitation program is a dynamic entity. The team needs to maintain a
dynamic, creative effort.
Failure to identify those patients who can and cannot be helped creates a lack of credibility.
Disturbances in self-awareness after brain injury are often poorly understood and poorly managed.
Competent patient management and planning depend on understanding mechanisms of recovery and
deterioration.
The rehabilitation of patients with higher cerebral decits requires both scientic and
phenomenological approaches.
Therapeutic
milieu: the
organization of the
environment to
ensure maximum
support to the
process of
adjustment and to
increase social
participation
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cognitive compensation (e.g., using visual imagery to compensate for a defective verbal memory, using a mental routine for managing impulsivity or anger,
and clarifying to ensure effective communication);
external aids (e.g., using a diary for managing memory problems, checklists to
remember exercise routines, alarms to
increase attention to tasks, cue cards for
keeping on track during conversation);
and
environmental adaptationsmodifying
relevant environments in order to reduce cognitive demands (e.g., working
in a quiet, nondistracting room to aid
Wilson
SUMMARY
Following denitions of neuropsychology, rehabilitation, and NR, this review discusses
some of the ways the eld has changed
in recent years. The particular focus is on
(a) goal setting as a way of structuring rehabilitation, (b) the realization that the emotional and psychosocial consequences of brain
injury are as important as the cognitive consequences, (c) the increasing use of technology
in rehabilitation, and (d ) a recognition that
a wide range of theoretical models and approaches is needed to inform the assessment
and treatment of people who have survived
a brain injury. The three main components
of NRcognitive, emotion, and psychosocial functioningare looked at in more detail. Given that how we feel affects how we
think, how we behave, and how we interact
with others, all three functions need to be
addressed in any rehabilitation program. Evidence is provided to show that difculties in
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these areas can be reduced through NR. Because the eld is broad and complex, clinicians
need to be informed by a number of models
and theories to reduce the everyday problems
faced by people who have survived brain injury. Some of the most inuential models and
theoretical approaches used to plan rehabilitation are described, particularly those relevant
to cognitive functioning, emotion, behavior,
and learning. The review concludes with recommendations for good practice in the rehabilitation of people with brain injury.
SUMMARY POINTS
1. Neuropsychological rehabilitation (NR) is concerned with the amelioration of cognitive, emotional, psychosocial, and behavioral decits caused by an insult to the brain.
2. The main purpose of NR is to enable people to return to their own most appropriate
environments; for this reason, meaningful goals should be set in the areas of vocation,
education, recreation, social relationships, and independent living.
3. Although cognitive decits are perhaps the major focus of NR, emotional and psychosocial consequences of brain injury need to be addressed in rehabilitation programs. There is an interaction between these different functions, and it is not always
easy to separate them from one another.
4. Technology is increasingly used to help people compensate for cognitive difculties.
Some technological aids are described and evaluated.
5. NR requires a broad theoretical base and some of the most inuential models and
theories inuencing current practice are described.
6. Evidence is provided to show that NR can reduce difculties in the three main areas
of cognitive, emotional, and psychosocial functioning.
7. Suggested guidelines for good clinical practice are outlined.
DISCLOSURE STATEMENT
The author is not aware of any biases that might be perceived as affecting the objectivity of
this review.
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