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University of Toronto Scarborough
Kris Romero

Neuropsych rehabilitation, by Wilson  Introduction: What is neruopsych rehab? - pts tend to have both cognitive and non-cognitive problems, behavioral, social and sometimes emotional problems - neuropsych: the study of the relationship btwn brain and behavior - major diff btwn academic and clinical neuropsychs is the manner in which the needs of brain injured ppl are determined. Academic neuropsychs- believe that detailed assessments inform by theoretical models highlight areas that require rehab. Clinical neuropsychs- they don’t care about theories but rather target real life problems identified by pts and family -Neuropsych Rehabiliation: a 2 way interactive process wherby ppl who are disabled by injury or disease wrk together w/professional staff, family, and community to achieve their optimal physical, psych, social and vocational well being. - In the past the rehab staff determined wat areas to wrk on, what goals to set, and what was/wasn’t achievable. Where as today, clients/families are asked about their expectations, and rehab goals are discussed & negotiated btwn all parties involved. This will prob increase motivation, since they are working on real life problems How has neuropsych rehab changed in recent years? - NR today is alot similar to the way that soldiers in Germany during WWI and WWII where they stressed cognitive and personality deficits following TBI, today called as cognitive rehab strategies. - an ongoing debate is whether to try to restore lost functioning or compensate for lost/impaired functions - functional adaptation: intact skill is used to compensate for a damaged one - 3 main approaches to rehab: compensation, substitution, & direct re-training ----4 major changes: 1.) Goal setting to plan rehab programs- - goal: state or change in state that is hoped or intended for an intervention or course of action to achieve. Serve as regulators and motivators of human performance/action - involves... i. Negotiation with pts, family and rehab team. The goal shud be something the pt wants to do. TAILORED to individual needs, thus client centered ii. Long term with short term goal that proceed toward it and focuses on real world problems. Long term goals are expected to be achieved by the time of discharge iii. Progress shud be able to be measured iv. Simple-focuses on practical everyday problems - this approach provides direction for rehab, identifies priorities for intervention, evaluates progress, breaks rehab into small steps, promotes team wrk, and results in better outcomes. The method to achieve the goals is written in a way that everyone can read it. --SOME PRINCIPLES OF GOAL PLANNING: SMART- specific, measurable, achievable, realistic, & timely - a chairperson is allocated, they role is... i. Conduct meetings and limits it to the agreed upon time ii. Clarifies the aims of admission and length of stay. iii. Does documentation iv. Part of rehab team v. Good communicator, attends case conferences, coordinate reports, encourage clients/relatives/staff to be realistic, argues if discharge date needs to be changed. - after a detailed assessment, a problem list is made and long term goals are identified. The goals are then discussed with the client/family, negotiated, document, if necessary a copy is given to the client/family, progress is reviewed every 1-2 weeks in a 30 min meeting w/the rehab team. - if short or long term goals are not achieved, they are recorded and attributed to ¼ reasons: client or carer, staff member, internal administration (transportation failed), or external administration (funding). - goal setting is a main component in emotional and cognitive disorders 2.) Cognitive, emotional, and psychosocial difficulties shud all be addressed in rehab - emotional and psychosocial problems also influence the effectivess of a rehab program. Since emotion can affect cognition, behavior and exacerbate emotional distress. - holistic programs include group & individual therapy in which pts are: encouraged to be more aware of their strengths/weakness, helped to understand/accept them, taught strategies to compensate for cognitive difficulties, and offered vocational guidance and support. These lead to less emotional distress, increased self esteem, and greater productivity. - these programs are expensive in the short term but pay off in the long run. Survivors of brain injury are at risk of developing mood disorders 3.) Technology use shud be increased to compensate for cognitive difficulties: - tech reduces everyday problems of ppl w/neuro damage especially ones with cognitive impairments. Ex/ computers can be used as cognitive prosthetics, compensatory devices, assessment tools or training. - ex 2/ paging system for ppl with memory/planning difficulties. For ppl w/ executive deficits (poor planning, divided attention) content free reminder wrk. But this doesn’t wrk for ppl w/severe memory problems as they need specific reminders. - virtual reminders (VS): used to stimulate real life situations, thus good for assessment/treatment 4.) NR requires a broad theoretical base: - a single framework doesn’t wrk becaz a person life is more complex. - 4 main theories of rehab: cognitive functioning, emotion, behavior and learning. - CBT is the most carefully worked out and clinically useful models of emotion - ethical and effective NR requires a synthesis and integration of several frameworks, theories, and methodologies to achieve its aims and ensure the best clinical practice. Cognitive aspects of neuropsych rehab: - its not easy to separate the cognitive, emotional and psychosocial consequences of BI - some common cognitive deficits include memory, attention, executive functioning, and speed of processing info - for stroke pts language problems are common for LH damange, unilateral neglect for RH damage - RCTs didn’t in general reveal much about the effectiveness of cognitive rehab in general. - the outcome of cognitive rehab is improvement in daily functioning but many studies use intermediate measures (tests) however this doesn’t predict improvement in real life function. - ultimate goal or rehab: enable ppl w/disabilities to function as adequately as possible in their most appropriate environment. - some studies address real life issues. Ex/ paging use: target behaviors improved sig., after giving their pagers back behavior dropped but was still higher than baseline, suggesting learning of target behaviors had taken place during the pager phase - Retraining is effective for language deficits while compensation was effective for memory deficits. Further research needs to be done to determine which therapy factors/pt characteristics optimize clinical outcomes of cog rehab Emotional aspects of neuropsych rehab: rehab is likely to fail if emotional issues aren’t dealt with. - some emotional issues are PTSD, social isolation, anxiety, and depression. --- Gainotti identified 3 main factors causing emotional/psychosocial problems after TBI: 1. Neurological factors: brain stem damage leading to catastrophic reaction (rapid swings of laughter and tears), or anosognosia (unawareness of ones deficits, mostly due to organic impairment) 2. Psychological or psychodynamic factors: includes personal attitudes toward disability. Ex/ acquired dyslexia which causes loss of self esteem and depression.Also denial (pts are aware of their disorder but cant accept it). - PTSD: fe
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