Neuropsych rehabilitation, by Wilson
Introduction: What is neruopsych rehab?
- pts tend to have both cognitive and non-cognitive problems, behavioral, social and sometimes emotional
- 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
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, &
- 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
- 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
- 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
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