How does the treatment and recovery work? - Chapter 5

What is neuropsychological rehabilitation?

After acquired brain injury (ABI) there is always some degree of spontaneous recovery. To what extent can treatment (or neuropsychological rehabilitation) promote recovery? There are many methods that fall within neuropsychological rehabilitation, but it has to be given by a neuropsychologist, and medicinal or medical treatments are not included.

What is important to remember about recovery and plasticity?

Recovery is not the same as a complete return to the level of functioning such as before the brain injury. Recovery is an improvement in cognitive performance compared to the condition during and immediately after the injury.

Recovery after brain injury

Most recovery takes place in the first months after the ABI, and after a year there is hardly any improvement. This is the neurological end state. Behavioral functioning can still improve in the long term, because patients learn to cope better with their limitations. In this context, recovery takes place on a behavioral and psychological level. At the time of the neurological end state, there will be negative and / or positive residual symptoms according to Hughlings-Jackson (1888). Negative symptoms refer to loss of function; Positive symptoms include the patient's attempts to deal with this functional loss (the coping strategy). Goldstein (1942) renamed this dichotomy as direct versus indirect symptoms respectively. The dichotomy in symptoms fits well with the dichotomy of recovery: if the direct symptoms recover, there is recovery at the neurological level, while the indirect symptoms manifest themselves at the behavioral level of recovery. Subsequently, there is also a distinction between approaches to neuropsychological rehabilitation: the restorative approach is mainly focused on achieving recovery at the neurological level, while the compensatory approach tries to promote recovery at the psychological level. The coping strategies and other compensatory methods will also result in changes at brain level in the long term.

Types of plasticity

The developmental stage of the brain is key to plasticity processes. On the one hand, the Kennard principle states that prognosis after brain damage is better at a young age than when this damage is sustained later in life. On the other hand, there is the double hazard hypothesis that younger children with contracted brain injury have the worst prognosis. Many underestimate the severity of the impact if the brain injury develops early in life, because children often experience the real nature of their defects later in life (partly because the executive functions are not fully grown until around the fourteenth year). For example, indicators for dyslexia are already present at brain level, but this is only noticed once the child learns to read. This is called 'growing into deficit'.

Neural plasticity

Neural plasticity affects the entire brain and is a continuous and lifelong process in which all learning experiences create new connections or strengthen old ones. An experienced taxi driver, who needs a lot of spatial insight because he constantly has to drive new routes, has more volume of gray matter in the hippocampal areas than bus drivers who only drive fixed routes. The years of driving experience correlated with the hippocampal changes. Learning new spatial skills seems to be at the expense of this positive adaptation (Maguire, Woollett & Spiers, 2006). Learning complex tasks influences the plasticity of the brain: experienced piano players have a larger dendritic network in motor, auditory and visual-spatial areas of the brain (Gaser & Schlaug, 2003). Even without active interventions, the brain shows plasticity. This is mainly noticeable in the spontaneous recovery. The most likely explanatory hypothesis is restitutive reconnection. This hypothesis suggests that neurons in areas adjacent to the damaged area quickly create new neural connections in order to replace lost connections. Kolb (1995) suggested that this restitutive reconnection is possible when there is a minor injury, but for serious injuries the recovery is mainly achieved at the behavioral and psychological level (Robertson and Murre (1999) state the same as Kolb).

How can plasticity be stimulated?

According to Robertson and Murre (1999), different types of focused stimulation are the most effective way of stimulating the plasticity of the brain after brain injury. An example of this is bottom-up stimulation, in which external stimuli are administered in an attempt to stimulate the formation of new neural connections. The goal is that new neural connections will be made, which is in line with the idea of ​​''cells that wire together, fire together". Unfortunately, little research has been done into the stimulation of neuroplasticity. 

What is learning?

Rehabilitation is (re)learning. The purpose of a learning process is a relatively permanent change in behaviour that is the result of experience. To achieve this goal, frequent and correct associations must be made between the triggering factor (the stimulus) and the desired behavior (the response). According to Shiffrin and Schneider (1977), if the triggering factor and the behavior occur repeatedly in the same combination, the strong connection is made. This is called "consistent mapping". When multiple responses are triggered by the same stimulus, there is no learning outcome. This is called "varied mapping". Mulder (1992) talks about the importance of direct verbal feedback on the learning process, such as “knowledge of results” (KR): to what extent has the learning objective been achieved and how can it be done more efficiently, or how is the object achieved? "State-dependent learning" means that learned behavior is applied more easily if the situation in which the behavior is desired shows strong similarities with the situation in which this behavior is learned. In this case, there must be a transfer from one situation to another, or (more preferably) a generalization of the learned behavior to all other situations in which this behavior is desired. Learning behavior must therefore be anchored as much as possible, but independent of the specific context. There are two ways to stimulate the transfer to a different context. The first is "variability of practice" (VP): variations can be made to the learning context early in the learning process. The second is "linkage to the site of application" (LA): during the learning process, learning behavior in the learning phase is already related to the target situation in which that behavior is desired.

The ICIDH model

The Internal Classification of Impairments, Disabilities and Handicaps (ICIDH) model is a WHO classificated system that dates back to 1980 and subdivides the behavioral consequences of illness and injury into three different levels: impairments, disabilities, and handicaps. Disabilities are the consequences of impairments at a personal level. They relate to all the activities that can be carried out by a person and that can be affected by the impairment. A handicap refers to an adverse effect on societal functioning as a result of an impairment and a disability; it is a restriction that hinders the patient's normal role fulfilment. In 2001 the successor of the ICIDH was introduced, namely the ICF. The main difference is that the ICF model is based on overall health (as opposed to only illness and / or injury) and there is also room to describe the consequences of an illness and / or injury in positive terms. The ICF describes functioning in terms of body functions, activities and participation, and both environmental and personal factors can be mapped.

Neuropsychological intervention.

Gross and Schutz (1986) distinguish different levels of learning ability. These different levels are:

1. The level of learning ability.

2. Influencing behaviour using conditioning.

3. Skill training.

4. Strategy training.

The degree of learnability is mainly dependent on the extent to which the executive functions are intact and the patient's insight into the disorder and its consequences (the latter determines the motivation). Below is an overview of the relationship between five training options and four possible effects. At the first level, the environment is adjusted and the patient's learning capacity is nil.

Example: marking the route from the bedroom to the toilet with red dots on the floor. SR conditioning is equal to stimulus-response conditioning. Here, instrumental conditioning is used (making a link between a stimulus and a response) or operant conditioning (influencing the frequency of the desired behavior by means of reinforcement or punishment). A behavioral routine is taught. On the third level, situation-based behavioral routines and activities are trained that consist of several actions. Compensation strategies are only taught at the fourth level. Here a considerable input from the individual is required and the external structure is less important. A cognitive cycle is used at the highest and fourth levels: the patient can set realistic learning objectives, make plans and execute and provide feedback.

What is neuropsychological rehabilitation?

The difference between the recovery model and the compensatory model

First, the recovery model was the most popular model, based on training aimed at repairing the damage in cognitive function and the underlying brain structure. Lashley, Goldstein and Luria are well-known names. In the first place, it was thought that the effect of targeted training would be generalizable. The compensatory model, on the other hand, assumes that neural damage is irreversible; does the treatment not only focus on the individual but also on the environment (as long as it benefits the patient), and; treatment does not focus on the disorder itself but on the consequences in daily life and improving functioning at participation level and activity level.

Job training?

Every training within the recovery model is a functional training. During a function training the patient must continuously perform the same task. This is called the 'repeated practice approach'. This method is also used to train damaged muscles. For this reason, it is also called the 'mental muscle approach'. Other names for the same type of training are: cognitive retraining, 'mental bodybuilding', brain gymnastics, 'drill and practice' and ''stimulation training''. However, the training should have an effect on the underlying brain function. This is not apparent from the task-specific results. Cicerone and colleagues (2005) stated that there is no effective treatment within the restorative approach yet.

Compensatory treatments

There is a lot of supporting evidence for treatment methods that fall within the compensatory treatment. Skill training is a compensatory method that trains situation-related skills: just as with functional training, one action is trained each time but the underlying purpose of both forms is completely different. If a patient has sufficient executive capacities, a top-down approach can be chosen: the strategy training (such as “coping with time pressure”). The patient has to perform a number of steps or ask himself a number of questions in a situation (such as "preparing a meal").

Further intervention options

In psychoeducation, the patient is provided with explanations and information about the consequences of the brain injury in general, as well as the consequences for that particular patient. The latter is based on the strength-weakness analysis of the patient's functioning. This analysis is achieved using neuropsychological assessment. Because of psychoeducation the patient is somewhat reassured about the 'normal' consequences of the brain injury and the patient gains (more) insight into his limitations (the motivation for the treatment can be increased by this). Environmental modifications are the changes that have to be made to the physical and social environment so that the patient is provided with structure to enable them to function as well as possible with their disability. Finally, neuropsychotherapy is also part of a neuropsychological treatment. This therapy is aimed at the specific emotional and psychosocial problems of patients with brain injury. Sometimes this also includes behavioural modification. This means that unwanted behavior is extinguished and desired behavior is promoted.