Rehabilitation of Neuropsychological Disorders

A Practical Guide for Rehabilitation Professionals

Brick Johnstone, Henry H. Stonnington, Brick Johnstone, Henry H. Stonnington

• Publisher: Psychology Press
• Year: 2011
• Print ISBN: 9781848728004
• eBook ISBN: 9781136874024
• Topic: Psychology
• Subtopic: Cognitive Neuroscience & Neuropsychology
• Index: Psychology

Many contemporary neuropsychology texts focus on neuropathology, the description of specific tests, and the differential diagnosis of central nervous system disorders. However, increasingly sophisticated neuroradiological techniques, managed care factors, and the growth of rehabilitation necessitates that rehabilitation professionals provide more functionally (versus diagnostically) useful evaluations to improve the neuropsychological functioning and community integration of persons with brain injuries or diseases. This book aims to fill this gap and to provide an overview of standard neuropsychological treatment strategies for specific cognitive impairments that are identified on testing. The new edition enhances this goal with three chapters outlining important recommendations, services, and issues for rehabilitation professionals.

Written by a team of experienced scientists and professionals, the volume provides a universal taxonomy of neuropsychological abilities (emphasizing relatively simple terms), with a list of basic rehabilitation strategies to improve impairments identified in general cognitive domains. Specific chapters are included on the neuropsychological remediation of memory, attention, language, visual-spatial skills, and executive function impairments. Each chapter proposes a taxonomy of relatively unitary cognitive constructs (e.g., divided attention, sustained attention, focused attention), lists tests which may be used to assess each cognitive construct, and provides specific rehabilitation strategies to improve or accommodate the identified neuropsychological impairments. The final chapters cover basic resources and issues of which the rehabilitation professional needs to be aware (vocational rehabilitation, disability determination, and guardianship issues).

This new edition provides a wealth of useful information for family members, rehabilitation professionals, and others who work with persons with brain injury in improving the community functioning for those with brain dysfunction. An accompanying website facilitates access to the resources and strategies from the book, allowing the practitioner to cut and paste these recommendations into their clinical reports.

1

Introduction

BRICK JOHNSTONE and HENRY H. STONNINGTON

CONTENTS

Neuropsychological Assessment in Rehabilitation

History of Neuropsychological Rehabilitation

Origins of Neuropsychology

Issues in Neuropsychology Training Guidelines

The Evolution of Neuropsychological Rehabilitation

Advanced Neuroradiologic Techniques

Managed Care

The Growth of Rehabilitation

Future Needs in Neuropsychological Rehabilitation

Suggested Solutions

References

Knowledge regarding the specific nature of brain structures and functions has significantly increased over the past century. One only has to review the case of Phineas Gage, the unfortunate individual who had a railroad tamping rod explode through his skull and left frontal lobe in 1848, to understand how much progress has been made (Barker, 1995). Back then, little was known about how the brain specifically controls cognition, affect, and behavior, and Gage’s contemporaries did not know what to make of the changes in his personality and demeanor, let alone what to do about them. Interest in brain functioning has increased so much that the 1990s were designated as the decade of the brain, and even laypeople’s interest in and knowledge of brain functioning increased based on popular readings such as Oliver Sacks’ (1986) The Man Who Mistook His Wife for a Hat.However,although significant strides have been made in the development of tests to assess brain functions, there is still the need to develop effective treatment interventions to improve specific neuropsychological impairments and, ultimately, the lives of persons with brain dysfunction.

It is universally understood that the brain is responsible for individual characteristics and that it specifically controls:

• Intellect and thinking skills (e.g., memory, attention, reasoning)

• Personality (e.g., identity, demeanor, sense of humor, uniqueness)

• Emotions (e.g., depression, anxiety, euphoria)

• Behaviors (e.g., traits, habits)

• Communication (e.g., ability to express oneself, understand others)

• Social skills (e.g., ability to read social cues, interact with others)

• Motor abilities (e.g., ability to control gross and fine motor movements)

• Sensory-perceptual abilities (e.g., ability to taste, see, hear, feel, and smell)

These brain-based abilities and traits are constantly affected by both environmental and physiological factors from childhood through old age. For example, the brain is constantly changing, as evidenced by the hierarchal development of cognitive skills in children (for example, concrete to abstract reasoning, the development of reading and academic abilities, or learning how to socialize with other children) to the decline of cognitive (such as forgetfulness) and physical abilities (such as vision, hearing, and motor skills) in old age. Furthermore, the brain is made of millions of neurons and glial cells in complicated neural networks that still are not fully understood. Injuries to any of these neurons or networks can affect a multitude of skills. Neuropsychological abilities (that is, cognitive, behavioral, and emotional abilities) are controlled by many factors, including brain structures (such as cortical tissue, blood vessels, and protective membranes), electrical impulses, neurotransmitters and chemicals, protective and nourishing fluids (such as cerebral spinal fluid or blood), and other homeostatic functions that regulate and maintain specific brain abilities (for example, intracranial pressure). Obviously, the brain is a very complicated organ and its many functions can be affected by many factors.

It is difficult to understand what “normal” brain functioning is until one has the chance to observe abnormal brain functioning, such as that evidenced by Phineas Gage following his brain injury. Most individuals take their brain for granted, not appreciating its role in defining one’s personality and controlling one’s abilities until after the brain is injured or develops a debilitating disease. For example, many individuals who suffer brain injuries or diseases (strokes, Alzheimer’s or Parkinson’s dementia, tumors, epilepsy, multiple sclerosis, sleep apnea, toxin exposure, or connective tissue diseases such as lupus, for example) have difficulties understanding why they can no longer express simple thoughts, move the left side of their body, remember routine things, control their emotions, or suppress their frustrations. Consequently, it is the role of rehabilitation professionals to assist individuals with brain injuries and diseases to understand how their injury or disease has affected them, what they can expect in the future, and most importantly, what they and their families can do in order to compensate for the impairments and return to productive roles at home and in the community.

Because the brain is such a complicated organ and because nobody is exactly the same, rehabilitation professionals have had difficulties agreeing upon standard ways in which to describe, measure, and treat brain dysfunction. All rehabilitation professions (physiatrists, psychologists, speech pathologists, occupational and physical therapists, nurses, physicians, and so forth) participate at some level in the evaluation and treatment of neuropsychological impairments; unfortunately, none use the same language to describe impairments or administer similar tests to quantify these deficits. Indeed, the Association of Schools of Allied Health Professions (2000), in suggesting a national research agenda for health professionals, reported that there was a major need to improve cross-disciplinary communications by developing clear, common, standardized definitions across disciplines. In addition to this lack of a common taxonomy in neuropsychological rehabilitation, there are very few standard treatment strategies that have been developed for consistent use for even the most basic of neuropsychological impairments (for example, the use of a notebook for memory impairments). Several panels of expert rehabilitation professionals have stated that standard neuropsychological remediation strategies must be developed and validated, although efforts to date have been poorly coordinated and relatively limited (Rehabilitation of Persons with Traumatic Brain Injury, 1998; Association of Schools of Allied Health Professions, 2000).

It may be most important for rehabilitation professionals to develop relatively uniform procedures given the increasing number of nonrehabilitation professionals who are being asked to participate in the rehabilitation of persons with brain dysfunction. Due to financial factors, individuals with brain dysfunction are being discharged from hospitals sooner than before, which necessitates that their family members and significant others learn strategies to help people with brain dysfunction return home. In addition, employers, coworkers, and teachers are being asked to assist in implementing rehabilitation strategies so that the affected individual can successfully return to work, school, and other community activities, which in turn leads to greater self-worth, community involvement, and financial independence. Furthermore, numerous other professions (for example, vocational rehabilitation counselors, attorneys, physiatrists, judges, clergy, insurance agents, health and public policy administrators, legislators) use information from neuropsychological evaluations to help their clients cope with their disabilities or to make decisions (vocational, educational, legal, and so forth) about how brain injuries and diseases impact their clients’ abilities to function in the community.

With these factors in mind, we have attempted to develop a book that proposes a universal taxonomy of neuropsychological abilities (employing relatively simple terms) and emphasizes basic strategies that can be used by rehabilitation professionals and laypeople alike to assist those with neuropsychological impairments to accentuate their strengths and accommodate their weaknesses. It is acknowledged that comprehensive inpatient and outpatient neuropsychological rehabilitation programs can provide the most coordinated, intensive strategies to improve the functioning of those with traumatic brain injury (TBI). However, for those with brain injuries who do not have the resources or who do not have severe enough impairments to attend such programs, we argue that more simple strategies must be developed for use by all.

NEUROPSYCHOLOGICAL ASSESSMENT IN REHABILITATION

The past two decades have seen significant changes in the delivery of health care in the United States. With the growth of managed care, all health care disciplines have been forced to improve the efficiency of their evaluation methods and treatment interventions, as well as to demonstrate the practical utility of their services. In neuropsychological rehabilitation, no longer is it possible for psychologists, speech-language pathologists, occupational therapists, or learning skill specialists to evaluate patients and solely describe test results that may have no or limited relationship to real-world functioning. Similarly, due to advances in neuroradiological techniques, tests of neuropsychological abilities are no longer needed to infer structural or physiological impairments in brain functioning. Rather, rehabilitation professionals need to offer services that provide practical recommendations for ways to accommodate impairments for those with brain dysfunction, their families, and other rehabilitation professionals. In the future, it will be those professions and specialties that best adapt to meeting the needs of those individuals with neuropsychological impairment who will be the most successful.

Although managed care is forcing all rehabilitation disciplines to become more efficient, improvements in the remediation of specific cognitive deficits have been slow to develop (Cicerone, 1997; Parente & Stapleton, 1997). For example, several articles (Carney et al., 1999; Rehabilitation of Persons with Traumatic Brain Injury, 1998) suggest that neuropsychological rehabilitation probably works and is worthy of continued clinical application, although it is also clear that much improvement needs to be made in the manner in which cognitive impairments are both evaluated and treated. Numerous books have been published on the assessment of various types of brain injury and disease, but most focus on describing the neuroanatomical and neuropathological conditions of brain disorders and their associated neuropsychological impairments, and those tests that can be used to evaluate the impairments (see, for example, Lezak, Howieson, & Loring, 2004). Even those books that purportedly have an emphasis on the rehabilitation of cognitive disorders can be argued to emphasize brain functions and tests, with minimal suggestions for remediation and compensatory strategies (see, for example, Rosenthal, Griffith, Kreutzer, & Pentland, 1999; Prigatano, 1999). Unfortunately, there are very few books in neuropsychology, rehabilitation psychology, or cognitive rehabilitation that specifically present methods by which to compensate for impairments (see, among others, Sohlberg & Mateer, 1989). However, in the future, and in order to be most helpful to those with brain dysfunction and their families, rehabilitation professionals must develop more uniform methods to evaluate cognitive impairments as well as relatively simple strategies to improve identified impairments.

Specifically, the field of neuropsychological rehabilitation is in need of a book that proposes a universal taxonomy of cognitive domains to be assessed in rehabilitation, as well as a list of strategies by which to compensate for identified impairments. It is also essential that strategies be presented in simple terms that are understandable to all rehabilitation professionals, individuals with brain dysfunction, and their families, so that these strategies can be used in community settings. It is our hope that this book can meet these needs by (1) reviewing the history of the evaluation and treatment of neuropsychological disorders and presenting arguments for why neuropsychological rehabilitation must evolve; (2) proposing a common language of cognitive abilities to be used by all rehabilitation professionals, based on relatively unitary cognitive constructs; and (3) providing lists of relatively simple strategies to compensate for identified impairments in distinct cognitive domains.

HISTORY OF NEUROPSYCHOLOGICAL REHABILITATION

The history and future of neuropsychological rehabilitation has been succinctly described by several well-known contributors to the field (Boake, 1991; Cicerone, 1997; Parente & Stapleton, 1997). Boake (1991) reviews the development of cognitive rehabilitation primarily from the early 1900s until the present, suggesting that such practices developed based on the needs of the population at that time. Specifically, following wars in the first half of the 20th century, rehabilitation professionals in Germany...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• Preface to the First Edition
• Preface to the Second Edition
• Editors
• Contributors
• 1 Introduction
• 2 The Assessment and Rehabilitation of Attention Disorders
• 3 The Assessment and Rehabilitation of Memory Impairments
• 4 The Assessment and Rehabilitation of Executive Function Disorders
• 5 The Assessment and Rehabilitation of Visual-Spatial Disorders
• 6 The Assessment and Rehabilitation of Language Disorders
• 7 State Vocational Rehabilitation Programs
• 8 Disability Determinations
• 9 Resources for Individuals With Neuropsychological Disorders
• 10 Understanding Guardianship Issues: An Overview for Rehabilitation Professionals
• Glossary
• Author Index
• Subject Index