Cognitive Rehabilitation of Memory

A Clinical-Neuropsychological Introduction

Helmut Hildebrandt

• Publisher: Academic Press
• Year: 2019
• ISBN:
  9780128169827
• Topic: Psychology
• Subtopic: Neuropsychology
• Index: Psychology

Cognitive Rehabilitation of Memory: A Clinical-Neuropsychological Introduction comprehensively reviews evidence-based research for each clinical tool, defining guidelines on how to assess patients and set treatment goals and best practices for creating individualized rehabilitation programs. The book also provides essential background knowledge on the nature and causes of memory impairment. Dr. Helmut Hildebrandt describes a wide range of interventions, including memory aids, learning strategies and non-cognitive treatment options

• Outlines guidelines for treating patients with memory disorder
• Reviews rehabilitation programs to improve memory function
• Examines non-cognitive approaches for improving memory impairments

Chapter I

Evidence-Based Medicine in Rehabilitation Research

Abstract

The chapter starts with a discussion of which goals can be formulated in neurorehabilitation and distinguishes between restitution and compensation of impaired functions. The choice of a specific intervention to achieve one of these two goals must be based on a scientific rationale. During the past two decades, the concept of evidence-based medicine (EBM) was extremely successful in providing scientific justifications for choosing between interventions. EBM argues for the importance of basing any health intervention on a sound scientific foundation and promotes three steps to achieve this aim: The first step establishes double-blinded randomized controlled trials (RCTs) as the gold standard for proving the efficacy of any intervention. The second step involves a rigorous reviewing process to evaluate the results of intervention studies. The final step is to develop guidelines to help professionals stay informed about the newest scientific knowledge. Moreover, EBM focuses on establishing which type of evidence (experimental, clinical, and economical) is the most relevant for health care interventions. The chapter discusses the meaning and the problems of EBM in neurorehabilitation and especially in memory rehabilitation. It informs about the problems of defining outcome parameters in memory rehabilitation. There is a discussion of the reasons why RCT are so important for offering high-level information about the efficacy of interventions, as well as why it is hard to design and conduct RCTs in neurorehabilitation. One problem in this respect is that in neurorehabilitation a triple blinding is necessary (and only achievable with great difficulty). Furthermore, placebo treatments are difficult to design. The chapter then introduces the concept of risk and offers information about calculating the necessary number of cases to conduct clinical studies. In a last step, the method of single-case experimental design (SCED) is introduced. This method is well suited to show treatment effects in rare diseases or in rare clinical syndromes, where randomization will not work. SCED was a dominant research strategy in neuropsychology during the 1990s. Although it is now clear that neuropsychological rehabilitation should strive to involve RCTs, there are some recent developments in the context of SCEDs that strengthen the methodology and make it a valuable alternative for specific symptom complexes.

Keywords

Goal setting in neurorehabilitation; Evidence-based medicine; Levels of evidence; Outcome measure in memory rehabilitation; Randomized controlled trials; Single case experimental design; Doubling blinding in rehabilitation research; Statistical evaluation of treatment effects; Power calculation

1 Introduction

Neuropsychological rehabilitation is a part of neurological rehabilitation; the discipline of helping patients with acquired brain damage cope with the short- and long-term consequences of their disease. The definition and goals of neuropsychological rehabilitation are therefore included in a definition of neurological rehabilitation. The question thus becomes: How is neurological rehabilitation defined? On a very global level, one can define it as successful attempt to improve independence in daily life, the ability to work, and the ability to attain satisfying interpersonal relationships in patients that suffer from enduring consequences of organic brain damage. Being focused on the goal of neurological rehabilitation, this definition is not specific enough to distinguish it from other medical and health interventions. For example, treating patients with antiepileptic drugs also has the goal of helping patients cope with the consequences of organic brain damage and to increase their independence. Therefore, the definition above must be complemented by a specification of the methods of neurological rehabilitation that clearly differ from other attempts in health care. In contrast to medical interventions, neurological rehabilitation uses specific training schedules, introduction of external aids, and environmental restructuring as treatments. Pharmacological, surgical, and injection-based methods are used in rehabilitation, but only as an additional, accompanying, and endorsing treatment (not as an essential method). Rehabilitation may be defined as a learning process of lost functions, or as an external and internal adaptation to a temporary or chronic impairment due to damage of the nervous system.

Two aspects of this definition of neurorehabilitation should be discussed a little bit further before moving on to its more specific goal settings. First, neurorehabilitation shares a common mechanism with psychotherapy, i.e., learning. One may argue that the difference between behavioral therapy and neurorehabilitation is the etiology of maladaptation: Classical behavioral therapy concerns functionally acquired maladaptive behavior, or behavior that relies on problematic reinforcing schedules of the environment, or on problematic cognitive frames for interpersonal relationships. Neurorehabilitation concerns somatically acquire maladaptive behavior due to the loss of a motor, sensory, or cognitive ability.

Although there is clearly a parallel between behavioral therapy and neurorehabilitation, there are also some fundamental differences. The first difference is that most of the impairments do not concern the behavioral intentions of the patients, but rather their poor performance in specific cognitive processes. The treatment is focused to enhance and speed up relearning. The correction of maladaptive behavior is only a secondary aspect, which comes into play if the patients choose solutions that are not optimal or even limiting. The second difference is that patients in neurorehabilitation do not feel like patients in psychotherapy: They suffer from an often acute and significant disease that causes the (often focal) impairment. They must live with that impairment and try to improve their functioning without a long period of experience with it and without any clear prognosis of its development. In psychotherapy, the patients suffer due to a combination of internal and environmental factors, but this suffering often has a long history. Patients with neuropsychological impairment may also despair and need psychotherapy, but this is of comparatively smaller concern and is more often present or urgent during the chronic phase, i.e., at a time point where no further recovery of the impaired functions are expected.

The second aspect of the definition of neurorehabilitation that should be made more explicit is that attempting to achieve a maximum level of independence for the patient through neurorehabilitation may lead to a profound conflict between the professionals and the patients. Many patients find solutions for adapting to their impairment and handicap that are suboptimal. These solutions may rely on the help offered by relatives or nurses. They may also imply a restriction in mobility or in working abilities (early retirement, etc.). As defined above, neurorehabilitation is not focused directly on the quality of life of the patients, but instead on their maximal independence. One may argue that attaining the highest degree of independence is a prerequisite to reach the highest quality of life. Obviously, that would be a philosophical statement, and not always true for every patient. In the process of offering neurorehabilitation, it is often the case that patients are exhausted and refrain from additional efforts in training, despite the assertion of therapists that additional progress can be made. The opposite may also be the case: Patients might ask for more and specific training sessions without making further progress. Following the definition for neurorehabilitation as provided above will lead to actions that may “harm” the quality of life of the patients. In this respect, neurorehabilitation does not differ from other medical interventions: The goal is more to help the patients live independently and less to increase their happiness (but each therapist would be happy to do so. As it relies on learning processes, neurorehabilitation is only possible in cooperation with the patient). Consequently, goal setting and timing of rehabilitative effort must be legitimized, because it is the patient and his or her relatives that must be convinced of the reasons leading to the ultimate decision.

2 Strategies of Neurorehabilitation: Restitution and Compensation

The ultimate goal of neurorehabilitation is the recovery of the patient in all his or her abilities and the attainment of a high quality of life. This should happen as cost effectively as possible. In scientific terms this goal is called restitution. Restitution after acquired brain damage implies either the possibility of regeneration of nervous tissue or the ...