Brain Insult Neuropsychological Rehabilitation
Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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Epidemiology of stroke in Germany
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Incidence (new cases in a year) • 300-400 per 100,000 inhabitants in a year • it means 240 000 – 320 000 new cases in a year Prevalence (number of patients) • 800 per 100 000 inhabitants • approximately 640 000 patients in Germany Mortality (number of death in a year) • 100 per 100 000 inhabitants
Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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Epidemiology of stroke in Germany
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The prospective study involved 101.450 inhabitants The incidence of: • the cerebral hemorrhage (Apoplexy):
137 per 100 000
• The intra-cerebral hemorrhage :
24 per 100 000
• The subarachnoidal hemorrhage :
6 per 100 000
Age justified incidence of brain apoplexy : • 182 per 100 000 inhabitants • (200 / 100000 male & 170 / 100000 female) Source: Center for Public Health of University Erlangen-Nürnberg, Germany, 2005
Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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Epidemiology of stroke in the world
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Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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Epidemiology of stroke in the world
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Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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Prognosis (German Stroke database)
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Follow-up after 90 Days 0.147 0.572
0.186
0.094
died heavy impairments middle impairments moderate impairments Grau A.J. et al. Stroke 2001:32:2559-2566
Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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Brain Insult - Neuropsychological Rehabilitation
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Prof.M.Lezak: “Traumatic brain injury is a family affair ”
cognitive + personality + emotional deficits represent the most devastating longtime problems faced by patients and their families
Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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Outline for the future ?
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advances in neuroscience research
+
improvements in emergency/ trauma services
+
The Center for Disease Control :
=
“...approximately 5.3 million individuals live with disabilities ”
advances in acute medical management
Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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What happens with the survivors? spontaneous restitution TBI
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spontaneous restitution CVI
verbale Intelligenz
non-verbale Intelligenz
Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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“Cognitive impairment” - What does it mean ? What did you say ?
Damned left side!
Magic objects !
Globale Aphasie
Konstruktive Apraxie
Ideomotorische Apraxie
In the scaphandre !
Locked-In-Syndrome
Quarling brothers !
Alien-Hand-Syndrome
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Pushed world !
Neglect
The wold withou forms !
Konstruktive Apraxie
Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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What are their problems ?
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Prosiegel, 1991
Attention
80%
Prosiegel, 1991
Memory
65%
Schuri, 1988
Memory
60%
DeRenzi, 1992
Aphasia
30-70%
Hartje & Sturm, 1992
Space orientation 30-40%
Kerkhoff et al., 1992
Visus deficits
20-30%
Prosiegel&Säring, 1988
Apraxia
20-80%
Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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Deficits ? ATTENTION DISORDERS
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~ 80 %
Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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Deficits ? MEMORY DISORDERS
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60%-70%
Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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Deficits ?
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SPEECH & COMMUNICATION DISORDERS 30-70%
RED, BLUE, GREEN =
RET, PLOO, KREEN
LOCKED-IN SYNDROME Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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Deficits ?
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MOTIVATION, DRIVE, PERSONALITY, PROBLEM-SOLVING, DECISION-MAKING
• Programming, regulation and verification of activity (Luria 1966) • Goal formulation, planning, and carrying out goal-directed plans effectively (Lezak 1983) • Problem-solving behaviour, trying out hypotheses and learning from failed attempts (Shallice 1988) • May be able to work along routine lines, but have difficulties in new situations (Baddeley and Wilson 1988) Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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Treatment of deficits WHAT TO DO ?
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Assessment and Rehabilitation (of specific functions)
HOW TO DO ?
• Adequate stimulation • Acute/early rehabilitation
• family consultations • behavior modification • social functioning training • vocational rehabilitation • & others... Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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REHABILITATION -What does it mean ?
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A definition of cognitive rehabilitation (Official statement by the US National Academy of Neuropsychology, May 2002)
“..activities, based on an
assessment and understanding of the person’s brain-behavior deficits.”
“Services are directed to achieve functional changes by (1) …reinforcing, strengthening or reestablishing
previously learned patterns of behavior or…”
“ (2) establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems”
Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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What tells us the theory ?
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1. Functional Therapy restitution using “drill and practice“ as soon as possible
2. compensational therapy fitting the reality to patient, substitution for functional therapy, if this does not work
3. Integrative treatment methods working with the patient and his family Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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Phase model of rehabilitation in Germany
Acute treatment
Early Rehabilitation
Post primary Rehabilitation
General Rehabilitation
Phase D/E Phase C Phase B Phase A
Phase F
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Aftercare
Preparing the professional reactivation
Working on daily living activities, 35<Barthel< 65
Early rehabilitation of motor and cognitive functions, Barthel < 35
Restitution of vital functions
Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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The therapeutic team Occupational therapy Ergotherapy
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Physio-therapy
Therapeutic nursing
Therapeuticpedagogy
Logopedics
Patient Medical care
Neuro psychology
Orthoptic
Social service Dietetics
Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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Cognitive therapy works !
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Neurocognitive Enhancement Therapy With Work Therapy: Effects on Neuropsychological Test Performance,Bell, M., et.al..Archives of General Psychiatry, 58, 763-768 (2001) Computer-Assisted Cognitive Rehabilitation of Chronic Psychiatric Inpatients, Burda, P.C.,et.al:Computers in Human Behavior, 10, 3, 359-368, (1994)
Computer-Assisted Cognitive Rehabilitation Reduces Negative Symptoms in the Severely Mentally Ill, Dona M. Bellucci et.al: Schizophrenia Research,Volume 59, 2002, pages 225 - 232 Evidence-Based Cognitive Rehabilitation: Recommendations for Clinical Practice Cicerone, K.D., et.al.:Archives of Physical Medicine and Rehabilitation, 81 (12), 1596-1615 (2000)
Rehabilitation of Persons with Traumatic Brain Injury, From the NIH Consensus Statement, Volume 16, Number 1, October 26-28, 1998
EEG Changes on TBI Patients During Cognitive Tasks After Cognitive Rehabilitation, Stathopoulou S., & Lubar J.F., Presented at the SNR convention, Monterey, CA, 2001
Changes After EEG Biofeedback and Cognitive Retraining in Adults with Mild Traumatic Brain Injury and Attention Deficit Hyperactivity Disorder,Tinius, T.,Tinius, K.A. J.Neurotherapy,4,2, 27 Computerized Cognitive Training for Severely Emotionally Disturbed Children With ADHD,Slate, S.E., Meyer, T.L., Burns, W.J., Montgomery, D.D. Behavior Modification, 22, 3, 415-437 (July 1998) Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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Cognitive therapy works !
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Yes, but… … there is some evidence that interventions focused on training problem solving skills can be effective, but that evidence is very limited
… we do not know what the active ingredients are in the rehabilitation interventions … only a sub-group of people with brain injury are likely to benefit from current interventions … we cannot conclude with any certainty that the interventions promote recovery of damaged neural circuits and as a result restore ability in executive function Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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Why use a computer for therapy?
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...computer is not a magical instrument , but ...number of potential benefits can be derived from its proper use. Guidelines for Computer-Assisted Neuropsychological Rehabilitation and Cognitive Remediation, 1991
... properly constructed and presented software programs can minimize the
patient s frustration
... context of learning to use the computer itself - regardless of the software package – can provide the patient with an experience of mastery and a sense of control. ... therapist can be freed to focus on treatment rather than data collection ...
efficient medium for tasks that would otherwise require extensive set-up and/or preparation time the computer is a particularly
Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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Why use a computer for therapy?
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What did we learn in the meantime (1991 – 2008) ? COMPUTER = new treatment possibilities: ...new ways of cognitive stimulation – multi media presentations ...possibilities for a simple and fast change of the task’s content used – “give the farmer the tractor and the public servant a calculator” ...new ways of treatment – cognitive training at home and teletherapy ...easy standardized testing – cognitive abilities and personality ... and
last but not least :
Computer supported training – one of the instruments to handle the continuously rising costs of neurological rehabilitation (rising number of patient + long lasting treatment)
Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012
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