Cognitive Rehabilitation for Spanish-speakers with Brain Injury in the United States

Denise Krch, PhD • Anthony H. Lequerica, PhD

Disparities in Traumatic Brain Injury

Ethnic disparities have been documented in traumatic brain injury (TBI). The incidence of TBI among Hispanics is significantly greater than that within Non-Hispanic Whites (NHW).1 In a recent study using the Ohio State University Traumatic Brain Injury Identification Method, 25% of the sample, which comprised over 700 Spanishspeakers from Latin America, Spain, and the U.S., reported a lifetime history of TBI with loss of consciousness.2 This statistic contrasts with meta-analyses which place general population prevalence at around 12.1% within developed countries.3 Access to rehabilitation for TBI is disproportionate as well. Minorities, including Hispanics, receive fewer and less intensive rehabilitation services,4,5 and are more likely to be discharged home versus to inpatient rehabilitation compared to NHW.6

According to various mortality studies, outcomes after TBI are disproportionately worse for Spanish-speaking Hispanics relative to NHW 1,7. For example, research demonstrated that Hispanic patients were five times more likely to live with severe disabilities than NHW, and that Spanish-speaking Hispanics were 15 times more likely to live with a severe disability six months post-injury relative to NHW 8. A lack of access to rehabilitation in one’s native language may be a primary contributing factor to disparities.9 Additionally, culture, education, and other social determinants may interact with language in complex ways to influence outcomes.

Cognitive Rehabilitation for Spanish Speakers

Given the significant number of Hispanics in the U.S. and their disproportionately higher prevalence of TBI and poorer rehabilitation outcomes, there is a compelling need for appropriate treatments for this population. However, the field of Spanish cognitive rehabilitation is nascent and studies establishing the efficacy of interventions are difficult to find in the literature. For comparison, a meta-analysis of Spanish cognitive rehabilitation treatments in neurologic disorders published in 201210 evaluated 24 studies, whereas systematic reviews of English cognitive rehabilitation treatments in TBI and stroke published up until 201111 had evaluated a total of 370 articles (with a more recent 2019 publication having evaluated a cumulative 491 articles12). Nonetheless, the extant literature on cognitive rehabilitation studies in Spanish-speakers is promising, and thus, may be used as a guide for cognitive rehabilitation programs in the U.S. The 2012 metaanalysis indicated that approximately 58.3% of the studies to date had focused on retraining strategies, 33.3% targeted compensatory systems, and 8.3% used a combination of both.10 Further, a trend was noted showing increasing effect sizes for interventions on quality of life in more recent years, suggesting progress.

Some studies have evaluated strategy-based techniques to improve recall among Spanish-speaking individuals.

For example, the effect of self-generation on learning and memory among Spanish speakers with TBI has been shown regardless of the level of TBI severity or cognitive impairment.13 This suggests that the incorporation of self-generation into cognitive rehabilitation programs may prove beneficial. Another strategy-based treatment that has shown strong efficacy in English-speakers with TBI 14 and preliminary efficacy in Spanish-speakers with MS, is the modified Story Memory Technique (mSMT). The mSMT is a 10-session intervention that teaches imagery and context to facilitate learning. Pilot research conducted in Mexico showed that Spanish-speakers with MS and impaired learning who received the mSMT improved on objective measures of learning and memory and patients and their families reported increased life satisfaction and everyday functioning relative to a placebo control group.15 Class I evidence in TBI in English and preliminary efficacy in Spanish in MS suggests the mSMT may be a promising treatment option for Spanish-speakers with TBI, although further research would be needed to confirm this. Still other studies incorporate strategy-based techniques into their treatment approaches with good success. In one such study, a mixed sample of individuals with various neurologic conditions, including TBI, reported improved quality of life, subjective memory, and mood after 14 weeks of treatment.16 Although this study was limited by a lack of control condition and objective outcome measures, it importantly placed a focus on the patients’ perspective of benefit or clinical significance, which is often an omission in efficacy research. Together, the findings from strategy-based cognitive rehabilitation treatments in Spanish reflect the recommendation for use of these approaches in treatment of memory deficits after brain injury in English-speakers.12

The growing body of Spanish cognitive rehabilitation literature has also begun evaluating language treatments in brain injury. Triviño and colleagues investigated a treatment specifically targeting confabulations after acquired and traumatic brain injury.17 They found a significant decrease in confabulations and significant improvement on objective cognitive measures in the experimental group relative to the wait-list control group. Case control and case studies using varying treatment approaches have additionally demonstrated improvements in language deficits in individuals after stroke and TBI.18,19 While positive findings in these smaller studies are encouraging, more research is needed to confirm efficacy. In recent years, there has been a growing trend toward development of computerized cognitive rehabilitation programs. These programs fall into two categories, namely those that are designed to be administered to patients under the guidance of a trained clinician, and those that commercially available to the general public as brain training. GRADIOR, the Guttman NeuroPersonal Trainer, and NeuronUP are examples of clinician-guided treatments. GRADIOR was developed in the late 90s and contains over 12,000 exercises designed to be used in evaluation and treatment of patients with a wide array of conditions. It has been used in clinical practice in more than 500 clinical and social settings in Spain, serving over 11,000 patients. Its usability, feasibility, and preliminary effectiveness have been reported in mild cognitive impairment and early dementia and a larger trial is now underway.20 The Guttman NeuroPersonal Trainer (GNPT) consists of 95 different tasks addressing attention, memory and executive function domains.21 The GNPT has been integrated into clinical routine in several rehabilitation centers in Spain serving a mixed patient population, which includes TBI and stroke. To date, over 1600 patients have been treated using this protocol, and usability and cost analysis have been quite favorable. Future research is still required to establish efficacy. NeuronUP is a more recently developed program that contains over 10,000 activities and is designed for a wide range of patient populations. No studies have been conducted in TBI to date, however, various studies are underway in various patient populations including acquired brain injury.

Several brain training programs are available commercially in Spanish (e.g., BrainHQ, Lumosity, Rehacom), with some tested in acquired and traumatic brain injury in Spanish and other languages.22,23 Such tools are particularly attractive as they can be implemented in rural locations where accessibility or transportation is a barrier to treatment. However, while brain trainings have shown feasibility and acceptability; many studies demonstrate a lack of evidence to support effectiveness on subjective or objective cognition.24 This underlines guidance from a large-scale systematic review of the English cognitive rehabilitation literature, citing that computer-based interventions should be an adjunct to clinician-guided treatment and sole reliance on computer-based tasks without some involvement and intervention by a clinician is not recommended.12

There are cognitive rehabilitation treatments that have shown efficacy in other patient populations with neurologic compromise that could potentially be adopted for a TBI population. One of particular interest is the REHACOP, an integrative cognitive rehabilitation program, comprised of more than 300 paper-andpencil tasks. The REHACOP, developed in Spain, was initially established as efficacious in the schizophrenia population, but later research extended efficacy to MS and Parkinson’s disease. It is administered by a trained rehabilitation professional and can delivered in individuals or group format. As the protocol broadly covers the major domains of cognition, it would be applicable to the impairments common in TBI.25

Although additional research is needed to test the generalizability of the findings to the larger population of Spanish speakers across the U.S., these studies make important contributions to the literature that can provide a foundation for developing effective cognitive rehabilitation interventions and studies that further our understanding of the underlying mechanisms of action.

Although additional research is needed to test the generalizability of the findings to the larger population of Spanish speakers across the U.S., these studies make important contributions to the literature that can provide a foundation for developing effective cognitive rehabilitation interventions and studies that further our understanding of the underlying mechanisms of action. As more studies become published, it may be feasible to use combinations of treatments studied in different populations that have commonalities across multiple cohorts of Spanish speakers. Establishing this type of generalizability is an attractive alternative to having separate treatment protocols based on country of origin or patient population. In any case, a balance should be sought taking into account generalizability while being mindful of the individuality of the patient in the interest of patient-centered care.

Conclusions

In light of the vast number of Hispanics with TBI in the U.S. in need of cognitive rehabilitation services and limited number of evidencebased options available in Spanish, it is a substantial challenge to provide appropriate services to this population. Nonetheless, there is a growing body of literature evidencing promising results. Indeed, the Spanish neuropsychological landscape today is vastly different from even a decade ago when virtually no formalized treatment options existed. Further, although many of the Spanish treatments that exist have not yet been tested specifically in TBI, their established efficacy in other populations bodes well for a crosswalk to TBI, where overlap of cognitive impairments may be shared. Certainly, the field will call for researchers to continue establishing an evidence-base in TBI. There is also a dire need of clinicians in the U.S. who can provide services in Spanish and research to develop efficacious methods of treatment delivery through an interpreter where Spanish-speaking clinicians are unavailable. With the currently available resources, we can begin to form a basic framework for serving the diverse Hispanic culture in the U.S. and abroad to improve quality of life after brain injury.

References

1. Bruns J, Jr., Hauser WA. The epidemiology of traumatic brain injury: a review. Epilepsia. 2003;44 Suppl 10:2-10. 2. Lequerica AH, Botticello A, O'Neill J, et al. Relationship Between Hispanic Nativity, Residential Environment, and Productive Activity Among Individuals With Traumatic Brain Injury: A TBI Model Systems Study. J Head Trauma Rehabil. 2019;34(1):E46-E54. 3. Frost RB, Farrer TJ, Primosch M, Hedges DW. Prevalence of traumatic brain injury in the general adult population: a meta-analysis. Neuroepidemiology. 2013;40(3):154-159. 4. Meagher AD, Beadles CA, Doorey J, Charles AG. Racial and ethnic disparities in discharge to rehabilitation following traumatic brain injury. J Neurosurg. 2015;122(3):595-601. 5. Burnett DM, Kolakowsky-Hayner SA, Slater D, et al. Ethnographic analysis of Traumatic Brain Injury patients in the National Model Systems Database. Arch Phys Med Rehabil. 2003;84:263-267. 6. Asemota AO, George P, Cumpsty-Fowler CJ, Haider AH, Schneider EB. 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Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008. Arch Phys Med Rehabil. 2011;92(4):519-530. 12. Cicerone KD, Goldin Y, Ganci K, et al. Evidence-Based Cognitive Rehabilitation: Systematic Review of the Literature From 2009 Through 2014. Arch Phys Med Rehabil. 2019;100(8):1515-1533. 13. De los Reyes Aragon CJ, Arango-Lasprilla JC, Perea Bartolome M, Ladera Fernandez V, Krch D. The effect of cognitive impairment on self-generation in Hispanics with TBI. NeuroRehabilitation. 2012;30(1):55-64. 14. Chiaravalloti ND, Sandry J, Moore NB, DeLuca J. An RCT to Treat Learning Impairment in Traumatic Brain Injury: The TBI-MEM Trial. Neurorehabil Neural Repair. 2015. 15. Krch D, Lequerica A, Aguayo Arelis A, Rabago Barajas BV, Arango-Lasprilla JC, Chiaravalloti ND. Efficacy of the Spanish modified Story Memory Technique in Mexicans with multiple sclerosis: A pilot randomized controlled trial. NeuroRehabilitation. 2019;45(3):349-358. 16. Saux G, Demey I, Rojas G, Feldberg C. Cognitive rehabilitation therapy after acquired brain injury in Argentina: psychosocial outcomes in connection with the time elapsed before treatment initiation. Brain Inj. 2014;28(11):1447-1454. 17. Triviño M, Ródenas E, Lupiáñez J, Arnedo M. Effectiveness of a neuropsychological treatment for confabulations after brain injury: A clinical trial with theoretical implications. PLoS ONE. 2017(3). 18. Solovieva Y, Quintanar L. Rehabilitation of semantic aphasia in a spanish-speaking patient. Psychology in Russia: State of the Art. 2018;11(1):137-150. 19. Berthier ML, Edelkraut L, Mohr B, et al. Intensive aphasia therapy improves low mood in fluent poststroke aphasia: Evidence from a case-controlled study. Neuropsychol Rehabil. 2020:1-16. 20. Franco-Martin MA, Diaz-Baquero AA, Bueno-Aguado Y, et al. Computer-based cognitive rehabilitation program GRADIOR for mild dementia and mild cognitive impairment: new features. 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Author Bios

Denise Krch, PhD, is a Senior Research Scientist at Kessler Foundation, an Assistant Research Professor in the Department of Physical medicine and Rehabilitation at Rutgers New Jersey Medical School, and a neuropsychologist, licensed in psychology in the state of New York. Dr. Krch conducts research on cognitive rehabilitation across neurologic populations, including TBI. A primary focus of her research is on the effectiveness of cognitive rehabilitation interventions across Hispanic cultures and the role of cultural factors on outcomes in TBI.

Anthony H. Lequerica, PhD, is a Senior Research Scientist at Kessler Foundation’s Center for TBI Research and a Research Associate Professor at Rutgers – New Jersey Medical School in the Department of Physical Medicine and Rehabilitation. As Director of the Brain and Behavioral Outcomes Lab, his research focuses on cultural and sociodemographic factors affecting brain injury rehabilitation outcomes. He is Co-Chair of the Inclusion, Diversity, Equity, and Accessibility Special Interest Group within the Traumatic Brain Injury Model Systems sponsored by the National Institute on Disability, Independent Living, and Rehabilitation Research. He is a Staff Neuropsychologist at Kessler Institute for Rehabilitation where he provides neuropsychological services to Spanish-speakers with a variety of neurological conditions. He has over 50 peer-reviewed publications and has given numerous presentations across the U.S. and abroad to researchers, health care professionals, and individuals with brain injury and their families.

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September 21-24, 2022 New Yorker Hotel New York, New York

North American Brain Injury Society Canoeing at Vinland’s main campus in Loretto, Minnesota

drug & alcohol treatment for adults with disabilities2022 Medical Legal Conference Vinland Center provides drug and alcohol treatment for adults with cognitive disabilities, including traumatic brain injury, fetal alcohol on Brain Inj spectrum disorder and learning disabilities. We make all possible accommodations for cognitive deficits and individual learning styles. ury Located in Loretto, Minnesota — just 20 miles west of Minneapolis. www.international(763)479-3555 • VinlandCenter.org brain.org

Restore-Ragland Restore-Roswell Restore-Lilburn

Restore Neurobehavioral Center is a residential, post acute healthcare organization dedicated exclusively to serving adults with acquired brain injury who also present with moderate to severe behavioral problems. Services range from intensive inpatient neuro-rehabilitation and transitional community re-entry services to long term supported living services. Restore Neurobehavioral Center, located in a suburb north of Atlanta, is the site of our inpatient post acute neuro-rehabilitation program as well as one of our supported living sites. We operate two other community living sites, Restore-Lilburn (GA) and Restore-Ragland (AL).