Archive for category Cognitive Rehabilitation
INTRODUCTION: Long-term functional cognitive impairments are common sequelae of stroke, often resulting in decreased participation in daily life activities. Earlier research showed the benefits of training paradigms targeted at memory, attention, and some executive functions.
METHODS: The current study examined the feasibility of a functionally relevant training program called Strategic Memory Advanced Reasoning Training (SMART). The SMART program teaches strategies to improve abstract reasoning skills and has been shown to enhance aspects of functional cognition, strengthen brain networks, and improve participation in daily life activities across clinical populations. The current study describes the benefits of the SMART program in adults (N = 12) between 54 and 77 years (64.46 ± 8.14 years) with chronic stroke. Participants had 10 sessions of the SMART program over a period of 6 weeks.
RESULTS: The findings showed significant gains in abstract reasoning (p < .05) and participation in daily activities after the SMART program. These gains were relatively stable 6 months later.
CONCLUSION: These findings offer the promise of cognitive gains, even years after stroke. Limitations of the study include a small sample size, potential confounding as a result of additional ongoing therapy, and a relatively short period of follow-up. Further research is needed to examine the benefits of the SMART program. [Annals of International Occupational Therapy. 2020;X(X):xx–xx.]
Source: Annals of International Occupational Therapy. https://doi.org/10.3928/24761222-20200116-03
[ARTICLE] Efficacy of Virtual Reality Combined With Real Instrument Training for Patients With Stroke: A Randomized Controlled Trial – Full Text
To investigate the efficacy of real instrument training in virtual reality (VR) environment for improving upper-extremity and cognitive function after stroke.
Single-blind, randomized trial.
Enrolled subjects (N=31) were first-episode stroke, assessed for a period of 6 months after stroke onset; age between 20 and 85 years; patients with unilateral paralysis and a Fugl-Meyer assessment upper-extremity scale score >18.
Both groups were trained 30 minutes per day, 3 days a week, for 6 weeks, with the experimental group performing the VR combined real instrument training and the control group performing conventional occupational therapy.
Main Outcome Measures
Manual Muscle Test, modified Ashworth scale, Fugl-Meyer upper motor scale, hand grip, Box and Block, 9-Hole Peg Test (9-HPT), Korean Mini-Mental State Examination, and Korean-Montreal Cognitive Assessment.
The experimental group showed greater therapeutic effects in a time-dependent manner than the control group, especially on the motor power of wrist extension, spasticity of elbow flexion and wrist extension, and Box and Block Tests. Patients in the experimental group, but not the control group, also showed significant improvements on the lateral, palmar, and tip pinch power, Box and Block, and 9-HPTs from before to immediately after training. Significantly greater improvements in the tip pinch power immediately after training and spasticity of elbow flexion 4 weeks after training completion were noted in the experimental group.
VR combined real instrument training was effective at promoting recovery of patients’ upper-extremity and cognitive function, and thus may be an innovative translational neurorehabilitation strategy after stroke.
Stroke is currently the leading cause of disability and death worldwide, and stroke survivors often experience chronic functional impairment and cognition deficits, which are associated with a reduced quality of life including difficulties in social and personal relationships.1, 2 It is well known that patients with stroke have a limited use of their upper extremities owing to motor dysfunction, and such patients experience sensory-motor deficits that affect their ability to perform daily activities. Stroke increases the risk of dementia 4 to 12 times,3 and up to 69% of subjects have a poststroke cognitive impairment.4 Consequently, the aims of the current rehabilitation strategies for these patients are to improve functional ability and cognitive impairments through optimal and comprehensive rehabilitation processes.
Previous studies have reported that a considerable amount of practice using real instruments is required to stimulate functional improvement and neuroplastic changes.5, 6 Conventional occupational therapies promote the recovery of upper-extremity dysfunction by utilizing task-oriented repetition training with real instruments.7, 8 Conventional therapy using real instruments is essential for poststroke rehabilitation, but environmental, individual, and financial limitations are associated with it.9, 10
Over the past 2 decades, the advancement of computer technology has resulted in the development of interventions that involve virtual reality (VR) devices, which are defined as computer hardware and software systems that generate simulations of imagined environments via visual, auditory, and tactile feedback.11 VR environments may be perceptual, such as creating situations with multiple sensory feedback regarding the patients’ kinematic movements, which are passive or active assisted in a virtual environment, and providing high-intensity repetitive multisensory interaction and goal-oriented tasks.12 Repetition and intensity are key factors for promoting neural plasticity in patients with brain damage.13 Additionally, studies have reported that VR training promotes motor recovery and cognition by inducing experience-dependent neural plasticity through repetitive tasks of varying time, high intensity, and complexity levels.14 Various studies have revealed that adaptive neuroplasticity, defined as the reorganization of movement representation in the motor cortex, premotor cortex, supplementary motor area, and somatosensory cortex due to synaptic efficacy and remodeling of the dendritic spines, can be induced by conducting repetitive goal-oriented tasks in VR-based interventions after stroke.15, 16, 17
Recently, various reports have highlighted the potential utility of VR-based rehabilitation strategies for improving upper-limb motor weakness,18, 19 cognitive dysfunction, and balance in patients poststroke.20, 21, 22 Furthermore, research has shown that compared to conventional therapy, VR training can improve the quality of neurologic rehabilitation and enhance productivity.23 Even more, it has more beneficial effects in poststroke rehabilitation, such as an increased motivation and engagement,24 cost, and usability.25, 26, 27 In addition, VR training is able to facilitate an increased therapy time without necessarily having to rely on a therapist.28 For these reasons, the number of complex and realistic VR-based interventions is increasing in neurorehabilitation programs in order to enhance the variability and adaptability of the intervention, as well as patients’ motivation, after stroke. However, comparing the effects of VR training with conventional therapy is still unclear. According to previous mentions, the combination of VR and real instruments is expected to have a synergy effect rather than a conventional occupational therapy in patients with stroke, and we investigated to see the clinical effect by using actual devices combined with a VR system to perform numerous tasks related to real daily activities.
In the present study, we developed a novel rehabilitation training that combined the benefits of real instrument training and VR-based intervention. The aim of this study was to investigate whether the VR combined with real instrument training would be an efficient translational intervention for improving the functional abilities of the upper-extremity and cognitive function in patients with stroke.
- Make a memory board (with important names and frequently used phone numbers). Hang somewhere visible, so it can be seen and utilized daily. Update the same day weekly or as schedules change.
- Create a life story book, photo album or something digital that is labeled to help identify who and what is important to remember (people, places, experiences). Get assistance to from someone you trust (such as a family member or professional) to do this. This can include pictures, question and answer format, or whatever works for your particular needs. This serves as a dual purpose as well, as it can also be used by professionals or caregivers to understand more about you as well.
- Cognitive stimulation. This involves activities and exercises that stimulate thinking, concentration, communication and memory. Utilizing brain exercise sites such as Lumosity , Constant Therapy, and CogniFit Brain Training; play strategy games (like cards, checkers, chess, crossword puzzles, word finds, puzzles); coloring, drawing, or listening to different types of music.
- Utilize a reminder system (this may include calendar, white boards, chart on the wall). It could be color coded as well (so a different color for each person or different color for each appointment on schedule – just make sure you use same color each time you do the schedule). Using A Planner or a Calendar App? – write down things right away – without exception. Always keep the planner with you wherever you go. If you get a call about an appointment, write it down IN THE PLANNER. If something changes in the schedule, write it down IN THE PLANNER. Label cupboards and storage containers as a reminder of where things are kept; label doors as a reminder of which room is which.
- LISTS are your friends and great reminders (note: if you have trouble writing, use a voice recorder or dictaphone to make lists). Consider making permanent signs – even having them laminated, to remind you of things you need to do regularly (for example – sign by the sink reminding you to wash your hands before cooking or before leaving the bathroom). Make a list for things you are running out of and leave attached to the refrigerator door (this is a great way to make a grocery list you take to the store with you). Make a list of what bills are due on what days and how much each bill is that is due, along with how it is paid. Make a list of daily tasks that need accomplished. Make (or have someone make) a checklist to hang by the front door that includes what you need when you leave (for example: purse/wallet, phone, phone charger, planner, meds, bottle of water, keys, sunglasses, ear plugs, jacket, etc). Use the checklist EVERY TIME before you walk out the door. This reduces chances of forgetting things.
- Use post-it/sticky notes. You can use them anywhere in your home or personal workspace to remind you to do specific tasks (such as a sticky on a library book that has to be returned by a certain date, or start load of laundry today, etc).Once you have completed the task, it’s important to throw the post-it/sticky note away. This way you won’t accidentally redo what you already finished.
- Use a mobile smartphone (cell phone). Many mobile phones have a built-in voice recorder. Use this to record information that you need to remember or add items to your virtual calendar. You could also leave recorded notes, play it back later, or review those notes at the same time each day. Also cell phones are great resources for text reminders, checking emails, and having access to a GPS (such as Google maps) to utilize to keep from getting lost. Use your phone to take picture of your whiteboard schedule that week so when you leave home you can look at the picture even if you aren’t at home to see it. Use an app to record incoming/outgoing phone calls (check your State or Country laws first though, about recording these in your particular location).
- Medicine/Pill reminder box. This will help you see whether you have taken your medications for that day (this helps to prevent taking your medications more than once). Some models have am/pm, and other times of the day; some can be set to remind you when to take your pills, with an alarm, vibration or flashing light.
- Use an alarm clock, a watch with an alarm, or a kitchen timer to remind you when you need to leave the house for an appointment, or when you have to check something cooking in the oven. Write down why you have set the alarm – so you know why it is going off. (I cannot tell you the number of times I have had an alarm going off and then sat there wondering why I set it. So notes are very helpful – put by the alarm)
- Never leave the room when you are cooking. You may forget what you were doing and this increases risk of burning your food, burning up a pan, or causing a fire. Never leave the room when water is running in a sink or bathtub. You may forget about it and cause a flood.
- Appointments and Meetings. In advance, make a detailed list of what you want to say, questions you have, agenda for meeting, etc. If you are going to a medical appointment, bring a pre-typed list to leave with the provider of all other providers/specialists (make sure this includes their addresses, phone numbers or contact information), all medications and their dosages (remember to list any herbs, supplements taking), and list of concerns. Record meetings or appointments to go back and listen to later and take notes from the recording.
- Don’t procrastinate. Whenever possible, doing things when they’re on your mind rather than later so you don’t have to worry about forgetting them. Try to utilize the same routine every day as much as possible. Routine reduces chances of forgetting.
Cognitive-behavioral therapy (CBT) is one of the most commonly practiced forms of psychotherapy today. It’s focus is on helping people learn how their thoughts color and can actually change their feelings and behaviors. It is usually time-limited and goal-focused as practiced by most psychotherapists in the U.S. today.
Dialectical behavior therapy (DBT) is a specific form of cognitive-behavioral therapy. DBT seeks to build upon the foundation of CBT, to help enhance its effectiveness and address specific concerns that the founder of DBT, psychologist Marsha Linehan, saw as deficits in CBT.
DBT emphasizes the psychosocial aspects of treatment — how a person interacts with others in different environments and relationships. The theory behind the approach is that some people are prone to react in a more intense and out-of-the-ordinary manner toward certain emotional situations, primarily those found in romantic, family and friend relationships. DBT was originally designed to help treat people with borderline personality disorder, but is now used to treat a wide range of concerns.
DBT theory suggests that some people’s arousal levels in certain situations can increase far more quickly than the average person’s. This leads a person to attain a much higher level of emotional stimulation than normal, and it may take a significant amount of time to return to normal emotional arousal levels.
DBT differs in practice in one important way. In addition to individual, weekly psychotherapy sessions, most DBT treatment also features a weekly group therapy component. In these group sessions, people learn skills from one of four different modules: interpersonal effectiveness, distress tolerance/reality acceptance skills, emotion regulation, and mindfulness skills. A group setting is an ideal place to learn and practice these skills, because it offers a safe and supportive environment.
Both CBT and DBT can incorporate exploring an individual’s past or history, to help an individual better understand how it may have impacted their current situation. However, discussion of one’s past is not a focus in either form of therapy, nor is it a differentiation between the two forms (it is completely dependent upon the individual psychotherapist).
Whether cognitive-behavior therapy or dialectical behavior therapy is right for you is a determination best made in conjunction with an experienced therapist. Both types of psychotherapy have strong research backing and have been proven to help a person with a wide range of mental health concerns.
- It is by now well established that exercise has positive effects on the brain, especially as we age.
- Less clear has been why physical activity affects the brain in the first place.
- Key events in the evolutionary history of humans may have forged the link between exercise and brain function.
- Cognitively challenging exercise may benefit the brain more than physical activity that makes fewer cognitive demands.
In the 1990s researchers announced a series of discoveries that would upend a bedrock tenet of neuroscience. For decades the mature brain was understood to be incapable of growing new neurons. Once an individual reached adulthood, the thinking went, the brain began losing neurons rather than gaining them. But evidence was building that the adult brain could, in fact, generate new neurons. In one particularly striking experiment with mice, scientists found that simply running on a wheel led to the birth of new neurons in the hippocampus, a brain structure that is associated with memory. Since then, other studies have established that exercise also has positive effects on the brains of humans, especially as we age, and that it may even help reduce the risk of Alzheimer’s disease and other neurodegenerative conditions. But the research raised a key question: Why does exercise affect the brain at all?
Physical activity improves the function of many organ systems in the body, but the effects are usually linked to better athletic performance. For example, when you walk or run, your muscles demand more oxygen, and over time your cardiovascular system responds by increasing the size of the heart and building new blood vessels. The cardiovascular changes are primarily a response to the physical challenges of exercise, which can enhance endurance. But what challenge elicits a response from the brain?
Answering this question requires that we rethink our views of exercise. People often consider walking and running to be activities that the body is able to perform on autopilot. But research carried out over the past decade by us and others would indicate that this folk wisdom is wrong. Instead exercise seems to be as much a cognitive activity as a physical one. In fact, this link between physical activity and brain health may trace back millions of years to the origin of hallmark traits of humankind. If we can better understand why and how exercise engages the brain, perhaps we can leverage the relevant physiological pathways to design novel exercise routines that will boost people’s cognition as they age—work that we have begun to undertake.
FLEXING THE BRAIN
To explore why exercise benefits the brain, we need to first consider which aspects of brain structure and cognition seem most responsive to it. When researchers at the Salk Institute for Biological Studies in La Jolla, Calif., led by Fred Gage and Henriette Van Praag, showed in the 1990s that running increased the birth of new hippocampal neurons in mice, they noted that this process appeared to be tied to the production of a protein called brain-derived neurotrophic factor (BDNF). BDNF is produced throughout the body and in the brain, and it promotes both the growth and the survival of nascent neurons. The Salk group and others went on to demonstrate that exercise-induced neurogenesis is associated with improved performance on memory-related tasks in rodents. The results of these studies were striking because atrophy of the hippocampus is widely linked to memory difficulties during healthy human aging and occurs to a greater extent in individuals with neurodegenerative diseases such as Alzheimer’s. The findings in rodents provided an initial glimpse of how exercise could counter this decline.
Following up on this work in animals, researchers carried out a series of investigations that determined that in humans, just like in rodents, aerobic exercise leads to the production of BDNF and augments the structure—that is, the size and connectivity—of key areas of the brain, including the hippocampus. In a randomized trial conducted at the University of Illinois at Urbana-Champaign by Kirk Erickson and Arthur Kramer, 12 months of aerobic exercise led to an increase in BDNF levels, an increase in the size of the hippocampus and improvements in memory in older adults.
Other investigators have found associations between exercise and the hippocampus in a variety of observational studies. In our own study of more than 7,000 middle-aged to older adults in the U.K., published in 2019 in Brain Imaging and Behavior, we demonstrated that people who spent more time engaged in moderate to vigorous physical activity had larger hippocampal volumes. Although it is not yet possible to say whether these effects in humans are related to neurogenesis or other forms of brain plasticity, such as increasing connections among existing neurons, together the results clearly indicate that exercise can benefit the brain’s hippocampus and its cognitive functions.
Researchers have also documented clear links between aerobic exercise and benefits to other parts of the brain, including expansion of the prefrontal cortex, which sits just behind the forehead. Such augmentation of this region has been tied to sharper executive cognitive functions, which involve aspects of planning, decision-making and multitasking—abilities that, like memory, tend to decline with healthy aging and are further degraded in the presence of Alzheimer’s. Scientists suspect that increased connections between existing neurons, rather than the birth of new neurons, are responsible for the beneficial effects of exercise on the prefrontal cortex and other brain regions outside the hippocampus.
UPRIGHT AND ACTIVE
With mounting evidence that aerobic exercise can boost brain health, especially in older adults, the next step was to figure out exactly what cognitive challenges physical activity poses that trigger this adaptive response. We began to think that examining the evolutionary relation between the brain and the body might be a good place to start. Hominins (the group that includes modern humans and our close extinct relatives) split from the lineage leading to our closest living relatives, chimpanzees and bonobos, between six million and seven million years ago. In that time, hominins evolved a number of anatomical and behavioral adaptations that distinguish us from other primates. We think two of these evolutionary changes in particular bound exercise to brain function in ways that people can make use of today.
For more, visit —-> Why Your Brain Needs Exercise – Scientific American
The effects of neurological damage from events like trauma and stroke can be devastating to the individual and those close to them. Brain injury can result in lifelong physical, cognitive, and behavioral changes. The impact of behavior changes can profoundly alter how the injured person functions day to day, even impeding rehabilitative goals and impacting the ability to live independently. Changes in personality and behavior following traumatic brain injury (TBI) often represent the most significant barrier to a successful outcome including reintegration into the community whether for basic daily tasks, work or recreational/social activities.
Common behavior issues following brain injury include behavioral excesses (occurring too much) such as irritability (e.g., poor tolerance, short temper) and aggression (e.g., hitting, grabbing, kicking), property destruction (e.g., striking furniture, throwing items) and inappropriate vocalizations (e.g., cursing, yelling, threats). Also presenting a concern are behavior deficits (do not occur enough) such as compliance with tasks (e.g., cooperation with requests), social skills (e.g., overfamiliar discussions, uncharacteristically rude remarks), initiation (e.g., knowing when to begin tasks) and the academic and return to work skills (e.g., being on time, following directions) to be successful. Some of the most difficult behaviors can be dangerous to the patient and others around them. Treating these dangerous and challenging behaviors, which may include physical aggression toward others, self-injurious behavior, sexual disinhibition, and escape or elopement, requires a treatment commitment across the continuum of care.
In the early, acute stages of recovery from brain injury, many of the behavioral complications demonstrated are considered to be a normal phase of recovery. When these behaviors continue beyond those early phases, however, and form on-going negative patterns of interaction with others, very specialized treatment is required. These behaviors can be disturbing to families and staff, disruptive to therapy, and jeopardize patient safety. The future quality of life for the patient and their family depends on effective interventions, provided with a great deal of consistency and structure. Behavior analysts (professionals in Applied Behavior Analysis) add value to interdisciplinary rehabilitation teams by helping to develop both skill acquisition and behavior reduction programs throughout the patient’s recovery (i.e., acute, post-acute, long term care). Behavior analysts spend a great deal of time directly observing interactions, determining what may be motivating the difficult behaviors, and what responses may need to be strengthened and reinforced. The behavior analyst must then provide training to all those who may interact with the patient, including most importantly, the family. This skilled, specialized intervention establishes more effective and acceptable response patterns that allow the patient to have their needs met and be better understood without displaying problem behavior. The structured behavior plan can also help the patient develop positive, prosocial responses, and more efficient functional skills.
The effects of brain injury are highly individual, which then challenges the behavior analysts, family and others on the treatment team to continually evaluate the responses, goals, and outcomes throughout recovery (e.g., monitoring response to new medications).
Considering the risk to patients and families, the rising healthcare cost and the possibility of reduced services being available, a focus on efficient and effective interventions such as behavior analysis seems essential to a well-integrated, interdisciplinary rehabilitation treatment team. The quality of life for those affected by brain injury depends on having the opportunity to receive not just the standard rehabilitation one might get following knee surgery but rather specialized, experienced and effective treatment specifically designed to address the unique difficulties they face including difficult behavior.
[Abstract] Music Therapy Enhances Executive Functions and Prefrontal Structural Neuroplasticity after Traumatic Brain Injury: Evidence from a Randomized Controlled Trial
Traumatic brain injury (TBI) causes lifelong cognitive deficits, particularly impairments of executive functioning (EF). Musical training and music-based rehabilitation have been shown to enhance cognitive functioning and neuroplasticity, but the potential rehabilitative effects of music in TBI are still largely unknown. The aim of the present crossover randomized controlled trial (RCT) was to determine the clinical efficacy of music therapy on cognitive functioning in TBI and to explore its neural basis.
Using an AB/BA design, 40 patients with moderate or severe TBI were randomized to receive a 3-month neurological music therapy intervention either during the first (AB, n = 20) or second (BA, n = 20) half of a 6-month follow-up period. Neuropsychological and motor testing and magnetic resonance imaging (MRI) were performed at baseline and at the 3-month and 6-month stage. Thirty-nine subjects who participated in baseline measurement were included in an intention-to-treat analysis using multiple imputation. Results showed that general EF (as indicated by the Frontal Assessment Battery [FAB]) and set shifting improved more in the AB group than in the BA group over the first 3-month period and the effect on general EF was maintained in the 6-month follow-up. Voxel-based morphometry (VBM) analysis of the structural MRI data indicated that gray matter volume (GMV) in the right inferior frontal gyrus (IFG) increased significantly in both groups during the intervention versus control period, which also correlated with cognitive improvement in set shifting. These findings suggest that neurological music therapy enhances EF and induces fine-grained neuroanatomical changes in prefrontal areas.