Posts Tagged cognitive functions

[BOOK Chapter] Long-Lasting Mental Fatigue After Traumatic Brain Injury – A Major Problem Most Often Neglected Diagnostic Criteria, Assessment, Relation to Emotional and Cognitive Problems, Cellular Background, and Aspects on Treatment

By Birgitta Johansson and Lars Rönnbäck

1. Introduction

Fatigue after traumatic brain injury (TBI) is common, but often overlooked. But for people fighting their fatigue after brain injury day after day, fatigue is a major problem. This post-injury mental fatigue is characterized by limited energy reserves to accomplish ordinary daily activities. Persons who have not experienced this extreme exhaustion which may appear suddenly, and without previous warning during mental activity, do not understand the problem. This is especially difficult to understand as the fatigue may appear even after seemingly trivial mental activities which, for uninjured persons, are regarded as relaxing and pleasant, as reading a book or having a conversation with friends. A normal, well-functioning, brain performs mental activities simultaneously throughout the day, but after a brain injury, it takes greater energy levels to deal with cognitive and emotional situations.

In this chapter, we highlight mental fatigue after TBI. In the case of long-lasting mental fatigue, it could be the only factor that keeps people from returning to the full range of activities that they pursued prior to their injury with work, studies and social activities. We describe mental fatigue and suggest diagnostic criteria and we also give a theoretical explanation for this. At the end of the chapter, we discuss treatment strategies and give some examples of possible therapeutic alternatives which may alleviate the mental fatigue.

Normally, the brain works in an energy-efficient manner and prominent energy reserves are present. This is due to well-functioning ion channel and amino acid transport systems and other effective physiological processes. After brain injury, some of these systems are down-regulated, and when mental energy requirements are high the physiological processes do not function to their full capacity; these cease to function efficiently with a resultant energy loss. This may be an explanation as to why the mental fatigue appears.

1.1. When does mental fatigue occur?

Annually, about 100-300/100 000 individuals sustain a TBI, and most of the injuries are mild in severity [1]. A majority of patients recover within one to three months following mild TBI [23].

Fatigue is one of the most important long-lasting symptoms following TBI, and is most severe immediately after head injury. However it is difficult to arrive at any clear figure as to how common fatigue or, in particular, mental fatigue is. The reason for this is that different results have been obtained, and these are attributable to differences in definitions and differences in the methodology in the various studies. In follow-up studies, the frequency of prolonged fatigue varies from 16 up to 73 % [46]. There is no correlation between persistent fatigue and severity of the primary injury, age of the person at injury or time since injury [78]. For those suffering from fatigue 3 months after the accident the fatigue remained relatively stable during longer periods [9]. In particular, for those subjects who were suffering from the syndrome one year after the accident improvement in the fatigue was limited [10].

In the above reports, fatigue is discussed in terms of a single construct, i.e. not differentiated between the physical or mental aspects. In this chapter, we consider mental fatigue as a separate construct and we discuss its relationship to cognitive and emotional symptoms.

1.2. Mental fatigue is not a separate diagnostic entity

Mental fatigue is not an illness, rather it represents a mental sequel, probably due to a disturbance of higher brain functions, either physical or psychological in origin. It is included in, and defined within the diagnoses Mild cognitive impairment (F06.7), Neurasthenia (F48.0) and Posttraumatic brain syndrome (F07.2) [11].

1.3. Typical characteristics of mental fatigue

A typical characteristic of pathological mental fatigue after TBI is that the mental exhaustion becomes pronounced during sensory stimulation or when cognitive tasks are performed for extended periods without breaks. There is a drain of mental energy upon mental activity in situations in which there is an invasion of the senses with an overload of impressions, and in noisy and hectic environments. The person feels that their brain is overloaded after a tiny load. Another typical feature is a disproportionally long recovery time needed to restore the mental energy levels after being mentally exhausted. The mental fatigue is also dependent on the total activity level as well as the nature of the demands of daily activities. Fatigue often fluctuates during the day depending on the activities carried out. Thus, this fatigue is a dynamic process with variations in the mental energy level. The fatigue can appear very rapidly and, when it does, it is not possible for the affected person to continue the ongoing activity. Common associated symptoms include: impaired memory and concentration capacity, slowness of thinking, irritability, tearfulness, sound and light sensitivity, sensitivity to stress, sleep problems, lack of initiative and headache [12].

For many persons, this mental fatigue is the dominating factor which limits the person’s ability to lead a normal life with work and social activities. For most people, fatigue subsides after a period of time while, for others, this pathological fatigue persists for several months or years even after the brain injury has healed. Interestingly, however is that as many as 30% of family or friends interpreted fatigue as laziness [9].

Theories as to the mechanisms accounting for mental fatigue including our own theory, suggest that cognitive activities require more resources and are more energy-demanding after brain injury than usual [1314]. Thus, more extensive neural circuits are used in TBI victims compared to controls during a given mental activity [15]. This indicates an increased cerebral effort after brain injury.

Figure 1.
Schematic representation of recovery of mental energy after TBI. The green line represents a full recovery while the blue and red lines represent impaired recovery in terms of the mental energy levels. Persons whose recovery follows the blue line recover partially. On their return to work and daily activities, they are not able to manage and they become exhausted. Persons whose recovery follows the red line do not recover and are not able to return to work and daily activities.

 

Therapist Luann Jacobs describes mild TBI and the lack of energy and lack of endurance that many can experience. As they are able to do what is normal and what appears normal, they run the risk that their symptoms will be misunderstood [16].

“Mild brain injury is a real misnomer, as it conveys the idea that nothing much is a problem when quite the opposite is more often true. It is called “mild” because, in fact, the mildly brain injured can walk, talk, eat and dress independently, often times drive a car, shop, cook, go to school, or even work.

What the term fails to account for is the inherent limits of how often, for how long (endurance), and the all-important, how consistently (e.g., every day, once a week) these activities can be performed. Even more elusive is the concept of how many of these daily activities can be done sequentially in a given day as is normal in the lives of people who are not brain injured.

The fatigue they feel defies description, going far beyond and far deeper than anything a non-brain-injured person would consider profound exhaustion.”

Continue —-> Long-Lasting Mental Fatigue After Traumatic Brain Injury – A Major Problem Most Often Neglected Diagnostic Criteria, Assessment, Relation to Emotional and Cognitive Problems, Cellular Background, and Aspects on Treatment | IntechOpen

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[WEB SITE] Why Your Brain Needs Exercise

Why Your Brain Needs Exercise

Credit: Bryan Christie Design

Why Your Brain Needs Exercise

The evolutionary history of humans explains why physical activity is important for brain health

IN BRIEF

  • 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.

Graphic shows how increased production of the protein BDNF may promote neuron growth and survival in the adult brain.

Credit: Tami Tolpa

[…]

For more, visit —->  Why Your Brain Needs Exercise – Scientific American

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[BOOK Chapter] Assessment and Rehabilitation Using Virtual Reality after Stroke: A Literature Review – Abstract + References

Abstract

This chapter presents the studies that have used virtual reality as an assessment or rehabilitation tool of cognitive functions following a stroke. To be part of this review, publications must have made a collection of data from individuals who have suffered a stroke and must have been published between 1980 and 2017. A total of 50 publications were selected out of a possible 143 that were identified in the following databases: Academic Search Complete, CINAHL, MEDLINE, PsychINFO, Psychological and Behavioural Sciences Collection. Overall, we find that most of the studies that have used virtual reality with stroke patients focused on attention, spatial neglect, and executive functions/multitasking. Some studies have focused on route representation, episodic memory, and prospective memory. Virtual reality has been used for training of cognitive functions with stroke patients, but also for their assessment. Overall, the studies support the value and relevance of virtual reality as an assessment and rehabilitation tool with people who have suffered a stroke. Virtual reality seems indeed an interesting way to better describe the functioning of the person in everyday life. Virtual reality also sometimes seems to be more sensitive than traditional approaches for detecting deficits in stroke people. However, it is important to pursue work in this emergent field in clinical neuropsychology.

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via Assessment and Rehabilitation Using Virtual Reality after Stroke: A Literature Review | SpringerLink

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[WEB SITE] Brain Injury Rehabilitation – Cognitive

Brain injury rehabilitation involves two essential processes: restoration of functions that can be restored and learning how to do things differently when functions cannot be restored to pre-injury level.

Brain injury rehabilitation is is based on the nature and scope of neuropsychological symptoms identified on special batteries of test designed to measure brain functioning following brain injury. 

While practice in various cognitive tasks–doing arithmetic problems, solving logic puzzles, concentration skills, or reading–may help brain rehabilitation, this is usually not enough. 

Brain injury rehabilitation must be designed taking into account a broad range of neuro-functional strengths and weaknesses. Basic skills must be strengthened before more complex skills are added. Only through comprehensive neuropsychological analysis can the many possible effects of brain injury be sorted out. This pattern of functional strengths and weaknesses becomes the foundation for designing a program of brain rehabilitation. 

Brain recovery follows patterns of brain development. Gross or large-scale systems must develop (or be retrained) before fine systems. Attention, focus, and perceptual skills develop (or are retrained) before complex intellectual activity can be successful.

What Are the Cognitive and Communication Problems That Result From Traumatic Brain Injury?

  • Cognitive and communication problems that result from traumatic brain injury vary from person to person. These problems depend on many factors which include an individual’s personality, preinjury abilities, and the severity of the brain damage.
  • Cognitive functions refer to what or how much (e.g., How much does s/he know? What can s/he do?. So long as the executive functions are intact, a person can sustain considerable cognitive loss and still continue to be independent, constructively self-serving, and productive. 
  • When executive functions are impaired. the individual may no longer be capable of satisfactory self-care, of performing remunerative or useful work on his or her own, or of maintaining normal social relationships regardless of how well preserved are his or her cognitive capacities — or how high his or her  scores on tests of skills, knowledge, and abilities. 
  • Moreover, cognitive deficits usually involve specific functions or functional areas; impairment in executive functions tend to show up globally, affecting all aspects of behavior.
  • Executive functions consist of those capacities that enable a person to engage in independent, purposive, self-serving behavior successfully. They differ from cognitive functions in a number of ways.  Questions about executive functions ask how or whether a person goes about doing something (e.g., Will s/he do it and, if so how?) 

(Source: Dr. Muriel Lezak,  Neuropsychological Assessment)

  • The effects of the brain damage are generally greatest immediately following the injury. However, some effects from traumatic brain injury may be misleading. The newly injured brain often suffers temporary damage from swelling and a form of “bruising” called contusions. These types of damage are usually not permanent and the functions of those areas of the brain return once the swelling or bruising goes away. Therefore, it is difficult to predict accurately the extent of long-term problems in the first weeks following traumatic brain injury.
  • Focal damage, however, may result in long-term, permanent difficulties.Improvements can occur as other areas of the brain learn to take over the function of the damaged areas. Children’s brains are much more capable of this flexibility than are the brains of adults. For this reason, children who suffer brain trauma might progress better than adults with similar damage. 
  • In moderate to severe injuries, the swelling may cause pressure on a lower part of the brain called the brainstem, which controls consciousness or wakefulness. Many individuals who suffer these types of injuries are in an unconscious state called acoma. A person in a coma may be completely unresponsive to any type of stimulation such as loud noises, pain, or smells. Others may move, make noise, or respond to pain but be unaware of their surroundings. These people are unable to communicate. Some people recover from a coma, becoming alert and able to communicate. 
  • In conscious individuals, cognitive impairments often include having problems concentrating for varying periods of time, having trouble organizing thoughts, and becoming easily confused or forgetful. Some individuals will experience difficulty learning new information. Still others will be unable to interpret the actions of others and therefore have great problems in social situations. For these individuals, what they say or what they do is often inappropriate for the situation. Many will experience difficulty solving problems, making decisions, and planning. Judgment is often affected.
  • Language problems also vary. Problems often include: 
    • word-finding difficulty 
    • poor sentence formation 
    • and lengthy and often faulty descriptions or explanations. 
  • These are to cover for a lack of 
    • understanding or inability to think of a word. 
    • For example, when asking for help finding a belt while dressing, an individual may ask for “the circular cow thing that I used yesterday and before.”
    • Many have difficulty understanding multiple meanings in jokes, sarcasm, and adages or figurative expressions such as, “A rolling stone gathers no moss” or “Take a flying leap.” 
  • Individuals with traumatic brain injuries are often unaware of their errors and can become frustrated or angry and place the blame for communication difficulties on the person to whom they are speaking. Reading and writing abilities are often worse than those for speaking and understanding spoken words. Simple and complex mathematical abilities are often affected. 
  • The speech produced by a person who has traumatic brain injury may be slow, slurred, and difficult or impossible to understand if the areas of the brain that control the muscles of the speech mechanism are damaged. 
    • This type of speech problem is called dysarthria
    • These individuals may also experience problems swallowing. 
    • This is called dysphagia. Others may have what is called apraxia of speech, a condition in which strength and coordination of the speech muscles are unimpaired but the individual experiences difficulty saying words correctly in a consistent way. 
    • For example, someone may repeatedly stumble on the word “tomorrow” when asked to repeat it, but then be able to say it in a statement such as, “I’ll try to say it again tomorrow.”
  • How Are the Cognitive and Communication Problems Assessed? 
    • The assessment of cognitive and communication problems is a continual, ongoing process that involves a number of professionals. 
    • Immediately following the injury, a neurologist (a physician who specializes in nervous system disorders) or another physician may conduct an informal, bedside evaluation of 
      • attention 
      • memory 
      • and the ability to understand and speak. 
    • Once the person’s physical condition has stabilized, a 
    • speech-language pathologist may evaluate cognitive and communication skills, and a 
    • neuropsychologist may evaluate other cognitive and behavioral abilities. 
    • Occupational therapists also assess cognitive skills related to the individual’s ability to perform “activities of daily living” (ADL) such as dressing or preparing meals. An audiologist should assess hearing. All assessments continue at frequent intervals during the rehabilitative process so that progress can be documented and treatment plans updated. The rehabilitative process may last for several months to a year.
  • How Are the Cognitive and Communication Problems Treated?
    • The cognitive and communication problems of traumatic brain injury are best treated early, often beginning while the individual is still in the hospital. 
    • This early therapy will frequently center on increasing skills of alertness and attention. They will focus on improving orientation to person, place, time, and situation, and stimulating speech understanding. 
    • The therapist will provide oral-motor exercises in cases where the individual has speech and swallowing problems.
  • Longer term rehabilitation may be performed individually, in groups, or both, depending upon the needs of the individual. This therapy often occurs in a rehabilitation facility designed specifically for the treatment of individuals with traumatic brain injury. 
  • This type of setting allows for intensive therapy by speech-language pathologists, physical therapists, occupational therapists, and neuropsychologists at a time when the individual can best benefit from such intensive therapy. 
  • Other individuals may receive therapy at home by visiting therapists or on an outpatient basis at a hospital, medical center, or rehabilitation facility.
  • The goal of rehabilitation is to help the individual progress to the most independent level of functioning possible. For some, ability to express needs verbally in simple terms may be a goal. For others, the goal may be to express needs by pointing to pictures. For still others, the goal of therapy may be to improve the ability to define words or describe consequences of actions or events. 
  • Therapy will focus on regaining lost skills as well as learning ways to compensate for abilities that have been permanently changed because of the brain injury. Most individuals respond best to programs tailored to their backgrounds and interests. The most effective therapy programs involve family members who can best provide this information. Computer-assisted programs have been successful with some individuals.

What Research Is Being Done for the Cognitive and Communication Problems Caused by Traumatic Brain Injury?

  • Researchers are studying many issues related to the special cognitive and communication problems experienced by individuals who have traumatic brain injuries.
  • Scientists are designing new evaluation tools to assess the special problems that children who have suffered traumatic brain injuries encounter. 
  • Because the brain of a child is vastly different from the brain of an adult, scientists are also examining the effects of various treatment methods that have been developed specifically for children. 
  • These new strategies include the use of computer programs. In addition, research is examining the effects of some medications on the recovery of speech, language, and cognitive abilities following traumatic brain injury.

Source: Brain Injury Rehabilitation – Cognitive

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