Brain Insult - Neurological rehabilitation

Brain Insult Neuropsychological Rehabilitation

Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012

1

Epidemiology of stroke in Germany

2

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

2

Epidemiology of stroke in Germany

3

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

3

Epidemiology of stroke in the world

4

Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012

4

Epidemiology of stroke in the world

5

Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012

5

Prognosis (German Stroke database)

6

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

6

Brain Insult - Neuropsychological Rehabilitation

7

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

7

Outline for the future ?

8

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

8

What happens with the survivors? spontaneous restitution TBI

9

spontaneous restitution CVI

verbale Intelligenz

non-verbale Intelligenz

Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012

9

“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

10

Pushed world !

Neglect

The wold withou forms !

Konstruktive Apraxie

Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012

10

What are their problems ?

11

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

11

Deficits ?

ATTENTION DISORDERS

12

~ 80 %

Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012

12

Deficits ?

MEMORY DISORDERS

13

60%-70%

Brain insult – Cognitive rehabilitation • Frank Schulze, Germany • Wednesday, September 19, 2012

13

Deficits ?

14

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

14

Deficits ?

15

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

15

Treatment of deficits WHAT TO DO ?

16

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

16

REHABILITATION -What does it mean ?

17

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

17

What tells us the theory ?

18

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

18

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

19

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

19

The therapeutic team Occupational therapy Ergotherapy

20

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

20

Cognitive therapy works !

21

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

21

Cognitive therapy works !

22

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

22

Why use a computer for therapy?

23

...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

23

Why use a computer for therapy?

24

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

24