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Clinical and Neuropsychology - 1 > NPch.5 - Recovery and Treatment > Flashcards

NPch.5 - Recovery and Treatment Flashcards

1
Q

Recovery

A
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2
Q

What are the 3 types of recovery?

A
  • Spontaneous
  • Non-invasive brain stimulation
  • Experience-dependent learning
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3
Q

What is Spontaneous recovery (injury induced change)?

A

Changes that occur at response to injury at neuronal level (recovery happens automatically by itself)
- Recovery takes usually 12-14 weeks
- (See 1st image of slides for trajectory of recovery)
~ PROBLEM with improvement: maybe it’s due to learning effects (you just improve because you do the same test repeatedly, so in truth improvement is due to familiarity with the test, not cognitive improvement)

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4
Q

What are some possible mechanisms behind spontaneous recovery?

A
  • Diffuse and redundant connectivity: Recovery takes place by activating other areas within a network (if brain region 1 of a network is damaged, all other regions of the same network are activated even more to compensate for loss of brain region 1)
  • Cortical re-organization: New structural and functional connections between cortical areas
  • Restitutive re-connection: Neurons in areas adjacent to the damaged area quickly create new connections in order to replace lost ones
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5
Q

What will happen if an injury is too severe?

A

Reconnection and associated recovery will be impossible:
- Cognitive impairments will be chronic
- Recovery will only be available to happen through compensation at a behavioral level (exercising, training, perseverance etc.)

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6
Q

What is Non-invasive brain stimulation?

A

Stimulate or inhibit specific brain areas
- Has small short-term effects
- Has limited long-term effects
- Future: could be used as an add-on therapy (alongside anything else)

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7
Q

What is Experience-Dependent Learning?

A

Through learning, we are able to promote plasticity (e.g. Brain of Taxi drivers, see flashcard 13)

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8
Q

What recovery type is typical after a brain injury?

A

Usually a brain injury is followed by spontaneous recovery
- Extent of recovery depends on severity, location and type of brain injury

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9
Q

What are the two types of neuropsychological symptoms according to Goldstein (Hughlings-Jackson)?

A

Direct (negative) and indirect (positive) symptoms.

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10
Q

What are direct (negative) symptoms?

A

They’re are a loss or change in behavior or cognitive processes because of damage to brain (e.g. slowness of info processing because of TBI)
- Recovery of these symptoms is at the neurological level

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11
Q

What are indirect (positive) symptoms?

A

These symptoms are the observed and actual attempts of the patient to deal with the impairment
- Depend on patient’s premorbid functioning, social support, and coping skills:
~ adaptive coping: restructuring tasks around impairment so that you can function as much and efficiently as possible
~ maladaptive coping: Avoid all tasks out of fear/unwillingness to try
- Recovery at the psychological level

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12
Q

Where is most of our knowledge on recovery focused on?

A

Cognitive functioning
- We have a limited understanding of recovery of emotional and behavioral functioning
- We have charted the course of cognitive functioning by repeatedly carrying out measurements at different times of recovery (See 1st image in slides)

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13
Q

Can a patient ever recover fully and go back to premorbid functioning?

A

NO: even after recovery, patients still perform worse than controls on any task.

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14
Q

What is the chronical timeline of recovery on different aspects of recovery?

A
  • After one year, recovery of brain tissue is finished
  • Behavioral functioning may continue improving through:
    -> restructuring tasks and activities: represents psychological recovery
    !!! (First neurological recovery, then either simultaneously or either after, psychological recovery)
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15
Q

Neuroplasticity

A
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16
Q

What is Neuroplasticity?

A

It’s the brain’s ability to modify itself (functionally or structurally), either:
- in response to injury
- due to influence of stimulation
- due to learning/experience
- because of development

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17
Q

What are some factors to achieve stimulation of plasticity following a BI?

A
  • Stimulation can only achieve an effect in the case of mild or moderate brain injury
  • Timing of stimulation is important in achieving good results
  • Apart from non-specific stimulation, focused stimulation helps as well:
    -> An example is bottom-up stimulation: external stimuli are administered in order to stimulate the formation of the new neural connections (Based on Hebb’s principle: “neurons that fire together wire together”)
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18
Q

What are some factors that (might) influence neuroplasticity?

A
  • Salience
  • Development
  • !!! Age (Kennard principle) !!!
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19
Q

How does Salience affect neurplasticity?

A

Relevant and important exercises will be processed better and thus will affect the brain’s neuroplasticity even more

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20
Q

How does development of the brain affect neuroplasticity?

A

Development of the brain in the prenatal period is key to plasticity. Injury during this period affects life-time neuroplasticity

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21
Q

(Age) What is the Kennard principle?

A

Kennard stated that age matters, and that the younger one is the more neuroplasticity this person has.

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22
Q

Has Kennard’s principle been confirmed?

A

NO -> evidence against this principle:
- children with diffuse damage from TBI recover less well than adults with the same injury
- Severe or moderate TBI: younger subjects have a poorer prognosis than older children

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23
Q

(What is prognosis?)

A

(A clinician’s judgment of the likely or expected development of a disease or of the chances of getting better)

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24
Q

What is a double hazard?

A

A double hazard is the worst possible prognosis that can come about when there’s a very serious brain injury at a very young age (the more the severity and the younger the patient, the worse the prognosis)

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25
Q

Why is the double hazard underestimated?

A

Because damage at such a young age facts brain areas that haven’t matured yet (mature later on), so you can’t see the damage because the brain area’s damaged aren’t even being “used” yet.

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26
Q

What does growing into deficit mean?

A

If a patient at a young age has a very serious injury, and this injury affects brain areas that haven’t matured yet, this patient will develop even worse impairments when these areas develop, than somebody who had the same brain injury in the same areas, but at a later age.

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27
Q

Rehabilitation

A
28
Q

What are the 2 approaches to rehabilitation?

A
  • Restorative approach (most dominant in the past)
  • Compensatory approach (currently most dominant approach)
29
Q

What is the restorative approach?

A

Focus on recovery (restoration) of a damaged cognitive function and its underlying brain structure -> improve functioning with regard to activities and participation level by using intact abilities
- Focused training: used to stimulate damaged cognitive function, result is recovery

30
Q

What is the compensatory approach?

A

Damage is irreversible, but can be compensated by deployment and use of patients intact functions and abilities
- Embraces all methods that bring about better functioning of patient
- treatment extends to physical and social environment of patient (e.g. help family of patient as well)

31
Q

Out of the 2 approaches, which one is better?

A

Compensatory. Only treatment that focus on compensation are sufficiently based. There is no effective treatment to restore cognitive functioning to premorbid levels.

32
Q

What are the aspects of rehabilitation?

A
  • Cognitive rehabilitation
    ~ Learning
    ~ Models
  • Neuropsychological rehabilitation
33
Q

(Cognitive rehabilitation - Learning)

A
34
Q

Why is Learning in patients with BI important?

A

Following BI patients’ old skills are lost or affected and will have to be re-learned. Also, the patient will have to learn new skills as well

35
Q

What is Learning?

A
  • (In psychological terms): A relatively permanent change in behavioral repertoire that is the result of experience
  • (In terms of recovery): Learning experiences or a stimulating environment leads to neuroplasticity
36
Q

What are some examples of Learning in terms of recovery?

A
  • Taxi drivers -> increased gray matter volume in mid-posterior hippocampi (better memorization of streets)
  • Bus drivers -> better spatial skills
  • Musicians -> more gray matter in regions with motor, auditory and visuospatial areas
37
Q

What are some factors that influence learning (in both terms of learning)

A
  • Extent to which a link between trigger and target behavior is frequently and constantly made
    ~ Connection between stimulus and response is established when they co-occur constantly (consistent mapping)
    ~ Connection between stimulus and response isn’t established when there’s always a different response (varied mapping
  • Variability of context (confounding factors)
  • Knowledge of results (confounding factors)
    ~ Has to be immediate
    ~ Applies for both motor and cognitive learning
  • Patient’s insight into own disorder, and consequences of awareness on everyday life
  • Consequences of brain injury (specifically how intact executive functions are)
    (Through feedback, learning processes can be optimized and adjusted)
38
Q

What is the influence of the environment on learning?

A

Many times, a learned behavior is highly dependent on the context (context being physical or social environment):
- State-dependent learning: learned behavior will be easier to demonstrate if context is similar to the one in which you learned the behavior. (e.g. if you learned to walk again with therapist, it will be a lot easier for you to walk if your therapist is next to you)

39
Q

What is the problem with this?

A

Goal of rehabilitation is to learn a behavior independently of context:
- Either transfer learned behavior to another situation, or:
- Generalize behavior to all situations (this specifically is difficult for patients with BI)

40
Q

How can we achieve generalization or transfer of behavior to other situations?

A
  • Variability of practice (VP) -> The more the variations in learning process and contexts, the easier it is to generalize
  • Linkage to site of application (LA) -> The earlier on the link between learning behavior and situation in which behavior must be performed is made, the better the learned behavior (Diary example)
41
Q

What is one common factor on which VP and LA depend on?

A

Executive functions: enable people to evaluate what behavior is required, plan it out, initiate it, and carry out the behavior

42
Q

(Cognitive Rehabilitation - Models)

A
43
Q

What is the use of classification models?

A

Give us insight into the consequence of a serious brain injury and how they affect a patient’s learning ability.

44
Q

What are the two main classification models?

A
  • International Classification of Diseases, Impairments and Handicaps (ICDIH Model)
  • International Classification of Functioning, Disability and Health (ICF)
45
Q

What does the ICDIH state?

A

(See image on PowerPoint)
Facilitates the distinction between the consequences of illness/disease for the individual functioning of patients at 3 different levels: Impairment, Disease, and Handicap
- classifies consequences of illness

46
Q

What are the differences between Impairment, Disease and Handicap?

A
  • Impairment: Manifestation of disorders at an organ level (description correlates to function of an organ)
  • Disabilities: consequences of impairment at functional level
  • Handicap: consequences of impairment at societal level
47
Q

What does the ICF state?

A

(See image in PowerPoint)
- Focuses on classification of “health components” (compared to classification of illnesses and problems of the ICDIH)
- Guide for classifying treatment goals according to the level of functioning on which treatment goals focus on

48
Q

What is Gross’ and Schultz’s diagram, and what does it show us?

A

(See image on PowerPoint)
- It shows us the various relationships between various training options and their possible effects

49
Q

What is the 1st level - Environmental control?

A

Lowest level in how much the patient actually changes:
- patient’s learning ability is very limited: somebody has to constantly modify the patient’s physical and social environment

50
Q

What is the 2nd level - Stimulus-Response Conditioning (S-R Conditioning)?

A

Because of conditioning, limited routine is triggered by a stimulus (Even though it’s limited, it’s still a routine, indicating a first step in autonomy for the patient)

51
Q

What is the 3rd level - Skill training?

A

Train skills for a task through repeated exercise (e.g. how to use your phone or any machine)
!!! IN GENERAL: learning of the primary objective !!!
- not aimed at improving an underlying cognitive function
- Highly task-specific, not aimed at generalization

52
Q

What is a Strategy?

A

A general, abstract, top-down approach that aims to achieve improved functioning through restructuring of tasks, tighter planning of activities and stricter control over one’s own behavior

53
Q

What is the 4th level- Strategy training?

A

Train skills that apply in multiple tasks or situations where multiple cognitive functions are called upon (e.g. STOP-THINK-ACT Model)

54
Q

What is the 5th level - Cognitive Cycle?

A

(patient must have intact executive functions to reach this level). Patient engages in the following thinking
1/. set realistic learning goals
2/. Make plans
3/. Carry them out
4/. Compare results with original plans’
5/. Adjust plans if necessary

55
Q

What is the Hierarchy of Neuropsychological intervention methods?

A

The less able patients are to learn and the less able they are to play an active role in the learning process, the more external structure from the environment is required (Structure here is everything that guides behavior externally)

56
Q

(Neuropsychological rehabilitation)

A
57
Q

What is the focus of Neuropsychological rehabilitation?

A

cognitive, EMOTIONAL & BEHAVIORAL disorder resulting from brain injuries

58
Q

What is function training?

A

Use computer tasks that utilize specific exercises to train memory, reaction skills and attention.
- based on repeated practice approach: if I constantly perform e.g. a memory task, my memory will improve

59
Q

What is a problem with function training?

A

Too non-specific and simplistic: Improvement is only on task or similar tasks, and results don’t generalize
(if training had effect on underlying brain structure, the effect wouldn’t be task specific, which isn’t in line with rehabilitation, which is to generalize improvements of functioning)

60
Q

General final notes

A
61
Q

What is Psychoeducation?

A

Provide patients with explanation and info about neuropsychological consequences of brain injury in general, as well as neuropsychological consequences for that person in general
- Reassure patients about “normal” consequences of brain injury

62
Q

What are environmental modifications?

A

Changes that have to be made in physical and social environment so that the patient is provided with a structure that will enable them to function as well as possible with their disability

63
Q

What is Neuro-psychotherapy?

A

A therapy aimed at specific emotional and psychosocial problems of patients with brain injury.

64
Q

What are the steps for Neuro-psychotherapy?

A

1/. Increase insight into own problems
2/. Boost motivation to engage with treatment
3/. Teach adaptive coping skills
4/. Teach how to cope with problems caused by loss of options and future opportunities

65
Q

What are interventions on Behavior Modification?

A

Interventions for patients with more severe behavioral disorders
- Derives its principles from learning theory
- Entails Behavior Therapy to extinguish unwanted behavior

Clinical and Neuropsychology - 1 (21 decks)

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