Recovery Factors Flashcards
8 components of recovery methods
- Common recovery misconceptions
- Anosognosia
- Age
- Lesion size
- Chronic vs acute injuries
- Environmental factors
- Secondary effects
- Compensation
Many people falsely believe that…
4 things about recovery
- recovery from brain dysfunction depends primarily on the injured person’s efforts or attitude
- full recovery from severe brain dysfunction is always possible
- all effects of brain dysfunction are externally visible
- people with brain dysfunction always have good insight into their own impairments
Anosognosia
- “without knowledge [gnosis] of disease [nosos]”
- An error of self-awareness, one’s judgment of one’s own functioning
- Can occur on a spectrum: mild (underestimate degree of impariment) -> severe (completely unaware of impairment)
Where can anosognosia be observed?
- Psychiatric disorders (schizophrenia, bipolar)
- Movement disorders
- Contralateral neglect
- Memory disorders
- Stroke
- Dementia (20-80% of people with AD)
- TBI (97% of severe TBI while in hospital; in a small minority, some anosognosia persists for decades)
- MORE
When does Anosognosia come about?
Often transient following an injury and self-resolving, but not always
Is Anosognosia a unitary process?
Not a unitary phenomenon – can separate into subcomponents
Crosson hierarchical awareness model
- Anticipatory awareness
- Emergent awareness
- Intellectual awareness
Anticipatory Awareness
Crosson hierarchical awareness model
Predicting how current deficits may impact future
“it’s probably not safe for me to return to snowboarding yet”
Emergent Awareness
Crosson hierarchical awareness model
Self-monitoring and error detection during task performance
“My skills are off but will be fine next time”
Intellectual Awareness
Crosson hierarchical awareness model
Self-awareness of current deficits
Domain-specificity
Anosognosia
- Patients could have separate unawareness of their neglect, their hemiparesis, and/or their illness
- Not just a blanket failure of self-awareness
Consequences of anosognosia
- Low engagement with rehab
- Medication non-compliance
- Poorer treatment outcomes
- Poorer use of compensatory strategies
- Stress and isolation for both affected person and their care partners
- Need for more supervised or structured living arrangements
Methods of diagnosis
- Clinician judgment (structured interview e.g., Self-Awareness of Deficits Interview)
- Patient-care partner discrepancy (questionnaires e.g., Awareness Questionnaire)
- Self-appraisal performance discrepancy (variety of cognition & memory measures)
Neurological correlations with anosognosia
- In AD, anosognosia is associated with reduced metabolism, cell density, or blood flow in a set of frontal, cingulate, and medial temporal regions associated with cognitive processing of self and the default mode network
- Likely similar in TBI – “dorsal ACC, frontal-parietal regions” (Ham et al., 2014)
Anosognosia impairs functional recovery
Better self-awareness after TBI → greater anxiety and stress at discharge → better psychosocial functioning (work and leisure outcomes, relationships, independent living skills)
Treatment
Anosognosia
Some intellectual awareness necessary to start
Usually through occupational therapy
Multimodal training with feedback:
- Real-life settings
- Guided experience
- Multimodal feedback
- Dialogue between therapist and patient
Anosognosia vs psychological denial
+ denial definition
Is anosognosia just denial?
- Denial: avoiding or rejecting information that is stressful or painful
- Different reactions when confronted with evidence
- Anosognosia: respond with surprise or confabulation (“its my brother’s arm”; “I just walked to the bathroom myself. I’m just too tired to show you now.”)
Denial: respond with resistance, anger, refusal to discuss
Cultural factors in diagnosis
Unwillingness to self-report deficits may be higher among groups with (deserved) mistrust of healthcare providers → probable overestimation of anosognosia among marginalized groups
Recovery from injury across age
- Damage to a given brain area at different times in life leads to very different outcomes
- Margaret Kennard (1899-1975) showed that the impact of motor cortex damage was age-dependent
Age-dependent recovery
8 components of recovery methods
Across age, brains change in their: (Giza et al., 2009)
- Receptor expression
- Level of synaptic pruning
- Level of neurite (axon/dendrite) outgrowth
- Blood flow
- Metabolic patterns
- Myelination
- …
All of these factors shape responsiveness to injury (good & bad)
Impact of lesion size on recovery
8 components of recovery methods
- Larger lesions tend to result in greater functional impairments
- Bilateral lesions show less recovery than unilateral - don’t have that counterpart area on the other side of the brain that could lessen the load
Chronic vs acute dysfunction
8 components of recovery methods
- Massive slow-growing tumour > little impairment
- VERSUS
- Sudden stroke with associated damage of comparable size > functionally devastating
Environmental factors - in animals, which housing is best for recovery from brain injury?
enriched environment»_space; typical housing
For humans, what are the benefits of an enriched environment in brain injury recovery?
8 components of recovery methods
FROM ENRICHED ENVIRONMENT STROKE STUDY:
* activity levels increased (sustained after discharge)
* length of stay shorter
* modified Rankin scale (6-point measure of functional independence) not different at discharge
Secondary effects of injury - edema
8 components of recovery methods
Edema – following stroke or brain injury, there may be considerable swelling
Secondary effects of injury - blood flow
8 components of recovery methods
- Blood flow – locally changes following injury
- These can be temporary
Secondary effects of injury - Diaschisis
8 components of recovery methods
Diaschisis (“shocked throughout”) – sudden change of function (metabolic depression) in a portion of the brain connected to a distant, damaged area
Post-injury improvements (3)
A MIX OF:
- Dissipation of secondary effects
-
Compensation – substitution of new behaviour (“a new way to do an old thing”)
- e.g., Carrying a notebook, walking with an aid, using notation software…
- e.g., rat reaching following motor cortex injury (doing other actions to eat a pellet - sticking tongue out - rather than just reaching for it) - Plasticity – “rewiring” of the brain’s connections [more later]
