Intensive Cognitive Rehabilitation Research Articles

Measuring Impairment-Specific Gains in Individual Cognitive Rehabilitation Through a Systematic Therapy Protocol.

This study investigated treatment-induced performance gains in memory function following therapy through the Intensive Cognitive Communication Rehabilitation (ICCR) program for young adults with acquired brain injury (ABI). We aimed to determine the utility of a novel approach to measuring memory performance improvement across semesters of therapy using (a) systematic treatment tasks called Individualized Quantitative Protocols (IQPs) as compared to (b) standardized measures of memory function. Retrospective IQP data spanning five consecutive ICCR semesters were collected from patients (N = 13) with ABI. Raw task-accuracy data were scaled to account for task difficulty gradation. Linear mixed-effects models (LMMs) were used to evaluate the degree of memory improvement-measured by scaled IQP scores-as a function of therapy duration, age, time postinjury, and aphasia; pre- to posttreatment effect sizes were also calculated. For comparison, similar LMMs were run using standardized metrics of memory abilities as the outcome measure. Results showed significant treatment-induced improvements, with gains at the session level (β = 2.76; t = 2.23; p = .047), when improvement was measured using IQP scaled scores. Standardized metrics did not show significant improvement as a function of therapy. Effect size analysis mirrored LMM results, with a large (d = 0.92, 95% confidence interval [0.35, 1.49]) pre- to posttreatment effect when change was measured using IQP scaled scores and a small effect for standardized measures. This preliminary study demonstrates the utility of a granular, individualized metric to index significant impairment-based performance gains following ICCR treatment. These results introduce promise for future analysis of complex treatment data. Additionally, they provide another lens with which to assess treatment progress and its significance. https://doi.org/10.23641/asha.27045937.

Long-Term Effects of Intensive Rehabilitation on Memory Functions in Acquired Brain-Damaged Patients.

Memory difficulties after brain injury are a frequent and concerning outcome, affecting a wide range of daily activities, employment, and social reintegration. Despite the importance of functional memory capacities throughout life, most studies examined the short-term effects of memory interventions in brain-damaged patients who underwent a rehabilitation program. In the present study, we investigated the long-term outcomes and intensity of memory interventions in acquired (traumatic brain injury [TBI] and non-TBI) brain-damaged patients who participated in an intensive cognitive rehabilitation program and either suffered or did not suffer from memory impairments. We measured pre-post-treatment memory performance of patiients (N = 24) suffering from memory deficits in four common and validated memory tasks (e.g. ROCFT). We compared them to other acquired brain injury patients treated at the same rehabilitation facility who did not suffer from memory impairments (N = 16). Patients with memory deficits showed long-term improvements in three out of four tasks, while patients without memory deficits showed memory enhancements in only one task. In addition, rehabilitation intensity and type of brain damage predicted the extent of the memory change over time. Long-term improvements in objective memory measures can be observed in patients suffering from brain injury. These improvements can be enhanced by intensifying the treatment program. Findings also suggest that these memory improvements are more pronounced in non-TBI than TBI patients. We discuss the implications of these results in designing optimal memory rehabilitation interventions.

Young Adults With Acquired Brain Injury Show Longitudinal Improvements in Cognition After Intensive Cognitive Rehabilitation.

The aim of this study was to assess the effect of an intensive cognitive and communication rehabilitation (ICCR) program on language and other cognitive performance in young adults with acquired brain injury (ABI). Thirty young adults with chronic ABI participated in this study. Treatment participants (n = 22) attended ICCR 6 hours/day, 4 days/week for at least one 12-week semester. Deferred treatment/usual care control participants (n = 14) were evaluated before and after at least one 12-week semester. Pre- and postsemester standardized cognitive assessment items were assigned to subdomains. Between-groups and within-group generalized linear mixed-effects models assessed the effect of time point on overall item accuracy and differences by item subdomain. Subdomain analyses were adjusted for multiple comparisons. Between-groups analyses revealed that treatment participants improved significantly faster over time than deferred treatment/usual care participants in overall item accuracy and specifically on items in the verbal expression subdomain. Investigating the three-way interaction between time point, group, and etiology revealed that the overall effects of the treatment were similar for individuals with nontraumatic and traumatic brain injuries. The treatment group showed an overall effect of treatment and significant gains over time in the verbal expression, written expression, memory, and problem solving subdomains. The control group did not significantly improve over time on overall item accuracy and showed significant subdomain-level gains in auditory comprehension, which did not survive correction. Sustaining an ABI in young adulthood can significantly disrupt key developmental milestones, such as attending college and launching a career. This study provides strong evidence that integrating impairment-based retraining of language and other cognitive skills with "real-world" application in academically focused activities promotes gains in underlying cognitive processes that are important for academic success as measured by standardized assessment items. These findings may prompt a revision to the current continuum of rehabilitative care for young adults with ABI. https://doi.org/10.23641/asha.19320068.

Multi-level outcomes for young adults with acquired brain injury through a remote intensive cognitive rehabilitation approach: a pilot intervention study

ABSTRACT Objective To investigate the effects of the Intensive Cognitive and Communication Rehabilitation (ICCR) program for young adults with acquired brain injury (ABI) using a quasi-experimental pilot intervention study design while transitioning to remote implementation. Method Twelve young adults with chronic ABI (treatment n = 7; control n = 5) participated in ICCR (i.e., lectures, seminars, individual cognitive rehabilitation (CR), technology training) for six hours/day, four days/week, for one or two 12-week semesters. Outcomes included classroom metrics, individual therapy performance, including Goal Attainment Scaling (GAS), standardized cognitive-linguistic assessments, and participation and health-related quality of life (QOL) measures. Results In the first semester (in-person and remote), treatment participants significantly improved in classroom exams; individual therapy (i.e., memory, writing, GAS); executive function and participation measures, but not QOL. In the second semester (remote), treatment participants significantly improved in classroom exams; essay writing; individual therapy (i.e., writing and GAS); and memory assessment, but not in participation or QOL. Treatment participants enrolled in consecutive semesters significantly improved in classroom exams, individual therapy (i.e., memory), participation and QOL, but not on standardized cognitive assessments. Controls demonstrated no significant group-level gains. Conclusion These preliminary results highlight the benefit of intensive, integrated, and contextualized CR for this population and show promise for its remote delivery.

Neuroimaging Biomarkers Predicting the Efficacy of Multimodal Rehabilitative Intervention in the Alzheimer's Dementia Continuum Pathology.

In this work we aimed to identify neural predictors of the efficacy of multimodal rehabilitative interventions in AD-continuum patients in the attempt to identify ideal candidates to improve the treatment outcome. Subjects in the AD continuum who participated in a multimodal rehabilitative treatment were included in the analysis [n = 82, 38 Males, mean age = 76 ± 5.30, mean education years = 9.09 ± 3.81, Mini Mental State Examination (MMSE) mean score = 23.31 ± 3.81]. All subjects underwent an MRI acquisition (1.5T) at baseline (T0) and a neuropsychological evaluation before (T0) and after intervention (T1). All subjects underwent an intensive multimodal cognitive rehabilitation (8–10 weeks). The MMSE and Neuropsychiatric Inventory (NPI) scores were considered as the main cognitive and behavioral outcome measures, and Delta change scores (T1–T0) were categorized in Improved (ΔMMSE > 0; ΔNPI < 0) and Not Improved (ΔMMSE ≤ 0; ΔNPI ≥ 0). Logistic Regression (LR) and Random Forest classification models were performed including neural markers (Medial Temporal Brain; Posterior Brain (PB); Frontal Brain (FB), Subcortical Brain indexes), neuropsychological (MMSE, NPI, verbal fluencies), and demographical variables (sex, age, education) at baseline. More than 50% of patients showed a positive effect of the treatment (ΔMMSE > 0: 51%, ΔNPI < 0: 52%). LR model on ΔMMSE (Improved vs. Not Improved) indicate a predictive role for MMSE score (p = 0.003) and PB index (p = 0.005), especially the right PB (p = 0.002) at baseline. The Random Forest analysis correctly classified 77% of cognitively improved and not improved AD patients. Concerning the NPI, LR model on ΔNPI (Improved vs. Not Improved) showed a predictive role of sex (p = 0.002), NPI (p = 0.005), PB index (p = 0.006), and FB index (p = 0.039) at baseline. The Random Forest reported a classification accuracy of 86%. Our data indicate that cognitive and behavioral status alone are not sufficient to identify best responders to a multidomain rehabilitation treatment. Increased neural reserve, especially in the parietal areas, is also relevant for the compensatory mechanisms activated by rehabilitative treatment. These data are relevant to support clinical decision by identifying target patients with high probability of success after rehabilitative programs on cognitive and behavioral functioning.

I can\u2019t count, but I can beat you playing cards: a case report on autoimmune encephalitis

BackgroundAutoimmune encephalitis (AE) is a rare inflammatory disorder characterized by important psychiatric and neurologic symptoms. The literature documents high rates of neuropsychological dysfunction in N-methyl D-aspartate-receptor (NMDAr) encephalitis but papers don’t consider specifically calculation disturbances between the long-term deficits, although deficits in executive control and episodic memory were less likely to resolve.Case reportHere we present a severe case of NMDAr encephalitis in a young patient without a relevant past medical history. Upon first examination he presented psycho-motor slowdown, speech disorders, severe cognitive deficits in all areas: concentration, attention, memory, language, dual task functions, increased latency in responses, severe dyscalculia. Upon first evaluation, the young patient underwent a battery of neuropsychological tests and he showed a dysexecutive syndrome with performances significantly low for age and education. Our patient hence underwent 1 month of intensive cognitive rehabilitation. After the rehabilitation treatment, he presented an amelioration in all domains except calculations.ConclusionsIn our patient the calculation disorder has proved to be the most relevant problem and the most difficult to treat. Clinicians should consider a careful approach to determine the prognosis of this syndrome because of the wide range of deficits, the need of prolonged treatment and the rate of long-term sequelae.

Acquired Brain Injury in Adults: A Review of Pathophysiology, Recovery, and Rehabilitation.

To summarize existing literature from a range of fields (i.e., neurology, neuropsychology, neuroscience, neuroimaging, rehabilitation, speech-language pathology) that is relevant to the development and/or revision of cognitive rehabilitation programs for individuals with acquired brain injury (ABI) and in particular, for young adults. This paper reviews a range of ABI-associated topics including: 1) mechanisms of injury; 2) biological, individual-specific, and behavioral drivers of recovery; and 3) current methods of cognitive rehabilitation. It then narrows focus to young adults, a frequently affected and growing population to sustain ABI. The paper concludes by providing: 1) suggestions for key components of cognitive rehabilitation for young adults with ABI; 2) an example from our own research providing intensive academically-focused cognitive rehabilitation for young adults with ABI pursuing college; and 3) recommendations for future behavioral and neuroimaging studies in this area. ABI is on the rise in the United States. Young adults have been sustaining ABI at higher rates over the past several decades. These injuries occur when they would otherwise be advancing their academic and career goals, making the cognitive deficits that often accompany ABI especially devastating for this group. Review of existing literature suggests cognitive rehabilitation programs that combine aspects of restorative, comprehensive, and contextualized approaches could promote recovery for young adults with ABI. Future intervention studies may benefit from including both behavioral and neural outcomes to best understand how principles of neuroplasticity- naturally embedded within many cognitive rehabilitation approaches-could be manipulated to promote cognitive recovery and long-lasting brain reorganization in this group.

Mania with Malignant Catatonia Due to Nonparaneoplstic Anti-N-Methyl-D-Aspartate Receptors Encephalitis in a 29-Year-Old Female

Anti-N-methyl-D-aspartate receptors (NMDARs) encephalitis is a rare neurological autoimmune encephalitis. Its symptoms may mimic psychosis as this disease is a neurological disorder in psychiatry costume. Disparity in clinical symptoms and nonsupportive laboratory investigations except the cerebrospinal fluid (CSF) analysis delays the diagnosis. We are presented with a case of 29-year-old female with psychiatric symptoms such as suspiciousness, decreased sleep, and boastfulness. Within a few days, the patient developed neurological symptoms such as seizures and disorientation, while the patient was on an antipsychotic along with benzodiazepines. Her symptoms worsened with autonomic instability, and the patient entered into catatonic phase of the illness. We reached a positive diagnosis of anti-NMDAR encephalitis through CSF analysis. The patient recovered completely with the help of immunotherapy and intensive cognitive rehabilitation. This case emphasizes the need of a multidisciplinary approach in the management, early detection, and adequate treatment of this challenging illness for better results for patients.

Young Adults with Acquired Brain Injury Show Significant Gains in Cognitive Domains Following Intensive Cognitive and Communication Rehabilitation

Young Adults with Acquired Brain Injury Show Significant Gains in Cognitive Domains Following Intensive Cognitive and Communication Rehabilitation

Intensive computer-assisted cognitive rehabilitation in persons with multiple sclerosis – results of a 12-week randomized study

Intensive computer-assisted cognitive rehabilitation in persons with multiple sclerosis – results of a 12-week randomized study

Beneficial effects of early attention process training after acquired brain injury: A randomized controlled trial.

Evaluation of outcome after intensive cognitive rehabilitation early after brain injury is complicated due to the ongoing biological recovery process. To evaluate the efficacy of Attention Process Training early after acquired brain injury through time-series measurement with statistical process control. Randomized controlled trial. Patients with acquired brain injury (n = 59) within 4 months' post-injury in interdisciplinary rehabilitation received an additional 20 h of attention training with Attention Process Training or with activity-based attention training. The primary outcome variable was Paced Auditory Serial Attention Test (PASAT) evaluated using statistical process control. Both groups improved (p < 0.001), although a higher number of patients improved with attention process training (χ2 (1, n = 59) = 5.93, p = 0.015) and the variability was significantly decreased. The Attention Process Training group maintained or improved performance at 6 months follow-up (χ2 (1, n = 51) = 6,847, p = 0.033). Attention Process Training required fewer intervention hours for improvement. Based on individual performance, 3 improvement trajectories were identified: stationary, steady, and rapid improvers. The results indicate that attention training is promising early after acquired brain injury and that Attention Process Training boosts functional improvement. Notably, in the present group of relatively homogeneous patients, 3 different trajectories were identified for recovery after acquired brain injury regardless of intervention.

CSD Program Makes College Possible After Brain Injury

CSD Program Makes College Possible After Brain Injury

Making More of IT: Enabling Intensive Motor Cognitive Rehabilitation Exercises in Geriatrics Using Information Technology Solutions.

Although the health benefits of physical activity and exercise for older people are well established, a largely sedentary lifestyle still prevails in ageing western societies. Finding new ways to make exercise more accessible and acceptable for older adults must be developed to fully unleash its potential in preventing and weakening age-related physical and cognitive decline. Existing barriers to implement effective exercise-based treatment plans include motivational reservations on both the clinician's and patient's side, but also physical limitations caused by disease or deconditioning. Particularly in the more senior population, debilitating conditions do not allow adherence to currently recommended exercise regimes. A major rethinking of age- and user-adapted exercise is overdue. The high intensities required for physical and mental adaptations must be modifiable and personalized according to the functional status of each patient. Emerging information and communication technologies (ICT) have brought forward a plethora of attractive solutions for smart and adapted exercise, but there remains a vast gap between technological advancement and clinical relevance. Where in the beginning ICT for active ageing mainly focussed on aspects of usability and user experience, the current status of IT as applied in ageing populations noticeably shifted toward new services, applications, and devices that can be offered with the aim to prevent, compensate, care, and/or enhance daily life functioning of senior citizens. In this perspective paper, we aim to summarize the current state of the art in ICT-based interventions aimed at improved motor-cognitive control and make suggestions about how these could be combined with high-intensive interval exercise regimes to make rehabilitation for the impaired older adults more effective, and more fun.

Intensive cognitive rehabilitation therapy for chronic traumatic brain injury: a case study of neural correlates of functional improvement

ABSTRACTBackground: Some four million Americans are living with chronic disability related to traumatic brain injury (TBI). Yet, very little research has investigated training-induced neuroplasticity over many hours of treatment well into the chronic stage for the most commonly impaired functions (attention, executive functions (EFs), and prospective memory (PM)).Aims: The purpose of the present study was to investigate whether a 30-h course of intensive evidence-based treatments of attention, EFs, and PM would show behavioural gains and associated brain structural and/or functional changes in an individual well into the chronic phase of recovery from TBI.Methods & Procedures: An A-B single-participant quasi-experimental design with 1 month post-treatment follow-up was employed for cognitive rehabilitation of a 54-year-old man, 7.5 years after severe TBI. After an initial 4-week pre-treatment baseline phase, 30 hours of therapy was provided over 3 weeks, targeting attention, PM, and EFs, with follow-up testing at 1-month post-treatment. Treatments (selected from evidence-based practice guidelines) consisted of attention process training, metacognitive strategy instruction, and PM training. Neuroimaging (auditory oddball paradigm, resting state, and diffusion tensor imaging) was conducted weekly from the end of the A-phase, through the end of the B-phase, and then at 1-month follow-up.Outcomes & Results: Results demonstrated gains to behavioural and quality of life measures for attention and EFs, with evidence of associated structural and functional neuroplasticity. There was no evidence of change to PM skills.Conclusions: Intensive evidence-based treatment of attention and EFs improved functioning and quality of life in an individual well into the chronic phase of TBI, and may be associated with structural and functional neuroplasticity.

Intensive Cognitive Communication Rehabilitation (ICCR) Program for Young Adults With Acquired Brain Injury

Purpose This study investigated the effects of an intensive cognitive-communication rehabilitation (ICCR) program for young individuals with chronic acquired brain injury. Method ICCR included clas...

A feasibility study of working memory training for individuals with paediatric-onset multiple sclerosis

ABSTRACTObjective: To investigate the feasibility and experiences of paediatric-onset multiple sclerosis (MS) patients completing a working memory training programme.Methods: Nine paediatric-onset MS patients (mean age 19.3 ± 4.1 years) identified as having attention and/or working memory difficulties underwent a five-week (five days/week) internet-based working memory training programme (Cogmed™); weekly coaching was provided. Measures of adherence and tolerance were used to establish the feasibility of implementing computerised cognitive training. Qualitative experiences reported by the patients were analysed and factors that may modulate the effects of training were explored.Results: Six of the nine enrolled patients completed the programme within the recommended time, and all individuals, with the exception of one, were considered to tolerate the training well. Eight of the nine participants acknowledged that training was helpful in one or more ways. All but one participant reported improvements in working memory, although evidence for improvement on objective neuropsychological testing was limited. Lower normalised brain volume emerged as a potentially important variable in predicting extent of improvement on the training programme.Conclusion: Selected paediatric-onset MS patients can tolerate and complete an intensive cognitive rehabilitation programme. Future investigation of moderators of training effects and the stability of the findings over time is needed.

Noninvasive tongue stimulation combined with intensive cognitive and physical rehabilitation induces neuroplastic changes in patients with multiple sclerosis: A multimodal neuroimaging study.

BackgroundMultiple sclerosis (MS) patients have central nervous system (CNS) lesions that may impede cognitive and sensorimotor function. Few rehabilitative therapies are available.ObjectivesThe objective of this paper is to study effects of noninvasive tongue stimulation using the Portable Neuromodulation Stimulator (PoNS™) combined with intensive cognitive and physical rehabilitation on working memory, gait, balance and concomitant changes in the brain.MethodsFourteen MS patients, seven each in an active and a sham stimulation group, participated. Participants received intensive physical therapy and working memory training for 14 weeks. Functional magnetic resonance imaging (fMRI) using motor imagery and working-memory tasks were completed prior to and following therapy, as were sensory organization tests (SOT), motor performance measures, and neuropsychological assessment.ResultsOn the SOT, the active group showed significant improvement from baseline. fMRI revealed significant blood oxygen level-dependent signal changes in the left primary motor cortex for the Active Group, while the sham group had increased activity in bilateral premotor cortices. All individuals improved on working-memory tasks, but only the active group showed increased dorsolateral prefrontal cortex activity.ConclusionsIn this cohort of MS patients, the results suggest that PoNS stimulation can enhance motor performance and working memory while also driving neuroplasticity. Further studies are warranted to explore these findings.

Malignant catatonia due to anti-NMDA-receptor encephalitis in a 17-year-old girl: case report

Anti-NMDA-Receptor encephalitis is a severe form of encephalitis that was recently identified in the context of acute neuropsychiatric presentation. Here, we describe the case of a 17-year-old girl referred for an acute mania with psychotic features and a clinical picture deteriorated to a catatonic state. Positive diagnosis of anti-NMDA-receptor encephalitis suggested specific treatment. She improved after plasma exchange and immunosuppressive therapy. Post-cognitive sequelae (memory impairment) disappeared within 2-year follow-up and intensive cognitive rehabilitation.

Combination of intensive cognitive rehabilitation and donepezil therapy in Alzheimer's disease (AD)

Acetylcholinesterase inhibitors (AchEIs) are extensively used in Alzheimer's disease (AD) while reality orientation therapy (ROT) is a cognitive rehabilitation indicated for mentally deteriorated patients. We aimed to evaluate the efficacy of the combination of donepezil with an intensive ROT with active participation of the caregiver. Patients with AD ( n = 100, mean age 78.4 ± 4.3 years) initiated treatment with donepezil, 5 mg/day; 62 of them underwent a 3-week, daily ROT and physical reactivation training with the caregiver (Group A); 38 participants received only donepezil therapy (Group B). All subjects were tested for cognitive and functional abilities at baseline, at the end of the training program, and after 2 months of follow-up. There was a significant improvement in mini-mental state examination (MMSE) score ( p < 0.001) and the AD assessment scale-cognitive (ADAS-Cog) subscale ( p < 0.001), without changes in impaired activity of daily living (ADL) and instrumental ADL (IADL) after intensive ROT training in Group A. MMSE was maintained after 2 months in-home ROT continuation. There were no significant changes in MMSE in drug-only treated patients (Group B) after 3 weeks, with a non-significant tendency to improvement in ADAS-Cog. Our results suggest benefit of an intensive ROT program in dementia patients receiving donepezil that seems to be maintained as far as ROT is continued by the caregiver.

Efficacy and specificity of intensive cognitive rehabilitation of attention and executive functions in multiple sclerosis

Objective To evaluate the efficacy of a computer-based intensive training program of attention, information processing and executive functions in patients with clinically-stable relapsing–remitting (RR) multiple sclerosis (MS) and low levels of disability. Design, patients and interventions A total of 150 patients with RR MS and an Expanded Disability Status Scale (EDSS) score of ≤ 4 were examined. Information processing, working memory and attention were assessed by the Paced Auditory Serial Addition Test (PASAT) and executive functions by the Wisconsin Card Sorting Test (WCST). Twenty patients who scored below certain cut-off measures in both tests were included in this double-blind controlled study. Patients were casually assigned to a study group (SG) or a control group (CG) and underwent neuropsychological evaluation at baseline and after 3 months. Patients in the SG received intensive computer-assisted cognitive rehabilitation of attention, information processing and executive functions for 3 months; the CG did not receive any rehabilitation. Setting Ambulatory patients were sent by the MS referral center. Outcome measures Improvement in neuropsychological test and scale scores. Results After rehabilitation, only the SG significantly improved in tests of attention, information processing and executive functions (PASAT 3″ p = 0.023, PASAT 2″ p = 0.004, WCSTte p = 0.037), as well as in depression scores (MADRS p = 0.01). Neuropsychological improvement was unrelated to depression improvement in regression analysis. Conclusions Intensive neuropsychological rehabilitation of attention, information processing and executive functions is effective in patients with RR MS and low levels of disability, and also leads to improvement in depression.