Cognitive retraining

Cognitive Retraining is a systematically applied set of medical and therapeutic services designed to involve practicing one area of cognition (attention, memory, visuospatial processing)in an attempt to restore the ability through practice and mastery. For example, visuospatial training can help with difficulties orienting to or responding to objects, or pictures shown on the side opposite to the site of the injury, attention training is a technique used to help people with brain injury to improve attention, and language training can help with problems producing and/or comprehending language that is often experienced after a stroke. Such retraining techniques often include specific drills and exercises, using paper and pencil tasks, computerized programs, and these activities are done both at home and in a clinical setting.

There are other terms for cognitive retraining like, cognitive rehabilitation, neurorehabilitation, neuropsychological rehabilitation, cognitive remediation, etc.

Aims of cognitive retraining :

  • To reinforce / strengthen / establish previously learned pattern of behavior which were restricted by neurological disorders.
  • To establish new patterns of cognitive abilities through internal compensatory cognitive mechanism for impaired neurological systems (Eg: creating mnemonics).
  • To establish new pattern of cognitive activities through external compensatory mechanism, providing external cues. Eg., setting alarms/ sticky notes for remembering).
  • To enable the person to adapt cognitive disability, making the person realize his/her strength/ weakness/ current level of functioning.

Approaches to cognitive retraining:

  1. Education: To educate the patient about the prognosis, course of illness, and to develop awareness about problem and treatment.
  2. Process training: To stimulate poorly functioning neurological pathways.
  3. Strategy development and implementation: As per patients deficits – precisely developing strategies to provide cognitive rehabilitation.
  4. Functional applications: Remediating functional deficit, so that the patient can perform his daily activities. Making a person prepare to perform daily and skillful activities (applicable in real life).

Principles of cognitive retraining :

  1. It is possible to overcome or optimize the effects of cognitive deficits to enable the individual to become a better problem solver in real life situations.
  2. Rehabilitation combines education and treatment process.
  3. Structured activities can ameliorate some of the emotional and adjustment difficulties that occur following brain injury.
  4. Continued appropriate program of cognitive stimulation will lead to better recovery.
  5. The first goal is to reduce client generalized cognitive confusion.
  6. Developing awareness and acceptance of strength and deficit is an important part of the process.
  7. Therapy should aim to restore real-life abilities rather than abstract skills.
  8. Active participation by family members in the rehabilitation process should be encouraged.
  9. Client should be encouraged to maintain appropriate eating and sleeping habits.
  10. Long term rehabilitation is necessary after brain injury.

SPECIFIC AREAS FOR REHABILITATION

  • Attention and Vigilance: One of the most common disruptions secondary to TBI is dysfunctional attentional regulation. Brain injury affects multiple aspects of attention including shorter attention span, distractibility, and increased effort for harnessing attentional resources (Bennett, Malia, Linton, Raymond, & Brewick, 1998; Palmese & Raskin, 2000; Wood, 1988). Functionally, these deficits may cause problems with information processing, communication, social awareness, memory, task completion, and the ability to self-monitor behavior (Bennett et al., 1998). Furthermore, impaired orientation may translate into misinterpreting the environment in terms of person, place, time, and circumstance, which may lead to confusion, aggression, and inappropriate social responses (Watanabe, Black, Zafonte, Millis, & Mann, 1998).
    • Retraining: Engelberts et al. (2002) compared compensation versus retraining. In the retraining group, patients had to rehearse responses on a divided attention task, wherein task difficulty automatically increased. Patients in the compensation group were made aware of their functional attention and memory failures and were taught rules to compensate for those failures. Daily homework assignments were used to help patients apply these strategies. While both methods were found to be effective, compensation showed slightly more benefits, and the authors suggested that the methods be applied together.
    • Compensation and Environmental Restructuring: Behavioral approaches may involve rewarding behaviors that resemble appropriate attention and can include punishment for failure to attend to designated information (Robinson & Winner, 1998). Although it has low generalizability, response-cost contingencies have been employed in treatment for attentional problems, along with direct retraining, which includes repeated exposures and practice (Mateer et al., 1996). Shaping strategies have also been implemented to improve functioning of processing speed (Park & Ingles, 2001). Unilateral Neglect and Related Disorders Unilateral neglect occurs when patients do not report, respond, or orient to stimuli presented to the contralesional hemisphere, given that the deficit cannot be attributed to sensory or motor impairments (Heilman, 1979). Neglect deficits can be personal or spatial (body, environment, object centered). Several behaviors are associated with neglect and differ across patients including inattention/sensory neglect, extinction/suppression to simultaneous stimulation, motor neglect, spatial neglect, allesthesia and allokinesia, and anosognosia (Heilman, Watson, & Valenstein, 2003).
  • Memory: Memory training interventions have been shown to be effective in older adults with subjective and objective memory decline (De Vreese, Belloi, Iacono, Finelli, & Neri, 1998) and in those with severe brain injury. However, there appears to be a deficit in the literature investigating the ecological generalizability of such techniques. The literature also lacks comparisons of memory rehabilitation strategies across types of brain damage in varied ages and levels of recovery (Cappa et al., 2003).
    • Repetitive Recall Drills: Despite insufficient empirical support for this practice, repetitive recall drills have been identified as the most commonly utilized technique in memory rehabilitation (Cuesta, 2003). This method attempts to enhance memory by providing multiple exposures to information as well as repeated recall. If utilized, it is important to note that “depth of encoding” is a signifi cant predictor of accurate recall (Chiaravalloti, Demaree, & Gaudino, 2003). Their findings suggested that initial thorough learning may be more important than repeated exposures to information.
    • Mnemonic Techniques: Designed for use with normal populations, mnemonic techniques are widely used in rehabilitation. This strategy requires the patient to structure and package information for enhanced retrieval and recall. Critics of mnemonic techniques argue the gains do not generalize from artificial settings to real experiences (Cuesta, 2003). Because mnemonic strategies often require increased skill, they may be more appropriate for those with mild, rather than severe, neurocognitive deficits (Kaschel et al., 2002). There is also evidence that younger individuals benefit significantly more from mnemonic strategies to recall word lists than older adults (Richardson & Rossan, 1994).
    • Visual Imagery: This strategy requires individuals to produce images of nonvisual information to facilitate storage and to cue retrieval. Storage should occur even with distraction and should hold over time (Kaschel et al., 2002). One commonly used technique is the rhyming peg method (one-bun, two-shoe, etc.) where the first item to be remembered is visually paired with a bun, the second item paired with a shoe, and so forth. Another method, the face–name association, involves pairing a feature of the to be- remembered person’s name with a visual cue to their name. For example, to recall Barry Locke, the patient could visualize a blueberry with a padlock around it. For both of these techniques, learning is enhanced by breaking down material into simple components (Tate, 1997).
    • Biofeedback: Biofeedback involves positioning devices on a participant’s body, which promotes awareness of physiological activity. Thus, a patient is presented with information regarding their brain activity. According to Thornton (2000), 59 patients receiving Quantitative EEG (QEEG) biofeedback achieved normal levels of functioning, with dramatic improvement for some patients. Improvements ranged from 68% to 181% and were experienced in participants with brain injury as well as normal participants.
    • External Memory Aids: External memory aids are commonly used and consist of storage devices, cuing devices, and restructured environments. These devices, when taught to be used properly, can be inexpensive, enhance daily functioning, and increase patient autonomy.
    • Domain Specific Learning: The principle with this type of learning is that it should be highly practical by teaching tasks and providing exposure to useful information to increase generalization. Vanishing cues, based on shaping and backward chaining, addresses the problem that information may be cued, but it is not readily accessible. This technique requires the therapist to begin with complete stimulus cuing with progressive cues fading across trials. Training is individualized and specific and emphasizes priming and procedural learning. Use of external aids and time management are some techniques successfully aided by vanishing cues (Hutchinson & Marquardt, 1997).
    • Errorless Learning: The errorless learning method was developed in response to observed learning difficulties in amnesic patients in the 1950s. While implicit memory is still relatively intact in most amnestic patients, explicit memory is usually deficient. Although common trial-and-error methods address explicit memory deficits, errors may be implicitly primed and create stores of “error” memories (Bier, Vanier, & Meulemans, 2002). Thus, errorless learning may be better for severely impaired individuals, but may only work for short periods of time (Evans et al., 2000). However, errorless learning has been found to reduce forgetting better than errorful training (Wilson, Baddeley, Evans, & Shiel, 1994).
  • Language: Though classical nomenclature of aphasia and language syndromes is not without its problems (e.g., lack of treatment validity, overlapped symptoms, heterogeneous categorization, etc.), most studies of language rehabilitation continue to utilize those traditional descriptions (Caplan, 2003). Moreover, any given patient may present with various deficits affecting lexical, phonological, semantic, pragmatics, and syntactic language processes. Keeping this in mind, we review rehabilitation techniques as they apply to commonly referenced conditions and deficits.
    • Aphasia: Cicerone et al. (2005) suggested that a series of group interventions promoting social and pragmatic communication are benefi cial. Within those approaches, feedback, selfmonitoring communication behavior, and behavioral techniques such as correction contingency (e.g., actively correcting inappropriate remarks) appear to be worthy components (Lewis, Nelson, Nelson, & Reusink, 1988). For instance, Ehrlich and Sipes (1985) reported a positive outcome for a model of pragmatic-based interventions that focused on improving nonverbal communication, communication in context, and message repair (becoming aware of communication breakdown, etc.). Those authors indicated that group members actively evaluated each others’ videotaped role plays.
    • Alexia/Agraphia: Another language-based complication of brain injury relates to reading and writing functions. While multiple disorders can arise, many do not occur in strict isolation of one another (Coslett, 2003; Roeltgen, 2003). Alexia is a disturbance of reading with relatively preserved writing skills. A number of techniques have been used to address such problems, including tactile-kinesthetic letter identification approach, motor cross-cuing strategy, speeded stimulus presentation, rapid whole word recognition, along with rapid whole word reading and multiple oral re-reading (Cherney, 2004). Moreover, computer-based programs with hierarchical language stimuli have been shown to improve comprehension (Cicerone et al., 2000).
  • Executive Functions and Problem Solving: Goal-setting, planning, monitoring/organizing behaviors, and making adjustments toward a goal are all considered executive functions. These abilities are commonly impaired after TBI and typically associated with damage to the frontal and prefrontal cortex. They are frequently barriers to community reentry and prevent patients from resuming normal premorbid activities (Sohlberg, Mateer, & Stuss, 1993; Stuss, 1987). Sohlberg and Mateer (1989) developed one of the first interventions that specifically targeted remediation of executive functions. Their program emphasized organization and structure. Generally, the patient is trained in time management, self-regulation, and how to appropriately select cognitive plans and then execute them. Specific treatment components are planning, initiation, speed of response, time scheduling, awareness, and impulse control. The focus is on real-world application.
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