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Case Report

COGNITIVE RETRAINING AND ITS EFFICACY IN HEAD INJURY

G. S. Kaloiya1 N. Grover2 & T.B. Singh3

1 Asst. Prof, National Drug Dependence Treatment Centre, AIIMS, New Delhi.

2 Asst. Prof, Dept. of Clinical Psychology, Institute of Human Behaviour & Allied Sciences (IHBAS), Delhi.

3Ex. Professor & Head, Dept of Clinical Psychology; IHBAS, Delhi.

Abstract

Background: Cognitive deficits are ubiquitous in head injured patients. Neuropsychological assessment taps these deficits and helps in planning the cognitive retraining. Since cognitive deficits lead to a failure to respond adequately and appropriately to the demands of oneís immediate environment and create many problems in day-to-day life. Thus planning of appropriate cognitive retraining programme helps to improve the cognitive functions.

Aim: The aim of this case study was to demonstrate the components of cognitive retraining. The present case study of a brain-injured patient highlights the role of cognitive retraining in the overall management.

Methodology: A patient with head injury assessed on PGI Memory Scale and NIMHANS Neuropsychological Battery and given several sessions of cognitive retraining.

Neuropsychological assessment revealed significant impairment in cognitive functions especially in attention, memory, and learning. Cognitive retraining was planned and started initially on weekly basis and then on fortnightly basis. After 33 sessions of cognitive retraining, over a period of 16 months, patient showed significant improvement on different cognitive functions. Not only her cognitive functions improved but her social and occupational functioning also improved.

Conclusion, neuropsychological assessment and cognitive retraining programme play important role in improving cognitive functions.

Key words: Traumatic Brain Injury, Neuropsychological Assessment, Cognitive Retraining.

Introduction

Cognitive deficits are ubiquitous in head injured patients. Due to head injury not only structural changes occurred in the brain but functional capacity also gets affected. This leads to cognitive deficits and inability to perform activities of daily living1. Head trauma victims may display any combination of neuropsychological deficits and later in recovery may show specific patterns of focal impairment, the general sequence of recovery in severe head trauma is marked by a relatively orderly process involving a predictable sequence of events for example unconsciousness followed by amnesia. Although the sequence is constant, the phases of recovery may vary in length across different severities of head injury. The earliest acute phase typically involves a period of altered consciousness ranging from seconds in mild injuries to weeks or months in severe head trauma2. Neuropsychological assessment taps these deficits and helps in planning the cognitive retraining. Since cognitive deficits lead to a failure to respond adequately and appropriately to the demands of oneís immediate environment and create many problems in day-to-day life. Thus planning of appropriate cognitive retraining programme helps to improve the cognitive functions.

Cognitive retraining is a process through which cognitive functioning of the brain injured is improved.3 Cognitive retraining is a therapeutic strategy that seeks to improve or restore a person's skills in the areas of paying attention, remembering, organizing, reasoning and understanding, problem solving, decision-making, and higher-level cognitive abilities. These skills are all interrelated. Cognitive retraining is one aspect of cognitive rehabilitation, a comprehensive approach to restoring such skills after brain injury or other disability.

Natural or spontaneous recovery i.e. plasticity of the brain initiate the process of restoration of function. The pace of recovery is fast up to three months and gradually slows down, but usually lasts for a year. Neuropsychological rehabilitation facilitates the recovery in the early stages and mediates recovery in the later and chronic stages.4 The overall purpose of cognitive retraining is to decrease the everyday problems faced by individuals with cognitive difficulties, thereby improving the quality of their lives.

The present case study of a brain-injured patient highlights the role of cognitive retraining in the overall management.

Clinical history & case description

Ms. R 25 year old married housewife with 2 kids, 5 and 1 year old, belongs to lower socio-economic and urban background. Her husband was working as a school bus driver. She was having good interpersonal relationships with family members and neighbours. She was taking care of her children and house. She was well adjusted and doing her duties efficiently. She met with a road accident and was unconscious for 15 days. She had bleeding from ear and nose and developed right hemiparesis. She was hospitalized for a month and 3 Computed Tomography (CT) studies were done: first NCCT head showed intra cerebral haematoma of left parietal region with compression and displacement of ipsi-lateral ventricle around the middle and dilatation of contra lateral ventricle. Second NCCT- head showed hydrocephalus, hypo-dense lesion in left tempo-parietal region. Third NCCT head showed ventricle dilated areas of gliosis and atrophy in left tempo-parietal region. She was treated with medicines. She gained sensorium and came out from coma. Her hemiparesis was improved and she was discharged from the hospital after 1 month.

After almost 6 months, she started having seizures characterized by tonic-clonic movements of all the four limbs, up-rolling of eyeballs, turning head to right side, loss of consciousness, post-ictal headache and diagnosed as Generalized Tonic-Clonic Seizures (GTCS). CT head showed left parieto-temporal gliosis. She was put on antiepileptic drugs. Her seizures were controlled but she had difficulty in performing day-to-day activities and had memory problems. Significant changes in her behaviour and mood were reported by her husband. She remained irritable and used to beat her children on trivial issues. She started avoiding domestic work. She stopped going out for purchasing grocery items which she was doing earlier. She would forget things and their names quite often.

Neuropsycholgical assessment

PGI Memory Scale5 and NIMHANS Neuropsychological Battery6 were administered. The assessment was completed in three sessions. On PGI Memory Scale impairment was found in recent & remote memory, mental balance, attention and concentration, delayed and immediate recall, verbal and visual retention. Her overall performance on PGI Memory Scale was poor. On NIMHANS Neuropsychological Battery, minimal impairment was noticed in attention and concentration, kinetic melody and working memory. Ideational fluency and abstraction were severally impaired. Perceptual gestalt was minimally impaired. Ideational apraxias and agnosias for pictures and objects were present. Verbal and visual learning and memory were severally impaired. Neuropsychological assessment suggested diffused type of involvement. The major functions affected were attention and memory, and Anomia especially blocking and circumlocution were present.

Cognitive retraining programme

Cognitive retraining (CR) was planned and structured keeping the patientís impaired cognitive functions, needs and her abilities in mind. Cognitive retraining was planned and started initially on weekly basis and then on fortnightly basis. Total 33 sessions of cognitive retraining, over a period of 16 months, were given.

In initial sessions, psycho-education was given to family members in detail in which, information related to brain damage, plasticity of brain, role of medication and CR, and prognosis were explained. Psycho-education helped the caregivers to understand their emotions and frustrations. Since the patient and her family members shown the inability to come daily for CR, so sessions were planned on weekly basis. Each session were lasted for about one hour. The main care giver was her husband.

Attention and Concentration Retraining Since attention is the basic function and other higher functions depend on it, so CR was started with improving attention. This type of cognitive retraining aims to improve several abilities, including focusing attention; dividing attention; maintaining attention while reducing the effects of boredom and fatigue; and resisting distraction. Attention has been considered the foundation of other more complicated cognitive skills, and therefore an important skill for cognitive retraining. Within the domain of attention, focused attention was targeted first followed by tasks to improve sustained and divided attention in that order. To improve the attention, patient was given grain-sorting, trail-making and letter-cancellation tasks from simpler to complex in order. The same task that was performed during the session at hospital was given as homework assignment. Caregiver (i.e. husband) was advised to keep records of the homework in a diary and bring it for sessions. It took six weeks to improve the attention.

Memory Retraining After attention memory was taken. Memory retraining involved teaching of several strategies to the patient that can be used to recall certain types of information. She was taught to go through each letter of the alphabet until she remembers someone's name. Difficulty of the task was matched to the patientís capacity. Task difficulty was progressively increased in step with the patientís improvement. In the initial level cues were provided which are gradually faded out.

Her anomic aphasia was major concern for her family members. There are six basic types of error likely to be observed in anomia and most patients produce more than one type of error. These are- Blocking (inability to think objectís name), Circumlocution (empty sentence or description of the object or its functions), Misarticulation (incorrect pronunciation of a word), Semantic paraphasia (substitution of the correct word with a real word), Phonemic Paraphasia (approximate correct articulation) and Neologism.7 In this patient blocking and circumlocution were present and for this, compensation techniques were used. Compensation techniques refer to those strategies which are external to the patient but help the patient in discharging the disabled function.

Results

After 33 sessions of CR for a period of one year four months, neuropsychological assessment was repeated. She has shown improvements on all the functions that were impaired during pre-therapy assessment. Her attention and concentration, ideational fluency, and kinetic melody were improved, though minimal impairment was still noticed on abstraction and working memory. Anomia was present but infrequently, now it became manageable for the patients. Her sentence repetition, comprehension and visual integration were found to be intact. Verbal learning & memory and visual learning & memory were improved. Her irritability and careless attitude also improved. She started taking care of her children and house, and also started interacting with others. She started going to market for purchasing of grocery items and vegetables, and for other works which she stopped doing after head injury.

The patient has shown significant improvement on different cognitive functions. Not only cognitive functions but her social and occupational functioning also improved. After improvement in attention and other memory functions her irritability also improved. Following graph depicts her improvement on different cognitive functions:

20= Intact; 40= Minimal Impairment; 60= Moderate Impairment

80= Severe Impairment; 100= Total Impairment

Discussion

The present case study shows the efficacy of cognitive retraining in the management of head injury. Patient has shown significant improvement on different cognitive functions like attention, memory etc. Her performance on different items came down from severe or moderate category of impairment to either minimal or intact category. Cognitive retraining included a considerable amount of repetitive practice that targeted the skills of interest. In fact, repetition is essential for the newly retrained skills to become automatic. Consistent practice of learned strategies is critical to become proficient in their use. Patience is the key word. It takes time for the brain to heal, and it takes time to learn new ways to do familiar things. The results are worth the effort.

Retraining begun with simpler skills and proceeded to more complicated skills. Methods of restoration, compensation, and functional skills training including training in basic functions were applied. An important part of therapy is training and education of caregivers. It is important that caretakers of the patient understand these cognitive strategies and encourage the practice of cognitive retraining skills taught.

Not only her performance on test items improved but her day-to-day functioning also improved. This shows that generalization also occurred. This happened most probably because of the nature of the tasks (domestic items like - grain sorting, naming kitchen items or vegetables etc.) and homework assignments. Patientís husband has worked as a co-therapist and remained motivated throughout the programme. This suggests that family members may be involved in such programmes. Involving family members in the program not only take care of their anxiety and depression but also take care of their expressed emotions which may create several problems in successful completion of the therapy. Though the patient came after 3 years of head injury for CR even the effects of CR were encouraging. If she would have come earlier she might needed less of number of sessions to show the same results.

The patient has shown significant improvement on different cognitive functions. Not only cognitive functions but her social and occupational functioning also improved.

Conclusion

Thus, neuropsychological assessment and cognitive retraining programme play important role in overall management of head injured patient.

 

References

1.        Richardson, J.T.E.. Clinical & Neuropsychological Aspects of Closed Head Injury. (2nd Edition), Psychology Press, a member of the Taylor & Francis group. 2000

2.        Smith, R.J., Barth, J.T., Diamond, R., & Giuliano, A.J. Evaluation of head trauma. In G. Goldstein, P.D. Nussbaum & S.R. Beers (eds.), NeuropsychologyPlenum Press, New York. 1998, (pp. 135-170).

3.        Rao, S.L. Neuropsychological consequences of head injury. In reading material of National Workshop in Clinical Neuropsychology. NIMHANS, Bangalore. 1996.

4.        Rao, S. L. Cognitive rehabilitation. In Tally, A.B., Nair, K.P.S. & Murali, T. (eds.) Neurorehabilitation Principles & Practice. NIMHANS, Bangalore 1998

5.        Pershad, D. & Wig. N.N.. PGI Memory Scale. National Psychological Corporation, Kacheri Ghat, Agra 1984

6.        NIMHANS Neuropsychological Battery. Reading material of National Workshop in Clinical Neuropsychology. NIMHANS, Bangalore 1996

7.        Varney, N.R. Neuropsychological assessment of aphasia. In G. Goldstein, P.D. Nussbaum & S.R. Beers (eds.), Neuropsychology, Plenum Press, New York. 1998(pp. 357-378).