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.
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
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.
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.
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.
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
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
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.
assessment and cognitive retraining programme play important role in overall
management of head injured patient.
Clinical & Neuropsychological Aspects of Closed Head Injury. (2nd Edition),
Psychology Press, a member of the Taylor & Francis group. 2000
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).
Neuropsychological consequences of head injury. In reading material of National
Workshop in Clinical Neuropsychology. NIMHANS, Bangalore. 1996.
Rao, S. L. Cognitive
rehabilitation. In Tally, A.B., Nair, K.P.S. & Murali,
T. (eds.) Neurorehabilitation Principles &
Practice. NIMHANS, Bangalore
Pershad, D. & Wig. N.N.. PGI Memory Scale. National Psychological Corporation, Kacheri Ghat, Agra 1984
NIMHANS Neuropsychological Battery.
Reading material of National Workshop in Clinical Neuropsychology.
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).