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Sohlberg and Mateer's landmark introductory text helped put cognitive rehabilitation on the map for a generation of clinicians, researchers, educators, and students. Now, more than a decade later, the discipline has come of age. This new volume provides a comprehensive overview of this fast-evolving field. More than a revised edition, the text reflects the dramatic impact of recent advances in neuroscience and computer technology, coupled with changes in service delivery models. The authors describe a broad range of clinical interventions for assisting persons with acquired cognitive impairmentsincluding deficits in attention, memory, executive functions, and communicationand for managing associated emotional and behavioral issues. For each approach, theoretical underpinnings are reviewed in depth and clinical protocols delineated. Difficult concepts are explained in a clear, straightforward fashion, with realistic case examples bringing the material to life. Also included are samples of relevant assessment instruments, rating scales, and patient handouts. Throughout, the new volume emphasizes the need to work from a community perspective, providing a framework for forming collaborative partnerships with families and caregivers. It is an essential resource for professionals across a wide variety of rehabilitation specialties, and will serve as a text in courses on rehabilitation methods and neurogenic disorders.
|Publisher:||Guilford Publications, Inc.|
|Edition description:||Second Edition|
|Product dimensions:||6.12(w) x 9.25(h) x (d)|
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Cognitive RehabilitationAn Integrative Neuropsychological Approach
By McKay Moore Sohlberg Catherine A. Mateer
The Guilford PressCopyright © 2001 The Guilford Press
All right reserved.
Chapter OneIntroduction to Cognitive Rehabilitation
It has been almost a quarter of a century since the long-term impact of acquired brain injury (ABI), particularly traumatic brain injury (TBI), has been recognized. In that time there has been a surge of interest in understanding the underlying mechanisms of injury, as well as the nature of acquired physical, cognitive, behavioral, and emotional consequences of such injuries. Rehabilitation professionals have met the challenge of working individuals with acquired brain injury and their families in thoughtful, creative, and dynamic ways. In the United States, at least, these efforts have occurred in the context of major changes in health care delivery and technology.
The term cognitive rehabilitation was perhaps always too narrow, and focused too heavily on remediating or compensating for decreased cognitive abilities. The term rehabilitation of individuals with cognitive impairment probably better captures the emphasis on injured individuals that has will always be the target of cognitive rehabilitation. Although some of fundamental goals of improving and compensating for cognitive abilities continue tobe mainstays of rehabilitation efforts with this population, last 25 years have allowed a richer appreciation for the influence of contextual variables; the personal, emotional, and social impacts of brain injury; and their interactions with cognitive function. All of these factors have been incorporated to an even greater degree into treatment plans and goals. Short- and long-term emotional and social supports are needed for many individuals dealing with persistent sequelae of brain injury.
For decades the field seemed to be trapped in an internal struggle over whether it is better to focus on training processes, skills, or functional abilities, and in what ways and in what contexts that training might be accomplished. Though the struggle is perhaps not entirely over, it is increasingly acknowledged that functional changes must be the goal of treatment, and that there are many ways to go about facilitating those functional changes. If we have learned anything, it is that a cookie-cutter approach will not work. Individuals and families respond differently to different interventions, in different ways, at different times after injury. Premorbid functioning, personality, social support, and environmental demands are but a few of the factors that can profoundly influence outcome. In this variable response to treatment, cognitive rehabilitation is no different from treatment for cancer, diabetes, heart disease, Parkinson's disease, spinal cord injury, psychiatric disorders, or any other injury or disease process for which variable response to different treatments is the norm. Below, we outline some of the major forces that have shaped and continue to shape cognitive rehabilitation.
MAJOR FORCES SHAPING COGNITIVE REHABILITATION
New Perspectives and Findings with Regard to Neuroplasticity
Researchers now know that the brain is a far more plastic organ than was long thought to be the case, and that following injury, it is capable of considerable reorganization that can form the basis of functional recovery. New experimental work has clearly demonstrated changes in regional dendritic arborization that result in increased connections among surviving neurons (Kolb & Gibb, 1999). What are especially important from the point of view of cognitive rehabilitation are the demonstrated relationships among dendritic growth, structured environmental stimulation, and the recovery of lost functions. Our challenge is to understand the principles underlying this recovery and the types of postinjury experience that optimally drive it. This potential to reinstate function in damaged brain region as a consequence of neuroplasticity is discussed in greater length in Chapter 3 of this volume.
Advances in Technology
The exponential growth in new technology has had profound influences on rehabilitation. One way in which these effects can be felt is in the growth and development of powerful information-based tools that can be adapted for individuals with cognitive limitations. Increasingly smaller yet more powerful computers and chip-based technology are putting sophisticated devices for storing and retrieving information at our fingertips. Watches, cell phones, paging systems, and hand-held computer devices can all be linked to other computers and systems to expand ways in which individuals with physical and/or cognitive impairments can interact with the world. Moreover, as the technological revolution continues to advance, costs and size are coming down, and usability and flexibility are going up.
New applications of already existing technology can support sophisticated tracking, orienting, and signaling devices for people with severe memory impairments. The ability to develop skills and knowledge in a functional context is being met in brand new ways through the use of "virtual reality" environments. Individuals with severe physical limitations (even high-spinal-cord injuries) can now interact with and affect their environment through computers signaled by eye movements, or even by keyboards placed on the roof of a person's mouth!
Whole apartments have been adapted and wired to support increased independence in the community. Appliances can be monitored for safety; flexible devices for paging or communicating are available; and adapted equipment allows efficient cooking, bathing, cleaning, gardening, and selfcare. These innovations are being fueled not only by technological advances, but by the increased proportion of older adults in our society. Changes are occurring so rapidly that it is difficult to anticipate fully how they will help increase independence even in the next few years.
Emphasis on Empowerment
Over the last few decades, there has been an increased focus on self-sufficiency and self-help. Books, magazines, and opportunities for involvement with groups have promoted a take-charge approach to health, adjustment, and satisfaction. Widespread access to the Internet is arming people with disabilities and their families and caregivers with information, resources, and a wide range of mechanisms for support; as a result, they are beginning to feel less isolated. For example, there is a Web site run for and by individuals with the relatively rare neurological disorder prosopagnosia, which affects a person's ability to recognize even familiar faces. Accessible at choisser.com/faceblind/, it affords individuals with prosopagnosia the opportunity to gain information and share experiences with others who are "faced" with the same challenges.
A number of empowerment principles should guide rehabilitation efforts. Interventions should have as their ultimate goal an increase in skill or knowledge, a belief, a change in behavior, and/or the use of a compensatory strategy that will increase or improve some aspect of independent function. Interventions sometimes need to balance maximization of safety with risk taking as an individual takes on new skills and challenges. The rehabilitative process should work to reinforce individuals and families by building on their strengths. Individuals and families should be involved in setting goals, but also in selecting, developing, participating in, and evaluating the intervention plan. The role of a therapist in cognitive rehabilitation has been likened to that of a teacher or coach. This is because much of the emphasis in any rehabilitation program is on providing education, fostering awareness, and facilitating goals, rather than on treatment per se, as performed by a doctor or dentist.
Changes in the Health Care Sector in the United States
Rehabilitation professionals and the individuals and families they work with have faced cutbacks similar to, if not more extreme than, those faced by other medical professionals and consumers of health care. This has translated into shorter inpatient stays, reduced outpatient coverage, fewer day treatment programs, and more limited ancillary support services. Every rehabilitation professional has felt the loss of team autonomy in decision making about rehabilitation needs, together with the mandate to reduce costs above all else. The changes have forced rehabilitation professionals to use time as effectively as possible and to focus on short-term, measurable, functional outcomes. Long-term needs are likely to be met by families themselves and other community service agencies, which need to be educated about the effects of brain injury. There is no doubt that families, schools, mental health agencies, and communities have taken up the burden of managing the often lifelong consequences of significant brain injury. Many of the techniques that have been developed and shown to work in increasing independence and promoting self-sufficiency and community involvement, including return to work, are simply now not funded for many people. Restriction of health care dollars to "medical healing" leaves the great majority of clients with brain injuries and their families alone, scrambling to heal functionally, psychologically, and emotionally. It seems ironic that in a time of such unprecedented economic prosperity in the United States, hospitals, rehabilitation programs, outpatient services, and access to psychological support are being cut back or phased out altogether. At the same time, programs in some parts of the world have seen tremendous growth in and commitment to this segment of the population. Let us hope that the pendulum will swing back again.
Focus on Function
Although meaningful changes in an individual's everyday life have always been the goals of rehabilitation, it has been a challenge to articulate and measure appropriate goals and successful outcomes in individuals who have such a broad range of difficulties in many aspects of life. The emphasis on function has, however, encouraged the development of more ecologically based and relevant assessment scales and tools. Individuals affected by brain injury and their families are now much more likely to be involved from the beginning in identifying treatment goals. Indeed, mutual goal setting and involvement of families, friends, and coworkers in the rehabilitation process are now very common.
MANAGEMENT OF ATTENTION, MEMORY, AND EXECUTIVE FUNCTIONS
Although we have broadened the scope of this text to address behavioral issues, issues related to working with families, and a broader range of strategies designed to address emotional and adjustment issues, a strong emphasis on the important role of cognitive impairment remains. It is common in rehabilitation texts to consider the cognitive processes of attention, memory, and executive functions as separate units. Several reasons encourage us to integrate a discussion of the theoretical backdrop for these three cognitive domains. First, these areas are commonly targeted in neurorehabilitation programs. Second, impairments in each of these cognitive processes can have devastating effects on people's day-to-day functioning. Most importantly, the cognitive components involved in attention, memory, and executive functions overlap and interact in complex ways that make it difficult to discuss one process without referring to one of the other domains. The circuitry and structures subserving attention, memory, and executive functions are widely shared and are particularly vulnerable to disruption following acquired brain injury (Finlayson & Garner, 1994; Sohlberg & Mateer, 1989). In particular, these functions are commonly disrupted following injury to anterior frontal and temporal brain systems-areas that are often affected by TBI resulting from acceleration-deceleration forces. Reviews of treatment efficacy have often focused on attention, memory, and executive functions. Coelho, DeRuyter, and Stein (1996), for example, organized a review of treatment efficacy for cognitive-communicative disorders according to these three domains, as did Mateer, Kerns, and Eso (1996) in discussing the management of children with acquired disorders of attention, memory, and executive functions.
It is well established that impairments in attention, memory, and executive functions can profoundly affect an individual's daily functioning. Even mild changes in the ability to attend, process, recall, and act upon information can have significant effects on effectively completing basic everyday tasks. Consider the cognitive skills required for successful meal preparation as an example. The individual must plan a menu, identify needed ingredients, develop a shopping list for required items, and leave sufficient time for shopping and preparing the meal. Then the individual must sequence many food preparation activities in an organized way so that everything is ready at dinner time. Even a mild attention or executive function deficit can render this difficult, ineffective, or even impossible.
Attention, Memory, and Executive Function as Interdependent Processes
Attention, memory, and executive functions are related and interdependent. Their close interdependence stems from both a functional association and their shared neurocircuitry. Various components and subcomponents for each process may be identified, depending upon one's conceptualization of the specific process; however, regardless of one's theoretical framework, a great degree of overlap exists. When attempting to parcel out or define the components of attention, memory, or executive functions, a researcher necessarily borrows from the other two processes. For example, most researchers conceptualize attention as a hierarchy of subcomponents. High in the attention taxonomy are complex attention abilities such as working memory, selective attention, and the ability to shift attention between different tasks (Posner & Petersen, 1990; Sohlberg & Mateer, 1987; Sturm, Willmes, Orgass, & Hartje, 1997). These subcomponents of attention mirror certain abilities one often attributes to executive functions. For example, the ability to make mental shifts and engage in flexible thinking is an accepted subcomponent of executive functions (Lezak, 1993; Stuss & Benson, 1986). Similarly, it is difficult to distinguish between selective attention and mental flexibility.
When one considers the neurocircuitry serving attention, memory, and executive functions, the overlap becomes further evident.
Excerpted from Cognitive Rehabilitation by McKay Moore Sohlberg Catherine A. Mateer Copyright © 2001 by The Guilford Press. Excerpted by permission.
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Table of Contents
I. Fundamentals for Practicing Cognitive Rehabilitation
2. Neurological Disorders Associated with Cognitive Impairments
3. Variables Contributing to Neurological and Neurobehavioral Recovery
4. Assessment of Individuals with Cognitive Impairments
II. Management Approaches for Cognitive Impairments
5. Management of Attention Disorders
6. Memory Theory Applied to Intervention
7. The Use of External Aids in Cognitive Rehabilitation
8. Management of Dysexecutive Symptoms
9. The Assessment and Management of Unawareness
10. Communication Issues
III. Interventions for Behavioral, Emotional, and Psychosocial Concerns
11. Managing Challenging Behaviors
12. Management of Depression and Anxiety
13. Working Collaboratively with Families
IV. Working with Special Populations
14. Rehabilitation Strategies of Children with Acquired Cognitive Impairments
15. Management Strategies for Mild Traumatic Brain Injury
Professionals and students across a wide variety of rehabilitation specialities, including neuropsychology, clinical and cognitive psychology, psychiatry, and neurology.