Excerpts

Introduction 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 with 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 and will always be the target of cognitive rehabilitation. Although some of the fundamental goals of improving and compensating for cognitive abilities continue to be mainstays of rehabilitation efforts with this population, the last 25 years have allowed a richer appreciation for the influence of contextual variables; the personal, emotional, and social impacts of brain njury; 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.

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