RehaCom for TBI/Stroke Rehabilitation

– [Peter] And thank you everybody, for takin’ time out of your
busy schedule to join us today. We appreciate your attention. And also, I look forward
to seeing your questions. Joining me in the chat box, as you heard, is Dr. Anne-Marie
Kimbell, who like myself, is a licensed psychologist. She has a Certificate of Proficiency in clinical Geropsychology, her PhD was in counseling
psychology from Texas A&M, and she has spent time in the field. She did a clinical internship
post-doctoral training in the VA system, and so she has clearly worked with patients
that have rehab needs. She was a staff psychologist
for two different VA systems, and she did palliative care hospice rehab, and worked in neuropsychology. I’ll give a little bit a
background about myself. I started work in a children’s
psychiatric hospital. I went to work in a public
school for a number of years. Then I was appointed
Chief of Child Psychology on an inpatient psychiatric
unit South of Boston. After that, I went to
work at a rehab hospital. So like many of you on the call today, I’ve had experience with
patients with rehab. And from there, I went into
teaching in a university. And after that, I came to Pearson, to join their clinical assessment team. So welcome everybody. And this is what we’re going to do today. We’re going to talk about
cognitive rehabilitation for TBI and stroke victims. We talk about using technology, under the guidance of
a trained commission, to support the improvement
of cognitive deficits. So we’re going to look at
all the different areas, where you can improve the
patient’s performance. You need to consider this a tool, what provide deficit specific therapies, and it does focus on the
rehabilitation of patients with cognitive impairment. So we will focus on a computerized cognitive training program, that was developed initially
at Magdeburg University, 25 years ago in Germany, called RehaCom. We’ll look at the evidence for its use, and how it will be valuable to you, as you deal with patients that have either a CVA or a TBI. First, we’ll begin by
reviewing TBI and CVA. And I just want to quickly review some of the material that was covered in the webinar last time by Dr. Kimbell. So my first question to all of you is, did you attend the previous workshop? In which case, I will be brief. If you could answer yes or no, I can see how much time I
need to devote to that topic. I don’t want to repeat
it for a lot of you, if you heard it already. So if you could take a
minute to just say yes or no. Were you able to join
that webinar previously? So this is what we covered in part one. What is cognition? What is a cognitive deficit? What can be done to improve
the functioning of individuals who have that cognitive deficit? What components should be treated? How is cognitive rehabilitation defined? What are some of the
characteristics of cognitive rehab? Is that the same thing as
cognitive training or brain games? And is there any way modern
technology can be incorporated into these new techniques? So let me just go back to the poll, see if we have anymore answers. And I’m not seeing many showing. So with that information, I’m going to assume that
we have a lot a people who weren’t able to listen to
the previous part one version. And–
– Peter, I’m not sure why the poll is not working. But in the chat box people
have been answering, and it’s probably about
half and half, yes and no. – Okay, so we won’t cover it in detail. Thank you Anne-Marie. – [Anna-Marie] Mm-hmm. – [Peter] So this is what we covered. What is cognition? It’s all these actions and processes that help us to acquire
knowledge and understanding. So cognitive processes
use existing knowledge and generate new knowledge. Some of the patients you have, when they experience a cognitive deficit, are gonna ask questions. How is this gonna impact me? What does this mean? What is the nature of
this disorder I have? Is this serious? Is it pervasive? Will these problems persist? Am I going to require treatment? Is this just temporary, or is it going to go on for some time? So those are some of the
questions patients will ask you. And these are some of the
deficits that we’ll see resulting from brain trauma. And we see the adverse
impact on attention, memory, executive skills, visual
spatial, and visual field. All of this was described
for you last time. CVA and TBI are two of the
most disabling conditions. So let’s just quickly define it. I’ll review the symptoms, and you can begin to understand
the consequences of the CVA, just as you would describe
it to your patients. So a stroke, or a
cerebro-vascular accident, is something that occurs in their head. So it’s important to
recognize, that you will see, either blood vessels carrying oxygen and blood to the brain, will be deprived of oxygen. And if it’s brief, it’s called hypoxia. But if it’s for a longer period of time, we will call that anoxia, and
that can be quite serious. Because stroke is a disease
that affects the arteries, leading to and within the brain. And it’s one of the
leading causes of death, as we see from the graph here. However, as Anne-Marie
pointed out last time, a significant number only
have a mild impairment. So that stroke that occurs when the blood supply is
caring oxygen and nutrients, is either blocked by a clot,
or it bursts and ruptures. That means that the blood and oxygen is not going to the part
of the brain that needs it. Also, it’s not taking some of the things away from the brain,
so just carbon dioxide. And so as a result, you may
get a build up of toxicity. What are the types of stroke? Stroke can be caused by a
clot obstructin’ the flow, which is called an ischemic stroke, or by a blood vessel rupturing, and it prevents blood
flow going to the brain, in which case we call that hemorrhagic. Now you may also get a
transient ischemic attack, or mini stroke, and that’s
just a temporary clot, but these can still be serious. Now my son said to me, well
dad, you’ve just described some things, just like
saying a car has four wheels. But what causes a person
to have that stroke? And the simple answer is, it
could be from atherosclerosis. What is that? It’s the narrowing and
hardening of the arteries. What else could occur? Well, patients that have
high blood pressure, or who smoke a great deal, and
have a build up of nicotine, patients who are diabetic, or who may have obesity,
and excess weight, can also be at increased risk for a stroke. Now beyond those factors,
it’s important to realize, that some medications can also cause a person to be at increased risk. So for example, if a patient
taking blood thinners, and for some reason they
need to stop takin’ it, it may have that adverse impact. And as Anne-Marie pointed out last time, one of the biggest
issues of course, is age. As we get older, we have increased risk. The older we get, the
greater the chances are that we are at risk for stroke. So what are some of the symptoms? Weakness and numbness, loss of vision, problems with sensation,
understanding speech, particularly, loss of vision
in one eye, balance problems, hiccups, severe headaches,
loss of consciousness, dizziness, these can all be associated. So those are the physical symptoms. What does that mean to
us as neuropsychologists? What are the effects going to be? One of them might be problems with vision. We may see patients that have an inability to see the whole picture. They may experience visual neglect, or so called hemianopsia. We may have other patients
that have an aphasia, they may have problems formulating and comprehending language. Some of the patients we see,
will have loss of balance. They will feel a loss of
coordination, loss of sensation. So we may ask them to show us
how they do certain things, like how would you open the door, or show me how you make a fist. And that may be very hard for them. And then they just
automatically go and do it when their timing is appropriate. What we also reviewed with Anne-Marie, is that sometimes damage
is very circumscribed. So if that is the case, for example, there’s damage only to the fusiform gyrus, you may find a very narrow
effect, and that is, the patient may not be able to recognize very familiar faces. And I know you’re familiar with books that have described patients
that have that disorder. Now a different type of injury,
is traumatic brain injury, or acquired brain injury. And Anne-Marie described
for you last time, some of the problems are
caused by rotational force, and some of them are caused by acceleration and deceleration factors. So if you were in a car accident, and you were to hit that
windshield, or some other object, you may experience bruising
caused by coup and contre-coup. That is the movement of
the brain within a skull, causing it to be damaged, on both the side where they initially force the injury, and then on the opposite side. This results sometimes in
bruising, and bleeding, on the inside, and so you will hear about subarachnoid hemorrhaging. We also see evidence of different types of axonal sheering. So the connections between brain matter become stretched, and torn, and that diffuse axonal injury, sometimes is a sign of just how severe some of that traumatic
brain injury can be. So one of the famous ones,
of course, was Phineas Gage, and that temping eye and
the pictures of his skull, can still be seen at the Harvard Medical
School in Cambridge. So here’s one of the first
individuals, back in 1848, to experience a very severe head injury. And he was described by his physician in those following terms. These are the personality
changes that he went through. Surprisingly, he lived. But what was most striking, was the damage to the
frontal lobes of the brain, and the effect that had on his behavior and personality afterwards. Just a good reminder to all of us, that when we’re working
with patients that have had an acquired brain injury, sometimes there are personality
problems that follow that. So the person may be quickly frustrated, they may become labile, they may misperceive social situations. And so here are some
of the patient symptoms that they will report to us. That they may feel sluggish. They may find that they
can’t remember things. Sometimes it’s hard for them to remember the correct word, that
they may have trouble with word retrieval, or comprehension
of what we’re saying. They may have trouble
comprehending syntax. They may also lack insight, and they may be very easily distracted. So some of those symptoms are what we see accruing from injury. These are some of the physical symptoms that Anne-Marie reviewed with you. Paralysis, you may see hemiparesis, you may see impaired problems
with motor skills, ataxia. Or you may also see double vision, or some type of hemianopsia as a result. Problems moving the tongue and producing speech sounds. On a different point of view, what are the cognitive characteristics that these patients
sometimes will reveal to us? Primary amongst those, are areas of attention and concentration. And as you’ll see later, that’s a very good place
to start with individuals that have had an acquired brain injury. We’ll often hear problems with memory, or the recall of new information, particularly working memory. They may be slowed in their processing. They make react impulsively, without thinkin’ ahead to
what are the consequences. We may see problems with
flexibility, judgment, and the ability to
discern non-verbal cues, particularly in social situations. So it just goes to show, that
the cognitive characteristics don’t stand alone, but rather
they do need to be seen, in relation to other problems
that the person may be having. Other problems they may have. So these are some of the
behaviors that we’ll see. Dis-inhibition, social
skills deficit, impulsivity, denial of disorder is a very common one. Babinski use to refer
to this as anosognosia. But what we realize now, is the patient just may not be aware of the nature of their problems, or when it’s pointed out to them, they may have a nano dysphoria, which means they may make light of it. Now, one of the questions
that these patients are gonna turn to you and ask is, is there any hope for improvement? What can the patient
themselves, and their family, and caregivers expect? And the answer is, we can now say, that there is a program of
cognitive rehabilitation, who’s job it is, to help optimize
the patient’s functioning, following this type of injury. So you may see that
there is a restitution, there’s a re-establishment,
and strengthening, of damaged pathways. And recently when I went to a CRM, Corbetta was talking about
this being the main pathway for a lot of individuals that have had some kind of head injury. We need to get some of
those brain structures up and running again. Or in some cases, where
there’s damage, for example, there may be a stroke or two, let’s say the left medial temporal lobe, you may need to have other pathways, other parts of the brain, take over some of that functioning so the person can continue to communicate. And lastly, when we
realize there are problems, such as you’ll find in memory, we may need to have patients
learn how to compensate for some of those weaknesses. Relying on external aids,
perhaps on an iPhone app, to remind them about
when to take medicine, or what they need to get from the store. So as part of all this,
what we’re saying is, it’s very important for
patients to have an awareness of what the problem is, and how the injury may have affected them. And to become engaged in goal setting, so that they can now begin to say, these are areas I need to work
on to improve my functioning. And as clinicians in the field, we can rely on computer
assisted rehabilitation to support this goal. But it’s important to make a distinction. I had a person once sayin’ to me, oh, it’s just like a brain game, why don’t we just do that instead? Well there are some differences. One of the intervention
characteristics is this, that the, a task is
going to be structured, it’s going to be systematic, it’s going to be customized
for the individual patient, so they’re workin’ on things
that are meaningful to them. It will involve practice, and
repetition, and persistence. And it will be monitored. So one of the key features that Anne-Marie referred to last time,
is this entire process requires supervision and monitoring. And it’s not just
something that you can do in a whimsical fashion. So can you use computers to assist rehab? The answers yes. So is that the same as brain training? Absolutely not, it is not the same, because of all those characteristics that are mandatory for it to be effective. And as such, individuals as Ben-Yishay, and Prigatano point out,
it should be done as part of a therapeutic milieu, where we’re focusing on
the needs of the patient. So what kind of computer
cognitive training is available to us? And here’s one example. The RehaCom program, now
available from Pearson. So I’m going to quickly review with you what some of those client
and patient populations are. The role of the clinician, because sometimes
therapists have said to me, oh, that’s gonna do me out of a job. No, it isn’t. If anything, it’s going to assist you in your efforts to work with patients that require rehabilitation. We’ll look at some of
the distinctive features. We’ll also look at the screening modules that are available to you, so you can identify areas of weakness. And then the training modules
that are linked to those. I know for many of you,
it’s going to be important to look at research, what has been done over the past few years with this program, and do we have any evidence that it works. So let’s review that. When we think about
computerized cognitive training, one of the areas that the
RehaCom program focuses on, is visual field. So you’re going to see some of the modules will screen for that, and some
will also provide therapy. One of the key ones that
we’ll start lookin’ at, is the area of attention. We’ll also look at memory
and executive function. So what you can see,
is that there are over 20 training modules that are configurable. It’s also important to recognize that the program will
auto adapt to the needs, to the level, and
performance of the patient. One of the issues that
comes up sometimes is, will this go low enough for those that have had severe deficits? And the answer is yes. However, don’t be misled into thinkin’ it’s only gonna be easy,
for many patients actually, it’s quite challenging. So what are the client
patient populations? Who can it be used with? Well we may see patients that
have a cognitive deficit, that results from a degenerative
neurological disorder. So it has been used
with patients that have Multiple sclerosis for example. Our focus today is on traumatic
brain injury and stroke, and certainly individuals that have had this type of brain insult,
or this type of infarct in their brain, may
benefit from the program. But there are other
clinical conditions as well, that will be benefited from this. The range is from mild to severe. And in some cases, our focus will be on restoring function to some kind of premorbid level, to help optimize that patient. In other cases, we’re going to compensate where parts of the brain
may have been damaged, and help the patient better come to terms with the problem their experiencing, so that they can move on. Clients will work in a
clinic or a hospital setting. And often this will be a rehab center. Now who’s going to provide this program? And the answer is, it can only be accessed
through a clinician. It is clinician mediated. So although some you may be thinkin’, well it’s gonna replace
me, the answer is no, that is not the case. Why does this matter? Because what we do know, is that if a patient’s left to themselves, and they have a problem
that may be diagnosable, they tend not to finish programs. So we’ve had a number of people say, well I’ve been workin’ on something, let’s say workin’ memory,
and I did some program that’s commercially available. And if you ask, well how much did you do, how far did you go, the answer might be, well I actually didn’t finish it. Because often with self
administered programs, as they get challenging, and
they require persistence, that doesn’t happen. Another feature, is that the relationship between a clinician and the
patient is very important. Now I pointed out early on, that it’s important for those
working in rehabilitation, to really have an
approach towards a patient where we can help them better understand what their problems are,
help them become aware of areas of difficulty,
the nature and extent of the problems they
have, how it’s adversely impacting them, what they need to do to be able to overcome that. So we need to engage them in goal setting. We need to engage them
in formulating a plan, taking into account
how they were early on, and how they are now, so that
we can help them optimize their functioning, and
achieve goals which are measurable and achievable. There’s a acronym called SMART. So some of you will be very
familiar with SMART or SMARTER, where these goals are actually
realistic and achievable, and need to be something
that’s simple enough for the patient to be working
on, and that they buy into. It’s important for us
to work with a patient, so that we can say, this
is why you’re doing it, this is how it’s gonna help you, this is gonna help you
achieve some of those goals that you have set for yourself. And that relationship that
you, as a clinician have, is very important, to engage them, and to facilitate persistence. So what we know, is that even if you were to do some kind of computerized
cognitive training, when you have a more severe disorder, or it will be very aware for that to be a standalone treatment. Clinical expertise, your experience, your knowledge and
understanding, your oversight, is integral to be able
to manage the process. In some cases, you’re going to see that the patient’s able to easily perform tasks at a simpler level. You can make it harder. Or in some cases, they don’t need to have the instructions repeated. Or in other cases, they
may not need to have the stimuli exposed as long. And that call all be changed. So you are integral to the patient’s success. It also helps by automating
some elements of treatment, and creating greater
efficiency and efficacy. So if you know you’ve
been spending a lot a time trying to create a task that
will meet the patient’s need, and also you need to document
the goals you’re working on, and document the progress
the patient’s been having, if you can automate some of that process, it actually might make the task a little bit easier for your job too. So by having tasks available
that the patient can work on, and having tasks that
can then be automated, it means that you can actually
have more than one patient doin’ this at one time. And what we know in a
lot of rehab centers, is that you as therapists, may need to engaged with
more than one patient, in order to maximize your efficiency. Accessibility, this means
that you have more opportunity to oversee the overall
treatment management, and not just take care of small details. So as care becomes complicated, and as you work with your colleagues, in tryin’ to achieve goals
in that therapeutic milieu, it’s gonna be very important
to take a step back sometimes and say, what is it we’re
tryin’ to achieve here, is this enabling the patient
to get where they need to be, and do we need to adjust
some of those goals, or do we need to review and perhaps add more detail to that. Now what clinicians would be involved in this entire process? As you can see, clearly,
we recognize the value of physical therapists,
occupational therapists, speech therapists, and
perhaps even physicians that are experienced with
psychiatric problems. And so in cases like traumatic
brain injury and CVI, you might need to have somebody working on the behavior and the physical aspects. But you would also need to have
somebody who’s focus will be on how can I help optimize this person’s, let’s say fine motor
coordination, or their muscle, or their balance, and their coordination. As well as, can we help them
with any word finding problems they may have, or language formulation, or language comprehension
problems they may experience? So speech therapy is one more group that we know is gonna
be actively involved. I know for example, when I presented on traumatic brain injury to a
group of speech therapists, just outside of Washington
DC about a year ago, many many people in the audience were qualified clinicians with a
speech therapy background, working in rehab settings. So they needed to be recognized for their contribution to
the overall treatment plan of these patients. However, other professionals
may also play a role. So you may get a physiatrist, you may get other types of
physicians, or clinical staff. Many of you on today’s
call are psychologists or neuropsychologists, and you appreciate and understand the role that you play, and how you can collaborate with some of these other treating
therapists and clinicians. So we are suggesting that
a comprehensive approach, involving a variety of
clinicians, may be the way to go. It’s very rare that you’d
have only one clinician working with a patient, that
has this type of disorder. And those multiple perspectives,
will allow you to have, let’s say a trans-professional
type of point of view, on what is it they’re working on, and what part is that going to achieve in the patient’s overall care. Now development and distinctive features. First of all, it’s important
that the program be relevant. As we indicated, the
program Cogmed, I’m sorry, the program RehaCom, was
developed by clinicians, in particular, university
neuropsychologists at Magdeburg University, so
the clinicians could use this in a rehabilitation setting. So from the outset, the program
was intended to be relevant. And feedback from clinicians,
over the use of this program, and over some of the
challenges, obstacles, problems they were facing,
allowed the clinicians, who were developing the
program, to work on it, to improve it, to expand it, so that it can be improved from the very
early modest beginnings. It offers a distinctive and
broad range of training. I mentioned the Cogmed program, which enhances workin’
memory, but as you can see, this is broader. It includes other types of memory, as well as some executive
skills, and visual scanning. Breadth, unlike some
programs, this is somethin’ that can be done on an inpatient basis, with patients who are severely impaired. And it will allow them to progress. As well as individuals who are, let’s say mildly impaired, who’s difficulty level may not be as low, and as a result, they are
looking for more challenge. I was talking to a rehab
team at a hospital, which had a very large teaching university affiliated with it, and they were saying, we get a lot a faculty, we
also get doctors, and lawyers, and others, who come in with some problem of a neurological nature, but
their premorbid functioning would’ve been above average to superior. So we need to have something
that is gonna challenge them, and allow them to go back to some type of very
advanced premorbid level. And there’s a breadth to this program. The other thing to bear in mind,
is that it is configurable. So you can refine and revise treatment. You can prioritize, you can
shift levels of challenge. And that’s important now. On the one hand, it can
be done automatically, by the computer. And I am told by some of
our psychology colleagues in Germany, that a lot of the OTs, PTs, using this program in
those rehab settings, allow the computer to
automatically do that. But it’s important to
recognize, as a clinician, you can go in and change
some of those parameters, and adjust them, and
make them configurable. So once again, you can customize it for the particular patients
that you’re dealing with. Now what are some of those features? The first thing to note, is
that it provides a screening. So you can get initial baseline
measure, a reference point. You can see what the screening modules are for that very soon. And that will allow you to then determine if there’s a problem. As we indicated, that the program adjusts. There’s an algorithm,
that is semi-autonomous, and you can modulate that yourself, but you can also rely on
the computer to do it. Lastly, there are therapeutic modules, and
then there are reports, based upon both the
screening and the reporting. And these include, graphs,
and numerical data, which you can then export, print, and enter into some type of
medical record as you need. So one of the things to bear in mind, is that it really is individualized. You will start off with certain areas, and then you’ll be able to see, is this too easy for the patient, do I need to make it harder, or is this too hard for the patient, should I make it easier. So there’s flexibility in the
administration of this tool. So it allows you to be
effective and efficient, in the way in which you conduct your work. If you have a severe deficit, patients can be given
tasks that are challenging at their level. You can also find some
of the very top levels to be extremely challenging,
if you try to do them yourself. One of the key features
about this program, is that we provide a keyboard. So if there’s some patients
that have problems with dyspraxia or dysarthria, so they’re unable to move their
hand in a coordinated way, this is gonna make the
performance much easier. So it adapts to the needs of the patient. And you will see, that there
are very large okay buttons, on the right and the left hand side. So even with patients
that have a broad range of physical problems,
this is gonna allow them to optimize their functioning,
rather than to rely on the keyboard that may
be attached to a computer. So screening is a very
good place to start. And this can guide what you do. What you’ll also see, is that you can start
with almost any module. So you start with training, in the areas of attention
and concentration, which we recommend. And patients that have problems, let’s say with their workin’ memory, or perhaps with their visual attention, may find this is a good place to start. One thing to bear in mind, is
that when you talk to patients about attention, they will rarely say, that’s a weakness for them. So you may need to describe,
what are some of the tasks that are involved with divided attention, or visual attention, or remaining vigilant sustaining attention. So they can understand, what
is that, in layman’s terms, and why would I need to work on that. And so you will be able to screen, to see if that’s an area of weakness, and therefore is that
a good place to start. There are 20 training modules. And the same principles and
structure apply throughout. So it does make training faster, and more intuitive to
people as they do it. The screening modules,
let’s start with those. In the area of attention, you
can see there is alertness, selective attention, divided
attention, and spacial numbers. And so if you have patients
that are referred to, following a CVA or a TBI, you may find that one of their areas
of particular weakness, is area of attention and concentration. And you may have to say to them, these are some tasks that
are hard for you to do. For example, when you
go to a grocery store, can you find the particular ingredients that you’re looking for? If you’re looking to cook something, can you get the ingredients that require, and have them in the order that you need? And can you attend to the amount, or measurement, that is required? And can you select the right ingredients? So can you keep your mind
on what you’re doing? And are you easily distracted? For example, if you’re cooking something, do you find the telephone rings, and you want to go and answer it, and you’re leaving the hot stove? So are you attending? Divided attention, you might
use an analogy like this, you may say, you know
when you’re driving along, and you’re paying attention
to the speed limit, and you’re paying attention to the visual stimuli around
you, do you also listen to a conversation that may be going on, or perhaps a song on the radio? So is your mind focused
on the task at hand? Or is your mind being
asked to pay attention to more that one type of stimuli? So these types of explanations
help our patients understand, attentions an area that
often they need to improve. When we look at memory, you’ll see that we’re
screening for memory for words, and for workin’ memory. Can you hold things in mind
while performing some task? And as we look at logical reasoning, can the person perform tasks that require some executive functioning? Lastly, visual field and visual scanning, are places that you may
explore with patients. Often you’re going to find, that they’re unaware
that this is a challenge. So they’ve said the
different screening modules. Can they react appropriate
under time pressure? Control their impulsivity? Can they select the right stimuli? Can they learn verbal and
visual spacial material? And do they have the ability
to see their visual field? Now, I know this is very busy, but I will try to walk you through it. The long bar refers to, how far below is this
person’s performance. So what you will see, is that the data are converted into T scores,
with a mean of 50, and standard deviation of 10. These are Z scores. You may also see percentile ranks. So how far below is this
person’s performance? Well you start at 50, or average,
you can see this bar here, let me use this one, this one here, is going to show you, this is
significantly below average. This one is also in the red
zone, and is way below average. So the longer the bar, the further the deviation from the norm. And this is going to tell you,
here’s the training module. And this is what is
recommended for this patient, based upon their performance. You may find in other
cases for example, here, where they’re doing spacial numbers. And are there any problems with perception of their visual field? Well green is still in the
average, or normal range, and so it’s not that bad. But what you can see, is
that you’re gonna get graphs, you’re gonna get numerical
data with percentile ranks. And then you can use this, to see how does this patient
do compared to others. Now in the area training modules, these are the areas that are
part of the RehaCom program. Attention, there are train, 10 training modules for attention. And what we do know, is a
significant number of patients have problems with
attention and concentration, after they’ve had a stroke or TBI. As I alluded to earlier, you will sometimes find the
patients themselves don’t say, I have trouble keepin’ my
mind on what I’m doing, but they may find that family
members will tell them, I just said that to you. Or you’re not working hard enough. And what you’ll also find, is that when the person’s
having trouble paying attention to instructions, directions, maybe the location of something they need, they may present with
confusion, or even fatigue. Or they may find they
have to read something more than one time. And it’s rare. And there’s even case with
mild competent impairment, and Alzheimers, that a patient
will actually say to you, I have problems paying attention. So you may have to say to them,
here’s some illustrations, here is some examples of something that may be harder for you right now. For example, when somebody
introduces their name to you, do you remember what they
just said their name was? Or what they do? Do you remember where you saw that person? Can you remember their face
is you were to see them again? So there are different aspects that you may want to
point out to patients. One of the issues to be aware of, is that just because a person
has an attention problem, does that mean any attention program is going to be sufficient? And the answer is no. What you can see from this research by Sturm and others, from ’97, if the task requires too
complex requirements, with a patient that
has impaired attention, that doesn’t actually help them. If anything, it may aggravate, and exacerbate their performance. That’s the reason why it’s
important to recognize, where are they now, what is
their capacity at this time. And if you screen, you
may find that the patient may have very subtle attention problems, and it will suggest what the
starting point should be. We also know there are
different kinds of attention, and they’re located in
different parts of the brain. So for example, when you consider this is the cerebellum down here, and here’s the cerebellum here. I’m gonna get rid of that,
let’s use this instead. Here’s the cerebellum. What we can say, is when a
person alternates attention, it’s going to involve
some of the frontal lobes, as well as some of the cerebella area. On the other hand, can the patient select what they’re going to pay attention to? This might involve some
of the frontal lobe, as well as some of the parietal lobe. And as you can see, we’re now looking at the right hemisphere, and up here is the left hemisphere. So for selective attention,
you’re going to see an increase focus on the
parietal modules here, as well as the dorsolateral
prefrontal cortex, and not so much the temporal area here. So depending on the type of attention, you may see it localized in
different parts of the brain. And that’s one more reason
why we need to pay attention to what’s the nature of
that attention problem, what kind are they presenting with, and what do they need help with. So this will be one way to
help you better understand, that you might start
with selective attention. There are 24 different levels. If it’s too hard, you can
go back to easier modules, such as alertness, reaction behavior. Or if that’s too easy,
you can go down here to 3D operations, or spacial
or divided attention tasks. So you can see there’s a lot
a different types of attention that can be trained. If you were to look at
one very simple task, you’ll see that, can you
match for this particular set of flowers on the right here. So when you click start here,
this is going to be level six. Can the person find the correct match? In that case it’s here. And was this too easy with the patient, then it will suggest where
you should go next to, something more challengin’, such as spacial and divided attention. On the other hand, if it’s too hard, you can go back to an easier one. So notice how this is level six. You could go back to level one. At one time I was talking
to some OTs and PTs, and they said, we find this is too hard for some of our patients. I said, well where are you starting? And they said level six. Are you going back to level
one, or to an earlier level? They weren’t even aware that was the case, and you can adjust it. You can also escape, to go
and do that for the patient. So on the left hand side,
you can see alertness. Here’s a child crossing
the road on a bicycle, so these are very lifelike pictures. Here’s some reaction behavior tasks. Can the person respond appropriate to a visual stimulus
or a triangle this way? With vigilance, can
they keep their mind on what they’re doing, and
find those correct stimuli as they’re required to. Down here we have some spacial tasks and some three dimensional spacial tasks. Over on the right, are
some of the harder ones. Now I mentioned earlier, that you want to bring the
issue of awareness to patients, and also engage them on goal setting. And so here’s one where you can say, I know you’d really like to get back behind the wheel of a car. Here’s a divided attention task that’s gonna ask you to monitor
and modulate your speed. You’re gonna have to pay
attention to the police car that’s in your rear view mirror, particularly if it’s got flashing lights. There are speed signs along here, so you need to go slower, and
brake when it’s appropriate. So can you react appropriately given the visual field task here? So as you can see, this is one
of the more challenging ones, and yet it is one of the
most popular in Germany. And of course, they have autobahns, where a lot a patients may want
to go back to driving again. Memory is also a very common
deficit for a lot a patients. There are different kinds of
memory, as you may be familiar. On the left hand side we
see declarative memory. So can a patient remember facts? Can they remember episodes,
perhaps they were involved with, such as their wedding day? On the other hand, there
are non-declarative or implicit memories. Some of those are classically conditioned. You may find some refer
to emotional reactions to certain stimuli. Some may involve procedural memory. So they’ve learned how to perform a task, like playing a guitar,
skiing, riding a bicycle, maybe even drivin’ a car. And we also know that it depends on the age of an individual, as to how certain skills may be acquired. So one of the things to be aware of, is that children under the age of seven, seem to rely on more
procedural implicit memory for a new language acquisition. Whereas adults may have to learn
those rules and vocabulary. And I remember reading
Howard Gardner’s book on the Shattered Mind, about a linguist, who was very proficient in such languages as German and French. And so when he had a stroke,
those were actually preserved, but his English, his
first language was not. So very interesting to see, how does the brain cope
with language demands. Now for memory, there are
these different areas, workin’ memory, topological,
physiognomic, or face memory, memory for words, figures,
and verbal memory. So workin’ memory, this is a
little bit like a card game, where you have to remember
what was that card, and where was it located. So it’s selective and spacial, and it requires some mental manipulation. Can you memorize the
content and their positions? Can you remember figures? And can you remember words? So there are different
degrees of complexity. And lastly, we’re going
to have stories read, and can the person remember those stories. With physiognomic, that
would be a face memory task. And this can even be
personalized to family members, or doctors, and nursing staff, that the patient may have to deal with. Executive function, is another area that RehaCom does focus on. So these are skills that require planning, logical reasoning, and
the ability to return to certain types of daily life. So it’s necessary for purposeful behavior. All those ADLs and IADLs
will be mediated through the executive functioning. And we do know it’s a very common deficit in a lot a patients. It clearly is going to effect how the person progresses in their rehab. So it’s very important
to be able to produce a coherent goal directed result. So in the RehaCom program, the tasks involve logical reasoning, planning a vacation, or shopping. All of those are areas
that are ecologically valid for our patients. They may tell you, this
is somethin’ they want to go back to doing. It enhances their independence,
their self-reliance. And so planning a shopping
trip, where am I gonna go? What do I need? What am I gonna get in the store? As well as a vacation. Very important for a lot of
people to be able to plan ahead, and to anticipate potential
challenges and problems. So we don’t have to
motivate folks to do these. They do want to become more
independent and self-reliant. And if they can perform
some of these tasks, it actually will give them a better feeling about themselves. So you may see lower levels of fatigue. Or perhaps lower levels of
anxiety, and depression, in some individuals that do have a TBI. Lastly, we’re going to be
looking at the visual field. And as you can see, some task that patients have to deal with may involve depth perception. Such as, can you walk up this bridge? Can they appreciate mental rotations? Can they reproduce some kind
of visual constructional skill? So can they appreciate the
complexity and copy that? And by the way with the Rey-Osterrieth we do have to remember that, and recall it, and repeat it. Or can a person put together
different objects and space? Or use visual spacial skills
for certain types of dressing, reading, grasping an object, appreciating the location
of arrows on a clock, and also being able to
dress appropriately, or navigate themselves in space? So can I find my way? I read one study done in
Scandinavia, with diary entries, patients following an
acquired brain injury, and a program to enhance
their functioning said, I feel better about finding my way home. And also knowing why I went out to get certain things from the store. And then lastly, we
have certain challenges, such as, can you set a table,
can you find the right pot for the right kinds of ingredients. And one of my favorite ones
would be, as the child grows, can they move in space without bumping into
things and falling over. Or in the case of some of our older folks, are we finding the inability to deal with this kind of visual perceptual challenge, is gonna result in trips,
and falls, and collisions. And sometimes a patients will
present as quite bruised, and they may also say they
hurt because they fell. This may actually precipitate
admission to a hospital, in a number cases where we do see some evidence of other cognitive decline. Can the person get help? Or are we finding that they are having a great deal of difficulty moving around? And then lastly one of
my favorite ones is this. That could’ve been me. I went to IKEA to get a book shelf, and it said they have to
be at a 90 degree angle. Boy, I had a hard time
getting that all to fit. And actually went back to the store, and talked to a girl about how
to use the corner of a room to make sure I had the
correct angle to force it. So with visual spacial
processing tasks such as these, we may find it particularly challenging if you have a visual problem. And as we said earlier, there may be problems with such things as, appreciating the angles,
being able to see a pattern. And also, we may see that there’s a problem with visual field perception. Now this doesn’t happen a great deal, but you might find that
sometimes individuals don’t appreciate the entire visual field. So we do see, following a stroke, between 45 and 65% of
patients will have a deficit in their visual field perception. It’s less common after a period of time. It’s relatively uncommon
in traumatic brain injury, but it is still a problem that faces a lot of us. Because what we see, is that the patient may even be unaware that there’s a challenge. They will say the following,
that they bump into things. They have trouble
because of poor lighting. People have moved things on them, they didn’t think they were there. They think it might be a visual problem, I need stronger glasses. And here’s a very good illustration. So when you have a person that
has a visual field deficit, on the right hand side
is what it looks like. They just don’t see it. And often a driver will
say, I didn’t see them. On the left hand side, as you can see, here are two children
chasing after a ball. And so I’m very familiar with one case, where a woman had complained
about a husband’s driving, saying that he doesn’t
seem to see that well. And yet when the child
chased after a ball, he braked very rapidly. Whereas the examiner
who was driving behind, almost rear ended him, because
she wasn’t paying attention, and yet she is the one
judging his fitness to drive. So it’s very interesting to me how sometimes people are
unaware of a visual field. They may neglect, they
just may not see it. And that is something they
may also report to doctors, that I don’t think I’ve got a
problem with my visual field. So we have visual field training programs. These involve saccadic
training, or restoration. It also obviously is gonna
effect what you read. You know, does the person
see the whole word or not? With saccadic eye movement training, which is frequently results
of a traumatic brain injury, you may find that there’s a real need to help the person deal with
different types of visual field that they are there for. So we’ve done the testing,
we’ve done the screening, we’ve provided therapy, what
kind of results do we get? So you can get very detailed information. You can progress with the
different training levels. And you can see how does
the person do over time. You can export the data, and
it can also be configured. Operating RehaCom, these
are the things you need. You’re going to need a quiet space, with minimal distractions. If you’re using multiple workstations, it may be also helpful to have headphones. We do encourage the use
of the RehaCom program in rehab settings, where there are staff that can support the
person doing the test, but there are also other people doing it, so that they don’t feel alone. And then the question might be, does it need to be networked
to some other hospital program or internet, for
downloading and recording? So these are some of the
features you’ll need. I’m not gonna go over that in detail. I just want to quickly check
to see if there are any actual questions that Anne-Marie
would like me to answer before I go into the research. Anne-Marie are you there? – [Anne-Marie] I am, and there are no waiting
questions at this point. – [Peter] Excellent, thank you very much for the answers you’ve been providing. I recommend, if this is an
area of real interest to you, to put your questions down, so Anne-Marie can help
you to answer those. Now some of you are going to be asking about research, so let
me quickly show you this. We’ve reviewed the training programs. We’ve gone over the features. You saw that it was auto adaptive, and you can use it to progress monitor, and also report patient outcomes. You can use it in a variety of settings, but we do recommend inpatient
and outpatient rehab settings, as being one of the primary places that this could really be helpful. It can be used with a number
of different patients, involving TBI, and stroke,
and other clinical conditions. And as we said earlier, you can restore, or help the patient learn to compensate. There are studies that have
looked at its effectiveness. Now what I’m going to do, is quickly review some of the research. As we’ve said, Hans Regel originated the RehaCom program back in 1986, so it’s been
around for over 25 years. There have been numerous studies that have looked at the
effectiveness of this program. In particular, we know
that there are studies by Keith Cicerone and Rohling
that have done metro-analysis of larger numbers of patient groups, using computerized programs
to show their effectiveness. But here’s a few for you to think about. In the Yoo study, in 2015, he looked at the effect of
computerized cognitive rehab on individuals that have had a stroke. In the Jiang study, in
2016, they looked at it in combination with an
acupuncture treatment program. And specifically, Kim Merle Richter and others, in 2014, showed how it could be
helpful in stroke rehab. And in particular, how it
may enhance workin’ memory, and how it may add to the benefits of semantic
structure in programs for cog rehab. So what she argued, is that
this experimental groups have improved significantly in workin’ memory and word fluency. And it generalized at
prospective memory tasks. In another study, this time
by Claudia, Claudia Modden, and others, published in 2011, they looked at traditional OT versus OT plus Cogmed, for the treatment of visual field loss. So what she argued, is that
improved functional deficits, compared to the standard OT, show the intervention
showed significant benefit. So it was suggested, that
they start to look at legion location in the
analysis, but she found that it was better than just relying on the standard OT alone. With TBI, there’ve been
studies by such individuals as Galbiati, as you heard Cicerone and Rohling, and others, have looked at the effectiveness
of cog rehab programs, for individuals that have
had an acquired brain injury. And in particular, Fernandez
published a study done in Cuba, and that’s here, where she
looked at memory improvement, particularly on the works of memory scale, and parts of the trails test. And in her study, which
was not randomized, but it was one looking at the effects of this program, on such areas an mental fatigue, headache, and eye irritation, and she found that it was useful
with 100% of the patients, showing improvement in
the trained functions. So there are a number of studies, and you can refer to the, the page devoted to research on the RehaCom website,
to learn more about these, and some other studies that have reviewed the evidence for the support. What we can conclude, is
that there’s certainly research to show that it has efficacy, and not just with these
two clinical groups, but with other groups as well. This is not really
surprising since Cicerone has documented how this
could be a useful adjunct, and there are very specific
modules in the therapy that could be helpful. And Anne-Marie did refer to those in the earlier webinar that was conducted. So yes, there’s data to show it works. And yes, some of these studies do come from all over the world. Are there any additional
questions Anne-Marie, that you’d like me to try to respond to before we run out of time today? – [Anne-Marie] Peter, there’s not. But Scott and myself have been answering a few questions here. There’s one unanswered question that I’m tryin’ to get clarification to. So if the person who sent the question, how do you handle
performance validity issues, would clarify your question
a little bit for us, we will be able to respond
in an email, please. – [Peter] Very good Anne-Marie. – [Anne-Marie] But
that’s it (over-talking). – [Peter] Thank you once
again everybody for attending. Thank you everybody for your questions. Thank you Scott and Anne-Marie, for diligently answerin’ the questions that have come up here. We do hope that this program
is gonna be of interest to you. And if you have questions about it, please do be in touch with us. Anne-Marie and I both work
with Scott at We would like to hear more from you. If you have questions about,
can I use it in my facility, could you answer particular questions, please do be in touch, so that we can help you get those questions answered. I see that Anne-Marie has
provided our email addresses, and I will go back, perhaps
to the very first page, so you can see how to spell our name. There we are. So I’m [email protected] And Dr. Kimbell is
[email protected] and Scott Pawson is
[email protected]

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