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NeuropsychologicalRehabilitation

Barbara A. Wilson

Cognition and Brain Sciences Unit, Medical Research Council, AddenbrookesHospital, Cambridge CB2 2QQ, United Kingdom;email: [email protected]

Annu. Rev. Clin. Psychol. 2008. 4:14162

First published online as a Review in Advance onDecember 11, 2007

The Annual Review of Clinical Psychology is onlineat http://clinpsy.annualreviews.org

This articles doi:10.1146/annurev.clinpsy.4.022007.141212

Copyright c 2008 by Annual Reviews.All rights reserved

1548-5943/08/0427-0141$20.00

Key Words

brain injury, cognition, emotion, psychosocial, holistic program

Abstract

Neuropsychological rehabilitation (NR) is concerned with

amelioration of cognitive, emotional, psychosocial, and behavdeficits caused by an insult to the brain. Major changes in NR

occurred over the past decade or so. NR is now mostly centon a goal-planning approach in a partnership of survivors of b

injury, their families, and professional staff who negotiate and sgoals to be achieved. There is widespread recognition that co

tion, emotion, and psychosocial functioning are interlinked, anshould be targeted in rehabilitation. This is the basis of the ho

approach. Technology is increasingly used to compensate for co

tive deficits, and some technological aids are discussed. Evidenceffective treatment of cognitive, emotional, and psychosocial

culties is presented, models that have been most influential inare described, and the review concludes with guidelines for g

practice.

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Contents

INTRODUCTION: WHAT ISNEUROPSYCHOLOGICAL

REHABILITATION?............ 142HOW HAS

NEUROPSYCHOLOGICALREHABILITATION CHANGED

IN RECENT YEARS? . . . . . . . . . . . 144Goal Setting to Plan

Rehabilitation.. . . . . . . . . . . . . . . . 144Cognitive, Emotional, and

Psychosocial Deficits are

Interlinked . . . . . . . . . . . . . . . . . . . . 145Increasing Use of Technology in

NeuropsychologicalRehabilitation.. . . . . . . . . . . . . . . . 146

Rehabilitation Needs a BroadTheoretical Base . . . . . . . . . . . . . . 147

COGNITIVE ASPECTS OFNEUROPSYCHOLOGICAL

REHABILITATION..... . . . . . . . . 147EMOTIONAL ASPECTS OF

NEUROPSYCHOLOGICALREHABILITATION..... . . . . . . . . 149

PSYCHOSOCIAL ASPECTS OF

NEUROPSYCHOLOGICALREHABILITATION..... . . . . . . . . 151

MODELS AND THEORETICALAPPROACHES

CONTRIBUTING TONEUROPSYCHOLOGICAL

REHABILITATION..... . . . . . . . . 153GUIDELINES FOR GOOD

PRACTICE INNEUROPSYCHOLOGICAL

REHABILITATION..... . . . . . . . . 154SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . 156

INTRODUCTION: WHAT ISNEUROPSYCHOLOGICALREHABILITATION?

Most people receiving rehabilitation for the

consequences of brain injury have both cog-nitive and noncognitive problems. A typ-

ical patient in a rehabilitation center has

several cognitive problems such as poo

tention, poor memory, and planning andganizational difficulties, together with s

emotional problems such as anxiety, depsion, or in some cases, post-traumatic s

disorder. The patient may exhibit beha

problems such as poor self-control or aoutbursts and may experience some su

motor difficulties leading to reduced stamand unsteady gait, as well as problems

nected with social skills and relationshipaddition, the patients family members ma

unable to comprehend what has happenethe person they once felt they knew and

derstood, and the patient will probably stgle with issues connected with the cont

ation of work or education. Tables 1 a

show the main patient groups seen by ropsychologists working in rehabilitationthe main problems these patients face.

We can define neuropsychology as

study of the relationship between band behavior. One of the major differe

between academic neuropsychologists gaged in rehabilitation research and c

cal neuropsychologists working in rehatation centers is the manner in which

needs of brain-injured people are determi

Academic neuropsychologists believe thatailed assessments informed by theoremodels can highlight areas that require

habilitation. Thus, testing of different cponents contained in a model of langu

can identify a particular deficit as the

to work on in rehabilitation (Caramazz

Table 1 Main patient groups seen by

neuropsychologists working in rehabilitati

Main groups seen for rehabilitation

Traumatic brain injuryStroke (cerebrovascular accident; CVA)

Infections of the brain (e.g., encephalitis)

Hypoxic brain damage

Other groups sometimes seen

Progressive conditions

(e.g., Alzheimers disease, multiple sclerosis

Cerebral tumors

Epilepsy (idiopathic)

142 Wilson


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Hillis 1993). Clinical neuropsychologists, on

the other hand, are less likely to determinerehabilitation needs through theoretically in-

formed models and are more likely to targetreal-life problems identified by patients and

their families. As discussed below, both ap-

proaches play a part in the rehabilitation ofindividuals whohave sustained an insult to the

brain.A good definition of rehabilitation is pro-

vided by McLellan (1991). He suggests thatrehabilitation is a two-way, interactive process

whereby people who are disabled by injury ordisease work together with professional staff,

relatives, and members of the wider commu-nity to achieve their optimum physical, psy-

chological, social, and vocational well-being

(McLellan 1991). UsingMcLellans definitionas a guide, we can define cognitive rehabilita-tion as a process whereby people with brain

injury work together with professional staff

and others to remediate or alleviate cognitivedeficits arising from a neurological insult. Al-

though cognitive rehabilitation is often a ma-jor part of the work of clinical neuropsychol-

ogists, they are also increasingly involved ina wider range of issues. Thus, it could be ar-

gued, neuropsychological rehabilitation (NR)

is broader than cognitive rehabilitation, as itis concerned with the amelioration of cogni-tive, emotional, psychosocial, and behavioral

deficits caused by an insult to the brain.McLellan (1991) believed that rehabilita-

tion, unlike surgery or drugs, is not something

that is done to or given to individuals. Instead,the disabled person is part of a two-way inter-

active process. This view reflected a growingchange in rehabilitation. For many years, per-

sons with a disability were told what to ex-

pect in and from rehabilitation; the rehabili-tation staff determined what areas to work on,what goals to set, and what was and was not

achievable. Sometime in the 1980s, the phi-losophy began to change, at least in some cen-

ters, so that in many rehabilitation programstoday, clients and families are asked about

their expectations, and rehabilitation goalsare

discussed and negotiated between all parties

Table 2 Problems faced by survivors of brain injury

A. Problems faced by B. Typical cognitive problems

survivors of brain injury

Motor Memory

Sensory Attention

Cognitive Communication

Behavioral

Planning

Social

Organization

Emotional Reasoning

Pain Perception

Fatigue, etc. Spatial awareness

C. Typical emotional and D. Typical behavior problem

psycho-social problems

Anxiety Temper outbursts

Depression Shouting

Anger Swearing

Fear Physical aggression

Social isolation Disinhibition

Grief

Poor self control

Poor self-esteem

Refusal to cooperate, etc.

Lack of confidence

NR:neuropsychologrehabilitation

Goal: the state change in state) an intervention course of actionintends to achie

Stroke: a braininjury caused bysudden interrupof blood flow

involved. The focus of treatment is on im-proving aspects of everyday life and, as

Ylvisaker & Feeney (2000, p. 13) say, reha-bilitation needs to involve personally mean-

ingful themes, activities, settings and inter-actions. An example of this is provided by

Wilson et al. (2002), who describe the treat-

ment of a man with both a stroke and a headinjury. One of this mans goals was to fly hismodel helicopter againan important goal

for him that would never have been consid-

ered30yearsago.Tateetal.(2003),indescrip-tions of their service for people with brain in-

jury, also imply that partnership is important,and Clare (2007) describes how people with

dementia are encouraged to select their owntargets for treatments. This is a much health-

ier state of affairs than providing clients with

experimental or artificial material on whichto work. Motivation is likely to be increasedbecause all those involved are working on

real-life problems, which also prevents gen-eralization difficulties. Because the ultimate

goal of rehabilitation is to enable people with

disabilities to function as adequately as pos-sible in their own, most appropriate, envi-

ronments (Ben-Yishay 1996), real-life issues

www.annualreviews.org Neuropsychological Rehabilitation 143


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Acquired braininjury: anondegenerativeinjury to the brain

that has occurredsince birth

should be at the forefront of rehabilitation

programs.

HOW HASNEUROPSYCHOLOGICALREHABILITATION CHANGEDIN RECENT YEARS?

In some ways, NR today is similar to that pro-vided to soldiers in Germany in World War I

and in Russia and the United Kingdom inWorld War II. In their historical review of

NR in Germany, Poser et al. (1996) remindus, Many of the rehabilitationprocedures de-

veloped in special military hospitals duringWorld War I are still in use today in mod-

ern rehabilitationat least to some extent

(p. 259). The vocational rehabilitation de-scribed by Poppelreuter in 1917 (translated

by Zihl & Weiskrantz 1991) is not unlikethat provided today. In addition, Poppelreuter

(1917) argued for an interdisciplinary ap-proach between psychology, neurology, and

psychiatry, and in a paper published in 1918,he emphasized the importance of the patients

own insight into the effects of disabilitiesand treatment. Goldstein (1942), also writing

about the First World War, stressed the im-

portance of cognitive and personality deficitsfollowing brain injury and touched upon whattoday would be called cognitive rehabilita-

tion strategies (Prigatano 2005). In 1918,Goldstein (quoted by Poser et al. 1996) was

concerned with decisions as to whether to try

to restore lost functioning or to compensatefor lost or impaired functions, and this debate

is still ongoing today.During the Second World War, Luria in

the (then) Soviet Union and Zangwill in the

United Kingdom were both working withbrain-injured soldiers. One important princi-ple, stressed by both Luria and Zangwill, was

that of functional adaptation, whereby an in-tact skill is used to compensate for a damaged

one. Goldstein was also committed to a sim-ilar concept. Lurias publications of 1963 and

1970 and his book with Naydin, Tsvetkova,

and Vinarskaya (Luria et al. 1969) are well

worth reading today for the insights the

fer. So too is Zangwills (1947) paper in whe discusses, among other things, the pr

ples of re-education and refers to three mapproaches to rehabilitation: compensa

substitution, and direct retraining.

Despite these similarities in concthere have been major changes, four of ware addressed in this section. The fir

goal setting to plan rehabilitation progr

second is a growing recognition that cotive, emotional, and psychosocial difficu

should all be addressed in rehabilitation; tis theincreasing use of technology to com

sate for cognitive difficulties; and fourthrealization that NR requires a broad theo

ical base or indeed a number of theore

bases.

Goal Setting to Plan Rehabilitatio

The Concise Oxford Dictionary (1999) defingoal as an object of effort or a destinati

In a discussion of rehabilitation goals, W(1999) suggests, A goal is the state or cha

in state that is hoped or intended for an invention or course of action to achieve. W

we negotiate goals with our patients,

families, and the rehabilitation team, welooking for something that the client/paboth will do and wants to do; this sh

be something that reflects the longer-t

targets and indeed the steps toward thGoals are important regulators and mo

tors of human performance andaction (A& Vancouver 1996) and a desired outcom

which progress can be measured.Goal setting has been used in rehabi

tion for a number of years with various d

nostic groups including people with cerepalsy, spinal injuries, developmental leing difficulties, and acquired brain in

(McMillan & Sparkes 1999). Because planning is simple, focuses on practical ev

day problems, is tailored to individual ne

and avoids the artificial distinction betwmany outcome measures and real-life f

tioning, it is usedincreasingly in rehabilita

144 Wilson


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programs. This approach provides direction

for rehabilitation, identifies priorities for in-tervention, evaluates progress, breaksrehabil-

itation down into achievable steps, promotesteam working, and results in better outcomes

(Nair & Wade 2003).

McMillan & Sparkes (1999) proposed sev-eral principles involved in the goal-planning

approach. First, the patient should be en-gaged in setting his or her goals. Second, the

goals set should be reasonable and client cen-tered. Third, patients behavior when a goal

is reached should be described. Fourth, themethod to be used in achieving the goals

should be defined in such a manner that any-one reading the plan would know what to

do. In addition, goals should be specific and

measurable and have a definite deadline. Inmost rehabilitation centers, long-term goalsare those that the patient or client is expected

to achieve by the time of discharge from the

program, whereas short-term goals are thesteps set each week or fortnight in order to

achieve the long-term goals. An acronym thatsummarizes the main principles is SMART:

Goals should be specific, measurable, achiev-able, realistic, and timely.

The process of goal planning typically in-

volves the allocation of a chairperson whoconducts all meetings, limits meetings to theagreed upon time, clarifies for team members

the aims of admission and the length of stay,actively participates as a member of the re-

habilitation team, and ensures documentation

is complete. The chairperson should also en-sure good communication between all rele-

vant parties, attend case conferences, coordi-nate reports, encourage clients, relatives, and

staff members to be realistic, and make clear

arguments to the relevant people for changesto the discharge date. Following a detailed as-sessment period, the first goal-planning meet-

ing is held, a problem list is drawn up, andpotential long-term goals are identified. The

goals are then discussed with the client andthe family, and the final goals are negoti-

ated and agreed upon. Both long-term and

short-term goals are documented. If it is con-

SMART: acronapplied to goalsare specific,measurable,

achievable, realiand timely

sidered helpful, the client and the family

members involved are given a copy of theshort-term goals to be achieved by the fol-

lowingweekorfortnight.Progressisreviewedevery one or two weeks in a 30-minute meet-

ing with the rehabilitation team. Additional

short-termgoalsaresetand,ifnecessary,addi-tional long-term goals are added. If any long-

or short-term goals are not achieved or areonly partially achieved, the reasons for this

are recorded. Failure to achieve a goal is at-tributed to reasons in one of four main cate-

gories: (a) client/patient or carer (e.g., clientunwell); (b) staff member (e.g., staff member

absent through illness); (c) internal admin-istration (e.g., transport failed to arrive); or

(d) external administration (e.g., fund-

ing withdrawn by rehabilitation purchaser)(McMillan & Sparkes 1999).

Wilson et al. (2002) describe a success-

ful goal-planning approach for a man who

sustained both a head injury and a stroke.Manly (2003) discusses the targeting of func-

tionalgoals in treatment. Williams (2003)saysgoal-setting procedures are one of the main

components of programs dealing with cog-nitive and emotional disorders. Most British

rehabilitation centers follow a goal-planning

approach (Sopena et al. 2007). Further sup-port comes from Kendall et al. (2006), whosemeta-analysis suggests, [D]irect patient in-

volvement in neurorehabilitation goal settingresults in significant improvements in reach-

ing and maintaining those goals (p. 465).

Cognitive, Emotional, andPsychosocial Deficits are Interlinked

Although cognitive deficits are, perhaps, the

major focus of NR, there is a growing aware-ness that the emotional and psychosocialconsequences of brain injury need to be

addressed in rehabilitation programs. Fur-thermore, it is not always easy to separate cog-

nitive, emotional, and psychosocial problems

from one another. Not only does emotion af-fect how we think and how we behave,but also

cognitive deficits can be exacerbated by



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emotional distress and can cause apparent be-

havior problems. Psychosocial difficulties canalso result in increased emotional and behav-

ioral problems, and anxiety can reduce the ef-fectiveness of intervention programs. There

is clearly an interaction between all these as-

pects of human functioning, as recognized bythose who argue for the holistic approach to

brain injury rehabilitation. This approach, pi-oneered by Diller (1976), Ben-Yishay (1978),

and Prigatano (1986), is founded on the be-lief that the cognitive, psychiatric, and func-

tional aspects of brain injury should not beseparated from emotions, feelings, and self-

esteem. Holistic programs include group andindividual therapy in which patients are(a)en-

couraged to be more aware of their strengths

and weaknesses, (b) helped to understand andaccept these, (c) given strategies to compen-sate for cognitive difficulties, and (d) offered

vocational guidance and support. Prigatano

(1994) suggests that such programs appear toresult in lessemotionaldistress, increasedself-

esteem, and greater productivity. Prigatano(1999, 2005) and Sohlberg & Mateer (2001)

describe the importance of dealing with thecognitive, emotional, and psychosocial con-

sequences of brain injury. Wilson et al. (2000)

present a British holistic program, basedon the principles of Ben-Yishay (1978) andPrigatano(1986), that is followed at theOliver

Zangwill Center for Neuropsychological Re-habilitationin Ely, Cambridgeshire. Although

these programs appear to be expensive in the

short term, they are probably cost-effectivein the long term (see Prigatano & Pliskin

2002).Williams (2003), who is concerned with

the rehabilitation of emotional disorders fol-

lowing brain injury, suggests that survivors areat particular risk of developing mood disor-ders. He argues that this is one of the key

areas for development in neurological ser-vices. Alderman (2003) targets behavior dis-

orders in work with some of the most severelydisturbed brain-injured people in the United

Kingdom.

Increasing Use of Technology inNeuropsychological Rehabilitatio

The increasing use of sophisticated tech

ogy such as positron emission tomograand functional magnetic resonance imagi

enhancing our understanding of brain d

age (see, for example, Coleman et al. 20To what extent these methodologies canprove our rehabilitation programs remain

be seen. What is clear is the value of techogy for reducing everyday problems of pe

with neurological damage. One of the mthemes in rehabilitation is the adaptatio

technology for the benefit of people with

nitive impairments. Computers, for exammay be used as cognitive prosthetics, as c

pensatory devices, as assessment tools, or

means for training. Given the current exsion in information technology, this is lto be an area of growth and increasing im

tance in NR in the next decade. One ofearliest papers referring to the use an e

tronic aid with a person with brain damwas that by Kurlychek (1983). This was

portant because the aid assisted in tacklireal-life problem, which was to teach a

to check his timetable. In 1986, Glisky

colleagues taught memory-impaired pe

computer terminology;as a result, oneofparticipants was able to find employmea computer operator. Kirsch and collea

(1987) designed an interactive task guidsystem to assist brain-injured people in

forming functional tasks. Since then, repof successful use of technology with br

injured people have appeared in many papBoake (2003) includes discussion of som

the early computer-based cognitive rehatation programs, and Wilson et al. (2001

scribe a randomized control crossover dethat demonstrates it is possible to reduceveryday problems of neurologically impa

people withmemory and/or planning diffities by using a paging system. The remin

do not always have to be specific. Basework by Robertson et al. (1997) and M

et al. (1999), Fish et al. (2007) found

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sending general reminders to stop, think,

organize and plan led to improvement in aprospective memory task. These content-free

reminders work for people whose prospec-tive memory problems result from execu-

tive deficits such as poor planning or divided

attention difficulties. For those with severememory problems, however, a specific re-

minder would be required.Virtual reality (VR) represents another

technology that will likely play an increasingrole in rehabilitation. VR can be used to sim-

ulate real-life situations and thus be benefi-cial for both assessment and treatment. Rose

et al. (2005) provide a review of the way VRhas been used in brain injury rehabilitation;

in addition, they discuss the use of VR for the

assessment and treatment of memory prob-lems, executive deficits, visuo-spatial difficul-ties, and unilateral neglect.

Rehabilitation Needs a BroadTheoretical Base

People with brain injury are likely to face

multiple problems, including cognitive, so-cial, emotional, and behavioral, and no one

model or group of models is sufficient to deal

with all these issues. In order to improve cog-nitive, social, emotional, and behavioral func-tioning in the everyday life of these indi-

viduals, we should not be constrained by a

single theoretical framework. Of the manytheories that affect rehabilitation, four are

perhaps of particular importance, namely the-ories of cognitive functioning, emotion, be-

havior, and learning. Consideration shouldalso be given to theories of assessment, recov-

ery, and compensation. Wilson (2002) argues

for a broad-based model and provides a ten-tative comprehensive model of rehabilitation.Boake (2003) describes the different method-

ologies that influenced some of the historicalfigures in the field. Manly (2003) refers to nu-

merous theories of attention that have guided

treatment approaches to this difficult area.Williams (2003) is particularly influenced by

cognitive behavior therapy (CBT), which is

Virtual reality(VR): a technothat allows a useinteract with a

computer-simulenvironment

CBT: cognitivebehavior therap

Traumatic braiinjury (TBI): asudden traumacausing damagethe brain (also chead injury)

certainly one of the most carefully worked

out and clinically useful models of emotionat this time. The neurobehavioral model of

Wood (1987, 1990) is one that has influencedAldermans work in the treatment of brain-

injured people with severe behavior problems

(Alderman2003).InasurveyofBritishclinicalneuropsychologists working in brain injury

rehabilitation, 57 different models were re-ported as influencing clinical practice (Sopena

et al. 2007). Ethical and effective NR requiresa synthesis and integration of several frame-

works, theories, and methodologies to achieveits aims and ensure the best clinical practice.

COGNITIVE ASPECTS OFNEUROPSYCHOLOGICALREHABILITATION

It is worth restating that it is not easyto separate the cognitive, emotional, and

psychosocial consequences of brain injury.However, because many of the studies in

the literature report these three componentsseparately, I examine them individually. Un-

less the brain damage is very mild, cognitivedeficits are almost invariably found in sur-

vivors of an insult to the brain. Problems with

memory, attention, executive functioning,and speed of information processing are themost typical difficulties faced by those who

have sustained traumatic brain injury (TBI).

For survivors of stroke, language problemsare common after left hemisphere damage,

and unilateral neglect is seen frequentlyafter right hemisphere damage. Numerous

studies have been published on the efficacy ofcognitive rehabilitation, ranging from single-

case experimental designs to randomized

controlled trials (RCTs).Chesnut et al. (1999) traced 2536 abstractsfrom articles on rehabilitation to find answers

to five questions, one of which was concernedwith cognitive rehabilitation. This particular

report was based on 363 articles, of which

114 related to cognitive rehabilitation. Theauthors asked specifically, Does the applica-

tion of compensatory rehabilitation enhance



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outcomes for people who sustain TBI? Of

the 114 potential articles, only 32 reached thefinal selection to evaluate effectiveness; the re-

maining 82 articles were excluded for variousreasons, such as because they were review ar-

ticles that were purely descriptive, reports on

studies in which there were fewer than fivesubjects,andsoon.Ofthe32selectedforeval-

uation, 11 were RCTs, with 5 measuring rele-vant health outcomes and 6 measuring inter-

mediate outcomes. The authors of the reportconcluded, along with the small size of the

studies and the narrow range of interventionsstudied, the lack of information about the rep-

resentativeness of the included patients makesit difficult to apply thefindings of these studies

to cognitive rehabilitation practice generally

(p. 55). In other words, the RCTs did not re-veal much about the effectiveness of cognitiverehabilitation in any general sense.

The cognitive rehabilitation section of the

report was published separately (Carney et al.1999). The authors state that although the

desired outcome of cognitive rehabilitationis improvement in daily function, many of

the outcome measures are intermediate mea-sures rather than health outcomes. By in-

termediate measures, the authors mean test

scores (123 tests of cognition were describedin the studies). The question was posed as towhether improvements on test scores predict

improvement in real-life function. The au-thors concluded that although there appeared

to be some relationship between intermedi-

ate measures and employment, the associa-tion was not strong. One could argue that the

use of test scores irrespective of whether theyare intermediate or direct is not a good way

to evaluate rehabilitation. The ultimate goal

of rehabilitation is to enable people with dis-abilities to function as adequately as possiblein their most appropriate environment, so in-

formation on changes in scores on the Wech-sler scales or any other standardized test will

not yield the required information. For ex-ample, JC, a densely amnesic patient (Wilson

1999), has shown no improvement on stan-

dardized tests over a 10-year period, yet he

is self-employed and completely indepen

thanks largely to excellent use of compsatory strategies. By most standards of t

involved in rehabilitation, these outcomevery good indeed, yet if standardized tests

been used as measures of success, JC w

have failed dismally.Some studies address real-life functi

issues. For example, Wilson et al. (2001

ported a randomized control study to eval

a paging system in which memory-impapatients were randomly allocated to the p

or to a waiting list. Patients and their famidentified real-life problems involving t

such as taking medication, feeding the and collecting children from school. In

baseline period, these behaviors were m

itored and there was no difference betwthe two groups. Those allocated to the ing condition then received their pagers

the same behaviors were monitored asfore. The achievement of the target be

iors significantly improved, whereas thos

the waiting list experienced no change. pagers were then returned and given to

people who had been on the waiting list. Tgroupthen improved significantly. Those

had returned their pagers dropped back

tle but were still better than they had beebaseline. This suggested that some learof the target behaviors had taken place du

the pager phase.Tackling real-life targets and individu

ing programs within a specified framewisor should bethe way forward in

nitive rehabilitation. Clare and collea

(Clare et al. 1999, 2000, 2001) appliedprinciple to people with Alzheimers dis

Patients and families selected the targe

haviors they wanted to achieve and a wayfound to teach new information. The mstrategies used in this series of studies w

errorless learning and spaced retrieval.Cicerone and colleagues (2000, 2005)

carried out major investigations into thecacy of cognitive rehabilitation. In their 2

paper, they used search engines to locate nitive rehabilitation studies and identifie

148 Wilson


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studies that fulfilled certain inclusion crite-

ria. They looked at several cognitive domainsincluding attention difficulties, visuo-spatial

deficits, apraxia, languageand communicationproblems, memory deficits, executive func-

tioning, problem solving, and awareness. On

the issue of retraining versus compensation,they found that retraining was effective for

some cognitive functions (for example, lan-guage), whereas compensation was necessary

for others (such as memory deficits). Theiroverall conclusion was, There is now a sub-

stantial body of evidence demonstrating thatpatients with TBI or stroke benefit from cog-

nitive rehabilitation (Cicerone et al. 2005,p. 1689). These authors also state, Future re-

search should move beyond the simple ques-

tion of whether cognitive rehabilitation iseffective, and examine the therapy factorsand patient characteristics that optimize the

clinical outcomes of cognitive rehabilitation

(p. 1681). Halligan & Wade (2005) provide asummary of much of the work on the effec-

tiveness of rehabilitation for cognitive deficits.

EMOTIONAL ASPECTS OFNEUROPSYCHOLOGICALREHABILITATION

The management and remediation of emo-tional consequences of brain injury have be-

come increasingly important in recent years.

Prigatano (1999) suggests that rehabilitationis likely to fail if clinicians do not deal with

the emotional issues. Consequently, an under-standing of theories and models of emotion

is crucial to successful rehabilitation. Socialisolation, anxiety, and depression are com-

mon in survivors of brain injury. Kopelman &

Crawford (1996) found that 40% of 200 con-secutive referrals to a memory clinic were suf-fering from clinical depression. Bowen et al.

(1998) found that 38% of survivors of TBIexperienced mood disorders. Williams et al.

(2002) found that estimates of the prevalence

of post-traumatic stress disorder (PTSD) fol-lowing TBI range from 3% to 27%. In

their own study, they found that 18% of 66

community-living survivors of TBI experi-

enced PTSD.Gainotti (1993) distinguishes three main

factors causing emotional and psychosocialproblems after brain injury: those result-

ing from neurological factors, those due to

psychological or psychodynamic factors, andthose due to psychosocial factors. An exam-

ple of a neurological factor is an individualwith brain stem damage leading to the so-

called catastrophic reaction, in which swingsfrom tears to laughter may follow in rapid suc-

cession. Anosognosia, or lack of awareness ofones deficits, is also frequently due to organic

impairment. An important book on the topicof unawareness (Prigatano & Schacter 1991)

posits several rationales for the existence of

anosognosia. Gainotti (1993) also addressesunawareness in detail, and Clare & Halligan(2006) characterize some of the key clini-

cal issues concerned with assessing and man-

aging pathologies of subjective or consciousawareness.

The second factor identified in Gainottis(1993) three-part classification, that is, emo-

tional problems that are due to psychologicalor psychodynamic causes, includes personal

attitudes toward the disability. An example is

someone with an acquired dyslexia and con-sequent loss of self-esteem together with de-pression because of an inability to read. De-

nial is also thought to be relevant to somecases of this second type of emotional disor-

der. At some level, patients are aware of their

disabilities but are unable to accept them. Be-cause denial can occur in conditions without

any damage to the brain, there must be (atleast in some cases) nonorganic reasons for it

(Gainotti 1993). PTSD also fits into this clas-

sification. Fear of what might happen in thefuture, panic because one cannot rememberwhat has happened in the past few minutes,

grief at loss of functioning, and reduced self-esteem because of changes in physical appear-

ance may all contribute to emotional changes.The third category put forward by

Gainotti (1993) includes problems that arisefor psychosocial reasons. An example is an



10/24

Psychosocialfunctioning:encompasses work,leisure, and social

relationships;overlaps withemotional well-being

individual who loses all his or her friends and

colleagues following a brain injury and thus isvery socially isolated. Social isolation is seen

in up to 60% of survivors of TBI (Hoofienet al. 2001). One aspect not covered by

Gainottiistheinfluenceofpremorbidperson-

ality. This is discussedby Moore & Stambrook(1995), Williams et al. (1999), andTate(1998).

Tate, however, found that premorbid person-ality had less effect on psychosocial function-

ing than did severity of injury. In understand-ing emotion after brain injury, we need to

consider neurological, physical, and bio-chemical models such as those described by

Robinson & Starkstein (1989). Although suchmodels address the issue of why emotional

problems arise followingan insultto thebrain,

they do not offer much help in understandingthe psychodynamic andpsychosocial causes ofemotional and mood disorders. Perhaps the

most helpful models come from CBT.

Ever since Becks highly influential book,Cognitive Therapy and Emotional Disorders, ap-

peared in 1976, CBT has been one of the mostimportant and best-validated psychothera-

peutic procedures (Salkovskis 1996). A ma-jor strength of Becks updated model (Beck

1996) has been the development of clinically

relevant theories. Beck presents several theo-ries not only for depression and anxiety butalso for panic, obsessive-compulsive disor-

ders, and phobias. Mateer & Sira (2006) sug-gest that CBT is well suited for improving

coping skills, helping clients to manage cog-

nitive difficulties, and addressing more gen-eralized anxiety and depression in the context

of a brain injury. Williams et al. (2003) de-scribe the use of CBT with two survivors of

TBI. One was a young man whose girlfriend

was killed in a car crash while he was driv-ing. The other was a young woman, knownas CM, who had been severely assaulted while

traveling on a train (described in more detailbelow). Williams et al. (2003) discuss the pos-

sible mechanisms for PTSD after TBI. Theseconditions were once thought to be mutually

exclusive because the survivor would lack a

memory for the event from which to develop

vivid intrusive cognitions and avoidance

haviors (Sbordone & Liter 1995). Howegiven that PTSD seems to occur even w

there is a loss of consciousness for the evthere could be two main mediating me

nisms to suggest how trauma-related mat

may be processed to lead to PTSD symptFirst, survivors may evoke islands of mory for their trauma, such as being trap

in a crashed car, or other secondary exp

ences that could fuel intrusive ruminat(McMillan 1996). Second, survivors ma

reminded of elements of their trauma ewhen exposed to similar situations that s

to produce intrusive thoughts and fuel avance behaviors (Brewin et al. 1996). Mc

& Greenwood (1996) described a survivo

TBI who was hyperaroused in, and avoiof, situations that were similar to the traevent, a road traffic accident, even tho

he had no declarative memory of the evIf an event is unexpected but has biolo

significance and, hence, emotional salie

McNeil & Greenwood (1996) suggestemayleadtotheeventbeingstored(orbu

in to memory) despite disruption to aof the brain that store declarative memo

(see Markowitsch 1998). Such a view w

be compatible with the concept that PTScaused by a conditioning of fear. The menism responsible is one in which traumati

periences can be processed independenthigher cortical functions (see Bryant 20

Analytic psychotherapy is also used in rbilitation, particularly in the United St

Prigatano is perhaps the best-known pr

nent of psychotherapy treatment of indivals surviving TBI. He describes his appr

(based on the milieu therapy approach of B

Yishay) in Principles of Neuropsychological Rbilitation (Prigatano 1999).Dealing with the emotional conseque

of brain injury may make the differencetween a successful and an unsuccessful

come. CM, mentioned above, was stabthrough the head in the right temp

parietal area with a hunting knife while teling on a train. She was 19 at the time

150 Wilson


11/24

did not lose consciousness, probably because

the knife did not enter her brain stem. She de-scribed feeling a pain in her head and a weight

as if the carriage had fallen on top of her. Shestood up and realized that something terrible

had happened. She went into the next carriage

where a man told her to sit down and stay stilland he would get help. She felt the knife with

herhandandaskedifshewasgoingtodie.Theman said No and that he would get help. At

the next stop, an ambulance arrived and tookher to the hospital.

A few months later, she came to our reha-bilitation center. She had a number of cogni-

tive problems, including visuo-spatial issuesand memory deficits, but the emotional dif-

ficulties took priority in treatment. She was

anxious and avoided many social situations;she would not look at people, feared for herfamily, and had classic symptoms of PTSD

including flashbacks and nightmares; and she

refused to use public transport. Like all otherpatients there, she had both group and in-

dividual therapy, including a considerableamount of psychological support and treat-

ment for the emotional problems identified(Williams et al. 2003). This involved CBT,

including stress inoculation, and graduated

exposure to situations she avoided. She wasalso treated for her cognitive difficulties, butif these had been the only problems treated,

it is doubtful that she would have been ableto make such a good recovery and return to a

full and meaningful life.

A recent study (Tiersky et al. 2005) exam-ined the effects of a rehabilitation program

offering psychotherapy and cognitive rehabil-itation and compared a treatment group with

a control group. The treatment group showed

significantly improved emotional function-ing, including lessened anxiety and depres-sion. The authors concluded, Cognitive

behavioral psychotherapy and cognitive re-mediation appear to diminish psychologic

distress and improve cognitive functioningamong community-living persons with mild

and moderate TBI (Tiersky et al. 2005,

p. 1565).

WHO: WorldHealth Organiz

PSYCHOSOCIAL ASPECTS OFNEUROPSYCHOLOGICALREHABILITATION

Considerable overlap exists between psy-chosocial and emotional difficulties. In-

deed, one definition of a psychosocial

disorder is a mental illness caused or in-fluenced by life experiences, as well as mal-adjusted cognitive and behavioral processes

(www.healthatoz.com). In brain injury re-habilitation, however, the term is more often

used to refer to psychosocial outcomes such aswork, friendships, and community activities.

In other words, psychosocial functioning is

close to participationas definedby theInter-national Classification of Functioning, Disability

and Health (World Health Org. 2001). Wade

(2005) says that the World Health Organi-zation (WHO) framework was developed asa means of describing the totality that is the

experience of illness (p. 32). The frameworkconsists of four levels: pathology, impairment,

activity, and participation. Thus, in the case ofa brain-injured person, the pathology might

be damage to the cerebral cortex and the re-sulting impairment might be a poor memory.

This, in turn, causes limitations to the persons

everyday activities; so, for example, s/he is un-

able to remember appointments. This prob-lem might affect the extent of participation inthe persons social environment, causing diffi-

culties with work, the duties of parenthood, orthe ability to engage in leisure activities. The

WHO model also considers three major con-texts influencing behavior: personal, physical,

and social contexts. Wade (2005) says thesecontexts might be considered to affect the

interactions between pathology and impair-ment, impairment and activities and activi-

ties and participation (p. 34). Personal con-text includes the relevant characteristics of anindividual such as expectations, beliefs, and

attitudes. Physical context refers to the en-vironment in which the individual finds him-

self or herself, and social context refers to theculture in which the individual functions. All

these factors contribute to the quality of life



12/24

as experienced by the person with a disabil-

ity. For the purposes of this review, psychoso-cial problems are seen as synonymous with the

WHO definition of participation.Twenty-first century rehabilitation pro-

grams are typically concerned with psychoso-

cial adjustment to disability (Sopena et al.2007, Yates 2003). Included in this category

are employment or other productive activ-ity, social relationships, and leisure. Some

believe that the psychosocial problems associ-ated with TBI may actually be the major chal-

lenge of rehabilitation (Morton & Wehman1995). Survivors of brain injury face prob-

lems of social isolation and decreased leisureactivities, thus creating a renewed depen-

dence on their family members. Karlovits &

McColl (1999) interviewed 11 survivors of se-vere brain injury to discover impediments toreintegration into the community. Nine stres-

sors were identified: orientation, transporta-

tion, living situation, loss of independence, re-lationships, loneliness,routine, problems with

studying, and work. Much of the focus of postacute rehabilitation is on helping people to

return to a productive lifestyle (Petrella et al.2005). Indeed, the success of NR programs

is often measured by such outcomes. Lack

of productivity, particularly employment, de-creases the opportunity for individuals withbrain injury to develop social contacts and

leisure activities, which in turn contributes todepression and low self-esteem. In contrast,

engagement in paid and nonpaid productive

activities, such as volunteering or homemak-ing, has a beneficial impact on community in-

tegration (Petrella et al. 2005).Return to work is one of the major

goals that clients in brain-injury rehabilita-

tion programs want to achieve. A numberof studies have addressed the issue of re-turning to work after rehabilitation. Failure

to succeed at work is associated with poorself-awareness, impaired executive function-

ing, and poor metacognition (Ownsworth &Fleming 2005). In a multicenter study, Walker

et al. (2006) found that that those who were

employed prior to the onset of their brain

injury, in comparison with those who w

unemployed, were more likely to work rehabilitation. The type of occupation

influenced return to work: Those in prosional or managerial jobs were more like

return to work than were those in other p

tions. In another meta-analysis, Kendall (2006) said, [T]he use of a narrow detion of return-to-work (i.e., full-time com

itive work only) produced more apparent

employment than an inclusive definition any competitive work or productive activ

(p. 149). Although this is not surprisinhighlights the fact that a return to full-

employment after severe brain injury isalways achievable and, in rehabilitation

need to consider a range of productive a

ities for our patients/clients. In the wordKendall et al. (2006), The definition ofployment and the nature of preinjury emp

ment is crucial to anyinterpretation of retto-work in TBI. The current study

highlights the importance of measuring

ployment outcomes using multiple pover time, rather than single data poin

first return-to-work (p. 149). In an examtion of the effects of rehabilitation on re

to work for military personnel, Cullen e

(2007) found moderate evidence to supthe view that inpatient rehabilitation resusuccessful return to work and return to

for the majority of military service membThey also suggested that increasing the

tensity of rehabilitation not only reducedlength of stay but also improved short-t

functional outcomes. Turner-Stokes e

(2005) also found strong evidence to port the claim that intensive rehabilita

led to more functional gains than did

intensive rehabilitation. In summary, pewho are given intensive rehabilitation an improved likelihood of returning to w

and the definition of return to work shbe expanded to include part-time work

other meaningful functional activities rathan simply full-time competitive work.

Social isolation is common after Tin part because of deficits in social s

152 Wilson


13/24

(McDonald 2003). An increase in social skills

and social relationships should be one of themajor goals for rehabilitation. Some studies

have shown that it is possible to achieve thesegoals ( Johnson & Davis 1998, Ownsworth

et al. 2000, Ylvisaker et al. 2005). In their

work with stroke patients, Haslam et al. (2007)found that the number of social groups peo-

ple belonged to before their stroke predictedtheir sense of well-being after the stroke

and that this was a result of them beingmore likely to retain membership of more

groups.Another study looking at personal rela-

tionshipsisthatofWood&Rutterford(2005),who found that five factors predicted prob-

lems with social relationships. These were

(a) loss of self-control (e.g., aggression, so-cial and/or sexual disinhibition), (b) emotionaldysfunction (e.g., mood swings, quick tem-

per), (c) adynamia (e.g., lack of motivation for

leisure activities, fatigue, loss of libido, loss ofsocial interests), (d) personality change (e.g.,

obsessiveness), and (e) cognitive dysfunction(e.g., memory loss, attention/concentration

difficulties, organization and planning prob-lems). These are all factors that are or should

be addressed in rehabilitation.

Another area of research is leisure. ADanish study by Engberg & Teasdale (2004)found that maintenance of leisure-time inter-

ests and general life satisfaction was poorerin survivors of a cerebral lesion compared

with patients with a cranial fracture. A French

study (Quintard et al. 2002) looked at late out-come and satisfaction of life of 79 patients

with severe TBI. Up to 85% were indepen-dent in activities of daily living, 55% were in-

dependent in social life, but only 36% were

satisfied with leisure activities. In some reha-bilitation programs, leisure goals are amongthe most common goals set. For example,

Bateman et al. (2005) looked at 680 goals setfor 95 clients at the Oliver Zangwill Center

in the United Kingdom. The most commongoals were connected with managing activi-

ties of daily living (248); leisure goals (154)

came second jointly with goals pertaining to

NeuroPage: areminding systeusing radio-pagtechnology

understanding the consequences of brain in-

jury, followed by goals connected with workor study skills (119).

It is clear that rehabilitation for psychoso-cial difficulties is an important part of the care

of survivors of brain injury. Physical difficul-

ties are less likely to affect the quality of lifeof a brain-injured person than are the cog-

nitive, emotional, and psychosocial sequelae,so these should be the focus of rehabilitation

programs. In the words of Khan et al. (2003),Cognitive and behavioral changes, difficul-

ties maintaining personal relationships andcoping with school and work are reported by

survivors as more disabling than any residualphysical deficits (p. 290).

A collection of papers on biopsychosocial

approaches in neurorehabilitation edited byWilliams & Evans (2003) summarizes muchof the work tackled in this field.

MODELS AND THEORETICALAPPROACHES CONTRIBUTINGTO NEUROPSYCHOLOGICALREHABILITATION

Most neuropsychologists working in rehabili-

tation believe that treatment should be driven

by theory, although they may also believethat theories are not necessarily sufficient ontheir own. For example, NeuroPage, a paging

system for helping memory-impaired peo-

ple remember everyday tasks, was developedby an engineer with no knowledge of psy-

chological theory who had a son with a se-vere TBI (Hersch & Treadgold 1994). Even

though it is not theoretically driven, Neu-roPage has led to theoretically driven ques-

tions such as the effect of executive function-

ing on successful use of the pager (Fish et al.2007). Perhaps the most influential modelsand theories in NR over the past two decades

are those of cognition, emotion, behavior,and learning. Models of cognitive function-

ing that have proved useful in rehabilita-

tion include language, reading (Howard 2005,Mitchum & Berndt 1995), memory (Baddeley

1992, 2007), attention (Robertson 1999), and



14/24

perception (Bruce & Young 1986). Given the

increasing recognition of the importance ofaddressing emotional and psychosocial diffi-

culties, emotional models are essential in NR.One of the most important of these, CBT,

is discussed above. Models and theories from

behavioral psychology have been employed inNR for more than 40 years. They have pro-

vided some of the most useful and influen-tial theoreticalcontributions to rehabilitation,

not only for the understanding, management,and remediation of disruptive behaviors, but

also for the remediation of cognitive deficits(Wilson et al. 2003). Behavioral theories are

valuable in NR because they inform assess-ment, treatment, and the measurement of re-

habilitation efficacy.

Learning theory is one of the cornerstonesof behavior therapy and behavior modifica-tion, with the other main theoretical influ-

ences coming from biological, cognitive, and

social psychology (Martin 1991). There is lit-tle doubt, though, that the original behav-

ioral treatments grew out of learning theory.Eysenck (1964), for example, defined behav-

ior therapy as the attempt to alter humanbehavior and emotion in a beneficial man-

ner according to the laws of modern learning

theory (p. 1).Believingthat thepurpose of rehabilitation

is to help people achieve their optimum level

of physical, psychological, social, and voca-tional functioning, Wilson (2002) attempted

to synthesize a number of approaches and

models used in rehabilitation to reflect thecomplexity of the field and the range of is-

sues to be dealt with. Wilson published aprovisional model of cognitive rehabilitation

in which she argued that one model, or one

group of models such as those from cognitiveneuropsychology, is insufficient to (a) deter-mine what needs to be rehabilitated, (b) plan

appropriate treatment for neuropsychologi-cal impairments, and (c) evaluate response to

rehabilitation. Rehabilitation is one of manyfields that need a broad theoretical base in-

corporating frameworks, theories, and mod-

els from a number of different areas. C

straint of rehabilitation workers to one mcould lead to poor clinical practice bec

important aspects of patients lives coulneglected.

GUIDELINES FOR GOODPRACTICE IN

NEUROPSYCHOLOGICALREHABILITATION

Although there are no definitive trials to

port the holistic approach, it has probbeen subjected to more evaluation stu

than have other approaches (e.g., Ciceet al. 2004, Diller & Ben-Yishay 2002)

at present, is probably the most effective

ically(Ciceroneetal.2007).Mostholisticgrams are concerned with increasing a cli

awareness, alleviating cognitive deficitsveloping compensatory skills, and provi

vocational counseling. All such programsvide a mixture of individual and group the

This approach possibly could be imprby incorporating ideas and practical app

tions from learning theory, such as task ansis, baseline recording, monitoring, and

implementation of single-case experime

designs to individual treatment programsother potential improvement would be r

ring to cognitive neuropsychological moin order to identify cognitive strengths

weaknesses in more detail to explain obsephenomena and make predictions about

nitive functioning.Prigatano (1999) lists 13 principles of

derived from a holistic approach, and theno doubt that his work has considerably i

enced current rehabilitation practice. T

principles are described in Table 3.The Oliver Zangwill Center, influeby Prigatanos approach, bases its NR o

core components that are described herillustrate the principles of good clinical p

tice in NR. More detail on the componen

available from the Oliver Zangwill Webwww.ozc.nhs.uk.

154 Wilson


15/24

Table 3 Summary of Prigatanos 13 principles of neuropsychological rehabilitation

Principle No. Principle

1 Begin with the patients subjective or phenomenological experience.

2 The symptoms presented are a mixture of premorbid cognitive and personality characteristics tog

with the neuropsychological changes resulting from the brain pathology.

3 Neuropsychological rehabilitation focuses on both the remediation of higher cerebral disturbance

their management in interpersonal situations.4 Neuropsychological rehabilitation helps patients observe their behavior to teach them about the d

and indirect effects of brain injury.

5 Failure to study the interaction of cognition and personality leads to an inadequate understanding

many issues.

6 Little is known about how to retrain cognitive dysfunction, but general guidelines of cognitive

remediation can be specified.

7 Psychotherapeutic interventions help patients (and families) deal with their personal losses.

8 Working with patients who have dysfunctional brains produces affective reactions in the patients f

and the rehabilitation staff. Appropriate management of these reactions facilitates adaptation.

9 Each neuropsychological rehabilitation program is a dynamic entity. The team needs to maintain

dynamic, creative effort.

10 Failure to identify those patients who can and cannot be helped creates a lack of credibility.11 Disturbances in self-awareness after brain injury are often poorly understood and poorly managed

12 Competent patient management and planning depend on understanding mechanisms of recovery

deterioration.

13 The rehabilitation of patients with higher cerebral deficits requires both scientific and

phenomenological approaches.

1. Provide a Therapeutic Milieu

Derived from Ben-Yishays concept of thetherapeutic milieu (Ben-Yishay 1996), the

therapeutic milieu in holistic rehabilitationrefers to the organization of the complete en-

vironment (physical, organizational, and so-cial aspects) to maximize support for the

process of adjustment and to increase socialparticipation. The milieu embodies a strong

sense of mutual cooperation and trust, whichunderpins the working alliance between client

and clinicians.

2. Establish Meaningful and Functionally

Relevant Goals for Rehabilitation

Meaningful functional activity refers to

all day-to-day activities that form the basisfor social participation. These can be cate-

gorized into vocational, educational, recre-ational, social, and independent living realms.

It is through participation in these areas thatindividuals gain a sense of purpose and mean-

Therapeuticmilieu: the

organization of environment toensure maximumsupport to theprocess ofadjustment and increase socialparticipation

ing in their lives. Although it is probably not

thought about consciously in everyday life,activity enables individuals to achieve certain

aims or ambitions that are personally signif-

icant and thereby contributes to the sense ofidentity.

3. Ensure Shared Understanding

The notion of shared understanding comes

from the use of formulation in clinical prac-tice (Butler 1998). A formulation is seen as

a map or guide to intervention that com-bines a model derived from established the-

ories and best evidence with the clients and

familys personal views, experiences, and sto-ries. This concept, which should be applied

to all individual clinical work, influences theway the rehabilitation experience is organized

as a whole. The shared understanding con-cept incorporates team philosophy, includ-

ing shared team vision, explicit values, andgoals. Understanding of research and theory,



16/24

sharing knowledge and experience with other

professionals and families, peer audit of theservice, and the views and contributions of

past clients areadditional aspectsof thesharedunderstanding ideal.

4. Apply Psychological InterventionsPsychological interventions are based

upon certain ways of understanding feelings

and behavior. Specific psychological mod-

els (particularly those described above) areused to guide work depending upon the spe-

cific needs of the individual. Approaches fromthese models provide ways team members can

engage patients/clients in positive change andthe tackling of specific problems.

5. Manage Cognitive ImpairmentsThrough Compensatory Strategies and

Retraining Skills

Compensatory strategies are alternativeways to enable individuals to achieve a desired

objective when an underlying function of thebrain is not operating effectively. Compen-

satory approaches to managing impairmentstake a number of forms, including:

cognitive compensation (e.g., using vi-

sual imagery to compensate for a defec-tive verbal memory, using a mental rou-

tine for managing impulsivity or anger,and clarifying to ensure effective com-

munication);

enhanced learningtechniques such aserrorless learning or spaced retrieval

that lead to more effective learning ofnew knowledge or skills;

external aids (e.g., using a diary for man-

aging memory problems, checklists toremember exercise routines, alarms to

increase attention to tasks, cue cards forkeeping on track during conversation);

and

environmental adaptationsmodifying

relevant environments in order to re-duce cognitive demands (e.g., working

in a quiet, nondistracting room to aid

concentration, holding important

versations when less fatigued).

Retraining is undertaken to improve

formance of a specific function of the brato improve performance on a particular

or activity. Retraining also helps to add

skills lost through lack of use, e.g., thronot being at work since an injury.

6. Work Closely with Families and Ca

Families and carers sometimes report

ing like an afterthought in rehabilitation.

cent policy (National Service FrameworLong Term Conditions, Dep. Health, Lon

2004) highlights how families and carerperience a significant burden following

quired brain injury and recommends prsion of support. Many kinds of support ca

offered, for example, providing informafurnishing opportunities for peer support

volving family and carers in rehabilitationproviding individual family consultatio

therapy.

SUMMARY

Following definitions of neuropsychology

habilitation, and NR, this review discusome of the ways the field has chain recent years. The particular focus i

(a) goal setting as a way of structuring

habilitation, (b) the realization that the etional and psychosocial consequences of b

injury are as important as the cognitive coquences, (c) the increasing use of techno

in rehabilitation, and (d) a recognition a wide range of theoretical models and

proaches is needed to inform the assessm

and treatment of people who have surva brain injury. The three main componof NRcognitive, emotion, and psych

cial functioningare looked at in moretail. Given that how we feel affects how

think, how we behave, and how we inte

with others, all three functions need taddressed in any rehabilitation program.

idence is provided to show that difficulti

156 Wilson


17/24

these areas can be reduced through NR. Be-

cause the field is broad andcomplex, cliniciansneed to be informed by a number of models

and theories to reduce the everyday problemsfaced by people who have survived brain in-

jury. Some of the most influential models and

theoreticalapproachesused to plan rehabilita-

tion are described, particularly those relevantto cognitive functioning, emotion, behavior,

and learning. The review concludes with rec-ommendations for good practice in the reha-

bilitation of people with brain injury.

SUMMARY POINTS

1. Neuropsychological rehabilitation (NR) is concerned with the amelioration of cogni-

tive, emotional, psychosocial, and behavioral deficits caused by an insult to the brain.

2. The main purpose of NR is to enable people to return to their own most appropriate

environments; for this reason, meaningful goals should be set in the areas of vocation,education, recreation, social relationships, and independent living.

3. Although cognitive deficits are perhaps the major focus of NR, emotional and psy-chosocial consequences of brain injury need to be addressed in rehabilitation pro-

grams. There is an interaction between these different functions, and it is not alwayseasy to separate them from one another.

4. Technology is increasingly used to help people compensate for cognitive difficulties.Some technological aids are described and evaluated.

5. NR requires a broad theoretical base and some of the most influential models andtheories influencing current practice are described.

6. Evidence is provided to show that NR can reduce difficulties in the three main areasof cognitive, emotional, and psychosocial functioning.

7. Suggested guidelines for good clinical practice are outlined.

DISCLOSURE STATEMENT

The author is not aware of any biases that might be perceived as affecting the objectivity of

this review.

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