Neuropsychological approach to rehabilitation in patients with cerebral damage

Introduction. Neuropsychological rehabilitation is needed in case of disorders of higher mental functions (HMF) due to various brain diseases of traumatic, hypoxic, vascular, inflammatory, atrophic or neoplastic genesis.

The severity of HMF disorders is associated with many factors, including the volume and location of brain damage, the presence and duration of a coma and post-comatose unconscious state in the acute phase of brain trauma. A coma up to seven days' results in moderate disability or so-called complete recovery, whereas a longer coma increases the risk of severe disability. Even a one-to-two-day post- comatose unconscious state triples (17 to 56%) the risk of low-reversible cognitive disorders in the late period after TBI. Only 7% of patients having a post-comatose unconscious state for more than one month end up with moderate to mild cognitive disorders.

Neuropsychological rehabilitation should start as early as possible, ideally as soon as vital functions stabilise. The recovery is fast within the first five months after TBI and then it slows down significantly. New neural ensembles formed as a result of neurogenesis, are meant to increase the adaptivity in the changing conditions of the internal and external environment. Thus, in order to integrate new neurons into functional neural networks, the environment must be restructured as to get problem areas activated. Newly formed functions can appear only in a specially designed problem environment. However, neuropsychological rehabilitation has not been developed enough so far to provide evidence-based options and standards for this type of patient care.
Developing strategies for neuropsychological care in patients with cerebral damage at different stages of HMF recovery.

Subjects and methods. Based on the analysis of neuropsychological rehabilitation in 93 patients (57 with traumatic brain injuries, 36 with cerebral vascular disorders), the principles of a rehabilitation intervention to restore HMF were defined and further elaborated.

Results. It has been found that neuropsychological rehabilitation should start with an in-depth general assessment of the initial state, preferably an interdisciplinary one, and of the patient's level of HMF in particular. This enables to diagnose correctly the intact and damaged parts of mental activity, as well as to set aims and targets for rehabilitation. Neuropsychological diagnostics is based on such criteria as a neurodynamic potential, the degree of preservation of analyzer functions, the ability of voluntary movement, the degree of speech impairment, the level of voluntary control over mental activity.

The first stage of neuropsychological rehabilitation starts when the patient's state is stabilising, immediately after a coma or unconscious state. During this period, psychostimulotherapy techniques should be used, consisting of direct impacts of various modalities on the patient who emerges from a coma and demonstrates severe mental impairment. Then neuropsychological rehabilitation should mostly aim at the enriching the environment to create conditions for a differentiated response. This method lays the foundation for solving three main tasks: a) restoring the patient's past and knowledge gained by the time of illness; b) reviving mental skills and social behavior; c) restoring a voluntary initiative, a complex sequence of psychomotor activity. This approach takes into account a low level of consciousness in patients, and, on the other hand, their individual reactions, and also dynamically reveals foundation for a further rehabilitation. The neuropsychologist's work at this stage is aimed at restoring the patient's connection with one's bodily processes, processing afferent information, and also differentiating reactions to the stimuli of one's immediate environment.

The second stage begins with formally clear consciousness. At this stage, the rehabilitation work focuses on emphasising an active role of the patient, with sensory integration, psychomotor and vestibular training being the leading methods. These methods are aimed at increasing the integrative capacity of the brain needed to perform more and more complex tasks. Afferent and efferent centers should be consistently integrated in an effectively working network. Thus, the reintegration of separated functional systems is the main objective at this stage. The patient is actively engaged in a rehabilitation process, becoming an increasingly active participant.

The third stage of rehabilitation reintegrates acquired skills at the level of cognitive activity. The neuropsychologist moves on to the conventional cognitive training. At the same time, rehabilitation is aimed directly at the patient's speech impairment, memory, attention, perception, and deficient regulatory functions. It is important not only to restore all the functions, but also to reintegrate them into daily routine.

A suggested integrative approach to neuropsychological rehabilitation after organic brain damage, while promoting a better understanding of current and prospective tasks by specialists, has proved to be efficient in accelerating mental recovery, improving adaptive and compensatory abilities, and decreasing the depth of disability in patients.

Further accumulation of empirical data and understanding of experience in neuropsychological rehabilitation are needed to provide an efficient patient care, and also to develop its design and to do research within evidence-based medicine. Thus, scientifically and practically proven standards and options will be designed to correct different HMF disorders and mental activity in general.
Maria Kamenetskaya, Oleg Zaitsev, Olga Maksakova. N.N. Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia

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