By Harold L. Burke, Ph.D.
Neuropsychological rehabilitation, cognitive rehabilitation (cognitive retraining) for brain injury
Neuropsychological rehabilitation is a treatment modality employed by a neuropsychologist to assist patients who have sustained cognitive, emotional, and behavioral impairments as the result of an acquired brain injury. Causes of brain injury include traumatic brain injury (TBI), hypoxia, and stroke. There are two types of neuropsychological rehabilitation:
Although restorative rehabilitation tends to be employed in the earlier stages of rehabilitation, the needs of the particular patient will dictate exactly which type will be utilized. In fact, at any given time during a program, a patient may receive one type for one particular function and the other type for yet another function.
From the beginning of a program, the neuropsychologist will be helping the patient and often the family to cope with the emotional and behavioral sequelae of the injury. Depending on the severity of the injury, life may never be the same. This can be frightening and depressing. Brain injury may also cause irritability, anger, temper outbursts, emotional lability, and impulsivity. In addition to private therapy and family counseling, the neuropsychologist will often refer to other professionals and support groups. It is very important that patients realize that they are not alone in this ordeal.
On the other hand, it often happens that patients may be unaware of their deficits, a condition known as anosagnosia. In that case, the neuropsycholgist will help patients to become aware of and to comprehend the consequences of impairments. This critical process helps patients to understand their limitations and increases their motivation to work harder in the program.
Regardless of the specific treatments used, the patient will likely need to have a comprehensive neuropsychological assessment performed. This will help to determine the extent of injury and to understand as completely as possible the strengths and weaknesses of the patient. At the Brain Therapy Center, this thorough assessment is required although a prior neuropsychological assessment will be accepted if it is fairly current and if it is deemed to meet acceptable standards.
How exactly is restorative rehabilitation conducted at the Brain Therapy Center?
At the Brain Therapy Center, the patient always receives treatment on a one-on-one basis either by a neuropsychologist or by a professional who is closely supervised by a neuropsychologist. The treatment typically involves four therapeutic modalities although they are very intimately intertwined and work synergistically.
What is the difference between neuropsychological rehabilitation and cognitive rehabilitation or cognitive retraining?
Both neuropsychological rehabilitation and cognitive rehabilitation (or cognitive retraining) assist patients who have acquired brain injuries to resume normal lives as much as possible. Both may utilize restorative rehabilitation and compensatory rehabilitation. What differentiates neuropsychological rehabilitation from cognitive rehabilitation is that the former is performed by or under the direction of a licensed clinical neuropsychologist. Since neuropsychologists are also licensed clinical psychologists qualified to conduct psychotherapy, they can dovetail more effectively psychotherapy with exercises or other techniques used for brain retraining per se. In addition, it is the neuropsychologist who has conducted the comprehensive neuropsychological assessment often performed after an acquired brain injury. Therefore, he/she has the most comprehensive understanding of the strengths and weaknesses (cognitive, emotional, and behavioral) of any given patient.
This is not to imply that other professionals (e.g., physicians, speech therapists, physical therapists, occupational therapists) who work as members of rehabilitation teams do not perform very valuable functions. For example, speech therapists help patients recover language functions; and physical therapists and occupational therapists help patients to recover motor functions and ADL’s (activities of daily living). However, there is a distinct advantage in having neuropsychologists perform or oversee those portions of programs that focuses on restoring brain functions and that deal with the emotional problems that patients inevitably have while engaged in this often difficult process. Ultimately, an entire team of professionals, in addition to the extremely important families of patients, is often required for the complete rehabilitation of the patient.
At the Brain Therapy Center, we specialize in neuropsychological rehabilitation. Typically a patient is referred to our center after having already undergone an intense inpatient rehabilitation program with speech therapy, physical therapy, and occupational therapy. Often the patient has usually been stabilized on a medication. It is then our job to further the difficult rehabilitation of cognitive functions and to help the patient to cope with the emotional sequelae of cognitive impairments.
When is the best time to begin neuropsychological rehabilitation?
Ideally the sooner treatment begins, the better as with most medical treatments. However, for practical reasons, the principal one being financial, it is more typical that patients will enter such a program after at least three months post-injury. This is particularly the case if an inpatient rehabilitation program has been available for the first several months. Another reason is that the period of spontaneous recovery is most intense in the first three months with further significant recovery expected during the next three months and some additional recovery expected over the next six months. Therefore, insurance companies are reluctant to pay for outpatient programs that start sooner than three months. Even though many inpatient programs do not put enough emphasis on cognitive or neuropsychological rehabilitation, they do focus on important immediate problems such as restoration of language and motor skills, and medical stabilization.
Even if neuropsychological rehabilitation cannot be started after three months, neuropsychologists should still be consulted for at least two reasons. First, it is often very helpful to have comprehensive neuropsychological assessments to assist patients’ treating physicians and families in making important case management decisions (e.g., placement, long-term prognosis, competency). Second, neuropsychologists will be very helpful in helping patients and their families to deal with the emotional aspects of brain injuries.
Is there a “window of opportunity” for neuropsychological rehabilitation?
There is no convincing evidence that such a window exists even though it is true that rehabilitation should be started during the first year — the sooner the better. There are documented cases in the literature of patients who benefited from but had not started such programs until several years had elapsed since the original brain injury.
How long do such programs last?
This depends greatly on the severity of impairments and the individual patient. Programs, such as the one conducted at the Brain Therapy Center, can last from three months to over a year. However, case management and other assistance may be required for several years or even for the lifetime of the patient. Some patients require outpatient assistance (e.g., home care) or formal residential settings for years or for the remainder of their lives. The Brain Therapy Center can help patients to find resources for long-term assistance, but currently its programs are not designed for such long-term care.
Is neuropsychological rehabilitation reimbursed by insurance companies?
Often such programs are covered; it depends on the individual policy. However, persistence and advocacy by patients and their families are often required. In addition, it is very important to have documented proof that patients have impairments that are sufficiently severe as to warrant neuropsychological rehabilitation. The gold standard for such proof is a comprehensive neuropsychological assessment.