Computerized Cognitive Rehabilitation: A Case Study
Some sustained benefit of cognitive rehabilitation for a man with anoxic brain injury
STUDY AIM
Would regular student-assisted computerized cognitive rehabilitation improve
cognitive function in this man with a severe anoxic brain injury more than two
years post arrest?
INTRODUCTION
Cognitive rehabilitation follows a process of:
Identifying areas of impairment
Facilitating compensatory mechanisms to rapidly improve some function
Challenging the brain to restore function
Michael J Gilewski, PhD
Base = raw of total or Z-score
++ Z-score improve of 1.0+
+ Improve Z of +0.5 to +1.0
– Decline Z of -0.5 to -1.0
-- Z-score of -1.0 or worse
Elizabeth M. Zelinski, PhD
Physical Medicine & Rehabilitation
Leonard Davis School of Gerontology
Loma Linda Univ School of Medicine
University of Southern California
There is substantial evidence to show the benefit of cognitive rehabilitation in persons with
acquired brain injury, specifically:
•attention,
•visual spatial function
•executive functions
•some aspects of language
•some aspects of memory
Because there is limited research on computerized training and even less research on training
with persons with old brain injuries, the results of this study could be informative.
•Most research is focused on where treatment is provided and reimbursed, that is, in acute
inpatient rehabilitation post medical stability, in structured residential or day treatment
programs, and in outpatient rehabilitation.
•Recent research, e.g., constraint-induced treatment in stroke, is demonstrating some potential
long-term benefit of some treatment for persons outside formal treatment and long after a brain
injury was acquired.
Neuropsychologist screen with options to monitor and direct training
6 Cognitive domains x 12 graded tasks x 3-4 difficulty levels/task
CASE STUDY
Consistency of sustained attention was very difficult – he never mastered the task
Variable
Level 1
Level 2
Level 3
Level 4
Start Date
2011-01-15
0000-00-00
0000-00-00
0000-00-00
14
0
0
0
0
0
0
0
Total Time on Task (minutes)
33
0
0
0
# Clicks (baseline)
39
0
0
0
Aver. RT (last 5 - baseline)
295
0
0
0
Aver. RT (overall - baseline)
421
0
0
0
Variance (last 5 - baseline)
8582.00
0.00
0.00
0.00
Variance (overall - baseline)
94201.00
0.00
0.00
0.00
5
0
0
0
50
0
0
0
Aver. RT (last 5 - most current)
295
0
0
0
Aver. RT (overall - most current)
372
0
0
0
Variance (last 5 - most current)
6382.00
0.00
0.00
0.00
Variance (overall - most current)
31563.00
0.00
0.00
0.00
4
0
0
0
Date (most current)
2011-07-25
0000-00-00
0000-00-00
0000-00-00
Total Clicks (overall)
433
0
0
0
Consecutive Passes
0
0
0
0
Total Passes
1
0
0
0
13
0
0
0
Submissions
Restarts
# Clicks (most current)
Background
Age 60 at baseline assessment
14 years education, owned successful film production business
Married to wife and their daughter in her 20s at home
# errors (most current)
Total Fails
Grade - most current
Computerized cognitive rehabilitation program:
www.neuropsychonline.com
Browser-based program by subscription. Data stored in HIPAA-compliant
database by Neuropsychology vendor.
f
Executive skills – he spent a long time on task but passed first difficulty level
Neuropsychonline Cognitive Rehabilitation Therapy System
Progress Report - Track 02 - Executive Skills - Organizing Information
(Commonality)
Variable
Level 1
Level 2
Level 3
Level 4
Start Date
2011-01-15
0000-00-00
0000-00-00
0000-00-00
88
0
0
0
0
0
0
0
310
0
0
0
% Correct (baseline)
55
0
0
0
% Correct (current)
100
0
0
0
Date (most current)
2011-08-01
0000-00-00
0000-00-00
0000-00-00
Consecutive Passes
3
0
0
0
Total Passes
24
0
0
0
Total Fails
64
0
0
0
p
n
n
n
Submissions
Restarts
Total Time on Task (minutes)
93rd
Demographic predicted ability =
%ile, AM-NART estimated =
%ile
Blessed and Folstein mental status tests (some items analyzed separately)
Attention – Digit span, trail making, letter-number sequencing, digit-symbol coding
Learning-Memory – Logical Memory story, California Verbal Learning Test
Language – Boston naming, Letter fluency (FAS), Category fluency (animals, vegetables),
Token Test (substituted Rule Governed Drawing)
Visual-spatial – Block design
Geriatric Depression Scale
Added physical – full-tandem standing time and 12-foot walking speed
Added behavior/QOL – Frontal Systems Behavior Scale and Mayo-Portland
Mental Status
Folstein 22 of 30
0
-
-
Attention
Blessed ment. control
0
+
+
“ ”
Serial 7s - 3 of 5
+
+
0
“ ”
Digit span 8F, 5B
++
+
+
“ ”
Trails A Z = -7.3
+
0
0
“ ”
L-N Seq Z = -2.3
0
+
+
“ ”
Digit sym Z = -2.7
0
0
0
A
Jan 2011
assess
B
Sep 2011
assess
A
Jan 2012
assess
Ability
June 2010 test
baseline
Learn/mem.
All delayed recall=0
0
0
0
“ ”
Story immediate Z = -2.7
0
0
0
“ ”
Word list total Z = -1.7
0
0
-
“ ”
Recognition corr. NA
Z = -5.0
++
++
“ ”
Recog. d’ Z = -3.0
-
+
+
“ ”
Forced choice recog
81%
-
-
A
Jan 2011
assess
B
Sep 2011
assess
A
Jan 2012
assess
B
Grade - most current
Task
Visuospatial skills were a strength
Track 04 - Visuospatial Skills
Progress Report - Task Status
Date Started
Levels Passed
Date Completed
Luminosity Discrimination
2011-01-15
passed all
2011-06-20
Line Discrimination
2011-03-05
1 of 4
na
Angle Discrimination
2011-07-05
1 of 4
na
Design Completion
na
Shape and Pattern Discrimination
na
Complex Animated Pattern Discrimination
na
Ball In A Box :right
na
Ball In A Box :left
na
How Many Blocks?
na
Paddle Ball :right
na
Paddle Ball :left
na
Designer Patterns
na
Visual Analysis and Synthesis I
na
Visualization From Blueprints I
na
B
Memory was the worst cognitive function. Some improvement in recognition.
Ability
June 2010 test
baseline
Language
Naming Z = -2.4
0
+
++
“ ”
Letter Fluency Z=-1.2
+
+
--
“ ”
Cat. Fluency Z = -3.0
++
++
+
“ ”
Token Test Z = 0.9
“ ”
Rule Gov Drawing (time)
Z = -2.1
+
--
“ ”
RGD Exec (corr)
Z = -3.2
++
++
“ ”
RGD Exec (time)
Z = -1.5
++
--
A
Jan 2011
assess
B
Sep 2011
assess
A
Jan 2012
assess
B
Language – Improved naming, generally sustained fluency, some improved language comprehension.
Last assessment performance was very slow.
Ability
June 2010 test
baseline
Visuospatial
Block Design Z= -0.7
0
-
Depression
GDS = WNL
0
0
0
A
Jan 2011
assess
B
Sep 2011
assess
A
Jan 2012
assess
Wife rated
Assessment
86th
June 2010 test
baseline
Task 01 - Simple Visual Reaction - Fixed Point - Right Hand
# errors (baseline)
A-B-A-B Single Case Study Design
June 2010 – Alzheimer’s Coordinating Center neuropsychological test battery
at USC
Jun–Dec 2010 - Initial control phase A: OT nonspecific cognitive
enhancement with computer 2-3 x/wk
January 2011 – Readminister tests
Feb–Aug 2011 Initial training phase B: Student-assisted computerized
cognitive rehabilitation 2-3 x/wk
September 2011 – Readminister tests
Sep–Dec 2011 – 2nd control phase A: Group games and nonspecific
cognitive enhancement or computer use 3+ x/wk at residential setting
January 2012 – Readminister tests
February 2012 – started 2nd training phase B
Ability
Mental status – worse but orientation not trained
Attention – some sustained improvement in attn capacity and working memory
When computerized programs for cognitive rehabilitation are used, recommendations are to
also have active involvement of a therapist and not just solely rely on the impaired person to
self-train.
DN is a man, who suffered a severe anoxic brain injury following several
episodes of ventricular cardiac arrest in June 2008
•After internal defibrillator and medical stability, went through a course of acute
inpatient rehabilitation, intensive outpatient and residential treatment through
March 2009.
•Discharge to home with full-time caregivers for supervision
•May 2010 – his wife consulted USC Neurology for other treatment or research
options
Results
Apathy
FrSBe
Z = -5.8
+
+
Disinhib.
FrSBe
Z = -3.4
0
+
Exec Dys.
FrSBe
Z = -5.8
+
+
Ability
Mayo-Portland
Z = -0.8
+
Adjustment
Mayo-Portland
Z = -1.3
+
Not depressed. Some sustained improvement in brain-related behavior as rated by wife.
The second training episode has begun with an aim to sustain
or improve cognitive functions and behavior.
The study was given a human subjects exemption by USC IRB.
There would be no case study with the support and assistance
of Teresa Diaz (USC staff) and student assistants to facilitate
the computer cognitive rehabilitation:
Natalie Abrahamian
Rachel Anderson
Robert Grijalba
Erin Lee
Joanna Marantidis
Josh Van Zak
This work was partially funded by NIA P50 AG005142,
Project 1, E. M. Zelinski, Project Director
B