Cognitive rehab helps people with acquired brain injury

Age at injury, type of injury, timing and specificity of treatment matter

WASHINGTON, 14 jan 2009 — Cognitive rehabilitation after a serious brain injury or stroke can help the mind in much the same way that physical therapy helps the body, according to a new meta-analysis. Because the data suggest that treatment may work best when tailored to age, injury, symptoms, and time since injury, the findings may help establish evidence-based treatment guidelines. A full report is in the January issue of Neuropsychology, which is published by the American Psychological Association.

Researchers at the University of South Alabama and the University of North Carolina at Charlotte analyzed and updated the data found in systematic reviews, published in 2000* and 2005**, of several hundred studies of cognitive rehabilitation. The researchers took those studies whose samples and methods were most amenable to rigorous statistical techniques and documented the extent to which various treatments improve the language, attention, memory and other cognitive problems that appear after acquired brain injury (such as from trauma, stroke or loss of oxygen – in other words, not congenital).

The meta-analysis examined 97 articles, comprising 115 studied treatment samples and 45 control samples. These samples collectively included 2,014 individuals who underwent cognitive rehabilitation after brain injury and 870 individuals in a variety of control conditions. The authors of the initial reviews had concluded there was enough evidence to generally support the use of a variety of rehabilitative treatments. To develop specific treatment guidelines, this new analysis documented the extent to which treatment type and timing, origin of the injury, recovery level, and participant age affected the odds of success.

Given the patterns they found, the authors offered initial treatment guidelines:

• Generally, it is better to start treating patients as early as possible, rather than waiting for a more complete neurological recovery.
• Even older patients (age 55 and up) may benefit from cognitive rehabilitation, particularly if the brain injury is due to stroke.
• Clinicians should focus their efforts on direct cognitive skills training in specific cognitive domains (such as attention or visuospatial processing). More holistic, non-targeted interventions appear to be less effective.

Especially if they were treated soon after the event, language training helped older people after stroke with aphasia, problems producing and/or comprehending language. However, language training was still effective, just not as much, when it started more than a year after the stroke.

Attention training helped people with acquired brain injury and seemed to work best with younger patients less than a year after injury. It was the most specific treatment, improving nothing but attention.

Visuospatial training helped stroke patients with visuospatial neglect, the inability to respond or orient to something shown on the side opposite to the site of the injury. Visuospatial training also tended to improve performance in other cognitive domains.

Memory treatment did not produce clear results. Nor did comprehensive treatments that attempted to treat cognitive problems holistically.

Other specific findings emerged. For one thing, patients treated less than a year after injury did better than those treated more than a year later. For another, older patients tended to improve more after stroke than younger patients improved after traumatic brain injury (TBI). However, because strokes are more common in old age and TBI is more common in youth, further research is needed to disentangle the roles of age and injury type.

Thus, in the field of cognitive rehabilitation, one size does not fit all. Additional research should fill remaining gaps in understanding the effectiveness of and optimizing conditions for specific interventions.

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Article: "Effectiveness of Cognitive Rehabilitation Following Acquired Brain Injury: A Meta-Analytic Re-examination of Cicerone et al.'s (2000, 2005) Systematic Reviews," Martin L. Rohling, PhD, University of South Alabama; Mark E. Faust, PhD, University of North Carolina at Charlotte; Brenda L. Beverly, PhD, University of South Alabama; George Demakis, PhD, University of North Carolina at Charlotte; Neuropsychology, Vol. 23, No. 1.

(Full text of the article is available from the APA Public Affairs Office and at http://www.apa.org/journals/releases/neu23120.pdf).

Hypothalamopituitary Dysfunction Following Traumatic Brain Injury and Aneurysmal Subarachnoid Hemorrhage


Harald Jörn Schneider, MD
Context Neuroendocrine dysfunction following traumatic brain injury and aneurysmal subarachnoid hemorrhage may occur with a much higher prevalence than previously suspected. This sequela is a potentially serious but treatable complication of brain injury.

Objective To review research on hypothalamopituitary dysfunction as an underdiagnosed consequence of traumatic brain injury and subarachnoid hemorrhage, the natural history of this complication, and the potential clinical and public health implications of posttraumatic hypopituitarism.
Evidence Acquisition The MEDLINE database was searched for articles published between 2000 and 2007 using any combination of the terms traumatic brain injury or subarachnoid hemorrhage with pituitary, hypopituitarism, growth hormone deficiency, hypogonadism, hypocortisolism, hypothyroidism, or diabetes insipidus. The reference lists of articles identified by this search strategy were also searched. All articles reporting original data on endocrine outcomes after traumatic brain injury or aneurysmal subarachnoid hemorrhage in peer-reviewed journals with regard to prevalence, pathogenesis, risk factors, outcomes, and clinical course were selected. We pooled data and calculated prevalence rates and 95% confidence intervals (CIs).

Results We identified 19 studies including 1137 patients. The pooled prevalences of hypopituitarism in the chronic phase after traumatic brain injury and aneurysmal subarachnoid hemorrhage were 27.5% (95% confidence interval [CI], 22.8%-28.9%) and 47% (95% CI, 37.4%-56.8%), respectively. The pooled prevalence of hypopituitarism was greater in patients with severe compared with those with mild or moderate traumatic brain injury. Early neuroendocrine abnormalities were transient in some patients while, less commonly, hypopituitarism evolved over time in others. Patients with posttraumatic hypopituitarism showed an impaired quality of life and an adverse metabolic profile.

Conclusion Hypopituitarism is a common complication of both traumatic brain injury and aneurysmal subarachnoid hemorrhage and might contribute to morbidity and poor recovery after brain injury.

Deep-Brain Stimulation Restores Awareness After Six Years

NEW YORK, Aug. 2 -- After deep-brain stimulation, a man in a minimally conscious state for six years has regained awareness, speech, and controlled movement, surgeons here reported. The 38-year-old man had been left unable to eat by mouth or communicate verbally after a mugging in which his skull was crushed, causing massive blunt trauma and bilateral subdural hematomas, reported Nicholas D.
Animation: Deep Brain Stimulation
Listen: Press Briefing Schiff, M.D., of Weill-Cornell Medical College, and colleagues, in the Aug. 2 issue of Nature.
The work challenges the existing practice of early treatment discontinuation for this patient population and also changes the approach to assessment and evaluation of the minimally-conscious state patient," said Dr. Schiff.
Joseph T. Giacino, Ph.D., of the New Jersey Neursocience Institute, in Edison, a co-author, said that "prior to the use of deep-brain stimulation, the patient's communication ability was inconsistent, including only slight eye or finger movements. Now, he regularly uses words and gestures and responds to questions quickly."
Dr. Giacino continued, "In addition, he now chews and swallows his food and no longer requires a feeding tube. Before, he could not use his limbs for functional movement, but he can now perform some complex movements, including those required for drinking from a cup or brushing hair. Years of severe immobility and tendon contracture, however, do greatly limit him from carrying out these tasks."
The man's mother, who asked that the family not be identified, said that he now laughs, cries, watches movies with apparent awareness, and can express both pain and love.
Although he had been left unable to communicate reliably, the man was not in a persistent vegetative state, and there was evidence from imaging studies to suggest that he had enough intact brain structures to allow for recovery, the authors said.
"Functional MRI showed preservation of a large-scale, bi-hemispheric cerebral language network, indicating that a substrate for further recovery might exist," they wrote. "Additional studies using positron emission tomography showed that the patient's resting global cerebral metabolism was markedly reduced. These observations supported our hypothesis that the patient's inconsistent behavioral responsiveness and communication reflected a global reduction in neuronal activity resulting from widespread de-afferentation and compression injuries to the thalamus and midbrain."
Deep-brain stimulation, which involves surgical implantation of electrodes and low-voltage stimulation of key brain regions, has helped reduce motor symptoms of Parkinson's disease, relieving pain from severe, intractable cluster headaches, and decreasing symptoms of severe drug-resistant depression.
The authors hypothesized that deep-brain stimulation to the central thalamus might mimic the normal role of mesial frontal cortical and brainstem circuits, which regulate cognition and help to maintain metabolic activity in the brain during wakefulness by adjusting firing rates in central thalamic neurons.
Two days after the electrodes were implanted in a 10-hour procedure, the surgeons tested the voltage potentials of the leads, and saw that patient had signs of increased arousal and sustained eye opening, and he would turn his head in both directions in response to voices.
Two months after the surgery, the investigators started titrating the patterns of electrical stimulation to search for the best response, and then tested the stimulation in a double-blind crossover phase in which the device would be switched on or off for a month at a time. This was done to help the researchers identify whether any observed improvements were due to deep-brain stimulation, the rehabilitation program the patient was undergoing, or to gradual recovery.
They found on logistic regression analysis improvements during the periods when the device was switched on that could not be accounted for by gradual improvement alone. In addition, they saw that improvements in intelligible speech and limb control occurred when the brain was being electrically stimulated during titration.
"This work reflects the exciting emerging idea that some neurological disorders can be treated by focusing on neural circuit changes rather than drug treatments and gene therapy," said Joseph J. Pancrazio, Ph.D., of the National Institute of Neurological Disorders and Stroke, which funded he study. "However, we still need to understand how deep-brain stimulation works for these disorders and to define which patients can benefit from this treatment."
In an accompanying editorial, Michael N. Shadlen, M.D., Ph.D., and Roozbeh Kiani, of the University of Washington in Seattle, said that although this was only a single case report, it offers hope to the families of patients with impaired consciousness.
"Philosophers and scientists may argue about the definition of consciousness, but neurologists have little trouble identifying its absence," they wrote. "Now, physicians are beginning to understand how it can be restored in some patients with severe brain damage."
The study was supported by the NINDS, Charles A. Dana Foundation, Cleveland Clinic Foundation Brain Neuromodulation Center, Ohio Department of Development Biomedical Research and Technology Transfer Partnership Program and Third Frontier Program, Jane and Lee Seidman Neuromodulation Research Fund, Cleveland Clinic Innovations, IntElect Medical and the National Institute on Disability and Rehabilitation Research. Authors conflicts of interest, if any, were not listed.Primary source: NatureSource reference: Schiff ND et al. "Behavioral improvements with thalamic stimulation after severe traumatic brain injury." Nature 2007. 448:600-604.