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Home based neuropsychological rehabilitation in severe traumatic

brain injury: a case report
Manju Mohanty and Sunil K. Gupta
Department of Neurosurgery, PGIMER, Chandigarh

Abstract

Traumatic Brain Injury (TBI) is the most common cause of death and disability in young people. The patients
with TBI often suffer impairments in psycho motor speed, memory, attention, speed of information process-
ing, executive functioning, fluid intelligence, language and visuo-spatial skills. These impairments need to be
addressed as these have a significant impact on their social and occupational functioning. Neuropsychological
rehabilitation has been found to be useful in improving cognitive and day to day functioning. It focuses on the
improvement of basic abilities which in turn enhance cognitive functioning. The aim of the present study was
to develop a home based neuropsychological rehabilitation programme and examine its usefulness in severe
Corresponding Author: TBI. A single case study method was adopted. A detailed assessment was done at 1½ months (pre-assessment)
Manju Mohanty, Ph.D and 9 months (post-intervention) to evaluate the changes. Post-intervention improvement was observed in her
Department of Neurosurgery, cognitive functions and day to day functioning. She had resumed her previous job also. Home based neurop-
Postgraduate Institute of Medical sychological rehabilitation emerged to be useful in brain damaged patients.
Education and Research, Chandigarh
Tel: +91-8872016129
E-mail: [email protected] Key words: Brain injury, Neuropsychological impairment, Cognitive remediation, Rehabilitation

doi : 10.5214/ans.0972.7531.200111

Introduction and memory strategy training for mild memory impairments

including the use of internalized strategies (eg, visual imag-
Traumatic Brain Injury (TBI) is the most common cause of death
ery) and external memory compensations (eg, notebooks).10
and disability in young people.1 In India an estimated 1.6 mil-
Studies have shown neuropsychological rehabilitation to be
lion persons sustain head injury each year with 200,000 deaths
useful in improving the cognitive functions and day to day
and 1 million requiring rehabilitation services at any point of
functioning.11,12
time. The prevalence of patients with TBI in India is estimated to
be 9.7 million, out of which approximately 16% sustain severe Despite its utility, the cognitive retraining is not in the reach of
TBI.2 The patients with severe TBI often suffer impairments in many affected in India. The reasons could be the lack of trained
psycho motor speed, memory, attention, speed of information manpower to cater to the increasing rehabilitative needs and
processing, executive functioning, fluid intelligence, language the high cost of treatment combined with hassles of frequent
and visuo-spatial skills.3 These impairments have a significant hospital visits which make treatment adherence difficult. Hence
impact on their social and occupational functioning. there is a need to develop a cognitive retraining programme
which is easy to implement, inexpensive and can be carried out
The natural or spontaneous recovery initiates the process of by caregivers. A home based cognitive retraining programme is
restoration of functions. The pace of natural recovery is fast up the need of the hour and also has been reported to be useful in
to 3 months and gradually slows down, but usually lasts for brain damaged patients.13,14
a year. Neuropsychological rehabilitation facilitates the recov-
In the present study an attempt has been made to develop a
ery in the early stages and mediates recovery in the later and
home based cognitive retraining programme and to explore its
chronic stages.4 Neuropsychological rehabilitation is based on
usefulness in improving cognitive and day to day functioning in
the concept of neuronal plasticity, involving the principles of
a patient with severe TBI.
re-establishment and re-organization of the lost functions of
the brain.5 It uses systematically organized procedures (manual Case Report
or computerized) that focus on specific core processing abilities
which in turn enhance cognitive competency of the affected A 24 year old female, an engineering graduate, previously work-
patients. It involves assessment of cognitive functions, goal set- ing in a private firm was admitted to Advanced Trauma Centre
ting and applying appropriate cognitive exercise to improve the of Postgraduate Institute of Medical education and Research,
cognitive function.6 Chandigarh following a road traffic accident. She presented with
a history of loss of consciousness and vomiting. Her Glassgow
Long term outcome and restoration of cognitive functions in Coma Scale score was 8 (E2 V2 M4), classified as severe TBI. She
various conditions have been always an area of concern in was diagnosed to have left parieto-occipital EDH and left tem-
neuropsychology.7–9 Efficacy studies have recommended di- poral pole EDH. She had to undergo two surgical procedures:
rect attention training and meta-cognitive training during post i) left parieto-occipital craniotomy, posterior fossa craniotomy
acute rehabilitation, cognitive-linguistic therapies during acute and evacuation of EDH and ii) left temporal craniotomy and
and post-acute rehabilitation, cognitive interventions for spe- evacuation of EDH. She had no past history of any medical or
cific language impairments such as reading comprehension psychiatric illness. She had no associated physical or neurological

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deficits. At the time of discharge her Glassgow Outcome score 3. Dysfunctional Analysis Questionnaire17: measures dysfunc-
was 4 indicating a good outcome. She was referred for neu- tion in the area of social, vocational, personal, familial and
ropsychological assessment and rehabilitation at 1½ months cognitive functioning.
post injury with complaints of forgetfulness, inattention, diffi-
culty naming objects, inability to read, increased irritability and Procedure
anxiety.
Based on the obtained profile (pre-assessment) a home based
Tools neuropsychological remediation plan was developed. Patient’s
father, 65 years old, educated up to higher secondary and retired
With the consent of the patient and family a detailed assess-
air force official was incorporated as co-therapist. The train-
ment was carried out at 1½ months (pre-intervention) and
ing programme developed for the present study included tasks
9 months (post-intervention) using following tools:
that could be performed by the patient in the home setting un-
1. PGI Battery of Brain Dysfunction15: It is a measure of cogni- der the supervision of the caregiver. The tasks were presented
tive impairment consisting of following subtests: in a graded fashion. The method of saturating cueing was fol-
• Verbal Adult Intelligence Scale lowed. The difficulty level and the complexity of the tasks were
• Revised Bhatia’s Short Battery of Performance Tests of In- gradually increased and provision for scoring for error and time
telligence is provided.18 The cognitive retraining tasks used in the present
• PGI Memory Scale study have been found to be useful by many Indian research-
• Nahor and Benson Test: a measure of perceptuo-motor ers. These included tasks of enhancing attention11, temporal
functions encoding tasks to enhance verbal learning and memory,12 tasks
• Bender Visuo-Motor Gestalt Test: a measure of perceptuo- to improve verbal fluency12 and naming and describing things
motor functions to improve expressive speech. For restoring reading skills both
sight word approach and phonetic approach were used. Su-
2. Selected tests from NIMHANS Neuropsychological Battery16
pervised reading practice with error and time monitoring was
• Digit Symbol Substitution Test : a measure of information
done. A brief description of the cognitive training tasks and
processing speed
domains targeted has been given in the Table 1.
• Digit Vigilance Test : a measure of sustained attention
• Controlled Oral Word Association Test : a measure of pho- Prior to cognitive retraining the family and the patient were
nemic fluency psycho-educated regarding the nature of difficulties, their im-
• Animal Names Test : a measure of category fluency pact on daily living, the possible outcome and the principles of

Table 1: A brief description of the home based cognitive retraining programme

Cognitive domain Retraining task Task description

Verbal memory Temporal encoding 4 lists of 12 words each with increasing level of difficulty (immediate
recall and delayed recall)

Expressive speech Naming and describing things Subject is asked to name given objects (initially cues were provided).
(cueing and semantic analysis) Subject is asked to describe a thing or a picture)

Verbal fluency Word generation Similar to Controlled Oral Word Association Test (COWAT) and Animal
Names Test (ANT). Subject is asked to generate words from a given let-
ter and words belonging to category viz. round objects, things made
of wood, etc. within a stipulated time. The letters used in COWAT and
animal names were not used

Attention Sorting colours and objects Subject was asked to sort particular objects or colours. The difficulty
level was gradually increased by combining the objects and colours.
Letter and digit cancellation Subject was asked to cancel two digits or letters in a given array of
randomly arranged letters/digits on a sheet. Increase in the difficulty
level was achieved by increasing the number of rows and columns and
decreasing the font size. To minimize the practice effect the numbers
used in Digit Vigilance Test were never used.

Information processing Letter symbol substitution Similar to Digit Symbol Substitution Test. The task involved substituting
speed designated symbols corresponding to letters. Increase in difficulty level
was achieved by increasing the number of target symbols and number
of letters to which corresponding symbols had to be inserted.

Reading ability Sight word approach The subject was made to read aloud selected words from a paragraph
written on the flash cards and after mastering made to read the para-
graph and errors and time was noted down.
Phonetics approach Reading aloud a list of words belonging to particular phonetic family.

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therapy. The goals were set as per the patients need. At the on- Table 3: Comparison of Pre and Post Performance on PGI Memory
set of each session the tasks selected for a particular week were Scale
first demonstrated and then rehearsed by the co-therapist in
the hospital setting. Subsequently the exercises were given to Sub-Tests Pre-assessment Post-
be carried out at home under the supervision. The co-therapist assessment
was asked to monitor without being punitive. The number of th th
Remote memory 30 * 50
tasks to be carried out each day was also designated. In the
th th
following sessions the performance was reviewed and the tasks Recent memory 50 50
for next week were advised only if previous goal was accom- th th
plished. Counseling sessions were also held to take care of anxi- Mental Balance 30 * 50
ety and realistic expectation setting. The review was done once Attention & concentration 90
th
90
th

a week during the first 2 months, once in fortnight during the

th th
next 2 months and then once a month for the next 6 months. Delayed recall 30 * 70
Total number of sessions was 18. At the end of the programme th th
Immediate recall 30 * 30 *
(9 months) post assessment (post-intervention) was done to
review the improvement. Similar pairs 50
th
50
th

Results Dissimilar pairs 10 **

th
30 *
th

The cognitive profile of the patient was compared with norma- th th

Visual retention 90 70
tive data. The pre-assessment revealed severe impairment on
th th
the tests of information processing speed, sustained attention Visual Recognition 10 ** 50
(visual), phonemic fluency, category fluency, delayed recall,
dissimilar pairs (new learning) and visual recognition. Moder-
*
moderate impairment
**
severe impairment
ate impairment was observed on the tests of perceptuo-motor
functions, remote memory, mental balance (working memory),
delayed recall and immediate recall (Table 2,3). Though her Table 4: Comparison of pre and post assessment on measures
mean IQ was average i.e. 102 (Verbal IQ = 99 and Performance of perceptuo-motor functions, verbal fluency, sustained atten-
IQ = 104) but there was significant scatter across various sub- tion, information processing speed and reading skills
tests (Table 1). Informal assessment of reading showed signifi-
cant impairment in her reading skills (Table 3). Dysfunctional Sub-Tests Pre-assessment Post-assessment
Analysis Questionnaire showed significant dysfunction in all
Bender Visuo-Motor 5 errors* No error
the areas of functioning i.e. social, vocational, personal, famil-
Gestalt Test
ial and cognitive (Table 4). Clinical interview revealed features
of anxiety. She was over concerned with her looks after the sur- Nahor & Benson Test 1 error 1 error
gery and impairment in expressive language and reading skills
that made her to avoid social interactions. Controlled Oral Word 6 average words** 9 average words
Association Test
After the intervention marked improvement was observed in her
performance on the tests of remote memory, mental balance Animals Name Test 6/minute** 9/minute*

Digit Symbol 291 secs** 245 secs**

Table 2: Comparison of Pre and Post Performance on Intelligence Substitution Test
Tests
Digit Vigilance Test 2040 secs** 1210 secs**
Sub-Tests Pre-assessment Post-assessment
Reading Test Grade 2** Grade 5**
Verbal Adult Intelligence Scale
moderate impairment
*

Information 71* 93 severe impairment

**

Arithmetic 89 120
(working memory), delayed recall, visual recognition, perceptuo-
Comprehension 97 110 motor functions and phonemic fluency. Though improvement
Digit span 139 139 was also observed in her performance on measures of dissimilar
pairs (new learning), sustained attention (visual), information
Verbal IQ 99 116 processing speed, category fluency and reading skills but have
Revised Bhatia’s Short Scale of Performance Tests not yet reached the normal level of functioning (Table 2-3). Her
mean IQ also improved from average to superior intelligence i.e.
Koh’s Block design 105 158 128 (Verbal IQ = 116 and Performance IQ = 139) (Table 1). The
Alexander’s Pass along 104 120 scores on Dysfunctional analysis Questionnaire (Table 4) revealed
normal level of functioning in the vocational, personal and fa-
Performance IQ 105 139 milial areas of functioning but mild dysfunction still persists in
Mean IQ 102 128
the areas of social and cognitive functioning. Parents reported
significant improvement in her anxiety and social interactions.
Impairment present
*
She had also resumed her previous work.

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Table 5: Comparison of Pre and Post Performance on Dysfunc- anxiety and increased irritability. Thus there is a need to have
tional Analysis Questionnaire more frequent contacts with the patient and family to monitor
the process.
Area Pre-assessment Post-assessment
Though a significant improvement in cognitive functioning was
Raw score (Dysfunction) observed only in few domains yet there was a marked improve-
ment in the dysfunction level of the patient. The parents also
Social 96 (profound) 46 (mild)
reported improvement in her day to day activities like going
Vocational 90 (profound) 34 (no dysfunction) out, social interactions etc. The patient has also resumed her
previous occupation. Evidence shows that even mild changes in
Personal 60 (mild) 34 (no dysfunction) ability to attend, recall and act upon information can have sig-
Familial 62 (moderate) 36 (no dysfunction) nificant affect on the basic everyday tasks.20 Clinically, there is
consensus that cognitive rehabilitation should not be focused
Cognitive 64 (moderate) 48 (mild) exclusively on the remediation of impairments, but should re-
duce disability and help restore social role functioning.26 But
whether the gains obtained are maintained and generalized to
Discussion other situations, are yet to be seen.
The aim of the present study was to develop a home based cog- Another limitation of the present study was the difficulty in as-
nitive retraining programme and to explore its usefulness in im- certaining whether the improvement in the patient’s cognitive
proving cognitive and day to day functioning in a patient with performance was due to the natural or spontaneous recovery
severe TBI. Initially the memory and expressive language (nam- or the remediation programme as it involves only a single case.
ing difficulty) deficits were targeted as these were the most But it has been advocated that rehabilitation should begin at
distressing for the patient and also have been recommended the earliest as it facilitates the recovery in the early stages and
in the acute phase of recovery. Once some improvement was mediates recovery in the later and chronic stages.4
reported in recall and naming ability, the training focused
Despite several limitations home based neuropsychological
on reading impairment and verbal fluency after 2 months of
rehabilitation seems to be useful in improving cognitive func-
initiation of remediation programme. The impairments in at-
tions and is cost effective but its efficacy needs to be assessed
tention and information processing speed were targeted in
in a larger population.
the 5th month i.e. 6 months post injury. The duration of the
sessions were gradually increased as more tasks were incorpo- Conclusions
rated. The sessions were limited to twice a day with average
duration of 45 minutes to 1 hour. The present study emphasizes the role of care givers in the neu-
ropsychological rehabilitation of brain damaged patients.
In the present study the direct training of cognitive processes
was adopted involving repetitive stimulation of distinct com- References
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