An examination of technology to support restitution strategies following a brain injury

1. Technology for
Restitution
Derek Jones PhD, MBA
FIXXL Ltd and Anatomical Concepts (UK) Ltd
Evidence

2. TBI survivors - can experience
decades of debilitation and
functional loss
Attention Deficits?
Memory impairments?
Executive impairments?
Visual field?

3. A link
between
severity of
injury
& likely
long term
impairment
But
It’s a fuzzy
&
weakening
link

4. The percentage of TBI patients with
unmet cognition needs 1 year
post-injury?
Corrigan et al (2004) “Perceived needs following traumatic brain injury” J Head Trauma Rehabil, 2004; 19: 205-216

5. Even if we do have all
“the pieces”
they don't always fit
together as
well as they should

6. Compensation - assistance

7. Restitution - Once
it’s gone can it be
recovered?

8. Strategies to
compensate
for what is lost
“Meaningful
” Goals
Strategies to
recover what can
be recovered
•Know-how
•Technology
•Systems
•Processes
Retraining
Stem Cells
Pharmacological
Enhanced Learning
Mnemonics
External Aids
Environmental Mods

9. Cognitive Training Cognitive Rehabilitation
Versus
Retraining
Improving Everyday
Functioning
Improve Cognitive
Function

10. General Aim
Compensating - Rebuilding - Stabilising
those functions that endanger self determination and place in society
Other Aims
•Improve brain performance and motor abilities
•Strategies for learning and problem solving
•Perform activities of former life once more
•Social reintegration
•Processing and gaining awareness of the injury

11. Basic Principles
First - Encourage functions
that are still in good condition
Second - Training disorders specifically
• Building confidence
• Increase readiness to deal with deficits
• Training specific functions
• Tasks “concrete” then “abstract” later
• Increase difficulty with care
Self confidence?

12. Basic Principles
Variety
• Variety of therapy
content
• Variety of material
(motivation)
• Different functions
• To reflect client interests
• Multiple modalities
•Visual - linguistic -
tactile - auditory

13. Computer Technology
Is NOT the Complete Answer
to Either Cognitive Training
or Rehabilitation
However….

14. Computer Technology like RehaCom
Can provide some effective
tools for the clinician

15. Challenges & Opportunities
• Computer training gains might
not automatically transfer to
real-life
• Training alone may not
improve all aspects of
cognition - evidence suggests
attention issues and working
memory benefit more than long
term memory for example.
• Evidence in support has grown
but more high quality English
language studies would be
ideal
• Effective tool in the care process - not
an alternative to a therapist
• Helps training to be specifically
targeted to client deficits, to be
frequent, intensive & cost effective.
Clients can work with supervision -
even at a distance with tele-health
methods
• Can highlight current deficits -
strengths and weaknesses and
provide leverage for the therapist to
develop coping strategies.
• Tools like RehaCom have
“assessment modules” built-in to
help identify deficits

16. What do we mean by
Evidence?
it’s not so simple

17. Evolution of Evidence-Based Healthcare
Quality
Improvement
Doing things
better
Increased
Effectiveness
Doing the right
things
Efficiency
Doing things
cheaper
Doing the right things - right
1970’s 1980’s 1990’s 2000’s

18. Seeking Evidence - It’s about “Cause” and “Effect”

19. “Black Box
Problem”

20. Lies, Damn Lies and Statistics

21. Great technology alone doesn’t guarantee a great “result”
No quick fixes
It can enable better therapy but it’s
hard to isolate it’s specific impact

22. Derek Jones PhD MBA
Anatomical Concepts (UK) Ltd - Masters of Rehabilitation Engineering
Fixxl Ltd - Bringing Technology to Life

23. Attention Disorders - Meta Analysis
Walter Sturm (2010)
“Evidence-based procedures in neuropsychological rehabilitation: treatment of attention deficit disorders”
(German)
Neurol Rehabil 2010; 16 (2): 55-62
Evidence-based evaluation of the efficacy of neuropsychological rehabilitation measures dealing
with Attention Deficits have revealed that therapy has to be tailored to the specific attention
impairment. This holds especially true for deficits in attention intensity (alertness, sustained attention,
vigilance).
Administration of too complex therapy methods with deficits in attention this domain might lead to even
further impairment due to an "overload" of the system. In contrast to other cognitive
domains computerised attention retraining programs which address specific attention in everyday-like
domain scenarios have proven to be efficient. Both a high frequency and sufficient duration of training
measures have proven to be inevitable for efficacy.
Further therapeutic approaches based on behavioural therapy help with the organisation of
everyday situations but also the involvement of the patient's social surrounding adds the above mentioned
measures in primary aim of a restitution of function.

24. Memory Disorders - Meta Analysis
A. Thöne-Otto
Neurol Rehabil 2010; 16 (2): 63-74
“Evidence-based procedures in neuropsychological rehabilitation: treatment of memory disorders”
(German)
Within the last years there has been an increase in methodological quality of published studies in the field
of memory rehabilitation. Thus evidenced-based practice guidelines meanwhile can rely on a number of
high quality studies. The following review summarises studies on memory rehabilitation published in the
years 2000 – 2010.
Randomised control-group studies, meta-analyses, systematic reviews, as well as relevant class II or III
studies are presented. A number of studies show that patients with mild to moderate memory deficits,
especially after traumatic brain injuries, benefit from a training of internal learning strategies. There was a
positive correlation between the number of training sessions and training effects. In addition there is high
evidence for the application of external memory aids, i.e. memory books or electronic devices, in order to
compensate everyday memory deficits.
In patients with severe memory deficits, however, a caregiver may be necessary in order to enter relevant
information into the patient’s memory aid. In order to teach patients with memory deficits domain-specific
personally relevant information or skills errorless learning seems to be a relevant technique. Avoiding
errors can be achieved by the method of vanishing cues or by spaced retrieval. Those learning techniques,
which seem to rely on implicit memory, are especially relevant for brain injured patients with severe
memory deficits.

25. Executive Function - Meta Analysis
SV Müller (201)
Evidence-based methods in the rehabilitation of executive interference
Neurol Rehabil 2010; 16 (2): 75-81
The paper reviews therapeutic approaches for the treatment of executive dysfunction with special emphasis
on therapy trials in the decade (2000 - 2010) introduced. Randomised controlled group studies, meta-
analyses and systematic review work were considered. Importance case studies with lower levels of
evidence were also considered. A narrowing of focus to a specific etiology was not carried out.
In summary, most convincing evidence was found for cognitive repetitive training like working memory
tasks or double tasks. When using the methods of behaviour management there is clear evidence of
efficacy.

26. Available Literature on RehaCom Applications
• Stroke/Visual Field
• ADHD
• Multiple Sclerosis
• Traumatic Brain Injury
• Stroke - cognition
• Education
• Schizophrenia
• Other psychiatric
• Dementia
• Parkinson’s disease
• Elder person - cognitive decline
• Downs Syndrome
• Telehealth
• Epilepsy
• Working memory
www.rehacom.co.uk