Case Report

Cognitive Rehabilitation for a Person with Traumatic Brain Injury and Aphasia

Yukihiko Ueda*

Professor, Department of Human Welfare, Okinawa International University, 2-6-1 Ginowan, Ginowan city, Okinawa, Japan
Corresponding Author: Yukihiko Ueda, Okinawa International University, 2-6-1 Ginowan, Ginowan city, Okinawa, Japan, Tel: +81988921111; Email: y.ueda@okiu.ac.jp

Received Date: June 02, 2020; Accepted Date: June 29, 2020; Published Date: July 06, 2020

Citation: Yukihiko Ueda, Cognitive Rehabilitation for a Person with Traumatic Brain Injury and Aphasia, J clinical Case Rep Case Stud 2020: 85-92.

Abstract

A man in his 50s diagnosed as having cognitive impairments related to memory, attention, and executive function and developed mild sensory aphasia, as well as problems in social behavior, after a traffic accident. His neuropsychological assessment indicated the possibility of an attention deficit for selecting appropriate words. As a result, cognitive training and speech therapy were included in his cognitive rehabilitation program, which consisted of group therapy and individual therapy. The results of group therapy indicated improvements in language and memory because of treatment for attention. The neuropsychological assessment conducted 30 months after the treatment program showed improvements in attention, executive function, and verbal functions. His mood disturbances decreased. It became possible for him to go out shopping and attend his daughter’s wedding by himself. It is suggested that cognitive rehabilitation should include both cognitive training and group therapy. Moreover, individual therapy should be combined with group therapy to enhance the effect.

Keywords

Cognitive rehabilitation; Traumatic brain injury; Aphasia; Group therapy; Individual therapy

Introduction

Traumatic brain injury (TBI) contributes to worldwide death and disability. Sixty-nine million individuals worldwide are estimated to sustain a TBI each year [1].

Traumatic brain injury has not only many medical problems but also several types of cognitive impairments: deficits in arousal, attention, memory, and capacity for new learning; problems in initiating, maintaining, organizing, or engaging in goal-directed behavior; self-monitoring and awareness of deficits; impaired language and communication; visuoperceptual deficits; and agitation, aggression, disinhibition, and depression [2]. The cognitive, behavioral, and personality changes accompanying TBI bring about burden also on family members [3][4]. The family members of persons with TBI often experience depression, anxiety, and stress [5,6.]. Therefore, the support for family members is indispensable in the rehabilitation of patients with TBI [7].

A large number of clinical trials for cognitive impairments in TBI have been conducted. Attention interventions using direct training methods, memory treatments using external assistive devices, interventions for visuospatioal impairments, and interventions for executive impairments using problem-solving strategy [8] have been used for patients with cognitive impairment. The systematic reviews of these interventions recommend that visuospatial interventions, training for attention, and interventions for executive impairments are practice standards, whereas memory intervention is a practical guideline [9]. Although the cognitive rehabilitation for genetic disorder such as Autism Spectrum Disorder (ASD) or Attention Deficit-Hyperactivity Disorder (ADHD) have been carried out recently, the efficacy for ADHD is questionable [10], and for ASD is limited [11].    

In cognitive rehabilitation of patients with TBI, however, it is necessary to treat social behavioral problems, problems of awareness, and self-consciousness, in addition to conducting cognitive training. Furthermore, it is difficult to stipulate when each of these treatments should be implemented. Sholberg and Mateer [12] proposed that interventions for decreasing problem behaviors should be implemented at an early stage of rehabilitation, soon after the patient’s injury. Cognitive-behavioral approaches to improve self-control should be conducted in the intermediate stage, and psychotherapy for reorganizing these patients should be undertaken at a later stage. Ben-Yishey et al. [13] reported that the maximum efficacy of cognitive rehabilitation was observed by using a therapeutic milieu that consisted of group therapy and individual therapy. They simultaneously conducted cognitive remediation, interpersonal training, and treatment for improving awareness and self-consciousness of clients within this milieu and suggested that their cognitive rehabilitation method was a holistic approach. This holistic approach was recommended as a practice standard [9, 14]. For communication problems in brain injury such as aphasia, speech language therapy should be conducted on various theoretical backgrounds: program learning [15, 16], stimulation approach [17], and reorganization of functional systems theory [18]. After the 1980s, the information process model based on cognitive neuropsychological theory has been used for analysis of symptoms [19, 20]. The neuropsychological model of auditory language comprehension [21] includes four processes: (1) fluency analysis and feature extraction of sound information; (2) recalling memories of phonemes from long-term memory, which are stored in Wernicke cortical areas, into short-term memory; (3) collating the results of feature extraction and memories, deciding which phonemes are equivalent to sound information and recognizing language sounds; (4) identifying the vocabulary based on collating the series of recognized sounds and vocabulary memory and recalling semantic memories from long-term memory into short-term memory, which is equivalent to the vocabulary, and then recognizing the meaning. This information process is not unidirectional or top-down but bidirectional and includes figuring out unclear phonemes according to the vocabulary or recognizing language sounds by using semantic memory and context clues. Because the feedback loop does not function well with cognitive activities related to speech, patients with Wernicke’s aphasia are often unaware of their mistakes and cannot correct them [22]. Auditory language comprehension is related not only to the temporal and parietal lobes but also to the frontal lobe [21]. Attention is involved in the process of selecting nerve representation (sensory, motor, memory, somatic) that is activated by external stimuli [23]. Moreover, attention is involved in integrating actions that are involved in the feedback of the consequences of behavior [24].

This case study reports the detailed interventions of individual therapy in the holistic cognitive rehabilitation and recovery process of a man who sustained cognitive impairments, aphasia, and social-behavioral problems after a TBI caused by a traffic accident.

Case Presentation

This case study describes a man in his 50s who suffered from cognitive impairments related to memory, attention, and executive function and developed mild sensory aphasia, as well as problems in social behavior, after a traffic accident. He was born in X city in Japan. After graduating high school, he was employed by a supermarket company. He married his present wife and had one son and two daughters. He was a mild-mannered and honest man. He had been working hard for over 40 years and then obtained an appropriate position in the company.  In March of the 2004, he crashed his car into a signpost and was taken to hospital A by ambulance. He was diagnosed as having intracranial hemorrhage, compound fractures of the left leg, intraperitoneal hemorrhage, and multiple organ failure. In June of the same year, he began to show personality changes, including impulsivity, hyperstimulation, and irritability. In October, he was hospitalized in the psychiatric hospital B for delusional and violent behavior. He was violent in the hospital if he was stopped from doing what he wanted. He diagnosed as having organic personality disorders and was given medication (carbamazepine; 3tab, haloperidol; 2tab, biperiden; 2tab, chlorpromazine; 1tab) in hospital B. However, no treatment was conducted to improve his cognitive impairments. Consequently, he was transferred to hospital C, which had a physical rehabilitation program. His wife was required by the hospital to stay with him in a private room 24 hours a day. He did not show any violent behavior in this hospital, but he was sometimes incontinent and also showed topographical disorientation, losing his way in and around the hospital. He was discharged from hospital C, and he returned home around December. He did not show any emotional explosions or agitation after returning home. However, when he got on a bus with his wife for the first time since returning, he strongly insisted, “I want to get on the subway.” Then, he beat her because she refused it. Hospital A staff informed him of a cognitive rehabilitation program in the rehabilitation center in his city, and he visited the center with his wife.

In February of 2005, during the initial interview in the rehabilitation program, his narratives soon became inconsistent. His memory of events immediately before and after the accident was unclear. Nevertheless, he felt guilty about causing the accident. He wanted go out every day, and then his wife had to accompany with him. His wife was distressed when she went with him on the subway because he complained loudly about the people around him and her. His wife was exhausted and confused on how to interact with her husband. His chief complaint at the time was: “I want to know what’s going on inside me.”  He strongly desired to participate in the rehabilitation program.  His wife desired her husband to be cured or even recover slightly. It was decided that his rehabilitation program would start 4 months later in June because he needed rest as he had only recently been discharged from the hospital. He and his wife gave permission for the author to publish this case study.

Assessment

Neuropsychological assessment was conducted from June to August in 2005 (Table 1). The results indicated that he showed reducing simultaneous attention and shifting attention in the domain of cognitive functions. He also showed difficulties in solving tasks with different solutions, which is related to construction ability and executive function. His memory was not significantly decreased, whereas his scores for tasks using words were inadequate. The Standard Language Test of Aphasia [25] indicated difficulties in making phonological connection between words and things. Therefore, executing tasks by using words, such as correctly making requests to others and correctly understanding other’s requests, was difficult for him in daily life.  The Profile of Mood States [26] showed that his energy was low, although he had only a few emotional disturbances. His self-esteem [27] was decreased. The discrepancy in the ratings on the Patient Competency Rating Scale (PCRS) [28] between he and his wife indicated that he did not have any awareness of his difficulties and had a low awareness of his disability.

 

Table 1: Neuropsychological Assesment

TMT = Trail Making Test; WCST = Wisconcin Card Sorting Test; RBMT = Rivermead Behavioral Memory Test; WAIS-R = Wechsler Adult Intelligent Scale Revised; POMS = Profile of Mood State; PCRS = Patient Competency Rating Scale

 

Based on the results of the assessment, we developed a hypothesis for the treatment that his difficulty in daily life was caused by his inability to use words appropriately, which was possibly caused by the deficit in simultaneous attention and shifting attention. Therefore, the treatment plan included cognitive training for improving attention, speech therapy for improving hearing and word selection by the speech therapist, and group therapy for ameliorating awareness and self-esteem. Moreover, supportive counseling was implemented for his wife, which included education on dealing with her husband at home and reducing her stress. He and his wife were informed in writing about the results of his assessment and the treatment plan. After hearing the assessment results, he stated, “My goal is to take back self-esteem.”

Treatment

He participated in a cognitive rehabilitation program, which was designed to be a comprehensive, holistic approach [29]. This program consisted of individual therapy and group therapy. The individual therapy included cognitive training and counseling by the clinical psychologist and speech therapy by the speech therapist. In the counseling, the therapist validated the patient’s experience, motivated him to engage in the rehabilitation program, and reduced his stress.

The group therapies included small group and large group, with each group aimed at cognitive remediation, interpersonal training, and treatment for improving awareness and self-consciousness. The group therapies were conducted by 13 rehabilitation specialists, which included the psychologist and the speech therapist mentioned above. The timeline of the treatment is shown in the (Figure 1). Cognitive training started in September by using the attention training sheets [30] in the individual therapy. The program began with an extended attention training in which he found one target in numbers of figures. Although he could reach only half of 10 lines of training sheets in 2 minutes at the beginning of cognitive training, as a result, the duration of attention gradually increased. The results of cognitive training were presented to him each time. In the last 10 days of September, the simultaneous attention training task, which used finding two targets, was implemented. However, he soon became confused, which made it impossible to continue this task. He tried to report about episodes that he experienced at home. However, he did not have any memories of the previous week. In the speech therapy, perseveration, paraphasia, and new onomatopoeias frequently appeared. He did not notice his mistakes.

 

Figure 1: The timeline of the treatment-Along the axis of time, the patient’s changes of behavior and memory, the status of cognitive training, speech therapy and group therapies are shown.

 

 

In October, the cognitive training program was successfully changed from the extended attention training to the simultaneous attention training, and he could begin to complete the last line of the simultaneous attention training sheets. In the speech therapy, the copy training of newspaper titles was settled; however, the word-finding training was not progressing adequately, and he could not accomplish his homework. However, his wife reported that he sometimes had past memories when he was watching television.

Individual cognitive training continued until January and February of next year. He also began to participate in a small group therapy for cognitive remediation in which it was not necessary to have conversations with other members. In the individual therapy, he began to talk about events that he experienced in group therapy. In the large group therapy for improving awareness and self-consciousness, he said with the assistance of the speech therapist that he had been working very hard away from home in the decade of high economic growth in Japan and then built his position in the company, but lost his job by his mistake and to his regret. Other members in the large group empathized with him and told him, “The traffic accident was not your guilt.” He cried. He became able to read aloud workbooks during speech therapy, even though he did not understand their meaning. However, he did not notice his mistake in speaking at home and insisted, “I’m not wrong.”

He did not make any mistakes during simultaneous attention training from March to June of the same year. He also began participating in a small group therapy that required taking part in conversations. He began to notice his mistakes during speech therapy and attempted to correct them. After that, his mistakes were decreased gradually, until finally, he made no mistakes. He voluntarily took his homework back home, even though he did not complete it every day. His walking and mobility improved so much that he could come to the rehabilitation center alone by transferring from a bus to a train. At this time, medication had been decreased (carbamazepine; 4tab, haloperidol; 1tab, biperiden hydrochloride). In the assessment conducted in June, however, he showed slight improvements in the Wechsler Adult Intelligence Scale–Revised comprehension test and Trail-Making Test–Part B (Table), and there were not any other improvements in cognitive and verbal function. Moreover, his mood disturbances were increased.

From June to December, a more challenging simultaneous attention training task, which used four targets, was implemented in cognitive training. His response speed increased during this training, and he did not make any mistakes. He reported the results of the Olympic Games in the large group therapy, which showed that his memories were nearly accurate. Even on occasions when he had difficulties in recalling the name of specific athletes, he could remember the athletes by their initials. His free conversation improved during speech therapy, and he became able to talk about himself: “I can understand the speech of others but can’t recall the name of the person, and writing Chinese characters is difficult.” He had no problems in having conversations at home during this period, and he did his daily homework voluntarily. His wife reported that he could go out shopping alone, and if he did make a mistake with his purchase, he could go back to the store and change it. In November, he wanted to show his wife his cognitive training. By December, he could go with a shopping list and do shopping. In March of the following year, he attended the wedding of his daughter, which he had been looking forward to doing, and he successfully completed his duties as the bride’s father.

The neuropsychological assessment conducted after 30 months indicated improvements in attention, executive function, and verbal functions. Mood disturbances that had increased at the 1-year posttreatment assessment had decreased, and his energy was improved compared to the pretreatment period. Moreover, the discrepancy in the PCRS was decreased (Table). He finished the cognitive rehabilitation program on June in 2007. After finishing the program, he negotiated with his company about going back to work.

Discussion

In the beginning of the treatment, it was difficult to conduct cognitive training that mainly uses language with this client. Therefore, we started the training to improve attention and concentration by using tasks that did not require language. Slight improvement was observed in attention training. As a result of maintaining and increasing these gains, he displayed overt behavior improvements, including retention and recalling memory, awareness of speech errors, and reduced paraphasia and new onomatopoeias. It is suggested that decreasing paraphasia and new onomatopoeias were the results of improving attention, which caused a heightened awareness of speech errors, and increased the ability to correctly choose a word from those popping up in his mind. Moreover, memory improvements were the result of an enhanced ability to observe things around him and understand the surrounding phenomenon by using correct words to describe them. Therefore, this case study indicates the relationship between attention, language, and memory.

Cognitive training by itself is insufficient for people with emotional disturbance or reduced self-esteem, and therefore individual psychotherapy or group therapy is necessary for treating such individuals. However, psychotherapy can be challenging with patients with speech difficulties and memory problems, because psychotherapy relies on these capacities. In this case study, attention training was conducted prior to individual speech therapy because it was hypothesized that the attention deficit of him was based under language disability. As a result of first conducting attention training, we observed improvements in language and memory abilities, with the improvement of attention. However, speech therapy was effective after only 1 year. The attention training is a top-down approach, whereas the speech therapy is a bottom-up approach [31]. Simultaneously applying these techniques might have augmented the improvements observed in him. If we had separately conducted speech therapy and cognitive training, the effect of speech therapy might have appeared later. Moreover, the overall effects might have taken more time to appear even if we introduced psychotherapy after the treatment of language deficiencies.

Sufficient overall effects still needed more than 30 months in this case study. He did not show much improvement in neuropsychological assessments at more than 1 year; moreover, he showed deterioration in emotion. It is supposed that the reason for this deterioration was that slight improvement of his cognition enabled him to notice his mistakes or difficulties, so he felt depression, anxiety, and hostility. Depression and anxiety often increase depending on the improvement of awareness [32]. The cognitive training should be continued until much improvement can be gained for fewer mistakes and less difficulties. One limitation of this case study was that the self-esteem was not recovered sufficiently. The first goal of this cognitive rehabilitation for him was to gain back self-esteem. Self-esteem is determined by the relation to circumstances [33]. For sufficient recovery of his self-esteem, he needed to go back to and be accepted by his company or his community with his renewed cognitive ability.

Despite the limitation, the results of this study suggest that cognitive rehabilitation of people with TBI should be a comprehensive program that includes both cognitive training for improving their cognition and group therapy for improving their emotions, self-esteem, and awareness. Moreover, it is suggested that these two interventions should be combined with individual therapy for enhancing the effects of group therapy. In individual therapy, the therapist can identify minute changes in the patient’s cognitions and emotions, which could be immediately incorporated into group therapy to maximize the advantages of group therapy. This interactive process is crucial for improving the efficacy of rehabilitation.

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