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Improving Outcomes After Brain Injury

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Wednesday, March 4, 2020 - 09:15

By Amanda Sacks-Zimmerman, PhD, and Jessica Spat-Lemus, PhD

Cognitive remediation after any kind of brain injury — whether from trauma, stroke, surgery, or other event — has been shown to be valuable in helping patients regain function.

At the Weill Cornell Medicine Brain and Spine Center, we place a high priority on treating the whole patient. Although we are a neurosurgical department, it is important to us that we offer our patients related services they need for the best possible outcome. That’s why many of our patients, whether they’ve had a cerebrovascular accident such as a stroke, suffered a traumatic injury, or have undergone neurosurgery, are referred to us for cognitive remediation. Just as speech or physical therapy can help a patient regain abilities in those areas, cognitive remediation helps a patient regain cognitive function.

In neuropsychology we break down cognitive functions into different domains, including attention, memory, language, visual spatial functioning, and executive functioning. Any or all of those domains may be affected by an injury to the brain, and deficits in one domain affect functioning in others. These changes and deficits can contribute to difficulties in a variety of daily tasks at home, work, or school. Using the concept of neuroplasticity – the brain’s ability to rewire itself when needed – neuropsychologists can greatly improve a patient’s outcomes.

There are two aspects of cognitive remediation:

  1. To restore impaired cognitive functioning through repetitive stimulation of the impaired domain  
  2. To compensate for cognitive dysfunction by calling on reserved cognitive strengths in other areas

Every brain injury is different, but the most commonly affected domains are attention, memory, and executive function – all of which are critical to carrying out basic tasks.

The attention domain includes several functions that, when compromised by injury, can make it difficult to accomplish everyday tasks:

  • Focused attention: The ability to focus on a task in the face of distraction
  • Sustained attention: The ability to maintain attention during entire task
  • Divided attention: The ability to pay attention to more than one demand of the same task (for example, reading one step of a set of instructions and performing that step)
  • Alternating attention: The mental flexibility to switch between aspects of a task that have different cognitive demands (for example, completing a task and then checking for accuracy)
  • Complex attention/working memory: The capacity to active holding information in order to be able to manipulate it and organize it

Cognitive remediation includes attention training that provides stimulation for all these aspects of attention. The repetitive nature of these drills expedites the process of establishing new neural organization. For the patient, attention training can provide:

  • Increased awareness of their attention lapses
  • The understanding that attention is not an automatic process like breathing, but a learned skill that can be improved
  • Related improvements in learning, recall, and working memory capacity, which can help the patient take in and process information more effectively

This domain includes several discrete steps required to form and retrieve a memory:

  • Encoding and consolidation take place in the initial stage, during which the brain analyzes, organizes, and categorizes the  material to be remembered
  • Storage refers to transfer of transient memory to permanent retention
  • Retrieval refers to searching for or activating an existing memory

None of this happens automatically, and remediation teaches an individual a strategy for organizing information based on meaning and associations. Association involves anchoring an item to be remembered to an existing related memory or idea. We also teach patients a metacognitive strategy of organizing retrieval of information specifically for words – an inner script to follow when they run into difficulty that involves semantic searching and phonetic searching.

Executive Function
This domain is what allows us to organize tasks into steps, unconsciously for simple tasks and more consciously for more complicated ones. Executive function includes:

  • Problem solving
  • Planning
  • Prioritizing and Sequencing
  • Self-monitoring performance
  • Prospective Memory: “remember to remember”

Someone with deficits in this domain usually has difficulty breaking a task into steps, knowing where to start, and formulating efficient steps for the task. They are often unaware of errors and have difficulty integrating multiple pieces of information. They are also impulsive, and have an impaired ability to anticipate consequences of their behavior. Cognitive remediation teaches these individuals a problem-solving strategy in which they learn to approach any given problem in a systematic manner by going through a four-step process we call SWAP:

  1. Stop
  2. What is the problem?
  3. Alternatives and options
  4. Plan

Brain injuries can also affect other cognitive domains, including language, visual-spatial, and sensory and motor functions. Be sure to watch the webinar for information on those domains as well as on the emotional aspects of a brain injury. We also cover the emerging technology of computer-based cognitive remediation programs such as Lumosity and CogMed.

The strategies and treatments of cognitive remediation work, and we feel strongly that neuropsychological treatment should be incorporated into the standard of care. We are proud to be the only facility in New York City that integrates cognitive remediation into the neurosurgical team. We believe this is a benefit not only for patients after a brain injury, cerebrovascular accident, or neurosurgery, but also for those with epilepsy and other chronic neurological conditions such as multiple sclerosis and Parkinson’s disease, to expedite recovery and improve quality of life.

More about our Cognitive Remediation Program