Docstoc

2010-July-23 2 Herring - Cog Rehab

Document Sample
2010-July-23 2 Herring - Cog Rehab Powered By Docstoc
					      Cognitive Rehabilitation:
      State of the Art?


      Sheldon Herring, Ph.D.
      Brain Injury and Young Stroke Programs
      Roger C. Peace Rehabilitation Hospital




      Cognitive Rehabilitation?




SCHIMA 2010 AC&E                               Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                                                       1
      Putting things into perspective…..

      A recent internet posting:

      “Rehab Types or Others:
      Can someone inform me whether there is a
        critical period for cog rehab after TBI or
        whether timing is not important?
      Thanks in advance.”

      Doctor X




      Skepticism Continues……

      “Rehab Types or Others:
      Can someone inform me whether there is a critical
        period for cog rehab after TBI or whether timing
        is not important?
      Thanks in advance.”
      Dr. X


      Dr. X.
      Your question assumes that "cog rehab" is
        effective at any point in time. What is the
        evidence for that? Dr. Y.




      Keeping our bearings

      Despite our history and biases:
       Can the damaged brain learn?
       Can that learning generalize?
       What effect does that learning have
       on daily functioning?
       What role does behavioral status
       play?




SCHIMA 2010 AC&E                                       Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                                                               2
      THE WHAT




SCHIMA 2010 AC&E   Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                           3
      Definitions


         Intellectual rehabilitation
         Neurocognitive Remediation
         C     iti
         Cognitive R     di ti
                    Remediation
         Cognitive Rehabilitation
         Cognitive-neuropsychological
         rehabilitation
         Neuropsychological rehabilitation




      On Definitions

      BIAA recognizes that a number of
        different labels and definitions
        are used to describe the mix of
        services and supports that assist
        individuals in overcoming
        cognitive impairments that
        interfere with productive living,
        healthy relationships and functional
        independence




      The Brain Injury Interdisciplinary Special Interest Group (BI-ISIG) of
      the American Congress of Rehabilitation Medicine




      A systematic, functionally oriented
        service of therapeutic activities,
        based on assessment and
        b    d               t   d
        understanding of the person’s brain-
        behavior deficits….directed to
        achieve functional changes by:




SCHIMA 2010 AC&E                                                          Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                                                                                  4
      The Brain Injury Interdisciplinary Special Interest Group (BI-ISIG) of
      the American Congress of Rehabilitation Medicine




      A systematic, functionally oriented
        service of therapeutic activities,
        b    d               t
        based on assessment and  d
        understanding of the person’s brain-
        behavior deficits….directed to
        achieve functional changes by:




      The Brain Injury Interdisciplinary Special Interest Group (BI-ISIG) of
      the American Congress of Rehabilitation Medicine




      A systematic, functionally oriented
        service of therapeutic activities,
        based on assessment and
        b    d               t   d
        understanding of the person’s brain-
        behavior deficits….directed to
        achieve functional changes by:




      The Brain Injury Interdisciplinary Special Interest Group (BI-ISIG) of
      the American Congress of Rehabilitation Medicine




      A systematic, functionally oriented
        service of therapeutic activities,
        based on assessment and
        b    d               t   d
        understanding of the person’s brain-
        behavior deficits….directed to
        achieve functional changes by:




SCHIMA 2010 AC&E                                                          Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                                                                                  5
      The Brain Injury Interdisciplinary Special Interest Group (BI-ISIG) of
      the American Congress of Rehabilitation Medicine




      A systematic, functionally oriented
        service of therapeutic activities,
        based on assessment and
        b    d                t    d
        understanding of the person’s
        brain-behavior deficits….directed
        to achieve functional changes by:




    Reinforcing, strengthening, or
    reestablishing previously learned
    patterns of behavior

    Establishing new patterns of cognitive
    activity through compensatory cognitive
    mechanisms for impaired neurological
    systems




     Establishing new patterns of activity
     through external compensatory
     mechanisms, such as personal orthoses
     or environmental structuring and
     support or
     Directing efforts toward enabling persons
     to adapt to their cognitive disability,
     even though it may not be possible to
     modify their cognitive functioning
     directly, to improve their overall levels of
     functioning and the quality of their lives




SCHIMA 2010 AC&E                                                          Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                                                                                  6
   Defining Cognitive Rehab
      Theoretical models of cognitive
        rehabilitation (BIAA 2007)
        Vary along several different
        di      i
        dimensions.
        Treatments may be process
        specific, focused on improving a
        particular cognitive domain such as
        attention, memory, language, or
        executive functions.




   Defining Cognitive Rehab
      Theoretical models of cognitive
        rehabilitation (BIAA 2007)
        Treatments may be skill-based,
         i   d ti         i    f        f
        aimed at improving performance of
        particular activities.




   Defining Cognitive Rehab
 Theoretical models of cognitive rehabilitation
   (BIAA 2007)
   Treatments may be skill-based, aimed at
   improving performance of particular activities.
   Th overall goal may b restoring function in a
   The         ll   l      be    t i    f   ti    i
   cognitive domain or set of domains or teaching
   compensatory strategies to overcome domain
   specific problems, improving performance of a
   specific activity, or generalizing to multiple
   activities.




SCHIMA 2010 AC&E                                 Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                                                         7
   Defining and Defending Cognitive Rehab

      The term cognitive rehabilitation was
        perhaps too narrow, and focused
        too heavily on remediating or
       compensating for decreased
       cognitive abilities. The term
       rehabilitation of individuals with
       cognitive impairment better
       captures the emphasis on injured
       individuals that has and always will
       be the target of cognitive
       rehabilitation.62




   Defining and Defending Cognitive Rehab
      The term cognitive rehabilitation was perhaps too narrow,
        and focused too heavily on remediating or
                                              The
        compensating for decreased cognitive abilities.
        term rehabilitation of
        individuals i h
        i di id l with cognitive  i i
        impairment better captures the emphasis on
        injured individuals that has and always will be the
        target of cognitive rehabilitation.62

            Implications for coding?




      THE SO WHAT




SCHIMA 2010 AC&E                                              Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                                                                      8
      “There is insufficient evidence from
        properly structured research
        protocols to establish the general
        acceptance of cognitive
        rehabilitation as a proven medical
        treatment.”

                                 Says Who?




      Says Who!

      “There is insufficient evidence from
        properly structured research
        protocols to establish the general
        acceptance of cognitive
        rehabilitation as a proven medical
        treatment.”
      United States Secretary of Defense
        Robert Gates




      Say What?

      Secretary Gates continues to defend
       TRICARE’s lack of coverage of
       cognitive rehabilitation…..
       Whil the     i ti      id
      …While th existing evidence i  is
       supportive of cognitive
       rehabilitation, the rigor of the
       research by which that evidence
       was produced has not yet met the
       required standard




SCHIMA 2010 AC&E                             Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                                                     9
                      What


      is                                  the

“Correct”

      Standard?




      Cochrane says….
       Cognitive rehabilitation for spatial neglect
       following stroke

       The benefit of cognitive rehabilitation for unilateral
       spatial neglect, a condition that can affect stroke
       survivors, is unclear. Our review of 12 studies
       in ol ing 306 participants found that rehabilitation
       involving       pa ticipants fo nd      ehabilitation
       specifically targeted at neglect appeared to improve a
       person's ability to complete tests such as finding visual
       targets and marking the mid-point of a line. However,
       its effect on their ability to carry out a
       meaningful everyday task or to live
       independently was not clear. Patients with neglect
       should continue to receive general stroke rehabilitation
       services but better quality research is needed to
       identify optimal treatments.




      Cochrane says….
       Cognitive rehabilitation for memory deficits
       following stroke

       It is uncertain whether cognitive rehabilitation
       can improve memory problems after stroke.
       Neuropsychological rehabilitation, and cognitive
         ehabilitation   particular, may play    ole
       rehabilitation in pa tic la ma pla a role in the
       recovery of memory functions, or in the individual's
       potential to adapt to the deficits. Memory rehabilitation
       can address both these aspects and is a standard part
       of rehabilitation in many settings. This review of two
       trials involving 18 participants found that there was
       little evidence to support the effectiveness of cognitive
       rehabilitation for memory problems after stroke and
       more research in this area is needed.




SCHIMA 2010 AC&E                                             Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                                                                     10
      Cochrane says….

       Cognitive rehabilitation for
       attention deficits following
       stroke
       Cognitive t i i
       C    iti               improve
                 training can i
       alertness and sustained attention
       but there is no evidence that it
       helps people to do daily activities
       without help after stroke.




      Do we therefore not treat?


       “…lack of the most rigorous evidence does
       not equate to complete ignorance abut
       what rehabilitation treatment to choose”

       Clinician must still choose “ but will be
       less certain of that choice”

       Must be much more strategic and
       theoretically driven




SCHIMA 2010 AC&E                                   Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                                                           11
      Recommendations for Clinical
      Practice

   Practice Standards
     Visuospatial rehabilitation for deficits associated
     with visual neglect after right hemisphere
     stroke.
     Cognitive-linguistic therapies f language
     C     i i    li    i i h       i for l
     deficits related to left hemisphere stroke.
     Functional communication and pragmatic
     conversational training following TBI.
     Compensatory memory strategy training for
     mild memory impairments following TBI.




      Recommendations for Clinical
      Practice

      Practice Standards(continued)
       Gestural or strategy training for
       apraxia after left hemisphere
        t k (      t    h b)
       stroke (acute rehab)
       Strategy training for attention
       deficits during post-acute rehab for
       TBI.




      Recommendations for Clinical
      Practice

   Practice Guidelines
     Visual scanning training, particularly when
     neglect is present, after right hemisphere stroke.
     Cognitive interventions for specific language
     impairments after stroke or TBI
     Problem solving strategies for everyday
     situations and functional activities following
     stroke or TBI
     Comprehensive-holistic neuropsychological
     rehabilitation to address cognitive and functional
     disability following TBI.




SCHIMA 2010 AC&E                                  Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                                                          12
      Recommendations for Clinical
      Practice

      Practice Guidelines(continued)
       Treatment intensity should be
       considered as a key factor in rehab
        fl         d fi it ft l ft
       of language deficits after left
       hemisphere stroke




      Recommendations for Clinical
      Practice

      Practice Guidelines(continued)
       Treatment intensity should be
       considered as a key factor in rehab
        fl         d fi it ft l ft
       of language deficits after left
       hemisphere stroke
          Recent study on movement pracitce by
          Lang et al (2009) : “It is possiblle that
          current doses of task-specific practice
          during rehabilitation are not adequate
          to drive the neural re-organization
          needed to promote function poststroke
          optimally”




      Recommendations for Clinical
      Practice

      Practice Guidelines(continued)
       Treatment intensity should be
       considered as a key factor in rehab
        fl           d fi it ft l ft
       of language deficits after left
       hemisphere stroke
       External compensations directly
       applied to functional activities for
       persons with severe memory
       deficits after TBI or stroke




SCHIMA 2010 AC&E                                 Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                                                         13
      Recommendations for Clinical
      Practice

   Practice Options
     Systematic training of visuospatial and
     organizational skills without neglect after
     right hemisphere stroke (but not TBI)
     Verbal self-instruction, self-questioning, and
     self monitoring to promote self-regulation for
     executive deficits following TBI.
     Integrated treatment (cognitive and
     psychosocial) in the context of holistic
     neuropsychological rehabilitation
     Computer based interventions if therapist
     mediated and part of a multi-modal program.




      Recommendations for Clinical
      Practice
   Practice Options(continued)
    Limb activation or electronic
    technologies for visual scanning
    training for neglect after right
    hemisphere stroke
    Computer based interventions intended
    to produce extension of damaged visual
    fields (may not withstand further
    literature review)




      Recommendations for Clinical
      Practice

      Practice “Warnings”
       Sole reliance on computer based
       tasks
       Isolated use of computer training
       for left neglect




SCHIMA 2010 AC&E                               Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                                                       14
      Further support

        Rohling et al. subjected Cicerone et
        al. studies to statistical meta-
        analyis
        Support found f
        S       tf    d for
           Attention training for TBI
           Language training for aphasia
           Visuo-spatial training for neglect after
           stroke




      EBM, Academy of Neurologic
      Communication Disorders

      Practice Guidelines
        With considerations and conditions,
        attention training
        Use of memory aids
        Behavioral interventions
        Metacognitive strategy instruction
        (problem solving,etc)




      Evaluation of cognitive rehabilitation as a treatment
      paradigm (Shutz and Trainor)




        What are the characteristics of
                   th t         t ff ti
        programs that are most effective in i
        cognitive rehabilitation?
        Does level of specialization really
        matter?




SCHIMA 2010 AC&E                                         Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                                                                 15
      Evaluation of cognitive rehabilitation as a treatment
      paradigm (Shutz and Trainor)




                          VS




      Model 3

                               The “Lone Ranger”
                                 Stand alone therapy
                                 Seen as distinct
                                 modality
                                 Weak on integration
                                 with other
                                 interventions
                                 Theory up to therapist
                                 Most common




 Models 1 and 2

        “Transdisciplinary”
        -unified front
        Intensive
        Complex
        Therapies across a
        number of content
        areas
        Based on theories
        of neurocognitive
        functioning




SCHIMA 2010 AC&E                                         Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                                                                 16
      Who wins in this battle?




      Characteristics of effective cognitive
      rehabilitation



       Theoretically based
       Multifaceted
       Interdisciplinary
       Integrates cognitive and skill
       training
       Addresses generalization




SCHIMA 2010 AC&E                          Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                                                  17
      Characteristics of effective cognitive
      rehabilitation


        Addresses self-awareness
        Psychotherapy and social skills
        Provides sufficient time for
        cognitive and behavioral change
        Evaluation of interventions




      Therapist’s Considerations

        Need to be a constant student of the
        professional literature
        “Do I have the time and resources needed
        to address this issue for this patient?”
        Be up front with patient and families
        about the “exploratory” nature of your
        intervention
        Develop treatment protocols that allow
        you to begin to evaluate your intervention
        strategies




      Therapist’s Considerations

      Based on the limits of current EBM, need to
        include:
        Assessment of effectiveness and
        efficiency of your intervention
          Using ecologically valid measures
          U i       l i ll     lid
          Goal attainment scaling
        Establish specific generalization goals and
        probes
        Use of single subject design (multiple
        baselines, ABAB)




SCHIMA 2010 AC&E                                Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                                                        18
      What then, will cognitive rehab look
      like?




      Or is it rehab of persons with brain
      injury who also have cognitive
      deficits…


        97530:Therapeutic activities
        97532: Development of cognitive
        skills
        97535:Self-care/home management
        97537:Community/work
        reintegration




SCHIMA 2010 AC&E                             Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                                                     19
      BIAA Summary and
      Conclusions




      BIAA Summary and Conclusions

      The provision of cognitive
        rehabilitation should be effective
        and cost-conscious. In order to
                        goals,
        achieve these goals providers
        must recognize their
        responsibilities in maintaining
        professional standards and
        monitoring delivery of treatment.




SCHIMA 2010 AC&E                             Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                                                     20
      BIAA Summary and Conclusions

      The fact that research questions
       remain about cognitive
       rehabilitation should not be an
       excuse to withhold payer support
       for treatment, any more than heart
       surgery should be withheld because
       surgical techniques are being
       continuously refined through clinical
       research




      BIAA Summary and Conclusions

      Persons with brain injury must have
        treatment services for cognitive
        problems and best practices must
        be based on the available body of
        knowledge at any given time.




      Recommendations (BIAA 2007)



   Cognitive rehabilitation should be
   provided by qualified practitioners.
   Qualified practitioners are clinicians who
   have fulfilled the requirements for
   professional certification and licensure in
   their respective medical and allied health
   disciplines.




SCHIMA 2010 AC&E                            Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                                                    21
      Recommendations (BIAA 2007)




   …..should respect the long-term scope and
     changing needs of persons with brain injury.
     Necessary treatment for cognitive problems
     should not be constrained by arbitrary
     time limits or caps on the number of
     treatment sessions.




      Recommendations (BIAA 2007)



    The particular needs of children with
    brain injury and their families, including
    developmental and educational
                              rehabilitation,
    implications of cognitive rehabilitation
    and issues pertaining to transition to
    adulthood, have to be addressed by
    providers, payers and the entire health
    care system.




      Recommendations (BIAA 2007)



     Cognitive rehabilitation should be
     integrated into and coordinated with
     vocational services, special education,
     and community based programming
     such as supported living, support
     networks, and recreation groups so that
     individuals move seamlessly within a
     comprehensive, coordinated system of
     care that is adequately funded




SCHIMA 2010 AC&E                               Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                                                       22
      Recommendations (BIAA 2007)



     All states should have an external
     review process for medical claims, and
     individuals who have been denied
     coverage for cognitive rehabilitation
     should fully avail themselves of all
     internal and external processes




      Private Sector Approaches to Cognitive
      Rehabilitation Coverage

     Approaches vary based on the payer’s
     long-term financial responsibility for
     the individual who is injured.
     Individuals who sustain moderate or
     severe brain injuries are often unable to
     continue paying health insurance
     premiums. Hence, the long-term
     contractual liability is more limited,
     and accident and health carriers have
     less motivation to minimize permanent
     disability.




      Private Sector Approaches to Cognitive
      Rehabilitation Coverage


     Many carriers favor short-term cost
     containment
     One such strategy is the automatic
     denial of coverage for any cognitive
     rehabilitation service (or even cognitive
     goals)




SCHIMA 2010 AC&E                               Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                                                       23
      Private Sector Approaches to Cognitive
      Rehabilitation Coverage



    “Plateau” is synonymous with termination of
    benefits

    Occasionally, treatment for cognitive
    rehabilitation is covered only in acute or post-
    acute settings.




      Private Sector Approaches to Cognitive
      Rehabilitation Coverage

     No provisions are made for the dynamic
     challenges of living with brain injury and the
     necessity for additional cognitive treatment or
     strategy development as life circumstances
     change.

     The operational definition of cognitive
     rehabilitation, whether narrow or broad, affects
     covered services and can lead to coverage
     denial depending on how a service is labeled.




      Public Responsibility16A

   In 14 of the 25 states, cognitive rehabilitation
   is included among the menu of services offered
   frequently under Medicaid waivers
   Therapy caps have impacted some service
   delivery
   Specific legislation at state or national level
   may be needed to mandate coverage (BIAA
   Business College Proceedings ,Las Vegas 2006)




SCHIMA 2010 AC&E                                 Cognitive Rehabilitation   S. Herring - GHS Roger C. Peace Rehab Hosp
                                                                                                                         24

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:8
posted:9/7/2011
language:English
pages:24