factorial designs

1. Computerized Cognitive Rehabilitation—
Evidence and case study demonstration
Michael Gilewski, PhD
Neuropsychologist
Dept. of Physical Medicine & Rehabilitation
LLU School of Medicine

2. Disclosures (of Potential Conflicts of Interest)
None

3. Learning Objectives
»To verbalize the loop of sensory, cognitive and and
behavioral functions that cognitive rehabilitation or any
learning needs to utilize
»To state which cognitive functions demonstrate the
greatest evidence for training efficacy
»To understand areas of benefit achieved by subject with
severe brain injury in case study following extensive
cognitive rehabilitation

4. Related issues not addressed
» The brain is universal. Although the focus is on application to brain injury,
the same principle underlie any learning
» Will not address cognitive enhancement in healthy adults
» There are many Web-based or local computer programs available. Time
won’t allow elaboration on efficacy of each of these
» Come to poster for demonstration of the cognitive rehabilitation program in
this talk.
» Can entertain some questions but feel free to email me for information of
details resources and such.

5. This program has been approved to meet
the School of Medicine’s promotion criteria for
CME for Education.

6. BRAIN REHAB BASICS
Computerized cognitive rehabilitation:

7. What is Cognitive Rehabilitation?
» A brain injury often dismantles the capacity for or at least timing and
coordination of various brain functions
Antonio Damasio –
“In the brain, timing is everything!”
» Cognitive rehabilitation follows a process of:
~ Identifying areas of impairment
~ Facilitating compensatory mechanisms to rapidly improve some function
~ Challenging the brain to restore function

8. Retrain the brain from the bottom up
» Brain stem: wakefulness, internal self-regulation, attentional control, basic
sensory coordination
~ Compensation: Routine and daily structure, managing energy, checking
in with oneself, balanced rest and activity
• Goldilocks as role model
~ Challenge: Constant striving for balance, improve internal awareness,
mindfulness, meditation, and increased focused, sustained and
challenged attention
• Physical balance is very important; also basic coordination of eyes,
vestibular system and body in motion

9. Retrain the brain from the bottom up
» Diencephalon: Thalamus, hypothalamus and radiating pathways for basic
brain activation
~ Control of stimulation, sleep, hormonal control and regulation of
complex internal states, emotional control
~ Compensation: Breathing and other relaxation, daily schedule, external
control of drives, adapt environment to needs, “retreat,” accept
feedback from others, general stress management
~ Challenge: Gradual building of stimulation tolerance,
controlled increase of behavioral control, shift from
supervision to self-control, learn from mistakes,
discover chain of acceleration to problems

10. Retrain the brain from the bottom up
» Sensory functions: Accurate perception of somatosensory, auditory and
visual stimuli as it builds from simple to complex
~ Compensation: Simplify input, increase ease of perception, use external
feedback to check for accuracy
~ Challenge: Gradual building of accuracy and speed with simple stimuli
to more complex integration of information, activate both hemispheres,
complex aspects of nonverbal and verbal communication, complex
nonverbal visual discrimination and written material, academic and
intellectual capabilities, and integration with memory
~ The focus of much of cognitive rehabilitation

11. Retrain the brain – then top down
» Executive functions: Directing attention, motor control, thinking, complex
language, behavioral activation and control
~ Compensation: SLOW DOWN, stop and think, accept and learn
from feedback on errors
~ Challenge: Maintain goal focus despite distraction, divide
attention, activate and shift set with task demands, complex
thinking (abstract, divergent thinking, inductive and deductive
reasoning…), monitor and predict performance
~ Another major area of focus in cognitive rehabilitation

12. Retrain the brain – then top down
» Cerebellum: “Software library” of skills and habits, judgment, timing and
coordination of thinking/action with situation
~ Compensation: errorless learning, frequent small
practice, evidence of results, build behavior
chains, use routines to compensate for effortful
thinking problems
~ Challenge: Increase speed while maintaining accuracy, go up
skill difficulty ladder, learn a new skill

13. EVIDENCE
Computerized cognitive rehabilitation:

14. Cognitive Rehabilitation: Evidence
» Source: Keith Cicerone et al., Arch Phys Med Rehabil, 2000, 2005, 2011
» Beta version of evidence-based Cognitive Rehabilitation Manual (Edmund
Haskins, 2011) through American Congress of Rehabilitation Medicine
www.acrm.org

15. Cognitive Rehabilitation: Evidence
» Attention
~ Practice standard for remediation of attention after brain injury
~ Practice option for computerized attention training with therapist
involvement and intervention
» Visual-spatial/praxic functions (selected)
~ Practice standards for remediation of left neglect in right brain stroke
and gestural strategies for apraxia with left brain stroke
~ Practice options for systematic training of visuospatial deficits and visual
organization skills and for computerized training to expand visual fields

16. Cognitive Rehabilitation: Evidence
» Language/communication
~ Practice standard for language skill training in left brain stroke and
social communication deficits in traumatic brain injury
~ Practice guidelines for language formulation and reading and for greater
treatment intensity with left brain stroke
~ Practice options for group or computerized interventions for cognitive
linguistic deficits
» Memory
~ Practice standard for memory strategy training with mild TBI
~ Practice guideline for external compensation strategy training for severe
deficits
~ Practice options for errorless learning techniques and group
interventions

17. Cognitive Rehabilitation: Evidence
» Executive functions
~ Practice standard for metacognitive strategy training (self-monitoring
and self-regulation)
~ Practice guideline for training in formal problem solving strategies
related to functional problems and everyday situations
~ Practice options for group-based interventions of executive deficits and
problem solving

18. CASE STUDY

19. Subject DN
» Man who suffered a severe anoxic brain injury following several episodes
of ventricular cardiac arrest in June 2008
» After internal defibrillator and medical stability, went through a course of
acute inpatient rehabilitation, intensive outpatient and residential treatment
through March 2009.
» Discharge to home with full-time caregivers for supervision
» May 2010 – wife consulted USC Neurology for other treatment or research
» Background
~ Age 60 at baseline assessment
~ 14 years education, owned successful film production business
~ Lives with wife and their daughter (in her 20s)

20. Anoxic brain injury
» Absence of oxygen leads to cell death
» Secondary chemical cascade harming or destroying other cells
» Typically the poorest prognosis for an acquired brain injury compared to
trauma of similar severity, bleeds, nonmalignant tumors, etc.
» Anoxia disproportionately affects memory and basic executive functioning
» The most vulnerable are watershed areas of brain (depend on distal
circulation from two artery systems) or areas of high metabolism (e.g.,
areas involved in memory consolidation)
» Imaging (as for DN) typically reveals widespread atrophy (his was mild to
moderate)

21. A-B-A-B Single Case Study Design
» Study aim: Would regular student-assisted computerized cognitive
rehabilitation improve cognitive function in this man with a severe anoxic
brain injury more than two years post arrest?
» June 2010 – Alzheimer’s Coordinating Center neuropsychological test battery at
USC
~ Jun–Dec 2010 - Initial control phase A: OT nonspecific cognitive enhancement
with computer 2-3 x/wk
» January 2011 – Readminister tests
~ Feb–Aug 2011 Initial training phase B: Student-assisted computerized cognitive
rehabilitation 2-3 x/wk
» September 2011 – Readminister tests
~ Sep–Dec 2011 – 2nd control phase A: Group games and nonspecific cognitive
enhancement or computer use 3+ x/wk at residential setting
» January 2012 – Readminister tests
~ February 2012 – started 2nd training phase B

22. Computerized Cognitive Training
»www.neuropsychonline.com
»6 domains, 12 graded
tasks/domain, 3-4
difficulty levels per task
»Students trained to assist
»Attention
»Executive functions
»Memory
»Visuospatial skills
»Problem solving
»Verbal/nonverbal
communication
Other cog rehab programs do exist!

25. NEUROPSYCHOLOGICAL ASSESSMENT
» Demographic predicted ability = 86th %ile, AM-NART estimated = 93rd %ile
» Blessed and Folstein mental status tests (some items analyzed separately)
» Attention – Digit span, Trail Making, Letter-Number Sequencing, Digit-
Symbol Coding
» Learning-Memory – Logical Memory story, California Verbal Learning Test
» Language – Boston Naming, Letter fluency (FAS), Category fluency
(animals, vegetables), Token Test (substituted Rule Governed Drawing)
» Visual-spatial – Block Design
» Geriatric Depression Scale
» Added physical – full-tandem standing time and 12-foot walking speed
» Added behavior/QOL – Frontal Systems Behavior Scale (FrSBe) and
Mayo-Portland
Z-scores compared to age norms as possible; change compared to baseline

26. RESULTS TO DATE
Ability June 2010 test
baseline
A Jan 2011
assess
B Sep 2011
assess
A Jan 2012
assess
B
Mental Status Folstein 22 of 30 0 - -
Attention Blessed ment. control 0 + +
“ ” Serial 7s - 3 of 5 + + 0
“ ” Digit span 8F, 5B ++ + +
“ ” Trails A Z = -7.3 + 0 0
“ ” L-N Seq Z = -2.3 0 + +
“ ” Digit sym Z = -2.7 0 0 0
Base = raw of total or Z-score
++ Z-score improvement of 1+
+ Improve (or – worse) 0.5-1.0
-- Z-score worsening of 1-
Mental status – worse but orientation not trained
Attention – some sustained improvement in attn capacity and working memory

27. RESULTS TO DATE
Ability June 2010 test
baseline
A Jan 2011
assess
B Sep 2011
assess
A Jan 2012
assess
B
Learn/mem. All delayed recall=0 0 0 0
“ ” Story immediate Z = -2.7 0 0 0
“ ” Word list total Z = -1.7 0 0 -
“ ” Recognition corr. NA Z = -5.0 ++ ++
“ ” Recog d’ Z = -3.0 - + +
“ ” Forced choice recog 81% - -
Base = raw of total or Z-score
++ Z-score improve of 1+
+ Improve (or – worse) 0.5-1.0
-- Z-score worse of 1-
Memory is worst cognitive function. Some improvement in recognition.

28. RESULTS TO DATE
Ability June 2010 test
baseline
A Jan 2011
assess
B Sep 2011
assess
A Jan 2012
assess
B
Language Naming Z = -2.4 0 + ++
“ ” Letter Fluency Z=-1.2 + + --
“ ” Cat. Fluency Z = -3.0 ++ ++ +
“ ” Token Test Z = 0.9
“ ” Rule Gov Drawing
(time)
Z = -2.1 + --
“ ” RGD Exec (corr) Z = -3.2 ++ ++
“ ” RGD Exec (time) Z = -1.5 ++ --
Base = raw of total or Z-score
++ Z-score improve of 1+
+ Improve (or – worse) 0.5-1.0
-- Z-score worse of 1-
Language – Improved naming, generally sustained fluency, some improved
Language comprehension. Last assessment performance was very slow.

29. RESULTS TO DATE
Ability June 2010 test
baseline
A Jan 2011
assess
B Sep 2011
assess
A Jan 2012
assess
B
Visuospatial Block Design Z= -0.7 0 -
Depression GDS = WNL 0 0 0
Wife rated
Apathy FrSBe Z = -5.8 + +
Disinhib. FrSBe Z = -3.4 0 +
Exec Dys. FrSBe Z = -5.8 + +
Ability Mayo-Portland Z = -0.8 +
Adjustment Mayo-Portland Z = -1.3 +
Base = raw of total or Z-score
++ Z-score improve of 1+
+ Improve (or – worse) 0.5-1.0
-- Z-score worse of 1-
Not depressed. Some sustained improvement in brain-related behavior
as rated by wife.

30. DN Training

31. DN Sustained attention

32. Variable Level 1 Level 2 Level 3 Level 4
Start Date 2011-01-15 0000-00-00 0000-00-00 0000-00-00
Submissions 14 0 0 0
Restarts 0 0 0 0
Total Time on Task (minutes) 33 0 0 0
# Clicks (baseline) 39 0 0 0
Aver. RT (last 5 - baseline) 295 0 0 0
Aver. RT (overall - baseline) 421 0 0 0
Variance (last 5 - baseline) 8582.00 0.00 0.00 0.00
Variance (overall - baseline) 94201.00 0.00 0.00 0.00
# errors (baseline) 5 0 0 0
# Clicks (most current) 50 0 0 0
Aver. RT (last 5 - most current) 295 0 0 0
Aver. RT (overall - most current) 372 0 0 0
Variance (last 5 - most current) 6382.00 0.00 0.00 0.00
Variance (overall - most current) 31563.00 0.00 0.00 0.00
# errors (most current) 4 0 0 0
Date (most current) 2011-07-25 0000-00-00 0000-00-00 0000-00-00
Total Clicks (overall) 433 0 0 0
Consecutive Passes 0 0 0 0
Total Passes 1 0 0 0
Total Fails 13 0 0 0
Grade - most current f
Task 01 - Simple Visual Reaction - Fixed Point - Right Hand

33. DN Executive skills – inductive reasoning

34. Variable Level 1 Level 2 Level 3 Level 4
Start Date 2011-01-15 0000-00-00 0000-00-00 0000-00-00
Submissions 88 0 0 0
Restarts 0 0 0 0
Total Time on Task (minutes) 310 0 0 0
% Correct (baseline) 55 0 0 0
% Correct (current) 100 0 0 0
Date (most current) 2011-08-01 0000-00-00 0000-00-00 0000-00-00
Consecutive Passes 3 0 0 0
Total Passes 24 0 0 0
Total Fails 64 0 0 0
Grade - most current p n n n
Neuropsychonline Cognitive Rehabilitation Therapy System
Progress Report - Track 02 - Executive Skills
Task 01 - Organizing Information (Commonality)

35. Task Date Started Levels Passed Date Completed
Luminosity Discrimination 2011-01-15 passed all 2011-06-20
Line Discrimination 2011-03-05 1 of 4 na
Angle Discrimination 2011-07-05 1 of 4 na
Design Completion na
Shape and Pattern Discrimination na
Complex Animated Pattern Discrimination na
Ball In A Box :right na
Ball In A Box :left na
How Many Blocks? na
Paddle Ball :right na
Paddle Ball :left na
Designer Patterns na
Visual Analysis and Synthesis I na
Visualization From Blueprints I na
Track 04 - Visuospatial Skills
Progress Report - Task Status

36. Conclusions
»The brain is plastic
and can improve even
despite severe injury
»Computers are one
method to facilitate
training
»Gains will be modest
and may sustain
»Need lots of practice
»Focus training on
attention, some
executive skills
»Include fun/
easy as well
as challenge

37. A recipe for cognitive training
»25% challenge – hard – perhaps 75% correct or worse
»50% enjoyable – modest – 85-90% or better correct
»20% speed – easy but do quickly at 90% or better
correct
»5% new learning – pull everything together periodically
to learn something new

38. Thanks
» Elizabeth Zelinski, PhD
The Rita and Edward Polusky Chair in Education and Aging
Professor of Gerontology and Psychology
Leonard Davis School of Gerontology, Univ. of Southern California
» Teresa Diaz (USC staff)
» Student assistants for case study
~ Natalie Abrahamian
~ Rachel Anderson
~ Robert Grijalba
~ Erin Lee
~ Joanna Marantidis
~ Josh Van Zak
Study given a human subjects exemption by USC IRB.

39. Contact
Michael Gilewski, PhD
LLUHC Neuropsychology
East Campus AS-107
909-558-6220
mgilewski@llu.edu