Integrating Interventions after
Traumatic Brain Injury: A Synergistic
Approach to Neurorehabilitation
Kristen Dams-O’Connor and Wayne A. Gordon
Department of Rehabilitation Medicine, Ichan School of Medicine at Mount Sinai, New York, NY, USA
Deficits in attention, processing speed and executive functioning are among the
most commonly reported and functionally limiting cognitive impairments among
individuals with TBI. Changes in mood can exacerbate cognitive deficits and reduce
life quality. Contemporary hierarchical models of cognitive functioning suggest that
attention/arousal processes underlie and support higher-order functions. Building
on decades of clinical research, a synergistic, integrative approach to neurorehabilitation is described, which combines bottom-up and top-town cognitive interventions in addition to psychotherapeutic interventions for mood. This approach
is intended to address directly impairments in both foundational (i.e., attention)
and higher-order (i.e., executive functions) processes. Executive dysfunction is
addressed in a top-down fashion through the application of a series of problemsolving and emotional regulation modules that teach and integrate strategies that
can be generalised across situations with practice. Attention, arousal and information processing are necessary prerequisites of successful higher-order thinking,
attention skills, and are addressed in a bottom-up fashion through intensive individualised attention and processing training tasks. Combining top-down and
bottom-up approaches within a comprehensive day-treatment programme can
effect a synergistic improvement of overall functioning.
Keywords: traumatic brain injury, neurorehabilitation, executive functioning
Traumatic brain injury (TBI) can result in a wide
range of consequences that include cognitive,
behavioural, emotional and physical challenges;
many of these can have a longstanding or lifelong
impact on day-to-day functioning (Brown &
Vandergoot, 1998; Dijkers, Brown, & Ashman,
2004; Ruff, 2005; Stratton & Gregory, 1995).
Cognitive deficits commonly include impairments
in attention, speed of information processing,
memory and executive functioning (Gordon &
Hibbard, 2005; Lezak, Howieson, & Loring,
2004). Injury-related alterations to neuromodulatory systems can also affect mood and behaviour
(NIH Consensus Development Panel on Rehabilitation of Persons with Traumatic Brain Injury, 1999; Silver, McAllister, & Yudofsky, 2005),
and there is often considerable psychological
distress associated with adjustment to disability. Behavioural and emotional symptoms experienced after TBI may include depression, anxiety,
impaired social communication, social isolation, post-traumatic stress, impulsivity, agitation/
aggression or apathy (Ashman, Gordon, Cantor,
& Hibbard, 2006; Hibbard, Rendon, Charatz, &
Kothera, 2005; Hibbard, Uysal, Kepler, Bogdany,
& Silver, 1998). Commonly reported physical
symptoms include fatigue, headaches, perception
and visual changes, balance problems, seizures
and endocrine dysfunction (Hibbard, Uysal,
Sliwinski, & Gordon, 1998).
There is tremendous heterogeneity across
individuals in the constellation of symptoms
Address for correspondence: Kristen Dams-O’Connor, PhD, Assistant Professor, Department of Rehabilitation
Medicine, Ichan School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1240, New York, NY 10029, USA.
E-mail: Kristen.dams-o’[email protected]
c The Author(s), published by Cambridge University Press on behalf of Australian
BRAIN IMPAIRMENT VOLUME 14 NUMBER 1 MAY pp. 51–62 Academic Press Pty Ltd 2013 doi: 10.1017/BrImp.2013.9
51
KRISTEN DAMS-O’CONNOR AND WAYNE A. GORDON
experienced after TBI. Therefore the degree of
functional impairment associated with post-TBI
deficits can vary greatly. The myriad consequences
of TBI can impact multiple aspects of daily functioning, social relationships, community integration and quality of life. The cumulative impact of
multiple deficits on daily functioning becomes particularly evident when one considers the fact that
most tasks of daily living require the integration
of multiple cognitive, behavioural and emotional
skills. It is important to bear in mind that unlike
more focal brain injuries such as stroke or neoplasm, TBI resulting from closed head injury usually causes diffuse injury throughout many areas
of the brain and results in deficits in a variety of
functional domains (Bernstein, 1999). A comprehensive, integrative approach to neurorehabilitation is required to rehabilitate the diverse array of
capacities that support adaptive functioning. This
manuscript presents an argument for an integrative
approach to neurorehabilitation, and offers a model
for a comprehensive neurorehabilitation intervention.
Top-Down and Bottom-Up
Interventions
Cognitive rehabilitation interventions are commonly classified as either restorative or compensatory. Restorative or ‘bottom-up’ interventions target basic cognitive skills/functions such
as arousal processes, attention and information
processing, and directly engage these fundamental skills through repetitive drills or graded exercises (Mahncke, Bronstone, & Merzenich, 2006;
Merzenich, Tallal, Peterson, Miller, & Jenkins,
1999). This approach is based on the notion that
by training the brain to encode and process increasingly complex stimuli, more accurately and
more quickly through intensive procedural learning, restoration of these basic cognitive functions
may occur with repeated practice. Improvement
of these foundational cognitive skills is theoretically an important prerequisite for advanced training in higher-order cognitive skills (memory, selfmonitoring, executive functioning), but restorative
interventions alone are unlikely to generalise to untrained tasks (Cicerone et al., 2011). While there is
some limited evidence suggesting that intensive
bottom-up interventions can be associated with
improvements on tasks of daily living (Edwards
et al., 2002, 2005; Serino et al., 2007) and overall self-esteem (Parish & Oddy, 2007), most of the
research suggests that significant gains are typically only seen in the specific tasks being trained.
Although the exclusive use of therapist-led drills
and exercises to remediate focal impairments is no
52
longer commonly seen in clinical contexts (Wilson,
1997), in more recent years a few computerised
programmes designed to restore basic cognitive
functions through computer-administered graded
exercises have received preliminary empirical support (Barnes et al., 2009; Smith et al., 2009).
Compensatory or ‘top-down’ approaches address deficits in higher-order ‘executive’ functions through the instruction and systematic practice of principles, strategies or rules that can be
generalised across a variety of situations. Executive functions are a set of cognitive abilities
that regulate and coordinate other abilities and
behaviours. In defining executive functions, Cicerone and Giacino (1992) refer to the capacity
for anticipation of consequences, goal formation,
planning/organisation, initiation/execution of activities and self-monitoring, with correction of errors. Rieger and Gauggel (2002) cite planning, anticipation, action sequencing, cognitive flexibility,
monitoring and inhibition as key components of
executive function. Top-down interventions teach
a guiding principle or rule for how to complete a
higher-order task that can be applied across diverse
contexts, as opposed to relying on ‘bottom-up’ approaches to re-learn a specific lower-order task or
skill. In order to optimise self-regulation, metacognitive strategies rely on behavioural routines and
internalisation of ‘self-talk’ to address executive
function deficits (Cicerone & Giacino, 1992;
Cicerone & Wood, 1987; Honda, 1999; Hux, Reid,
& Lugert, 1994; O’Callaghan & Couvadelli, 1998).
Individuals are trained to consciously use internal
verbalisation of strategies and self-monitoring procedures across a variety of situations in which they
experience difficulty (Mateer, 1999).
Problem-solving deficits have been a primary focus of executive dysfunction interventions (Foxx, Martella, & Marchand Martella, 1989;
Levine et al., 2000; Luria & Tsvetkova, 1964;
Rath, Simon, Langenbahn, Sherr, & Diller, 2003;
von Cramon, Matthes-von Cramon, & Mai, 1991;
Webb & Glueckauf, 1994). One approach to problem solving training (D’Zurilla, 1988; D’Zurilla
& Goldfried, 1971) teaches the patient ways to
make available a variety of potentially effective
response alternatives for dealing with problematic situations, and thereby increases the probability that the person will select the most effective response from among the various alternatives
(D’Zurilla & Goldfried, 1971). The goal of training is to ensure that the pervasive problem-solving
deficits of day-to-day life are addressed, rather than
to provide the individual with discrete, situationbound learning strategies. Using this approach, executive dysfunction is addressed in a top-down
fashion through a multistep process that generally
A SYNERGISTIC APPROACH TO NEUROREHABILITATION
involves recognising and defining a problem, identifying and choosing between possible solutions,
enumerating steps required to enact the chosen solution, and evaluating the outcome (Ben-Yishay
et al., 1985; D’Zurilla & Goldfried, 1971; Levine
et al., 2000; Rath et al., 2003; von Cramon et al.,
1991). By learning a set of guiding principles that
can be applied across situations, the individual is
able to learn to respond adaptively to situational
demands as they arise.
Metacognitive interventions can also be used
to ameliorate deficits in more foundational functions by teaching executive strategies to manage
environmental demands and monitor performance
(e.g., time pressure management; Fasotti, Kovacs,
Eling, & Brouwer, 2000). Compensatory strategies
can involve the employment of external prostheses,
such as a memory notebook or calendar. These external tools, which some may consider a bottomup intervention that replaces rather than restores
once-intact skills, allow an individual with injuryrelated deficits to achieve similar functional outcomes through the systematic use of compensatory
strategies. The over-arching goal of all metacognitive or top-down interventions is to allow processes
that may have happened automatically prior to the
TBI to become achievable through the deliberate
use of structured compensatory strategies.
Emotion and Neurorehabilitation
A crucial element to consider within neurorehabilitation is the role and impact of emotions on
the overall functioning of TBI survivors (Ashman
et al., 2004; D’Zurilla, 1988; Prigatano, 1999).
Changes in mood, emotional control and behavioural regulation represent common consequences of brain injury which may hinder or facilitate treatment and daily functioning. Put simply,
our feelings impact our thoughts and behaviours.
Emotional changes can result from neuropathological and neurochemical changes following TBI,
stress disorders related to the traumatic events surrounding the injury, adjustment reactions to disability and injury-related limitations, pre-existing
psychological factors, or a combination of each.
The cognitive interventions discussed above do
not traditionally address or incorporate emotional
factors, although substantial research suggests that
mood can impact motivation for treatment, participation and outcomes (e.g., Jorge, Robinson, Starkstein, & Arndt, 1994).
Individuals with TBI often have difficulty
regulating their emotions and behavioural reactions, which can result in inaction or impulsivity,
and hinder the use of already-impaired thinking
skills (Cicerone & Giacino, 1992; Gordon, Cantor,
Ashman, & Brown, 2006a; Rath et al., 2003; Simon, 2001). Effective emotional regulation is considered a necessary prerequisite for problem solving and ‘clear thinking’ (Rath et al., 2003). To understand this concept, it is helpful to consider that
productive, targeted thinking requires substantial
cognitive energy. Cognitive energy is a finite resource, at least until it is restored through rest or
relaxation. Emotional reactions can divert a substantial proportion of a person’s cognitive energy,
resulting in diffusion and exhaustion of mental resources.
Emotions, and the energy they require, must
be monitored and calibrated to allow for purposeful adaptive functioning. Accordingly, it is important to integrate into cognitive remediation a treatment that addresses emotional reactions and the
maladaptive self-talk that often accompanies negative emotions (Meichenbaum & Cameron, 1974).
Strategy training that draws on tenets of cognitive behavioural therapy can facilitate emotional
regulation, reduce impulsive reactions, provide alternatives to adynamic or ‘do nothing’ responses,
and increase acceptance of problems as part of
life. The ability to regulate emotions can foster a
person’s confidence in his or her ability to cope
with and solve problems (D’Zurilla, 1988), both
in general and in the moment (i.e., during an emotionally charged situation). Finally, emotion recognition and emotional regulation strategies assist individuals in understanding the ways in which emotions affect cognitive functioning, thereby facilitating awareness of the functional impact of the TBI.
Functionally Relevant
Neurorehabilitation
The traditionally drawn distinction between
restorative interventions and compensatory interventions has motivated clinicians and researchers
to debate which is superior, which creates the impression that a clinician should choose one of these
approaches to guide his or her work with cognitively compromised individuals. However, it is
clear that ‘real-world’ tasks do not require either
foundational attention/arousal skills or executive
abilities. Instead, everyday tasks require multiple
cognitive systems that work together in an integrated fashion.
Although bottom-up and top-down interventions may facilitate improvements in both trained
and untrained domains of functioning, neither
alone is likely to promote lasting functional improvement. Bottom-up approaches are essential ingredients to improving basic capacities for attention and arousal, which are necessary prerequisites
53
KRISTEN DAMS-O’CONNOR AND WAYNE A. GORDON
for learning, memory and other higher functions.
However, transfer of skills to complex tasks of
daily living is a challenge that is difficult to meet
with bottom-up interventions alone. Top-down approaches provide generalizable strategies or guiding principles that are widely applicable and relevant for ‘real-world’ functioning, but without adequate attention and information processing skills,
the individual will be unable to learn, remember,
process and incorporate feedback from the environment.
Real-world functioning requires the integration of foundational and higher-order cognitive
skills. Moreover, cognition does not occur in isolation: emotions and emotional reactions can support
or undermine the effective use of cognitive skills.
Thus the rationale for providing an integrative intervention is clear: meaningful improvements in
productive real-world functioning can be achieved
through the incorporation of bottom-up and topdown cognitive training along with emotional regulation training.
Empirical and Theoretical Support for
an Integrative Approach to
Neurorehabilitation
Evidence-based reviews have suggested that the
most efficacious approach to cognitive rehabilitation is comprehensive day-treatment programmes
(CDTPs) that include individual and group sessions for several hours per day, several days per
week (Ben-Yishay et al., 1985; Cicerone et al.,
2000, 2005). These programmes include a series
of bottom-up and top-down approaches to cognitive rehabilitation, and many also strive to address mood and adjustment issues. Across several
studies, CDTPs have been shown to be effective
in improving rehabilitation outcomes, including
cognition and mood (Ben-Yishay et al., 1985;
Cicerone et al., 2000, 2005; Cicerone, Levin,
Malec, Stuss, & Whyte, 2006; Cicerone, Mott,
Azulay, & Friel, 2004; Donnelly et al., 2011;
Gordon et al., 2006b; Klonoff, Lamb, &
Henderson, 2000; Klonoff, Lamb, Henderson, &
Shepherd, 1998; Malec, 2001; Malec & Basford,
1996; Scherzer, 1986).
Given the diversity and range of symptoms
experienced by survivors of TBI, the benefit of
CDTPs is that they are designed to address a wide
range of post-TBI cognitive and behavioural difficulties. Research suggests that many cognitive
skills are functionally interrelated, providing support for comprehensive neurorehabilitation. Executive functioning, problem solving, emotional
regulation and learning are mediated by atten54
tion and processing speed. Deficits in executive
functioning are among the most disabling consequences of TBI, as they pose considerable challenge to social autonomy, community integration
and vocational success (McDonald, Flashman, &
Saykin, 2002; Sohlberg & Mateer, 1987). Clearly,
being able to attend to external and internal events
and process information accurately is a core prerequisite for intentional learning, emotional regulation and problem solving. Shallice (1981) postulates that regulation and verification of behaviour
are controlled by an attentional supervisory executive system. Stuss, Shallice, Alexander, & Picton (1995) view attention, memory and executive
functions as intimately related, and Stuss and Benson’s (1986) hierarchical model of cerebral organisation defines attention as the foundation of the
hierarchy of functional systems. Indeed, several
studies (Gray, Robertson, Pentland, & Anderson,
1992; Niemann, Ruff, & Baser, 1990; Sohlberg &
Mateer, 1987; Sturm, Willmes, Orgass, & Hartje,
1997) have demonstrated that individuals with executive dysfunction benefit from interventions to
improve attention. Research has also shown that
processing speed is an important determinant of
executive function (Frencham, Fox, & Maybery,
2005; Nelson, Yoash-Gantz, Pickett, & Campbell, 2009; Rassovsky et al., 2006). CDTPs are
well positioned to address these functionally relevant challenges by addressing basic and more sophisticated cognitive functions using a variety of
interventions.
Top-down interventions for executive dysfunction are often embedded in CDTPs to enhance their
efficacy. For example, Scherzer (1986) found that
the effectiveness of a CDTP was significantly enhanced when a problem-solving approach was incorporated in the programme. These interventions
not only view problem-solving from a neuropsychological perspective (Ben-Yishay et al., 1985;
Levine et al., 2000; Luria, 1963), but also take into
account the motivational, emotional and attitudinal
factors that affect the problem-solving process as
it unfolds in ‘real life’ (Rath et al., 2003).
Intervention research on programmes other
than CDTPs suggests that restorative interventions
have a greater functional impact and are more effective when combined with training in compensatory or metacognitive strategies (Cicerone et al.,
2005). Several studies have demonstrated the importance of incorporating both direct restorative
interventions and compensatory strategy training
to maximise treatment results and to enhance generalisation of learned skills to community activities
(Meinzer, Djundja, Barthel, Elbert, & Rockstroh,
2005; Poggel, Kasten, & Sabel, 2004; Sohlberg
et al., 2003; Tiersky et al., 2005).
A SYNERGISTIC APPROACH TO NEUROREHABILITATION
Guiding Principles for the
Development of an Integrative
Neurorehabilitation Intervention
An integrative approach to neurorehabilitation for
the diversity of TBI-related deficits is supported by
the following clinically and empirically supported
principles (Ben-Yishay et al., 1985; Cicerone et al.,
2004, 2005; Gordon et al., 2006a; Malec, 2001): (a)
effective ‘real-world’ functioning requires both basic and complex cognitive skills; (b) higher-order
cognitive skills, such as self-monitoring, problem
solving, and acquisition and execution of metacognitive strategies, are all mediated by foundational
skills of attention and arousal; and (c) emotional
factors can either facilitate or hinder effective cognitive functioning.
Real-world Tasks are not Domain Specific
It may be impossible to identify a real-life situation
in which only one circumscribed cognitive skill is
required (Sun & Zhang, 2004). Making a cup of
tea requires sustained attention, sequencing, memory and executive self-monitoring skills. Even rote
tasks, such as brushing one’s teeth, can require executive input when unanticipated events arise (e.g.,
running out of toothpaste). Similarly, most cognitive rehabilitation interventions, including those
traditionally described as being either restorative
or compensatory, do not rely exclusively on one or
the other approach. It is well known that all learning (whether facilitated by bottom-up or top-down
approaches) is a product of use-induced changes
in the brain’s structure and functional organization (Buonomano & Merzenich, 1998). The distinction between compensatory and restorative approaches is actually quite nebulous, and attempts to
design and deliver exclusively restorative or compensatory interventions do not reflect the multidimensionality of real-world functional task demands.
Foundational Cognitive Skills Underlie and
Support Higher-order Thinking
There is a growing body of evidence that demonstrates that a central mechanism supporting all
learning is the interaction between bottom-up and
top-down neurocognitive processes that is made
possible by structural and functional connections
between underlying neural systems. Evidence suggests that the primary sensory cortex and posterior
cortical regions play an important role in bottomup processes, and the frontal–parietal association
cortex is involved in top-down processes (Adcock
et al., 2009). The intricate interconnectedness of
these neural systems is essential for adequate func-
tioning. Basic science research on auditory processing conducted using animal models suggests,
for example, that enduring receptive field plasticity in the adult auditory cortex requires repeatedly presented sensory stimuli, which are shaped
by top-down regulatory mechanisms in the prefrontal cortex, parietal cortex or higher auditory
areas (Polley, Steinberg, & Merzenich, 2006). Experimental evidence in humans reveals that cognitive processes that are typically classified as topdown behavioural phenomena, such as executive
control and self-monitoring, require the integration of multiple brain systems, and rely on input
from both primary sensory and cortical areas (Kastner, De Weerd, Desimone, & Ungerleider, 1998;
Kastner & Ungerleider, 2000). When sensory inputs are unclear, undifferentiated or ‘noisy’, there
is a greater cognitive load involved in the processing of these inputs, which results in impaired functioning due to competition for top-down cognitive
resources (Adcock et al., 2009).
Emotions Mediate Clear Thinking
TBI-related cognitive deficits rarely exist in isolation: when a TBI survivor becomes aware of
functional consequences of these deficits he or
she can experience feelings of anxiety, frustration, failure and helplessness. When an individual finds himself unable to return to pre-injury
roles and responsibilities, he must begin an often
painful process of renegotiating and reconstructing
an identity (Levack, Kayes, & Fadyl, 2010). The
feelings of loss and sadness that can accompany
this process can influence motivation for treatment,
participation in the community and maintenance
of social support networks. On a more immediate level, the in-the-moment experience of deficitrelated failure can cause a cascade of physiological changes, thoughts and feelings that serve to
overwhelm cognitive resources, resulting in cognitive ‘flooding’ that derails effective thinking. Previous research suggests that providing training in
cognitive behavioural strategies for emotional selfregulation (D’Zurilla & Goldfried, 1971; D’Zurilla
& Nezu, 2001) prior to initiating metacognitive
strategy training for problem-solving disorders results in improvements in self-reported problemsolving abilities and role-playing activities, which
were maintained 6 months post treatment (Rath
et al., 2003).
The Pyramid of Cognitive Functioning:
A Hierarchical Model
A visual model of TBI-related impairments helps
to conceptualise the treatment needs of individuals
55
KRISTEN DAMS-O’CONNOR AND WAYNE A. GORDON
FIGURE 1
(Colour online) A hierarchical model of cognitive functioning.
with TBI. Cognitive processes can be functionally
described as being hierarchically organised into a
pyramid in which foundational skills such as attention, arousal and processing speed are at the bottom
of the pyramid. These basic skills underlie and support higher-order, more complex functions that are
located at the top of the pyramid. An individual
with TBI have can have a range of deficits in both
basic skills and higher-order functions. Therefore,
a comprehensive approach to neurorehabilitation
that integrates the treatment of both foundational
and supervisory skills through a combination of
bottom-up and top-down interventions (see Figure 1) is needed in order to provide patients with
the maximum opportunity to benefit from treatment. This pyramidal structure is based partially
on a hierarchical model of independent but interactive brain operations proposed by Stuss and Benson (1986), and supports an integrative approach
to treatment that is based on clinical and empirical
evidence ((Ben-Yishay et al., 1985; Cicerone et al.,
2004; Gordon et al., 2006a; Malec, 2001).
As seen in Figure 1, at the base of the hierarchy lie the foundational skills of arousal, attention, and drive or motivation. The abilities to
maintain arousal and alertness, initiate activation,
and attend to external and internal events are core
prerequisites for information processing, which is
56
necessary for intentional learning and subsequent
recall. The ability to assimilate and integrate information and sensory experiences relies upon the
accurate input and processing of incoming information. Thus, memory and learning are hampered
by problems with attention and decreased processing speed. Next in the hierarchy are the executive or
higher-order functions of goal-setting, anticipation
and problem-solving. These executive functions
integrate incoming information across domains of
cognitive skills in order to successfully orchestrate
and execute cognitive tasks. The top of the pyramid represents supervisory control, also known as
the ability to self-monitor and make use of internal and external feedback. Based on elaborate networks of sensory, perceptual and cognitive input
from all levels of the cognitive hierarchy, these
functions adjust and direct ongoing automatic and
intentional behaviours.
Two psychological processes that can support
or thwart functioning at any level of this pyramid are emotions and self-awareness. It is well
known that poor emotional regulation can undermine and disrupt adaptive functioning directly and
by interacting with and exacerbating cognitive impairments. Emotional control can help an individual to manage perseverative or impulsive responding, regulate and monitor emotional reactions,
A SYNERGISTIC APPROACH TO NEUROREHABILITATION
inhibit mood-related distractions, and facilitate
clear thinking (Rath et al., 2003). Similarly, awareness of deficits can support adaptation, while low
awareness (a common sequela of TBI) can be a major barrier to successful rehabilitation (Prigatano &
Schacter, 1991). Awareness can be understood as
the ability to use feedback from the environment
and monitor performance, and adjust one’s strategy
based on this information. Unawareness of deficits
can negatively impact functioning (e.g., failure to
recognise a memory problem, and needing to make
several trips to the store due to refusal to use compensatory tools such as a grocery list). Individuals
with reduced awareness are unlikely to be motivated to engage in rehabilitation aimed at ameliorating those deficits. Moreover, since changes in
awareness are often accompanied by changes in
mood or emotional state (particularly as individuals begin to appreciate the severity or chronicity of
their impairments) (Lezak & O’Brien, 1990), the
interaction between emerging awareness and the
accompanying emotional reactions is likely to influence (enhance or degrade) cognitive functioning
at any level of the hierarchy.
TBI may affect one or more skills at any level
in the hierarchy (Sohlberg, Mateer, & Stuss, 1993).
As can be seen in this visual model (Figure 1), an
interruption in functioning at any level in the hierarchy can impact overall adaptive functioning. For
example, disruption at the most fundamental level
may result in inability to initiate or carry out previously automatic tasks effectively (e.g., grooming);
whereas disruption of executive control may result
in poor planning, organisation and sequencing of
components of more complex behaviour or inappropriate triggering of behavioural responses.
Applying an Integrative Model
of Neurorehabilitation
The essential feature of an integrative approach
to neurorehabilitation is the incorporation of both
bottom-up and top-down approaches into all training activities, and emotional aspects of adjustment are addressed throughout training. This does
not mean that restorative and compensatory approaches should be offered as distinct aspects of
a training programme (i.e., first training attention
skills and then treating executive functions), but
rather that both approaches should be incorporated
throughout programme activities and provided simultaneously. Individually tailored metacognitive
strategies will be identified and practised during
training of foundational cognitive skills, and principles of restorative interventions (e.g., practice
and repetition) will add predictability and structure
to metacognitive training for executive dysfunction. The rationale for integrating restorative, compensatory and metacognitive approaches should be
made explicit during training, as explaining the intent and functional relevance of the interventions
will allow individuals with TBI to be active participants in their neurorehabilitation. Moreover, the
relevance and applicability of specific strategies
or compensations to other cognitive domains or
untrained tasks should be pointed out to facilitate
generalisation of training. Strategies for managing
emotional reactions and adjustment-related issues
are embedded throughout training, instead of being offered as distinct components (e.g., individual
psychotherapy) of the intervention. The integrative approach described herein builds on relevant
empirical literature and clinical observations from
comprehensive day-treatment programmes for individuals with TBI.
Integrated Remediation of Foundational
Cognitive Skills
Intensive training of attention and processing skills
strengthens the fundamental skills that are required
for daily functioning, and facilitates the learning
and implementation of higher-order metacognitive
strategies. Attention training involves the use of
empirically supported interventions that target and
selectively train attention using graded, systematic
exercises (Sohlberg & Mateer, 1987). Whereas a
purely restorative approach might involve repetitive drill exercises to retain specific abilities,
an integrative approach incorporates metacognitive strategies, highlights the personal relevance of
trained tasks and strategies, and thereby maximises
generalisation of training to everyday tasks.
The provision of feedback by a trained therapist during structured bottom-up tasks is essential to the integrative approach. Individually tailored feedback facilitates awareness of strengths
and weaknesses, and teaches an individual to monitor and correct behaviour. Feedback can also allow
training tasks to serve as an experiential demonstration of the ways in which factors such as
neurofatigue, emotional dysregulation and motivation can interact with basic cognitive skills.
One example of an awareness-building intervention (Goverover, Johnston, Toglia, & Deluca, 2007)
that can be incorporated into the training of foundational cognitive skills involves asking the participant to define their goal for a particular task, predict their performance, anticipate barriers or obstacles and identify strategies to overcome them, and
compare actual with expected performance immediately following task completion. Ever vigilant of
the impact of emotions on cognitive functioning,
57
KRISTEN DAMS-O’CONNOR AND WAYNE A. GORDON
the therapist orchestrates a collaborative, almost
empirical approach: together, as a team, the therapist and patient gather data (objective performance
on training tasks) to either confirm or modify a
patient’s perceived abilities, and to identify and
circumvent barriers to success. In some ways, the
training tasks themselves serve as a vehicle for
the development of individualised metacognitive
strategies that can be used to maximise attention
(i.e., breaking a task into smaller pieces, removing
external distractions during the task that require
focus, taking rest breaks). These skills provide a
foundation for the learning and practice of topdown strategies used in the treatment of executive
dysfunction. Individually tailored attention strategies can be applied throughout the programme,
including during the learning of metacognitive
compensatory strategies and emotional regulation
strategies, to maximise concentration during learning of these higher-order skills.
During training of foundational skills, emotional reactions should be addressed pre-emptively,
and also as they arise. Emotions and the thoughts,
physiological reactions, and behaviours that can
accompany them are an excellent example of internal distractions, and can be discussed in this context in the early stages of cognitive remediation. If
an emotional internal distraction is identified prior
to or during a cognitive training session (e.g., I
got in an argument with my friend this morning
and I’m still upset about it), metacognitive strategies for emotional regulation can be employed in
the moment. Similarly, participation in structured
cognitive tasks and receiving feedback can provide
awareness of emotional triggers. Feelings of failure
or frustration can serve as cognitive distractions,
and anxiety over the implications of task performance can undermine further productive cognitive
training during that session. Cognitive behavioural
therapy approaches can be helpful in identifying
thoughts that accompany these emotions (e.g., I
made far more errors than I had hoped; now I’ll
never be able to work again), and deconstructing
and reframing maladaptive self-talk. It is appropriate to recognise and label cognitively demanding
tasks as an emotional trigger, so that the patient can
practice individually tailored strategies to prepare
for the feelings that may arise (e.g., initiating deep
breathing exercises to achieve a feeling of calm
before starting the training task).
Integrative Remediation of Executive
Functions
A top-down approach, in which guiding rubrics
or processes are taught that can be generalised
across situations, is ideal for remediating execu58
tive deficits. First, from a theoretical perspective,
the hierarchical organisation of cognitive functions
– with executive functions controlling subsidiary
mental operations – suggests that top-down approaches are likely to be most effective in treating executive dysfunction (Stuss & Benson, 1986).
Second, top-down approaches, by their very nature are more likely to generalise across situations
and lead to enduring functional change. This can
be facilitated by contextualising training activities into the daily lives of participants. Third, empirical findings consistently support the efficacy
of top-down approaches to cognitive rehabilitation (Cicerone et al., 2000; Cicerone & Giacino,
1992; Levine et al., 2000; Ownsworth & Mcfarland, 1999).
Problem-solving training is one commonly
cited example of using a metacognitive step-bystep approach to treat executive deficits. Although
several empirically supported problem-solving interventions exist (Cicerone et al., 2005, 2011),
most involve identifying and defining the problem,
generating alternative solutions, choosing between
viable alternatives, implementing a plan based on
the chosen solution, and evaluating the outcome
of this process (Gordon et al., 2006a). Constant
repetition and practice of the trained metacognitive strategies is encouraged across diverse situations and contexts. An integrative approach to
neurorehabilitation emphasises the fact that extensive practice is required for learning and eventual habituation of metacognitive skills. The goal
is that with sufficient practice the metacognitive
skills being worked on will ‘kick in’ automatically
when they are needed. As discussed above, the
incorporation of individualised strategies indentified in attention training and a constant emphasis on structure and self-monitoring can maximise
learning and independence in executive tasks. Implementing a problem-solving plan, for example,
is an exercise that requires attention to detail and
self-monitoring to ensure accuracy. The same individualised skills and methods that are identified
and implemented during training of these foundational skills (e.g., removing distractions, building
in external reminders, double-checking for accuracy) should be implemented during the execution
of metacognitive strategies.
External compensations can be incorporated
for individuals whose cognitive impairments
cannot be ameliorated through restorative and
metacognitive approaches alone. For example, an
alarm reminder system may help a person who
has difficulty initiating or who forgets to stop and
check for errors during a task. External tools can
also scaffold and strengthen gains made in restorative and metacognitive interventions. For example,
A SYNERGISTIC APPROACH TO NEUROREHABILITATION
keeping a written log of deficits and compensatory
strategies as they are identified during restorative
interventions can help a person to achieve fuller
awareness of injury-related deficits and the strategies that have been helpful in the past. A planner
or memory notebook can be used to help a person organise his or her time. More specifically, a
planner can be used to schedule time to implement
components of a plan that is identified through a
metacognitive problem-solving exercise. The steps
involved in a particular metacognitive strategy can
be recorded on a wallet-sized card, abbreviated
with an acronym and printed on a bracelet, or otherwise cued by external memory aids that facilitate
generalisation of strategies to everyday activities.
Emotional reactions can be explicitly addressed by providing metacognitive training in
emotion regulation, through the incorporation of
top-down principles for processing and modulating emotional reactions. For example, individuals
might be taught a series of strategies to maximise
emotional regulation when confronted with problematic situations. One strategy involves the observation of behaviours, emotions, thoughts and
physiological experiences that are manifest during
a problem situation, and identifying the ways in
which these reactions can interfere with cognitive
functioning. Another strategy involves the identification of precursors to problem situations or
identification of triggers for maladaptive emotional
responses. A final, but crucial, strategy involves
the reframing of problem situations, and identifying and practising more adaptive emotional,
cognitive and behavioural reactions. As described
elsewhere (Gordon et al., 2006b), the emotional
and cognitive components of executive function
are so intricately interconnected that concurrent
treatment is warranted. In order for these principles to be implemented an individual must be able
to recognise triggers of distressing and maladaptive emotions and their physiological, cognitive,
behavioural and emotional consequences. Awareness of these factors can be facilitated by repetitive practice of structured self-monitoring exercises to observe physical sensations, thoughts and
feelings in response to emotional triggers. As discussed above, constant repetition and practice of
metacognitive strategies is required for the learning and eventual habituation of adaptive emotion
regulation skills.
Conclusions
An integrative approach to neurorehabilitation
combines top-down and bottom-up approaches
with cognitive behaviourally based interventions
for emotional regulation within a comprehensive
neurorehabilitation programme to exert a synergistic impact on improving overall day-to-day functioning. It is recognised that neither a restorative nor compensatory approach alone is sufficient for real-world functional change; instead,
beneficial effects of both top-down and bottomup approaches are enhanced by their integration. Bottom-up attention training can improve
sustained attention, inhibition of distraction and
arousal regulation. Improvements in these areas
allow for more efficient learning and initiation of
top-down strategies, which enhance the ability to
benefit from strategy training. Improvements in
real-world functioning require an integrative approach that addresses emotional and adjustment
reactions in addition to simultaneously employing
both top-down and bottom-up approaches in the
remediation of cognitive and functional skills after
TBI.
Acknowledgements
This work was supported by Grant No.
H133B040033, National Institute on Disability and
Rehabilitation Research, US Department of Education; Grant No. 5R49-CE-001171, Centers for
Disease Control and Prevention. The authors report no conflict of interests.
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