: THE REHABILITATION OF BRAIN FUNCTIONS Principles, Procedures, and : Techniques of Neurotraining Edited by JAMES F. CRAINE, Ph.D. HOWARD E. GUDEMAN, Ph.D. Neuropsychology Service : Hawaii State Hospital Kaneohe, Hawaii With Contributions by Melinda Ahn, B.A. Judy Costne Joseph Gonsalves, B.A. Irene Higashi Bess Inouye, B.Ed. i Glenda Takata, B.A. Michael Tamanaha, B.Ed. A complete introduction to neurotaining forthe habitation of persons with brain damage Is presented in this book. The fst of three sections delineates the principles of neurotaning 2st Shows how to devel raining program, I includes dzcusions of the rlloale, applica tion, modifeation, and fllon-hrough ofthat program, Training techniques are covered tn the Central segment ofthe text, which provides Indices and Its of theso techniques for case of : reference. The final section offers case stules, traning plans, references, and alist of soucces for training materia Charles C Thomas © Publisher © Springfield © MinoisTHE REHABILITATION OF BRAIN FUNCTIONSTHE REHABILITATION OF BRAIN FUNCTIONS Principles, Procedures, and Techniques of Neurotraining Edited by JAMES F. CRAINE, Ph.D. and HOWARD E. GUDEMAN, Ph.D. Neuropsychology Service Hawaii State Hospital Kaneohe, Hawaii With Contributions by Melinda Ahn, B.A. Judy Cosme Joseph Gonsalves, B.A. Irene Higashi Bess Inouye, B.Ed. Glenda Takata, B.A. Michael Tamanaha, B.Ed. CHARLES C THOMAS ¢ PUBLISHER Springfield * Illinois * U.S.A.Published and Distributed Throughout the World by CHARLES C THOMAS # PUBLISHER 2600 South First Street Springfield, illinois, 62717, U.S.A. This book is protected by copyright. No part of it may be reproduced in any ‘manner without written permission from the publisher. ‘© 1981 by CHARLES:C THOMAS © PUBLISHER: ISBN 0-398.04605-0 Library of Congress Catalog Card Number: 81:52727 With THOMAS BOOKS careful attention is given to all details of manufacturing and design. itis the Publisher's desire to present books that are satisfactory as to their physical qualities and artistic possibilities and appropriate for their particular use. THOMAS BOOKS will be true to those laws of quality that assure ‘@ good name and good will Printed in the United States of America RXT Library of Congress Cataloging in Publication Data Craine, James F., & Howard E. Gudeman The rehabilitation of brain functions Springfield, IL: Thomas, Charles C, Pub. 300 p. 8110 810716ACKNOWLEDGMENTS The ideas and techniques described on the following pages have evolved over the past eight years in the Neuropsychology Program at Hawaii State Hospital. This manual is the result of the group effort of a number of skilled and dedicated individuals all working together in an attempt to in- prove the lives of a select portion of the population. The current Neuro- psychology Service staff is as follows: Ahn, Melinda, B.A. .sseeseeeeeeeee Neurotraining Therapist Cosme, Judy, PMA .. eevee Neurotrainer Gonsalves, Joseph, B.A. ..s++++++, Neurotraining Therapist Higashi, Irene, PMA ...ssesseesee8 Neurotrainer Inouye, Bess, B.Ed. ......+sesee-. Newrotraining Therapist Kaneshiro, Morris, PMA ......+.+.+ Assessment Technician Okawa, Lois, PMA Assessment Technician Takata, Glenda, B. Neurotraining Therapist Yoshida, Helen Secretary Some staff menbers have moved on to other endeavors but have left their mark on this manual during their stay with us. We would also Tike to acknowl- edge the contribution of these people: Betty Albers, Nancy Cramer, Allen Fukumitsu, Alice Hong, Alice Morrison, Dr. Steven Orenstein, Alma Takata, Robin Takata, and Harriet Zakahi.CONTENTS SECTION ONE — INTRODUCTION Page Principles of Neurotraining a Developing a Neurotraining Program . . 21 Rationale . 21 Application . . 30 Modification and Follow Through 34 Conclusion... 39 SECTION TWO — TRAINING TECHNIQUES Key to Use of Index of Neurotrai Techniques . - 4B Index of Neurotraining Techniques . ... 44 List of Training Techniques . AT Training Techniques .. . 51 SECTION THREE — CASE STUDIES Case Studies and Training Plans 2 References. 345 348 Sources of Training MaterialsTHE REHABILITATION OF BRAIN FUNCTIONSSECTION ONE Zz 9 - Vv 2 a 9 & Ee 7INTRODUCTION The principles, procedures, and techniques presented in this manual de- scribe the neurotraining that is being practiced by the Neuropsychology Service at the Hawaii State Hospital. The principles are proposed as a comprehensive and systenatic guide for structuring training activities for patients with defi- cits resulting from central nervous system dysfunction. We present them to encourage others to become more active in the rewarding and intriguing work of training to help reestablish persons with brain damage. Clients are being assessed and diagnosed on a regular basis at the Hawaii State Hospital Neuropsychology Laboratory. The assessment procedures are able to consistently and systenatically differentiate deficits that are the conse- quence of brain dysfunction. After the assessment is completed and the diagnosis made, there emerges the frustrating question of what can be done to help the client overcome or adjust to the deficits that have been identified. In response to this question the staff of the Neuropsychology Service have developed the neurotraining procedures that are described in this manual. Neurotraining is the systematic application of psychological and neurolo- gical principles for the purpose of enabling individuals to overcome deficits that result from central nervous system dysfunction. The procedures and knowledge that make it possible for us to structure neurotraining programs have emerged only in the last three decades. The pioneering work of Ward Halstead and the practical application of his ideas by Ralph Reitan, plus additional supplementary testing, provide us with the comprehensive data needed to structure the deficit~ specific activities that are basic and crucial to neurotraining.C 6 rq In presenting these ideas we feel it is necessary to emphasize the essential mo relationship between the procedures and the manner in which they are applied. In addition, the practice of neurotraining and the application of the techniques a I described in this manual can be maximally effective only if they are consistent with the principles that are also presented. The techniques that are described are intended to serve as examples of the types of training activities that may be used in working with brain dysfunctional patients. Nany other techniques i may be needed and can be structured. The essential point we wish to emphasize, . however, is that in doing neurotraining, the manner in which the training | activities are implemented is far more important than the specific techniques c ! or activities that may be employed. In this sense, neurotraining is more a philosophy or theory of training rather than a catalog or listing of recipes to be applied. PRINCIPLES OF NEUROTRAINING Overview of Principles The following eight principles describe the neurological and psychological theory that underly the practice of neurotraining and provide the rationale for structuring training activities: Principle 1 establishes that recovery of function following cortical damage is possible and reviews current explanations as to how it occurs. Principle 2 characterizes the neurological organization of the cerebral cortex as an “open system" that is highly malleable and adaptive. Principle 3 notes that environmental influences can and do bring about altered processes or reorganization of the cerebral cortex's functions. Principle 4 emphasizes the hierarchical nature of human development which culminates in DEE ee en Heer aera higher mental functions which Principle 5 characterizes as a complex integration of multi-modal processes. Principle 6 emphasizes the “dynamic” or “process” aspects of neurotraining in contrast to its content. Finally, Principle 7 ae eee ail| 7 stresses the need for neurotraining to be deficit-specific for each individual and Principle 8 points out the importance of consistent systematic feedback. In summary, the following principles attempt to substantiate that brain- damaged patients can be assisted in their recovery of cerebral functions by systematic training activities that recapitulate the normal growth and develop- ment of the human organism. These training activities follow well-recognized theories and principles of learning. Principle 1 - The plasticity of function within the central nervous system provides the basis for structuring neurotraining activities to promote and enhance recovery from brain damage. The observation that there can be considerable recovery of function follow- ing organic damage to the central nervous system has been recorded for at least 2,000 years and possibly longer (Stein, 1974). This observation demonstrates that there is a plasticity of the central nervous system that provides the basis for and serves as a contributing factor to the recovery of function following brain damage. That recovery takes place has been well documented. How it takes place and the processes involved in the recovery of function have not been clearly ‘identified and continue to be the focus of considerable research activity and attention. The documentation that recovery does occur is sufficient to justify the development of neurotraining activities designed to enhance and promote recovery from brain damage. The conditions under which recovery takes place and the mechanisms by which it occurs are pertinent and related to what kinds of training can be effective when working with patients with brain damage. Rosner (Stein, 1974) has outlined four possible explanations as to why recovery takes place. These explanations can be summarized briefly as follows: —————— |1. Hierarchical (Compensation) - The neurologist, HughTings Jackson (1873), described the "Principle of Compensation". This principle holds that a given function is represented in the central nervous system several different times at different levels. Therefore, if there is damage at a higher level, a disinhibition of lower level occurs and allows the Tower level to assume responsibility for the function previously maintained by a higher level. An updated, somewhat modified, and more current model of hierarchical representation has been provided by E. Roy John (John, 1976) who has outlined a new theory for how the brain works. . . . “Each brain region has a characteristic signal-to- noise ratio for a particular operation (noise refers to cell-firing in rhythn and with other cells performing the same operation). The more signal and the less noise, the greater the contribution of a given region of cells to a specific function. The regions conventionally thought to control a given function are actually those with the most signal and least noise for that function. Almost every other region of the brain is involved in the same function, but with comparatively more noise and less signal." Substitution - Nunk (1881) considered that recovery of function takes place because other areas of the brain are able to take over the func- tion of the damaged part. For example, if a specific region in one hemisphere is damaged, it would be possible for the alternative hemisphere to assume responsibility for the function. 3. Diaschisis - Diaschisis was initially described by Monakow (1914) and can be understood as a particular type of shock. then the brain is damaged, the areas adjacent to the lesion or site of damage experience shock which results in a loss of input to these specific areas imme- mdiately following the trauma. Monakow felt that the spontaneous recovery resulted when the diaschisis or shock passed and the area of the brain became fully functional again. Dynamic Reorganization Through Retraining - Alexander Luria, a contem- porary neuropsychologist, has hypothesized a functional system to structure retraining activity of the brain damaged individual. Bowden (Bowden, 1966) has summarized Luria's work into four postulates: a. The cerebral component of any functional cortical system results from the interaction of a constellation of cerebral areas. A functional system is localizable in the sense that damage to any one of the areas involved destroys the functional system. b. A given psychological activity may be performed in different ways, that is, by different functional cortical systems. Thus, a psy- chological activity is not localizable in the sense that if damage to a structure destroys a functional cortical system upon which it i is based, another functional system can be developed which would carry out the same activity. c. The most important adaptive functions that man possesses such as abstraction, computation and speech depend upon functional cortical systems which are acquired rather than innate. d. The most important determinants of functional cortical systems in man are derived from the organization of the social environment. Therefore, restoration of function (based upon new learned connec- tions) can be established within the functional cortical system. The method for doing this consists of detailed stimulus-response situations.10 It 4s plausible that all four explanations are possible. They do not preclude one another, Each may apply in different degrees and in different situations and be equally valid in explaining how recovery of function takes place. Spontaneous recovery, particularly following cerebrovascular accidents, is a conmonly observed phenomena. There is general agreement that spontaneous recovery occurs during the first twelve to eighteen months post trauma, This recovery may occur because the patients’ environment continues to stimulate in more or less the same manner, thereby inducing an automatic "compensation", "substitution", “rerepresentation" or “reorganization” within the central ner- vous system, Regretfully, environmental stimulation fs happen-stance and it is a matter of circumstance if the damaged individual does, in fact, receive the type and degree of specific stimulation required to adequately compensate for the damage incurred. The normal level of environmental stimulation may not be sufficient nor hierarchically organized enough to overcome the deficits that are the sequela of the trauma. Therefore, the environment should not be trusted to do so. Rather, there should be careful evaluation and a detailed program of activities prescribed to enable the patient to make as optimal a recovery as possible. Principle 2 - The cerebral cortex is a dynamic process of neurological organi- zation that can be completely halted or slowed by injury or by environmental deprivation or it can be greatly increased or heightened by carefully planned environmental stimulation. This principle is adapted from Lewinn (Lewinn, 1965) and refers to the learning capacity of the central nervous system. Brain processes can be seen as the internal representation of external events or activities. Through repetition and habituation, complex data and/or C ma myeortm mo Emuw activities become internalized by the process we call learning. In order for the brain processes (functional organizations) to be established and for learning to take place, it is necessary that the organism be stimulated. As the organism is stimulated, learning occurs. It follows, that if we wish to teach something to somebody, it is necessary to stimulate them in the direction we wish them to learn. Likewise, if we wish to assist someone in relearning a function that has been lost because of brain damage, it is equally as neces- sary to stimulate them in the direction we wish for them to develop. When an organism is stimulated, the sensory stimuli are conveyed to the brain by afferent tracts leading from the receptor organs up through the spinal column to specific projection areas of the brain. Since these afferent tracts represent the sole avenue by which learning takes place, or by which the pro- cesses and organization of the brain becomes modified, it is appropriate to use the term afferent training to describe the activities prescribed to modify brain processes. The idiom "input precedes output* is basic to the activities of neurotraining. Kephart (Kephart, 1968) has noted that it is the task of the brain to enable the organism to adapt to its environment. As the environment dictates, accordingly does the brain develop. Although this seems apparent and obvious, it is necessary to stress this function of the brain because it allows for the possibility of neurotraining. The central nervous system with its brain, even in a pathologi- cal condition, is not a closed system impervious to external influences, There is evidence to indicate that the cerebral cortex continues to be affected by external events throughout all of its existence and to be modified by them re- gardless of age and damage. Theoretically, if the individual is able to perceive stimulation, it would follow that he would also be susceptible to changes in hisEERE Hee eee oreo PPPoE EeePC CP oeee Pree eee eee eee eae E 12 cas behavior as the consequence of changes in his environment. On this basis it is possible to structure neurotraining activities to promote recovery of function. Principle 3 - The organization of learning within the cerebral cortex results from the repeated activity on the part of the individual and becomes organized into functional systems of behavior. Learning in man may be considered as the consolidation and integration mom of behavior into functional systems within the cerebral cortex (Luria, 1963). When learning occurs initially, an abundance of external cues are required to m structure the behavior. Thus in learning to write, the child's initial efforts are hesitant, awkward and painfully deliberate. Each movement must be con- = sciously planned and carefully executed to produce the expected pattern. A te slight loss of full concentration can result in a very noticeable defect in the i early states of learning. However, with repeated attempts and with continued practice the process of writing becomes internalized and increasingly automatic L as the performance becomes smoother and less hesitant. Practice brings é about habituation. The long hours of penmanship make it possible for us to 7 write with a minimum of external cues so that we can write at the same time we z are involved in other complex activities. When the neurotrainer attempts to help an individual reestablish a skill L ‘that has been lost because of brain damage, it is vital that an abundance of — | external cues be provided initially and that repeated practice sessions be ail scheduled for the patient. Repeated practice should take place beyond the point of habituation. For the purpose of neurotraining, the brain may be considered like a muscle that develops as it is stimulated. Practice, repeated to the point of 7 overlearning, will bring about maximal development. These exercises, although Eee |13 repeated, must also be progressively more difficult in order to maximize their effectiveness. Our observations are consistent with those made by Ruthven, Lewis, and Goldstein in their conclusions based on a three-year project. (Ruthven, Lewis and Goldstein, undated) "It is felt that a crucial dimension of the rehabilitation program vas the constant exposure of the subjects to new learning situations and problem-solving tasks that required attempts at ego mastery. 1. It 4s felt that most of the benefits for brain-damaged indivi- duals accrue from their attempts to master new learning situations. They need a constant variety of exposure to new tasks and situations. Traditional sheltered employment for the brain damaged subject fs felt to have only limited value for the individual, particularly if the work assignments change little in terms of modality, complexity, or the like. The subject's exposure to a daily regime of performing the same work activities would have only limited value for him." (P. 112) Principle 4 - The activities of neurotraining must recapitulate the developmental stages involved in the individual's original acquisition of the learning or skill that is being trained. The hierarchical nature of human learning and development has been described by various authors in a variety of different ways (Kephart, 1968; Plaget, 1954; Strauss & Kephart, 1955; and Johnson & Myklebust, 1967). The basic idea is that the development of one stage is essential and a prerequisite to the develop- ment of the next stage. This means that activities of a later more mature stage of development are dependent upon an adequate performance of activities at an earlier stage. The general idea is that one must crawl before one can walk and | || | |i v 3 & 14 also that one must be able to walk before being able to run. Inherent in this hierarchical. sequence is the consequence that a less than complete or adequate performance at an early level has implication for all later phases or more complex levels of learning. Thus if one does not have complete mastery of laterality and body image, it is probable that he or she will have difficulty learning spatial relations. Neurotraining acknowledges the importance of this hierarchical aspect of learning both in describing and specifying a patient's deficits and in structuring the goals of the training activities. Developmentally early tasks are trained first and in turn are used to structure later more complex training activities. In this way the stages of neurotraining attempt to recapitulate the stages of de- velopment that are followed in the normal growth of an individual or in the normal acquisition of skilled behavior. This enables retraining to occur in all phases jeavoF} from the most basic motor movenents through increasingly more ‘complex spatial, speech, and decision-making activities to the very highest cognitive functions. Our experiences to date suggest that it may be a disregard of the develop- mental sequence of learning that has been most responsible for the lack of success in working with brain-damaged patients, Faflure to initially meet a patient at a level well within his or her grasp and to then progressively carry him through more complex stages of development, may have made it difficult or impossible for the brain-damaged patient to reestablish the functional system. Principle 5 - Complex higher cortical functions represent _an integration of multiple sensory modalities which supplement each other in the acquisition of learning. It has become popular to describe the brain in terms of computer language. Accordingly, it is possible to characterize the central nervous system as a45 computer system that 4s equipped with five input channels for the collection of data. Each channel or sensory modality is equipped to handle specific types of data and each makes its unique contribution to the overall learning that takes place. AT1 modalities are essential to the fully functioning intact individual, although some play a more central role than others in the total organization of behavior. Within the human organism, visual and auditory modal- ities are predominant while taste and smell are relatively minor and the haptic) senses appear to fall somewhere -in between. Accordingly, the bulk of our training activities in the neuropsychology program have involved the visual, auditory and haptic modalities. It has been our experience that in most brain damaged patients all moda- lities are not equally damaged but rather that some remain more ‘intact and functional than others. We have further found that the relatively more intact ‘or functional modalities can be used to retrain or redevelop the less intact and more handicapped modalities. Visual cues can be employed to promote auditory processing or alternatively auditory cues can be used to train visual deficits. The pairing of stimul1 across modality and then systematically diminishing the stimulation in the intact modality was introduced by Luria (1963) and has been employed in a number of different situations. Many of the neuropsychological deficits found on psychometric procedures result froma failure of integration across sensory modalities. Repeatedly, test findings have demonstrated that although the reception and acuity of sensory stimulation may be intact, the brain dysfunctional patient fails to effectively integrate stimulation across modalities. This failure of the integrative level of cortical functions presents one of the most challenging of problems. It 1s necessary to structure training activities so as to combine various modalities into an integrated functional unit.16 Principle 6 - The primary objective of neurotraining is to promote and develop the processes underlying learning and is concerned with the dynamics of learning rather than the specific content of any area, Kephart (1968) has observed that. learning is an integrating process and that integration can be considered to be a function of generalization. The “rigidity; “perseveration? and “stimulus-boundedness" of organic patients makes it difficult or impossible for them to be able to generalize. The deficits underlying the organic's failure to generalize are the focus of neuro- training activities. These deficits may vary from one patient to another and be represented with different degrees of emphasis across many patients. The crucial distinction that characterizes neurotraining from other rehabilitation and remedial programs Ties in its emphasis upon the learning process itself rather than upon any specific content area, i.e., reading, vocational, and other more specialized areas. The brain-danaged patient is often precluded from traditional rehabili- tation programs because he lacks the capacity to benefit from the training that is offered. Nany of the traditional rehabilitation programs are pessimistic about brain-damaged patients and drop them from programs or do not accept them because in good faith they are not able to hold out to the patient a realistic expectation of improvement. The emphasis and procedures of neurotraining focus particularly upon the deficits that render the organic patient unable to "learn". As the goals of training are achieved, it becomes more and more possible for the patient to benefit from the more traditional rehabilitation programs. Kephart (1968), Strauss and Kephart (1955) and Lewinn (1965) have written and described the potential of the brain damaged individual's ability to “learn how to learn" and have described procedures, particularly within the visual modality, for increasing an individual's capacity for generalization. Terms ma rm ee =a Ft mar [ [ i, [ [ c mr - |LT and concepts used by these authors include “plasticity in the solution of psychological problems", "balancing a figure-ground relationship", “building a space-schena", and integrating the relativity of perceptions, and maintenance of a "body-image". These are also representative of one level of training that concerns the neurotraining therapist and thus are seen as the deficits that are delineated in the neurotraining plan and become the focus of neurotraining activities. Principle 7 - The effectiveness of neurotraining activities is dependent upon and relative to the degree to which the deficits can be specified for each individual patient. The consequences of brain dysfunction are multiple and vary greatly in the degree to which they can be specified. On the one hand, the term diffuse is employed to describe a general effect that cannot be circumscribed to a specific type of behavior or action. On the other hand, however, and particularly within the motor area, it is possible to describe a specific and relatively circum scribed deficit. The more diffuse and global a patient's deficits the more difficult it is to structure effective neurotraining activities. The more specifically a deficit can be articulated in behavioral terms the easier it is to structure effective neurotraining. In this sense, neurotraining as practiced at Hawaii State Hospital can be structured only after thorough assessment procedures carefully delineate and describe the total array of the patient's deficits. Thus, the Halstead-Reitan Battery, with its systematic review of the individual's adaptive capacity, or some other such comprehensive assessment of brain-behavior relationships, is an essential prerequisite for structuring neurotraining activ- ities.18 The initial stages of neurotraining consist of assessment techniques to specify the areas of deficits. As the assessment techniques successfully dif= ferentiate and specify deficits, the training activities and procedures will emerge. Likewise, as assessment is a necessary step to initiate neurotraining activities, it continues to be an essential ingredient throughout the entire neurotraining program. Training activities in turn often provide assessment data that can also be used to develop or refine the training procedure. In this sense, there is no clear demarcation between assessment and training procedures. One merges and blends into the other until it is impossible to do one without at the same time affecting the other. It should be emphasized that specificity of deficit is not synonymous with localization of lesion in the assessment of brain dysfunction for neurotraining. Neurotraining is concerned with gaps in performance rather than with lesions in the brain, Although there is a definite relationship between the status of the physical brain and the performance of the individual, neurotraining starts with the individual's performance and makes use of the brain model only as it has implication for the performance of the organism. Traditional rehabilitation programs have tended to become somewhat pessimis- tic about working with brain-damaged patients. This is true primarily because controlled evaluation studies have demonstrated that rehabilitation programs do not show greater recovery than would be expected from spontaneous recovery alone without the assistance of rehabilitation. Me believe the reason traditional rehabilitation has not been more successful in working with the brain-damaged patient stems from their failure to specify in detatl the deficits of their patients and subsequently to structure their rehabilitative activities to be deficit-specific. In other words, retraining activities have not been tailor- made to the unique needs of the patient and thereby may have overhwelmed the mo st toes19 patients rather than helping them to regain their previous capacity. If careful attention is paid to determining specific deficits for the patients and if their training activities are structured on the basis of these deficits, it is possible to promote greater recovery of brain-damaged patients. In this way our observations are in agreement with those of Ruthven and his associates who have done comparable work in Wichita, Kansas. “In summary, our data indicate that moderate to severely brain-damaged {ndividuals need to be involved in a very intensive rehabilitation program providing a wide number of services for maximum recovery and restoration of functions to take place. There is a pessimistic and anti-rehabilitation atti- tude about brain-damaged individuals on the part of many professionals which are not supported by our data and by our experience." (Ruthven, Lewis, & Goldstein, undated) Principle 8 - Consistent and direct feedback to the patients about their per- formance is a crucial aspect of neurotraining. Growth and learning are maximized by having a specific objective clearly in mind and a direct system of feedback to enable the individual to monitor his activity or performance. In the process of neurotraining, the patient needs to know how close or how far he is from his objective and what kind of change he can make to improve his performance. In order for neurotraining to be effective, the goal or purpose of the training must be known and accepted by the patient and he must be in position to receive regular and consistent feedback concerning the adequacy of his performance. In addition, the patient needs to know how to modify his response in order to bring it closer to his expectations. Without consistent feedback and without continuous progress, the patient tends to be overwhelmed by the environ-20 ment and by his limitations. Many times he is aware that he is not able to per- form adequately and yet is unable to alter his behavior to do better. Piotrowski (1937) in describing the organic patient's performance on the Rorschach, uses ‘the term impotence, which he defined as "the giving of a response in spite of + recognition of its inadequacy, together with an inability to withdraw or improve Pr it". Neurotraining activities must take into account this concept of impotence and lead organic patients to more productive ways of dealing with their complex and at times overwhelming environment by providing them with clear direct feed- back and abundant external cues. |a DEVELOPING A NEUROTRAINING PROGRAM This text proposes to spell out the essential steps involved in the actual application of the neurotraining process to clients with brain dysfunction. From the accumulation of experience in a number of these kinds of training cases over a period of time, we derived some important and useful rules for proceed- ing. During the earliest days of our retraining work the foremost question was, "can it be done?" After witnessing a number of clients achieving varying degrees of success, we recognized that the original question was answered with an un- qualified yes. We now see the question more appropriately asking, "How can it best be done?" The following presents the structure and the mechanics of the neurotraining process. RATIONALE I. Recapitulation of Normal Growth and Development: It is interesting to note that each animal species seems to have a natural progression of growth and learning with much in common to all, but also with some highly specific differences natural to a given spectes. As we observe the development of hunans from the newborn through childhood and adolescence to adulthood, we can also note a readily observable pattern and order of activity. Children in their play and games are actively preparing thenselves to be able to meet the demands that may be made upon then as adults. We also note that children in their play tend to have a definite progression according to their age, maturity, and experience so that the games played by the younger children serve to prepare them for participation in the activities that are to follow. Through these play activities, children learn to manipulate their bodies and to cope with changing environmental situations. Spatial and motor activities22 are practiced over and over again in order that all of the senses become integrated and their messages meaningfully evaluated. The games played by humans become more and more complex and begin to involve long-range planning, abstract reasoning, and elaborate strategy. when an accident occurs that results in the impairment of brain functions, an individual so afflicted is handicapped and his deficits will make it appear as if an important phase of his growth and learning has been erased. The specific parts of the brain originally responsible for certain func- tions are no longer able to perform adequately. Reorganization, using alternative routes, is necessary. In order for a training program to properly benefit this individual, it will be necessary to reconstruct the foundation of missing skills. This will necessitate an attempt to re- create the activities and games through intensive practice that originally provided the knowledge, with special emphasis upon FIRST THINGS FIRST. The developmental sequence of learning should be recapitulated with the anare- ness that we cannot effectively progress to the next step until we have successfully mastered the preceding one. Fortunately it is possible for a retraining program to isolate the activi- ties upon which work is needed, and this serves to limit the total nunber of training activities necessary. This allows the work to be compressed ‘into @ much shorter time period than was needed during normal maturation. When formulating a training plan, a trainer should continually be aware of the developmental sequences of learning and the hierarchies involved. The selection of suitable training techniques can then be made with the aim of trying to recapitulate normal growth and development. 7 my res orsi. IIL. 23 Personal Attention - Training on a One-to-One Basis It has been our observation that neurotraining works best on a one-to- one level. The complexities involved in the retraining of brain functions require that a program is specifically developed to meet the needs of the client. Maximum benefit from such a highly individualized program can best be achieved through the personal attention given in a one-to-one setting. The personal attention given creates an environment where the client is free to express his feelings, both negative and positive, to the trainer. This interaction can provide valuable insight to the client and will produce for the trainer direct feedback on the effectiveness of training. As a result, the trainer can respond fnmediately to an individual's needs, both as a client and as a person. In this way the training is seen as a dynamic, ongoing, changing, and developing process rather than a dull, cut-and-dried and monotonous series of practice sessions. Although the requirements of one-to-one training may seem to be an ex- travagant use of manpower, we have found that the uniqueness of this process makes it a necessity. Fortunately, some additional special ad- vantages accrue because clients will tend to respond ‘more positively to such an environment in which they do not have to compete with anyone else for attention or for results. In addition, the personal attention helps to generate enthusiasm and aids in developing and maintaining motivation. Provide Constant and Systenatic Feedback: Neurotraining requires the active involvenent of both client and trainer. It is essential that the client be continuously informed of the progress being made, the purpose of the exercises, and the achievement of sub-goals along the way. An effective way to involve our clients in the process24 WV. is to tell them the scores they make in each of their exercises and to frequently show them their graphs so that they can understand and identify with then. In our experience, some of our clients become quite interested in this process. This active involvement should be welcomed and encouraged in order to stimulate their motivation. It is apparent that progress is usually quite slow and laborious in this kind of training and we continuously need to fight against client dis- couragement and depression. Appropriate regular feedback about the Client's method of performance, and the unique aspects of each activity needs to be communicated, because this is one of the keys to successful learning. Our clients often fail to recognize the small improvements being made, but with proper feedback, can be kept informed regularly in a positive manner. Maximal_Stimulation: Whether the objective is to improve motor functioning, sensory perception, communication, or other high level central nervous system functioning, the aim must be achieved through means of stimulation. The best gain from time spent appears to result from a maximum amount of stimulation that is properly Presented and coordinated. The brain responds to any and all types of stimulation; thus any stimulation in general will be of benefit to the brain as a whole. The stimulation may not need to be as specific as would be necessary for other organs or for muscle groups until we wish to focus upon some highly specific brain functions. In neurotraining, we find that the stimulation (1) should be prolonged and intensive through repe- titive practice and (2) should consist of multimodal stimulation and ‘integration whenever possible. EEE EES eee eee ete ets rm m725 It is not sufficient in this kind of training merely to make the stimulation available to a brain-damaged client and expect to see achievement of goals. The client needs repeated stimulation on a regular basis in order to recon- struct or bolster the impaired function. The behavior, and thereby the function, must be continually produced until it is so readily available that it overcomes compensatory behavior and is used in everyday life. Essentially, unselected stimulations occur naturally as life in general offers constant stimulation. This natural stimulation plays an important role in so-called "spontaneous recovery" of brain functions after an accident. This recovery is often far from complete, however, and in order for it to be effective, the stimulation should be repetitive for as Jong a_period of time as necessary. It should be as specific as needed for a given function, and should be as intense as the client can accept without undue discomfort. This kind of stimulation is possible in neuro- training through a precise mapping of deficits, a careful selection of exercises, and hours of expertly monitored repetitive practice. Special emphasis should also be placed on the importance of multimodal stimulation; namely, providing stimulation for a given function through as many sensory modalities as possible. This method utilizes the maximum possible number of avenues available in order to provide stimulation of the brain. Although we may have a preferred sense for dealing with a given function (such as auditory for communication), other senses often are (or can be) used to supplement the function. It is especially impor- tant for the impaired individual to be exposed to a wide variety of inputs and then learn to integrate these into an organized and meaningful whole.26 ve In addition, it is often the case that one sensory modality may be more impaired than other sensory modalities, and some special emphasis and attention is needed for this deficit. It is at this point that we may well resort to a method called “bridging” in which a connection is es- tablished between an intact sense or ability to the one that is impaired (such as bridging from an intact visual sense to an impaired tactile sense as in Finger Agnosia Training). By properly pairing modalities, combined with careful practice, it is possible to gradually diminish the use of the intact sense while at the same time the impaired sense is able to provide more and more useful and valid information for processing by the brain. Eventually the impaired modality will be able to function independently. In some cases, however, the functional deficit may be modality-specific, but does not lend itself to "bridging". In these cases, the function must be stimulated directly through that modality. Regardless of which one of the above methods are employed, the principle of maximal stimulation still applies. The function must be consistently, continuously, and intensively stimulated at a specific level until it again becomes part of the client's functional repertoire. Entering Training at the Proper Level: We may lose the benefits gained from a well-conceived training plan unless we are able to commence training at the proper level for each client, in accordance with current abilities. If we commence training at a level that is too easy, our client will not benefit from the ex- perience and no progress will be made. Conversely, if we begin at a level that is too difficult, failure will be evident along with dis- couragement and loss of motivation. Again, no learning will result from rn | ms ro mm mt [Vie 27 the experience except that the client may decide that this is an activity to be avoided or that he cannot make progress in this area. This is why We lay great stress upon orienting our efforts so that our client can experience success, but has to put out an effort to do so, and is thus forced to work and “reach” in order to succeed. Recognizing the need to begin training at the proper level, it is necessary to establish a baseline for each client and for each technique used. This is achieved by first making a brief survey of the range of ability in the specific technique through sampling at a very easy level and progressing in a few steps to a point of excessive difficulty. When this is completed, we have a clear picture of our client's range of ability for this parti- cular technique. Me can then select a level at which to enter training that will insure success the major part of the time but will have a high enough level of difficulty to cause some errors. We can commence our training at this point with confidence because we know our client will have to work to achieve the established criterion for success. Increase Difficulty in Smal] Increments: Once training has begun, it is then necessary to insure that each selected task increases in difficulty in small steps, at regular intervals. This requirenent is necessary in order to force each indivdual to "stretch" and to continue to improve. It is for this reason, as detailed later, that each training technique be capable of being calibrated in terms of increasing degrees of difficulty. In addition, each step of increased difficulty will carry with it a criterion of success which will signal when to move to the next higher step. It is preferable that each step be relatively small so that the progression in difficulty from one to the next will not be too great. This particular point may often require28 VIL. close scrutiny because there will be times when the step upward seems to be small and orderly but a client will respond to it as if it were a very large and insurmountable barrier, When this reaction occurs, it may be necessary to backtrack and either make the step smaller or, if that is not practical, to break the activity down into two or three Separate exercises. When proficiency has been gained in these separate parts, it may then be possible to put the original activity back together again and find that the previous barrier is no longer insurmountable. When properly done, learning occurs and orderly improvement and progress will result. Insure Successful Endeavors: It is imperative that clients have success in their training experiences. Because we are training in areas of specific deficit, this requirement may at times pose some rather challenging problems but should always be observed. Although there is the popular saying, "We learn by our mistakes," this is not the kind of learning used in neurotraining; instead, the emphasis should be on accentuating the positive. Failure in certain instances may bring about the development of avoidance reactions. Because we are training in deficit areas, our clients may already be inclined to avoid the activity. Life experiences frequently provide these failures and our clients may often build elaborate ways of avoiding further failure in the area. Thus it is doubly important that we provide successful experiences in these areas as we lead our clients through their exercises and they find to their surprise that they can succeed in these kinds of activities. Unless the efforts result in some measure of success, there will be little or no learning taking place and r L [1 mb Se rt my mt rm my29 the learning that is achieved will certainly not be in the desired direction. IIT, Insist Upon Overlearning: It is quite discouraging to discover that a seemingly well-learned skill can be quickly forgotten after a short pertod of disuse. When this occurs, we can be quite certain that the learning process was terminated prematurely. The best way to guard against this happening is to insist that the skill be overlearned to the point that it becomes automatic. When this point is reached, disuse will not readily erase the skill] as it will have become a permanent part of that individual's repertoire. It is for this reason that we insist upon overlearning in neurotraining. Because we are working with deficits that have to be relearned, we are in effect using substitute or weaker tools to achieve our aims. The learning is tenuous and needs to be well consolidated and established in order to become a permanent skill. Periodic use of exercises simply to refresh our learning will also guard against the weakening or loss which will occur even in overlearned skills if these are not reinforced through regular use. These newly restored skills, in addition to the target skills, can be utilized to insure that these abilities are maintained at peak efficiency.30 APPLICATION Goal-Directed Orientation: Considerable care and attention should be taken in developing a set of Long-Range Goals and Inmediate Goals that are appropriate for each client based on his personal needs and his central nervous system dysfunctions. (See Appendix for examples.) A, Counseling: An initial step in the training process is an interview with the client and a family member, counselor, or a representative from an involved agency. This is to ensure that the persons concerned are aware of the specific dysfunctions and that they have a good picture of the recovery process. It is important that family, friends or other agencies are aware of exactly what this kind of training will do for the client so that they will maintain realistic expectations of the client's progress and goals. Because neurotraining is in- volved in the recovery of the client's specific neurological deficits, the support of these "special others” plays an important role in the restoration of behavior, B. Long-Range Goal: The training program spells out as specifically as possible the level at which the client is expected to be able to function when training is completed. This Long-Range Goal should be selected with the active participation of the client in order to promote better coopera- tion and motivation. The goals are stated in global terms describing the client's adaptive behavior to reach the goals specified. The long-range goals must necessarily be individually based and can range from an academic or a professional level to a skilled level or even Lk my l room mom J ae eae31 to a higher level of self-reliance. Consequently, not only the spe- cific dysfunctions but also the complex interaction of the client's neurological, medical, and social needs must be involved in setting realistic long-range goals. C. Immediate Goals: The Immediate Goals are specified in behavioral or operational terms and state a realistic level of competency of the necessary function. They are formulated on the basis of the Neuropsychological Assessment and are also directly related to the long-range goal. Stated by these goals are the specific levels at which the client is expected to be functioning when recovery of deficit areas are completed and the total list of behavioral dysfunctions that must be ameliorated in order to reach the long-range goals. It is important that the specific deficits are distinguished as primary or secondary areas of training, Based on the initial assessment, observations, and baselines of training activities, the most prominent problem areas are elicited. The initial attention in ‘the neurotraining process will most appropriately concentrate in these areas. In many cases, the alleviation of the primary deficits will be sufficient to complete the training process to a satisfactory level. Il. Identifying Areas of Dysfunction: In planning for training, it is important to make a comprehensive assess~ ment of each client's abilities, The more precisely the areas of deficit are identified, the more accurate and effective the training plan will be, The brain is such a complex organism that numerous samples of sensory adeptness, motor agility, cognitive adaptability and academic aptitude32 Mi. are gathered in a variety of situations to provide the detailed information that is necessary to design a training plan. It is for this reason that clients who are being considered for neurotraining usually receive far more tests than are necessary for a diagnosis alone. The assessment reveals areas of strength as well as areas of dysfunction and this differentiation is important in appreciating the deficit and in planning neurotraining programs. It is necessary that each deficit whether sensory, motor, cognitive, memory, or attention, be described as accurately as possible as it is demonstrated by the individual client. The next step is to arrange these areas into a functional hierarchy. Appropriate training techniques may be selected to ameliorate those func- tional deficits that are independent of any other deficient skills. It is important that the techniques selected do not require more than one unresolved deficit skill to accomplish the task. Since the client will be having difficulty, techniques in which more than one deficit skill is necessary may compound the difficulty to an extent that it becomes over- whelming, A careful selection of techniques, presented in the proper sequence, will integrate restored functions into more complex tasks. This firmly estab- Vishes these skills into the client's repertoire of behavior. Developing Neurotraining Activities: Neurotraining Techniques are created as they are needed for individual clients. The inventory has grown to such a number that a whole program of new techniques need not be invented for each new client. (Many tech- niques have been appropriate for a number of neurotraining plans.) How- ever, when a client has a particular dysfunction that cannot be ameliorated by the present realm of activities, it is necessary to invent one or adapt am mcm ¥ : rE ro moot Mm ry 433 one from another source. The development or adaptation of new neuro- training techniques is an important phase in training. A. Creating the Technique: Basically, it is important that the techniques used in training are effective. The design of the activity must allow the client to perform the behavior that 4s desired. It should not be assumed that the client will by chance learn the function by practicing or parti- cipating in these "games", It is necessary that the technique be precise in its ability to exhibit the correct behavior. Initially, the technique may require that the client show the correct function by externalizing the actual behavior, such as verbalizing in problem- solving activities. As the initial levels of difficulty are mastered, the activity is varied so that the function can be adapted in increas- ingly more difficult and complex situations. In order to efficiently devise the technique for a client, the behavioral objective is spelled out for each set of activities. The activity is then varied to allow for different levels of difficulty or diverse situations of application. Finally, a level of competency is assumed for the client that is based on the inmediate goals. Con- sequently, activities may need to be changed slightly to fit the neurotraining needs of individual clients. B. Quantification: ‘Another aspect of developing training techniques is to provide objec- tive, measurable results for the purpose of monitoring progress and supplying direct and objective feedback to the client. An objective scoring system, using, for example, a ratio of errors, totaling of correct responses, or time, is required of each activity so that the34 I progress is not based on a subjective observation by varying trainers. In this way, the client has a concrete level of competency toward which to aim. This quantifying method involves calibrating the be~ havioral results at all levels of difficulty and assigning a range of meaningful numerical values that can depict the client's performance at different levels of competency. MODIFICATION AND_FOLLOI IROUGH Observation: Accurate observations are a necessary part of the neurotraining process. It is important that the client is performing the appropriate function rather than achieving accuracy through some compensatory means. The trainer should keep the desired function clearly in mind and observe each client closely in order to make sure the exercises are provoking the correct type of response. This focus should also be openly conmu- nicated to the client as well. Thus, it is essential that the client understand what specific behavior is expected for each task as well as the level of accuracy for which he must aim. Observations are also the means by which undisclosed areas of deficits, and consequently the essential training areas, are discovered. Training will be most efficient if these areas are known as early as possible in the training program. Realistically, however, these areas are not always elicited from testing. Constant observations throughout training provide a means of discovering these elusive areas that need attention. The observation process can also be aided by some well-chosen questions. A few questions to consider are: (1) Is the client consistent in his method? (2) Does he do better using one method rather than another? oF o +o Haare Hee Eee eee eet ma teat mc ams peecere rece et ee35 (3) How reliable is the method? (4) Is the client using a compensating strategy or the proper mediator to accomplish the task? (5) Is there a prerequisite skill that the client repeatedly has trouble performing? (6) Is there a conmon problem that underlies several activities? I, Monitoring Progress: In order to obtain the maximum benefit from training, it is necessary to keep complete records of daily results for each technique used. It is particularly important to note the progress or lack of progress for each activity and this can best be done graphically. Because each technique is quantified, it is possible to have an accurate record of all phases of an activity by recording these numbers and plotting a curve as a graphic picture of the progress, If the training is proceeding as desired, the graph should show a picture of steady progress to a criteria | evel with only a normal amount of fluctuation. When a graph indicates ‘| reverse progress, lack of progress, or perhaps a great variability of performance, this should be perceived as a warning to indicate that addi- tional attention is required to assist in the client's ability to master the specific skill. A close examination of the activity, observations from the trainer, and re-analysis of the skill requirements are considered | in an attempt to understand and “pin-point” the problem area and to pos- tulate solutions. By amending the technique, the proper learning pattern is then accomplished and will be reflected graphically. Il. Contraindications for Training: During the process of neurotraining it has become obvious that several things interfere with success in training. It is important to attend to these obstacles although termination or refusal of training is not necessarily advised. |36 8. Drugs: Prescribed medication, unrestricted drugs and illegal substances can adversely affect progress in neurotraining. Manifestations of their influence are diverse in severity and in specificity but abstinence or substitution of the influential substances results in a return of function or continuation of progress. It has been observed for example, that a client may suddenly plateau, regress or display ex- treme erratic performances in language function, motor coordination, memory ability and sensory sensitivity, depending on the nature and frequency of the substance they consume, It is for this reason that prospective clients with a drug intoxication problems, including alcohol, are obligated to abstain from their consumption before training is initiated, Emotional : Clients may have psychological problems stemming from their adjustment to past organic dysfunction or they may be clients with a history of severe emotional problems. In the former case the comprehension of the nature of their disability and the concrete evidence of progress in training can minimize the pathological characteristic of depression and other maladjusted behaviors. However, it is often needed and recom- mended that clfents receive other profressional counseing to facilitate their adjustment. With clients whose emotional problems have a degree of permanence, a regular combination of neurotraining and counseling is necessary for success. Progress can be observed in neurotraining areas but failure to achieve goals may occur due to severe emotional disturbance. This failure of neuro-behaviors to generalize into the a oo mo my oe st mane aMSart j 4 Pe 7 37 client's life-style can result in an eventual regression of newly gained ability. Severity: Global, generalized impairment of a severe nature is always a complex problem, Even with the best of programs, it is best to assume that progress will be slow and training may take literally years but good success and satisfaction can result from the effort. The difficulty usually lies in the planning of the training program. Unfortunately there is no answer that is appropriate for all clients. Here are some things to consider: 1. Is there a function that interferes with a number of functioning areas? 2. Is there an ability that can promote positive change in the client's life-style? 3. M71 some signs of immediate success in a minor area encourage the client to work on other frustrating kinds of activities? 4. Does the client have a strong desire to improve in a specific area? Developing Organic Pathology: Diagnosis of this kind. of process usually is very contraindicative for acceptance or continuation of training. However, in several kinds of situations training has been an asset. In one case, re- gression in training was the first sign of the developing problen and continued training provided a quantitative picture of the severity and velocity of the organic involvement. Secondly, continued training may encourage the client to maintain optimum ability until the patho- logical problems are solved or become overwhelming. Finally, factors38 gE such as normal aging will limit the final outcome of training but should not by itself be a contraindication against participation in a neurotraining program. Intellectual Indication: The client's basic potential to acquire new information affects the speed of progress as well as the goals for training. If a client has a limited intellectual capacity previous to the organic involvement, he will maintain this limitation. His learning speed will be in agree- ment with his basic mental aptitude; however, amelioration of specific organic dysfunction has been profitable for these clients even within their intellectual boundaries. Litigation: The dilerma with clients who are involved in litigation or monetary compensation for their disability is in itself a contraindication to progress in training. The more optimistic the prognosis the smaller the settlement. Ideally it would be best that the client postpone training until the determination and litigation are completed. Un- fortunately, settlements sometimes take years to finalize and neuro- training is most successful during this same period after the injury. In these situations, training is maintained with the assumption that the client is caught in these contradictory views of himself. Other Interfering Organic Dysfunctions: Some clients experience exceptional difficulty in neurotraining due to the specific kind of organic deficit they have incurred. This is especially true with clients who have damage to the frontal Tobe or subcortical areas. The degree and specific kind of difficulty the client has is as varied as the number of clients in this group. For ct rc eee39 example, the client may have difficulty fn all areas of training because of a basic inability to notice errors, inhibit repetition of mistakes, prevent an impulsive dectsion or action, change from one approach to another view, plan and accurately facilitate a behavior or attend to a stimulus for a specific duration. These kinds of inter- ference can be dealt with directly or incorporated in other activity but until they are minimized, it is forseen that progress in reacquiring specific functions wil] be erratic, interrupted or non-existent. CONCLUSION This text has attempted to enumerate in brief detail the most important methods and procedures considered necessary to put a plan of training for brain-damaged individuals into operation. Actual case histories can be reviewed in the Appendix. A nunber of training techniques will be necessary in order to achieve the desired objectives and the bulk of this manual is devoted to descriptions of these techniques. This kind of training requires resourcefulness and imagination. If these ingredients are mixed in with the proper methods and procedures, and a good choice and selection of training techniques, a larger and larger number of brain- damaged individuals are certain to benefit in a very positive and surprising manner.