Recent findings regarding recovery from brain injury

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Recent findings regarding recovery from brain
injury

• Plasticity - Brian Kolb
• Use of virtual reality
• Use of smart technology

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Brain plasticity

• Changes that occur in the organization of the
  brain as a result of experience
• The brain is constantly changing in response to
  experience.
• Those events that alter the normal brain can be
  recruited to change the injured brain and,
  hopefully, stimulate functional improvement.

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• Changes in neuronal organization can be shown at
  various levels of analysis from behaviour to
  molecules.

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• Synapse number can be estimated by knowing the
  length of the dendritic fields and the spine
  density.
• One key feature is that both measures can go up
  or down with experience - thus reflecting an
  increase or decrease in synapse number.
• These changes have implications for behavioural
  change..

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The cortex is altered by many events including

• 1. sensory motor experience
• 2. task learning
• 3. gonadal hormones
• 4. psychoactive drugs
• 5. natural rewards
• 6. neurotrophic factors
• 7. ageing
• 8. stress
• 9. anti-inflammatories
• 10. diet
• 11. electrical stimulation

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Experiential Treatments
Complex Housing Brains are larger, have more
connections, the animals have enhanced
cognitive motor behaviour BUT, age is
critical
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Complex housing and age

• Complex housing in adults Increased dendritic
  length
• (including old adults) Increased spine
  density
• Heavier brain
• Complex housing at weaning Increased dendritic
  length
• Decreased spine density
• Heavier brain
• Complex housing prenatally Decreased dendritic
  length
• Increased spine density
• Heavier brain
• All treatments provide behavioural benefits
• They also interact with later plasticity

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There are sex differences in connections
Females have more than males in the GRAY areas
and Males have more in the BLUE areas.
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Implications

• Expect sex differences in behavior
• Expect sex differences in response to
• other experiences
• Expect sex differences in response to
• brain injury
• Expect sex differences in response to treatments.

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Different regions of the brain react differently
to medication

• Psychomotor stimulants all have opposite effects
  in the orbital cortex compared to the frontal
  cortex
• i.e., there is a decrease in dendritic length
  and/or spine density in response to psychomotor
  stimulants compared to an increase in the frontal
  cortex.
• Thus, the same drug can alter differently the
  function of different regions, much like hormones
  do.

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Experience

• Multisensory/motor/social experience induces
  widespread synaptic changes in the normal brain.
• Thus, such experience should enhance
  synaptogenesis that will reverse stroke-induced
  atrophy AND
• induce synaptic growth in residual motor areas.

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RESULT

• Complex housing is powerful in
• stimulating functional improvement
• But not if only for short periods each day

How do we apply this to brain- injured people?
Best guess is intense, multidisciplinary treatment
s.
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Summary of Repair Treatments

• Treatments that improve functions
• Nicotine amphetamine (conditionally)
• Olfactory or tactile stimulation
• Complex housing
• Exercise
• Electrical brain stimulation
• NTFs

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Summary of Repair Treatments
2. Treatments that do not improve
functions Diet (but) COX-2 inhibitors Repetit
ive practice
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Summary of Repair Treatments
3. Treatments that make functions
worse Fluoxetine (ie., Prozac) social change
(stress??)
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Is plasticity necessarily good?

• 1. Shifting functions may interfere with
• other functions.
• One plastic change may prevent a later one.
• But, remember, the brain is going to change
• regardless of what we do

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Conclusions
1. Plastic changes in synaptic organization can
support functional improvement after cerebral
injury.
2. Both pre- and post-injury experience can
affect outcome from cerebral injury.
3. A wide range of factors can influence outcome
from injury.
4. There are limits to recovery Animals with
high spontaneous recovery show little benefit
from experience or chemicals.
5. There are synergistic interactions between
behavioural and pharmacological treatments.
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Virtual Reality

• Uses in neuropsychological assessment and
  rehabilitation

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Dependent on information technology rapid
advances

• Computer technology is moving from automating
  the paradigms of the past to creating new ones
  for the future
• Kruegar 1993

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Advantages of VR

• Ecological validity can standardise real life
  tasks rather than relying on artificial tasks
• Can simulate virtually any real world environment
  from a city to a kitchen
• Can simulate the tasks people experience in their
  daily lives (eg food preparation shopping
  banking office skills use of public transport
  driving

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McGeorge et al. 2001

• VR Multiple Errands task in a simulated office
  (collecting office equipment, preparing
  refreshments)
• TBI did not differ from healthy controls on BADS
  but were impaired on VR ME
• There was a significant correlation between
  performance on real and virtual tasks
• Advantage over real world testing (ease of
  administration, systematic stimulus control, more
  accurate response measurement)

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Providing distractions and stressors

• Conventional tests devoid of these yet those with
  executive disorders often said to have an
  inability to inhibit external distractions
• In VR they can be manipulated to produce
  conditions which are controlled yet more like
  real life
• In rehab distractions can be initially removed
  and then gradually re-ntroduced

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V-STORE

• Virtual fruit shop
• Representation of user in front of conveyor belt
  with baskets (1-3) crossing the room
• Can introduce distractions light going on/off,
  progressive dimming, phone ringing, belt speed
  changing to increase difficulty and time
  pressure
• Able to look at how participants compensated

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Flexibility, self-initiation and organising

• IN VR limitations of monitoring and recording
  behaviour are removed
• Eg Morris et al. (2002) virtual bungalow used
  to assess prospective memory, strategy formation
  and rule breaking in 35 patients following
  pre-frontal surgery with 35 IQ-matched controls
• Task to help owner of 4 room bungalow move to a
  larger 8 room house collect items in specified
  order, remember to put fragile notices on
  specified items

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Morris et al. (2002)

• Both able to do the task but patients used less
  efficient strategies, exhibited more rule breaks
  and more prospective memory deficits

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Introducing a social dimension

• Avatars
• Even basic avatars with limit repertoire of
  behaviour found to be a promising way on
  including a social dimension to assessment
  (Pertaub et al. 2002, Blascovich et al. 2002)

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Ecological Validity

• VR ensures test materials of consistent quality,
  reduces errors and inconsistencies of
  administration by the clinician and avoids
  unwanted/uncontrolled changes in the environment

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Zalla et al. 2001

• VR apartment consisting of a bedroom, bathroom,
  kitchen and living room.
• Task to verbally formulate a plan to get ready
  for work in the morning and then use this in the
  virtual apartment
• 7 patients with prefrontal damage and 16 controls
• Patients showed more action slips, omissions and
  failure to initiate
• Controls took longer to execute plan than to make
  it, patients spent similar amount of time on
  planning and executing

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Compliance and Motivation

• VR allows tasks to resemble video games and this
  may be more motivating , particularly for young
  tbi patients.
• Elkind et al. 2001 developed a version of the
  WCST which involved a virtual beach and
  delivering frisbees, sodas, popsicles and beach
  balls to bather under umbrellas depicting these
  items
• Compared to computer version of WCST found VR to
  be more difficult, interesting and enjoyable

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Conclusions

• Work is only at preliminary stages of development
• The theoretical advantages of VR in
  neuropsychological assessment have been shown to
  be advantageous in practice but only in small
  scale pilot studies
• No VR instruments have yet been developed
• Costs/skills involved in their development hinder
  their development
• The potential is there but needs to be realised

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Smart technology

• Technology that includes a level of intelligence
• Able to provide autonomatic assistance rather
  than simply detecting problems and calling for
  help
• 1.Behaviour monitoring sensors, 2. assistive
  support technology, and 3. a communication link
  between the two

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Sensors

• Readily available
• Can detect
• Movement, smoke, CO, toilet use, fridge use, bar
  codes, epileptic seizures

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Support devices

• automatic cooker shut-off valves
• bath tap shut-off devices that dont take control
  away from the user
• means for providing prompts and reminders eg
  detect movement near an external door and,
  knowing it is an inappropriate time to go out, to
  prompt them with a message to that effect.

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An example

• A client was often restless and would often
  wander out of his room at night.
• A wander reminder detected movement near a door
  during the night, and replayed a message to
  discourage the client from going out.
• He would still go looking for staff in the night.
  
• Discussions with him indicated that his sleeping
  was severely affected by night-time anxieties.
• He reported that he would often wake up with some
  deep concern that he wished to talk about, and
  couldnt get back to sleep. He said that he knew
  his memory was poor, and that if he had waited
  until the morning he would have forgotten all
  about the issue that was bothering him.
• Consequently he would go and try to find a staff
  member to relay his anxious thoughts.

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• Given this understanding, a piece of technology,
  a voice recorder was developed that would enable
  him to record his concerns during the night
  rather than go and search for a staff member. He
  could then replay it to the staff in the morning.
  
• He seemed quite happy with this proposal as it
  meant that the issue would still be dealt with in
  the morning even thought he knew he would have
  forgotten about it.
• A design was constructed that just used one large
  record button on the top. He found this very
  easy to operate, as he just had to reach over to
  his bedside cabinet, press the button, and say
  what was bothering him. Several messages could be
  recorded.
• Unfortunately the messages that he recorded were
  not very coherent, and it was difficult for care
  staff to understand what was bothering him.
• Although he couldnt remember what the issue was
  by the morning he did realise staff were not
  clear and this reduced his satisfaction.
• Illustrates both the potential of simple
  technological interventions once a clear
  understanding of the problem is known, and also
  of the need for close and careful involvement of
  the user in any design solutions.