Neurocognitive Rehabilitation Using Non-Emotionally Charged Material to Re-Learn How to Learn: A Case Report

doi:10.4236/psych.2014.52023

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Psychology

2014. Vol.5, No.2, 148-150

Published Online February 2014 in SciRes (http://www.scirp.org/journal/psych) http://dx.doi.org/10.4236/psych.2014.52023

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Neurocognitive Rehabilitation Using Non-Emotionally Charged

Material to Re-Learn How to Learn: A Case Report

Murray R. Berkowitz

Department of Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine, Director of Family

Medicine/OMM Clerkships, Director of Preventive and Community-Based Medicine, Philadelphia College of

Osteopathic Medicine—Georgia Campus, 625 Old Peachtree Road NW, Suwanee, Georgia 30024, USA

Email: [email protected]

Received December 18th, 2013; revised January 16th, 2014; accepted February 15th, 2014

Attribution License, which pe rmits unrestricted use, distribu tion, and reproduction in any medium, provided the

original work is properly cited. In accordance of the Creative Commons Attribution License all Copyrights ©

2014 are guarded by law and by SCIRP as a guardian.

Cognitive disorders following hypoxic ischemic brain injury involve a variety of disorders including con-

sciousness, behavior, mood and affect, impairment of attention, and memory dysfunction. The case of a

45-year-old former military aviator and engineer, now a physician in residency training, presenting with

cognitive difficulties, is described. The patient described having difficulty remembering medical knowl-

edge and feeling fatigued. After almost nine months without any medical intervention and the patient’s

deteriorating condition, the patient was finally evaluated medically. It was ultimately discovered that the

patient suffered from a variety of neurologic impairments that were the direct result of exposures to vari-

ous toxic substances during his military service. Significant diagnoses included hypoxic ischemic brain

damage, severe mixed sleep apnea, and cognitive disorder NOS. Relevant literature about the application

of neurocognitive rehabilitation and retraining to treating patients suffering from brain injuries is dis-

cussed. The overlap of the neuroscience of emotion with cognitive learning and how emotion and affect

impacts learning and education is presented. This case also serves to demonstrate the application of learn-

ing and co gnition to individu al differences and disabilities. Further research is needed to evaluate whether this

result is rep roduci ble a nd ge neral iza ble to oth er p atie nts with similar pre sent ing signs an d sym ptoms.

Keywords: Neurocognitive Rehabilitation; Hypoxic Ischemic Brain Damage; Learning; Effects of

Emotion on Learning; Re-Learning How to Learn

Introduction

Bhatoe stated that cognitive disorders following hypoxic

ischemic brain injury involve a variety of disorders including

consciousness, behavior, mood and affect, impairment of atten-

tion, and memory dysfunction (Bhatoe, 2011). There are many

etiologies of anoxic and hypoxic brain injuries, consequently no

epidemiologic data are known. There are similarities between

the sequelae and symptoms demonstrated by patients who sus-

tained traumatic brain injury (TBI) and anoxic/hypoxic brain

injury. Relevant literature about the application of neurocogni-

tive rehabilitation and retraining to treating patients suffering

from brain injuries is discussed below.

The 1980s saw the development of cognitive rehabilitation.

Diamant and Hakkaart integrated various analytical information

processing models of cognitive rehabilitation concluding that

these models are based on the principles of “functional speci-

ficity”, “functional hierarchy”, and “training circuits (tracks)”

(Diamant, 1989). Cullen and associates reported that patients

with anoxic brain injury are slower to recover than patients with

traumatic brain injury (TBI) (Cullen, 2009). Rajan and asso-

ciates reported structured, systematic cognitive retraining to be

effective in ameliorating cognitive dysfunction in patients suf-

fering from hypoxic brain damage (Rajan, 2010).

Independent studies have demonstrated the effectiveness of

functional magnetic resonance imaging (fMRI) in measuring

neural changes in cognitive rehabilitation and reported positive

association and increased neural connectivity following cogni-

tive rehabilitation (DeGutis, 2007; Minnebusch, 2009; Dalry m-

ple, 2011). Samuel reported that cognitive rehabilitation tech-

niques are more successful with patients suffering from “re-

versible” brain injuries while it is only marginally successful in

patients suffering from “progressive” brain injuries (Samuel,

2008). Fernandez-Ballesteros and associates have studied cog-

nitive plasticity and learning potential in the elderly and have

found that there is a positive association of the effects of learn-

ing training in normal elderly, and in elderly patients with both

mild cognitive impairment (MCI) and Alzheimer’s disease (Fer-

nandez-Ballesteros, 2003; Fernandez-Ballesteros, 2012). Sales-

Galan and associates found measuring cognitive plasticity to be

useful in helping identify patients with MCI (Sales-Galan,

2013). Berlucchi discussed that all areas of the brain retain

plasticity and even neurogenesis throughout life, even in old

age (Berlucchi, 2011).

Dams-O’Connor and Gordon recognized the role of emotion

and its impact on cognitive rehabilitation of patients with TBI.

“Due to the various cognitive, physical, and emotional changes

M. R. BERKOWITZ

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149

after a TBI, individuals with TBI are constantly confronted with

things they cannot do as well as or the same way they did be-

fore the accident. Each time this happens, they are confronted

with the discrepancy between previous and current abilities,

which can cause overwhelming feelings of loss and trigger

frustration, depression, and anxiety.” They cite studies showing

that “emotional regulation appears to be an important mitigat-

ing factor in the impact of cognitive rehabilitation, and cogni-

tive interventions that include training in emotional control tend

to have a strong impact on functional outcomes” (Dams-O’Con-

nor, 2010).

The case below illustrates how emotional considerations both

negatively and positively impact the neurocognitive rehabilita-

tion of a previously extremely highly intelligent and function-

ing, professionally and socially successful patient. The case will

be discussed with emphasis on the application of using posi-

tively charged emotional constructs to enhance the patient’s

ability to re-learn how to learn.

Case

A 45-year-old former military aviator and engineer, now a

physician in residency training, presented with cognitive diffi-

culties. The patient described having difficulty remembering

medical knowledge and feeling fatigued. The patient reported

to his supervising attending physician these concerns and was

summoned before the clinic director who admonished the pa-

tient to perform better. After almost nine months without any

medical intervention and the patient’s deteriorating condition,

the patient was finally evaluated medically. It was ultimately

discovered that the patient suffered from a variety of neurologic

impairments that were the direct result of exposures to various

toxic substances during his military service. Significant diag-

noses include hypoxic ischemic brain damage, severe mixed

sleep apnea, and cognitive disorder NOS. Based on neuropsy-

chological testing, the patient’s IQ declined from 186 to 133.

The patient’s blood oxygenation saturation declined to between

70% and 76% while “asleep”; note that patients with blood

oxygenation saturation levels of between 88% - 90% are typi-

cally placed in the intensive care unit (ICU) and intubated. The

patient was placed in a stressful situation to perform duties as a

resident physician while struggling to remember medical in-

formation. No attempt at neurocognitive rehabilitation was ever

performed by the military health care system and the patient

received a medical discharge from military service due to his

service-connected disabilities.

The patient attempted to “re-learn” his medical knowledge,

but the emotional distress of having had a previously excellent

military career (including early, “below-the-zone” promotions

and the awarding of numerous military awards and decorations)

ending by not being able to recall medical information, was

determined as interfering with the patient being able to re -learn

medical knowledge. The patient was started on a protocol of

attempting to “re-learning how to learn” by studying material

involving advancing his aviation knowledge. The emotional

component of learning aviation had previously been a very

positive experience. The patient was able to re-learn both avia-

tion “book knowledge” and “hands-on” performance know-

ledge and was also able to learn “new” aviation-related know-

ledge and skills, albeit as a civilian. Following this, the patient

was able to apply the techniques he had employed in both

“re-learning” older aviation knowledge and skills and learning

“new” aviation knowledge and skills to re-learning medical

knowledge and information. The patient ultimately earned a

Master of Public Health degree and achieved Board Certifica-

tion in three medical specialties.

Discussion

Hypoxic ischemic brain injuries often have the unfortunate

sequelae of dysfunctions of consciousness, behavior, mood and

affect, impairment of attention, and memory. This patient

clearly presented with these problems, fully consistent with

Bhatoe above. Further, Bhatoe stated that “Recovery … is to be

anticipated over one or two years” (Bhatoe, 2011). This patient

is also consistent with the cases presented by Samuel in consi-

dering restorative vs. compensatory rehabilitation. Samuel’s

findings are limited in that they are based upon only two cases

—one demonstrating each of the reversible and progressive

conditions—and, while illustrated by this case, may not be ge-

neralizable (Samuel, 2008).

This patient, in working with previously positively emotional

component to re-learn how to learn (i.e., aviation), is fully con-

sistent with Wilson and associates, who reported the positive

results of a case of a patient suffering from severe head injury

and vascular involvement as a result of a motor vehicle accident

using a goal planning approach to cognitive rehabilitation. The

Wilson case demonstrated the success of applying a holistic,

goal planning approach in patients with non-progressive brain

injuries (Wilson, 2002). Levine and associates reported a large-

scale randomized trial using goal-planning and hierarchies to

increase executive deficits. They reported the gains based upon

simulated real-life tasks (SRLTs) “were maintained at long-

term follow-up” (Levine, 2007). Crai k, Winocur, and associa tes

reported improvements in memory encoding and retrieval based

on a blocked randomized controlled trial of cognitive training

(Craik, 2007; Winocur, 2007). Clearly, this patient regaining

his medical knowledge and subsequently earning a Master of

Public Health and achieving board certification in three medical

specialties is consistent with the long-term gains reported by

Craik, Levine, and Winocur above.

McDonald and associates reported the results of a small, pilot

cross-over study on the use of external memory aids to improve

performance in subjects suffering from impaired memory as a

result of acquired brain injuries (McDonald, 2011). This patient

only needs minimal use of external memory aids.

This patient is also clearly demonstrates the positive impact

of the Dams-O’Connor and Gordon role of emotion and its

impact on cognitive rehabilitation of patients with brain injury,

albeit with hypoxic ischemic brain injury. The patient in this

case clearly confronted with initially not being able to do things

he previously was able to do (i.e., recall medical knowledge)

and was frustrated every time he tried to re-learn his lost medi-

cal knowledge. The negative emotional impact of having lost

his career as a military physician triggered the feelings of loss,

frustration, and anxiety described by Da ms-O’Connor and Gor-

don. These negative emotions exacerbated the patient’s diffi-

culties in achieving a return to function. Immordino-Yang and

Damasio describe the overlap of the neuroscience of emotion

with cognitive learning and discuss how emotion and affect

impacts learning and education. They report research showing

that learning, attention, memory, and decision-making “are both

profoundly affected by and subsumed within the processes of

emotion” (Immordino-Yang, 2007). This patient is again fully

M. R. BERKOWITZ

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150

consistent with these findings. This patient is also fully consis-

tent with the findings of brain plasticity in later life reported by

Berlucchi (Berlucchi, 2011).

Summary and Conclusion

This case shows how positive emotional component of cog-

nition provides a template for re-learning how to learn in pa-

tients suffering from hypoxic ischemic brain injury. Had this

been done earlier in the course of treatment and cognitive reha-

bilitation, preferably as soon as practical after the patient had

presented with cognitive symptoms, this patient’s condition

might not have deteriorated to the extent it did and the patient

may have returned to function earlier. This case also serves to

demonstrate the application of learning and cognition to indi-

vidual differences and disabilities. Further research is needed to

evaluate whether this result is reproducible and generalizable to

other patients with similar presenting signs and symptoms.

REFERENCES

Berlucchi, G. (2011). B rain plasticity and cognitiv e neuroreh abilitation.

Neuropsychological Rehabi litation, 21, 553-559.

http://dx.doi.org/10.1080/09602011.2011.573255

Bhatoe, H. S. (2011). The hypoxic-ischemic brain injury: Beyond se-

mantics. Indian Journal of Neurotrauma, 8, 65-66.

http://dx.doi.org/10.1016/S0973-0508(11)80001-8

Craik, F. I. M., Winocur, G., Palmer, H., Binns, M.A., Edwards, M.,

Bridges, K., Glazer, P., Chavannes, R., & Stuss, D. T. (2007). Cogni-

tive rehabilitation in the elderly: Effects on memory. Journal of the

International Neuropsychological Society, 13, 132-142.

http://dx.doi.org/10.1017/S1355617707070166

Cullen, N. K., Crescini, C., & Bayley, M. T. (2009). Rehabilitation

outcomes after anoxic brain injury: A case-controlled comparison

with traumatic brain injury. PM & R Journal, 1, 1069-1076.

http://dx.doi.org/10.1016/j.pmrj.2009.09.013

Dalrymple, K. A., Oruc, I., Duchaine, B., Pancaroglu, R., Fox, C. J.,

Iaria, G., Handy, T. C., & Barton, J. J. S. (2011). The anato mic basis

of the right face-selective N170 in acquired prosopagnosia: A com-

bined ERP/fMRI study. Neuropsychologia, 49, 2553-2563.

http://dx.doi.org/10.1016/j.neuropsychologia.2011.05.003

Dams -O’Connor, K., & Gordon, W. A. (2010). Role an d i mpact of cog-

nitive rehabilitation. Psychiatric Clinics of North America, 33, 893-

904. http://dx.doi.org/10.1016/j.psc.2010.08.002

DeGutis, J. M., Bentin, S., Robertson, L. C., & D’Esposito, M. (2007).

Functional plasticity in ventral temporal cortex following cognitive

rehabilitationof a congenital prosopagnosic. Journal of Cognitive

Neuroscience, 19, 1790-1802.

http://dx.doi.org/10.1162/jocn.2007.19.11.1790

Diamant, J. J., & Hakkaart, P. J. W. (1989). Cognitive reghabilitation in

an inform at ion-proce ssing pe rs pective. Cognitive Rehabilit ation, 22-29.

Fernandez-Ballesteros, R., Botell, J., Zamarron, M. D., Molina, M. A.,

Cabras, E., Schettini, R., & Tarraga, L. (2012). Cognitive plasticity

in normal and patho logical aging. Clinical Interventio ns in Aging, 7,

15-25. http://dx.doi.org/10.2147/CIA.S27008

Fernandez-Ballesteros, R., Zamarron, M. D., Tarraga, L., Moya, R., &

Iniguez, J. (2003). Co gnitive plasticity in healthy, mild co gnitive im-

pairment (MCI) subjects and Alzheimer’s disease patients: A re-

search project in Spain. European Psychologist, 8, 148-159.

http://dx.doi.org/10.1027//1016-9040.8.3.148

Immordino-Yang, M. H., & Damasio, A. (2007). We feel, therefore we

learn: the relevance of affectiv e an d social n euros cience to education.

Mind, Body, and Education, 1, 3-10.

http://dx.doi.org/10.1111/j.1751-228X.2007.00004.x

Levine, B., Stuss , D. T., Winocur, G., Binns, M. A., Fahy, L., M andic,

M., Bridges, K., & Robertson, I. H. (2007). Cognitive rehabilitation

in the elderly: Effects on strategic behavior in relation to goal man-

agement. Journal of the International Neuropsychological Society,

13, 143-152. http://dx.doi.org/10.1017/S1355617707070178

McDonald, A., Hasla m, C., Yates, P., G urr, B., Leeder, G., & Sayers, A.

(2011). Google calendar: A new memory aid to compensate for

prospective memory deficits following acquired brain injury. Neu-

ropsychological Rehabilitation, 21, 784-804.

http://dx.doi.org/10.1080/09602011.2011.598405

Minnebusch, D. A., Suchan, B., Koster, O., & Daum, I. (2009). A bila-

teral occipitotemporal network mediates face perceptio n. Behaviour-

al Brain Research, 198, 179-185.

http://dx.doi.org/10.1016/j.bbr.2008.10.041

Rajan, J., Udupa, S., & Bharat, S. (2010). Hypoxia: Can neuropsycho-

logical rehabilitation attenuate neuropsychological dysfunction. In-

dian Journal of P s ychological Medi cine, 32, 65-68.

http://dx.doi.org/10.4103/0253-7176.70544

Sales-Galan, A., Melendez-Moral, J. C., & Mayordomo-Rodriguez, T.

(2013). Us ing a cognitive plas ticity measure to detect mild co gnitive

impairment. Archives of Clinical Neuropsychology, 1-8.

Samuel, R. (2008). Cog nitive rehabilitation f or reversible and progress-

sive brain injury. Indian Journal of Psychiatry, 50, 282-284.

http://dx.doi.org/10.4103/0019-5545.44752

Wilson, B. A., Evans, J. J., & Keohane, C. (2002). Cognitive rehabilita-

tion: A goal-planning approach. Journal of Head Trauma Rehab ilita-

tion, 17, 542-555.

http://dx.doi.org/10.1097/00001199-200212000-00006

Winocur, G., Craik, F. I. M., Levine, B., Robertson, I. H., Binns, M. A.,

Alexander, M., Black, S., Dawson, D., Palmer, H., McHugh, T., &

Stuss, D. T. (2007). Cognitive rehabilitation in th e elderly: Overview

and future directions. Journal of the International Neuropsychologi-

cal Society, 13, 166-171.

http://dx.doi.org/10.1017/S1355617707070191