Recent findings regarding recovery from brain injury

1. Recent findings regarding recovery from brain injury • Plasticity - Brian Kolb • Use of virtual reality • Use of smart technology

2. 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.

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

4. 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..

5. 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

6. Experiential Treatments Complex Housing Brains are larger, have more connections, & the animals have enhanced cognitive & motor behaviour BUT, age is critical…

7. 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

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

9. 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.

10. 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.

11. 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.

12. 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 treatments.

13. Summary of ‘Repair’ Treatments • Treatments that improve functions: Nicotine; amphetamine (conditionally) Olfactory or tactile stimulation Complex housing Exercise Electrical brain stimulation NTFs

14. Summary of ‘Repair’ Treatments 2. Treatments that do not improve functions: Diet (but…) COX-2 inhibitors Repetitive practice

15. Summary of ‘Repair’ Treatments 3. Treatments that make functions worse: Fluoxetine (ie., Prozac) social change (stress??)

16. 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…

17. 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.

19. Virtual Reality Uses in neuropsychological assessment and rehabilitation

20. 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

21. 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

22. 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)

23. 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

24. 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

25. 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

26. 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

27. 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)

28. 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

29. 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

30. 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

31. 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

32. 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

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

35. Support devices • automatic cooker shut-off valves • bath tap shut-off devices that don’t 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.

36. 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 couldn’t 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.

37. 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 couldn’t 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.