ACUTE OUTPATIENT NEURO-COGNITIVE REHABILITATION
NEUROLOGY MERGES with COGNITIVE THERAPY to REMEDIATE ACQUIRED BRAIN INJURIES from TBI and STROKE
Cognitive rehabilitation is most often defined by health industry professionals as a systematic, goal-oriented treatment program designed to improve cognitive functions and functional abilities and increase levels of self-management and independence following neurological damage to the central nervous system. Although the specific tasks may be individualized to patients' needs, treatment generally emphasizes restoring lost functions; teaching compensatory strategies to circumvent impaired cognitive functions; and improving competence in performing instrumental activities of daily living (IADL) such as managing medications, using the telephone and handling finances. The term cognitive rehabilitation may be used to describe a variety of intervention strategies or techniques that are intended to help patients reduce, manage or cope with cognitive deficits. Cognitive rehabilitation may be provided as an integrated holistic program, or as a separate component used to treat a specific cognitive defect.
Restorative and compensatory approaches are utilized in cognitive rehabilitation. The restorative approach, also referred to as direct intervention or process-specific, is based on the theory that repetitive exercise promotes recovery of damaged neural circuits and restores lost function. Restorative cognitive rehabilitation targets specific internal cognitive processes in an effort to generalize improvements to real-world settings. Interventions typically involve exercises designed to isolate specific components of impaired cognition (e.g., selective attention, visual perception, prospective memory) and to rebuild cognition skills in a hierarchical manner. Restorative techniques include auditory, visual and verbal stimulation and practice, number manipulation, computer-assisted stimulation and practice, performance feedback, reinforcement, video feedback and meta-cognitive procedures such as behavior modification.
The compensatory approach, also referred to as the functional approach, focuses on teaching patients to employ various strategies to cope with underlying cognitive impairments and accompanying social deficits. The compensatory approach is based on the assumption that lost neurological functioning cannot be restored. The goal, therefore, is to teach strategies to circumvent impaired functioning, and encourage and reinforce intact abilities and strengths. Compensatory techniques generally focus on activities of daily living and social interactions. Group therapies may be important to strengthen the patient’s ability to interact effectively with others. Memory impairment may be addressed by external and internal methods of rehabilitation. External aids include memory notebook systems, electronic memory devices, alarms, calendars, posted reminders, and standardized locations for necessary items. Internal aids include learning of mnemonic strategies (e.g., acronyms, peg word systems, and associated imagery). Compensatory cognitive rehabilitation may involve modifying the physical or social environment in a way that cues a specific behavior and eliminates distraction or unwanted behavior. Although the compensatory approach to cognitive rehabilitation has been more widely accepted than the restorative approach, these techniques are not mutually exclusive. Many therapeutic programs employ both techniques.
Cognitive rehabilitation is currently provided by various professionals, including speech/language pathologists, occupational therapists, psychiatrists, psychologists, neuropsychologists, psychiatric nurses, cognitive remediation therapists, physical therapists, and occupational therapists. There are no established and widely accepted guidelines among either Payors or Providers; and none of these disciplines provide specific training guidelines for cognitive rehabilitation. Cognitive rehabilitation is usually provided on an outpatient basis, although other settings may be indicated depending on the patient’s stage of recovery and acuity level. Prior to initiation of a cognitive rehabilitation program, patients generally undergo comprehensive neuropsychological testing to evaluate and identify specific baseline deficits and impairments as well as to direct a treatment plan and develop measurable goals.
There is substantial variation in the delivery of cognitive rehabilitation with respect to essential components, program design and emphasis. The market consensus though is that cognitive rehabilitation interventions should be structured, systematic, goal-directed (long- and short-term goals), individualized and restorative. There is no evidence in the medical literature to support a specific treatment intensity or duration for cognitive rehabilitation. Cognitive rehabilitation should be evaluated on the basis of goal achievement, including quantifiable rates of improvement in functional abilities and documented treatment outcomes. Contraindications to cognitive rehabilitation include the inability of the patient to participate in a treatment plan (i.e., orthopedic, medical, psychosocial or behavioral issues). Cognitive rehabilitation often involves the services of a multidisciplinary team.
Most published evidence evaluates cognitive rehabilitation for treatment of cognitive deficits resulting from moderate or severe traumatic brain injury (TBI) and stroke/cerebral infarction. The available evidence, although not robust, indicates that cognitive rehabilitation may improve functional outcomes for some patients with moderate or severe TBI. Evidence is limited due to the heterogeneity of subjects, interventions and outcomes studied, small sample size, failure to control for spontaneous recovery, and the unspecified confounding effects of social contact. Evidence from available studies indicates, however, that cognitive rehabilitation may reduce anxiety, improve self-concept and relationships for people with TBI, and may improve memory, attention and executive skills. There is insufficient evidence in the published medical literature, however, to support the use of cognitive rehabilitation for patients with mild TBI, including concussion and post-concussion syndrome.
Patients who sustain a stroke may exhibit symptoms similar to those experienced by TBI patients, with cognitive deficits in the areas of memory, reasoning and perception. Both TBI and stroke may result in impairment of localized, higher-order, sensory and motor function corresponding to affected anatomic structures, but may also result in loss of a variety of functions that are not clearly localized, such as the ability to abstract and to reason. Although the evidence supporting the use of cognitive rehabilitation to treat cognitive deficits following stroke is limited, there is some evidence that it contributes to visuospatial rehabilitation and improvement in aphasia and apraxia. In addition, the medical community has recognized cognitive rehabilitation as a standard treatment modality for stroke as well as for TBI.
NATURE OF NEURO-COGNITIVE REHABILITATION SERVICES
NeuroHealth Solutions (NHS) delivers cognitive rehabilitation services for neurological disorders including Acquired Brain Injury. NHS’s core team of doctors and technicians with backgrounds in acquired brain injury, clinical electroencephalography, quantitative electroencephalography (qEEG), psychology and neurophysiology, work together to assess, analyze and determine neuro-optimization approaches for recovery and rehabilitation of neurological maladies.
Health professionals at NHS develop and implement an individualized rehabilitation care plan for each patient or client – based on their whole-person needs – to optimize, re-organize and normalize brain function. This cutting-edge approach, which is an integration of multiple biofeedback, neurofeedback and neuro-stimulation modalities, contributes to an efficacious change in brain morphology. It is the integration and insightful deployment of these modalities, as the core of whole-person care plans, that provides individuals with the opportunity to heal from a traumatic brain injury and return to normal function – with significantly reduced long-term risks to their health and well-being.
NATURE OF NEURO-COGNITIVE REHABILITATION DECISION MAKING AND DELIVERY
NeuroHealth Solutions provides its revolutionary model for cognitive rehabilitation services to individuals with a diagnosed concussion (i.e., a traumatic brain injury) from an independent MD by first using Neurology based Clinical EEG which is then reviewed utilizing qEEG analytics which provides both an objective quantitative measure to confirm or indicate a diagnosed concussion and symptoms along with other neurological assessments. These neurological assessments include the Brain Functions Survey, and the “Heads Up to Concussion” for Clinicians, Acute Concussion Evaluation (ACE) certification, established by the Center for Disease Control (CDC) and the American College of Sports Medicine (ACSM) which applies to motor vehicle accidents, sports concussions or “any bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth.” (Please see HEADS UP to Health Care Providers [Feb 2015]. The qEEG is an objective quantitative measure used to assess the initial neurological dysregulation; but it also can confirm diagnoses of a concussion by an MD and determine severity of traumatic brain injury against normative function via normative comparative analysis. In addition to its assessing and determining a cognitive rehabilitation plan for recovery, the qEEG is an analysis of raw Clinical EEG recording utilized to verify the efficacy of the training regimen and to determine when the individual has returned to normalized brain function.
NHS then provides an alternative approach to cognitive rehabilitation using cutting-edge developments in neuroscience technology via an integrated neuro-optimization training approach. These services are clinically evidenced and scientifically valid using both qualitative neuropsychological assessments designed by clinical psychologists to assess cognitive dysfunction and quantitative real-time z-score neurofeedback training utilizing Clinical Quantitative Electroencephalography (qEEG) which assists in returning dysregulated neurological function to normalized standards. This is a proprietary and advanced approach that is based on well-established science, and its documented successful deployment as integrated care model will be further enhanced by future developments in neuroscience and information technology. The basic component for the services provided at NHS is qEEG. QEEG has been shown to meet the four factors established by the U.S. Supreme Court’s 1993 Daubert criteria of the scientific method standards of “general acceptance” for admissibility of evidence in the U.S. Federal Court. The four factors of the Daubert criteria are: (a) hypothesis testing, (b) estimates of error rates, (c) peer-reviewed publication and (d) general acceptance (Daubert v. Merrell Dow Pharmaceuticals, 61 U.S.L.W 4805 (U.S. June 29, 1993)). It has also been shown that utilizing qEEG to measure the degeneration of neurological and psychiatric dysfunction meets the standards for “technical” and “other specialized” knowledge established in the U.S. Supreme Court case of General Electric Co v. Joiner, 1997; Kumho Tire Company, Ltd. v. Carmichael, 1999. Clinical qEEG objective analysis has therefore been clinically validated and admissible in the evaluation of brain injury and neurological impairment (Duff et al., 2004).
Neuroscience equipment and devices used at NeuroHealth Solutions for both assessment and training are FDA-registered medical devices and tested for safety. Our doctors and staff are trained in the use and administration of the equipment by the manufacturer, and have completed certifications in biofeedback, neurofeedback, heart rate variability and all neuro-optimization modalities provided directly by the manufacturer. All the services provided by NHS are recognized as reimbursable services by either the Center for Medicare Services or commercial medical insurers.
Application of Cutting-Edge Proven Technology to Achieve Superior Outcomes
Our Team of World-Class Specialists and Certified Technicians on the cutting-edge of advances in health care and health management. The equipment, methodology and protocols utilized at NHS have been developed and demonstrated efficacious by a team of doctors including Dr. Michael Hillman, MD, Neurologist and Chief Medical Officer; Dr. DenBoer, PhD, Neuropsychologist and Sports Psychologist; Dr. Sean Southland, PhD, MDAST, Certified Brain Injury Specialist; clinical neuroscientist and pioneer in qEEG and objective data analysis and Founder of Applied Neuroscience, Dr. Robert Thatcher, PhD,; Psychologist, Psychotherapist and Founder of Newmind, Dr. Richard Soutar, PhD., AAPB, BCIA,; and Psychotherapist, Psychologist and Founder of NeuroField, Dr. Nicholas Dogris, PhD.
The patient cognitive rehabilitation protocols at NHS have been developed to enhance our ability to provide an integrated approach to return to well-being for our patients and clients. The NHS team also includes, as clinical staff and consulting advisors, renowned leaders in neurology, orthopedic medicine, nutrition and physical activity. For example, each individual’s Rehabilitation Care Plan is implemented under the clinical supervision of Michael Hillman, MD. Dr. Hillman works closely with our health and wellness professionals to review both initial patient diagnoses by independent Physicians and subsequent NeuroFitness Assessments so that our medical decision team can provide clinical guidance on developing, managing and measuring the impact of each Care Plan.