Learning Objectives Introduction

Beyond the Physical: Cognitive Syndromes and Rehabilitation After StrokeGail A. Eskes, Ph.D.October 23, 2008

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DALHOUSIE UNIVERSITYDepartment of Psychiatry,Psychology and Medicine(Neurology)

Nova Scotia Rehabilitation Centre

Gail Eskes, Ph.D.Dalhousie University

[email protected]

Beyond the Physical:Cognitive Syndromes andRehabilitation After Stroke

Nova Scotia Rehabilitation Centre

With inspiration from manystudents and colleagues,including:•Esther Lau•Bev Butler•Dawnette Benedict•Patricia Ebert•Ed Harrison•Stephen Phillips•Don Stuss

Cognitive Health and RecoveryResearch Laboratory

Learning Objectives

Learn to recognize the major cognitive andbehavioural syndromes due to stroke

Have a better understanding of theassessment of these syndromes formanagement and intervention planning

Learn a basic approach to optimizecognitive recovery

Introduction Stroke produces a variety of deficits which

differ for each individual Syndrome approach: Similar patterns can

be seen across some individuals, however,depending on the type and location of thestroke

Syndromes provide a guide tomanagement, although individualdifferences must be kept in mind

Cognitive/PerceptualSyndromes

Why relevant? Cognitive and perceptual deficitsare common and chronic after stroke

Impact on success of rehabilitation in general Important to be aware of potential issues

Education of patient and family re prognosis &outcome

Clinical management Rehab/discharge planning

Cognitive Deficits Post Stroke

Neuropsychological assessment of 229 patients 2 months post stroke


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Subjective complaints 9 months post stroke

Hochstenbach et al., 2005

Hochstenbach etal., 2005 cont.

Cognitive change 27.7 months post stroke (n=65)

Hochstenbach et al 2003

Conclusions: 1. Cognitive impairment is present in the majority of all strokes

(60.7% had cognitive abnormality in first 2 weeks)2. Cognitive impairment may be the sole presentation

(22.5% had cognitive impairment without sensori-motor deficits)

Cognitive Screening onRehab Admission

4.43.9Judgment5.04.0*Similarities3.02.3*Calculation8.7*6.5*Memory2.2**2.7**Construction

75.5*Naming10.4*8.2*Repetition5.23.7*Comprehension6.64.8*Attention

10.07.8*OrientationRight CVA meanLeft CVA meanCognistat SubTest

Baseline=3 wks post stroke

Followup=7 months


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Cognition after Stroke:Yarmouth Stroke Project

Problems with: Remembering things: 69% Concentrating: 55% Thinking, remembering or understanding: 44% Doing things without making mistakes: 41% Getting organized: 33% Solving problems: 27%




Education of patient and family re prognosis &outcome

Rehab/discharge planning Clinical management

Significant PredictorsAcute Stroke

85.0%88.2%72.4%75.4%Overall %correct

0.74Orientation0.620.630.860.81Clock test

2.662.341.57Pre-strokehandicap

1.040.96Age

RankinBarthelsIndex

DepressionDementia

Outcomes

Predictors


85.0%88.2%72.4%75.4%Overall %correct

0.74Orientation0.620.630.860.81Clock

2.662.341.57Pre-strokeHandicap

1.040.96Age

RankinBarthelsIndex

DepressionDementia

Outcomes

Predictors


85.0%88.2%72.4%75.4%Overall %correct

0.74Orientation0.620.630.860.81Clock

2.662.341.57Pre-strokeHandicap

1.040.96Age

RankinBarthelsIndex

DepressionDementia

Outcomes

PredictorsCognitiveDomain

Lengthof Stay

Barthelsat D/C

Rehab.Efficiency

RehabResponse

Self-Medication

DischargeDestination

Orientation ** * ** **

Attention

Memory * **Language * ** **Visuospatial ** ** ** ** ** **

VerbalReasoningHemispatialNeglect

* ** ** ** ** *

EmotionalFunctioning

** * * * **

Significant Predictorsat Rehab Admission

Ebert, Eskes et al, 2007


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Demographic Information

Lengthof Stay

DischargeBI

RehabEfficiency

RehabResponse

Self-Medication

DischargeDestination

Step 1: Age, Barthels atAdmission, Timeto Admission

*** *** ** * ** **

Step 2: CognitiveDomainOrientation * * *Verbal Attention * (t) **Visual MotorAttention

* * (t) * *

Memory ** *Language (t) (t) *Visuospatial *VerbalReasoningHemispatialNeglect

* * *

EmotionalFunctioning

(t) *

Significant Predictors at Rehab Admission

Ebert, Eskes et al, 2007

Cognitive deficits and outcome

Discharge Self Medication

Yes NoHome Other

% P

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No Neglect

Neglect

Home

Neglect and WheelchairMobility

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Eskes et al., 20050

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Admission Discharge

Total Left SSTotal Right SS

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Total Left DHTotal Right DH

Admission Discharge

WheelchairHits

WheelchairSideswipes

de Haan, et al., 2006

“Neuropsychological datain the early phase of strokemay enhance prognosticmodels” [using medical data]




Clinical management Education of patient and family re prognosis &

outcome Rehab/discharge planning

UnderstandingCognition/Behaviour

Cognition/Behaviour after stroke is multi-factorial

Cognitive function depends upon interaction of Cognitive abilities - strengths and weaknesses Other Psychological factors (e.g., premorbid

personality, emotional status, awareness/denial ofdeficit)

Physical health factors (e.g., sleep/fatigue, bloodsugar, illness, pain)

Environmental factors (physical and social) Thus, assessment and intervention can target

any level of COPE


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General Principles forManagement/Intervention

Understanding of the problem facilitates intervention Behavioural observations, screening Formal assessment may be needed

Issues usually multi-factorial; problem-solving teamapproach to COPE

Intervention in the context of Goal setting: Functional, SMART goals (Specific, Measurable, Achievable,

and Realistic within a defined Time period) Take stage of recovery and prognosis into account Set goals with patient, family - Collaboration vs treatment

Consistency and repetition is key

Cognitive Strengths and Weaknesses

Alertness and arousal Attention and concentration Memory and orientation Language and voluntary motor skills Visuo-spatial and perceptual abilities Executive/frontal systems function

Other Psychological Factors Personality - post stroke changes common

Motivation to adapt (optimism vs pessimism) Conscientiousness Willingness to collaborate

Emotional changes - abulia, emotional lability,post stroke depression and anxiety - GeriatricDepression Scale

Lack of awareness and insight; denial ofdeficit

Post-stroke Depression Common in the immediate and long-term post stroke Symptoms and treatment as per typical depression

(although diagnosis might be harder) Mood symptoms: sadness, decreased interest, anxiety Cognitive symptoms: Thoughts of worthlessness, helplessness,

guilt, self-harm Physical: Poor sleep, appetite, fatigue, concentration

Geriatric Depression scale useful to elicit symptomsfrom self-report

Standard screening important

Recognizing Post-Stroke Depression

Depression Symptoms Mood symptoms:

sadness, decreasedinterest, anxiety

Cognitive symptoms:Thoughts ofworthlessness,helplessness, guilt, self-harm

Physical: Poor sleep,appetite, fatigue,concentration

Stroke Symptoms Emotional lability, abulia,

flatness, catastrophicreactions

Cognitive symptoms canbe hard to elicit in contextof aphasia, disorganizedthinking

Pain, hospitalenvironment, dysphagia,post-stroke fatigue andcognitive deficits

Physical Health Factors Basic sensory and motor systems dysfunction

Visual acuity, visual field defect Hearing loss Poor limb sensation and weakness

Sleep/fatigue Fatigue is common complaint - up to 68% at one year Disrupted sleep also contributes Sleep apnea common in this population

Pain, fatigue, hunger often triggers for behavioural issues Fluctuations in ability may indicate/mask physical cause - be

alert Underlying illness (e.g., UTI, aspiration pneumonia, delirium) Medications (e.g., benzodiazepines)


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Delirium Common in the elderly Related to many medical conditions (e.g., UTI, aspiration

pneumonia, medication side-effects) Hallmark is fluctuating attention, disorientation and confusion;

worsening at night Poor memory, change in emotions Treated by treating underlying cause Can be a long-term effect in frail elderly

Environmental Factors Physical

Lack of routine or structure Noise, distractions in environment External cues or triggers for behaviour Lack of accommodations for sensory or perceptual

limits Social

Family or friends available for support, caregiving Past roles in family Staff and family education critical Behavioural management may be key

What is cognitiverehabilitation?

Wilson, Evans & Keobane, 2002. “Cognitiverehabilitation is a process whereby peopledisabled by injury or disease work together withhealth service professionals to remediate oralleviate cognitive deficits arising from aneurological insult”.

Robertson, 1999 – “Rehabilitation – the provisionof planned experience to foster brain changesleading to improved daily life functioning”


Ben-Yishay and Prigatano, 1990 – “theamelioration of deficits in problem-solvingabilities in order to improve functionalcompetence in everyday situations”.

Cicerone et al, 2000: “Cognitive rehabilitation isdefined as a systematic, functionally orientedservice of therapeutic activities that is based onassessment and understanding of the patient’sbrain-behavioral deficits…cognitive rehabilitationservices should be directed at achieving changesthat improve each person’s function in areas thatare relevant to their everyday lives”.


Planned experience to foster brain changes Dynamic interaction between recovering

neurophysiological processes, environmentalinput and plasticity of remaining structures

Based on assessment and understanding of thepatient’s brain-behavioral deficits

Designed to remediate or alleviate cognitivedeficits Cognitive abilities vs functional abilities

People disabled by injury or disease work togetherwith health service professionals

Goal is to improve everyday function inpersonally relevant areas

Approaches toCognitive Rehabilitation

Restore cognitive ability - Direct retraining (CIT);optimize remaining ability, (e.g., remove negativeinfluences-depression, treat physical illness)

Internal Compensatory behaviour - Find strengths tocompensate for weaknesses (writing for expression; teachexplicit strategy to “look left” in neglect)

External compensation via environmental aids/control -External cues, aids to compensate for weaknesses (i.e.,reminder signs, differential reinforcement of behaviours)

Accommodate to disability - Find alternative goals,solutions involving others

May use one or all approaches for single goal


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Evidence-basedRehabilitation

Recent reviews of cognitive rehabilitation techniques(Cappa et al 2003,2005; Cicerone et al, 2000, 2005;Teasell et al., 2006 - EBRSR; several Cochrane reviews)

In general, strong evidence is limited by: Atheoretical approaches Lack of randomized control trials (RCT) Heterogeneity of the population studied Variability of results Lack of valid outcome measures, evidence of generalization or

measurement of maintenance over time Lack of appropriate control measures (e.g., randomization,

blinding) Efficacy vs effectiveness?

Outcome MeasuresWhat Level?

Restricted Participation

Sensori-motor/Cognitive Impairments

Activity Limitations

Cognitive Syndromesafter Stroke

Major Syndromes

Frontal Lobe dysfunction Attentional disorders Spatial Neglect Memory disorders

OUTPUT INPUT

Functional Geography of the Brain

Behaviour arisesfrom networks

Stroke Syndromes

Anterior Cerebral Artery

Middle Cerebral Artery

Posterior CerebralArtery

Perforating arteries:Subcortical strokes-thalamus, caudate

ACA/PCA

MCA


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Frontal Lobe Function Stuss & Levine, 2002; Stuss & Alexander, 2007 4 categories of frontal lobe function

Executive capacity (attentional control): task-setting(left lateral), monitoring (right lateral) Control of lower-order processes; domain-general Flexibly recruited according to context, complexity, intention Can see issues in any cognitive domain (e.g., language,

memory, perception) Energization (superior medial; right?) Behavioural self-regulation (ventro-medial) Metacognition (frontal poles; right?) - humour, theory

of mind

Frontal Function“Conductor of the Orchestra”

Brings to attention Starting, stopping Putting in the right order Planning, organizing Monitoring, changing i.e., Cognitive and behavioural regulation

Cognitive/BehaviouralSyndrome

Both ACA and MCA territories; ACoAaneurysm

Regulation of behaviour Broad range from basic motor function to

complex social behaviour Continuum with opposites (e.g., loss of

initiation vs disinhibition Basic cognitive abilities often preserved -

erratic function is hallmark

Frontal Lobe Syndromes Medial (Energizing)

Loss of initiation: Apathy, abulia, akinesia to akinetic mutism Apraxia, alien hand syndrome Environmental dependency, utilization

Ventral (Affective) Disinhibition (impulsive, senseless joking, inappropriate

playfulness, outbursts, distractible) - ‘self-regulatory disorder’ Diminished self-awareness, unconcern Decreased empathy, lack of social tact

Lateral (Cognitive) Disruption of goal directed planning, organizing, following

intentions Poor problem-solving, cognitive rigidity Perseveration, confabulation

Assessment Cognitive operations

Language: fluency Memory: CVLT Working memory: Digit span (backward) Brown-

Peterson Trigrams [Self-ordered pointing;Conditional Associative Learning]

Planning, organizing, sequencing - Tower of Hanoi Attention

Shifting: Wisconsin Card Sorting Test, Trailmaking B Selective: Stroop Sustained: Susutained Attention to Responding Test

Affective/Metacognitive domains - ?

Stuss&Levine, 2002


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SART - Respond to all except “3”

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Tower of Hanoi

Frontal Lobe Rehabilitation Challenge to define deficit - often multi-factorial

involving a number of categories Direct remediation:

Dual-task training (Stablum et al 2000) Problem-solving training (von Cramon et al 1991) Goal Management Training to restore ability/compensate

(Levine et al., 2000, 2007) External compensation for everyday activities:

Neuropage (Evans et al. 1998) Periodic alerts (Manly et al, 2002)

Self-regulation deficits - Some compensation available, e.g., Verbal regulation Environmental control may be key May need to re-interpret behaviour and accommodate

ID: 50 yr old female c/o: Needs 24 hr care by husband for prompting for daily

tasks, distractible, disorganized, spent 1.5 hrs in bath everymorning

PMHx: infarction in right frontal lobe, discharged home


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Current Intervention Goals:

Take meds consistently at 9am & 6pm Watering plants Washing underwear regularly Reduce time in bath

Interventions (conditions): NeuroPage/checklists No intervention

Anatomy of the study

Question: Can the use of the Neuropage/checklistsimprove timing of medications and reduce time inthe bath?

Design: Experimental ABAB or ABCAC single-case experimental design Within subject

Subjects: Frontal lobe infarction with dysexecutive syndrome; normal

general intellect, memory Independent variable

Neuropage/checklist Dependent variables

Medication time deviation Time spent in bath

Evans et al., 1998A=Baseline; B=NeuropageEvans et al., 1998A=Baseline; B=Checklist; C=List&Self-timing

“Stop” -task demands?“State”-define main task“Split”-split into subtasks and monitor

Levine et al, 2007:Cognitive aging

Levine et al, 2000

Levine etal., 2000


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Behavioural Management Environmental factors: Environmental control common - can

use it to modify behaviour Poverty of behaviour - structure and routine key Excess of behaviour:

ABCs of behaviourAntecedents

BehaviourConsequences

Target antecedents (remove triggers) Target consequences

Behavioural Management ofConsequences

Increasing desirable behaviours Positive reinforcement: immediate, consistent, clear feedback Shaping Practice, practice, practice with desired behaviour

Decreasing unwanted behaviours Redirection Immediate feedback reprimand Differential reinforcement of other behaviours Extinction (planned ignoring) Time out (from social reinforcement)

Consistency needed for success!

Middle Cerebral ArteryRight Hemisphere Syndromes

Arousal and attentional dysfunction Spatial Neglect Syndrome= inability to orient,

attend, respond to information on left Spatial Relations Syndrome = problem with

perceiving spatial relationships between objects,or between objects and own body (includesconstructional apraxia)

Rare: Anosagnosia, Delusions (false beliefs);misidentification; reduplicative paramnesia

What is Attention? "Everyone knows what attention is. It is the

taking possession by the mind in clear andvivid form, of one out of what seem severalsimultaneously possible objects or trains ofthought...It implies withdrawal from somethings in order to deal effectively with others,and is a condition which has a real opposite inthe confused, dazed, scatterbrained state."

--William James

Attention Vigilance (distractibility) Orienting and Selection (Spatial neglect) Control (limited capacity)

Dividing Switching Filtering ‘working memory’

Models of Attention

Alternating attentionDivided attention

Divided attentionConflict control -resolving conflictamong responses

Selective attentionSelective attentionOrienting - selectionof information fromsensory input

Focused attentionSustained attention

Alertness (phasic)Vigilance (sustained)

Alerting- achievingand maintaining analert state

SohlbergSturmPosner


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Clinical Tests for Attention

• Vigilance - Continuous Performance Test• Focused attention and Selection - Digit

Span, Brief Test of Attention, FigureCancellation

• Control - Brown Peterson Technique, PacedAuditory Serial Attention Test (PASAT)

Spatial Neglect Cognitive changes:

Inattention to left side - could be in all modalities Extinction Many subtypes

Not a sensory-motor defect Distractibility Denial of illness (Anosagnosia)

Behavioural changes: Impulsive Agitation, delusions

Sensory-motor, visual field impairmentscommon

Neglect: Presentation Looks away to right in conversation Trouble with self-care on left side of body Leaves left arm, leg behind when transferring or

moving Bumps into objects on left when navigating Can’t find objects on the left Distractible, impulsive

Neglect Dyslexia

• When asked to read individual words, SSwould often neglect the left half of theword. For example:• Luck as duck• Chicken as sicken• Curb as serb• Brooch as pooch

Attention Rehabilitation Retraining available for some aspects of nonspatial attention

Sturm et al - AIXTENT: computer-based training Deficit specific training (vigilance vs selective vs divided) 30-60 min sessions - 14 sessions over 3-4 weeks

Sohlberg - Attention Process Training Hierarchically organized Different levels of complexity, task demands May work best for executive control/WM functions

Levine - Goal Management Training Compensatory strategies

learning to reduce distractions need for control (one thing at a time) verbal regulation (self-talk)

Sturm et al 1997 - specificity of effects


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Sohlberg et al2000

Rehabilitation of Neglect Restore or enhance basic function

Visual scanning training (Diller & Weinberg; Antonucci et al) Limb activation (Robertson initially, then others) Prism adapation (Rossetti, Frassinetti et al) Eye Patching

Training in awareness and compensatory strategies Look left - needs feedback and family, staff education

Use of environmental aids Bright cues on left Reminders to look left

Family education to accommodate Limited evidence yet for any one technique (Bowen A,

Lincoln NB. 2007. Cochrane Database of Systematic Reviews 2: 1-46)

Copyright restrictions may apply.

Frassinetti, F. et al. Brain 2002 125:608-623; doi:10.1093/brain/awf056

Effects of prism treatment on the patients' performance (percentage of correct responses) in theBIT battery (BIT-C = BIT conventional; BIT-B = BIT behavioural) for the experimental group (EG)and the control group (CG) as a function of time: before treatment (first session) and 2 days, 1

week and 5 weeks after treatment (second, third and fourth sessions, respectively)

Frassinetti et al, 2002

Passive Movement GroupL vs. R Targets Detected per Condition

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Eskes, Butler, McDonald, Harrison and Phillips, 2003

Individual Results - Left Side Only

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Active Movement Group (N=3)

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Posterior Artery Syndromes Memory deficit

Inability to form new memories Old memories can be preserved Problems with word-finding, color semantics

Language deficits Color agnosia Alexia without agraphia = poor reading, writing

preserved Agnosias

Prosopagnosia = unable to recognize familiar faces Object agnosia = unable to recognize familiar objects

What is memory?

Memory

Declarative Procedural

Episodic Semantic Priming Skills ClassicalConditioning(Amnesia) (Agnosias)

Stages of memory

Encoding (Acquisition) Attention, comprehension

Storage (Consolidation)Physiological changes

Retrieval (Access)Monitoring

Memory tests Domain: Verbal vs Visual

Organization of material (related vs unrelated) Time frame: Anterograde vs retrograde Retrieval mode: Recall vs recognition Test batteries

Wechsler Memory Test California Verbal Learning Test

Warrington Recognition Test - words, faces

Rey Complex Figure: drawing and recall ofabstract figures

Memory Rehabilitation Stages of memory relevant Direct remediation - no evidence Compensatory strategies - Mild deficit -

strategies to improve acquisition, retrieval canbe useful

Focus and elaborate, spaced retrieval, distributed practice

External devices: Signs and lists Alarms and notebooks Severe deficit - pagers, voice organizers with

considerable training or caregiver support Gianutsos,1980

Case studyof a lefttumour/MCAinfarction


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Wilson et al., 1997

N=20 subjects with CVA/TBIOutcomes = everyday memory tasks (medications, etc.)

Memory Errorless learning - compensation strategy based

on implicit learning (Glisky et al) Errors produced during learning interfere with the

correct responses Errors stored in memory through intact implicit

learning Procedure involves cueing to prevent errors,

with gradual fading of the cue Meta-Analysis concluded amnesic patients

benefit most from errorless learning approach

Summary - Cicerone et al 2000Deficit Practice Standards Practice Guidelines Practice OptionsAttention Attention training,

including variedstimulusmodalities, levelsof complexity andresponse demands(post-acute)

Memory Compensatorymemory strategytraining

Memory notebooks inindividuals withmoderate-severememory deficit

Neglect,Perception

Visuo-spatialrehabilitation withscanning

Visual scanningtraining

Training in visuospatialand organization skills inright hemisphere stroke

Executivefunction

Training in formalproblem-solvingstrategies and theirapplication toeveryday activities(post-acute)

Verbal self-instruction,self-questioning, andself-monitoring topromote self-regulation

SummaryCognitive Rehabilitation in Context

Cognitive deficits after stroke are varied andcomplex Multiple cognitive domains can be affected Multiple factors influence cognitive abilities

Ideally, cognitive rehabilitation functions in ateam-based approach related to COPE

Management by stroke team ideal according toevidence

Functional goal setting with patients andfamilies should be focus

What is the future? Rehabilitation needs a model of brain plasticity and

cognitive recovery Animal models Functional MRI

New approaches to optimizing plasticity & learning: Intensity - Constraint-induced therapy Other variables (e.g., sleep)

Better technology: Cell-phones, pagers, “virtual reality”computers, “smart” apartments

Emphasis on empowerment Functional, personally relevant goals Balance safety with risk-taking Therapist = “coach”

Focus on gathering strong evidence needed Development of stronger approaches to measure outcomes

References-cited literature Evans JJ, Emslie H, Wilson BA. 1998. External cueing systems in the rehabilitation of executive

impairments of action. Journal of the International Neuropsychological Society 4: 399-408 Gianutsos R. 1980. What is cognitive rehabilitation? Journal of Rehabilitation Medicine

July/August/September: 36-40 Hochstenbach J, Mulder T, van Limbeek J, Donders R, Schoonwaldt H. 1998. Cognitive decline following

stroke: A comprehensive study of cognitive decline following stroke. Journal of Clinical and ExperimentalNeuropsychology 20: 503-17

Hochstenbach J, Prigatano G, Mulder T. 2005. Patients' and relatives' reports of disturbances 9 months afterstroke: subjective changes in physical functioning, cognition, emotion, and behavior. Archives of PhysicalMedicine and Rehabilitation 86: 1587-93

Hochstenbach JB, den Otter R, Mulder TW. 2003. Cognitive recovery after stroke: A 2-year follow-up.Archives of Physical Medicine and Rehabilitation 84: 1499-504

Levine B, Robertson IH, Clare L, Carter G, Hong J, et al. 2000. Rehabilitation of executive functioning: anexperimental-clinical validation of goal management training. Journal of the InternationalNeuropsychological Society 6: 299-312

Levine B, Stuss DT, Winocur G, Binns MA, Fahy L, et al. 2007. Cognitive rehabilitation in the elderly:Effects on strategic behavior in relation to goal management. Journal of the InternationalNeuropsychological Society 13: 143-52


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References-cited literature Manly T, Hawkins K, Evans J, Woldt K, Robertson IH. 2002. Rehabilitation of executive function:

Facilitation of effective goal management on complex tasks using periodic auditory alerts.Neuropsychologia 40: 271-81

Robertson IH, Murre JMJ. 1999. Rehabilitation of brain damage: Brain plasticity and principles of guidedrecovery. Psychological Bulletin 125: 544-75

Sohlberg MM, McLaughlin KA, Pavese A, Heidrich A, Posner MI. 2000. Evaluation of attention processtraining and brain injury education in persons with acquired brain injury. Journal of Clinical andExperimental Neuropsychology 22: 656-76

Stablum F, Umilta C, Mogentale C, Carlan M, Guerrini C. 2000. Rehabilitation of executive deficits inclosed head injury and anterior communication artery aneurysm patients. Psychological Research 63: 265-78

Stuss DT, Levine B. 2002. Adult clinical neuropsychology: Lessons from studies of the frontal lobes.Annual Review of Psychology 53: 401-33

Wilson BA, Evans JJ, Emslic H, Malinek V. 1997. Evaluation of NeuroPage: A new memory aid. Journalof Neurology, Neurosurgery and Psychiatry 63: 113-5

Wilson BA, Evans JJ, Keohane C. 2002. Cognitive rehabilitation: a goal-planning approach. Journal ofHead Trauma Rehabilitation 17: 542-55

References-reviews Bowen, A., Lincoln, N. B. & Dewey, M. (2002) Cognitive rehabilitation for spatial neglect following

stroke (Cochrane Review) Oxford: Update Software.

Cicerone, Keith, D., Dahlberg, C., Kalmar, K. et al (2000). Evidence-based cognitive rehabilitation:Recommendations for clinical practice. Arch Phys Med Rehabil, 81, 1596-1615.

Kessels, R.P.C., & deHaan, E.H.F. (2003). Implicit learning in memory rehabilitation: A meta-analysis on errorless learning and vanishing cues methods. J. Clin. Exp. Neuropsychol., 25 (6), 805-814.

Lincoln, NB, Majid MJ, Weyman N. (2003). Cognitive rehabilitation for attention deficits followingstroke (Cochrane Review). Oxford: Update Software.

Majid, MJ, Lincoln NB, Weyman N. (2003). Cognitive rehabilitation for memory deficits followingstroke (Cochrane Review). Oxford: Update Software.

Teasell, R., Foley, N., Bhogal, S., Salter, K., Jutai, J. & Speechley, M.,. &. (2004). Evidence-basedreview of stroke rehabilitation. Found at: http://www.ebrsr.com

References-Resource Books Sohlberg, M & Mateer, C. 2001. Cognitive rehabilitation:

An integrative neuropsychological approach. NY: GuilfordPress.

Stuss, DT, Winocur, G. & Robertson, IH. (eds).1999.Cognitive neurorehabilitation. Cambridge: CambridgeUniv. Press.

Mills, VM, Cassidy, JW, Katz, D. (eds). 1997. Neurologicrehabilitation. Malden, Blackwell Science.

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