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Neurorehabilitation in brain injury: dual tasks and new technologies.

The performance of neurorehabilitation activities that require the involvement of different processes allows a more comprehensive and realistic approach to how our brain works and how it recovers after suffering brain damage. Nowadays, new technologies allow us to perform these integrated tasks in an effective and motivating way for patients. As a result, we promote better results in the rehabilitation process.

Brain injury and neurorehabilitation

Suffering brain damage usually causes patients to be affected in different spheres of their functioning, the most common being those that compromise the motor, cognitive, emotional and behavioral spheres (Wilson et al., 2017). Such involvement causes significant changes in their daily functioning, as well as in that of their family members (D’Ippolito et al., 2018).

Traditionally, from neurorehabilitation, each professional has intervened in the corresponding sphere. On many occasions, physiotherapists, occupational therapists, speech therapists, neuropsychologists, etc. have performed an ideally coordinated and complementary, but independent, approach. However, the human brain functions in an integrated way, the different processes work in an interconnected way, for example, any relatively complex motor activity requires an adjusted cognitive performance in order to be performed as efficiently as possible.

Thus, in everyday life, we never perform an activity such as walking in isolation, at the same time we are thinking about where we are going, where we should go, what we will do when we arrive at our destination, or even talking to our companion. In the same way, doing an activity like cooking, we have to stand up, move around the kitchen, use our hands handling food and utensils, and at the same time plan the different steps of the recipe, remember where the ingredients are, which step we have done, which one comes next, etc.

The dual task paradigm

Habitual in our daily life, we must take it to the plane of neurorehabilitation of brain damage, and include it in the programs, activities and procedures that integrate different processes. Based on this idea, for some years now, in neurorehabilitation it has been common to use the dual tasks paradigm (Woollacott & Shumway-Cook, 2002), in which the patient, within his rehabilitation activity, must perform several tasks simultaneously in a coordinated manner, generally one with a motor component and another cognitive one.

Adaptation of dual tasks to the profile of the patient with brain injury

In a patient who, after brain damage, has difficulty walking properly, as well as attentional problems or various executive function processes, it is common to perform activities in which, while the patient walks in a more or less complex environment (which can be modified sequentially), he/she is asked to perform some more or less demanding tasks at a cognitive level, such as counting the number of times the therapist makes a certain gesture or says a word, performing mental calculations, or talking on the phone. The use of these dual tasks within the rehabilitation program of patients with brain injury has been shown to be effective (Kim et al., 2014; Park & Lee, 2019).

Sometimes we work with patients with high impairment after brain injury, and we might think that the use of this type of tasks is not appropriate or is difficult to carry out. However, the possibility of adaptation and adjustment of this type of tasks is very wide. In fact, we have been able to use it with most of the patients who have suffered brain damage.

A case of brain damage after a traffic accident

For example, with a patient with brain damage who, after a very severe traffic accident, is severely affected at the motor level (in addition to cognitive and emotional sequelae). The current goal at this level is to be able to stand with as little assistance as possible. However, because of the pain in his leg due to the severity of the injury he had, and the amount of fractures and time of complete rest, this becomes a really complex and difficult task for him.

Performing a simultaneous cognitive activity, in addition to the benefit of performing the activity itself, produces in this case a reorientation of the attention towards that activity, a lesser concentration on the pain, and consequently a greater benefit in the standing motor exercise. Thus, for example, standing alone, concentrating on the posture and the time invested, is possible for five or ten minutes; however, by performing a simultaneous cognitive activity, the patient with brain damage can maintain and perform it effectively for more than half an hour.

Dual tasks and new technologies

New technologies are indispensable tools nowadays in the approach to patients with brain damage. There are a large number of technological and robotic resources that help patients and allow them to advance in their rehabilitation process.

Returning to the patient with brain damage, he is not yet able to stand independently, supporting all his weight on his legs. The use of a device such as the Raysen (the only 3D weight-bearing system in the world, which allows the approach of balance and gait) allows the device to support the desired percentage of the patient’s weight through a harness. This allows its regulation and gradual advancement, so that the patient can support more and more of his or her weight. In this way, while the patient is standing, we can introduce a second cognitive task adapted to his performance level.

Cognitive and motor work with NeuronUP and Raysen

In addition, using NeuronUP with some patients who need training in certain affected cognitive processes. For some time now, we have also had a large touch screen, which allows better interaction of patients with it, greater immersion and motivation in its use, the use of both limbs with greater range of motion, as well as the performance of standing work.

In the aforementioned case, while the patient was standing with the Raysen, we placed the screen in front of him with NeuronUP activities adapted to his characteristics. With him, because of his cognitive sequelae due to brain damage, it is important to work at the visual, attentional and executive function levels. In this sense, a very useful activity is the “Copy of plans“. In this activity, the patient must look at a model plan with a series of boxes, and reproduce it by placing the exact elements in each corresponding place.

Likewise, if we want to introduce moving elements and increase the demand for more complex attentional processes, as well as working memory, activities such as “Bottlecaps” are very interesting and motivating for the patient with brain damage. In this activity, a series of plates with numbers move across the screen and the patient has to look for them and mark them from highest to lowest. In addition, it allows us to work on supervision and inhibitory control.

Rehabilitation of a brain-damaged patient using NeuronUP and Raysen, through the dual-task paradigm and the use of new technologies.

Another recently introduced and motivating activity for the patient is “Word Association“, in which he/she must match pairs of words according to their semantic relationship. It allows us to work at a cognitive level on reasoning and at a motor level on upper limb movement with a greater range of arm movement, having to drag the words across the screen while keeping them pressed.

Conclusions

In this way, we have achieved that the brain-damaged patient remains standing while performing activities for much longer periods of time than when no other activity was incorporated, making an attentional refocusing, with less attention to pain and more to external demand. In addition, it allows us to work different motor and cognitive processes in an integrated way, more similar to day-to-day activities.

The neurorehabilitation of patients who have suffered brain damage is a field in constant progress and advancement. The coordinated and integrated work of the different professionals involved using techniques and tools with proven scientific evidence, as well as the use of new technologies, allows us to develop individualized programs that substantially help the progress of patients.

References

D’Ippolito, M., Aloisi, M., Azicnuda, E., Silvestro, D., Giustini, M., Verni, F., Formisano, R., & Bivona, U. (2018). Changes in Caregivers Lifestyle after Severe Acquired Brain Injury: A Preliminary Investigation. BioMed Research International1, 1–14. https://doi.org/10.1155/2018/2824081

Kim, G. Y., Han, M. R., & Lee, H. G. (2014). Effect of dual-task rehabilitative training on cognitive and motor function of stroke patients. Journal of Physical Therapy Science26(1), 1–6. https://doi.org/10.1589/jpts.26.1

Park, M. O., & Lee, S. H. (2019). Effect of a dual-task program with different cognitive tasks applied to stroke patients: A pilot randomized controlled trial. NeuroRehabilitation44(2), 239–249. https://doi.org/10.3233/NRE-182563

Wilson, L., Stewart, W., Dams-O’Connor, K., Diaz-Arrastia, R., Horton, L., Menon, D. K., & Polinder, S. (2017). The chronic and evolving neurological consequences of traumatic brain injury. The Lancet Neurology16(10), 813–825. https://doi.org/10.1016/S1474-4422(17)30279-X

Woollacott, M & Shumway-Cook, A. (2002). Attention and the control of posture and gait: a review of an emerging area of research. Gait Posture, 16: 1–14. https://doi.org/10.1016/S0966-6362(01)00156-4

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