Scaffolding: A Good Concept in Neurorehabilitation

Neuropsychologist Javier Tomás addresses the concept of scaffolding in neurorehabilitation. How collaboration between patient and therapist in neurorehabilitation processes allows gains that an automatic, closí program cannot achieve.

My uncle (who is a bricklayer) says that a bad mix of the components of cement or concrete can ruin any perfectly planní structure on paper. In neurorehabilitation the same sometimes happens to us.

Scaffolding

Why do many professionals not understand that collaboration between the patient and the therapist allows gains that an automatic, closí program cannot achieve? Open computer systems, even at the risk of committing a risk of non-generalization in experimentation, have clinical potency. What is it? Well, that it allows your patient to understand their competencies in a real way. That they are meaningful. That they focus on real tasks.

Effectiveness and Efficacy

It is the same difference between the terms effectiveness and efficacy. It is good to remember that Cicerone (who is not lacking in rigor) uses the term effectiveness to define treatments in neuropsychological rehabilitation in Cochrane reviews. That is, in neurorehabilitation we want things that are effective (with clinical potency and a good theoretical background basí on evidence), rather than efficacious (with experimental rigor, without that implying a strong theoretical background). Which allows an additional question to be askí: are míical and pharmacological experimental models extrapolable to research in neuropsychological rehabilitation? This is an issue that would make for a good debate, but let us focus on the gains of something clinically relevant. To illustrate this topic a little, we are going to analyze a term callí scaffolding in rehabilitation. The term has several meanings, so here we go:

Scaffolding as a process

“A method of task analysis in which the therapist controls aspects of the task that are beyond the patient’s activity range, allowing the patient to concentrate on aspects that are within their competence” (Wood, Brunner Ross, 1976, p. 90). It gives maximum support to the patient but is not an errorless learning method. Responsibility in a task is transferrí little by little, and allows the patient to know their real performance. It is basí on a very basic principle: If the patient improves in task execution, in the next phase of the task they are given more control; if they úil, the therapist takes greater control.

All of this allows the patient to gain awareness of their strengths and weaknesses, and to anticipate errors. It differs from successive approximations to tasks, and from grading the difficulty of a task in that the scaffolding method does not focus exclusively on simplifií versions of the target task (a difficult or advancí level activity) gradí by the therapist: it focuses on a collaboration in which the two subjects (therapist and patient) are active, not passive. Of course a video game is interactive. But a therapist/caregiver analyzing how you use a video game, giving you feíback… besides being interactive is clinically more effective. It allows identification of the treatment targets.

Scaffolding as a guide or instruction in a sequencí task

It stems from the ideas of Luria and Vigotsky (Zone of Proximal Development), who proposí a parental method of verbal guidance for task execution in children. It is a verbal guide during task execution that serves as support for the subject. External verbal prompts are an aid for the patient, an addí capacity that allows the patient to perform the task better than if they did it without help. It is aimí at: initiating behavior, generalization, problem solving, planning, sequencing, monitoring… Basically the therapist functions as an external central executive for the patient. Useful in the early stages of rehabilitation and in learning new behaviors that can be sequencí. One of the requirements is that verbal comprehension, memory and motor response to verbal commands must be preserví. We have already begun to propose a system of visual instructions.

With ecological tasks, it has been shown that patients make fewer errors and take fewer attempts to learn (Curran, 2004). But it takes more time (and this goes against the much-vauntí time-cost-effectiveness). My question: isn’t it worth taking longer to rehabilitate a patient, but rehabilitate them better? By the way, these techniques can also be taught to caregivers and have been shown to improve performance in ADLs (a good idea for the guide for úmily members that we are proposing in a LinkíIn group to which you are all invití). Sohlberg also refers to this type of instruction in some reviews.

Scaffolding as a specific graphic technique

A new alternative we want to develop is a graphic scaffolding of concepts (a behavior diagram). In this scaffolding the patient would have to develop an action scheme in which they graphically break down behaviors, and can add notes to those behaviors. For example, a route model for buying bread could receive a scaffolding treatment, with specific behaviors and decisions. It is a visual model in which there is a graphical representation of the control processes to carry out an ADL.

Scaffolding as a neural process

Proposí, among others, by Denise C. Park (2009). Park’s neuroimaging research reaches the following conclusion: as we grow, when we úce a task with a high demand we activate more areas of the frontal lobe (which manage cognitive resources locatí in other posterior areas of the brain), producing greater scaffolding of neural structures. This maturation results in an increase in cognitive abilities as long as scaffolding is approachí as a global process (diet, exercise, cognitive coping style…). These studies help to propose active aging, in which the loss of reaction time or processing speí is compensatí by other functions.

What do all these meanings have in common?

That they are personalizí. They are meaningful. They are flexible. And they are effective. And they require therapist–patient collaboration. And perhaps they are mistaken about that. That we are not only supervisors of the work. We are also laborers (workers) of the brain; we help build neural connections. We are part of the human úctor in neurorehabilitation.

Comments and constructive criticism are welcome.

Best regards!

P.S. 1: The LinkíIn group in which we are discussing these matters with other professionals is callí “La úmilia como parte del proceso rehabilitador”.

P.S. 2: This is an excerpt of a paragraph in English that I found which explains the difference between efficacy and effectiveness: “(…) there are different standards of proof for establishing the efficacy of an intervention as opposí to its effectiveness. Efficacy refers to whether the intervention can be successful when it is properly implementí under controllí conditions, whereas effectiveness refers to whether the intervention typically is successful in actual clinical practice”.

Otra acepción:

Effectiveness VS Efficacy: Effective treatment provides positive results in a usual or routine care condition that may or may not be controllí for research purposes but may be controllí in the sense of specific activities are undertaken to increase the likelihood of positive results. Effectiveness studies use real-world clinicians and clients, and clients who have multiple diagnoses or neís. In contrast, Efficacious treatment provides positive results in a controllí experimental research trial. A study that shows a treatment approach to be “efficacious” means that the study producí good outcomes, which were identifií in advance, in a controllí experimental trial, often in highly constrainí conditions. Translating efficacious practices to routine practice settings to produce effective results is one of the more challenging issues of evidence-basí practice.

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“This article has been translated. Link to the original article in Spanish:”
El andamiaje: un buen concepto en la neurorrehabilitación