The goal of neuropsychological rehabilitation is to improve an individual’s performance and to compensate for the impairments resulting from brain injury in order to reduce functional limitations and increase the ability of the person to perform activities of daily living (Bernabéu & Roig, 1999) with the purpose of improving quality of life (Christensen, 1988; Prigatano, 1984; Sohlberg, & Mateer, 1989).
Cognitive functions are interrelated, and interdependent on a functional and anatomical level. Functional activities involve multiple types and levels of processing. When an activity of daily living is carried out, neural combinations that recruit specific neuropsychological processes to perform it are put into play. From those motivations that initiate behavior, all the way through to visual recognition, impulse control or the development of cognitive strategies to resolve these impulses, to plan behavior or to learn. Therefore, from a professional approach, it is logical to formulate rehabilitation activities from an ecological perspective.
The goal of NeuronUP is to identify those processes in order to calibrate and design useful activities for neuropsychological rehabilitation and occupational therapy, as well as providing a platform and flexible materials for neuropsychology professionals. NeuronUP was founded in response to several urgent questions in the field of neuropsychological rehabilitation in general, and clinical and experimental practice in particular. In line with the urgent need to carry out a more ecological neuropsychological assessment (Tirapu, 2007) that allows clinicians to assess the accurate functional condition of individuals who come for a consultation, there has emerged a school of thought that seeks to use more ecological, motivational and personalized contents in the process of cognitive stimulation and rehabilitation. Therefore, in addition to the assessed functions, an ecological approach can be applied to neuropsychological rehabilitation (Wilson; 1987, 1989).
Ecological validity refers to—Kvavilashvili & Ellis (2004)—both the representativeness of a task (the degree of correspondence in form and context in regards to a real life situation), and the generalizability of the results produced by that task. There are three different levels of generalizability:
Level 1. Keeping the outcomes from session to session, using the same situations and materials.
Level 2. The achieved progress has to reflect in similar tasks.
Level 3. Transferring the skills acquired during training sessions to activities of daily living.
In NeuronUP we design materials involving activities and situations of daily living that are related not only to basic neuropsychological functions— since they are multifaceted activities—but also to variables of daily functioning (Yantz, Johnson-Greene, Higginson, & Emmerson, 2010).
Taking advantage of the “cognitive profile” (weak and strong cognitive points) requires our scheme of rehabilitation to be at least as comprehensive as the neuropsychological tests used to establish a baseline (we have 40 neuropsychological processes divided among 11 cognitive functions). This comprehensiveness allows an accurate analysis of the neuropsych
“The planning of the rehabilitation activities and times is under the control of the therapist”. Thus, the therapist decides which type of activities each patient must perform, the duration of each activity, and at which level of difficulty the tasks will be adjusted (Muñoz-Céspedes & Tirapu, 2004). NeuronUP adopts this principle as one of the basis of its approach, and the activities have been designed so that the therapist can adjust the parameters of those activities without compromising the record of the data.
Incorporating the general observations on neuropsychological rehabilitation given by Muñoz-Céspedes & Tirapu (2001), NeuronUP:
- Calibrates the complexity of the tasks.
- Divides tasks into their different component parts.
- Gives simple and clear instructions that help give structure to the task and its performance. If the therapist considers the language suggested by NeuronUP inappropriate for the person undergoing rehabilitation, we give the option to customize the instructions of the activities.
- Makes resources more accessible for the patient in terms of understanding while also saving expenses and travel.
Why use a web platform of computer-assisted rehabilitation? Although it would be incorrect to conceptualize NeuronUP as solely computer-based (since many materials can be printed out), below we propose some advantages in the use of computer format (Ginarte-Arias, 2002; Lynch, 2002; Roig & Sánchez Carrión, 2005):
• It enables the accurate control of certain variables such as stimulusexposure time and reaction time. This allows suitable control of patient evolution and his/her monitoring.
• Data collection is more reliable and consistent, and its analysis is facilitated. In this way, it is possible to plan a strategic neuropsychological
• The stimuli presented are more attractive, which increases the motivation of the individual. Customization of activities.
• Integration of multimedia materials.
• Provides quick and accurate feedback because it allows the construction of an interactive system of changing images depending on whether the answers are correct or not while allowing for independent work from home. This helps build awareness of the deficit.
• Connection of peripheral devices for motor or visual problems.
• Allows flexibility since computer-based materials can be programmed to permit alteration of different variables such as the type of stimulus used, the level of difficulty, or exposure time in such a way that alternative procedures can be selected in accordance with the specific needs of each patient. In fact, one of the advantages of NeuronUP is that it adapts to the patient based on the decisions of the therapist, and it is not the patient who has to adapt to the level or the materials of the activities.
• Some programs and platforms have a reasonable cost–benefit since they save the therapist time. NeuronUP allows access to the platform and data from any place
How have we corrected problems associated with computer-assisted neuropsychological rehabilitation?
- We have developed a flexible system so that it is not applied in a rigid and inappropriate manner (Ginarte Arias, 2002).
- We adapt the contents to the evolutionary moment of the persons undergoing rehabilitation (Tam & Man, 2004). Additionally, this expert system can adapt to language, educational level, or the type of brain injury of patients.
- We believe that the use of cognitive rehabilitation platforms and programs cannot replace the contact, support, effort and supervision of the therapists.
- The programs must be continually revised and updated based on patient evolution and performance (Sánchez Carrión, Gómez Pulido, García Molina, Rodríguez Rajo, & Roig Rovira, 2011). To consider an intervention that only takes into consideration the cognitive sphere without acknowledging psychosocial, emotional and behavioral disorders is an insufficient approach (Salas, Báez, Garreaud, & Daccarett, 2007).
Assistive technologies for cognition (ATC) are being used to support a wide range of activities, from communication to social participation (Gillespie, Best & O´Neill, 2012). This is due to different improvements and changes in the concept of “technologies for cognitive rehabilitation along the last 40 years”. From first generation computers to videogames and finally to “social communication” devices, the use of technology for cognitive rehabilitation has evolved from isolated (lab) use to functional and ecological intervention in which ATC are a part of a holistic model that empowers functional and emotional outcomes.
Computer-Based Cognitive Rehabilitation Technologies may be used in a wide range of populations. Cole (1999) has already shown that cognitive orthoses should be highly customizable to the needs of the person. Moreover, the use of “therapist-friendly” and “user-friendly” interfaces (Cole, Ziegmann, Wu, Yonker, Gustafson & Cirwithen, 2000) should be used. These interfaces should provide a simplified file access, save and print commands for word processing to increase the ability to access, modify, and print longer, detailed amounts of information. According to Lynch (2002), these types of activities should be used to train tasks related to Activities of Daily Living, including work.
Due to heterogeneity in cognitive profiles (strengths and weaknesses), materials and guides used in computer-based technologies must be adapted in terms of complexity–number and difficulty of decision-making points-presentation of information sequentially, and others (LoPresti, Mihailidis & Kirsch, 2004). For that purpose, users must be included in the design process, according to the concept of “user sensitive inclusive design” proposed by Newell & Gregor (2000). These recommendations point to the need for a computer-based personalized cognitive training in neuropsychological rehabilitation. Peretz, Korczyn, Shatil, Aharonson, Birnboim & Giladi (2011) compared a computer-based personalized cognitive training group with a group that received a classical computer games training. Improvements in the personalized condition were significant in all the cognitive domains trained (focused attention, sustained attention, recognition, recall, visuospatial learning, visuospatial working memory, executive functions, and mental flexibility), while classical computer games group improved significantly only in four domains (focused attention, sustained attention, memory recognition and mental flexibility).
For a more extensive review, the reader can consult the following: Gillespie et al. (2012); Kueider, Parisi, Gross & Rebok (2012); Cicerone et al. (2011); Stahmer, Schreibman & Cunningham (2010); Faucounau, Wu, Boulay, De Rotrou, Rigaud (2009); Lange, Flynn & Rizzo (2009); Tang & Posner (2009); LoPresti et al. (2004), Kapur, Glisky & Wilson (2004), Bergman (2002) and Lynch (2002).
In relation to specific neuropsychological functions, a broad amount of research has been done to date. Computer-based interventions have proved effective in the rehabilitation of different domains such as attention (Borghesse, Bottini & Sedda, 2013; Jiang et al., 2011; Flavia, Stampatori, Zanotti, Parrinello & Capra, 2010; Barker-Collo et al., 2009; Dye, Green & Bavelier, 2009; Green & Bavelier, 2003; Cho et al., 2002; Grealy, Johnson & Rushton, 1999; Gray, Robertson, Pentland, Anderson, 1992; Sturm & Wilkes, 1991; Niemann, Ruff & Baser, 1990; Sohlberg & Mateer, 1987), memory (Caglio et al., 2012, 2009; das Nair & Lincoln, 2012; McDonald, Haslam, Yates, Gurr, Leeder & Sayers, 2011; Bergquist et al., 2009; Gillette & DePompei, 2008; Wilson, Emslie, Quirk, Evans & Watson, 2005; Ehlhardt, Sohlberg, Glang & Albin, 2005; Glisky, Schacter & Tulving, 2004; Kapur, Glisky & Wilson, 2004; Tam & Man, 2004; Webster et al., 2001; Wilson, Emslie, Quirk & Evans, 2001; van der Broek, Downes, Johnson, Dayus & Hilton, 2000), visuospatial skills (Boot, Kramer, Simons, Fabiani & Gratton, 2008), language (Allen, Mehta, McClure & Teasell, 2012; Fink, Brecher, Sobel & Schwartz, 2010; Lee, Fowler, Rodney, Cherney & Small, 2009; Kirsch et al., 2004b; Wertz & Katz, 2004; Katz & Wertz, 1997), social cognition (Grynszpan et al., 2010; Bernard-Opitz, Srira & Nakhoda-Sapuan, 2001), and executive functions (Nouchi et al., 2013; Johansson & Tornmalm 2012; López Martinez et al., 2011; O´Neill, Moran & Gillespie, 2010; Westerberg et al., 2007; Ehlhardt et al., 2005; Kirsch et al., 2004a; Gorman, Dayle, Hood & Rumrell, 2003).
Computer-based interventions (and micro-computing interventions) have also been applied with positive outcomes to a wide range of psychological impaired profiles such as those occurring due to TBI (Cernich et al., 2010; Gentry, Wallace, Kvarfordt & Lynch, 2008; Thornton & Carmody, 2008; Michel & Mateer, 2006), strokes (Cha & Kim, 2013; Lauterbach, Foreman & Engsberg, 2013; Akinwuntan, Wachtel & Rosen, 2012; Cameirão, Bermúdez I Badia, Duarte Oller & Verschure, 2009; Michel & Mateer, 2006; Deutsch, Merians, Adamovich, Poizner & Burdea, 2004; Teasel et al., 2003; Wood et al., 2004), dementia (Crete-Nishihata et al., 2012; Mihailidis, Fernie & Barbenel, 2010; Cipriani, Bianchetti &Trabucchi, 2006; Cohene, Baecker & Marziali, 2005; Alm et al., 2004; Hofman et al., 2003; Zanetti et al., 2000), multiple sclerosis (Flavia et al., 2010; Shatil, Metzer, Horvitz & Miller, 2010; Vogt et al., 2009; Gentry, 2008), autism spectrum disorders (Sitdhisanguan, Chotikakamthorn, Dechaboon & Out, 2012; Wainer & Ingersoll, 2011; Tanaka et al., 2010; Beaumont & Sofronoff, 2008; Sansosti & Powell-Smith, 2008; Stromer, Kimball, Kinney & Taylor, 2006; Goldsmith & LeBlanc, 2004; Silver & Oakes, 2001; Werry, Dautenhahn, Ogden & Harwin, 2001; Lane & Mistrett, 1996), ADHD (Steiner, Sheldrick, Gotthelf & Perrin, 2011; Rabiner, Murray, Skinner & Malone, 2010; Shalev, Tsal & Mevorach, 2007; Mautone, DuPaul & Jitendra, 2005; Shaw & Lewis, 2005), learning
disabilities (Nisha & Kumar, 2013; Seo & Bryant, 2009 –with recommendations regarding effectiveness-; Kim, Vaughn, Klingner & Woodruff, 2006; Hasselbring & Bausch, 2005; Lee & Vail, 2005; Maccini, Gagnon & Hughes, 2002; MacArthur, Ferretti, Okolo & Cavalier, 2001; Hall, Hughes & Filbert, 2000), intellectual disabilities (Cihak, Kessler & Alberto, 2008; Mechling & Ortega-Hurndon, 2007; Ayres, Langone, Boon & Norman, 2006; Ortega Tudela & Gómez-Ariza, 2006; Standen & Brown, 2005; Furniss et al., 1999), schizophrenia (Sablier et al., 2011; Suslow, Schonauer & Arolt, 2008 –with recommendations for future research-; Medalia, Aluma, Tryon & Merriam, 1998; Hermanutz & Gestrich, 1991), or social phobia (Neubauer, von Auer, Murray, Petermann, Helbig-Lang & Gerlach, 2013; Schmidt, Richey, Buckner & Timpano, 2009). Computer-based interventions can also be a tool for training of cognitive skills in normal aging (Kueider, Parisi, Gross & Rebok, 2012; Cassavaugh & Kramer, 2009; Basak, Boot, Voss & Kramer, 2008; Flnkel & Yesavage, 2007; Rebok, Carlson & Langbaum, 2007; Jobe et al., 2001).
Some experimental and clinical issues should be controlled to adequately assess the factors and effect of computer-based cognitive rehabilitation. Santaguida, Oremus, Walker, Wishart, Siegel & Raina (2012) recently identified some methodological flaws in strokes rehabilitation reviews. These aspects extend to computer-based studies and therefore must be addressed. They showed that primary studies had problems with randomization, allocation concealment, and blinding. Also, baseline comparability, adverse events, and co-intervention or contamination were not consistently assessed in all studies. Oremus, Santaguida, Walker, Wishart, Siegel & Raina (2012) recommend that researchers rationalize the number of outcome measure instruments used in their studies. The control of additive effects of other coadjutant therapies must also be taken into account. Jack, Seelye & Jurick (2013) have already addressed the generalization of trained tasks versus to untrained tasks in computer-based cognitive rehabilitation. According to their results, “fewer studies have demonstrated improvements in untrained tasks within the trained cognitive domain, non-trained cognitive domains, or on measures of everyday function. Successful cognitive training programs will elicit effects that generalize to untrained, practical tasks for extended periods of time”. Reviews of meta-analysis recommend stronger methodological designs. For a good review of the principles that should be taken into account in computer-based learning research, we recommend Cook (2012, 2005). Van Heugten, Gregório & Wade (2012) suggest the development of “an international checklist to make standardised description of non-pharmacological complex interventions possible”.
In conclusion, computer-based interventions can effectively facilitate improvement in many activities that would otherwise not be possible, but future research must control relevant parameters in computer-based cognitive rehabilitation studies.
BASES OF REHABILITATION
Hierarchical model of the CNS
The central nervous system can be divided into three
hierarchical axes with functional specialization.
Anterior-posterior or rostral-caudal axis
In which anterior or frontal areas manage abstract content rather than specific, and more complex types of information possibly involved in the monitoring and integration of contents and processes. In this respect, we can observe control processes in cognitive and emotional functions. While the anterior regions contain more complex representations of the emotional contents, regarding emotional functions, the insula, the posterior regions—posterior cingulate cortex, posterior insula—and the middle cingulate cortex, all support the functionality of first-order processes that manage sensory information. In general, this happens too with attentional and cognitive contents. In attentional processes we can see how the most frontal areas monitor and guide the search based on complex contents (for example, goals), while the most posterior cortical regions (for example, the parietal lobe) guide the process based on the stimuli and not on reflective process.
The cognitive content of the anterior regions is more complex as well. The anterior frontal regions, for instance, control conscious and reflective processes, monitor the actions that we perform and use modality-specific information that is received from different areas of the brain directly (communication between frontal areas), and through association areas.
On the whole, the complexity of the representations contained in the rostral regions is greater, and is used to develop abstract schemata, higher-level cognitive functions and conscious and volitional action commands. In addition, the rostral regions in this plane are capable of integrating different kinds of information from other more posterior parts of the brain, for example, simple inputs about locations or luminance.
Cortical-limbic or dorsal-ventral axis
In which dorsal regions are responsible for reflective or cognitive processing. By contrast, the ventral regions are responsible for a stimulus-driven or emotional processing. Among the more dorsal structures we find the anterior cingulate cortex or ACC—especially the rostral ACC—and in ventral regions we find the amygdala”, which is an automatic node of emotion. It is logical to think that these have a more automatic processing such as, for example, situation-based strategies, as is the case with the implication of the rostral ACC in modulating the amygdala in the resolution of conflict. On the other hand, the reappraisal, which is a cognitive control of the emotional processing, a reflective strategy based on oneself.
In which medial structures are responsible for processing focused on the individual and his/her internal cues, while lateral structures are responsible for visual and spatial aspects and the representation of characteristics of the external world. In this sense, medial areas are closer to the emotional centers, and as a result, they have a greater number of interconnections due to the cytoarchitectonic organization and therefore, both influence or regulate each other. In fact, the emotional structures are those responsible for giving information to the subject about his/her internal states, thus the further we move away (cytoarchitecturally) from these areas, the functional relationship grows smaller. Structures with more depth have connections with the autonomic nervous system and, therefore with the arousal, these structures influence those data-driven events. By contrast, more superficial structures in some way modulate the structures that belong to the autonomic nervous system with reflective processes.
Brain plasticity refers to the brain’s capacity to reorganize its patterns of neuronal connectivity and readjust its functionality. Neural plasticity is not only found in acquired brain injury but also in active aging and even in Alzheimer’s dementia (though neuronal degeneration attacks new hippocampal structures that reduce the ratio of neurogenesis).
Functional rehabilitation takes advantage of this phenomenon to generate new synapses, even though the effect may be limited in the recovery of functional deficits. As of today, there are no parameters that guarantee a permanent therapeutic window for this phenomenon because it depends on factors such as the type of injury, age and others such as recovery. Brain-computer interfaces have been used to augment plasticity and outcomes for neurological rehabilitation. Skill learning after brain injury and other diseases draws upon spared neural networks for movement, sensation, perception and cognitive functions. Physiological basis for neurorehabilitation depends on these mechanisms (Dobkin, 2007):
- Changes in neuronal tuning to parameters of movement.
- Variability of neuronal firing as practice and reward proceed.
- Hebbian strengthening of neural ensembles with remapping of representations for movements.
- Recruitment of remote or correlated activity from ensembles within a network.
- Other self-regulation and learning-associated processes.
New neurons are continuously generated in the adult human brain (Ming & Song, 2011; Boyke, Driemeyer, Gaser, Büchel & May, 2008; Ge, Sailor, Ming & Song, 2008; Fuchs & Gould, 2000; Gross, 2000; Eriksson, Perfilieva, Björk-Eriksson, Alborn, Nordborg et al., 1998). From this point of view, plasticity may result from two potential different mechanisms (Ming & Song, 2011): renewing neurons and/or multi-potential differentiation of neurons. Rates of these processes are significantly slower in the adult brain than in the child brain.
But, how can a small number of neurons affect the global functioning of a brain? Ming & Song (2011) mention that the answer may reside in the capacity of adult-born neurons both as encoding units and as active modifiers of mature neuron firing, synchronization, and network oscillations. They propose some principles by which this can be possible:
- Adult-born neurons are preferentially activated by specific inputs
- Adult-born neurons actively inhibit local circuitry output
- Adult-born neurons also modify the local circuitry through selective activation of modulatory pathways
- Newborn neurons could contact several distinct subtypes of local interneurons
Plasticity could enhance learning processes in three levels (Berlucchi, 2011): a neuronal level, a synaptic level (changing connectivity spines or newly formed neurons as a consequence of experience and adaptation) and a network level (changes in functional connectivity as a result of the modification of existing synapses or the formation of novel synaptic connections). These levels are not mutually excluding. Short-term and long-term spine remodeling, including formation, elimination and shape and size changing, as well as axonal sprouting, are principal means by which both maturation and experience can organize neuronal connectivity (Álvarez & Sabatini, 2007) through long-term potentiation and depression of synaptic transmission caused by neurotrophic factors, which modulate synaptic strength. Neurotrophic factors are also influenced by experience through epigenetic regulation of genes (Cowasange, LeDoux & Monfils, cited by Berlucchi, 2011).
Plasticity is a natural phenomenon that entails brain adaptation to tasks and age. In older brains, compensatory mechanisms are required for a better performance in specific working memory tasks: elder brains show widespread activity, with a diffuse cortical activation. This may represent a compensatory response (Dennis & Cabeza, 2011). Regardless, plasticity as a maturation and learning phenomenon and plasticity that takes place after brain injury are not the same, and differences among these processes should be clarified before making any conclusion.
There are diverse environmental factors that can affect plasticity. Among others, stress or insulin deficiency syndromes (a profile that could be related to Alzheimer’s disease) decrease the rate of neuroplasticity in adult brains. On the other hand, physical exercise increases cell proliferation (van Praag et al., 1996; cited by Ming & Song, 2011). Learning modulates adult neurogenesis in a specific fashion (Zhao, Deng & Gage, 2008). For example, some types of adult neurogenesis are only influenced by learning tasks that depend on the hippocampus. Studies have suggested significant contribution of adult hippocampal neurogenesis to (Deng et al., 2010):
- Spatial-navigation learning and long-term spatial memory retention.
- Spatial pattern discrimination.
- Trace conditioning and contextual fear conditioning.
- Clearance of hippocampal memory traces.
- Reorganization of memory to extrahippocampal substrates.
How to rehabilitate
The therapeutic strategy will be selected based on the severity of deficits, the elapsed time since injury, and the profile of the cognitive deficit. But in a general manner we can establish the following distinctions (Lubrini, Periáñez, & Ríos-Lago, 2009):
- Re-establishing previously learned patterns of behavior and cognitive activity
- Establishing new patterns of cognitive activity by means of substitution strategies.
- The introduction of new patterns of activity thanks to internal and external compensatory mechanisms.
Rehabilitation helps patients and their families to adapt to the new condition of disability in order to improve the patients’ overall level of functioning.
Zangwill (1947) distinguished compensation, a reorganization of behavior aimed at minimizing a particular disability, from substitution, the accomplishment of a task by new methods different from those naturally employed by the intact brain in the performance of that particular task.
The evolution of functional recovery following brain injury may be ascribed to four basic events and principles (Edelman & Gally, 2001):
- a spontaneous disappearance of the acute effects of traumatic or ischaemic lesions.
- a reversal of diaschisis, that is, a reversal of the temporary depression of activity in uninjured brain regions following their disconnection from the injured region.
- the principle of vicarious function, that is, the taking over of the functions of the injured part of the brain by distant back-up areas endowed, inherently or by acquisition, with the same functional capacity.
- the principle of redundancy, that is, the maintenance of the function of a damaged system by those parts of the same system that have escaped injury.
- the principle of degeneracy, that is, the performance of the same function by multiple differentiated neuronal systems either through similar mechanisms or by applying different strategies.
The essence of therapy is progressive practice of subtasks and more complete intended goals using physical and cognitive cues with feedback about performance and results (Dobkin, 2005). Nonetheless, we have to take care of the strategy implied in our therapy because the potential for functional recovery of a damaged neuronal system may be suppressed through a disuse process caused by compensation and substitution strategies (Belucchi, 2011).
Cognitive rehabilitation should be guided by the following principles:
- Be based on theoretical models and scientific evidence.
- Have a multidisciplinary perspective.
- To establish a priority of objectives.
- Use tools as a help to get objectives, not as a solution by itself.
- Adjust time and intensity of the treatment according to the patient´s characteristics and evolution.
- Consider autonomy as the main goal instead of cognitive deficits.
- Be focused on preserved skills with the objective to enhance weak cognitive skills, functional outcomes, and behavior.
- Take care about motivational intervention. Identify significant reinforcers for the patient.
- Include tasks that help generalization.
- Design a flexible rehabilitation schedule that allows objective modification.
- Environment of the patient should be analyzed to find significant reinforcers.
Orientation is a cognitive function whose goal is to locate the subject in a specific parameter of his/her environment. As a result, it requires information relating to spatial location, in addition to functions of attention, memory (episodic and semantic), and working memory. Orientation is defined as the awareness of oneself in relation to the characteristics of one’s surroundings: place, time, and personal history. It requires the integration of attention, perception and memory (Lezak, 2004). Deficits in perception or memory can result in mild impairments in orientation, while alterations in the subsystems of attention can result in severe impairment in orientation at all levels. The dependence on other systems makes orientation especially vulnerable (however, its presence does not rule out cognitive damage since orientation is also influenced by routine).
There are three types of orientation:
Temporal orientation: are updating processes whose output informs about situations related to the day, time, month, year, moment of performing behaviors, public official holidays, seasons, etc. Temporal orientation depends largely upon sustained attention and semantic memory, while selective attention captures the changes in the environment that determine an organized process of time—the moment of performing an action (to have dinner, to get up), what does it mean (in relation to the weather) that it is snowing, etc—. Temporal orientation differs from temporal estimation, since this metacognitive process entails:
– Either an estimate of elapsed time (vigilance, decision making, perception).
– Or an estimate of the amount of time we can spend on an activity (which depends on planning and prospective
Spatial orientation: are updating processes in which the subject is able to locate himself/herself in a spatial continuity (where he/she is coming from, where he/she is at a specific moment, where he/she is going). Spatial orientation depends, in the first place, on the orientation of visual attention, sustained attention, selective attention and memory.
Personal orientation: personal orientation is the most complex process out of the three, as it usually requires multimodal information that involves personal identity, and a mechanism of control that verifies the information (in case of failure, confabulations could occur). Some authors have referred to this type of orientation as autonoetic consciousness (Tulving, 2002). Autonoetic consciousness involves the reorganization of contents of the autobiographical episodic memory in relation to the present moment, involving a sense of self-continuity. In order to have access to this type of information, encoding algorithms are required in the first place and then, the working memory updates that content, thereby connecting it to the present time and moment resulting in a sense of self-continuity
Dependence of functional systems
Orientation involves remembering. Therefore, it is a system whose traces are cortically distributed throughout the whole central nervous system but with special relevance for the hippocampus. The influence of some hippocampal structures differs depending on the type of orientation, but it is a function particularly linked to this structure. In fact, orientation tasks are usually used mainly with persons with dementias associated to this structure. There are several reasons for this:
In the first place, the type of information that is required changes quite often (especially temporary information) and depends on very recent memory traces. If the hippocampus has not been able to develop algorithms that connect mnestic information to cortical traces as a result of brain injury, those neural traces disappear. Secondly, the update of contents depends largely upon working
memory. Though it is true that working memory is an executive process widely distributed throughout the central nervous system (although with functional predominance of the dorsolateral prefrontal cortex), in dementias there is usually a general alteration in white matter tracts that affect the integrity of the task-positive network (in opposition to the default-mode network). This alteration causes a disconnection between systems responsible for retrieving and updating information (prefrontal cortex, longitudinal fasciculi), memory traces (grey matter), and mechanisms that generate algorithms to facilitate access to those traces (hippocampus).
This disconnection is progressive and decline in orientation occurs in parallel to it. Thus, the most recent and variable data (day, time, new place, recent births within the family, names of people we recently met, age…) is the first lost, while older data is more resistant to decay because neural algorithms belong to more consolidated networks.
Models used to design materials
The principles used in the design of orientation activities are primarily based on two models: the Reality Orientation and Reminiscence Therapy—a flexible model that relies on external aids—and the Orientation Remediation Module developed by Ben-Yishay (Ben-Yishay et al., 1987) that is based on Posner and Petersen’s model of
The Reality Orientation and Reminiscence Therapy has as its objective temporospatial re-orientation and the reinforcement of the foundations of the patient’s personal identity by repetitively presenting information regarding orientation with the use of various external aids (ArroyoAnlló, Poveda Díaz-Marta, & Chamorro Sánchez, 2012). The materials are designed based on two factors: an individual one, with activities that the therapist administers to the patient daily, and a group one, with activities that can be performed by several subjects using interactive scoreboards. Specifically, reminiscence interventions manage similar age groups and encourage the sharing of autobiographical stories that promote group cooperation to build meanings from the biography (personal and shared) of the persons in the group. In order to do so, it is necessary to integrate content such as photographs, videos, songs, words, etc. NeuronUP provides user-friendly and easy-to-use (by both therapists and patients) interfaces to share those contents.
The Orientation Remediation Module created by Ben-Yishay possesses a more defined attentional nature and a significant theoretical structure that agrees with the general premises we use in NeuronUP, especially the concept of functional hierarchy. In functional hierarchy, activities designed for orientation stem from the first hierarchical stage of the modules developed by Ben-Yishay that focuses on increasing the level of alertness. Additionally, some concepts from the Montessori Intervention Model have been adapted to design the activities in this area. This is due to the fact that orientation activities are mainly formulated (although not exclusively) for intervention in dementias.
Attention is a complex cognitive function involving several subsystems and has been explained in different manners. Next, I will briefly explain Posner’s definition (1995). For Posner, attention is “the selection of information for conscious processing and action, as well as maintaining an alert state required for attentional processing” (Posner & Bourke, 1999, mentioned by Benedet, 2002.). attention is a limited capacity function that distributes cognitive resources of the central nervous system based on situation schemata (ORIENTATION), and according to information priority. It has two main functions: maintaining a vigilant or alert state, and the selection of relevant information that the resources are going to manage (MONITORING AND CONTROL). The characteristics of attention are the following (Posner, 1995):
A.- Attention does not process information; it either allows or inhibits that processing. attention is anatomically separate from the information processing systems.
B.- Attention utilizes a network of anatomical areas. It is neither the property of a specific area of the brain, nor a general result of the brain.
C.- The brain areas involved in attention do not have the same function, but different areas carry out different functions. attention is not a unitary function.
Which anatomical networks underlie attention?
In attention there are three anatomical networks that function as “small-world networks” connected on a large scale.
– Ascending reticular activating system (Posner, 1995): controls tasks of tonicity, regulates the sleep-wake cycle and the state of arousal. Its main nuclei are found in the brainstem although its networks extend through the ascending pathways throughout the cerebral cortex. Its main neurotransmitter is the norepinephrine (NE). The main NE inputs of the locus coeruleus project to the parietal area, the pulvinar nucleus of the thalamus and the culliculi, that is, the areas that constitute the posterior
– Cingulo-opercular network (Dosenbach et al., 2008): consists of the anterior prefrontal cortex, anterior insula, dorsal ACC, and thalamus. It provides stable set-maintenance throughout task execution.
– Frontoparietal network (Dosenbach et al., 2008): includes the dor- NeuronUP Theoretical framework: General Concepts 23 solateral prefrontal cortex, inferior parietal lobule, dorsal frontal cortex, intraparietal sulcus, precuneus, and midcingulate cortex. It plays a role in initiating and adjusting cognitive control responding differentially depending on the feedback that is received from our behaviors.
The frontoparietal and cingulo-opercular networks work in parallel and are connected through the cerebellum, which functions as a hub between the thalamus (cinguloopercular) and the precuneus, the inferior parietal cortex, and the dorsolateral prefrontal cortex (frontoparietal), acts as an error-detecting mechanism, and connects with those areas that detect (anterior cingulate cortex) and adopt strategies (frontoparietal network) for the perceived error.
These anatomical networks are integrated in two different ways or forms (Corbetta et al., 2008), creating a double network of attentional execution:
• A ventral network, dedicated to detecting salience of environmental stimuli
• And a dorsal network that is activated during focal attention tasks sustaining attention over time and that also acts by being directed by the ventral network.
Both networks are indirectly related through the prefrontal cortex.
Which cognitive processes define
We have established a hierarchical model similar to the one developed by Ben-Yishay but focused on functional concepts. Each one of the processes involves a different complexity because the tasks (activities) designed by NeuronUP start from simple levels in which the activity in its most isolated form is put into play, while in complex levels of those same activities, the neurocognitive processes are combined depending on internal attentional control (demand) that the subject must maintain. We have distinguished the following functions:
• Perceptual speed: refers to the speed of processing. While originally this variable was included in the visuospatial skills, the factorialization carried out by Miyake et al. (2000) demonstrates that the executive demand in this kind of tasks is very low in comparison to other visuospatial processes that require working memory.
• Sustained attention: is the ability to maintain a continuous focus of attention.
• Selective attention: is the ability to focus on a stimulus while discriminating other environmental stimuli.
• Alternating attention: is the ability to alternate two (or more) cognitive sets, which in turn requires the ability to maintain them in the phonological loop.
• Heminegligence: Inability to alternate, orient, and/or direct the focus of attention from a sensory hemifield—visual, auditory, body, etc.—to the opposite (usually the affected hemisphere is the left one). We consider that, although heminegligence can be considered a problem of spatial orientation (Lezak, 2004), there is also literature that considers it an attentional disorder for its therapeutic approach (Sohlberg & Mateer, 1987, among others). We distinguish this disorder from those problems in the orientation of somatic hemifields that involve a lack of recognition of the body schema.
Models used to design materials
There are several main models we use to base our rehabilitation of attention on. Before explaining these models, it is necessary to remember that attentional processes are not separated from other functions such as memory,
executive functions or social cognition, and they are the anatomic functional basis to all of those:
- Orientation Remediation Module developed by Ben-Yishay (1987): reaction time tasks; attentional control and awareness of
attentional processes; maintenance of attentional processes; attentional control processes and alternation.
- Attention Process Training Programs (Sohlberg & Mateer, 1987): we utilize a concept in which tasks are hierarchically ordered according to their difficulty levels that finally include complex components of attentional control and working memory. The authors conceptualize the rehabilitation of attention from specific subprocesses that define it.
- Specific attentional skills training.
- Time Pressure Management Fasotti, Kovacs, Eling & Brouwer (2000).
- Metacognitive strategies (Ehlhardt, Sohlberg, Glang, & Albin, 2005).
Clinical syndromes characterized by a failure of recognition that cannot be attributed to the loss of primary sensory function, inattentiveness, general mental impairment, or lack of familiarity with the stimulus (Frederiks, 1969), and neither attributed to deficits in aphasia. Agnosias are sensory modality specific: the access to recognition can occur through a different sensory modality.
In Neuropsychology there is a problem in the conceptualization of perceptual disorders that could be labeled as historical. Since the concept was formulated, it has not yet been clarified whether the gnostic problem or disorder is due to an alteration in the memory store, to a perceptual alteration, or even to an attentional problem.
In this section we will principally focus on visual agnosias for we consider them as the most disabling since we are beings that process the external world mainly through vision.
The difficulties in the formulation of a theory of visual recognition have not been resolved, despite attempts by several authors to develop approaches regarding the phenomenon. This dichotomy derives from two schools of thought: one based on a computational analysis of visual perception, and another based on neuropsychological data that seeks to corroborate a theory of visual perception.
Thus, Marr and Nishihara’s representational model (1978; Marr & Vaina, 1982) proposes a computational solution that has received empirical support, but not enough to be completely corroborated. Biederman’s “geons” (geometric ions) model has more psychophysical support than Marr and Nishihara’s, but the theory is not clear in regards to the quantity of existing primitive geons and this makes it less accessible. During the era of computational theories of vision, there are references to the high-level analysis but not to the lower levels of visual processing.
At NeuronUP we accept as valid (due to the amount of empirical support) an extension of Marr and Nishihara’s model, specifically, Humphreys and Riddoch (2001). We also consider that there is enough empirical evidence to take into account alternative models such as Farah (2004), or Warrington and Taylor (1978).
Warrington and Taylor propose a model that overlaps in some way with the apperceptive and associative agnosias proposed by Lissauer. A visual analysis takes place during the first stage of the perception process and is carried out in the same way in both hemispheres. The next stage is termed perceptual categorization and represents those processes that enable object constancy by establishing that two different views of an object are in fact representations of the same thing. After perceptual categorization comes semantic categorization. This involves the attribution of meaning to the percept.
To Farah, there are two independent recognition systems: one based on part-based processing (that analyzes the parts of the object based on stored representations of such characteristics) and another system based on holistic processing (that analyzes the match between the stored holistic representations and the input). This is compatible with the structural-description models—part-based system—and with the view-based models— holistic system—. Farah uses these two systems to explain the evidence of disorders of recognition, which are explained based on the dysfunction of these two systems:
– Prosopagnosia responds to a dysfunction in the holistic system.
– Alexia responds to a dysfunction in the part-based system.
– Object agnosia is explained based on a partial deterioration of one or both systems. The deterioration is defined by the degree to which an object is recognized on the basis of configural or featural information.
Therefore, Farah proposes a viewpoint continuum in which the extremes are the analysis systems that explain pure syndromes. The difference in intensity between both extremes would explain the diversity of gnostic deficits.
According to Kolb and Wishaw, there are several theories that establish relations between neural networks and specific aspects of spatial behavior. Thus, the dorsal stream subserves “vision for action”, unconsciously guiding the actions in space in relation to the distribution of the objects and ourselves in space (thereby involving egocentric spatial behavior). On the other hand, the ventral stream subserves “vision for perception”, consciously guiding the actions in relation to the identity of the objects (involving allocentric spatial behavior).
Humphreys and Riddoch’s model (2001) is an extension of Marr and Nishihara’s, complementing it with a series of intermediate steps and including the integration of top-down and bottom-up perceptual processes. In the first stage there is a processing of the basic features of the stimuli (color, form, depth, motion) generating a primal sketch (from the perceptual representation systems—see Schacter, 1994). In the second stage, a general contour of the object is sketched in 21/2D to afterwards represent a 3D sketch to perceive the object in a canonical view (although objects can be also recognized by salient features in non-canonical views). Once we gain access to stored knowledge about the features of the object, we search in the memory traces for two types of information: one regarding the object’s form, and the other regarding its semantic characteristics.
A special case of visual processing is that of face processing, for which the reader can refer to Ellis and Young (2000) and to Marta Farah’s theory.
Types of agnosias
- No access to the perceptual structure of visual sensations.
- Subject can neither draw nor match.
- Awareness of the deficit.
- Search for features of the object that can lead to recognition but are usually sources of constant error.
- In mild forms (of apperceptive agnosia): errors in the identification of overlapped images.
- Location: heterogeneous, unilateral or bilateral posterior lesions; damage can be extensive and diffuse—lesions are localized in the posterior parieto-temporo-occipital area bilaterally although sometimes lesions are focal, and affect the inferior temporooccipital gyri, the lingual gyrus and the fusiform gyrus.
The apperceptive nomenclature for all deficits observed is not exhaustive. Many patients show specific deficits and can perform some perceptual tasks while not others (e.g., the patient can discriminate forms and not objectdepth discrimination):
- Form agnosia
- Transformation agnosia / Perceptual categorization deficit: inability to recognize objects from their non-canonical or unusual view
- Integrative agnosia: inability to recognize the overall relation between the details of a whole. Object-decision tasks with simple line drawings and silhouettes
- Simultanagnosia: inability to recognize complex images while perceiving the details, parts or the isolated objects but without being able to integrate the parts into a coherent whole; subjects cannot see more than one object at the same time
- Dorsal: results from bilateral parieto-occipital lesions; related to oculomotor disorders.
- Ventral: due to left temporooccipital lesions; associated to perceptual problems.
- Deficit in recognition despite normal perceptual ability. In order to distinguish it we have to check if the subject stores the description of an object and is able to copy it.
- Subjects cannot not match objects by categories or functionality, and make morphological, functional and perseverative errors.
- To try presenting the stimulus through another sensory modality.
- Lesions are usually localized in the posterior region of the left hemisphere.
• Structural: failures in the structural representation of objects. Tactile recognition is preserved. Subject can make copies of drawings. Real objects better recognized than images. Bilateral lesion of lingual and fusiform gyri.
• Multimodal: failures in the recognition of objects and their functions. Perseverative and semantic errors in naming. On verbal command, the subject is unable to mime the use of objects. It is typical that access does not occur through other sensory modalities. Drawing performance is poor, as well as the descriptions of objects in contrast to the abstract words. Lesion in BA39—left angular gyrus—or in its afferent pathways, the lingual and fusiform lobes.
• Category-specific: deficit at the level of structural description system or at the level of accessing such system. Dissociation between object recognition and action recognition. The deficit contrasts with the preservation of verbal knowledge in object naming from its verbal definition. Deficit in semantic memory may exist.
Disorders of color recognition and cerebral achromatopsia
Subject is unable to name colors visually presented or unable to select a color named by the examiner.
– Cerebral achromatopsia: inability to perceive color in all or in a part of the visual field. It results from unilateral or bilateral lesions in the inferior ventromedial sector of the occipital lobe, the lingual and fusiform gyri, specialized regions of the brain for the encoding of color.
– Color agnosia: failure to match colors with objects.
– Color anomia.
Inability to recognize and/or integrate facial features into a recognizable or coherent whole:
– Usually bilateral temporo-occipital lesions, although it can result from right unilateral lesion of the occipito-temporal junction in connection with the right parahippocampal region.
• Primary progressive prosopagnosia.
• Amnesic prosopagnosia.
Other types of agnosia based on sensory
Models used to design materials
There is not a specific model to rehabilitate agnosias, since they depend on each specific modality. However, there are specific techniques for the compensation of functional deficits caused by agnosia. In this sense, although it is probable that the rehabilitation models based on virtual reality and hardware may improve the rehabilitation of some types of specific agnosia (especially spatial and tactile agnosias, and imaginative processes), software can also be applied to the rehabilitation of visual and auditory agnosias, and even helps in the interventions of other modalities.
The goal of our activities is to favor visual scanning and discrimination of visual features (visual agnosias); construction and discrimination in 3D; to associate auditory stimuli and specific forms/objects/persons by means of discrimination strategies; to differentiate words from non-words, etc. To that end, we carry out specific training of visual exploration by designing materials that can be analyzed by using self-instructions.
– Design of cutout materials that can be used to discriminate forms, to make a step-analysis of the differential features of the object, to estimate depth, etc.
– Discrimination of shades of colors.
– Hue-discrimination tasks.
– 3D construction tasks.
– Discrimination between similar salient stimuli.
– Activities in which there can be recognizable stimuli in order to discriminate similar objects of different nature (dangerous vs. safe objects).
– Design of drawings and maps for spatial orientation.
– 3D puzzles.
– Design of programmes for discrimination within and between spatial hemifields.
– Design of instructions and guidelines for object analysis.
Clarification: Those disorders apparently praxic that are due to a deficit or impairment
of the conceptual system (involving knowledge) of objects (i.e., the subject
does not know that X is a tool) are not included. Other aspects of the conceptual system
involved in praxis are included: motor act schemas using tools, objects, or execution
of movement with body parts, recognition of gestures and motor planning
(Sequencing in motor execution). In addition, deficits in executing motor commands
in relation to space-time are included—production system. Sensory deficits
or deficits due to bradykinesia or other motor disturbances are not included, nor
are disturbances in comprehension, executive functioning (planning), or deficits
Apraxia is not a disorder due to the loss of the ability to find meaning in objects, nor to a primary motor dysfunction. Apraxia is a heterogeneous deficit of cognitive-motor nature, in which the ability to execute or carry out purposeful movements is disturbed, not attributable to deficiencies in understanding, agnosia or motor problems (tremor, ataxia, posture disturbances).
Apraxia is strongly associated with corticobasal degeneration, lesions in the left hemisphere, and dementia. Despite its importance in clinical reality, the problem in the formulation of apraxias is much worse than in the formulation of agnosias, as previously mentioned. This is due to two aspects: on the one hand, the original description of the concept (Liepmann, 1900); and on the other hand, the extensive distribution of the main anatomical networks that support this function (frontotemporal and frontoparietal circuits—”mirror neuron system”—, basal ganglia, cerebellum and white matter).
A model widely used in the explanation of apraxias is the one proposed by Rothi, Ochipa and Heilman (Junqué, 1999); this model distinguishes two visual pathways to access information (imitation and object action) and one verbal pathway (action performed to command). Visual and auditory analyses enable access to input lexicons, while the output action lexicon is responsible for the production and execution of movement. The types of motor actions that are altered in apraxia are:
• Transitive movements: related to the use of objects.
• Intransitive movements: related to the execution of symbolic gestures, nonverbal communication [meaningful], or intransitive meaningless gestures [imitation].
Types of apraxia
Spatial and temporal components of motor execution: action programs, execution of motor act (spatial and temporal).
Conceptual component of motor execution: knowledge of object’s purpose, knowledge of actions, and knowledge about the organization of actions into sequences.
Buccofacial and ocular
Clarification: Language disorders such as apraxia of speech and apraxic agraphia
are not included in this section, although some authors conceptualize them as disturbances
in the execution and/or conceptualization of the motor engrams for speech
production. This type of disorder is discussed in the section of Language.
Buccofacial: ability to perform intentional movements with facial structures including the cheeks, lips, tongue and eyebrows.
Ocular: eyelid apraxia and ocular apraxia are included. Eyelid: ability to perform eyelid movements. Ocular: ability to perform saccadic eye movements on command.
It is the ability to perform the motor act, correctly distributing (the whole-part relationship) the execution of movement in its spatial and temporal parameters. It requires planning—in relation to visuospatial estimates of the object made by the subject—to execute the action. The difference with planning (in EF) is that this is a specific case that involves the motor act and its execution, while that (EF) involves semantic and temporal estimates of acts, but not necessarily the execution of motor engrams. In this section are included visuospatial skills that involve motor execution and mental transformations with objects, as long as they have no relation to transformation agnosia.
Brief considerations on apraxias: An alternative classification according to neuropsychological assessment may be established (transitive gestures, intransitive gestures, gestures to imitation, gestures to command, with tools, spontaneous gestures, single acts, serial acts). This classification could also be complemented with the models proposed by Cubelli et al. (2000) or with the model of Buxbaum & Coslett (2001).
Functional systems in apraxia
The functional systems involved in apraxia are diverse. We can distinguish
up to six systems involved in movement. Each one of those systems has a functional specificity, but as in the case with attention, movement is an activity composed of interrelated subprocesses.
is involved in the fine-tuning of movements and its temporospatial execution. It is a node that contains motor learning and assists in correcting movements, by carrying out monitoring.
they are important nodes for movements, and their function is to regulate and filter neuronal information from other areas (i.e. thalamus) to be processed in cerebral cortex. Basal ganglia have an opposite effect on movement depending on the pathway involved in it. The direct pathway increases the excitatory drive from thalamus to cortex, turning up motor activity. The indirect pathway decreases the excitatory input from thalamus to cortex, turning down motor activity. Also, basal ganglia have an important role in the reward system, taking part in the prediction of immediate and future rewards (Tanaka, Doya, Okada, Ueda, Okamoto, & Yamawaki, 2004).
Parietal lobe (areas 5 and 7):
area 5 is especially involved in the manipulation of objects, while area 7 is involved in visuospatial skills regarding movement.
Left inferior parietal lobe:
stores engrams that are automatized with each experience; when we perform automatic movements in order to make decisions, these areas are a “store” where patterns of previously learned movement can be found.
Brodmann areas 39 and 40 (left angular and
are multimodal or polymodal areas that are important for the integration of sensory information which allows to transform the representations into movement.
As we move towards an anterior pole of the brain, functions become less automatized and involve high-level cognitive processes (planning, temporal sequencing, retrieval of memory schemas, decision making, flexibility).
Cortico-thalamic-basal ganglia loop:
supplementary motor area, premotor cortex and primary motor cortex. It is an articulatory loop of motor nature, a network that processes movements at a high cognitive level to send them to the different nuclei responsible for motor execution.
carries out the necessary computations for decision making regarding movement, adapts motor strategies, monitors the feedback of the motor act, and generates patterns of movement.
Strategies for the rehabilitation of
Analysis of motor execution in each patient enables the establishment of the specific cognitive processes that are altered. Depending on the altered process, during rehabilitation an emphasis is put on one or another technique. It is also relevant to establish the type of behavior to be rehabilitated. In some occasions, the goal of rehabilitation is the imitation of gestures, while in other cases the goals are to carry out purposeful sequences or rehabilitation involving the use of a particular tool. In any case, the goal (Buxbaum et al., 2008) should not be to cure apraxia, but to compensate for impairments, to aim at enabling independent function, and to minimize the extent to which apraxia influences performance of daily life.
The treatment of apraxia (and other deficits involving spatial functions) usually includes proprioceptive stimulation.
There are two main approaches in the rehabilitation of apraxia (Edman, Webster, & Lincoln, 2000): generalization of the training, and functional approximations.
Generalization of the training begins with the notion that a patient can generalize the training in a functional area that is characterized by simple content and functional activities more complex but similar.
Functional approximation aims at rehabilitating or compensating the symptom rather than the cause, and employs specific activities of daily living.
Both models have been used in the activities that we have designed.
The materials are designed with the purpose of being meaningful and entertaining for the subject undergoing rehabilitation, establishing the sequentiality of actions, and the adaptation of those motor sequences to changing contexts.
For behavioral rehabilitation we have conceived a project in which the subject can see his/her actions simultaneously on the computer through axes that divide space, so that the subject receives immediate feedback about his/her performance.
The principles that guide the design of materials are shaping, chaining, successive approximations, and errorless learning (although in many apraxias, the cerebellum is preserved and capable of storing new learnt information, so that in order to receive feedback and train movements errorful learning may be required).
We have also incorporated some techniques and aids into the activities and are considering the possibility of introducing personalization into the instructions used for the analysis of movement sequences, the cues in the execution of movement sequences, the use of imitation and the possibility to incorporate in the platform videos featuring imitation and repetition.
One of the future goal in the rehabilitation of apraxia is the systematization of multiple behaviors with the possibility of personalizing the successive approximations.
Visuospatial skills are the abilities to perceive, apprehend and manipulate an object mentally. Since they are abilities requiring intrapsychic orientation and mental manipulation of spatial elements, we distinguish them from perceptual skills—addressed under visual agnosias—location in space—addressed under orientation and body agnosias—and from the spatial component of movement—addressed under apraxias.
Therefore,visuospatial skills are a specific component of visuospatial function that deals exclusively with perception, apprehension and manipulation of mental objects. Alterations in visuoconstructive skills are “disturbances in formulative activities, in which the spatial form of the product proves to be unsuccessful without there being an apraxia of single movements” (Benton, 1969). They are associated with lesions of the nonspeech hemisphere of the brain, and frequently appear with defects of spatial perception. These deficits are among the most probable dysfunctions following damage to the parietal lobe, independently of the hemisphere. They involve an alteration in the ability to construct two-dimensional or three-dimensional forms. Occasionally they seem to be associated with defects in perception. Lesions of the right and left hemisphere tend to have different effects on construction.
Visuospatial skills: Visuospatial working
Visuospatial working memory is considered a subcomponent of working
memory, related but not overlapped with executive functions.
The visuospatial sketchpad serves as a working system with limited storage capacity, is not specific (of a sensory modality), and is capable of integrating visual and spatial information into a unitary representation (Baddeley, 2007).
Visuospatial processes (less automatized than verbal processes, composed of less familiar items, and with a more complex verification process of the result) demand greater executive involvement and therefore are more sensitive to disruption during the performance of other tasks that require greater attentional/executive load.
Miyake, Friedman, Rettinger, Shah, & Hegarty (2001) have proposed a triple functional model composed of: spatial visualization, spatial relations, and visuospatial perception.
Spatial visualization comprises processes of apprehending, encoding, and mentally manipulating spatial forms (3D).
Spatial relations (rotation) are mental transformations that involve manipulations of two dimensional objects, and in which speed is a relevant factor.
Mental rotation involves two processes: first, the representation of an object; and second, the mental transformation of that representation, so that the resulting figure is compared with the original.
Finally, visuospatial perceptual speed is the speed and efficiency to make perceptual judgements involving no spatial transformations.
The three factors are separable but they are correlated.
These processes differ in the degree in which they demand executive components (factorially determined by oxygen concentration in brain areas).
Spatial rotation tasks are found at a halfway point of executive demand.
By contrast, spatial visualization tasks require greater executive control while visuospatial perception tasks require lesser executive demand.
The greater the executive demand of the process is—in terms of attentional control and mental manipulation—the greater the relationship with reasoning and psychometric intelligence (Conway, Kane, & Engle, 2003).
Due to the aforementioned, we have included the first of the three factors in the function of attention, since it requires low executive demand and are processes dependent on reaction times.
Anatomical bases of visuospatial skills
Visual imagery and retention of objects are crucial to understand the anatomical bases of visuospatial skills.
Although the current consensus is that visuospatial functions share the neural substrates of visual functions, there is also a visuospatial function that manipulates stable visual representations independent of visual inputs (Moulton & Kosslyn, 2009), transforms them and verifies the responses to the situations.
This skill is strongly related to working memory.
Therefore due to its multifactorial nature it is necessary to understand that these functions are found throughout large-scale neural networks that involve the entire brain.
Because visuospatial skills depend on working memory components, we consider that the dorsolateral prefrontal cortex is fundamental to execute this type of processes.
Besides, the right parietal cortex contains spatial schemas that allow the spatial analysis of objects and even the spatial component of numerical sequences.
Left hemisphere lesions cause disturbances in the sequence of the necessary movements for constructional activity.
Right hemisphere lesions result in the alteration of spatial relations or mental manipulation of spatial relations.
Finally, since this type of cognitive deficits needs to be treated (sometimes even before motor rehabilitation), all the structures involved in movement should be taken into account (i.e., the cerebellum, an important component in mental spatial rotation) (Molinari, Petrosini, Misciagna, & Leggio, 2003).
Rehabilitation of visuospatial skills
The materials designed for the rehabilitation of visuospatial abilities are hierarchical (in terms of analytical complexity) and are based on techniques that have demonstrated effectiveness (Cicerone et al., 2000).
As mentioned by Weinberg et al.
(1979), deficits in visuospatial skills can improve with treatment on multiple levels of visuospatial processing, and can be beneficial to use tasks involving complex academic skills, visual processing tasks, and manipulative tasks in order to yield solid, generalizable results.
Some of the techniques that we have used to design our materials are: – Visual scanning training and visual analysis.
– Rotations of three-dimensional objects.
– Aids for the analysis of visual components.
– Training in the analysis of the stimuli main features such as depth, size and distance between objects.
– Training in visuospatial orientation.
– Simple and complex visuospatial organization training.
– Somatosensory awareness training (recommendations).
– Training in spatial organization skills.
– Visual imagery techniques.
Materials allow the training of visuospatial skills at various levels.
In addition, materials include not only entertaining tasks involving abstract elements, but that are also meaningful to the subject performing them.
Thus, we design activities that also integrate visuoconstruction with dimensional materials (3D) to form real elements and spatial cues for reading, among others.
As can happen with praxis, many of these materials are used to acquire strategies with which to compensate for the deficits rather than to cure the problems, and to aim at teaching generalizable strategies for daily life.
The training of visuospatial skills in persons with heminegligence, accompanied by training in visual scanning, is a recognized and effective practice that allows for generalizing results in various areas of life (educational, employment, reading, activities of daily living, etc.) (Gordon, Hibbard, Egelko, Diller, Shaver, & Lieberman, 1985), being the stage-by-stage intensive practice the best strategy possible.
Memory is the ability to effectively retrieve previously learned information (encoded and stored). According to Wilson (2009), memory can be conceptualized in different terms: as memory dependent on time; as memory dependent on the type of information; as modality-specific memories; as stages of recall, retrieval or recognition; as implicit or explicit memory; or as retrograde or anterograde memory. Next, we briefly present the model developed by Larry Squire. Nevertheless, we would like to emphasize that models focused on memory processes also play an important role (since they complement system models) and that even if this approach is not explicit in the conceptual framework of the platform, it has been taken into account in the design of materials.
Squire (1987) proposes a schematic representation in which memory systems are broken down based on whether theirs contents can be verbalized (declarative memory), in contrast to a procedural knowledge without the need for conscious retrieval processes (non-declarative memory). Declarative memory distinguishes between facts (semantic
memory) and events (episodic memory).
The properties of each system are:
conscious recollection of events and facts; allows information to be compared and contrasted; encodes memories in terms of the relationships among multiple items and events; is composed of flexible representations, and autobiographical experiences and knowledge about the world. Declarative memory is either true or false. Propositional. Principle of exclusivity (what is distinctive about the item or the event).
is neither true nor false (it does not possess that characteristic); is dispositional and does not recollect events but performs and processes behaviors. This type of memory occurs as modifications within specialized performance systems; is activated through reactivation of the systems involved in the original learning. Principle of commonality (extraction of common elements). Procedural memory is an automatic process, an implicit knowledge that facilitates the execution of motor tasks.
Both types of memory serve distinct purposes and are functionally incompatible despite being related, which satisfies the criteria for postulating memory systems formulated by Tulving. They operate in parallel to support behavior in such a way that if one form of knowledge is damaged, the other can take control to maintain the necessary learning in a different format. For other proposals on this topic, the reader can consult the Moscovitch (1994), who proposes three modular, domain-specific components of memory and a frontal central-system, each of which mediates processes that dominate performance on different memory tasks (see model below).
According to Damasio´s Theory of Convergence Zones (1989), the early and intermediate posterior sensory cortices “contain fragmentary records of featural components which can be reactivated, on the basis of appropriate combinatorial arrangements”. The patterns of neural activity that correspond to distinct physical properties of entities are recorded in the same neural ensembles in which they occur during perception, but the binding codes that describe their spatial and temporal coincidences are stored in separate neural ensembles called convergence zones. Convergence zones trigger and synchronize neural activity patterns corresponding to topographically organized fragment representations of physical structure, that were pertinently associated in experience, on the basis of similarity, spatial placement, temporal sequence, or temporal coincidence, or combinations thereof.
Memory processes are carried out in order to learn/encode, store or retrieve information which is done through, from or for the memory systems.
Memory processes are divided into:
- Processes of acquisition and storage: implicit, associative, procedural,
elaborative, and constructive processes.
- Processes of retrieval: activation and fluency, familiarity, associative
search, constructive, and inferential retrieval.
- Processes of forgetting: decay, interference, inhibition, distortions.
- Processes of consolidation and reconsolidation.
Functional systems of memory
Our conception is similar to the memory trace theory proposed by Damasio
Medial temporal lobe structures are necessary to archive declarative information and to recall it during a limited period of time. However, consolidated declarative information ends up being independent of the hippocampus, distributing itself throughout the cerebral cortex, and depending upon every characteristic of the encoded information. Different areas of the brain are involved in remembering. In the first place, the hippocampus is responsible for implementing an algorithm that is a storage code of the distributed information. In Squire’s model, declarative memory depends on the hippocampus while non-declarative memory does not. In this model, the prefrontal and parietal cortices would be involved in working memory processes; procedural memory would depend on the basal ganglia; instrumental conditioning on the basal ganglia and cerebellum, and classical conditioning might depend on emotional priming, in such way that the activation of the amygdala triggers a rapid associative memory process.
Junqué (2009) provides an anatomical model for the explanation of memory. For information processing to persist as long-term memory, medial temporal lobe structures must mediate the process. Damage to this structure could result in retrograde amnesia. Projections from the neocortex arrive in the hippocampal cortex and perirhinal cortex; further processing occurs next at the entorhinal cortex, and in the several stages of the hippocampal formation (CA3 and CA1, dentate gyrus). This connectivity provides the hippocampus with access to cortical activity at widespread sites throughout the neocortex. The information can then return to neocortex via the subiculum and entorhinal cortex.
Information processed in the medial temporal lobe is also sent to critical areas for memory in the diencephalon and from here to the anterior nucleus of the thalamus via the mammillothalamic tract. The dorsomedial thalamic nucleus and the projections from the amygdala receive information from perirhinal cortex
The prefrontal lobe is an important target of diencephalic and medial temporal lobe structures. The anterior thalamic nucleus and the dorsomedial thalamic nucleus send projections to both ventromedial and dorsolateral frontal cortex. Additionally, the entorhinal cortex and the subiculum send prominent projections to ventromedial cortex.
Medial temporal lobe structures and the medial thalamus are components of the memory system that is essential for long-term declarative memory. This system is required at the time of learning and during a period of time thereafter, while the process of consolidation slowly develops in the neocortex, presumably thanks to sleep.
Short-term memory is independent of this system. Habits, skills, priming and some forms of conditioning are also independent of the medial temporal structures and the medial thalamus. Procedural memory depends on the frontoparietal system, the neostriatum and the cerebellum. Perceptual priming depends on posterior cortical areas.
Principles and techniques for the
rehabilitation of memory
Using specific techniques to design rehabilitation materials requires knowledge of some basic principles of memory training that serve to improve the process of information acquisition and its retrieval in every subject. To employ any technique on any subject is neither useful nor practical for the professional. The first thing to be done is we have to adapt the strategies and materials to our subjects. According to Wilson (1989):
- Material must be simple, with reduced load of information— at least, in the initial phases, we believe.
- Instructions must be clear and concise.
- Subject must understand the instructions.
- Material must be adapted, both in form and language employed.
- Associations must be established between elements previously known (persons, songs, contexts, dates, activities) and elements to be learned.
In addition, at NeuronUP we follow the levels of processing theory proposed by Craik & Lockhart (1972), by which we consider subjects to be active manipulators and not passive recipients of learning. To design significant material that is linked to daily life situations is a principle that can also adapt to the levels of processing postulates.
On the one hand, there is the training in internal memory strategies; on the other hand, the environmental adaptations and external aids. The activities we design are based on both realities but also have different treatment depending on the type of activity or tool that is going to be designed.
Training in internal strategies of encoding, storage and retrieval
- Organization: encoding strategies such as grouping words/ items into distinct categories, or phonetic strategies—less effective. To adapt the stimuli to the patient.
- Association: to give a semantic context to the processed information, to make up stories, rhymes, songs (auditory processing), contextual association, etc.
- Acronyms (a word formed from the initial letters of a name or thing) and mnemonics.
- Errorless learning.
- Backward chaining (the method of vanishing cues).
- The spaced retrieval technique (Landauer & Bjork, 1978) with distributed practice (Baddeley, 1999).
- Trial-and-error (is not the most effective method but occasionally can generate results).
- Visualization: paired-associate technique in order to form images. Words and drawings. Generation of visual strategies for
- Method of loci (places or locations).
Environmental adaptations and external aids
They are methods and devices aimed at establishing adaptations in the environment, so that demands on memory are reduced to more manageable levels.
– Training in the use of labels with images, colors, names, words, etc.
-Devices that facilitate access to previously stored information: alarms, timers.
– To record information: tape recorders or personal digital assistants (PDAs). Design of memory aids through which to easily access relevant information.
– Sometimes the use of these strategies requires training the patient’s immediate environment.
The main characteristics of these kinds of adaptations are:
– Active, timely and specific (simple commands)
– Generalization to other situations is easier.
– More effective than internal strategies: aimed at reducing the demands on the patient’s memory.
– Very useful in the most severely impaired patients. Notebooks and PDAs (personal digital assistants)
– It is more effective when the patient, despite memory problems, has:
- Average or above average intelligence
- Reasoning (ability)
- Awareness of deficits
- Skills to initiate behaviors
Training in the use of a memory notebook
Sohlberg & Mateer (1989): orientation (autobiographical information),
memory (activities to be performed), calendar, tasks, transport, names of known people, work activities, maps.
– Acquisition: learning sections, purposes and use of the notebook
– Application: where and when to use the notebook.
– Adaptation:demonstration of appropriate use of the notebook in
Schmitter-Edgecombe, Fahy, Whelan, & Long (1995): personal notes (autobiographical information), diary, calendar, names, work activities…
identifying memory weaknesses and the need for external aids.
– Acquisition: learning the purpose of each notebook section.
– Application: how to take notes.
Language is the ability to produce and communicate thought processes through motor execution of a system of gestures (nonverbal communication), symbols (writing and reading), and sounds (speech). It is a phenomenon that requires the coordination of a distributed neural network, with areas that change regarding their functional specificity. Even though the left hemisphere (in right-handers) is dominant for language, lesions of the right hemisphere can also cause language disturbances such as aprosody or the inability to detect intent (ironies). Lesion in each one of the nodes necessary for efficient functioning can cause disturbances in a specific aspect of the linguistic process; these can occur in:
- Production (articulation, execution, modulation)
- Elaboration and organization
Language disturbances can occur on four levels: syntactic, semantic, phonological and morphological.
To carry out an exhaustive classification of these disturbances is not the goal of this document. For an exhaustive classification of the different communication disorders (excluding the autism spectrum disorders) consult Junqué & Barroso (2009), or Martinell Gispert-Saúch (2012). Next, we define the main deficits observed in language: aphasia, alexia, agraphia and aprosody.
Aphasia: loss or disturbance of speech as a consequence of acquired brain injury. Deterioration of linguistic production and comprehension. The severity of the disorder varies in every area. The main disturbance is found in linguistic processing. It is not a perceptual or motor problem, nor an alteration in the thought processes. Rather, aphasia occurs when a lesion damages the neural network that allows the transformation of the internal images or thoughts into symbols and appropriate linguistic structures, or prevents the translation of heard words or written text into nonverbal ideas and thoughts.
Alexia: is a disorder of reading subsequent to brain injury in individuals who had previously acquired the ability to read. Thus, it can be distinguished from dyslexia, a disorder that occurs during the acquisition of reading.
Agraphia: a loss, to a greater or lesser degree, of the ability to produce written language as a result of brain injury. In most aphasic patients, the deterioration of writing properties has similar characteristics to the deterioration of oral expression.
Aprosody: language disorders that affect normal speech characteristics such as intonation, melody, cadence and accentuations. There are three types of aprosody: hyperprosody (excessive use of prosody), dysprosody (or ataxic prosody, a change in the quality of voice which can result in a “foreign accent”; this deterioration remains even after recovery from non-fluent aphasia), and aprosodia (limited capacity to modulate intonation).
Classification of language functions
We have partially followed the classification of language functions developed by Lezak (2004).
Ability to identify and transform written symbols—in a code—into internal representations. Reading involves the discrimination of symbols and words, their phonetic association, and the comprehension of grammatical relation schemes (phonemes, words, phrases, paragraphs, and texts) in written language. Reading does not include comprehension, nor is included in Repetition or Spontaneous Language when spoken language is read aloud. It is not form agnosia either (subject is capable of recognizing two identical letters or numbers).
Ability to produce written language that does not include comprehension. There are three main variants: copying of texts, words or writing texts to dictation, or spontaneous writing.
Ability to understand the semantic meaning when combining symbols (written) or phonemes (spoken language) into grammatical structures (words, phrases, texts, clauses, etc). It does not include the interpretation of linguistic formulas—ironies, double meanings, etc—nor alternative meanings of the message (these require Abstraction, such as in the meaning of proverbs). It does not include prosody and does not extent to the perception of emotional tone of the speech.
Ability to name and/or identify objects, persons, activities or actions presented on visual (drawings or pictures) or verbal confrontation (definitions). The alteration of this ability can arise as a consequence of the total or partial destruction of the semantic storage, or as a consequence of an alteration in word-retrieval abilities (for example, in the phenomenon of linguistic approximation). Anomias which are due to difficulties in comprehension, language production or recognition failures are not included.
Quantity of information relating to words in the semantic storage (quantity of words that the subject possesses).
Ability to transform phonemes and activate the representations and motor engrams of language to produce the same sounds that the subject hears. Sounds can be vocal and non-vocal.
Ability to produce language (written and spoken) in a rapid and effective manner. This production depends on two main strategies: a semantic (semantic fluency) or phonetic (phonetic fluency). It entails the preservation of the semantic storage, as well as the representations of the phonological pathway. It also involves Flexibility. There are three types of fluency: spoken Fluency (spontaneous or not), written fluency, and reading fluency. We do not consider fluency as a main measure of processing speed (therefore reading is excluded), but of production speed. Fluency is not included either as a production measure of complex spontaneous language (in this case it is included in the section of spontaneous Speech), but of words.
Ability to recognize different frequencies, intensities and tones that help us to identify phonemes, phrases, or identical words –always as a result of linguistic processes- without the need of understanding.
Anatomofunctional models of language
According to Damasio and Damasio (1992),there are 3 major functional systems in language:
– Conceptual representation system: activates the concepts associated with the record of words. This system depends on extensive cortical areas of different hierarchies and modalities that are distributed in the parietal, temporal and frontal areas bidirectionally (arcuate fasciculus). – Linguistic representation system (phonemes, words and syntactic rules for combining words): is located in the left hemisphere and includes various areas. The anterior perisylvian sector contains structures that are responsible for the assembly of phonemes into words, and of words into sentences; by contrast, the systems in the posterior perisylvian sector hold auditory and kinesthetic records of the phonemes and phoneme sequences that make up words. Comprehension begins in this system, although depends on the access to representation and association areas.
– The mediation system: the left temporal cortex, outside the classical language areas, is the intermediary between the other two systems, the mediator in lexical retrieval. It is involved in the access to the names of people, things, animals, etc.
The authors also insist on the involvement of other areas in this language system: the basal ganglia and the thalamus, the supplementary motor area and the anterior cingulate gyrus (medial frontal cortex), involved in the initiation and maintenance of speech; and the right hemisphere, involved in verbal automatisms, narrative aspects and prosody. In addition to the model of Damasio and Damasio, we use the model developed by Marcel Mesulam. For a cognitive model of language, consult the model by Ellis & Young (1992).
Techniques for the rehabilitation of
Language depends on and supports other cognitive functions. Therefore, language rehabilitation must rely on the preserved processes and functions, while also adapting treatment individually. It is necessary to take into account that language rehabilitation must comprise different cognitive modules and occasionally, neuromuscular training, so that a multidisciplinary intervention is important for significant improvement. In addition, language deficits produce social isolation, so it is necessary to integrate the intervention into the community, without forgetting functional communication strategies.
The intervention must be functional but must also focus on the deficits, thus rehabilitation materials must meet both demands; they must focus on situations and activities of daily living but combining these tasks with basic aspects of language processing. Daily living situations are usually very useful in the rehabilitation of language, as well as motivating.
The designed materials must fulfill certain principles, especially the required aids to begin treatment. The formulation of written, phonetic, and/ or iconic instructions and prompts must be always clear and concise with augmentative communication boards if necessary, and multimedia material. According to Cuetos (1998), the main language rehabilitation techniques can be divided into:
• Techniques directed at functional recovery: cueing, relearning, reorganization based on preserved functions
• Compensatory techniques: alternative communication techniques and language processing strategies. We design materials that are based on different stages of language processing. From the basic stages of language processing (letter discrimination) to the use of metacognition for discourse production.
- Gradual articulation training by means of auditory examples.
- Auditory discrimination.
- Phoneme association and word
- Picture association.
- Lexical decision tasks.
- Phonological judgements.
- Rhyme training.
- Identification of lexical words.
- Production and identification of meanings.
- Word association.
- Discrimination between phonetically similar words.
- Word articulation tasks (syllables and letters).
- Modulation of prosody with visual external feedback from the sound wave.
- Generalization of repeated words.
- Analysis of conversational topics.
- Arrangement of sentences.
- Gradual acquisition of vocabulary.
- Result matching tasks.
- Text analysis activities.
- Text production activities.
- Identification of sentence constituents.
- Repetition by approximation.
- Functional definitions of words.
- Training in taking turns in conversation.
In order to carry out these activities, there are utilities and tools at the subject’s disposal that the therapist can personalize for rehabilitation.
No consensus has been reached concerning the definition of executive functions.
We will now outline some of the existing definitions.
Executive functions (EFs) are cognitive processes or capacities that control and regulate thought and action (Friedman et al, 2006).
Lezak (1999) defines executive functions as mental abilities essential for carrying out effective, creative and socially accepted conduct.
According to this author, these executive functions can be grouped around a series of components: the necessary capacities to formulate goals (motivation, self-awareness, and way in which one perceives one’s relationship to the world), the abilities employed in the planning of processes, and the strategies to achieve goals (the ability to adopt an abstract attitude—Abstraction—to evaluate different possibilities— Decision making— and to develop a conceptual framework that enables managing activity—Reasoning), the abilities involved in the execution of plans (the capacity to initiate, continue and stop complex behavioral sequences in an orderly and integrated manner), and the abilities to perform those activities affectively (monitoring, correcting and self-regulating time—time estimations—intensity, and other qualitative aspects of performance—such as Dual-task Performance and Branching-Multitasking).
According to Banich’s definition (2004), the main goal of executive functions is the intentional, purposeful, and coordinated organization of behavior.
Executive functions have been even considered as a construct that encompasses a series of control processes of thought, emotions and behavior.
Some authors consider that that they are modular in nature and depend on multiple control processes that have a high correlation with intelligence (Tirapu-Ustárroz & Luna-Lario, 2009).
According to Verdejo-García & Bechara (2010), executive functions are higher-order skills involved in the energization, regulation, sound execution and on-line readjustment of goal-directed behaviors.
They constitute mechanisms of inter-modal and inter-temporal integration that allow us to project cognitions and emotions towards future scenarios in order to best resolve novel complex situations (Fuster, 2004)
Miyake et al (2000), by means of a structural equation model, found that
executive functions can be grouped in three latent aspects:
• Shifting: related to the ability to shift the attentional set. This variable allows the person to disengage his/her attention from irrelevant tasks and to maintain attention on tasks that are relevant.
• Updating: is the ability to code and monitor representations in
memory. It refers to both the update of content—understood as the insertion or elimination of that information in the shortterm memory—and also refers to the manipulation of content in memory. Due to this last reason, the dimension Updating can be considered most similar to Working memory.
• Inhibition: refers to the ability to inhibit dominant or prepotent responses and to ignore irrelevant information.
Working memory is a mental workspace that can be flexibly used to perform cognitive activities that require processing, retrieval, storage, and decision-making. Its storage capacity is limited and an overload in any dimension results in the loss of information in continuous performance tasks (Gathercole & Alloway, 2006).
Working memory is supported by a series of limited attentional resources.
Baddeley proposes a structure composed of multiple subsystems: a central executive and three “slave” subsystems (Tulving, 1999)—the phonological loop, the visuospatial sketchpad, and the episodic buffer—although initially he only suggested two, not taking into account the episodic buffer.
The central executive is a supervisory attentional system of limited capacity that coordinates the “slave” systems, manipulates contents, and updates them.
The phonological loop is a system dedicated to the retrieval, temporary storage, and rehearsal of auditory representations, while the visuospatial sketchpad performs analogous functions for visual representations of stimuli and their location in space.
The phonological loop has two components: a shortterm store that is subject to rapid decay, whose function is maintaining the auditory representations, and a subvocal rehearsal process that helps to maintain and update those representations.
The visuospatial sketchpad is a system specialized in the temporary storage of that kind of information.
The episodic buffer integrates information from working memory and from long-term memory systems in multimodal representations.
Baddeley proposes a Working memory that:
– Is multimodal with regard to the type of information that is managed and integrated.
– Is composed of autonomic processes of maintenance, suppression and monitoring (which implies certain independence from other
Explanatory models of executive
Among formal models that aim at explaining executive functions, we can find various proposals (Verdejo- García & Bechara, 2010):
– Models of multiple control processes based on hierarchical process with top-down modulation.
Models of action-oriented temporal integration related to the construct of working memory.
– Models that assume that executive functions comprise specific representations related to goal-oriented action sequences.
– Models that address specific aspects of executive functioning omitted by other models.
Our approach approximates most the third group of models, without denying evidence emerging from the other models.
Neuroanatomical models: the frontal lobes
The frontal lobe is a theoretical classification that serves to define a brain area specialized in higher-level cognitive functions and is characterized by a spatial localization with unique cytoarchitectonic structure.
It is a theoretical structure because the brain functions as a whole and the classification gives us an approximate idea of the functional and anatomical specificity.
The hierarchical organization of the brain proposed by several authors spatially divides the organ both into functional specificity and connective specificity.
Functionally, the frontal lobe presents three spatial components and one spatial limitation: it occupies a limited space; its posterior limit is defined by the central sulcus; it is bounded by the Sylvian fissure or lateral sulcus inferiorly; and the cingulate sulcus, just above the corpus callosum, is its medial limit.
Functionally, it is possible to assume a hierarchy of control and contents.
In the first place, by establishing an anterior-posterior axis, the frontal lobe contains the most abstract representations, and is responsible for exerting significant control over specific contents, monitoring them, integrating information into more complex contents, establishing control strategies, and guiding complex behaviors.
Therefore, the frontal lobe contains complex commands from a cognitive point of view, although this does not have to be seen as a defense of the modular model of the brain.
From a dorsal-ventral axis, dorsal areas refer to aspects of the external world and also to cold cognitive functions while medial and ventral regions show associations with content of internal cues and emotions.
We can draw a parallel with the cortical-limbic classification by establishing that cortical areas are characterized by more reflective processes while limbic zones are characterized by stimulus-driven processes.
Finally, from a medial-lateral axis, while medial areas show a relationship between internal contents, lateral areas represent spatial relations, and aspects and representations of the external world.
Regarding connections, the frontal lobe receives two types of connections: the cortico-cortical, that are associations with other regions of the cortex; and the cortico-limbic, that occur between the limbic and sublimbic structures.
With respect to the cortico-cortical connections, the frontal cortex, and especially the prefrontal cortex, contains a great number of internal connections.
Thereby, functionally, the prefrontal cortex is subdivided into several areas: a dorsal area, that has connections with cortical centers responsible for motor action and spatial processing; a medial area, with indirect connections towards the parietal lobe; and a ventral or inferior area, that has direct connections with the cingulate cortex and the emotional and
memory centers of the brain.
There are several classifications of the functional anatomy of the frontal lobe.
An acceptable definition dissociates the prefrontal system from the motor and premotor cortices.
Stern and Prohaska (196) describe three differentiated areas within the prefrontal system: dorsolateral, orbital, and medial.
In this explanation we will include the orbital and the medial as one system, the ventromedial system.
• The dorsolateral system is mainly occupied by areas 9, 9/46 and 46, belongs to an extensive circuit that includes the posterior parietal cortex, the caudate nucleus, and connections with the caudate nucleus and lateral dorsal nucleus of the thalamus. This system is responsible for monitoring attention, possibly by managing working memory, retrieval, and spatial attention. However, this system’s most important function is the integration of complex cognitive processes involved in planning and behavioral control.
• The ventromedial system is integrated in a main network, the so-called paralimbic system. In addition to the orbitofrontal cortex, this system is composed of the cingulate gyrus, the parahippocampal cortex, the temporal pole, the insula, and the amygdala. It is a system implicated in emotional and motivational processes, hence we also have to keep in mind that memory contains all information related to the learning that modulates the multiple aspects that make up personality. Some authors have suggested that both systems converge in Brodmann area 10 (or frontopolar prefrontal area), this being an area specialized in the coordination of complex processes that entail very abstract cognitive and emotional representations. BA10, which is the most rostral area of the brain, is a prefrontal region of maximum integration, modulation, and coordination that manages the most reflective contents that guide behavior. BA10 has direct connections with prefrontal areas but very few connections with other frontal areas, and no direct connection with the parietal, occipital, and temporal lobes. The ventromedial system is, therefore, an afferent system of information, and of control over the rest of processes that require reflection and control not driven by stimuli.
In addition to the aforementioned, for more information about the extensive neural network implicated in executive functioning we recommend Dosenbach et al. (2008) where the default mode network and the taskpositive network are explained.
Rehabilitation of executive
Executive functions gain importance in rehabilitation because they are quite sensitive to acquired brain injury, and essential for the execution of activities of daily living because they are responsible for managing preserved functions. Considering that, we want to emphasize that they are functions whose deficit directly affects the independence of individuals even if they preserve the rest of functions intact.
Systematic instructional methods:
• Vanishing cues
• Errorless learning:
- Dividing tasks into smaller components
- Pre-rehearsal and rehearsal models
- Do not question decisions
- Immediate correction of errorsa
• Distributed practice
• Instructions (strategy)
Conventional instructional methods:
Trial-and-error + reinforcement
- Social skills (training)
- Action observation
- Role playing
- Educational approaches in community
Some explicit direct instructions:
- Task analysis
- Errorless learning
- Cumulative reviews of performance
- Metacognitive strategies
To Ehlhardt, Sohlberg, Glang, & Albin (2005), most effective is establishing a direct instruction based on metacognitive strategies. They allow training in the management of self-regulation.
Models of systematic, explicit instruction (techniques):
- Step-analysis (sequences)
- Modeling: errorless or guided
- Comprehensive feedback
- Massed practice: massed, mixed and spaced
- Diagrams of spaced practice
- Action observation
Models of strategy-based instruction (goal: to monitor thinking)
– Procedural facilitators
– Scaffolded instruction
– Metacognitive strategies
- Estimates (of skills)
- Self-monitoring and self-regulation processes (comparison)
- Problem analysis
- Goal management training
- Self-instructional sequences
- Verbal self-regulation
- The prediction-reflection technique
Design of instructions (Sohlberg, Ehlhardt, & Kennedy, 2005)
1. Analysis of content to identify “big ideas”, concepts, rules, and generalizable strategies.
2. Determine necessary skills and prerequisites.
3. Sequence skills from simple to more complex.
4. Develop task analyses.
5. Develop and sequence a broad range of training examples to facilitate generalization.
6. Develop simple, consistent, clear instructions and scripts to reduce confusion and focus learner on relevant content.
7. Clearly establish learning objectives.
8. Establish high mastery criteria.
9. Provide models and gradually fade cues and prompts to facilitate errorless learning.
10. Pre-correct by instructing prerequisite skills first, or isolating difficult steps for instruction.
11.Provide consistent, rapid feedback (immediately provide the correct model if the patient makes a mistake).
12. Provide high amounts of correct, massed practice followed by distributed practice.
13. Provide sufficient, cumulative review (integration of new and old material).
14. Individualize instruction (language, pacing, time, capacities…).
15. Conduct ongoing assessment to gauge skill retention.
The combined model (direct instruction and programmed instruction) yields the best results. Afterwards come strategy instruction, direct instruction, and then, nondirect instruction (such as social skills training or trialand-error).
Which instructions yield the best result?
1. Explicit practice: distributed practice and review, repeated practice, sequenced review, daily feedback, and daily reviews.
2. Orientation to task/advanced organizers: establishment of instructional objectives, review of materials prior to instruction, instruction to focus on particular information, providing prior information about the task
3. Presentation of new learning material: diagrams, mental representations, curriculum implemented in the task, information from previous lessons that are related.
4. Modeling of steps to complete the task.
6. Systematic Investigation/Validation and reinforcement: use of probes and daily feedback.
Primary goal: eliminating errors during the acquisition phase of learning by:
1. Breaking down the activity into discrete and small steps or units.
2. Providing sufficient models before the client performs the target task.
3. Instructing the client to avoid guessing about the causes or reasons regarding the task.
4. Immediately correcting errors.
5. Carefully fading prompts.
Errorless learning is normally applied to persons with impaired procedural memory and declarative memory loss. Errorful learning (for example, trial-and-error learning or discovery learning) consists of encouraging the patient to guess about the targeted response before being provided with the correct information.
Possible applications of errorless learning (according to Barbara Wilson) to ADLs:
• Face-name associations
• Programming an electronic organizer
• Memorizing telephone numbers
Conditions that facilitate errorless learning
High amounts of correct practice. The patient correctly executes a task if given the opportunity to put it into practice repeatedly. And also vice versa—Pay attention, this does not involve generalization and maintenance, just execution.
Distributed practice—and spaced retrieval.
To use forward and backward chaining. Chaining is used in multi step techniques to improve recall of complex guidelines. It can be done in a “direct” (to begin with the first step) or reverse manner (to begin with the last step). A form of backward chaining is the technique of vanishing cues. This method can also be direct (fading cues) or reverse (adding cues).
Effortful processing and Self Generation. Effortful processing facilitates the mnesic trace, but it is not error free. Therefore, there must be regulation regarding the administration of this technique. Self
generation refers to cues or prompts self generated by the individual and not by the therapist (for example, questions generated by the therapist vs questions generated by the client about relevant factors —i.e., about a face).
To apply the technique during the acquisition phase.
The prediction reflection technique (metacognitive) can be useful to generate active processing of the material or to generate new strategies.
Scaffolding is a metacognitive method.
(Other metacognitive methods: self-instructional sequences, verbal self-regulation, prediction techniques).
Two important characteristics of any effective metacognitive strategy are:
– Feedback given to the patient must maintain focus on the task.
– Metacognitive strategy training must involve ambiguous situations, for example, in Social Skills must manage ambiguity and planning.
Scaffolded instruction consists of mental representations or knowledge structures that establish relationships between concepts such as diagrams, abstracts, representation of results (real or estimated, etc…).
Improve instructional efficiency (which is the relation between mental effort—recruited resources by executive demand—and task performance in a particular learning condition).
This method relies on two aspects:
1. A dual processing (Paivio), visual and verbal, that boosts the mental representations that establish relationships between concepts. This theory is evident in transfer tasks that require integration of information. It provides graphical representation of mental reality with schematic and semantic representation.
2. Reduction of the amount of information on working memory. Mental models enable the reduction of the cognitive load associated with complex tasks by making relations between structural components in a clear and efficient manner.
Cuevas, Fiore, & Oser (2002) propose a model of metacomprehension (an aspect of metacognition). There are various aspects that correlate metacognition and the ability to transfer knowledge and learning.
Beyond the proposed classification, we want to mention a program that has been a pioneer in the rehabilitation of executive functioning and has served as a model for some of the activities that we have designed.
TEACH-M (Ehlhardt, Sohlberg, Glang, & Albin, 2005)
1. Task Analysis: break the task into small steps. Chain the necessary steps together.
2. Errorless learning: keep errors to a minimum during the acquisition phase. Gradually fade support.
3. Assessment of performance: assess skills before initiating the task (prerequisites). On-going performance. Assess before introducing a new step.
4. Cumulative review: regularly assess previously learned skills.
5. High rates of correct practice.
6. Training in metacognitive strategies: the prediction technique is used to encourage active processing of the material.
– Pre-exposure to stimuli that are going to be employed.
– Screenshots that reflect performance.
– Guided practice with multiple opportunities.
– Spaced retrieval.
– Varied training examples.
– Training to stipulated and always updated criteria.
Social cognition is a neurobiological, psychological, and social process through which social phenomena are perceived, recognized and evaluated in order to construct a representation of the environment where individuals interact, and to subsequently generate social behavior, that is, the most appropriate response according to the specific circumstance. social cognition is related to aspects ranging from social perception (initial stages of evaluating the intentions of others by their behavior—gaze direction and body movement) to attributional style (how the behavior of other people is explained) (Sánchez Cubillo, 2011).
In order to explain social cognition, we base from the model of social-emotional processing stream (Ochsner, 2008). This model enables considering social cognition as a multi-factorial reality that depends on various levels of processing that differ in complexity and interrelation of components. As argued by Adolphs (2001), social cognition is based on a distributed set of neural mechanisms for perceiving, recognizing, and evaluating stimuli, which are then used to construct central representations of the social environment.
Social cognition involves cold executive functions (for they are responsible for neutral neuropsychological contents and processes) and hot executive functions (which involve the management of emotional evaluative components).
This dichotomy is explanatory since emotion and cognition form a continuum in which both influence each other by bottom-up processes (emotional interference) and top-down processes (for example, in the reformulation of emotions—see Ochsner & Gross, 2005).
Ochsner’s “Processing Stream” comprises five constructs (from lowest to highest level of complexity):
– Acquisition of social-affective values and responses
– Recognizing and responding to social-affective stimuli
– Low-level mental state inferences
– High-level mental state inferences
– Context-sensitive emotion regulation
We include Theory of Mind (Baron Cohen, Leslie, & Frith, 1985) within the low and high-level inferences. The concept ‘theory of mind’ (ToM) refers to the ability to understand and predict other people’s behavior, their knowledge, their intentions, and their beliefs. Accordingly, this concept refers to a metacognitive ability, since we refer to how a cognitive system is able to understand the contents of another cognitive system that is different from the one carrying out the knowledge (Tirapu-Ustárroz, Pérez-Sayes, Erekatxo-Bilbao, & Pelegrín-Valero, 2007).
Empathy is the ability to carry out the theory of mind in its different levels. There are two types of empathy, emotional and cognitive.
Functional models on which social
Social cognition is a complex process whose components recruit different nodes of processing in order to achieve effective output. Drawing a parallel between the “Processing Stream” components and the main neuroanatomical nodes that support them, we find that:
- Acquisition of social-affective values and responses: amygdala, striatum and hippocampus.
- Recognizing and responding to social-affective stimuli: superior temporal sulcus, inferior parietal cortex, amygdala and insula.
- Low-level mental state inferences: mirror-neuron system.
- High-level mental state inferences: mirror-neuron system, superior temporal sulcus, medial prefrontal cortex and temporal poles of the frontal lobe.
- Context-sensitive emotion regulation: dorsolateral prefrontal cortex, ventral prefrontal cortex and orbitofrontal cortex, amygdala and striatum.
The mirror- neuron system
There are two main neural networks that make up the mirror-neuron system (Cattaneo & Rizzolatti, 2009): a network comprised of areas of the parietal lobe and premotor cortex, as well as the caudal part of the inferior frontal gyrus; and another network comprised of the insula and the anterior medial frontal cortex. The first mirror system involves learning based on observation and imitation. The second mirror system is the emotional, and is involved in the adoption of empathic attitudes but it does not necessarily work separately from the first system. The role of mirror neurons in empathic attitudes such as the adoption of facial expressions and postures in interactive imitative behaviors is essential in association with emotional empathy (limbic system). Mirror neuron computations are guided by consequences of action and goals. This knowledge serves as a base for social cognition, together with the second system of emotional integration. To learn more about the networks that make up the mirror-neuron system, there is an open access document downloadable from our website.
Rehabilitation of social cognition
When social cognition fails, some of the following changes can occur:
– We are not capable of establishing or inferring intentions, thoughts, desires, etc. in others (mentalization).
– We are not capable of recognizing an emotion or nuanced look, a tone of voice, or a situation (recognition of emotions in different formats).
– We are not capable of coping with a situation because we do not know how to/cannot gather information of the environment (working memory, problem solving).
– We cannot initiate conversations or requests with others out of fear or because we do not have the required skills (communicative and/or expressive language).
– We create false theories about reality that are usually based on erroneous ideas.
– We cannot envision social situations as a whole, focusing instead on specific details.
Social cognition is a function composed of various levels of processing; hence the intervention must be carried out based on analysis of the entire process (selective attention, recognition, language, memory, executive functions). Therefore, the first level of intervention corresponds with the identification of internal emotional states (estimation of attributed valence) and external environmental factors that produce such valence. Afterwards, we have created a series of activities aimed at the identification of emotional states in others, first by using body gestures and then, with elements that become more subtle and ambiguous.
We have created a variety of activities to train how to infer both internal and external emotional states, and thought processes in others. The components have a significant visual load, since on many occasions disturbances in social communication are accompanied by deficits in language, and therefore, the materials must fulfill certain requirements that we have stipulated.
The goal is to train processes of inference about others and social skills (which also involve the contextualization of language in the form of detection of ironies, lies, etc.). Social skills focus on two main aspects: on the one hand, they are directed towards managing behaviors of interaction in social situations; on the other hand, they are directed towards self-regulation and management of internal emotional states in diverse contexts.
Among the intervention activities, we would like to mention a specific one that we have used to design the most complex materials: the social stories.
The social stories are a script for training persons with impaired social cognition and theory of mind to acquire skills at the moment of interaction with other people that indicate the appropriate behavior expected in social situations. Social stories attempt to be “social translations”. This training can focus on interaction behaviors, self-regulation, inference of intentionality, reading and management of someone else’s emotions, etc.
It is necessary to differentiate the social stories from other two types of training:
– Social cognition, which involves more basic aspects of theory of mind that have to do with perceptive or linguistic aspects. It is true that social scripts entail social cognition, but they are combined with more complex processes (unlike social cognition tasks, which usually are more simple).
– Training in routines such as self-care, housework, dressing, etc. that do not require social involvement.
There are different formats in social stories. These stories can be designed with pictograms (drawings that represent the context that we are going to work on), with words, or with mixed formats. It seems that among all subjects with whom we train these activities, persons with ASD in any degree usually benefit more from pictograms. It is important that situations catch the selective attention of patients but without distracting them.
The contexts that we will use will be diverse and will be useful in grading activities, depending on the quantity of ambiguity, number of interactions, quantity of employed concepts and complexity of emitted social behavior.
Situations are as diverse as life, but we can begin with the following categories that are non-exclusive:
- Self regulation
- Interactions with close people (relatives/friends/teachers/etc.)
- Rules for specific places of social activity (hospitals, school, theater, cinema, park, train…)
- Explicit prohibitions regarding behavior
- Personal care (AS LONG AS IT REQUIRES INTERACTION, for example, to go shopping for clothes)
- Exceptions to a rule
- Violent / embarrassing / awkward situations
- Exceptional situations
- Emotional situations (meaning of gestures, e.g., crying=sadness)
- Inferences of internal states in others
In addition to these categories, we must take into account the language employed in the activity, even in tasks whose only purpose is the acquisition of language.
Activities of daily living
When a neuropsychological deficit occurs, this can have a variable impact on the functionality of people. Functionality is related to the performance of ADLs. Independece has an impact on emotional aspects and quality of life and has a direct impact on the construction of personality and people’s environment. The primary goal in any neuropsychological or occupational therapy intervention is to help the person achieve the highest level of function possible. Thus, a significant impact in a specific area of the brain may have little or no impact in the functionality of the person, which is generally determined by the context.
Activities of daily living are tasks performed by individuals on a daily basis. Following brain injury (whether acquired or not), the priority and nature of those activities need to be reformulated. In many cases, those activities will be taken up again, while in other cases, the activities will be replaced with new ones or with techniques of substitution and compensation, depending on the person’s preserved abilities.
The main types of activities of daily living have been extracted from Rogers & Holm (1994).
Basic activities of daily living.
They are activities oriented toward taking care of one’s own body.
• Bathing, showering— Obtaining and using supplies; soaping, rinsing, and drying body parts; maintaining bathing position; and transferring to and from bathing positions.
• Bowel and bladder management— Includes completing intentional control of bowel movements and urinary bladder and, if necessary, using equipment or agents for bladder control (Uniform Data System for Medical Rehabilitation, 1996, pp. III–20, III–24).
• Dressing— Selecting clothing and accessories appropriate to time of day, weather, and occasion; obtaining clothing from storage area; dressing and undressing in a sequential fashion; fastening and adjusting clothing and shoes; and applying and removing personal devices, prostheses, or orthoses.
• Eating— “The ability to keep and manipulate food or fluid in the mouth and swallow it; eating and swallowing are often used interchangeably” (AOTA, 2008).
• Feeding— “The process of setting up, arranging, and bringing food [or fluid] from the plate or cup to the mouth; sometimes called self-feeding” (AOTA, 2008).
• Functional mobility— Moving from one position or place to another (during performance of everyday activities), such as in-bed mobility, wheelchair mobility, and transfers (e.g., wheelchair, bed, car, tub, toilet, tub/shower, chair, floor). Includes functional ambulation and transporting objects.
• Personal device care— Using, cleaning, and maintaining personal care items, such as hearing aids, contact lenses, glasses, orthotics, prosthetics, adaptive equipment, and contraceptive and sexual devices.
• Personal hygiene and grooming— Obtaining and using supplies; removing body hair (e.g., use of razors, tweezers, lotions); applying and removing cosmetics; washing, drying, combing, styling, brushing, and trimming hair; caring for nails (hands and feet); caring for skin, ears, eyes, and nose; applying deodorant; cleaning mouth; brushing and flossing teeth; or removing, cleaning, and reinserting dental orthotics and prosthetics.
• Sexual activity— Engaging in activities that result in sexual satisfaction.
• Toilet hygiene— Obtaining and using supplies; clothing management; maintaining toileting position; transferring to and from toileting position; cleaning body; and caring for menstrual and continence needs (including catheters, colostomies, and suppository management).
Instrumental activities of daily living
They are activities to support daily life within the home and community that often require more complex interactions than self-care used in ADL.
- Care of others (including selecting and supervising caregivers)— Arranging, supervising, or providing the care for others.
- Care of pets—Arranging, supervising, or providing the care for pets and service animals.
- Child rearing—Providing the care and supervision to support the developmental needs of a child.
- Communication management—Sending, receiving, and interpreting information using a variety of systems and equipment, including writing tools, telephones, typewriters, audiovisual recorders, computers, communication boards, call lights, emergency systems, Braille writers, telecommunication devices for the deaf, augmentative communication systems, and personal digital assistants.
- Community mobility—Moving around in the community and using public or private transportation, such as driving, walking, bicycling, or accessing and riding in buses, taxi cabs, or other transportation systems.
- Financial management—Using fiscal resources, including alternate methods of financial transaction and planning and using finances with long-term and short-term goals.
- Health management and maintenance—Developing, managing, and maintaining routines for health and wellness promotion, such as physical fitness, nutrition, decreasing health risk behaviors, and medication routines.
- Home establishment and management—Obtaining and maintaining personal and household possessions and environment (e.g., home, yard, garden, appliances, vehicles), including maintaining and repairing personal possessions (clothing and household items) and knowing how to seek help or whom to contact.
- Meal preparation and cleanup—Planning, preparing, and serving well-balanced, nutritional meals and cleaning up food and utensils after meals. Religious observance—Participating in religion, an organized system of beliefs, practices, rituals, and symbols designed to facilitate closeness to the sacred or transcendent.
- Safety and emergency maintenance— Knowing and performing preventive procedures to maintain a safe environment as well as recognizing sudden, unexpected hazardous situations and initiating emergency action to reduce the threat to health and safety.
- Shopping—Preparing shopping lists (grocery and other); selecting, purchasing, and transporting items; selecting method of payment; and completing money transactions.
Includes activities needed for learning and participating in the environment.
• Formal educational participation—Including the categories of academic (e.g., math, reading, working on a degree), nonacademic (e.g., recess, lunchroom, hallway), extracurricular (e.g., sports, band, cheerleading, dances), and vocational (prevocational and vocational) participation.
• Informal personal educational needs or interests exploration (beyond
formal education)—Identifying topics and methods for obtaining topic-related information or skills.
• Informal personal education participation— Participating in classes, programs, and activities that provide instruction/training in identified areas of interest.
• Includes activities needed for engaging in remunerative employment or volunteer activities (Mosey, 1996, p. 341).
• Employment interests and pursuits—Identifying and selecting work opportunities based on assets, limitations, likes, and dislikes relative to work.
• Employment seeking and acquisition—Identifying and recruiting for job opportunities; completing, submitting, and reviewing appropriate application materials; preparing for interviews; participating in interviews and following up afterward; discussing job benefits; and finalizing negotiations.
• Job performance—Job performance including work skills and patterns; time management; relationships with co-workers, managers, and customers; creation, production, and distribution of products and services; initiation, sustainment, and completion of work; and compliance with work norms and procedures.
• Retirement preparation and adjustment—Determining aptitudes, developing interests and skills, and selecting appropriate avocational pursuits.
• Volunteer exploration—Determining community causes, organizations, or opportunities for unpaid “work” in relationship to personal skills, interests, location, and time available.
• Volunteer participation—Performing unpaid “work” activities for the benefit of identified selected causes, organizations, or facilities.
Any spontaneous or organized activity that provides enjoyment, entertainment, amusement, or diversion.
• Play exploration—Identifying appropriate play activities, which can include exploration play, practice play, pretend play, games with rules, constructive play, and symbolic play (adapted from Bergen,1988, pp. 64–65).
• Play participation—Participating in play; maintaining a balance of play with other areas of occupation; and obtaining, using, and maintaining toys, equipment, and supplies appropriately.
• A nonobligatory activity that is intrinsically motivated and engaged in during discretionary time, that is, time not committed to obligatory occupations such as work, self-care, or sleep (Parham & Fazio, 1997, p. 250).
• Leisure exploration—Identifying interests, skills, opportunities, and appropriate leisure activities.
• Leisure participation—Planning and participating in appropriate leisure activities; maintaining a balance of leisure activities with other areas of occupation; and obtaining, using, and maintaining equipment and supplies as appropriate.
Organized patterns of behavior that are characteristic and expected of an individual or a given position within a social system (Mosey, 1996, p. 340).
• Community—Engaging in activities that result in successful interaction at the community level (i.e., neighborhood, organizations, work, school).
• Family—Engaging in “[activities that result in] successful interaction in specific required and/or desired familial roles” (Mosey, 1996, p. 340).
• Peer, friend—Engaging in activities at different levels of intimacy, including engaging in desired sexual activity.
The goal is to increase autonomy of brain-injured people or to maintain it at an optimal level for as much time as possible. NeuronUP integrates the characteristics of occupational therapy and neuropsychology by carrying out a comprehensive analysis of the activities that constitute these fields, but without denying a detailed analysis of the neuropsychological processes involved in each and every behavior. By implementing sequences, an exhaustive analysis of the neuropsychological processes involved in the activities can be conducted. The purpose is to establish an appropriate classification of the complexity levels.
NeuronUP approaches the rehabilitation of the activities of daily living in a gradual and operative manner but without being less ecological. We integrate everyday objects in simulators that people can use to train the use of objects and the sequence of activities with the therapist and therefore have a number of cognitive resources when facing real contexts that they may find complex in some cases. We have also designed interactive games and pencil and paper tasks (also available in digital format) in which the contents are ecological and personalized. As a result of using real objects as material, the possibility that an effective generalization exists can increase and the motivational effect is verifiable. In general, we use many of the metacognitive strategies that we have outlined in the rehabilitation of executive functioning, adapting the activity, the materials, and the instructions to the patient’s current functional status.
The functional analysis of sequences is a priority in our approach. The record of results and the accuracy in the formation of behavioral and cognitive sequences that integrate this type of activities are aspects that occupational therapists recommend, and whose purpose is to evaluate the effectiveness of treatments, achieving a higher level of evidence.
According to Beauchamp & Anderson (2010), social skills must be integrated into a comprehensive framework that “incorporates the biological underpinnings and socio-cognitive skills that underlie social function (attention/executive function, communication, socio-emotional skills), as well as the internal and external (environmental) factors that mediate these skills”. We can consider that social skills are the implementation of social cognition abilities in a socio-emotional context, emitting and maintaining effective behaviors and strategies.
Parsons & Mitchell (2002) consider two ways to promote social skills in ASD:
– Behavioral, structured one-to-one settings of behaviors. They are very effective in teaching children new behaviours or skills, but suffer from a lack of generalization in terms of transferring learned behaviours to new tasks or contexts.
– Embedding interventions within the child’s natural settings, such as home and school.
The goal for social skills in NeuronUP is to develop a system that would be integrated into different contexts. By now, we have developed contextual simulations that allow the patients to learn and put into in practice basic
social cognition processes –learnt in cognitive functions areas-, as well as get an automatic feedback to correct their behavior. Social skills exercises are more complex than media as they contain flexible aspects of behavior (contexts change depending on the patient´s answers).
Social Skills are directly related to quality of life, and treatment has to be comprehensive by providing a wide range of contexts that require complex and diverse neuropsychological processes. These complex processes entangle widespread neural mechanisms (such as language, perception, motor and memory). Working memory, flexibility and social cognition are the key processes in this area.
The specific contents of this area are those which are not already included in basic neuropsychological processes:
– Proxemic aspects of social interaction.
– Paralinguistic issues of communication.
– Complex social cognition aspects.
– Conversational issues such as adequate themes of conversation, initiation, etc.
– Ecological tools and activities regarding changeling changing contexts.
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