Traumatismo craneoencefálico y su rehabilitación neuropsicológica en funciones ejecutivas

Neuropsychological rehabilitation of executive functions following traumatic brain injury


Traumatic brain injury (TBI) is a critical public health problem due to both its high mortality rates and the disabilities experienced by TBI survivors such as cognitive, emotional, familial, social and occupational difficulties that affect their quality of life (Arango-Lasprilla, Quijano and Cuervo, 2010); Corrigan, Selassie and Orman, 2010; García-Rudolph and Gibert, 2015; Park et al., 2015; Santana et al., 2015). In neuropsychology, the design of rehabilitation programs is based on a cognitive approach since improving the mental capacity of patients with traumatic brain injury has a direct effect on their function.

What is traumatic brain injury (TBI)?

TBI is defined as an alteration in brain function caused by an external force (Menon, Schwab, Wright and Maas, 2010).

Types of traumatic brain injury (TBI):

Open TBI

Openhead injuryoccurs when the skull is fractured or perforated, resulting in damage to the brain tissue and exposure ofthe brain substancetothe environment.

Closed TBI

Closedhead injury only affectsthe brain tissue(León-Carrión, 1995).

Both types of injurycan befocal or diffusedepending on the location of the damage. Focal injuries areconfined to one area of the brain while diffuse injuriesdo not occupy a well-defined volume within the intracranial compartment but, just as focal injuries do, cause neurological sequelae (González, Pueyo and Serra, 2004). Commonly, focal brain injury is characterized by functional alterations in the frontal and temporal lobes, as these are the most susceptible regions in closed TBIs; in open head injuries, it will depend onthe region of the skull that isimpacted. In turn, diffuse brain injury often leads to loss of complex cognitive functions such as processing speed, concentration and overall cognitive efficiency (Kolb &Whishaw, 2014).

Severity of traumatic brain injury

Traumatic brain injury severity is commonly classified into mild, moderateor severe categories, based on duration of loss of consciousness orpost-traumatic amnesia.The Glasgow Coma Scale (GCS) is the most common instrument for classifying TBI severity. The GCS assesses a person’s level of consciousness based on three parameters (verbal response, motor response, and eye opening). The higher the score, the higher the patient’s level of consciousness.This scale classifies traumatic brain injuriesas mild (14-15), moderate (9-13), or severe,with scores less than or equal to 8(Hoffmann et al., 2012; Muñana-Rodríguez and Ramírez-Elías, 2013; Santa Cruz and Herrera, 2006; Poca, 2006).

Ideally, assessment of brain injury severityshould occur immediately following the injury event or as soon as possible to provide a baseline for future assessments and to actpromptly, both to stabilize the patient medically and to initiate rehabilitation interventions if required(Hoffmann et al., 2012; Muñana-Rodríguez and Ramírez-Elías, 2013; Santa Cruz and Herrera, 2006; Poca, 2006).

InterventionfollowingTBIoften includes physical and cognitive rehabilitation. Cognitive rehabilitation should be directed toward higherlevel cognitive functions such as executive function, for this is usually one of the most often affected by TBI as a result of both focal and diffuse injury(García-Molina, Enseñat-Cantallops, Sánchez-Carrión, Tormos and Roig-Rovira, 2014).

Executive functions in people with traumatic brain injury

Executive functions (EFs)refer tohigher-ordercognitive processes(such as planning, decision making, and flexibility) involved in the control and regulation of goal-directed behavior, thus allowing humans to formulate goals and planfor their achievement.

These mental capacities are also considered essential for performing creative and socially acceptable behavior. In addition, EFs becomemore complex overthe life span; some executive functions begin to emerge early, thereby enabling the development of more complex executive functions(Bombín-González et al., 2014; Tirapu-Ustárroz, García-Molina, Luna-Lario, Verdejo-García and Ríos-Lago, 2012).

The systematic reviewof factorialmodels of executive control carried outby Tirapu-Ustárroz et al. (2017) resulted in an integrative proposal ofexecutive functionssuch as:

Executive functions play a key role in human life, since they are a set of cognitiveprocesses with independent yet interconnected components to control and regulate behavior. Whenexecutive function is affected by brain damage, as in a traumatic brain injury, deficitscause a multiplicity of cognitive, behavioral and emotional manifestations which interfere with the person’s adequatefunctioningin daily life thereby compromising the person’s capacityto return to a normal, productive life.

Neuropsychological rehabilitation in patients with TBI

Cognitive rehabilitation can be defined as “a systematic, functionally oriented service of therapeutic activities that is based on assessment and understanding the patients’ brain– behavioral deficits” (Cicerone et al., as cited in Van Heugten, Gregório and Wade, 2012). Interventions must have ecological validity so to have a real impact on patients’daily livesso that patientsare able to extrapolate and generalize what they have learned during rehabilitationin their everyday life (Carvajal-Castrillón and Restrepo, 2013).

A contemporary neuropsychology perspective on cognitive rehabilitation proposes the development of individualized assessment and rehabilitation programs for each condition, with clear and common expectations and goals for patients and their families(Calderón, Cadavid-Ruiz y Santos, 2016); Carvajal-Castrillón and Restrepo, 2013; Ríos, Muñoz and Paúl-Lapedriza, 2007; Tate, Aird and Taylor, 2013). Cognitive rehabilitation programsconsist of tasks organized hierarchically by levels of difficulty that requirerepetitive use of impaired functions.To these programs is clear that the degree of functional recovery of the patient will depend on the number of repetitions and the type of task performed throughout treatment (García-Rudolph and Gibert, 2015).

In neuropsychology, the design of rehabilitation programs is based on a cognitive approach since improving the mental capacity of patients has a direct effect on their function. In addition, these programs emphasize the importance of tailoring programs to individualneedsthrough restorative and compensatory techniques.Restorative strategies aim at reinforcing, strengthening, or restoring the impaired cognitive processes; compensatory techniquesteach ways of compensating for the impaired function with the use of assistive devices such as reminders or alarms, among others (Barman et al., 2016; Evald, 2015; Tsaousides, D’ Antonio, Varbanova and Spielman, 2014).

Cognitive rehabilitation, however, should keep in mind that traumatic brain injury is a medical condition that affects differentareas of health; it requires:

  • Neurological intervention: to monitor brain tissue damage.
  • Neuropsychological intervention: to restore as much function as possible in patients.
  • Social intervention: to improvepatients’ functioning in the everyday context.

Research findings from rehabilitation research in patients with traumatic brain injury indicate that the greatest improvement in psychosocial functioning is achieved when intervention programs are based on an integrated and interdisciplinary approach, including patients’ cognitive, emotional, familial and social contexts. These initiatives should not only aim at the rehabilitation of patients with TBI, but should also aim at the promotion of health, which involves the implementation of measures to adopt healthy lifestyles.

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