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Page 1: Contributes of Neuropsychology for the evaluation and ... · PDF fileContributes of Neuropsychology for the evaluation and rehabilitation of a severe Traumatic Brain Injury ... Figura

AIMAIM

METHODMETHOD CONCLUSIONCONCLUSION

Contributes of Neuropsychology for the evaluation and rehabilitaContributes of Neuropsychology for the evaluation and rehabilitation of a severe Traumatic Brain Injury tion of a severe Traumatic Brain Injury (TBI)(TBI)

Susana V. Silva1, Luís Simões da Cunha1, Rute F. Meneses1, & Joana Pais2

1 Faculdade de Ciências Humanas e Sociais – Universidade Fernando Pessoa , Porto; 2 Laboratório de Neuropsicologia, Serviço de Neurologia, Hospital de São Sebastião, Santa Maria da Feira

Traumatic Brain Injury (TBI) is an important public health problem

(Junqué, Bruna, & Mataró, 2001; Portellano, 2005; Santos, 2002)

since there is: (a) a progressive increase in the number of affected

individuals; (b) a high proportion of young patients involved; and (c) an

increase in survival rates due to technological and medical advances

(Junqué et al., 2001; McMillan & Greenwood, 2003).

The high global prevalence of TBI confers a crucial position to it in the

field of neuropsychological evaluation and rehabilitation (Portellano,

2005), making the health technicians responsible for paying special

attention to the physical, cognitive and emotional effects related to this

type of brain damage (Senra & Oliveira, 2003).

REFERENCESREFERENCES

RESULTSRESULTS

Neuropsychological Anamnesic Guidelines (Gonçalves & Castro-

Caldas, 2003);

Zung Self-rating Depression Scale (Zung, 1965);

Subtests of the Lisbon Dementia Assessment Battery (Guerreiro,

1998): Orientation Questionnaire (personal, temporal and spatial);

subtest of “A´s” cut, digit span, language (identification, nomination,

repetition, comprehension, token test, writing and reading), logic

memory, visual memory, words learning, motor initiative, grapho-

motor initiative, symbolic gesture, calculus, clock drawing, WAIS

cubes and proverbs interpretation;

Subtest of the Integrated Program of Neuropsychological

Exploration (Peña-Casanova, 1990): Mental control;

California Verbal Learning Test (CVLT) (Baeta, 2002; Delis et al.,

1987/2000, as cited in Lezak, Howieson, & Loring, 2004);

Wisconsin Card Sorting Test (Heaton, Chelune, Talley, Kay, &

Curtiss, 1993);

Trail Making Test (Spreen & Strauss, 1998);

Portuguese Neuropsychological Stroop (Castro, Martins, & Cunha,

2000);

Complex Figure Copy Test (Rocha & Coelho, 1988).

The aim of the present study is to systematize the

neuropsychological evaluation and rehabilitation of an adult patient

with severe TBI. The neuropsychological evaluation focused the

cognitive, behavioural and emotional impairments.

An adult patient with severe TBI (age: 25 yrs; education: 7 yrs)

Type of brain injury: Diffuse axonal injury.

PARTICIPANTS

MATERIAL

In this case-study, it was possible to see recovery in several aspects of

the patient’s psychological functioning. In the second evaluation, five

months after the first one, there was an improvement in the depressive

and behavioural symptomatology, and in all of the higher mental

functions, except verbal initiative. However, it is important to recognize

that in case-study methodologies it is hard to distinguish the changes

due to spontaneous recovery and those due to specific effects of the

treatment (McMillan & Greenwood, 1997). Nevertheless, even if

spontaneous recovery has taken place, it is widely believed (Cicerone,

1999, as cited in Callahan, 2001) that the implementation of a

systematic neuropsychological rehabilitation plays a major role in

recovering cognitive functions.

Baeta, E. (2002). Bateria para avaliação neuropsicológica de adultos com epilepsia.

Psicologia, 16(1) 79-96.

Callahan, C. D. (2001). The assessment and rehabilitation of executive function disorders.

In B. Johnstone & H. H. Stonnington (Eds.), Rehabilitation of neuropsychological

disorders (pp. 87-124). Hove: Psychology Press.

Castro, S. L., Martins, L., & Cunha, L. S. (2000). Stroop Neuropsicologico Português. Porto:

Centro de Psicologia UP [Unpublished material]

Gonçalves, M., & Castro-Caldas, A. (2003). Guião de anamnese neuropsicológica.

Psychologica, 34, 257-266.

Guerreiro, M. (1998). Contributos da Neuropsicologia para o estudo das demências.

Dissertação de doutoramento não publicada, Faculdade de Medicina de Lisboa,

Lisboa.

Heaton, R. K., Chelune, G. J., Talley, J. L., Kay, G. G., & Curtiss, G. (1993). Wisconsin Card

Sorting Test Manual: Revised and expanded. Odessa, FL: Psychological Assessment

Resources.

Junqué, C., Bruna, O., & Mataró, M. (2001). Traumatismos cranioencefálicos: uma

abordagem da neuropsicologia e fonoaudiologia (M. L. Pedro, Trans.). S. Paulo:

Livraria Santos.

Lezak, M. D., Howieson, D. B., & Loring, D. W. (2004). Neuropsychology assessment (4th

ed.). Oxford: Oxford University Press.

McMillan, T. M., & Greenwood, R. J. (1997). Head injury. In R. Greenwood, M. P. Barnes, T.

M. McMillan, & C. D. Ward (Eds.), Neurological rehabilitation (pp. 437-450). Hove:

Psychology Press.

McMillan, T. M., & Greenwood, R. J. (2003). Head injury rehabilitation. In R. J. Greenwood,

M. P. Barnes, T. M. McMillan, & C. D. Ward (Eds.), Handbook of neurological

rehabilitation (2nd ed., pp. 465-486). Hove: Psychology Press.

Penã-Casanova, J. (1990). Programa Integrado de Exploração Neuropsicológica: Test

Barcelona. Barcelona: Ediciónes Masson.

Portellano, J. A. (2005). Introducción a la neuropsicología. Madrid: McGraw-Hill.

Rocha, A. M. M., & Coelho, M. H. (1988). Figura Complexa de Rey: Manual. Lisboa:

CEGOC-TEA.

Santos, M. E. (2002). Traumatismos crânio-encefálicos: Características e evolução.

Psicologia, 16(1) 97-122.

Senra, H., & Oliveira, R. A. (2003). Avaliação neuropsicológica no traumatismo

cranioencefálico grave: Estudo de caso. Psychologica, 33, 123-143.

Spreen, O., & Strauss, E. (1998). A compendium of neuropsychological test: Administration,

norms and commentary (2nd ed.). New York: Oxford University Press.

Zung, W. K. (1965). A self-rating depression scale. Archives of General Psychiatry, 12, 63-

70.

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"A´s" cuted Time in seconds on the "A´s" cut subtest

Figure 1. ATTENTION

Figure 2. MEMORY AND LEARNING

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CVLT First Recall CVLT Fifth Recall CVLT Total Recall

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Copy quality Time in minutes

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Categories achieved Perseverative responsesPerseverative errors

Figure 3. EXECUTIVE FUNCTIONS

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Trail A (time in seconds) Trail B (time in seconds)

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Read - Correct responses Nomination - Correct responses

PROCEDURE

The neuropsychological intervention started three months after the

brain lesion, with a detailed evaluation that occurred along six weekly

sessions, each one lasting 40 minutes.

Since not all of the administrated instruments have Portuguese

normative data, part of the interpretation had a qualitative character.

The evaluation showed the presence of severe depression and a

deficit in higher mental functions, such as attention, memory,

visuoconstructional abilities and executive functions, including low

verbal initiative. This data guided the development of a

neuropsychological rehabilitation program that consisted primarily in

the (development and) administration of alternative versions of the

neuropsychological instruments previously administered.

Afterwards, 10 rehabilitation sessions were conducted, each one with

an approximate duration of 45 minutes. Finally, in order to evaluate

the efficacy of the developed cognitive rehabilitation program, a

second evaluation was made, five months after the first one.

Figure 4. VERBAL FLUENCY

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Semantic fluency Phonological fluency

SUMMARY OF FIRST AND SECOND EVALUATIONS

Figure 5. “CONSTRUCTIVE ABILITY ”

RESULTS (CONT.)

Observing the graphics depicting a summary of the subject’s

performance on the two assessment moments (initial vs. final, i.e.

after 10 rehabilitation sessions), it can be easily perceived that there

is a systematic gain in terms of cognitive functioning, the only

exception being in phonological fluency (semantic fluency does

improve, thought).

The kind of data collected, in association with the fact that only one

subject was assessed, limit the use of statistical procedures that

could support the gains apparent in the graphics.

Even so, the paired-samples t-test conducted on the CVLT sub-

scores revealed a statistically significant difference between the final

and the first evaluation moments (t(7)=-2,696; p=0,031).

In respect to the scores that couldn’t be submitted to statistical

analysis, it must be stated that they seem clearly informative about

the positive impact of the intervention.

Figure 6. DEPRESSIVE SYMPTOMATOLOGY

11st st InternationalInternational SymposiumSymposium onon Neuropsychology Neuropsychology andand RehabilitationRehabilitation

CRPG CRPG –– 26th26th--28th 28th OctoberOctober, 2006, 2006

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Zung Self-rating Depression Scale