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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