Finding the right path Finding the right path Finding the right - PDF document

Building bridges to improve Building bridges to improve Brain I njury Treatment and Research Brain I njury Treatment and Research California Pacific California Pacific VA Medical Centers in Regional Rehabilitation Regional Rehabilitation Martinez and San Francisco Center Center Program in Program in Rehabilitation Rehabilitation Neuroscience Neuroscience Neuroscience Institute, University UCSF Neuro-Rehab & of California, Berkeley Neuroscience Imaging Center Rehabilitation of Frontal Rehabilitation of Frontal Systems Functioning Systems Functioning Finding the right path Finding the right path Finding the right path Finding the right path after TBI after TBI after TBI after TBI Anthony J- -W Chen MD W Chen MD Anthony J Program in Rehabilitation Neuroscience Program in Rehabilitation Neuroscience VA Medical Centers, SF and Martinez VA Medical Centers, SF and Martinez University of California, Berkeley and University of California, Berkeley and UCSF UCSF 1

I n the moment of an I n the moment of an instant… … instant •A • A blas blast blast went off blas went off next to our vehicle next to our vehicle •We plowed into a • We plowed into a ditch– – My head My head ditch struck the side of struck the side of the vehicle. the vehicle. I must have blacked out for a minute… I must have blacked out for a minute … and I can’ ’t remember much of what happened t remember much of what happened and I can in the next half hour… in the next half hour … …to the aftermath to the aftermath …  I vaguely remember getting out of the I vaguely remember getting out of the  vehicle and shooting. vehicle and shooting.  After the mission, I felt dazed (but we After the mission, I felt dazed (but we  always felt dazed and confused in the always felt dazed and confused in the field.) field.)  I tried to I tried to ‘ ‘shake it off. shake it off.’ ’ I think I did my I think I did my  job pretty well on job pretty well on ‘ ‘ autopilot autopilot . .’ ’  I really had problems I really had problems after I got after I got  home … … home 2

…to the aftermath … to the aftermath… …  Difficulty concentrating, easily distracted  Sensitive to non-relevant noise (environmental or otherwise)  Easily overwhelmed, especially by multiple tasks  Poor organization, difficulty prioritizing, planning and solving problems  Can’t get things done…  Symptoms of ‘executive control dysfunction’  Often ‘invisible’ yet extremely disabling. extremely disabling.  Most apparent in Most apparent in  complex, complex, unstructured unstructured environments– environments – when when we we’ ’re re not not told what told what to do to do Provided by Tatjana Novakovic-Agopian 3

‘Executive Control Dysfunction??? ‘ Executive Control Dysfunction???’ ’ Adju just stmen ments of s of Establi ablishing ng Self-Awareness Self-Awareness beh behavior or attentiona attentional s l set Error Error monitoring monitor ng Ma Maintena intenance o nce of ‘Automatic’ ‘Automatic’ Selection of lection of information information attention a attention and d information information Dis Discrepa crepancy ncy orienting orienting base based on d on goal- goal- de detection tection relevance releva ‘E ‘Exe xecut cutive’ ve’ Prospective Prospective manipulation of manipulation of memor me mory information information Episo isodic ic Motiv tivation tion me memor mory Emotional self- otional self- Energization Energization Sc Schem hematiza tization tion regula regu lation on Prior Pr ioritization tization St Stra rategic gic Reward- Reward-based ased & Se & Sequenci quencing ng retrieval retrieval Goal-s Goal-sub- ub- feed feedback back goa goal learning learning Multi- Multi- ma mana nagement gement ta tasking Pla Plannin nning … to Treatment Targets?? to Treatment Targets?? … Who cares about cognitive Who cares about cognitive dysfunction? (Why should dysfunction? (Why should we focus on this?) we focus on this?)  Who solves this person Who solves this person’ ’s problems? s problems?  – The brain as its own teacher – The brain as its own teacher– –allows the person to allows the person to adapt and learn. adapt and learn. – E.g. When a limb is injured E.g. When a limb is injured… …adaptation adaptation – – E.g E.g When motor cortex of the brain is When motor cortex of the brain is – injured… injured …rehabilitation rehabilitation – E.g. When cognitive functioning is injured E.g. When cognitive functioning is injured… … ??? ??? –  Where is this person going? Where is this person going?  – Re – Re- -integration into the home, work, community integration into the home, work, community – What happens if he/she can – What happens if he/she can’ ’t take care of herself? t take care of herself? 4

Treatment Development: From Treatment Development: From Theory to I ntervention, Theory to I ntervention, Measurement and Testing Measurement and Testing THEORY of Function (and Dysfunction) Treatment theory Intervention Measurement(s Measurement(s) ) What are What a e ‘Executive control ‘Executive control functions’? functions’?  Aspects of the direction of neural Aspects of the direction of neural- -  behavioral processes to achieve behavioral processes to achieve goals goals • Depend on • Depend on frontal systems frontal systems Basic mechanisms for top- -down down Basic mechanisms for top control control 1. Selection 1. Selection 2. Maintenance and 2. Maintenance and manipulation manipulation  Disrupted by not only frontal Disrupted by not only frontal  injuries, but also disconnection injuries, but also disconnection of networks of networks 5

Focus on Gateways as Focus on Gateways as Treatment Targets Treatment Targets ATTENTION ATTENTION WORKING WORKING MEMO MEMORY Pathway from information to Pathway from information to action and goal attainment: action and goal attainment: Gateway to Executive Control Gateway to Executive Control Selection of information 6

All information All information Goal-relevant Goal-relevant information information Target processes: Selection Information Selection Gateway Working Working Memory Memory Guidance Guidance Maintenance Maintenance Of Neural- Of Neural- Learning Learning Behavioral Behavioral Sequencing Sequencing Processes Processes Planning, Planning Problem-solving Review (Review) Off Off Goal attainment GOAL ATTAINMENT track track Targeting the I nformation GATEWAY Targeting the I nformation GATEWAY to Executive Control- - to Executive Control A pilot integrated rehabilitation neuroscience study A pilot integrated rehabilitation neuroscience study  I. Targets: Selective information processing for I. Targets: Selective information processing for  goal attainment goal attainment  II. Intervention: Goal II. Intervention: Goal- -directed attentional self directed attentional self- -  regulation regulation – “ “Goal Goal- -based self based self- -management management” ” (GBSM) (GBSM) –  III. Measurements: III. Measurements:  – Neuro – Neuro- -cognitive test performance cognitive test performance– – selective selective information processing information processing – Biomarkers: Goal Biomarkers: Goal- -direction of information processing direction of information processing – in the brain (fMRI in the brain ( fMRI ) ) – Functional Outcomes in the Functional Outcomes in the ‘ ‘real world real world’ ’ – 7

I NTERVENTI ON I NTERVENTI ON Training of goal- Training of goal -directed directed attention regulation attention regulation ‘Goal ‘ Goal- -based Self based Self- -Management Management’ ’ training protocol training protocol Novakovic-Agopian, Chen, Rome, 2006 I ntervention synopsis I ntervention synopsis  Intro of the importance of goal Intro of the importance of goal- -directed directed  selection selection – Stop Stop- -Relax Relax- -Refocus Refocus – – Practice holding goal – Practice holding goal- -relevant information in relevant information in mind, while ‘ ‘letting go letting go’ ’ of of distractors distractors (non (non- - mind, while relevant) relevant)  Application and progressive applied Application and progressive applied  practice practice – Apply to progressively more challenging – Apply to progressively more challenging situations in training sessions and daily life situations in training sessions and daily life 8