Recovery - Environment

Evidence for enriched environments (animals)

Animals in enriched environments show greater recovery from brain injury than animals in typical housing

Enriched environment for humans: what could it include?

Social support, exercise, and specific rehab

Problem with typical stroke hospital care

Patients are often inactive, alone, and in bed or their bedroom for large portions of the day

Enriched environment stroke study: design

N = 62; half received usual care, half received an "enriched" environment

Enriched environment stroke study: what the enriched group got

Unlimited access to self-directed exercise programs, iPads with apps, iPods with music, books, board games, puzzles, magazines, newspapers; interactive shared meals; family education

Enriched environment stroke study: results

Activity levels increased (sustained after discharge); length of stay was shorter; Modified Rankin scale was not different at discharge

Modified Rankin scale

6-point measure of functional independence

Why is the enriched environment study evidence mixed?

Activity and length of stay improved, but functional independence (Modified Rankin scale) did not differ at discharge

Cognitive rehabilitation therapy

Treatments aimed at improving cognitive functioning through the combined action of compensation, plasticity, and recovery

Cognitive rehab: populations most studied

TBI and stroke

Cognitive rehab: two components

1) Training the affected behaviours (targets recovery + plasticity); 2) Offering external supports (targets compensation)

Cognitive rehab: training the affected behaviour (examples)

Mnemonic strategies to remember words; looking to the neglected side

Cognitive rehab: external supports (examples)

Using a notebook; neck muscle vibration

How does cognitive rehab relate to plasticity?

Training affected behaviours targets recovery and plasticity (experience-dependent rewiring), while external supports target compensation

Cognitive rehab example for attention

Computer tasks where you remember and copy the order in which items lit up; evidence of transfer to other working memory measures after stroke

Cognitive rehab: areas with good evidence

Attention deficits after TBI/stroke; visual scanning for neglect after right-hemisphere stroke; compensatory strategies for mild memory deficits; language deficits after left-hemisphere stroke; social communication deficits after TBI; metacognitive strategy training for executive function deficits

Cog rehab evidence: attention

Attention deficits after TBI or stroke

Cog rehab evidence: neglect

Visual scanning training for neglect after right-hemisphere stroke

Cog rehab evidence: memory

Compensatory strategies for mild memory deficits

Cog rehab evidence: language

Language deficits after left-hemisphere stroke

Cog rehab evidence: social communication

Social communication deficits after TBI

Cog rehab evidence: executive function

Metacognitive strategy training for executive functioning deficits

Social determinants of health (SDoH)

Social and structural factors (e.g., race, culture, education, income, discrimination) that shape health outcomes

What does most neurological disorder research focus on?

Biomarkers, genetics, drug A vs drug B, optimal timing/dose/type of rehab

What does most neurological research overlook?

Race, culture, and other social determinants of health

Why do SDoH matter for brain dysfunction and recovery?

They affect diagnosis, risk, treatment access, and treatment outcomes, so ignoring them leaves out major influences on who gets sick and who recovers

SDoH and diagnosis

Unwillingness to self-report deficits may be higher in groups with deserved mistrust of health providers, leading to probable overestimation of anosognosia among marginalized groups (e.g., Black and Latinx Americans)

Why might anosognosia be overestimated in marginalized groups?

Deserved mistrust of health providers may make people unwilling to self-report deficits, which can look like unawareness

SDoH and risk of cognitive decline and dementia

Risk factors include low education, employment, income, and marital status

SDoH and treatment access/outcomes: stroke in Black Americans (risk)

Experiences of discrimination lead to stress, hypertension, and diabetes, which raise stroke risk

SDoH and treatment access/outcomes: stroke in Black Americans (access)

Higher neighbourhood segregation means differential health services, and longer waits than White Americans to see a healthcare provider

SDoH and treatment access/outcomes: stroke in Black Americans (care received)

More likely to receive a toxicology screen when presenting with stroke; less likely to receive tPA and more likely to decline it (possibly ineffective communication with healthcare providers)

tPA

Tissue plasminogen activator, a clot-dissolving treatment for stroke

Stroke in Black Americans: outcome

All of these factors lead to worse outcomes

TBI in Indigenous Canadians: risk factors

Poor road conditions on reserve (unpaved, poorly maintained, remote) and intergenerational trauma leading to intimate partner violence

TBI in Indigenous Canadians: treatment access

Lack of access to culturally appropriate health care; well-founded distrust of "help" from settlers

TBI in Indigenous Canadians: outcome

All of these factors lead to worse outcomes

Cultural factors and neurorehabilitation

Cultural beliefs and values shape what rehab is acceptable and effective

Indigenous views of dementia: normal part of life

Seen as a normal part of the "circle of life"

Indigenous views of dementia: caregiving

Supported by cultural values of interdependence and reciprocity

Indigenous views of dementia: approach

Emphasis on acceptance and adaptation; traditional remedies and ceremonies are essential to wellness

Indigenous views of dementia: causes

Multifactorial: normal aging, adoption of Western diet, less active lifestyle, environmental pollutants, trauma, etc.

Culturally appropriate rehab for Indigenous communities

Attention to spiritual health; active role for the injured person; shared decision-making; individualized traditional healing practices; learning to "live well" vs. fixing problems; incorporating traditional healers into the health care system

Scenario: culture and dementia care

A family sees dementia as part of the circle of life and relies on interdependent caregiving, ceremonies, and traditional remedies; a rehab plan focused only on "fixing" deficits clashes with this, whereas shared decision-making, spiritual health, traditional healers, and a "live well" goal fit the family's values and improve engagement

Why might a standard Western dementia approach fail?

It may focus on fixing problems and ignore spiritual health, traditional healing, and cultural values of acceptance, interdependence, and reciprocity