Clinical neuropsychology: Treating the brain for behavioural issues – The Star Online

The brain is a powerful tool, but when it is impaired, who do you turn to for help?

Those with mental health problems are usually referred to counsellors, psychologists and psychiatrists.

For stroke patients, the usual approach is to consult a neurologist, who will then stabilise and manage the disease before sending the patient to a physiotherapist for rehabilitation.

Often, rehabilitation focuses only on physical disability, even though many stroke patients also exhibit cognitive impairment (disturbances of attention, memory, language and orientation).

According to studies, approximately 30% of stroke patients will develop dementia within the first year of a stroke, which significantly affects his or her quality of life.

Hence, it is important to manage the post-acute care of stroke holistically and comprehensively via an interdisciplinary approach.

This is where clinical neuropsychologists like Dr Vigneswaran Veeramuthu step in.

Brain-behaviour link

We are a breed of psychologists who specialise in brain-behaviour relationships.

We look at patients with stroke, inflammation of the brain, concussion, traumatic brain injury, brain tumours basically, any alteration internally or externally that can be associated with brain changes, he says.

Clinical neuropsychology grew out of the study, assessment and treatment of the behavioural expression of brain dysfunction.

Much of the early clinical work in neuropsychology focused on assessing the effects of moderate to severe brain injuries, particularly those sustained on the battlefield during World Wars I and II.

An emerging field locally, these specialised personnel evaluate and treat people with various types of nervous system disorders.

Illnesses, injuries and diseases of the brain and nervous system can affect the way a person feels, thinks and behaves.

Their job is to conduct neuropsychological assessments to help identify cognitive impairment, and subsequently, provide targeted and individualised care recommendations for patients with cognitive problems.

Neuropsychological tests evaluate functioning in a number of areas, including intelligence, executive functions (such as planning, abstraction and conceptualisation), attention, memory, language, perception, sensorimotor functions, motivation, mood state, emotions, quality of life and personality styles.

As one of only three clinical neuropsychologists in Malaysia, Dr Vigneswaran is trained, among others, in the functions of neuroanatomy, neurochemistry and cognitive functioning, and how the biological process affects all these.

He says, Clinical psychologists are trained in dealing with mental health issues, problems due to life stressors, experiential factors, etc, but they do not undergo the extensive training in neuroanatomy that we do.

In Malaysia, because of the lack of qualified neuropsychologists, clinical psychologists have stepped in to help, and they do so by trial and error.

As there is now an established science to fall back on, the Society of Clinical Neuropsychologist (Division 40) is proposing that those interested in this area have to undergo standardised supervised clinical training before they can specialise in it.

As simple as psychology may sound, neurospsychology deals with a patients life and death.

When you miss out a certain diagnosis because you assume it is associated with, for example, depression, which can mimic cognitive deterioration (they can have memory problems), then you wont be able to provide the correct treatment, says Dr Vigneswaran.

This 'video game' tests a patient's brain-hand connection and coordination.

Stimulating nerve cells

We all know that different parts of the brain regulate different functions.

In a healthy brain, these functions are well-regulated and they work as a networked system.

In stroke patients, blood supply to a part of the brain is interrupted or reduced, depriving the affected brain tissue of oxygen and nutrients.

If prompt action is not taken, the brain cells begin to die within minutes.

When brain cells die, the brain reorganises itself by forming new neural connections.

However, these neurons need to be stimulated through activity in order to reform the connections in the affected area.

The most common type of stroke occurs when the middle cerebral artery is affected.

Symptoms of this type of stroke include disturbances in movement and sensation, difficulty swallowing (dysphagia), loss of bladder control and impaired speech.

It can also result in weakness in one side of the body, i.e. the side opposite to the part of the brain affected.

Dr Vigneswaran says, We are also trained to look at imaging, but in the acute stages, it is the neurologist, neurosurgeon or physician who manages the patient.

We only step in after the patient is stabilised, depending on the hospital setting.

Ideally, cognitive or physical rehabilitation should start in the intensive care unit, and not wait until the patient is discharged, as time is of essence.

The longer the delay in intervention, the more the deficit.

If the patient is able to communicate, the neuropsychologist gathers an objective view of the areas of deficit and shares the information with the occupational therapist (OT), who will then prescribe exercises to target those specific areas.

We need to stimulate the function of that area.

Say a patient has a problem with his working memory we give him a short story and ask him to repeat it.

The patient should be able to repeat the story immediately, but if you ask him 10 minutes later to repeat the same story, he probably wont be able to do it because his ability to retain the information is impaired, says Dr Vigneswaran.

Patients are put through repetitive tasks, which are broken down into smaller tasks some with the help of a computer to activate the affected part of the brain.

Cognitive therapy includes using pictures to visually recognise something, using shapes, puzzles, gadgets, mirrors, games, etc.

With certain types of cognitive impairment, the patient isnt able to put together a simple face puzzle, so they have to relearn this.

At times, the patient also has to be restrained because they resist doing the task out of frustration.

Again, because there is a lack of neuropsychologists here, stroke rehabilitation is done by the OT, but they use a different approach.

They are more functional, while we stimulate the affected area. Now, we work together, says Dr Vigneswaran.

Rehab helps, not cures

Every specialisation has a job to do, even though they may sometimes overlap.

A better understanding of how the brain works enables therapists to do their jobs better.Dr Vigneswaran demonstrates how a simple game of lights like this one, can show the speed of brain activation in a person.

Theoretically, in terms of stroke recovery prognosis, it diminishes as time passes.

From what we know, after 24 months, there may still be some improvement, but it will not be as quick as in the earlier months. As you age, it also gets harder.

However, we have seen patients, after five years of lingering, improving tremendously.

The natural recovery process also plays a part in the earlier stage as the brain is wired to heal itself over time.

Not everything that recovers is completely induced by rehabilitation, points out Dr Vigneswaran.

He is quick to add that rehabilitation does not necessarily mean the patient will be able to go back to being 100% normal afterwards.

He explains, For example, with dementia, there is nothing that we can do to stop what is going on, as their brain tissues will continue to degenerate. Pharmacological intervention slows it down.

Cognitive rehabilitation may also slow down the deterioration, but what is more important is that we are helping the patient to do the task.

The cost of rehabilitation, unfortunately, is not covered by most insurance companies.

And sadly, many patients do not realise this or the insurance company fails to inform them.

Rehabilitation is time-consuming, and by the time you see improvement, it would have been a costly affair.

But if patients dont seek the right intervention, they end up suffering because they dont get the best advice they should in terms of helping with recovery, says Dr Vigneswaran.

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