Optimising Physical and Cognitive Health After Traumatic Brain Injury
Original Editor - Ahmad Rifai Sarraj:Ahmad Rifai Sarraj
Cognitive difficulties are very common in individuals with traumatic brain injury and can be a substantial sources of morbidity for them but also a major problem for their caregivers and their society.  Domains of cognitive impairment can include attention, processing speed, episodic memory, and executive function.
Attention disorders may affect concentration, necessary for planning, organization and synchronization of complex actions. Information processing speed is a slowness of the ability of the brain and the nervous system to process and conduct information. Although, Information processing speed usually tends to slow with age , it is frequently and remarkably impaired after traumatic brain injury.
Episodic Memory was defined by Tulving (1983, 2002) as a declarative memory that contains information specific to the time and place of acquisition, which is concerned with knowledge not tied to its context of acquisition. A recent meta-analysis  concluded and confirmed the conclusions of Vakil  “The profile of the memory deficit in patients with traumatic brain injury resembles that of patients with frontal injury rather than that of patients with amnesia.”  The authors of this meta-analysis recommended that following traumatic brain injury, it would be efficient to focus on remediation of executive functions, as well as directly on memory processes, to ameliorate memory functioning.
Finally, executive function can be considered as the most critical domain for goal-directed and complex behaviour. Planning, novel problem solving, monitoring, inhibition, initiation, updating, flexibility, set shifting, self-regulation and organization, can reflect the integrity or not of the executive function and abilities.
Physiotherapists and rehabilitation team members must evaluate and optimize cognitive health and behaviour in individuals after traumatic brain injury. Evidence about the effectiveness of rehabilitation in reducing the impact of brain injury related cognitive impairments, is still growing and consolidating. Results of studies are largely affected by the complexity and the heterogeneity of brain injuries.
Physical Activity and Cognition
Experimental evidence suggested that brain health is positively influenced by moderate-to-vigorous physical activity that is regularly performed. Physical activity enhances several components of cognition, including executive function (organizing daily activities, planning for the future, and self-regulation of impulsive behavior and sensation seeking), memory, treatment speed and attention. These performance improvements are corroborated by evidence from neuroimaging techniques demonstrating parallel changes in brain structure and function. 
Beneficial effects are observed in a variety of physical activities, including aerobics and bodybuilding activities, and populations with cognitive deficits as in traumatic brain injury.
Memory Improvement Strategy
Recall or retrieval of memory refers to the subsequent re-accessing of events or information from the past, which have been previously encoded and stored in the brain. The retrieval practice strategy led to large memory improvements among persons with chronic memory impairment following a traumatic brain injury.
The retrieval practice is defined as the act of retrieval or calling information to mind in order to strengthen storing processes in long term memory. Therapist works with patient following traumatic brain injury in subacute and chronic phases, to practice remembering specific information such persons, time to take medications and how to use walkers or any additions technical aids. Time between practices must be short (5 to 30 seconds) then we can increase this time until the person can learn or retrieve these specific informations.
In retrieval practice, we must first identify the person’s/client’s need and his specific tasks and behavior during daily life. This can also identify how far the person can benefit from such a strategy and to assess his abilities and if this strategy can be appropriate and relevant to his case. We may use visual, auditory and/or tactile cues to identify link between elements of a defined task. Instructions must be continuously given to patient making sure that he/she understands the objective of the learning.
The second phase is to develop relevant and lead questions related to the learned/remembered tasks and to formulate explicitly the response. Sometimes, these link question-answer can incorporate physical tasks.
In retrieval practice, we must not tell the persons that they give wrong answers, therapists provide them with correct answers trying to explain again and again the link and the corresponding tasks.
Another aim of the strategy is to shorten the time between the question and the answer trying to formulate a problem-solving parallel strategy in order to find corresponding answers. Additional exercises about retrieval practice can be found in Benigas et al. 2016.
Attention Improvement Strategy
Attention is defined as a “complex mental activity that refers to how an individual receives and begins to process internal and external stimuli”. Attention retraining typically requires persons to perform series of repetitive exercises or drills in which they respond to visual or auditory stimuli, often classifying items on the basis of a rule.
A metanalysis conducted by Park and Ingles  demonstrated that acquired deficits of attention are treatable. Results from the specific-skill studies, reviewed by the metanalysis clearly showed that performance on attention-demanding tasks can be improved.
Several ways exist in the literature in order to increase your attention. One of these ways can be based on mindfulness-based attention training exercises. These aimed to increase your focus on what is happening in the present moment and doing so with an accepting attitude towards whatever you notice. In this way you become the watcher or observer of whatever you are experiencing (i.e., your breath, body sensations, thoughts, feelings, sensory experiences, etc). Mindfulness involves practicing how to notice when your attention has wandered away from the present, and then skillfully redirecting your attention back to the what you are doing now.
A Mindfulness Attention Program designed for brain injury could positively impact emotional regulation with a mixed brain injury population. Hypothesis of this program was to target emotional regulation in patients with a mixed brain-injured population. Improved performance on a measure associated with emotional regulation can improve awareness, confident self-acceptance, and the practice of repeatedly refocusing attention.
- Arciniegas DB, Held K, Wagner P. Cognitive Impairment Following Traumatic Brain Injury. Curr Treat Options Neurol. 2002 Jan;4(1):43–57.
- Wortzel HS, Arciniegas DB. Treatment of post-traumatic cognitive impairments. Curr Treat Options Neurol. 2012 Oct;14(5):493–508.
- Royall DR, Lauterbach EC, Cummings JL, Reeve A, Rummans TA, Kaufer DI, et al. Executive control function: a review of its promise and challenges for clinical research. A report from the Committee on Research of the American Neuropsychiatric Association. J Neuropsychiatry Clin Neurosci. 2002;14(4):377–405.
- 4. Ferreira D, Molina Y, Machado A, Westman E, Wahlund L-O, Nieto A, et al. Cognitive decline is mediated by gray matter changes during middle age. Neurobiol Aging. 2014 May;35(5):1086–94.
- Ríos M, Periáñez JA, Muñoz-Céspedes JM. Attentional control and slowness of information processing after severe traumatic brain injury. Brain Inj. 2004 Mar;18(3):257–72.
- Moscovitch M, Cabeza R, Winocur G, Nadel L. Episodic Memory and Beyond: The Hippocampus and Neocortex in Transformation. Annu Rev Psychol. 2016;67:105–34.
- Vakil E, Greenstein Y, Weiss I, Shtein S. The Effects of Moderate-to-Severe Traumatic Brain Injury on Episodic Memory: a Meta-Analysis. Neuropsychol Rev. 2019 Aug 13;
- Vakil E. The effect of moderate to severe traumatic brain injury (TBI) on different aspects of memory: a selective review. J Clin Exp Neuropsychol. 2005 Nov;27(8):977–1021.
- Gioia GA, Isquith PK, Guy SC. Assessment of executive functions in children with neurological impairment. In: Psychological and developmental assessment: Children with disabilities and chronic conditions. New York, NY, US: Guilford Press; 2001. p. 317–56.
- Zimmermann N, Pereira N, Hermes-Pereira A, Holz M, Joanette Y, Fonseca RP. Executive functions profiles in traumatic brain injury adults: Implications for rehabilitation studies. Brain Inj. 2015;29(9):1071–81.
- Chaddock-Heyman L, Erickson KI, Chappell MA, Johnson CL, Kienzler C, Knecht A, et al. Aerobic fitness is associated with greater hippocampal cerebral blood flow in children. Dev Cogn Neurosci. 2016 Aug 1;20:52–8.
- Erickson KI, Voss MW, Prakash RS, Basak C, Szabo A, Chaddock L, et al. Exercise training increases size of hippocampus and improves memory. Proc Natl Acad Sci U S A. 2011 Feb 15;108(7):3017–22.
- Maass A, Düzel S, Brigadski T, Goerke M, Becke A, Sobieray U, et al. Relationships of peripheral IGF-1, VEGF and BDNF levels to exercise-related changes in memory, hippocampal perfusion and volumes in older adults. NeuroImage. 2016 01;131:142–54.
- Colcombe SJ, Erickson KI, Scalf PE, Kim JS, Prakash R, McAuley E, et al. Aerobic exercise training increases brain volume in aging humans. J Gerontol A Biol Sci Med Sci. 2006 Nov;61(11):1166–70.
- Sexton CE, Betts JF, Demnitz N, Dawes H, Ebmeier KP, Johansen-Berg H. A systematic review of MRI studies examining the relationship between physical fitness and activity and the white matter of the ageing brain. NeuroImage. 2016 01;131:81–90.
- Mossberg KA, Amonette WE, Masel BE. Endurance Training and Cardiorespiratory Conditioning after Traumatic Brain Injury. J Head Trauma Rehabil. 2010;25(3):173–83.
- Memory Recall/Retrieval - Memory Processes - The Human Memory [Internet]. [cited 2019 Sep 29]. Available from: http://www.human-memory.net/processes_recall.html
- Sumowski JF, Wood HG, Chiaravalloti N, Wylie GR, Lengenfelder J, DeLuca J. Retrieval practice: a simple strategy for improving memory after traumatic brain injury. J Int Neuropsychol Soc JINS. 2010 Nov;16(6):1147–50.
- Benigas PhD CCC-SLP J, Brush MA CCC-SLP J, Elliot MA G. Spaced Retrieval Step by Step: An Evidence-Based Memory Intervention. First edition. Baltimore: Health Professions Press; 2016. 168 p.
- Tsaousides T, Gordon WA. Cognitive rehabilitation following traumatic brain injury: assessment to treatment. Mt Sinai J Med N Y. 2009 Apr;76(2):173–81.
- Park NW, Ingles JL. Effectiveness of attention rehabilitation after an acquired brain injury: a meta-analysis. Neuropsychology. 2001 Apr;15(2):199–210.
- Azulay J, Mott T. The Impact of the Mindfulness Attention Meditation (MAP) with a Mixed Brain injury Population to Improve Emotional Regulation Enhance Awareness. Phys Med Rehabil Int. 2016;3(6):1101.