The History of Rehabilitation Research at the Cognition and Brain Sciences Unit
As documented in the main history pages on this website, the Unit began its existence in World War II as the Applied Psychology Research Unit. The very first progress report dated 1946 includes a short summary of rehabilitation studies relating to war injuries. Applications in focus in the immediate post-war period were in areas such as performance at work, driving skills, selection of appropriate people for challenging jobs, limitations in normal human memory and so forth. From these applied beginnings considerable theoretical developments took place including Donald Broadbent’s theories of attention, Alan Baddeley and Graham Hitch’s working memory model, Donald Norman and Tim Shallice’s Supervisory Attentional System framework and Phil Barnard and John Teasdale’s ICS. While cognitive neuropsychology – thinking about how the normal brain works by looking at what happens when it is damaged – formed a strong plank of the Unit’s work from the 1970/80s (with researchers such as Tim Shallice, Paul Burgess, Karalyn Patterson, John Duncan and Andy Young) the application of these ideas to clinical problems did not come to the fore until the late 1980s when Alan Baddeley, then Unit Director, began a series of collaborations with Barbara Wilson, a practicing clinical neuropsychologist. Barbara had trained as a clinical psychologist at the Institute of Psychiatry and originally worked in the area of developmental learning difficulties. When she began working with neurological patients (including Rivermead Rehabilitation Centre in Oxford) she was struck by how much clinical neuropsychology was dominated by assessment rather than attempts to rehabilitate (and indeed the general pessimism about how much rehabilitation could achieve). Over the years (and influenced by people such as Lindsay McLellan in the UK and George Prigatano in the States) she broadened the idea of what constitutes rehabilitation. She argued that cognitive rehabilitation referred to any technique that helped patients and their families to reduce, compensate for or live with deficits occasioned by brain injury. Outcomes, she argued, should be judged in terms of functional goals (such as the ability to use a compensatory memory aid) rather than through change in performance on neuropsychological tests.
Above right: Alan Baddeley. Left: Barbara Wilson, before joining the CBU, leading the successful protest to keep the Rivermead Rehab Unit open in the 1980s.
Barbara was persuaded to move from the University of Southhampton’s Rehabilitation Studies Department to the MRC Unit in 1990. During this time she has worked with a long list of colleagues, many of whom have gone on to establish international reputations in the field of Neuropsychological Rehabilitation. Notably Ian Robertson (of whom more below), Jon Evans who went on to become clinical director of the Oliver Zangwill Centre in Ely and is now a Professor in the University of Glasgow (as well as maintaining strong collaborative links with the Unit and Oliver Zangwill Centre), Linda Clare who is now a professor at the University of Bangor and Agnes Shiel who now holds a chair and founded a course in Occupational Therapy at the University of Galway, Ireland. More recently Bonnie-Kate Dewar has gone on to establish a memory aids clinic in London. In addition to core MRC staff, Barbara hosted many visitors between 1990 and her retirement in 2007. These included Tom Teasdale, Robyn Tate, and Margaret Crossleyfrom the University of Saskatchewan, Canada.
In 1995 Barbara Wilson and Ian Robertson’s programmes move to Elsworth House, part of the CBU based at Addenbrooke’s Hospital.
Notable projects led by Barbara during this period (click on the titles to go to a summary).
Experimental and clinical analyses of errorless learning
Many patients with severe memory impairments have normal or nearly normal implicit memory functioning and can thus learn some new information. Implicit memory, however, is not a good system for eliminating errors. In order to benefit from our mistakes we need to remember them, something memory impaired people cannot do. In the 1990’s Alan Baddeley and Barbara posed the question “Do amnesic people learn better if prevented from making mistakes while learning?” The answer was a resounding “yes” . The principle of errorless learning as a memory rehabilitation technique was born. It is a teaching technique whereby people are prevented, as far as possible, from making mistakes while they are learning a new skill or acquiring new information. Instead of teaching by demonstration, which may involve the learner in trial-and-error, the experimenter, therapist or teacher presents the correct information or procedure in ways that minimise the possibility of erroneous responses. In the absence of episodic memory once errors are in the system, it is hard to eliminate them.
Development and evaluation of the Neuropage system (now fully translated into an NHS clinical service).
Problems in remembering to do things in the future (prospective memory difficulties) are among the most commonly reported complaints following brain injury. When people forget important activities such as taking medication, picking up the children from school and so forth, this can result in very serious consequences.for everyday living. Furthermore, when relatives or partners need to continually remind someone to do something, relationships may become very strained. The Neuropage system was developed by [Larry Treadgold] the Engineer father of a young man who sustained a severe head injury. The idea is wonderfully simple and consists of drawing up a list of things that need to be done at particular times (take medication, walk the dog, begin to prepare a meal etc). These are then held on a computer and automatically sent as message to a pager worn by the individual at the appropriate time. A strength of the system is that the patient, who almost certainly has memory problems, does not have to learn how to use complex equipment – simply to respond to the incoming message signal and read the message from the screen. Whether something actually works in practice is a different matter and evaluating the system has been an important project in the rehabilitation group at the Unit and at the Oliver Zangwill Centre. The Neuropage Service is now run by the NHS, for details please click here.
Papers on Neuropage:
Emslie, H., Wilson, B. A., Quirk, K., Evans, J. J., and Watson, P. (2007). Using a paging system in the rehabilitation of encephalitic patients. Neuropsychological Rehabilitation, 17 (4/5), 567-581. [request reprint]
FISH, J., MANLY, T., EMSLIE, H., Evans, J.J. & WILSON, B.A. (In Press). Compensatory strategies for acquired disorders of memory and planning: Differential effects of a paging system for patients with brain injury of traumatic versus cerebrovascular aetiology, Journal of Neurology, Neurosurgery and Psychiatry [request reprint]
Wilson, B. A., Emslie, H., et al. (2001). Reducing everyday memory and planning problems by means of a paging system: A randomised control crossover study. Journal of Neurology, Neurosurgery and Psychiatry, 70, 477-482. [request reprint]
Wilson, B. A., Emslie, H., et al. (2005). A randomised control trial to evaluate a paging system for people with traumatic brain injury. Brain Injury, 19(11), 891-894. [request reprint]
Wilson, B. A., Emslie, H., et al. (1999). George: Learning to live independently with NeuroPage. Rehabilitation Psychology, 44, 284-296. [request reprint]
Wilson, B. A., Evans, J. J., et al. (1997). Evaluation of NeuroPage: A new memory aid. Journal of Neurology, Neurosurgery and Psychiatry, 63, 113-115. [request reprint]
Wilson, B. A., Scott, H., et al. (2003). Preliminary report of a NeuroPage Service within a health care system.Neurorehabilitation, 18, 3-8. [request reprint]
Development of the Behavioural Assessment of the Dysexecutive Syndrome (BADS) test battery
The Dysexecutive Syndrome refers to a range of cognitive and emotional problems. These include in (realistic) planning, following a stated plan, inhibiting inappropriate responses, flexibly adapting one’s behaviour in light of feedback, generating novel solutions, detecting errors and flattened or overly volatile emotional responses. The Behavioural Assessment of the Dysexecutive Syndrome (BADS) consisted of a series of tasks designed to measure some of these cognitive difficulties and a questionnaire that aimed to assess cognitive, behavioural and emotional components of the syndrome. The publishers of the test are Pearson (recently taken over from Harcourt Assessment).
Selected BADS papers:
Burgess, P.W., Alderman, N., Evans, J., Emslie, H. & Wilson, B.A. (1998) The ecological validity of tests of executive function., Journal of the International Neuropsychological Society, 4, 547- 558. [request reprint]
Evans, J.J., Chua, S.E., McKenna, P.J. & Wilson, B. A. (1997) Assessment of the dysexecutive syndrome in schizophrenia., Psychological Medicine, 27, 635-646 [request reprint]
Wilson, B.A., Evans, J.J., Alderman, N., Burgess, P.W., & Emslie, H. (1997) Behavioural assessment of the dysexecutive syndrome.In P. Rabbitt (Ed.), Methodology of Frontal and Executive Function, pp.239-250. Hove: Psychology Press. [request reprint]
Children’s and advanced versions of the Rivermead Behavioural Memory Test.
The original Rivermead Behavioural Memory Test (RBMT) was published in 1985 (Wilson, Cockburn, & Baddeley). It was designed to (a) predict everyday memory problems in people with acquired, non-progressive brain injury and (b) monitor change over time. The RBMT comprises tasks analogous to everyday situations that appear to be troublesome for memory impaired patients. There are four parallel versions of the RBMT, which has been translated into 14 languages and is widely used both as a clinical and a research tool. Norms for elderly people appeared in 1989 (Cockburn & Smith); adolescent norms appeared in 1990 (Wilson, Forester, Bryant & Cockburn); and a version for children aged 5-10 years appeared in 1991 (Wilson, Ivani-Chalian & Aldrich). Thus norms exist for people aged 5-96 years of age. A new version the RBMT-3 is to be published in 2008. This includes new subtests and better norms.
The establishment of the Oliver Zangwill Centre for Neuropsychological Rehabilitation in Ely
(For current information, visit the Centre’s website)
The Oliver Zangwill Centre for Neuropsychological Rehabilitation was established in 1996 by Barbara A Wilson to provide help with cognitive, emotional and social difficulties for people aged 16-60 who have survived an insult to the brain. The interdisciplinary team provides an out-patient service that offers specialist assessment and rehabilitation to adultsfrom all over the UK with non-progressive brain injury and provides support for their families. The centre is a partnership between the local NHS Trust and the Medical Research Council. All patients who attend the centre receive both group and individual therapy to help them understand and come to terms with what has happened to them, to learn strategies to reduce their cognitive and emotional difficulties and to help increase independence. The centre allows for the integration of research findings into clinical practice.
Following Barbara Wilson, the next major appointment was Ian Robertson in June of 1991. Before joining the Unit (and after a period building trains in Germany) Ian had been at the University of Edinburgh and Astley Ainslie Rehabilitation Hospital, where he was head of clinical neuropsychology (1984-1991). In 1989 he spent a year in Rome at the Universita la Sapienza/Clinica S Lucia) on an MRC travelling fellowship. Ian left in 1991 to move to Trinity College Dublin as the head of the psychology department, the founding director of the 26 million Euro Trinity College Institute of Neurosciencewhich opened in 2005 and recently Dean of Research at Trinity.
Major projects under Ian’s direction included the following (click on title for more information)
- The effect of limb activation on unilateral spatial neglect.
- Development of the The Test of Everyday Attention TEA.
- Locomotion in Unilateral neglect
- Non-lateralized capacity limitations in Unilateral Neglect
- Proprioceptive feedback training in unilateral neglect
- The Sustained Attention to Response Test (SART)
- Goal Management Training
The effect of limb activation on unilateral spatial neglect.
For general information on spatial neglect see here. It had been observed in single cases that when patients with left neglect performed a task with their left hand, they seemed to show less rightward bias in that task. This could be for a number of reasons including the acting hand forming a salient visual cue to the left. Ian Robertson and colleagues systematically examined these effects in a series of single case and group studies. Crucially, these investigations considered whether movements of the left hand would continue to have a beneficial effect when they were not visible to the patient (e.g. when the hand was moving under a table). Other questions examined in this series of studies considered whether the space in which the hand was moving was important – for example, if the left hand was moving to the right of the body midline or the right hand was moving to the left of the midline and whether the effects persisted during bimanual movements (e.g the possibility that if the right hand were moving it would ‘extinguish’ benefits of the left hand moving). Broadly the results of these studies indicated that
1. Movement of the left hand could produce benefits in terms of visual neglect even when those movements were not visible.
2. The effects were strongest when the left hand was moved on the left side of the body. Movements on the right hand on the left side of the body did not produce benefits.
3. Simultaneous bi-manual movements appeared to abolish the benefits of the left hand moving.
4. Benefits of left limb movements were seen on ecological tasks as well as on paper and pencil tests.
5. For some patients at least, lasting benefits of left limb movements on spatial neglect were seen after the end of formal training. These may be explained by increased spontaneous use of the left hand.
Spatial neglect and spatial bias.
A patient with left spatial neglect’s drawing of a man from memory.
Unilateral Neglect is a debilitating and, in the early stages, common consequence of stroke in which patients have difficulty in noticing or acting on information from one side of space. Although it is seen at a high frequency following damage to the left or right hemispheres of the brain in the acute stage (e.g. within 3 days of the stroke) almost all patients with persistent neglect have right hemisphere lesions and miss information on the left. Patients may be observed to ignore people approaching from their left, miss out the left side of the body when washing or dressing, eat food only from the right side of plate and collide with objects as they move about. Importantly, patients may also fail to make use of residual function in their left arm or leg. It is worth noting that what is the ‘left’ can vary from one context of perspective to another. A patient with very severe neglect for example, may miss many targets on the right sides of cancellation sheets although this area of omission will often be the left of a region in which targets were detected. As demonstrated by Jon Driver and Peter Halligan, the ‘left’ which is ignored may be defined as the left side of an object rather than the entire visual field (e.g. a patient may be able to detect another object which is to the left of the first and still miss details on the left side of that first object). Left may also be defined conceptually rather than spatially. For example, if a building like drawing is presented at an angle such that some of the ‘left of the building’ is in fact on the right side of the drawing right.
What is Goal Management Training (GMT)?
Goal Management Training was originally developed by Ian Robertson, Brian Levine and colleagues as a group or individual therapy approach for patients with acquired dysexecutive disorders (e.g. poor planning, forgetting to do things in the future, poor decision making and impulse control etc). The training had an educational/insight component. Here people learned about common problems that could arise following brain injury and, in this context, were encouraged to think about any difficulties that they might be experiencing. A likely advantage of a group approach in this respect is that people may feel more able to share experiences, observe and think about others’ problems and feel less defensive and judged: these are a set of problems to be solved or avoided rather than simply a list of shortcomings. The training also encouraged participants to engage collectively in exercises that highlighted particular difficulties and try out new strategies. An example might be a logical puzzle in which patients may have a tendency to rush to a conclusion or feel so overwhelmed that they give up. Here they would be encouraged to adopt a step-by-step approach, breaking the problem down into relevant components, thinking of different solutions and weighing the pros and cons of each and so forth. There is growing evidence that this type of training can be effective in encouraging a more measured and effective approach. A revision of Goal Management Training as therapeutic package has recently been developed by Brian Levine, Ian Robertson and Tom Manly and is currently being evaluated. It is not yet available. Further information on this will appear here as soon as possible.
Levine, B., Robertson, I. H., Clare, L., Carter, G., Hong, J., Wilson, B. A., et al. (2000). Rehabilitation of executive functioning: An experimental-clinical validation of Goal Management Training. Journal of the International Neuropsychological Society, 6, 299-312.
Levine, B., Stuss, D. T., Winocur, G., Binns, M. A., Fahy, L., Mandic, M., et al. (2007). Cognitive rehabilitation in the elderly: Effects on strategic behavior in relation to goal management. Journal of the International Neuropsychological Society, 13(1), 143-152.
An issue with this type of training approach is that, while patients may improve on the type of tasks which they have practiced in the sessions, do they generalize from these tasks and context to their everyday lives? Given the nature of some dysexecutive difficulties (poor abstraction, a tendency towards concrete, literal thinking etc) there are good reasons why this may be a problem (see von Cramon & Matthes-von Cramon, 1994) and it is certainly something that needs to be built in to the therapeutic package. One possibility, that arises from our work discussed above, is to use some form of automated cueing to help patients ‘take’ the therapeutic context into their everyday lives.
The Sustained Attention to Response Test (SART)
The Sustained Attention to Response test was developed by Ian with Tom Manly, Jackie Andrade, Bart Baddeley and Jenny Yiend. To read more about the SART