Brain injuries are associated with an increased risk of low mood and anxiety. In part this is a normal reaction to a terrible event and the changes it can cause such as loss of previous occupation, changes in relationships and reduced activity levels. In addition, changes in cognitive function (such as difficulty in controlling thought and rumination, impaired memory for positive experiences and a lack of problem solving ideas) can help to maintain low mood. Even in people without a brain injury, low mood is linked with changes in cognition and cognitive style (e.g. people can get stuck in a certain way of thinking and not see a way out). Accordingly, a brain injury can trigger a self-supporting cycle in which low mood effects cognition and cognitive problems help perpetuate low mood. If we are to improve outcome, both must be targets for intervention.

With clinical partners at the Oliver Zangwill Centre for Neuropsychological Rehabilitation, Cambridgeshire Community Services and the Cambridge Paediatric Brain Injury Rehabilitation team we are developing a new programme of research in this area. This strongly benefits from our links at the CBU with Tim Dalgleish and Emily Holmes and their expertise in mood theory and intervention in the non-brain injured population.

Key researchers: Fionnuala Murphy, Ausaf Farooqui

Relevant publications

Manly, T. & Murphy, F.C., (2012) Rehabilitation of Executive Function and Social Cognition Impairments after Brain Injury. Current Opinion in Neurology, 25, 656-661.

Murphy, F.C., Michael, A. & Sahakian, B.J. (2012). Emotion modulates cognitive flexibility in patients with major depression. Psychological Medicine, 42(7), 1373-1382.

Barnard P.J., Murphy F.C., Carthery-Goulart M.T., Ramponi C., & Clare L. (2011). Exploring the basis and boundary conditions of SenseCam-facilitated recollection. Memory, 19(7), 758-767.

Murphy F.C., Barnard P.J., Terry K.A.M., Carthery-Goulart M.T., & Holmes E.A. (2011). SenseCam, imagery, and bias in memory for well-being. Memory, 19(7), 768-777.

People with executive impairment following brain injury can benefit from educational/training approaches. Goal Management Training (GMT), for example, is a collaborative approach that seeks to develop awareness and anticipation of common cognitive errors and develop strategies to offset these problems (http://www.youtube.com/watch?v=EI39qivSl08). This includes a systematic approach to breaking down intentions into sub-goals and employing strategies to monitor and keep those sub-goals active in mind.

An important issue is how best to help people generalise strategies from training to everyday situations. One approach, based on our experimental work, is to link key messages in the training with a particular cue and send this cue periodically to patients via text messaging, helping to keep the ideas they have developed more actively in mind (Assisted Intention Monitoring: AIM).

In a good example of the links between CBU science and the work of our colleagues in clinical services, we recently completed a 3-year Randomised Control Trial of the effects of brief GMT + automated cues (generously funded by the National Institute for Health Research: NIHR). The outcome of that trial will be reported shortly and the results have already influenced the development of local clinical practice. The challenge ahead lies in combining ideas in goal management with strategies to help patients develop resilience to mood problems.

Research team: Fergus Gracey, Eve Greenfield, Jessica Fish, Andrew Bateman, Gemma Hardy, Jessica Ingham, Mariella Gregori, Jon Evans & Barbara Wilson.

Relevant publications

Fish, J., Evans, J. J., Nimmo, M., Martin, E., Kersel, D., Bateman, A., . . . Manly, T. (2007). Rehabilitation of executive dysfunction following brain injury: “content-free” cueing improves everyday prospective memory performance. Neuropsychologia, 45(6), 1318-1330.

Levine, B., Schweizer, T. A., O’Connor, C., Turner, G., Gillingham, S., Stuss, D. T., . . . Robertson, I. H. (2011). Rehabilitation of executive functioning in patients with frontal lobe brain damage with goal management training. Frontiers in Human Neuroscience, 5.

Manly, T., Davison, B., Gaynord, B., Greenfield, E., Parr, A., Ridgeway, V., & Robertson, I. H. (2004). An electronic knot in the handkerchief: “Content free cueing” and the maintenance of attentive control. Neuropsychological Rehabilitation, 14(1-2), 89-116.

Manly, T., Hawkins, J., Evans, J. J., Woldt, K., & Roberson, I. H. (2002). Rehabilitation of Executive Function: Facilitation of effective goal management on complex tasks using periodic auditory alerts. Neuropsychologia, 40(3), 271-281.

Schweizer, T. A., Levine, B., Rewilak, D., O’Connor, C., Turner, G., Alexander, M. P., . . . Stuss, D. T. (2008). Rehabilitation of executive functioning after focal damage to the cerebellum. Neurorehabilitation and Neural Repair, 22(1), 72-77.

Unilateral Spatial Neglect (USN, also called hemispatial neglect) is a curious consequence of one-sided brain injury in which patients have difficulty in noticing and acting on information on the side of space opposite to the lesion (e.g. a patient with damage to the right hemisphere of the brain will tend to ignore information from the left). Although vision may be normal, patients may fail to respond to somebody approaching from one side, only wash or dress on one side of the body and only eat from one side of a plate. Such bias is very common immediately following a stroke to either hemisphere but, in its persistent form, is overwhelmingly associated with right hemisphere damage and affects left space. Persistent neglect is a pressing clinical problem because it is associated with slowed recovery in general and greater dependence on others for many activities of daily living.

Work at the CBU has demonstrated that persistent USN is linked to problems in maintaining an alert state and that temporary increases in alertness reduce spatial bias. This led us to examine whether other groups with poor alertness might also be at risk of spatial bias. We have demonstrated in a series of single-case and group studies with children, for example, that quite marked biases away from the left occur in children who had problems sustaining their attention. This, in turn, led us to examine changes in spatial awareness in the normal population with low alertness (e.g. as a result of sleep deprivation or long-periods spent performing repetitive tasks). The results were consistent with members of the general public showing a similar pattern to patients with USN, albeit in a much more subtle form.

Our current projects are looking into the neural basis of this relationship, how it might inform our understanding of USN, the clinical implications of spatial bias in development, and, critically, how we can best harness the effect for rehabilitation.

Key researchers: Tristan Bekinschtein (A Wellcome Trust funded researcher at the CBU) Corinne Bareham, Fionnuala Murphy, Ausaf Farooqui.

Relevant publications

Manly T, Robertson IH, Verity C. Developmental unilateral visual neglect: A single case study. Neurocase. 1997;3(1):19-29.

Robertson IH, Manly T, Beschin N, Daini R, Haeske-Dewick H, Homberg V, et al. Auditory sustained attention is a marker of unilateral spatial neglect. Neuropsychologia. [Clinical Trial]. 1997 Dec;35(12):1527-32.

Dobler VB, Manly T, Verity C, Woolrych J, Robertson IH. Modulation of Spatial Attention in a Child with Developmental Unilateral Neglect. Dev Med Child Neurol. 2003;45(4):282-8.

George M, Dobler V, Nicholls E, Manly T. Spatial awareness, alertness, and ADHD: the re-emergence of unilateral neglect with time-on-task. Brain Cogn.

George MS, Mercer JS, Walker R, Manly T. A demonstration of endogenous modulation of unilateral spatial neglect: the impact of apparent time-pressure on spatial bias. J Int Neuropsychol Soc. 2008 Jan;14(1):33-41.

Manly T, Dove A, Blows S, George M, Noonan MP, Teasdale TW, et al. Assessment of unilateral spatial neglect: scoring star cancellation performance from video recordings–method, reliability, benefits, and normative data. Neuropsychology. 2009 Jul;23(4):519-28.

Manly T, Dobler VB, Dodds CM, George MA. Rightward shift in spatial awareness with declining alertness. Neuropsychologia. 2005;43(12):1721-8.

Dobler VB, Anker S, Gilmore J, Robertson IH, Atkinson J, Manly T. Asymmetric deterioration of spatial awareness with diminishing levels of alertness in normal children and children with ADHD. J Child Psychol Psychiatry. 2005 Nov;46(11):1230-48.

Attempts to retrain cognitive functions through repetitive exercises have produced generally disappointing results in brain injury rehabilitation. Instead, the most effective forms of rehabilitation in general focus on setting and achieving real-life functional goals and minimising the effects of impairment. However, the remarkable technological advances of recent years have potentially changed this landscape. In particular, the availability of home computers, smart phones etc. mean that patients can train very intensively at the time and location of their choosing on tasks that can track and adapt to performance, provide feedback, and have attractive game-like interfaces. Such training can be delivered to people around the world who may have little access to specialist rehabilitation services. Establishing whether and which sort of training is effective is a very important enterprise.

Recent evidence from controlled studies suggest that a particular form of intensive, progressive Working Memory training can produced generalised gains on untrained tasks (see LINK TO SUES PAGES).
Our current projects are examining whether we can systematically enhance generalisation of training gains to everyday situations and, in a collaboration with John Duncan, Duncan Astle and Polly Peers, the benefits for adults with attention problems following brain injury.

People can best be helped by appropriate rehabilitation etc. when their needs and strengths are known. The CBU has a long history of translating from precise experimental measures of different capacities (e.g. working memory, semantic memory, prospective memory, attention) to practical and widely used clinical tests. Tests developed at the CBU include The Behavioural Assessment of the Dysexecutive Syndrome (BADS; executive function), The Test of Everyday Attention (TEA), The Doors and People Test (memory), Pyramids and Palm Trees (semantic memory), Speed and Capacity of Language Processing Test (SCOLP), later versions of the Rivermead Behavioural Memory Test (RBMT), Test of Receptive Grammar (TROG), The Behavioural Assessment of the Dysexecutive Syndrome in Children (BADS-C) and the Test of Everyday Attention for Children (TEA-Ch). The TEA-Ch (Manly, Anderson, Robertson and Nimmo-Smith, 1998) has been translated into 11 languages and is in use in over 20 countries. In our current research we are interested in the application of new technologies to streamline assessment.

Relevant publications

Manly T, Anderson V, Nimmo-Smith I, Turner A, Watson P, Robertson IH. The differential assessment of children’s attention: the Test of Everyday Attention for Children (TEA-Ch), normative sample and ADHD performance. J Child Psychol Psychiatry;42(8):1065-81.

Manly T, Davison B, Heutink J, Galloway M, Robertson IH. Not enough time or not enough attention?: Speed, error and self-maintained control in the Sustained Attention to Response Test (SART). Clinical Neuropsychological Assessment. 2000;3:167-77.

Manly T, Robertson IH. The Sustained Attention to Response Test (SART). In: Rees G, editor. Neurobiology of Attention. New York 2005.

Manly T, Robertson IH, Anderson VA, Nimmo-Smith I. TEA-Ch – The Test of Everyday Attention for Children. London: Pearson Assessment; 1998.

Manly T, Dove A, Blows S, George M, Noonan MP, Teasdale TW, et al. Assessment of unilateral spatial neglect: scoring star cancellation performance from video recordings–method, reliability, benefits, and normative data. Neuropsychology. 2009 Jul;23(4):519-28