For our computer-based rehabilitation system we had initially adopted a very simplistic 'exercise' model. The basic idea being that if a brain injured patient is deficient in some basic abilities or processes, a programme of structured stimulation and challenge requiring the use of these processes will somehow improve these processes in the same sort of way that exercise strengthens muscle. The applicability and suitability of this model to human cognitive rehabilitation is a subject of much debate.

   The programme of cognitive rehabilitation that we have developed makes very extensive use of relatively inexpensive small, home microcomputers. The following is a list of benefits obtained by use of computers in this fashion. Some of these were apparent from the start and others revealed themselves during the development and application of the system.   

1. The effective use of the best features of a microcomputer, for example, the sound, the coloured graphics and the immediate feedback, can be extremely motivating such that the brain injured patients will spend much more time and effort than they would have otherwise. This may be the most salient feature in terms of any therapeutic efficacy.

 

2. Microcomputers are potentially cost-effective in terms of providing essentially unlimited access to appropriate retraining material. The degree to which this potential can be realized depends on the availability of suitable and reasonably priced software.

 

3. Given a reasonable degree of available programming expertise, microcomputers can be extremely flexible in that new or amended programs can be quickly and easily generated to meet particular patient needs. As the rehabilitation programme was designed to assist recent brain injured patients from the point of emergence from post-traumatic amnesia (PTA) through to more or less complete recovery we knew that the range of required material was going to be extensive. From the outset we also knew that the abilities of many of the patients would be fairly rapidly changing over time due to both 'natural recovery processes and - hopefully - to the effect of the rehabilitation - and that it would be necessary to design a system with sufficient flexibility so that any program would be well-matched to the patient's level at that point in time. The computer has been invaluable in these aspects.

 

4. The transportability of small micros allows rehabilitation to take place outside of the hospital environment. From the outset it was intended that this form of cognitive rehabilitation would be able to occur in the home environment for a number of reasons. A home-based system would allow the patient more access to the rehabilitation material. The patients would be able to work when they wanted to and for as long as they wanted to. Also for many patients the home environment is where they feel most comfortable and secure and hence might perform a bit better. Another substantial advantage of bringing cognitive rehabilitation into the home is that it is usually possible to involve the relatives as 'helpers' in the rehabilitation process. This involvement can be of substantial benefit to both the patient and the family.

 

5. The computer - by not being human - is not viewed by the patient in the same way as is a therapist. This has both advantages and disadvantages. On the plus side, the use of the computer does not generally create a strong emotional tone in the therapeutic situation. The patients do not seem to be as upset by demonstrating difficulty or failure to the computer as to they do to the therapist. The computer is also more consistent in its responses and feedback to the patient. The computer, unlike the therapist, doesn't have good and bad days. On the negative side it is far easier for the patient to prematurely terminate an exercise when it gets a bit difficult. Whereas the therapist might be able to exhort or cajole the patient to continue, once the 'reset' button is pressed the computer's influence has gone.

 

6. The computer provides greatly increased opportunities for maintaining tight control over the rehabilitation programme by automatically selecting the most appropriate material, monitoring performance, providing feedback and so on. These are features that should be immensely valuable in both clinical and research contexts.

   The system of computer-based cognitive rehabilitation that we've developed has three separable but interlinked components - the hardware, the software the patient uses for rehabilitation and the software for controlling the rehabilitation programme. Let us consider each briefly in turn.

Hardware

At the time we began this work, small 8 bit microcomputers had just become affordable. We chose the machine called the 'BBC Micro'  made by an English company (Acorn Computers Ltd.) for this project. We have continued with the successors from the same manufacturer (Master 128 and the 32 bit Archimedes range) for our own work. The software we supply covers the Acorn Archimedes , RISC PC computers. and Windows PC  
 

Rehabilitation Software

 When this project started it was intended that we would use existing commercial and educational software as there were literally hundreds of software programs and packages that seemed as though they might be appropriate. After a number of months of solid evaluation it became obvious that there was not a single bit of software that was usable as it stood. There was therefore no choice but to develop our own software.

   At present we have more than 70 programs that we use for cognitive rehabilitation. There are another 10 or so that are used solely for assessment. The programs can be loosely classified into areas such as attention, learning and memory, sensorimotor skills, language, numeracy and problem solving. There are certain characteristics common to all of our rehabilitation programs that are a reflection of the type of system we wanted to develop. These are:

   1. The rehabilitation programs are all designed to be stimulating and enjoyable to maximise the patient's use of the material. This is particularly important as patients would often be working unsupervised and at a distance.

 

   2. All of the recent programs have the facility to automatically change the difficulty of the task over a wide range. This is to ensure that the patient's will be working at an appropriate level.

 

  3. All of the recent programs have the facility to interact with the control system software to set the values of particular variables. This facility allows central control of most of the options, such as starting level, time allowances, input device and sound level.

 

4. As a patient may not experience a particular program before receiving it over the network at home, it is important that each program has sufficient instruction included.

   Although the material was written for head injury survivors, it has been used successfully in other centres with stroke patients, geriatrics, children with and without learning disability and Alzheimers sufferers. 

Control and Monitoring Systems for the Rehabilitation Programme

 The control and monitoring software is part of the Cognitive Rehabilitation system developed to assist people recovering from the effects of serious head injury. This component of the system is concerned with the automatic control of the patient's rehabilitation programme. This aspect is crucial if the patient is to be allowed to work independently. The two aspects of the control system involve determining the choice of material and getting the results of past performances. In operation the performance information is typically used to guide the selection of rehabilitation material.