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Description of The Cognitive
Rehabilitation Software System
In general terms the aim of cognitive rehabilitation is
to improve the quality of the patient's mentation and thus the quality of
his or her interaction with the world. It is axiomatic that for any
individual patient, the particular pattern of deficit and dysfunction is
somewhat patient and injury specific. There are - however - some general
problems associated with nearly all head injuries. For example, most head
injury patients display some degree of fatigability, an impaired memory,
diminished attention capacity, decreased motivation and slowness of both
thought and action. These sequelae can be considered general - not only in
that they are nearly universal - but that within each individual these
deficiencies permeate and diminish all levels of cognitive activity. It is
primarily these 'general' defects that we are attempting to remediate with
our microcomputer-based cognitive retraining programme.
For our computer-based rehabilitation system we had initially adopted a
very simplistic 'exercise' model. The basic idea being that if a 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 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 head injury 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.
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