20Q: Assessing the Role of Context in Cognitive Rehabilitation

Kinsuk Maitra, Role of Context in Cognitive Rehabilitation

Dr. Kinsuk Maitra is a Fellow in AOTA, and a distinguished professor and researcher. He has published several manuscripts and has received external and internal support for his research. He is currently the Inaugural Chair and Professor of the Occupational Therapy Department at Georgia State University in Atlanta.

Franklin Stein, PhD, OTR/L, FAOTA

Contributing Editor

Salute to OT Leaders Series

                20Q: Assessing the Role of Context in Cognitive Rehabilitation

Neurorehabilitation

1. Neurorehabilitation has been a significant part of your scholarly career. How would you define neurorehabilitation?

Neurorehabilitation is an interdisciplinary intervention to restore functions at an optimal level following an incident such as a stroke or a traumatic brain injury. Function is a part of our daily life and always happens in a physical space when performing an activity of daily living (ADL) at home or in a leisure occupation. Technically, one occupies a physical space to perform a function that is meaningful to the person. Therefore, in neurorehabilitation, the relationship between physical space and function is significant. For example, in a crucial daily function, like toileting, the client and the therapist need to consider the elements (ergonomics) in the physical space such as the height of the toilet and the cognitive ability of the client to understand the relationship between the physical capacity of self and the space. This understanding is the key to successful neurorehabilitation in this particular function.

2. Of your findings from the research studies, how can they be applied to clinical practice?

In early 2000, we conducted research studies that explored the relationship between performing an action like “reaching” immediately following visually seeing an action word like “REACH” on a screen. We found that action word visualization may "prime" an action, or in other words, improve the action. Scientists also found that visualizing action words (examples are lick, pick, or kick) also activates brain areas responsible for that particular action (tongue, hand, or leg) area. Therefore, we suggested that in the clinic if the client observes the action word the client is going to perform, the word may help to "prime" the movement and facilitate the action leading to a better outcome.

3. Specifically, you have been on a number of funded research projects in traumatic brain injury (TBI). Can you discuss the typical research protocol?

I was involved in traumatic brain injury (TBI) inpatient research at Rush University Medical Center, Chicago. The research project led by Dr. Susan Horn was National Institute of Health (NIH) funded research on practice-based evidence for TBI. Practice-based evidence (PBE) involves collecting a large data set on the patient, the context, and the facility characteristics for every encounter of the patient by every discipline. These processes generated a robust and rich data set that was analyzed to identify the key elements (e.g., patient and treatment characteristics) required for safe, appropriate, and cost-effective use of interventions for TBI in the study population. The idea of PBE is different than evidence-based practice. The argument is that evidence generated through a randomized controlled trial (RCT), cannot be extended. Therefore, the opposite approach is that the evidence needs to come from the practice settings where context and co-treatments need to be incorporated into the effective treatment plan.

The protocol involved data collection in every point-of-encounter (POC) with a client on a program specific form (e.g., OT, PT, nursing, etc.) that was generated through an exhaustive discussion with the clinicians of that particular discipline. A typical POC form contains all the activities and interventions checklists that are carried out in a particular facility for a particular condition, like a stroke. The POC form also has a checklist of contexts like co-treatment, inpatient clinic side, or bedside information along with patient characteristics like mood, emotion, exhaustion, etc. This data is then analyzed to ascertain the combination of activities and interventions that produced the most favorable outcome for patient care. These analyses help to develop a model specific to a facility for a specific rehabilitation outcome. Later, we used a similar protocol on patients with multiple sclerosis and performed a retrospective chart analysis, and published the results in the American Journal of Occupational Therapy. We found that occupational therapy interventions significantly improved upper extremity dressing and memory. These analyses also confirmed the relationship between cognition and action that is vital for performing a meaningful and purposeful function in ADLs.

4. Based on your research evidence, how can outcomes be improved in the acute rehabilitation for patients with TBI?

The acute or inpatient rehabilitation process is sometimes called a "black box of rehabilitation." Once a patient enters the inpatient rehabilitation, multiple health professionals treat the patient, sometimes collaboratively and oftentimes individually. The outcome is a combined effort of many healthcare disciplines. There is no definitive way to determine the benefit of an individual therapy discipline. For example, if a client in an inpatient rehabilitation improves lower extremity function, several disciplines can claim that the improvement is due to the therapy they performed. Physical therapy can claim that the improvement was due to PT intervention of strength and endurance training; occupational therapy (OT) can claim that the improvement was due to balance and posture intervention during a standing kitchen task activity, nursing can claim that the improvement was due to their intervention of walking the client from the bed to the toilet, and so on. It would be better if we could find a way to assess the individual discipline’s contribution through robust regression analysis. Perhaps then, we could say that 30% variance in improvement in lower extremity function can be explained by OT intervention, another 30% by PT, and the remaining 40% by other types of interventions. To do this, the best approach would be to take advantage of the state-of-the-art electronic documentation system where client encounter data of each discipline could be systematically entered and seamlessly integrated into one built-in effective model that determines the right combination of all therapy interventions for a particular patient with a specific condition in a specific context/space, like a specific hospital or rehab facility. Fine tuning data collection for specific rehabilitation procedure(s) could help us to design the optimum rehab intervention for a particular condition. 

5. What are your current research projects in neurorehabilitation?

My current research involves looking at home space design that supports the cognitive health of the resident(s), especially older adults with or without failing cognitive health. Aging in place has become increasingly important as the number of older adults is changing rapidly in the United States. The number of older adults is expected to be double in the next twenty-five (25) years. One of the most important implications of this change in the older adult demographic is designing home or living environments suitable or adaptable for older adults. Occupational therapists and architects need to and are working together to find exciting opportunities to create solutions for older adult living spaces to promote functionally independent living, physical well-being, and increase longevity. My current research focuses on this aspect of OT and ADLs in spaces.

Research has found that older adults living in a neighborhood with high street connectivity and integration (meaning there are more ways and options to reach a destination) have exhibited higher cognitive health than that of older adults living in more isolated communities. The plausible theory is that highly connected neighborhoods offer cognitive challenges to the brain for navigation, and such in-built cognitive challenges are good for the aging brain. In this area, we have collected demographic, cognitive, and psychosocial data like loneliness, depression, social participation, and residential living satisfaction from older adults living in different neighborhoods. We also collected the measures of the physical layout of these homes. Our hypothesis was to test whether the observed association between neighborhood street connectivity and cognitive functions holds true in the case of the room connectivity and cognition of the older adults in their homes. Room connectivity simply means how many doors or openings one room has with another room. One door between two rooms means the rooms have one connection. However, if there are two doors between rooms, the connectivity is two. The connectivity is important in the sense that it opens the possibility of going from one room to the other in many different ways. More connectivity and movement mean that the brain needs to figure out which connection to use when moving from one room to other. In other words, more connectivity means there are more challenges and options for the brain to figure out. The room layouts and associated connections may create a subtle puzzle to the brain, and thus a house with more connectivity may be associated with better cognitive function of the residents controlling other factors like age, education, sex, etc. Our results suggest that older adults living in higher connected houses indeed performed better in the Montreal Cognitive Assessment Test (MoCA) than the older adults living in lesser connected homes. The results have implications not only for older adults aging in their homes but also for the neurorehabilitation of patients with neurocognitive incidents returning to their homes from inpatient rehabilitation. This is probably one of the first studies showing that modification of a home using ergonomic and design principles to increase connectivity may have cognitive benefits.

Cognitive Rehabilitation

6. You have published a number of studies on cognition. What is the significance of cognitive rehabilitation for occupational therapists?

Occupational therapists are concerned with maximizing the functional potential of individuals in their homes and community. Cognitive rehabilitation does just that—functional independence is a function of cognitive abilities. One of the crucial ingredients of living and aging in place is to have good cognitive health. Cognitive health is collectively defined as the ability to clearly think, learn, and remember, and is an important determinant of performing everyday activities of daily living (ADLs). Excellent cognitive health is correlated with a delay in Alzheimer's disease onset, and the ability to "age in place." "Aging in place" not only can keep older adults functionally independent in their later years, but it also has economic implications. Gesine Marquardt and her colleagues published a study in 2011 in which they studied the relationship between space layout characteristics of homes and activities of daily living (ADL) among people with dementia. Their results imply that enclosed rooms with a clear meaning and function (e.g., enclosed kitchen versus open kitchen) were better memorized and resulted in better ADL functions. Our study follows a similar pattern in older adults. The results suggest that older home designs where spaces are broken down and demarcated by walls attributing to specific functional areas like kitchen, family room, and bedroom assists clients or patients with mild cognitive impairment (MCI) or first stage Alzheimer's dementia (AD) to perform ADLs with less dependency on others. Therefore, OTs could suggest improved home modification layout for people with MCI or mild AD living in an open concept home to help improve the design with demarcated spaces with functions.

7. How can the results of your research be applied to individuals with learning or cognitive deficits?

The cognitive process depends largely on two types of memory, implicit memory and explicit memory. Oftentimes, implicit memory is also called non-conscious memory. Implicit memory is consolidated over the repetitive practice of a procedure like driving, bicycling, etc. The majority of our ADL skills are acquired through repetitive practice and are governed by implicit memory. On the other hand, explicit memory is about events, episodes, etc. Normally, implicit and explicit memory interact to perform complex functions like driving. For example, driving a car is largely a procedural function; however, if a pedestrian suddenly comes in front of the car, the explicit memory kicks in and provides feedback to push the break. And, the driver actually remembers the event to recall later.

Learning deficits are basically cognitive deficits, and most of the time they are due to deficits in implicit memory. One of the techniques that researchers use to elicit implicit memory is to prime the memory by a process called “repetition priming” of visual-spatial memory. I mentioned this before. In the priming method, the subjects are shown a fraction of a visual scene to prime them about an upcoming visual scene. The subject recognizes the visual scene better and faster when they are primed versus when they are not. A practical example of repetition priming in our life would be when we see a series of arrow signs in a bending road. The series of arrows repeatedly and visually reminds us of a sharp bend ahead and demands the action of slowing down. If we are tuned with the visual scene, an automatic implicit slowing down occurs. We can use the same technique in therapy to address learning deficits. In psychology, oftentimes, researchers use a term called "creating prosthetic environments." This means either with caregivers or with technology one can create an environment that can anticipate the need of the clients and assist them to function and account for their physiological, sociological, or cognitive deficits. I would recommend creating a prosthetic environment in the home using technology to introduce repetition priming for patients with learning or cognitive deficits. For example, if a patient with AD and cognitive deficits would like to go to the kitchen, one can prime the movement by voice control device uttering softly, "Go to the kitchen," or "Go through the door," etc.

8. What is the relationship between cognitive function and physical capacity?

When conceptualized at the person-level (rather than impairments in particular body functions or structures), physical capacity refers to strength, range of motion, stamina, and balance. Physical capacity is a key indicator of the ability of an individual to carry out daily activities (ADLs). There is now substantial evidence that physical activity is beneficial to cognitive health, although the molecular mechanisms involved remain unknown. In other words, the evidence currently available regarding the effectiveness of physical activity training for improving cognition, functionality, and behavior in addressing dementia is insufficient. Therefore, randomized studies are needed. These studies should assess the quality of life in patients and the need for hospitalization.

An important aspect of physical activity is that it also determines social participation, involvement with group activities, and/or outdoor travel. These all have an influence on cognitive function. An environment that provides opportunities for social gatherings and group activities also promotes cognitive function. There is an excellent systematic review paper by Donnelly and his colleagues, published in 2016, which examined the relationships among physical activity, fitness, cognitive function, and academic achievement in children and found positive associations between them. These findings should inform OTs in their practice to evaluate the richness of context and environment in promoting physical capacities, social activities, and cognitive health.

9. What are some strategies that occupational therapists can use in applying cognitive rehabilitation to people with Alzheimer's Disease?

The hallmark of Alzheimer’s disease (AD) is gradual memory loss, especially working memory and long-term declarative memory. The gradual memory loss is reflected in the progressive decline in cognitive, functional, and social abilities. In addition, AD also puts a burden on the family members and caregivers.  Since AD is a progressive disease, a progressive rehabilitation strategy is needed. To aid the declarative memory loss, developing memory aids like an agenda, a calendar, and notes to remember daily tasks, kitchen activities, or appointments are useful. Helping them to use electronic devices, or adapting technologies for communication is also useful. Anything that helps the patient to aid the working or declarative memory is helpful. Since AD is a progressive disease, cognitive rehabilitation may not be the right term to use. However, if the rehabilitation approaches are taken, the goal should be towards improving functional ability, enabling the clients to attain personally relevant goals, and improving social participation with family and dear ones. Creating small challenges within the environment that requires decision-making would be helpful. For example, asking whether the patient likes a "muffin" versus a "cookie," and eliciting a response would allow the person to think for a choice. As I mentioned earlier, clearly marked spaces with functions are also helpful.

10. What do occupational therapists need to learn in order to apply a holistic cognitive rehabilitation program?

The home or the living space is at the center of a holistic cognitive rehabilitation program. The home or the living space should be considered in the context of physical, social, and personal elements in which functions or individual abilities would interact. The "physical home" comprises the spatial layout of the home and arrangements of furniture and objects. The physical home should create dynamic interactions between the residents and the structures and layout to facilitate the performance of daily activities. The physical layout of the home also provides the context of the "social home." The "social home" provides a platform and a context of social exchange and opportunities for the maintenance of relationships with family and friends. Alternatively, the "social home" also serves as a "social boundary," protecting the privacy of the resident when needed. The "personal home" provides a sense of place with its physical objects and collections. The "personal home" also provides biographical meaning and roles of the residents within social networks. The function of the "personal home" is to provide a symbolic identity. A holistic cognitive rehabilitation program must address the personal, physical, and social social components of the client living in a home. 

Personal, Educational, and Career Development

11. Where did you grow up and what was your family structure like?

I grew up in a small town in Northeast India. I grew up with three brothers and my parents. All boys! There were lots of childhood adventures as part of our growing up. My mother had a big family with quite a few siblings. She was originally from Dinajpur, now part of Bangladesh.  My mother’s family were watch repairers, a tradition my maternal uncles carried on in Northeast India. I used to spend a lot of time in my uncles' shop in after school. I loved to see how a dead watch came alive after the magic touch from one of my uncles.

12. Where did you go to elementary, and high school?

I completed my elementary and high school years in Raiganj, India. My brothers and I walked to school every day. In those days, everyone knew each other in the neighborhood. I completed high school at Raiganj Coronation School.  

13. Why did you select occupational therapy as your career profession and where did you obtain your undergraduate and graduate degrees in occupational therapy?

I got my bachelor's and master's degrees in Human Physiology from Calcutta University, India, and my PhD in Neuroscience from Jadavpur University, Calcutta, India. After two Post-Doctoral Fellowships in Germany and Canada, I joined the Occupational Therapy Department at Ithaca College, NY to teach kinesiology and neuroscience. I received my OT degrees from Ithaca College, NY.

14. After graduating as an occupational therapist what were your clinical experiences?

I was a faculty practitioner at the Medical College of Ohio and at Rush University Medical Center in Chicago.

15. Describe your current position as an educator, researcher, and administrator at Georgia State University?

I joined Georgia State to develop the OT program at the University. Georgia State’s mission encompasses teaching, research, and service in unique ways, and it is a national leader in graduating students from diverse backgrounds. I am humbled to be here. I, along with the excellent faculty, have developed an occupational therapy program committed to excellence in education, research, and service. In five years, we have successfully developed an MSOT program with a high rate of application and a 100% national board pass rate.  We are now transitioning to an entry-level Doctoral Degree in OT or OTD. I thoroughly enjoy interacting with our students. We, as a team, are committed to providing the best education to our students. We are partnering with Georgia Tech, Emory, and other institutions nationwide on research. We are also fully committed to working with our many community partners.

Views Towards the Profession of Occupational Therapy

16. How would you define occupational therapy to your first-year graduate students?

My research focuses on the intersection of design, space, cognition, and rehabilitation. I always think of occupational therapy in relation to the shape of a space, (e.g., physical space). Occupation to me is occupying a space for doing something important. Therefore, the construct of a physical space is very important for a meaningful function. I remember the saying of Winston Churchill after the British Common Chamber (the parliament) was destroyed by a German bombing during WWII in 1943. Churchill insisted that the chamber needed to be rebuilt exactly the same way as before. He argued that the shape of the chamber’s seating arrangement was important for the two-party system to function. His famous remark was, “We shape our buildings, and afterward, our buildings shape us.” I personally think this is appropriate in occupational therapy. We really need to help our clients shape their environment, so the environment can facilitate their function. Occupational therapy to me is a stable but dynamic interaction between space and function.

17. What do you perceive as the current trends in occupational therapy research?

Occupational therapy research is in the process of becoming an organized effort nationwide with the focus on organizations like AOTA, AOTF, as well as third-party payers like insurance companies and individuals. As the profession moves towards doctoral education, research is becoming an integral part of education, not an afterthought. In addition, many research-intensive or extensive universities are opening occupational therapy programs with a focus on establishing externally funded research programs. Now, more than ever, we have a growing number of NIH-funded OT research. As we are increasing our professional research portfolio, our collaborations with researchers in other fields are growing as well. The OT profession is becoming better known and respected in health care. Other professions are pleasantly surprised by the depth and breadth of occupational therapy research. Moving forward, the future of OT research would be integrating the knowledge of occupations with technology, telerehabilitation, aging-in-place, and more.

18. What are your thoughts on graduate education and the future of occupational therapy?

Graduate education in occupational therapy should study the meaning of occupations, and the purpose of occupations in our life and the society in-depth. Our ultimate job as occupational therapists is to improve the lives of individuals in terms of their performances in their preferred occupations and settings. Personally, I think the central theme of occupational therapy education should be "what we do-who we are-where we are." Graduate education in OT should encompass inquiry-based education in knowledge, in practice, and in service to the community.

19. How can we improve the everyday practice of occupational therapy?

One of the best ways to improve the everyday practice of occupational therapy is explaining the importance of occupations in the life of a person. I always tell my students and patients/clients that who you are and your meaningful existence in society depends on what you do and where you do it. Many clients have the idea that occupational therapy means playing cards on a table or buttoning a shirt. While in some cases that might be true, but there is a much broader application of OT. We need to explain to our clients that ADLs are vital as is participation in society. OTs teach the techniques to do simple yet valuable activities of daily living after an accident, injury, stroke, or any other health-related setback.

20. How would you summarize your major contributions to the occupational therapy profession?

I have been fortunate to serve different institutions in leadership roles and have had the opportunity to work with AOTA. If I have to think and reflect on my contributions to the profession of occupational therapy, I humbly feel the following:

Academic Leadership: I believe that one of the best ways to majorly contribute to the profession is to create an excellent research-focused academic program in a Research 1 university. The opportunity to come to Georgia State University provided me just that opportunity. In a short span of five years, we have been able to develop a department that has a mix of talented research and clinical faculty with a national reputation. Starting the OTD program speaks to my commitment to research and practice in the profession.

New knowledge contribution: My research intersects cognition, space, and functioning. Our collaborative research with GTECH found that cognition and motor processes are interdependent on each other. We also found that in-home design or layout of spaces influences cognitive function in humans. Therefore, we conclude that all occupational therapy assessments of patients/clients must include a cognitive and physical space evaluation to design effective intervention.

References

Donnelly, J. E., Hillman, C. H., Castelli, D., Etnier, J. L., Lee, S., Tomporowski, P., . . . by, T. s. w. w. f. t. A. C. o. S. M. (2016). Physical Activity, Fitness, Cognitive Function, and Academic Achievement in Children: A Systematic Review. Med Sci Sports Exerc, 48(6), 1223-1224. https://doi.org/10.1249/MSS.0000000000000966

Grossi, J. A., Maitra, K. K., & Rice, M. S. (2007). Semantic priming of motor task performance in young adults: implications for occupational therapy. Am J Occup Ther, 61(3), 311-320. https://doi.org/10.5014/ajot.61.3.311

Horn, S. D., DeJong, G., & Deutscher, D. (2012). Practice-based evidence research in rehabilitation: an alternative to randomized controlled trials and traditional observational studies. Arch Phys Med Rehabil, 93(8 Suppl), S127-137. https://doi.org/10.1016/j.apmr.2011.10.031

Horn, S. D., Gassaway, J., Pentz, L., & James, R. (2010). Practice-based evidence for clinical practice improvement: an alternative study design for evidence-based medicine. Stud Health Technol Inform, 151, 446-460.

Maitra, K. K. (2007). Enhancement of reaching performance via self-speech in people with Parkinson's disease. Clin Rehabil, 21(5), 418-424. https://doi.org/10.1177/0269215507074058

Maitra, K. K., Telage, K. M., & Rice, M. S. (2006). Self-speech-induced facilitation of simple reaching movements in persons with stroke. Am J Occup Ther, 60(2), 146-154. https://doi.org/10.5014/ajot.60.2.146

Marquardt, G., Johnston, D., Black, B. S., Morrison, A., Rosenblatt, A., Lyketsos, C. G., & Samus, Q. M. (2011). Association of the spatial layout of the home and ADL abilities among older adults with dementia. Am J Alzheimers Dis Other Demen, 26(1), 51-57. https://doi.org/10.1177/1533317510387584