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Cognitive neurorehabilitation
  1. Christopher D Ward

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    Edited by Donald T Stuss, Gordon Winocur, and Ian H Robertson (Pp 385, £64.95). Published by Cambridge University Press, Cambridge, 1999. ISBN 0 521 58102 8

    As the French term “re-education” implies, learning is a key process in rehabilitation. Nothing might seem more challenging than to effect useful learning in people with cognitive impairments. Until recently, a cloud of pessimism hung over cognitive deficits, but the later sections of this useful book provide authoritative evidence that interventions can produce positive changes in people with impairments in memory, in attention, perhaps in executive function, and in language processing.

    Is it rehabilitation? Most of the convincing effects described here are at impairment rather than disability level and therefore are not necessarily positive rehabilitation outcomes. But the book takes account of social factors, as well as problematic psychological categories such as motivation, which provide a pragmatic context within which future interventions might operate. It seems likely that more will be achieved in this new field.

    Is it cognitive? One source of pessimism about therapy for cognitive impairment has been the dead hand of verbal learning, the “old paradigm” for cognitive science. It is hard, and often futile, to teach word lists to people with amnesia. A much more achievable goal is to alter their behaviour. A sort of neobehaviourism is creeping into cognitive science, inspired by artificial learning (neural) networks. The most relevant aspect of a chapter on the potential benefits of constraining an unaffected limb in hemiplegia is the account of “learned non-use” as a possible barrier to inducing movement in the plegic limb. Might the same mechanism lead a person with aphasia to use less speech, or someone with amnesia to become more restricted? Learned non-use can be described in terms of operant conditioning, as can other therapeutically fruitful concepts such as errorless learning. A good deal of cognitive rehabilitation is not really cognitive. The restitution of cognition (in its classical sense, as the handling of information in the conscious domain) still eludes us. But this book provides some signposts along the way.

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