Cognitive recovery in acute stroke

412 Pages·2017·5.82 MB·English

by  Hannah Tehan

Cognitive recovery in acute stroke: Measurement and facilitation of change

Hannah Tehan
Bachelor of Psychology (Honours)

Submitted as part fulfilment of the requirements for the degree of
Masters of Psychology (Clinical)/Doctor of Philosophy.
School of Psychology,
Australian Catholic University.
June, 2015.
COGNITIVE RECOVERY ii

Statement of Authorship and Sources
This thesis contains no material published elsewhere or extracted in whole or in part from a
thesis by which I have qualified for or been awarded another degree or diploma. No parts of
this thesis have been submitted towards the award in any other tertiary institution. No other
person’s work has been used without due acknowledgment in the main text of the thesis. All
research procedures reported in the thesis received the approval of the relevant Ethics
Committee.

Name: Hannah Tehan
Date: 04/06/2015
Signed:
COGNITIVE RECOVERY iii

Acknowledgements

Completion of this thesis would not have been possible without the encouragement
and support of the stoke patients who participated in my study, my supervisors, colleagues,
family and friends.
My primary supervisor Anne Tolan who has shown me infinite support, who has
guided me through this project, who has kept me company in my highs and lows, has never
pretended that this was going to be easy, or doubted that I could do it. You are so appreciated.
My secondary, but no less wonderful supervisor, Kate Witteveen who could remember the
pain, but also knew the rewards. Kate, on more than one occasion your calm sense of reason
and gentle warmth kept this project, and multiple people from falling apart. Thank you for
coming to my presentations, they were better for having you there.
Thank you to my panel members at ACU (and USQ) who provided important
guidance and advice to make my thesis the best it could be.
Thank you to Donna Ward, Donna Pinsker, Mia Mariani and the whole clinical
neuropsychology team at The Prince Charles Hospital who took me in as one of their own,
and supported me to get the project off the ground and keep it running. A further thank you to
Dr Lan and Dr Chan and the staff at the Acute Stroke and Rehabilitation Ward at TPCH for
welcoming me while I collected data.
And an important thank you to the patients at TPCH who agreed to participate in my
study, to my friends and family who were guinea pigs for me, and for stretching their
networks so I could have a good normative sample. This project would of course not be
possible without people’s generosity with their time and cognitive effort.
And lastly, thank you to my dad who, beyond the immeasurable support he has given
me for this project every day for the last five years, has been teaching me every minute for
the last twenty-six. Above sandcastles, 80s music, and an affinity for vests, you have taught
me what strong, independent and fiercely intelligent women look like. You recognised them,
supervised them, befriended them, and to your credit and astonishing luck, married one. And
you shared them with me, thank you. You have demonstrated strength, compassion,
generosity, of course style, and what it is to be a thoroughly decent human being, so that I can
recognise and find them for myself. And I have.
COGNITIVE RECOVERY iv

Contents
Statement of Authorship and Sources .................................................................... ii
List of Tables ......................................................................................................... xx
List of Figures ..................................................................................................... xxiv
Abstract .................................................................................................................... 1
Chapter 1: Stroke and the Neural Underpinnings of Spontaneous Recovery ....... 4
1.1 Thesis Overview ................................................................................................. 4
1.2 Stroke: Types, Symptomatology and Diagnosis................................................ 9
1.3 Natural Recovery – Repair Mechanisms ........................................................ 12
1.3.1 Animal Studies .......................................................................................... 12
1.3.1.1 Damage ................................................................................................ 13
1.3.1.2 Recovery. ............................................................................................. 14
1.3.2 Studies using Human Participants ........................................................... 15
1.4 Therapy ............................................................................................................ 17
1.4.1 Types of Intervention ................................................................................ 18
1.4.1.1 Molecules and cell-based therapies ....................................................... 18
1.4.1.2 Electromagnetic stimulation ................................................................. 18
1.4.1.3 Behavioural interventions. .................................................................... 19
1.4.2 The Therapeutic Process ........................................................................... 19
1.4.2.1 Restoration, recruitment and retraining ................................................. 19
1.4.2.2 Timing of interventions. ....................................................................... 23
1.5 Chapter Summary ........................................................................................... 24
Chapter 2: Cognitive Recovery and Training after Stroke .................................. 27
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2.1 Chapter Overview ............................................................................................ 27
2.2 Scoping out Cognitive Impairment ................................................................. 28
2.2.1 Breadth and Complexity ........................................................................... 28
2.2.2 Approaches to Cognition .......................................................................... 28
2.2.3 Cognitive Psychology and Interventions .................................................. 32
2.3 Assessing Cognitive Impairment Following Stroke ........................................ 34
2.3.1 Screening Tools ......................................................................................... 34
2.3.1.1 Mini-Mental State Exam. ..................................................................... 35
2.3.1.2 Montreal Cognitive Assessment. .......................................................... 38
2.3.2 Neuropsychological Tests .......................................................................... 39
2.4 Cognitive Domains affected by Stroke ............................................................ 42
2.4.1 Acute Phase ............................................................................................... 43
2.4.2 Chronic Phase ........................................................................................... 48
2.5 Natural Recovery of Cognitive Functions ....................................................... 53
2.5.1 Recovery in the Chronic Phase ................................................................. 54
2.5.2 Recovery in the Acute Phase ..................................................................... 60
2.5.3 Section Summary ...................................................................................... 63
2.6 Cognitive Training ........................................................................................... 65
2.6.1 Cognitive Training in the Chronic Phase following Stroke ..................... 68
2.6.2 Section Summary ...................................................................................... 74
2.6.3 Cognitive Training in the Acute Phase following Stroke ......................... 76
2.7 Recovery versus Training in Chronic Phase ................................................... 76
2.8 Characteristics of Effective Training Programs ............................................. 79
2.9 Literature Review Conclusions and Aims of Study ........................................ 83
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2.9.1 Conclusions................................................................................................ 83
2.9.2 Aims and Objectives. ................................................................................ 87
Chapter 3: Development of Neuropsychological and Cognitive Tasks ................ 92
3.1 Chapter Overview ............................................................................................ 92
3.2 Neuropsychological Tests ................................................................................ 94
3.3 Developing the Cognitive Tasks ...................................................................... 97
3.3.1 Associative Networks .............................................................................. 100
3.3.2 Working Memory and Dual Task Performance .................................... 105
3.4 Cognitive Tasks .............................................................................................. 109
3.5 Task Battery ................................................................................................... 113
3.5.1 Stroop Colour Word Task ...................................................................... 113
3.5.2 Digit Span ................................................................................................ 114
3.5.3 Rey Tangled Lines Test. .......................................................................... 115
3.5.4 Phonemic and Semantic Verbal Fluency Tests ...................................... 116
3.5.4.1 Similarities. ........................................................................................ 117
3.5.4.2 Differences. ........................................................................................ 118
3.5.4.3 The two processes approach ............................................................... 120
3.5.4.4. Phonemic fluency. ............................................................................. 123
3.5.4.5 Semantic fluency. ............................................................................... 123
3.5.5 Common Associates Test ........................................................................ 123
3.5.5.1 Primary task. ...................................................................................... 124
3.5.5.2 Dual task component. ......................................................................... 126
3.5.5.3 Scoring. .............................................................................................. 126
3.5.6 Immediate Serial Recall .......................................................................... 127
COGNITIVE RECOVERY vii

3.5.6.1 Primary task. ...................................................................................... 127
3.5.6.2 Dual task component. ........................................................................... 129
3.5.6.3 Scoring. .............................................................................................. 130
3.5.7 The Snap Task ......................................................................................... 130
3.5.7.1 Primary task ....................................................................................... 130
3.5.7.2 Dual task component. ......................................................................... 131
3.5.7.4 Scoring. .............................................................................................. 132
3.5.8 The Anagram Task ................................................................................. 132
3.5.8.1 Primary task ....................................................................................... 133
3.5.8.2 Dual task component. ......................................................................... 134
3.5.8.3 Scoring. .............................................................................................. 135
3.6 Testing Protocol ............................................................................................. 135
3.7 Chapter Summary ......................................................................................... 137
Chapter 4: Evaluation of the Cognitive Tasks.................................................... 140
4.1 Chapter Overview .......................................................................................... 140
4.2 Experiment 4.1A ............................................................................................ 144
4.3 Method ........................................................................................................... 145
4.3.1 Ethics ....................................................................................................... 145
4.3.2 Participants ............................................................................................. 145
4.3.3 Materials .................................................................................................. 145
4.3.4 Procedure ................................................................................................ 145
4.4 Results ............................................................................................................ 146
4.4.1 Response Production ............................................................................... 146
4.4.2 Reliability ................................................................................................ 147
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4.5 Discussion ....................................................................................................... 149
4.4 Experiment 4.1B ............................................................................................ 149
4.5 Method ........................................................................................................... 149
4.5.1 Participants ............................................................................................. 149
4.5.2 Materials .................................................................................................. 149
4.5.3 Procedure ................................................................................................ 149
4.6 Results and Discussion ................................................................................... 150
4.6.1 Production of the Associate .................................................................... 150
4.6.2 Single Event Monitoring (Test 1) ............................................................ 152
4.6.3 Dual-Event Time-Switching (Test 2) ...................................................... 153
4.6.4 Reliability ................................................................................................ 154
4.7 General Discussion of Experiment 4.1 .......................................................... 155
4.8 Experiment 4.2 ............................................................................................... 156
4.9 Method ........................................................................................................... 157
4.9.1 Participants ............................................................................................. 157
4.9.2 Materials .................................................................................................. 157
4.9.3 Procedure ................................................................................................ 157
4.10 Results .......................................................................................................... 158
4.10.1 Snap Task .............................................................................................. 158
4.10.1.1 Repetition and benchmarks. .............................................................. 158
4.10.1.2 Reliability......................................................................................... 158
4.10.2. Anagram Task ...................................................................................... 160
4.10.2.1 Repetition and benchmarks. .............................................................. 160
4.10.2.2 Reliability......................................................................................... 161
COGNITIVE RECOVERY ix

4.10.3 Immediate Serial Recall Task ............................................................... 162
4.10.3.1 Repetition and benchmarks ............................................................... 162
4.10.3.2 Reliability......................................................................................... 163
4.11 Discussion ..................................................................................................... 165
4.12 General Discussion ....................................................................................... 166
4.13 Chapter Summary ....................................................................................... 169
Chapter 5: Normative Data for the Full Battery ................................................ 170
5.1 Chapter Overview .......................................................................................... 170
5.2 Characteristics of Normative Group ............................................................. 171
5.3 Evaluating Improvement ............................................................................... 173
5.3.1 Slopes and Intercepts .............................................................................. 173
5.3.2 Temporal stability confidence intervals ................................................. 176
5.4 Experiment 5.1 ............................................................................................... 179
5.5 Method ........................................................................................................... 180
5.5.1. Ethics ...................................................................................................... 180
5.5.2 Participants ............................................................................................. 180
5.5.3 Materials and Procedure ........................................................................ 180
5.6 Results ............................................................................................................ 182
5.6.1 Snap Task ................................................................................................ 182
5.6.1.1 Repetition. .......................................................................................... 182
5.6.1.2 Pair detection and dual task detection. ................................................ 183
5.6.1.3 Slopes and intercepts. ......................................................................... 183
5.6.1.4 Temporal stability confidence intervals. ............................................. 183
COGNITIVE RECOVERY x

5.6.1.5 Reliability. ......................................................................................... 184
5.6.2 Anagram Task ......................................................................................... 185
5.6.2.1 Repetition. .......................................................................................... 185
5.6.2.2 Anagram errors and dual task detection. ............................................. 186
5.6.2.3 Repetition and Benchmarks. ............................................................... 187
5.6.2.4 Slopes and intercepts. ......................................................................... 188
5.6.2.5 Temporal stability confidence intervals. ............................................. 188
5.6.2.6 Reliability. ......................................................................................... 188
5.6.3 Stroop Colour Word Task ...................................................................... 189
5.6.3.1 Repetition. .......................................................................................... 189
5.6.3.2 Slopes and intercepts. ......................................................................... 191
5.6.3.3 Temporal stability confidence intervals. ............................................. 191
5.6.3.4 Reliability. ......................................................................................... 191
5.6.4 Digit Span ................................................................................................ 193
5.6.4.1 Repetition and benchmarks. ................................................................ 193
5.6.4.2. Slopes and intercepts. ........................................................................ 194
5.6.4.3 Temporal stability confidence intervals. ............................................. 194
5.6.4.4 Reliability. ......................................................................................... 194
5.6.5 Rey Tangled Lines ................................................................................... 196
5.6.5.1 Repetition. .......................................................................................... 196
5.6.5.2 Slopes and intercepts. ......................................................................... 197
5.6.5.3 Temporal stability confidence intervals. ............................................. 197
5.6.5.4 Reliability. ......................................................................................... 197
5.6.6 Phonemic Fluency Test ........................................................................... 198
5.6.6.1 Repetition. .......................................................................................... 199