Community- and home-based daily intense cognitive rehabilitation (CR) of traumatic brain injury (TBI) clients was initiated on the basis on knowledge mentioned in Chapter 17. In the CR, statistically significant changes were demonstrated in attention and reading abilities in sixteen severe TBI clients by one-year daily CR. Improvement of memory and executive functions required more training periods as shown later. The temporary minimum scores of four neuropsychological tests required for social reentry, namely, 50 in TEA, 15 in RBMT, 80 in BADS and 40 in JART, were determined as a goal of our CR. In addition to the drill (pen and paper) method mainly using workbooks, a more advanced program for CR, particularly in clients who reached the required level, was developed together with the clients.
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The remediation of cognitive deficits caused by TBI is particularly important because TBI clients are often young people (men are approximately 3 times more than women), who have just reached their productive stage or their last educational level (high school or university). Therefore, it is indispensable for the clients to improve their impaired cognitive functions such as attention, memory, and executive functions for their work reentry. TBI clients desire a convenient center for a daily training CR program near the place of their residential area, which is particularly necessary because they are widely distributed in a community and TBI remediation takes much time, even if they practiced without missing their daily trainings. A center for CR will be therefore indispensable in every city or prefecture, but community-based intensive CR centers are currently lacking in Japan. Under such a condition, the need for an effective community-based CR model increases. With progress in motorization, more developmental approaches in community-based and cost-effective CR become indispensable for TBI clients (Rehabilitation of persons with TBI, 1999), generating positive effects that can supersede residential-, hospital- or comprehensive day-treatment-based rehabilitation.
Home-based daily CR is a practical idea in the local areas where a convenient CR center is not available as is the case in Japan. In general, the rehabilitation of clients with TBI has been discussed mainly in terms of behavioral aspects or family dynamics, and also cost effectiveness as compared with residential- and hospital-based rehabilitation (Wood et al., 1999). Although there is some effort in hospital-based comprehensive rehabilitation in Japan (Hashimoto et al., 2006), it does not relate to long-term CR, which results in brain reorganization. Generally, CR as a part of daily activities may be ideal. The future establishment of local- and community-based CR center will make it easy to provide permanent services to local population cost-effectively (Oddy and McMillan, 2001). This process in our center may be supported by continuation of self-transcending process of knowledge creation (Nonaka and Takeuchi, 1995) for a better quality of life (QOL) in TBI clients. In addition to the psychosocial aspect, the concept of our daily intensive CR also agrees closely with the recent paradigm shift in neurorehabilitation to form reorganized cortical system for a permanent remediation of cortical functions, as mentioned in chapter 17. According to the concept, our CR is aimed to create the reorganization in the prefrontal and lateral cortical association areas although the anatomical demonstration of the cortical reorganization may remain difficult.
The CR of TBI clients has already started in Europe and USA but its outcomes are not always consistent (Pace et al., 1999; Boman et al., 2004) due to different rehabilitation methodologies and concerns related to TBI remediation. We considered that the CR of TBI clients was most effective in the case of exclusive cognitive daily practices at home in an area where there is no CR center nearby. The pen-and-paper trainings using workbooks or dictation tasks are familiar for daily practice and are cost-effective. The effects of training in an educational system (as a place of training and development of human cognitive function) seemed in a sense to be similar final goal of brain reorganization.
From 1997 to 2001, our research on CR of TBI clients was started at the Human Science Laboratory, in a university (a part of the CR mentioned in chapter 17). From the results of a study of CR over five years and the follow-up studies after that, fundamental information concerning CR of TBI clients has been accumulated. Further knowledge could be obtained from a practical book for TBI (e. g., Ponsford, 1995) and the World Congress of Brain Injury started from 1995. From 2002 up to now, the Nonprofit Organization (NPO) TBI Rehabilitation Center was initiated in Tokyo for the implementation of the knowledge on CR, previously gained. The basic administration principle is community- and home-based rehabilitation service for daily practices at home. In addition to productions of CR tools, various workbooks and audiotapes for dictation tasks, CR classes (the name of our group session) once a week was also started to promote daily home-based CR in the community setting. These activities proved the efficacy of CR tools we made. This is the first attempt of applying the CR approach as a community- and home-based daily practice in Japan.