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Cognitive Functioning in Individuals with Spinal Cord Injury
(SCI)
Nancy D. Chiaravalloti, Ph.D.
Director of Neuroscience and Neuropsychology and Traumatic Brain
Injury Research
Kessler Foundation
Professor of Physical Medicine and Rehabilitation Rutgers-New
Jersey Medical School
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Disclosures
Dr. Chiaravalloti has no disclosures to report.
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Outline • Defining Cognition
– Cognitive domains
• SCI and Cognitive Functioning
• Potential causes/ sources of Cognitive
Deficits in SCI
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Outline • Defining Cognition
– Cognitive domains
• SCI and Cognitive Functioning
• Potential causes / sources of Cognitive
Deficits in SCI
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Cognition
• "the mental action or process of acquiring knowledge and
understanding through thought, experience, and the senses.”
– conscious and unconscious
– Concrete and abstract
– Intuitive and conceptual
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Cognition • Includes the concepts of
– Knowledge
– Attention
– Memory
– Judgment and evaluation
– Reasoning and "computation”
– Problem solving and decision making
– Comprehension and language production
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Cognition
• Cognitive processes use existing knowledge and generate new
knowledge
• Ongoing changing process.
• We rely on cognition EVERY day.
• Central to who we are and what we do with our lives.
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Impact of Cognition on Daily Life
• Cognitive deficits lead to: – Depression, anxiety – Decreased
participation – Increased unemployment – Decreased quality of
life
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So What? • Age of onset and career productivity
– Career development may slow or stop
• Physical and cognitive impairments lead to early
retirement
• Biggest Obstacles to maintaining employment – information
processing deficits – memory deficits
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What does this mean?
• MUST identify cognitive deficits when they present and treat
them effectively
• First step: Reliably identify the deficits experienced
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Cognitive Domains
• Attention • Working Memory • Processing Speed • Visuospatial
processing • Long Term Memory • Executive Functioning
Intelligence - not a cognitive domain, culmination of cognitive
abilities
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Breaking Down the Domains
• Attention – Simple – Sustained – Divided
• Working Memory – Maintenance – Manipulation
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• Long Term Memory – Verbal and Non-verbal – Episodic,
procedural – Retrospective, Prospective – Encoding, Consolidation,
Retrieval
• Executive Functioning – Fluency – Mental flexibility –
Disinhibition – Problem Solving – Abstract Reasoning
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Learning & Memory
Attention Working Memory
Visuospatial Processing
Executive Functions
Processing Speed
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Outline • Defining Cognition
– Cognitive domains
• SCI and Cognitive Functioning
• Potential causes / sources of Cognitive
Deficits in SCI
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Sample Characteristics Tetraplegia N=18 C3-C8
High Para N=5 T1-T5
Low Para N=14 T7-T12
Older Controls N=14
Age Matched Controls N=18
Age
38±8
39±6
34±6
60±3
36±8
Duration of Injury
14.2±8.9
13.6±5.1
8.4±4.5
n/a
n/a
Education
14.1±2.8
13.8±1.5
13.3±2.2
16.3±2.5
15.9±2.0
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Our Data (unpublished)
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Our Data (unpublished)
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Our Data (unpublished)
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Our Data (unpublished)
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Thinking about treatment
• EXACTLY what is the deficit? – Off to a good start – Learning,
immediate recall, long term recall – Processing speed
• Are there other deficits?
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Learning & Memory
Attention Working Memory
Visuospatial Processing
Executive Functions
Processing Speed
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How does Processing Speed affect memory?
• When information is coming in fast – Cannot process all of it
– Certainly cannot process it correctly
• All working memory tasks requiring one to process information
within a circumscribed period of time – Tasks may not be timed, but
there is a decay of
information (decay occurs over time) • What does this mean?
– Poor PS poor learning and memory
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Impact of PS on treatment efficacy
CVLT Learning Trials
PS Intact PS Impaired
* No significant group difference pre-treatment
p=.006
Chart1
Trial 1Trial 1
Trial 2Trial 2
Trial 3Trial 3
Trial 4Trial 4
Trial 5Trial 5
Treatment
Control
6.41
5.84
10.14
8.68
11.72
10.03
12.79
10.52
12.93
10.94
Sheet1
TreatmentControl
Trial 16.415.84
Trial 210.148.68
Trial 311.7210.03
Trial 412.7910.52
Trial 512.9310.94
To resize chart data range, drag lower right corner of
range.
Chart1
Trial 1Trial 1
Trial 2Trial 2
Trial 3Trial 3
Trial 4Trial 4
Trial 5Trial 5
Treatment
Control
5.64
5.8
7.36
8
8.86
8.6
9.93
9.3
9.64
9
Sheet1
TreatmentControl
Trial 15.645.8
Trial 27.368
Trial 38.868.6
Trial 49.939.3
Trial 59.649
To resize chart data range, drag lower right corner of
range.
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Memory Impairment
PS Impaired PS
Intact
If memory still impaired,
treat the memory deficit
Memory Treatment
Treat PS
Model Decision Tree
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Memory Impairment
PS Impaired PS
Intact
If memory still impaired,
treat the memory deficit
Memory Treatment
Treat PS
Model Decision Tree
Need to know the source of the deficit
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Outline • Defining Cognition
– Cognitive domains
• SCI and Cognitive Functioning
• Potential sources / causes of Cognitive
Deficits in SCI
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Potential Causes of Cognitive Deficits in SCI Population
• Cerebrovascular Insufficiency • Concomitant TBI
– Dual Diagnosis – TBI may be mild
• Both
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Methods for Determining Cause
• Cerebrovascular Testing during cognitive performance
• Imaging – Brain – DTI, fMRI
• Observing trajectory of change
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MAP Data (unpublished)
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MAP and Memory Data (unpublished)
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MFV Data (unpublished)
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MFV and Memory Data (unpublished)
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fMRI Data (unpublished) subset (n=29)
Increased activation in frontal and parietal areas in LP
compared to AM (red), Less activation (blue) in memory areas
More activation in frontal and motor regions than AM controls
during PS task, performance required more cerebral resources in
Tetra
** fMRI findings corroborate behavioral findings
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What does this mean? Informing Treatment
• Data indicate a contribution of cerebrovascular insufficiency
– Treat low BP and observe cognition
• Ongoing with Mitodrine • Observing immediate and long term
effects
• Also observing fMRI abnormalities – Early CR
• Launching cognitive rehab trial in SCI – Treat for mild TBI
early
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Collaborators
Jill Wecht, PhD Glenn Wylie, D.Phil.
Trevor Dyson-Hudson, MD Steve Kirshblum, MD
William Baum, MD Kathy Chiou, PhD
Erica Weber, PhD Ekaterina Dobryakova, PhD
Nancy Moore, MA Caitlyn Katzelnick, M.A.
Christopher M. Cirnigliaro, M.S.
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Funding Sources
NJ Commission on SCI Research
Craig Nielson Foundation
Kessler Foundation
Kessler Institute for Rehabilitation
Cognitive Functioning in Individuals �with Spinal Cord Injury
(SCI)��Slide Number 2Slide Number 3Slide Number
4CognitionCognitionCognitionImpact of Cognition on Daily LifeSo
What? What does this mean?Cognitive DomainsBreaking Down the
DomainsSlide Number 13Slide Number 14Slide Number 15Sample
CharacteristicsOur Data (unpublished)Our Data (unpublished)Slide
Number 19Slide Number 20Thinking about treatmentSlide Number 22How
does Processing Speed affect memory?Impact of PS on treatment
efficacySlide Number 25Slide Number 26Slide Number 27Potential
Causes of Cognitive Deficits in SCI PopulationMethods for
Determining CauseSlide Number 30MAP and Memory Data
(unpublished)MFV Data (unpublished)MFV and Memory Data
(unpublished)fMRI Data (unpublished)�subset (n=29)What does this
mean?�Informing TreatmentCollaboratorsFunding Sources