2014. Vol.5, No.2, 148-150
Published Online February 2014 in SciRes (http://www.scirp.org/journal/psych) http://dx.doi.org/10.4236/psych.2014.52023
Neurocognitive Rehabilitation Using Non-Emotionally Charged
Material to Re-Learn How to Learn: A Case Report
Murray R. Berkowitz
Department of Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine, Director of Family
Medicine/OMM Clerkships, Director of Preventive and Community-Based Medicine, Philadelphia College of
Osteopathic Medicine—Georgia Campus, 625 Old Peachtree Road NW, Suwanee, Georgia 30024, USA
Received December 18th, 2013; revised January 16th, 2014; accepted February 15th, 2014
Copyright © 2014 Murray R. Berk owitz. This is an op en access article distributed under the Creative Commons
Attribution License, which pe rmits unrestricted use, distribu tion, and reproduction in any medium, provided the
original work is properly cited. In accordance of the Creative Commons Attribution License all Copyrights ©
2014 are reserved f or SCIRP and the owner of the intellectual property Murray R. B erkowitz. All Copyright ©
2014 are guarded by law and by SCIRP as a guardian.
Cognitive disorders following hypoxic ischemic brain injury involve a variety of disorders including con-
sciousness, behavior, mood and affect, impairment of attention, and memory dysfunction. The case of a
45-year-old former military aviator and engineer, now a physician in residency training, presenting with
cognitive difficulties, is described. The patient described having difficulty remembering medical knowl-
edge and feeling fatigued. After almost nine months without any medical intervention and the patient’s
deteriorating condition, the patient was finally evaluated medically. It was ultimately discovered that the
patient suffered from a variety of neurologic impairments that were the direct result of exposures to vari-
ous toxic substances during his military service. Significant diagnoses included hypoxic ischemic brain
damage, severe mixed sleep apnea, and cognitive disorder NOS. Relevant literature about the application
of neurocognitive rehabilitation and retraining to treating patients suffering from brain injuries is dis-
cussed. The overlap of the neuroscience of emotion with cognitive learning and how emotion and affect
impacts learning and education is presented. This case also serves to demonstrate the application of learn-
ing and co gnition to individu al differences and disabilities. Further research is needed to evaluate whether this
result is rep roduci ble a nd ge neral iza ble to oth er p atie nts with similar pre sent ing signs an d sym ptoms.
Keywords: Neurocognitive Rehabilitation; Hypoxic Ischemic Brain Damage; Learning; Effects of
Emotion on Learning; Re-Learning How to Learn
Bhatoe stated that cognitive disorders following hypoxic
ischemic brain injury involve a variety of disorders including
consciousness, behavior, mood and affect, impairment of atten-
tion, and memory dysfunction (Bhatoe, 2011). There are many
etiologies of anoxic and hypoxic brain injuries, consequently no
epidemiologic data are known. There are similarities between
the sequelae and symptoms demonstrated by patients who sus-
tained traumatic brain injury (TBI) and anoxic/hypoxic brain
injury. Relevant literature about the application of neurocogni-
tive rehabilitation and retraining to treating patients suffering
from brain injuries is discussed below.
The 1980s saw the development of cognitive rehabilitation.
Diamant and Hakkaart integrated various analytical information
processing models of cognitive rehabilitation concluding that
these models are based on the principles of “functional speci-
ficity”, “functional hierarchy”, and “training circuits (tracks)”
(Diamant, 1989). Cullen and associates reported that patients
with anoxic brain injury are slower to recover than patients with
traumatic brain injury (TBI) (Cullen, 2009). Rajan and asso-
ciates reported structured, systematic cognitive retraining to be
effective in ameliorating cognitive dysfunction in patients suf-
fering from hypoxic brain damage (Rajan, 2010).
Independent studies have demonstrated the effectiveness of
functional magnetic resonance imaging (fMRI) in measuring
neural changes in cognitive rehabilitation and reported positive
association and increased neural connectivity following cogni-
tive rehabilitation (DeGutis, 2007; Minnebusch, 2009; Dalry m-
ple, 2011). Samuel reported that cognitive rehabilitation tech-
niques are more successful with patients suffering from “re-
versible” brain injuries while it is only marginally successful in
patients suffering from “progressive” brain injuries (Samuel,
2008). Fernandez-Ballesteros and associates have studied cog-
nitive plasticity and learning potential in the elderly and have
found that there is a positive association of the effects of learn-
ing training in normal elderly, and in elderly patients with both
mild cognitive impairment (MCI) and Alzheimer’s disease (Fer-
nandez-Ballesteros, 2003; Fernandez-Ballesteros, 2012). Sales-
Galan and associates found measuring cognitive plasticity to be
useful in helping identify patients with MCI (Sales-Galan,
2013). Berlucchi discussed that all areas of the brain retain
plasticity and even neurogenesis throughout life, even in old
age (Berlucchi, 2011).
Dams-O’Connor and Gordon recognized the role of emotion
and its impact on cognitive rehabilitation of patients with TBI.
“Due to the various cognitive, physical, and emotional changes
M. R. BERKOWITZ
after a TBI, individuals with TBI are constantly confronted with
things they cannot do as well as or the same way they did be-
fore the accident. Each time this happens, they are confronted
with the discrepancy between previous and current abilities,
which can cause overwhelming feelings of loss and trigger
frustration, depression, and anxiety.” They cite studies showing
that “emotional regulation appears to be an important mitigat-
ing factor in the impact of cognitive rehabilitation, and cogni-
tive interventions that include training in emotional control tend
to have a strong impact on functional outcomes” (Dams-O’Con-
The case below illustrates how emotional considerations both
negatively and positively impact the neurocognitive rehabilita-
tion of a previously extremely highly intelligent and function-
ing, professionally and socially successful patient. The case will
be discussed with emphasis on the application of using posi-
tively charged emotional constructs to enhance the patient’s
ability to re-learn how to learn.
A 45-year-old former military aviator and engineer, now a
physician in residency training, presented with cognitive diffi-
culties. The patient described having difficulty remembering
medical knowledge and feeling fatigued. The patient reported
to his supervising attending physician these concerns and was
summoned before the clinic director who admonished the pa-
tient to perform better. After almost nine months without any
medical intervention and the patient’s deteriorating condition,
the patient was finally evaluated medically. It was ultimately
discovered that the patient suffered from a variety of neurologic
impairments that were the direct result of exposures to various
toxic substances during his military service. Significant diag-
noses include hypoxic ischemic brain damage, severe mixed
sleep apnea, and cognitive disorder NOS. Based on neuropsy-
chological testing, the patient’s IQ declined from 186 to 133.
The patient’s blood oxygenation saturation declined to between
70% and 76% while “asleep”; note that patients with blood
oxygenation saturation levels of between 88% - 90% are typi-
cally placed in the intensive care unit (ICU) and intubated. The
patient was placed in a stressful situation to perform duties as a
resident physician while struggling to remember medical in-
formation. No attempt at neurocognitive rehabilitation was ever
performed by the military health care system and the patient
received a medical discharge from military service due to his
The patient attempted to “re-learn” his medical knowledge,
but the emotional distress of having had a previously excellent
military career (including early, “below-the-zone” promotions
and the awarding of numerous military awards and decorations)
ending by not being able to recall medical information, was
determined as interfering with the patient being able to re -learn
medical knowledge. The patient was started on a protocol of
attempting to “re-learning how to learn” by studying material
involving advancing his aviation knowledge. The emotional
component of learning aviation had previously been a very
positive experience. The patient was able to re-learn both avia-
tion “book knowledge” and “hands-on” performance know-
ledge and was also able to learn “new” aviation-related know-
ledge and skills, albeit as a civilian. Following this, the patient
was able to apply the techniques he had employed in both
“re-learning” older aviation knowledge and skills and learning
“new” aviation knowledge and skills to re-learning medical
knowledge and information. The patient ultimately earned a
Master of Public Health degree and achieved Board Certifica-
tion in three medical specialties.
Hypoxic ischemic brain injuries often have the unfortunate
sequelae of dysfunctions of consciousness, behavior, mood and
affect, impairment of attention, and memory. This patient
clearly presented with these problems, fully consistent with
Bhatoe above. Further, Bhatoe stated that “Recovery … is to be
anticipated over one or two years” (Bhatoe, 2011). This patient
is also consistent with the cases presented by Samuel in consi-
dering restorative vs. compensatory rehabilitation. Samuel’s
findings are limited in that they are based upon only two cases
—one demonstrating each of the reversible and progressive
conditions—and, while illustrated by this case, may not be ge-
neralizable (Samuel, 2008).
This patient, in working with previously positively emotional
component to re-learn how to learn (i.e., aviation), is fully con-
sistent with Wilson and associates, who reported the positive
results of a case of a patient suffering from severe head injury
and vascular involvement as a result of a motor vehicle accident
using a goal planning approach to cognitive rehabilitation. The
Wilson case demonstrated the success of applying a holistic,
goal planning approach in patients with non-progressive brain
injuries (Wilson, 2002). Levine and associates reported a large-
scale randomized trial using goal-planning and hierarchies to
increase executive deficits. They reported the gains based upon
simulated real-life tasks (SRLTs) “were maintained at long-
term follow-up” (Levine, 2007). Crai k, Winocur, and associa tes
reported improvements in memory encoding and retrieval based
on a blocked randomized controlled trial of cognitive training
(Craik, 2007; Winocur, 2007). Clearly, this patient regaining
his medical knowledge and subsequently earning a Master of
Public Health and achieving board certification in three medical
specialties is consistent with the long-term gains reported by
Craik, Levine, and Winocur above.
McDonald and associates reported the results of a small, pilot
cross-over study on the use of external memory aids to improve
performance in subjects suffering from impaired memory as a
result of acquired brain injuries (McDonald, 2011). This patient
only needs minimal use of external memory aids.
This patient is also clearly demonstrates the positive impact
of the Dams-O’Connor and Gordon role of emotion and its
impact on cognitive rehabilitation of patients with brain injury,
albeit with hypoxic ischemic brain injury. The patient in this
case clearly confronted with initially not being able to do things
he previously was able to do (i.e., recall medical knowledge)
and was frustrated every time he tried to re-learn his lost medi-
cal knowledge. The negative emotional impact of having lost
his career as a military physician triggered the feelings of loss,
frustration, and anxiety described by Da ms-O’Connor and Gor-
don. These negative emotions exacerbated the patient’s diffi-
culties in achieving a return to function. Immordino-Yang and
Damasio describe the overlap of the neuroscience of emotion
with cognitive learning and discuss how emotion and affect
impacts learning and education. They report research showing
that learning, attention, memory, and decision-making “are both
profoundly affected by and subsumed within the processes of
emotion” (Immordino-Yang, 2007). This patient is again fully
M. R. BERKOWITZ
consistent with these findings. This patient is also fully consis-
tent with the findings of brain plasticity in later life reported by
Berlucchi (Berlucchi, 2011).
Summary and Conclusion
This case shows how positive emotional component of cog-
nition provides a template for re-learning how to learn in pa-
tients suffering from hypoxic ischemic brain injury. Had this
been done earlier in the course of treatment and cognitive reha-
bilitation, preferably as soon as practical after the patient had
presented with cognitive symptoms, this patient’s condition
might not have deteriorated to the extent it did and the patient
may have returned to function earlier. This case also serves to
demonstrate the application of learning and cognition to indi-
vidual differences and disabilities. Further research is needed to
evaluate whether this result is reproducible and generalizable to
other patients with similar presenting signs and symptoms.
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