Learning after acquired brain injury. Learning the hard way

Background: When the brain has suffered damage, the learning process can be considerably disturbed. Brain damage can influence what is learned, but also how learning takes place. What patients can learn can be viewed in terms of ‘learning ability’ and how patients learn in terms of ‘learning style’. Aims: To examine methods of measuring learning ability (what) and learning style (how) in patients with brain injury, and to determine the role of learning and other neuropsychological factors in predicting inpatient rehabilitation outcomes. Methods: Current clinical practice and expert opinion were explored, a systematic review was executed and retrospective and prospective cohort studies were performed. An online survey and interviews were used to examine Dutch clinicians’ views on learning ability and learning style. An aspect of learning ability is patients’ potential to learn and benefit from training or guidance, their so-called ‘cognitive learning potential’. A one-session dynamic cognitive testing procedure can be used to explore patients’ cognitive learning potential. A systematic review was performed to explore the concept and methodology of dynamic cognitive testing and to evaluate its added and predictive value in adult patients with cognitive impairments. In a prospective cohort study, the validity of the most frequently used dynamic cognitive test, the dynamic Wisconsin Card Sorting Test (dWCST) was examined in inpatients with ABI. Further, the validity and cognitive correlates of a learning style instrument, the Adapted Learning Style Inventory (A-LSI), was examined. Finally, in a longitudinal study, neuropsychological predictors of participation and health-related quality of life (HRQoL) three months after inpatient ABI rehabilitation were examined. Results: The survey revealed that the vast majority of clinicians take learning ability into account when making a prognosis. Commonly used methods for the assessment of learning ability were cognitive tests and observations during therapy. The systematic review provided preliminary support that dynamic cognitive tests can provide a valuable addition to conventional cognitive tests to assess patients’ cognitive abilities. Although promising, there was a large variability in methods used for dynamic cognitive testing. The most frequently used dynamic cognitive test, the dWCST, showed adequate psychometric properties in a cohort of patients with ABI. Regarding learning style, interviews revealed that Dutch rehabilitation professionals were generally positive about using learning style in ABI rehabilitation. However, no support was found for an association between learning style on the A-LSI and cognitive impairment, and doubts were raised about the validity and feasibility of the A-LSI for patients with ABI. Hence the role of learning in predicting inpatient ABI rehabilitation outcomes was only examined for cognitive learning potential and not for learning style. The results showed that neuropsychological factors, and in particular passive coping, significantly contributed to predicting HRQoL and participation after inpatient rehabilitation when controlling for demographic and injury-related factors. Cognitive learning potential on the dWCST was not significantly associated with HRQoL and participation. Conclusion: The findings in this thesis contribute to our understanding of learning after ABI and can act as a starting point for further research into learning after ABI.