Collaborative efforts strengthen both clinical practice and research. In this special issue on cognition we have assembled papers from individuals with expertise in experimental psychology, neuropsychology, movement science, and clinical practice. We have chosen to focus on three domains of cognition, ie attention, executive function, and memory. For each area, first we present a paper that provides the foundations for our understanding of that domain of cognition. By design, these papers are written by individuals who are not physical therapists. Each of these three papers has a companion paper that takes a more translational approach, beginning to link the research to clinical practice. These papers, written by physical therapists, introduce perspectives on the role of cognitive skills in physical functioning.
Our interest in the relationship between cognitive deficits and neurologic physical therapy began more than ten years ago. Here at the University of Kansas Medical Center, Stephanie Studenski, MD, MPH and Pamela Duncan, PT, PhD recruited and assembled teams of clinicians and researchers to study issues in the area of stroke rehabilitation. As part of these collaborations we began to examine the attentional abilities of those with chronic stroke and the relationship of these abilities to function.1
As a physical therapist (PSP) I thought I had some knowledge of the importance of cognition on neurologic rehabilitation. In retrospect I realize that while I appreciated that cognitive changes were an issue in working with adults with traumatic brain injury, it was less obvious to me in other areas of practice. For example, in stroke attentional deficits usually referred to hemi-inattention or neglect and not to deficits in switching attention or divided attention. My shortcoming in understanding cognitive deficits was made clear to me by one unforgettable research subject.
Early in my career here at the University of Kansas Medical Center, I had the privilege of working with Pam Duncan on one of her research projects. One subject (we will call him Bill) was a chronic stroke survivor who was now living back at home. Bill was ambulatory and had passed all of our screening tests; I had met him many times. When he failed to show up for a return visit to the medical center, we tried to find out what happened. After some concerned phone calls, we learned that yes, the taxi service had dropped Bill off at the medical center and no, he had not returned home. After a search of the grounds, we found Bill sitting in a wheelchair by the front door of the hospital. It was not where he had been left off, and it was not near our lab. When I asked Bill what he was doing, he seemed unconcerned that he had sat there for more than an hour. He was waiting for a taxi, he said, although none had been called.
Among the screening tests that Bill passed was the Mini-Mental Status Examination.2 To my limited understanding at the time, his cognition was intact. Apparently I had a lot to learn. Working with Pam and a colleague whose background is in experimental psychology, ie Joan McDowd, PhD, the co-editor of this special issue, I learned much more about cognition and its impact on rehabilitation.
We have both learned a lot about cognition and physical function over the course of our collaboration. I (JMM) remember the first person with stroke who we ran through a battery of experimental cognitive tasks in my laboratory. Watching him slowly and awkwardly get out of the taxi that had brought him for testing, I was convinced that he would be unable to do many of the tasks we had waiting for him. But his physical slowness had misled me - he completed the cognitive battery with little trouble. Obviously good cognitive status cannot completely overcome significant physical injury or damage, but it appears to have a significant role in the rehabilitation process following injury or damage.
Today the role of cognition in rehabilitation is appreciated by many physical therapists. In one of the leading textbooks for entry-level physical therapy programs, we read that understanding cognitive impairments "is critical to therapists engaged in retraining functional movement in patients with neurologic deficits."3 The importance of an understanding of cognition in neurologic physical therapy was recognized at the IIISTEP Conference held in Salt Lake City, Utah in 2005. Cognition was a special topic for a break-out session led by James Gordon, PT, PhD and Rebecca Craik, PT, PhD. From the discussion in this session, the need for the dissemination of more information on cognition was noted. This issue is one step in meeting this need.
We thank each of the authors for their contributions to this special issue. We tried to provide some guidance on the direction of each paper, but chose not to constrain their own unique perspectives on what was the important message to share with our readers. If the readers gain some greater understanding of these three domains of cognition, ie attention, executive function, and memory, and a greater appreciation for the impact of these abilities on neurologic physical therapy, we have met our goals.
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