Neuropsychological evaluation (T0) showed a global cognitive impairment. In particular, the most critical aspects were disorientation on the spatial-temporal and autobiographic parameters. She showed alteration in attention, learning, and immediate and delayed memory. Language speech presented some abnormalities. Visuo-spatial abilities and executive functions were impaired (problem solving, planning and integration of information, decision making). Nevertheless, there were some residual cognitive abilities, such as automatic and imitation behavior, recognition and copying of simple visual stimuli and procedural memory. The mood was characterized by emotional liability. Neuropsychological rehabilitative training was carry out for period of 4 months, for a total of 24 sessions. Each session lasted 50 minutes. Cognitive rehabilitation was performed with exercises for temporal and spatial orientation, memory, and attention: reality orientation therapy (ROT), attention and vocal training, and pencil-paper exercises. In addition, external devices such as calendar, clock, family photos, city map, and diaries were used. Some exercises were focused on training of abstract reasoning (similes, metaphors, and proverbs). Overall, exercise difficulty gradually increased among the rehabilitative sessions. Each session was accompanied by emotional support and psycho-educational interventions to improve the problem-solving ability and her emotional self-regulation.
Motor rehabilitation was carried out twice a day for 6 days a week. This included standard physiotherapy exercises and verticalization by static bed for about 60 minutes. Two months after the rehabilitation treatment, at the second psychometric evaluation (T2), patient showed improvements on relationship's quality, language, and visuo-spatial immediate memory. A good recovery of cognitive and depression symptoms was performed at T2. Although the standing position is possible using a static bed, the patient improved her daily life autonomy and her quality of life.
MRI showed no physiological abnormalities on hippocampus bilaterally and both hippocampi were reduced in volume (Fig. 2).
The limbic system includes thalamus, hypothalamus, amygdala and hippocampus, areas involved in the emotions, memory, social, and sexual behavior. Damages in these regions are associated with confusion, psychiatric symptoms, convulsions, memory deficit, apathy, anxiety, thought alterations, and myoclonus.
Memory deficits, after limbic encephalitis  include autobiographic events. Cognitive impairment also affects the quality of life, social commitment, and daily activities. Compensatory approaches to memory rehabilitation minimize the impact of perceived disability.
In these patients, awareness deficit could obstruct the effective rehabilitative training worsening quality of life of the patient and their family members. For this reason, it is important to recognize these situations and develop appropriate tools to improve the patient's condition. Neuropsychological rehabilitation encourages metacognitive elaboration and improves motivational and cognitive processes.[20–24]
Our patient rehabilitative program, improved cognitive functions and the enhancement of daily life activities through successful attention working memory and processing speed training.[25,26]
Neuro-rehabilitative program was focused on strengthening of cognitive functions and on the development of alternative strategies, Objective measures showed an improvement of memory, attention, shifting, and metacognition domains. Moreover, relational aspects were improved, showing proactivity in seeking interactions with others. However, persisted some residual motor disturbances.
The multidisciplinary approach by using pharmacological therapy, motor, and cognitive rehabilitation were important for a global recovery of compromised abilities. Cognitive-behavioral psychotherapy contributed to enhancement emotional area of our patient. In particular, this treatment was based on reducing psychiatric symptoms, anxiety, and depression. Mood and behavioral changes contributed to improve autonomy and quality of life of the patient. Also caregiver's psychological support revealed useful for a returning to living his daily life. Despite rehabilitation objectives were achieved, a long-term healthcare assistance, with multidisciplinary interventions, by social services will be useful.
Conceptualization: Francesco Corallo.
Data curation: Simona De Salvo, Rosa Morabito.
Investigation: Francesco Corallo, Marcella Di Cara.
Resources: Marcella Di Cara.
Supervision: Viviana Lo Buono, Placido Bramanti, Silvia Marino.
Validation: Silvia Marino.
Visualization: Viviana Lo Buono, Caterina Formica, Daniela Floridia, Concetta Pastura, Carmela Rifici, Giangaetano D’Aleo, Edoardo Sessa, Silvia Marino.
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Keywords:Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.
cognitive rehabilitation; limbic encephalitis; neuropsychological improvement