Cognitive Rehabilitation after Polytrauma
Don MacLennan, Minneapolis VAMC
ASHA: Polytrauma Short Course
Miami FL
November 18th, 2006
I Cognitive Rehabilitation
• Definition of Cognitive Rehabilitation: “The application of techniques and procedures, and
the implementation of supports to allow individuals with cognitive impairment to function as
safely, productively, and independently as possible within their environment.” Mateer, 2005
• Restorative Treatment: Direct treatment of cognitive impairment with intention of improving
underlying cognitive abilities.
o E.g. repetitive drills to improve attention.
• Compensatory Treatment: Development of strategies that enable people to circumvent
everyday problems resulting from impaired skills & abilities
o E.g. developing strategies to improve memory, problem-solving, pragmatic
communication, return to work/school
II Treatment of Attention
• Primarily restorative – use a modification of Sohlberg and Mateer’s (1987) Attention Process
Training©
• Sohlberg & Mateer’s levels of attention
ƒ Sustained - Performing one task over time
ƒ Selective - Performing one task in presence of distraction
ƒ Alternating - Alternating attention between two tasks
ƒ Divided - Dividing attention between two tasks
• Treatment Principles
ƒ Interventions should include training with different stimulus modalities – especially
verbal
ƒ Treatment should be individualized
ƒ Therapists need to provide feedback and strategies
ƒ Most effective when directed at complex tasks
ƒ Incorporate treatment into functional tasks
• Based on Attention Process Training
ƒ Vigilance tasks (auditory, visual)
ƒ Self-generated tasks (serial addition / subtraction tasks)
ƒ Video games can be used with excellent benefit for visual attention tasks (e.g.
Nintendo Game Cube – WarioWare, Donkey Konga, mini games on MarioParty 7;
Playstation 2 – Guitar Hero)
ƒ Card Sorts (e.g. BLINK)
• Combining APT tasks with functional tasks can help generalize attentional skills
ƒ E.g. reading software, work simulation software, map reading,
ƒ Can combine APT in conjunction with OT or PT tasks
• Countdown Timers – Dealing with distractibility
o The Problem of Distractibility: Intrusive Thoughts in Conversation
• Self-Instructional Training
• E.g. patient RB
• Develop self-instructions
• Have pt say instructions aloud Æ whisper Æ silently
• Use countdown timer from 1 min Æ min intervals
ƒ Mid-long term distractibility affecting task completion
• Countdown timer set to a patient’s typical attention span can greatly enhance
goal maintenance and task completion.
•
Modifications to attention treatment
o Amplification for hearing impairment
o Aphasia: attention-oriented treatment for aphasia
o Visual impairment:
ƒ Enlarging stimuli
ƒ Use of low-vision technology
• Magnifiers
• Monocular devices
• CCTV
• Dynavision
III Beginning Compensatory Treatment: Treatment of Unawareness of Impairment and the
Therapeutic Alliance
• Phenomenology of TBI
ƒ Confusion
ƒ Frustration
• Therapeutic Alliance
ƒ An agreement of the client and the therapist on the tasks and goals of therapy, as well
as the interpersonal bond between client and therapist (Bordin, 1979).
ƒ May be most critical factor in treatment of awareness (Sherer, 2005)
• Establishing Therapeutic Alliance
ƒ Convey some level of understanding of their experience and that you have something
to offer that will help
ƒ Offer a some metaphor of therapeutic interaction that is collaborative in nature
• e.g. presidential advisor
• Unawareness of Impairment
ƒ The ability to understand that a function is impaired, recognize the impairment as it is
manifested, and anticipate that a problem will result as a result of the impairment
(Crosson et al., 1989).
• Intellectual Awareness
ƒ Shallow appreciation of impairment without ability to specify examples
ƒ Treatment implication: Strong need for education to provide information re: what TBI is
and is not.
• Emergent Awareness
ƒ Shows awareness of impairment at the time that they are experiencing difficulty
ƒ Treatment implication: Provide experiences in which people can test themselves
• Evaluation of predicted vs. actual performance
• Anticipatory Awareness
ƒ Awareness of strengths and weaknesses is sufficient to predict difficult situations
ƒ Treatment implication: Provide a range of experiences so that people can begin to see
patterns of impairment
• Education
ƒ General
• Handouts with sequelae of TBI
• Convert memory book to an awareness book
ƒ Patient-specific
• Records review
ƒ Independent research Æ Transitional video
• Transitional Videos
• Awareness & Depression
ƒ Depression is correlated to the perception of disability (Malec, 2005)
ƒ Treatment implication: accentuate the positive
•
•
Maintaining Hope While Treating Awareness
ƒ Recovery phase
ƒ Emphasize strengths as well as weaknesses
ƒ Demonstrate the effectiveness of strategies
Strategy Development
ƒ Collaborative
ƒ Intent is to use a person’s strengths to overcome weaknesses and still be successful
ƒ Critical to follow-up to experiential tasks that identify impairments with strategies that
will allow people to be successful
IV Executive Functions
• Executive Functions
o Formulating Goals
o Developing a plan
o Initiating the plan
o Monitoring and correcting the plan
• Workbook Therapy
o No strong evidence that workbook stimulation therapy works
o Need to apply to functional activities
ƒ “difference between knowing and doing”
ƒ Somatic marker hypothesis?
o Workbooks are useful structured practice when used as a tool to practice specific
compensatory strategies
• Executive Functions: Developing Awareness
o Education
o Predicted vs actual performance
ƒ Locate BIA meeting
ƒ ID return to driving procedures
• Compensatory Treatment of Executive Functions: External Cueing Strategies
o Structured problem-solving guides
o ShadowPlan to be used in conjunction with Palm Pilot
V Pragmatic Communication
• Pragmatic Communication: Developing Awareness
o Education
o Hollywood Videos
o Patient Video
• Case Study EC: Structured Exercises
o ↓ Initiation
ƒ Structured practice exercise (Sohlberg, Sprunk, & Metzelaar, 1988)
o Verbose/tangential
ƒ Structured tx task: Card activity
o Generalization strategy
ƒ Self-talk
o Good conversation
• Pragmatics Groups
• Compensatory Treatment of Pragmatics: Collaboration with Families
o Goal of direct training is to train a “best fit” style of communication
o Families can assist with generalization of conversational skills to wider contexts
ƒ Assisted cue and review
ƒ Advance scripting
o
Combine these with external cueing strategies such as countdown timer to increase
generalization
Education: Memory Problems after TBI
Memory Problems after TBI: Problems with memory occur frequently after TBI. However, the types of
memory difficulties that occur are often not what people expect. When someone gets hit on the head
in the movies, they wake up and can’t remember their name or where they live or who their family and
friends are. They are said to have amnesia. The truth is, this type of memory difficulty never
happens after TBI. It is true that there can be a period of confusion after TBI and, during this time,
people may not be clear about personal information. However, this period of confusion usually
resolves in days or weeks. What follows is a list of the types of memory difficulties that frequently
occur after TBI.
•
Period of Confusion: When people with TBI wake up from coma, they are usually confused. This
confused period is called post-traumatic amnesia and is sometimes abbreviated as PTA.
Generally, people in PTA remember who they are but are otherwise very disoriented. They may
not remember how old they are or where they lived. They often do not remember where they are.
They are usually very confused about time and may not accurately remember the year, month,
day or date. In addition, people in PTA sometimes appear to “make things up.” For example,
someone in ICU with legs in a cast may say that they went horseback riding that morning. Stating
things as facts that obviously didn’t happen is called confabulation. People who are confabulating
are not lying – they really believe the things they say. What seems to happen is that past
memories can blend into the present and form a “memory soup” in which it is difficult to separate
current reality from past events. The good news is that this confused period is temporary and
disappears after a period of days or weeks.
•
Remembering new information after the injury: People with TBI usually continue to experience
memory difficulties after they clear from post-traumatic amnesia. Unlike Hollywood amnesia that
you see in the movies, people usually do fairly well at remembering old information that they knew
before the injury. People remember where they work and who their friends are and where their
favorite restaurant is. The problems come when people need to remember new information.
People may forget that someone called this morning and left a message for their wife. They may
forget things they did earlier in the day and wonder later if they remembered to take their
medications or pay a bill. People find that it is sometimes hard to learn new information. When
people go to work or school after a TBI, it can be difficult to learn all of the new information well
enough to be successful.
•
Remembering to do things in the future: Life is busy. We all have lots of things we need to do
each day. Remembering to do things in the future is called prospective memory and is a very
important part of daily life. Each day we are expected to remember to do many things from paying
bills on time to running errands to taking medications at the right times. People with TBI often
have difficulty remembering all the things they need to do and sometimes important obligations
“fall through the cracks.” This can cause many problems when important activities don’t happen
because of memory problems. In addition, people who have problems remembering to do
important tasks frequently are thought of as unreliable or untrustworthy.
•
Remembering things before the injury: People often notice that it is difficult to remember events
just before the injury as well. This is called retrograde amnesia. The length of retrograde amnesia
varies with the severity of the injury. With milder injuries, people may not remember events that
occurred minutes to hours before the injury. With more severe injuries, people may not remember
events that occurred days, weeks, or months before the injury. As people recover from their
injury, this period of retrograde amnesia shrinks as people begin to remember some of the events
before the injury. However, most people never recover memory for the events of the injury itself.
Will my Memory Improve? The good news is that you are in the recovery phase of your injury. Things
are going to get very much better than they are right now and this includes your memory. The bad
news is that, in most cases, not everything heals completely. Most people with TBI have some
permanent problems with memory.
What can I do to Improve Memory? Fortunately there is a lot you can do to help you remember
important information.
• First, you may be asked to participate in a home attention program. This program is designed
to improve your attention and concentration. Attention is the foundation of many thinking
processes including memory. As you concentrate better, you remember information better.
• Second, there are strategies that you can use to help you remember important information.
These are not strategies just for people with brain injury. These are strategies that everyone
uses to help remember all the things they need to keep track of in their busy lives. Examples
of strategies include using post-it notes to remember to do something the following day, using
PDAs (e.g. Palm Pilots) to remember to take medications at the right time, and using
calendars or message boards to remember appointments. We will be working closely with you
to develop strategies that you find useful to help you remember important information.
• Third, we will work with you on strategies that can help you learn new information. When
people go to work or school, they often have to learn lots of new information and we will help
you to find strategies that will help you to be able to do this.
1
Post-Test
1. People who “confabulate” really believe the things they say
T
F
2. Most movies accurately show the memory problems seen with TBI
T
F
3. After TBI, old information is harder to remember than new information.
T
F
4. Prospective memory involves remembering to do things in the future.
T
F
5. Returning to work or school after TBI may be difficult if learning new
information is required.
6. People with TBI usually do not have problems remembering daily
daily errands or important tasks.
T
F
7. Someone with TBI may have trouble remembering events before
their injury.
T
F
8. Most people with TBI have some permanent problems with memory.
T
F
9. Use of a Palm Pilot is one example of a memory strategy.
T
F
10. Memory strategies are only used by people with brain injury.
T
F
Experience: Prospective Memory
Rationale: Memory problems are one of the most frequent problems after brain injury.
One of the most frequent complaints from people with TBI is that they have trouble
remembering the things they need to do in the future. The technical term for this is
prospective memory. You need to remember many different things throughout the
day. You need to remember medications, take food out of the oven when you’re
cooking, pay bills on time, and meet friends at the right time when you socialize.
When these important activities “fall through the cracks”, problems develop.
Procedure: Over the next two days, you will be asked to remember to do 6 things.
These won’t be given to you all at once and you will never need to remember more
than three things at a time. The time interval over which you will need to remember
these tasks will range from relatively short (20 minutes) to fairly long (over 24 hours).
For some of these tasks you will need to keep track of the time interval yourself and
remember to do the task (uncued tasks). For other tasks, you will be given a cue or a
signal of when you need to do something but you will still need to remember what it is
you need to do (cued tasks).
Again, you will be asked to predict how well you will remember these tasks:
•
How many of the uncued tasks will you remember? _______
•
How many of the cued tasks will you remember?
_______
Self Assessment:
How would you rate your ability to remember to do things in the future? (circle one)
Strength
Weakness
What are some problems that might occur when you can’t remember to do things in
the future?
What are some strategies you might use to better remember future intentions?
Experience: Learning 5 Facts
Rationale: Memory is not just remembering what happened in the past. Memory is
also learning new information. When you start a new job, you must learn new policies
and procedures. When you meet a new friend, you must learn new information
about them. If one of you goals is to go to college, you will need to learn lots of new
information. Brain injury can affect a person’s ability to learn new information. This
exercise helps you self-evaluate your own learning abilities at this time.
Procedure: You will work on-line with your speech therapist at 3 p.m. today. Together
you will see how long it takes you to learn five facts about TBI. When you begin the
task, your speech therapist will say about all five facts. Then you will say as many of
them as you can remember. That is one “trial.” You will continue with additional trials
(your speech therapist first saying the facts, then you trying to remember all of them)
until you remember all five facts.
You will be asked to predict in advance how many trials, or how many times do you
need to hear the facts before you learn all five facts.
• I will learn all five facts in ________ trials
After you complete the exercise with you speech therapist, compare the number of
trials you predicted with the number of trials it took you to learn all five facts.
•
•
Predicted number of trials to learn the facts: _________
Actual number of trials to learn the facts: __________
Self-Assessment:
Does new learning seem to be a strength or a weakness for you? (circle one)
Strength
Weakness
What are some situations in which difficulty learning new information could create a
problem for you?
What are some strategies you might use to help learning new information?
Education: Executive Functions Difficulties after TBI
Executive function: Executive functions is the term that describes what we need to do to
follow-through with goal-directed behavior. Although you often don’t think about it, almost
everything you do during the day – from brushing your teeth to fixing a leaky faucet – is done
for a purpose, that is, it is goal-directed activity.
The Process of Executive Functions: To get the feel of what executive functions are, it can
help to compare it to what a chief executive does for a company.
• Set Goals: The first thing an executive does for the company is to help set the
company’s goals. For example, this company will increase its market share by 10% in
the next year.
• Develop a Plan: The goal will not happen without a plan. The executive needs to
make sure that a plan is developed that will allow the company to reach its goal.
• Initiate the Plan: No plan will work unless it is put into motion. The executive needs to
ensure that the plan is implemented throughout the company.
• Monitoring & Adjusting the Plan: The executive needs to make sure that the plan is on
target. The executive will be alert for parts of the plan that need fixing to make sure
the company reaches the goal.
Executive Functions and TBI: The brain’s frontal lobes direct the executive functions. People
with TBI often have injury to the frontal lobes which means that difficulties with executive
functions are frequently seen after TBI. This section discusses some of the ways in which
TBI can affect the executive functions processes. Note that people with executive functions
impairments do not need to show problems in all of the executive functions processes.
• Goal Setting: Developing goals can sometimes be difficult after TBI. Some people find
it difficult to think of goals. When asked what they want to do today, they just say, “I
don’t know, I can’t think of anything.” At other times, people with TBI can think of
goals but the goals aren’t reasonable or appropriate. For example, someone may
have a goal of buying a new car. This is an excellent goal – but if the person does not
have enough money to afford the car in the first place, following through with the goal
will lead to trouble.
• Organization and Planning: Once you have a goal, the next step is to develop a plan to
achieve it. People with TBI can have difficulties in a number of areas related to
organization and planning. First, they can sometimes not consider all the variables
before putting a plan into action. As an example, there was a man who wanted to burn
some yard waste outside of his home in Missouri. Ordinarily this would have been an
appropriate plan. However, he failed to consider that his county was in the middle of a
drought and the winds were gusting to 40mph. If he had followed through with his
plan, he may have started a dangerous and costly fire. Second, people may have
problems with time management that undermines their goals. For example, someone
may schedule an appointment for 9am – but if they fail to estimate how long it takes
them to get ready in the morning, the plan may backfire and the goal will fail.
• Initiation: The best plan in the world is useless if it is not put into place. One potential
difficulty after TBI, is problems with initiation. People with initiation problems find it
hard to “jump start” themselves and do the things they want to do. They may spend a
great deal of time sitting in front of the TV and talking about doing things but never
actually doing them. Often, people with initiation difficulties get labeled as
“unmotivated” or “lazy” – but this isn’t the case. Problems with initiation can result
from injury to the frontal lobe.
•
Self-Monitoring and Error Correction: To make sure that you truly reach your goal, it is
important to be able to self-evaluate your performance. People with difficulties selfmonitoring after their injury may have difficulty correcting their mistakes. Some
mistakes are minor inconveniences – for example, buying the wrong brand of
toothpaste at the store. However, some mistakes can prove to be very costly, such as
adding an extra zero when writing a check.
What Can I Do to Improve Executive Functions?
Developing Awareness: The first, and most important step in improving executive functions is
to develop a self-awareness of the areas in which you are having difficulty. This is what this
first week of telehome therapy has been about – identifying potential problem areas in a way
that you can see them. Development of awareness is critical because there are no exercises
that will fix executive functions. Treatment involves developing strategies so that you can use
your strengths to overcome your weaknesses and still be successful.
Developing Strategies: The second step in improving executive functions is to devise
strategies that will help you be successful. For example, if organization and planning is a
problem, it may help to formally write out your plan including the sequence of steps and
materials you need before you start. If time management is a problem you may need to
adopt a strategy of allowing yourself twice the time you think you need to get things done.
The important point is this: strategies will be individualized to your strengths and your level of
comfort in using the strategies. We, as therapists, are your advisors and will work together
with you to find the strategies that will work best to keep you on track.
Post-Test
1. The brain’s occipital lobes direct the executive functions.
T
F
2. The term “executive functions” describes what we must do to follow-through
with goal-directed behavior.
T
F
3. One of the most common problems after TBI is initiating or getting started
with activities.
T
F
4. There are exercises that will fix problems with executive functions.
T
F
5. Sometimes plans don’t work the first time and need to be adjusted.
T
F
6. Time management does not usually affect organization and planning.
T
F
7. The process of executive functions begins with goal-setting.
T
F
8. People who are aware of areas of difficulty are more likely to be successful.
T
F
9. People with initiation problems are usually just lazy.
T
F
10. Planning and organization allow you to look at all the potential variables
before putting them into action.
T
F
Experience: Finding a Support Group
Background: Each day we are confronted with problems. Some of these problems are
familiar and easy to solve. Others are less familiar and require more thinking to figure out the
best solution. The frontal lobe injuries often seen in TBI can undermine this problem-solving
process and make it harder to figure out the best solution for a problem.
In addition, recovery from TBI is a journey that often takes many months or years.
Sometimes it’s easy to feel as though you are the only person in the world that is facing the
challenges that you face every day. This is not the case. There are 1.5 million new cases of
TBI in this country every year. The truth is that there are a great many people living in your
area that are dealing with the challenges of TBI just as you are. Sometimes, when faced with
challenges, it’s helpful to talk with people who have been there before. Support groups are
one way of doing this. The Brain Injury Association is a national group dedicated to the
advocacy and independence of people with brain injury. Every state in the country has its
own chapter of the association and sponsors support groups for people with brain injury.
Problem: Your job is to gather all the information you need so that when you go home, if you
want, you will be able to attend a Brain Injury Association support group. When you are
finished, you should have a complete plan of action for attending the support group. As you
develop your plan, I will keep track of the amount of assistance you need. Remember you
need to get all the information you need to make it to the support group.
Predicted Performance:
How long do you expect it to take you to develop your plan ____________
How many times will you need assistance to develop your plan __________
Actual Performance:
How long did it actually take to develop your plan ___________
How many times did you need assistance to develop your plan ___________
Is this a strength or a weakness for you? (circle one)
0
Strength
Weakness
Discussion:
• Difficulties: What are some of the problems you could face when you can’t plan things out
and solve problems?
•
Solutions: What can you do to help yourself plan and solve problems better?
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