Cognitive Rehabilitation after Polytrauma

1. Cognitive Rehabilitation after Polytrauma Don MacLennan Minneapolis VAMC AVASLP Conference May 3rd, 2006

2. Cognitive Rehabilitation (Mateer, 2005) “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.”

3. Restorative Treatment • Direct treatment of cognitive impairment with intention of improving underlying cognitive abilities.

4. Restorative Treatment • Drills • Hierarchical in difficulty • Repetition • Attention Treatment

5. Compensatory Treatment • Development of strategies that enable people to circumvent everyday problems resulting from impaired skills & abilities • People use residual strengths to overcome weaknesses in order to be successful

6. Compensatory Treatment • Environmental modifications • External cueing strategies • Internal cueing strategies • Collaboration with others

7. Polytrauma • Trauma induced injury to two or more body systems, at least one of which is life threatening.

8. Barriers to Cognitive Rehabilitation Associated with Polytrauma • Amputation • Pain • Hearing Loss • Blindness, Low-Vision • Aphasia

9. Cognitive Rehabilitation: targeted areas for treatment • Attention primarily restorative • Awareness of Impairment • Memory • Executive Functions compensatory • Pragmatic Communication

10. Attention

11. Sohlberg & Mateer’s Levels of Attention • Sustained • Performing one task over time • Selective • Performing one task in presence of distraction • Alternating • Alternating attention between two tasks • Divided • Dividing attention between two tasks

12. Treatment PrinciplesCicerone et al (2000); Fasotti et al (2000); Cicerone (2002); Sohlberg et al (2003) • Use variety of stimulus modalities – verbal • Treatment should be individualized • Therapists need to provide feedback and strategies • Most effective when directed at complex tasks • Incorporate attention treatment into functional tasks

13. Restorative Approaches • Attention Process Training • APT I • APT II

14. Auditory Tasks:Levels of Attention Auditory Sustained • Listening for ↓ numbers Alternating • ↓ numbers / ↑ numbers Divided • ↓ numbers + computer task

15. Visual Tasks:Levels of Attention Visual Sustained • Scanning R/I: beginner Alternating • Scanning R/I: intermediate Divided • Scanning R/I + answering questions

16. Self-Generated Tasks: Levels of Attention Self-Generated Sustained • Serial subtraction by 2s Alternating • Subtract by 4 / Add by 1 Divided • Serial subtraction by 2s + card sort

17. Tasks need to be difficult 70-90% correct Subjective difficulty rating Level of Difficulty

18. Attention Training: Video Games • Videogames can provide challenging visual tasks involving alternating and divided attention • e.g. WarioWare for Nintendo Game Cube • Involves rapid set-shifting

19. Attention Training: Card Sorts • Can sort playing cards • by color, suit, number • Commercially available games • eg. “Blink” – sorting cards by multiple variables such as number, shape, color

20. Combining with functional tasksComputer work simulation + APT • Example: • Pt performs divided attention task in which he • Performs a computer data entry work module and • An APT sustained attention task at the same time

21. Combining with functional tasksMap Navigation + APT • Example • Navy pt who plotted navigational courses for submarines did a divided attention task in which he • Plotted the shortest route between 2 towns on an atlas, calculated the distance, and estimated the travel time at 60mph while • Doing an APT sustained attention task

22. Modifications: Hearing Impairment • Essential to have good access to audiology and provide amplification where needed.

23. Modifications to attention treatment: Aphasia • Attentional treatment for aphasia

24. Modifications to attention treatment: Visual Impairment • Enlarging stimuli • Use of low-vision technology • Magnifiers • Monocular devices • CCTV • Dynavision

25. Modifications for visual impairment: CCTV • CCTV = a closed circuit television that enlarges printed stimuli for display on a television screen • Can use this to enlarge visual attention tx stimuli for use in therapy

26. Modifications for Visual Impairment:Dynavision • Used to enhance use of peripheral vision in people with low-vision • Pt faces concentric circles of buttons and must quickly find and press a button when it lights up • Can be used for divided attention in conjunction with other attentional tasks

27. Compensatory Treatment of Attention: Environmental Modification • Managing fatigue • Rest, diet, exercise • Reducing noise • Ear plugs • Reducing visual clutter

28. Compensatory Treatment of Attention:External Cueing Strategies • Post-its to increase task focus • Countdown timers • Can be used to keep people on task for longer intervals. Very useful to help people finish tasks.

29. Compensatory Treatment of Attention:Internal Cueing Strategies • Strategies to regulate attentional resources • Self-pacing during treatment tasks • allows pts to see relationship between speed and errors • Self-Instructional Training (e.g. Webster & Scott, 1983)

30. Compensatory Treatment of Attention:Collaboration with others • Assist with pacing • Realistic expectations for productivity • Strategic scheduling of difficult tasks

31. Unawareness of Impairment:Phenomenology of TBI • Prigatano: top two responses to what does it feel like to have a TBI • Confusion • Frustration

32. Phenomenology of TBI • Why can’t I do the things I used to do? • Why do people treat me differently? • When will I get better? • What if I don’t get better?

33. Threats to the self after brain injury • Loss of abilities • Inability to return to pre-injury activities • Loss/altered relationships with friends • Loss/altered relationships with family • Personality change • A general sense that things aren’t right • Impaired self-awareness

34. Therapeutic Alliance • 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). • May be most critical factor in treatment of awareness (Sherer, 2005)

35. Establishing Therapeutic Alliance • Convey some level of understanding of their experience and that you have something to offer that will help • Offer a metaphor of therapeutic interaction that is collaborative in nature • e.g. advisor: therapist is advisor that provides information and suggestions but it is always the patient who ultimately decides direction of treatment

36. Unawareness of Impairment • 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).

37. Levels of Awareness • Intellectual Awareness • Emergent Awareness • Anticipatory Awareness

38. Intellectual Awareness • Shallow appreciation of impairment without ability to specify examples • Treatment implication: Strong need for education to provide information re: what TBI is and is not.

39. Emergent Awareness • Shows awareness of impairment at the time that they are experiencing difficulty • Treatment implication: Provide experiences in which people can test themselves • Evaluation of predicted vs. actual performance

40. Anticipatory Awareness • Awareness of strengths and weaknesses is sufficient to predict difficult situations • Treatment implication: Provide a range of experiences so that people can begin to see patterns of impairment

41. Education • General • Handouts with sequelae of TBI • Convert memory book to awareness book • Patient-specific • Records review • Independent Research • Transitional Video – borrowed from Ylvisaker. Pt scripts and participates in a video tape that describes their injury, how it has affected them, strategies they are using, and how others can support them • Can be shown to friends and families to help them understand the effects of the injury

42. Awareness & Depression • Depression is correlated to the perception of disability (Malec, 2005) • Treatment implication: accentuate the positive & demonstrate effectiveness of strategies

43. Maintaining Hope While Treating Awareness • Recovery phase • Emphasize strengths as well as weaknesses • Demonstrate the effectiveness of strategies

44. Strategy Development • Collaborative • Intent is to use a person’s strengths to overcome weaknesses and still be successful • Critical to follow-up to experiential tasks that identify impairments with strategies that will allow people to be successful

45. Compensatory Treatment • Developing awareness • Developing strategies to improve skills • Engaging in structured activities to practice strategies • Generalize strategies to functional contexts

46. Memory

47. Memory:Developing Awareness • Education • Memory handout • Predicted vs actual performance • Prospective memory handout • Learning 5 tasks handout

48. Compensatory Treatment of Memory: Environmental Modification • Labeling • Post-its • Strategic placement • Specific locations for important items

49. Compensatory Treatment of Memory:External Cueing Strategies • Checklists • Memory books • Palm Pilots • Reminder watches • Electronic locators • Record information (storage) • Find info (retrieval) • Alerting mechanism to cue retrieval

50. Memory Checklists