Cognitive Rehabilitation and Traumatic Brain Injury

1. Cognitive Rehabilitation and Traumatic Brain Injury Mary Pepping, Ph.D., ABPP-CN Professor and Director Neuropsychological Evaluation Service and Outpatient Neuro-Rehabilitation Program UW Department of Rehabilitation Medicine

2. A quick bit of history for cognitive rehabilitation • Pioneer Yehuda Ben-Yishay, Ph.D. and injured Israeli soldiers • Observed problems in thinking and behavior for the first generation of long-term survivors • Development of milieu-based interdisciplinary neuro-rehabilitation - a day hospital model to address problems

3. Evolution of Cognitive Rehabilitation • Identifying and understanding TBI changes in thinking and behavior • How much caused by injury to brain? • How much caused by injury to the self? • Is the person aware of deficits? • Are they able to tolerate treatment? • Can they form an alliance with the clinicians?

4. What produces the common pattern of difficulties > TBI? • Architecture of skull and brain • Mechanical forces impacting brain • Frontal and temporal lobe injuries common • Primary effects, e.g., contusion, shear • Secondary effects, e.g., swelling, subdurals • Tertiary effects, e.g., chemical cascade • Severity of injury - mild, moderate, severe • Whose brain was injured?

5. Frontal Lobe Impairments:Neurocognitive problems • Attention, concentration, distractibility • Tangentiality • Problems with planning & organization • Impaired initiation and follow-through • Trouble with main ideas and inference • Concrete thinking, literal-mindedness • Problems with word retrieval

6. Frontal Lobe Impairments:Neurobehavioral Difficulties • Poor self-regulation of behavior • Impulsivity, Disinhibition, Judgment • Perseveration • Inappropriate behavior • Child-like demeanor or response • Flat affect and/or emotional lability • Reduced awareness of deficits • Lack of empathy for others

7. Temporal Lobe Impairments:Neurocognitive • Memory - Verbal and/or Spatial • Immediate or Working Memory OK • Old, Well-Learned Memory OK • Storage of New Memories Impaired • Short Term Memory Badly Affected • Reduced New Long Term Learning • Reduced Prospective Memory Skills

8. Temporal Lobe Impairments:Neurocognitive - 2 • Auditory Processing • Reduced Language Comprehension • Changes in Melodic Processing • Changes in Prosody • Problems with Visual Item Recognition • Misperception of Interpersonal Events

9. Temporal Lobe Impairments:Neurobehavioral • Heightened Irritability • Rage reactions (Limbic dyscontrol) • Interpersonal “viscosity”

10. Parietal Lobe Deficits:Sensory-Perceptual • Changes in sensation and perception of: • Touch • Pain • Temperature • Position and Location, on body and in space • Vibration • Integration of sensory perceptual information (agnosias)

11. Parietal Lobe Deficits:Further disturbances • Apraxia - inability to perform skilled movements in the abstract • Difficulty apprehending the Gestalt • Visual field disturbances • Neglect • Paranoia or misperception of people and events

12. Parietal Lobe: SpecificNeurocognitive Problems • Visual perception - lines and angles • Facial perception • Mechanical skills - visual and tactual • Path-finding, Interpretation of maps, directions • Difficulty with reading • Difficulty with writing

13. Occipital Lobes • Primary visual cortex • Elaboration of visual information • Synthesis of visual information • Visual field defects • Abundant connections with other regions of the brain - role in reading, executive functions, visual memory

14. Brain stem and Cerebellum • Cranial nerves damaged • Spasticity, dysarthria, dysphagia • Balance, coordination, gait • Motor learning • Cerebellar affective sydrome

15. Role of Neuropsychological Evaluation • Evaluations designed to identify brain-related abilities and deficits in higher level functions • Can winnow through many domains of function and identify main concerns • Provides good pre-injury history • Look at current levels of emotional distress and coping abilities • Identifies personality strengths and vulnerabilities that can affect outcome • Can help outline effective treatment plan

16. Neuropsychological Evaluation: The Process • Referral Question • Record Review • Interview with Patient and Family • Test Selection and Administration • Behavioral Observations • Test Scores and Normative Data • Analysis and Integration of All Results • Review of Results • Report with Findings, Recommendations

17. Neuropsychological Evaluation: The Content • Intellectual skills: verbal and nonverbal • Attention: simple and complex • Memory - verbal, spatial, simple, complex • Acquisition, Retention, Retrieval, Recognition • Language and Academic abilities • Visual spatial and tactual spatial processing • Executive functions • Sensory Perceptual abilities • Fine motor speed • Current emotional status, ability to engage tx

18. Neuropsychologically-Based Treatment Plans • What are the primary obstacles to improved function? • Cognitive and communication issues • Behavioral disturbances (neurologic) • Speed of thinking and performance • Reactive emotional problems • Physical limitations • Personality difficulties (characterologic) • Lack of family and social support • Disincentives to return to productivity • Other risk factors

19. Neuropsychologically-based treatment plans: • What are the person’s major strengths? • Pre-injury experiences that developed cognitive, emotional, interpersonal, artistic, musical, athletic, vocational, behavioral, common-sense, good judgment or skill-based abilities • Any special talents or interest? Pilot? Carpenter? • Residual abilities in any or all of the above areas • Personal ability to rally coping resources • Features of personality strengths • Degree and nature of family support • Friends and other supports, including pets

20. “Blended” Case Example • 20 year old single male • High school educated • In college at time of accident • Severe traumatic brain injury in MVA • 2-week coma - 9 months post-injury • Classic frontal-temporal injury • Very mild residual right hemiparesis

21. Cognitive Rehab Targets: • Attention: vulnerable to distraction • Memory: spontaneous retrieval • Executive functions: plan, organize, time management • Speed of thinking mildly reduced • Reading comprehension • Missing the main idea • Not taking effective notes

22. Treatment Plan:Residual Strengths • Good pre-morbid school and work history • Good basic reasoning skills • Strong desire to return to school • Able to withstand constructive feedback • New learning ability present • Willing to participate in treatment • Supportive family

23. Laying the groundwork for treatment success • Updated Rehab MD review of injury related health concerns and meds • Re-establish good sleep-wake cycle • Trazadone for sleep was helpful • Re-establish decent nutrition • Reduce alcohol consumption • Review and update exercise regimen • Secure or modify basic living situation

24. Three key places to begin for this patient: • Find and use a single effective memory compensatory device • Establish a routine schedule • Start work on ways to reduce distraction

25. Find and use a single memory system: • Some trial and error to find right system • The memory system has to be with the person at all times and used every day, multiple times for entries and review • Choose a single calendar or device that the person likes and is willing to use • iPhone calendar that syncs to Google? • Daytimer or Week at a Glance systems? • Small pocket calendar? • Watch with calendar and alarms?

26. Establish a predictable schedule with a set of routines • Evening routine: • Check appt book for next day’s schedule • Gather items needed for next day’s departure and place them by door to garage or bus • Plan route and double estimated time needed • Have wallet, cell phone, keys in one place • Put out clothes you will wear tomorrow • Start quiet time at 9:30pm: relax, light reading, meditation, quiet music, snuggle time with pets • No TV, no computer, no thrilling movies, no late exercise • Check to make sure alarm is set; in bed by 10pm

27. Morning routine • Morning routines • Get up when alarm goes off - no snooze! • Reward yourself with coffee, tea, or juice • Shower and dress • Re-check the day’s schedule and to do list • Have breakfast, take meds if appropriate • Check that burners and lights are off • Make sure you have all you need to take with you, e.g., wallet, phone, keys, books, backpack, laptop, money for meals at school

28. Key elements of daytime routine • Follow established schedule • Class days and times mapped out for term • Therapy appts: Time, place, person • Bring therapy notebook and school homework • Study time scheduled for homework and tests • Extra time scheduled for projects and papers • Break times and meal times scheduled • Exercise or gym time • Open time to relax, visit with friends, have fun • Bring future assignments and graded papers or tests to speech treatment for review

29. Methods to reduce distraction • External distractions • Find quiet place to study • Turn off phone, TV, music, radio • If study materials are on-line,consider printed copies to allow single-minded focus on article, and avoid “pop-ups” or “dings” alerting you to incoming email or messages • Read aloud to maintain focus on material • Underline what you think is important to know • Take brief breaks every 30 minutes after jotting down some of those main ideas

30. Internal distractions • What is it that keeps popping into mind? • Worries • Jot it down for consideration at a scheduled “worry time review” later • Something you don’t want to forget? • Quickly jot it down in memory system at hand • Are you hungry or thirsty? • Are you sleepy? • Have some coffee, do 10 minutes of exercise • What is your optimal time of day for focus?

31. Use of ABODES system for planning and organizing - “A” • Assess the situation • What is it you want to do? • When? • Where? • With whom? • How? • Why?

32. Use of ABODES • Break the task, goal, project or activity into as many possible steps as you can brainstorm • The more steps, the better • Even if you are not sure a step is needed, better to include it than not to list it • Order the steps from first to last as they would most likely need to be accomplished • First break the long list of steps into smaller subgroups that have something in common • Then go back and put the steps within each of the subgroups in order

33. Use of ABODES • Decide what is needed to accomplish the task, goal, project or activity • Materials, supplies, tools or information • Reservations, tickets, visas, appointments • Money, credit card, debit card, photo ID • Space in which to work or gather • Help or participation by others • A certain kind of weather or time of year?

34. Use of ABODES • Estimate time it will take to accomplish the task, goal, project or activity • Estimate the time you think is needed to complete each of the specific steps you listed • Add in any time needed for coordination with others • Triple the time estimated to complete each step • Enter each of the steps, in order, into your schedule system on specific dates and times to begin accomplishing them

35. Use of ABODES • Survey your work and re-adjust project needs and time frame for completion • None of us has perfect ability to plan and implement an entire project without some changes you’ll only learn are needed once you’ve begun! • Do not tackle massive organizational projects alone or with limited time, space and resources, unless you know: • It can be completed in one day (organizing your spices) • You can leave the not-yet-completed steps in reasonably neat order so your overall situation is not worsened

36. Reading Comprehension • Getting the main ideas • What is the title of the chapter, story or article? • Read a paragraph and see if you can put the main point into your own words • Is the story about a person, place, thing or idea? • Sometimes the first and last line of each paragraph will introduce or summarize main points • Are certain nouns (people, places, objects, concepts) mentioned frequently in the paragraphs? • Is there something new that you learned by reading the story? • Can you go jot down a few main points and details?

37. Taking effective notes • For reading comprehension & retention • Correct any visual problems as much as possible • Use good lighting by which to read • Keep a list of main characters and events for books you read on a 4 x 6 card in book • Write a brief summary of each chapter’s main people, events or ideas • Participate in a study group or book group to discuss main ideas and characters and events • Read aloud for multi-sensory input • See, say, hear, listen

38. Taking effective notes while listening in classroom • Make sure your hearing is okay • Sit at front of lecture space • Use an outline form to capture main ideas and key details • If handouts, slides or outlines are available on-line prior to lecture, review those • Review your notes immediately after lecture and try to fill-in or clarify as you can • Borrow notes from good note-takers • Digitally record lectures and review them

39. Taking effective notes in class • You don’t have to jot down everything • Try to alternate your listening and writing, so there are times when you are fully focused on the speaker, and not writing • Ask occasional questions of the speaker to clarify what has been said • Write as good a summary note as possible at the end of the presentation or discussion

40. Final comments on Cognitive Rehabilitation • An essential component is the mind of the therapist who understands the underlying causes of cognitive problems and can create, implement, monitor and modify treatment as appropriate. • This occurs as part of a larger informed and compassionate view of human needs, limitations, strengths and behaviors. • The person with TBI must ally him or herself with the treatment effort, personnel and goals