Cognitive Rehabilitation for Veterans with Traumatic Brain Injury

1. Cognitive Rehabilitation for Veterans with Traumatic Brain Injury Celeste Campbell, Psy. D. Megan Kelly, M.S. CCC-SLP Washington DC VA Medical Center

4. Mechanism of Injury Shock waves Shrapnel Acceleration/Impact

5. What is cognition? The mental action or process of acquiring knowledge and understanding through thought, experience, and the senses.

6. Parietal Lobe(Visual and Sensory Integration, Spatial Orientation, Academic Performance) Frontal Lobe (Executive Functions) Occipital Lobe(Vision and visual processing) Cerebellum (Balance, Muscle Coordination Temporal Lobe(Auditory Comprehension, Memory) Brain Stem (Involuntary processes - Respiration/ heart beat/blood pressure, Arousal/Alertness, Regulation of Appetite/Sleeping)

7. Neurons – the infrastructure of cognition

8. Frontal Lobe Executive Functions Planning/Organization Judgment Initiation Abstraction Emotional Regulation Self-Monitoring

9. The Limbic System The seat of emotion

10. Impairments Resulting From Brain Injury • Physical • Mobility • Coordination/balance/skilled motor activity • Vision/hearing • Cognitive • Attention • Memory/New learning • Conceptual skills/abstraction • Problem-solving/ Decision-making • Initiation • Self-Monitoring • Perceptual-Motor • Visual neglect/field cuts • Motor apraxia/sequencing • Motor speed

11. Impairments Resulting From Brain Injury • Communication • Articulation • Tangential speech • Word-finding • Perseveration/ hyperverbal • Confabulation • Reading comprehension • Writing • Behavior • Impulsivity/ disinhibition • Poor judgment • Poor motivation/ apathy/ lethargy • Emotional lability/ angry outbursts/ depression • Poor goal-setting and planning • Social • Withdrawal • Inability to learn from social interactions • Argumentative • Lack of empathy • Irresponsibility and lack of dependability

12. A Word About mTBI AND PTSD Overlapping Symptoms • Sleep disturbances/insomnia/fatigue • Irritability/anger/aggression • Problems thinking and remembering • Changes in personality/mood swings • Withdrawal from social, work, family activities • Hypersensitivity to noise

13. Distinctive Symptoms Concussion: • Headaches • Dizziness/vertigo/balance problems • Reduced alcohol tolerance • Sensitivity to light PTSD: • Flashback/ intrusive memories • Increased startle response • Hypervigilance, physiological arousal • Nightmares, night terrors “TBI does, however, have a unique physical origin that sets it apart from mental illness and is best addressed by a multidisciplinary approach that includes a sensitivity to the cognitive, emotional, and behavioral manifestations of brain trauma.” - Dr. Gerald Cross, Acting Principal Deputy Under Secretary For Health, Department Of Veterans Affairs, Before The Subcommittee On Health, House Committee On Veterans’ Affairs, Thursday, September 28, 2006

14. WHAT IS COGNITIVE REHABILITATION? • A systematic, functionally-oriented service of therapeutic cognitive activities based on an assessment and understanding of the person’s brain-behavior deficits -The Brain Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine Remediationcompensation Working ON a deficit to correct it Working AROUND a deficit to accomplish a task

15. everyday activities that present difficulty: • Recalling appointments and daily tasks • Buying groceries • Cooking • Medication management • Money management • Withdrawing money from ATM • Social interactions • Academic and work re-entry • Managing emotions

16. Considerations when doing cognitive Rehabilitation • Cognitive functioning cannot be isolated • Cognition is complex, have to be creative in order for it to be successful • Engage the patient and their family or caregivers/dependents • Other factors affecting cognition • Age/developmental level • Health • Co-morbidities (substance abuse, PTSD, mental illness) • Emotional state/stressors • Training generalization - is not automatic • Communication • Pacing • Repetition • Concrete • Accessible • Structured

17. Treatment Approaches • Top-down & bottom-up rehabilitation • Higher order cognitive processes & more basic processes • Rehearsal & practice - Repetition • Ecological validity - Relevance to real life • Teamwork & partnering • Establish social support and feedback • Time outs, relaxation & affect regulation • Self-regulation for frustration with cognitive tasks • Reinforcement - Reward • Confidence building - Reality based

18. Team Approach • Veteran • Family/Friends/Supports • Neuropsychology/Psychology • Speech-Language Pathology • Occupational Therapy • Physiatry • Sleep medicine • Vision • Audiology • Recreation therapy • Driver’s rehabilitation • Legal advocacy • Vocational Rehabilitation • Substance abuse treatment • Complementary/alternative medicine

19. Domains of Cognition

21. Therapy for Attention • Adapting Environment • Direct Attention Training • Metacognitive Approaches • Behavior Therapy • Pharmacological

22. EXECUTIVE FUNCTIONS • Planning and organizing daily tasks • Planning a weekly menu and grocery list • Selecting class schedule around work schedule • Selecting day of the week for book club • Planning a weekend trip • Organizing a party

23. Memory

24. Therapy for Memory • Education: • Sleep hygiene • Routine • Nutrition • Exercise • Internal Strategies: • Mnemonics • Visualization • Association • Chunking Shirley Smith Jim Crew

25. Therapy for Memory • Paper calendar • Memory journal • Checklists • Medication pill box • Keychain voice recorder • Captain’s Log, Wii (Big Brain Academy, Nintendo DS) • GPS

27. There’s an App for That! • iCal • Taskmaster • Timer • Grocery List • Tripit • Med Reminder • PTSD Coach • Where’s My Droid? • Brain Trainer • Words Free

28. There’s an App for that! • Dragon Dictation Naturally Speaking software

29. There’s an App for that! • Evernote

30. Academic Reentry • Pomodoro, Flashcard Plus, Dictionary/ Thesaurus • ebooks/Kindle • Note-taking • Outlining templates • Active reading strategies • Organizing binder/ notebook • Study skills strategies

31. Vocational Reentry • Organization • External devices and software • Compensatory strategies • Recalling colleagues’ and clients’ names • Accommodations • Job coaches

32. “Independence Way” • Simulated grocery store, Metro stop, ATM • “Ambu Track” (grass, brick, and cobble stone surfaces)

33. GROUP THERAPY • Living with TBI • Problem Solving • Social Cognition • Speech/OT Cognitive • Academic • Geo-caching • Recreational Therapy/outings

34. SOCIAL COGNITION GROUP • Emphasizes dynamic, emotional factors rather than “cold cognition” • MODULES • Emotion Perception and Expression • Identity and Readjustment • Social Problem Solving • TECHNIQUES • Psychoeducational handouts • Videotaping and mirrors • Role plays • Real life examples • Homework activities • Field trips • Long-term projects

35. Telehealth • Convenient for the patient • Decreased anxiety • Decreased no-show rate • Adequate quality of signal • We want to get into patients’ homes

36. research • TRICARE does not pay for cognitive rehabilitation • ECRI Institute report concluded the evidence supporting cognitive rehabilitation is too inconclusive to justify coverage • “If one applies the standards of the ECRI report to other aspects of rehab, I believe that one must reach the conclusion that there is insufficient evidence to support the effectiveness of neurological management, psychiatric treatment, physical medicine interventions or pharmacologic treatments for traumatic brain injury” (Cicerone, 2011) • Institute of Medicine has launched it’s own study

37. research • “There is substantial evidence to support interventions for attention, memory, social communication skills, executive function, and for comprehensive-holistic neuropsychologic rehabilitation after TBI” (Cicerone, 2011) • PRACTICE STANDARDS (at least 1 class I study with class II or II evidence) • Meta cognitive strategy training is recommended for deficits in executive functioning after TBI including impairments of emotional self-regulation,…attention, neglect, and memory. • Specific interventions for functional communication deficits, including pragmatic conversational skills, are recommended for social communication skills after TBI. • Memory strategy training is recommended for mild memory impairments from TBI, including the use of internalized strategies and external memory compensations.

38. Take Home Points • Anchor treatment in goals that are important to the patient • Focus on a team based approach • Do not underestimate the importance of including friends, family, and caregivers in treatment • Remember the impact of personal, emotional and social factors on cognitive functioning • Compensatory strategies and devices must be individually configured to the patients’ needs • Be creative! • Be responsive to new developments in medicine and technology • Continued research is imperative!