Cognitive Rehabilitation after Polytrauma

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Cognitive Rehabilitation after Polytrauma

• Don MacLennan
• Minneapolis VAMC
• AVASLP Conference
• May 3rd, 2006

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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.

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Restorative Treatment

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

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Restorative Treatment

• Drills
• Hierarchical in difficulty
• Repetition
• Attention Treatment

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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

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Compensatory Treatment

• Environmental modifications
• External cueing strategies
• Internal cueing strategies
• Collaboration with others

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Polytrauma

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

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Barriers to Cognitive Rehabilitation Associated
with Polytrauma

• Amputation
• Pain
• Hearing Loss
• Blindness, Low-Vision
• Aphasia

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Cognitive Rehabilitation targeted areas for
treatment

• Attention primarily restorative
• Awareness of Impairment
• Memory
• Executive Functions compensatory
• Pragmatic Communication

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Attention
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Sohlberg Mateers 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

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Treatment Principles Cicerone 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

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Restorative Approaches

• Attention Process Training
• APT I
• APT II

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Auditory TasksLevels of Attention

• Auditory
• Sustained
• Listening for ? numbers
• Alternating
• ? numbers / ? numbers
• Divided
• ? numbers computer task

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Visual TasksLevels of Attention

• Visual
• Sustained
• Scanning R/I beginner
• Alternating
• Scanning R/I intermediate
• Divided
• Scanning R/I answering questions

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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

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Level of Difficulty

• Tasks need to be difficult
• 70-90 correct
• Subjective difficulty rating

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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

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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

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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

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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

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Modifications Hearing Impairment

• Essential to have good access to audiology and
  provide amplification where needed.

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Modifications to attention treatment Aphasia

• Attentional treatment for aphasia

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Modifications to attention treatment Visual
Impairment

• Enlarging stimuli
• Use of low-vision technology
• Magnifiers
• Monocular devices
• CCTV
• Dynavision

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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

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Modifications for Visual ImpairmentDynavision

• 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

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Compensatory Treatment of Attention
Environmental Modification

• Managing fatigue
• Rest, diet, exercise
• Reducing noise
• Ear plugs
• Reducing visual clutter

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Compensatory Treatment of AttentionExternal
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.

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Compensatory Treatment of AttentionInternal
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)

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Compensatory Treatment of AttentionCollaboration
with others

• Assist with pacing
• Realistic expectations for productivity
• Strategic scheduling of difficult tasks

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Unawareness of ImpairmentPhenomenology of TBI

• Prigatano top two responses to what does it feel
  like to have a TBI
• Confusion
• Frustration

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Phenomenology of TBI

• Why cant I do the things I used to do?
• Why do people treat me differently?
• When will I get better?
• What if I dont get better?

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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 arent right
• Impaired self-awareness

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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)

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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

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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).

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Levels of Awareness

• Intellectual Awareness
• Emergent Awareness
• Anticipatory Awareness

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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.

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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

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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

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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

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Awareness Depression

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

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Maintaining Hope While Treating Awareness

• Recovery phase
• Emphasize strengths as well as weaknesses
• Demonstrate the effectiveness of strategies

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Strategy Development

• Collaborative
• Intent is to use a persons 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

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Compensatory Treatment

• Developing awareness
• Developing strategies to improve skills
• Engaging in structured activities to practice
  strategies
• Generalize strategies to functional contexts

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Memory
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MemoryDeveloping Awareness

• Education
• Memory handout
• Predicted vs actual performance
• Prospective memory handout
• Learning 5 tasks handout

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Compensatory Treatment of Memory Environmental
Modification

• Labeling
• Post-its
• Strategic placement
• Specific locations for important items

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Compensatory Treatment of MemoryExternal Cueing
Strategies

• Checklists
• Memory books
• Palm Pilots
• Reminder watches
• Electronic locators

1. Record information (storage)
2. Find info (retrieval)
3. Alerting mechanism to cue retrieval

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Memory Checklists
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External Cueing Strategies structured practice

• Acquisition
• Learn what sections are for how to enter data
• Application
• Role play specific situations
• Adaptation
• Applying to everyday activities

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External Cueing StrategiesLocators

• Work like pagers on wireless phones
• Sensor is placed on a frequently misplaced object
  that can be located by pressing a button the base
  unit
• Different styles available through both Sharper
  Image and Radio Shack

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Compensatory Treatment of MemoryInternal Cueing
Strategies

• Mnemonics not useful for general memory
  compensation but may be excellent for learning a
  limited amount of domain-specific information

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Compensatory Treatment of MemoryCollaboration
with others

• Provide reminders
• Assistance in developing routines
• Provide support to use external cueing strategies
• Reminders to use
• May input information directly

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Modifications for visual impairment Internal
cueing strategies

• Use of tactile-kinesthetic modeling for
  route-finding

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Modifications for aphasia

• Pictorial memory book
• Pictorial checklists
• Notes and hourly reminder alarms
• VoiceMate

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Executive Functions
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Executive Functions

• Formulating Goals
• Developing a plan
• Initiating the plan
• Monitoring and correcting the plan

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Workbook Therapy

• No strong evidence that workbook stimulation
  therapy works
• Need to apply to functional activities
• difference between knowing and doing
• Somatic marker hypothesis?
• Workbooks are useful structured practice when
  used as a tool to practice specific compensatory
  strategies

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Executive FunctionsDeveloping Awareness

• Education
• Predicted vs actual performance
• Locate BIA meeting
• ID return to driving procedures

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Compensatory Treatment of Executive Functions
Environmental Modification

• Routines
• Schedule boards
• Highlight modifications of routines in a separate
  color

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Compensatory Treatment of Executive Functions
External Cueing Strategies
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Compensatory Treatment of Executive Functions
External Cueing Strategies

• ShadowPlan is a sophisticated outlining program
  compatible with use on Palm Pilots
• Allows pts to develop complex outlined routines
  that they can use to guide them through complex
  tasks
• Checkoff boxes, alarms are available
• Obtainable through www.codejedi.com for about 20

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Compensatory Treatment of Executive Functions
Internal Cueing Strategies

• Internalization of external cueing strategies

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Compensatory Treatment of Executive Functions
Collaboration with others

• Establishing routines
• Preparation for changes in routines
• Supporting use of cognitive strategies

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Pragmatic Communication
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Pragmatic CommunicationDeveloping Awareness

• Education
• Hollywood Videos
• Patient Video

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Example EC

• Poor initiation
• Sohlberg, Sprunk, and Metzalaar, 1988
• Verbose/tangential
• Structured tx task Card activity (Schumacher)
• Generalization strategy Self-talk
• Good conversation

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Compensatory Treatment of Pragmatics Internal
Cueing Strategies

• Self-Instructional Training
• Metaphor (Ylvisaker Feeney, 2000)
• Combine these with external cueing strategies
  such as countdown timer to increase generalization

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Compensatory Treatment of Pragmatics
Collaboration with others

• Assisted cue and review
• Advance scripting