The Brain, injury, and a few things to overcome!

Presented by: Kim MacNeil Occupational Therapist April 2012

Outline

     A little about the brain What is an Acquired Brain Injury (ABI)?

Recognizing symptoms of ABI and strategies to work with Positive Everyday Routines Hypothesis Testing

THE BRAIN

The Brain

ANATOMY: The Brain

NEURON

NEURONS: It’s grey and white

ANATOMY: The Skull

The Brain in Bed The Brain’s Bed

What is an Acquired Brain Injury (ABI)?

  Traumatic Brain Injury – result of external trauma  fall, car accident, fight, gun shot, Non-traumatic – result of internal source injuring the brain  Hypoxia (lack of oxygen) - near drowning, heart attack, “fainting game”, stroke (block)  Toxicity, meningitis, rabies, infection, stroke (bleed)

NEURONS & BRAIN INJURY

Focal (LOCAL) VS Global (DIFFUSE) Effects:

      Coup Contra coup Acceleration & Deceleration Rotational & Shearing Hematoma’s Edema Disruption of neural connection

Did you know:

    Level of severity is not necessarily directly related to outcome A concussion is a brain injury too Don’t have to loose consciousness to sustain a brain injury Younger is not necessarily better when it comes to recovery

NS Leading way in preventing ABI

As of Nov 1, 2012 everyone in Nova Scotia is required to wear protective helmets while downhill skiing or snowboarding at ski hills.

Recovery/Long Term Effects

     Most (but not all) recovery occurs within first 2 years Area and extent of damage Physical recovery Individual Environment

HOPE

   Outcomes vary Severity of injury does not always coincide with severity symptoms To have hope is to envision something beyond what is…therefore there is a goal to work towards. Break it up into smaller achievable goals and work on them one day at a time.

Invisible Injuries of the Brain



By Debbie Wilson ( survivor from Murphysboro, Illinois)

Critical factors for successful reintegration:

– EDUCATION of persons involved regarding brain injury – OPEN COMMUNICATION between all persons involved

Previous Approaches:

 Common mistakes include: quizzing people, and allowing people to make the same mistakes over and over again “so they will learn from their mistakes”  Previously gave lists to remember then “tested” later

Errorless Learning

   Methods of learning whereby attempts are made to prevent (or reduce the likelihood of) errors being made during the learning process.

Avoid trial and error learning or attempting to learn from ones mistakes Compensate for the memory deficit by providing the person with the right answer from the start and prevent mistaken guesses.

Errorless Learning

   When the right answer is not given and the individual is forced to guess or “figure out” the answer, errors are likely to result. When wrong answers are repeated, the person may learn the wrong answer (i.e. reinforced) instead of learning the correct information. Errorless learning is not an intervention or treatment but rather a principle of learning i.e. cueing instead of quizzing during transfer practice

Impairments associated with ABI & Strategies

SYMPTOMS OF ABI : COGNITION

        New Learning Attention and Concentration Memory Organization Perception Reasoning Problem Solving Initiation

New Learning

       New material in small amounts Repeat and summarize previous relevant info Offer varied opportunities to use info Use relevant & meaningful examples Check comprehension frequently Allow additional time Errorless Learning

Attention & Concentration

     Consistent, predictable, regular routines Limit distractions (e.g. doors, windows, other students media) Redirect Provide breaks Monitor for signs of decreased attention/concentration (redirect, cue, allow for rest)

Memory

      Links to prior knowledge Categorize or “chunk” info into small amounts Repetition, repetition, repetition… Memory aids (e.g. sticky notes, phones apps…) Cues (visual, verbal, physical) Rhymes, songs

How dinosaurs became extinct!

Organization

      Establish & maintain daily routines Daily Schedule Provide outlines & check for note taking Cue “I will give you a moment to write that down, put that in your calendar/phone” Use checklists Repetition, repetition, repetition…

Perception - Vision

   Visual Stimulation (e.g. over/under stimulation, clutter) Use arrows/highlighters Contrast colours to encourage important information to be identified

VISUAL CONTRAST

LOW CONTRAST HIGH CONTRAST

Perception - Auditory

    Limit excess noise (e.g. lower voices) Establish clear eye contact Be clear and specific, check for understanding Use non-verbal cues

Reasoning

    Provide concrete examples Allow them to do the task whenever possible Be direct “Lets review your plan (Goal/plan/do/review), how did that work out for you?” Set up opportunities to learn elsewhere (e.g. at home)

Problem Solving

     Frequent feedback Compensate (lists of options) Step by step (e.g.“ok you checked off the first thing on the list, next it says you will….” “hmmm, you have completed step 1, step 2 says…”) “What do you think about? Could you?” Plan ahead, role play scenarios – Develop Scripts (e.g. no answer for test)

Initiation

    Cues (verbal, visual, physical) Schedule/journals/apps/reminders Give options, lead (“you got your pencil and the paper…) Structure, predictability, routine

ABI SYMPTOMS: BEHAVIOUR/EMOTION

     Agitation/frustration Disinhibition Aggression Poor social behaviour & poor awareness of consequences to actions Depression/Self Image

Frustration

      Allow opportunities for success Identify antecedents to frustration Chunk work into smaller manageable parts Provide alternatives to acting out Take a break Recognize symptoms and feelings

Disinhibition

     Provide chance for open, safe, communication, Respond consistently (e.g. script), respectfully and clearly If possible practice ahead of time When possible be context specific Use script to respond when inappropriate

Aggression

     Be aware of signs of escalation Use redirection Be calm and aware of your body language Cue them to increase awareness of their feelings ( “I sense you may be frustrated”) Manage triggers (e.g. overstimulation: noise, light, colours, fatigue)

Social Behaviours

     Provide opportunities to practice appropriate behaviours Be direct, specific, non-judgmental Create Scripts Set social goals Role model/role play

Depression & Self Image

    Focus on abilities, avoid comparisons to pre-injury “self” Validate emotions and work on changing them Recognize symptoms: withdrawal, lethargy, lack of interest in appearance, feelings of hopelessness Liaise with family, friends, health care professionals

ABI SYMPTOMS: PHYSICAL

     Pain/discomfort, FATIGUE, Seizures, Sleep Disturbances, Headache and/or Tinnitus Sensory disturbances Musculoskeletal issues Poor environment/person fit Visual field neglect

Physical

   Cognitive and Physical Fatigue – Allow for rest, shorter days, frequent breaks Seizures – Educate on protocols, monitor, log, aware of med side effects Sleep – Insomnia or excess, need for “naps”, everyday predictable routines

Physical continued…

    Fine Motor – Use computer, reduce written work, verbalize, time extensions Mobility – Seating issues, adaptive equipment, accessibility Self Care – Cue if necessary Visual field neglect – Seating, large print, other modalities

Transfer of Training

   “If you want people to learn something teach it to them. Don’t teach them something else and expect them to figure out what you really want them to do.” - Thorndike Teach what needs to be learned in the context of when and where it will be used Everyday functional activities are the best context for cognitive intervention

Positive Everyday Supportive Routines (PESR)

    Positive: Successful and Supported Everyday: In the context of everyday life, supported by everyday people, using functional teaching goals Support: Social collaborative, goal oriented work, in a natural context Routine: Habit, organized scripts and supports in the context of everyday life

Basic Principles of PESR

   The person is the core of all intervention and support efforts Interventions and supports are organized around personally meaningful activities with everyday people (person, teachers, classmates, family, friends etc) Positive everyday routines are the context for pursuit of meaningful goals

Basic Principles of PESR

     Reduction of supports is part of the plan Feedback is context sensitive and meaningful Components of life must be integrated Assessment is ongoing and context sensitive Behavioral concerns are addressed via positive behavioral supports

Importance of Routines:

 Routines have a positive impact on – Independence – Problem Solving – Planning – Organization – Learning (i.e. able to learn physio exercises but can not remember am care)

Everyday:

  Find out what is meaningful to them and explain everyday things to them (i.e. their progress, a procedure and so on) in that context Examples: NASCAR, Electrical Work

Steps to Organize Routines

1. Identify successful and unsuccessful routines of everyday life. What’s working, what’s not working?

2. Identify changes that have the potential to transform unsuccessful routines into successful routines (including changes in the environment and the behaviors of others.)

Steps to Organize Routines

3. Identify how changes in routines include activities that are motivating to the person.

4. Implement needed supports to organize routines so that the individual experiences success and receives intensive practice in context.

5. Gradually withdraw supports and expand contexts as much as possible.

Goal

Review

Plan

Predict

Do

Hypothesis Testing

• Common sense approach of systematically teasing out what contributes to failure and what contributes to success. • Poor performance happens for many reasons, we can perform well by applying many different supports and strategies

Steps to Hypothesis testing:

 Identify a problem  Formulate all hypothesis  Select a hypothesis  Test hypothesis  Review results

Scripts

      Scripts structure involvement / interaction with promote procedural learning (steps to do, knowing how to do it, automatic) Conversation non-threatening Well selected language Mass practice Embedded in meaningful activities Across everyday partners (team, family…)

Scripts

Positives: – Allows people to think out loud – Gain self awareness – Coach person to be their own coach – Facilitates typical development of executive functions (Higher level cognitive tasks such as problem solving, reasoning, attention, self awareness…)

Scripts

Scripts may be used for different daily interactions including: – Orientation Script – Problem Solving – Behavioural – Big deal/Little Deal – Experimental Routine

Example: Orientation

Say “Hi _insert persons name__, it is a ___weather__(i.e. fairly mild day) for December __. I can’t believe Christmas is in only_____ days. The year 2004 is almost over. I know you have been meeting many people since you came into the hospital on October 16 so you may not remember me. My name is ____________ I am your _____________ (i.e. friend from __________, your therapist…). I just came by to see if …….”

Contextualized Collaborative Hypothesis-Testing What’s the problem?

(Using the two strangers in the doorway rule) Hypothesis Formulation (Why is s/he doing this?) Hypothesis Selection (Begin with easiest to test or most obvious) Hypothesis Testing (Protocol for experimentation Plan A - Plan B - Plan C Testing time line)

Summary of CLASSROOM STRATEGIES

        Emphasize function Provide low stimulus environment Role play socially appropriate beh Assist with organizational skills and attention to task Allow for frequent breaks and rests Allow for extra time Repeat new information frequently Maximize opportunity to practice new skills

Summary of CLASSROOM STRATEGIES cont…

       Prepare ahead of time for transitions Recognize signs of frustration and assist in decreasing Consistent and predictable routines Clear expectations Focus on positive everyday supportive routines Communicate regularly with stakeholders Become informed about ABI

Just because…

  One strategy is learned doesn’t mean it will be used again OR generalized to other tasks Someone can tell you all the steps to complete a task it doesn’t mean they can do it

Patience, Flexibility, & Forgiveness

References:

Bennett, Dr. S., Good, Dr. D., Kumpf, J., (2003). Educating Educators about ABI. Brock University and the Ontario Brain Injury Association. Wilson, D. Invisible injury of the brain. Newsletter of the Brain Injury Association of Canada (2012, February). Retrieved from http://biac aclc.ca/en/category/newsletters-biac-impact-pathways-ahead/ Ylvisaker, M. & Feeney, J. T. (1998). Collaborative Brain Injury Intervention: Positive everyday routines. Singular Publishing Group, Inc. San Diego, CA Websites: Brain Injury Association of Canada: http://biac-aclc.ca/ Brain Injury Association of Nova Scotia: http://biac-aclc.ca/en/ Learnnet: http://www.projectlearnet.org/