Cognitive Rehabilitation after Polytrauma

Don MacLennan Minneapolis VAMC AVASLP Conference May 3 rd , 2006

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.”

Restorative Treatment

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

Restorative Treatment

 Drills  Hierarchical in difficulty  Repetition  Attention Treatment

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

Compensatory Treatment

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

Polytrauma

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

Barriers to Cognitive Rehabilitation Associated with Polytrauma

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

Cognitive Rehabilitation: targeted areas for treatment

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

Attention

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

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

Restorative Approaches

 Attention Process Training – APT I – APT II

Auditory Tasks: Levels of Attention

Auditory Sustained  Listening for ↓ numbers Alternating  ↓ numbers / ↑ numbers Divided  ↓ numbers + computer task

Visual Tasks: Levels of Attention

Visual Sustained  Scanning R/I: beginner Alternating  Scanning R/I: intermediate Divided  Scanning R/I + answering questions

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

Level of Difficulty

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

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

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

Combining with functional tasks Computer work simulation + APT

 – 1.

2.

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

Combining with functional tasks Map Navigation + APT

 – 1.

2.

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

Modifications: Hearing Impairment

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

Modifications to attention treatment: Aphasia

 Attentional treatment for aphasia

Modifications to attention treatment: Visual Impairment

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

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

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

Compensatory Treatment of Attention: Environmental Modification

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

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.

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)

Compensatory Treatment of Attention: Collaboration with others

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

Unawareness of Impairment: Phenomenology of TBI

 Prigatano: top two responses to what does it feel like to have a TBI – Confusion – Frustration

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?

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

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)

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

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).

Levels of Awareness

 Intellectual Awareness  Emergent Awareness  Anticipatory Awareness

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.

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

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

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

Awareness & Depression

 Depression is correlated to the

perception

of disability (Malec, 2005)  Treatment implication: accentuate the positive & demonstrate effectiveness of strategies

Maintaining Hope While Treating Awareness

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

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

Compensatory Treatment

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

Memory

Memory: Developing Awareness

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

Compensatory Treatment of Memory: Environmental Modification

 Labeling  Post-its  Strategic placement – Specific locations for important items

Compensatory Treatment of Memory: External 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

Memory Checklists

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

External Cueing Strategies Locators

 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

Compensatory Treatment of Memory: Internal Cueing Strategies

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

Compensatory Treatment of Memory: Collaboration with others

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

Modifications for visual impairment: Internal cueing strategies

 Use of tactile-kinesthetic modeling for route finding

Modifications for aphasia:

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

Executive Functions

Executive Functions

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

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

Executive Functions: Developing Awareness

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

Compensatory Treatment of Executive Functions: Environmental Modification

 Routines  Schedule boards – Highlight modifications of routines in a separate color

Compensatory Treatment of Executive Functions: External Cueing Strategies

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

Compensatory Treatment of Executive Functions: Internal Cueing Strategies

 Internalization of external cueing strategies

Compensatory Treatment of Executive Functions: Collaboration with others

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

Pragmatic Communication

Pragmatic Communication: Developing Awareness

 Education  Hollywood Videos  Patient Video

Example EC

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

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

Compensatory Treatment of Pragmatics: Collaboration with others

 Assisted cue and review  Advance scripting