COGNITIVE REHABILITATION FOR VETERANS WITH TRAUMATIC BRAIN INJURY

Celeste Campbell, Psy. D.

Megan Kelly, M.S. CCC-SLP

Washington DC VA Medical Center

MECHANISM OF INJURY

Shock waves

Shrapnel

Acceleration/Impact

WHAT IS COGNITION?

The mental action or process of acquiring knowledge and understanding through thought, experience, and the senses.

Brain Stem (Involuntary processes - Respiration/ heart beat/blood pressure, Arousal/Alertness, Regulation of Appetite/Sleeping)

Frontal Lobe (Executive Functions)

Cerebellum (Balance, Muscle Coordination

Occipital Lobe(Vision and visual processing)

Parietal Lobe(Visual and Sensory Integration, Spatial Orientation, Academic Performance)

Temporal Lobe(Auditory Comprehension, Memory)

Neurons – the infrastructure of cognition

Frontal LobeExecutive Functions

Planning/Organization

Judgment

Initiation

Abstraction

Emotional Regulation

Self-Monitoring

The seat of emotion

The Limbic System

Impairments Resulting From Brain Injury

Physical

•Mobility

•Coordination/balance/skilled motor activity

•Vision/hearing

Perceptual-Motor

•Visual neglect/field cuts

•Motor apraxia/sequencing

•Motor speed

Cognitive

•Attention

•Memory/New learning

•Conceptual skills/abstraction

•Problem-solving/ Decision-making

•Initiation

•Self-Monitoring

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

Communication

•Articulation

•Tangential speech

•Word-finding

•Perseveration/ hyperverbal

•Confabulation

•Reading comprehension

•Writing

Impairments Resulting From Brain Injury

A Word About mTBI AND PTSD

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

Overlapping 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

Distinctive Symptoms

“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

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

REMEDIATION COMPENSATION Working ON a deficit to correct it

Working AROUND a deficit to accomplish a task

EVERYDAY ACTIVITIES THAT PRESENT DIFFICULTY:

Recalling appointments and daily tasksBuying groceriesCooking Medication management Money managementWithdrawing money from ATMSocial interactionsAcademic and work re-entryManaging emotions

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

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

TEAM APPROACH o Veterano Family/Friends/Supportso Neuropsychology/

Psychologyo Speech-Language

Pathologyo Occupational Therapyo Physiatryo Sleep medicineo Visiono Audiologyo Recreation therapyo Driver’s rehabilitationo Legal advocacyo Vocational Rehabilitationo Substance abuse treatmento Complementary/alternative

medicine

DOMAINS OF COGNITION

Cognition

Memory

Executive Function

Attention

Sustained Attention

Selective Attention

Divided Attention

Alternating Attention

THERAPY FOR ATTENTION

Adapting Environment

Direct Attention Training

Metacognitive Approaches

Behavior Therapy

Pharmacological

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

MEMORY

Immediate/WorkingMemory

Short Term Memory

Long TermMemory

THERAPY FOR MEMORY

Education:Sleep hygieneRoutineNutritionExercise

Internal Strategies:MnemonicsVisualizationAssociation Chunking

Shirley Smith

Jim Crew

THERAPY FOR MEMORY Paper calendar

Memory journal

Checklists

Medication pill box

Keychain voice recorder

Captain’s Log, Wii (Big Brain Academy, Nintendo DS)

GPS

PDAs

Blackberry

Android

iPhone, iTouch, iPad

THERE’S AN APP FOR THAT!

iCal Taskmaster Timer Grocery List Tripit Med Reminder PTSD Coach Where’s My Droid? Brain Trainer Words Free

THERE’S AN APP FOR THAT!

Dragon Dictation Naturally Speaking software

THERE’S AN APP FOR THAT!

Evernote

ACADEMIC REENTRY

Pomodoro, Flashcard Plus, Dictionary/ Thesaurus

ebooks/Kindle Note-taking Outlining templates Active reading

strategies Organizing binder/

notebook Study skills strategies

VOCATIONAL REENTRY

Organization External devices

and software Compensatory

strategies Recalling

colleagues’ and clients’ names

Accommodations Job coaches

“INDEPENDENCE WAY”

Simulated grocery store, Metro stop, ATM

“Ambu Track” (grass, brick, and cobble stone surfaces)

GROUP THERAPY

Living with TBI Problem Solving Social Cognition Speech/OT

Cognitive Academic Geo-caching Recreational

Therapy/outings

Emphasizes dynamic, emotional factors rather than “cold cognition”

SOCIAL COGNITION GROUP

TECHNIQUES Psychoeducational

handouts Videotaping and

mirrors Role plays

Real life examples Homework

activities Field trips Long-term

projects

MODULES• Emotion Perception and Expression• Identity and Readjustment• Social Problem Solving

TELEHEALTH

Convenient for the patient

Decreased anxiety Decreased no-show

rate Adequate quality of

signal We want to get into

patients’ homes

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

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.

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!