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C OGNITIVE R EHABILITATION FOR V ETERANS WITH T RAUMATIC B RAIN I NJURY Celeste Campbell, Psy. D. Megan Kelly, M.S. CCC-SLP Washington DC VA Medical Center.

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Presentation on theme: "C OGNITIVE R EHABILITATION FOR V ETERANS WITH T RAUMATIC B RAIN I NJURY Celeste Campbell, Psy. D. Megan Kelly, M.S. CCC-SLP Washington DC VA Medical Center."— Presentation transcript:

1 C OGNITIVE R EHABILITATION FOR V ETERANS WITH T RAUMATIC B RAIN I NJURY Celeste Campbell, Psy. D. Megan Kelly, M.S. CCC-SLP Washington DC VA Medical Center

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4 M ECHANISM OF I NJURY Shock waves Shrapnel Acceleration /Impact

5 W HAT IS COGNITION ? The mental action or process of acquiring knowledge and understanding through thought, experience, and the senses.

6 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 )

7 Neurons – the infrastructure of cognition

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

9 The seat of emotion The Limbic System

10 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

11 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

12 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

13 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

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 R EMEDIATION COMPENSATION 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 C ONSIDERATIONS WHEN DOING COGNITIVE R EHABILITATION 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 T REATMENT A PPROACHES 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 T EAM A PPROACH o Veteran o Family/Friends/Supports o Neuropsychology/Psychology o Speech-Language Pathology o Occupational Therapy o Physiatry o Sleep medicine o Vision o Audiology o Recreation therapy o Driver’s rehabilitation o Legal advocacy o Vocational Rehabilitation o Substance abuse treatment o Complementary/alternative medicine

19 D OMAINS OF C OGNITION

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21 T HERAPY FOR A TTENTION 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 M EMORY

24 T HERAPY FOR M EMORY Education: Sleep hygiene Routine Nutrition Exercise Internal Strategies: Mnemonics Visualization Association Chunking Shirley Smith Jim Crew

25 T HERAPY FOR M EMORY Paper calendar Memory journal Checklists Medication pill box Keychain voice recorder Captain’s Log, Wii (Big Brain Academy, Nintendo DS) GPS

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27 T HERE ’ S AN A PP FOR T HAT ! iCal Taskmaster Timer Grocery List Tripit Med Reminder PTSD Coach Where’s My Droid? Brain Trainer Words Free

28 T HERE ’ S AN A PP FOR THAT ! Dragon Dictation Naturally Speaking software

29 T HERE ’ S AN A PP FOR THAT ! Evernote

30 A CADEMIC R EENTRY Pomodoro, Flashcard Plus, Dictionary/ Thesaurus ebooks/Kindle Note-taking Outlining templates Active reading strategies Organizing binder/ notebook Study skills strategies

31 V OCATIONAL R EENTRY Organization External devices and software Compensatory strategies Recalling colleagues’ and clients’ names Accommodations Job coaches

32 “I NDEPENDENCE W AY ” 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 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

35 T ELEHEALTH 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 T AKE H OME P OINTS 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!


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