LIFESTYLE RESTORATION PROGRAM TRAINING SESSION PHASE 2 June 6 & 7, 2015 Halifax, Nova Scotia Ingrid Neufeld, BMR(OT) Reg (Ont) Occupational Therapist

Advanced Treatment for LRP CBI Health DAY #2 Advanced Treatment for LRP CBI Health REVIEW of DAY 1: Diagnostic categories Setting up the program Team member roles Treatment techniques for all of our clients but particularly so for the LRP: building rapport; setting goals; scheduling; exercise therapy We also discussed dealing with resistance with motivational interviewing techniques as well as CBT basic principles. Today we are focusing on evidenced based practise broken down into

DAY 2 AGENDA Neuroplasticity Overview Depression Chronic Pain Anxiety/Panic Disorders Mindfulness Practise Addictions

DAY 2 AGENDA Concussion Management CBT-I: Treatment for Sleep Disorders 8. Cognitive Work Hardening & RTW 9. Managing the Files 10. Marketing

NEUROPLASTICITY RESOURCES THE BRAIN’S WAY OF HEALING, Dr. Norman Doidge. THE BRAIN THAT CHANGES ITSELF, Dr. Norman Doidge.

NEUROPLASTICITY Changes in neural pathways and synapses due to changes in behavior, environment, neural processes, thinking, emotions, as well as changes resulting from bodily injury. In the old days…strokes… So the way we think, what we do, how we feel and what we pay attention to changes the connections in our brain.

NEUROPLASTICITY CORE LAW # 1 Neurons that fire together wire together MEANS THAT Repeated mental experience leads to structural changes in the brain neurons that process that experience MAKING the synaptic connections stronger Neurons fire faster, stronger, sharper signals together Learning a new skill – repeating it Malcolm Gladwell – Wayne Gretzky, Bill Gates

NEUORPLASTICITY CORE LAW #2 Converse is also true USE IT OR LOSE IT If you stop performing an activity, the connections get weaker and over time may be lost. You lose it because the real estate space in the brain gets taken over. Using a language – Mikaela – 50% loss of a language after 2 years of not using it. Can be good if we want to extinguish a habit

NEUROANATOMY 101 Neurons communicate by sending messages back & forth in the synapse. Messengers are called neurotransmitters. How a message is interpreted depends on where it is received. Neural networking – emotion, thought and physical sensations all recorded together in the memory of an experience. Example – smell of bread Car wheels screeching

NEUROTRANSMITTERS GLUTAMATE: brain’s go signal GABA: the stop signal Serotonin: the regulator Norepinephrine: energizer bunny Dopamine: feel good message & helps with attention Oxytocin: bonding & safety Glutamate – signals or ignites neurons to fire., to send out their neurotransmitters. In all parts of the brain. Because all neurons need signals to fire. GABA – slows and stops the firing of neurons. Also found throughout the brain.When not working, can rsult in muscle tension that exacerbates the physical pain andaches. Serotonin – regulates mood, keeps appetite and sleep patterns stable, helps with impulse control, modulates pain perception. to Norepinephrine – keeps you mentally alert and your body energetic.Need it to run to catch the bus. Too much and your feel jittery, tense. Too low and you feel lethargic Dopamine – Depends on the part of the brain that it is working. In higher levels helps with attention. In situations of trauma/crisis, is released at a high level in the amygdala which increases the attention paid to details of the trauma.Intensifies the tendency of the amygdala to signal trouble whenever a similar situation arises. Necessary to have enough dopamine to feel drive to meet goals and feel pleasure in accomplishment.

STRUCTURES OF THE BRAIN: MORE BORING NEUROANATOMY The Nervous System Parasympathetic nervous system – the calmer Sympathetic nervous system- fight or flight The Limbic System Thalamus-quarterback Hypothalamus-internal fact finder Hippocampus-data clerk Amygdala-smoke detector for your brain The Basal Ganglia-motivator PNS: slows or calms agitation and restores balance to the brain and the body. Carries messages to and from the skin. SNS: tells organs in your body to get busy and respond to a demand for action. SNS gets involved from walking up a steep flight of stairs to thinking about something that scares you. To facing something that really scares you. Works overtime when you are stressed out. Hippocampus: registers details. Without emotion, just the facts. Sends facts to the cortex. Which thinks about them. But does not file, just records. Other parts of the brain file short and long term memory. Amygdala: reacts immediately to the signals from the thalamus and the hypothalamus. Does not think. Reacts bigtime. DANGER, FAILURE, Notifies the brain if need to prepare for problems. PREFERS NOTICING TROUBLE FIRST. Basal Ganglia: located under the cortex and over the limbic system. The basal ganglia in particular registers pleasure with the neurotransmitter dopamine. Coordinates physical movement with emotion. So really part of how physical exercise generates good feelings. Induces motivation, creates energy to meet goals. The Limbic System: emotional work of the brain. This system works together to form emotion and memory. Thalamus – receives information from the outside world through the senses and sends it to where it needs to go. Passes crisis info to the amygdala, also passes information to the cortex. Hypothalamus – measures what is happening inside your body. Gathers information from your blood about the functioning of your organs. If receives the message that your body is under stress, responsible for further starting the stress response.

STRUCTURES OF THE BRAIN CONTINUED The Cortex Anterior cingulate gyrus - the VP Orbitofrontal cortex - the brainstormer Insula - empathy Pre-frontal cortex – the CEO Left side – verbal work occurs here, problem solver Right side-non verbal decision maker – space, time and emotion. Anterior cignulate gyrus: filters and amplifies information. Orgnizes, forms context, prepares reports for the VP. (Shawn/levels of gov’t). Sends recommendations back out. So takes the details from the hippocampus and the emotional tone from the amygdala. Gathers data from the thalamus and the hypothalamus. Then filters all of the information This area sluggish in people with depression making it difficult to suppress negative thoughts. Orbitofrontal cortex: commands working memory.compares informaton with other memories of other similar experiences. Helps with problem solving. When functioning properly , good impulse control. Don’t jump the gun. When not enough neurotransmitters, may have difficulty making decisions, may lead to drinking to deal with problems. Insula – Collects infor from the body about how you are feeling. Gives a sense of self and body awresness and plays a roll in perception of pain. Responding to a gut feeling. People who have more volume in this part of the brain have more empathy and meditate. Pre-frontal cortex: Buck stops here. Decides if information should be placed in long term memory or iscarded.Creates new solutions to problems. LEFT: person creates and understands the meaning of experiences. Categorizes , solves problems and analyzes new information. Optimistic brain because it can form helpful conclusions about negaitve informaiton. Comprehaneds time for knowing when things happened.Noticing the here and now engages the left pre-frontal cortex. RIGHT: makes deisions in the non verbal realm. Your creative brain, figuring out prblems of space and time and emotion. When depressed relying too much o the right brain in taking emotions into play.

DEPRESSION TREATMENT: THE RELENTLESS PURSUIT OF THE POSITIVE

DEPRESSION RESOURCES The Mindful Way Through Depression. Williams, Teasdale, Segal, Kabat-Zinn. The 10 Best Ever Depression Management Techniques. Margaret Wehrenberg. Depressed & Anxious: The Dialectical Behaviour Therapy Workbook for Overcoming Depression & Anxiety. Thomas Marra. The Feeling Good Handbook. David D. Burns.

RESOURCES CONT’D Mind Over Mood: Change How You Feel by Changing the Way You Think. Dennis Greenberger & Christine Padesky. The Mindful Way Workbook, John Teasdale, Mark Williams, Zindel Segal. The Anxiety & Phobia Workbook. Edmund J. Bourne. www.nicabm.com

DEPRESSION: THE BRAIN Neurotransmitters: Serotonin: regulates us – mood, sleep, pain. Low serotonin results in difficulty feeling satisfied, poor control over thinking Norepinephrine: responsible for helping us to be awake and alert. Overactive produces jittery, agitated feeling Dopamine: allows us to feel pleasure. Also helps prefrontal cortex with concentration.

DEPRESSION: THE BRAIN Chronic stress depletes the neurotransmitters which results in: Decreased mental/physical energy Decreased interest in the world Decreased pleasure Decreased problem solving with lack of clarity.

WELL-BEING Balance in 4 areas: Goals Attention Cognition Affect

DEPRESSION & NEURAL NETWORKING NEURONS THAT FIRE TOGETHER WIRE TOGETHER OUR GOAL? INTERRUPT THE NEGATIVE NETWORKING WITH DELIBERATE SHIFT TO POSITIVE.

NEGATIVE NEURAL NETWORKING Because of the way human beings retrieve and store memories – when something triggers one memory, a network of similar memories is automatically activated including emotions and details. SO ONE NEGATIVE THOUGHT LEADS TO ANOTHER…AND ANOTHER…AND ANOTHER

INTERVENTION REVIEW BUILD THE RELATIONSHIP THERAPEUTIC GOAL-SETTING BUILD CONFIDENCE OVERCOME BARRIERS

SELF-SOOTHING TECHNIQUES

SELF SOOTHING CONTINUED Prepare a list of activities Identify a lifeline Make reminder cards Journaling A feeling is just a feeling Spend 10 minutes doing something different

JOURNAL QUESTIONS What do I feel in my body? Are these sensations familiar? What is the earliest age I remember feeling this way? Can I get a memory of situation when I felt this way in the past? Are the situations similar? Different? What did others do then?

JOURNAL QUESTIONS #2 What did I do then? What are others doing now? What do I want to do now? Brings the pre-frontal cortex to the situation

GOAL-SETTING Three domains: self-care/productivity/social & leisure Visualize accomplishing the goal Walk through and anticipate what might go wrong. Replace with a positive forecast. Build in a reward Next time: review the experience with them Important to include physical goals

FOCUS ON POSITIVE Think of a commonplace experience or event. Rate your level of pleasure of the experience. Now recount the activity or event. Rate your level of pleasure of the experience.

USE OF ACTIVITY LOG Rate all activities on pleasure continuum. 0-10 Most activities not completely unpleasurable. How can the client increase pleasurable activities in their day/their week? For those activities that were pleasurable, thinking about them, go over them, remember them….boosting dopamine.

4 SIMPLE STEPS OF TAKING IN THE GOOD: HEAL (Dr. Hanson) Have a positive experience – notice one present or make one happen Enrich it – for 10 seconds or longer. Absorb it – let it sink into you as you sink into it. Link positive and negative material.

CHANGING THOUGHTS =CHANGING BRAIN Lots of little bad things got us into a bad place, lots of little good things (seconds at a time) will get us into a better place. This knowledge in itself instills hope.

BUILDING CONFIDENCE Two themes predominate depression: Feeling inadequate Feeling worthless Lethargy and inability to feel rewarded make those beliefs seem true – self-fulfilling prophecy.

BUILDING CONFIDENCE Have clients list their positive qualities. Carry the list with them. Read multiple times/day. If can’t imagine positive qualities, have them think about qualities they had or would like to have. Keep in mind over 10 seconds. Make a graph – list strengths on top and days of the week on the side. Identify daily when used that strength

USING MINDFULNESS & CBT Negative thoughts are not predictions, they are just thoughts Stop, look, listen Think about past exceptions – when did I predict a negative outcome that did not happen?

CHANGING NEGATIVE LANGUAGE LISTEN TO THE CLIENT’S LANGUAGE AND HAVE THEM NOTICE For example, the use of “yes but….” Purpose focus on shifting to the positive: Up until now Apart from that Whatever! EVERYTIME WE INTERRUPT NEGATIVE SELF-TALK, WE WEAKEN THE POWER OF THE NEGATIVE TO CONTROL THOUGHTS

FOCUS ON STRENGTHS 1/3 OF OUR INNER STRENGTHS ARE INNATE MEANS THAT 2/3 ARE LEARNED AND GATHERED OVER TIME.

DEPRESSION AND EXERCISE THERAPY Exercise raises serotonin levels – serotonin increases the sense of accomplishment. Vigorous activity uses up the adrenaline of the stress response and helps get rid of cortisol. Exercise promotes relaxation because muscles are first stressed then relaxed. Sense of self-efficacy provided from participation in exercise

EXERCISE AND DEPRESSION: THE WILLPOWER MIRACLE CHANGES THE BRAIN

ENDING ISOLATION Email Telephone Walks – practice mindfulness Set up social dates Perform acts of random kindness Notice the positive traits of others Expand social horizon Also nb to inclulde cultural issues – very negative stigmatizing words to describe depression, mental health issues in genral.

LINDA July 31, 2014 – March 12, 2015 OT, KIN, PT Total of 23 OT sessions Total spent: $4,869.90

CLIENT 59 years old Crown corporation executive Major depressive disorder 2 bouts with cancer: 2001 & 2014 Also back issue At home in bed except for appointments

TREATMENT SESSION #1: COPM. Sessions #2-6: Goals - make a list of what needs to be done at home. Start with #1 and set timer for 1 hour. Get in touch with closest friend. Sessions #2-6: Work through goals related to self-care productivity and social/leisure Gather more information as she feels comfortable disclosing Nutrition

TREATMENT Sessions 2 – 6: Participate in exercise program Basic CBT education as barriers to meeting goals arise: Not meeting a goal is an opportunity to learn more about yourself Keep activity logs to notice progress. Teach diaphragmatic breathing and meditation Team meeting POINT OUT PROGRESS/POINT OUT POSITIVE

TREATMENT Sessions 7 – 12: Cog/beh JDA Cognitive testing Establish cognitive work hardening program Volunteer work Crafts at home Lumosity Talk about work Upgrade resume

TREATMENT Weeks 7 - 12: Initiate social activities with friends Meetup.com: museum group, belly dancing, learning Italian Meet with work friends RTW plan established

TREATMENT Weeks 13 – 23 Start 10 week RTW Ergo assessment Discuss how to incorporate home/social/exercise activities with work – scheduling Discuss strategies to deal with any barriers arising REINFORCE THE POSITIVE Back FT Read:ODE TO MY A-TEAM When my insurance sent me to CBI, I was terrified. I was depressed, anxious and ashamed of my condition. If not completely broken, I was at least lopsided, physically, mentally, emotionally.... Well, maybe I WAS broken. I entered a quiet reception area where I was greeted as if I was expected!  I  was soon in Ingrid's capable hands. I proceeded to tell her I could not and would not open up to her... and then did just that. This was the beginning of my route to recovery.  Ingrid, Pam, Chelsey and later Marysa and Jen, listened attentively to my long list of "hurts", took notes, asked questions. They were personable, professional and showed real sympathy without making me feel like the whiner that I was. They each explained what we could accomplish together and gave me hope that I would someday feel better. Much sooner than I expected, I started seeing results.  At first twice a week and then once a week, I went to CBI. I was greeted by name every time I walked in. The team was so well prepared, we were able to just pick up where we left off the previous visit. I could feel my team working together with one purpose and I could easily see the respect they felt for each other. Never did they lose focus. Never did I have to repeat some tidbit I had already told them on a previous visit. I trusted them absolutely! Best of all, they made me feel as if I were their only client. That is the ultimate compliment... it is after all the definition of customer service. As for results... I went back to work, picked up a few hobbies, started dancing again, rebuilt my social life.  Thank you all my for my new life

YOUR BRAIN ON PAIN: NEUROPLASTIC TRANSFORMATION BRAIN WITH CHRONIC PAIN BRAIN WITH NO PAIN As briefly discussed yesterday, there are many different diagnoses used when labelling a persistent pain condition. Dr. Doidge’s books have opened up my eyes to the possibilities in working with this group. And have caused me to do more searching for answers.

PAIN RESOURCES THE BRAIN’S WAY OF HEALING. Norman Doidge, M.D. THE BRAIN THAT CHANGES ITSELF. Norman Doidge. EXPLAIN PAIN. David Butler, G. Lorimer Moseley. NEUROPLASTIC TRANSFORMATION: YOUR BRAIN ON PAIN. Michael H Moskowitz & Marla D Golden.

A LESSON IN PAIN – THE KILL SWITCH Dr. Moskowitz Bary Area Medical Associates Sausalito, California Clinic to treat intractable pain with injections, drugs and electrical stimulation Now world leader in the use of treating neuroplasticity for pain In 1999, at 49 years of age…read page 3. Immediately after, pain was 10/10 ( 10 being dropped into boiling oil). But he realized that while lying motionless he literally had no pain at all.

LABELS Fibromyalgia Somatoform pain disorder Myofascial syndrome Non specific back pain Psychosomatic pain syndrome Repetitive strain injury Neuropathic pain Tissues heal and the alarm system and brain have chnged to protect the client, diagnoses based on tissue processes no longer fit.. The diagnosis received depends on where people live and which particular health professional they see.

THE KILL SWITCH The brain can shut off the pain. The pain is not in the body part itself – the body part sends signals to the brain. General anaesthesia – if the brain does not process the pain, we do not feel it IT IS THE BRAIN THAT DECIDES WHETHER SOMETHING HURTS OR NOT, 100 % OF THE TIME, WITH NO EXCEPTIONS The actual function of pain is not to torment us but to alert us to danger. Talks more about opiods later, but he also learned the wise use of sufficient morphine during the acute stage prevents nerves from becoming chronically stimulated and saves people from developing a chronic pain syndrome. Even if problems exist in your joints, muscles, ligaments, nerves, immune system or anywhere else, it won’t hurt if your brain thinks you are not in danger. In the same way, even if no problems whatsover exist in your body tissues, nerves or immune system, it will still hurt if your brain thinks you are in danger. Pain is like the top of a Christmas tree – there is a lot going on in and under the tree. If the brain thinks that experiencing pain is not the best thing for your survival, such as a wounded soldier hiding from the enemy, you won’t experience pain, no matter how serious the injury. Badly burned parent running into a burning house to save their child. Football player who scores will have his whole team jump on him. 16 areas of the brain that determine how either perceiv pain or not. Pain is not experienced until the signal gets to the perceptual part of our brain (pg 26) Pain is complex. Couvade syndrome in which the father experiences labour pain. Acupuncture proven to work best if performed by a Chinese man or woman. I

PAIN RELIES ON CONTEXT A painful stimulus will hurt more if you are told it is hot, than if you are told it is cold. Pairing a painful stimulus with a red light hurts more than when it is paired with a blue light. The more information that a patient has the less the pain, for example, about a surgical procedure. Depends on who is around Post breast surgery, patients who attribute pain to returning cancer have more intense and unpleasant pain than those who attribute it to another cause, ragardless of what is happening in the tissues. Males have a higher pain threshold if tested by females. Patient with a very attentive and caring spouse will have more or less pain? (more)

GATE CONTROL THEORY OF PAIN OLD THEORY: one way signal up to the brain & intensity of the pain is proportional to the seriousness of the injury. GATE CONTROL THEORY: pain perception system spread through the brain/spinal cord. Brain controls how much pain we feel. Brain can close the gate and block the pain by releasing endorphins. In other words that pain files an accurate damage report about the extent of the body’s injury and the role of the brain was to accept that report. Pain messages sent from damaged tissue through the nervous system, must pass through several controls starting in the spinal cord if the brain gives permission after determining if they are important enough to go through. If allowed to pass through, gate will open and certain neurons will be allowed to turn on and transmit their signals. When the demand from inflamed, scarred or acidic tissues increases, the spinal cord adapts to meet the demand. The spinal danger messenger neurone increases its sensitivity to the incoming excitatory chemicals. This means that things that used to hurt now hurt more. And thigns that didn’t hurt before now hurt. Enhanced sensitivty of the alarm system is nearly always a main feature in persistent pain. The brain is being told that there is more danger at the tissues than there actually is.

BRAIN MAPS External areas of our body represented in our brain Organized topographically – virtual body in the brain. When neurons in our brain maps get damaged, they fire incessant false alarms Acute pain develops an afterlife – chronic pain Touch a part of the body’s surface and a specific part of the brain map will fire. Areas adjacent to each other in the body are adjacent on the map Long after the body has healed the pain system is still firing Changes is the brain include smudging – brain areas normally devoted to different body parts or different functions start to overlap. The brain is ‘looking out for you’ by making the body part difficult to use (smudging of motor areas in the brain, thus limiting movement) or by making nearby body parts sensitive too (smudging of sensory areas in the brain). Smudging is reversible.

NEURONS THAT FIRE TOGETHER WIRE TOGETHER: BLESSING OR CURSE? Blessing when sensory input is pleasurable Curse when receiving ongoing pain system signals. Eg slipped disc, pressing on the nerve root. Pain maps can also enlarge their receptive field Pain signals in one map can spill into adjacent pain maps. The more the receptors in the pain system fire, the more sensitive they become. Pain map becomes hypersensitive – start to feel pain not just when the pain hits the nerve when she moves the wrong way, but even when the disc is not pressing hard. Starts to map a greater area of the body’s surface, so begin to feel pain over a wider surface.. Astrocytes – brain cells that do not use electrical signals to communicate. They use chemical signals instead. Astrocytes release inflammatory chemicals to gith off dangerous substances. At the connective tissue level, fibroblasts release inflammatory checmicals. If this release doesn’t stop, local nerve signals to the brain set off a process called wind-up pain, leading to spinal cord and brain nerve cells firgiht without stopping and at higher rates. This causes the astrocytes to continue to send anti-inflammatory checmicals. A vicious cycle.

USE IT OR LOSE IT Constant competition for cortical real estate The activities the brain performs regularly take up more and more space in the brain by stealing resources from other areas. Chronic pain pain notice expanding over large areas including: processing thoughts, sensations, memories, movements, emotions, beliefs Monkey example Explains why when we are in pain have harder time concentrating or thinking well, why can’t tolerate light or sounds, why can’t control emotions

ACUTE PAIN BRAIN Acute pain is an alarm gong off in the brain that signifies danger and/or damage to the body. The experience of pain may be the single most important perception we have to help us survive. 16 regions of the brain process it and turn it into the perception of pain.

GOOD BRAIN GONE BAD Pain nerves in the spinal cord and the brain fire more intensely and fire independently from the nerves in the injured part of the body. This cuases the pain pathways to expand and take over nerves and their connections from other regional brain activites. Also causes release of inflammatory chemicals at the site of the injury that make it impossible to fully heal. The brain perceives ongoing danger and the pain pathway are reinforced instead of inhibited. In the brain more brain cells are being recruited to sense pain. Taking away from other important brain functions, such as planning and problem soliving. These ignited brain parts are all connected – like the picture on an airline brouchure with all the routes across the country.

WHEN PAIN IS EPERIENCED AS AN UNPLEASANT EVENT Invokes a series of actions: Multiple brain centres and circuits are activated Area responsible for vigilance is turned on Stress hormone – cortisol – is released Chronic cortisol release leads to deconstruction of nerve cells of the brain responsible for memory storage Sensory and motor areas of the brain activated Lymphocytes reenter the circulation and make their way to injury sites

NO PAIN By activating the thinking part of the brain to stimulate other networks, nerve cells are reassigned to those networks and are taken from the expanded pain map. Looking at the above picture, - if my brain looks like this I can feel o pain – stimulates visual processing, which in turn activates problem solving, planning, conflict resolution, autobiographical memory, emotional regulation and pain relief.

AREAS WHERE PAIN IS PROCESSED Somatosensory 1 and 2 – pain, touch, temperature, pressure Prefrontal area – pain, executive function, creativity, planning, empathy Anterior cingulate – pain, emotional self control, sympathetic control And notice what else happens in these areas

PAIN PROCESSING POINTS Posterior parietal lobe – pain, visual & auditory perception Supplementary motor area – pain, planned movement Amygdala – pain, emotion, emotional memory, pleasure

STILL MORE PAIN POINTS Insula – pain, quiets the amygdala, empathy, emotional self awareness Posterior cingulate – pain, visuospatial cognition, memory retrieval Hippocampus – helps to store pain memories Orbital frontal centre – pain, evaluates whether something is pleasant vs. unpleasant

NOW THAT WE KNOW THIS: WHAT DO WE DO? USE COMPETITIVE PLASTICITY Instead of allowing areas to be pirated and taken over for pain processing….take them back for original main activities Key brain areas that target pain and also do other mental functions Flood with the other mental functions while in pain Acute pain takes 5% of area fires: chronic 10-20%

THE POWER OF VISUALIZATION Every time an attack of pain, would visualize the brain maps to remind himself that the brain can really change Greeted every twinge of pain with an image of the pain map shrinking – forcing posterior parietal lobes and posterior cingulate to process a visual image. 6 weeks pain had shrunk to original area; 4 months having pain free areas; a year pain free. Act like you don’t have pain – that is why that works Repeat to yourself that if my brain ooks like the picture without pain, I can have no pain. Do this several times throughout the day. Memorize those two pictures. Imagine the lights going off and repeat there can be no pain if those areas are shut off.

PEOPLE TAKING BACK CONTROL OF THEIR PAIN I picture the spots and spray them with a spray bottle, sizzling them out. I start rubbing my finger tips together and picture the spots in my brain that are lit up from pain and rub them out one by one. When the pain starts bothering me I recite the alphabet and picture an image for each letter of the alphabet and my pain decreases.

SHRINKING THE PAIN http://www.neuroplastix.com/movies/files/page3-1016-pop.html This is a small movie that shows the pain areas shrinking

MIRROR APPROACH M: motivation – active vs. passive approach, take charge I: intention – immediate intention is not to get rid of pain but to focus the mind in order to change the pain R: relentlessness – pain intruding into consciousness is signal to push back but need intense focus R: reliability – can rely on the brain to restore and maintain function. Brain seeks a stable state – will go back to stable state of pain free if provided the opportunity Pain is an opportunity

MIRROR O: Opportunity: turn each episode into an opportunity – a change in attitude will lessen the work of the amygdala R: Restoration: not to mask pain but to restore normal brain activity. Different than placebo because not immediate effect but will last once brain rewired – 6-8 weeks

NOT JUST VISUALIZATION Can use: Touch Understanding Sound Planning Vibration Action Movement Creativity Pressure Problem solving Empathy Already use movement and action in our clinics

TOUCH: THE INFLAMMATORY PROCESS In persistent pain states, the nerves in the skin are recruited to signal pain instead of touch and people cannot stand to be touched in the painful areas. Inflammatory state is established because painful signals are sent to and from the brain. Have to re-establish signals with gentle touch. Skin signals faster than pain so will shut the gate on pain. Some credence for RMT. Massaging with gentle but consistent pressure helps relieve pain by reversing the inflammatory process.

THE ROLE OF THE AMYGDALA First perception of pain is at the amygdala – a place designed to deal with the threat to our body. During traumatic events, the amygdala is ON, the higher functioning brain is OFF. In persistent pain, the brain perceives that this danger continues to exist. Recognizing we are in our amygdala gets our higher brain function to work. Fight/flight centre. Our first perception of pain is at the amygdala and is a place designed to deal with the threat to our body. During traumatic events, the amygdala is turned on and the highest functioning brain is selectively shut down. Problem is if we stay in the amygdala after the danger has passed. We continue to live within our most extreme emotions and experience an immediate state of danger that no longer exists. In persistent pain, the brain perceives that this danger continues to exist. We need to turn back on the higer functioning brain reminding ourselves that the danger has long ago passed. First step to getting out of the amygdala is realizing we are in it. When people experience traumatic events, language centers in the brain and higher reasoning centers are selectively shut off. The hippocampus, a memory storage area is then activated. This storage area is not connected to our language to become part of our personal narrative. When we don’t integrage these outside of fight or flight, then whenever a similar emotion is experienced, we react with the amygdala pulling the memory from the hippocampus. This is experienced as an emotional jolt to one’s brain, turning off our higher functioning brain and reacting as if there is extreme personal danger that occurred when we were originally emotionally or physically traumatized. Recognizing we are in our amygdala turns on the higher brain centers

SELF SOOTHING – BEEN THERE DONE THAT AGAIN Soothing music, progressive muscle relaxation, gently stroking the skin, smelling a pleasant scent – lavender, peppermint, citrus, recalling a pleasurable experience, looking through old pictures. Again allows the frontal cortex to work. Self soothing extremely important to emotional balance, making life decisions, reward behaviour. Foundation is a loving parent. But with neuroplasticity if we make it a regular routine, can be developed.

WE BECOME WHAT WE BELIEVE Consciously rejecting the notion of a life to be lived in pain is the first step in relief Reclaims brain real estate in the pain sensory areas of the brain By expecting soothing to overcome persistent pain, beliefs about pain’s inevitability can be challenged and changed. Reinforced by practitioners declaring that their patients will have to learn to live with some amount of pain for the rest of their lives – this strengthens the belief that the person is defined by persistent pain.

PLEASURE VS. PAIN Pleasure is the cure for pain. Write a gratitude list of what you are grateful to have in your life. Two columned list: Pain I want to avoid/ Pleasure I want to pursue. Go on a pleasure hunt once a week, actively seeking pleasurable experiences and avoiding painful ones. Pain and plesure both perceived in the amygdala. Pain and pleasure share many circuits in the brain. The neurotransmitters released during pain are directly opposite in effect to plleasure neurotransmitters. Whicever dominates determines the experience.

PAIN VS. PLEASURE Pain and pleasure are not actual feelings, but are values placed upon sensation mingled with emotion and thoughts.

PAIN VS PLEASURE Endorphins are released by the EXPECTATION of pleasure, hence the mere expectation produces a more pleasurable experience. The EXPECTATION of less pain produces the experience of less pain. Me and the dentist

CENTRALIZATION OF PAIN: THERAPIES Strong evidence Education Aerobic exercise CBT Weak evidence Acupuncture Chiropractic Manual/massage Ultrasound Modest evidence Strength training Hypnotherapy Biofeedback No evidence Tender tripper point injections

FINAL POINT ON PAIN - OPIODS Brain adapts to being inundated with long-term opioids by becoming less sensitive to them. Increased sensitivity to pain-increased dependence on drugs-chronic pain worsens. Important to wean slowly.

GEORGE 45 year old custodian IPR – OT/Kin/PT/Psych Total spent thus far: $6,267.50. Total to be spent: $10,000

TREATMENT Education, education, education Gave client chapters of Explain Pain and Neuroplastic Transformation Use of activity logs Education on pacing CBT very important as client is a catastrophizer Crisis management

ANXIETY MANAGEMENT

ANXIETY RESOURCES ANXIETY AND PHOBIA WORKBOOK, Edmund J. Bourne. THE 10-BEST EVER ANXIETY MANAGEMENT TECHNIQUES, Margaret Wehrenberg. RECOVERING FROM TRAUMA AND PTSD, Deborah A Lee, Sophie James. MASTER YOUR PANIC AND TAKE BACK YOUR LIFE, Denise F Beckfield.

ANXIETY/TRAUMA RESOURCES CONVERSATIONS WITH A RATTLESNAKE: RAW AND HONEST REFLECTIONS ON HEALING AND TRAUMA, Theo Fleury & Kim Barthel. TEN DAYS TO SELF-ESTEEM, David D Burns.

THE BRAIN – KEY AREAS FOR ANXIETY Thalamus – quarterback: Information from the external world through five sense is received in the thalamus and directed to other parts of the brain Amygdala –alarm system: main job to react to the threat. Tends to be trigger happy. Also where trauma memories are stored. Responsible for conditioning. Hippocampus – filing clerk: noting times and place of events. The brain can learn to become frightened of the things we have associated with threat in our body.

THE BRAIN AND ANXIETY The frontal cortex-the CEO: orchestrates the emotional regulation systems.

NEUROTRANSMITTORS Serotonin – the regulator: too low. Norepinephrine – the energizer bunny: too high. Dopamine – the feel good and pay attention: too high or too low. GABA – the ‘stop’ signal: too low. affects mood, appetite, sleep, libido, stress response, pain response, satisfaction. When serotonin is low, havoc ensues. with anxiety and sets tone of tension in the brain and body. Too low – absence of good feelings. Too high in the cortex – too much drive

STEP #1: EDUCATION Threat Emotion Regulation System Designed to protect us and keep us safe from physical/psychological harm. Faster at detecting and reacting to unpleasant emotions than to pleasant ones. Better safe than sorry the most important education we can provide to the client is the education on fight, flight, freeze.

THREAT AND POSITIVE EMOTIONS The threat system is designed to override positive emotions Therefore when feeling stressed, hard to feel positive emotions because threat system is activated. Having dinner out and the babysitter calls and says somsething has happened.

FIGHT OR FLIGHT IN THE BODY Increase in heart rate Increase in respiratory rate Tensing of muscles Reduced blood flow to hands and feet Increased blood flow to muscles Increased production of sweat People think are having a heart attack or at the very least feel very unpleasant. Provide education on why the brain sends the danger message to the body

FIGHT OR FLIGHT: WHAT WE FEEL & WHAT WE THINK Dizzy Heart pounding/chest pain Short of breath Clammy hands and feet Nauseous Blurred vision Sweaty I’m going to die. I’m going to have a heart attack. I’m gong to have a stroke. I’m going to pass out. I’m going to embarrass myself. INCREDIBLY EMPOWERING TO LEARN THIS

STEP #2: BREATHE Most effective way to stop a panic attack because: Slows sympathetic arousal and stimulates the parasympathetic nervous system. Paying attention to your breath engages your frontal cortex

PRACTISE, PRACTISE, PRACTISE For 30 days, practise a breathing minute 10 or more times a day. Whenever you are waiting for something like: At a stoplight On hold on the phone Waiting in line at a store Watching commercials Waiting for a text message

STEP #3: MINDFULNESS Anxiety is preoccupation on the past and the future – worry about what was or will be. Mindfulness is being fully in the present.

MINDFULNESS AND ANXIETY When you feel a sense of panic building, notice what is happening around you. 5 things you feel, hear, smell, touch, see. Notice what is happening in your body when you feel panic. Don’t judge, just notice. Notice your thoughts and bring them back to focus on the here and now and your breath. LORI WILL TAKE THROUGH A TRADITIONAL MINDFULNESS EXERCISE. BUT JUST LIKE WITH DEPRESSION AND PAIN, WE CAN DO BITS OF IT ALL THE TIME.

MINDFULNESS AND ANXIETY Self observation and being in the present requires prefrontal cortex activity We use the brain to control the brain

TECHNIQUE #4: RELAXATION Progressive muscle relaxation particularly helpful due to the physical tension from too much norepinephrine. Intentional relaxation of muscles helps the PNS to slow heart rate and respiration.

RELAXATION Diaphragmatic breathing Mindfulness Progressive muscle relaxation Imagery Physical exercise Tai chi Yoga Calming music

TECHNIQUE #5: EXERCISE!!!! Increases blood flow to the brain and benefits neurotransmitter levels Affects serotonin levels Fosters a sense of self-efficacy that promotes a willingness to take charge of one’s life in other ways Produces some of the fight or flight sensations in a ‘normal’ way Uses up the adrenalin of the stress response and gets rid of cortisol. Promotes relaxation because muscles are stretched, then relaxed.

ATTENTION TO POSTURE

TECHNIQUE #6: MANAGING THE ANXIOUS MIND React to the “Oh no” Use CBT to engage the pre-frontal cortex by: Paying attention to the thoughts and stop the catastrophizing…I am NOT dying, I am just panicking Tell yourself that a feeling is just a feeling – they are unpleasant but not lethal; the brain of the worrier looks for reasons to explain the feelings in the worried body. Amygdala reacting to slight changes, trigger happy

MANAGING THE ANXIOUS MIND For the person who fears losing control: And then what would happen? And then what? Taking the example of panicking in a grocery store or a car…can often result in laughing at how ridiculous and unrealistic the thoughts are. Melanie and car.

MANAGING THE ANXIOUS MIND: EXPOSURE THERAPY Make a hierarchical list with SUDS for each. Start somewhere in the low end but not the bottom. Reinforce coping strategies learned. Visualize the entire experience first. Break it down and make it manageable. Have a panic plan written down. Evaluate how it went…celebrate the victories!

MANAGING THE ANXIOUS MIND: THOUGHT STOPPING & REPLACEMENT Pathways are ingrained so have to frequently stop the thought to change the pathway. Have them say: STOP! Replace the thought with an equally intense positive thought. Have it ready, written down. Compete with anxious thoughts by singing (in the car) – takes more parts of the brain. Distract yourself

MAKE A TWO P LIST: PLEASANT & PRODUCTIVE Every day take 60 seconds to identify things you could think about during the day – errands to run, vacation to plan, things you could enjoy that day. Post this list in sight. Whenever you thought stop, then look at the list to divert your attention. Shifts away from the overactive limbic system.

MELANIE 34 years old Reception/admin OT/Psych/Kin Had not left her house in 2 years

MELANIE TREATMENT 7 Psych sessions to start OT/Kin weekly thereafter November 28, 2014 – present Total spent thus far: $5,283.57

OT TREATMENT 8 sessions so far Start with COPM: Issues to deal with first-sleep and driving anxiety. Goals week 1: bed at midnight, meditation if can’t sleep and out of bed after 20 minutes. Drive to husband’s store.

OT TREATMENT Other homework: create hierarchy lists. Sessions 2-4: Provide fight or flight education. Review goals and CELEBRATE THE PROGRESS. Continue with sleep and driving goals-build on success. Add walking and pleasurable activities. Keep journal with positive thing that happens each day. Identify list of daughter’s strengths.

OT TREATMENT Sessions 5 – 8: Continue to build on driving goal - visualization before each next step. Now driving to the clinic…high five! Build a schedule to work on online class that has registered for. Go for dinner to neighbour’s house. Go to a restaurant with family. Review all the positive accomplishments in minute to minute detail. Throughout, provide reading that is pertinent to discussion. Reviewed ABC model of CBT. Build affirmations.

MINDFULNESS PRACTISE

MINDFULNESS RESOURCES WHEREVER YOU GO THERE YOU ARE: MINDFULNESS MEDITATION IN EVERYDAY LIFE. Jon Kabat-Zinn. RADICAL ACCEPTANCE: EMBRACING YOURSELF WITH THE HEART OF A BUDDHA. Tara Brach. THE MINDFUL THERAPIST. Daniel J. Siegel.

MINDFULNESS RESOURCES FULL CATASTROPHE LIVING: USING THE WISDOM OF YOUR BODY AND MIND TO FACE STRESS, PAIN AND ILLNESS. Jon Kabat-Zinn. THE MINDFUL WAY WORKBOOK. John Teasdale, Mark Williams, Zindel Segal. THE MINDFUL PATH TO SELF-COMPASSION. Christopher K. Germer.

RECOVERY FROM ADDICTIONS

ADDICTIONS RESOURCES IN THE REALM OF HUNGRY GHOSTS, Gabor Mate. MOTIVATIONAL INTERVIEWING: HELPING PEOPLE CHANGE, William Milner & Stephen Rollnick. THE WILLPOWER INSTINCT, Kelly McGonigal. A RETHING OF THE WAY WE DRINK, DocMikeEvans, you tube.

UNDERLYING CAUSES – GABOR MATE Painful early experiences program both the neurophysiology of addiction & the distressing psychological states that addiction promises to relieve. Addiction is about running from different emotions or hanging on to enticing ones. Addiction is used to calm anxiety, an unease about life or about a sense of insufficient self.

NEUROPLASTICITY – THE DARK SIDE Dr. Doidge

WILLPOWER – Kelly McGonigal Three types: I won’t power – resisting urges I will power – motivation & energy to do things that are overwhelming I want power – knowing what you really want in the big picture

WHERE IN THE BRAIN? Pre-frontal cortex – keeps track of goals Right side – controls attention and behaviour Left side – motivation to move towards something

1 BRAIN – 2 MINDS WISE MIND – Think of ourselves related to others NOT SO WISE MIND – Amygdala’s promise of reward, focus on short-term, immediate gratification.

OTHER LITTLE FACTS Willpower decreases when blood sugars are low Experience of wanting something and liking something are completely different from each other – different systems in the brain. Wanting produces its own stress of giving in. Makes you feel like you want it even more

WANTING VS. LIKING The craving produces the anxiety – it is a trickster. Stress shifts the brain into a reward state – when stressed we are more distracted into temptation, lose focus on long-term goals. Guilt and shame send us more into the behaviour

ADDICTIONS SCREENING Screens for drugs and alcohol 40% abstain: green 35% low risk: green 20% at risk: yellow 5% substance use disorder: red

TREATMENT – MOTIVATIONAL INTERVIEWING Collaborative conversation style for strengthening a person’s own motivation & commitment to change. Important points: Guiding not directing Ambivalence to change is normal, expected and should be predicted by the therapist

MOTIVATIONAL INTERVIEWING If the therapist argues for change, will increase the resistance HAVE to accept the person and honour his/her perspective: EMPATHY OF THERAPIST THE MOST PREDICTIVE OUTCOME OF POSITIVE TREATMENT Support autonomy to choose their own way Affirm their strengths and efforts EVERY SESSION Mindful problem-solving goes much farther than skill teaching

MOTIVATIONAL INTERVIEWING MI works on the assumption that the person already has what they need within them OARS: Open questions: affirming the positive; reflecting; summarizing the change process. Avoid arguments/blaming/coaxing/pursuading/power struggles – change is up to them Walk with the person – don’t drag them. Watch for change talk – move from why to how to change

RULER EXERCISE On an imaginary scale from 0-10, how important would you say it is for you to cut back on your drinking? And why are you not at a (lower number)? On that same scale how ready are you to cut back on your drinking? Why are you not at a (lower number)?

USE REDUCTION Use reduction is acceptable You Tube Mike Evans Activity logs should be 24 hours and have client note: time using; time thinking about using: time recovering.

BACK TO WILLPOWER According to Dr. McGonigal and other brain experts, what is the most effective way to improve willpower???

MEDITATION 5 minutes of focused meditation simply focusing on the breath, noticing when the mind wanders and back to the breath. Engages pre frontal cortex and anterior cingular cortex Balances PNS and SNS You don’t even have to be good at it for it to work. Reduces relapses

PAUSE & PLAN VS. FIGHT OR FLIGHT When notice a craving, pay attention between wanting and liking. Notice the experience of wanting in the brain and the body. Pre-commit to 10 minute delay and do something to put distance between the craving and the acting. Have a plan ready. Important to have self-compassion when slips happen. Avoids the “what the hell, I blew it”

GABOR MATE SUGGESTS? MEDITATION

MINDFUL AWARENESS Mindful awareness is key to unlocking the automatic patterns that fodder the addicted brain & mind. Mindful awareness consists of noticing ebb & flow of automatic thoughts – desiring and longing, judging and rejecting – without being hooked by them.

MORE SPECIFICALLY Step 1: Re-label Label the addictive thought for what it is: I don’t need alcohol I am only having an obsessional thought that I have such a need Conscious awareness results in change to brain patterns Changes from a need to a dysfunctional thought.

FOUR STEP TREATMENT Step 2: Re-Attribute Place the blame on your brain: This is my brain sending me a false message. Neurological circuits were programmed a long time ago. This is “circuits that fire together wire together” gone wrong. Instead of self-blame, asking calmly why these desires have exercised such a powerful hold

FOUR STEP TREATMENT Step 3: Re-focus It’s not how you feel that counts; it is what you do. Find something else to do – buy time. 10-15 minutes Do something you like. Again brings the frontal cortex to play

FOUR STEP TREATMENT Step 4: Re-Value Remind yourself why you are going to this trouble. Addicted mind has been fooled into making the addiction the highest priority…trickster De-value the false gold What has the addictive urge done for me? Write out several times a day.

ADDICTIONS SUMMARY Motivational Interviewing – accurate empathy, no judgement, respect and walking with/not dragging the client Focus on positive, relentless focus on gains made Encourage mindfulness and the 10 minute pausing & planning Encourage self-compassion

NAOMI Time in Program: January 5, 2012 to July 18, 2013. Money spent: $7,276.25 Team members: OT/PT/KIN

NAOMI Important learnings: Watch for use while in the program No judgement from the team Flexibility is key Client benefits from ongoing participation in addiction supportive programs May start with us, go to rehab, then finish with us Potential for relapse greater prior to work return Relapse greater after first year of sobriety Went to her 1 year celebration. We were like proud parents

Concussion Management

Overview Case management OT role Pacing Role of vision efficacy Assessment Treatment

Overview Case management OT role Pacing Role of vision efficacy Assessment Treatment

Case Management MVA WSIB LTD MIG vs non-MIG MTBIPOC vs Conventional OT sessions LTD Advocacy for other team members on the file MIG vs nonMIG If they come within the MIG Flag initially to insurer Ensure there is documentation of the concussion – diagnose Continue to assess function within the MIG OT sessions under MIG supp or use PT visits. MTBIPOC Complete initial MTBI assessment to determine function issues Complete mini report with treatment cost estimation – start 8 weeks Call adjuster Can ask for kin as well for Ask for PT/Chiro assessment if MSKPOC (for neck) is not already initiated. LTD More flexible treatment structure

Assessment History of injury Rivermead Post Concussion Symptom Questionnaire Functional status – self-report Education: MTBI Pacing (brain rest)

Case Management Advocate for the client with LTD, WSIB or MVA Lack of comprehension on behalf of the WSIB / CSST Complete as much of the standardized testing as possible for supported argument Contact the physician & communicate Co-ordinate Assessment Vision efficacy Identify possible Cognitive changes Cardiovascular responce Likely some mechanical neck or shoulder (or both) pain as well Co-ordinate Treatment Education Vision retraining Anxiety management The WSIB in Ontario is way behind in respect to their research on Concussion management and expectations of recovery CBI has a concussion manual that can be ordered from the Intranet and there is an excellent course provided by X – a PT from Toronto who teaches nationally most of the clinicians in Ottawa have taken it and are using the protocols and are having huge successes For the vision tests – not just symptom provocation – positive findings with aberrant eye movement As some clinicians may not be familiar with the testing or the treatment protocols – the OT can assign tasks to the team members most suited for the needs based upon the findings of the evaluations

Pacing Foundation for concussion recovery Key to pacing is staying below symptom threshold Two-point rule Gas tank analogy Timers (apps, egg timer, stove) Use of scheduling (we are the masters at this…) Pacing Points system – think weight watchers. Number of points per day and every activity gets points.

So now they are starting to feel better, having consistent days and low symptoms. Next step is to effectively move them out of rest keeping their symptoms under control.

We need the safe zone to increase We need the safe zone to increase. Aka they can do more activity with the same level of symptoms. Slowly adding a little bit every day.

Dealing with Sponsors MVA WSIB LTD MIG vs non-MIG MTBIPOC vs Conventional OT sessions LTD Advocacy for other team members on the file MIG vs nonMIG If they come within the MIG Flag initially to insurer Ensure there is documentation of the concussion - we need GP or specialist to make note of it to switch them out of the MIG Continue to assess function within the MIG OT sessions under MIG supp or use PT visits. MTBIPOC Complete initial MTBI assessment to determine function issues Complete mini report with treatment cost estimation – start 8 weeks Call adjuster Can ask for kin as well for PT as again there is more than likely other areas involved Ask for PT/Chiro assessment if MSKPOC (for neck) is not already initiated. LTD More flexible treatment structure More understanding of the impact of a long time untreated and expectations of concussion treatment (sometimes)

Assessment History of injury Rivermead Post Concussion Symptom Questionnaire Functional status – self-report What are their cognitive / visual demands? Education: MTBI Pacing (brain rest) Recovery Obviously the greater the length of time from the date of the concussion – the more complicated the issues can be – particularly if left untreated – or treated poorly Get a sense of how their concussion symptoms are impacting their function and their cognitive processes – from symptoms provoked (and still working ) to bed ridden

Smooth Pursuits Test the ability to follow a slow moving target. The patient and the examiner are seated. The examiner holds a fingertip at a distance of 3 ft from the patient. The patient is instructed to maintain focus on the target at the examiner moves the target smoothly in the horizontal direction 1.5 ft to the right and 1.5 ft to the left of midline. One repetition is complete when the target moves back and forth to the starting position, and 2 repetitions are performed. The target should be moved at a rate requiring approximately 2 seconds to go fully from left to right and 2 seconds to go full from right to left. The test is repeated with the examiner moving the target smoothly and slowly in the vertical direction 1.4 ft above and 1.5 ft below midline for 2 complete repetitions up and down. Again, the target should be moved at a rate requiring approximately 2 seconds to move the eyes fully upward and 2 second to move fully downward. Record: Headache, Dizziness, Nausea & Fogginess ratings after the test.

Pacing Foundation for concussion recovery Key to pacing is staying below symptom threshold Two-point rule Timers Use of scheduling (activity & breaks)

Vision Assessment Vison Efficacy The ability of the eyes and brain to coordinate and work in unison Many different facets to this that are very commonly taxed daily One of the two biggest factors in treatment outcomes (Cardio is the other) Vision efficacy is affected by concussion – does not mean changes to vision acuity but the eyes are no longer working insync - ie – the two eyes may not be moving together – therefore two different images are sent to the brain Use the Terminator Eye Screen example – we are always scanning everywhere = this extra movement can be very taxing to the brain if the images are not overlapping or if they are delayed Obviously activities that are visually demanding are going to be impacted – driving = reading = computer cell etc.. Should be assessed ASAP VOMS – UPMC Vestibular/Occular Motor Screening for Concussion Collection of key vision and vestibular tests Rivermead Post concussion Symptom Questionnaire MOCA, MMSE

Questions??

CBT FOR INSOMNIA

CBT FOR INSOMNIA RESOURCES CBT FOR INSOMNIA, A COGNITIVE BEHAVIOURAL APPROACH, Jack Edinger & Colleen Carney. SLEEP HISTORY QUESTIONNAIRE, Duke University (available online) STOP BANG QUESTIONNAIRE.

INSOMNIA Difficulty sleeping (initiating and/or maintaining sleep or nonrestorative sleep) Difficulty functioning: contemporary views of insomnia conceptualize it as a 24-hour disorder (daytime component) and/or distress 1-6 months duration

GOOD SLEEP Dependent on: Adequate sleep drive (sleep debt) Proper timing (consistent sleep/wake schedule) Low physiological and psychological arousal

SESSION #1: ASSESSMENT Rule out: Obstructive sleep apnea Restless leg syndrome Periodic leg movement disorder Circadian sleep disorders

APNEA SCREEN: STOP BANG QUESTIONAIRE S - SNORE T - TIRED O - OBSERVED TO STOP BREATHING P - HIGH BLOOD PRESSURE B - BMI OVER 35 A - AGE OVER 50 N - NECK CIRCUMFERANCE GREATER THAN 40 G - GENDER MALE Does client snore loudly enough to be heard behind closed door Often feel tired or sleepy during the day

SLEEP DIARIES Complete for 2 weeks Calculate percentage of time sleeping to time spent in bed averaged over the 2 weeks.

SESSION #2: BEHVIOURAL TREATMENT EDUCATION Myth – everyone needs 8 hours of sleep Body clock-circadian clock Owl or lark? Sleep debt Myth – can make up for lost sleep by napping or sleeping in Average 6-8 thought some 3-4 others 10-12 Relationship between body temperature and sleep/wake cycle- main sleep period begins when body temperature is falling and ends after temperature rising again. Stress the importance of maintaining a set sleep and wake time. How we sleep at night is dependent on amount of sleep drive we build over the day. Adenosine. Why beginning of night is deepest sleep. Adenosine built up the more active we are.

TREATMENT GUIDELINE #1 SELECT A STANDARD WAKE TIME STICK TO IT REGARDLESS OF AMOUNT OF SLEEP

TREATMENT GUIDELINE #2 USE THE BED ONLY FOR SLEEPING…and sex Wakeful activities include blackberries, telephones, food Limit screen time an hour before bed. Study of 12 health adults: ½ read an ereader 4 hours before bed. Other half read print books. Those who read e books reported lower subjective sleepiness and showed impact on melatonin secretion: they did not get the same late evening rise in melatonin. Also decrased ability to achieve REM sleep.

TREATMENT GUIDELINE #3 GET OUT OF BED IF YOU CAN’T SLEEP AFTER 20 MINUTES TRAINING YOURSELF TO BE AWAKE IN BED JUST INCREASES FRUSTRATION Nothing one can do to bring on sleep on demand Do something non stimulating

TREATMENT GUIDELINE #4 DO NOT WORRY OR PLAN IN BED IF YOU ARE, GET UP AND GO TO ANOTHER ROOM SET ASIDE TIME EARLIER IN THE EVENING

TREATMENT GUIDELINE #5 AVOID DAYTIME NAPPING If you have to, less than an hour and before 3 PM.

TREATMENT GUIDELINE #6 GO TO BED WHEN SLEEPY AND NOT TOO EARLY DETERMINING TIME IN BED PRESCRIPTION: TIME IN BED = AVERAGE TOTAL SLEEP TIME + 30 MINUTES Distinguish being sleepy from being tired. Find average amount of sleep. Calculate back from wake up time. Would you rather choose 8 lousy hours of sleep or 6 good quality hours? Want the body to crave sleep Increase time if sleep efficiency greater than 85% Start to see improvement in 2-3 weeks If tired in the daytime despite sleeping soundly at night, then add 15 minutes per week If takes more than 30 minutes to fall asleep or routinely awaken more than 30 minutes, then too much time in bed.

SLEEP HYGIENE RECOMMENDATIONS Limit use of caffeinated food and beverages. Limit use of alcohol. Moderate exercise late afternoon or early evening. Light bedtime snack – cheese, milk, peanut butter Make sure bedroom is dark and quiet. Comfortable cool bedroom temperature. 1 hour wind down before bed 3 cups of coffee max and none late afternoon or evening

SESSION #3: COGNITIVE THERAPY COMPONENT Insomnia Brain – noisy and very focused on the effects of not sleeping. Unrelenting negative thoughts Bed has become a signal for worry and upset TAKE THE INSOMNIA BRAIN OUT OF BED Leave the bedroom when the mind takes over

CONSTRUCTIVE WORRY WORKSHEET CONCERNS I won’t get this course prepared in time. SOLUTIONS I will schedule 1 hour every day to work on it. Solution – the next step to fix the problem. Fold the worksheet in half and place on nightstand. At bedtime if you start to worry remind yourself you have done what you can for today. Could also use thought records. Considering the evidence for or against a worrisome thought. Can review cognitive disortions.

OTHER STRATEGIES Mindfulness Breathing Progressive muscle relaxation Cognitive distraction – imagine next plot lines for a book. How would you spend lottery money. Do math equations.

BEHAVIOURAL EXPERIMENTS BELIEF: I need to nap to get through the day. ALTERNATIVE THOUGHT: If I don’t nap, my nighttime sleep will improve, and I can cope. EXPERIMENT: Monitor napping, tiredness and coping for one week of naps and one week without.

STRATEGIES TO GETTING OUT OF BED Go directly into the shower Make a special breakfast Buy favourite coffee beans Take the dog for a walk. Schedule a visit with a friend. Remind self that if you sleep more, will be light sleep at best.

COGNITIVE WORK HARDENING AND RTW PLANNING

COGNITIVE WORK HARDENING & RTW PLANNING RESOURCES HARDWIRING HAPPINESS, Rick Hanson Ph. D. LUMOSITY BRAIN HQ – Michael Merzenich COURSERA.ORG – free for content courses for Yale & Harvard CANCER AND RETURNING TO WORK: www.bccancer.bc.ca JOB ACCOMMODATION NETWORK: www.jan.wvu.edu

COGNITIVE WORK HARDENING Toughening the “cerebral muscle” Cognitive work demands such as concentration; memory; multi-tasking; meeting deadlines and working with time pressures; computer literacy; report writing; attention to detail.

COGNITIVE WORK HARDENING & NEUROPLASTSICITY Taking back the cerebral real estate. Strengthen connections: the brain that fires together wires together London cabbies

BEHAVIOURAL WORK HARDENING Toughening the “emotional muscle” Behavioural work demands such as getting to and staying at work; interacting with coworkers and customers; dealing with emotional or confrontational situations; reliability and responsibility

COGNITIVE & BEHAVIOURAL WORK HARDENING How do we build a program? Hint…think of physical work hardening. Know the job demands Evaluate the client’s current abilities. Simulate cognitive demands of the job. Measure change.

COGNITIVE & BEHAVIOURAL PROGRAM Review job description Complete the Cog/Beh Demands Analysis Establish goals Simulate demands in clinic or offsite – volunteer work. Graded activities to build confidence Don’t forget about physical job demands!

EXERCISE, EXERCISE, EXERCISE Combination of physical exercise and mental stimulation is key to good outcome – Doidge Aerobic exercise is helpful in improving cognitive function in adults in terms of memory, attention, processing speed and ability to form and act on plans-Ahlskog 2.5 hours per week of exercise and notice significant enlargement in hippocampus -Doidge

AND IF YOU ARE NOT CONVINCED RE: EXERCISE? Combination of learning & physical exercise maintains and enhances ability to learn related to an increase in a chemical in the hippocampus that turns short term memory to long term- Cohen Some evidence for strengthening as well-brain is responding to the challenges in the same way the body responds to the stress of the exercise - McGonigal

FIVE EVIDENCED BASED WAYS TO IMPROVE BRAIN FUNCTION Do/learn something new every day Do something new & out of your comfort zone (multiple firing of sensory and cognitive brain structure) Cardiovascular and strengthening exercise Good sleep 10 minutes of meditation a day 1 &2. When brain experiences novelty it fires faster. And you see vascular growth.

RETURN TO WORK PLANNING Special Considerations for LRP Mental health stigma “Protective” professional supports Work environments Self-confidence/self-esteem Importance of gradual return options and ongoing support Meeting with coworkers prior to return: role playing what to say, why off? Krista. New wardrobe Emotional preparation SOMETIMES NO JOB TO GO BACK TO OR MAY BE LAID OFF - LAURA 186

RETURN TO WORK PLAN Gradual return – 6 or 8 or 10 or 12 or even 16 weeks Increasing by hours vs. by days Support throughout is crucial Job Accommodations? Work from home part time? Ergonomic Assessment? Treatment coinciding with RTW SOMETIMES WE DO, SOMETIMES REHAB CONSULTANTS DO. MAKE SURE YOU KNOW WHAT THEY WANT. RTW IS PART OF RECOVERY PREDICT THEY WILL BE EXHAUSTED

CASE SPECIFIC EXAMPLES POST CANCER CLIENT CFS CLIENT CONCUSSION CLIENT ADHD/ASPERGER’S POST CANCER: 2 years after finished all of treatment to gain back cognitive function

POST CANCER CWH & RTW POST TREATMENT FOGGY BRAIN/FATIGUE/DECREASED SELF CONFIDENCE/ANXIETY Cancer Smart Rehab Brief Fatigue Inventory Cognitive testing baseline and follow-up Important to request exercise as part of program Cancer survivors have difficulty estimating work readiness

CANCER CONT’D Beware of facing difficulties the first days back – helps if can go ahead of time to clean up work area Energy conservation – pacing/planning Job site visit – particularly if have had surgery, have physical impairments Lisa – emails, calendar medical appointments

CHRONIC FATIGUE SYNDROME VO2 testing – working within heart rate ranges Avoid crashes Cognitive and social activities count PACING/PACING/PACING Provide education, leave them be, then re-assess

ADHD/ASPERGER’S Important considerations: Communication strategies Sometimes dragon speak helps How to use outlook tutoring Education to the employer Extra time needed for some work INDICATE WILL PROVIDE WORK ACCOMMODATIONS FOR WORKERS WITH DIFFERENT COGNITIVE LIMITATIONS

CONCUSSION Do not increase both frequency and job demands…slow and steady Keep brain breaks until full time Adjust RTW plan if symptoms spike Consider a work site visit to look at environment.

WORKING WITH THE SPONSORS: CLOSING THE GAP

UNDERSTANDING THE LTD WORLD STD VS. LTD Date of Definition: Own occupation vs. any occupation vs. own job Duty to Accommodate Case Manager vs. Rehab Consultant RTW meetings Disability vs performance issues

COMMUNICATION IS KEY Call often, set up time in schedule, let RC’s know when you are available

MANAGING THE FILES: DO’S Keep the sponsor happy AND be client-centered – think outside the box – use treatment techniques and locations that will inspire/encourage Timely reporting Team meetings – everyone on the same page. Invite the sponsor to team meetings esp first and last. Communicate with physicians Manage the budget Know the specific needs/wishes of the sponsor Pull the plug when you need to

MANAGING THE FILES: DO’S Understand benefits in question and timeframes for C.O.D. Understand who is to communicate with employer (the RC or you) Ensure the client is aware of the program goals from the outset

MANAGING THE FILE: DON’TS Avoid communicating with the sponsor when things are going south Overspend or ask for a huge amount when prognosis is guarded Ask for more than 15 minutes of coordination/communication per week EVER speak negatively about sponsor to the client. Stay out of insurer/client conflict. Be afraid to say the client is not ready for treatment.

OUTCOME MEASURES In process Will be used across the country Demonstrate the positive outcomes

MARKETING THE PROGRAM A successful outcome is number one! Effective case coordination Education, education, education…any chance you get. Review current files - what could be converted to LRP, speak to your OR sponsors about the program. Ask sponsors what they need…reflectively listen…. 201

MARKETING THE PROGRAM Presentations to LTD companies – provide education AND lunch. Provide sponsors with outcome stats from Ottawa – 8/10 successfully back to work. Stress early intervention = better outcomes. Think about what makes us unique …. Combined physical, psychological AND functional components; flexibility of service delivery; ‘normalized’ gym environments.

MARKETING THE PROGRAM Keep current with trends and needs Perhaps picked an experienced clinician to help with marketing Negotiate – try 3 files Partner with specialists/market to specialists Find your niche Extended health?

AND LAST BUT NOT LEAST: GOOD SELF CARE

CONTACT INFORMATION Ingrid Neufeld, BMR(OT) Reg (Ont) Occupational Therapist CBI Ottawa West (613) 820-5545 ineufeld@cbi.ca THANK YOU! 205