Rehabilitation: A Journey to. Independence By: Lauren Smith, CCC-SLP, CBIS and Nicole Bylander, OTR/L, CBIS 5/5/16

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1 Rehabilitation: A Journey to Independence By: Lauren Smith, CCC-SLP, CBIS and Nicole Bylander, OTR/L, CBIS Rehabilitation: A Journey to Independence Purpose: Describe the rehabilitation process and the benefits of early, intense therapeutic treatment. Describe the current best practice treatment techniques. u Objectives u 1. Identify the costs of stroke u 2. Identify the benefits of intense inpatient rehabilitation u 3. Describe an outcome-driven rehabilitation process u 4. Identify common cognitive deficits after a brain injury u 5. Describe the cognitive rehabilitation process Costs of a brain injury Estimated 10 million Americans are affected by brain injuries yearly by the year 2020 will likely surpass many diseases as the major cause of death and disability (Ficker-Terrill, Flippo, Antoinette, & McMorrow, 2009) 3.8% of population is currently living with disability from stroke/tbi (Ficker-Terrill, Flippo, Antoinette, McMorrow, 2009) Average hospital stay for moderate TBI is approximately 9 days (up to 3 months) (brainandspinalcord.org, 2016) CDC estimates that medical costs of TBI in the year 2000 totaled $60 billion (brainandspinalcord.org, 2016) Expenses (medical & nonmedical) for average TBI patient is estimated at $151,000 within the first year of injury Cost for patients who don t survive the injury are typically higher due to expensive treatments (ex. Ventilators, Tracheostomy cares) that are used to give the brain a chance to heal (brainandspinalcord.org, 2016) 1

2 Costs continued Psychosocial Many patients never recover full social independence, even though they may have no physical disabilities and a normal life expectancy (Humphreys et al, 2013) 4 years post injury, most survivors did not work or go to school posing a significant psychological burden on family (Humphreys et al, 2013) The more serious the injury, the more likely the survivor is to have a divorce (Kreutzer, Godwin, and Marwitz, 2010) In a recent study, 23% of participants thought of suicide and 17% attempted suicide (Gainer, 2011) 53.1% of TBI patients experience major depressive disorder at least once within the first year of injury (Gainer, 2011) Deficits Following a Brain Injury Impairments in: Mobility Motor Function Sensory Impairments Vision/Hearing Impairments Bowel & Bladder Function Cognition Memory Executive Functioning Initiation Speech and Language Behavioral and Emotional Changes- including personality Benefits of intense & early rehab Regain independence with mobility and self cares Family education on brain injury Improved cognition and safety Increased quality of life Intense rehab stays are shorter compared to less intense therapy with improved outcomes (resulting in reduced impairments) Evidence that starting rehab 7 days post injury improved cognition, perception and motor recovery in brain damaged patients, which resulted in shorter length of hospital stay (24 days versus 45 days for patients treated later) Rehabilitation following acquired brain injury improves health outcomes, reduces disability, and improves quality of life. Cooney & Carroll, 2016 p

3 What is Cognitive Rehabilitation? Cognitive rehabilitation therapy is one form of therapy available for patients with traumatic brain injury, who as a result of their injury suffer from cognitive deficits such as memory loss or attention problems (ECRI Institute, 2011., p.2). Addresses: Executive functions Attention Memory Working Memory Time Pressure Management Hemispatial Neglect What is Cognitive Rehabilitation? Uses compensatory and internalizing strategies Memory Notebook (compensatory) Self talk (internalizing) 4 Outcomes of Rehabilitation The patient never learns to be independent in compensating for deficits and relies on simple routines and action sequences The patient learns to use memory aids independently and can use some internal strategies, but still requires external cues (Haskins et al, 2012) What is Cognitive Rehabilitation? 4 Outcomes of Rehabilitation Cont. The patient is able to completely internalize strategies and is able to independently select and apply these strategies to specific situations. The patient can generalize learned skills and apply to a range of different situations and tasks. (Haskins et al, 2012) Cognitive Rehabilitation can continue for years after an acquired brain injury 3

4 Outcome Driven Rehab What is outcome driven rehab? Systematic process Functional Goals Team approach Discharge plan (Antonionette, Strauss, & Trudle, 2009) Goals & Process of Cognitive Rehab Goals: Problem Orientation, awareness, and goal setting Compensation Internalization Generalization Process/Stages of Treatment: Acquisition Application Adaptation (Haskins et al, 2012) Keys to Effective Implementation Tag-On to an existing routine Avoid or limit direct, explicit teaching of routines Consistency Train routines in their natural context (Hoepner, 2016) 4

5 High Tech Aids Bioness Integrated Therapy Systems (BITS) Dynavision Bioness H200 and L300 Electrical Stimulation (estim) Functional Electrical Stimulation Cycle (FES Cycle) Bodyweight Supported Treadmills Balance systems Mainstream technology ipad, cellular phones, Amazon echo, WeMo, Nest, Wii, environmental control systems Other Low Tech Aids/Treatment Strategies Attention ü Downloading ü Table top approach ü Modify Environment ü Direct Attention Training Memory ü Spaced Retrieval (SRT) External Memory Aids ü Memory Wallet ü Memory Book ü Technology delivered prompts ü Low-no tech delivered prompts Visual-spatial ü Myer s Cupcake task ü Edgeness & Bookness Attention Attention Downloading Emptying mental space and feelings that consume working memory fuel/ attention Table Top Approaches Set items on the table of tasks you need to complete Change the environment Reduce demands in current environment or change to a different environment Direct Attention Training Key features: Task salience Monitoring Modalities 5

6 Memory Direct approaches Improve the impairment Ex. Spaced retrieval, rehearsal, association techniques, imagery, chunking, etc. Indirect approaches Work to compensate Ex. External memory aids, partner cueing or support Adaptive Approaches Work to alter demands Ex. Environmental modifications Direct Approaches (Memory) Spaced Retrieval Implicit training with errorless learning Used for naming, recall of tasks, or sequencing steps of tasks Indirect Approaches (Memory) Memory Wallets Memory Book Technology delivered prompts Low-No Tech delivered prompts Apps to consider Nudge Reminders RxMindMe or Pill Monitor Google Calendar To Do List Digital recorders Mainstream Technology 6

7 Visual-Spatial Lighthouse Scanning Myer s Cupcake Task Edgeness & Bookness Edgeness Ex. If you can find the edge of a plate, you can find food on it. If you can find the edge of a table, you can find cards on it. Bookness Object centered Ex. If you can find the left edge of a book, you can locate the beginning of the column. If you can located the center crease, you can locate the beginning of the 2 nd column. Cognition during functional tasks Picture/Sequencing boards ADL retraining Functional tasks Scripting Self talk Purposeful cuing Chaining Therapeutic Use of Self Patient and Family Buy In Carryover is one of the most important things! Errorless learning Builds confidence and provides an opportunity for success Self Reflection May need to start with guided reflection Building Rapport Insight Patient factors 7

8 References Brain And Spinal Cord (2015). Medical Expenses for a Trauma4c Brain Injury. h<p:// injury- medical- expenses. Retrieved April 12, Brain Injury AssociaOon of America (2009). The Essen4al Brain Injury Guide. 4 th EdiOon. Livonia, MI: Rainbow RehabilitaOon Centers. Cooney, M. & Carroll, A. (2016). Cost EffecOveness of InpaOent RehabilitaOon in PaOents with Brain Injury. Clinical Medicine 16(2): ECRI InsOtute (2011). CogniOve RehabilitaOon Therapy for TraumaOc Brain Injury: What We Know and Don t Know about Its Efficacy. h<ps:// rapy_ecri_insotute_ pdf Retrieved January 28, Gainer, R. (2011). Depression and Suicide Among PaOents with TraumaOc Brain Injuries. h<ps:// suicide- TBI/. Retrieved April 12, Haskins, E., Cicerone, K., Dams- O Connor, K., Eberle, R., Langenbahn, D., Shapiro- Rosenbaum, A., Trexler, L. (2012). Cogni4ve Rehabilita4on Manual: Transla4ng Evidence- Based Recommenda4ons into Prac4ce. Reston, VA: ACRM Publishing. References Hoepner, J. (2016). CogniOve RehabilitaOon: TherapeuOc Strategies for EffecOve IntervenOon. Eau Claire, WI: Pesi, Inc. Humphreys, I., Wood, R., Phillips, C., Macey, S. (2013). The costs of traumaoc brain injury: A literature review. ClinicoEconomics and Outcomes Research. 5: Kreutzer, J., Godwin, E., Marwitz, J. (2010). The Truth About Divorce AHer Brain Injury. The Challenge Mazaux, J., De Seze, M., Joseph, P., Barat, M. (2001). Early RehabilitaOon Afer Severe Brain Injury: A French PerspecOve. Journal of Rehabilita4ve Medicine. 33: Niemeier, J. (1998). The Lighthouse Strategy: Use of visual imagery technique to treat visual ina<enoon in stroke paoents. Brain Injury, 12, Niemeier, J.P., Cifu, D.X., & Kishore, R. (2001). The Lighthouse Strategy: Improving the funcoonal status of paoents with unilateral neglect afer stroke and brain injury using a visual imagery intervenoon. Top Stroke Rehabilita4on, 8(2) QUESTIONS??? 8

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