Cognitive Rehabilitation Therapy

Transcription

1 Cognitive Rehabilitation Therapy Empirically validated for Traumatic Brain Injury Rehabilitation Rachita Sharma, PhD-C, LPC, CRC University of North Texas

2 Outline Traumatic Brain Injury Facts and figures Neuroplasticity & Repair Cognitive Rehabilitation Cognitive Rehabilitation Therapy (CRT) Definition, Key terms Restoration vs. Compensation Goal Planning Example of techniques Professional demands Best practices Wrap Up 2

3 What is A Traumatic Brain Injury? TBI is a blow or jolt to the head that disrupts the normal function of the brain. It may knock you out briefly or for an extended period of time, or make you feel confused or see stars. Not all blows or jolts to the head result in a TBI. TBI can be mild, moderate, severe or penetrating. The most common form of TBI in the military is mild, more commonly known as a concussion. Approximately 75-90% mild. 3

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5 2 types of TBIs Closed Head Injuries Caused by a blow or jolt to the head that does not penetrate the skull Penetrating Head Injuries Occurs when an object goes through the skull and enters the brain 5

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7 Severity varies Not every TBI is alike. Each injury is unique and can cause changes that affect a person for a short period of time, or sometimes permanently. The majority of people will completely recover from symptoms related to a concussion (mild TBI). However, persistent symptoms do occur for some people and may last for weeks or months. The long-term effects of TBI depend on: the number and nature of hits to the head, the age and gender of the individual, the speed with which the person received medical attention, and genetic and other factors. 7

8 How widespread is the problem? Annual estimates suggest between million incidents of TBI. Since 2000, more than 333,000 service members have sustained a TBI. TBI is a contributing factor to a third (30.5%) of all injury-related deaths in the United States. Direct medical costs and indirect costs of TBI, such as lost productivity, totaled an estimated $60 billion in the United States in

9 TBI by External Cause Falls are the leading cause of TBI. Rates are highest for children aged 0 to 4 years and for adults aged 75 years and older. Falls result in the greatest number of TBI-related emergency department visits (523,043) and hospitalizations (62,334). Motor vehicle traffic injury is the leading cause of TBIrelated death. Rates are highest for adults aged 20 to 24 years. 9

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11 TBI by age Adults aged 75 years and older have the highest rates of TBI-related hospitalization and death. Children aged 0 to 4 years, older adolescents aged 15 to 19 years, and adults aged 65 years and older are most likely to sustain a TBI. Almost half a million (473,947) emergency department visits for TBI are made annually by children aged 0 to 14 years. 11

12 TBI by gender In every age group, TBI rates are higher for males than for females. Males aged 0 to 4 years have the highest rates of TBI-related emergency department visits, hospitalizations, and deaths combined. 12

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16 Neuroplasticity and repair 16

17 Neuroplasticity and Repair (Pekna & Pekny, 2012) Brain tissue s capacity to regenerate is extremely limited. Nervous tissue has a remarkable ability to adapt its function rather than to regenerate its structure in response to a changing environment; This ability constitutes the basis for learning! In neurobiological terms, this ability to adapt to and learn from experiences is called neural plasticity. Neural plasticity peaks within one to three months after injury; thus creating a unique window of opportunity. During this window, neurorehabilitation is most effective. However, significant improvements can occur even at later stages, especially when rehabilitation combines task-specific training with therapies that activate neural plasticity. 17

18 5 important factors involved in plasticity 1. Stimulation Seriousness of Purpose is vital for new connections. 2. Frequency Frequent stimulation (daily practice) is more effective. 3. Duration Too short and learning is not encoded and too long causes boredom. 4. Intensity Optimum arousal is the correct balance between boredom and stress. 5. Consistency The same exercises or stimulation are consistently repeated. 18

19 Cognitive Rehabilitation Therapy Deemphasis on computer software Deemphasis on rote retraining exercises More naturalistic approach in real-world, community environment training More holistic approaches produce most convincing outcome data Whyte & Rosenthal, 1993 Rehabilitation Medicine-Principles & Practice p

20 Cognitive Rehabilitation Therapy 20

21 Cognition (Parente & Hermann 1996) Complex collection of mental skills that includes attention, perceptions, comprehension, learning, remembering, problem solving, reasoning and so forth. These mental attributes allow us to understand our world and to function in it. After a brain injury, a person typically loses one or more of these skills. Cognitive rehabilitation is the art and science of restoring these mental processes after injury to the brain. Cognitive problems are one of the most disabling long-term consequences of brain injury (NIH, 1999). 21

22 National Institutes of Health Consensus Development Conference Statement: Rehabilitation of Persons with TBI (1988) Although TBI may result in physical impairment, the more problematic consequences involve the individual s cognition, emotional functioning, and behavior. Recommendations: Rehabilitation of persons with TBI should include cognitive and behavioral assessment and intervention. 22

23 Cognitive Problems: They happen to the best of us! 23

24 Had any of these experiences in the past week? Getting to the top of the stairs (or anywhere) and have forgotten why you went there? Knowing that you knew the name of someone or something and couldn t quite retrieve it (tip of the tongue)? Losing the thread of what you were saying when you became distracted? Forgetting an appointment or something else you should have done? Finding it hard to divide your attention between two tasks? Following a brain injury these difficulties become more pronounced. 24

25 Cognitive Impairments Arousal and Attention Learning and Remembering Frontal Executive Function Language Visuospatial Perception and Construction 25

26 National Academy of Neuropsychology position statement on Cog Rehab (2002) Cognitive impairment in memory, reasoning, attention, judgment, and self awareness are prominent roadblocks on the path to functional independence and a productive lifestyle for persons with a brain injury it [has] become dramatically evident to professionals, patients, and their families that cognitive impairments, which interact with personality disturbance, [are] among the most critical determinants of ultimate rehabilitation outcome. Therefore, cognitive rehabilitation [has] become an integral component of brain injury rehabilitation. 26

27 Definitions in Rehabilitation Disease (atherosclerosis in peripheral arteries) Impairment - organ level (below the knee amputation) Disability - person level (inability to walk without a prosthesis) Handicap - societal level (inability to walk up stairs with prosthesis) International Classification of Impairment, Disease, & Handicap, WHO

28 Cognitive Rehabilitation Therapy The process of CRT comprises 4 components: 1. Education about cognitive weaknesses and strengths. The focus here is on developing awareness of the problem. 2. Process Training. This refers to the development of skills through direct retraining or practicing the underlying cognitive skills. The focus here is on resolving the problem. 3. Strategy Training. This involves the use of environmental, internal and external strategies. The focus here is on compensating rather than resolving the problem. 4. Functional Activities Training. This involves the application of the other three components in everyday life. The focus here is on real life improvements. 28

29 Key issues in Neurorehab The brain does not regenerate after damage due to stroke or head injury. But long term functional improvements do occur over months or years. Lost skills can sometimes be re-taught or compensatory strategies can be taught to help get round the deficit. Restoration and Compensation are essential components of cognitive rehabilitation. 29

30 Restoration vs. Compensation Two ways in which people can recover from brain injury. Restoration is recovery of function as it was prior to the accident Compensation is an adaptive reaction, the person changes his or her behavior to accommodate the effects of the injury in their lives. SCR Rec 5.1: CRT treatments should encompass attempts at restoration of the lost function at the same time as teaching compensatory strategies to minimize cognitive impairments. 30

31 Example: Memory Restoration Strategy Helping client to remember for themselves through memory games, practice mnemonics etc Compensation Strategy Keeping a diary Having a personal organizer/siri Keeping a daily routine 31

32 Speech Restoration Strategy Speech therapy and every day practice. Recovery of Left Hemisphere (speech areas) Compensation Strategy Context gesticulation and sign language. Learning limited speech with Right Hemisphere? 32

33 Movement Restoration Strategy Physiotherapy, exercise Regaining use of right hand Compensation Strategy Wheelchair, stick or frame Learning to use Left hand 33

34 Executive Restoration Strategy Planning and awareness practice Compensation Strategy Personal organizer or diary, keeping a routine. 34

35 Senses Restoration Strategy Practice use as much as possible. Stimulation through arts etc. Compensation Strategy Sensory Aids, hearing etc. Having a caretaker do cooking Making others aware 35

36 Mechanisms of Functional Recovery (Whyte & Rosenthal, 1993) Recovery is believed to occur at multiple levels (from alterations in biochemical processes to alterations in family structure). It may involve: Resolution of Temporary Factors Neuronal Regeneration Synaptic Alterations Functional Substitution Learning of New Skills 36

37 What is CRT American Congress of Rehab Medicine (1997) CRT is a systematic, functionally oriented service of therapeutic cognitive activities and an understanding of the person s behavioral deficits. Services are directed to achieve functional changes by: Reinforcing, strengthening or establishing previously learned patterns of behavior, or Establishing new patterns of cognitive activity or mechanisms to compensate for impaired neurological systems Above definition has been adopted by the Commission on Accredition of Rehabilitation Facilities (CARF) and by the National Academy of Neuropsychology (NAN) 37

38 To keep things simple CRT IS: A subset of Cognitive Rehabilitation that aims to facilitate the development of cognitive skills to improve Functional attention Memory Problem solving Includes compensatory and restorative training in a context of direct one-to-one participant contact with the therapist. Chapter 512: Traumatic Brain Injury Waiver Services ( ) 38

39 The growth of CRT CRT has developed as a result of growing knowledge about the long-term effects of brain injury. Was used by the British and German military in their attempts to rehabilitate troops during the two world Wars (Pentland et al., 1989; Poser et al., 1996). It can no longer be said that cognitive rehabilitation is a new field. (Sohlberg & Mateer, 2001). All those who are involved with the patient who has a brain injury must understand cognitive impairments and how they alter what the patient is able to comprehend, comply with, and achieve (British Society for Rehabilitation Medicine). 39

40 The Process of CRT (Raymond 1994) General cognitive therapeutic strategies consist of teaching compensatory skills and brain retraining. Through practice and repetition, impaired cognitive functions can be strengthened. This may occur by reinforcing foundation skills such as attention, concentration, reaction time, visual processing, and the ability to organize new information. These basic building blocks can be integrated into more complex functional behaviors such as dressing, cooking, balancing a checkbook, and operating an automobile. Pencil and paper tasks, computer software programs, and video feedback are used for developing these skills. 40

41 Components of Cognitive Rehabilitation Therapy (Wilson et al 2009) CRT is made up of: 1. Education about cognitive weaknesses and strengths. Education in groups less threatening. 2. Setting of clear goals and development of goal management plans. Using SMART goals/objectives 3. The development of skills through direct retraining or practicing the underlying cognitive skills Often referred to as process training 4. The use of external and internal compensatory strategies diaries, electronic aids and mental strategies to remember things. 5. Application of these in everyday life, and using functional tasks to improve cognitive skills functional activities training. 6. Input about the emotional aspects of adjustment. 41

42 SMART Goals The acronym SMART ensures that goals are: Specific Measurable Attainable Realistic Timely (time-bound) 42

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44 SMART Goals SMART Goals provide a structure for the brain-injured person Allows patient and professional to monitor progress and see improvements. Develop a clear objective for each session or activity An objective is something that can be stated clearly and precisely, which you can observe the person doing. Exactly what the person should be able to do by the end of the session. State clearly what is to be achieve, under what specific conditions, by when, and the level of correct responses required. Be realistic in setting these aims and objectives. Do not set the patient for failure. Each of the components represented by the SMART acronym should be present! 44

45 Models CRT cannot be informed by a single model Holistic model of treatment that addresses cognitive, social, emotional, and functional aspects of brain injury together works best. Cognitive skills should be considered as a hierarchy. 5 cognitive skill areas should be comprehensively assessed and wherever necessary, treated. Executive Functions Memory Information Processing Visual Processing Attention 45

46 All of these are problems with attention, but the kind of attention required varies from task to task. As a result, the rehabilitation exercises vary depending on the problem. Example: Attention (Lee, 2009) Complaints from patients: I try to watch TV but I just drift off. I can t seem to stay focused on anything even when I m relaxed and there are no distractions. I can t cook while there is noisy construction work happening next door. I get too distracted. I can t listen to the lecture and take notes at the same time. I can t switch back and forth quickly enough. I can t brush my daughter s hair while I talk on the phone. I can t do two things at once anymore. 46

47 Sustained Attention I try to watch TV, but I just drift off. I can t seem to stay focused on anything even when I m relaxed and there are no distractions. Most basic exercise, have the person listen to a tape and hear a series of numbers. Push a button every time he/she hears a specific number, for example 4. Practice increasing the amount of time that person can continue the task without errors. The task can be made much more difficult by changing the rules for responding. For example, you could be asked to press the button every time you see a number that is 2 less than the number that came before it (* = push button): 10, 12, 8, 6*, 4*, 9, 7*. The task could use letters or words rather than numbers as well. In a second type of task, ask person to count backwards from 100 by 3 s, 4 s etc. Can be made more difficult by adding more rules. For example, counting backward by 3 then adding 1: 100, 97, 98, 95,

48 Selective Attention I can t cook while there is noisy construction work happening next door. I get too distracted. To treat selective attention, your patient would perform exercises like those previously mentioned, but with added background noise, often on tape. Ideally, the background noise should be the same type as that which is a problem for patient in real life. Many individuals are distracted by internal stimuli such as thoughts or worries. For this, encourage writing down thoughts and worries before beginning the task. Being distracted by internal stimuli also can be a sign of depression or an anxiety disorder. 48

49 Alternating Attention I can t listen to the lecture and take notes at the same time. I can t switch back and forth quickly enough. Present patient with a list of numbers. Ask him/her to cross out odd numbers until (you) the therapist says change. Patient would then begin to cross out even numbers. The task becomes more difficult as the length of time between changes shortens. Alternately, patient could be presented with pairs of numbers and be asked to change back and forth between adding and subtracting when cued. Present words that are printed differently from the meaning of the word: BIG little LITTLE BIG LITTLE big little LITTLE. Ask patient to first to read the words and then to say the size of each words. In this example, the response should be big little little big little big little little and then the size of each word big little big big big little little big. 49

50 Divided Attention I can t brush my daughter s hair while I talk on the phone. I can t do two things at once anymore. Use a buzzer and ask patient to push the buzzer in response to a specific number as in the aforementioned sustained attention example. The difference here is that patient will both, hear numbers through a headset and see number flashed individually on a screen. They will not be the same numbers. Patient must push the buzzer if either tape or screen has the specific number. Alternately, patient may be asked to perform sorting exercises. For example, present him/her with a deck of cards and ask to sort the cards by suit. During the sorting, ask them to turn over any card that contains a specific letter, such as the letter n (one, seven, nine, ten, Queen, King). 50

51 Individuals involved In CRT 51

52 Individuals involved in CRT CRT is a cross-disciplinary provision and is not, nor should be, the sole domain of any single discipline. Primary practitioners of CRT should be licensed/qualified in a relevant discipline. It is incumbent upon staff to develop as many opportunities as possible in which cognitive difficulties are the focus of treatment, and to incorporate remedial strategies in all therapeutic encounters to maximize learning and outcome (Waxman & Gordon, 1992). Certification in the Practice of Cognitive Rehabilitation Therapy (CPRT) is the current credential available to providers via Society for Cognitive Rehabilitation. 52

53 Counseling Education Medicine Neuropsychology Occupational Therapy Physical Therapy Psychology Recreation Therapy Special Education Social Work Speech-Language Pathology 53

54 Acute Care Hospital Treatment Settings for Rehabilitation Management Acute Inpatient Rehabilitation Hospitals Skilled Nursing Facilities Outpatient Rehabilitation Services Home Health Services 54

55 At-home interventions (Univ. of Alabama Home Stimulation Program) Playing with cards Molding Clay Daily activities Finger Tapping Nuts and bolts Sequencing activities Working with money Search and find Recall of pictures and places Visual scanning/cancellation Number sequences Auditory attention Shell game Tossing bean bags 55

56 The Society for Cognitive Rehabilitation Recommendations for Best Practices in CRT 56

57 The Brain Injury Interdisciplinary Special Interest Group (BI-ISIG) of the American Congress of Rehabilitation Medicine "systematic, functionally-oriented service of therapeutic cognitive activities, based on an assessment and understanding of the person's brain-behavior deficits." "Services are directed to achieve functional changes by (1) reinforcing, strengthening, or reestablishing previously learned patterns of behavior, or (2) establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems" (Harley, et al., 1992, p.63). 57

58 Recommendations Rec 3.3: The person with brain injury should be seen as an integral member of the team. Rec 3.4: The person with the brain injury must be involved in the cognitive treatment endeavor. Rec 3.5: The family/support system of the person with brain injury plays an important role in intervention and should be actively involved throughout treatment. 58

59 Section two: Assessment & Treatment Rec 4.1: A standard battery of assessments should be administered in each setting that provides CRT Rec 4.2: The assessment battery should provide sufficient information to form a hypothesis about the underlying cognitive impairments and deficits that interfere with the person s cognitive functioning. Rec 4.3: The results of the assessment battery should enable the therapist to make decisions about which treatments are necessary, rather than merely describing the problems. Rec 4.4: In rehab settings, standardized psychometric assessments, questionnaires, structured interviews, and behavioral observations across a range of functional settings should all be used without giving stronger emphasis to any one approach. 59

60 Section two: Assessment & Treatment contd. Rec 4.6: Wherever possible, assessments results should be shared with the brain-injured person. They should be explained in terms that the individual can understand and explicitly related back to the functional problems that have been identified. Rec 4.7: A cognitive treatment plan should be drawn up with the brain-injured person, as a direct result of the assessments. Agreement should be reached on this between the therapist and brain-injured person. Rec 4.8: Reassessment should be undertaken at regular intervals in order to monitor and report on progress. Rec 4.10: The assessment results should be used by the therapy team to help make a prognosis for what they can achieve with the person with brain injury. These form Outcome goals. Rec 4.11: Treatment goals should be specified as a result of the assessment. These should include outcome goals, long-term goals, and short-term goals. These should be agreed with the person with brain injury. Rec 4.12: All goals should be written as SMART goals and clearly documented. 60

61 Last words Set realistic goals. Manage expectations. The person with the brain injury should never be told that his or her cognitive functions can be filly restored; instead advise them that the aim is to maximize or optimize these skills, while learning new ways of doing things to minimize the problems. Explore different techniques based on individual needs. Include the entire village if possible! 61

62 Questions? 62