©2014 mfmer | slide-1 cognitive rehabilitation strategies for individuals with mtbi leanne elmer,...

©2014 MFMER | slide-1

Cognitive Rehabilitation Strategies for Individuals with mTBI

Leanne Elmer, M.S. CCC-SLPDivision of Speech PathologyDepartment of Neurology

April, 2015


Objectives for Today’s Presentation

• Describe 3 strategies patients with mTBI benefit from implementing each day.

• Identify which team members can help when treatment is not going as expected.

• Understand how mTBI impacts communication.


What?

Mayo TBI Severity Classification System

(Malec, J., Brown, A., Leibson, C., Flaada, J. et al., 2007)


Classify as Moderate-Severe (Definite) TBI if one or more of the following criteria apply:

1. Death due to this TBI

2. Loss of consciousness of 30 minutes or more

3. Post-traumatic anterograde amnesia of 24 hours or more

4. Worst Glasgow Coma Scale full score in first 24 hours <13

5. One or more of the following present:

• Intracerebral hematoma

• Subdural hematoma

• Epidural hematoma

• Cerebral contusion

• Hemorrhagic contusion

• Penetrating TBI (dura penetrated)

• Subarachnoid hemorrhage

• Brain Stem Injury


If none of the previous criterion apply, classify as Mild (Probable).

1. Loss of consciousness of momentary to less than 30 minutes

2. Post-traumatic anterograde amnesia of momentary to less than 24 hours

3. Depressed, basilar or linear skull fracture (dura intact)


If none of the previous criterion apply, classify as Symptomatic (Possible) TBI if one or more of the following symptoms are present:

• Blurred vision

• Confusion (mental state changes)

• Dazed

• Dizziness

• Focal neurologic symptoms

• Headache

• Nausea


Who?


When?


Where?


Why?


“It is not only the kind of injury that matters, but the kind of head.”

(Mateer, Sira, and O’Connell, 2005)


How Can We Offer the Best, Evidence-Based Care?

• Become the expert on the patient

• Ask questions

• Observe the patient

• Use all available tools

• Collaborate

• Educate

• Offer feedback

• Continue to observe and ask questions


Dave Before mTBI

Physical

Mental

Emotional

Social


Dave

• 50 y.o.

• MVA in January, 2014

• +LOC

• GCS of 15

• Negative CT

• On SLP schedule April, 2014-September, 2014


Dave After mTBI

Physical

Mental

Emotional

Social


Time to Sell Cognitive Rehab

• We train the basics.

• We need to boost some skills in this season of life.

• Therapy won’t last forever.

• You’ll improve!

• Take what you want, leave what you want.


Strategies for Interacting with Family/Friends

• Take breaks before events.

• Ask questions to get into the role of the listener if I’m tired.

• Use "Let me think about it," "Let's talk about it later," or "We should talk about that on (give a day),” when his son was too much.

• Let them know of time restrictions.


Tools We Used in Therapy

• Try what the rest of the world does

• Different brain breaks

• E-mail/Patient Portal

• Start reading manuals

• Use a timer

• TED talks

• List of roles


How did we part ways?

• 5 sessions over 5 months

• Self-dismissal after a session with him, his wife, and the SLP

• E-mail/Patient Portal


Maris Before Moving to a New State with mTBI

Physical

Mental

Emotional

Social


Maris

• 53 y.o.

• On SLP schedule April, 2014-February, 2015

• Other team members:• Mental health provider in the community• NP• OT• PT• SW• Her brothers• Her pastor


Maris After Moving to a New State with mTBI

Physical

Mental

Emotional

Social


Time to Plan Dismissal

• Discuss it at the time services are initiated

• Be sensitive to:• Her chronic condition• Her support system• Her need for follow-up• Ending on a positive note


Strategies for Improving Pragmatic Language

• Watch for getting “derailed" in conversation (Answer the question and move on, when eating, check how much I've eaten vs. the person across from me. This helps me gauge how much I've been talking.)

• Reciprocate questions in conversation

• When sending e-mails• Double-check that I answered all of the questions• Make sure I asked questions• Check that my jokes fit the time/place/audience


Tools We Used in Therapy

• Team

• Speaker phone

• Spaced out appointments to accommodate family members’ schedules

• E-mail with family members

• Training for communication partners

• Feedback



• We empowered her!

• E-mail

• Lunch

• Open door policy


Zack Before mTBI

Physical

Mental

Emotional

Social


Zack

• 24 y.o.

• MVA on June 18, 2014

• Probable TBI

• Evaluated by SLP on

October 10, 2014

• 5 sessions


Zack After mTBI

Physical

Mental

Emotional

Social


Time to Change Things Up

• Are you writing everyday?

• Are you reading everyday?

• Are you spending any time with people?

• Are you doing things you enjoy?

• Are you advocating for yourself?


Strategies for When Zack is Lost in Conversation

• Slow down.

• Ask for help by saying something such as "What were we talking about?"

• Make a note before I forget it.

• Interject a quick comment such as, "Remind me to tell you about . . . "

• Listen for a bit in conversation to see if the idea comes back to me.


Tools We Utilized in Therapy

• Team

• Recordings

• Education regarding “cognitive power” and taking brain breaks

• Word-finding strategies

• Small giant steps

• Done list

• Try to see “gray” instead of “black” or “white”



• I went to the team.• Clinical Nurse Specialist• Social Work• Neuropsychology• Speech-Language Pathology

• I’m keeping the door open.


Heathermarie Before mTBI

Physical

Mental

Emotional

Social


Heathermarie

• 40 y.o.

• MVA on January 13, 2014

• Negative CT

• Unknown LOC

• Posttraumatic amnesia for accident and sometime thereafter

• Consult with SLP

February 26, 2014


Heathermarie After mTBI

Physical

Mental

Emotional

Social


Time to Hear Her Out

• Word-finding challenges

• Memory deficits

• Outbursts


Strategies for When Heathermarie is Getting Back to Daily Activities

• Take a break when I feel frustrated.

• When I feel like it's time to "just push through," it's time to take a break.

• I can work on a project for a set amount of time and then clean it up.

• Taking breaks does not mean I am lazy.

• Spend time doing what I want to get better at doing.


Tools We Utilized in Therapy

• “Brain dump”

• Problem-Solving Format

• Goal-Plan-Do-Review forms

• 5 Ws

• FlyLady

• You Tube videos on home organization

• Slow down to think about thinking

• Say “yes” to something



• 6 Sessions

• Made certain appointments with local mental health providers were scheduled

• Reassured her that she has made excellent gains and has all of the “tools” for her “toolbox”

• Advertised our open-door policy


Joe Before mTBI

Physical

Mental

Emotional

Social


Joe

• 17 y.o.

• Concussion in June, 2012

• Concussion in August, 2012

• Concussion in June, 2013

• Arrived at Mayo January,

2015

http://affiliates.allposters.com/link/redirect.asp?item=1499095&AID=266088839&PSTID=1&LTID=2&lang=1


Joe After mTBI

Physical

Mental

Emotional

Social


Time to Provide Excellent Customer Service

• More information on Pain Rehab

• Talking with someone who has been through the program

• Option to come back (schedule, call or schedule and cancel)


Tools

• Offer Brainline, Model Systems Knowledge Translation Center Fact Sheets, and BIA

• Provide education on how saying “yes” to something = saying “no” to something else


Parting Ways

• No follow-up scheduled

• In touch with his father

• Option to return at any time


The Factors I need to Assess to Give the Best Care Possible

• The patient’s communicative abilities

• The patient’s cognitive abilities

• The whole person (physical, spiritual, mental, emotional)

• Their life leading up to this (circumstances, hardships, life-long mental health concerns, team players, etc.)

• Their involvement in/outside of their home (at baseline and after injury)


How to Know if My Patient May Not be Benefitting From My Treatment

• We continually review the same information.

• My patient can’t report on how he/she is implementing strategies outside of therapy.

• My patient wants to talk about many topics, but not specifically communication/cognition.

• My patient is struggling to participate in therapy week-to-week.

• The next step is unknown/unclear.

• I can’t see where our time together is leading.


When Progress Deviates from the Expected Course, I Can:

• Talk the case over with a colleague to get other ideas.

• Bring in another team member.

• Find a friend/family member of the patient and train him/her on how to help.

• Shake things up (make a phone call in place of a visit one week, exchange e-mails, conference call with family members during therapy sessions, take a break and come back together in a few weeks).

• Provide education to others in his/her life.


Strategies to Weave into My Sessions

• If I keep doing what I’m doing, I’ll keep getting what I’m getting.

• I can see things as “gray” rather than “black or white.”

• When I say, “Yes” to something, it means I’m saying “No” to something else.

• I need to spend time thinking about thinking.

• I can stack the deck in my favor.

• I need to advocate for myself.

• What if I said, “Yes” to something?


ReferencesBilbao, A., Kennedy, C., Chatterji, S. et al. (2003). The ICF: Applications of the WHO model of functioning, disability and health to brain injury rehabilitation, NeuroRehabilitation, 18: 239-250.

Cicerone, K. et al. (2000). Evidence-based cognitive rehabilitation: Recommendations for clinical practice, Archives of Physical Medicine and Rehabilitation, 81: 1596-1615.

Hanks, R., Rapport, L., Waldron-Perrine, B., & Millis, S. (2014). Role of character strengths in outcome after mild complicated to severe traumatic brain injury: A positive psychology study, Archives of Physical Medicine and Rehabilitation, 95: 2096-102.

Malec, J., Brown, A. W., Leibson, C., Testa Flaada, J., et al. (2007). The Mayo Classification System for Traumatic Brain Injury Severity, Journal of Neurotrauma, 24(9): 1417-1424.

Mateer, C., Sira, C., & O’Connell, M. (2005). Putting humpty dumpty together again: The importance of integrating cognitive and emotional interventions, Journal of Head Trauma Rehabilitation, 20 (1): 62-75.

Ponsford, J., Grant, M., Peter, C., & Fitzgerald, M., Mikocka-Walus, A. (2012). Predictors of postconcussive symptoms 3 months after mild traumatic brain injury, Neuropsychology, 26 (3): 304-313.

Quattlebaum, P. & Steppling, M. (2010). Preparation for ending therapeutic relationships, International Journal of Speech-Language Pathology, 12 (4): 313-316.

Spira, J., Lathan, C., Bleiberg, J., & Tsao, J. (2014). The impact of multiple concussion on emotional distress, post-concussive symptoms, and neurocognitive functioning in active duty United States marines independent of combat exposure or emotional distress, Journal of Neurotrauma, 31: 1823-1834.

©2014 mfmer | slide-1 cognitive rehabilitation strategies for individuals with mtbi leanne elmer,...

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