The Brain, injury, and a few things to overcome!

1. The Brain, injury, and a few things to overcome! Presented by: Kim MacNeil Occupational Therapist April 2012

2. Outline • A little about the brain • What is an Acquired Brain Injury (ABI)? • Recognizing symptoms of ABI and strategies to work with • Positive Everyday Routines • Hypothesis Testing

3. THE BRAIN

4. The Brain

5. ANATOMY: The Brain

6. NEURON

7. NEURONS: It’s grey and white

8. ANATOMY: The Skull The Brain in Bed The Brain’s Bed

9. What is an Acquired Brain Injury (ABI)? • Traumatic Brain Injury – result of external trauma • fall, car accident, fight, gun shot, • Non-traumatic – result of internal source injuring the brain • Hypoxia (lack of oxygen) - near drowning, heart attack, “fainting game”, stroke (block) • Toxicity, meningitis, rabies, infection, stroke (bleed)

10. NEURONS & BRAIN INJURY

11. Focal (LOCAL) VS Global (DIFFUSE) Effects: • Coup Contra coup • Acceleration & Deceleration • Rotational & Shearing • Hematoma’s • Edema • Disruption of neural connection

12. Did you know: • Level of severity is not necessarily directly related to outcome • A concussion is a brain injury too • Don’t have to loose consciousness to sustain a brain injury • Younger is not necessarily better when it comes to recovery

13. NS Leading way in preventing ABI As of Nov 1, 2012 everyone in Nova Scotia is required to wear protective helmets while downhill skiing or snowboarding at ski hills.

14. Recovery/Long Term Effects • Most (but not all) recovery occurs within first 2 years • Area and extent of damage • Physical recovery • Individual • Environment

15. HOPE • Outcomes vary • Severity of injury does not always coincide with severity symptoms • To have hope is to envision something beyond what is…therefore there is a goal to work towards. Break it up into smaller achievable goals and work on them one day at a time.

16. Invisible Injuries of the Brain • By Debbie Wilson ( survivor from Murphysboro, Illinois)

17. Critical factors for successful reintegration: • EDUCATION of persons involved regarding brain injury • OPEN COMMUNICATION between all persons involved

18. Previous Approaches: • Common mistakes include: quizzing people, and allowing people to make the same mistakes over and over again “so they will learn from their mistakes” • Previously gave lists to remember then “tested” later

19. Errorless Learning • Methods of learning whereby attempts are made to prevent (or reduce the likelihood of) errors being made during the learning process. • Avoid trial and error learning or attempting to learn from ones mistakes • Compensate for the memory deficit by providing the person with the right answer from the start and prevent mistaken guesses.

20. Errorless Learning • When the right answer is not given and the individual is forced to guess or “figure out” the answer, errors are likely to result. When wrong answers are repeated, the person may learn the wrong answer (i.e. reinforced) instead of learning the correct information. • Errorless learning is not an intervention or treatment but rather a principle of learning • i.e. cueing instead of quizzing during transfer practice

21. Impairments associated with ABI & Strategies

22. SYMPTOMS OF ABI: COGNITION • New Learning • Attention and Concentration • Memory • Organization • Perception • Reasoning • Problem Solving • Initiation

23. New Learning • New material in small amounts • Repeat and summarize previous relevant info • Offer varied opportunities to use info • Use relevant & meaningful examples • Check comprehension frequently • Allow additional time • Errorless Learning

24. Attention & Concentration • Consistent, predictable, regular routines • Limit distractions (e.g. doors, windows, other students media) • Redirect • Provide breaks • Monitor for signs of decreased attention/concentration (redirect, cue, allow for rest)

25. Memory • Links to prior knowledge • Categorize or “chunk” info into small amounts • Repetition, repetition, repetition… • Memory aids (e.g. sticky notes, phones apps…) • Cues (visual, verbal, physical) • Rhymes, songs

26. How dinosaurs became extinct!

27. Organization • Establish & maintain daily routines • Daily Schedule • Provide outlines & check for note taking • Cue “I will give you a moment to write that down, put that in your calendar/phone” • Use checklists • Repetition, repetition, repetition…

28. Perception - Vision • Visual Stimulation (e.g. over/under stimulation, clutter) • Use arrows/highlighters • Contrast colours to encourage important information to be identified

29. VISUAL CONTRAST LOW CONTRAST HIGH CONTRAST

30. Perception - Auditory • Limit excess noise (e.g. lower voices) • Establish clear eye contact • Be clear and specific, check for understanding • Use non-verbal cues

31. Reasoning • Provide concrete examples • Allow them to do the task whenever possible • Be direct “Lets review your plan (Goal/plan/do/review), how did that work out for you?” • Set up opportunities to learn elsewhere (e.g. at home)

32. Problem Solving • Frequent feedback • Compensate (lists of options) • Step by step (e.g.“ok you checked off the first thing on the list, next it says you will….” “hmmm, you have completed step 1, step 2 says…”) • “What do you think about? Could you?” • Plan ahead, role play scenarios • Develop Scripts (e.g. no answer for test)

33. Initiation • Cues (verbal, visual, physical) • Schedule/journals/apps/reminders • Give options, lead (“you got your pencil and the paper…) • Structure, predictability, routine

34. ABI SYMPTOMS:BEHAVIOUR/EMOTION • Agitation/frustration • Disinhibition • Aggression • Poor social behaviour & poor awareness of consequences to actions • Depression/Self Image

35. Frustration • Allow opportunities for success • Identify antecedents to frustration • Chunk work into smaller manageable parts • Provide alternatives to acting out • Take a break • Recognize symptoms and feelings

36. Disinhibition • Provide chance for open, safe, communication, • Respond consistently (e.g. script), respectfully and clearly • If possible practice ahead of time • When possible be context specific • Use script to respond when inappropriate

37. Aggression • Be aware of signs of escalation • Use redirection • Be calm and aware of your body language • Cue them to increase awareness of their feelings ( “I sense you may be frustrated”) • Manage triggers (e.g. overstimulation: noise, light, colours, fatigue)

38. Social Behaviours • Provide opportunities to practice appropriate behaviours • Be direct, specific, non-judgmental • Create Scripts • Set social goals • Role model/role play

39. Depression & Self Image • Focus on abilities, avoid comparisons to pre-injury “self” • Validate emotions and work on changing them • Recognize symptoms: withdrawal, lethargy, lack of interest in appearance, feelings of hopelessness • Liaise with family, friends, health care professionals

40. ABI SYMPTOMS:PHYSICAL • Pain/discomfort, FATIGUE, Seizures, Sleep Disturbances, Headache and/or Tinnitus • Sensory disturbances • Musculoskeletal issues • Poor environment/person fit • Visual field neglect

41. Physical • Cognitive and Physical Fatigue • Allow for rest, shorter days, frequent breaks • Seizures • Educate on protocols, monitor, log, aware of med side effects • Sleep • Insomnia or excess, need for “naps”, everyday predictable routines

42. Physical continued… • Fine Motor • Use computer, reduce written work, verbalize, time extensions • Mobility • Seating issues, adaptive equipment, accessibility • Self Care • Cue if necessary • Visual field neglect • Seating, large print, other modalities

43. Transfer of Training • “If you want people to learn something teach it to them. Don’t teach them something else and expect them to figure out what you really want them to do.” - Thorndike • Teach what needs to be learned in the context of when and where it will be used • Everyday functional activities are the best context for cognitive intervention

44. Positive Everyday Supportive Routines (PESR) • Positive: Successful and Supported • Everyday: In the context of everyday life, supported by everyday people, using functional teaching goals • Support: Social collaborative, goal-oriented work, in a natural context • Routine: Habit, organized scripts and supports in the context of everyday life

45. Basic Principles of PESR • The person is the core of all intervention and support efforts • Interventions and supports are organized around personally meaningful activities with everyday people (person, teachers, classmates, family, friends etc) • Positive everyday routines are the context for pursuit of meaningful goals

46. Basic Principles of PESR • Reduction of supports is part of the plan • Feedback is context sensitive and meaningful • Components of life must be integrated • Assessment is ongoing and context sensitive • Behavioral concerns are addressed via positive behavioral supports

47. Importance of Routines: • Routines have a positive impact on • Independence • Problem Solving • Planning • Organization • Learning (i.e. able to learn physio exercises but can not remember am care)

48. Everyday: • Find out what is meaningful to them and explain everyday things to them (i.e. their progress, a procedure and so on) in that context • Examples: NASCAR, Electrical Work

49. Steps to Organize Routines 1. Identify successful and unsuccessful routines of everyday life. What’s working, what’s not working? 2. Identify changes that have the potential to transform unsuccessful routines into successful routines (including changes in the environment and the behaviors of others.)

50. Steps to Organize Routines 3. Identify how changes in routines include activities that are motivating to the person. 4. Implement needed supports to organize routines so that the individual experiences success and receives intensive practice in context. 5. Gradually withdraw supports and expand contexts as much as possible.