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

Presented by:Presented by:

Kim MacNeilKim MacNeil

Occupational TherapistOccupational Therapist

April 2012April 2012

OutlineOutline

A little about the brainA little about the brain What is an Acquired Brain Injury What is an Acquired Brain Injury

(ABI)?(ABI)? Recognizing symptoms of ABI and Recognizing symptoms of ABI and

strategies to work withstrategies to work with Positive Everyday RoutinesPositive Everyday Routines Hypothesis TestingHypothesis Testing

THE BRAINTHE BRAIN

The BrainThe Brain

ANATOMY: The Brain ANATOMY: The Brain

NEURONNEURON

NEURONS:NEURONS: It’s grey and white It’s grey and white

ANATOMY: The SkullANATOMY: The Skull

The Brain in BedThe Brain in Bed The Brain’s BedThe Brain’s Bed

What is an Acquired What is an Acquired Brain Injury (ABI)?Brain Injury (ABI)? Traumatic Brain Injury – result of Traumatic Brain Injury – result of

external traumaexternal trauma fall, car accident, fight, gun shot, fall, car accident, fight, gun shot,

Non-traumatic – result of internal Non-traumatic – result of internal source injuring the brainsource injuring the brain

Hypoxia (lack of oxygen) - near drowning, Hypoxia (lack of oxygen) - near drowning, heart attack, “fainting game”, stroke (block)heart attack, “fainting game”, stroke (block)

Toxicity, meningitis, rabies, infection, stroke Toxicity, meningitis, rabies, infection, stroke (bleed)(bleed)

NEURONS & BRAIN NEURONS & BRAIN INJURYINJURY

Focal (LOCAL) VS Focal (LOCAL) VS Global (DIFFUSE) Global (DIFFUSE) Effects:Effects: Coup Contra coup Coup Contra coup Acceleration & DecelerationAcceleration & Deceleration Rotational & ShearingRotational & Shearing Hematoma’sHematoma’s EdemaEdema Disruption of neural connectionDisruption of neural connection

Did you know:Did you know:

Level of severity is not necessarily Level of severity is not necessarily directly related to outcomedirectly related to outcome

A concussion is a brain injury tooA concussion is a brain injury too Don’t have to loose consciousness Don’t have to loose consciousness

to sustain a brain injuryto sustain a brain injury Younger is not necessarily better Younger is not necessarily better

when it comes to recoverywhen it comes to recovery

NS Leading way in NS Leading way in preventing ABIpreventing ABI

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

Recovery/Long Term Recovery/Long Term EffectsEffects Most (but not all) recovery occurs Most (but not all) recovery occurs

within first 2 years within first 2 years Area and extent of damageArea and extent of damage Physical recoveryPhysical recovery IndividualIndividual EnvironmentEnvironment

HOPEHOPE

Outcomes varyOutcomes vary Severity of injury does not always Severity of injury does not always

coincide with severity symptomscoincide with severity symptoms To have hope is to envision To have hope is to envision

something beyond what is…therefore something beyond what is…therefore there is a goal to work towards. there is a goal to work towards. Break it up into smaller achievable Break it up into smaller achievable goals and work on them one day at a goals and work on them one day at a time. time.

Invisible Injuries of the Invisible Injuries of the Brain Brain

By Debbie Wilson By Debbie Wilson ( survivor ( survivor from Murphysboro, Illinois)from Murphysboro, Illinois)

Critical factors for Critical factors for successful successful reintegration:reintegration:

– EDUCATION of persons involved EDUCATION of persons involved regarding brain injuryregarding brain injury

– OPEN COMMUNICATION between all OPEN COMMUNICATION between all persons involvedpersons involved

Previous Approaches:Previous Approaches:

Common mistakes include: quizzing Common mistakes include: quizzing people, and allowing people to make people, and allowing people to make the same mistakes over and over the same mistakes over and over again “so they will learn from their again “so they will learn from their mistakes”mistakes”

Previously gave lists to remember then Previously gave lists to remember then “tested” later“tested” later

Errorless LearningErrorless Learning

Methods of learning whereby attempts Methods of learning whereby attempts are made to prevent (or reduce the are made to prevent (or reduce the likelihood of) errors being made during likelihood of) errors being made during the learning process.the learning process.

Avoid trial and error learning or Avoid trial and error learning or attempting to learn from ones mistakesattempting to learn from ones mistakes

Compensate for the memory deficit by Compensate for the memory deficit by providing the person with the right providing the person with the right answer from the start and prevent answer from the start and prevent mistaken guesses. mistaken guesses.

Errorless LearningErrorless Learning

When the right answer is not given and the When the right answer is not given and the individual is forced to guess or “figure out” individual is forced to guess or “figure out” the answer, errors are likely to result. When the answer, errors are likely to result. When wrong answers are repeated, the person wrong answers are repeated, the person may learn the wrong answer (i.e. reinforced) may learn the wrong answer (i.e. reinforced) instead of learning the correct information. instead of learning the correct information.

Errorless learning is not an intervention or Errorless learning is not an intervention or treatment but rather a principle of learningtreatment but rather a principle of learning

i.e. cueing instead of quizzing during i.e. cueing instead of quizzing during transfer practice transfer practice

Impairments associated Impairments associated with ABI & Strategieswith ABI & Strategies

SYMPTOMS OF ABISYMPTOMS OF ABI: : COGNITIONCOGNITION

New LearningNew Learning Attention and Attention and

ConcentrationConcentration Memory Memory OrganizationOrganization PerceptionPerception ReasoningReasoning Problem SolvingProblem Solving InitiationInitiation

New LearningNew Learning

New material in small amountsNew material in small amounts Repeat and summarize previous Repeat and summarize previous

relevant inforelevant info Offer varied opportunities to use infoOffer varied opportunities to use info Use relevant & meaningful examplesUse relevant & meaningful examples Check comprehension frequentlyCheck comprehension frequently Allow additional timeAllow additional time Errorless LearningErrorless Learning

Attention & Attention & Concentration Concentration Consistent, predictable, regular Consistent, predictable, regular

routinesroutines Limit distractions (e.g. doors, windows, Limit distractions (e.g. doors, windows,

other students media)other students media) RedirectRedirect Provide breaksProvide breaks Monitor for signs of decreased Monitor for signs of decreased

attention/concentration (redirect, cue, attention/concentration (redirect, cue, allow for rest) allow for rest)

Memory Memory

Links to prior knowledgeLinks to prior knowledge Categorize or “chunk” info into small Categorize or “chunk” info into small

amountsamounts Repetition, repetition, repetition…Repetition, repetition, repetition… Memory aids (e.g. sticky notes, Memory aids (e.g. sticky notes,

phones apps…)phones apps…) Cues (visual, verbal, physical)Cues (visual, verbal, physical) Rhymes, songsRhymes, songs

How dinosaurs became extinct!

OrganizationOrganization

Establish & maintain daily routinesEstablish & maintain daily routines Daily ScheduleDaily Schedule Provide outlines & check for note Provide outlines & check for note

takingtaking Cue “I will give you a moment to Cue “I will give you a moment to

write that down, put that in your write that down, put that in your calendar/phone”calendar/phone”

Use checklistsUse checklists Repetition, repetition, repetition…Repetition, repetition, repetition…

Perception - VisionPerception - Vision

Visual Stimulation (e.g. Visual Stimulation (e.g. over/under stimulation, clutter)over/under stimulation, clutter)

Use arrows/highlightersUse arrows/highlighters Contrast colours to encourage Contrast colours to encourage

important information to be important information to be identifiedidentified

VISUAL CONTRASTVISUAL CONTRAST

LOW CONTRASTLOW CONTRAST HIGH CONTRASTHIGH CONTRAST

Perception - AuditoryPerception - Auditory

Limit excess noise Limit excess noise (e.g. lower voices)(e.g. lower voices)

Establish clear Establish clear eye contacteye contact

Be clear and Be clear and specific, check for specific, check for understandingunderstanding

Use non-verbal Use non-verbal cuescues

ReasoningReasoning

Provide concrete examplesProvide concrete examples Allow them to do the task Allow them to do the task

whenever possiblewhenever possible Be direct “Lets review your plan Be direct “Lets review your plan

(Goal/plan/do/review), how did (Goal/plan/do/review), how did that work out for you?”that work out for you?”

Set up opportunities to learn Set up opportunities to learn elsewhere (e.g. at home)elsewhere (e.g. at home)

Problem SolvingProblem Solving

Frequent feedbackFrequent feedback Compensate (lists of options)Compensate (lists of options) Step by step (e.g.“ok you checked off Step by step (e.g.“ok you checked off

the first thing on the list, next it says the first thing on the list, next it says you will….” “hmmm, you have you will….” “hmmm, you have completed step 1, step 2 says…”)completed step 1, step 2 says…”)

““What do you think about? Could you?”What do you think about? Could you?” Plan ahead, role play scenariosPlan ahead, role play scenarios

– Develop Develop ScriptsScripts (e.g. no answer for test) (e.g. no answer for test)

InitiationInitiation

Cues (verbal, visual, physical)Cues (verbal, visual, physical) Schedule/journals/apps/remindersSchedule/journals/apps/reminders Give options, lead (“you got your Give options, lead (“you got your

pencil and the paper…)pencil and the paper…) Structure, predictability, routineStructure, predictability, routine

ABI SYMPTOMS:ABI SYMPTOMS:BEHAVIOUR/EMOTIONBEHAVIOUR/EMOTION

Agitation/frustrationAgitation/frustration DisinhibitionDisinhibition AggressionAggression Poor social behaviour & poor Poor social behaviour & poor

awareness of consequences to awareness of consequences to actionsactions

Depression/Self Image Depression/Self Image

FrustrationFrustration

Allow opportunities for successAllow opportunities for success Identify antecedents to frustrationIdentify antecedents to frustration Chunk work into smaller Chunk work into smaller

manageable partsmanageable parts Provide alternatives to acting outProvide alternatives to acting out Take a breakTake a break Recognize symptoms and feelingsRecognize symptoms and feelings

DisinhibitionDisinhibition

Provide chance for open, safe, Provide chance for open, safe, communication, communication,

Respond consistently (e.g. script), Respond consistently (e.g. script), respectfully and clearlyrespectfully and clearly

If possible practice ahead of timeIf possible practice ahead of time When possible be context specificWhen possible be context specific Use script to respond when Use script to respond when

inappropriateinappropriate

AggressionAggression

Be aware of signs of escalationBe aware of signs of escalation Use redirectionUse redirection Be calm and aware of your body Be calm and aware of your body

languagelanguage Cue them to increase awareness of Cue them to increase awareness of

their feelings ( “I sense you may be their feelings ( “I sense you may be frustrated”)frustrated”)

Manage triggers (e.g. overstimulation: Manage triggers (e.g. overstimulation: noise, light, colours, fatigue)noise, light, colours, fatigue)

Social BehavioursSocial Behaviours

Provide opportunities to practice Provide opportunities to practice appropriate behavioursappropriate behaviours

Be direct, specific, non-Be direct, specific, non-judgmentaljudgmental

Create Create ScriptsScripts Set social goalsSet social goals Role model/role playRole model/role play

Depression & Self Depression & Self ImageImage Focus on abilities, avoid comparisons Focus on abilities, avoid comparisons

to pre-injury “self”to pre-injury “self” Validate emotions and work on Validate emotions and work on

changing themchanging them Recognize symptoms: withdrawal, Recognize symptoms: withdrawal,

lethargy, lack of interest in lethargy, lack of interest in appearance, feelings of hopelessnessappearance, feelings of hopelessness

Liaise with family, friends, health care Liaise with family, friends, health care professionalsprofessionals

ABI SYMPTOMS:ABI SYMPTOMS:PHYSICALPHYSICAL

Pain/discomfort, FATIGUE, Pain/discomfort, FATIGUE, Seizures, Sleep Disturbances, Seizures, Sleep Disturbances, Headache and/or TinnitusHeadache and/or Tinnitus

Sensory disturbancesSensory disturbances Musculoskeletal issuesMusculoskeletal issues Poor environment/person fitPoor environment/person fit Visual field neglectVisual field neglect

PhysicalPhysical

Cognitive and Physical FatigueCognitive and Physical Fatigue– Allow for rest, shorter days, frequent Allow for rest, shorter days, frequent

breaksbreaks SeizuresSeizures

– Educate on protocols, monitor, log, Educate on protocols, monitor, log, aware of med side effectsaware of med side effects

SleepSleep– Insomnia or excess, need for “naps”, Insomnia or excess, need for “naps”,

everyday predictable routineseveryday predictable routines

Physical continued…Physical continued…

Fine MotorFine Motor– Use computer, reduce written work, Use computer, reduce written work,

verbalize, time extensionsverbalize, time extensions MobilityMobility

– Seating issues, adaptive equipment, Seating issues, adaptive equipment, accessibilityaccessibility

Self CareSelf Care– Cue if necessaryCue if necessary

Visual field neglect Visual field neglect – Seating, large print, other modalitiesSeating, large print, other modalities

Transfer of TrainingTransfer of Training

““If you want people to learn something If you want people to learn something teach it to them. Don’t teach them teach it to them. Don’t teach them something else and expect them to figure something else and expect them to figure out what you really want them to do.”out what you really want them to do.”- Thorndike- Thorndike

Teach what needs to be learned in the Teach what needs to be learned in the context of when and where it will be usedcontext of when and where it will be used

Everyday functional activities are the best Everyday functional activities are the best context for cognitive interventioncontext for cognitive intervention

Positive Everyday Positive Everyday Supportive Routines Supportive Routines (PESR)(PESR) PositivePositive: Successful and Supported: Successful and Supported EverydayEveryday: In the context of everyday : In the context of everyday

life, supported by everyday people, life, supported by everyday people, using functional teaching goalsusing functional teaching goals

SupportSupport: Social collaborative, goal-: Social collaborative, goal-oriented work, in a natural contextoriented work, in a natural context

RoutineRoutine: Habit, organized scripts and : Habit, organized scripts and supports in the context of everyday supports in the context of everyday lifelife

Basic Principles of Basic Principles of PESRPESR The person is the core of all The person is the core of all

intervention and support effortsintervention and support efforts Interventions and supports are Interventions and supports are

organized around personally organized around personally meaningful activities with everyday meaningful activities with everyday people (person, teachers, classmates, people (person, teachers, classmates, family, friends etc)family, friends etc)

Positive everyday routines are the Positive everyday routines are the context for pursuit of meaningful goalscontext for pursuit of meaningful goals

Basic Principles of Basic Principles of PESRPESR Reduction of supports is part of the Reduction of supports is part of the

planplan Feedback is context sensitive and Feedback is context sensitive and

meaningfulmeaningful Components of life must be integratedComponents of life must be integrated Assessment is ongoing and context Assessment is ongoing and context

sensitivesensitive Behavioral concerns are addressed via Behavioral concerns are addressed via

positive behavioral supportspositive behavioral supports

Importance of Importance of Routines:Routines: Routines have a positive impact onRoutines have a positive impact on

– IndependenceIndependence– Problem SolvingProblem Solving– PlanningPlanning– OrganizationOrganization– Learning (i.e. able to learn physio Learning (i.e. able to learn physio

exercises but can not remember am exercises but can not remember am care)care)

Everyday:Everyday:

Find out what is meaningful to Find out what is meaningful to them and explain everyday things them and explain everyday things to them (i.e. their progress, a to them (i.e. their progress, a procedure and so on) in that procedure and so on) in that contextcontext

Examples: NASCAR, Electrical Examples: NASCAR, Electrical WorkWork

Steps to Organize Steps to Organize Routines Routines 1.1.Identify successful and unsuccessfulIdentify successful and unsuccessful

routines of everyday life. What’sroutines of everyday life. What’sworking, what’s not working?working, what’s not working?

2.2.Identify changes that have the potentialIdentify changes that have the potentialto transform unsuccessful routines intoto transform unsuccessful routines intosuccessful routines (including changessuccessful routines (including changesin the environment and the behaviors in the environment and the behaviors of others.)of others.)

Steps to Organize Steps to Organize RoutinesRoutines3.3.Identify how changes in routines includeIdentify how changes in routines include

activities that are motivating to the activities that are motivating to the person.person.

4.4.Implement needed supports to organize Implement needed supports to organize routines so that the individual experiences routines so that the individual experiences success and receives intensive practice insuccess and receives intensive practice incontext.context.

5. Gradually withdraw supports and expand 5. Gradually withdraw supports and expand contexts as much as possible.contexts as much as possible.

GoalGoal

PlanPlan

DoDoReviewReview

PredictPredict

Hypothesis TestingHypothesis Testing

• Common sense approach of Common sense approach of systematically teasing out what systematically teasing out what contributes to failure and what contributes to failure and what contributes to success. contributes to success.

• Poor performance happens for many Poor performance happens for many reasons, we can perform well by reasons, we can perform well by applying many different supports applying many different supports and strategiesand strategies

Steps to Hypothesis Steps to Hypothesis testing: testing:

Identify a problemIdentify a problemFormulate all hypothesisFormulate all hypothesisSelect a hypothesis Select a hypothesis Test hypothesisTest hypothesisReview resultsReview results

ScriptsScripts

Scripts structure involvement / Scripts structure involvement / interaction with promote procedural interaction with promote procedural learning (steps to do, knowing how learning (steps to do, knowing how to do it, automatic)to do it, automatic)

Conversation non-threateningConversation non-threatening Well selected languageWell selected language Mass practiceMass practice Embedded in meaningful activities Embedded in meaningful activities Across everyday partners (team, Across everyday partners (team,

family…)family…)

ScriptsScripts

Positives:Positives:– Allows people to think out loudAllows people to think out loud– Gain self awarenessGain self awareness– Coach person to be their own Coach person to be their own

coachcoach– Facilitates typical development of Facilitates typical development of

executive functions (Higher level executive functions (Higher level cognitive tasks such as problem cognitive tasks such as problem solving, reasoning, attention, self solving, reasoning, attention, self awareness…)awareness…)

ScriptsScripts

Scripts may be used for different Scripts may be used for different daily interactions including:daily interactions including:– Orientation ScriptOrientation Script– Problem SolvingProblem Solving– BehaviouralBehavioural– Big deal/Little DealBig deal/Little Deal– Experimental RoutineExperimental Routine

Example: OrientationExample: Orientation

Say “Hi _Say “Hi _insert persons name __insert persons name __, it is a , it is a ___weather_____weather__(i.e. fairly mild day) for (i.e. fairly mild day) for December __. I can’t believe Christmas December __. I can’t believe Christmas is in only_____ days. The year 2004 is is in only_____ days. The year 2004 is almost over. I know you have been almost over. I know you have been meeting many people since you came meeting many people since you came into the hospital on October 16 so you into the hospital on October 16 so you may not remember me. My name is may not remember me. My name is ____________ I am your _____________ ____________ I am your _____________ (i.e. friend from __________, your (i.e. friend from __________, your therapist…). I just came by to see if therapist…). I just came by to see if …….”…….”

Contextualized CollaborativeContextualized CollaborativeHypothesis-TestingHypothesis-Testing

What’s the problem?What’s the problem?(Using the two strangers in the doorway rule)

Hypothesis FormulationHypothesis Formulation(Why is s/he doing this?)

Hypothesis SelectionHypothesis Selection(Begin with easiest to test

or most obvious)

Hypothesis TestingHypothesis Testing(Protocol for experimentation

Plan A - Plan B - Plan CTesting time line)

Summary of Summary of CLASSROOM CLASSROOM STRATEGIESSTRATEGIES Emphasize functionEmphasize function Provide low stimulus environmentProvide low stimulus environment Role play socially appropriate behRole play socially appropriate beh Assist with organizational skills and Assist with organizational skills and

attention to taskattention to task Allow for frequent breaks and restsAllow for frequent breaks and rests Allow for extra timeAllow for extra time Repeat new information frequentlyRepeat new information frequently Maximize opportunity to practice new skillsMaximize opportunity to practice new skills

Summary of Summary of CLASSROOM CLASSROOM STRATEGIES cont…STRATEGIES cont… Prepare ahead of time for transitionsPrepare ahead of time for transitions Recognize signs of frustration and assist in Recognize signs of frustration and assist in

decreasingdecreasing Consistent and predictable routinesConsistent and predictable routines Clear expectationsClear expectations Focus on positive everyday supportive Focus on positive everyday supportive

routinesroutines Communicate regularly with stakeholdersCommunicate regularly with stakeholders Become informed about ABIBecome informed about ABI

Just because…Just because…

One strategy is learned doesn’t One strategy is learned doesn’t mean it will be used again OR mean it will be used again OR generalized to other tasksgeneralized to other tasks

Someone can tell you all the Someone can tell you all the steps to complete a task it steps to complete a task it doesn’t mean they can do itdoesn’t mean they can do it

Patience, Flexibility, & Patience, Flexibility, & ForgivenessForgiveness

References:References:

Bennett, Dr. S., Good, Dr. D., Kumpf, J., (2003). Bennett, Dr. S., Good, Dr. D., Kumpf, J., (2003). Educating Educating Educators about ABI. Educators about ABI. Brock University and the Ontario Brain Brock University and the Ontario Brain Injury Association. Injury Association.

Wilson, D. Invisible injury of the brain. Wilson, D. Invisible injury of the brain. Newsletter of the Brain Newsletter of the Brain Injury Association of Canada Injury Association of Canada (2012, February). Retrieved (2012, February). Retrieved from from http://biac-aclc.ca/en/category/newsletters-biac-impact-pathways-ahead/

Ylvisaker, M. & Feeney, J. T. (1998). Ylvisaker, M. & Feeney, J. T. (1998). Collaborative Brain Injury Collaborative Brain Injury Intervention: Positive everyday routines.Intervention: Positive everyday routines. Singular Publishing Singular Publishing Group, Inc. San Diego, CAGroup, Inc. San Diego, CA

Websites:Websites:

Brain Injury Association of Canada: http://biac-aclc.ca/Brain Injury Association of Canada: http://biac-aclc.ca/

Brain Injury Association of Nova Scotia: http://biac-aclc.ca/en/Brain Injury Association of Nova Scotia: http://biac-aclc.ca/en/

Learnnet: Learnnet: http://www.projectlearnet.org/