Describe safety first with TBI patients. What should the therapist do? What should you watch out for?
- ¡Plan for the unexpected, anticipate
- ¡Organize the environment
- ¡Remove items that can be used as a weapon, projectile
- ¡Position yourself for your own safety
- ¡Watching for warning signs and take them seriously
- ¡Sensitivity to lights
- ¡Sensitivity to Sounds
- ¡Cognitive Load
- ¡Work in pairs if necessary, get help when needed
Describe interaction with TBI patients. How should voic be kept? What should be modified/limited? How often should you pause?
¡Don’t take it personally
¡Keep your voice calm and steady
¡Modify the Environment (“Quiet Environment”)
¡Limit stimulation (TV, bright lights, music, talking)
Describe working with TBI patients. What should you give them when possible? What should your instructions be? What should be reviewed? What should be redirected? What should be established?
- ¡Give choices when possible (Do you want to do speech or PT now?)
- ¡Give simple, direct instructions
- ¡Keep it simple and concrete, give facts
- ¡Review orientation information often
- ¡Redirect behaviors, perseveration
- ¡Use behavior management techniques
- ¡ABCs of behavior
- ¡Establish a reinforcement system
- ¡Establish a consistent structure (same schedule, predictable routines)
What are cognitive domains that should be assessed?
¡Following a Plan
Describe attention areas from most basic to most complex
- ¡Basic level: eye opening, eye contact, tracking/scanning (Eg. Point to the ______)
¡Sustained Attention - sorting task
- ¡Sustained Attention: Focusing on a single task for increasing intervals of time
- ¡Can be any simple, concrete task (eg. sorting task)
- ¡Initially use tasks that emphasize their strengths and interests- make sure they can be successful
- ¡Increase difficulty of task to be done and the interval in later stages
- ¡Selective Attention: focusing on a task in a busy environment
- ¡Keep the task simple
- ¡Start with a low level of background stimuli (white noise, a couple other people in the room
- Gradually increase
¡Attention Switching - listen to story, clean pieces
- ¡Attention Switching (divided/alternating attention)
- ¡Start simple
- ¡Start with two different modalities (motor task and speech task) then make modalities more similar as they progress.
- Consider memory
Describe orientation evaluation
¡Oriented x1: Oriented to Self (Person)
¡Oriented x2: Oriented to Person and to Place
¡Oriented x3: Oriented to Person, Place and Time (month, year)
¡Oriented x4: Oriented to Person, Place, time and reason for injury
¡Oriented x1: What is your name?
¡Oriented x2: Where are we?
¡Oriented x3: What month, year is it?
¡Oriented x4: Why are you in the hospital (therapy)?
Describe advanced orientation skills
¡Advanced orientation skills- advanced temporal concepts:
- ¡Oriented to day and Date
- ¡Oriented to time (with about 30 min margin of error)
- ¡What was the day before yesterday?
- ¡What is next month?
Describe memory types and assessment
- ¡PTA: GOAT, MOAT, COAT
- ¡Immediate memory: Digit span, story recall
- ¡Short-term memory: 3 word recall, Delayed story recall, Verbal learning task
- ¡Long-term: how did you meet you spouse?
- ¡Procedural memory: remembering how to do a familiar task (different from describing how to do a familiar task)
- ¡Episodic memory: recalling events, can be long-term or short-term
- ¡Prospective memory: recalling future events
Describe orientation and memory therapy. What cues should be included? What should be reviewed? What should friends and family be trained to do? What should you create?
- ¡Include environmental cues about time and place in the environment
- ¡Teach patients where to go/look to find the information
- ¡Review orientation information regularly
- ¡Train friends and families to
- ¡Introduce themselves every interaction
- ¡Re-orient frequently
- ¡Create a “Memory Book” that includes orientation information, daily schedules, family information and information about the injury
- ¡Write important information in the Memory book
- ¡Teach families to log info in the book
Describe language evaluation. What should be evaluated? What should you look for?
¡Evaluate for basic language skills (aphasia)
¡Evaluate higher level discourse skills
- ¡Topic Maintenance
- ¡Cohesion and cohesiveness of discourse
- ¡Tangential output
Describe organization evaluation and treatment. What kind of tasks?
¡Sorting tasks of increasing difficulty
¡Sequencing steps of an activity
¡Sequencing alphabetically or by other attribute (size, cost, etc.)
¡Flexibility of thinking: Organization items in multiple way
Describe planning/following a plan evaluation and treatment. What should you begin with? What tools should you use?
- ¡Begin with simple, concrete plans about daily needs (how to get help, when to use the bathroom)
- ¡Help patient both verbalize the plan and follow through with the plan
- ¡Use schedules, calendar, journal, logbook to predict future events and make decisions about daily routines
- ¡Help patient outline steps to an activity then follow the written plan
- ¡Provide structure for patient to think about long-term planning
Executive Functioning: Self-Regulation and Self-advocacy
- ¡Make abstract or implied ideas explicit and concrete (Pragmatics)
- ¡Establish a set of expectations (“Rules”)
- ¡Have the patient help identify their own rules when ever possible
- ¡Make list specific to that patient
- ¡Review ‘rules’ frequently
- ¡Set up tasks that give the patient an opportunity to use the rules.
- ¡Use ‘rules’ as a mechanism for self-assessment
Executive functioning: inhibition. How should this be addressed in therapy?
¡Should be directly addressed in therapy
¡Identify areas where impulsivity is problem
¡Set up tasks that will tempt the patient’s weakness, then provide structure so they can be successful
- ¡Don’t say this word
- ¡TMI lists
Describe insight. What is this an impaired ability to do?
- ¡Impaired ability to recognize own abilities and limitations, or relate injury to changes in functioning
- ¡May also have difficulty understanding of therapist’s role or that therapy is meant to help them
- ¡Work with neuropsychologist to identify underlying cause of decreased insight
- ¡Impaired Reasoning?
What are some high-level common complaints?
- ¡I can’t start ___ it’s just too big
- ¡I can’t figure out how to get myself dressed in the morning
- ¡I can’t get anywhere on time (often many hours late)
- ¡He used to take care of things on his own, now I have to ask him to do everything
- ¡My space is a mess and I can’t get organized
- ¡If someone interrupts me, I have to start over from the beginning
- ¡I can’t concentrate if there is too much noise, or too much going on around me
High Level Cognitive Skills, Executive Functioning. What should you find out? What should you focus on?
- ¡Find out what the person is having difficulty with
- ¡Focus on functional daily tasks and skills that generalized to difficult activities
- ¡Executive functioning
- ¡Problem Solving
- ¡Flexibility of Thinking
- ¡Establish plans, carryover and homework are key.