Cognitive Rehabilitation in practice Steve Shears MSc

Headway UK – the brain injury association Headway UK – a registered charitable organisation in the UK supporting and providing information to people living with acquired brain injury and their relatives. We also provide information and training about acquired brain injury to health and social care professionals. We deliver this service through a network of 117 local support groups in all four countries of the UK. We are involved in bridging the gap between the excellent work done by acute medicine to save people following brain injury and cognitive rehabilitation services.

Aims for today To consider aspects of assessment and treatment of cognitive problems and how the client’s emotional needs should be part of a holistic assessment and treatment programme.

My role in Headway I head the training services but also see people for psychotherapy who are having problems with the psychological adjustment to their brain injury. I also see partners and relatives of people living with brain injury. I have a specialised interest and training in psychosexual therapy and I am interested in sexuality and relationships as a rehabilitation concern following acquired brain injury (Baker, M and Shears, S 2010) I need to modify my therapeutic approach in order to engage clients with cognitive deficits.

Key brain sites and implications for injury.

Key issues in neurorehab Restoration versus Compensation. 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.

Cognitive problems – like those in our everyday lives but more frequent?

Had any of these in the past week? In the past week have you had an experience of:- Getting to the top of the stairs (or anywhere) and have forgotten why you went there? Knowing that you knew the same 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.

A quote “We do not lack cognitive rehabilitative strategies following brain injury. In the last few decades we have developed a lot of them. It is getting patients/clients to do them that is the challenge” Rick Parente PhD His talk at a cognitive rehabilitation conference in Denver was subtitled ‘stuff we tried in brain injury rehab over the past 25 years and it worked!’ A key factor was a person-centred approach of the client seeing it as something that solved a problem for them –therefore they might be more motivated towards achieving their goals. Clear goals are an important part of treatment.

Holistic Assessment and Treatment It is helpful to have a through assessment, clear goals and multidisciplinary input but the cognitive rehabilitation might not be successful if the client’s emotional needs are not addressed (Prigatano 2002). This is particularly salient when some researchers have said that a significant proportion of people living with brain injury are suffering from depression and anxiety (Wilson et al 2009) As cognition improves due to rehabilitation people may also become more aware of their deficits and changes to their lives thus increasing anxiety and depression.

Cognitive Rehabilitation Therapy 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. (Wilson et al 2009) 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.

Case 1 – Ian – Hidden Disability Synopsis 28 year old man knocked down by a car when crossing the road. Unconscious for three days. Treated in hospital in an acute medical ward and required surgery for broken bones. Released home and treated for Post Trauma Stress by psychological therapist. Brain Injury element not followed up on. Referred to me for seven week anxiety management course for residual effects of post trauma stress.

Ian (Continued) Treatment (7 Sessions) Education and information about causes and effects of acquired brain injury. Videoing of sessions to reinforce points discussed in sessions - due to his attention and memory problems Ian had a copy of the sessions to review at home. Development of cognitive strategies to help Ian compensate for his memory problems at work. Anxiety management strategies to use at work. Self monitoring sheets for Ian to use regarding his anger management. Counselling for the emotional adjustment issues related to his awareness that he had a brain injury. Referral to neuropsychology and neurology.

Case 2 - Heather Synopsis Sub-arachnoid haemorrhage Damage to frontal lobe and hypothalamus areas. Alteration in executive function and hypersexuality with behavioural problems and risk-taking behaviours due to poor insight and impulse control.

Heather (Continued) Treatment (Over a five year period) Medication to lower libido and hormone replacement. Education for Heather about her brain injury. Behavioural therapy aimed at reducing incidences of inappropriate behaviour. Supervision Whole family/friendship networks educated to give consistent response to Heather’s behaviour. Husband was very involved in co-ordinating this. Counselling for Heather to deal with her emotional adjustment to the loss of her pre- injury self and status. Social Services have now involved Heather in a volunteer training programme and this is meeting her vocational needs. Her insight and behaviour are such improved now.

Conclusion Holistic assessment and treatment incorporating cognitive rehabilitation therapy and counselling support can lead to better outcomes for clients following acquired brain injuries.

References Baker, M and Shears, S (2010) Sexuality training for health and social care professionals working with people with an acquired brain injury. Social Care and Neurodisability Volume 1 Issue 3 November 2010 © Pier Professional Ltd Parente, R (2007) Society of Cognitive Rehabilitation Conference, Westminster, Denver, Colorado Powell, T (2004) Head Injury – A Practical Guide, Speechmark. What Do Patients Need Several Years After Brain Injury?(2002) Prigatano, G.P. Barrow Quarterly. Vol18 No2 Wilson, BA, Gracey, Evans, J, Bateman, A. (2009). Neuropsychological Rehabilitation: Theory, Therapy and Outcome. Cambridge University Press.

Web references s/Publications/PublicationsPolicyAndGuidance/D H_ (2005http:// s/Publications/PublicationsPolicyAndGuidance/D H_ (2005 (NSF Long Term Conditions- UK Department of Health Website)

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