Interventions for Cognitive Dysfunction of Persons with Traumatic Brain Injuries OT 460A

11/16/09OT 460A2 Remedial Approach Also called Cognitive Retraining Focuses on cognitive domains, e.g., attention, that are identified through assessments Belief is that cognitive skills can be dealt with in isolation Interventions consist of cognitive exercises, e.g., computer programs, are used to work on deficits Progress is measured through measuring percentage correct and speed of performance

11/16/09OT 460A3 Graded Cognitive Exercises Abreu and Toglia’s (1987) recommendation to gradually increase demands on the information processing system Interventions consist of pencil and paper tasks such as mazes and work sheets Computer-based activities and board games are also used.

11/16/09OT 460A4 Cognitive Remediation Strategies Pencil and Paper and Tabletop Activities –“Drill and practice” tasks, mazes, work sheets –Computer-based exercises Offers repetition and consistency There is specialized cognitive remediation software that offer assessment and intervention Effectiveness hasn’t been well supported empirically –Some studies demonstrating correlation between drill and practice strategies and improvement in attention and memory –May be secondary gain of facilitating initial acceptance of disability (See Practice 29-1 on p. 756 for examples of interventions to improve self-awareness

11/16/09OT 460A5 Adaptive Strategies Change the context so as to lower the cognitive demands –Physical context: Examples: Use labels on drawers; decrease visual stimulation –Social context: Example: Teaching loved ones dignified methods for prompting and cueing

11/16/09OT 460A6 Adaptive Strategies Establish Behavioral Routines and Habits –Loss of effortless predictability has profound impact on energy level and sense of continuity, competence, and self –Habit learning: Form of implicit learning Includes “automaticity”: the ability to perform a skilled task with minimal or no processing resources Context and encoding are associated; so, if you change the context, the person may not be able to retrieve the task-relevant information

11/16/09OT 460A7 Adaptive Strategies Guidelines for establishing behavioral routines and habits –Select target of intervention –Analyze physical and social contexts in which the routine is expected to occur –Complete a task analysis –Collaborate with client and significant others to decide optimal sequence of steps and the use of chaining, prompting, and reinforcement –Facilitate consistent repetition of routine beyond mastery to promote overlearning

11/16/09OT 460A8 Adaptive Strategies Learn compensatory strategies –Includes the use of aids, devices, and thinking techniques in multiple contexts –Use of Toglia’s Dynamic Interactional Model of Cognition: cognition is a product of the dynamic interactions between the person, the activity, and the environment

11/16/09OT 460A9 Adaptive Strategies The General Model for Learning Compensatory Strategies –Organized around 4 training phases: Anticipation: experience consequences of cognitive deficits Acquisition: use of drill and practice exercises to learn compensatory tool or strategy Application: use of compensatory strategies during clinic- based simulated work tasks Adaptation: strategy is adapted to personal preferences and multiple applications in real life

11/16/09OT 460A10 Adaptive Strategies Internal Information-Processing Strategies: –Teach client to use mental strategies that facilitate encoding and storage of information –Techniques are similar to remedial approach and include strategies like rehearsal, visual imagery, semantic elaboration (see Table 29-4– it may help you with your study habits!)

11/16/09OT 460A11 Adaptive Strategies Memory Prostheses –Include day planners, diaries, memory notebooks (some studies demonstrate effectiveness of use of memory notebooks) –Did you know that you were using a prosthesis everyday? –In order for the use of this to be successful, the client must carry it with her, religiously record information in appropriate sections, and look at it regularly during the day

11/16/09OT 460A12 Adaptive Strategies Other Memory Prostheses –Alarm watches, pagers, phones –Can be used for occupations like medication management –Client factors and not clinician preferences should be the most important determinants of selection of devices

11/16/09OT 460A13 Adaptive Strategies Problem-Solving & Decision-making skills are comprised of: –A Situation (task, environment, and person) –A Process: Problem definition Evaluation of alternative solutions Determining and implementing a plan Evaluating the results of a implementation

11/16/09OT 460A14 Adaptive Strategies Strategies for minimizing the demands on problem solving: –Change the environment –Establish consistent routines –Employ problem solving schemas Means-end analysis IDEAL Problem Solver

11/16/09OT 460A15 Adaptive Strategies Strategies for minimizing the demands on problem solving –Means-Ends Analysis (Divide and Conquer ) Used to organize multi-step, unstructured projects Involves a 4 step process: –List the major task components –Write down sub-steps under each component –Number the sub-steps –Determine deadlines

11/16/09OT 460A16 Adaptive Strategies Strategies for minimizing the demands on problem solving: –IDEAL Problem Solver involves 5 steps: Identify the problem Define the problem Evaluate all possible solutions Act Look back

11/16/09OT 460A17 What Does the Evidence Tell Us? Strategy training can be successful for some clients in the post-acute phase of TBI, but there is insufficient evidence to support use of it in acute or inpatient phases Compensatory training using notebooks, electronic devices, and internal strategies are most successful when applied to functional situations

11/16/09OT 460A18 What Does the Evidence Tell Us? Training where problem-solving strategies are applied to functional situations is recommended in the post-acute phase There is no evidence for effectiveness of interventions to restore memory function in clients with severe impairments Therapists need to be involved where there is sole reliance on repeated exposure and practice on computer-based and workbook tasks