mTBI Leanne Elmer MS CCCSLP Division of Speech Pathology Department of Neurology April 2015 Objectives for Todays Presentation Describe 3 strategies patients with mTBI benefit from implementing each day ID: 688999
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Slide1
Cognitive Rehabilitation Strategies for Individuals with mTBI
Leanne Elmer, M.S. CCC-SLPDivision of Speech PathologyDepartment of Neurology
April, 2015Slide2
Objectives for Today’s Presentation Describe 3 strategies patients with mTBI benefit from implementing each day.
Identify which team members can help when treatment is not going as expected.Understand how mTBI impacts communication.Slide3
What?
Mayo TBI Severity Classification System(Malec, J., Brown, A.,
Leibson
, C.,
Flaada
, J. et al., 2007)Slide4
Classify as Moderate-Severe (Definite) TBI if one or more of the following criteria apply:
1. Death due to this TBI2. Loss of consciousness of 30 minutes or more3. Post-traumatic anterograde amnesia of 24 hours
or more
4. Worst Glasgow Coma Scale full score in first 24
hours <13
5. One or more of the following present:
• Intracerebral hematoma
• Subdural hematoma
• Epidural hematoma
• Cerebral contusion
• Hemorrhagic contusion
• Penetrating TBI (dura
penetrated
)
• Subarachnoid hemorrhage
• Brain Stem
InjurySlide5
If none of the previous criterion apply, classify as Mild (Probable).
1. Loss of consciousness of momentary to less than 30 minutes2. Post-traumatic anterograde amnesia of momentary to less
than 24 hours
3. Depressed, basilar or linear skull fracture (dura intact)Slide6
If none of the previous criterion apply, classify as Symptomatic (Possible) TBI if one or more of the following symptoms are present:
• Blurred vision• Confusion (mental state changes)• Dazed
• Dizziness
• Focal neurologic symptoms
• Headache
• NauseaSlide7
Who?Slide8
When?Slide9
Where?Slide10
Why?Slide11Slide12
“It is not only the kind of injury that matters, but the kind of head.”(
Mateer, Sira, and O’Connell, 2005)Slide13
How Can We Offer the Best, Evidence-Based Care?Become the expert on the patientAsk questionsObserve the patient
Use all available toolsCollaborateEducateOffer feedbackContinue to observe and ask questionsSlide14Slide15
Dave Before mTBISlide16
Dave50 y.o.MVA in January, 2014
+LOCGCS of 15Negative CTOn SLP schedule April, 2014-September, 2014Slide17
Dave After mTBISlide18
Time to Sell Cognitive RehabWe train the basics.We need to boost some skills in this season of life.Therapy won’t last forever.
You’ll improve!Take what you want, leave what you want.Slide19
Strategies for Interacting with Family/FriendsTake breaks before events.Ask questions to get into the role of the listener if I’m tired.
Use "Let me think about it," "Let's talk about it later," or "We should talk about that on (give a day),” when his son was too much.Let them know of time restrictions.Slide20
Tools We Used in TherapyTry what the rest of the world doesDifferent brain breaksE-mail/Patient Portal
Start reading manualsUse a timerTED talksList of rolesSlide21
How did we part ways?5 sessions over 5 monthsSelf-dismissal after a session with him, his wife, and the SLPE-mail/Patient PortalSlide22
Maris Before Moving to a New State with mTBISlide23
Maris53 y.o.On SLP
schedule April, 2014-February, 2015Other team members:Mental health provider in the communityNPOTPT
SW
Her brothers
Her pastorSlide24
Maris After Moving to a New State with mTBISlide25
Time to Plan DismissalDiscuss it at the time services are initiatedBe sensitive to:Her chronic condition
Her support systemHer need for follow-upEnding on a positive noteSlide26
Strategies for Improving Pragmatic LanguageWatch for getting “derailed
" in conversation (Answer the question and move on, when eating, check how much I've eaten vs. the person across from me. This helps me gauge how much I've been talking.)Reciprocate
questions in conversation
When
sending
e-mails
Double-check that I answered all of the questions
Make sure I asked questions
Check that my jokes fit the time/place/audienceSlide27
Tools We Used in TherapyTeamSpeaker phoneSpaced out appointments to accommodate family members’ schedules
E-mail with family membersTraining for communication partnersFeedbackSlide28
How did we part ways?We empowered her!E-mailLunch
Open door policySlide29
Zack Before mTBISlide30
Zack24 y.o.MVA on June 18, 2014
Probable TBIEvaluated by SLP on October 10, 20145 sessionsSlide31
Zack After mTBISlide32
Time to Change Things UpAre you writing everyday?Are you reading everyday?Are you spending any time with people?
Are you doing things you enjoy?Are you advocating for yourself?Slide33
Strategies for When Zack is Lost in ConversationSlow down.Ask for help by saying something such as "What were we talking about?"
Make a note before I forget it.Interject a quick comment such as, "Remind me to tell you about . . . "Listen for a bit in conversation to see if the idea comes back to me.Slide34
Tools We Utilized in TherapyTeamRecordingsEducation regarding “cognitive power” and taking brain breaks
Word-finding strategiesSmall giant stepsDone listTry to see “gray” instead of “black” or “white”Slide35
How did we part ways?I went to the team.Clinical Nurse SpecialistSocial Work
NeuropsychologySpeech-Language PathologyI’m keeping the door open.Slide36
Heathermarie Before mTBISlide37
Heathermarie40 y.o.MVA on January 13, 2014
Negative CTUnknown LOCPosttraumatic amnesia for accident and sometime thereafterConsult with SLP February 26, 2014Slide38
Heathermarie After mTBISlide39
Time to Hear Her OutWord-finding challengesMemory deficitsOutburstsSlide40
Strategies for When Heathermarie is Getting Back to Daily ActivitiesTake a break when I feel frustrated.
When I feel like it's time to "just push through," it's time to take a break.I can work on a project for a set amount of time and then clean it up.Taking breaks does not mean I am lazy
.
Spend time doing what I want to get better at doing.Slide41
Tools We Utilized in Therapy“Brain dump”Problem-Solving FormatGoal-Plan-Do-Review forms
5 WsFlyLadyYou Tube videos on home organizationSlow down to think about thinkingSay “yes” to somethingSlide42
How did we part ways?6 SessionsMade certain appointments with local mental health providers were scheduledReassured her that she has made excellent gains and has all of the “tools” for her “toolbox”
Advertised our open-door policySlide43
Joe Before mTBISlide44
Joe17 y.o.Concussion in June, 2012
Concussion in August, 2012Concussion in June, 2013Arrived at Mayo January, 2015Slide45
Joe After mTBISlide46
Time to Provide Excellent Customer ServiceMore information on Pain RehabTalking with someone who has been through the program
Option to come back (schedule, call or schedule and cancel)Slide47
ToolsOffer Brainline, Model Systems Knowledge Translation Center Fact Sheets, and BIAProvide education on how saying “yes” to something = saying “no” to something elseSlide48
Parting WaysNo follow-up scheduledIn touch with his fatherOption to return at any timeSlide49Slide50
The Factors I need to Assess to Give the Best Care PossibleThe patient’s communicative abilitiesThe patient’s cognitive abilities
The whole person (physical, spiritual, mental, emotional)Their life leading up to this (circumstances, hardships, life-long mental health concerns, team players, etc.)Their involvement in/outside of their home (at baseline and after injury) Slide51
How to Know if My Patient May Not be Benefitting From My TreatmentWe continually review the same information.My patient can’t report on how he/she is implementing strategies outside of therapy.
My patient wants to talk about many topics, but not specifically communication/cognition.My patient is struggling to participate in therapy week-to-week.The next step is unknown/unclear.I can’t see where our time together is leading.Slide52
When Progress Deviates from the Expected Course, I Can:Talk the case over with a colleague to get other ideas.Bring in another team member.
Find a friend/family member of the patient and train him/her on how to help.Shake things up (make a phone call in place of a visit one week, exchange e-mails, conference call with family members during therapy sessions, take a break and come back together in a few weeks).Provide education to others in his/her life.Slide53
Strategies to Weave into My SessionsIf I keep doing what I’m doing, I’ll keep getting what I’m getting.I can see things as “gray” rather than “black or white.”
When I say, “Yes” to something, it means I’m saying “No” to something else.I need to spend time thinking about thinking.I can stack the deck in my favor.I need to advocate for myself.What if I said, “Yes” to something?Slide54
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Archives of Physical Medicine and Rehabilitation
, 81: 1596-1615.
Hanks, R., Rapport, L., Waldron-Perrine, B., & Millis, S. (2014). Role of character strengths in outcome after mild complicated to severe traumatic brain injury: A positive psychology study,
Archives of Physical Medicine and Rehabilitation
, 95: 2096-102.
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, J., Brown, A. W.,
Leibson
,
C., Testa
Flaada
, J., et al. (2007). The
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, 24(9
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, C.,
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