This post is by associate Triage Practitioner, and guest blogger, Matthew Savage
Acquired brain injuries (ABI) are one of the leading causes of death for those under the age of 40 and the numbers of admissions to hospital have been steadily rising (Headway, 2017). A brain injury can lead to a number of physical, mental and behavioural changes in the person, and often changes their life indefinitely. Some of the main challenges which can occur include impaired attention, decreased concentration, increased distractibility, impaired viso-spatial conceptualisation, slower information processing, impaired memory, communication issues, poor Judgement and impaired executive function.
However, with the right support, many skills which may have been lost can be relearnt, improved, or compensated for through the process of cognitive rehabilitation. Cognitive rehabilitation is a system of therapeutic activities that are based on the brain-behaviour relationship. These strategies aim to achieve functional change by re-establishing previous learned patterns of behaviour and thus, enable a person to adapt to their new condition and improving overall function. Functional improvement is key in all rehab programmes with the strengthening of intact function, relearning of social interaction skills and learning of new skills to substitute for lost function all an important part of the process. We cannot fix broken neurons, but we can strengthen existing neuronal pathways and improve overall function with the correct approach.
The Four Tiers of Cognitive Rehabilitation
There are four tiers of cognitive rehabilitation, and all these strategies are needed to work together. These are:
- Education – This involves developing awareness and insight in the patient. Part of the education process is learning about the injury sustained and why compensations are needed. Constant feedback and insight is key to education. Improvements in meta-cognition can be achieved and this has marked positive outcomes for cognitive function.
- Process Training – This process involves a focus on resolving the problem and improvement of cognitive skills. Development of retraining or practicing of cognitive skills underlying function is key.
- Strategy Training – Teaching compensatory changes including environmental, external and internal strategies.
- Functional Activities – Functional transfer and specific real-life tasks must be practiced to reduce deficits and encourage transfer to everyday life situations.
Specific Strategies
External strategies – These are outside the body, such as using smart phones, other examples include alarms, daily planners, calendars, whiteboards, lists, dossett boxes and other smart. They must be integrated gradually and not all at once. These external prompts increase organisation and can aid in memory function. However, a patient cannot remain reliant on these strategies indefinitely, and they must remain short term. It is important to prioritise, plan and set a good pace for activities so they do not become overwhelming. These strategies aid in the development of internal prompts. Scaffolding is a great example of external strategies aimed at supporting functions which are weakened. They aim to compensate, not fix or remove, the deficit entirely. Often, scaffolding involves placing external prompts around the patient so they will be reminded to complete a particular task. Over time, these strategies can slowly be removed as the patient relearns the task or starts to remember the routine. This is relearning, of which the brain is extremely good at doing, even when damaged. This process can lead to automatic strategies in the future which patients will no longer have to worry about, such as the process of remembering where items are, for example where they left their house keys.
Internal strategies – These are a reliance on one’s own mental processes (which is much harder for those with dysfunction). Mental imagery techniques, visualisation, remembering an experience without an external prompt (trying to encourage prompts to improve memory), association (linking visual and verbal information), and categorisation/chunking (grouping information into categories) are all very helpful techniques to improve brain function. For example, shopping lists can be arranged in order of aisles or department and repetition of the process will lead to rote learning.
Environmental – Examples of environmental strategies include implementing morning, afternoon, and evening routines for increased productivity. These are very important for many people, but particularly important for those with an ABI to allow for a distraction free environment and aid in concentration and keeping attention. Another example is having a place for everything which reduces search errors and fight or flight responses when patients cannot find what they need, which leads to frustration. Constant reminders of where to put these items is needed to habituate a patient to the process but leads to less chances of errors and less disruption in the long term.
How to Implement a Strategy Successfully
It is important to consider the below flow diagram when implementing a strategy with a patient or your loved one to progress it for optimum success. The process should function as follows and is very similar to the process of learning any new skill for everyone, improving memory and executive processing:
Suitable environment > Motivating > Demo > Practice > Errorless > Positivity > Task breakdown > Habituation > Progression > Suitable environment
- Environment – It Important to think of all of the above and to teach strategies in a suitable environment. Think about where you are when teaching new strategies. Consider the time of day, focus, attention deficits, organisation, busy household etc.
- Strategy needs to be motivating – The strategy must be motivating, and the patient must believe in the strategies.
- Demonstrations of strategies – It is important to show the strategy first to encourage the development of mirror neurons. Cementing learning through watching and doing is very important and repetition is key. Consistency is also key and generally it will sink in, allow these strategies to be tapered off in the future if all goes well.
- Errorless learning – If not checked, errors will continue to be repeated. Strategies must be cemented before allowing trial and error. This should be done in a procedural and simple way.
- Positivity – Must be positive and reframe the patients view. Show a positive future for the strategy.
- Task breakdown – Chunking is important in strategies to break them into manageable blocks.
- Habituation – Moving from the conscious to the subconscious is the ultimate goal and this will occur with habituation and constant use of the strategy.
- Progressing – Making sure patients know the strategy is not permanent. Tapering the strategies and taking them when no longer needed is a great way to show progress on a goal.
A Final Note
Brain injuries can be a life changing event and rehabilitation is a vital step in the process of improving cognitive function following an accident. If you are the care-giver to someone who has suffered an ABI, it is important to understand the above strategies to aid your loved one in their relearning process. It is also important that care-givers remain positive and motivated throughout a process that can last for many years. Seeking psychological support is also important for care-givers, please do not hesitate to get in contact with Sparta Health for more information around our treatment and support services.
About Matt Savage
Matthew Savage is an associate Triage Practitioner, has an MSc in Psychology, is a qualified personal trainer, and has worked within the field of cognitive rehabilitation for 5 years. He is an FA qualified football coach, with a keen interest in moral behaviour and wellbeing within team sports.