Cognitive Rehabilitation and
Traumatic Brain Injury
Mary Pepping, Ph.D., ABPP-CN
Professor and Director
Neuropsychological Evaluation Service and
Outpatient Neuro-Rehabilitation Program
UW Department of Rehabilitation Medicine
A quick bit of history for
cognitive rehabilitation
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Pioneer Yehuda Ben-Yishay, Ph.D. and
injured Israeli soldiers
Observed problems in thinking and
behavior for the first generation of longterm survivors
Development of milieu-based
interdisciplinary neuro-rehabilitation - a
day hospital model to address problems
Evolution of Cognitive
Rehabilitation
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Identifying and understanding TBI
changes in thinking and behavior
How much caused by injury to brain?
How much caused by injury to the self?
Is the person aware of deficits?
Are they able to tolerate treatment?
Can they form an alliance with the
clinicians?
What produces the common
pattern of difficulties > TBI?
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Architecture of skull and brain
Mechanical forces impacting brain
Frontal and temporal lobe injuries common
Primary effects, e.g., contusion, shear
Secondary effects, e.g., swelling, subdurals
Tertiary effects, e.g., chemical cascade
Severity of injury - mild, moderate, severe
Whose brain was injured?
Frontal Lobe Impairments:
Neurocognitive problems
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Attention, concentration, distractibility
Tangentiality
Problems with planning & organization
Impaired initiation and follow-through
Trouble with main ideas and inference
Concrete thinking, literal-mindedness
Problems with word retrieval
Frontal Lobe Impairments:
Neurobehavioral Difficulties
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Poor self-regulation of behavior
Impulsivity, Disinhibition, Judgment
Perseveration
Inappropriate behavior
Child-like demeanor or response
Flat affect and/or emotional lability
Reduced awareness of deficits
Lack of empathy for others
Temporal Lobe Impairments:
Neurocognitive
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Memory - Verbal and/or Spatial
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Immediate or Working Memory OK
Old, Well-Learned Memory OK
Storage of New Memories Impaired
Short Term Memory Badly Affected
Reduced New Long Term Learning
Reduced Prospective Memory Skills
Temporal Lobe Impairments:
Neurocognitive - 2
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Auditory Processing
Reduced Language Comprehension
Changes in Melodic Processing
Changes in Prosody
Problems with Visual Item Recognition
Misperception of Interpersonal Events
Temporal Lobe Impairments:
Neurobehavioral
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Heightened Irritability
Rage reactions (Limbic dyscontrol)
Interpersonal “viscosity”
Parietal Lobe Deficits:
Sensory-Perceptual
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Changes in sensation and perception of:
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Touch
Pain
Temperature
Position and Location, on body and in space
Vibration
Integration of sensory perceptual information
(agnosias)
Parietal Lobe Deficits:
Further disturbances
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Apraxia - inability to perform skilled
movements in the abstract
Difficulty apprehending the Gestalt
Visual field disturbances
Neglect
Paranoia or misperception of people
and events
Parietal Lobe: Specific
Neurocognitive Problems
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Visual perception - lines and angles
Facial perception
Mechanical skills - visual and tactual
Path-finding, Interpretation of maps,
directions
Difficulty with reading
Difficulty with writing
Occipital Lobes
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Primary visual cortex
Elaboration of visual information
Synthesis of visual information
Visual field defects
Abundant connections with other
regions of the brain - role in reading,
executive functions, visual memory
Brain stem and Cerebellum
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Cranial nerves damaged
Spasticity, dysarthria, dysphagia
Balance, coordination, gait
Motor learning
Cerebellar affective sydrome
Role of Neuropsychological
Evaluation
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Evaluations designed to identify brain-related
abilities and deficits in higher level functions
Can winnow through many domains of
function and identify main concerns
Provides good pre-injury history
Look at current levels of emotional distress
and coping abilities
Identifies personality strengths and
vulnerabilities that can affect outcome
Can help outline effective treatment plan
Neuropsychological
Evaluation: The Process
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Referral Question
Record Review
Interview with Patient and Family
Test Selection and Administration
Behavioral Observations
Test Scores and Normative Data
Analysis and Integration of All Results
Review of Results
Report with Findings, Recommendations
Neuropsychological
Evaluation: The Content
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Intellectual skills: verbal and nonverbal
Attention: simple and complex
Memory - verbal, spatial, simple, complex
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Acquisition, Retention, Retrieval, Recognition
Language and Academic abilities
Visual spatial and tactual spatial processing
Executive functions
Sensory Perceptual abilities
Fine motor speed
Current emotional status, ability to engage tx
Neuropsychologically-Based
Treatment Plans
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What are the primary obstacles to improved
function?
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Cognitive and communication issues
Behavioral disturbances (neurologic)
Speed of thinking and performance
Reactive emotional problems
Physical limitations
Personality difficulties (characterologic)
Lack of family and social support
Disincentives to return to productivity
Other risk factors
Neuropsychologically-based
treatment plans:
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What are the person’s major strengths?
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Pre-injury experiences that developed cognitive,
emotional, interpersonal, artistic, musical, athletic,
vocational, behavioral, common-sense, good
judgment or skill-based abilities
Any special talents or interest? Pilot? Carpenter?
Residual abilities in any or all of the above areas
Personal ability to rally coping resources
Features of personality strengths
Degree and nature of family support
Friends and other supports, including pets
“Blended” Case Example
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20 year old single male
High school educated
In college at time of accident
Severe traumatic brain injury in MVA
2-week coma - 9 months post-injury
Classic frontal-temporal injury
Very mild residual right hemiparesis
Cognitive Rehab Targets:
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Attention: vulnerable to distraction
Memory: spontaneous retrieval
Executive functions: plan, organize,
time management
Speed of thinking mildly reduced
Reading comprehension
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Missing the main idea
Not taking effective notes
Treatment Plan:
Residual Strengths
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Good pre-morbid school and work history
Good basic reasoning skills
Strong desire to return to school
Able to withstand constructive feedback
New learning ability present
Willing to participate in treatment
Supportive family
Laying the groundwork for
treatment success
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Updated Rehab MD review of injury
related health concerns and meds
Re-establish good sleep-wake cycle
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Trazadone for sleep was helpful
Re-establish decent nutrition
Reduce alcohol consumption
Review and update exercise regimen
Secure or modify basic living situation
Three key places to begin for
this patient:
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Find and use a single effective memory
compensatory device
Establish a routine schedule
Start work on ways to reduce distraction
Find and use a single memory
system:
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Some trial and error to find right system
The memory system has to be with the
person at all times and used every day,
multiple times for entries and review
Choose a single calendar or device that the
person likes and is willing to use
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iPhone calendar that syncs to Google?
Daytimer or Week at a Glance systems?
Small pocket calendar?
Watch with calendar and alarms?
Establish a predictable
schedule with a set of routines
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Evening routine:
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Check appt book for next day’s schedule
Gather items needed for next day’s departure and
place them by door to garage or bus
Plan route and double estimated time needed
Have wallet, cell phone, keys in one place
Put out clothes you will wear tomorrow
Start quiet time at 9:30pm: relax, light reading,
meditation, quiet music, snuggle time with pets
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No TV, no computer, no thrilling movies, no late exercise
Check to make sure alarm is set; in bed by 10pm
Morning routine
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Morning routines
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Get up when alarm goes off - no snooze!
Reward yourself with coffee, tea, or juice
Shower and dress
Re-check the day’s schedule and to do list
Have breakfast, take meds if appropriate
Check that burners and lights are off
Make sure you have all you need to take with you,
e.g., wallet, phone, keys, books, backpack, laptop,
money for meals at school
Key elements of daytime
routine
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Follow established schedule
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Class days and times mapped out for term
Therapy appts: Time, place, person
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Bring therapy notebook and school homework
Study time scheduled for homework and tests
Extra time scheduled for projects and papers
Break times and meal times scheduled
Exercise or gym time
Open time to relax, visit with friends, have fun
Bring future assignments and graded papers
or tests to speech treatment for review
Methods to reduce distraction
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External distractions
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Find quiet place to study
Turn off phone, TV, music, radio
If study materials are on-line,consider printed
copies to allow single-minded focus on article, and
avoid “pop-ups” or “dings” alerting you to incoming
email or messages
Read aloud to maintain focus on material
Underline what you think is important to know
Take brief breaks every 30 minutes after jotting
down some of those main ideas
Internal distractions
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What is it that keeps popping into mind?
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Worries
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Something you don’t want to forget?
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Quickly jot it down in memory system at hand
Are you hungry or thirsty?
Are you sleepy?
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Jot it down for consideration at a scheduled “worry time
review” later
Have some coffee, do 10 minutes of exercise
What is your optimal time of day for focus?
Use of ABODES system for
planning and organizing - “A”
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Assess the situation
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What is it you want to do?
When?
Where?
With whom?
How?
Why?
Use of ABODES
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Break the task, goal, project or activity into as
many possible steps as you can brainstorm
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The more steps, the better
Even if you are not sure a step is needed, better to
include it than not to list it
Order the steps from first to last as they
would most likely need to be accomplished
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First break the long list of steps into smaller
subgroups that have something in common
Then go back and put the steps within each of the
subgroups in order
Use of ABODES
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Decide what is needed to accomplish
the task, goal, project or activity
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Materials, supplies, tools or information
Reservations, tickets, visas, appointments
Money, credit card, debit card, photo ID
Space in which to work or gather
Help or participation by others
A certain kind of weather or time of year?
Use of ABODES
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Estimate time it will take to accomplish the
task, goal, project or activity
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Estimate the time you think is needed to complete
each of the specific steps you listed
Add in any time needed for coordination with
others
Triple the time estimated to complete each step
Enter each of the steps, in order, into your
schedule system on specific dates and times to
begin accomplishing them
Use of ABODES
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Survey your work and re-adjust project
needs and time frame for completion
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None of us has perfect ability to plan and
implement an entire project without some changes
you’ll only learn are needed once you’ve begun!
Do not tackle massive organizational projects
alone or with limited time, space and resources,
unless you know:
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It can be completed in one day (organizing your spices)
You can leave the not-yet-completed steps in reasonably
neat order so your overall situation is not worsened
Reading Comprehension
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Getting the main ideas
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What is the title of the chapter, story or article?
Read a paragraph and see if you can put the main
point into your own words
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Is the story about a person, place, thing or idea?
Sometimes the first and last line of each paragraph will
introduce or summarize main points
Are certain nouns (people, places, objects, concepts)
mentioned frequently in the paragraphs?
Is there something new that you learned by reading the
story?
Can you go jot down a few main points and details?
Taking effective notes
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For reading comprehension & retention
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Correct any visual problems as much as possible
Use good lighting by which to read
Keep a list of main characters and events for
books you read on a 4 x 6 card in book
Write a brief summary of each chapter’s main
people, events or ideas
Participate in a study group or book group to
discuss main ideas and characters and events
Read aloud for multi-sensory input
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See, say, hear, listen
Taking effective notes while
listening in classroom
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Make sure your hearing is okay
Sit at front of lecture space
Use an outline form to capture main ideas
and key details
If handouts, slides or outlines are available
on-line prior to lecture, review those
Review your notes immediately after lecture
and try to fill-in or clarify as you can
Borrow notes from good note-takers
Digitally record lectures and review them
Taking effective notes in class
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You don’t have to jot down everything
Try to alternate your listening and writing, so
there are times when you are fully focused on
the speaker, and not writing
Ask occasional questions of the speaker to
clarify what has been said
Write as good a summary note as possible at
the end of the presentation or discussion
Final comments on Cognitive
Rehabilitation
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An essential component is the mind of the
therapist who understands the underlying
causes of cognitive problems and can create,
implement, monitor and modify treatment as
appropriate.
This occurs as part of a larger informed and
compassionate view of human needs,
limitations, strengths and behaviors.
The person with TBI must ally him or herself
with the treatment effort, personnel and goals