The Brain, injury, and a
few things to overcome!
Presented by:
Kim MacNeil
Occupational Therapist
April 2012
Outline
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A little about the brain
What is an Acquired Brain Injury (ABI)?
Recognizing symptoms of ABI and
strategies to work with
Positive Everyday Routines
Hypothesis Testing
THE BRAIN
The Brain
ANATOMY: The Brain
NEURON
NEURONS:
It’s grey and white
ANATOMY: The Skull
The Brain in Bed
The Brain’s Bed
What is an Acquired Brain
Injury (ABI)?
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Traumatic Brain Injury – result of
external trauma
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fall, car accident, fight, gun shot,
Non-traumatic – result of internal
source injuring the brain
Hypoxia (lack of oxygen) - near drowning,
heart attack, “fainting game”, stroke (block)
 Toxicity, meningitis, rabies, infection, stroke
(bleed)
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NEURONS & BRAIN
INJURY
Focal (LOCAL) VS Global
(DIFFUSE) Effects:
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Coup Contra coup
Acceleration & Deceleration
Rotational & Shearing
Hematoma’s
Edema
Disruption of neural connection
Did you know:
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Level of severity is not necessarily
directly related to outcome
A concussion is a brain injury too
Don’t have to loose consciousness to
sustain a brain injury
Younger is not necessarily better when
it comes to recovery
NS Leading way in
preventing ABI
As of Nov 1, 2012 everyone in Nova Scotia is
required to wear protective helmets while
downhill skiing or snowboarding at ski hills.
Recovery/Long Term
Effects
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Most (but not all) recovery occurs
within first 2 years
Area and extent of damage
Physical recovery
Individual
Environment
HOPE
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Outcomes vary
Severity of injury does not always
coincide with severity symptoms
To have hope is to envision something
beyond what is…therefore there is a
goal to work towards. Break it up into
smaller achievable goals and work on
them one day at a time.
Invisible Injuries of the
Brain
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By Debbie Wilson ( survivor from
Murphysboro, Illinois)
Critical factors for
successful reintegration:
– EDUCATION of persons involved
regarding brain injury
– OPEN COMMUNICATION between all
persons involved
Previous Approaches:
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Common mistakes include: quizzing people,
and allowing people to make the same
mistakes over and over again “so they will
learn from their mistakes”
Previously gave lists to remember then
“tested” later
Errorless Learning
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Methods of learning whereby attempts are
made to prevent (or reduce the likelihood
of) errors being made during the learning
process.
Avoid trial and error learning or attempting
to learn from ones mistakes
Compensate for the memory deficit by
providing the person with the right answer
from the start and prevent mistaken
guesses.
Errorless Learning
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When the right answer is not given and the
individual is forced to guess or “figure out” the
answer, errors are likely to result. When wrong
answers are repeated, the person may learn
the wrong answer (i.e. reinforced) instead of
learning the correct information.
Errorless learning is not an intervention or
treatment but rather a principle of learning
i.e. cueing instead of quizzing during transfer
practice
Impairments associated
with ABI & Strategies
SYMPTOMS OF ABI:
COGNITION
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New Learning
Attention and
Concentration
Memory
Organization
Perception
Reasoning
Problem Solving
Initiation
New Learning
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New material in small amounts
Repeat and summarize previous
relevant info
Offer varied opportunities to use info
Use relevant & meaningful examples
Check comprehension frequently
Allow additional time
Errorless Learning
Attention & Concentration
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Consistent, predictable, regular
routines
Limit distractions (e.g. doors,
windows, other students media)
Redirect
Provide breaks
Monitor for signs of decreased
attention/concentration (redirect, cue,
allow for rest)
Memory
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Links to prior knowledge
Categorize or “chunk” info into small
amounts
Repetition, repetition, repetition…
Memory aids (e.g. sticky notes,
phones apps…)
Cues (visual, verbal, physical)
Rhymes, songs
How dinosaurs became extinct!
Organization
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Establish & maintain daily routines
Daily Schedule
Provide outlines & check for note
taking
Cue “I will give you a moment to write
that down, put that in your
calendar/phone”
Use checklists
Repetition, repetition, repetition…
Perception - Vision
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Visual Stimulation (e.g. over/under
stimulation, clutter)
Use arrows/highlighters
Contrast colours to encourage
important information to be identified
VISUAL CONTRAST
LOW CONTRAST
HIGH CONTRAST
Perception - Auditory
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Limit excess noise
(e.g. lower voices)
Establish clear eye
contact
Be clear and
specific, check for
understanding
Use non-verbal
cues
Reasoning
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Provide concrete examples
Allow them to do the task whenever
possible
Be direct “Lets review your plan
(Goal/plan/do/review), how did that
work out for you?”
Set up opportunities to learn
elsewhere (e.g. at home)
Problem Solving
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Frequent feedback
Compensate (lists of options)
Step by step (e.g.“ok you checked off
the first thing on the list, next it says
you will….” “hmmm, you have
completed step 1, step 2 says…”)
“What do you think about? Could you?”
Plan ahead, role play scenarios
– Develop Scripts (e.g. no answer for test)
Initiation
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Cues (verbal, visual, physical)
Schedule/journals/apps/reminders
Give options, lead (“you got your
pencil and the paper…)
Structure, predictability, routine
ABI SYMPTOMS:
BEHAVIOUR/EMOTION
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Agitation/frustration
Disinhibition
Aggression
Poor social behaviour & poor
awareness of consequences to actions
Depression/Self Image
Frustration
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Allow opportunities for success
Identify antecedents to frustration
Chunk work into smaller manageable
parts
Provide alternatives to acting out
Take a break
Recognize symptoms and feelings
Disinhibition
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Provide chance for open, safe,
communication,
Respond consistently (e.g. script),
respectfully and clearly
If possible practice ahead of time
When possible be context specific
Use script to respond when
inappropriate
Aggression
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Be aware of signs of escalation
Use redirection
Be calm and aware of your body
language
Cue them to increase awareness of
their feelings ( “I sense you may be
frustrated”)
Manage triggers (e.g. overstimulation:
noise, light, colours, fatigue)
Social Behaviours
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Provide opportunities to practice
appropriate behaviours
Be direct, specific, non-judgmental
Create Scripts
Set social goals
Role model/role play
Depression & Self Image
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Focus on abilities, avoid comparisons
to pre-injury “self”
Validate emotions and work on
changing them
Recognize symptoms: withdrawal,
lethargy, lack of interest in
appearance, feelings of hopelessness
Liaise with family, friends, health care
professionals
ABI SYMPTOMS:
PHYSICAL
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Pain/discomfort, FATIGUE, Seizures,
Sleep Disturbances, Headache and/or
Tinnitus
Sensory disturbances
Musculoskeletal issues
Poor environment/person fit
Visual field neglect
Physical
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Cognitive and Physical Fatigue
– Allow for rest, shorter days, frequent
breaks
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Seizures
– Educate on protocols, monitor, log, aware
of med side effects
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Sleep
– Insomnia or excess, need for “naps”,
everyday predictable routines
Physical continued…
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Fine Motor
– Use computer, reduce written work,
verbalize, time extensions
Mobility
– Seating issues, adaptive equipment,
accessibility
Self Care
– Cue if necessary
Visual field neglect
– Seating, large print, other modalities
Transfer of Training
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“If you want people to learn something
teach it to them. Don’t teach them
something else and expect them to figure
out what you really want them to do.”
- Thorndike
Teach what needs to be learned in the
context of when and where it will be used
Everyday functional activities are the best
context for cognitive intervention
Positive Everyday
Supportive Routines (PESR)
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Positive: Successful and Supported
Everyday: In the context of everyday
life, supported by everyday people,
using functional teaching goals
Support: Social collaborative, goaloriented work, in a natural context
Routine: Habit, organized scripts and
supports in the context of everyday
life
Basic Principles of PESR
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The person is the core of all
intervention and support efforts
Interventions and supports are
organized around personally
meaningful activities with everyday
people (person, teachers, classmates,
family, friends etc)
Positive everyday routines are the
context for pursuit of meaningful goals
Basic Principles of PESR
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Reduction of supports is part of the
plan
Feedback is context sensitive and
meaningful
Components of life must be integrated
Assessment is ongoing and context
sensitive
Behavioral concerns are addressed via
positive behavioral supports
Importance of Routines:
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Routines have a positive impact on
– Independence
– Problem Solving
– Planning
– Organization
– Learning (i.e. able to learn physio
exercises but can not remember am care)
Everyday:
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Find out what is meaningful to them
and explain everyday things to them
(i.e. their progress, a procedure and
so on) in that context
Examples: NASCAR, Electrical Work
Steps to Organize
Routines
1. Identify successful and unsuccessful
routines of everyday life. What’s
working, what’s not working?
2. Identify changes that have the potential
to transform unsuccessful routines into
successful routines (including changes
in the environment and the behaviors
of others.)
Steps to Organize
Routines
3. Identify how changes in routines include
activities that are motivating to the person.
4. Implement needed supports to organize
routines so that the individual experiences
success and receives intensive practice in
context.
5. Gradually withdraw supports and expand
contexts as much as possible.
Goal
Plan
Predict
Review
Do
Hypothesis Testing
• Common sense approach of
systematically teasing out what
contributes to failure and what
contributes to success.
• Poor performance happens for many
reasons, we can perform well by applying
many different supports and strategies
Steps to Hypothesis testing:
 Identify
a problem
 Formulate all hypothesis
 Select a hypothesis
 Test hypothesis
 Review results
Scripts
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Scripts structure involvement / interaction
with promote procedural learning (steps
to do, knowing how to do it, automatic)
Conversation non-threatening
Well selected language
Mass practice
Embedded in meaningful activities
Across everyday partners (team, family…)
Scripts
Positives:
– Allows people to think out loud
– Gain self awareness
– Coach person to be their own coach
– Facilitates typical development of
executive functions (Higher level
cognitive tasks such as problem
solving, reasoning, attention, self
awareness…)
Scripts
Scripts may be used for different daily
interactions including:
– Orientation Script
– Problem Solving
– Behavioural
– Big deal/Little Deal
– Experimental Routine
Example: Orientation
Say “Hi _insert persons name__, it is a ___weather__(i.e. fairly mild day) for
December __. I can’t believe Christmas is in
only_____ days. The year 2004 is almost
over. I know you have been meeting many
people since you came into the hospital on
October 16 so you may not remember me.
My name is ____________ I am your
_____________ (i.e. friend from
__________, your therapist…). I just came
by to see if …….”
Contextualized Collaborative
Hypothesis-Testing
What’s the problem?
(Using the two strangers in the doorway rule)
Hypothesis Formulation
(Why is s/he doing this?)
Hypothesis Selection
(Begin with easiest to test
or most obvious)
Hypothesis Testing
(Protocol for experimentation
Plan A - Plan B - Plan C
Testing time line)
Summary of CLASSROOM
STRATEGIES
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Emphasize function
Provide low stimulus environment
Role play socially appropriate beh
Assist with organizational skills and attention
to task
Allow for frequent breaks and rests
Allow for extra time
Repeat new information frequently
Maximize opportunity to practice new skills
Summary of CLASSROOM
STRATEGIES cont…
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Prepare ahead of time for transitions
Recognize signs of frustration and assist in
decreasing
Consistent and predictable routines
Clear expectations
Focus on positive everyday supportive
routines
Communicate regularly with stakeholders
Become informed about ABI
Just because…
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One strategy is learned doesn’t mean
it will be used again OR generalized to
other tasks
Someone can tell you all the steps to
complete a task it doesn’t mean they
can do it
Patience, Flexibility, &
Forgiveness
References:
Bennett, Dr. S., Good, Dr. D., Kumpf, J., (2003). Educating Educators
about ABI. Brock University and the Ontario Brain Injury
Association.
Wilson, D. Invisible injury of the brain. Newsletter of the Brain Injury
Association of Canada (2012, February). Retrieved from http://biacaclc.ca/en/category/newsletters-biac-impact-pathways-ahead/
Ylvisaker, M. & Feeney, J. T. (1998). Collaborative Brain Injury
Intervention: Positive everyday routines. Singular Publishing Group,
Inc. San Diego, CA
Websites:
Brain Injury Association of Canada: http://biac-aclc.ca/
Brain Injury Association of Nova Scotia: http://biac-aclc.ca/en/
Learnnet: http://www.projectlearnet.org/