Category Archives: Working on Skills

It’s Ok To Do It Differently

When I was a senior in high school, I had a physics teacher whose outlook differed from that of most science teachers.  Early in the year she told us that when we answered questions on her tests, she did not care about how we came to a given answer.  As long as that answer was correct, the method by which it was arrived upon did not matter.  Work did still have to be shown as in any other science class.  Even if that work bore no resemblance to that which she had prescribed though, a result was perfectly acceptable provided that the answers matched.

In many ways a healthy approach to rehabilitation is similar to this outlook championed by my former physics teacher.  Due to their injuries, rehabilitation patients are often unable to complete tasks in the same manner as they did before.  For instance, a patient with only one functioning hand will not be able to cut vegetables for a salad as he or she did prior to the injury but utilizing a one-handed rocker knife produces the same results.  A patient who has trouble speaking may not be able to verbally place an order at a restaurant but typing the order into an Ipad speech app produces the same results.  As you can see, there are often multiple methods by which to accomplish a given goal.  Effectiveness is the most important measure of a method’s worth, not whether it is identical to a previous method.

The idea of reaching the same goal through different methods sometimes bothers patients and their families.  In some cases, patients and their families refuse to use alternative methods because they are focused on doing things in exactly the same way as they have in the past.  A patient completing minor tasks just as he or she did prior to an injury holds strong appeal as a signifier of a return to normalcy.  However, due to the injuries this may not be realistic either at this stage of rehabilitation or for the foreseeable future.  Accepting alternative methods consistently allows patients to be far more functional in both work and home environments.  These alternative methods often allow patients to be more independent whereas insistence upon pre-injury methods can  bring with it a dependence on others.  It is important that patients and their families embrace alternative methods of accomplishing daily goals so that patients can achieve at their highest levels.  This open-minded attitude often yields the best long-term therapy results.

Learn about brain injury treatment services at the Transitional Learning Center: http://tlcrehab.org/

Quick Points on Wheelchair Safety in Parking Lots

Following their injuries, many brain injury survivors are left depending upon wheelchairs to meet basic mobility needs.  This change in mobility creates new safety considerations that must be taken into account on a daily basis.  One of these considerations surrounds strategies for safely navigating a parking lot while in a wheelchair.

Most adults are between 5 and 6.5 feet tall.  They are accustomed to being easily visible to drivers distractedly circling a parking lot and through rear windshields as drivers back up vehicles out of parking spaces.  When sitting in a wheelchair though, normal adults are often effectively no taller than  young children.  Even the most conscientious driver can struggle while exiting a parking space to see a pedestrian in a wheelchair.  These survivors are also often harder to see by a driver making the turn from one parking lot lane on to another.  Due to this change in baseline visibility, survivors in wheelchairs and their families must be more vigilant of vehicle activity and the abilities at every identifiable moment of drivers to see the survivors.  They must spend more time looking around to observe vehicle activity, just as they would when in the presence of a small child who may slip the notice of nearby drivers.

Another issue regarding parking lot safety is that survivors in wheelchairs are generally slower than the average person would be while moving across the same parking lot.  Since it takes more time to traverse any distance, survivors and their families must add extra time in their calculations as to whether there might be enough time to safely cross in front of an approaching vehicle.   If the result of such calculations inspire even the suggestion of doubt, erring on the side of patience is always the best policy.  Sometimes, family and friends may need to push the survivors’ wheelchairs to help move quickly enough to safely avoid traffic.  Additionally, typical adults generally can step up onto the curb from the parking lot at any location they choose.  Survivors in wheelchairs must use curb cut ramps which often means that they have to take a longer route to get onto the curb and consequently spend more time in the path of vehicles.  Again, survivors and their families must be aware of this additional urgency when choosing a path across any parking lot.

These are just a few quick points on wheelchair safety in the parking lot.  I hope everyone has a safe time in their travels, particularly in parking lots!

Learn about brain injury treatment services at the Transitional Learning Center: http://tlcrehab.org/

 

Post-Traumatic Amnesia

In fairy tales the stricken princess lies still on the bed, oblivious to the world around her.  With the prince’s kiss, she suddenly wakes from her stupor and greets the world as if she had just simply been asleep.  Unfortunately, returning to life after a brain injury is no fairy tale and brain injury survivors do not simply wake with all of their skills intact.  For most survivors of serious brain injuries, there is a period of time after they “wake” from their comas in which they are in a state called Post-Traumatic Amnesia (PTA).  PTA contains many unique features and experiences which are important to understand.

Two of the main features of PTA are an inability to make new memories and disorientation.  This inability to make new memories (hence the “amnesia” portion of PTA’s name) manifests itself in many ways.  For instance, a brain injury survivor may report that though a coma suffered lasted for only two weeks, he or she has no memories of his or her first three months of therapy.  Brain injury survivors often relay that they were told  of visits by significant others and acquaintances during the survivors’ hospital stays, but due to PTA the survivors have no memory of these visits.  When PTA is particularly severe, a visitor may simply walk out of the room for a minute and find upon return that he or she is greeted by the survivor as a fresh arrival.  Sometimes family and friends can become unnecessarily upset that a survivor does not remember a visit, not understanding that making new memories is generally beyond the emerging skill level of a survivor in PTA.  Moreover, due to these memory difficulties survivors have significant difficulty learning new information in therapies (though they may still benefit from repetition of desired behaviors).

The second hallmark characteristic of PTA is disorientation.  Survivors in the midst of PTA often have difficulty recalling the month or year when prompted to do so.  They might not be able to accurately relate which city they are currently in or even state their own ages.  It is often helpful to have such information readily available, possibly on a notebook in front of the survivor or on a large board in a survivor’s room (though others may still need to cue the survivor to look at the accurate information).  Sometimes, a survivor may dispute accurate orientation information.  For instance, a survivor undergoing inpatient therapy in Galveston may argue that the therapist is crazy and that he or she is actually in Houston.

While survivors contending with PTA will often have a “deer in the headlights” look, as they improve this look eventually fades.  Families and therapy staff might notice that the survivor’s pupils may be dilated.  PTA is frequently accompanied by agitation.  Survivors often say and do things they normally would not say or do.  This excessive agitation may see expression in threatening or lashing out at loved ones or tearing out tubes and monitors attached to survivors’ bodies. It is not uncommon for a survivor to attempt to remove even an item as critical to his or her continued well-being as a breathing tube when in PTA.  Doctors may put the survivor on medication to help with agitation, though some are wary to do so as this may cause the PTA to take longer to resolve.

Survivors under the effects of PTA may struggle with hallucinations or delusions.  These hallucinations and delusions can take a paranoid flavor, such as believing that doctors are trying to poison them or that nurses are trying to steal their money.  Survivors in PTA may try to escape the hospital or take other unhealthy risks, such as trying to walk to the restroom when they are unable to physically do so.  As survivors with PTA generally have poor awareness of their injuries and can be impulsive, they will usually require 24/7 supervision and careful monitoring.

When survivors are in PTA, it is helpful to reduce the number and intensity of stimuli around them.  Making sure that a room is generally quiet and limiting the number of people in the room with the survivor at a given time can help lessen issues arising from agitation.  All important information should be easy to find, and a good example of a handy way to accomplish this is to put the date and what happened to the survivor on a dry-erase board or on the front of a notebook he or she is using.  Repetition is also important, as survivors with PTA may pick up information after many repetitions.  This can be as verbal repetition (e.g. repeating the year) or physical repetition (e.g. practicing a wheelchair transfer).  There is no way to “rush” a person through PTA nor is there a “magic pill” to cure it.  Families need to be patient as for some survivors, it may take months to emerge out of PTA.  Unfortunately, a few survivors will never quite fully emerge from it.

It is also important not to take negative words or behaviors from the survivor as personal attacks.  Such negativity is generally due to the brain injury and is not reflective of how a survivor really feels.  When brain injury survivors become healthier and are no longer in PTA, they often feel embarrassed by their PTA behaviors.  The survivors did not intend to be rude or mean, but their injuries were not yet healed enough to allow them to behave in a normal fashion.

Hopefully this post helped to clarify the symptoms of Post-Traumatic Amnesia.  Feel free to leave a comment below with any questions!

Learn about brain injury treatment services at the Transitional Learning Center: http://tlcrehab.org/

Using Unique Characteristics to Help Memory

Following a brain injury many survivors face great struggles in the realm of memory.  This can be especially embarrassing when a brain injury survivor has difficulty remembering the name of a person with whom he or she is already well acquainted.  Utilizing techniques that make use of unique characteristics can make it far easier for survivors to remember important names in their lives.

Each person possesses many different characteristics.  These can include height, weight, eye color, tone of voice, expressed clothing preferences, etc.  Trying to remember a person’s name while matching it with all these disparate features can be a daunting task.  When meeting someone for the first time, it is often easier to find the one unique characteristic of the person that stands out most and pair that with the person’s name (e.g. “Paul is the tall guy” or “Susie has a rainbow tattoo on her neck”).  In this way the survivor only has to remember one characteristic in order to recall a person’s name rather than contend with the confusion that would accompany recalling many characteristics.  Unique characteristics can include aspects of physical appearance, dress, voice and behavior.  Let’s give a few examples in each category, using celebrities as examples, to demonstrate how one might execute this technique.

Physical appearance can include height, hair, size/shape of facial features, scars and tattoos.  For instance, former NBA player Shaquille O’Neal has brown eyes, a shaved head and a bright smile.  None of these features necessarily make him stand out.  However, if you were to meet him on the street and were picking one unique characteristic to match with his name, you would likely pick that he is over seven feet tall.  The pairing between height and name would clearly provide a more memorable association than anything involving those other  mentioned characteristics, and would make it far easier to recall Shaq’s name at a later time.  Similarly, comedian Carrot Top is of medium height with fair skin.  Again, these common features would not be useful to pair with his name as an aid to memory.  However, his striking red hair is quite unique and by pairing this unique characteristic with Carrot Top’s name, a survivor would be more likely to later recall his name.

Some people dress in a manner that is simply different from everyone else.  These differences in dress can also be paired with a person’s name in order to make it easier to recall that name.  Michael Jackson was known for wearing one white glove.  No one else was known for effecting that particular fashion choice.  If a survivor would have met Michael and wanted to remember his name, he or she could have paired Michael’s name with the one white glove.  Another example of this can be found in former United States Secretary of State Madeleine Albright.  Albright always wore pins on the upper left shoulders of her jackets.  A survivor could pair the pin with her name in order to better recall her name, rather than attempt to utilize any number of additional characteristics she possesses.

Just like a unique physical characteristic or a unique manner of dress, a unique voice can be paired with a person’s name to help remember him or her.  A voice might be recognized as unique due to a distinct tone, a particular accent or use of a singular delivery.  Actor James Earl Jones has a baritone voice which makes him a favorite choice for voice-over work in commercials and the like.  By pairing his deep voice with his name, a survivor could more easily identify him by name at a future meeting.  Similarly, actress Fran Drescher has an unmistakable New York accent which she played up in the television show “The Nanny.”  If a survivor was to meet her for the first time, the survivor could pair her accent with her name to help remember her at a later time rather than trying to remember any other likely more common of her features.

Sometimes, a new acquaintance may demonstrate a behavior that is so different from that of others that it can be used as one of these unique characteristics to aid in memory.  This can sometimes prove a little harder to use for memory unless the person in question demonstrates the identified behavior all of the time.  For instance, Elvis Presley often had a lip twitch/snarl when speaking which other people do not have.   In a different vein, John Wayne walked with his legs spread in a wide gait.  Both a constant lip twitch/snarl and idiosyncratic pattern of walking can be paired to names to more easily remember a person at a later time.

Survivors should not worry about whether the characteristic being used is complimentary to the other person.  If pairing the name “Julie” with “giant nose” helps the survivor remember Julie later, then this is fine.  There is no need to share with the other person that this technique is being used to aid memory.  The key is whether the characteristic is so memorable to the survivor that pairing the characteristic with the name will make it easier for the survivor to remember.  Further, this technique does not prevent the survivor from adding other, more mundane characteristics to his or her memory of the other person.  This technique is primarily designed for when a survivor is first trying to learn the other person’s name.

Hopefully this method will help survivors remember others’ names and be spared the embarrassment of forgetting!

Learn about brain injury treatment services at the Transitional Learning Center: http://tlcrehab.org/

 

Return to Play is Important But Return to Learn is Vital

With a rise in awareness in the world of sports regarding the strikingly prevalent danger of brain injury and its deleterious effects, there has been a corresponding increase in the development of various concussion protocols for returning to active participation in sports following an injury.  These protocols are now the norm in the major sports leagues such as the NFL, NHL, MLB and NBA.  These “Return to Play” protocols are important for ensuring that athletes do not suffer a second concussion that can compound the damage of a not yet fully healed first one, causing an even more serious injury.  Schools around the country are following suit, pushing for more training on concussions.  In many school districts, concussion training for school athletic trainers and/or coaches is mandatory.  There is also a considerable amount of discussion in the media about return to play policies at the school-age level.  Just as professional athletes do, student athletes need to avoid the effects of compounding brain injuries.  However, there is a subject that seems to be garnering less public conversation but is even more important than when a student may be “ready to play”.  There is far too little discussion about an immensely more important topic, namely when a student is “ready to learn”.

School-age youth universally have one primary “job” in their lives, and that is to perform at their best in school classes.  Though sports are enjoyable and often quite meaningful to students, only a tiny few will go on to earn a sports scholarship to college and just a small fraction of those will ever play professional sports.  And even of this small fraction, only a handful will play more than a few years in professional sports.  Sports are not likely to be any particular student’s full time future job.  However, almost every single student’s future is tied in some way to his or her ability to learn information in a school setting. Most every job, and adult life in general, will require extensive dependence upon skills learned in the classroom such as writing and math.

School is similar to an adult’s full-time job as it encompasses the majority of daytime activities and requires a significant expenditure of cognitive energies on a daily basis to ensure performance at optimal levels.  Pushing a child back to school too quickly post-injury can engender an inability to learn effectively which can lead to a downward spiral of emotional distress and academic failure.  Schools need to work with parents and health professionals in order to create a plan for return to school after a brain injury, whether that injury be suffered on the playing field, in a car accident or by any other means.  Not every child will be able to return quickly or to a full load of classes.  Adjustments may be necessary to the schedule, format or setting of classes and school material.  The child may require special assistance from aids, tutors and note-takers.  The child may also benefit from breaks in the day to when he or she has crossed a threshold of cognitive overload.  If injuries are particularly serious and long-lasting, a Section 504 plan may be necessary.  The Brain Injury Association of Vermont has a sample return to learn protocol that can help guide parents, educators and health professionals as to when a child would likely be ready to healthily engage in different school tasks.

 

http://biavt.org/concussion-kit-documents/Section%207%20-%20RTL%20Protocol-pub%20final_5-9-13.pdf

http://biavt.org/concussion-kit-documents/Section%207%20-%20RTL%20Protocol-pub%20final_5-9-13.pdf

A healthy return to play protocol following a brain injury is important, but we need to remember that a child ultimately does not need to play a sport.  However, every child most assuredly does need to learn in school. So let’s increase the discussion on “ready to learn” plans and needs!

Learn about brain injury treatment services at the Transitional Learning Center: http://tlcrehab.org/

Give Me Your Best 40%

Good days, bad days.  Everyone has them.  No one minds the good days, but those bad days can be such headaches.  Maybe you didn’t sleep well the previous night.  Perhaps your children were sick and were thoughtful enough to pass their germs on to you.  Those bad days pose a regular struggle that we can only push through.  However, sometimes bad days have potential to knock traumatic brain injury and stroke survivors to emotional low points markedly lower than anything experienced in their lives prior to the injury experience.

Often, patients will apologize to their therapists when they are having bad days, even though they would not feel the need to do so when going through a similar bad day at a job in their pre-injury lives.  In reality, no apology is truly necessary.  Having good days and bad days is not only a natural part of life, but is just as natural a component of the journey to recovery.  The progress of a healthy recovery can usually be observed to resemble that of a healthy stock market.  We can track plenty of ups and downs, but a general upward trend is just as persistently evident.

On rare occasions, a patient may ask a therapist if he or she can skip a session because he or she is having a bad day.  Unless the patient is deemed unable to participate in therapy by a facility nurse or doctor, the patient will be strongly encouraged to engage in therapy.  This can be a bit confusing for patients.  After all, why shouldn’t they be able to skip rehabilitation when having a particularly bad day?  I will explain some of the logic involved in having patients stay in therapy even on those bad days.

First, as stated earlier, bad days are a natural part of life.  Therapists know that on some days a patient will simply be unable to contribute that normal 100% effort.  This is fine.  Advances in therapy can be made even on bad days.  A therapist will always take a patient’s best effort, whether it be that patient’s best 80%, best 60% or even a 40% effort.  Every step forward in rehabilitation is a step in the right direction.  Second, it is important to remember that every activity in rehabilitation is aimed at facilitating success following discharge.  At home, just like in rehabilitation, there will be good and bad days.  Survivors need to be just as prepared to handle bad days at home as they are to handle the good ones.  For example, a patient may not want to work on hand skills necessary to use adaptive flatware on a bad day.  But what is that patient going to do when he or she is hungry at home on a bad day?  Will the patient not eat because he or she is having a bad day?  Good day or bad day, the same skills will be used to succeed at home and therefore they need to be practiced both on good days and bad days in therapy.

So don’t worry about having a bad day.  Just give therapy your best effort, even if on that day your best effort is only 40%!

Learn about brain injury treatment services at the Transitional Learning Center: http://tlcrehab.org/

Using Stories To Aid In List Memory

The human brain is fascinating for so many reasons.  One of these reasons can be seen in the expression of its preference for different styles of memory.  The brain generally has a preference for remembering stories as opposed to random lists of information, even though there are many more words in a story to remember than there are in a list.  It can be demonstrated though that this preference for stories can in fact be used to help bolster the memory for lists of items.

Individuals generally encounter lists of items in areas of daily life related to shopping, school, work, and other like activities.  You may have a list of items that you need to buy at a supermarket.  Your boss may ask you to pick up a list of items from the stockroom to place on shelves.  A teacher may ask you to bring in certain items for a class project.  Although it is of course advisable to write down or record in some manner any such list of items, you may not always have a pen and paper or other recording device available.  If you take such a list of items and turn it into a brief story though, you might be surprised by how much easier it becomes to remember.

Let’s say you have three items to remember to buy at the store: milk, cookies and napkins.  You can use to your advantage the brain’s natural preference for having these items organized as components of a story over simply having them listed one after the other.  It takes little effort to come up with a brief, one-line story that uses these words.  For example, the story in this instance could be “I like to dip my cookies and milk and then wipe my mouth with napkins.”  Most people will find it easier to remember this short story than to remember those same three words in list form.  A similar scenario could be encountered working at a large store like Wal-Mart or Target.  Your  boss may ask you to bring out light bulbs, toilet paper and paper cups.  This is a pretty random list of items which may be difficult to remember in its current form.  Turning this list into a short story may be beneficial.  For instance, the story here could be “There is no light bulb in the bathroom so he tripped over the toilet paper and knocked over the paper cups.”  Again, by putting the list of words into a brief story, the brain will find it easier to remember the information.

There are a few handy pointers to keep in mind when turning a list of items into a story.  First, the story should be relatively brief.  If you are trying to remember three or four words, the story should not be much longer than a single complex sentence.  Five or six items may require a story to be two to three lines long.  A story cannot be so long that it becomes itself difficult to remember.  The story should also create a visual image in your mind.  If you can “see” the story in your mind, then chances are that you’ve succeeded in creating a story useful in achieving the objective of bolstering memory in this way.  Using one of the previous examples, you may be able to imagine someone in a dark room tripping over toilet paper and knocking over cups sitting by the sink.  If you can see this happening in your mind, then the story worked for you.  It is very important that the story be one that is functional for you.  You should not concern yourself about whether others would like your story or find your story odd.  Too often, brain injury survivors using this method will self-censor their stories because they feel that others might not like those stories as they initially occur to the survivors.  These stories exist only to aid our memories.  The opinions others might hold of them therefore are not truly relevant.

This method of improving memory takes practice but once you get comfortable with the method, it can be very useful!  Please leave me a comment below with any questions, thoughts or ideas!

Learn about brain injury treatment services at the Transitional Learning Center: tlcrehab.org

Attention Process Training

Attention is a foundational skill that lays the groundwork for much of our cognitive functioning.  For instance, absent sufficient attention paid to your supervisor’s directions, it is impossible for you to remember and then follow those directions.  Similarly, without proper attention given to driving one cannot solve critical problems that may come up (such as avoiding a potential accident).  These examples of how attention affects other cognitive domains such as memory and problem-solving are just the tip of the iceberg when it comes to understanding the importance of attention.  One research-demonstrated method of improving attention after a brain injury is through Attention Process Training.

Attention Process Training (APT) is a multi-session exercise designed to help improve the brain injury survivor’s ability to focus on relevant material while ignoring irrelevant distractions.  Further, it helps improve the speed of processing information.  Speed of processing is a very important factor to success in areas such as driving, as the driver must pay attention to a myriad of information (even more so at high speeds).  The APT version used by the Transitional Learning Center consists primarily of the patient listening to audio tracks presenting a variety of information and then being asked to press a buzzer when information previously identified as relevant is given.  For instance, the audio track may consist of a long list of numbers and the patient must press the buzzer every time he or she hears the number 5.  These tracks are always first read slowly, and then repeated at an increased speed.  The therapist listens for errors of omission (missing the relevant information) as well as errors of commission (pressing the buzzer as an indication of having heard distractor information).  The APT tracks become steadily more difficult as the tasks progress.  After completing the tracks without any background noise, the tracks are repeated but this time including a different voice reading newspaper articles in the background.  Again, the patient must press the buzzer for the relevant information and ignore the distracting information (now including that background voice).  This skill is important since most life tasks involve some form of background distraction.  As example, a parent may cook a meal while his or her children are watching television.  If the parent is not able to sufficiently ignore the background noise of the children and the television, there may be a large kitchen disaster.  When a patient demonstrates good skill on these first tasks, he or she will be moved to a more difficult version of APT in which he or she must not only listen for relevant information but also alternate between sets of information to which he or she must pay attention.  For instance, a patient may have to alternate between listening for names of sports and names of animals.  This alternating attention is also important in our daily lives.  One common example of an alternating attention task would be found at a cookout, when a cook has to alternate between watching the meat grilling on the barbecue and cutting vegetables for condiments.  A failure to alternate attention adequately could lead to a charred dinner or a lost finger.

By working with Attention Process Training, patients can strengthen these vital attentional skills and thereby be more successful in their daily lives.  TLC has seen many patients improve in their overall functioning through this training program.

Learn about brain injury treatment services at the Transitional Learning Center: tlcrehab.org

When Can I Return To Work?

One of the main roles we fill in life, and subsequently one of the chief ways in which we define our identities, is through our jobs.  Work is also incredibly important as it provides the money needed to cover the expenses of daily life.  Further it is one of the primary ways we spend our time during the week, taking up at least 40 hours per week for most employed adults.  When a person receives a brain injury, he or she often struggles with being out of work.  Staff at TLC will commonly be asked by a patient “When can I return to work?”  However, this question is far more complex than it appears on the surface.  This post will address some of the issues involved in returning to work following a brain injury.

Jobs differ greatly one from another.  The skills necessary and education required to become a lawyer are completely different from benchmarks met on the journey to a career as a plumber.  Both are highly skilled positions, but each has a very different set of job demands.  For instance, if a plumber lost functioning of his hands he would not be able to return to his job as relying upon excellent hand coordination is an essential aspect of that job.  However as a lawyer’s job generally does not require much or any mandatory use of the hands, that job could be more easily modified to allow the injured lawyer to return to work.  As one example, the task of typing reports could be replaced with use of voice recognition computer software.  The first question that needs to be asked regarding such a return to work is whether the survivor’s current skills are sufficient to facilitate that return, and within that consideration it must be determined what level of modifications might be appropriate.  Does the survivor have the requisite skills to fulfill the demands of the job?  This is a different question than whether the survivor remembers how to do the job.  Most people who have worked the same job for a few years can recite their job requirements in perfectly accurate detail.  This is generally true for brain injury survivors as well.  Following a brain injury, a survivor will more often than not have a functionally intact memory of life prior to his or her injury and therefore be able to easily describe the job activities engaged in that pre-injury life.  The issue is not whether the survivor remembers the job, but whether he or she possesses the skills to do the job right now.

To help determine whether the survivor is capable of meeting the challenges posed by a given job, it is often helpful to make a list of job requirements to be set against a list of the survivor’s strengths and weaknesses.  Each task making up an essential part of the job should be listed.  Often, employers will make available job descriptions and/or task analyses that can help in this process.  Next, survivors should write down their current strengths and weaknesses.  During this activity many survivors tend to report what they excelled at in their lives pre-injury, as the injury itself will generally do little to change that innate understanding of one’s self.  Keep in mind though that the past is in the past; the pertinent question at hand regards what skills the survivor retains at present. Also, the survivor and his or her loved ones should not attempt to take into account how skills might soon improve when creating this list.  As the future is ultimately unknown, it is vital to complete this task listing only the skills the survivor has today.  As weaknesses that may affect job performance are identified, the survivor and loved ones should attempt to identify whether there are ways to remediate a given weakness. For instance, if a survivor’s wheelchair will not fit under a worktable, perhaps lifts can be placed under the legs of the table so as to raise the table and enable the front of the wheelchair to fit under.  In employment law parlance, these relatively minor remediations are generally called “reasonable accommodations.”  It is as a rule mandatory for employers to provide these reasonable accommodations to employees once notified of need.  (For those interested in learning more about these laws, please click on this link to Americans with Disabilities Act: Questions and Answers http://www.ada.gov/q&aeng02.htm)

Unfortunately, not every brain injury survivor can return to a former employment situation.  In some cases, the survivor’s injury deficits may provide simply too great an obstacle to achieving the level of success once enjoyed by that survivor in his or her pre-injury career.  In other cases, a survivor may have been let go by an employer post-injury.  Additionally, some survivors may have been unemployed at the time of their injuries.  To find a new job, the survivor and his or her loved ones need to consider the matching of the survivor’s strengths to possible employment positions.  An important part of this process is listing the survivor’s strengths.  One way of doing this is by creating an employment skills inventory.  It is helpful to break up the various skills into categories.  One such breakdown is as follows:

Cognitive/Physical/Sensory Skills (For example: Walking or Speaking)

Skills and Areas of Knowledge Gained at Previous Jobs (For example: Using a cash register)

Skills and Areas of Knowledge Gained through School/Training (For example: Algebra)

Skills and Areas of Knowledge Gained from Family Members and Friends (For example: Speaking Spanish)

When creating an inventory, it is important to identify each particular skill and area of knowledge as specifically as possible rather than writing them down as more broad statements.  For example, a survivor might want to add to the list skill as a salesperson.  However sales positions are often made up of many distinct component parts such as selling items, servicing customers, completing billing, collecting money and using computerized inventory software.  Each and every skill and area of knowledge should be listed independently regardless of how unimportant one may seem.  Once all of the skills and areas of knowledge are listed on the inventory, survivors and their families can see how these skills and areas of knowledge can combine to match different lines of work.  For instance, a survivor may list that he or she naturally has good speech and organizational skills, has well-developed managerial skills after having served as an officer in the military, has substantial inventory skills gained while working as a clerk in a factory and is fluent in Spanish due to growing up in a Spanish-language home.  In assembling these once disparate facts, it suddenly becomes clear that this survivor may be a strong candidate for a bilingual inventory manager position in a warehouse.

With all of this in mind, it is still not easy to return to work.  Many survivors have been out of work for months or even years prior to attempting a return to the workforce.  It is generally recommended that a survivor return to work on a part-time basis and then slowly move toward a fuller schedule.  There are a few very good reasons supporting this approach.  First, after being out of the employment scene for quite some time, most people lose to a certain degree their “work hardiness.”  Many survivors find that when they first return to work, they become tired far more easily than expected.  It is often necessary for them to build up their strength over time in order to enable them to physically and mentally stay on task for an extended period of time.  Second, by working a shorter day it is easier to identify and correct any possible areas of difficulty that a survivor may encounter due to his or her injury.  As example, if a survivor is working four hours a day and finds that attention deficits are negatively impacting performance, he or she can simply try different methods designed to assist in blocking distractions.  If the survivor is working ten hours a day, it is hard to discern if poor performance is due to injury deficits or is rather due to the unavoidable fatigue that comes with working long hours.  If the survivor is beginning a new line of work (particularly if that work earns the survivor less money or carries less prestige than the survivor’s former employment), it is important to encourage the survivor.  Just getting back to work after a serious brain injury is a tremendous accomplishment.  Further, the first job after a brain injury does not have to be the survivor’s “forever” job any more than a first job out of high school was necessarily his or her “forever” job.  These first jobs can be seen as stepping stones to greater employment success in the future.  Overall, patience is vital in its role central to any successful return to work.

Unfortunately, some brain injury survivors may simply never reach the point at which a return to paid employment becomes feasible.  However, there may be volunteer opportunities that the survivor could engage in which can both occupy his or her time and bring a missing sense of accomplishment and contribution to the larger community into his or her life.  Volunteers are the lifeblood of many charities, hospitals and religious organizations.  Volunteering also provides a useful opportunity to practice post-injury work skills in a safe environment in anticipation of future employment.

There are several organizations that can help a survivor through the post-injury employment process.  In the State of Texas, the Department of Assistive and Rehabilitative Services (DARS) has a Vocational Rehabilitation (VR) department that can help provide therapy and support for brain injury survivors who are strong candidates for employment (http://www.dars.state.tx.us/drs/vr.shtml). In fact, the Transitional Learning Center often works with VR candidates from DARS in order to help those individuals return to employment in their post-injury lives.  The Job Accommodation Network offers excellent information for both employment seekers and employers looking to facilitate the return-to-work process (http://askjan.org/).

Hopefully this post helped outline a few of the considerations important to a post-injury return to work.  Please leave me a comment below with any questions, thoughts or ideas!

Learn about brain injury treatment services at the Transitional Learning Center: tlcrehab.org

Tips for Improving Attention

Attention is an important skill. It plays an integral role in almost everything we do. Attention is vital when we engage in daily activities such as paying bills, driving a car and safely walking through a busy parking lot. After a brain injury, many survivors notice significant challenges in the realm of attention.  Their attention spans may be much shorter, they may find themselves now to be far more easily distracted than they once were, and multitasking may no longer be in any real way feasible. Here are a few tips to help improve attention:

1.  Find a quiet location to work on activities. The more quiet the surroundings, the less likely distraction is to present as a significant factor while completing those activities.

2.  Remove all distracting items such as cell phones, Ipads and radios while involved in activities.  One should also silence ringer/alarms on phones and watches.

3.  Let other people in the vicinity know that silence is needed when working on an activity so as to minimize likely instances of disruption.  Often, a “Do Not Disturb” sign works well to notify others to be quieter.

4.  Break down activities into smaller, simpler tasks. It is much easier to pay attention to smaller, simpler tasks than it is to contend with larger, more complex activities.

5.  Do one activity at a time.  All people, whether they have a brain injury or not, are better at focusing on a task if they tackle just one activity at a time rather than make an attempt to multitask.

6.  Organize activities before starting them. It is far easier to focus on organized activities than it is to grapple with disorganized ones.  Good organization also provides a road map for how one can most successfully approach a task.

7.  Schedule regular breaks during activities. Most people can only pay attention effectively for a limited period of time until they need a rest and that already limited period may be significantly diminished following a brain injury.

8.  Set up a reward to accompany completion of an activity so as to help with motivation and focus.  For instance,  watching a favorite movie or eating a favorite snack could be arranged as a reward to be enjoyed upon conclusion of a task.

9.  Make sure to eat well, stay hydrated and get plenty of rest. If a body is not functioning at its top level, attention skills will often be the first cognitive skills to suffer.  Many brain injury survivors find that strictly adhering to a well-considered health regimen is far more important to success after an injury than it was before.

10.  Ask people to speak slowly or repeat themselves if paying attention when they are speaking proves difficult.  People get far more upset if their audience misses what they are saying than if they have to repeat themselves in order to ensure that they are fully understood.

11.  If in a group of people, be sure to stay facing the person who is speaking.  If there are too many people around to effectively attend to, ask the person speaking if he or she could step away from the group to make focus more attainable.

12.  If in a classroom or meeting, make sure to sit in the front of the room so as to be closer to the speaker.  This not only removes as a factor distracting people and noise along the pathway to the speaker, but it also demonstrates interest in what the speaker has to say.

13.  Place a fan or a white noise machine by doors to help eliminate distracting noise coming from the outside of rooms.

14.  Place a bright colored piece of paper under a book being read.  This helps the eyes to stay focused on the book instead of on outside distractors since our eyes are naturally attracted to the bright color. Also, one can place a brightly colored ruler, index card or piece of paper under the line being read so as to help keep eyes focused on that line.

Hopefully this provided a few ideas on how to help improve attention!

Learn about brain injury treatment services at the Transitional Learning Center: tlcrehab.org