Category Archives: Working on Skills

Lessons from a Blind Man

We here at the Transitional Learning Center often host patients and family members that speak Spanish as a primary language.  Spanish-speaking TLC staff members are generally on-hand to translate during therapies and other necessary interactions, but on occasion TLC staff will have need to use a phone translation service (in a meeting updating family on progress, for example).  To utilize this service, a staff member will call the service phone number which connects directly to a translator.  The translator can then translate between all parties involved via speaker-phone.

When using such a translator, it is important to pause every few sentences so as to allow the translator to translate that which has just been stated.  On one memorable occasion a therapist spoke for too long without pause and upon realizing her error, stopped herself and apologized for not stopping sooner.  The translator agreed that to do his job effectively he would require more frequent pauses.  He then added that he cannot depend upon notes taken while someone is giving him information to translate because he is blind.  He was doing his job utilizing memory and language skills exclusively.

Reflecting upon this situation there is an important lesson to be learned for all individuals with disabilities, including brain injury survivors contending with long-term deficits.  A translator position is the perfect occupation for a bilingual blind person.  The job requires excellent speech and finely-honed cognitive skills, but in no way requires vision.  The job matches the person’s strengths to a central task while sidestepping the influence of any weaknesses.  After an injury, many brain injury survivors need to find new jobs because newly acquired deficits do not allow them to return to their previous occupations.  It is important during the job search process to honestly identify post-injury strengths and weaknesses in order to find jobs that rely on strengths while minimizing the impact of any weakness.  By taking this important step survivors are more likely to enjoy success in the working world, just like the blind translator from our story.

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

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New Technology Can Lead To More Success

Technology plays an ever-increasing indelible role in our modern lives.  Just as our phones and televisions are enhanced by new technological advancements,  so does neurorehabilitation from brain injuries benefit in a similar fashion.

Technological advances and applications for that new technology in rehabilitation come from different sources.  There has been a steady improvement in proprietary technologies catering to therapists and doctors who treat individuals with brain injuries.  These new technologies aid in a wide range of therapies, from helping a patient to re-learn swallowing skills to improving gait training.  Two common such examples can be seen in a patient working on a task while wearing electrodes to stimulate particular muscle groups or one walking laps while a programmable hoist unloads a percentage of that patient’s body weight.

Separately but related, most patients now integrate smart phones, Ipads, tablets and other such technology into their daily lives.  These items can be very useful in compensating for certain deficits.  For instance, many patients use their smart phones to keep track of their schedules and to program reminder alarms for daily activities.  There are numerous speech apps that can be downloaded to Ipads which enable patients to engage in more effective communication with others.  The cameras now included as feature of virtually every cell phone and tablet PC prove useful in compensating for deficits in visual memory.

These new technological advances benefit patients in multiple ways.  Many of these technologies enhance the effectiveness of therapies.  This brings greater success in individual therapies and thus in overall rehabilitation.  Other technologies provide new ways to compensate for deficits.  This helps reduce the lasting impact of injuries on patients’ daily lives.  Additionally, patients enjoy certain technologies that can make the daily work of therapies feel more fun or interesting.  This helps keep patients motivated in those therapies.  The pertinent role of the therapist is to identify which technologies will benefit which particular patient as each patient is different both in therapy needs and in personal comfort level with new technologies.

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

Different Parts, Different Speeds

Brain injury survivors and their families often ask doctors and therapists about how long it will take for brain injuries to heal.  This would seem like a simple and straightforward question, but the answer to this question is actually quite complex.  One of the chief factors that makes any such answer so complex is that different parts of the brain may heal at different speeds.

We often talk about the brain as if it were one unitary body part, but in truth it is made up of many interconnected parts.  For instance, there are distinct left and right sides of the brain that are connected by a set of neurons known as the corpus callosum.  Each side of the brain can be split into many different component parts.  These parts function interdependently, but each part has its own unique purpose.

When a survivor received a brain injury, different areas of the brain may have been damaged at different levels of severity.  Which parts suffered damage at what levels of severity will differ from person to person and from injury to injury.   With so many parts of the brain being impacted differently by an injury, it is very common that a brain injury survivor will see improvements in some areas faster than in others.  For instance, if the part of the brain responsible for speech comprehension was less injured than the speech production part of the brain, that survivor will likely gain back the ability to understand verbal communication well before ability to convey information through speech returns.  If the part of the brain governing leg movement was less injured than the part of the brain controlling the arms, then that person is likely to see a return of the ability to walk through a doorway prior to being able to once again turn a door knob to open that door.  Ultimately, having different skills return at different rates of speed should be understood as a normal and expected part of the brain injury recovery process.

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

What Language Do You Speak?

 

There is an interesting phenomenon often observed in brain injury survivors who were bilingual to the extent of fluency prior to their injuries.  In these survivors who have post-injury language deficits the first (native) languages tend to return more quickly and fully than do their second languages.  This is true even in survivors who were fully fluent in a second language and used that second language extensively in their everyday lives.  As TLC is located in Texas, our staff tends to observe this phenomenon most often in Spanish-English bilingual patients.  Many of these patients now contending with language difficulties who learned English later in life find it far easier to name objects or follow directions when Spanish is used, while prior to their injuries they would have been comfortable using either language.

This return of the first language sooner than a second language can have a number of practical consequences.  Many survivors understandably become frustrated at an inability to speak that second language with the same skill once demonstrated.  Being bilingual is often a point of pride and may have previously allowed the survivor to excel in activities (such as import-export business transactions) that the average person could not.  This sudden significant skill gap may even prevent these survivors from returning to jobs in which a second language was utilized as a vital portion of everyday business life.  Moreover, if the survivor was previously the primary translator for the family this may cause difficulties in the family’s ability to interact with the outside world.  For example, the survivor may have previously served as point person to get information from school regarding a child’s performance as that survivor could easily speak to school officials (and the rest of the family may struggle with casual exchanges in English).  If the survivor is now unable to converse fluently in English, the family may now face significant problems interacting with the school.

There are also practical therapy concerns when a survivor struggles with a second language if that second language is the primary language used in the larger community.  In America, English is obviously the dominant language.  As such, most pre-therapy evaluations are conducted in English.  There are a limited number of health care professionals who are comfortable conducting evaluations in another language.  However, if a survivor’s first language is not English and that survivor is significantly stronger in his or her first language, that first language will need to be the language used in evaluations so as to get the most accurate measurements of the survivor’s skills.  The same is true in therapy.  If a survivor understands therapy directions significantly better in a first language, then therapy should be conducted in the survivor’s first language.    Additionally, therapists should always inquire as to which language is used in the home.  If the survivor’s first language is different than the language used at home (seen when someone who speaks both Spanish and English marries a spouse who only speaks English), then that second language will need extra focus or alternative methods of communication (e.g. pictures or hand signals) may need to be introduced.  At TLC, we have a number of Spanish-English bilingual staff and have a contract with a translation service if other help is needed.  Overall, rehabilitation professionals must be aware of survivors’ language skills and adjust evaluations and therapy accordingly.

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

 

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/