Category Archives: Working on Skills

The Rehabilitation Partnership

One of the most basic truths of successful rehabilitation is that it involves a partnership between the patient and therapists/doctors.  It is important to understand what this partnership entails, namely that without both parties’ investments in the process the patient will only see limited improvements.  This also means that each side has a responsibility to the other side to ensure success.  The job of rehabilitation is a shared job between the patient and rehabilitation professionals.

There are a number of implications to this basic truth of the rehabilitation partnership.  A therapist/doctor cannot make a patient improve.  A therapist/doctor can only work with a patient to help the patient improve.  Keeping this in mind should dissuade rehabilitation professionals from imagining themselves to be like Superman, swooping in to save the patient from the patient’s brain injury.  Brain injury rehabilitation simply does not function like a comic book story.  This realization should also empower the patient with the knowledge that his or her thoughts, feedback and effort are a vital part of rehabilitation (without which success cannot be fully achieved). Professionals need the patient’s thoughts and feedback to best plan and implement therapy.  Every patient is different, so a method that helps one patient may hinder or even harm another.  There is no way for a professional to know this without feedback.  This should also dissuade patients from being too passive when engaging the therapy process.  Rehabilitation professionals cannot help a patient improve if the patient will not try to help him or herself.   They cannot do the work for the patient.

When this partnership between patient, therapists and doctors truly comes together, everyone becomes a vital member of the rehabilitation team.  However, it is important to remember who needs be recognized as “team captain.”  The patient is the “team captain” in the sense that the process is ultimately focused on the patient.  The patient needs to share with the team any and all goals, expectations and dreams.  When the entire team has this information (which has to be updated on a regular basis), the team can best determine the direction therapy needs to take.  For instance, if a patient was formerly a chef and dreams of returning to that former occupation, a great deal of therapy will be focused on activities in the kitchen.  If the patient never went in the kitchen outside of opening the refrigerator door, then therapy will clearly be focused on other activities.

A successful partnership will generally allow the patient and rehabilitation professionals to have a mutual understanding and appreciation of one another.  It will also foster openness, honesty and trust between the patient and the rehabilitation professionals.
Remember, teamwork makes the dream work!

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

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Give. It. A. Minute.

One of the most common mistakes that brain injury survivors’ loved ones make after an injury is not giving the survivors enough time to respond or take an action.  For instance, a survivor and his family may be at a restaurant for dinner.  When the survivor is struggling to place his order, a family member may jump in to place the order for him.  If given enough time, the survivor may have been perfectly able to place the order but the family member did not give him enough time to respond.

There are a few reasons why survivors’ loved ones tend to not give enough time to the survivor to respond or take an action.   One reason is that silence is uncomfortable.  For instance, if a survivor is needing extra time to respond, the silence may be so uncomfortable that the loved one will jump in and speak “for” the survivor.  A second reason is that is uncomfortable to watch someone struggle.  As an example, a survivor may be slowly, and with great effort, reach toward an item on a table.  The loved one may be so uncomfortable watching the survivor’s struggle that they reach over to get the item for the survivor.  A third reason is the feeling that the survivor and loved ones are in a rush or feel like they are causing someone else to slow down.  For instance, a survivor in a wheelchair may be pedaling down a hospital hallway but family members, concerned that the wheelchair is blocking the nurses, decide to push the survivor’s wheelchair to more quickly reach their destination.

However, it is important to give the survivor more time.  First, and most importantly, if the survivor is able to make a response or take an appropriate action when given extra time, they should be allowed the independence and respect to do so.  By unnecessarily jumping in, loved ones are taking away the power and the dignity of the survivor to take care of their own needs.  Second, although a survivor may need extra time and effort to complete a task, they are more likely to get faster and more efficient over time with practice.  By doing the task for them, the loved one is taking away vital practice from the survivor who is trying to master a task.  Third, the survivor may need extra time to safely complete an activity.  After an injury, certain tasks may have concrete steps which take time or require more processing time to successfully finish without risk.  For example, most uninjured individuals simply stand up when they are ready to leave a room.  A survivor may have to go through multiple steps to safely transfer from sitting to standing.  These steps require extra time so the survivor can safely transfer.

When wondering about the survivor’s need for extra time and if they should jump in, loved ones should ask themselves the following questions:

1.  Is the task truly out of the survivor’s skill range or do I just need to be more patient to allow them to complete the task?
2. Are we actually in a rush or is a little extra time a reasonable request?  For example, if a survivor needs an extra ten seconds to place an order at a restaurant, keep in mind that the waitstaff is getting paid to serve you.  Ten extra seconds is not an unreasonable request.
3. What message am I giving to the survivor if I do not allow them to do for themselves when they are able to so?
4. Is the issue really about the survivor needing extra time or my personal discomfort in this situation?
5. By going faster, have I compromised my or the survivor’s safety?

In most cases, a little extra time will help a brain injury survivor be more successful and allow everyone to have a better experience!

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

Using the Open Chair Technique

Survivors with brain injuries push themselves to get better.  Staff members at TLC see this every day.  Survivors push themselves to walk better.  They push themselves to speak better.  They push themselves to improve their memory.  They push themselves in every aspect of the rehabilitation experience, but recovery from a serious brain injury can be quite slow.  It is almost always slower than the survivor would prefer it to be.  Unfortunately, this leads some survivors to speak poorly about themselves.  They say things such as “I am a failure because I am not 100% improved” or “I should be much better than I am now.  I am failing at therapy”.  This negative self-talk can lead to emotional difficulties such as stress, low mood and sometimes even to depression.

If looked at objectively, this negative self-talk is often due to unrealistic expectations that the survivors have regarding their recoveries.  The survivors may believe that the amount of time necessary to recover is in excess to that which they expected, even when the medical research shows that they are progressing at a normal rate.  By expecting faster or better results than are humanly possible, survivors can cause themselves unnecessary frustration.

Interestingly, these same survivors who hold unrealistic expectations of themselves generally do not hold these same expectations of others.  They are often more logical and understanding of other survivors than they are of themselves.  It is common at TLC for the same patients who have unrealistic personal expectations to support realistic expectations in other patients.  They will make supportive statements to other patients such as “Don’t worry and take it slow.  You will get better over time.  You are running a marathon not a sprint.”  When the patients with unrealistic expectations are asked if they believe the advice they are giving to others, they almost always answer in the affirmative.  They understand that the brain injury recovery process is a slow one which requires lots of work.  They understand it is a long-term process.  But they decide for whatever reason that their personal recoveries should take less time than those of others, holding themselves up to unfair (often impossible) standards.
One way to manage this negative self-talk is by using the “open chair” technique.  How this technique works is that patients are asked to imagine they are sitting next to themselves and that the person occupying their seat is someone else with the very same issues and deficits that they have.  The patients are then asked to give this “other person” honest feedback about how the “other person” is doing.  Often, patients find that this leads them to soften their tones and to make more supportive personal statements regarding their own progress.  Similarly to when they are actually talking to other patients, when they address themselves as that “other person”  patients demonstrate more realistic expectations and are less likely to attack themselves.  The “open chair” technique often helps patients treat themselves not only better, but also more fairly and honestly.  By being more fair and honest to themselves, survivors tend to have an improved mood.  And the better the mood that survivors can maintain, the easier it is to navigate the rehabilitation process.

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

Practice Makes Proficient

Neurorehabilitation from a brain injury involves learning and re-learning a long list of common activities.  Patients spend hours honing skills such as naming well-known items, transferring to and from a wheelchair and using adaptive equipment.  Therapy sessions often consist of countless repetitions of the same action, drilling these essential skills over and over (and over).  Further, therapists will usually send patients home with discharge plans outlining continued practicing of these same skills at home.  Sometimes, patients will wonder why they have to practice these activities to such a degree.  After all, if they demonstrated the skill once (or more likely a multitude of times throughout inpatient therapy) doesn’t that serve as proof positive that they now possess said skill?  Why is this repeated practice necessary?

In reality, to truly become proficient at any skill a great deal of of practice is necessary.  Just because a patient has succeeded at demonstrating a skill on one occasion does not mean that he or she will succeed in the future.  This is true for any life activity or field of endeavor.  For instance, imagine hearing the following overhead announcement while taxiing an airport runway prior to takeoff:  “Ladies and gentleman, welcome aboard flight 683 to Phoenix.  My name is Captain Mike and I will be your pilot today.  I have successfully flown a plane once.  I anticipate a smooth flight today.”  After hearing this announcement, most passengers would probably scream for the exits immediately.  Who would trust a pilot to fly a plane with a history of only one successful attempt?  We instinctively recognize that lots of practice is necessary to trust that a person can reliably and competently complete a given task.  This holds just as true for therapy as it does for the for flying of a plane.  Repeated practice, both in therapy and at home, is necessary for a patient to hone the skills and competencies necessary to successfully accomplish rehabilitation goals.  It is only through practice that patients can become proficient.

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

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/

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/