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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 age.  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/

 

Who Will Be There When I Am Gone?

Fields related to the treatment of brain injury have improved by leaps and bounds over the last twenty to thirty years.  People who have suffered severe traumatic brain injuries are today surviving from injuries that would have once been fatal.  Health care professionals are able to manage associated medical issues and injury deficits left in the wake of traumatic brain injury better than ever before.  This has led to brain injury survivors with serious impairments being able to live longer than could have been imagined just a short time ago.  This also then means that many of these survivors will have need for others to serve as caregivers for them many years into the future (in some cases even for decades).  These caregivers may be called upon not only to help with day-to-day activities but also may be legally responsible for making medical, legal and financial decisions.  This brings us to an important question for those caregivers to consider. If something decisively unfortunate were to befall such a caregiver, have contingency plans been made to ensure that those care and legal responsibilities would continue to be sufficiently addressed?  For example, let’s say that a forty year-old man survives an aneurysm which leaves him unable to make his own decisions and subsequently his sixty-five year-old mother takes over these responsibilities for him.  A man that young in reasonably good health could fairly be expected to live at least another twenty years under such a circumstance, which would then put his mother at eighty-five.  Can anyone guarantee that his then eighty-five year old mother would continue to have the ability to make such decisions for him?  What happens if she faces a health issue such as Alzheimer’s or cancer that would effectively dismantle her ability to make his decisions for him?  Can anyone even guarantee that she will survive all the way to eighty-five?  Clearly, a plan needs to be put in place to designate a replacement to step into the mother’s critical role in this man’s life should she suffer incapacitation or pass away.

Putting together such a plan is no simple task and in many cases families will need to consult an attorney in order to formulate a coherent, legally binding plan.  These plans will generally involve issues such as daily care, financial management and legal responsibilities.  Questions have to be answered such as where the survivor will live and who will monitor disability or like payments should a current caregiver be unable to continue in his or her role.  Also, plans may need to be updated over time to reflect changes.  Using the earlier example, let’s say that in the mother’s will she appoints the survivor’s uncle to take over the legal responsibilities in her son’s life after she’s gone.  If this uncle’s wife developed a serious illness that suddenly demanded all his time and energy, the mother would likely want to update her will and appoint a new person to be responsible in case she became incapacitated or passed away.  Sometimes multiple people are listed in the plan (often in descending order), identifying a line of succession regarding those responsible for seeing to the survivor’s well-being.  This even further bolsters guarantee of a survivor’s continued security.  Sometimes roles are also divided among different individuals.  As example, one person may be responsible for daily physical care while a different person might be assigned ultimate authority over medical decisions.  No matter what plan is put in place (for this or for any other issue), the brain injury survivor should take part in the planning to the best of his or her abilities.

Planning for the future is a serious issue and should be started as early as possible.  Most survivors’ brain injuries make entrance into life suddenly and without warning, and caregivers can just as abruptly have their own issues present that prevent them from maintaining their caregiver roles.  For those that do not have the financial means to hire an attorney to develop a plan, there are legal aid offices throughout the United States that provide free legal services.  Follow the link below to search for a legal aid office in the United States.

 

http://www.lsc.gov/what-legal-aid/find-legal-aid

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/

July 4th Fireworks

Every July 4th, Americans across the country light up the sky with fireworks.  This patriotic spectacle is commonly enjoyed at large outdoor celebrations, though often fireworks are also set off at private homes.  This circumstance brings to the fore an issue that we as a society may not generally afford sufficient attention.  Namely,  how do our family and neighbors react to fireworks?

After a brain injury, many survivors are highly sensitive to loud noises.  Fireworks can be quite disturbing to a survivor, even if he or she enjoyed them in the past.  Fireworks may lead to agitation, frustration and acting out.  Prior to attending a fireworks celebration (whether public or private), loved ones should check with survivors and their therapists as to whether those survivors would do well at a fireworks display.  If the survivor chooses to attend a display event, loved ones should have an exit plan prepared just in case the event goes poorly for the survivor.  Neighbors should check with survivors and their families prior to setting off fireworks.  Fireworks are not truly a “private” matter, since everyone in the nearby vicinity will be hearing them whether they wish to or not.  It is not fair for the survivor to be put in serious distress just because a neighbor likes to set off fireworks.

This issue may prove even more pertinent when a survivor is a combat veteran.  Many combat veterans who suffered injuries in battle also have Post-Traumatic Stress Disorder (PTSD).  PTSD symptoms can include flashbacks in which the veteran feels like he or she is back contending with the relentless stressors of life in combat, painful memories of the trauma of friends dying and serious sleep disturbances. Fireworks can trigger all of these symptoms and more.  Additionally, many in the South have a custom of shooting guns in the air on July 4th.  If fireworks are a bad idea around combat veterans with PTSD, then shooting guns is a horrible idea.  (As a sidebar this practice is simply remarkably dangerous.  This writer knows a woman who was hit by a bullet that was shot by an unknown individual in the air to celebrate a holiday. The bullet fell into an open restaurant area and lodged in her lung.)  The combined effects of a brain injury and PTSD can make these situations especially tricky for veterans.  Loved ones should check with survivors and their therapists as to whether these veteran survivors may have a PTSD-type reaction around fireworks or guns.  Again, neighbors should check with combat veterans to ensure that the neighbors’ celebrations do not harm the psychological well-being of these individuals.  Some combat veterans have taken to putting signs on their lawns identifying themselves as combat veterans and asking others to be courteous with fireworks.  These signs should be taken seriously and neighbors should not shoot fireworks or guns near these veterans.  Again, no one should be forced to suffer in service of a neighbor’s idea of “fun.”

Wishing everyone a Happy July 4th!

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

Left Neglect vs. Field Cut

It is possible for multiple distinct symptoms of an acquired brain injury to present in remarkably similar fashions.  For instance, a brain-injured survivor’s failure to take medication could be due to a memory deficit leading that survivor to simply forget his or her medication or it could be due to an attention deficit leading the survivor to be too distracted to take the medication in question.  In each case the medication was missed, but for acutely separate reasons.  A similar issue comes to light in observation of post-injury visual deficits.  Did a survivor fail to notice information to his or her left due to left neglect or due to a field cut?

Let’s start off with outlining precisely what a field cut is, as it is the simpler of the two to understand.  Under the effects of a field cut, the survivor has actually permanently lost the ability to perceive a portion of the field of vision.  That area of the field formerly available has now been “cut” away.  Due to his or her injury, the survivor is now in effect partially blind.  In medical terms, this loss of vision is often called “hemianopsia.”  So a survivor contending with a field cut has had actual visual loss  in his or her left visual field and thereby misses seeing information on his or her left side.

Left neglect is an attention issue which often manifests in the visual attention domain.  It is associated with an injury to the right side of the brain.  With left neglect, the brain fails to pay attention to information to the left side of the survivor.  If you ask a survivor with left neglect to turn his or her head all the way to the right, he or she will generally turn until the chin reaches the right shoulder.  However if you ask the same survivor to turn to the left, he or she may only bring the chin half-way to the the left shoulder despite fully understanding the request and giving a best effort to fulfill it.  It is almost as if the survivor’s brain is saying, “the left side of the world does not exist.”  The survivor’s eyesight can be perfectly intact, yet his or her brain is ignoring information generated from the left side.  This ignoring is not voluntary; as far as the survivor is consciously aware, he or she did look all the way to the left even though an outside observer can clearly see that the survivor did not make it all the way over.  Again, though it appears functionally as if the survivor has lost vision, the underlying issue is one of attention.

In the case of a field cut, most survivors do reasonably well after becoming sufficiently aware of their field cuts.  They will after enough practice naturally turn and make that extra effort to look for the information in their blind spots.  For a survivor with left neglect, improvement requires not just awareness but also daily repetition of scanning exercises and consistent use of visual aids.  As example, a survivor with left neglect may practice scanning techniques by slowly looking for information on a piece of paper being sure to start all the way on the left of that page before scanning across.  It can also be helpful to put a brightly colored highlighter mark on the paper to identify the far left of the page.  Sadly, in some cases a survivor will suffer from both left neglect and a field cut.  This combination can of course make successful functioning especially difficult, but with appropriate dedication and determined effort most any such goal gains entrance into the realm of the attainable.

I hope this clarifies the differences between left neglect and a field cut.  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

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

Supporting Brain Injury Rehabilitation

Texas’ Department of Assistive and Rehabilitative Services (DARS) is one of the most important funding sources for survivors of brain injury.  Many insurance companies will not fund certain rehabilitation services, effectively removing survivors’ access to vital opportunities to receive professional care as they struggle through recovery.  Still other survivors were without insurance at the time of their injuries and have no means to pay for necessary therapies.  For many brain injury survivors, DARS is simply the only funding source which will allow them to access the intensive rehabilitation that they need.

As the Texas House and State Legislature are working on the 2016-17 State budget, there is a proposal to fund brain injury and spinal cord survivors on the DARS waiting list.  This would allow for almost 100 more survivors to receive treatment.  Please click on the link below and sign the petition to help bring treatment to these survivors.

http://biaatx.nationbuilder.com/crs_petition

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

Walk for Brain Injury

The Brain Injury Association of America-Texas Division will be hosting a Walk for Brain Injury on Saturday, May 2 at Discovery Green in Houston.  The Transitional Learning Center is proud to be a sponsor of the Walk.  This is a wonderful opportunity to show your support for survivors of brain injuries and their families.  If you are interested in attending the walk, please click on the link below for more information:

http://www.texaswalkforbraininjury.com/

TLC will be sending a team led by Music Therapist Amanda Gilbert to show support and to help raise funds for the Brain Injury Association.  If you would like to help Team TLC reach its fundraising goals, please click on the link below.  Every dollar counts!

http://biausa.donorpages.com/WalkHoustonTX15/TEAMTLC/

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

Passover Adaptations-A Brief Guide

Passover is the central family holiday on the Jewish calendar.  Jewish families come together to celebrate at the Passover Seder the Exodus of the ancient Israelites from Egypt.  Tables are packed with guests and overflow with food as participants read through the Passover Haggadah.  Weeks of cooking, cleaning and preparation all come together on the Seder nights into a full-blown celebration of freedom from Egyptian bondage.  Unfortunately, brain injuries suffered in the wake of a stroke or traumatic brain injury event can impact a survivor’s holiday experience.  There is a tremendous beauty in the Passover Seder but after a brain injury, there are new concerns that survivors and their families may need to consider.  This post will identify some of those concerns and make a few suggestions to aid in addressing them.

There are a number of issues that may need to be addressed regarding the location of a Passover Seder.  First, if the survivor is in a wheelchair or uses another assistive device to aid mobility and is going to someone else’s home, is that home sufficiently accessible?  Keep in mind that it is much easier to get a wheelchair across a hard floor than across carpeting.  Even thin carpet can present difficulties when attempting to turn a wheelchair.  Additionally, is there enough room in the bathroom for a wheelchair?  Should the survivor bring along a urinal if it is too hard to access the toilet?  If the survivor has problems with incontinence, is there somewhere available that the survivor could clean up or change clothes if necessary?  Some families of brain injury survivors may find that it is easier to host Seders at their own homes rather than travel to the homes of others since their own homes have already been adapted to the needs of the survivors. Survivors and their families should also consider the physical layout of the rooms where a celebration will take place.  For instance, it may help to move tables and chairs into a different configuration in order to make it easier for the survivor to move through.   Often, seders take place around a large table.  The survivor may find it easier to sit at the end of the table, particularly if he or she is in a wheelchair, than to sit at the side of that table.  Also, how close does the survivor need to be to a bathroom or an exit?  Some survivors have urinary urges that need to be attended to particularly quickly or may need to make a quick exit in order to counteract the detrimental effects of over-stimulation.  There are many other practical issues to consider regarding the set-up of the holiday meal.  Can the survivor reach a given dish or will he or she need help?  Has silverware been left on a counter that is too high for the survivor to reach?  Can the front of the survivor’s wheelchair fit under the table or will the table need to be raised?  If the survivor uses an augmentative speech device like a letter board, is there room at the table for it?  Is a side table perhaps needed for the device to be placed upon?  Small changes in room and furniture layouts can make a huge difference to both a survivor’s sense of inclusion and his or her overall enjoyment of  the Passover celebration.

Survivors and their families will also want to put thought into how loud a seder may be.  Some survivors find that they are more sensitive to noise than previously and that loud noises may now provide a catalyst for unwanted agitation and/or anger.  These survivors may benefit from attending smaller seders or from being sat away from loud children and other factors contributing unduly to agitation.

Another practical issue relates to the drinking of the four cups of wine on Passover.  The cups of wine take center stage during much of the seder, yet many survivors are unable to drink alcohol as it now presents that much more significant a health risk.  For instance, alcohol mixes poorly with many medications and this dangerous mixture can lead to serious health problems.  This obstacle to full participation may lead  survivors to feel conflicted about the four cups of wine.  The first thing to keep in mind is the vital relevance of consultation with a doctor.  If a doctor has identified consumption of alcohol as a serious health risk for the survivor in question, then by Jewish law that person cannot drink the alcohol.  It is important to keep in mind that maintaining one’s health is one of the 613 commandment in the Torah and it cannot be violated even to honor the four cups of wine at seder.  Many rabbis including Rabbi Soloveitchik (recognized as one of the great rabbinical minds of the 20th century) have ruled that grape juice can be used at seder instead of wine.  Families may wish to have grape juice for all seder attendees instead of wine so that a survivor does not feel left out.  For those that are unable to drink at all due to swallowing issues and may be worried that they are violating Jewish law by not drinking the four cups, a little historical perspective may provide some particularly helpful insight.  The idea that everyone needs to drink four cups is a stricture instituted by Tosafos (a group of rabbis in the Middle Ages).  Technically only the seder leader is required to drink.

There are other considerations that bear mention when it comes to the eating and drinking done on Passover.  Some individuals cannot eat green, leafy vegetables because they interact poorly with medicines such as blood thinners.  This can be an issue as many families use items like parsley during their seder meals.  Survivors and their families should consult with doctors to assess if the amounts of these substances being eaten in these circumstances will be enough to interfere with the the medications in question.  If that does prove to be the case, rabbis and doctors can help identify alternatives.  As example, instead of using parsley as the Karpas vegetable some people use potatoes.  Consulting with a doctor and rabbi can help one to make the best adjustments while still adhering to the requirements of the seder meal.

Some brain injury survivors utilize certain dietary aids after their injuries, such as meal supplements and drink thickeners.  Survivors and their families may have concerns about whether these items violate the laws of Passover due to being chametz (made from leavened items) and for Ashkenazim, if they are kitniyot (legumes).  However, most major supplements and thickeners are kosher for Passover use by those who are sick or are in medical need.  The Orthodox Union (OU) has a lengthy list of such options that are kosher for Passover.

https://oukosher.org/passover/guidelines/medicine-guidlines/nutritionals-and-dietary-supplements/

The OU also provides a brief guideline on caring for the infirm on Passover:

https://oukosher.org/passover/guidelines/medicine-guidlines/caring-for-infants-and-the-infirm/

For those who are Sephardic, as long as the items do not have chametz, they are kosher for Passover as the issue of kitniyot is just an Ashkenazic issue.

Again, as each survivor’s case differs from the next, it is important to check with both the survivor’s doctor and rabbi prior to deciding if something can or cannot be used or ingested.  For instance, many times people will believe that something is prohibited only to later find that a rabbi rules that it is in fact allowed.

Another issue that can arise is that seder meals tend to be very large with lots of food and this may impact a survivor’s blood sugar levels if he or she has diabetes.  It is important to plan meal choices around this health issue.  Survivors and families should tailor their Passover menus as needed to reduce the chance of dangerous fluctuations in blood sugar.  Also, it should be kept in mind that seder meals tend to be eaten later than is typical of a normal dinner.  For those that have diabetes, it is vital to discuss with a doctor what type of adjustments to medication schedules may be appropriate on the seder nights.  The Jewish Diabetes Association (via the Star-K Kosher organization) has a Passover guide for diabetics:

http://www.star-k.org/kashrus/kk-passover-diabetics.htm

Passover cleaning and meal preparation can be almost as big a component (and sometimes even  bigger) of the overall celebration as the actual seder meal itself.  Individuals spend many hours cooking and cleaning in preparation for the holiday.  This may be difficult for many survivors who are used to doing the cooking and/or cleaning themselves.  This may cause survivors to confront feelings of uselessness or worthlessness and can represent a significant alteration to roles as they have been thus far understood.  It is important that survivors be allowed to participate in this process in any way that they may be capable.  The survivor may not be fully able to cook the chicken that will be eaten as the main course, but perhaps he or she could chop some of the vegetables for the meal or the nuts to be used for the charoset.  The survivor may not be able to handle a vacuum to clean the carpet, but perhaps he or she could help with sweeping the floors.  The survivor may also be able to help set the table or put out the haggadahs.  There is almost always something identifiable that the survivor can help out with if all involved will simply put sufficient effort into determining just what that thing might be.  If a survivor is living on his or her own and is unable to sufficiently manage Passover cleaning unassisted, he or she may want to ask friends or family to clean for him or her.  Also, many synagogues and Jewish organizations can share means to contact individuals willing to volunteer to clean for those in need or can connect survivors with those willing to do so for a reasonable cost.

Another issue that can come up involves the structure of the Passover Seder.  Many brain injury survivors have shorter attention spans than they had previous to their injuries, and many seders tend to be quite lengthy.  Fortunately, in recent years there have been a number of haggadahs published designed specifically to make seders shorter.  For those with extreme difficulties with attention, Rabbi Yonah Bookstein of the Pico Shul states that he has the shortest kosher haggadah available (which allows one to complete the seder in around 10 minutes):

https://rabbiyonah.files.wordpress.com/2012/04/the-10-minute-haggadah.pdf

The 30 minute Seder is another haggadah option available to those seeking a briefer service.  This haggadah was edited by Rabbi Bonnie Kappel of Temple Chai and the US Army Reserves:

http://30minuteseder.com/

The seder is a very language-heavy service which may present particular difficulties for brain injury survivors with aphasia.  Gateways has published a haggadah which is more picture-oriented and includes the use of Boardmaker symbols that many survivors with aphasia already use in conjunction with augmentative speech devices.  This haggadah was written by Rebecca Redner and reviewed by a number of rabbis including Rabbi Neal Gold of Temple Shir Tikvah.  It was created more to aid youth with special needs, but may be more appropriate than other haggadahs for adult survivors with aphasia.

http://jgateways.org/Resources/GatewaysHaggadah

Matan, an organization serving Jewish youth with disabilities, has a number of Passover resources that translate verbal parts of the Seder into visual representations.  Though these picture-centered resources are strictly speaking intended for use by children, adults with aphasia may benefit from an integration of such materials into their Passover activities.

http://www.matankids.org/tag/passover/

As it is common for family and friends to take turns reading  sections of the haggadah during the seder, survivors with aphasia may feel especially left out of during the seder service.  But just as with the Passover preparation and cleaning, there is almost always a role the survivor can play in this portion of the seder.  For instance, it could be the responsibility of the survivor to dip the green vegetables into the salt water and/or to hand out pieces of matzah to everyone at the seder.  The survivor could have the job of pointing to the shankbone, matzah and bitter herb during the section regarding Rabbi Gamliel.  Survivors with aphasia do also tend to do better with familiar songs.  In spite of a survivor’s struggles with language, he or she might still be just as able to sing the refrain “Dayenu”, as this is a common line that a survivor may well have sung for many years.

Lastly, at some seders there is a general desire to rush through the haggadah to reach the meal or to finish the second half of the haggadah quickly.  Family members and loved ones need to take care to afford sufficient consideration to survivors now contending with slower processing speeds and keep in mind that these survivors will now require that the seder be proceeded through at a slower pace than most may be inclined to attempt.

These are just a few suggestions regarding areas in the Passover Seder that may need to be adjusted after a brain injury in order to better ensure a survivor’s full participation and enjoyment.  Wishing to all a wonderful and meaningful post-injury Passover!

Thank  you to Rabbi Joel Levinson of Temple Beth El of Patchogue for reviewing the content of this post and Rabbi Daniel Masri of Beth Rambam of Houston for providing information on Sephardic practice.

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