Tag Archives: aphasia

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

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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

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

The Role of Support Groups

Going through life with a brain injury can be a remarkably difficult experience for a brain injury survivor.  Life has changed, often in many dramatic ways.  Sometimes utilizing the most basic of skills, such as using the restroom or remembering to turn off an oven, can present the most complex of challenges.  Life is often just as hard (and in some aspects can be even harder) for the survivor’s family.  Everything has changed for them, too.  Family members often find that new roles are now required of them and that new stressors now confront them at every turn.  A wife may now find herself serving as her husband’s primary caregiver.  A brother may now necessarily be conscripted as his sibling’s chauffeur to constant doctor’s appointments.  On top of all this, there is so much to learn in a field with which both survivors and family members almost always have little to no previous familiarity.  This can make for an incredibly lonely experience.  Survivors and family members may ask themselves, “Is there anyone else in the world who knows what this feels like?”  While the brain injury survivor is a patient in an inpatient rehabilitation program (a very common experience in post-injury life), the survivor can often rely upon the camaraderie of fellow patients.  Family members may become friendly with the family members of other survivors and chat on a regular basis.  Both survivors and their families will have regular contact with staff who are able to provide support and knowledge.  However once the survivor discharges from that inpatient facility, he or she suddenly has little to no contact with other brain injury survivors.  Families lose contact with each other and no longer have available as an option just popping in to a therapist’s office for a quick question.  This is when the brain injury experience can be its most lonely.

 
Support groups can help fill this gap.  Support groups are groups of individuals with similar experiences that meet on a regular basis to discuss those experiences.  Individuals may offer suggestions and advice or just provide a shoulder to lean on.  Support groups exist for a wide selection of health-related issues ranging from living with cancer and diabetes to coping with grief, struggling with substance abuse, and of course, rebuilding one’s life in the aftermath of a brain injury.

 
There are two primary types of support groups that are most relevant to brain injury survivors, namely stroke support groups and brain injury support groups.  Stroke groups tend to be more common than brain injury support groups, though in most larger population areas one will be able to find a brain injury support group in addition to stroke support groups.  Among stroke support groups, there is a small subset that are specific to aneurysms (though survivors of aneurysms and their families are of course welcomed in a general stroke support group).  Support groups are often run out of hospitals, rehabilitation facilities, community centers and houses of worship.  If a group’s meetings take place in a hospital, usually the survivor does not have to be a patient (past or present) of that particular hospital in order to attend.  In addition to the aforementioned support groups, there are support groups designed to address certain specific symptoms of brain injuries.  For example, there are aphasia support groups, apraxia support groups and memory support groups.

 
Each support group tends to have its own individual program and essential dynamic.  Some provide more educational content while others tend to offer more of an emotional/social support program.  Some are survivor oriented, others family oriented and still others are oriented to both survivors and their families.  If you do not feel suitably comfortable at one group, you can always attend another group.  Also, there are available some online support groups necessarily better suited to those who have difficulty leaving their homes.  Some survivors and families will even create their own groups when confronted by a lack of groups tailored to their specific needs in their vicinity.

 
Below are a few links that may aid in finding a support group:

 

For brain injury support groups, click on your state affiliate of the Brain Injury Association of America and scroll to the Support Groups section:

http://www.biausa.org/state-affiliates.htm

Stroke support groups:

http://www.strokeassociation.org/STROKEORG/strokegroup/public/zipFinder.jsp

http://www.stroke.org/stroke-resources/stroke-support-groups

In addition, the American Stroke Association has a family support phone program called the Stroke Family Warmline.  The Warmline phone number is 1-888-478-7653.

Aneurysm support groups:

http://www.bafound.org/support

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

Hot Off the Press

Vital to the core mission of the Transitional Learning Center is the conducting of research designed to enhance understanding of and improve treatment strategies for brain injury. The result of this research finds its home in publication in a wide range of top professional journals and chapter after chapter in books relied upon by the traumatic brain injury treatment community. Recently, TLC staff neuropsychologists Drs. Dennis Zgaljardic and Matthew Lambert along with staff occupational therapist Rebekah Miller published a paper on the reliability and validity of a newer test to determine naming deficits. Difficulty with the naming of objects (for example: saying “fork” when you mean “pencil”), known as anomia, is not uncommon with patients who have brain injuries (particularly if the injury is to the left hemisphere of the brain). However since most tests of cognitive abilities are developed using members of the healthy population as a testing sample, it is unclear to what degree these tests might be appropriate when applied to other populations (such as patients with brain injuries). Identifying which tests should or should not be used with a brain injured population is an extremely important component of treatment. Using a test that is not appropriate for an individual with a brain injury can lead to misdiagnosis and based on that misdiagnosis, incorrect treatment.
The paper, titled Naming Test of the Neuropsychological Assessment Battery: Reliability and Validity in a Sample of Patients with Acquired Brain Injury, was published this past December in the Archives of Clinical Neuropsychology.  In the study, the researchers compared the Neuropsychological Assessment Battery (NAB) Naming test with various other neuropsychological tests. The Neuropsychological Assessment Battery is a relatively new group of tests designed to measure a wide range of cognitive skills including memory, attention and of course naming. For the NAB Naming test to be found appropriate for use in a brain injured population, the researchers first looked to see if the test scores correlated with scores on other similar tests that have been shown to be valid with such a population. For instance, a person who scores highly on the NAB Naming test should similarly do well on another naming test. The researchers found this to be true. Next, the researchers looked to see if the NAB Naming test scores were not correlated to unrelated tests. For example, a person’s score on the NAB Naming test should have nothing to do with his or her score on an attention task. This also was found to be true. Thus, the NAB Naming test was found to be an appropriate test to use with individuals who have brain injuries.

Below is a link to the paper abstract:

http://www.ncbi.nlm.nih.gov/pubmed/23714104

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

Aphasia Advice

Aphasia, the loss of language skills, is relatively common after a brain injury to the left side of the brain.  The video below was created by a stroke survivor in order to give some tips on how best to communicate with someone who has aphasia.

http://www.upworthy.com/a-lot-of-people-find-it-hard-to-talk-to-laura-so-she-put-together-4-easy-tips-cg7-4a?c=ufb1

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