Tag Archives: awareness

Bubba Smith and CTE

The phrase “larger than life personality” could have been invented to describe Bubba Smith.  Looming at 6’7″ and almost 300 pounds, he was the first pick of the 1967 NFL draft and earned his ring at Superbowl V with the Baltimore Colts.  His extraordinary defensive skills on the football field left many a shell-shocked quarterback lying prostate in his wake.  Following his nine year professional football career, he parlayed his fame into a second career in film and television.  He is best known in the acting world as Captain Moses Hightower in the Police Academy movies and for his appearances in Miller Lite commercials.  After he passed in 2011, his estate allowed researchers to study his brain for evidence of Chronic Traumatic Encephalopathy (CTE).  It was discovered that he had been living under the effects of level three CTE (the scale runs from one to four).  Follow the link below to read more about these findings.

http://www.nytimes.com/2016/05/25/sports/football/bubba-smith-cte-nfl-concussion.html?_r=1

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

 

 

 

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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!  Visit us at: 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

Holiday Adjustments-Part 3: Social Interactions and Attention

This is part 3 of a series on holiday adjustments.  As mentioned in parts 1 and 2, deficits suffered in the wake of a brain injury may impact brain injury survivors’ ability to participate in holiday celebrations to the degree that they had in previous years so adjustments may need to be made in order to provide a greater likelihood of those survivors enjoying a successful holiday.  Part 3 will be focusing on issues regarding social interactions and attention during holiday celebrations.

 
Our social skills are at the heart of what it means to be a connected person in our society, and holiday celebrations invariably present what can only be understood as key social situations.  It’s incredibly common for brain injury survivors’ proficiency in employing vital social skills to markedly suffer as they navigate post-injury life.  As a result, holiday celebrations can be tricky for brain injury survivors to negotiate.  In many cases, holiday celebrations are the first time that friends and family members have seen a survivor since his or her injury.  In other cases, holiday celebrations are the first time that friends and family members have seen the survivor since he or she was in the intensive care unit of the hospital since people are most likely to visit in that initial period immediately following an injury.  Often, holiday celebrations present dual areas of stress with which a brain injury survivor must contend.  The survivor is learning how to negotiate life with newly acquired often significant deficits commonly experienced in multiple distinct arenas.  At the same time, survivors must learn to accommodate an increase in the attention afforded them by friends and family as those loved ones understandably seek to spend extra time with survivors as an expression of concern felt.

 
Near death experiences catch our interest and spark our concern.  As such, friends and family often give survivors far more time and attention than they may have at previous holiday celebrations.  After a brain injury, many survivors are surprised to find that they are now the most popular person in the room.  Each family member comes by and asks what happened, how is the survivor doing, how is therapy, etc.  Even if one family member was standing right behind another while that member asked each of these questions, the second family member still may ask the exact same questions as the first.  These queries are generally made with the best of intentions.  Family and friends want to show their concern and caring for their injured loved ones.  However, many survivors find this to be a frustrating and annoying experience.  It is important for survivors to prepare for some version of this experience to occur at the holidays, particularly if many people have not seen a survivor since the initial injury.  And it’s just as important for survivors to remember that such a situation is just a reflection of the caring felt by those around them.  Family and friends are often searching for a way to show their feelings to the survivor.  Preparing a good deflection script can often be helpful (For example: “Thank you for asking about my health.  I appreciate the questions but it seems like that is all I have been talking about lately.  Can we please talk about something else?”)  Family and friends need to remember that constant questions can be stressful.  If the questioning goes well, the questions can be experienced as a friendly interview would.  If it goes poorly, it might start to resemble more a police interrogation.  Loved ones should put effort into talking about other issues as well, such as the Thanksgiving football games or favorite music.  Some survivors and/or their families may find a handy solution in sending an e-mail or some similar communication updating everyone on the latest information and requesting that brain injury questions be kept to a minimum.

 
A more positive aspect of this extra attention is that brain injury survivors may find that they receive more phone calls, cards and gifts at holiday times than in previous years.  Sometimes these come from people who are not very close to the survivor but are more distantly acquainted with the situation, such as a congregant at a family member’s church.  Again, though this may feel slightly strange to the survivor it still represents someone trying to reach out and show that he or she cares.

 
Changes in social skills can create big hurdles for survivors to overcome during social interactions at holidays.  Survivors and their families must keep in mind potential problems due to changes in social skills.  When a survivor has difficulties that impact social skills, it is important that friends and family members at holiday parties are informed of the best ways to interact with that survivor.  For survivors with language difficulties this may include giving extra time for the survivor to speak, having the survivor’s conversation partner slow his or her rate of speech, writing important words down for the survivor, pantomiming words or having the survivor use an augmentative communication device such as an Ipad equipped with a special speech program.  If survivors have problems with impulsivity issues, family and friends may need to pay extra attention to cueing those survivors to slowing down and maintaining the topic of conversation instead of going on tangents.  For survivors that have difficulty with nonverbal skills such as making eye contact or reading social situations accurately, family and friends may need to cue them to utilize proper nonverbal skills such as looking at the conversation partner’s face while speaking.  If a survivor now struggles with a newly intensified propensity to engage in clearly inappropriate behaviors, family and friends may need to cue that survivor in order to aid in avoiding such behaviors (obvious examples being cursing and sexual jokes).  It is important in all cases that family and friends who will be interacting with the survivor be given adequate information to best help the survivor succeed in his or her social interactions.  This information can be shared via e-mail, phone call or simple face-to-face personal discussion.  If a family member or friend is caught unawares in a situation in which a survivor’s social deficits are seeing expression, this can lead to a strain in relations.  For instance if a survivor’s friend does not know that the formerly soft-spoken survivor now needs help to reduce foul language, the foul language may be taken as a personal insult rather than as a function of the injury.
Survivors and their families should also consider the possibility of the survivor faring better in a smaller holiday celebration.  Some survivors find that larger parties lead to more stress, agitation and/or social errors.  Also, the noise and activity of larger parties can become overwhelming for some survivors.  Certain survivors find that young children, with their noise and activity, can be quite problematic.  Further, some survivors would rather have a small celebration, especially in the early stages of recovery when they are not yet sufficiently comfortable with their injury in public.  They may feel embarrassed by their deficits and would rather not have a large number of individuals learn so casually about the depth of their struggles.

 
It is often helpful for survivors, their families and their therapists to try to problem-solve in advance potential pitfalls and to practice skills such as how best to talk to others about an injury experience.
Hopefully, this post provided insight on a few holiday adjustments that can be made to mitigate attention and social interaction issues.

 

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

Holiday Adjustments-Part 1: Location

As Thanksgiving approaches, it is important to be aware of the potential need for adjustments to be made to holiday celebrations in order to accommodate a brain injury survivor’s injury-related deficits.  Having a brain injury does not stop a survivor from celebrating a holiday, but it may put a few wrinkles into holiday plans.  Part 1 in this series on holiday adjustments will focus on some thoughts regarding the location of celebrations.

 
There are a number of issues that need to be addressed regarding the location of holiday celebrations in such a scenario.  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 accessible?  Keep in mind that it is much easier to get a wheelchair across a hard floor than across carpeting and that for some survivors, a large pile (a term used to denote length of carpet fibers) carpet can provide quite the inconvenience.  Also, 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  be cleaned or change clothes if necessary?  Some families of brain injury survivors find that it is easier to host holiday celebrations at their own homes rather than travel to the homes of others since their homes have already been adapted to the needs of the survivor.

 
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.  A big issue to look for in the consideration of a given room is trip hazards, particularly around Christmas.  It is important that toys and gifts not be left around on the floor as these can easily become trip hazards and could cause the survivor to suffer a bad fall.  Alternatively, most toys tend not to fair well when a wheelchair runs them over.  Cords from Christmas trees or lights can also become trip hazards and should be placed in a manner that will not pose danger to a mobile survivor.  There are many other practical issues to consider regarding 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?  If the survivor uses an augmentative speech device like an Ipad, 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 a holiday celebration.

 
The weather can also play a notable role in adjustment to different locations.  Walking up an icy pathway can be quite difficult and possibly dangerous.  Some survivors who normally use a walker may be safer in a wheelchair over these icy surfaces.  Moreover, some survivors in wheelchairs may need more help getting across an icy or snowy surface.  In such a situation a loved one may need to aid in pushing more than would otherwise be required or just pay attention to helping keep the chair from sliding in the wrong direction.

 
Families of brain injury survivors may want to put some thought into how loud they allow holiday celebrations to be.  Some survivors find that they are more sensitive to noise than previously and loud noises may provide a catalyst for unwanted agitation and/or anger.  These survivors may benefit from attending smaller celebrations or spending their time in a quieter room away from the main celebrations.  This can also be a relevant issue when considering attendance of holiday religious services.  Some survivors may find busier houses of worship  or busier times at those houses of worship to be problematic and may do better at less busy times or benefit from selecting a less busy house of worship.

 
One more such consideration associated with location relates to how many celebrations a survivor and his or her family may be planning to attend.  Some families have the tradition of going from house to house to multiple holiday celebrations throughout the day.  However, survivors often become fatigued quite easily and holiday celebrations tend to be long and active events.  For many survivors, attending multiple celebrations in the same day may be very difficult.  Some survivors may benefit from spending a shorter amount of time at each such celebration.  Survivors and families must also consider the fatigue sure to accompany constant transferring to and from vehicles and the necessary related packing up and unpacking of equipment.  For instance, getting a wheelchair in and out of a car repeatedly throughout a day can be very taxing on the backs of survivors’ families.

 
These are some of the considerations regarding the location of holiday celebrations that survivors and their families may wish to think about when identifying adjustments that may need be made to holiday celebrations.  The next part of this series will focus more specifically on brain injury survivors’ participation in holiday celebrations.

 

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

 

Fatigue

It is common for brain injury survivors to suffer fatigue more acutely and to enter into states of fatigue more easily after their injuries.  For many survivors and their family members, this increase in fatigue comes as a bit of a surprise.  Why am I (or my loved one) exhausted by 6 p.m. when I (or my loved one) used to be active throughout the evening even after a long day of work?
Below are just a few of the reasons why brain injury survivors may be experiencing this greater post-injury fatigue:

 
1.  Survivors may still be healing from the injury.
2.  It often takes far more effort and concentration to engage in basic activities like walking and speaking than it did pre-injury.
3.  Survivors are almost always operating under far greater levels of stress than before.  This could be due to the inevitable stress of trying to get better or stress from other issues such as financial difficulties due to losing a job after an  injury.
4.  They may be experiencing significant post-injury pain and prolonged pain tends to contribute to fatigue.
5.  The survivors’ medications may be causing fatigue.
6.  The survivors may not be sleeping as well due to the injury.  Many brain injury survivors experience significant changes to sleep patterns post-injury.
7.  The survivors may be feeling depressed, anxious or angry. Any of these emotional states are conducive to greater fatigue.
8.  They might still be getting used to the “rehab” or “post-injury” schedule, which may be quite different from their pre-injury schedules.  For instance, a night shift worker may find that it takes some time to get used to the daytime hours of rehabilitation.
9.  The greater fatigue may simply be part of the brain injury itself.

 
Depending on the cause of the fatigue effecting each individual survivor, brain injury professionals may manage given circumstances in very different ways.  For instance, if it’s determined that a survivor is suffering fatigue due to depression, then the survivor would be encouraged to talk about those issues with a staff psychotherapist.  If fatigue is most likely attributable to medication being taken, a staff doctor may make adjustments to those medications.  If fatigue is due to to the added exertion of engaging in daily tasks, survivors may be encouraged to take appropriate rest breaks.  In all cases, patience and understanding go a long way to helping the survivor cope with fatigue.

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

Mood and Awareness

It can be scary when a brain injury survivor lacks sufficient awareness of the full effect an injury has had upon his or her life.   It can be all too easy for a survivor in such a circumstance to engage in what could potentially be extremely risky behavior. For instance, if a survivor does not realize that he can no longer walk, he may attempt to get up from his wheelchair anyway to walk to the bathroom. This could lead to a terrible fall. Similarly, a survivor who is not aware that she now suffers from severe memory deficits may turn on a curling iron for her hair and forget to turn it off. This could lead to a fire. When survivors gain in awareness of their situations post-injury, families understandably feel much more at ease as these risky behaviors can only decline.

However, there is one downside to such improved awareness. When a survivor first becomes significantly aware of his or her deficits, he or she often experiences a marked decline in mood. The survivor is suddenly aware of the severity and implications of the injury. It is depressing to realize that life has changed, in some cases irrevocably, and that success over these new challenges can only come after many trials and tribulations. It is important that the loved ones of brain injury survivors understand that this decline in mood is natural and expected. This is the time when a psychologist, counselor or psychotherapist can step in and help the survivor adjust to his or her new situation. With therapy and support, most brain injury survivors will see an improvement in mood after this initial decline due to increased situational awareness.

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

A Regular Routine

People are creatures of habit.  We operate at our best when life is predictable and structured.  Predictability and consistency allow us to organize our lives smoothly.  They invariably bring about greater effectiveness at work and at home and put us in a better position from which to allocate our time more intelligently and to accomplish more goals.

After a brain injury, the survivor’s life often loses the routine it had before.  He or she loses the daily rhythm that the survivor had grown accustomed to prior to the injury.  Rather than having a schedule based on school/work activities, social plans and home responsibilities, many survivors come home to a life without any set schedule.   This can be a big mistake.  A lack of a routine often increases disorientation and decreases the ability to track day-to-day activities.  Without a set routine, important activities may be pushed off to a later time or ignored altogether and forgotten.  Some survivors even become more agitated and aggressive when their days lacks predictability.  Further, a lack of a set schedule often causes greater stress on family and caregivers.  For instance, without a set schedule a survivor may argue with a spouse about when they should practice walking skills, since there is no agreed upon time to practice.

It is highly advisable for survivors and their family members to create a daily schedule to help incorporate routine back into the survivor’s life.  The daily schedule should be written and placed in a prominent location in the home, such as on a refrigerator door or on a dry erase board.  Creating the schedule should be a joint activity between the brain injury survivor and his or her family.  Mealtime, personal hygiene tasks, taking medication and wake/bedtimes should be at approximately the same time each day.  A set time each day should be created for activities such as physical exercises, cognitive exercises and recreational activities.  Doctor’s appointments, therapist visits and family events should be written on the schedule.  Schedules should be made for the entire week, including the weekend.  Although some brain injury survivors will initially try to rebel against a set schedule (“I am a grown man, how dare you tell me what to do!”), survivors generally get into the new schedule without too much difficulty.  Survivors with memory deficits or disorientation tend to take more time to get used to the new schedule.  Once the schedule is in place, survivors often show improved overall functioning.

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

Anosognosia – Part II

In Part I of this series I gave an introduction to anosognosia, a lack of awareness experienced regarding deficits which occur following a brain injury (https://tlcrehab.wordpress.com/2013/04/17/anosognosia-part-i/).  This lack of sufficient awareness of injury-caused deficits can be frustrating for both the brain injury survivor and the survivor’s family and can often lead the survivor to make poor decisions.  In this installment, I will address strategies by which a survivor can effect improvement of that awareness.

Anosognosia is particularly common when individuals who have suffered moderate to severe brain injuries are first coming out of their comas.  These individuals often suffer from Post-Traumatic Amnesia (PTA).  At this early stage, brain injury survivors are just beginning to heal.  They may walk or talk but will tend to say and do things stridently out of character, such as physically assaulting health care professionals and caretakers or making wild accusations (“You’ve poisoned my food”, etc.).  They also have a very poor understanding of the world around them and new memories established tend not to be very strong ones.  It can be argued that during PTA most brain injury survivors lack a full awareness of their injury.  After all, they are not really well enough connected to reality to allow for a full understanding of all that has happened and often cannot hold on to new memories for a long enough time in order to remember things they have been told.  Many brain injury survivors’ anosognosia simply improves as they gradually emerge out of PTA and attain a better understanding of their situation.

Anosognosia is improved by successfully teaching the brain injury survivor about his or her deficits.  Many people take it for granted that a patient in a wheelchair will automatically understand that he or she is unable to walk.  This is often not the case, particularly in the immediate aftermath of an injury.  Sometimes family and friends can forget that the brain injury survivor may not have all of the information about the injury to which they’ve been exposed.  After all, the survivor may have been unconscious or in PTA while doctors shared such information with the family and friends.  It is important that the brain injury survivor be taught, with rigorous repetition, about his or her brain injury and subsequent deficits.  It often helps to review medical records with the brain injury survivor so the survivor is able to see what happened laid out in an “official” form.  Since many survivors have deficits in memory and comprehension, it is generally helpful to review the information with the survivor on an excessively regular basis until he or she demonstrates a strong understanding of the injury and its consequences.

Brain injury survivors with anosognosia often benefit greatly from feedback on their performance during tasks.  This can aid in a very specific manner in efforts to teach them about their deficits.  For instance, a survivor with reading deficits may not believe he has a deficit until he attempts a reading test and learns that he got half the comprehension questions wrong.  Therapists may employ a method termed “guided failure.”  In this method, the patient is allowed to attempt a task (with safety precautions in place, as necessary) that the patient believes he or she is capable of completing but which the therapist knows will serve as a substantial obstacle.  This gives the patient an opportunity to try the task and learn from his or her struggles.  In some cases, the survivor may benefit from seeing a video which documents the attempted task and resultant poor performance.  Some survivors who minimize their difficulties quickly gain appreciation for their deficits when they see their difficulties on video.   The video provides objective evidence of performance.  Another method that therapists often use is asking patients to rate how they will do on a task prior to starting it and then comparing that rating with the actual results of the attempt.  This method allows the therapist to show patients the difference in performance between what those patients believe they are capable of achieving and what actually occurs.  As an example, a patient may estimate that he can walk 5 miles but when he tries to walk he is only able to accomplish 10 feet.  The therapist will then review with him the difference between his estimated performance and his actual performance.

Improvement in anosognosia, particularly for survivors with more serious injuries, can be a long, slow process.  Most survivors do show improvement over time.  Unfortunately, there are some cases in which a survivor does not make appreciable improvement in their anosognosia despite considerable effort.  In these cases, it is vital that the survivor’s family and treatment team develop a safety plan in order to minimize the impact anosognosia is allowed to have on the survivor’s general welfare and overall quality of life.

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

Anosognosia – Part I

Anosognosia is a scientific term meaning “lack of self-awareness.”  Many brain injury survivors suffer some form of anosognosia after their injuries.  Anosognosia will often find expression in a survivor’s inability to comprehend the full extent of the deficits he or she has been left with in the wake of an injury.  Part I of this series will explain about some of the common manifestations of and difficulties encountered due to anosognosia.

Anosognosia can cause many problems for brain injury survivors.  They may put themselves into risky situations because they do not realize how extensively their injuries have affected them.  For instance, prior to his admission to the Transitional Learning Center one of our patients with severe visual deficits attempted to drive his car.  This attempt resulted in the outcome of him flipping that car in a ditch.  If he’d had full awareness of and complete understanding regarding his deficits, he never would have gone through with such an obviously risky proposition.  His anosognosia therefore led to a very scary situation.

Wheelchair-bound survivors with anosognosia may endure falls because they will try to get up from their wheelchairs when a loved one or caretaker leaves them for a moment.  Were they fully aware of their deficits in this arena, they would remain in their wheelchairs in such situations.  Speech-impeded survivors with anosognosia may grow inappropriately angry that other people cannot understand their speech.  The survivor will often think that he or she sounds for the most part normal while in reality his or her speech is almost completely unintelligible.

Survivors with anosognosia tend to question or reject evaluations which show their deficits.  Since the survivor does not recognize their own deficits, the negative evaluation results appear confusing and bizarre.   For instance, a survivor with memory deficits may dismiss memory assessments as “stupid” or “useless.”  He or she may say “I could never do that test even before my injury” or “the doctor thinks he is smart but he is just a dummy.”  In truth, the assessments are not “stupid.”  The survivor is simply unable to detect the blind spots anosognosia has left obscuring perception of his or her own deficits.

Anosognosia can also lead brain injury survivors to question the very need for rehabilitation and medication.  Since he or she does not recognize the existence of any notable deficits, the patient can have a hard time seeing value in any treatment.  This will often frustrate family members who can easily observe the survivor’s deficits and understand how treatment will be of great benefit.  Sometimes in the absence of this recognition of a need for treatment, brain injury survivors with anosognosia will think that their family members or loved ones have sent them to treatment in order to simply get rid of them.

In many ways, anosognosia will magnify the impact of other brain injury deficits.  The survivor not only has to learn to manage life under the limits to capabilities that come with those more direct deficits,  but due to their lack of awareness it is hard for them to initiate methods by which to moderate those difficulties and avoid risks.  A survivor with poor memory already has enough difficulty remembering to take necessary medication.  If that survivor also suffers from anosognosia, he or she may also feel justified in refusing to write down medication times on a schedule in order to help bolster memory.

Hopefully this introduction gave the reader a basic understanding of anosognosia.  The next part of this series will address methods of improving anosognosia.

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