“Family members, dedicated caretakers, or paraprofessionals provide an important support system to individuals with cognitive or behavioral deficits due to TBI. This support system also plays an important role in the rehabilitation process.” (Sohlberg and Mateer 2001).
Cognitive impairments are very common when the brain has suffered severe trauma. Problems in cognition usually show up as deficit in memory, attention, visual and information processing and executive thinking skills such as: problem solving and goal setting. The rehabilitation field which is normally composed of licensed medical professionals might, in the not too distant future, see the addition of non-medical and paraprofessional support members (cognitive coaches) joining the team in the future.
The cognitive work that needs to be done can take months and years and insurance companies don’t always recognize these services as being vital. The majority of cognitive rehabilitation is usually being done by speech and language pathologists or cognitive rehabilitation therapists. Speech therapists usually see a client 2 -3 times a week for less than an hour. That simply was not enough time to address swallowing difficulties, lip and tongue placement, speech and cognition. Usually, it’s the cognition part that gets less attention because the other symptoms need to be tackled immediately, such as swallowing. That leaves an obvious gap in the cognitive stimulation.
Research has shown that Cognitive Rehabilitation Therapy is effective on various populations of people who have suffered traumatic brain injury such as stroke. The Brain Injury Interdisciplinary Special Interest Group (BI-ISIG) of the American Congress of Rehabilitation Medicine recognizes the need for the development of cognitive recovery manuals along with training workshops. So, progress is moving in the right direction, slowly but still very encouraging.
After working for eight years with my stroke client, I realized how important it was to create a home-based interdisciplinary cognitive training program (Curriculum for the Mind©) that utilized many of the strategies in a cognitive recovery therapy (CRT) program. I designed exercises to be achievable but provided opportunities for increased challenge both in motor skills and cognition. I modeled them after S.M.A.R.T., which stands for specific, manageable, attainable, realistic and timely.
The goals of Curriculum for the Mind© were to improve the different domains of cognition, including the higher functioning, executive processes of self-awareness, self-regulation, metacognition and independence. Naturally, before doing anything, I researched the different types of cognition and their domains. I knew that if I didn’t understand how cognition was identified, I wouldn’t be able to create effective exercises targeted to those areas. The main domains of cognition that are emphasized in cognitive rehabilitation therapy are:
- Visual Spatial
- Executive Function
These domains are considered as a hierarchy. If should also be mentioned that there is one step that precedes attention, although it is not a domain. It is called arousal and it implies that the patient is awake and aroused by their surroundings. The opposite of arousal would be diminished attention, and increased fatigue and apathy. Without the arousal being engaged, there can be not attention and therefore, no learning takes place.
It makes sense that if attention cannot be maintained, then the other cognitive processes won’t occur, such as processing information or problem-solving. So attention is considered a core cognitive ability. After much practice, my client showed substantial improvement in her ability to achieve focused or sustained attention. This was demonstrated through activities such as: typing, puzzles, reading, music playing, art, guided imagery and more. Directions that had more than two or three steps were challenging. She would often forget part of the instructions or forget what she was doing in the course of an activity, but overall, she showed strong improvement over time. In my opinion, I believe that motivation and interest play a big role in whether or not attention is maintained for any length of time. Therefore, I made sure that the activities interested her, such as art to help stay on track. I also provided large written instructions for her to refer to when needed.
Selective Attention is the ability to focus on one thing while ignoring other distractions. This was particularly difficult for my client. She would tell me how hard it was for her to focus at a gathering where multiple conversations were occurring or many people were talking at once. One of the activities I used to help her with selective attention was to focus on repeating one rhythmic pattern from a piece of music, or to maintain a certain rhythm while I play a different one. Another activity was singing rounds like, “Row, row your boat.”
Alternating Attention is the ability to shift focus between two different tasks with different cognitive demands. I introduced a pretend business activity into the program. It dealt with multiple tasks that needed to be completed at once. Some of the tasks included reading correspondence, counting money, recording the amount on a ledger and then writing out a receipt. Other aspects of the business required different tasks. Instructions were written out and visible, and a least one demonstration was given. This proved to be a very challenging activity.
Divided Attention is the ability to respond simultaneously to multiple tasks. This is the highest level of attention. The activity we used to practice this ability was playing the piano and keyboard. It required the skills of simultaneously: reading music, interpreting the symbols on a musical score, muscle memory, fine motor control, and respiratory control for singing.
Visual Spatial Domain
Visual information processing or visual-spatial skills refers to the process of interpreting meaning from the visual information that we receive our eyes. It is the ability to find things and notice characteristics in an object. It is the ability to distinguish one object from others in the environment and to be aware of the shape, size, color and orientation of objects. Visual processing allows us to organize our external space and to understand concepts like left/right, up/down, in/out, etc. Skills in this area allow us to move gracefully through space. Deficits in this area cause lack of coordination and balance, reversals of letters and some words like “no and on,” and even a tendency to work with one side of the body only. I did not notice my client experiencing difficulties in this area.
Visual-motor integration is another part of this ability and it allows one to coordinate what they see with body movements. To practice this ability, I had her practice a variety of specific paint brush and colored pencil techniques. One task was to hold a paint brush at a certain angle to create thin and steady lines from the bottom of the page to the top. Later, this practice was used to create delicate flower stems which came out beautifully. We also practiced cutting with a scissors, copying words, tracing letters, handwriting, puzzles, and board games and of course drawing.
Almost all of my client’s cognitive abilities, in all the domains had been affected. Her visual spatial domain seemed to be the least affected. Nonetheless, we did a lot of spatial activities (drawing, painting, and keyboarding) as well as work with images. Interestingly enough, her right brain (home of imagery/spatial awareness) was not the sphere her stroke occurred and it did not seem as affected. We attempted to draw upon its strengths in order to create new neural pathways for learning.
Language & Communication Domain
Under the language and communication domain, the cognitive training showed the following outcomes: listening skills and ability to understand concepts showed continual progress throughout the program, with the exception of the times when external factors were influencing her mental state. But, to achieve advanced proficiency in these two areas, I believe continued cognitive activities will be required. Even simple activities like watching an instructional video and then discussing the main concepts afterwards would be helpful. The same with listening to conversations and responding to specific points.
My client’s communication and speaking skills showed mild improvement but constant, daily repetition of speech exercises were necessary to keep her at a functional level. Although, I was fortunate to be able to communicate with her and understand her words, others had difficulty understanding her speech. Family members understood better then strangers did, whether this was due to better listening skills or motivation on both parties, I am not sure. But, throughout the time I worked with her, her speech had not reached levels where she can communicate and be understood readily by others.
Reading and writing also showed measureable improvement. Her journal writings went from three sentences to three paragraphs this was demonstrated by her ability to write mini stories, poems, journal writing and letters. At times, she showed a good grasp of the English language with her word choices and she also recognized and used both humor and sarcasm. Word finding ability proved difficult for her. She was not able to name objects although she could point to an object if she was asked to identify a pen or fork with 95% accuracy. When she wanted to name an object that she could not recall a name for, she would say something like, “the round thing.”
Memory is the ability to recall and retain information over a period of time. Long-term memory is the ability to recall past events that may have taken place years ago. My client showed fairly good recall of past memories. Therefore, I tried to connect a past memory to a current activity to hopefully create neural connections. This included discussions or activities that evolved around memories important to her such as: cooking, raising a pet duck, travel to Italy, college and family. An example of this would be that I would devote a week worth of sessions to the theme of cooking. We would watch cooking videos and talk about what we saw and then talk about a memory that it reminded her of. We might solidify the activity by drawing something related to the topic. It was important that whatever new information that I introduced to her had to hold some meaning to her. She needed to be motivated to want to remember it.
My client had difficulty with short-term memory. This was demonstrated by her inability to remember what happened the day before and even that morning. Although, interestingly, my client mentioned that whenever she went to sleep, she would forget everything that just happened. Constant mathematical and word exercises, questions that required her to recall her day, journal writing and music playing were some of the activities I used to help her improve her short-term memory. Progress in this area was never linear and there were plateaus and regressions as well as achievements. She was very aware of what she could not remember and commented on that fact frequently.
We practiced implicit memory drills such as: recalling the days of the week, months of the year, the seasons and anything with a certain amount of “sing song” tone to it was easier for her to recall, such as the alphabet song, counting by fives and tens, etc. We also practiced semantic memory which included things that are common knowledge, such as the names of states, the sounds of letters, the capitals of countries and other basic facts. Again, the progress was not linear and often difficult to gage. Some days she could recall information with 80% or better accuracy and other days not so well.
We seemed to have more consistent success when recalling episodic memories, those memories of a specific event that was emotionally charged, whether positively or negatively. Sometimes her recollection for detail amazed me as she recalled clothes she was wearing, who she was with and even what she ate or felt. I usually prefaced these exercises with the questions: “When was the first time you……” Or “Do you remember a time when…..” Or “What was the most …….experience of your life?”
Word finding ability proved difficult for her. She was not able to name objects although she could point to an object if she was asked to identify a pen or fork with 95% accuracy. When she wanted to name an object that she could not recall a name for, she would say something like, “the round thing.”
Executive Function Domain
Executive functions consist of those capacities that enable a person to engage in independent, purposeful behavior successfully. These include: self-awareness, goal setting, self-initiation, planning, organizing, self-monitoring, self-evaluation, flexible thinking, problem-solving and metacognition.
Behind all the exercises I used with my client, the underlying goal was always for her to achieve independence and self-empowerment. In the early years that was a distant goal, but over time, I could see where it could happen in increments. The first introduction to the executive thinking skills was in cognitive discussions about them with examples and real life stories given. Later activities in drawing that required decision making, self-correcting, self-critiquing were introduced.
My client showed substantial gain in cognitive abilities during the time I worked with her. I believe it is because she received a daily dose of cognitive re-training that stimulated many areas of her brain. I also observed that whenever the cognitive training was temporarily stopped or replaced by another therapy, there was a noticeable decline in her overall cognitive ability. Seeing the effect that stopping the cognitive recovery program had on my client, it seemed like a reasonable conclusion to me that the cognitive recovery activities needed to be continued on a daily basis for those recovering from extreme brain injury.
A word about the program I used for cognitive recovery:
Curriculum for the Mind© is an interdisciplinary cognitive training program that emphasizes music, art, writing and storytelling as the main teaching agents for cognition. But, it also includes language and communication exercises and motor exercises. It was specifically designed for a woman who suffered a devastating stroke to her left hemisphere but would be beneficial for anyone who has suffered a brain injury or experiencing age-related cognitive decline.