Cognitive Rehabilitation and Post Concussion Disorder – What Are We Really Treating?

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  • May 29, 2013
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Cognitive Rehabilitation and Post Concussion Disorder – What Are We Really Treating?

In my practice as an occupational therapist I have had the opportunity to work with many clients coping with post concussive disorder. Almost always, clients with this condition will tell me that they are having difficulty paying attention and can’t remember things the way that they used to.

In occupational therapy school we learn about “remedial” and “compensatory” strategies for cognitive rehabilitation.

A remedial approach implies that treatment is aimed at actually improving cognitive functioning in and of itself. For example, using the principal of neuroplasticity, an OT would use memory and attention drills aimed at helping the damaged part of the brain to heal and to relearn skills that were impacted by trauma or disease.

A compensatory approach does not intend to actually heal or repair the brain itself; rather the goal is to find ways to compensate for the deficits. Common examples include using iphone reminder alarms, agendas, post-it notes, etc.

When a client with post-concussive syndrome reports changes to cognitive function, more often than not they will have a CT or MRI scan that does not actually show damage to the brain structure itself. Despite this, again and again memory issues and difficulty with concentration are cited as symptoms of post-concussive disorder.

I’m often left wondering what approach I should use with clients in this situation. How can I use a remedial approach to “heal” the brain when imaging reports aren’t showing actual damage? Could it be that non-pathological factors such as pain, fatigue and anxiety are really what are influencing the cognitive changes? But if I use only a compensatory approach, isn’t there a risk that I am missing out on an opportunity to make real improvements in the client’s cognition, rather than just compensating for deficits?

While the jury is still out on the exact formula to best treat cognitive deficits in post-concussive syndrome, the recently published “Guidelines for Mild Traumatic Brain Injury and Persistent Symptoms” published by the Ontario Neurotrauma Foundation suggests a combination of “compensatory strategies and restorative approaches” when treating cognitive sequelae following mTBI[i].

Moreover, the study suggests that other variables such as pain, fatigue and anxiety contribute to the client’s report of cognitive difficulties.

In my practice with this client population, I almost always provide agenda-use training and advice on how to use a phone to send alerts with important reminders. The client and I will also work to remove clutter from the home environment and to stay organized to reduce environmental distractions.

At the same time, some clients really like drills and pen-and-paper type cognitive activities. They report that it helps them to feel they are taking an active role in their recovery. These are tools that I would typically provide some training with, for example, I might help a client sign up for a membership with an online cognitive rehab program or provide a cognitive work book, but the focus of our therapy sessions would be to provide cognitive strategies that would help the client function better on a day to day basis.

Finally, when working with clients with post concussive disorder I always try to go back to my OT roots. As an OT, I have extensive experience using activity and occupation to treat cognitive deficits. Given the many possible contributing factors to cognitive deficits following mTBI I also try to keep a focus on strategies aimed at improving function, such as energy conservationgoal setting, and activity activation.

The complexities of post-concussion syndrome make it a challenging condition to treat but by using clinical reasoning and maintaining a reflective practice, OTs can provide comprehensive treatment and promote positive functional outcomes for clients with post-concussion syndrome.

If you would like to learn more about GLA and our services, please visit our website.

Written by:  Kathryn Decker, MScOT. Reg. (Ont).

Occupational Therapy Team Leader

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Using Energy Conservation Strategies to Treat Mild Traumatic Brain Injury

  • by glarehab
  • May 29, 2013
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Using Energy Conservation Strategies to Treat Mild Traumatic Brain Injury

When mild traumatic brain injuries (sometimes known as concussions) don’t heal as expected, clients are sometimes diagnosed with a condition called post-concussive disorder. Symptoms of post concussive disorder include headaches, dizziness, light and noise sensitivity, impaired memory and concentration as well as changes to mood.

These clients frequently note that they have less energy to participate in daily activities. Often, clients have sleep difficulties that further deplete their energy resources.  Client will also comment that too much activity increases headache pain.

The result is that routine activities of daily living can be much more taxing than usual.

Occupational Therapists and Rehab Support Workers at Galit Liffshiz & Associates (GLA) use a strategy called “Energy Conservation” when working with clients with post-concussive disorder. This is a technique used to help clients engage in meaningful daily activity without increasing fatigue or headache pain associated with post-concussive disorder.

Here are some of the main components that we teach our clients:

PLAN

  • Plan days and weeks ahead of time so that activities requiring more energy and less energy are alternated.
  • Plan for days where there may be increased pain or fatigue – learn the “warning signs” that your body is telling you and stop an activity before you feel completely exhausted.
  • Plan to complete activities that are the most physically demanding at times when you have the most energy, e.g. some people have the most energy in the morning and then feel more tired in the afternoon.

PRIORITIZE

  • Recognize that everything may not get done and learn to be OK with that.
  • Work to change your perspective on what “productivity” means to you. It may be that you have to learn that it’s best to be satisfied with completing fewer tasks more efficiently and without feeling overwhelmed by fatigue.

PACE

  • Slow down the pace that you complete your daily activities. For example: every hour take a 5-10 minute break and use an alarm watch to remind you.

ELIMINATE

  • Think about the activities you try to complete each day. Is there anything you would be comfortable eliminating for a while?

ORGANIZE

  • Minimize clutter . Keep things in easy to find places so that little energy is used to locate them.
  • Make sure items you use regularly are easily accessible. For example, try labeling boxes/storage containers.

EQUIPMENT

  • Use technology/equipment whenever possible. Examples include an electric can opener, long-handled reachers, etc.

By using energy conservation techniques, therapists at GLA enable clients to lead more productive and satisfying lives with less fatigue and headache pain.

Please feel free to contact us for more information on the benefits of energy conversation in the treatment of mTBI.

Written by: Kathryn Decker, MScOT. Reg. (Ont).

Occupational Therapy Team Leader 

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