Most professionals in the field of post-acute rehabilitation of persons with traumatic brain injury (TBI) agree that cognitive rehabilitation is crucial to enhancing these individuals’ lives. Almost everything in a person’s life is tied to cognitive functioning and, once debilitated by injury, leaves devastating effects. TBIs, regardless of severity, can result in cognitive, psychological, and physiological deficits. It is the goal of the rehabilitative team to assess and respond to arising issues with deficits in cognition, executive functioning, and/or self awareness, which may impede potential gains. It is not unusual for individuals to become depressed and frustrated at their inability to function at their pre-injury level, while at the same time denying any cognitive impairment. In addition, post-acute continuing education for individuals after TBI can combine the best of both worlds — cognitive rehabilitation and real-world education.
While cognitive rehabilitation usually includes traditional cognitive intervention delivered by therapists (e.g., speech and language pathologists) and/or neuropsychologists, such therapy also offers a unique programming opportunity, including “post-graduate classes” for educating individuals with brain injuries. Post-acute adult continuing education as described in this article uses the format of a “university type” curriculum uniquely crafted to fit the needs of individuals with brain injuries. The system provides an inter-disciplinary approach for improving independent living, new learning, and cognitive-linguistic skills. It was demonstrated that individuals with significant neuro-cognitive deficits, despite severity or time elapsed since onset of injury, made improvements with cognitive new learning as seen on standardized testing and subjectively seen by analyzing social and behavioral skills. Participants considered in this study, included males and females from 18-60 years of age who were 2-25 years post mild to severe TBI. Specific goals and objectives were tailored to each individual’s needs for maintaining and establishing independence. All therapeutic interventions were reinforced by structured programming from 7:30 a.m. to 9:30 p.m., including four cognitive/social/behavioral classes a day, physical programming at an exercise center, and social outings into the community each evening. Cognitive testing that was performed both pre-treatment and post-treatment assisted in confirming improvements seen in functional daily living skills.
The goal of this post-acute program was to create a class structure and programming events based upon the premise of a holistic approach. Classes were introduced according to relevant topics generally affected by traumatic brain injury, as well as, general knowledge/expertise of staff and/or therapists. Therapists and staff worked together to develop a structure of classes fitting the needs and interests of the “students” while also learning how to make each topic a therapeutic experience. Additionally, therapists helped class instructors plan and organize their lessons to include appropriate memory strategies and evaluation techniques that fit the individual’s learning style. Teachers learned how to address each student’s strengths and weaknesses, as well as how to manage and engage everyone in the group. For example, Orientation class was developed to engage a person’s Temporal Orientation for recent events (i.e., current events including political elections, current holidays and festivities, sporting events and scores, etc). A staff member well rehearsed in current events (someone who reads the newspaper daily and or listens to the news) assists each morning in running this class. This particular class can cover relevant topics, according to the news, that affect their lives. The therapeutic intervention is built as certain topics are reviewed and discussions are engaged and/or redirected. Teachers are working to engage individuals with knowledge of local or world events which may assist in improving skills and/ or decreasing deficits, including the following: general awareness of events outside of their own lives (decreasing egocentric social skills), debating issues appropriately (increasing communication skills, flexible thinking) and developing empathy for others.
Some examples of the classes that are currently being offered with selected objectives include:
- Planning and Arrangements Meeting – This course assists participants with planning their week to include all classes, outings into the community, therapies, and individual needs. Staff members assist each person with coordination of activities, as well as allowing participants to focus on goal setting, budgeting expenses, and reviewing accomplishments from the previous week.
- Memory Games – The purpose of this course is to learn the rules of various interactive games, implementation of strategies, and how to socially interact accordingly. Different games allow participants to exercise many different cognitive abilities, including but not limited to: application/generalization of abiding rules, processing speed, problem solving, attention span, multi-tasking, task switching, verbal fluency, topic maintenance, etc. Gaming with others can teach individuals to handle adversity, respect other’s time, negotiate, lose and win. Gaming is a terrific way to forge friendships and allow extraordinary opportunity to communicate and collaborate with others.
- Cultures Around the World – This course offers a fun and engaging way to explore our outside world. Participants cover cities, countries, and cultures including topics of food, music, geography, customs, religions, art, systems of education, languages, sports, and much more. Participants are involved in many activities including general lectures, listening to music, tasting the foods, looking at pictures/artifacts, hands on activities, while being able to share personal experiences and stories of their own travels.
- Memory Jeopardy – This course offers a fun and friendly way to enhance memory skills. Questions are submitted by teachers from all of the classes in order to review information previously shared during the week. Participants recall details of these classes by using the compensatory strategy of note taking and they collaborate by working together on “final answers.”
- Bible Study – This course allows participants to address real life issues, through inspirational words and stories. Rehabilitation of individuals with brain injury should include training in all of the following: physical, cognitive-linguistic, occupational, vocational, and spirituality. Participants have the opportunity to engage in multi denominational spiritual discussions to grow in healing, grief, and understanding of individuals and others’ spiritual beliefs.
- Beginning Sign Language – This course enables participants to learn a second language through different senses. This class is a hands-on approach to learning by allowing participants with increased difficulty with reading, writing, or communication skills to demonstrate knowledge. This course engages a different style of presentation and stimulates visual, spatial and/or tactile learners.
- Rational Behavior Therapy – This course delivers a methodology for decreasing unwanted behaviors. The objective is to create a direct correlation between positive thoughts to positive outcomes. Changing the way in which a person looks at a situation can create positive solutions even if the situation does not change. Problem solving is merely breaking down situations into steps of how to think and behave in ways to obtain what they want.
These are 7 of the 19 classes available. Others included in the program are History (a window into the past that provides understanding of the present-day, and how individuals, nations, and the global community might develop in the future), Brain Injury Education (a comprehensive lesson in brain injury to assist survivors in understanding their injury), Rosetta Stone (learning Spanish through words and images), Tai Chi (Chinese discipline for health, relaxation, balance, flexibility, strength, meditation, self-defense and self-cultivation), Art Appreciation (self expression through creativity including wood working, sculpting, paper crafts, beadwork, mosaics, etc), Health and Nutrition (general condition of the body or mind, illnesses, or impairments, foods and their effects) Meditation (meditation as a form of therapy to cope with a variety of modern-day health problems, including hypertension, stress and chronic pain), Science (teaching systems and structure, scientific problem solving, and units that may cover any subject, from Solar System to Human Body), Meals on Wheels (reaching out to help others by providing nutritious meals for people sixty years and older who are homebound and unable to prepare meals). Weekly-Wrap Up (“final review” of participants’ week in detail including review of all materials learned in the weekly classes to increase immediate and recent memory with repetition), and Problem Solving for Life (task analysis within a structured setting as well as out into the community for functional problem solving skills). These classes are offered throughout the week at 10am class, 11am class, and a 4pm class, along with Orientation every morning at 9:30am. Participants have other structured activities including 8am stretch and 1 mile walk, 2:30pm community outing to the YMCA, and another social activity for community integration at 7pm. Individuals may choose to join the group for evening outings including: Mondays for Library, Tuesday for Arts-N-Crafts, Wednesdays to Billiards, Thursdays to Bowling, Fridays to Bingo/Golf, Saturdays for a Movie on or off the grounds, and Sunday to a local festival or community activity.
Many lessons and skills are learned in each class. The classes consist of activities that are meaningful to both the participants and the therapists/teachers. The participants help choose the topics and the therapists develop a method to make it a learning experience for all involved. Each class was developed with an individual theme in mind. For example, during Listening Comprehension class, participants can take turns picking a musical artist that they would like to study. The teacher finds songs where the lyrics are meaningful and will engage in an appropriate discussion. The class learns information about the artist/band history for cognitive recall. They read lyrics for increasing reading comprehension and abstract meanings, and they listen to the song for fun and dancing. Flexibility in participation is important to keep everyone active. Therapy or constructive activities occur in a structured group setting thus allowing the participants to accomplish their programming objectives. Various individualized therapeutic activities occur during class time. Some participants are active in class while some may be grocery shopping(constructive activity) and another may be seeing the therapist. Therapists can arrange their schedules to pull out certain participants during a particular class that may not be as beneficial as their therapeutic intervention. For example, a person with less anger/behavioral issues may be better suited to see the Physical Therapist (given physical needs) during Rational Behavioral Therapy while others are learning the difference between rational and irrational thoughts.
All topics are arranged in a format that encourages cognitive learning, communication building, and social pragmatic independence. Cognitive learning occurs during the classes as participants learn different facts about different subjects. They are required to learn information from each class, and they are encouraged to rehearse the materials using as many memory strategies as possible. Teachers use both intrinsic memory strategies, as well as, journaling for compensatory usage. Participants, after learning the materials in a class, rehearse the information in many different ways to maximize their learning. Participants recall their activities on a daily basis, and they are accountable for weekly recall and monthly demonstration of knowledge. Participants are asked to maintain a daily journal with details, listing all structured and unstructured activities. They are required to recall their day with or without a compensatory device twice daily.
Participants sit down with staff members during the afternoon and after the evening activity to review and reinforce what they have learned and recall from that particular day. This allows participants to get paid in tokens for their daily efforts as well as review strengths, weakness, and goals met for the day. Participants attend weekly recall sessions, Weekly Wrap Up and Memory Jeopardy. The Weekly Wrap Up class allows individuals the opportunity to review their notebook and recall each activity throughout the week as a group activity and take turns discussing the material that they learned in each class. Each participant verbally communicates the details within their journal or a fact about the subject. Many are very proud to elaborate on different facts that they have learned. After a fact is given from each person, the entire lesson may have been reviewed. Memory Jeopardy gives individuals the opportunity to recall information in a competitive game-like setting. Each teacher provides 5-10 questions from his/her class and participants work together to come up with the final answer. Competition for winning the game adds an entirely new concept for learning. Some individuals may be motivated extrinsically by competition when insight into deficits or awareness of subject importance may be lacking. For example, participants might not have thought they needed to go to Brain Functioning Education (learning about the lobes of the brain, each lobe’s functioning, or what happens after traumatic injuries), but they may go only in anticipation of winning the game of Memory Jeopardy. Both groups allow participants to be challenged to recall information from lessons that week, as well as, an opportunity to listen and review information being presented.
Lastly, teachers provide “tests” at the end of a unit. The participants are given non standardized tests in each class unit and are expected to demonstrate knowledge without compensatory devices, so that teachers can measure true learning (owning and producing back the information by some demonstration of knowledge). Each teacher formats a test for best retrieval of information taught in class. For example, a teacher in the Around the World class may do a unit on Mexico (cultures, foods, religions, languages, etc). After studying the country for a month, learning facts, tasting or cooking foods from their culture, listening to music, etc), they may be asked specific cognitive questions about examples of food, names of regional music, and/or how their country differs from ours. Tests may consist of fill in the blank, multiple choice, or matching questions. The entire learning system includes hearing the material in class, expounding upon it during subsequent classes, and reviewing the same material in daily recall sessions. In addition, it is recalled again weekly during Weekly Wrap and Memory Jeopardy, and monthly by demonstration of knowledge on a test. Individuals constantly have the opportunity to build upon their initial learning.
All topics can be a cognitive-linguistic challenge for all individuals involved no matter what the level of injury, pre-existing educational level, and/or ability for new learning. All individuals can walk away LEARNING information, despite pre-conceived notions that it is difficult to educate persons of different capabilities within one environment. Information is taught on a variety of subjects. It is challenging for most individuals to learn information within 8-10 different subjects. There are some classes that are naturally more challenging for individuals and other subjects that come easier to them. Scores on tests are considered comparable to expectation levels from their individual’s initial cognitive testing. Therapist/teachers look at the individual’s base of information going into a discussion about a topic from past knowledge and then what they will be learning. Therapists/teachers are aware of a person’s memory skills and the rate in which they generally learn something new. Some of the participants have little education, but they possess the ability to learn quickly. Other participants have high education but need maximal assistance with memory. As they teach the lesson, therapists and teachers can determine whether a person demonstrated a correct answer on a test because of long term memory or if the information was recently learned.
Teachers work with therapists to make class cognitive-linguistic objectives fitting for each individual. Some individuals are learning basic concepts of journaling (i.e. learning to summarize important facts, who, what, etc), while others are generalizing concepts from all classes. When a person learns the material, they may become assistant group leaders or a role model for others. Participants truly “own” the material when they are capable of teaching the material. This usually opens up an entire area to work with a client on social skills, empathy, deliverance of material, etc.
Objectives involve more than working within the cognitive framework. Social objectives are being met in every class and reinforced by the staff as well as the therapists. It is important to use several approaches and situations when teaching social skills. Social skills are difficult to teach because the dynamics of a conversation changes rapidly and the person is expected to be flexible. One can role play situations for examples, but one conversation does not necessarily generalize. Different communicative partners or different conversation topics add variables that allow one particular social skill difficult to master. For example, someone who is working on not interrupting others can work on this particular social skill in all the different classes where the conversation topics and group members are constantly changing. It is important for that individual to experience many subjects to master the social skill because they may or may not interrupt depending on the subject matter. The person can get feedback from multiple sources, rather than disregarding the Speech Therapist’s wishes. Communication skills being worked on in every class include some of the following: initiation of interaction, topic maintenance, turn taking, content relevance, eye contact, facial expressions, and non-verbal/ body language. Different classes offer individual speech tasks, group discussions, as well as, group role plays. Many participants can be working on different social skills on multiple severity levels. One individual is working on not “butting in” while a different individual may be working on a higher level social skill by assisting the instructor to teach the class; therefore, working on class management and delivery (how to engage peers, summarizing material in an appropriate manor, being a role model, etc). Every person can be engaged both cognitively and socially when there are many opportunities for learning. Repetition is a memory strategy that is both used within the structure and during classes. Multiple opportunities for learning provide positive results in both cognitive and linguistic skills.
The California Verbal Learning Test Second Edition Short Form (CVLT-II SF) was used to assess participants’ ability to learn and remember verbal information. It not only assesses the amount of verbal information remembered, but how verbal learning occurs or fails to occur. The CVLT-II SF is designed for examinees with more severe cognitive dysfunction, as compared to the CVLT-II Standard Form. This test was given after one year of participating in the highly structured class setting. Participants were given a standardized score based upon their age group, and the mean standard scores of all 12 participants, compared from 2008 to their mean in 2009. For all recall scores, the higher the values indicate better performance. Exceptions to this are the different error measures (i.e. repetitions, intrusions, & false positives). Trial 1 Free Recall measures the examinee’s initial auditory attention span, repeating a list of 9 words. Standard scores are derived for each trial following to assess the consistency of an examinee’s learning performance over repeated trials (i.e. distractibility, fluctuations, varying effort, or other non-neurological factors). Trials 1-4 index provides a global measure of immediate free recall performance. Short Delay Free Recall provides a measure of an examinee’s level of recall after a brief delay interval by asking the examinee to recall the same list after counting backwards by 100 for 30 seconds. Long Delay Free recall provides a measure of an examinees’ level of recall after a 10 minute, non verbal distraction task. The Long-Delay Cued Recall subtest requires the examinee to recall the same list initially presented, but within defined categories and the Long Delay Yes/No Recognition assess recognition of the words with distracter words intermixed. After another five minute, non-verbal distracter task, the examinee is then asked on the Long-Delay Forced Choice Recognition to choose which word out of a choice of two was on the list. Repetitions, intrusions, and false positives measure a person’s source memory impairment with increased numbers indicating increased difficulty with insight of what is true and/or untrue.
A statistical summary of performances of all examinees showed improvements in the overall majority of tested variables. A one-tailed dependent T test was performed to examine the significance of the difference in scores between the pre and posttests. The alpha value was set at 0.05. The change in scores for Trials 1 – 4, Short Delay Free Recall, Long Delay Free Recall and Long Delay Cued Recall was found to be significant. The Long Delay Forced Choice Recognition and the Long Delay Yes/No Recognition, changes were not found to be significant. It needs to be noted that most participants in the Long Delay Force Choice and Yes/No Recognition initially tested, showed high scores, and were subsequently not able to increase. Intrusions, false positives, and repetitions all declined; however, the changes were not seen to be significant. Additional statistical tests were completed, the results of those tests coincided with the findings of the current tests.
Overall, it was determined that standardized test scores for new learning improved for the majority of participants following one year of participation in a highly structured curriculum based residential brain injury facility. On the standardized testing, individuals were able to make improvements with their initial auditory attention span, consistency of learning performance over repeated trials (i.e. distractibility, fluctuations, varying effort, or other non-neurological factors), global measure of immediate free recall performance, recall after a brief delay, recall after a 10 minutes, and recalling the same list initially presented, but within defined categories. The decrease in repetitions, intrusions, and false positives assisted with increasing insight into responses and decreasing an individual’s tendency to confabulate from source memory impairments, as well as, seeing changes on a standardized test, teachers, therapists and staff members alike agree to social and linguistic changes seen over the course of the year. On a whole, subjectively noted, there were less overtly negative behaviors with the antecedent of confusion. Social skills were being met on a multitude of levels. Insight into memory skills and social skills were being taught extrinsically as an individual could perceive themselves succeeding in competition for Memory Jeopardy and within constant debates during class room discussions. When therapists attempt to give examples of social skills they have concrete examples to use in discussions so the participant can directly relate an issue to an example. Therapist and Program Directors assisted in creating objectives for individuals, and the participants were reinforced by multiple situations and multiple persons, giving increased chance of success.
This system employed provides an inter-disciplinary approach to improving independent living, new learning, and cognitivelinguistic skills. Individuals with significant neuro-cognitive deficits, despite severity and time elapsed, made improvements seen on standardized testing and also subjectively seen with social and behavioral skills. Specific goals and objectives were tailored to each individual to meet their needs for maintaining and establishing independence. Therapeutic interventions are reinforced by four cognitive/social/behavioral classes a day, physical programming at the YMCA, and social outings into the community each evening. Cognitive testing was performed both pretreatment and post-treatment, and these assessments assisted in confirming improvements in functional daily living skills. The strategy and goals of rehabilitation must pivot around the axis of self identity. In defining and establishing true-self identity, one finds the keys to guide satisfying work and establish meaning for the living of one’s life. The tools for living are unique, and once lost, they need replacing. A structured curriculum helps that individual step beyond his or her limitations. The model of intervention inclusive of all insightful domains builds bridges for our clients to obtain dignity, self-respect, redefinition, and active participation. It is an innovative approach to address the holistic needs of individuals, critical real life issues (not just medical needs) and addresses the core of what makes a person “alive”.
About the Authors
Stacy Levesque, M.A. CCC-SLP, CBIS, is a Speech-Language Pathologist for NRLCL. Her direct experience is with cognitive-linguistic deficits, social skills training, and behavioral disorders has assisted with development of the Post-Acute continuing education “University” curriculum. Ms. Levesque is a member of Brain Injury Association-Louisiana (BIALA) as well as North American Brain Injury Society (NABIS).
Justin Moses, CBIS, is the Program Director of NRLCL. Mr. Moses has been assisting with directing rehabilitation centers for 7 years. Mr. Moses, while at NRLCL, has created a staff training system that provides the staff with the tools and resources to assist in running one of the most active postacute rehabilitation centers in the Southern United States. Mr. Moses is a member of Brain Injury Association-Louisiana (BIALA) as well as North American Brain Injury Society (NABIS).
Hector Gutierrez, CBIST, is Executive Director at NRLCL and is currently a partner with Dr. Robert Voogt at NRLCL in Covington, LA. Mr. Gutierrez has been working in the brain injury field since 1976. Mr. Gutierrez directed an adolescent program for Mary Lee Foundation in the late 1970s, and was the Clinical Director to the Tangram Rehabilitation Network from the early 1980’s to 1998 and the Regional Director to ResCare’s brain injury programs from 1998 to 2003.
Christin Moses received her Bachelor of Science from Texas Women’s University. Ms. Moses is currently the Clinical Coordinator at Nuerological Rehabilitation Living Centers in Covington, LA. Ms. Moses coordinates the clinical and administrating programs.
From Brain Injury Professional, the official publication of the North American Brain Injury Society, Vol. 7, Issue 2. Copyright 2010. Reprinted with permission of NABIS and HDI Publishers. For more information or to subscribe, visit: www.nabis.org.
Brain Injury Professional is the largest professional circulation publication on the subject of brain injury and is the official publication of the North American Brain Injury Society. Brain Injury Professional is published jointly by NABIS and HDI Publishers. Members of NABIS receive a subscription to BIP as a benefit of NABIS membership. Click here to learn more about membership in NABIS.