Thinking / Cognitive Symptoms

Many people have sustained a concussion and walked away only to later find that their lives are somehow different after the injury. They may not realize that their changes in mood, behavior, and thinking abilities may have been altered by TBI. Because these invisible impairments tend to go undetected, they can often plague a person's life for weeks, months, or even years.

After a brain injury occurs, a number of cognitive symptoms can occur right away, while others can arise long after the injury.

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The Effectiveness of Cognitive Rehabilitation

The Effectiveness of Cognitive Rehabilitation
We're seeing more and more research on the effectiveness of what we call cog rehab or comprehensive group interventions for folks with traumatic brain injury. The accumulating evidence is that that form of intervention is effective and is probably the most effective type of intervention that one can apply. I think we're seeing that some of the interventions that you can use such as using the computer by yourself at home are very effective. I think we're beginning to see that some neuroimaging techniques may be useful in helping to pinpoint an injury where the absence of injury had been observed before, but that's not-- I think we're looking at various biomarkers in terms of blood that may be signs of injury. So those are all diagnostics. Those are all issues that tell us whether or not somebody has been injured. I think, to date, in terms of improving cognitive function, there have been no magic pills that people can take. It's all a matter of re-learning cognitive skills and doing that in very structured ways with a tremendous amount of practice.

Brain Games for People with TBI: Pros and Cons

Brain Games for People with TBI: Pros and Cons
A lot of the brain games that are on the website, they can't hurt. They're fun to play, they do stimulate the brain. Many of them are not scientifically based. They're kind of intuitively based and developed by people who develop computer games. Again, they don't hurt; they stimulate the brain. If you're looking for something that's going to be more therapeutic, you need to do some research to find out what the science and the evidence is behind the brain games, and I would also suggest that you do that in conjunction with a cognitive rehabilitation specialist because the particular skills that your daughter may need to work on are going to be very specific. And obviously, games that are out there for the general public on the Web are fairly general. They improve memory. But if you're not sure exactly why your daughter is having trouble with memory, then the games may not be addressing specifically what her issues are. They do have a role and a purpose because, as I said, they do keep your brain moving, they help you work on some tasks in between. I would not do it instead of cognitive rehabilitation; I would do it in conjunction with a cognitive rehabilitation therapist. And I would also be very careful to not let her use computer-based cognitive games as a substitute for interacting with the world, engaging in other rehab activities, social activities, getting back involved. It becomes very easy, especially for teenagers, to get sucked into the Internet world, so I certainly wouldn't allow her to do that for hours on end. You still want to have her engage in other activities and engage in the world and socialize with people and learn new skills and all that kind of thing. So as a piece of the total picture, they can't hurt. Some of them may help. The research is kind of equivocal on how helpful they are therapeutically, but it certainly is something that keeps people's interest and does stimulate the brain and does keep the cells moving in the absence of anything else.

Dr. Tedd Judd Talks About Errorless Learning After Brain Injury

Errorless Learning After Brain Injury
Errorless learning. Boy, we hear about that one and it sounds really cool. It's a nice name, and it really is a great concept. One of the things I love about the research on this--and I won't bore you with research-- but one of the reasons I like talking about this research is because it doesn't take numbers. I had a professor who said, "The really interesting phenomena "don't need statistics to bring them out." When the research teams--Barbara Wilson and others in Great Britain-- first started using errorless learning with people with severe amnesia, they took one group with amnesia and another group, and they used the usual means of instruction with one group and errorless learning with the other. And they said with errorless learning they learned it after so many sessions, and with the other method they never learned it. I said, "Great! This is really neat stuff." So what is it? It's based on the observation that comes from our research with people with amnesia, with brain injuries, that there are two major kinds of memory. There are a whole lot of minor kinds too, but the two major kinds that are important here are what we call declarative and procedural. Buzzwords--let me make it easier--it's learning what and learning how. Learning what is learning information. It's things like what's the capital of France, it's things like what did you have for lunch yesterday, it's things like two plus two makes five--oh, wait a minute. I think I got that one wrong. It's information. It's the kinds of things you learn in school or remembering specific experiences that you've had. Learning how is skill learning. It's learning the way to do something. One of the classic examples is riding a bicycle. You don't learn how to ride a bicycle by reading a book about it. You learn it by getting on the bicycle. Maybe you get a few words or instruction about how to do it, but you just do it over and over and hopefully you don't fall too much or too badly and eventually you're wobbly and you get it and you get there. And typically you hang on to that skill for a long, long time. You may get rusty at it, but it's mostly there. That's procedural learning. That means it's a procedure, it's a way of doing something. It doesn't have to be a motor skill; that is, a movement kind of skill. It can be a procedure like how to use a certain computer program or a cell phone or how to do a certain mathematical procedure. Or really, from what I can tell, it seems like learning melodies in songs is probably more procedural learning than it is information learning. And it sticks with you and seems to be one of the last things to go with Alzheimer's disease. So as it turns out, the what learning, the declarative learning, is very dependent on the hippocampus of the brain, the hippocampus and the amygdala, and those are two structures that are deep in the temporal lobes. And I'll try not to go very far into anatomy, but the reason they're relevant to this discussion is because their location is pretty close to the base of the skull. And with a lot of brain injuries, especially those in auto accidents, you tend to have the auto accident when you're moving forward and you stop suddenly and you hit your head and the brain gets jammed down into the base of the skull and the hippocampus and the amygdala get affected particularly, more than other areas, and so that kind of memory is affected, sometimes to the point of severe amnesia, of having a lot of difficulty learning anything new. But procedural learning is dependent on a number of other structures in the brain, some of which are affected by injury of that sort and some of which are less affected. So we often find in people that have severe memory impairments for that kind of what did you do yesterday kind of information, new learning, they have preserved ability to learn by procedures. That has an upside and a downside. That means they learn what they do, whether it's right or not. So if you try to teach somebody who has preserved procedural learning and poor declarative learning by the trial and error method, "Well, try it and see what happens," they may well remember their mistakes. So it can happen like this, for instance, in the hospital: If you're a neurologist or psychologist making rounds and you go by the bed of the person with amnesia and say, "Do you remember my name?" "No." "I'm Dr. Judd. I'd like you to try to remember that." A minute later, "Do you remember my name?" "No." "Well, take a guess." "Uh, umm, hmm, uh, Dr. Smith?" "No. It's Dr. Judd." And maybe you try again. "Do you remember my name?" "No." "Can you guess?" "Dr. Smith?" "No. It's Dr. Judd." And a little while later or next time you come by, you ask again. "Oh, hi, Dr. Smith," because they remember their mistake. That may be the mechanism also by which people will ask the same question repeatedly. They remember the question; they don't remember the answer. They remember the question because it's something that they did. They asked it. But they don't remember the answer because it's information coming in. So they remember their own action. So we try not to teach by a means in which we encourage guessing. We don't encourage guessing. You give the person the whole information or the whole procedure. So you may have a written phone number and dial everything but the last number and have them do the last thing. Or a procedure on a cell phone or on a computer, have them do the last one and then when they do that reliably, then you add the last two steps and have them do it reliably. You have them do things by copying you so that they're going through the action, doing it themselves and remembering what it is they're doing. And you never give them a chance to make a mistake. Now, that in itself is a bit of an art because you have to be able to guess when they're going to get it right or when they might not quite know, and you have to know the particular person because some people are more inclined to guess than others. But you use what we call vanishing cues. So you give them a little bit less information each time or enough information to allow them to finish the thing. Or if it's more motor, you just do it by doing it over and over again. And we find that we can train people more reliably that way.

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