Guidelines for Using Brain Injury Rehabilitation Techniques at Home

When I'm working with families around incorporating rehabilitation techniques into the home setting, the first thing that I emphasize is that you're a family member first. And you need to maintain and respect your role as a family member and maintain the love and the other things that are most important in that way. If part of that can include doing rehab as well, great, but if not, and if trying to do rehab is going to get in the way, then let your role as a family member come first and let that be first. Okay, that being said, then if you are able to furthermore incorporate rehab in, what I would look for more than anything is finding ways to make everyday activities things that you want to do anyhow, things that will also facilitate movement towards goals that you have. How do you do that? Well, you do them at what we call the zone of recovery. The zone of recovery, just to understand historically, comes from a psychologist named Vygotsky from the Soviet Union from the 1930's. He called it the zone of proximal development and talked about it in children, but we've used it in rehabilitation. That's the activity that the person can do with a little bit of help, that it's a challenge, but they're able to accomplish it, that it's not so easy that they're bored by it. Now, life includes lots of things that are boring and all of us have to do, and even if you've mastered that thing, and you can do it okay, there may be something to be gained from doing it because it has to be done anyhow, and you get better at it and so forth. It's not to say that you're not allowed to do boring things or things that are too easy, but if you wanted to be helpful, and if you've got a complicated activity that the person can do part of, what you want to look for is not just giving them the parts that they can do easily. It's also including the parts that are a challenge, but that eventually they're going to be able to succeed at, and something that's not so hard that they get too frustrated at it. This idea of the zone of recovery includes not only how hard it is, but what the nature of the interaction is with the family member. It implies that the family member is guiding, that the family member is perhaps cuing, coaching, indicating, answering questions. The family member isn't just sitting back and letting the person do it all by themselves and struggle with it or whatever. And the family member isn't showing them every little step, every little part of the way. Rather, they're--so if you think of it physically, it's not like you're walking behind pushing. You're not walking ahead and pulling them along. You're walking next to them and indicating and guiding when that's needed. That's the zone of recovery. That's the kind of activity that yeah, I think--yeah, okay I can do that. I think--yeah, that one. That's another principle that helps. Another thing is that it's a moving target, that people recover, and that makes it a bit of an art. People who are good teachers, people who are good at parenting often have that knack. It's a knack, and so one of the things that I do too, is I look for the family members who have that knack, who like to do that, and who have the time and the ability to do so and are motivated to do so. You pick the right ones for that also. But it's a learn-able knack, so that idea of looking for that zone often helps people to figure out what they should be doing. Another thing I like to do along those lines is we'll pick an activity that the person wants to be able to do, that they're not quite able to do yet. We'll say, "Okay, well, what is getting in the way?" Well, how could we deal with that? How could we get around it? We'll do problem solving together, and often what I can do when we work through a half a dozen problems, the family, along with the person, may then have a notion of a way to go about things, and they can tackle new problems themselves. Let's do a little example. Suppose we've got somebody who has got a new brain injury-- or not a new brain injury--it's several months. They're home now. Let's say that it's somebody, a young man in his early twenties-- which would be fairly typical--and has perhaps returned home to live with his parents. One of the things that he would really like to do is to go to the neighborhood soccer games 4 or 5 blocks away, like he used to do, and watch the games and see his friends and all that. Several problems that are getting in the way-- He can walk, but he gets tired easily, and 4 or 5 blocks to walk, that's going to be a lot. He just kind of gets tired generally at any kind of activity and when he gets tired or when he gets over stimulated, and there is too much noise and light and activity, he gets irritable and he gets anxious. Okay, so we've got some problems. Conventional rehabilitation, "Oh, well, we'll give him physical therapy to improve his stamina, so that he can do that, and we'll give him cognitive rehabilitation with the speech pathologist or an occupational therapist who will improve his attention, so that he can handle more stimulation, and we'll give him psychotherapy to deal with his irritability and anxiety." Okay, that's great, but it's 4 or 5 months before he can get to go watch the soccer match that way. Instead, what we'll do is we'll say, "Hm-mm, let's see what we've already got that can deal with this." We could look at desensitizing to the over-stimulation. We could look at learning to handle all of that going on by practicing at home by watching soccer on TV. Now, most of the time, I don't think of the TV as a rehabilitation machine, but if we've got a particular goal like that, and something we're going towards, it could be. We could work on that some. We could say, "Okay, for now, we're going to drive to the soccer game, or we're going to take the bus, so that you have a little more energy. We know you get tired before too long, so we won't stay for the whole game when we start out. Because the crowds are worse when everybody is arriving and that's difficult to handle, we'll come a little late, and we'll leave early. On top of that, we know we've got a routine worked out for when you get angry or when you get anxious that we call is a time out." Or for this person, maybe it's take a break or relax. We use whatever language works best for them. We'll have a plan B, so that if you're there at the game, and things get a little too rough, you'll have somewhere you can go and something you can do, and we'll figure out in advance where would be a good place for that. You'll go with a family member who can help you monitor that because maybe you're not too good yet at monitoring and noticing when you're starting to get irritable or anxious, and so that family member will be watching what you're doing. Okay, now we've got a whole plan in place to go to your first game. Then you go to your first game, some things work, some things don't. We'll talk about it afterwards, what worked, what didn't, what are we going to do next time. Then with the zone of recovery, next time, okay, we go for a little longer. The next time, I'm going to leave you alone for a little while while you're there and see how you do. Then maybe a few weeks, a month later, we're ready to walk there or to get a ride there and walk back. Now, we'll add bits and pieces that way. Then we'll be ready to--well, we'll walk by your side, but you tell me where we turn. You tell me which route we take. We're doing rehabilitation. We're using everyday activities. We're doing an analysis of what is going on with that activity to find out where the problems are and how to approach them. We're doing some compensations of putting things in place that allow the person to function better, and we're doing some kind of restoring of function by exercising it and doing it over and over again to build up the habits that are needed to make it work better. That's one kind of activity. We could do the same thing for going shopping or for washing the dishes or for going out on a date or to a party or any kind of motivating activity. Well, washing the dishes might not be all that motivating for some people, but it needs doing anyhow. There are all kinds of ways that you can take everyday activities and analyze them. It's cognitive. It's physical. It's emotional. You're looking at the whole thing, and you're working with all of it.

Neuropsychologist Tedd Judd shares his experience and advice about culture, ethnicity, and brain injury rehab.

Transcript of this video.

Tedd Judd

Tedd Judd, PhD is adjunct clinical faculty in psychology, University of Washington and adjunct faculty in psychology, Seattle Pacific University. Much of his work has focused on traumatic brain injury rehabilitation.

Posted on BrainLine April 29, 2009.

Produced by Victoria Tilney McDonough and Brian King, BrainLine.