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Neuropsychological rehabilitation

Professor Jonathan Evans


Institute of Health & Wellbeing
University of Glasgow

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Neuropsychological rehabilitation

• Enabling people with cognitive, emotional or


behavioural deficits arising from neurological
conditions to achieve their maximum
potential in the domains of psychological,
social, leisure, vocational and everyday
functioning.

2
Neuropsychological rehabilitation

• Neuropsychological rehabilitation requires


an interdisciplinary team (e.g. doctors,
speech and language therapists,
occupational therapists, physiotherapists,
psychologists, and others).

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Neuropsychological rehabilitation

• Relevant for people with stroke, head injury,


encephalitis, tumours, anoxia, other forms of
acquired brain injury and degenerative
conditions.

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NeuroRehabilitation Services

Acute care – e.g. Neurosurgery, Stoke Unit,

Post-Acute Inpatient Physical Disability


Rehabilitation Centre Rehabilitation Unit

Challenging
Community Brain
Behaviour Unit
Injury Team

Neuropsychological Rehabilitation
Day Programme 5
A very brief history of ideas in
neuropsychological rehabilitation

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History of neuropsychological rehabilitation

• Kurt Goldstein (1942)


– German neurologist, forced to leave Germany by the
Nazi’s. Moved to USA.
– Systematic and long-term follow up of patients
– Recognition of individual variability and variability over
time.
– Need for psychometric assessment, but recognition of
limitations
– A focus on the challenge of psychological adjustment
after brain injury
– Need to connect cognitive rehabilitation to ‘real world’
activities (e.g. return to work).

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Oliver Zangwill (1947)
• British psychologist, working with injured soldiers in WWII,
in Edinburgh and Cambridge.

• “We wish to know how far the brain injured patient may be
expected to compensate for his disabilities and the extent to
which the human brain is capable of re-education. At the
present state of our knowledge, no categorical answers can be
given”.

• Principles
– Compensation – finding ways to get around a problem, including
using external aids

– Substitution – using intact functions to substitute for impaired


functions

– Direct retraining – exercising a function in order to improve it

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Alexander Romanovitch Luria (1969)
• Later part of his career addressed issue of
rehabilitation.

• ‘Man with a Shattered World’ and


‘Restoration of higher cortical function
following local brain damage’.

• Emphasis on assessment to identify primary


deficits to guide rehabilitation intervention,
with focus on use of intact areas compensating
for (substituting for) damaged functions.
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History of neuropsychological rehabilitation

• The early pioneers influenced others such as


Yehuda Ben Yishay, Anne-Lise Christensen,
George Prigatano and Barbara Wilson.
• Development of ‘holistic’ rehabilitation
programmes
– New York (Ben Yishay)
– Oklahoma and then Phoenix (Prigatano, Klonoff)
– Copenhagen (Christensen, Humle)
– Oliver Zangwill Centre (Wilson, Evans, Gracey and
Bateman)
• Emphasis on integrated treatment of cognitive
and emotional problems, with focus on return
to productive activity.

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Principles and practice

• Core components of holistic


neuropsychological rehabilitation
1. Therapeutic Context
2. Shared understanding
3. Meaningful goal-directed activities
4. Learning compensatory strategies and
retraining skills
5. Psychological interventions
6. Working with families, carers and
others (employers, teachers).

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The importance of the therapeutic context
• The organisation of the environment including
the physical environment, the structure of the
programme and the social environment.
– Developing a sense of safety, trust and
cooperation.
– Physical environment is pleasant and easy to
navigate in.
– A structured predictable timetable for each day
– Working together with peers in group activities
– Activities in which all staff and clients participate
(daily meeting)
– Emphasis on respect and collaborative working
between staff and patient.

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Principles and practice

• Core components of holistic


neuropsychological rehabilitation
1. Therapeutic Milieu
2. Shared understanding
3. Meaningful goal-directed activities
4. Learning compensatory strategies and
retraining skills
5. Psychological interventions
6. Working with families, carers and
others (employers, teachers).

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Shared understanding of each person’s strengths
and weaknesses

• We take a ‘biopsychosocial’ approach to


understanding and representing the person
after his or her brain injury
• Influenced by World Health Organisation
International Classification of Functioning,
Disability and Health (ICF)
– Body Structures
– Body Functions
– Activities and participation
– Environmental Factors

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Family/social Pre-morbid
support Brain pathology factors
Stroke, head injury, etc e.g coping style

Cognitive Affect Physical


e.g. Memory e.g. Depression e.g. Hemiplegia
Perception Anxiety Sensory loss
Language Anger Dysarthria
Attention Confidence Pain
Executive Motivation
Insight Loss

Functional consequences
e.g. Work, Relationships, Activities of Daily Living
Leisure, Driving etc.
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Evans (2006), in Wilson, Gracey, Evans and Bateman, (2009)
Case example: Yusuf

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Yusuf – background to case
• 35 year old man
• Severe head injury in a road traffic accident:
– Coma: 7 days
– Post-traumatic amnesia: 1 month.
• CT: left fronto-temporo-parietal sub-dural haematoma
• Discharged from acute care and back living with his family.
• Prior to the head injury he was running his own
businesses with his brother
– Import-export trading house, trading in fabric.
– Wanted to return to his business
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Yusuf – background to case
• Yusuf’s brother reported that Yusuf had tried to return to
work but was making poor decisions, and would not listen to
advice.
• Yusuf’s wife said that Yusuf was slow at doing things, forgets
things.
• When he is told he has forgotten something becomes very
self-critical and depressed.
• He is irritable and cannot deal with the children or tasks
around the home.

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Multi-disciplinary assessment
• Clinical Neuropsychology
• Neuropsychiatry
• Occupational Therapy
• Speech and Language Therapy
• Physiotherapy

• Each did their own assessment and then bring the results
together in an integrated summary formulation

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Family/social Pre-morbid
Support Patient:Yusuf personality factors
Lives with wife & Successful
children- supportive but Severe head injury businessman
strained relationships
Sub-dural haematoma

Cognitive Affect Physical


Impairment  Confidence Fatigue
 Processing speed Pain
Frustrated Right sided
 Attention
 Memory
Anger, irritability weakness
Insight Anxiety/worry Sensory
 Decision making Limited insight into impairment
Impulsive cognitive problems  balance
and potential Deaf in R ear
impact
Double vision
Cannot stand for
Functional consequences more than 2-3mins
Strained relationships with family members
Avoiding work and other tasks, or acting impulsively.
Resistant to taking advice. Slow to do things.
Feels ‘overloaded’ when in work situation.
Poor communication with others 20
Principles and practice

• Core components of holistic


neuropsychological rehabilitation
1. Therapeutic Milieu
2. Shared understanding
3. Meaningful goal-directed activities
4. Learning compensatory strategies and
retraining skills
5. Psychological interventions
6. Working with families, carers and
others (employers, teachers).

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Meaningful goal-directed activities
• A major aim of rehabilitation is to enable people to participate in valued
activities
– Work
– Education
– Leisure
– Social
– Independent living

• Goal setting refers to the process in which the rehabilitation team and
patient (and family or advocate as appropriate) agree on a set of goals to
be achieved during the course of the rehabilitation programme.

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SMART Goals

• Goals should be ‘SMART’


– Specific
– Measurable
– Achievable, but challenging
– Relevant to the patient’s personal
aims/aspirations
– Timeframe set

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Yusuf: Goals

• By the end of his rehabilitation programme (six months) Yusuf will….

• Use strategies to complete specified work tasks effectively


• Use a memory and planning system to enable him to complete at least
70% of his planned activities on a weekly basis without excessive
fatigue
• Use strategies to manage stress, anxiety, and anger in the
rehabilitation centre, at home, work and in the community
• Demonstrate use of strategies to manage pain

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Principles and practice

• Core components of holistic


neuropsychological rehabilitation
1. Therapeutic Milieu
2. Shared understanding
3. Meaningful goal-directed activities
4. Learning compensatory strategies and
retraining skills
5. Psychological interventions
6. Working with families, carers and
others (employers, teachers).

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Where do we target our interventions?
• Body structures?
• Body functions?
• Activities and participation?

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Memory Attention Executive

Work Daily Leisure Relationships


Living

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Memory Attention Executive

Work Daily Leisure Relationships


Living

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Memory Attention Executive

Work Daily Leisure Relationships


Living

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Work

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Yusuf’s job analysis

Learn about new fabrics Remember to do things e.g. keep Plan work tasks e.g. organising
appointments, send information, visits to customers
complete paperwork

Remember what I have done – what Solve problems- changing schedule; Calculate and prepare invoices, fill in tax
have I read, who I have visited, what problem with delivery, etc. form
they said, what’s going on in their
life etc.

Talk to people face to face Listen to people 1:1 or


and on the phone Read and write reports Drive car
meetings

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Memory Attention Executive

Learn about new fabrics Remember to do things e.g. keep Plan work tasks e.g. organising
appointments, send information, visits to customers
complete paperwork

Remember what I have done – what Solve problems- changing schedule; Calculate and prepare invoices, fill in tax
have I read, who I have visited, what problem with delivery, etc. form
they said, what’s going on in their
life etc.

Talk to people face to face Listen to people 1:1 or


and on the phone Read and write reports Drive car
meetings

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www.sign.ac.uk

What interventions should we use?


• Consult the evidence!
• There are now various good sources of evidence including
systematic reviews, meta-analyses, databases and clinical
guidelines.

www.sign.ac.uk

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Cicerone et al (2011)
• There is substantial evidence to support interventions for
attention, memory, social communication skills, executive
function, and for comprehensive-holistic neuropsychologic
rehabilitation after TBI.

• “Comprehensive-holistic neuropsychologic rehabilitation is


recommended to improve post acute participation and
quality of life after moderate or severe TBI”. (p 526)

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Van Heughten, Wolters & Wade (2012)

• 95 randomised controlled trials were included from January


1980 until August 2010 relating to 4068 patients
• “There is a large body of evidence to support the efficacy of
cognitive rehabilitation”

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Family/social Pre-morbid
Support Patient:Yusuf personality factors
Lives with wife & Successful
children- supportive but Severe head injury businessman
strained relationships
Sub-dural haematoma

Cognitive Affect Physical


Impairment  Confidence Fatigue
 Processing speed Pain
Frustrated Right sided
 Attention
 Memory
Anger, irritability weakness
Insight Anxiety/worry Sensory
 Decision making Limited insight into impairment
Impulsive cognitive problems  balance
and potential Deaf in R ear
impact
Double vision
Cannot stand for
Functional consequences more than 2-3mins
Strained relationships with family members
Avoiding work and other tasks, or acting impulsively.
Resistant to taking advice. Slow to do things.
Feels ‘overloaded’ when in work situation.
Poor communication with others 36
The evidence base - Memory
• Patients with memory impairment after traumatic brain injury should be trained in the
use of compensatory memory strategies with a clear focus on improving everyday
functioning rather than underlying memory impairment.
• For patients with mild-moderate memory impairment both external aids and internal
strategies (eg use of visual imagery) may be used.
• For those with severe memory impairment external compensations with a clear focus
on functional activities is recommended.
• Learning techniques that reduce the likelihood of errors being made during the
learning of specific information should be considered for people with moderate-severe
memory impairment.
• Restorative strategies have regained significant popularity, given broader access to
computer technology; however, evidence for efficacy of these techniques remains
weak (INCOG Guidelines 2014)

www.sign.ac.uk
37
The evidence base - attention
• In relation to attention, there is evidence that impairment focused training
(e.g. computerised attention training) may produce small beneficial effects
in the post-acute phase after TBI, although evidence for generalisation of
these effects is weak.

• Patients with attention impairment in the post-acute phase after traumatic


brain injury should be given strategy training relating to the management of
attention problems in personally relevant functional situations.

www.sign.ac.uk
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The evidence base –executive functions
• Patients with traumatic brain injury and deficits in executive functioning
should be trained in meta-cognitive strategies relating to the management
of difficulties with planning, problem solving and goal management in
personally relevant functional situations.

www.sign.ac.uk
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Yusuf – Rehabilitation Programme
• 20 week rehabilitation programme.
• First 10 weeks attended three days per week.
• Then gradually reducing time at the rehabilitation centre and
increasing activities at home and work

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Yusuf – Interdisciplinary team approach

• Occupational Therapy sessions for developing


planning systems and work task analysis.
Training in the use of an electronic organiser
SLT PT
OT
• Speech and Language Therapy sessions for
communication, focusing on managing
Psych
impulsivity in social situations.
Memory & Pain
• Physiotherapy sessions for fatigue and physical Planning
pain management Communication Emotion &
Goal
• Psychological therapy sessions looking at Management
psychological aspects of pain, fatigue and
adjustment. Also training in problem solving
and task management.

• Work with his Yusuf’s family (brother and wife)


to help him generalise strategies learned in the
rehabilitation centre to his home and work life.
Work

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Occupational Therapy sessions
• Analysis of tasks involved in his job.
• Development of strategies for compensating for cognitive
deficits in order to manage work tasks.
• Use of an electronic organiser for scheduling tasks and
reminding him to do things.
• List of strategies for dealing with surprise demands.

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TASKS INVOLVED STRATEGIES IDENTIFIED
YARN BUSINESS

ORDERING STOCK · Ask employee to supply weekly stock figures and review on a
· Check current stock status weekly basis - Put on employee’s to do list
· Check or make a sales projection · Every 2 weeks or once a month (depending on season) check
· Check current status with suppliers stock currently available and sales projection to decide if need
· Make the order to cover sales projection to place an order - reminder on electronic organiser
· Receive the order confirmation · Check current status with supplier on a weekly basis -
· Get the documents from the bank and sign to guarentee reminder on electronic organiser
payment · Double check orders before they are faxed
· Receive the goods · Contact supplier about order after one day - reminder on
· Pay electronic organiser
· Monitor sales in comparison to projection · Contact supplier to check order has been shipped after 4
weeks - reminder on electronic organiser
· Chase bank after 6 weeks if no documents have been
received - reminder on electronic organiser
· Check employee has received bank documents, filed them,
entered into database, delivered to warehouse and date stock
arrived
- reminders into electronic organiser when need to check
· Have a set time each week to check above - part of
daily/weekly plan
· Organise working day - Complete daily plan and daily review
· Complete yarn related work in mornings and web related work
in afternoons
· Plan when to complete weekly, monthly, quarterly and annual
tasks

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TASKS AND SITUATIONS TRIGGERING STRATEGIES IDENTIFIED
NEGATIVE EMOTIONAL REACTION

· looking at to do list and planning at the start of the day · notice ‘negative predictions’ about own ability, time available
etc triggered by looking at morning’s plans
· take control of attention, use mindfulness to direct your
attention back to the task at hand, and away from the
negative predictions
· complete your plans for the morning
· tell yourself ‘once I start these tasks I will feel better’
· DO NOT REST unless it is a set rest time - STICK TO REST
TIMES

· ‘surprise demands’ · stay in the situation


· recite a phrase two or three times to distance yourself from
negative thoughts and keep your attention in the present
· ‘stop and think’
· ask the person to repeat or clarify if you have not fully taken in
what they have said
· be assertive with your response
· if necessary schedule any additional tasks arising during the
day for the time for this at the end of the day
· demonstrate status by saying “I’m tied up right now, but can
get back to you after 3.00pm 44
Speech and Language Therapy
• Sessions for communication, focusing on managing
impulsivity in social situations.

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Physiotherapist and Psychologist – Work on managing fatigue

• Monitoring fatigue, rest periods and thoughts and


feelings for 2 weeks
• Outcome of monitoring was evidence of a
fluctuating pattern:
– on waking: “do I feel okay?”
– if yes - do as much as possible, focus on physical
symptoms
– if no - anxious about what might happen, poor
performance at work, irritability with family and
friends, focus on physical symptoms
– if no - cautious, taking breaks, sleeping during the
day, focus on physical symptoms
• Sometimes falling asleep at lunchtime

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Yusuf – Work on managing fatigue
• Monitoring fatigue, rest periods and thoughts and feelings for 2 weeks

On waking in morning

If not feeling good If feeling ‘okay’

Worry about poor performance and Do as much as possible while I feel okay
making mistakes, avoid tasks, hyper-
vigilant to physical symptoms, take
- impulsive burst of action
lots of rest breaks, sleep in daytime.

Achieve some success, but


also likely to make errors
Achieve little, and feel fatigued
feel frustrated,
irritable
Over-focus on physical symptoms 47
Yusuf – Work on managing fatigue

• Activity pattern
– Added up total rest time for the 2 weeks and rationed it
– Amounted to approx 45 minutes per day
– Arranged with Yusuf how he would like to ration his rest time
• 10 minutes a.m., 20 minutes at lunchtime, 15 minutes p.m.
• Applied mindfulness meditation at lunch break instead of
sleep/worry
• Used planning system (on daily timetable then on personal
digital assistant) to schedule his activities
• Systematically reduced rest times
• Physiotherapy advice – stand and stretch after 30 minutes

– Challenge assumptions:
• Challenging the assumption that if he feels ok he should do as much
as possible.

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Yusuf – Rehabilitation programme

• Work on rules and assumptions


– Identified unhelpful ‘rules’ and assumptions:
• “a good businessman makes a quick decision”
• “if I don’t act now I will be seen as a failure”
• “I must keep up a strong image to maintain my status”
• Created formulation linking assumptions, impulsivity, stress

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Rules and assumptions
If things aren’t going well I should:
Act quickly before I forget
Make a quick decision so I am seen as a good businessman
Make a quick decision so I will not be challenged

Environment Current activity


Busy, noisy, Trigger How important it
distractions Unexpected situation or demand feels, deadlines,
rushing
Cognitive
impairment Increased stress Physical state
Executive deficit, levels Pain, fatigue, hunger
impulsive, poor
planning

Unhelpful thoughts
I must do this quickly
I mustn’t be seen to fail
I should be decisive

Impulsive decision or
action
NEGATIVE OUTCOME 50
Psychology sessions – Goal Management
Training

• Goal Management Training (Robertson, Manly & Levine)


– Training programme aimed at teaching patients how to control
attention during everyday tasks
– Can be supported by external electronic aids (alarms)

See Levine et al (2000), Levine et al (2007), Schwiezer et al (2008), Levine et al (2011)


for studies of GMT 51
Goal Management Training

(1) Stop and think what I am doing


(2) Define the main task
(3) List the steps required
(4) Learn the steps
(5) Whilst implementing the steps, STOP & THINK -
check that I am on track or doing what I intended to
do.

Use the Mental


Blackboard

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Yusuf – Rehabilitation programme

• Goal Management Training

• Used a mindfulness meditation method to manage his


thoughts and feelings

• Supported to think about, and change, his old ‘rules’

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Rules and assumptions
If things aren’t going well I should:
Act quickly before I forget
Make a quick decision so I am seen as a good businessman
Make a quick decision so I will not be challenged

Environment Current activity


Busy, noisy, Trigger How important it
distractions Unexpected situation or demand feels, deadlines,
rushing
Cognitive
impairment Increased stress Physical state
Executive deficit, levels Pain, fatigue, hunger
impulsive, poor
planning
Wise approach
Unhelpful thoughts STOP: THINK
Help from
I must do this quickly reflection, awareness, goal others
I mustn’t be seen to fail management, planning, Discuss plans
I should be decisive mindfulness, external aids to with others
support planning who may be
help

Impulsive decision or Planful decision or action


action POSITIVE OUTCOME
NEGATIVE OUTCOME ‘Things are going okay’ 54
Yusuf’s ‘New Rules for Business and Life’
• Planning
– Plan thoroughly and have a clear strategy in mind at all times. A daily
diary and a ‘to-do’ list is a must
• Pace yourself
– Don’t rush - Stop - Think…then Act. Use mindfulness meditation.
Control the environment (noise etc.)
• Information is power
– Understand your product
• Control
– Don’t lose track of money matters- reviews figures regularly.
• Be proactive rather than reactive
– Don’t keep things to yourself - be tactful and honest, but be assertive
and say what you mean

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Yusuf’s ‘New Rules for Business and Life’
• Don’t avoid the fight
– There will be many pitfalls and obstacles along the way but be determined and
once decided have the will power to go all the way
• Focus
– Keep focused at all times - stick to your plans
• No man is an island
– Exchange ideas- keep in touch with others- build a network and seek advice
• Take your time over major decisions
– Ask questions. Use the Goal Management Framework.
• Last but not least
– Walk away from potentially volatile situations
– Learn to say no
– Learn to say enough for the day
– Try your best and put your trust in the Almighty

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Yusuf: Goals
• By the end of his rehabilitation programme (six months) Yusuf will….

• Use strategies to complete specified work tasks effectively


– Achieved (as rated by his brother who observed Yusuf in work)

• Use a memory and planning system to enable him to complete at least 70%
of his planned activities on a weekly basis without excessive fatigue
– Achieved – monitoring of task completion showed performance over 70%

• Use strategies to manage stress, anxiety, and anger in the rehabilitation


centre, at home, work and in the community
– Rating scales showed reductions in stress and anxiety

• Demonstrate use of strategies to manage pain


– Achieved – stopped using his walking stick; used rest times according to his schedule;
better pacing;

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Yusuf – Outcome
Carer European Brain Injury Questionnaire
Scores
3.00

2.50

2.00
EBIQ Scores

1.50

1.00

0.50

0.00
Prelim Det Start End Dis
Programme Stages
EBIQ Cognitive Scale
EBIQ Communication Scale 58
EBIQ Consequence / Physical Scale
Yusuf – Outcome
Outcome - Hospital Anxiety & Depression
Scores
16

14

12
HADS Score

10

0
Pre Start End Dis

Stage of Rehabilitation
HADS - A HADS - D
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Summary
• Yusuf presented with multiple physical, cognitive, emotional and social
consequences of his injury

• An account relating cognitive appraisals, physical problems (pain and fatigue), and
behaviour (fluctuating rest and impulsive activity) was useful.

• Rest rationing, pacing, mindfulness, alteration of key cognitions and use of


cognitive strategies to manage impulsivity were useful.

• Outcome relied on interdisciplinary working and sharing the formulation with


Yusuf and the team

• Yusuf achieved the goals he and his family had set. Yusuf still had significant
cognitive impairment but his ability to function in his own environment was much
improved. His self-esteem and confidence were improved because he has the
strategies to manage his difficulties in his everyday life.

60
Principles and practice

• Core components of holistic


neuropsychological rehabilitation
1. Therapeutic Context
2. Shared understanding
3. Meaningful goal-directed activities
4. Learning compensatory strategies and
retraining skills
5. Psychological interventions
6. Working with families, carers and
others (employers, teachers).

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Спасибо

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