Lessons In TR

Today I want to share with you my notes on Traumatic Brain Injury from the PATH Intl 2018 Virtual Conference webiner Brain Injury: Overview, Strategies and Resources by Liz Gerdeman, MA of the Brain Center Alliance, Colorado. I started this post a long time ago and thought I finished and published it, but as I was looking through drafts today (frantically looking for something to blog about so I can maintain my one post a month trend), realized I hadn’t!

All talks I’ve heard about TBI have lumped it in with Veterans and PTSD, so I really liked that this seminar was about TBI on its own. There’s so many other ways people can get a TBI – for example, I’ve had riders that were in a car accident – so I found it helpful to focus just on this diagnosis alone. I don’t want to steal her presentation, just share what I found the most interesting and helpful as an instructor, so I’ve rearranged the information from how it was presented so that it’s most helpful to me as an instructor preparing for my riders, and hopefully for you!

(Remember this is not comprehensive, just important info from a presentation I want to share.)

Notes from “Brain Injury: Overview, Strategies & Resources” by Liz Gerdeman, MA of the Brain Center Alliance, Colorado

About TBI

• TBI = Traumatic Brain Injury
• Under “Acquired Brain Injury” there is both “Traumatic” and “Non Traumatic”
• Traumatic Brain Injury is from external forces (assault, falling, accident, etc.)
• Non Traumatic Brain Injury is from internal events (stroke, tumor, lack of oxygen, brain infection, etc.)
• Classifications depend on how long they lost consciousness: “mild” (0-30 min), “moderate” (30 min – 24 hr), “severe” (24+ hr)
• 90% of mild TBIs go unreported!
• The person may experience “A Multitude of Losses”:
  • Physical and cognitive abilities
  • Communication, emotional regulation, executive functioning, etc.
  • Life roles – spouse, friend, parent, sibling, etc.
  • Family life
  • Responsibilities – work, bread winner, role model, helping others, driving
  • Self esteem
  • Intimacy
• Almost half of adults with TBI who have no previous history of mental health problems DEVELOP mental health problems post TBI!
• TBI increases risk for homelessness, drug use, suicide, mental health issues
• TBI is associated with substance abuse – they can cause each other, and if TBI occurs before age 3 the person is more likely to abuse substance
• TBI impairs the mental processes one needs to be successful in society, skills that they had developed throughout life.
• The person may be tired all the time – their brain can’t absorb as much
• TBI presents most often behaviorally
• Don’t feel like you need to “treat” the injury, rather, adapt with simple strategies
• Consider first if the person is actually capable of doing what you are asking, instead of assuming they are willfully not complying

Common Symptoms & Adaptations

These are common “hallmarks of impairment” that you might see in someone with TBI, starting with lower level fundamental mental processes and working up toward higher level processes, all of which build up to overall functioning in life and as a “productive” member of society.

Impaired Attention

• Looks like…
  • Fidgets, interrupts, low frustration tolerance
• Adaptations
  • Make sure you have good eye contact
  • Work on one thing at a time
  • Keep instructions brief and simple
  • Let client participate in planning (their goals, their lesson, their next step, etc.)
  • Use discussion more than teaching-at
  • Reduce distractions and noises
  • Use cue words (look, listen)
  • Use nonverbal cues (eye contact, touch)

Delayed Processing

• Look like…
  • Slow to respond, appears to not be paying attention, looks confused, doesn’t follow instructions
• Adaptations
  • Give extra processing time
  • Speak slowly
  • Make sure they understand (aka they can repeat it back to you)
  • Use checklists and written schedules/routines
  • Use the cue “first…then…”

Short Term Memory Loss

• Looks like…
  • Can’t remember more than one thing at a time, or details
  • Asks you to repeat yourself a lot (which comes across as having an attitude problem)
  • Appears disorganized
  • Appears manipulative
• Adaptations
  • Use routines
  • Repeat info and summarize (be patient!)
  • Use written summaries and steps (such as on a whiteboard)
  • Review new info frequently
  • Use “chunking” – combining things in small groups to help remember them (it may be easier to remember 4 things together than 1 thing on  its own)
  • Streamline, only use relevant info
  • Practice, practice, practice

Impaired sensory motor skills

• Looks like…
  • Overwhelmed by senses, smells
  • Irritable
  • May appear oppositional
  • Emotionally melts down
  • Shuts down
• Adaptations
  • Control your environment –
  • Keep it quiet
  • Keep noise and lights down
  • Keep sessions short (to minimize headaches and fatigue)
  • Schedule rest breaks during activities

Impaired language skills (rules of social language)

• Looks like…
  • Doesn’t read body language (such as cues to end the conversation)
  • Uses inappropriate eye contact
  • May get in your space
  • May say too little or too much
  • Has little awareness of how their behavior may be inappropriate
• Adaptations
  • Give direct specific feedback (such as for expectations of responses to body language)
  • Do not depend on using your own body language to communicate
  • Role play

Impaired receptive language skills (understanding language)

• Looks like…
  • Confused at abstract language (sarcasm, metaphor, etc.)
  • Says “huh?” a lot
  • May withdraw or just follow along
• Adaptations
  • Be direct
  • Avoid abstract language
  • Give instructions slowly and one at a time
  • Ask if it would be helpful to repeat (or rephrase)
  • Let them know you value their input, thoughts, feelings, etc.

Impaired expressive language (ability to be understood)

• Looks like…
  • Poor grammar
  • Hard to follow in conversation
  • Inarticulate
  • Difficulty staying on topic
  • Difficulties navigating social rules
  • May withdraw
• Adaptations
  • Provide opportunities to practice what to say
  • Group setting is often not best
  • Redirect if they go off topic
  • Role play common real life conversations
  • Teach them to rehearse silently before replying
  • Be patient and give them time to respond

Impaired executive function (ability to start an action/activity)

• Looks like…
  • Lacks initiation
  • Appears lazy or unmotivated
  • Follower
  • Needs constant cuing
  • Lags in independent living skills
• Adaptations
  • Focus on one step at a time
  • Ask client to repeat instructions to make sure they understand
  • Break down complex activities into simple action steps
  • Use color coding
  • Use checklists
  • Help them get started! Then hand it over to them.
  • Repeat instructions many times and in different ways

Impaired mental flexibility

• Looks like…
  • Perseverates
  • Hard to take feedback
  • Resistant
  • Appears stubborn, argumentative
  • Appears to lack empathy
  • Not because they’re mean but because of how their brain functions
• Adaptations
  • Use routines, practice them, and plan ahead for changes
  • Prepare for transitions
  • Help develop alternative plans
  • Help break down goals into smaller tasks
  • Give respectful feedback for problem areas

Impaired reasoning

• Looks like…
  • Concrete thinkers
  • Can’t think of alternatives or consequences
  • Difficulty with open ended questions
  • Difficulty learning from experience
• Adaptations
  • Avoid open ended questions
  • Speak concretely
  • Be clear on expectations and consequences of risk taking behavior
  • Point out possible consequences (What might happen if…)
  • Teach problem solving step by step
  • Be supportive, encourage strengths

Impaired emotional/behavioral self regulation

• Looks like…
  • Overreacts and underreacts
  • Hard time managing anger
  • Melts down
  • Can appear emotionally “flat”
  • Can appear argumentative
  • Hard time making friends
• Adaptations
  • Education about their injury, but avoid focusing just on their deficits
  • Promote self awareness by addressing undesired behavior immediately
  • Don’t see lack of emotion as lack of interest
  • If irritable or agitate, suggest a break
  • Use mindfulness exercises (progressive relaxation, body scans, deep breathing, etc.) to help identify internal emotions
  • Practice positive social interactions

Conclusion

The presenter also mentioned that there is a screening tool for TBI that anyone can use if they go through the training. This may be helpful to have at your program because many people go undiagnosed, don’t seek treatment, or may be eligible for support services. Resources include the Brain Check Survey and the Ohio State TBI-ID.

I hope you found that helpful! I really appreciated her examples of “what it looks like…” and hope you did too.

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Note: This is not professional advice, this is a blog. I am not liable for what you do with or how you use this information. The activities explained in this blog may not be fit for every rider, riding instructor, or riding center depending on their current condition and resources. Use your best personal judgement! If you would like to contribute an activity or article, please contact me here, I would love to hear from you!