In-Service- Fieldwork II - CRT
- 1. Cognitive Rehabilitation: Practice and Implementation Jenna Bisignano
- 2. Objectives Understand the process of cognitive rehabilitation and what populations it most successful for Learn cognitive interventions to use in practice for individuals with cognitive disabilities Identify the use of cognitive rehabilitation in a sub-acute setting Understand collaboration with other disciplines in order to implement the best plan of care for patients Integrate cognitive techniques into everyday practice
- 3. What is cognitive rehabilitation therapy? “Cognitive Rehabilitation Therapy (CRT) is the process of relearning cognitive skills that have been lost or altered as a result of damage to brain cells or chemistry” A treatment that combines both medical and therapeutic services, specifically aimed at restoring as many cognitive functions as possible while proposing different compensatory strategies to help individuals live with cognitive deficits Based upon scientific theories that have been derived from various disciplines including cognitive neuroscience, neuropsychology, neurolinguistics and language and cognitive development If skills cannot be relearned, new ones can be taught to enable the patient to compensate for his or her loss in cognitive function http://www.societyforcognitiverehab.org/patient-family-resources/what-is- cognitive-rehab.php
- 4. History of CRT 1920s- the first use of CRT was seen postWorldWar I veterans returning home in Germany The German government created a “school for soldiers” which was a hospital for injured soldiers Assessments and evaluations of psychological skill performance were performed to determine deficits of soldiers 1963-Alexander Luria provided the first writings of CRT in Russia for postWord War II soldiers Focused on the rehabilitation of soldiers in the neurosurgical unit in the mountains for Russia His model included an assessment of neurocognitive functioning, analysis of various adaptive mechanism and evaluation skills to help preclude the deficits
- 5. Certification Level 1 certification: Must be a Qualified Independent Practitioner according to the American Congress of Rehabilitation Medicine's Guidelines for Cognitive Rehabilitation standards Must have appropriate credentials for an independent practice in their discipline according to state licensing agencies appropriate to their profession Level 2 certification: Those who are unable to practice their profession independently, and require supervision by a Qualified Independent Practitioner. The Qualified Independent Practitioner is accountable for the design, implementation and ongoing quality and appropriateness of evaluation and treatment services delivered to clients.
- 6. Qualifications for certifications Level I Certification: Minimum of a master's degree in an allied rehabilitation field from a regionally accredited institution where the degree is a prerequisite for licensure or certification (e.g., Psychology, Speech) OR Minimum of a bachelor's degree in an allied rehabilitation field from a regionally accredited institution where the degree is sufficient for licensure, certification or registration (e.g., Occupational Therapy) For Level II Certification: Bachelor's or master's degree in an allied rehabilitation field from a regionally accredited institution where the degree is insufficient for licensure, certification or registration OR When such licensure, certification or registration is not available
- 7. The process of CRT Educate the patient about cognitive weaknesses and strengths- awareness of the deficits Process training to develop skills through retraining- resolving the problem Strategy training- utilizing the environment to work on compensatory strategies Functional activities training- applying education, process and strategy into everyday life – real life improvements
- 8. Individuals that could benefit from CRT Hypoxic brain injury Stroke Dementia and other cognitive disorders Psychiatric or other mental disorders Multiple Sclerosis Optic neuritis Memory loss Epilepsy Aneurysm
- 9. Role of OccupationalTherapy in CRT in acute care Typically for individuals with a sudden onset such as stroke or TBI Evaluate the performance of safety awareness and independence in self-care activities Preparatory activities to facilitate balance and stability Family and caregiver education Home program may be developed, with client/caregiver training as needed
- 10. Role of OccupationalTherapy in CRT in a skilled nursing facility Follow up with acute care interventions when the incident is severe Intensive, daily therapy to improve all aspects of function Interventions to address attention, problem solving, and perceptual deficits, and to manage impulsive behavior
- 11. Functional cognitive activity interventions Communication Writing thank you cards Using a calendar or day planner Developing/using a memory book Using a telephone, computer Creating a list of important numbers Healthcare Schedule upcoming appointments
- 12. Functional cognitive activities Medication management Setting up a pill box Leisure Board games, card games, puzzles Following written directions for a craft or game Reading the newspaper Using theTV guide
- 13. Functional cognitive activities Meal Preparation Follow a recipe Following instructions in food box Understanding food labels Meal planning Money management Using money to pay for purchase Pay bills online or write checks Manage bank accounts Ordering from a take out menu Ordering from a a catalogue
- 14. Functional cognitive activities Shopping Clipping relevant coupons Developing grocery lists Budgeting Estimation of costs CommunityTasks Ordering from a menu in a restaurant Going to the store Riding public transportation Arranging transportation
- 15. Occupational therapy versus cognitive rehabilitation therapy Occupational therapy Help people across the lifespan participate in everyday ‘occupations’ that they want and need to do and are meaningful through the use of therapeutic use of activities Cognitive rehabilitation Restorative and compensatory treatment with the intent to improve the cognitive system to function in a wide variety of activities using different strategies
- 16. Cognitive Rehab for Multiple Sclerosis Patients Cognitive impairment is a major symptom of MS and has a negative impact on patients’ quality of life After 6 months of cognitive rehabilitation patients were asked to take these tests again and their scores increased significantly Selective reminding test Spatial recall test Symbol digit modalities test Paced auditory serial addition test Word list generation F-A-S test Subtests ofWAIS-III Boston naming test Trail making test The study showed a significant improvement related to learning and visual memory, executive function
- 17. Cognitive Rehab for individuals with dementia General cognitive stimulation and reality orientation approaches consistently produce improvements in general self-reported quality of life and well-being Researches performed a study regarding the use of contextualized individual cognitive rehabilitation, emphasizing collaborative goal-setting resulted in achieving self-rated competence and satisfaction with personally meaningful activities of daily living
- 18. Interventions for individuals who suffered a stroke Begin treating patients as early as possible in order to have a better outcome for individuals with neurological damage Focus interventions on direct cognitive skills training instead of broad generalization with a broader long term goal in mind Training for visual spatial neglect Participation in everyday life activities provides the most succesful outcome measure
- 19. Interdisciplinary team work CRT is practiced by a wide range of professionals in rehabilitation medicine, nursing, physical and occupational therapy, speech-language pathology, psychology, and neurology Body structures and functions (impaired memory) as a result of disease or injury limit one’s ability participate in everyday meaningful activities Collaboration with academic colleagues in other disciplines can facilitate functional outcomes for the individual
- 20. Interdisciplinary approach in practice
- 21. Interdisciplinary approach Study done to test if stroke patients could successfully complete a self medication program using an interdisciplinary cognitive rehabilitation approach Team made up of a nurse and speech-language pathologist to set up a self-medication program 81% of the stroke patients successfully completed the self medication program, compared to 36% of the debilitated patients An interdisciplinary approach to medication management for cognitively impaired stroke patients holds promise
- 22. Cognitive rehabilitation for individuals with traumatic brain injuries The intention of rehabilitation following a traumatic brain injury is to improve physical, cognitive, and psychosocial functioning; to promote independence, and to facilitate community integration Cognitive rehabilitation targets cognitive and psychosocial functioning directly and can improve physical functioning indirectly Sufficient evidence exists supporting the efficacy and effectiveness of cognitive rehabilitation, which has become the treatment of choice for cognitive impairments and leads to improvements in cognitive and psychosocial functioning
- 23. Summery The goal of cognitive rehabilitation is to improve the person’s ability to perform cognitive tasks, cope with affective distress, and increase self-confidence, self-efficacy, and self- awareness This is achieved by Retraining previously learned skills and residual abilities Teaching compensatory strategies Making environmental modifications to the person’s domestic and vocational setting Facilitating adjustment to the cognitive disability by increasing awareness These approaches are often combined to optimize the effects of treatment
- 24. References AOTA. (2016). OccupatioanlTherapy’s Role inAdultCognitive Disorders. Retrieved from: https:// www.aota.org//media/Corporate/Files/AboutOT/Professionals/WhatIsOT/PA/Facts/ Cognition%20fact%20sheet.pdf Bahar-Fuchs, A., Clare, L., &Woods, B. (2013). Cognitive training and cognitive rehabilitation for persons with mild to moderate dementia of the Alzheimer’s or vascular type: a review. Alzheimers ResTher, 5(4), 35. Gich, J., Freixanet, J., García, R.,Vilanova, J. C., Genís, D., Silva,Y., & ... Ramió-Torrentà, L. (2015). A randomized, controlled, single-blind, 6-month pilot study to evaluate the efficacy of MS-Line!: a cognitive rehabilitation programme for patients with multiple sclerosis. Multiple SclerosisJournal, 21(10), 1332-1343. doi:10.1177/1352458515572405 The Society for Cognitive Rehabilitation. (2013). What is Cognitive RehabilitationTherapy? Retrieved from: http://www.societyforcognitiverehab.org/patient- family-resources/what-is-cognitive-rehab.php Tsaousides,T., &Gordon, W. A. (2009). Cognitive rehabilitation following traumatic brain injury: assessment to treatment. Mount SinaiJournal of Medicine:AJournal ofTranslational and Personalized Medicine, 76(2), 173-181.
Editor's Notes
- #4: perception, memory, problem solving, attention, body awareness in addition to many others. In individuals who have sustained a stroke, these skills may be altered resulting in deficits in several areas of functioning such as communication, self-care, productivity and leisure.
- #5: Luria focused on strengthening a patient’s spared skills and teaching compensatory strategies.
- #7: Level 1: work experience: 2,000 hours of supervised post-master's experience (fieldowrk can count as those hours)—internships (50 of these hours must be face to face supervision) Level II: Minimum of 4,000 hours post-bachelor's degree (i.e., 2 years of supervised experience). applicable work experience must be in the direct provision of CRT and assessment of cognition for individuals. Work experience must be paid. Volunteer activities are not acceptable. Work must have been supervised. (100 of these hours must be face to face)
- #10: https://www.aota.org/-/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/PA/Facts/Cognition%20fact%20sheet.pdf
- #11: https://www.aota.org/-/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/PA/Facts/Cognition%20fact%20sheet.pdf
- #16: http://www.brainline.org/content/2012/06/what-about-cognitive-rehabilitation-therapy.html
- #17: Each session combined 25 minutes of written, manipulative and computer-based materials. Furthermore, patients and family members had to do a short daily cognitive exercise together at home lasting no more than 5 minutes (chosen from Soma 4, five-piece Tangram, Space Shuttle and Peg-Solitaire Hoppers Written consisted of crosswords, math problems, word search Manipulative-spacial games, blocks, origomi Computer based- logic and reasoning games FAS within one minute--executive control over cognitive process such as selective attention, mental set shifting, internal response generation, and self-monitoring. Tests of verbal fluency evaluate an individual’s ability to retrieve specific information within restricted search parameters Gich, J., Freixanet, J., García, R., Vilanova, J. C., Genís, D., Silva, Y., & ... Ramió-Torrentà, L. (2015). A randomized, controlled, single-blind, 6-month pilot study to evaluate the efficacy of MS-Line!: a cognitive rehabilitation programme for patients with multiple sclerosis. Multiple Sclerosis Journal, 21(10), 1332-1343. doi:10.1177/1352458515572405
- #18: Bahar-Fuchs, A., Clare, L., & Woods, B. (2013). Cognitive training and cognitive rehabilitation for persons with mild to moderate dementia of the Alzheimer’s or vascular type: a review. Alzheimers Res Ther, 5(4), 35.
- #19: The development and testing of cognitive intervention approaches should be carried out by a multidisciplinary team. Cognition is an overarching factor in all areas of function, and different professions have different expertise in addressing cognitive dysfunction. Physical therapists understand how cognition affects motor performance, speech therapists understand how cognition affects language, neuropsychologists understand how to capture cognitive dysfunction through standardized assessments, and occupational therapists understand how cognition supports performance in everyday life. Collaboration on multidisciplinary teams will enable occupational therapists to best contribute to the development of the science to support their role in this practice area. Bullet one: Past research and available evidence have shown that interventions in common use have a limited impact on changing everyday life outcomes for this client population Bullet 2: that do not take into account the context in which an activity will be performed will not produce changes in everyday life participation. Timothy J. Wolf; Rehabilitation, Disability, and Participation Research: Are Occupational Therapy Researchers Addressing Cognitive Rehabilitation After Stroke?. Am J Occup Ther 2011;65(4):e46-e59. doi: 10.5014/ajot.2011.002089. Rohling, M. L., Faust, M. E., Beverly, B., & Demakis, G. (2009). Effectiveness of cognitive rehabilitation following acquired brain injury: a meta-analytic re-examination of Cicerone et al.'s (2000, 2005) systematic reviews. Neuropsychology, 23(1), 20.
- #20: The world health organization framework recognizes impairments of body structures as and functions limit your ability to carry out ADLs and IADLs; limitations in activities and participation the ability to carry out important daily activates like doctor appoints or being able to participate in the community. The various disciplines share a common goal: each intends to help patients with cognitive impairments function more fully, either by focusing on the impairment itself or the activities affected by the impairment (as described by the WHO-ICF framework). Defining Cognitive Rehabilitation Therapy." Institute of Medicine. important daily activities PaCognitive Rehabilitation Therapy for Traumatic Brain Injury: Evaluating the Evidence. Washington, DC: The National Academies Press, 2011. doi:10.17226/13220. ×
- #21: A nurse and a pharmacist educated patients on their medications, and a speech-language pathologist provided cognitive rehabilitation to the stroke patients, which incorporated information from the SMP. OT- can test persons ability to cook toast PT- can work on standing endurance if the person can only stand for a certain amount of time Speech- can work on articulating common kitchen appliances
- #22: A nurse and a pharmacist educated patients on their medications, and a speech-language pathologist provided cognitive rehabilitation to the stroke patients, which incorporated information from the Self medication program Twenty-seven stroke patients and 36 debilitated patients with cognitive deficits participated in an self medication program. A nurse and a pharmacist educated patients on their medications, and a speech-language pathologist provided cognitive rehabilitation to the stroke patients, which incorporated information from the self medication program.
- #23: The intention of rehabilitation following TBI is to improve physical, cognitive, and psychosocial functioning; to promote independence, and to facilitate community integration. Cognitive rehabilitation targets cognitive and psychosocial functioning directly, and can improve physical functioning indirectly.
- #24: A systematic, functionally oriented service of therapeutic activities that is based on assessment and understanding of the patient’s brain-behavioral deficits’’ (Cicerone et al.,3 p 1597). Thus, as in all medical or psychological interventions, diagnosis and treatment are tied together.