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Types of Therapies

Type of Therapy  Area of Cognitive Impairment Specific Examples  Procedure/Treatment 
Attention Process Training Attention Letter cancellation tasks with distracting noice in background Consists of sequential hierarchial interventions aimed at specific attentional processes including sustained attention, selective attention, and divided attention. Increasing levels of distraction are introduced to gradually make the task more challenging.
Error Management Training
  • Attention
  • Memory
  • Executive functioning
  • Social pragmatics
Individual and group self-awareness training

A group support program that includes components of cognitive rehabilitation, cognitive behavioral therapy, and social skills training and focuses on self-regulation and psychosocial functioning.

The 16-week intervention is designed to improve self-awareness deficits that are common following TBI and targets error awareness and self-correction in real life settings at home and work.

Emotional Regulation Training
  • Attention
  • Memory
  • Executive funtioning
  • Social pragmatics
Anger Management Training

The goal is to increase the patient's awareness of their negative emotional states, particularly anger, through training in recognition of congnitive, physical and emotional reactions.

Patients are provided with an outline of anger syndromes and handouts summarizing the sessions as well as practice in relaxation techniques, self-talk methods and time outs.

External Cuing 
  • Attention
  • Memory
  • Executive functioning
  • Supervised living
  • BlackBerry
  • Cell phone
  • PDA

Provides the patient with technology aids such as alarm watches, pagers, etc. Includes restructuring the environment using labels, signs and directions.

Other aids for memory and executive functioning include voice organizers, mobile phone computer interactive systems, and devices such as PDAs and BlackBerry cell phones.

External cuing strategies may require family as well as individual treatments to select and train the appropriate cues.

Integrated Use
  • Attention
  • Memory
  • Executive functioning
  • Social pragmatics
 

Provide individual and group cognitive, psychological and functional interventions. These programs are multidisciplinary and employ multiple treatment modalities in a holistic program that is typically delivered to patients three to five times per week over several months.

Treatment is individualized and uses psychosocial interventions to enhance effectiveness. These programs also address self-awareness, behavioral and affective regulation, and community reintegration.

The group treatments focus on improving executive functioning and generalizing strategies learned in treatment to the naturalistic environment. The treatment team is usually comprised of a neuropsychologist, speech-language pathologist, occupational therapist, vocational therapist, recreation therapist, and physician and meets regularly to develop individualized treatment goals and monitor patient progress.

Community re-entry is a goal of this treatment, so outings to community settings to practice new skills are an integral component of this treatment; vocational trials are also often included. Families are involved in psychoeducation and family therapy to support the patient's treatment progress.

Memory Notebook
  • Attention
  • Memory
  • Executive functioning
  • Prosthetics
  • PDA

A memory compensation strategy in which the patient is taught how to use a diary and then how to use this diary to solve problems in daily activities.

A memory notebook includes sections for autobiographical and injury related information, a memory log, a calendar to-do list, transportation information such as bus schedules, names and identifying information, and a feelings log to record emotions that occur in specific situations. Other sections can be added that are personally relevant to the patient.

During the first phase of treatment, the patient is familiarized with the sections of the notebook and the overall purpose of the notebook. In the next phase of treatment, the patient learns to use the notebook with therapist guidance during simulated situations. During the final phase, the patient is coached about how to use the notebook at home or at work.

A PDA is the electronic equivalent of a memory notebook. PDAs and memory notebooks serve as memory prosthetics for the traumatic brain injury patient with impaired prospective memory.

An important component in this intervention is therapist facilitation of the patient's emotional acceptance of the necessity of using a memory notebook and the acceptability of the use of devices in the patient's social environment.

Problem-Solving Training
  • Attention
  • Memory
  • Executive functioning
  • Social pragmatics
  • Internal problem-solving
  • Internal dialogue

Problem-solving training interventions address issues in the ability to formulate goals, initiate behavior, anticipate the consequences of action; plan, organize, and monitor behavior; and to change behavior in accordance with feedback.

Training provides patients with techniques for analyzing complex problems by breaking them into manageable steps. Steps taught include defining the problem, generating alternatives, making a decision, and verifying the solution. The patient is taught to use an internal dialogue or self-instructions to approach problems in everyday life; self-awareness and self-regulation are emphasized.

Training methods include cue cards, feedback, modeling, and the keeping of a diary. Problem-solving training can occur in individual or group treatments.

Social Communications Skills Training Groups
  • Executive functioning
  • Social pragmatics
Group cognitive therapy

Social communication skills training is a group treatment approach that is jointly facilitated by mental health and rehabilitation professionals. These groups emphasize self-awareness to set individual goals.

Group process is used to foster interaction, problem solving, a social support system, and awareness that one is not alone. A treatment protocol has been used which was comprised of 12 ninety minute sessions.

Various Mneumonic Techniques Memory
  • Story method
  • Acronyms
  • Sentence/acrostics
  • Method of loci
  • Chunking
  • Repetition

Mnemonic Strategies are memory-enhancing strategies that help patients develop techniques to enhance registration and encoding of information.

Examples of mnemonic strategies include verbal organization strategies such as forming acronyms and making paired associations with target words and semantic elaboration which refers to linking target words or ideas in a story. Rehearsal or repetition is another strategy for improving retention of information.

These techniques are typically taught in individual treatment sessions as they are difficult to learn, require assistance to identify applicable situations for use in the patient's life, and require repeated practice for generalization from the treatment session to the patient's own environment to occur.

Additional efficiency can be achieved when a group format is used for practice after individual strategy training.

Visual Imagery Mneumonics     Memory Imagery-based training

Visual imagery is a popular mnemonic strategic in which the patient is taught to make a movie or picture of what needs to be recalled. Application of this technique is useful for improving recall of everyday verbal material such as stories, names, and appointments.

Treatment occurs three times weekly and is of 10 weeks' duration.

Working Memory Training Attention Completing two cognitive tasks simultaneously

Working memory training refers to a treatment designed to improve and optimize the temporary maintenance and manipulation of mental representations of information. This cognitive process is particularly important when information is presented rapidly or there are multiple sources of information.

Working memory training teaches patients strategies to improve their regulation and allocation of attentional resources. Tasks are administered in a hierarchical sequence with task complexity and additional components added as mastery is obtained. In the n-back procedure, for example, a sequence of stimuli is presented and the patient is asked to recall stimuli early in the sequence.

Number strings or playing cards presented in random sequence have been used for the training task. The therapist modifies the conditions of the task such as changing from self-paced to externally based presentation.

The working memory demands of the task can be further increased by having the patient engage in a secondary task while completing the n-back task to simulate the occurrence of interrupting an activity to respond to an additional task and being able to return to the original activity.

This treatment is conducted individually and part of the treatment time is spent discussing the patient's performance and helping the patient identify task variables which negatively or positively influenced their performance. The work with the therapist also includes attention to managing frustration and other emotional responses elicited by the task, analyzing attentional difficulties relevant to the patient's everyday functioning, and facilitating the application of strategies learned within the session to everyday functioning.

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