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June 6 & 7, 2015Halifax, Nova Scotia

Ingrid Neufeld, BMR(OT) Reg (Ont)Occupational Therapist

LIFESTYLE RESTORATION PROGRAMTRAINING SESSION

PHASE 2

DAY #2

Advanced Treatment for LRPCBI Health

DAY 2 AGENDA

1. Neuroplasticity Overview2. Depression3. Chronic Pain4. Anxiety/Panic Disorders5. Mindfulness Practise 6. Addictions

DAY 2 AGENDA

5. Concussion Management 6. CBT-I: Treatment for Sleep Disorders8. Cognitive Work Hardening & RTW9. Managing the Files10. Marketing

NEUROPLASTICITY RESOURCES

• THE BRAIN’S WAY OF HEALING, Dr. Norman Doidge.

• THE BRAIN THAT CHANGES ITSELF, Dr. Norman Doidge.

NEUROPLASTICITY

• Changes in neural pathways and synapses due to changes in behavior, environment, neural processes, thinking, emotions, as well as changes resulting from bodily injury.

NEUROPLASTICITY CORE LAW # 1

• Neurons that fire together wire together

MEANS THAT

• Repeated mental experience leads to structural changes in the brain neurons that process that experience MAKING the synaptic connections stronger

• Neurons fire faster, stronger, sharper signals together

NEUORPLASTICITY CORE LAW #2

• Converse is also true

• USE IT OR LOSE IT

• If you stop performing an activity, the connections get weaker and over time may be lost.

• You lose it because the real estate space in the brain gets taken over.

NEUROANATOMY 101

• Neurons communicate by sending messages back & forth in the synapse.

• Messengers are called neurotransmitters.• How a message is interpreted depends on

where it is received.

• Neural networking – emotion, thought and physical sensations all recorded together in the memory of an experience.

NEUROTRANSMITTERS

• GLUTAMATE: brain’s go signal• GABA: the stop signal• Serotonin: the regulator• Norepinephrine: energizer bunny• Dopamine: feel good message & helps with

attention• Oxytocin: bonding & safety

STRUCTURES OF THE BRAIN: MORE BORING NEUROANATOMY

• The Nervous SystemParasympathetic nervous system – the calmerSympathetic nervous system- fight or flight

• The Limbic SystemThalamus-quarterbackHypothalamus-internal fact finderHippocampus-data clerkAmygdala-smoke detector for your brain

• The Basal Ganglia-motivator

STRUCTURES OF THE BRAIN CONTINUED

• The Cortex Anterior cingulate gyrus - the VP

Orbitofrontal cortex - the brainstormerInsula - empathyPre-frontal cortex – the CEOLeft side – verbal work occurs

here, problem solverRight side-non verbal decision

maker – space, time and emotion.

DEPRESSION TREATMENT: THE RELENTLESS PURSUIT OF THE POSITIVE

DEPRESSION RESOURCES

• THE MINDFUL WAY THROUGH DEPRESSION. Williams, Teasdale, Segal, Kabat-Zinn.

• THE 10 BEST EVER DEPRESSION MANAGEMENT TECHNIQUES. Margaret Wehrenberg.

• DEPRESSED & ANXIOUS: THE DIALECTICAL BEHAVIOUR THERAPY WORKBOOK FOR OVERCOMING DEPRESSION & ANXIETY. Thomas Marra.

• THE FEELING GOOD HANDBOOK. David D. Burns.

RESOURCES CONT’D

• MIND OVER MOOD: CHANGE HOW YOU FEEL BY CHANGING THE WAY YOU THINK. Dennis Greenberger & Christine Padesky.

• THE MINDFUL WAY WORKBOOK, John Teasdale, Mark Williams, Zindel Segal.

• THE ANXIETY & PHOBIA WORKBOOK. Edmund J. Bourne.

• www.nicabm.com

DEPRESSION: THE BRAIN

• Neurotransmitters:– Serotonin: regulates us – mood, sleep, pain. Low

serotonin results in difficulty feeling satisfied, poor control over thinking

– Norepinephrine: responsible for helping us to be awake and alert. Overactive produces jittery, agitated feeling

– Dopamine: allows us to feel pleasure. Also helps prefrontal cortex with concentration.

DEPRESSION: THE BRAIN

• Chronic stress depletes the neurotransmitters which results in:– Decreased mental/physical energy– Decreased interest in the world– Decreased pleasure– Decreased problem solving with lack of clarity.

WELL-BEING

• Balance in 4 areas:

– Goals

– Attention

– Cognition

– Affect

DEPRESSION & NEURAL NETWORKING

NEURONS THAT FIRE TOGETHER WIRE TOGETHER

OUR GOAL? INTERRUPT THE NEGATIVE NETWORKING WITH DELIBERATE SHIFT TO POSITIVE.

NEGATIVE NEURAL NETWORKING

• Because of the way human beings retrieve and store memories – when something triggers one memory, a network of similar memories is automatically activated including emotions and details.

• SO ONE NEGATIVE THOUGHT LEADS TO ANOTHER…AND ANOTHER…AND ANOTHER

INTERVENTION REVIEW

1. BUILD THE RELATIONSHIP

2. THERAPEUTIC GOAL-SETTING

3. BUILD CONFIDENCE

4. OVERCOME BARRIERS

SELF-SOOTHING TECHNIQUES

SELF SOOTHING CONTINUED

1. Prepare a list of activities2. Identify a lifeline3. Make reminder cards4. Journaling 5. A feeling is just a feeling6. Spend 10 minutes doing something different

JOURNAL QUESTIONS

• What do I feel in my body?• Are these sensations familiar?• What is the earliest age I remember feeling

this way?• Can I get a memory of situation when I felt

this way in the past? Are the situations similar? Different?

• What did others do then?

JOURNAL QUESTIONS #2

• What did I do then?• What are others doing now?• What do I want to do now?

• Brings the pre-frontal cortex to the situation

GOAL-SETTING

1. Three domains: self-care/productivity/social & leisure

2. Visualize accomplishing the goal3. Walk through and anticipate what might go

wrong. Replace with a positive forecast.4. Build in a reward5. Next time: review the experience with them6. Important to include physical goals

FOCUS ON POSITIVE

• Think of a commonplace experience or event.

• Rate your level of pleasure of the experience.

• Now recount the activity or event.

• Rate your level of pleasure of the experience.

USE OF ACTIVITY LOG

• Rate all activities on pleasure continuum. 0-10• Most activities not completely unpleasurable.• How can the client increase pleasurable

activities in their day/their week?• For those activities that were pleasurable,

thinking about them, go over them, remember them….boosting dopamine.

4 SIMPLE STEPS OF TAKING IN THE GOOD: HEAL (Dr. Hanson)

1. Have a positive experience – notice one present or make one happen

2. Enrich it – for 10 seconds or longer. 3. Absorb it – let it sink into you as you sink into

it.4. Link positive and negative material.

CHANGING THOUGHTS =CHANGING BRAIN

• Lots of little bad things got us into a bad place, lots of little good things (seconds at a time) will get us into a better place.

• This knowledge in itself instills hope.

BUILDING CONFIDENCE

• Two themes predominate depression:– Feeling inadequate– Feeling worthless

Lethargy and inability to feel rewarded make those beliefs seem true – self-fulfilling prophecy.

BUILDING CONFIDENCE

• Have clients list their positive qualities. Carry the list with them. Read multiple times/day.

• If can’t imagine positive qualities, have them think about qualities they had or would like to have. Keep in mind over 10 seconds.

• Make a graph – list strengths on top and days of the week on the side. Identify daily when used that strength

USING MINDFULNESS & CBT

• Negative thoughts are not predictions, they are just thoughts

• Stop, look, listen

• Think about past exceptions – when did I predict a negative outcome that did not happen?

CHANGING NEGATIVE LANGUAGE

• LISTEN TO THE CLIENT’S LANGUAGE AND HAVE THEM NOTICE

• For example, the use of “yes but….”• Purpose focus on shifting to the positive:

– Up until now– Apart from that– Whatever!EVERYTIME WE INTERRUPT NEGATIVE SELF-TALK, WE WEAKEN THE POWER OF THE NEGATIVE TO CONTROL THOUGHTS

FOCUS ON STRENGTHS

• 1/3 OF OUR INNER STRENGTHS ARE INNATE

• MEANS THAT 2/3 ARE LEARNED AND GATHERED OVER TIME.

DEPRESSION AND EXERCISE THERAPY

• Exercise raises serotonin levels – serotonin increases the sense of accomplishment.

• Vigorous activity uses up the adrenaline of the stress response and helps get rid of cortisol.

• Exercise promotes relaxation because muscles are first stressed then relaxed.

• Sense of self-efficacy provided from participation in exercise

EXERCISE AND DEPRESSION: THE WILLPOWER MIRACLE

EXERCISE

CHANGES

THE

BRAIN

ENDING ISOLATION

• Email• Telephone• Walks – practice mindfulness• Set up social dates• Perform acts of random kindness• Notice the positive traits of others• Expand social horizon

LINDA

• July 31, 2014 – March 12, 2015

• OT, KIN, PT

• Total of 23 OT sessions

• Total spent: $4,869.90

CLIENT

• 59 years old• Crown corporation executive• Major depressive disorder• 2 bouts with cancer: 2001 & 2014• Also back issue• At home in bed except for appointments

TREATMENT

• SESSION #1: COPM.– Goals - make a list of what needs to be done at home. Start

with #1 and set timer for 1 hour.– Get in touch with closest friend.

• Sessions #2-6: – Work through goals related to self-care productivity and

social/leisure– Gather more information as she feels comfortable disclosing– Nutrition

TREATMENT

• Sessions 2 – 6:– Participate in exercise program– Basic CBT education as barriers to meeting goals

arise: Not meeting a goal is an opportunity to learn more about yourself

– Keep activity logs to notice progress.– Teach diaphragmatic breathing and meditation– Team meeting– POINT OUT PROGRESS/POINT OUT POSITIVE

TREATMENT

• Sessions 7 – 12:– Cog/beh JDA– Cognitive testing– Establish cognitive work hardening program

• Volunteer work• Crafts at home• Lumosity

– Talk about work – Upgrade resume

TREATMENT

• Weeks 7 - 12:– Initiate social activities with friends– Meetup.com: museum group, belly dancing,

learning Italian– Meet with work friends– RTW plan established

TREATMENT

• Weeks 13 – 23– Start 10 week RTW– Ergo assessment– Discuss how to incorporate home/social/exercise

activities with work – scheduling– Discuss strategies to deal with any barriers arising – REINFORCE THE POSITIVE– Back FT

YOUR BRAIN ON PAIN: NEUROPLASTIC TRANSFORMATION

BRAIN WITH CHRONIC PAIN BRAIN WITH NO PAIN

PAIN RESOURCES

• THE BRAIN’S WAY OF HEALING. Norman Doidge, M.D.

• THE BRAIN THAT CHANGES ITSELF. Norman Doidge.

• EXPLAIN PAIN. David Butler, G. Lorimer Moseley.

• NEUROPLASTIC TRANSFORMATION: YOUR BRAIN ON PAIN. Michael H Moskowitz & Marla D Golden.

A LESSON IN PAIN – THE KILL SWITCH

• Dr. Moskowitz• Bary Area Medical Associates• Sausalito, California

• Clinic to treat intractable pain with injections, drugs and electrical stimulation

• Now world leader in the use of treating neuroplasticity for pain

LABELS

• Fibromyalgia• Somatoform pain disorder• Myofascial syndrome• Non specific back pain• Psychosomatic pain syndrome• Repetitive strain injury• Neuropathic pain

THE KILL SWITCH

• The brain can shut off the pain.

• The pain is not in the body part itself – the body part sends signals to the brain.

• General anaesthesia – if the brain does not process the pain, we do not feel it

• IT IS THE BRAIN THAT DECIDES WHETHER SOMETHING HURTS OR NOT, 100 % OF THE TIME, WITH NO EXCEPTIONS

PAIN RELIES ON CONTEXT

• A painful stimulus will hurt more if you are told it is hot, than if you are told it is cold.

• Pairing a painful stimulus with a red light hurts more than when it is paired with a blue light.

• The more information that a patient has the less the pain, for example, about a surgical procedure.

• Depends on who is around

GATE CONTROL THEORY OF PAIN

• OLD THEORY: one way signal up to the brain & intensity of the pain is proportional to the seriousness of the injury.

• GATE CONTROL THEORY: pain perception system spread through the brain/spinal cord. Brain controls how much pain we feel. Brain can close the gate and block the pain by releasing endorphins.

BRAIN MAPS

• External areas of our body represented in our brain

• Organized topographically – virtual body in the brain.

• When neurons in our brain maps get damaged, they fire incessant false alarms

• Acute pain develops an afterlife – chronic pain

NEURONS THAT FIRE TOGETHER WIRE TOGETHER: BLESSING OR CURSE?

• Blessing when sensory input is pleasurable

• Curse when receiving ongoing pain system signals. Eg slipped disc, pressing on the nerve root.

• Pain maps can also enlarge their receptive field

• Pain signals in one map can spill into adjacent pain maps.

• The more the receptors in the pain system fire, the more sensitive they become.

USE IT OR LOSE IT

• Constant competition for cortical real estate

• The activities the brain performs regularly take up more and more space in the brain by stealing resources from other areas.

• Chronic pain pain notice expanding over large areas including: processing thoughts, sensations, memories, movements, emotions, beliefs

ACUTE PAIN BRAIN

GOOD BRAIN GONE BAD

WHEN PAIN IS EPERIENCED AS AN UNPLEASANT EVENT

• Invokes a series of actions:– Multiple brain centres and circuits are activated– Area responsible for vigilance is turned on– Stress hormone – cortisol – is released– Chronic cortisol release leads to deconstruction of

nerve cells of the brain responsible for memory storage

– Sensory and motor areas of the brain activated– Lymphocytes reenter the circulation and make their

way to injury sites

NO PAIN

AREAS WHERE PAIN IS PROCESSED

• Somatosensory 1 and 2 – pain, touch, temperature, pressure

• Prefrontal area – pain, executive function, creativity, planning, empathy

• Anterior cingulate – pain, emotional self control, sympathetic control

PAIN PROCESSING POINTS

• Posterior parietal lobe – pain, visual & auditory perception

• Supplementary motor area – pain, planned movement

• Amygdala – pain, emotion, emotional memory, pleasure

STILL MORE PAIN POINTS

• Insula – pain, quiets the amygdala, empathy, emotional self awareness

• Posterior cingulate – pain, visuospatial cognition, memory retrieval

• Hippocampus – helps to store pain memories

• Orbital frontal centre – pain, evaluates whether something is pleasant vs. unpleasant

NOW THAT WE KNOW THIS: WHAT DO WE DO?

• USE COMPETITIVE PLASTICITY

• Instead of allowing areas to be pirated and taken over for pain processing….take them back for original main activities

• Key brain areas that target pain and also do other mental functions

• Flood with the other mental functions while in pain

• Acute pain takes 5% of area fires: chronic 10-20%

THE POWER OF VISUALIZATION

• Every time an attack of pain, would visualize the brain maps to remind himself that the brain can really change

• Greeted every twinge of pain with an image of the pain map shrinking – forcing posterior parietal lobes and posterior cingulate to process a visual image.

• 6 weeks pain had shrunk to original area; 4 months having pain free areas; a year pain free.

PEOPLE TAKING BACK CONTROL OF THEIR PAIN

• I picture the spots and spray them with a spray bottle, sizzling them out.

• I start rubbing my finger tips together and picture the spots in my brain that are lit up from pain and rub them out one by one.

• When the pain starts bothering me I recite the alphabet and picture an image for each letter of the alphabet and my pain decreases.

SHRINKING THE PAIN

• http://www.neuroplastix.com/movies/files/page3-1016-pop.html

MIRROR APPROACH

• M: motivation – active vs. passive approach, take charge

• I: intention – immediate intention is not to get rid of pain but to focus the mind in order to change the pain

• R: relentlessness – pain intruding into consciousness is signal to push back but need intense focus

• R: reliability – can rely on the brain to restore and maintain function. Brain seeks a stable state – will go back to stable state of pain free if provided the opportunity

MIRROR

• O: Opportunity: turn each episode into an opportunity – a change in attitude will lessen the work of the amygdala

• R: Restoration: not to mask pain but to restore normal brain activity.

• Different than placebo because not immediate effect but will last once brain rewired – 6-8 weeks

NOT JUST VISUALIZATION

• Can use:

• Touch• Sound• Vibration• Movement• Pressure• Empathy

• Understanding• Planning• Action• Creativity• Problem solving

TOUCH: THE INFLAMMATORY PROCESS

• In persistent pain states, the nerves in the skin are recruited to signal pain instead of touch and people cannot stand to be touched in the painful areas.

• Inflammatory state is established because painful signals are sent to and from the brain.

• Have to re-establish signals with gentle touch.• Skin signals faster than pain so will shut the

gate on pain.

THE ROLE OF THE AMYGDALA

• First perception of pain is at the amygdala – a place designed to deal with the threat to our body.

• During traumatic events, the amygdala is ON, the higher functioning brain is OFF.

• In persistent pain, the brain perceives that this danger continues to exist.

• Recognizing we are in our amygdala gets our higher brain function to work.

SELF SOOTHING – BEEN THERE DONE THAT AGAIN

WE BECOME WHAT WE BELIEVE

• Consciously rejecting the notion of a life to be lived in pain is the first step in relief

• Reclaims brain real estate in the pain sensory areas of the brain

• By expecting soothing to overcome persistent pain, beliefs about pain’s inevitability can be challenged and changed.

PLEASURE VS. PAIN

• Pleasure is the cure for pain.• Write a gratitude list of what you are grateful

to have in your life.• Two columned list: Pain I want to avoid/

Pleasure I want to pursue.• Go on a pleasure hunt once a week, actively

seeking pleasurable experiences and avoiding painful ones.

PAIN VS. PLEASURE

Pain and pleasure are not actual feelings, but are values placed upon sensation mingled with

emotion and thoughts.

PAIN VS PLEASURE

• Endorphins are released by the EXPECTATION of pleasure, hence the mere expectation produces a more pleasurable experience. The EXPECTATION of less pain produces the experience of less pain.

CENTRALIZATION OF PAIN: THERAPIES

• Strong evidence– Education– Aerobic exercise– CBT

• Weak evidence– Acupuncture– Chiropractic– Manual/massage– Ultrasound

• Modest evidence– Strength training– Hypnotherapy – Biofeedback

• No evidence– Tender tripper point

injections

FINAL POINT ON PAIN - OPIODS

• Brain adapts to being inundated with long-term opioids by becoming less sensitive to them.

• Increased sensitivity to pain-increased dependence on drugs-chronic pain worsens.

GEORGE

• 45 year old custodian

• IPR – OT/Kin/PT/Psych

• Total spent thus far: $6,267.50. Total to be spent: $10,000

TREATMENT

• Education, education, education• Gave client chapters of Explain Pain and

Neuroplastic Transformation• Use of activity logs • Education on pacing• CBT very important as client is a catastrophizer• Crisis management

ANXIETY MANAGEMENT

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ANXIETY RESOURCES

• ANXIETY AND PHOBIA WORKBOOK, Edmund J. Bourne.

• THE 10-BEST EVER ANXIETY MANAGEMENT TECHNIQUES, Margaret Wehrenberg.

• RECOVERING FROM TRAUMA AND PTSD, Deborah A Lee, Sophie James.

• MASTER YOUR PANIC AND TAKE BACK YOUR LIFE, Denise F Beckfield.

ANXIETY/TRAUMA RESOURCES

• CONVERSATIONS WITH A RATTLESNAKE: RAW AND HONEST REFLECTIONS ON HEALING AND TRAUMA, Theo Fleury & Kim Barthel.

• TEN DAYS TO SELF-ESTEEM, David D Burns.

THE BRAIN – KEY AREAS FOR ANXIETY

• Thalamus – quarterback: Information from the external world through five sense is received in the thalamus and directed to other parts of the brain

• Amygdala –alarm system: main job to react to the threat. Tends to be trigger happy. Also where trauma memories are stored. Responsible for conditioning.

• Hippocampus – filing clerk: noting times and place of events.

THE BRAIN AND ANXIETY

• The frontal cortex-the CEO: orchestrates the emotional regulation systems.

NEUROTRANSMITTORS

• Serotonin – the regulator: too low.

• Norepinephrine – the energizer bunny: too high.

• Dopamine – the feel good and pay attention: too high or too low.

• GABA – the ‘stop’ signal: too low.

STEP #1: EDUCATION

• Threat Emotion Regulation System– Designed to protect us

and keep us safe from physical/psychological harm.

– Faster at detecting and reacting to unpleasant emotions than to pleasant ones.

– Better safe than sorry

THREAT AND POSITIVE EMOTIONS

• The threat system is designed to override positive emotions

• Therefore when feeling stressed, hard to feel positive emotions because threat system is activated.

FIGHT OR FLIGHT IN THE BODY

• Increase in heart rate• Increase in

respiratory rate• Tensing of muscles• Reduced blood flow

to hands and feet• Increased blood flow

to muscles• Increased production

of sweat

FIGHT OR FLIGHT: WHAT WE FEEL & WHAT WE THINK

• Dizzy• Heart pounding/chest

pain• Short of breath• Clammy hands and

feet• Nauseous• Blurred vision• Sweaty

• I’m going to die.• I’m going to have a

heart attack.• I’m gong to have a

stroke.• I’m going to pass out.• I’m going to

embarrass myself.

STEP #2: BREATHE

• Most effective way to stop a panic attack because:– Slows sympathetic

arousal and stimulates the parasympathetic nervous system.

– Paying attention to your breath engages your frontal cortex

PRACTISE, PRACTISE, PRACTISE

• For 30 days, practise a breathing minute 10 or more times a day. Whenever you are waiting for something like:– At a stoplight– On hold on the phone– Waiting in line at a store– Watching commercials– Waiting for a text message

STEP #3: MINDFULNESS

• Anxiety is preoccupation on the past and the future – worry about what was or will be.

• Mindfulness is being fully in the present.

MINDFULNESS AND ANXIETY

• When you feel a sense of panic building, notice what is happening around you. 5 things you feel, hear, smell, touch, see.

• Notice what is happening in your body when you feel panic. Don’t judge, just notice.

• Notice your thoughts and bring them back to focus on the here and now and your breath.

MINDFULNESS AND ANXIETY

• Self observation and being in the present requires prefrontal cortex activity

• We use the brain to control the brain

TECHNIQUE #4: RELAXATION

• Progressive muscle relaxation particularly helpful due to the physical tension from too much norepinephrine.

• Intentional relaxation of muscles helps the PNS to slow heart rate and respiration.

RELAXATION

• Diaphragmatic breathing• Mindfulness • Progressive muscle relaxation• Imagery• Physical exercise• Tai chi• Yoga• Calming music

TECHNIQUE #5: EXERCISE!!!!

• Increases blood flow to the brain and benefits neurotransmitter levels

• Affects serotonin levels

• Fosters a sense of self-efficacy that promotes a willingness to take charge of one’s life in other ways

– Produces some of the fight or flight sensations in a ‘normal’ way

– Uses up the adrenalin of the stress response and gets rid of cortisol.

– Promotes relaxation because muscles are stretched, then relaxed.

ATTENTION TO POSTURE

TECHNIQUE #6: MANAGING THE ANXIOUS MIND

• React to the “Oh no”

• Use CBT to engage the pre-frontal cortex by:– Paying attention to the thoughts and stop the

catastrophizing…I am NOT dying, I am just panicking– Tell yourself that a feeling is just a feeling – they are

unpleasant but not lethal; the brain of the worrier looks for reasons to explain the feelings in the worried body.

MANAGING THE ANXIOUS MIND

• For the person who fears losing control:– And then what would happen?– And then what?– And then what?

MANAGING THE ANXIOUS MIND: EXPOSURE THERAPY

• Make a hierarchical list with SUDS for each. • Start somewhere in the low end but not the

bottom.• Reinforce coping strategies learned.• Visualize the entire experience first.• Break it down and make it manageable.• Have a panic plan written down.• Evaluate how it went…celebrate the victories!

MANAGING THE ANXIOUS MIND: THOUGHT STOPPING & REPLACEMENT

• Pathways are ingrained so have to frequently stop the thought to change the pathway. Have them say: STOP!

• Replace the thought with an equally intense positive thought. Have it ready, written down.

• Compete with anxious thoughts by singing (in the car) – takes more parts of the brain.

• Distract yourself

MAKE A TWO P LIST: PLEASANT & PRODUCTIVE

• Every day take 60 seconds to identify things you could think about during the day – errands to run, vacation to plan, things you could enjoy that day.

• Post this list in sight.• Whenever you thought stop, then look at the

list to divert your attention.• Shifts away from the overactive limbic system.

MELANIE

• 34 years old

• Reception/admin

• OT/Psych/Kin

• Had not left her house in 2 years

MELANIE TREATMENT

• 7 Psych sessions to start

• OT/Kin weekly thereafter

• November 28, 2014 – present

• Total spent thus far: $5,283.57

OT TREATMENT

• 8 sessions so far

• Start with COPM: Issues to deal with first-sleep and driving anxiety. Goals week 1: bed at midnight, meditation if can’t sleep and out of bed after 20 minutes. Drive to husband’s store.

OT TREATMENT

• Other homework: create hierarchy lists.

• Sessions 2-4: Provide fight or flight education. Review goals and CELEBRATE THE PROGRESS. Continue with sleep and driving goals-build on success. Add walking and pleasurable activities. Keep journal with positive thing that happens each day. Identify list of daughter’s strengths.

OT TREATMENT

• Sessions 5 – 8: Continue to build on driving goal - visualization before each next step. Now driving to the clinic…high five! Build a schedule to work on online class that has registered for. Go for dinner to neighbour’s house. Go to a restaurant with family. Review all the positive accomplishments in minute to minute detail.

• Throughout, provide reading that is pertinent to discussion.

• Reviewed ABC model of CBT. Build affirmations.

MINDFULNESS PRACTISE

MINDFULNESS RESOURCES

• WHEREVER YOU GO THERE YOU ARE: MINDFULNESS MEDITATION IN EVERYDAY LIFE. Jon Kabat-Zinn.

• RADICAL ACCEPTANCE: EMBRACING YOURSELF WITH THE HEART OF A BUDDHA. Tara Brach.

• THE MINDFUL THERAPIST. Daniel J. Siegel.

MINDFULNESS RESOURCES

• FULL CATASTROPHE LIVING: USING THE WISDOM OF YOUR BODY AND MIND TO FACE STRESS, PAIN AND ILLNESS. Jon Kabat-Zinn.

• THE MINDFUL WAY WORKBOOK. John Teasdale, Mark Williams, Zindel Segal.

• THE MINDFUL PATH TO SELF-COMPASSION. Christopher K. Germer.

RECOVERY FROM ADDICTIONS

ADDICTIONS RESOURCES

• IN THE REALM OF HUNGRY GHOSTS, Gabor Mate.

• MOTIVATIONAL INTERVIEWING: HELPING PEOPLE CHANGE, William Milner & Stephen Rollnick.

• THE WILLPOWER INSTINCT, Kelly McGonigal.• A RETHING OF THE WAY WE DRINK,

DocMikeEvans, you tube.

UNDERLYING CAUSES – GABOR MATE

• Painful early experiences program both the neurophysiology of addiction & the distressing psychological states that addiction promises to relieve.

• Addiction is about running from different emotions or hanging on to enticing ones.

• Addiction is used to calm anxiety, an unease about life or about a sense of insufficient self.

NEUROPLASTICITY – THE DARK SIDE

• Dr. Doidge

WILLPOWER – Kelly McGonigal

Three types:

1. I won’t power – resisting urges

2. I will power – motivation & energy to do things that are overwhelming

3. I want power – knowing what you really want in the big picture

WHERE IN THE BRAIN?

• Pre-frontal cortex – keeps track of goals

• Right side – controls attention and behaviour

• Left side – motivation to move towards something

1 BRAIN – 2 MINDS

• WISE MIND – Think of ourselves related to others

• NOT SO WISE MIND – Amygdala’s promise of reward, focus on short-term, immediate gratification.

OTHER LITTLE FACTS

• Willpower decreases when blood sugars are low

• Experience of wanting something and liking something are completely different from each other – different systems in the brain.

• Wanting produces its own stress of giving in. Makes you feel like you want it even more

WANTING VS. LIKING

• The craving produces the anxiety – it is a trickster.

• Stress shifts the brain into a reward state – when stressed we are more distracted into temptation, lose focus on long-term goals.

• Guilt and shame send us more into the behaviour

ADDICTIONS SCREENING

• Screens for drugs and alcohol

• 40% abstain: green• 35% low risk: green• 20% at risk: yellow• 5% substance use disorder: red

TREATMENT – MOTIVATIONAL INTERVIEWING

Collaborative conversation style for strengthening a person’s own motivation & commitment to change.

Important points:– Guiding not directing– Ambivalence to change is normal, expected and

should be predicted by the therapist

MOTIVATIONAL INTERVIEWING

– If the therapist argues for change, will increase the resistance

– HAVE to accept the person and honour his/her perspective: EMPATHY OF THERAPIST THE MOST PREDICTIVE OUTCOME OF POSITIVE TREATMENT

– Support autonomy to choose their own way– Affirm their strengths and efforts EVERY SESSION– Mindful problem-solving goes much farther than

skill teaching

MOTIVATIONAL INTERVIEWING

– MI works on the assumption that the person already has what they need within them

– OARS: Open questions: affirming the positive; reflecting; summarizing the change process.

– Avoid arguments/blaming/coaxing/pursuading/power struggles – change is up to them

– Walk with the person – don’t drag them.– Watch for change talk – move from why to how to

change

RULER EXERCISE

• On an imaginary scale from 0-10, how important would you say it is for you to cut back on your drinking?

• And why are you not at a (lower number)?• On that same scale how ready are you to cut

back on your drinking?• Why are you not at a (lower number)?

USE REDUCTION

– Use reduction is acceptable

– You Tube Mike Evans

– Activity logs should be 24 hours and have client note: time using; time thinking about using: time recovering.

BACK TO WILLPOWER

• According to Dr. McGonigal and other brain experts, what is the most effective way to improve willpower???

MEDITATION

• 5 minutes of focused meditation simply focusing on the breath, noticing when the mind wanders and back to the breath.

• Engages pre frontal cortex and anterior cingular cortex

• Balances PNS and SNS• You don’t even have to be good at it for it to

work.• Reduces relapses

PAUSE & PLAN VS. FIGHT OR FLIGHT

• When notice a craving, pay attention between wanting and liking. Notice the experience of wanting in the brain and the body.

• Pre-commit to 10 minute delay and do something to put distance between the craving and the acting. Have a plan ready.

• Important to have self-compassion when slips happen. Avoids the “what the hell, I blew it”

GABOR MATE SUGGESTS?

• MEDITATION

MINDFUL AWARENESS

• Mindful awareness is key to unlocking the automatic patterns that fodder the addicted brain & mind.

• Mindful awareness consists of noticing ebb & flow of automatic thoughts – desiring and longing, judging and rejecting – without being hooked by them.

MORE SPECIFICALLY

• Step 1: Re-label– Label the addictive thought for what it is:– I don’t need alcohol– I am only having an obsessional thought that I

have such a need– Conscious awareness results in change to brain

patterns– Changes from a need to a dysfunctional thought.

FOUR STEP TREATMENT

• Step 2: Re-Attribute– Place the blame on your brain: This is my brain

sending me a false message. Neurological circuits were programmed a long time ago.

– This is “circuits that fire together wire together” gone wrong.

– Instead of self-blame, asking calmly why these desires have exercised such a powerful hold

FOUR STEP TREATMENT

• Step 3: Re-focus– It’s not how you feel that counts; it is what you do.– Find something else to do – buy time.– 10-15 minutes– Do something you like.

– Again brings the frontal cortex to play

FOUR STEP TREATMENT

• Step 4: Re-Value– Remind yourself why you are going to this trouble.– Addicted mind has been fooled into making the

addiction the highest priority…trickster– De-value the false gold– What has the addictive urge done for me? Write

out several times a day.

ADDICTIONS SUMMARY

• Motivational Interviewing – accurate empathy, no judgement, respect and walking with/not dragging the client

• Focus on positive, relentless focus on gains made

• Encourage mindfulness and the 10 minute pausing & planning

• Encourage self-compassion

NAOMI

• Time in Program: January 5, 2012 to July 18, 2013.

•

• Money spent: $7,276.25

• Team members: OT/PT/KIN

NAOMI

• Important learnings:– Watch for use while in the program– No judgement from the team– Flexibility is key– Client benefits from ongoing participation in

addiction supportive programs– May start with us, go to rehab, then finish with us– Potential for relapse greater prior to work return– Relapse greater after first year of sobriety

CONCUSSION MANAGEMENT

OVERVIEW

• Case management• OT role• Pacing• Role of vision efficacy• Assessment• Treatment

Overview

• Case management• OT role• Pacing• Role of vision efficacy• Assessment• Treatment

CASE MANAGEMENT

• MVA– MIG vs non-MIG

• WSIB– MTBIPOC vs Conventional OT sessions

• LTD– Advocacy for other team members on the file

ASSESSMENT

• History of injury• Rivermead Post Concussion Symptom

Questionnaire• Functional status – self-report• Education:

– MTBI– Pacing (brain rest)

Case Management• Advocate for the client with LTD, WSIB or MVA

– Lack of comprehension on behalf of the WSIB / CSST– Complete as much of the standardized testing as possible for supported argument– Contact the physician & communicate

• Co-ordinate Assessment – Vision efficacy – Identify possible Cognitive changes– Cardiovascular responce– Likely some mechanical neck or shoulder (or both) pain as well

• Co-ordinate Treatment – Education – Vision retraining– Anxiety management

PACING

• Foundation for concussion recovery• Key to pacing is staying below symptom

threshold• Two-point rule• Gas tank analogy• Timers (apps, egg timer, stove) • Use of scheduling (we are the masters at this…)

Dealing with Sponsors

• MVA– MIG vs non-MIG

• WSIB– MTBIPOC vs Conventional OT sessions

• LTD– Advocacy for other team members on the file

Assessment

• History of injury• Rivermead Post Concussion Symptom

Questionnaire• Functional status – self-report• What are their cognitive / visual demands?• Education:

– MTBI– Pacing (brain rest)– Recovery

SMOOTH PURSUITS• Test the ability to follow a slow moving target. The patient and the

examiner are seated. The examiner holds a fingertip at a distance of 3 ft from the patient. The patient is instructed to maintain focus on the target at the examiner moves the target smoothly in the horizontal direction 1.5 ft to the right and 1.5 ft to the left of midline. One repetition is complete when the target moves back and forth to the starting position, and 2 repetitions are performed. The target should be moved at a rate requiring approximately 2 seconds to go fully from left to right and 2 seconds to go full from right to left. The test is repeated with the examiner moving the target smoothly and slowly in the vertical direction 1.4 ft above and 1.5 ft below midline for 2 complete repetitions up and down. Again, the target should be moved at a rate requiring approximately 2 seconds to move the eyes fully upward and 2 second to move fully downward. Record: Headache, Dizziness, Nausea & Fogginess ratings after the test.

Pacing

• Foundation for concussion recovery• Key to pacing is staying below symptom

threshold• Two-point rule• Timers • Use of scheduling (activity & breaks)

Vision Assessment

• Vison Efficacy– The ability of the eyes and brain to coordinate and

work in unison– Many different facets to this that are very

commonly taxed daily– One of the two biggest factors in treatment

outcomes (Cardio is the other)

QUESTIONS??

CBT FOR INSOMNIA

CBT FOR INSOMNIA RESOURCES

• CBT FOR INSOMNIA, A COGNITIVE BEHAVIOURAL APPROACH, Jack Edinger & Colleen Carney.

• SLEEP HISTORY QUESTIONNAIRE, Duke University (available online)

• STOP BANG QUESTIONNAIRE.

INSOMNIA

• Difficulty sleeping (initiating and/or maintaining sleep or nonrestorative sleep)

• Difficulty functioning: contemporary views of insomnia conceptualize it as a 24-hour disorder (daytime component) and/or distress

• 1-6 months duration

GOOD SLEEP

• Dependent on:– Adequate sleep drive (sleep debt)– Proper timing (consistent sleep/wake schedule)– Low physiological and psychological arousal

SESSION #1: ASSESSMENT

• Rule out:– Obstructive sleep apnea– Restless leg syndrome– Periodic leg movement disorder– Circadian sleep disorders

APNEA SCREEN: STOP BANG QUESTIONAIRE

• S - SNORE• T - TIRED• O - OBSERVED TO STOP BREATHING• P - HIGH BLOOD PRESSURE• B - BMI OVER 35• A - AGE OVER 50• N - NECK CIRCUMFERANCE GREATER THAN 40• G - GENDER MALE

SLEEP DIARIES

• Complete for 2 weeks

• Calculate percentage of time sleeping to time spent in bed averaged over the 2 weeks.

SESSION #2: BEHVIOURAL TREATMENT EDUCATION

• Myth – everyone needs 8 hours of sleep

• Body clock-circadian clock– Owl or lark?

• Sleep debt

• Myth – can make up for lost sleep by napping or sleeping in

TREATMENT GUIDELINE #1

• SELECT A STANDARD WAKE TIME

• STICK TO IT REGARDLESS OF AMOUNT OF SLEEP

TREATMENT GUIDELINE #2

• USE THE BED ONLY FOR SLEEPING…and sex

TREATMENT GUIDELINE #3

• GET OUT OF BED IF YOU CAN’T SLEEP AFTER 20 MINUTES

• TRAINING YOURSELF TO BE AWAKE IN BED

• JUST INCREASES FRUSTRATION

TREATMENT GUIDELINE #4

• DO NOT WORRY OR PLAN IN BED

• IF YOU ARE, GET UP AND GO TO ANOTHER ROOM

• SET ASIDE TIME EARLIER IN THE EVENING

TREATMENT GUIDELINE #5

• AVOID DAYTIME NAPPING

• If you have to, less than an hour and before 3 PM.

TREATMENT GUIDELINE #6

• GO TO BED WHEN SLEEPY AND NOT TOO EARLY

• DETERMINING TIME IN BED PRESCRIPTION:

• TIME IN BED =• AVERAGE TOTAL SLEEP

TIME + 30 MINUTES

SLEEP HYGIENE RECOMMENDATIONS

1. Limit use of caffeinated food and beverages. 2. Limit use of alcohol.3. Moderate exercise late afternoon or early

evening.4. Light bedtime snack – cheese, milk, peanut

butter5. Make sure bedroom is dark and quiet.6. Comfortable cool bedroom temperature.7. 1 hour wind down before bed

SESSION #3: COGNITIVE THERAPY COMPONENT

• Insomnia Brain – noisy and very focused on the effects of not sleeping.

• Unrelenting negative thoughts

• Bed has become a signal for worry and upset

• TAKE THE INSOMNIA BRAIN OUT OF BED

CONSTRUCTIVE WORRY WORKSHEET

• CONCERNS

1. I won’t get this course prepared in time.

• SOLUTIONS

1. I will schedule 1 hour every day to work on it.

OTHER STRATEGIES

• Mindfulness

• Breathing

• Progressive muscle relaxation

• Cognitive distraction – imagine next plot lines for a book. How would you spend lottery money. Do math equations.

BEHAVIOURAL EXPERIMENTS

• BELIEF: I need to nap to get through the day.

• ALTERNATIVE THOUGHT: If I don’t nap, my nighttime sleep will improve, and I can cope.

• EXPERIMENT: Monitor napping, tiredness and coping for one week of naps and one week without.

STRATEGIES TO GETTING OUT OF BED

• Go directly into the shower• Make a special breakfast• Buy favourite coffee beans• Take the dog for a walk.• Schedule a visit with a friend.• Remind self that if you sleep more, will be

light sleep at best.

COGNITIVE WORK HARDENING AND RTW PLANNING

COGNITIVE WORK HARDENING & RTW PLANNING RESOURCES

• HARDWIRING HAPPINESS, Rick Hanson Ph. D.• LUMOSITY• BRAIN HQ – Michael Merzenich• COURSERA.ORG – free for content courses for

Yale & Harvard• CANCER AND RETURNING TO WORK:

www.bccancer.bc.ca• JOB ACCOMMODATION NETWORK:

www.jan.wvu.edu

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COGNITIVE WORK HARDENING

• Toughening the “cerebral muscle”

• Cognitive work demands such as concentration; memory; multi-tasking; meeting deadlines and working with time pressures; computer literacy; report writing; attention to detail.

COGNITIVE WORK HARDENING & NEUROPLASTSICITY

• Taking back the cerebral real estate.

• Strengthen connections: the brain that fires together wires together– London cabbies

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BEHAVIOURAL WORK HARDENING

• Toughening the “emotional muscle”

• Behavioural work demands such as getting to and staying at work; interacting with coworkers and customers; dealing with emotional or confrontational situations; reliability and responsibility

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COGNITIVE & BEHAVIOURAL WORK HARDENING

• How do we build a program?

Hint…think of physical work hardening.

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COGNITIVE & BEHAVIOURAL PROGRAM

• Review job description• Complete the Cog/Beh Demands Analysis• Establish goals• Simulate demands in clinic or offsite –

volunteer work.• Graded activities to build confidence• Don’t forget about physical job demands!

EXERCISE, EXERCISE, EXERCISE

• Combination of physical exercise and mental stimulation is key to good outcome – Doidge

• Aerobic exercise is helpful in improving cognitive function in adults in terms of memory, attention, processing speed and ability to form and act on plans-Ahlskog

• 2.5 hours per week of exercise and notice significant enlargement in hippocampus -Doidge

AND IF YOU ARE NOT CONVINCED RE: EXERCISE?

• Combination of learning & physical exercise maintains and enhances ability to learn related to an increase in a chemical in the hippocampus that turns short term memory to long term- Cohen

• Some evidence for strengthening as well-brain is responding to the challenges in the same way the body responds to the stress of the exercise - McGonigal

FIVE EVIDENCED BASED WAYS TO IMPROVE BRAIN FUNCTION

1. Do/learn something new every day2. Do something new & out of your comfort

zone (multiple firing of sensory and cognitive brain structure)

3. Cardiovascular and strengthening exercise4. Good sleep5. 10 minutes of meditation a day

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RETURN TO WORK PLANNING

Special Considerations for LRP• Mental health stigma• “Protective” professional supports• Work environments• Self-confidence/self-esteem• Importance of gradual return options and

ongoing support

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RETURN TO WORK PLAN

• Gradual return – 6 or 8 or 10 or 12 or even 16 weeks

• Increasing by hours vs. by days• Support throughout is crucial • Job Accommodations? Work from home part

time?• Ergonomic Assessment? • Treatment coinciding with RTW

CASE SPECIFIC EXAMPLES

• POST CANCER CLIENT

• CFS CLIENT

• CONCUSSION CLIENT

• ADHD/ASPERGER’S

POST CANCER CWH & RTW

• POST TREATMENT FOGGY BRAIN/FATIGUE/DECREASED SELF CONFIDENCE/ANXIETY

• Cancer Smart Rehab Brief Fatigue Inventory• Cognitive testing baseline and follow-up• Important to request exercise as part of

program• Cancer survivors have difficulty estimating work

readiness

CANCER CONT’D

• Beware of facing difficulties the first days back – helps if can go ahead of time to clean up work area

• Energy conservation – pacing/planning• Job site visit – particularly if have had surgery,

have physical impairments

CHRONIC FATIGUE SYNDROME

• VO2 testing – working within heart rate ranges• Avoid crashes• Cognitive and social activities count• PACING/PACING/PACING• Provide education, leave them be, then re-

assess

ADHD/ASPERGER’S

• Important considerations:• Communication strategies• Sometimes dragon speak helps• How to use outlook tutoring• Education to the employer• Extra time needed for some work

CONCUSSION

• Do not increase both frequency and job demands…slow and steady

• Keep brain breaks until full time• Adjust RTW plan if symptoms spike• Consider a work site visit to look at

environment.

WORKING WITH THE SPONSORS: CLOSING THE GAP

UNDERSTANDING THE LTD WORLD

• STD VS. LTD• Date of Definition: Own occupation vs. any

occupation vs. own job• Duty to Accommodate• Case Manager vs. Rehab Consultant• RTW meetings• Disability vs performance issues

COMMUNICATION IS KEY

MANAGING THE FILES: DO’S

• Keep the sponsor happy AND be client-centered – think outside the box – use treatment techniques and locations that will inspire/encourage

• Timely reporting• Team meetings – everyone on the same page. Invite the

sponsor to team meetings esp first and last.• Communicate with physicians• Manage the budget• Know the specific needs/wishes of the sponsor• Pull the plug when you need to

MANAGING THE FILES: DO’S

• Understand benefits in question and timeframes for C.O.D.

• Understand who is to communicate with employer (the RC or you)

• Ensure the client is aware of the program goals from the outset

MANAGING THE FILE: DON’TS

• Avoid communicating with the sponsor when things are going south

• Overspend or ask for a huge amount when prognosis is guarded

• Ask for more than 15 minutes of coordination/communication per week

• EVER speak negatively about sponsor to the client. Stay out of insurer/client conflict.

• Be afraid to say the client is not ready for treatment.

OUTCOME MEASURES

• In process

• Will be used across the country

• Demonstrate the positive outcomes

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MARKETING THE PROGRAM

• A successful outcome is number one!• Effective case coordination• Education, education, education…any chance

you get. • Review current files - what could be converted

to LRP, speak to your OR sponsors about the program.

• Ask sponsors what they need…reflectively listen….

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MARKETING THE PROGRAM

• Presentations to LTD companies – provide education AND lunch. Provide sponsors with outcome stats from Ottawa – 8/10 successfully back to work.

• Stress early intervention = better outcomes.• Think about what makes us unique ….

Combined physical, psychological AND functional components; flexibility of service delivery; ‘normalized’ gym environments.

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MARKETING THE PROGRAM

• Keep current with trends and needs• Perhaps picked an experienced clinician to

help with marketing• Negotiate – try 3 files• Partner with specialists/market to specialists• Find your niche• Extended health?

AND LAST BUT NOT LEAST:GOOD SELF CARE

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CONTACT INFORMATION

Ingrid Neufeld, BMR(OT) Reg (Ont)

Occupational Therapist

CBI Ottawa West

(613) 820-5545

ineufeld@cbi.ca

THANK YOU!

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