Adjustment to Disability

Jerrold Yeo, PsyDRehabilitation Neuropsychologist

UPMC Rehabilitation Institute, TBI Unit (Mercy)

Email: Yeoj@upmc.edu

Phone: 412-232-40641

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ObjectivesAttendees will learn about…• Common adjustment difficulties faced in the

immediate and long-term aftermath of having a head injury and/or new disability

• How to manage some of these mood/behavior difficulties

• Returning to work post-TBI• Resources available

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Types of Brain InjuriesAcquired Brain Injury (ABI):• Umbrella term for all brain injuries• Two types: Traumatic & Non-traumaticTraumatic Brain Injury (TBI):• A bump, blow or jolt to the head or a penetrating head injury that disrupts the

normal function of the brain (Faul, Xu, Wald, & Coronado, 2010)Non-traumatic Brain Injury:• Often also referred to as Acquired Brain Injury (ABI)• Damage to the brain by internal factors, such as lack of oxygen, exposure to

toxins, pressure from tumor, etc. Includes stroke, near drowning, aneurysms, meningitis, drug overdose etc. (Brain Injury Association of America, n.d.)

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Brain Injury Association of America. (n.d.). What is the difference between an acquired brain injury and a traumatic brain injury? [Infographic]. https://www.biausa.org/brain-injury/about-brain-injury/nbiic/what-is-the-difference-between-an-acquired-brain-injury-and-a-traumatic-brain-injury

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Common TBI Symptoms by Injury Severity

TBI Severity

Symptoms

Physical Cognitive Emotional Behavioral

Mild HeadacheDizzinessFatigueNoise/light intolerance

Memory complaintsBlurred/double visionFeeling "dazed and confused"Memory gaps

DepressionIrritabilityAnxietyMood lability

ClumsinessSlowed behaviorAgitation

Moderate and severe (in addition to all symptoms for mild TBI)

Observed physical trauma to headPupillary dilation/asymmetrySeizuresNausea and vomitingHypoxiaHypotensionCerebral herniationParalysisSpasticity

Visuospatial problemsProblems expressing or understanding languageInability to recognize people, places or thingsProblems reading and writingProblems with planning and organizing

Emotional dysregulationDenialAlexithymia

Disruption of motor functionUnable to follow commandsPain behaviorsPerseverationAggressionDisinhibitionLack of awarenessPoor motivation

McGarity, S., Brenner, L. A., & Corrigan, J. (2019).

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Other complicating factorsIn addition to common TBI/ABI symptoms, other factors that can influence adjustment difficulties include:• Hospital stay (and events surrounding thereof)• Social environment (family dynamics, friends)• Grief/loss• Justice system involvement• Pandemic• Disability status and lasting effects

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Addressing Adjustment Difficulties (Physical)

• Continued follow-up with PCP and other BI-related physicians (Physiatrist, Neurologist, Neurosurgeon, etc.)

• Physical, Occupation and Speech Therapy services as recommended

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Addressing Adjustment Difficulties (Cognitive)

• Continued follow-up with Speech Therapy services as recommended

• Cognitive Remediation– Restorative approaches such as dual task training, memory

drills, problem-solving exercises, conversational skill building (Cicerone et al., 2011)

– Compensatory approaches such as utilizing external memory aids (smart phone alerts, calendars), visual cues, self-monitoring, self-regulation techniques

• Consider Neuropsychological Evaluation (if recommended by physician)

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Helpful Memory Techniques• Make It Meaningful

– Look for connections in what you are learning. Focusing on the "Big Picture" helps provide meaning to the learning process and helps us to remember

• Create Associations– Associate something new with something you already

know. This creates a building process in your memory bank. If you already know a Bill Smith, think of the Bill you know and associate him with the new Bill Smith

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Helpful Memory Techniques• Learn It Actively

– Move your hands, pace back and forth, and use gestures as you recite a passage. If your body is actively involved, it will help you to remember

• Create Pictures– Draw diagrams, make up cartoons. Use them to

connect facts and illustrate relationships. This way you can "see" the connections, and it may help you to remember later on

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Helpful Memory Techniques• Recite and Repeat

– When you repeat something out loud, you anchor the concept better by using two or more of your senses. If you recite out loud in you own words, memory is enhanced even more

• Write It Down– Writing notes to ourselves help us to remember. If we

write down an idea or a passage several times, in different areas, we increase our chances to remember

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Helpful Memory Techniques

• Use It Before You Lose It– Information stored in the long-term memory may

become difficult to recall if you don't use it. Simply read it, write it, speak about it, and/or apply it

• Note When You Don't Remember– If you tried some memory techniques that do not seem

to work, it's all right. Try and experiment with other techniques and use what is best for you

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Addressing Adjustment Difficulties (Emotional)

• Consider following up with a psychologist– Working with a psychologist informed in the treatment of head

trauma– Cognitive Behavioral Therapy

• Depression• Anxiety• Insomnia

– Cognitive Processing Therapy/Prolonged Exposure Therapy• PTSD

– Problem-solving Therapy/Cognitive Behavioral Therapy• Hopelessness and Suicidality

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Addressing Adjustment Difficulties (Emotional) - cont'd

• Common issues targeted in psychotherapy– Adjustment to disability-related limitations– Identity loss (work and family role changes)– Chronic Pain– Depression– Grief– Substance Use– Posttraumatic Stress– Sexual intimacy and relationships

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Addressing Adjustment Difficulties (Emotional) - cont'd

• Minimize the use of maladaptive coping strategies

– Isolation

– Alcohol/Drug/Tobacco use

– Other maladaptive strategies including risky/self-harm behavior

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Addressing Adjustment Difficulties (Emotional) - cont'd

• Utilize positive coping strategies for management of emotional dysregulation– Self-care (Taking time for yourself, doing activities that

bring you and your family satisfaction)

– Mindfulness/meditation (Visualization exercises, breathing strategies)

– Progressive muscle relaxation to assist with pain and anxiety

– Problem-solving skills (finding different ways to do things)

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Addressing Adjustment Difficulties (Emotional) - cont'd

• The role of the family/caregiver– Family member/caregiver can be a major influence

– Understanding that roles may have changed, given emotional/cognitive changes post-BI

– Communication with loved one and other family members

– Self-care is important

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Addressing Adjustment Difficulties (Emotional) - cont'd

Type Steps for Meditation or Relaxation

Guided meditation • With the help of a teacher or guide, or even a pre-made recording, take yourself on a journey through a place you find calming or relaxing.

• Visualize your surroundings and try to incorporate as many senses as possible. Soak in the sounds, smells, and textures.

Mantra, or transcendental meditation • Choose a calming word or phrase. Repeat it over and over to yourself silently to prevent distracting thoughts from entering.

Mindful meditation • Take a break and make yourself acutely aware of your surroundings.• Take deep breaths and feel your lungs swell.• Allow yourself to think about your feelings but do so without judgment.

Prayer • Pray using your own words, or read prayers written by others.• Reflect on the meaning of the words or write in a journal.

Deep breathing • Take deep breaths from your diaphragm, rather than short, shallow breaths from your chest.• Continue until you feel calm.

Exercise • Try going for a walk or run to clear your mind and reduce stress.

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Addressing Adjustment Difficulties (Behavioral)

• Common behavioral disturbances include:

– Aggression

– Disinhibition

– Agitation/irritability

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Addressing Adjustment Difficulties (Behavioral) - cont'd

• Addressing behavioral disturbances:– Identifying antecedents (triggers) of problematic

behavior

– Determining the best method to modify or eliminate the behavior• Reinforcement of desired behavior

• Elimination of undesirable behavior

• Redirection

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Addressing Adjustment Difficulties (Behavioral) - cont'd

• Reduce behavioral issues such as confusion, aggression and overstimulation

– Avoid crowded and noisy events

– Ensure sufficient rest breaks and adequate sleep

– Introduce structure to daily activities and schedule

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https://www.freespirit.com/educational-games-posters-and-jars/stop-think-choose-poster/

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General Tips for Family Members/Caregivers

• Taking care of yourself– Often times, there is a sense of loss or grief for the

relationship prior to injury

– Rely on support from others, continue to rely on existing supports and develop new sources of support, such as family, friends and religious groups

– Other sources of support include support groups, support agencies, and the internet.

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Return to Work Post-TBI• 41% of TBI survivors were at work 1 – 2 years

post-injury• People with TBI who do not return to work

within 2 years are less likely to consider returning to work again

• People not returning to work are more likely to be depressed, anxious, and report a poorer quality of life

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Factors Influencing Successful Return to Work Post-TBI

• Pre-injury work status– High autonomy, high earning, stable work history

• Employment type– Managerial role

• Enterprise size– Larger employer

• Relationship between employee/employer• Participant's expectations of recovery

– Higher functional ability, lower anxiety, and higher health-related quality of life

• Education Level– Higher levels of educational and occupational attainment

• Age– Younger age at injury

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Common Difficulties Post-TBI• Slowed processing speed• Impaired attention/concentration• Memory difficulties• Executive Functioning

– Planning–Organization– Initiation– Disinhibition/Impulsivity

• Emotional Functioning

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Difficulties Specific to Return to Work

• Subjective (self-perception) and Objective (data-driven) of cognitive deficits

• Post-concussive/injury symptoms such as headache, fatigue, dizziness, cognitive fatigue

• Emotional consequences including depression, anxiety, irritability

• Perception of co-workers and employers

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Useful Accommodations/Strategies• Reduction of ambient distraction• Simplified/tailored work duties and environment (step-wise

approach)• Frequent review and practice of work tasks• Removal of self from potentially agitating situations• Utilization of cognitive-behavioral therapy and other intervention

techniques to address underlying mood concerns• Practicing good sleep hygiene to battle insomnia and other sleep-

related difficulties

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Skills Training

• Cognitive rehabilitation to address deficits of attention/concentration, memory, and executive function

– Also assists with recognizing impairments and utilizing compensatory strategies

• Memory logs

• Self-monitoring

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Returning to Work in Same vs. Different Role

• 52.4-66.6% of people with TBI returned to the same job and employer, while 5.5-17.8% of people returned to the same employer but in a different job

• Some people choose to return to a supervisory role vs. labor-intensive role

• Gradual return to work

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Helpful Resources

• Brain Injury Resource Line: 1-800-444-6443

• Brain Injury Association of Pennsylvania: https://biapa.org/

• Brain Injury Association of America: https://www.biausa.org/

• TBI Factsheets: https://msktc.org/tbi/factsheets

• Brainline.org: https://www.brainline.org/

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Helpful Resources

• Job Accommodation Network (JAN) https://askjan.org/

• Pennsylvania Office of Vocational Rehabilitation https://www.dli.pa.gov/Individuals/Disability-Services/ovr/Pages/default.aspx

• United States Brain Injury Alliance https://usbia.org/

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Helpful Books• Bouncing Back: Skills for Adaptation to Injury, Aging, Illness, and Pain by Richard

Wanlass– Skills, tips and strategies to assist with the multitude of adjustment and other difficulties

encountered after brain injury– https://read.amazon.com/kp/embed?asin=B06XP1BL2P&preview=newtab&linkCode=kpe&ref

_=cm_sw_r_kb_dp_KD7Y2XHTDT8P079RX3Y7

• The 36-Hour Day: A Family Guide to Caring for People who have Alzheimer Disease, Other Dementias, and Memory Loss by Nancy Mace and Peter Rabins– Assisting family members and caregivers address the challenges of caring for someone with

memory loss and other difficulties, and also simultaneously cope with their own emotions and needs

– https://www.amazon.com/36-Hour-Day-Alzheimer-Disease-Dementias-ebook/dp/B06XX2JRJ7/ref=sr_1_3?dchild=1

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Helpful Books

• Handbook of Return to Work: From Research to Practice by Izabela Z. Schultz and Robert J Gatchel– https://www.amazon.com/Handbook-Return-Work-Handbooks-

Disability/dp/1489976264

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Stress Management• Cognitive Behavioral Therapy

– Psychoeducation, self-monitoring, cognitive restructuring, assertiveness skills, time management strategies

• Graded Activity– Utilizing modified/reduced schedule, modified work tasks,

workplace accommodations

• Coping strategies– Utilizing relaxation exercises, self-help books, prioritization

of work tasks, planning/organization

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Managing Interpersonal Conflict• Concept of uncertainty and invisibility

– Stems from workplace colleagues/employers being unsure about expectations on the person returning to work, including accommodations

• Education for closest superiors and collaborators• Supportive supervisors providing education for co-workers• Setting expectations early in the return-to-work process• Management and discussion of guilt from impact of

absence at workplace

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ReferencesBrain Injury Association of America (n.d.). About Brain Injury: Brain Injury Overview. Brain Injury Association of America. https://www.biausa.org/brain-injury/about-brain-injury/basics/overview

Cicerone, K. D., Langenbahn, D. M., Braden, C., Malec, J. F., Kalmar, K., Fraas, M., Felicetti, T., Laatsch, L., Harley, J. P., Bergquist, T., Azulay, J., Cantor, J., & Ashman, T. (2011). Evidence-based cognitive rehabilitation: Updated review of the literature from 2003 through 2008. Archives of Physical Medicine and Rehabilitation, 92, 519-530. http://dx.doi.org/10.1016/j.apmr.2010.11.015

Faul, M., Xu, L., Wald, M. M., & Coronado, V. G. (2010). Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002-2006. [Powerpoint Slides]. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. https://cdc.gov/traumaticbraininjury/pdf/blue_book.pdf

McGarity, S., Brenner, L. A., & Corrigan, J. (2019). Traumatic Brain Injury. In L. A. Brenner, S. A. Reid-Arndt, T. R. Elliott, R. G. Frank, & B. Caplan (Eds.), Handbook of Rehabilitation Psychology (3rd ed., pp. 303-325). American Psychological Association.

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Kendall, E., Muenchberger, H., Gee, T. (2006). Vocational Rehabilitation following traumatic brain injury: a quantitative synthesis of outcome studies. Journal of Vocational Rehabilitation,25(3):149–160.

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Walker, W. C., Marwitz, J. H., Kreutzer, J. S., Hart, T., Novack, T. A. (2006). Occupational categories and return to work after traumatic brain injury: a multicenter study. Archives of Physical Medicine Rehabilitation, 87(12):1576–1582. doi:10.1016/j.apmr.2006.08.335.

Cancelliere, C., Donovan, J., Stochkendahl, M. J., Biscardi, M., Ammendolia, C., Myburgh, C., Cassidy, J. D. (2016). Factors affecting return to work after injury or illness: best evidence synthesis of systematic reviews. Chiropractic and Manual Therapies, 24(1):32. doi:10.1186/s12998-016-0113-z.

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