Multicontexual Cognitive strategies, Joan Toglia

Cognitive strategies ideally are used twice in one session on two different tasks to make sure the patient
can use it
It is best if the patient comes up with their own strategies rather than the therapist telling them what to
do
Self structured assessment
Strategy use fluctuates with difficulty of tasks, patients want to use strategies when they perceive the task
as difficult.
Shifting attention task: mark off all $2 items with a red marker, $3 items with blue marker
When performing higher level tasks, incorporate distractions and keeping track of time to mimic real life
Premorbid personality can affect their ability to accept when they make mistakes awareness vs.
personality, avoid the words errors problems. Point out the positive for these type of people I see that
you did _____ very well. Try and give them the control they want and need over the session.
Rather than cue in ADLs, sit back and ask the patient to ask you when they need help dont be so quick
to jump in and cue or help.
Strategies use: spontaneous checking, anchors, self assessment
Assessments used: SRSI, WCPA
Brain computer interfaces (BCI)- technology control through thoughts/emotions/brain oscillations- no
need for eye control or switches. 1924- EEG discovered 1970- BCI research in animals (operant conditioning)
1990s- human research with BCIs. The first BCI was a speller- took 16 hours to write about a paragraph long
letter.
BCIs can be invasive- epilepsy, locked-in syndrome- ECOG implanted directly on brain. provide
opportunities to communicate
Non-invasive- EEG cap
GOALS:
1. Compensatory (using thoughts to spell words)
2.Adaptive (teaching/re-training brain- This is what OT would focus on this application)
Not quite in rehab yet, but there is a possibility coming up
Real time fMRI Neurofeedback- process info second by second. People can learn to control their own brain
activity in specific regions
Used to control depression, pain, emotional regulation, motor improvement, attention, smoking
cessation, social skills, problem solving
-most individuals strengthened functional connectivity between PMC and SMA
Non-invasive Brain Stimulation: transcranial magnetic stim or transcranial electric stim
TMS- interferes with motor cortex. Inhibitory (inhibit function) or excitatory (promote function)
TES- 9 volt current, electric stim sent through the brain, similar to the electric chair (what?!) but on a
MUCH lower voltage. Used DURING therapy to boost neuroplasticity. normal patterns of brain function
-stimulate affected side, or
-decrease excitability on strong side
Use in combination with robotic hand
Its still very new: be skeptical, ask lots of questions:
-where in the brain does it say its recording?
-can we assume that it where the region is in our patient?
-do we know that this type of brain activity we are recording is associated with this behavior? how
reliable is the signal? How useful is the output?
-can I achieve this goal without the BCI?
www.openbci.com

Innovations in pain management: mirror visual feedback and immersive and non-immersive virtual
reality
-people can have kinesiophobia: fear of movement because of pain
-anticipation of the pain can make it worse so meditation and managing anxiety can be important
-nonimmersive treatment like the Wii
-pain and sensation can be reffered to other parts of the body. remember the humunculus
-mirror therapy: get rid of painful memories of limb use. Replace with happy memories
-evidence is not as strong: low # of participants, inconstistant methodology
-burn pain and virtual reality: distraction- reduce petson's perception of pain
- actual pain level on the brain is reduced with virtual reality
-typical gaming is violent and can increase anxiety
Virtual reality: can be used to reduce pain during medical tasks procedures: but no evidence about carryover
beyond when it is being used
Exercising the phantom limb in the mirror can relieve pain as well as for CRPS due to visual feedback
(temperature of the CRPS limb).
-bilateral use of limbs real or through virtual reality helps rewire the brain and change pain level. Sensory
deprivation.
-lifewave: crystal patches for pain. Deals with referred pain.
- Go into detail about what type of pain they are having and what the level each type is. Is it incision pain,
phantom pain, or emotional pain. Be holistic with pain.
Creative solutions to working in a SNF
Challenges of a SNF:
-environment:
-limited space
-wrong type of equipment
-no kitchen
-staff:
-poor follow through of CNA
-scheduling
-patients:
-too low level
-medically complex
-attitudes:
-of family members (they'll die there, they'll stay the rest of their lives, etc)
-our own attitudes (might as well just get out the cones, it is low on the
pecking order of jobs, not "elite" like inpatient rehab or specialty area).
-But, to work here you need to excel in everything so you should challenge yourself to be a very high level
therapist.
Break old habits, pursue clinical excellence
-best way to be client centered: listen to a patient and family member
-select enriched environments ( lots of research on this)
-use real life activities, BUT, more than that, modify it to get what you want
-scan the environment: go outside the gym!
-ex: tie in activity with bingo or with the hair salon in the facility , a quiet room or garden. No kitchen? get a
bread maker, lots you can do with this (sitting, standing, bilateral, etc). Instead of putting in pegs, hang
scarves on a hook.

-Make everything a teaching moment. For example, explain why you make then use the walker in the kitchens
nod ask them to explain to you why that us throughout the session.
-Doing the real activity as opposed to contrived activities allows you to see any problems they will have at
home. Often people get absorbed into the activity they are doing and they forget the precautions you taught
them. This allows FIFA good teaching moment so won't do it at home. Also, you can use these to discuss how
the strengthening/ROM you did earlier will benefit them.
The medically complex patient
-Believe that what you do makes a difference
-Thorough look at the medical record, especially for precautions
-what are the parameters for the person? Do you need to treat them in their room? WB precautions? Dietary
precautions?
-Don't assume medically complex patients are low functioning or bed bound
-choosing to do activities with these people (even when they're going to be in the facility for 10 years) gives
them quality of life.
Dealing with difficult behaviors:
-Dementia:
-Use simple touch
-Speak at eye level
-Find out what they are fearful of and acknowledge it. Don't assume they don't know what they are talking
about just because they have dementia.
-Structure your day: for these diagnoses, consider what else is going on (Meds, other disciplines), schedule
the early on in the day (try not to to put them at 4:30 or you usually won't do it)
Grab and go: a toolbox of ideas
-if you have occupation based stuff available, you will use it
-the shoe polish idea from class
-use resources: ha used old flowers from the florist
-dollar store
-look at jan johnsons fb page for ideas of items and activities
-utilize activities dept
-take away the cones and replace them with other things!
Sleep: the forgotten ADL
Sleep: the forgotten ADL
Annual cost of sleep disorders is $16 bil a year
OTPF- sleep is an occupation!
Rest, sleep (sleep prep, sleep participation)
Changes in sleep as you age- time decreases and interrupted sleep increases. Older adults have a reduction in
REM sleep. Reduction in recovery during sleep (sleep spindles). Sleep latency increases with age ( you should
fall asleep faster with age).
4 things that keep people awake:
1- Environment of care
2- Delirium
3- Mechanical Ventilation
4- Patient care
Characteristics of sleep in critically ill:
severely fragmented
total sleep time over 24 hrs is normal
Interventions:

1. night-time environmental interventions

2. non-pharmalogical
3. daytime
Impact on physical/cognitive functioning
1. Increased irritability, cognitive impairment, memory loss, impaired judgment, hallucinations, ADHD-like
symptoms
2. Decreased reaction time
3. Increased risk of diabetes/obesity
24 hours w/o sleep= same effects of blood alcohol level @ 0.10%
Inadequate sleep over time= cardio and GI diseases, metabolic disorders, depression, obesity, mortality
Address sleep and cognition together to improve reengagement in occupations
Delirium and Sleep: common pathway, shared mechanisms, imbalance of neurotransmitters is the leading
theory
Populations at risk (in hospital):
Older adults
Male
Obese
Immobile
Critically ill
Mech. Ventilated
Drug/alcohol
Delirious
Most common: sleep apnea
Consider deprivation vs. disruption
Intervention strategies:
Education regarding terminology/misconceptions
Prevention secondary conditions (physical and cognitive- decreased ROM, memory, etc)
Establish predictable routines
Manage pain and fatigue
address ADLs (particularly bed mobility and toileting)
Sleep hygiene routines
Cognitive restructuring techniques
Instruct caregivers on sensory processing
Modify environment
Mind-body techniques (guided meditation)
Advocacy
Visible daylight
Noise
Patient care
What does this all mean?
help with decision making
Identify if cog/physical deficits are related to sleep deprivation
Implement treatment strategies to facilitate recovery
www.icudelirium.org
Parenting with a disability
Barriers and challenges to parenting:
-dealing with social stigma

-pressure to prove yourself

-withhold info to avoid stigma
-inaccessible environment and activities (holding parent meetings on second floor without an elevator)
-these moms wanted mom activities that were accessible
Learning to "work it out"
-having social supports- peer support and mentoring
-have faith in own abilities
-being resourceful (arranging rides when she couldn't drive)
-knowing about resources and knowing how to use them
-unhelpful supports- paternalistic attitude, overly helpful
-moms want others to be educated about disability
OT implications
-recommend AE
-adaptive cribs (one side goes down all the way), neck pillow on w/c to keep child secure when sitting w/
parent, etc.
-build confidence
-refer to support groups/mentors
-advocate
Resources
-through the looking glass videos, parents with disabilities websites
Mindfulness-Based interventions and occupational therapy practice
Mindfulness means paying attention in a particular way on purpose in the present moment and nonjudgmentally. -John Kabat-Zinn, 1990
being fully awake in our lives
mindfulness is the opposite of multitasking
Mechanisms of Mindfulness:
Intention (focus, flexibility)
Attention (emotional flexibility)
Attitude (open, curious and accepting)
Characteristics of mindfulness: non-judgment, Acceptance, Impartial watchfulness, non-conceptual
awareness
During guidance:
- Feet flat on floor if seated in chair
- cross legs or straight out if seated on floor
- never standing
- Only instruct for one minute on the first time- some people never do deep breathing, so they may
get light headed
Mindful Practice- 1999
Mindfulness should not be used at certain or specific times, it should be used as a lifestyle
4 fold process
-taking stock, preparing:
- active ailability
-reflectivity
You cannot do this work with clients unless you do it with yourself
Video: Free the mind

Daily: Work on reaction to pain (anger, sorrow) and although the pain (anger, sorrow) doesnt go away but it
isnt as bad
MBSR Structure: (formal practices) Mindfulness based stress reduction
1. Body scan (start at toe think about each part of body, be mindful of it and relax)
2. mindful Hatha Yoga
3. Walking meditation
4. eating meditation
5. sitting meditation
6. class discussions focus on group members experiences in the formal meditation processes and the
application of mindfulness in day-to-day
7. Home practice is integral; commit to formalpractice supported by audio-recordings 45 mins/day 6
days/week
Theres more right with you than wrong with you.
Research findings- higher reports of satisfaction
-improved immunity
-changes in brain (decreased amygdala- anger center)
Mindfulness based cognitive therapy (MBCT):
Initially designed for severe/recurrent depression
Uses activity and mood exercises
Now used with suicidal ideation and bipolar disorder
Changes mindset to look at thoughts as just thoughts and not facts.
Structure:
Intro- body scan, daily mindful activity, mindful meal
2. Dealing with barriers- thoughts and feeling exercise, short sitting
3. mindfulness of breath- seeing/hearing, 3-minute breathing space (awareness-of the moment, gathering,
expanding, yoga nad walking meditation, pleasant events exercise(be aware of a pleasant event in the
moment)
4. staying present
5. Allowing/ letting be
6. Thought are not facts
7. How can I best take care of myself?
8. Using what has been learned as prevention
Mary Oliver tell me, what is it you plan to do with your one wild and precious life?
Perceptions, understanding and response to visually mapped social networks of youth with cognitive
differences
NOT social media. Social environment that envelops the individual
Youth with disabilities face unique challenges
fewer peers
fewer reciprocated relationships (they think their peers are friends, their peers do not think the
same)
To navigate social environment they need to understand surrounding social relationships
used Cognitive interviewing to analyze the personal network. Parents were present and prompted children as
necessary
1- forming networks- older kids were helpful in reaching out
scripted invitations to be friends: new kids, repeated invitations
rekindle peer interactions (from camp, special events, etc.) to connect them with new social networks
parents/siblings are great resources

2- social understandings- accept social self.

connect with other kids who are different
over-adhearance of social rules vs. weighing norms
Social negotiations: active and passive; in the moment awareness= more success in environment
Call to action: parents set up social opportunities
OT in First Aid- OTs role in natural disasters
MAke connections prior to visit/help- they called the University of OK
Connect to the REd Cross
Intrusionary Occupational Therapy
Natural disasters vs. Technological (human made)
Stage 1: Pre-Impact Stage
-warning of impending disaster
-time span: minutes to days
Stage 2: Impact stage
- disaster is in progress
-time span varies
-activitiy: altruism, concern, sharing resources is the norm
Stage 3: Immediate post-impact period
-time frame- hours to days
-activity: search and rescue, evacuation, media coverage, emergency organizations response
Stage 4: Recovery Period
- time: days to weeks
-Activities: debris cleared, preliminary reconstruction, essential services restored
Stage 5: Reconstruction period
- time: several monts to several years
-activities: rebuilding of structures, lifestyles, communities
psychological first aid:
Core actions:
-prepare yourself
-contact and engagement
-safety and comfort
-stabilization of survivors
-gather info about and offer practical assistance for current needs and concerns
-connect survivors to social supports
-assist survivors with coping skills
-link survivors with services
In helping survivors: help identify resources
facilitate engagement in occupations in order to enhance participation
Leave your ego at the door-- you might not be doing everything OT-esque. Do what needs to be done to help
Prior to a disaster:
-get in contact with American Red Cross, Community emergency Response Teams (CERTs)
Managing Movement in Ataxia- Glen Gillen
Tremors (intention, action, terminal)
Dysmetria (hypermetric vs hypometric)
Dyssynergia: moving one joint at atime
Tituabations proximital instabily, gravity dependent: gets worse when standing or sitting

See how patients are seeking stability and use the to your advantage
Key intervention:
Decrease degrees of freedom in limbs and trunk
Provide proximal stability
Change velocity of movement
Adaptive devices to: stabilize, control degrees of freedom, etc.
Assistive technology: tremor dampening electronic (W/C and PC), motion detecting spoon (liftware spoon),
stable slide, asta-cath (catheter for ataxia, allows for cathing while stabilizing against the body)

Research for the use of weights is not compelling, but should be in your bag of tricks
Emotional state of patient is particularly important with this population, work on relaxation

Evaluation:
What dampens or exacerbates ataxia? (positioning, control degrees of freedom, weight bearing) Distract
from movement and the movement will be improved because it becomes more automatic movement
Orthotics
Philadelphia collar
Opponens orthosis
Wrist support
CO-OP for stroke patients in the sub-acute phase
Cognitive strategy training :Based in learning using goal directed strategies, teach patients to develop and self
monitor skills.
Global vs domain specific:
Global: use problem solving techniques that apply across a wide range of
situations. Goalplan-do-check
Domain: specific circumstance although could be used in others, strategies: attention to task, feeling
the movement, verbal mnemonic, verbal script, mental imagery, relaxation techniques
Guided discovery: one thing at a time, ask dont tell, coach dont adjust, make it obvious
Understanding and Interpreting Neuroscience Research for Evidence-based OT Practice
How can we study neuroscience? At the cellular level, in animal models, imaging (MRI, fMRI)
Functional: several low resolution images collected every 2 seconds while doing something such as attention
of motor task. (cannot be done if patient is sedated or resting)
Magnetic: A static magnetic field is generated that is 60 times the magnetic field of the earth!!! Therefore any
metal can not be around it, such as pacemakers, some titanium is usually fine
Resonance: energy that is delivers to nuclei in tissue.
Imaging
MRIs are made up of voxels which are basically 3D pixels. There are about 630,000 neurons in one voxel.
BOLD signal: blood oxygen level dependent: deoxygenated blood is more sensitive to magnets and is what is
measured. Only meaningful when compared to control condition, activity is relative.
Put Down the Pegs

Functional and meaningful tx drive neuroplasticity

Barriers:
Productivity standards, lack of supplies, lack of tx ideas, lack of support/mentorship
Tx ideas:
Pancake group
T-shirt making (crafts from pinterest)
Sorting socks (fun hint: baby socks)
Lead by example, dont go in do the same thing as everyone else, dare to do something different
Document what you are doing as a skilled therapist to help your patient
Task Oriented Approach: mass practice-doing activities until the pt gets tired, important to do lots of
repetition all at once rather than a few reps then breaks.
Find your in with your patients, example of woman who doesnt bake but she loves her grandkids so
they baked brownies for them to motivate and engage her in the tx session
Later stage dementia patients take 30-45 seconds to process information
Ask a lot of questions! Do they like music? What kind? Do they have to sit on the toilet for a long time? All
their routines
Kits:
Wood working kits (can be a block of wood and sand paper)
Fine motor boxes
Laundry basket of clothes (carry basket from point A to B)
Jewelry making supplies
Socks to sort and fold
Feather duster and cleaning supplies
Grooming/ADL supplies
Cards/board games (making cards with stamps)
Pet care
Medication management
Child care items
Textured dominos for low vision (sort)
Jewelry (sort and match the earrings)
Get your patients involved with the activities in the facility, you can do this for tx sessions! Make sure you
introduce your patients to other patients in the therapy gym or activity room to help them build that social
network.