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MULTIPLE SCLEROSIS AND NEUROPSYCHOLOGICAL FUNCTIONING: MANAGING COGNITIVE DEFICITS

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MULTIPLE SCLEROSIS AND NEUROPSYCHOLOGICAL FUNCTIONING: MANAGING COGNITIVE DEFICITS Dr. Lesley Ritchie, C.Psych. Ms. Jodie Gawryluk, B.A. Department of Clinical Health ... – PowerPoint PPT presentation

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Title: MULTIPLE SCLEROSIS AND NEUROPSYCHOLOGICAL FUNCTIONING: MANAGING COGNITIVE DEFICITS


1
MULTIPLE SCLEROSIS AND NEUROPSYCHOLOGICAL
FUNCTIONING MANAGING COGNITIVE DEFICITS
  • Dr. Lesley Ritchie, C.Psych.
  • Ms. Jodie Gawryluk, B.A.
  • Department of Clinical Health Psychology
  • University of Manitoba

2
Overview
  • Introduction to the brain
  • Understanding MS
  • The treatment team
  • What is neuropsychology?
  • Neuropsychological assessment
  • Cognitive domains
  • Neuropsychological profile of MS
  • Managing neuropsychological deficits
  • Specific strategies
  • Special considerations

3
Overview
  • Introduction to the brain
  • Understanding MS
  • The treatment team
  • What is neuropsychology?
  • Neuropsychological assessment
  • Cognitive domains
  • Neuropsychological profile of MS
  • Managing neuropsychological deficits
  • Specific strategies
  • Special considerations

4
Introduction to the brain
  • The brain monitors and controls nearly everything
    that we do from our breathing and heart beats to
    our senses (e.g., vision, hearing), to our
    movements, speech, and personality

5
Introduction to the brain
  • The brain is divided into left and right
    cerebral hemispheres

Left Hemisphere is important for
Right Hemisphere is important for
  • language
  • (thinks in words)
  • math
  • logical abilities
  • movement of the right
  • side of the body
  • visual information
  • (thinks in pictures)
  • organization
  • creativity
  • movement of the left
  • side of the body

6
Introduction to the brain
Frontal Lobes
  • Movement
  • Speaking
  • Planning
  • Organizing
  • Reasoning
  • Decision making
  • Judgment
  • Personality

7
Introduction to the brain
Temporal Lobes
  • Memory
  • Recognition Hearing
  • Understanding Language
  • Emotions

8
Introduction to the brain
Parietal Lobes
  • Sensations
  • Reading and Writing
  • Ability to use Numbers
  • Spatial Reasoning
  • Perception

9
Occipital Lobes
  • Seeing objects
  • Locating objects in
  • space
  • Recognizing the
  • things we see

10
Introduction to the brain
Cerebellum
  • Maintaining balance
  • Coordination of
  • movement
  • Timing of movement

11
Introduction to the brain
Brain Stem
  • Connection between
  • brain and body
  • Breathing
  • Blood pressure
  • Swallowing
  • Appetite
  • Body temperature
  • Digestion
  • Sleeping

12
Introduction to the brain
  • Brain Anatomy
  • The brain is made up of two types of tissue
  • Grey matter (where information is processed)
  • White matter (the highways that take information
    to the processing stations)

White matter
Grey matter
13
Introduction to the brain
  • Functional Analogy

14
Overview
  • Introduction to the brain
  • Understanding MS
  • The treatment team
  • What is neuropsychology?
  • Neuropsychological assessment
  • Cognitive domains
  • Neuropsychological profile of MS
  • Managing neuropsychological deficits
  • Specific strategies
  • Special considerations

15
Multiple Sclerosis
  • Multiple more than one
  • Sclerosis area of stiffening/damage
  • Autoimmune disorder
  • Immune system attacks the CNS
  • Demyelination
  • White matter tissue is white because of myelin, a
    fatty covering that helps information travel to
    brain areas quickly

16
Multiple Sclerosis
  • Symptom onset btwn 20 40 years of age
  • 2-3x more common in women
  • Increased prevalence in northern latitudes

17
Multiple Sclerosis
  • Affects brain and spinal cord
  • Altered motor, sensory, and cognitive functioning
  • Common presenting symptoms (Olek 2005)
  • Symptoms vary according to disease course

Symptom Frequency ()
Sensory disturbance - limbs 30.7
Visual loss 15.9
Motor disturbance (subacute) 8.9
Diplopia 6.8
Gait disturbance 4.8
Motor (acute) 4.3
Balance problems 2.9
Sensory disturbance (face) 2.8
18
Multiple Sclerosis
  • Disease course
  • Relapsing and remitting MS (RRMS)
  • Clearly defined attacks and periods of remission
  • Triggers warm weather, infections, stress
  • Secondary progressive MS (SPMS)
  • 80 with initial RRMS show declines between
    attacks w/o periods of remission most common
  • Primary progressive MS (PPMS)
  • 10 who do not have period of remission following
    1st attack
  • Continuous decline
  • Older at onset
  • Progressive relapsing MS (PRMS)
  • steady decline with attacks

Bobholz Gremley (2011)
19
Overview
  • Introduction to the brain
  • Understanding MS
  • The treatment team
  • What is neuropsychology?
  • Neuropsychological assessment
  • Cognitive domains
  • Neuropsychological profile of MS
  • Managing neuropsychological deficits
  • Specific strategies
  • Special considerations

20
Treatment Team
  • GP manages all medical concerns
  • Neurologist manages concerns about MS or other
    brain conditions
  • Radiologist collects images of the brain
  • Neuropsychologist

21
Overview
  • Introduction to the brain
  • Understanding MS
  • The treatment team
  • What is neuropsychology?
  • Neuropsychological assessment
  • Cognitive domains
  • Neuropsychological profile of MS
  • Managing neuropsychological deficits
  • Specific strategies
  • Special considerations

22
Clinical Neuropsychology
  • is an applied science concerned with the
    behavioural expression of brain dysfunction
    (Lezak, 1995)

23
Normal Distribution - Test Interpretation
Average
AVERAGE
Low average
High Ave
High average
Low Ave
V. Superior
X
13.59
0.13
13.59
0.13
Z -3 -2 -1 0
1 2 3
24
Normal Distribution - Test Interpretation
Average
AVERAGE
Low average
High Ave
High average
Low Ave
V. Superior
X
X
13.59
0.13
13.59
0.13
Z -3 -2 -1 0
1 2 3
25
Normal Distribution - Test Interpretation
Average
AVERAGE
Low average
High Ave
High average
Low Ave
V. Superior
X
X
X
13.59
0.13
13.59
0.13
Z -3 -2 -1 0
1 2 3
26
Clinical Neuropsychology
  • What neural mechanisms underlie various cognitive
    abilities and different emotional states?
  • How do these mechanisms work ?
  • What are the effects of brain damage on behaviour
    ?
  • Application of appropriate intervention
    strategies

27
Overview
  • Introduction to the brain
  • Understanding MS
  • The treatment team
  • What is neuropsychology?
  • Neuropsychological assessment
  • Cognitive domains
  • Neuropsychological profile of MS
  • Managing neuropsychological deficits
  • Specific strategies
  • Special considerations

28
Clinical Neuropsychology
  • Neuropsychological Assessment
  • Specific nature of the injury
  • Pre-injury history ? strengths / weaknesses
  • Specific situation demands of life / work
  • Supports available
  • Personality factors
  • Emotional response to injury limitations
  • Adaptive coping skills
  • Beliefs / expectations of client family
  • Psychometrics

29
Clinical Neuropsychology
  • All neuropsychological tests are developed
    through research
  • Administered in a standardized manner
  • Results are compared to normative data

30
Clinical Neuropsychology
  • Cognitive domains
  • Estimated premorbid ability
  • General Intellectual ability
  • Attention
  • Speed of information processing
  • Sensory motor function
  • Language
  • Visual Perception Construction
  • Executive functions
  • Memory
  • Mood / Psychopathology / Personality
  • Validity Effort

31
Overview
  • Introduction to the brain
  • Understanding MS
  • The treatment team
  • What is neuropsychology?
  • Neuropsychological assessment
  • Cognitive domains
  • Neuropsychological profile of MS
  • Managing neuropsychological deficits
  • Specific strategies
  • Special considerations

32
Neuropsychological Profile of MS
  • 45-65 of people with MS have cognitive symptoms
  • 80 of those are mildly affected
  • Even mild problems can interfere with everyday
    activities
  • Cognitive deficits increase with prolonged
    disease duration
  • 20-30 of patients develop more severe
    impairments, such as dementia
  • Cognitive deficits dont tend to fluctuate

33
  • Greater deficits associated with
  • Progressive disease courses (PPMS, SPMS)
  • Duration of disease
  • Increased prevalence of cognitive decline in men
  • Quantity of MR abnormalities

34
Cognitive Impairment in MS
  • Processing speed
  • Attention/concentration
  • Sustained
  • Complex
  • Memory (40-60)
  • Episodic/recent memory
  • Working memory
  • Executive functioning (EF)
  • Abstract reasoning
  • Problem-solving
  • Language
  • Verbal fluency
  • Naming
  • Visuospatial skills

Table 20.3 Bobholz Gremley (2011)
35
Processing Speed
  • Speed of mental activity
  • Most common
  • Underlying factor
  • Memory
  • Working memory

http//www.mountsinai.on.ca/care/ebffrc/ms
36
Attention
  • Attention vigilance, capacity for information,
    switching attention, selective attention
  • 20-25 of MS patients
  • Deficits in rapid and complex info processing
  • Working memory
  • Attentional switching
  • Rapid visual scanning
  • Intact attention span

37
Information about Attention
Focused Attention is the ability to focus on
something in the moment. For example, focused
attention can be for things you see, such as
watching television or for things you hear, such
as listening to the radio.
38
Information about Attention
Sustained Attention allows you to focus on
something over a long period of time For
example, watching a movie or reading a book.
39
Information about Attention
Selecting Attention allows you to pick out
important information from unimportant or
distracting information For example, listening
to a conversation in a noisy cafeteria.
40
Information about Attention
Shifting Attention allows you to switch back and
forth between two different tasks. For
example, when you are cooking you may need to
shift your attention back and forth between
watching for a pot boil and preparing vegetables
to put in the pot.
41
Information about Attention Types of Attention
Divided Attention allows you to work on two
different tasks at the same time, and is
sometimes referred to as multi-tasking. For
example, singing along to the radio while driving
home.
42
Information about Attention
  • Symptoms of Attention Difficulties
  • Becoming easily distracted
  • Having trouble keeping track of what is being
    said and
  • done or have trouble making sense of things
  • Having trouble focusing on one person, thing or
  • conversation in crowded environments
  • Having trouble keeping track of more than one
    thing at a time
  • Having difficulty doing more than one task at a
    time
  • Having difficulty learning and remembering
    information
  • Becoming easily frustrated with yourself and
  • others
  • Feeling confused and overwhelmed
  • Avoiding contact with care givers, friends and
  • family

43
Memory
  • Ability to learn and recall information about
    previous experiences.
  • E.g., favorite song and the look of our home
  • Different types of memory are stored in
    different places in the brain.

Verbal information (such as words) are typically
stored on the left side of the brain
Visual information (such as pictures) are
typically stored on the right side of the brain
44
Facts about Memory Types of memory
  • Different types of memory based on time.
  • Short term memory, Working memory,
  • Recent memory, and Long term memory

45
Facts about Memory Short term memory
  • This is the ability to remember something in
    the moment or that you only need to remember for
    a few minutes
  • Remembering a phone number you have just been
    told
  • Short term memory is often impaired after a
    brain injury

46
Facts about Memory Working memory
  • This is the ability to remember in the moment or
    for a few minutes while you focus on something
    else or are distracted
  • An example is keeping a phone
  • number in mind while looking for a pen
  • and paper to write it down.
  • Working memory is often affected by
  • brain injury

47
Facts about Memory How are memories made?
If problems occur anywhere in these steps,
then memory difficulties will occur
The 3 Rs of Memory
48
Executive Functioning
  • Cognitive abilities required to complete
    goal-directed behaviors that are not automatic,
    overlearned, or routine (Sohlberg Mateer, 2001).

49
Executive Functioning
  • Initiation
  • Inhibition
  • Set-switching
  • Judgment/Reasoning
  • Goal identification
  • Working memory
  • Speed of processing
  • Cognitive flexibility/problem-solving
  • Sequential processing
  • Planning
  • Self-Monitoring
  • Perseveration
  • Prioritizing
  • Multi-tasking
  • Emotional control
  • Insight/Awareness

50
Executive Functioning
  • 15-20 of patients with MS exhibit executive
    dysfunction
  • Impaired goal-directed behavior
  • Verbal disinhibition
  • Poor self-monitoring (e.g., tangential speech)
  • Reduced insight
  • Deficits in planning and prioritizing
  • Problems with abstraction and conceptualization

51
Language and Visuospatial
  • Language
  • Mild confrontation naming deficits
  • Speech abnormalities (dysarthria, hypophonia)
  • Poor verbal fluency (retrieval deficit/speed)
  • 20-25
  • Visuospatial
  • Angle matching
  • Face recognition
  • impact of changes in vision/diplopia
  • Visual miscalculations

52
Overview
  • Introduction to the brain
  • Understanding MS
  • The treatment team
  • What is neuropsychology?
  • Neuropsychological assessment
  • Cognitive domains
  • Neuropsychological profile of MS
  • Managing neuropsychological deficits
  • Specific strategies
  • Special considerations

53
Managing Neuropsychological Deficits
54
Managing Neuropsychological Deficits
  • Neuropsychological rehabilitation
  • Interventions aiming to enhance or support
    cognitive abilities following brain injury, with
    an emphasis on achieving functional changes
    (Sohlberg Mateer, 2001)
  • Target reductions in cognitive, emotional,
    psychological functioning that encumber everyday
    functioning
  • Goal increase independent functioning by means
    of enhanced knowledge and skill, behavior change,
    or implementation of compensatory strategies

55
Managing Neuropsychological Deficits
  • Foundation of cognitive intervention
  • Tx based on current level of function
  • Build on strengths to support weaknesses
  • Collaborative
  • Goal-oriented
  • Education

56
Specific Strategies
  • Processing speed
  • Attention
  • Memory
  • Executive functioning
  • Language

57
Processing Speed
  • Complete one activity at a time
  • Schedule more time to complete tasks
  • Limit distractions
  • Record information for later review

58
Specific Strategies
  • Processing speed
  • Attention
  • Memory
  • Executive functioning
  • Language

59
Attention
  • Orienting procedures
  • What am I doing?
  • Minimizes gaps in attention
  • Pacing
  • Realistic expectations
  • Elongated performance times
  • Minimize frustration
  • Vary according to time of day
  • Schedule adequate rest

60
Attention
  • Environmental modification
  • Work in a quiet environment
  • Reduce clutter
  • Limit distractions
  • Refer to checklists to complete tasks
  • Set timers to prevent going overtime
  • Work on one task at a time
  • Double/triple check work to minimize errors
  • Have a significant other check work

61
Attention
  • Top Ten tips to help you manage attention
    difficulties
  • Practice
  • Check in
  • Modify your environment
  • Pace yourself.
  • Take care of yourself.
  • Monitor your mood.
  • Double check
  • Break tasks down
  • Do difficult tasks at your best time of day.
  • Use your family and friends for support.

62
Take care of yourself. Fatigue, hunger, and/or
thirst all adversely affect your
attention. Taking care of yourself will help
maintain optimum attention.
63
Specific Strategies
  • Processing speed
  • Attention
  • Memory
  • Executive functioning
  • Language

64
Memory
  • Repetition - Repeat the information over and over
    and over again.
  • Looking at something one time is never enough.
  • For example, if you are trying to learn someones
    name, repeating it over and over to yourself can
    help you remember it.

65
Memory
Multimodal learning It helps to learn the
same information in different ways. For
example, to learn a new recipe, it helps to read
over the steps in the recipe, listen to someone
telling you the steps, and practice the recipe by
doing it. See it, hear it, do it!
66
Memory
Break it down - Break up what you want to
remember into smaller steps. If you have
something really tough to learn, try to break it
down into small bits and then learn one bit at a
time.
67
Memory
  • Write it down - When something is important to
    remember, write it down, and keep it in a safe
    place. Remember to check your notes regularly.
  • Writing information down also allows for repeated
    exposure to the information (Hear, Write, Read
    3x exposure)
  • Calendar
  • Daytimer
  • PDA or cell phone
  • Notebook

68
Memory
Learn it right the first time - New skills are
easier to remember if you learn them the right
way (mistakes are hard to correct later)
Helpful Hints for Errorless Learning 1. Break
the task down into smaller steps. 2. Learn each
step at a time and avoid making errors that may
confuse you later . 3. Complete the task you are
trying to learn together with someone who has
done it before. Ask this person to talk through
the steps as you learn the task (this will
help you to avoid errors) 4. Use hints that will
help you remember the steps (you can ask someone
for hints or make up notes for yourself that
guide you to the next step) 5. Only try to do
the new skill when you are sure you know the
steps and can do it error-free
69
Memory
Elaboration This is a technique that you can
use to make information more meaningful and
easier to remember. Information can be easier to
remember if you think through all of the details.
Here are some questions to help you elaborate
  • Can you link this with anything or anyone you
    know?
  • Do you link this with any feelings?
  • Is there anything about it that is unique or
    special?
  • Can you link this with things in your daily
    life?
  • How does it look?
  • How does it feel?
  • How does it sound?
  • How does it smell?
  • How does it taste?

70
Memory
Space out your attempts to retrieve information
- Try to recall new information several times in
a row. If you can recall it correctly, then
gradually increase the time (from minutes to
hours) between attempts. For example, recall
information the first time after 20 seconds, then
space out your attempts to recall 30 sec, 1
minute, 5 minutes, 10 minutes, 30 minutes, 1
hour, 4 hours, later that day, and the next day.
Set up a Routine - Follow a daily or weekly
routine to help you remember events and times to
get regular tasks done each day.
71
Spaced Retrieval
Brooke Smith
72
Backward Chaining
  • 355-2941
  • 355-294_
  • 355-29_ _
  • 355-2_ _ _

73
Who is this?
74
Memory
  • External Aides (portable memory)
  • Labels on the outside of boxes, drawers, and
    cupboards to help you
  • find things.
  • Post-it notes to leave yourself reminders in
    places around your home.
  • A notepad beside the phone to write down
    messages and reminders
  • Checklists or shopping lists.
  • Diary for storing and planning
  • Alarm clock, or timer to help you remember when
    you are supposed
  • to do something
  • A calendar to keep track of appointments
  • A tape recorder to leave messages for yourself
  • A pill reminder box to keep track of medications

75
Memory
Get Organized It is easier to remember where
things are if they are kept in one place. For
example, if you are constantly losing your
wallet, you will find it faster if you always
leave it in the same spot.
Make A 'To Do' List Making a list of things
that you need to do can help you remember all
that you need to get done. For example, you can
make a list of chores to remind yourself of what
needs to be done.
76
Memory
  • Mnemonics
  • Consciously leaned
  • Require considerable effort
  • Verbal or visual
  • Richard of York gives battle in vain
  • Red, orange, yellow, green, blue, indigo, violet
  • My very elderly mother just sat upon a new pin
  • Mercury, Venus, Earth, Mars, Jupiter, Saturn,
    Uranus, Neptune, Pluto

77
Specific Strategies
  • Processing speed
  • Attention
  • Memory
  • Executive functioning
  • Language

78
Executive Functioning
  • Structure and Routine!
  • Do things that require the most initiation in the
    morning or after a rest
  • Set a small number of goals for each day
  • Set up (with assistance) organizational practices
  • Large family calendar
  • Online bill payment
  • Use labels
  • Schedules
  • Simplify activities
  • Prioritize
  • Checklists

79
Executive Functioning
  • Meta-cognitive strategies
  • To regulate behavior and increase goal-oriented
    behavior
  • Self-talk
  • Tracking behaviors
  • Self-monitoring
  • Tracking errors and attention lapses
  • Goal Management Training

80
Goal Management Training
Levine et al. (2000).
  • Maintaining intentions in goal-directed behavior
    is reliant on intact executive functioning
  • GMT based on theory of goal neglect resulting in
    disorganized behavior following frontal lobe
    injury

81
Specific Strategies
  • Processing speed
  • Attention
  • Memory
  • Executive functioning
  • Language

82
Language
  • Language
  • Communication skills training
  • Group interventions
  • Modeling and generalization
  • Building social networks
  • In MS, many language deficits are due to physical
    changes (i.e., dysphagia) and reduced speed of
    processing.
  • Allow more time for communication

83
Caveat
  • Neuropsychological interventions should be
    person-specific
  • Different presentations

Attention Processes
Executive Processes
Memory Processes
Working Memory Prospective Memory Awareness
Selective Attention Divided Attention Alternating
Attention Task Performance
Solberg Mateer (2001), Figure 8.3
84
Special Considerations
  • Common symptoms of MS
  • Emotional and psychological difficulties
  • Depression
  • Fatigue
  • Pain

85
EMOTIONAL DIFFICULTIES
  • Can impact neuropsychological functioning

86
EMOTIONAL DIFFICULTIES
87
EMOTIONAL DIFFICULTIES
88
Depression
  • Patients with MS have a 50 lifetime risk for
    depression
  • Higher prevalence than the general population and
    higher than in other brain disorders
  • Depression is treatable!
  • Prevalence of anxiety is 25 - usually associated
    with diagnostic uncertainty and decreases over
    time

89
Depression
  • Common Symptoms
  • Feelings of helplessness and hopelessness
  • Loss of interest in daily activities.
  • Appetite or weight changes
  • Sleep changes
  • Psychomotor agitation or retardation
  • Loss of energy
  • Self-loathing
  • Concentration problems

90
Depression
  • Self-management strategies
  • Schedule in activities each day
  • Make plans to see supportive friends/family
  • Consider joining a support group
  • Try a new hobby
  • Try activities that make you think (this will
    help with your recovery too!)
  • Stay away from drugs/alcohol
  • Exercise (e.g., go for a short walk)
  • Referral to a Clinical Psychologist
  • Psychotherapy

91
Depression Risk of Suicide
When feelings of depression are severe, it is
important for family members/friends to be aware
of suicide risk. If your family member/friend
talks about wanting to end their life or makes
statements such as "It would have been better if
I had died" he/she may be thinking about suicide.
It is important not to ignore these comments and
to contact a member of the healthcare team
immediately. For support from the mental health
crisis team (available 24 hours a day all week)
Call 1-877-435-7170 (MANITOBA SUICIDE LINE)
92
Fatigue
  • Why does MS cause fatigue?
  • The brain has to work harder to do the same
    activities it did before. Because the brain has
    to work so hard, it can become tired more
    quickly.
  • The brain may be trying to heal as you recover
    from a relapse and this takes more energy than
    usual, which can lead to fatigue.
  • MS can lead to problems with sleeping, which can
    leave you feeling exhausted.

93
Fatigue
When you have fatigue, you may feel suddenly
exhausted and lack the energy to do basic tasks.
Mental Fatigue Increased forgetfulness
Lack of motivation to plan your day Lack of
interest in things you enjoy Withdrawal
Slower speech Giving short answers in a
quiet/dull voice Increased irritability or
anxiety Slurred speech Difficulty finding
words Poor concentration
Physical Fatigue Shortness of breath
Slower movement Withdrawal
Cramps or weak muscles Poor coordination
or balance Falls Poor vision
94
Fatigue
It can help to figure out what triggers your
fatigue, and how long it takes you to become
fatigued. Keeping track of these factors can
help you tailor coping strategies to suit you
best. Once you know how fatigue affects you,
there are a number of strategies that can be used
to help you manage the fatigue that so often
results from a brain injury.
95
What makes fatigue worse?
  • Doing too many things.
  • Not taking breaks during the day.
  • Stress
  • Illness
  • Too little exercise.
  • Poor nutrition, such as eating junk food.
  • Alcohol and caffeine
  • Feeling depressed or anxious.
  • Poor sleep.

96
Fatigue
What are some strategies that can make fatigue
better?
  • Following a Routine
  • Environmental aids
  • Timing of activities
  • Pace Yourself
  • Sleep
  • Eat properly
  • Exercise your body
  • Exercise your mind
  • Plan ahead
  • Seek support

97
How to cope with Fatigue When should you ask for
help?
Talk with someone on your health care team
if.. You are having trouble using strategies to
cope with fatigue Your fatigue gets worse over
time You are too fatigued to get out of bed
during the day You have trouble sleeping and
aren't functioning properly You feel sadness and
lack of motivation along with fatigue You are
having trouble taking care of yourself Your
ability to think through daily activities is
affected by fatigue
98
Pain
  • Like emotional difficulties, pain can negatively
    impact cognitive functioning by
  • Stealing ones attention/focus
  • Reducing processing speed
  • Attention and processing speed deficits can
    negatively impact memory
  • Exacerbating psychological and
  • emotional difficulties

99
Pain
  • Coping strategies
  • Psychotherapy
  • Relaxation strategies
  • Abdominal breathing
  • Imagery
  • Progressive muscle relaxation
  • Cognitive restructuring
  • Behavior management
  • Planning
  • Prioritizing
  • Pacing
  • Learning how to communicate about pain

100
Final Considerations
  • Potential obstacles to successful interventions
  • Diminished insight
  • Poor engagement/motivation to change
  • Significantly compromised cognitive functioning
  • Poor generalization

Sohlberg Mateer (2001)
101
Final Considerations
  • Solutions
  • Include significant others
  • Build generalization into the treatment program.
  • Collaborative relationship with the patient and
    family
  • Homework
  • Real world examples
  • Work with patient to identify barriers to
    complete homework
  • Over-learning
  • Relapse planning and management

Sohlberg Mateer (2001)
102
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